Report - London Borough of Hillingdon
External Services Scrutiny Committee
Transition from Child to Adult Mental Health Services Working Group
....................
Monday 17 th March 2008
6.00 p.m.
Committee Room 3, Civic Centre, Uxbridge
Working Group Membership:
Councillors
Judith Cooper
Janet Gardner
John Hensley
Allan Kauffman
John Major
Mary O’Connor
Cllr Anthony Way
Cllr David Yarrow
Contact Officer:
Maureen Colledge
Democratic Services
Civic Centre
High Street
Uxbridge, UB8 1UW
Telephone: 01895 277 488
Facsimile: 01895 277 373
E-mail: mcolledge@hillingdon.gov.uk
Members of the public are welcome to attend the meeting and listen to the discussion in
Part 1 of the Agenda.
This Agenda is available online at
http://www.hillingdon.gov.uk/central/democracy/comm_reports/index.php
Smoking is not allowed in the Committee Room
Please ensure that all mobile phones are switched off
DESPATCH DATE: 7 th March 2008
Hugh Dunnachie
Chief Executive
London Borough of Hillingdon,
Civic Centre, High Street, Uxbridge, UB8 1UW
www.hillingdon.gov.uk
External Services Scrutiny
About the Committee
The Committee scrutinises services provided by non-Council organisations in
the Borough including the public, private and voluntary sector.
The Committee also undertakes the health scrutiny role required by the Health
& Social Care Act 2001.
The Committee has the power to identify areas of concern to the community
and instigate an appropriate review process.
It reports its findings to Cabinet, highlighting issues of concern for Hillingdon
residents.
About the Working Group
On the 19 th February 2008, the External Scrutiny Committee agreed to
establish a Working Group to review the transition from child to adult mental
health services within the borough.
This topic is a priority for the Department of Health and the review would
provide greater transparency on what is happening in Hillingdon.
The Working Group is a task and finish group, set up to carry out the review. It
will report back to the External Services Scrutiny Committee.
Hugh Dunnachie
Chief Executive
London Borough of Hillingdon,
Civic Centre, High Street, Uxbridge, UB8 1UW
www.hillingdon.gov.uk
EXTERNAL SERVICES SCRUTINY COMMITTEE
Working Group on the transition from Child to Adult Mental Health
Services
17.03.08 AGENDA
PART 1 – MEMBERS, PUBLIC AND PRESS
i.) Apologies for absence and to report the presence of any substitute
members
ii.) Declarations of Interest in matters coming before this meeting
iii.) Notes of the previous meetings – none as this is the first meeting
iv.) Exclusion of Press and Public - To confirm that all items marked Part 1 will
be considered in public and that any items marked Part 2 will be considered
in private.
1. Election of the Chairman of the Working Group
2. Review of the transition from child to adult mental
health services – scoping report
Page 1
PART 2 – PRIVATE, MEMBERS ONLY
i.) Any Business transferred from Part 1
GLOSSARY
CAMHS Child and Adolescent Mental Health Service
CFAC Child, Family and Adolescent Consultation Service
CNWL Central & North West London NHS Foundation Trust
Terms of Reference of the External Services Scrutiny
Committee
1. To undertake the powers of health scrutiny conferred by the Health and
Social Care Act 2001, including:
(a) scrutiny of local NHS organisations by calling the relevant Chief
Executive(s) to account for the work of their organisation(s) and
undertaking a review into issues of concern;
(b) consider NHS service reconfigurations which the Committee agree to be
substantial, establishing a joint committee if the proposals affect more than
one Overview and Scrutiny Committee area; and to refer contested major
service configurations to the Independent Reconfiguration Panel (in
accordance with the Health and Social Care Act);
(c) respond to any relevant NHS consultations.
2. To scrutinise the work of non-Hillingdon Council agencies whose actions
affect residents of the London Borough of Hillingdon.
3. To identify areas of concern to the community within their remit and
instigate an appropriate review process.
Terms of Reference of this Working Group
To be agreed at this meeting.
REVIEW OF THE TRANSITION FROM CHILD TO ADULT
MENTAL HEALTH SERVICES – SCOPING REPORT
ITEM 1
Contact Officer: Maureen Colledge
Telephone: 01895 277488
REASON FOR REPORT
When the External Services Scrutiny Committee discussed mental health
services on 10 th January 2008 with service providers, Members expressed
concern about continuing problems faced by young people during the transition
from child to adult mental health services. As a result, on 19 th February, the
External Services Scrutiny Committee decided to set up a Working Group to
review transition arrangements, with the aim of bringing greater transparency to
the services available. This report presents a scoping report for that review.
OPTIONS OPEN TO THE COMMITTEE
1. To agree the scoping report and work plan, without amendment.
2. To amend and agree the scoping report and work plan.
3. To reject the scoping report and work plan and call for further work.
INFORMATION
1. The scoping report (attached) proposes terms of reference for the review; sets
out the background and importance of the topic; identifies the key issues; and
proposes a methodology for carrying out the review. It is the key document
guiding the conduct of the review and is for consideration at this first meeting.
2. Attending this meeting to give advice to the Working Group will be:
Jane Wood, Head of Adult Services, Adult Social Care, Health & Housing
Julian Wooster, Deputy Director, Children and Families, or Pauline Nixon,
Head of Inclusion, Education and Children’s Services.
Attachments:
a. Draft scoping report - pages 3-8
b. Summary of local Mental Health services and transition arrangements –
pages 9-12
c. Mental Health in Children: Equalities Issues – short literature review –
pages 13-15
d. CAMHS to Adult Transition – A literature review for informed practice,
Department of Health
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SUGGESTED SCRUTINY ACTIVITY
• Seek officer advice on the issues that should be covered by this review.
• Consider whether the proposed terms of reference and key questions are
appropriate and sufficient.
• Review the proposed methodology and work plan, seek officer advice on
appropriate witnesses and visits, and suggest changes, if needed.
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DRAFT
London Borough of Hillingdon
EXTERNAL SERVICES SCRUTINY COMMITTEE
WORKING GROUP ON THE TRANSITION FROM CHILD TO ADULT
MENTAL HEALTH SERVICES
2007/8
REVIEW SCOPING REPORT
Proposed review title:
THE TRANSITION FROM CHILD TO ADULT MENTAL HEALTH SERVICES
Aim of review
To map, review and improve the transition from child to adult mental
health services for young people with mental illness in Hillingdon.
Terms of Reference
1. To map the provision of mental health services on both sides of
the transition from child to adult mental health services for young
people with mental illness in Hillingdon.
2. To investigate service users’, their families’ and advocates’
views on the transition from child to adult mental health services.
3. To investigate disparities in services to different groups of young
people with mental illness, and whether these are appropriate.
4. To investigate whether improvements are needed in relation to
the transition from child to adult mental health services.
Background and importance
1. One in four people suffer some form of mental illness at some point in their
life. If this starts in childhood then a crucial period can be when the young
person reaches their teenage years and moves after 18 years old from
help provided by child mental health services to adult mental health
services.
2. Increasing numbers of young people are presenting with mental illness
problems due to a variety of factors (better diagnosis, greater family and
societal awareness, drug and alcohol problems and the pace of modern
life), which causes pressures on services. Cause for concern is the
difficulties some young people experience in the transition from child to
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DRAFT
adult mental health services, which has been highlighted in a number of
influential reports and is a priority area for the Department of Health.
3. The consequences of failure to deal adequately with young people’s
mental illness can be seen in rates of suicide for young men, and in the
prevalence of mental illness among young people and young adults in
prisons or on probation. The cost of getting these services wrong falls not
just on the young people and their families, but also on society.
4. The Healthcare for London review did not initially give mental health
sufficient attention and a working group of London mental health trusts has
now been established to examine how to develop London’s mental health
services. The aim is to promote earlier intervention, provide effective
preventative strategies and promote recovery through greater social
inclusion of people suffering mental illness.
5. Mental health is at the forefront of moving health services into the
community. For example, only about 800 of Central and North West
London Mental Heath Trust’s 41,000 patients will be treated as inpatients
in a year. In this context, Council services such as housing, social services
and educational services also play an important a part in meeting needs at
the transition to adulthood.
Reasons for the review
6. Local mental health services providers and council service providers
support a review by Hillingdon of the transition of young people with
mental illness from child to adult services. The review recommendations
can feed in at a time when health providers and the council are looking to
make changes that improve local health care.
Equalities
7. There is a strong equalities aspect to investigating mental health services
for young people. Rates of mental illness and the prevalence of certain
types of mental illness, e.g. schizophrenia, are known to differ among
different ethnic groups. Account will need to taken of those patterns and
the review should seek information about how services respond to
differences around the transition. Users’ views will be important in this
context.
Who is this review covering?
8. Definitions of the key people and services to be covered by this review are:
• Young people with a clinically defined mental illness
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DRAFT
• Hillingdon Primary Care Trust (PCT) as the lead commissioner for both
Child and Adult Mental Health Services for residents in the borough
• Central and North West London (CNWL) Mental Health Trust as the
providers for both local Children’s and adult Mental Health Services.
Key issues
7. Key issues for the review are:
1. What services are available to help young people with mental illness as
they approach adulthood?
2. How does the transition from child to adult mental health services
happen?
3. How well do local community services and other health services work
with mental health services in meeting the needs of young people with
mental illness moving from child to adult service provision?
4. Are young people with mental illness, their families and advocate
groups happy with the way the transition from child to adult mental health
services works in Hillingdon?
5. Are there disparities in services provided to different groups of young
people with mental illness, and if there are, are these appropriate?
6. What, if any, improvements do service providers, service users,
families and advocate groups feel are needed in the way the transition
from child to adult mental health happens?
Methodology
A working group:
It is proposed that a working group be set up by the External Services
Scrutiny Committee to undertake this review, with membership of the working
group to contain representation from relevant Policy Overview Committees
(POCs), such as the Adult Health, Housing and Social Services POC, the
Education and Children’s Services POC and the Residents’ and
Environmental Services POC.
Brunel University, which has relevant staff and faculties for this issue, has
been approached to provide an expert advisor to the review and possibly
assistance with research.
