Transition from Child to Adult Mental Health Services in Ireland

1. Transition from Child to Adult Mental
Health Services in Ireland
Niamh McNamara BA, PhD
School of Medicine & Medical Science
University College Dublin
The National Mental Healthcare Conference
Thursday 27th September 2012

2. The importance of youth mental health

3. The ITRACK Project
• Research team: University College Dublin, Trinity
College Dublin, Lucena Clinic, Cluain Mhuire
Services.
• Collaborators: University of Warwick, University
of Exeter, University of Limerick, University of
Melbourne, NSUE, Bodywhys, HADD, SHINE.
• Funded by the Health Research Board
• Aims: To identify the barriers & enablers to
effective transition for adolescents from CAMHS
to adult services

4. Why focus on transition?
• Transition will become increasingly important as
Child & Adolescent Mental Health Services
(CAMHS) begin to take on new presentations of
16 and 17 year olds
• Reports place emphasis on developing &
improving mental health services for young
people
– No focus on crucial link between CAMHS and adult
services
• Lack of information on transition process in
Ireland
– Likely issues found abroad will be mirrored here

5. ITRACK Studies
• Study 1: Survey of transition policies &
procedures in CAMHS and AMHS nationwide
– Compare best practice for smooth transition with
current clinical practice
• Study 2: Semi-structured interviews with
consultant psychiatrists, GPs, and staff from
national youth organisations
– Identify organisational facilitators and barriers to
transition
– Explore professionals’ experiences of service
provision for older adolescents including transition

6. Best practice guidelines for transition
• International transition policies & best
practice recommendations:
– Young people should receive the most
suitable and effective care for their needs
– Transitions should be seamless and user-
centred
– Should involve period of joint working
between services

7. Study 1: An investigation of operational
policies for 16-18 year olds
• Structured interviews with 57 consultant
psychiatrists (32 CAMHS, 25 AMHS)
– Based on mapping tool used in TRACK study (Singh
et al., 2009)
• Questions addressed key areas:
– Transition boundaries & annual transition rates
– Co-ordination of the transition process
– Degree of collaboration between services
– Involvement of young person in the transition
process

8. Age Boundary
• 84% CAMHS teams reported upper age limit of
18
– Typically refers to existing cases
– Practice varies regarding re-referrals & new cases
aged 16-18
– 34% accept new referrals aged 16-18
• 52% AMHS teams reported lower age limit of 18
– 84% reported accepting cases between 16 -18

9. CAMHS Transition Numbers
Mean SD Range N
Cases suitable for transfer to AMHS 7.73 9.86 1 – 50 25
per year
Cases transferred to AMHS per year 4.50 3.33 1 – 10 20
Cases remaining in CAMHS past 5.46 6.37 0 – 21 26
transition boundary per year
AMHS Transition Numbers
Mean SD Range N
Cases referred for transfer to AMHS 4.63 3.52 0 – 10 19
per year
Cases transferred to AMHS per year 4.82 3.54 0 – 10 17
* numbers represent clinician recall

10. Lost in Transition?
• Most teams lack a structured process
– 67% report lack of agreed, accessible & known
transition care arrangements
– 48% believe professionals unaware of their role in
transition process and services each offers
• Good information exchange
– 93% report a comprehensive summary of notes is
made available (with permission) to AMHS
• Minimal interaction between services
– 7% always hold professionals transfer meeting
– 12% always hand-over care through meetings
involving both services & the young person

11. Reminder: Best Practice Guidelines for
Transition
• Young people should receive the most suitable
and effective care for their needs
– Issue of access to services for 16-18 year olds
• Transitions should be seamless and user-centred
– Seems to be an administrative event rather than a
process
• Should involve a period of joint working between
services
– Limited interaction between services

12. Study 2: Qualitative study of professionals’
transition experiences
• Face-to-face semi-structured interviews
– Consultant Child & Adolescent Psychiatrists (n=8)
– Consultant Adult Psychaitrists (n=8)
– GPs (n=8)
– Staff from national youth organisations (n=9)
• Interview length ranged from 35 to 70 minutes
• Questions addressed experiences providing mental
health services to older adolescents and factors
impacting on transition
• Interview recordings transcribed verbatim & data
analysed using thematic analysis

13. Questions for Today
• Are young people receiving the most suitable and
effective care for their needs?
• What are the potential barriers to close dialogue
and collaboration between child and adult mental
health services?

