Report - London Borough of Hillingdon

hillingdon.gov.uk

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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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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A Literature Review for Informed Practice

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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CAMHS to Adult Transition

A Literature Review for Informed Practice

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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CAMHS to Adult Transition

A Literature Review for Informed Practice

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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CAMHS to Adult Transition

A Literature Review for Informed Practice

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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CAMHS to Adult Transition

A Literature Review for Informed Practice

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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CAMHS to Adult Transition

A Literature Review for Informed Practice

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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CAMHS to Adult Transition

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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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A Literature Review for Informed Practice

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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A Literature Review for Informed Practice

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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A Literature Review for Informed Practice

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

A Literature Review for Informed Practice

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)

CAMHS to Adult Transition

A Literature Review for Informed Practice

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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4. Barriers to transition

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.

HASCAS Tools for Transition 27 y.anderson@hascas.org


CAMHS to Adult Transition

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

219040

Office for National Statistics (2000) Social Focus on Young People.

Printed copy available from:

http://www.statistics.gov.uk/STATBASE/Product.asp?vlnk=5442&More=Y

Phimister, D., (2004) CAMHS/Adult Transition Pilots Evaluation Report Stage 1. NIMHE

West Midlands Mental Health Development Centre

Pugh, K., and Meier, R., (2006) Stressed Out and Struggling Project Report 1: Servicemapping.

Young Minds

http://www.youngminds.org.uk/sos/servicemapping.php

Reder, P., McClure, M., & Jolley, A. (2000). Interface between child and adult mental health.

In Reder, P., McClure, M., and Jolley, A., (Eds). Family Matters: Interface Between Child

and Adult Mental Health. London: Routledge.

Reiss J.,G., Gibson, R.,W., and Walker, L.,R., (2005) Health Care Transition: Youth, Family,

and Provider Perspectives. Pediatrics. Vol. 115 No. 1, pp. 112-120

Richards, M., and Vostanis, P., (2004) Interprofessional perspectives on transitional mental

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

Royal College of Paediatrics and Child Health (2003) Bridging the Gaps Health Care for

Adolescents London: Royal College of Psychiatrists Council Report CR114

http://pb.rcpsych.org/cgi/reprint/27/10/397

Royal College of Psychiatrists (2003) The mental health of students in higher education

Council Report CR112 London: Royal College of Psychiatrists

http://www.rcpsych.ac.uk/files/pdfversion/cr112.pdf

Rutter, M. and Rutter, M. (1992) Developing Minds. Challenge and continuity across the life

span. London: Penguin.

Select Committee On Health (2000) Transitions between child/adolescent and adult

services. In Fourth Report. Provision of NHS Mental Health Services. London: TSO

http://www.publications.parliament.uk/pa/cm199900/cmselect/cmhealth/373/37312.htm

HASCAS Tools for Transition 28 y.anderson@hascas.org


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

between child and adult services. Psychiatric Bulletin. 2005; 29 pp 292-294

http://pb.rcpsych.org/cgi/reprint/29/8/292

Smith, K., and Leon, L. (2001). Turned upside down: developing community-based crisis

services for 16-25 years olds experiencing a mental health crisis. London: Mental Health

Foundation.

http://www.mentalhealth.org.uk/html/content/turned_upside_down.pdf

Social Exclusion Unit (2005) Transitions. Young Adults with Complex Needs. A Social

Exclusion Unit Final Report. Office of the Deputy Prime Minister

http://www.socialexclusionunit.gov.uk/downloaddoc.asp?id=785

Social Exclusion Unit (2004) Breaking the Cycle Taking stock of progress and priorities for

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

http://www.youngminds.org.uk/minorityvoices/MinorityVoices_Report.pdf

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

White, P.J., Ed., (2003) Breaking down the barriers - a strategy in development. London:

Youth Access

http://www.youthaccess.org.uk/publications/bdb-strategy.cfm

Wolpert, M., and Wilson, P., (2003) Child and Adolescent Mental Health Services: Million

Dollar Question. YoungMinds Magazine 65, pp28-29

http://www.youngminds.org.uk/magazine/65/YM65_Wilson.pdf

World Health Organisation (2005) European Strategy for Child and Adolescent Health and

Development. Copenhagen: WHO Publications

http://www.euro.who.int/document/E87710.pdf

World Health Organisation (2002) Programming for adolescent health and development:

Growing in Confidence

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World Health Organisation (2001) Broadening the horizon Balancing protection and risk for

adolescents WHO/FCH/CAH/01.20 (Revised)

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

Young Minds (2006) SOS - Stressed Out and Struggling A Work in Progress: the Adolescent

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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