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DRAFT
Relevant Documents:
“CAMHS to Adult Transition - A Literature Review for Informed Practice”
Health and Social Care Advisory Service (HASCAS) Tools for Transition,
Department of Health.
Department of Health: “Getting it Right”, 2006, dealing with the transition of
young people with long-term conditions needing health services (not restricted
to mental health)
Sheffield City Council, Health & Community Care and Children & Young
People’s Scrutiny and Policy Boards’ “Report of the Working Group into
Young People’s Mental Health Services”, 2006.
Service plans of the local mental health commissioner and providers.
Department of Health Policy Guidance for Mental Health Services
Witnesses:
Hillingdon Primary Care Trust (PCT) – commissioners of mental health
services.
Central and North West London Mental Health NHS Trust (CNWL) - providers
of child and adult mental health services
A “best practice” advisor from outside of Hillingdon services
Service users: young people with mental illness and their families
Advocacy groups: e.g. Hillingdon Mind
Related services: officers from Education, Social Services, Housing and drug
and alcohol services, and officers from services that experience the impact of
failures: Youth Offending Team and the Probation Service and possibly also a
psychologist from Feltham Young Offenders Institution.
Officers with relevant expertise from the Department of Health and Health
Care for London to be invited.
Stakeholders and consultation plan
The stakeholders are: mental and community service providers, young people
with mental illness and their families, and support and advocacy groups.
Consultation plan: representatives of stakeholders will be invited as
witnesses. The review could be publicised in Hillingdon People and on the
Council website and written contributions invited. Advocacy groups such as
Mind will be asked to publicise the review. Ethnic minority groups with an
interest in this matter will be consulted.
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DRAFT
Connected work (recently completed, planned or ongoing)
The Social Services, Health & Housing POC is reviewing customer
engagement with adult social care, health & housing services during 2007/8.
On 4th March the POC focused on how mental service providers in
Hillingdon engage their service users.
The External Services Scrutiny Committee will also maintain an interest in
mental health services through its health scrutiny work (in particular the
annual health check and scrutinising the Healthcare for London proposals).
Outcome
A report to the External Scrutiny Committee, with the aim that this would go to
the relevant service providers and the Hillingdon Cabinet. The report will
present the review findings and recommend any improvements. The aim will
be to make more transparent the transition from child to adult mental health
services in Hillingdon and encourage improvements in services, if they are
needed.
Proposed timeframe & milestones (to be completed and dates inserted
when work programme agreed)
Meeting/date Action Milestone
1. Mon 17 th
March
2008
Working Group to meet
Agree Chairman,
scoping report and
work plan
2. Mon 21 st
April
2008
3. Thurs 8 th
May
2008
4. Wed 4 th
June
2008
5. Tues 8 th
July
2008
6. June/July
/Aug 08
7. Mon 15 th
Sept
Evidence session – PCT and CNWL
to be invited
Evidence session – Hillingdon Mind
and child mental health service
providers invited
Evidence session – related services
YOT, Education, Social Services,
Housing and Drug & Alcohol.
Evidence sessions and/or consider
findings
Visits to services and meetings with
service users and their families
(advice on this to be sought from
service providers and Mind at earlier
sessions)
Consider report
Collect evidence on
services
Collect evidence on
services and
users/advocacy
Collect evidence
from related services
Collect evidence
and/or identify
recommendations
Collect evidence and
discuss issues from
earlier sessions
Agree report
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DRAFT
Risk assessment
What risks are there in undertaking this review now
Changes taking place in healthcare generally may impact on the services
being considered – this needs to be recognised and factored into the review
plans, e.g. by revisiting services if major changes are announced or occur.
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Hillingdon Mental Health Services
Hillingdon Mental Health Services are managed by Central and North West
London Mental Health NHS Trust (CNWL).
Hillingdon Primary Care Trust commissions (buys) these services on behalf
of Hillingdon residents.
The service comprises both acute inpatient and community services. It also
provides a range of specialist services comprising a Crisis and Home
Intervention Team, A&E Liaison Service, Assertive Outreach Team, Eating
Disorder Service and a community Drug and Alcohol Service.
Contact details for CNWL main adult (excluding older adult) sites and
children sites in Hillingdon are:
Adult services:
Riverside Centre
• Hillingdon Hospital Site, Pield Heath Road, Uxbridge UB8 3NN
01895 279 602 (main reception)
• Riverside has two wards – Frays (01895 279 614) and Crane (01895
279 612)
2 Colham Green Road (housing and rehabilitation)
• Hillingdon Hospital Site, Pield Heath Road, Uxbridge UB8 3NN
01895 279 826 (main reception)
Hillingdon Drug and Alcohol Service (HDAS)
• Old Bank House, Uxbridge High Street, Uxbridge 01895 207 777
Adult Community Mental Health Teams (CMHTs)
• North Hillingdon community mental heath team: based at the
Pembroke Resource Centre, 90 Pembroke Road, Ruislip Manor Tel
01895622 424.
• Hayes & Harlington community mental heath team– based at Mead
House Resource Centre, Hayes End Road, Hayes End Tel 020 8561
6676
• Uxbridge, Yiewsley & West Drayton community mental heath team
based at Mill House Resource Centre, 38 Riverside Way, Uxbridge
Tel: 01895 206 800.
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Specialist services
• HOST (Hillingdon Assertive Outreach Team): based at Old Bank
House (01895 207 766)
• A&E Liaison: based at the Hillingdon Hospital A&E
• CRHITT (Crisis and Intensive Home Intervention Team)
• Primary Care Counselling Service: a dedicated counselling service
based at Mount Vernon Hospital. Referral via GP.
• Central Psychological Service
• Eating Disorder Service: based at the Pembroke Centre.
Accessing services and referral criteria
• Referral by a GP to a local mental health team
• A&E if the situation is urgent and/or serious in nature
• NHS Direct for advice and/or information on local services
• Contact with the local mental health team directly. Each has a duty
desk that can give advice and deal immediately with concerns.
Child, Family and Adolescent Consultation Service (CFACS)
1 Redford Way, Uxbridge UB8 1SZ. Tel. 01895 256521
Service Manager: Dr Frances Carroll (Team Co-ordinator)
The Child, Family and Adolescent Consultation Service offers services for
infants, children, adolescents from the ages of 0-18 with emotional,
behavioural and other mental health problems. The service caters for
families in Hillingdon.
The service offers family therapy, individual therapy, group therapy and
parent/infant therapy.
Referrals can be made to the service from health, education or social
service professionals who have contact with children, young people and
families. Referrals can be discussed first over the telephone.
The transition of child to adult services is documented in a protocol –
the attached flow chart and glossary summarise the process.
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Timeline
By 17 th birthday
Actions
CAMHS and partner agencies, start planning and preparing, with young person (YP)
and family, for transfer. Paying particular attention to Family and Carers’ involvement
and agreements around sharing information.
From 17 th birthday
CAMHS Care Co-ordinator contacts Community Mental Health Team (CMHT)
manager by letter requesting transfer of care. Letter to include all paperwork requested
in the Transfer of Care Policy. YP put forward to Joint Placement Panel, (or
equivalent) if returning from ‘out of borough’ or in complex circumstances.
Referral received
CMHT manager considers the case and once accepted appoints Adult Care Coordinator
and Consultant who will take responsibility before transfer of care.
1-4 weeks from
referral being
accepted
Pre Care Programme Approach (CPA) meeting arranged by CAMHS for YP,
Consultants, Family/Carer, Adult Care Co-ordinator and appropriate others to prepare
for Transfer, agree Joint CPA Meeting date and also give attention to the changing
role of Carer as YP transfers e.g. confidentiality, degree of involvement, consent,
information sharing across services including Care Plans and invites to appointments.
Within 6 weeks after
referral accepted
Joint CPA meeting organised by Adult Care Co-ordinator in consultation with YP,
family, CAMHS worker and all other agencies involved. Group agree a transfer date
(and all decisions as per Transfer Of Care Policy).
CPA Care Plan and other relevant documents distributed by Adult Care Co-ordinator.
Period of joint working up until agreed transfer date before the age of 18 to
support young person and family and to enable Adult Care Co-ordinator to
establish links with the wider support network.
Final transfer
date– before
the age of 18
Final CPA transfer. CAMHS provide discharge summary and close the case –
copies to young person, carer and relevant others. Formal Carers
Assessment offered 1-2 months after Transfer
Transfer of Care Flow Chart Glossary
Transfer of Care
A purposeful, planned process that addresses the medical, psychosocial and
educational/vocational needs of adolescents and young adults as they move from childcentred
to adult-oriented health care systems. *
BTransfer of Care Policy
The full document setting out transfer guidance. Issued on 21 st January 2005 and subject to
two yearly review. Issued by the Nursing Directorate within Central North West London
Mental Health NHS Trust.
BCAMHS
Child and Adolescent Mental Health Services for 0-18 year olds.
BYP
Young Person
BCommunity Mental Health Team (CMHT)
Locality based, multi-disciplinary teams supporting adults with mental health needs.
BJoint Placement Panel
Multi-agency forum that meets fortnightly, chaired by the local authority, whose task it is to
approve and commission local placements.
BCare Co-ordinator
Within the Care Programme Approach, the Care-Co-ordinator is the person responsible for
overseeing the delivery of care.
As a young person is transferred to adult services they will be allocated a new Adult Care
Coordinator who will lead on creating and implementing their care plan (see below).
BCare Programme Approach (CPA)
The approach sets out that all users of specialist mental health services must have:
• a comprehensive ASSESSMENT of their health and social care needs
• a single CARE PLAN that addresses identified needs drawn from the assessment
• a designated CARE CO-ORDINATOR responsible for overseeing the delivery of care,
and
• a systematic and regular REVIEW of the care plan to reflect any change that occurs
Carers’ Assessment
Carers have a legal right to an assessment of their needs
•
Mental Health in Children: Equalities Issues
This briefing describes research carried out on BME young peoples use of
mental health services, based on a review of the literature. The key findings
are summarised below.
The Office for National Statistics Survey of the mental health of children and
adolescents in Great Britain (1999) revealed that nearly 10% of White children
and 12% of Black children were assessed as having a mental health problem.