14. Service Cultures
• Respondents identified key differences between
CAMHS and AMHS
– Focus of service
– Treatment model used
– Working practices
– Type of resources available
• Service culture impacts on:
– How service boundaries are defined
– Level of inter-agency communication and collaboration

15. Defining Service Boundaries:
Age
• As seen in Study 1, considerable variation in age boundaries
• Issue of who is responsible for 16-18 year old age group
impacts on quality of relationships between services
• Resources used as justification for setting age boundaries in
both services
“As a service we’re a bit rigid about the 18 year old
mark and that comes from, the management
team are very strict about it, it’s partly a resource
issue because we’re on an extremely tight budget
and we don’t , you know, we need to be careful about
that but we get clear instruction you cannot take
somebody under 18”
AMHS05 consultant

16. CAMHS02 Each sector has found its own unsatisfactory way of dealing
with it so for us if you’re unlucky enough to have been
vulnerable enough before you were sixteen you’ll still get a
service from us but if you were lucky enough to be resilient
enough until after you were sixteen you won’t get a service
from us you’ll go straight to adult so it’s not right but that’s
where it is
[…..]
Int And is the lower age for adult 16 years or is it 18?
CAMHS02 Em well we work off the em the kind of the agreement that if
they’re as I said earlier if they’re it they’ve been here before
they were 16 we’ll take them if they’re coming in cold at 16 we
don’t take them they go to adult
Int And are adult happy to [take them]?
CAMHS02 No
Int But will they take them?
CAMHS02 yeah, yeah

17. Defining service boundaries:
Clinical Presentation
“I mean you’re set up to meet needs I suppose, you know, and the needs we
address are, you know, from adult up to the age of 65, is major mental illness
em that’s that’s what that’s the need that needs to be met and that’s what
we’re good at”
AMHS04 Consultant
“….I suppose my logic on it was that if it was a child who was say psychotic
and was going to be requiring probably inpatient treatment at some point
[and] definitely going to be graduating to adult psych services I thought that
was less clearly ours whereas obviously a young person with difficulties within
a family setting, I thought that maybe we could do an intervention more
quickly and maybe discharge”
CAMHS05 Consultant
“…I think general adult psychiatrists are totally at sea with ADHD, with
Asperger’s syndrome, Autism, I think the, you know, our level of knowledge is
atrocious and I feel really sorry for people who are leaving child and adolescent
services and they have to face into that gulf of knowledge and services
available….”
AMHS01 consultant

18. Some flexibility around age depending
on clinical need
“There is a limited flexibility around it….traditionally this
area has had [a CAMH] service that did provide input up
to the age of 18 and that persists occasionally there are
people who kind of exceed the capacity of a child and
adolescent service….for example we have somebody
who’s under 18 attending who’s prescribed clozapine and
[the CAMHS] isn’t able to provide a clozapine service
because the infrequency with which it’s prescribed so
there is a kind of shared care arrangement there in place
so in circumstances where you know a case is made for
somebody under 18 that they have a particular need
which we can best meet we would try to come to some
kind of shared care arrangement”
AMHS05 consultant

19. Collaboration and communication
“….The reality is that there’s very little communication or
liaison between child psychiatry and adult services, they
are quite different, you know we don’t have in my view
we don’t have enough joint working, we don’t do things
together, and there’s very much a….I mean there’s very
much a bit of a fight really you know, it’s always maybe
the only time when there’s any discussion is about this
controversial 16 to 18 year and there’s a lot of
resentment on both sides I would say about that, so I
think that’s a real difficulty, you know once people go
into training, you know we might have trainees they go
into child psychiatry and that’s it, and child psychiatry as
I say we rarely meet if ever, I don’t know if we ever
meet”
AMHS03 Consultant

20. Study 2: Conclusion
• Variation in level of contact and quality of
relationships between child & adult mental health
services
– Underpinned by differing service cultures and
working practices
– Limited resources place constraints on what can be
achieved
• Urgent need to resolve issue of responsibility of
care for 16-18 year old group

21. Summary
• Study 1: Transition process is under-developed in
Ireland
• Study 2: Difficult to separate transition from
wider issue of mental health service provision for
16-18 year olds
• Need to encourage close dialogue and
collaboration between child and adult mental
health services
• Currently collecting data on transition experiences
of young people and parents/carers

22. Questions?
• Research team:
– Prof Fiona McNicholas (Principal Investigator)
– Dr Niamh McNamara (UCD), Dr Blanaid Gavin (Lucena
Clinic), Dr Siobhan Barry (Cluain Mhuire Services), Dr
Barbara Dooley (UCD), Prof Imelda Coyne (TCD), Prof
Swaran Singh (University of Warwick), Dr Moli Paul
(University of Warwick), Dr Tamsin Ford (Peninsula
College of Medicine), Prof Walter Cullen (UL)
– Dr Karen O’Connor, Dr Nicolas Ramperti
– Ms Cliana Doyle, Ms Erin Brennan (Lucena Clinic)
• Contact details: Dr Niamh McNamara
– niamh.mcnamara@ucd.ie