Mental health service transitions for young people
You can get lost in the system. The processes involved make it difficult to access services - there should be clearer protocols so young people are never left without support.(3)
This guide is for all staff working with young people with mental health problems who may need to move from one service to another - that is, to make a 'transition'. It will be of particular use for frontline staff, managers and commissioners providing services to young people aged 16-18 who may need to make the transition from CAMHS to AMHS or other services for young people and adults.
Policy concerns about mental health service transitions for young people are longstanding. Despite evidence of some promising and innovative practice, this is a serious issue for young people, their families, practitioners and policy-makers, both in the UK and abroad.
Evidence that young people often struggle to move between services, and in particular that they are poorly supported when they are referred by CAMHS to AMHS, has been highlighted in a number of government reports and policy guidance. (4, 5, 6) Reviews in Northern Ireland also highlight the need for good interagency working and arrangements to facilitate the transition of young people from CAMHS to adult mental health services. (25)
In February 2011, the coalition government published a mental health outcomes strategy, 'No health without mental health', (7) which states that service transition from CAMHS to adult services can be improved by planning early, listening to young people, providing appropriate and accessible information and focusing on outcomes and joint commissioning. In Northern Ireland the DHSSPS published a Service Framework for Mental Health and Wellbeing; Standard 31 of the Framework outlines good practice in transitions from CAMHS to adult mental health services. (26)
The final part of this section sets out the top 10 principles for supporting young people in transition.
What are CAMHS and who uses them?Open
CAMHS are made up of targeted, specialist services for children and adolescents, in addition to primary care (e.g. GPs, school nurses and child health), along with other services based in non-health sectors. These include youth offending teams, behaviour and education support teams, pupil referral units, looked-after children services, along with secure and other residential settings, including youth justice.
Specialist CAMHS teams – sometimes called 'Tier 3' – are multi-disciplinary community-based teams made up of child and adolescent psychiatrists, psychologists, social workers, mental health nurses and other mental health specialists. Working with children and young people with often complex, diagnosable mental health problems up to the age of 18, these teams are one of the main referral points for young people who need to make a transition to AMHS.
Voluntary sector services are important providers of mental health support to young people - for example, Youth Information Advice Counselling and Support services (YIACS) provide a wide range of counselling interventions and often work in partnership with both CAMHS and AMHS to support young people with many different psychological and emotional problems. In some areas of the country, YIACS is the agency through which the Department of Health's (DH) national initiative Improving Access to Psychological Therapies (IAPT)is being delivered in England and Wales.
Young people using CAMHS have a range of psychological, emotional or behavioural problems, such as early psychosis, clinical depression, emerging personality disorders, eating disorders, ADHD and ASDs. Problems with self-harm, alcohol and drug misuse are also common, and among young people using CAMHS the rates of substance misuse are especially high. Quite frequently, young people also have more than one problem - referred to as 'co-morbidity'.
Terms used in the literature for these problems vary and include 'mental health difficulties', 'mental health problems', 'mental illness' and 'mental disorders' - reflecting different discourses and models of mental health.
When might a young person leave CAMHS and move to AMHS?Open
Discharge from CAMHS and a potential move to AMHS takes place at varying ages, but most commonly when young people are aged between 16 and 18. However, transitions from children to adult services differ between sectors:
- children services are generally provided up to the age of 19
- the youth justice system works with children and young people aged between 10 and 17
- children who are looked-after can continue to receive services until the age of 21, or 25 if they are in education
- age boundaries also vary if a young person has a learning disability
- (However in Northern Ireland all children's services are provided to children up to 18 years of age, with the exception of looked after children who also can receive support up to the age of 21, or 25 if they are in education).
Clearly, age-related service moves are not confined to mental health services, and lessons can be learned from parallel experiences in other areas, including juvenile justice and child welfare.
Why it's important to get transition in adolescence right for young peopleOpen
Adolescence is a period of intense change for young people. The move from CAMHS to AMHS is likely to coincide with other transitions and young people emphasise the complexity of their lives and the multiple difficulties they may experience during this period. Pressures on young people may include relationships and friendships, education and training, pregnancy and childbirth, employment, housing and money. All of these highlight the importance of co-ordinated, multi-agency planning for transitions, involving a range of professionals from different disciplines.