The prevalence rates among Asian children were 8% of the Pakistani and
Bangladeshi and 4% of the Indian samples.
Key issues and findings:
• Many young BME people only reached help at a critical point in their
difficulties, sometimes after an emergency referral.
• The problems in accessing services: a proportion of BME families did
not access their GPs regarding mental health issues, cultural barriers
to accessing services and information, and spoken and written
language being a barrier in accessing services and information.
• Limited knowledge of existing mental health services and what it does.
• Stigma associated with mental health: even when young people
recognised that they needed help many did not know where to go - or
were wary of seeking help due to worries about stigma and
confidentiality.
• BME had experienced particular difficulties with the transitional phase
from CAMHS to the Care Trust.
• The lack of partnership working between CAMHS and voluntary sector
provision in many areas of the country was highlighted.
• Inadequate support for Black community initiatives and communitybased
crisis care.
• Lower satisfaction rates with the service provided.
• Young African Caribbean men are more likely than others to be
referred to mental health services through the criminal justice system,
rather than through their GPs.
• For young Asian people, there were some suggestions that their fears
of being ‘labelled’ are very marked since seeking help is viewed as
‘going outside of the family’.
Some examples of types of illnesses:
• Young Asian women have higher rates of suicide compared to other
young women. Rates of self-harm are also of particular concern
amongst this group. Studies show that factors such as forced marriage
and pressure to do achieve highly at school (for male and female) may
lead to depression, suicide, loneliness, isolation, and/or self harm.
• Suicide rates are high in young Indian men and in East African men
and women (using suicide data 1988-92 and country of birth). A
national clinical survey of patient suicides in England and Wales,
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suggests that different suicide prevention measures are needed for
different ethnic groups.
• The relatively higher rate of physical problems such as coronary heart
disease and diabetes amongst some Black and minority ethnic groups
is resulting in the early death of a significant number of fathers. The
knock-on effect of this is the expectation that the eldest son will
become the head of the household. Some services have reported
young men presenting for counselling due to anxieties about taking on
this role.
• Young Black males: Social risk factors include poverty, unemployment,
exclusion from school, loneliness and isolation, homelessness, contact
with the criminal justice system.
• A measure of general psychiatric morbidity in the Fourth National
Survey of Ethnic Minorities showed that a much higher proportion of
Bangladeshis may suffer from psychiatric illness (2.5 for men and 2.4
for women).
• Autism, psychosis and conduct disorders were more common in the
second generation African Caribbean children in the study.
• Young refugees and asylum seekers have significant mental health
needs, arising from their past experiences of trauma, bereavement,
loss and grief. Many also experience racial harassment on arriving in
the UK.
Factors to consider for development:
• How to reach and engage with young people from Black and minority
ethnic groups who may require help from mental health services.
• What needs to happen to aid the development of effective service
provision for young people from Black and minority ethnic groups.
• Training for staff in race equality and cultural competence.
• More flexibility: flexible hours when services are available, more
opportunities to drop-in or self-refer and greater choice of venues.
• Support and information for parents from minority ethnic groups in
order to help them understand CAMHS and to try and reduce the
stigma/fears connected with their child receiving help from these
services.
• Language barrier: Improving interpreting services.
• An effective policy in place that deals with discrimination by patients,
staff and institutions.
• The importance of considering diverse religious and cultural needs and
of professionals not making assumptions about young people on the
basis of these factors.
• New sources of information about CAMHS are needed, to be
disseminated more widely, including through ‘non-traditional’ routes
that young people may be more interested in using such as the
internet, media/radio, social and local faith groups.
• The important role of the voluntary sector needs to be recognised and
developed. This includes: building effective links between
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CAMHS/health service providers and voluntary sector providers;
involving the voluntary sector in the commissioning of services; sharing
good practice and, crucially, attention being given to providing more
sustainable funding of voluntary sector projects.
References:
• Sheffield City Council: Health and Community Care and children and
young people scrutiny and policy development boards report of the
working group into young people’s mental health services.
• CAMHS to Adult Transition: A Literature Review for Informed Practice
• http://www.actiondre.org.uk/positivesteps/bme.html
• http://www.youngminds.org.uk/publications/all-publications/minorityvoices
Minority Voices: Research & Guide
• http://www.mind.org.uk
• http://www.csip.org.uk/about-us/about-us/equality-and-diversity-.html
Nav Johal
Overview & Scrutiny team
Democratic Services
7 March 2008
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CAMHS to Adult Transition
HASCAS TOOLS FOR TRANSITION
A Literature Review for
Informed Practice
“
Adolescents
are a critical asset and at the
centre of social development.
We know what needs to be done.
”
We know how to do it.
World Health Organisation (2002)
CAMHS to Adult Transition
A Literature Review for Informed Practice
Contents
Page
Introduction 1
1. Working definitions 1
Young person, adolescent 1
Young adult 2
CAMHS 3
Adult Services 4
Transition 4
Summary box 1 4
2. The (mental) health of adolescents 5
The European dimension 5
The national picture 5
Trends in adolescent mental health 6
Policy 8
Summary box 2 12
3. The nature of transition 13
Life stage approaches 13
Life course approaches 14
Adolescent health transitions 14
Summary box 3 17
4. Barriers to transition 18
Age boundaries and service configuration 18
Differing thresholds and eligibility 19
Different professional cultures 20
Summary box 4 21
5. Planning, delivering and improving services for adolescents and 22
young adults
Service structure and components 22
Young people’s involvement and participation 24
Summary box 5 25
References 26
Glossary of abbreviations 31
Appendix: The tiered framework for CAMHS
i
HASCAS Tools for Transition
CAMHS to Adult Transition
A Literature Review for Informed Practice
CAMHS to Adult Transition
A Literature Review for Informed Practice
1.Introduction
The transition from a child and adolescent to an adult mental health service is necessary for
young people whose mental health problems are likely to be both severe and enduring.
Given the current age boundaries within service organisation in the UK, that transition, if it
occurs, will normally take place around the eighteenth birthday. Since the National Service
Framework for Mental Health covers adults of working age, ie from 16 th birthday, some
young people can, in theory, transit earlier.
The issue of concern is that some young people fail to make the transition, usually for
reasons of service design, configuration and ethos.
This review of the literature is part of a project funded by the Department of Health and
carried out by the Health and Social Care Advisory Service (HASCAS). Its purpose is to
collate and coordinate as much learning as possible and to be creative about ways of putting
the learning into practice. This is not a systematic review, nor a critical appraisal; the paucity
of literature necessitates a more pragmatic approach (See Vostanis, 2005, page 451). The
literature search has used broad parameters, drawing in texts and information from a wide
variety of sources. Wherever possible, documents relating specifically to mental health
issues in UK adolescents were used, but where findings from wider sources offered
underlying principles that could be applied, these were also included. 1
Working definitions
Young person, adolescent
Adolescence may be seen as beginning at puberty, around age ten and ending with young
adulthood, around age twenty. Conversely when people refer to adolescents they rarely
mean either ten year olds, or twenty year olds, but perhaps teenagers, 13-19.
Properly adolescence refers to a definable period of psychosocial development between
childhood and adulthood, when independence, identity and sexuality are salient. The Royal
College of Paediatrics and Child Health (2003, page 11) suggests:
1 Every attempt has been made throughout this document to be transparent about the origins and
nature of the various texts referred to. As part of its Tools for Transition pack, HASCAS has also
produced an annotated bibliography, in which all of the references from this document are outlined,
with many including a hyperlink to the source material.
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"Young people" is a phrase used as an alternative to "adolescents" and, in this
document, has the same meaning. We have not defined adolescence by age
because there would be difficulties in agreeing age limits, when adolescence is
essentially a developmental stage. In this report we are particularly interested in
the welfare of those young people on the cusp of adulthood, most of whom will be
in the age range 13-18. We recognise that many young people can be properly
thought of as adolescent before that age and similarly most professionals would
agree that adult characteristics are often developing well into a person's twenties.
Young adult.
There is a growing interest in the age group 16-25, which may be termed young adult. A
House of Commons Select Committee on Health (2000) took evidence from a range of
organisations and individuals, noting that provision of CAMHS for adolescents was patchy
and that age “cut-off” points were variable and arbitrary. In addition to age at transfer the
report also records cultural differences between child and adult services as a barrier. The
report, entitled Transitions between child /adolescent and adult services, records a strong
lobby for youth services designed for 16-25s, though the authors acknowledge these would
have boundary problems of their own.
Many voluntary sector youth services cover this age range, specifically the Youth Information
and Advice Centres (YIAC), covered by the umbrella organisation Youth Access. 2 The young
people’s mental health charity, Young Minds, has produced a number of documents within
its project on mental health for 16-25s, entitled SOS - Stressed Out and Struggling. 3 The
Mental Health Foundation published its influential report, Bright Futures in 1999, which
identified the gaps in provision for young people aged 16-25 with mental health problems.
This was followed by Turned Upside Down (Smith and Leon, 2001) in which an outline is
provided for mental health services for this age group, with an emphasis on responses to
crisis. Both reports are predicated on the understanding that the years 16 to 25 encompass
a period of rapid transition, both on a personal level from childhood to adulthood, and in
moving from child to adult services. The result is that young people find it difficult to access
services and are left with little or no support.
The rationale for Turned Upside Down, which proposes service models for this age group, is
that this period of significant change has a psychological impact on a young person, which
may lead to a crisis in their mental health, requiring support and intervention (Smith and
Leon, 2001, page 8). The justification for considering young adults as a discrete group may
also be inferred from the extract below from A Work in Progress: the Adolescent and Young
Adult Brain (Young Minds, 2006, page 2).
2 http://www.youthaccess.org.uk/
3 http://www.youngminds.org.uk/sos/outputs.php
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Just prior to puberty a wealth of grey matter is created and, as neurons develop,
a layer of myelin is formed which greatly increases the speed of transmission of
electrical impulses from neuron to neuron. A period of synaptic pruning then
occurs throughout adolescence, a process not completed until the early 20s,
which is believed to be essential for the fine-tuning of functional networks of
brain tissue, rendering the remaining synaptic circuits more efficient. The frontal
cortex [where this development takes place] is essential for such functions as
response inhibition, emotional regulation, analysing problems and planning.
