Niamh McNamara BA, PhD

The National Mental Healthcare Conference

Thursday 27th September 2012

Transition from Child to Adult Mental Health Services in Ireland

Niamh McNamara BA, PhD

School of Medicine & Medical Science

University College Dublin

The importance of youth mental health

The ITRACK Project

• Research team: University College Dublin, Trinity College Dublin, Lucena Clinic, Cluain Mhuire Services.

• Collaborators: University of Warwick, University of Exeter, University of Limerick, University of Melbourne, NSUE, Bodywhys, HADD, SHINE.

• Funded by the Health Research Board

• Aims: To identify the barriers & enablers to effective transition for adolescents from CAMHS to adult services

• Transition will become increasingly important as Child & Adolescent Mental Health Services (CAMHS) begin to take on new presentations of 16 and 17 year olds

• Reports place emphasis on developing & improving mental health services for young people– No focus on crucial link between CAMHS and adult

services

• Lack of information on transition process in Ireland– Likely issues found abroad will be mirrored here

Why focus on transition?

ITRACK Studies

• Study 1: Survey of transition policies & procedures in CAMHS and AMHS nationwide – Compare best practice for smooth transition with

current clinical practice

• Study 2: Semi-structured interviews with consultant psychiatrists, GPs, and staff from national youth organisations– Identify organisational facilitators and barriers to

transition– Explore professionals’ experiences of service

provision for older adolescents including transition

• International transition policies & best practice recommendations:

– Young people should receive the most suitable and effective care for their needs

– Transitions should be seamless and user-centred

– Should involve period of joint working between services

Best practice guidelines for transition

Study 1: An investigation of operational policies for 16-18 year olds

• Structured interviews with 57 consultant psychiatrists (32 CAMHS, 25 AMHS)– Based on mapping tool used in TRACK study (Singh

et al., 2009)

• Questions addressed key areas:– Transition boundaries & annual transition rates– Co-ordination of the transition process– Degree of collaboration between services– Involvement of young person in the transition

process

• 84% CAMHS teams reported upper age limit of 18– Typically refers to existing cases– Practice varies regarding re-referrals & new cases

aged 16-18– 34% accept new referrals aged 16-18

• 52% AMHS teams reported lower age limit of 18– 84% reported accepting cases between 16 -18

Age Boundary

Mean SD Range N

Cases suitable for transfer to AMHS per year

7.73 9.86 1 – 50 25

Cases transferred to AMHS per year 4.50 3.33 1 – 10 20

Cases remaining in CAMHS past transition boundary per year

5.46 6.37 0 – 21 26

CAMHS Transition Numbers

AMHS Transition NumbersMean SD Range N

Cases referred for transfer to AMHS per year

4.63 3.52 0 – 10 19

Cases transferred to AMHS per year 4.82 3.54 0 – 10 17

* numbers represent clinician recall

Lost in Transition?

• Most teams lack a structured process– 67% report lack of agreed, accessible & known

transition care arrangements– 48% believe professionals unaware of their role in

transition process and services each offers

• Good information exchange– 93% report a comprehensive summary of notes is

made available (with permission) to AMHS

• Minimal interaction between services– 7% always hold professionals transfer meeting– 12% always hand-over care through meetings

involving both services & the young person

Reminder: Best Practice Guidelines for Transition

• Young people should receive the most suitable and effective care for their needs– Issue of access to services for 16-18 year olds

• Transitions should be seamless and user-centred– Seems to be an administrative event rather than a

process

• Should involve a period of joint working between services– Limited interaction between services

• Face-to-face semi-structured interviews– Consultant Child & Adolescent Psychiatrists (n=8)– Consultant Adult Psychaitrists (n=8)– GPs (n=8)– Staff from national youth organisations (n=9)

• Interview length ranged from 35 to 70 minutes

• Questions addressed experiences providing mental health services to older adolescents and factors impacting on transition

• Interview recordings transcribed verbatim & data analysed using thematic analysis

Study 2: Qualitative study of professionals’ transition experiences

Questions for Today

• Are young people receiving the most suitable and effective care for their needs?