Adolescence is also the time when new mental health problems such as psychosis or eating disorders may first emerge, or existing difficulties may become more complex or severe. Recent studies 18 have found that in children aged between 11 and 16, the rate of 'mental health disorders' is 12 per cent, while up to 20 per cent of those aged between 16 and 24 have a mental health problem, most commonly anxiety and depression. Research 23 also indicates that the psychological and social changes that occur in adolescence raise the incidence of mental health problems and risk-taking behaviours.
Poor service transitions make it more likely that young people will disengage from mental health services despite continuing need. This can seriously affect a young person's health and wellbeing, as well as that of their parents, carers and wider family. Adverse outcomes in mental health are associated with difficulties in many aspects of life, including being able to take advantage of education, training and employment opportunities.
What is the issue? Barriers to effective transitionsOpen
Difficulties in providing good support during mental health service transitions are linked to broader issues in providing effective, age-appropriate, accessible mental health support to young people. (25) The mental health needs of this diverse group are distinct from those of both children and adults. The way in which CAMHS and AMHS are organised does not always fit easily with the ways in which mental health problems are experienced by young people.
A young person may find him- or herself without a service for various reasons. These include:
- Differences in referral criteria and entry thresholds in CAMHS and AMHS.
- Inconsistencies in age cut-off points, with some services ending when a young person is 16 while other services have a lower age limit of 18.
- For some groups (e.g. young people with learning disabilities, ADHD and ASDs), long-term experiences and outcomes into adulthood are not well documented. Young people with these difficulties who receive help from CAMHS are likely to need ongoing support as adults - however, there is a lack of adult services to cater for them.
Even when young people are successfully referred to adult services, the move may not go well. Practice is frequently inconsistent and often poor, resulting in negative experiences for young people and their families. The National Advisory Council8 reported few examples of adults' and children's service commissioners working together to provide appropriate transitional care and highlighted:
- poor understanding of young people's mental health problems and how resilience can be developed
- administrative and legal processes, including service thresholds, which made services inflexible and unresponsive
- 'unacceptable' variations in the level and type of services available in different areas.
The legal and policy context that underpins young people's mental health transitions in England and WalesOpen
The broad principles that should underpin transition services were summarised in 2005 by the then Social Exclusion Unit (9) as:
- actively managing the transition from youth to adult services
- taking a young person's thinking and behaviour into account, and building on it
- involving young people, their families and carers in designing and delivering services
- giving effective information about services and sharing information between services
- offering young people a trusted adult who can support them through the process.
There is an extensive array of policy guidance and legislation that is relevant to supporting young people in transition from CAMHS in England and Wales. This includes sections of the NHS Act 2006, the Children Act 1989 and the Children Act 2004.
Specifically relating to health provision, the National Service Framework (NSF) for Children, Young People and Maternity Services and the National Health Service (NHS) Outcomes Framework are both important. The NSF, while no longer part of the coalition government's health policy, sets out aspirations that are clearly part of the government's overall policy objectives and in Standard 9 makes important recommendations for when the CPA should be used with young people aged under 18. In the objectives set out in the outcomes framework for improving mental health, transition from children to adult services is mentioned.
A guide produced by the National Mental Health Development Unit (NMHDU), the National CAMHS Support Service (NCSS) and YoungMinds, entitled 'Transitions in mental health care',10 provides a detailed overview of the legal framework.
Legal and policy context in Northern IrelandOpen
In Northern Ireland the mental health care of children is usually provided under the general duty in Article 4 of the Health and Personal Social Services (Northern Ireland) Order 1972, and the Children (Northern Ireland) Order 1995. A programme of reform is underway in northern Ireland across mental health services as a result of the Bamford Review of Mental Health and Learning Disability in Northern Ireland (2006) (25). This review made recommendations for developments of CAMHS services. A recent inspection of CAMHS services (29) found that progress has been made to take forward the Bamford recommendations, however noted an absence of policy guidance and regional standards for CAMHS in Northern Ireland. Currently each health and social care trust area develops and provides services, without reference to a regional framework based on clinical standards and care pathways. Trusts have protocols governing the transition from CAMHS to adult mental health services, which, although not uniform, are flexible to respond to local need and the organisation of service provision across this interface. Guidance for transition from CAMHS to adult mental services is also outlined in Standard 31 of the DHSSPS Service Framework for Mental Health and Wellbeing. (26)