Many of these aptitudes continue to develop between adolescence and young
adulthood’, whereas spatial awareness functioning and sensory functions (such
as hearing and language processing) are largely mature by adolescence.
Perhaps the most comprehensive and influential document to provide a rationale for the 16-
25 age group is the Social Exclusion Unit’s (2004) Breaking the Cycle, which has found that
young people’s lives change rapidly and dramatically in a number of areas during this time
and has identified “disordered transitions”, which are more complex than previously
understood.
CAMHS
Wolpert and Wilson (2003, page 28) pose the question:
The acronym CAMHS - Child and Adolescent Mental Health Services - is now
used ubiquitously, but are we all meaning the same thing when we use it? And
who do we identify as part of it?
The term CAMHS may be used as a shorthand to refer to the (normally) health based,
specialist multidisciplinary teams, often known as child and family consultation services.
Increasingly, however, the term is being broadened, as described below (Wolpert and
Wilson, 2003, page 29):
To develop the idea of comprehensive provision we would like to see the term
"CAMHS" taken to mean all dedicated service provision that aims to meet the
mental health and emotional well being needs of children and young people in a
given locality. It does not imply a particular form of service organisation. It
assumes all such provision in a given area will link up to be able to form a
coherent, multi-professional, multi-agency strategy. Other workers, whose primary
role is not mental health provision, will also have a role to play promoting the
health and well being of children and will therefore need to be involved in creating
a comprehensive Child and Adolescent Mental Health strategy.
In this document the broad definition of CAMHS will be intended, unless a point is made
specifically about “specialist” or “Tier 2-3” (NHS Health Advisory Service, 1995) 4 CAMHS,
referring to community based multidisciplinary teams offering specialised mental health
services to children and young people with complex and severe mental health problems.
4 For readers without formal knowledge of the organisation of CAMHS, an explanation of the four tier
system is provided in the appendix.
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Guidance on the shape and nature of a “comprehensive CAMHS” is provided in the National
Service Framework for Children, Young People and Maternity Services (Department of
Health and Departments for Education and Skills, 2004).
Adult Services
The term Adult Services, as it is used in this document, refers broadly to any provision made
for adults that makes a key contribution to their positive mental health.
This then could include housing departments/associations, counselling groups and primary
care services, as well as specialist mental health services. The rationale for including a
possible wide range of adult services was based on the assumption that many young people
do not make a transition to adult mental health per se, but do go on to use other, related
provision, particularly that provided by the voluntary sector.
Where reference is made to specialist adult mental health services, these will be denoted by
the acronym AMHS. The service models and practice guidance for AMHS are provided in
the Mental Health Policy Guide (Department of Health, 2001).
Transition
Throughout the literature, transition is conceptualised as a process, distinguishing it from life
events, or turning points, which may be seen as the pre-cursors of transitions. Newman and
Blackburn (2002, page 1) have taken a broad view, taking (children’s) transition as,
SUMMARY BOX 1
…any episode where children are having to cope with potentially challenging
episodes of change, including progressing from one developmental stage to
another, changing schools, entering or leaving the care system, loss,
bereavement, parental incapacity or entry to adulthood.
• Adolescence refers to the period of psycho social development between childhood and
adulthood.
• Young people is an alternative phrase to adolescent and is usually taken to include those
in the age range 13-18.
• The period of young adulthood spans 16-25 years. This age group has received a great
deal of interest in recent years.
• Child and Adolescent Mental Health Services (CAMHS) may be taken broadly to include
all services that contribute to the psychological well being of children, young people and
families.
• “Tier 2-3 CAMHS refers to multidisciplinary teams offering specialist services to children,
young people and families with complex and severe mental health problems.
• Adult services may include any health or social care provision for people of working age.
• Adult Mental Health Services (AMHS) offer a specialist service to people of working age
with severe and enduring mental health problems.
• Transition is described as a process, distinct from life events, or turning points.
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2. The (mental) health of adolescents
The European dimension
The mental health of adolescents is addressed specifically by two of the World Health
Organisation’s (WHO) seven priorities for action on child and adolescent health in the
European context. These are provided in the European strategy for child and adolescent
health and development (World Health Organisation, 2005, page 5) ,
Adolescent Health, specifically tackling risky behaviours, the establishment of health
related preferences for adulthood and the need for participation and youth-friendly services.
Psychosocial development and mental health, focusing on investment in parenting
programmes and psychological well-being throughout the life-course and identifying
aggression, self-harm, suicide, depressive illness and eating disorders.
The strategy provides as its opening statement:
Children are our investment in tomorrow’s society. Their health and the way in
which we nurture them through adolescence into adulthood will affect the
prosperity and stability of countries in the European Region over the coming
decades.
(World Health Organisation, 2005, page 1):
Good health is seen as a social resource and poor health a social cost. The rationale for the
strategy has three strands:
Moral and legal obligation, enshrined in the UN Convention on the Rights of the Child
Investment in the future, with consequent personal, social and community benefits
Promotion of economic sustainability.
The guiding principles that informed the development of the strategy are:
Life-course approach. Policies and programmes should address the health
challenges at each stage of development from prenatal life to adolescence.
Equity. The needs of the most disadvantaged should be taken into account
explicitly when addressing health status and formulating policy and planning
services.
Intersectoral action. An intersectoral, public health approach that addresses the
fundamental determinants of health should be adopted when devising policies and
plans to improve the health of children and adolescents.
Participation. The public and young people themselves should be involved in the
planning, delivery and monitoring of policies and services.
(World Health Organisation, 2005, page 4)
The national picture
Bridging the Gaps, Health Services for Adolescents, a report into adolescent health
conducted by the Royal College of Paediatrics and Child Health (2003), concludes that
young people constitute a significant social group with major health needs.
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The authors find that adolescents between the ages of 10 and 20 make up 13-15% of the
total population of the UK and that the proportion is considerably higher among black and
minority ethnic (BME) communities, particularly those from Pakistani and Bengali groups.
Unlike other age groups, mortality among adolescents did not fall significantly in the second
half of the twentieth century. The main causes of death are accidents and self-harm, with a
recent rise in suicide among young men.
The report notes that ill health within this age group is largely due to chronic disease and
mental health problems. Furthermore it is concluded that patterns of health behaviour and
service usage during adult life are established in adolescence. A British Medical Association
(2003) report states that up to one in five adolescents may experience some form of
psychological problem, ranging from behavioural disorders to depression, eating disorders,
self-harm and neurosis. Mental health problems that develop in adolescence frequently
persist into adulthood and may deteriorate over time. There is a strong association between
mental health problems in adolescence and risk taking behaviour.
Bridging the Gaps was presaged by and acknowledges a report from the USA, which had
reached similar conclusions almost twenty years earlier (Irwin, 1986) and an address to the
Society for Adolescent Health six years later (Hein, 1992). Clearly these issues have been
receiving attention for some time.
Under the chapter heading, Young people have major health needs, the following rationale is
offered (Royal College of Paediatrics and Child Health, 2003, page 18),
It is clearly important that young people are nurtured so that they may become
healthy adults and contributors to society. This is increasingly important for sound
economic reasons in an ageing society.
This echoes much of the rationale behind WHO documentation on adolescent health,
including the European Strategy cited earlier: the significance of young people as a defined
group is conceptualised through their potential in becoming contributing adults. An
alternative and complementary view enshrined in much of the literature (Kay, 1999; Smith
and Leon, 2001; Street, et al, )is that young people are not simply adults in the making, but
are people in their own right, with entitlements, rights and responsibilities of their own.
Trends in adolescent mental health
In 2001 a research team at the Institute of Psychiatry was commissioned by the Nuffield
Foundation to undertake a research project on time trends in adolescent mental health. The
team analysed data from national surveys undertaken in 1974, 1986 and 1999, looking at
trends across same kinds of problems in UK adolescents over the entire 25 year period. At
each time point the focus of the study was 15-16 year olds.
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The results, reported to the foundation (Hagell, 2003) and subsequently published
(Collishaw, et al, 2004), showed clearly that the mental health of adolescents in the UK had
declined overall across this period. This was a significant study, set against a backdrop of
increasing concern over a long period about the perceived increase in adolescent mental
health problems, specifically regarding conduct problems, hyperactivity and suicide. The
authors note (page 1350),
However methodological limitations make it difficult to provide conclusive
answers. The comparison of rates of disorder assessed at different time points is
complicated by changing diagnostic criteria, differences in assessment methods,
and variations in official reporting practices.
The two main aims of the study were to:
Discover whether there had been any increases in parent-rated emotional and behavioural
problems over the 25 year period
Examine whether any changes observed were actually corroborated by real changes in
children or due to changes in reporting thresholds.
The major finding of the study was of a continuous rise for adolescent males and females
over the whole 25-year study period in conduct problems. Emotional problems in
adolescence (such as depression and anxiety) had increased for both girls and boys from
the mid 1980s. Conversely there were few systematic trends in adolescent hyperactivity over
the 25 years for either girls or boys.
The strength of associations between these problems and poor outcomes later in adulthood
had remained similar over time. This would suggest that the findings were not attributable to
changes in the reporting thresholds, but the outcome of real changes in problem levels.
Significantly, a later study by Simonoff, et al (2004) demonstrated that disruptive behaviour
in childhood is a powerful predictor of anti-social behaviour in adult life, enduring at least into
middle adulthood. The authors conclude (page 118),
The importance of number of symptoms, the presence of disruptive disorder, and
intermediate experiences highlight three areas where interventions might be
targeted.
Intermediate, or “stepping stone” experiences were found to mediate partially between
childhood disruptive behaviour and subsequent adult outcomes. Between adolescence and
early adulthood the authors propose a transitional period in which negative intermediate
experiences include early age at school leaving, involvement in crime, especially violent
crime, between the ages 17-21. With the caveat that longitudinal studies do not prove
causality, they state (page 126),
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Reducing subsequent high-risk experiences among those with early disruptive
behaviour might alter their life trajectory away from antisocial behaviour.
In England and Wales about 600 (10 per 100,000) 15–24 year olds take their own life each
year (more than 10,000 since 1982) and up to 20,000 teenagers go to hospital each year as
a consequence of deliberate self-harm (Social Exclusion Unit, 2000, page 20).