• What are the potential barriers to close dialogue and collaboration between child and adult mental health services?

• Respondents identified key differences between CAMHS and AMHS– Focus of service– Treatment model used– Working practices– Type of resources available

• Service culture impacts on:– How service boundaries are defined – Level of inter-agency communication and collaboration

Service Cultures

• As seen in Study 1, considerable variation in age boundaries

• Issue of who is responsible for 16-18 year old age group impacts on quality of relationships between services

• Resources used as justification for setting age boundaries in both services

“As a service we’re a bit rigid about the 18 year old mark and that comes from, the management

team are very strict about it, it’s partly a resource issue because we’re on an extremely tight budget and we don’t , you know, we need to be careful about that but we get clear instruction you cannot take somebody under 18”

AMHS05 consultant

Defining Service Boundaries:Age

CAMHS02 Each sector has found its own unsatisfactory way of dealing with it so for us if you’re unlucky enough to have been vulnerable enough before you were sixteen you’ll still get a service from us but if you were lucky enough to be resilient enough until after you were sixteen you won’t get a service from us you’ll go straight to adult so it’s not right but that’s where it is

[…..]

Int And is the lower age for adult 16 years or is it 18?

CAMHS02 Em well we work off the em the kind of the agreement that if they’re as I said earlier if they’re it they’ve been here before they were 16 we’ll take them if they’re coming in cold at 16 we don’t take them they go to adult

Int And are adult happy to [take them]?

CAMHS02 No

Int But will they take them?

CAMHS02 yeah, yeah

“I mean you’re set up to meet needs I suppose, you know, and the needs we address are, you know, from adult up to the age of 65, is major mental illness em that’s that’s what that’s the need that needs to be met and that’s what we’re good at”

AMHS04 Consultant

“….I suppose my logic on it was that if it was a child who was say psychotic and was going to be requiring probably inpatient treatment at some point [and] definitely going to be graduating to adult psych services I thought that was less clearly ours whereas obviously a young person with difficulties within a family setting, I thought that maybe we could do an intervention more quickly and maybe discharge”

CAMHS05 Consultant

“…I think general adult psychiatrists are totally at sea with ADHD, with Asperger’s syndrome, Autism, I think the, you know, our level of knowledge is atrocious and I feel really sorry for people who are leaving child and adolescent services and they have to face into that gulf of knowledge and services available….”

AMHS01 consultant

Defining service boundaries: Clinical Presentation

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

AMHS05 consultant

Some flexibility around age depending on clinical need

Collaboration and communication

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

AMHS03 Consultant

Study 2: Conclusion

• Variation in level of contact and quality of relationships between child & adult mental health services– Underpinned by differing service cultures and

working practices– Limited resources place constraints on what can be

achieved

• Urgent need to resolve issue of responsibility of care for 16-18 year old group

• Study 1: Transition process is under-developed in Ireland

• Study 2: Difficult to separate transition from wider issue of mental health service provision for 16-18 year olds

• Need to encourage close dialogue and collaboration between child and adult mental health services

• Currently collecting data on transition experiences of young people and parents/carers

Summary

• Research team: – Prof Fiona McNicholas (Principal Investigator)

– Dr Niamh McNamara (UCD), Dr Blanaid Gavin (Lucena Clinic), Dr Siobhan Barry (Cluain Mhuire Services), Dr Barbara Dooley (UCD), Prof Imelda Coyne (TCD), Prof Swaran Singh (University of Warwick), Dr Moli Paul (University of Warwick), Dr Tamsin Ford (Peninsula College of Medicine), Prof Walter Cullen (UL)

– Dr Karen O’Connor, Dr Nicolas Ramperti– Ms Cliana Doyle, Ms Erin Brennan (Lucena Clinic)

• Contact details: Dr Niamh McNamara– [email protected]

Questions?