Changes in access to higher education over recent years also reflect the trend in
adolescent/young adult mental health. The Royal College of Psychiatrists (2003, page 6)
reports that the number of higher education students presenting with symptoms of mental ill
health is increasing and furthermore there is a rise in the number presenting with more
severe mental health problems.
Policy
National policy should provide a framework for prioritising and implementation. In response
to the wealth of evidence that young people leaving school with low levels of educational
attainment have a higher risk of experiencing social exclusion throughout their lives, policy
aimed at 13–24 year-olds has focused on education, training and employment opportunities.
New policies to increase young people’s participation in learning and employment include
Connexions, Education Maintenance Allowances (EMA), the New Deal for Young People,
and Modern Apprenticeships (Social Exclusion Unit, 2004, pages 48-9) Whilst there is no
specific policy, either for adolescent health, or for 16-25s as a discrete group, there are four
major, over-arching policies that complement one another both implicitly and, in a few
instances, explicitly. These are:
National Service Framework for Mental Health: Modern Standards and Service Models.
(Department of Health, 1999)
National Service Framework for Children, Young People and Maternity Services, (Department
of Health, Department for Education and Skills, 2004)
Every Child Matters, Change of Children (Department for Education and Skills, Department of
Health, 2004) The Children Act 2004 provides the legal foundation for Every Child Matters
Youth Matters: Next Steps (Department for Education and Skills, 2005).
The National Service Framework for Mental Health covers adults of working age, starting at
age sixteen. It makes specific reference to provision for young people at several points, first
identifying the need for services that bridge the interface between child and adult provision
(Department of Health, 1999, page 5):
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The Framework also touches on the needs of children and young people,
highlighting areas where services for children and adults interact, for example
the interface between services for 16-18 year olds, and the needs of children
with a mentally ill parent. A major programme of service development, supported
by the Mental Health Grant and Mental Health Modernisation Fund, is
addressing the mental health needs of children and adolescents.
It is of particular note that this policy for adults, published in 1999, highlighted the interface
between child and adult services, because the issues around transition from CAMHS to adult
services could conceivably be understood as more problematical for CAMHS than for adult
practitioners. The rationale for this would be that CAMHS staff are left with the problem when
a young person fails to meet the criteria for a transition to an adult service, whereas their
colleagues in adult services continue in ignorance. The service transition is, after all, linear
and directional (White, 2003, page 37). Few other transitions to adulthood are linear,
however. Many transitions involve an aspect of ‘backtracking’ in which young people revert
to some form of dependence. This may be termed the ‘yo-yo’ transition between youth and
adulthood (Social Exclusion Unit, 2005, page 53).
A group of young people at particularly high risk of developing mental health problems is
identified as those with accommodation difficulties (Department of Health, 1999, page18).
Homelessness among young people also brings significant problems. Off to a
Bad Start, a study of homeless young people in London aged 16-21 years, found
that almost two thirds had suffered recently from psychiatric disorders. A third
also reported at least one attempted suicide at some point. Only one fifth,
however, had been in contact with psychiatric services in the past year.
Moreover, the needs of young people with a first episode of psychotic illness are addressed
specifically (Department of Health, 1999, page 44).
Prompt assessment is essential for young people with the first signs of a
psychotic illness, where there is growing evidence that early assessment and
treatment can reduce levels of morbidity. Clinical responsibility for the mental
health care of older adolescents can sometimes lead to disagreements between
child and adolescent mental health services and adult services if working
arrangements between the two services have not been addressed. Variations
exist for the ‘cut-off’ point for referral to adolescent services, for example, 16, 18,
21 years or school leaving. Local arrangements should be agreed to avoid
confusion and possible delays.
In fact the NHS Plan (Department of Health, 2000) promised that all young people aged 14-
35 with a psychosis should be able to receive early intervention via the establishment of 50
teams by 2004. The service model was subsequently described in chapter 5 of the Mental
Health Policy Implementation Guide (PIG), (Department of Health 2001).
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The National Service Framework for Children, Young People and Maternity Services
addresses the health needs of adolescents within a number of its standards. Standard four
addresses development and growing up (Department of Health, 2004, page 119),
Standard 4 Growing Up into Adulthood
Markers of good practice:
5. All transition processes are planned in partnership and focussed around the
preparation of the young person.
6. Young people up to eighteen years of age with mental health problems have
access to age-appropriate services.
7. All services for young people contribute towards assisting young people to
take on increasing responsibility for their own lives.
8. Services seek to support parents, in particular providing information and
advice on how they can appropriately support their child’s transition to adulthood.
A significant number of children and young people with a disability will also have a mental
health problem. Because of organisational responses to the primary health need, some of
these young people may not have had access to a specialist CAMHS. The marker of good
practice emphasise multi-agency planning for transition:
Standard 8 Disabled Children and Young People and those with Complex
Health Needs
Marker of good practice:
8. Multi-agency transition planning and services focus on meeting the hopes,
aspirations and potential of disabled young people, including maximising
inclusive provision, education, training and employment opportunities.
(Department of Health, 2004, page 6 of Standard 8).
The major strand of the NSF in relation to mental health is Standard 9, in which one marker
of good practice highlights the need for continuity of care during service transition:
Standard 9 The Mental Health and Psychological Well-being of Children
and Young People
Marker of good practice:
10. When children and young people are discharged from in-patient services into
the community and when young people are transferred from child to adult
services, their continuity of care is ensured by use of the ‘care programme
approach”
Department of Health, 2004, Page 5 (of Standard 9)
The reference to the care programme approach 5 in the NSF for children, young people and
maternity services may be cross-referenced to the NSF for Mental Health (Department of
Health, 1999, page 41), which states:
5 CPA has been used routinely by adult mental health services since the publication of the NSF in
1999 and has started to be introduced within Tier 4 CAMHS as a model of good practice.
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All mental health service users on CPA should: ~ receive care which optimises
engagement, anticipates or prevents a crisis, and reduces risk ~ have a copy of
a written care plan which:
- includes the action to be taken in a crisis by the service user, their carer, and
their care co-ordinator - advises their GP how they should respond if the service
user needs additional help - is regularly reviewed by their care co-ordinator - be
able to access services 24 hours a day, 365 days a year.
Every Child Matters, Change for Children is a holistic, all embracing national strategy for
children’s services, which emanates from the Laming inquiry into the death of Victoria
Climbié.
The outcomes framework (Department for Education and Skills, 2004, page 40)
encapsulates the objectives and consequences for children and young people of new,
integrated ways of working. Those outcomes relating to the mental health of young people
are:
Outcome: BE HEALTHY
6. Children & young people's mental health is supported.
Outcome: MAKE A POSITIVE CONTRIBUTION
2. Children & young people are helped to manage changes and respond to
challenges in their lives
2.1 Children & young people are supported at key transition points in their lives
3. Children & young people are encouraged to participate in decision making and
to support the community
3.4 Children & young people are encouraged to participate in the planning and
management of services and activities
Youth Matters, Next Steps covers the age range 14-19, in keeping with the Education and
Skills White Paper and subsequent implementation plan and the Better Schools White Paper
– described as “the transformation of the life chances of young people.”
Youth Matters Next Steps reports that many people responding to the green paper
consultation expressed concern about young people’s emotional health and resilience and
the document testifies to “the inseparable link between good physical and mental health and
young people’s ability to learn and achieve” (Department for Education and Skills, 2006,
page 20). Of the initiatives outlined in the document, a significant commitment is to “the
development of an adolescent health specialism and, in some areas, dedicated young
people’s health and support services.” (Department for Education and Skills, 2006, page 20).
Its vision is encapsulated in this statement (page 5)
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The Youth Matters proposals provide a balance of opportunity, support and
challenge to ensure a successful transition for every young person to adulthood.
We want young people to thrive and prosper, and to mature as active, healthy
and responsible citizens. As they progress through their teenage years we will
ensure that they receive impartial, personalised advice to make the right
choices; have access to a wider and better range of opportunities; and get extra
help when they need it.
Other national drivers that create an impact on services for young people, particularly those
in transition, include the annual performance indicators that determine the star rating of a
Trust and thus affect the extent to which it can act and invest autonomously.
These performance indicators contain an increasing number of criteria relating to
comprehensive CAMHS. The then Commission for Health Improvement (CHI) performance
indicator for mental health trusts 2002-3 was:
PCT-agreed and established (written) arrangements to ensure transition of care for service
users between child and adolescent mental health services and adult mental health services.
Of the 95 trusts recorded by CHI, 53 had an agreed protocol. 6
This was echoed by a
separate survey of CAMHS partnerships, in which 41% claimed to have a CAMHS to AMHS
protocol (Health and Social Care Advisory Service, 2004). But as Phimister (2004, page i
executive summary) states:
However recent care pathway analysis, most notably documented in the
experience of young people with first episode psychosis, contrasts starkly with
this apparently rosy picture. It is our experience in the West Midlands that the
needs of older adolescents, particularly those between 16 and 18, are met in an
ad-hoc fashion.
SUMMARY BOX 2
• The World Health Organisation (WHO) has addressed the mental health of adolescents in
two of its seven priorities for child and adolescent health.
• The WHO European Strategy for Child and Adolescent Health and Development states
that children should be nurtured through adolescence into adult life, with a rationale of
moral and legal obligation and investment in the future.
• The mental health of adolescents in the UK has declined over the past 25 years, with a
clear rise in conduct problems and emotional problems, though no rise in hyperactivity.
• Mental health problems in childhood and adolescence have been found to be good
predictors of mental health problems later in life.
• There are four over-arching, complementary national policies, which together address the
mental health needs of young people. These are the NSF for Mental Health, NSF for
Children, Young People and Maternity Services, Every Child Matters, Change for Children
and Youth Matters.
6 Table of results accessed at:
http://www.chi.nhs.uk/Ratings/Trust/Indicator/indicatorDescriptionShort.asp?indicatorId=3555
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3. The nature of transition
Life stage approaches
CAMHS to Adult Transition
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The spectrum of adolescent developmental transitions is given by McClure (2000, page 69)
as including, biological, cognitive, emotional, identity and social components. These form the
pathway from childhood to adult life and include turning points at key transition points.
The American Academy of Pediatrics, et al, (2002, page 1304) echoes a number of
established life cycle theories stating:
Transitions are part of normal, healthy development and occur across the life span.
This is an important consideration, which belies the idea that adolescence is the only period
of significant change within the life cycle. Two major theories in the field of life span and
transition were introduced by Erikson (1950) in Childhood and Society and Levinson, et al,
(1978) in their publication Seasons of a Man’s Life.
Erikson took Freud’s theory of psycho-sexual development, elaborated it by adding a social
dimension and extended the stages, continuing from where Freudian theory ends at the
genital stage (adolescence), by adding three further life stages of early, middle and late
adulthood. Erikson, less deterministic than Freud, stressed the need for the individual to
actively engage in the dilemmas that occur at each stage, leading to the development of
human virtues. During adolescence the dilemma is of identity versus role confusion and the
active resolution of the dilemma promotes the development of fidelity.
Levinson proposed a theory of human development in which the individual’s life structure, or
the underlying pattern and design, is the central concept. Levinson et al introduce the idea of
stable phases of life, in which the underlying structure is being built and transitional phases,
in which structures are changed and rebuilt. The early adult transition is a developmental link
between childhood and adulthood, in which a key theme is separation. Internal separation
refers to the formation of the adult identity.
The idea that people pass through various stages has appeal as a way of handling the idea
of development. People are seen as making systematic progress in a particular order, as,
step by step they move closer to some level of maturity. There are however a number of
concerns with such theories.
The first relates to the fact that these are universal theories and inevitably this generality
overlooks important aspects of cultural difference. Secondly, life stage theories may be seen
as mechanistic and reductionist with,
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(Rutter and Rutter, 1992, page 2)
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a mechanical predictability that is out of keeping with the dynamics of change, the
extent of the flux over time and the degree of individual variability that seems to be
the case.
Finally, when we construct our own narratives of our lives, they are rarely likely to follow a
predictable, universal path.
Life course approaches
McAdams et al (2005) are focused on the ways that the stories we tell about ourselves help
us to make sense of the major transitions in our lives. They contrast life stage theorists such
as Erikson and Levinson with life course theorists, those who favour explanations of the
socially contingent nature of human development. Whilst life stage theorists suggest a
relatively fixed structure for development, life course theorists tend to emphasise the
importance of roles, social context and timing. What they all share, however, is a focus on
both on-time, anticipated transitions, such as early or mid adult marriage, later life
retirement, etc., and off-time events such as divorce and unexpected bereavement.
This is exemplified below (McAdams, 2005, page xv)
Some transitions, some periods of change, stand out as especially
significant in the life course. We may see them as turns in the road,
changes in the direction or the trajectory of our lives.
McAdams and Bowman (2005) used Erikson’s concept of generativity to select participants
for their life story research. Generativity versus stagnation is the dilemma for the seventh
stage of development, in midlife. Following the establishment of identity in adolescence, then
intimacy in early adulthood, the individual is psychosocially ready to be involved in projects
that will benefit future generations.
The authors state, (page 11)
With respect to mental health, highly generative adults report lower levels of
depression and higher levels of life satisfaction, happiness, self esteem, and
sense of life coherence, compared to adults low in generativity.
Adolescent health transitions
It is suggested that childhood and adolescence are being extended within the familial and
social structures of the UK. The increasing numbers of young people entering further and
higher education and the concomitant rise in tuition fees have encouraged many students to
remain in the family home until they secure a job at age 21-2, whereas a few decades earlier
many young people had effectively left home at eighteen.
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In the 1970s approximately 70% of those aged sixteen were in paid employment, now the
figure is closer to 5%. (Office for National Statistics, 2000)
This is echoed in a report by Youth Access (White, 2003, page 32), which states,
For most of the population, youth transitions have been extended well into their
middle to late 20s.
This has implications for services: as discussed above, some organisations and agencies
are now choosing to focus on the 16-25 age group, partly because of the extension of youth
transition into the twenties, but also because the age 18 entry point into adulthood is seen as
either arbitrary and/or abrupt and not allowing for a genuine period of transition. (Youth
Access/White, 2003, Social Exclusion Unit, 2005, Young Minds, 2006, Mental Health
Foundation/Kay 1999, Smith and Leon 2001).
A Social Exclusion Unit report (2005, page 52) also highlights that whilst most young people
are now taking longer over the transition to adulthood, a disadvantaged minority experiences
an accelerated transition, which is often chaotic and difficult.
In the USA the Adolescent Health Transition Project (2005) has identified a number of
concerns for young people with any chronic health condition, needing to transit to adult
services.
Youth with chronic health conditions face two simultaneous transitions: a
developmental transition (from childhood to adolescence to adulthood) and a
situational transition (from pediatric to health care). They may also have a third
transition, from relative health to illness, depending on the progression of their
illness.
A consensus statement on health care transitions for young adults with special health care
needs (American Academy of Pediatrics, et al, 2002, page 1304) states,
The goal of transition in health care for young adults with special health care
needs is to maximize lifelong functioning and potential through the provision of
high-quality, developmentally appropriate health care services that continue
uninterrupted as the individual moves from adolescence to adulthood.
Evidently the above reports relate to adolescent health and chronic conditions in general and
any extrapolation to adolescent mental health should be made with this limitation in mind.
Significantly, a recent publication from the Department of Health (2006), which also focuses
on health transitions, deliberately excludes mental health with the explanation that,
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The guide specifically does not seek to describe the approach or approaches for
improving transition for young people that are users of Child and Adolescent
Mental Health (CAMH) services. While there are similar concerns about how best
to improve the transitions between CAMHS and adult mental health services,
there are a number of current developments in CAMHS provision, notably
improving the access to services for 16 and 17 year olds and the development of
services providing early intervention for young people with psychoses which
requires a partnership between CAMHS and adult mental health services. In
addition we are aware of a number of joint child and adult mental health services
around the country, that provide a model for how transition for young people with
mental health problems can work well.
(Department of Health, 2006, page 6).
Implicit in the literature being considered in this review is the need for a smooth,
uninterrupted transition of care, in which the transition is understood as a process, not an
event. In the report of a study into the transition from child to adult services by children with
long term chronic conditions, Forbes et al, (2001, page 13) offer a conceptual framework for
continuity of care,
Experienced continuity – the experience of a co-ordinated and smooth
progression of care from the service user’s point of view.
Continuity of information – excellent information transfer following the service
user.
Cross-boundary and team continuity – effective communication between
professionals and services and with service users.
Flexible continuity – flexibility and adjustment to the needs of the individual over
time.
Longitudinal continuity – care from as few professionals as possible, consistent
with other needs.
Relational or personal continuity – one or more named individual professionals
with whom the service user can establish and maintain a therapeutic relationship.
The research, using review and systematic review methods, critically appraised a range of
literature, research and examples of reported practice, identifying key aspects of effective
practice, as well as emerging themes. The authors (Forbes, et al 2001, page 7) identify four
models of transition, or “continuity promotion”,
1 Direct transition – focusing on good and communication and interagency
collaboration.
2 Sequential transition – developing special services for young people to help
them adjust to adult care.
3 Developmental transition – providing specific support to help young people
develop physically, psychologically and socially in adapting to their new care role
and in maximising their potential.
4 Professional transition – flexibility in moving expertise between child and adult
services.
The models are not mutually exclusive and the research found that a combination of the four
approaches could be used effectively.
An investigation that incorporated surveys, literature review, outcomes from study days and
observation of different models of practice was conducted in the West Midlands.
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One of the findings was that rigid entry criteria and service boundaries do not promote the
ability of practitioners to collaborate across service settings, thus preventing young people
and their families from receiving a good service. Specifically the authors (Gillam et al, 2005,
page 5) state,
Transition between CAMHS and AMHS services was seen as ‘difficult’ by over
90% of respondents working in children’s services.
SUMMARY BOX 3
• Transitions occur throughout life.
• One approach to understanding the nature of transitions is to describe life stages or
phases, which are fixed and predictable.
• An alternative or complementary way to conceptualise transition is through a life course
approach, with a greater emphasis on the socially contingent nature of transition.
• The transition from childhood (dependence) to adulthood (independence) has been
extended because of social changes.
• There is agreement among authors that service transitions during adolescence should be
smooth processes that offer uninterrupted continuity of care.
• A survey of services in one region of England found over 90% of contributors felt the
CAMHS to AMHS transition was difficult.
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CAMHS to Adult Transition
A Literature Review for Informed Practice
Age boundaries and service configuration
Richards and Vostanis (2004, page 120), quote a respondent as saying that society has
changed, but services have not. Since the entry point into adult (mental health) services lies
between ages 16-18, the fact that many of the young people in that age group may still be
living at home with their families raises questions about the differences in approach between
CAMHS and AMHS. In CAMHS the child is assessed and treated within the context of the
family and parents/carers are likely to be involved or at least consulted in decision-making,
whereas the approach within AMHS is focused on the needs of the client and parent/carer
involvement will be at the client’s behest.
There is agreement among authors about the lack of clarity regarding where CAMHS ends
and adult services begin. In recent findings the Social Exclusion Unit (2005, page 52)
reports,
There is little consistency or continuity – some services end abruptly for people
of a particular age, and in other areas there is not enough support for the
transition between youth and adult services. And if you have a troubled life, you
may well want to start accessing services just at the point where they are no
longer available to you – there is not enough support for ‘second chances’.
The Lifeline (substance misuse) project describes how it is particularly important during the
child to adult service transition period to attend to those issues relating to the “(dis)continuity
and (in)consistency” of care,
Because the threshold at which one can access an intervention tends to be
much lower for young people than it is for adults, once individuals become an
adult, they may not be able to access interventions or support for the same
things that they were able to as a young person, for example life skills or
befriending projects. Thus the interventions and support that they were
receiving may stop, regardless of their needs.
Phimister, (2004) has produced a baseline assessment of current provision for young people
in the transitional age range within two health economies in England. A significant finding
was that in those areas, a determinant of access to CAMHS was based on the criterion of
being in full time education for young people aged 16 and over. Additionally many AMHS
were found to set an implicit minimum age of 18 for access to services. Clearly this creates a
gap in provision, which, since the publication of the report, has been addressed by the
National Service Framework for Children, Young People and Maternity Services
(Department of Health, 2004).
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Continuity in the transition of care must be considered in parallel with the young person's
physical, social and psychological growth and development, according to Forbes et al (2001,
page 10), who go on to state,
Service configurations are sometimes unhelpful to the achievement of continuity of
care between child and adult services because they frequently involve different
care plans, care teams and funding arrangements. Further, an arbitrary age point
assumes that chronological age alone indicates a readiness for transfer, which
may disregard the complexity of adolescent development.
A report by Youth Access (White, 2003, page 12) asserts of its Youth Information and Advice
Centres (YIAC), which generally serve 16-25 year olds,
YIACs have been bridging the gap between CAMHS and AMHS for the past 25
years.
Within the same document, in calling for timely, appropriate services for young people,
Baroness Howarth of Breckland, (White, 2003, page 5) relates,
Working with children throughout my career, culminating in listening to their
concerns in ChildLine has reinforced my view that present structures make many
services unapproachable or inaccessible to them.
Differing thresholds and eligibility
The threshold for access to young people’s services is generally much lower than that to
adult services so that a young person’s need or problem may be less severe and enduring
than an adult’s in order to be eligible for a specialist service. This means that some or many
of the young people receiving a service will be unable to continue as an adult. Hence, it is
suggested, work with those young people at the upper age limit of a service should,
(Lifeline, 2003, page 2)
…incorporate an exit strategy that allows for the ending of an intervention, as well
as an exit strategy that allows for the move to adult services.
Some young people are at higher risk of developing mental health problems in adult life, yet
may not be eligible at age 18 to receive a specialist adult mental health service. This group
of vulnerable young people includes those looked after by the local authority, those who are
homeless and those seeking refugee or asylum seeker status. Many of these young people
may not even be accessing CAMHS, as illustrated by Street et al, (2005, page 3),
For example, some of the identified barriers preventing Black and Minority
Ethnic groups from accessing services included language problems, poor staff
training, limited information, racism, fear and mistrust of services, inappropriate
provision/interventions and issues such as socio-economic disadvantage.
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This finding was set within a context of increased risk of developing mental health problems
among some BME groups of young people, due to disproportionate rates of exclusion from
school, being looked after by the local authority or being homeless. The report also
highlights the very significant role played by voluntary organisations in meeting the needs of
young people from BME groups (Street et al, 2005, page 34). Street’s report reiterates
Rodriguez et al (2002, page 306) who note that identity formation for young people from
BME groups has the added dimension of an exploration of their cultural heritage.
Care leavers face the additional challenges of learning to live independently and often have
lower levels of educational achievement. They may also having special needs and/or
behavioural concerns (Lifeline, 2003).
Mapping of services for young people (Pugh and Meir, 2006) has found that over 50% of
CAMHS commissioners identified specific areas of unmet need, listed below,
dual diagnosis
self-harm
young people looked after
Attention Deficit Hyperactivity Disorder, (ADHD) autistic spectrum disorder (ASD), learning
difficulties (LD) and disabilities
support for carers
user-led initiatives
services for young people from Black and Minority Ethnic (BME) communities.
In an overview of the evidence Maughan, (2005) shows that the majority of young adults with
a psychiatric disorder had diagnosable problems much earlier in life and that furthermore, of
those with mental health problems at the age of 26, half had first met the criteria for the
disorder when they were aged15. The author suggests that many adult disorders could be
re-constructed as extensions of juvenile problems.
Different professional cultures
A detailed analysis of the differences in professional culture between CAMHS and AMHS
has been provided by Reder et al (2000), who describe the contrasting developmental
histories and evolution of the two branches of mental health specialism. The genesis of adult
psychiatry within the “paternalistic milieu” of the asylum is compared with the emergence of
mental health services for children and adolescents in the early years of the twentieth
century, concerned with vagrancy, destitution and offending behaviour (Reder et al, 2000,
pages 6-7).
The authors summarise that the different histories, leading to diverse theories and practices
have,
…prevented areas of common concern from being recognised or addressed. The
training of professionals has also exaggerated differences between specialities
rather than areas of mutual interest.
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On a positive note, the authors suggest that a point has been reached where it is possible to
leave behind the traditional polarities, a point echoed by Maitra and Jolley (2000, page 289),
who assert that there has been a considerable impetus in the development of innovative
services that promote greater working between child and adult mental health services.
Youth Access (White, 2003, page 37) calls for joint training between AMHS and CAMHS, on
informal referral, consent and confidentiality and service ethos. It identifies a huge need for a
review of professional attitudes, prejudices and preconceptions, particularly between the
statutory and voluntary sector, but also within organisations, claiming,
It is a horrible business when egos between different professions clash.
(White, 2003, page 44)
SUMMARY BOX 4
• The age boundaries for access to services are found to be arbitrary and not reflective of
individual differences in development.
• Transition between CAMHS and AMHS can be difficult because of the different service
configurations.
• Thresholds for access into CAMHS tend to be lower than for AMHS, which creates a gap
in service for some young people.
• There is a group of vulnerable young people, some of whom neither access CAMHS, nor
will be eligible for AMHS.
• Traditionally CAMHS and AMHS had different professional cultures, based upon both
different training profiles and also on their separate evolutions, but there is evidence of a
will to bring CAMHS and AMHS closer together.
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5. Planning, delivering and improving services for adolescents and
young adults
Service structure and components
The Lifeline (substance misuse) project identifies a set of risk factors for adolescents in
transition, which includes becoming lost in the system, having nobody to ensure attendance,
low expectations and becoming independent at an early age. Conversely the protective
factors that promote an effective transition are:
Having a transitional key worker
Experiencing a gradual transition
Access to wide range of services
Supportive adult friend(s)
Access to life skills services
(Lifeline, 2003, page 1).
The transitional key worker highlighted in the Lifeline briefing is echoed in the lead
professional role advocated in non statutory guidance emanating from Every Child Matters,
Change for Children (Department for Education and Skills, 2006, page 3) which states,
The lead professional role is not a job title or a new role, but a set of functions to
be carried out as part of the delivery of effective integrated support. These
functions are to: ~Act as a single point of contact for the child or family, who they
can trust and who can engage them in making choices, navigating their way
through the system and effecting change. ~ Co-ordinate the delivery of the
actions agreed by the practitioners involved, to ensure that children and families
receive an effective service which is regularly reviewed. These actions will be
based on the outcome of the assessment and recorded in a plan. ~ Reduce
overlap and inconsistency in the services received.
The notions of both lead professional and transitional key worker resonate with the findings
of the Social Exclusion Unit (2004, page 4), which found the benefits of a holistic service
were underpinned by,
…somebody to guide and advise the young person: this could be a personal
adviser, key worker, mentor or an independent visitor. Such individuals can help
ensure there is continuity of support, and promote trust between the young
person and particular services. They can also develop relationships with local
services to allow them to act as a broker for their clients, introducing them to a
range of specialist provision relevant to their personal needs.
In their recommendations for future services, Forbes et al, (2001, page 80) suggest that
transitional workers and/or transitional teams can enhance the process.
Other beneficial service structures include continual professional development (CPD),
information, use of existing continuous services, inter- and intra-organisation liaison and
agreements, organisational planning and frameworks and fostering equity and accessibility.
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The authors also specify process components, including specific actions, which they find to
be as important as service structures. These are reproduced below (Forbes et al, 2001,
page 80)
Preparation for transition
Active management of transition
Case management
Accountability for the process
Strong therapeutic relationships
Advocacy
Joint management of care
Flexibility regarding point of transfer
Specific communication systems
Regular audit of service provision.
Further agreement with some of the core principles is contained within the report of UK wide
qualititative research, which recommends any or a combination of the following types of
transition service:
Designated transition service
Designated transition team within a service
Designated staff trained in adolescent work seconded to adult teams
(Richards and Vostanos, 2004, page 127).
A key recommendation of the Youth Justice Board for England and Wales (2005) is to
promote continuity of care by the use of the care programme approach (CPA). Maitra and
Jolley (2003, pages 289-90) comment that CPA has required adult services to address a
broader spectrum of clinical and social functioning.
Singh et al (2005, page 293) see potential in the early intervention services that already
span the age range 14-35, suggesting,
Early intervention services that successfully manage the interface may
provide a template for other youth and even adult services dealing with a
broader range of mental disorders. One element, which could be adopted
relatively rapidly, would be for a reciprocal arrangement whereby staff from
child services are seconded for perhaps two sessions a week to work in the
early intervention service, and vice versa.
More broadly, a substantial project in the USA found the following to assist transition, across
a number of settings:
Building in and on what is stable in the young person’s life, particularly within the family and
others who are providing support.
Services that are family and young person-driven, taking into account their unique
situations and their particular capacities, needs, cultural values and goals.
Anticipation and preparation for transition well in advance with supports in place beyond the
actual point when a setting or situation changes.
(Walker, 2001).
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Another USA report (Reiss, 2005, page 119) was based on the lived experience of child to
adult health transition and found that participants understood it as a long-term
developmental process, involving the family, child, professionals, as well as the broader
health care system.
Reiss’ assertion that the transition process should start in childhood or at the time of
diagnosis by “envisioning a future” refers to those with chronic conditions and disabilities, but
the underlying principle of careful forward planning may be applied to a wider group of young
people.
The World Health Organisation, (2002, page 38) in international research on programmes for
adolescent health find common denominators for success ,
Programmes based on a clear understanding of the problems faced by adolescents.
A multi-sector, multi-disciplinary approach, understanding that there is no single solution.
Attention paid to how, when and where services are provided, ensuring that programmes are
acceptable to young people and to communities.
Attention paid to the social environment in which young people grow and respect cultural
values.
Challenge of social customs which limit the ability of adolescents to develop successfully.
Outcomes monitored to demonstrate that what they do makes a real difference.
Young people’s involvement and participation
Article 12 of the United Nations (UN) Convention on the Rights of the Child states:
State parties shall assure to the child who is capable of forming his or her own
views, the right to express those views freely in all matters affecting the child, the
views of the child being given due weight in accordance with the age and maturity
of the child.
The guidance paper, Building a Culture of Participation (Department for Education and
Skills, 2003) is predicated upon Article 12 and is referenced in the National Service
Framework for Children, Young People and Maternity Services and across a range of
documents that support Every Child Matters, Change for Children.
Forbes et al (2001, page 81) specify components of good practice regarding young people to
include:
Development of skills of self- management and self-determination
Supported psychosocial development
Involvement of young people
Peer involvement
Support for changed relationships with parents/carers
Provision of choice
Provision of information
Focus upon young person’s strengths for future development.
The Mental Health Foundation (Smith and Leon, 2001, page 30) found that young people
had rarely been asked about the services on offer.
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Although the report focused on crisis, it contains useful pointers from young people
themselves on what sorts of help they would like; these are given below,
Someone to talk to and listen
Support provided by staff with experience of mental health problems
Emotional support
Activities to get involved in, including outdoor activities
Safe spaces in which to meet
Practical help and support
Involving young people and users in the service.
(Smith and Leon, 2001, page 31)
All UK government policy of recent years has enshrined the concepts of patient/client led
services, stressing choice, voice and participation. Every Child Matters, Change for Children
emphasise the role of children and young people as key partners in service delivery, stating,
If they are encouraged to generate the ideas themselves and feel properly
involved in the creation of solutions, they are more likely to invest time and
effort to ensure their successful implementation.
(Department for Education and Skills, 2005).
A commitment of Youth Matters: Next Steps is for young people to have more influence
over what is being provided in their locality, with greater opportunity to be involved in the
planning and delivery of services. (Department for Education and Skills, 2006, page 7).
Within the National Service Framework for Children, Young People and Maternity Services
(Department of Health 2004) each of the standards is permeated with endorsements of
service user involvement and for CAMHS states,
The views of service users are systematically sought and incorporated into
reviews of service provision.
(Department of Health, 2004, page 13 of Standard 9).
SUMMARY BOX 5
• There is a need for a trusted adult to take on the key role of transition worker or link
worker, to be the sole point of contact for the young person experiencing CAMHS to AMHS
transition.
• Continuity of care can be effected by use of case management, care programme
approach (CPA), provision of choice and provision of information.
• Services should focus and build upon young people’s strengths and resilience.
• Young people should be involved in shaping the services of their choice.
• All the key policies and guidance related to adolescent mental health specify the full
participation of young people.
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contamination. In: McAdams, D., Josselson, R.., & A. Lieblich, A.. , Eds. (2001) Turns in the
Road: Narrative Studies of Lives in Transition, Washington: American Psychological
Association, pp. 3-34.
McAdams, D., Josselson, R.., & A. Lieblich, A.. , Eds. (2001) Turns in the Road: Narrative
Studies of Lives in Transition, Washington: American Psychological Association.
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A Literature Review for Informed Practice
McClure, M., (2000) Adolescence - the transition from childhood to adulthood. In Reder, P.,
McClure, M., and Jolley, A., (Eds). Family Matters: Interface Between Child and Adult
Mental Health. London: Routledge.
Newman, T., and Blackburn, S., (2002) Transitions in the Lives of Children and Young
People: Resilience Factors. Scottish Executive Education Department
http://www.scotland.gov.uk/library5/education/ic78.pdf
NHS Health Advisory Service (1995) Together We Stand, the commissioning, role and
management of child and adolescent mental health services. London: HMSO URL:
http://www.tso.co.uk/bookshop/bookstore.asp?FO=1159966&Action=Book&ProductID=0113
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Office for National Statistics (2000) Social Focus on Young People.
Printed copy available from:
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Phimister, D., (2004) CAMHS/Adult Transition Pilots Evaluation Report Stage 1. NIMHE
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Pugh, K., and Meier, R., (2006) Stressed Out and Struggling Project Report 1: Servicemapping.
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Reder, P., McClure, M., & Jolley, A. (2000). Interface between child and adult mental health.
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health services for young people aged 16-19 years. Journal of Interprofessional Care, 18,
No.2, pp115-128
Rodriguez, J., Cauce, A.M., and Wislon, L., (2002) A conceptual framework of identity
formation in a society of multi cultures.: applying theory to practice. In Dwivedi, K., (Ed.)
Meeting the needs of Ethnic Minority Children. London: Jessica Kingsley
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Adolescents London: Royal College of Psychiatrists Council Report CR114
http://pb.rcpsych.org/cgi/reprint/27/10/397
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CAMHS to Adult Transition
A Literature Review for Informed Practice
Simonoff, E., Elander, J., Holmshaw, J., Pickles, A., Murray, R., And Rutter, M., (2004)
Predictors of antisocial personality Continuities from childhood to adult life. British Journal of
Psychiatry (2004) 184, pp118 - 127
Singh, S.P., Evans, N., Sireling, L., & Stuart, H. (2005). Mind the Gap: The Interface
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Exclusion Unit Final Report. Office of the Deputy Prime Minister
http://www.socialexclusionunit.gov.uk/downloaddoc.asp?id=785
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the future. Office of the Deputy Prime Minister
http://www.socialexclusionunit.gov.uk/downloaddoc.asp?id=262
Social Exclusion Unit, (2000) Report of Policy Action Team 12: Young people
http://www.socialexclusionunit.gov.uk/page.asp?id=46
Street, C., Stapelkamp, C., Taylor, E., Malek, M., and Kurtz, Z., (2005) Minority Voices,
Research into the access and acceptability of services for the mental health of young people
from Black and minority ethnic groups. Young Minds Research
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Vostanis, P., (2005) Patients as parents and young people approaching adulthood: how
should we manage the interface between mental health services for young people and
adults? Current Opinion in Psychiatry 2005, 18, pp 449-454
Walker, J., (2001) Introduction: Transitions For Children And Youth With Emotional And
Behavioral Challenges. Focal Point Spring, 2001 Vol. 15 (1)
http://www.rtc.pdx.edu/FPinHTML/FocalPointSP01/pgFPsp01Intro.shtml
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Youth Access
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HASCAS Tools for Transition 29 y.anderson@hascas.org
CAMHS to Adult Transition
A Literature Review for Informed Practice
http://www.who.int/reproductive-health/publications/cah_docs/cah_01_20.pdf
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and Young Adult Brain
http://www.youngminds.org.uk/sos/outputs.php
Youth Justice Board for England and Wales (2005) Mental Health Needs and Effectiveness
of Provision for Young Offenders in Custody and in the Community.
http://www.youth-justice-board.gov.uk/Publications/Downloads/MentalHealthNeedsfull.pdf
Further reading
Audit Commission (1999). Children in Mind. London: TSO
http://www.audit-commission.gov.uk/Products/NATIONAL-REPORT/5C9F4553-27E2-413D-
A379-4AA5BF388159/ChildreninMind.pdf
Cohler, B.J.,(1982) Personal Narrative and the Life Course. In Baltes, P., and Brim, O.G.,
(Eds.) Life Span Development and Behaviour. Vol. 4, pp205-241. New York: Academic
Press
Crawford, M.J., de Jong, E., Freeman, G.K., & Weaver T. (2004). Providing continuity of
care for people with severe mental illness: a narrative review. Social Psychiatry & Psychiatric
Epidemiology, 39, pp 265-272.
Freeman, G., Weaver, T., Low, J., de Jonge, E. & Crawford, M. (2002). Promoting Continuity
of Care for people with Severe Mental Illness whose needs span Primary, Secondary &
Social Care: A multi- method investigation of relevant Mechanisms and Contexts. Report for
the National Co-ordinating Centre for NHS Service Delivery and Organisation R&D
(NCCSDO).
http://www.sdo.lshtm.ac.uk/pdf/coc_mentalillness_freeman.pdf
Hartley-Brewer, E., (2005) Perspectives on the causes of mental health problems in children
and adolescents. London: Young Minds
http://www.youngminds.org.uk/sos/YM_MH_Causes_Symposium.pdf
Johnson, K. (2003) Neighbourhood Watch: transition from child to adult mental health
services. Young Minds Magazine, Jul/Aug, No. 68, pp. 26-27.
http://www.youngminds.org.uk/magazine/65/johnson.php
Koroloff, N.M.(1990) Moving out: transition policies for youth with serious emotional
disabilities. Journal of Mental Health Administration. Spring; 17(1) pp 78-86
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=101044
13&dopt=Abstract
Russell, P. (1993) Kings Fund Project – Transition Between Children’s And Adult Services
For Young People With Disabilities. London. Council for Disabled Children.
http://www.valuingpeople.gov.uk/documents/PCPTransition1.doc
While, A., Forbes, A., Ullman, R. et al (2004). Good practices that address continuity during
transition from child to adult care: synthesis of the evidence. Child Care, Health &
Development, 30, 5,439- 452.
HASCAS Tools for Transition 30 y.anderson@hascas.org
CAMHS to Adult Transition
A Literature Review for Informed Practice
Glossary of abbreviations
ADHD
AMHS
ASD
BME
CAMHS
CPA
EMA
HASCAS
NSF
PIG
UN
WHO
YIAC
Attention Deficit Hyperactivity Disorder
Adult Mental Health Services
Autistic Spectrum Disorder
Black and Minority Ethnic
Child and Adolescent Mental Health Services
Care Programme Approach
Education Maintenance Allowance
Health and Social Care Advisory Service
National Service Framework
Policy Implementation Guide
United Nations
World Health Organisation
Youth Information and Advice Centre
HASCAS Tools for Transition 31 y.anderson@hascas.org
THE TIERED FRAMEWORK FOR CAMHS
NEED
NEED
SERVICES
Very serious
persistent problems
4
Pan-authority
specialist services,
Inpatient, Daycare,
Outreach
Severe and complex
problems, needing
multi-disciplinary
response
3
Multi-disciplinary
assessment and
treatment, consultation
and support to
Tiers 1 & 2
Moderately severe
problems needing
specialist help
2
Primary care,
assessment, early
intervention, brief uniprofessional
treatment,
referral
Mild early stage
problems
1
Health promotion,
primary prevention,
assessment, early
intervention, referral
i
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