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Journal ArticleDOI

Who is in the transition gap? Transition from CAMHS to AMHS in the Republic of Ireland

01 Mar 2015-Irish Journal of Psychological Medicine (Cambridge University Press)-Vol. 32, Iss: 1, pp 61-69

TL;DR: Despite perceived on-going mental health (MH) service need, many young people are not being referred or are refusing referral to the AMHS, with those with ADHD being the most affected.

AbstractObjective The ITRACK study explored the process and predictors of transition between Child and Adolescent Mental Health Services (CAMHS) and Adult Mental Health Services (AMHS) in the Republic of Ireland. Method Following ethical approval, clinicians in each of Ireland’s four Health Service Executive (HSE) areas were contacted, informed about the study and were invited to participate. Clinicians identified all cases who had reached the transition boundary (i.e. upper age limit for that CAMHS team) between January and December 2010. Data were collected on clinical and socio-demographic details and factors that informed the decision to refer or not refer to the AMHS, and case notes were scrutinised to ascertain the extent of information exchanged between services during transition. Results A total of 62 service users were identified as having crossed the transition boundary from nine CAMHS [HSE Dublin Mid-Leinster (n=40, 66%), HSE South (n=18, 30%), HSE West (n=2, 3%), HSE Dublin North (n=1, 2%)]. The most common diagnoses were attention deficit hyperactivity disorder (ADHD; n=19, 32%), mood disorders (n=16, 27%), psychosis (n=6, 10%) and eating disorders (n=5, 8%). Forty-seven (76%) of those identified were perceived by the CAMHS clinician to have an ‘on-going mental health service need’, and of these 15 (32%) were referred, 11 (23%) young people refused and 21 (45%) were not referred, with the majority (12, 57%) continuing with the CAMHS for more than a year beyond the transition boundary. Young people with psychosis were more likely to be referred [χ2 (2, 46)=8.96, p=0.02], and those with ADHD were less likely to be referred [χ2 (2, 45)=8.89, p=0.01]. Being prescribed medication was not associated with referral [χ2 (2, 45)=4.515, p=0.11]. In referred cases (n=15), there was documented evidence of consent in two cases (13.3%), inferred in another four (26.7%) and documented preparation for transition in eight (53.3%). Excellent written communication (100%) was not supported by face-to-face planning meetings (n=2, 13.3%), joint appointments (n=1, 6.7%) or telephone conversations (n=1, 6.7%) between corresponding clinicians. Conclusions Despite perceived on-going mental health (MH) service need, many young people are not being referred or are refusing referral to the AMHS, with those with ADHD being the most affected. CAMHS continue to offer on-going care past the transition boundary, which has resource implications. Further qualitative research is warranted to understand, in spite of perceived MH service need, the reason for non-referral by the CAMHS clinicians and refusal by the young person.

Summary (2 min read)

Introduction:

  • The report indicated that only 19 teams nationwide accept all new cases up to and including 17.
  • As a result some young people face difficulties accessing appropriate services.
  • This Irish study of transition policy and practice, ITRACK, is the first to explore the specific arrangements for transition between CAMHS and AMHS.

Methods:

  • A comprehensive list of all consultant psychiatrists from child and adult MH services in urban and rural areas throughout Ireland was generated from the HSE website and by making telephone contact with each clinic.
  • Clinicians were advised about the study and invited to participate.
  • Specifically, clinicians were asked to draw up a list of all young people whose cases were open when they reached age X between January 1st and December 31st 2010 (where X is the last chronological year of age for which they should be seen by CAMHS as defined by that service/team).
  • The diagnosis given by CAMHS was recorded on two occasions, at the time of initial presentation to CAMHS (D1) and at time of reaching the transition boundary (D2).
  • Descriptive statistics were initially derived for all variables and Pearson χ2 tests (Fishers exact tests where appropriate and Phi or Craemer’s V noted for strength of association) were used in order to determine significant associations (p<0.05).

Results:

  • From the 60 CAMHS teams contacted, 9 responded from the four Health Service Executive (HSE) service areas covering a population of 4.6 million and 1 CAMHS was ineligible as their cut off was age 12/13, transferring care to another CAMHS.
  • Young people who had a family history of MH problems had mothers who were less likely to attend.
  • Comorbidity was common among many of the service users, with 42 (70%) experiencing multiple MH difficulties at some point during engagement with CAMHS In addition to general support and psycho-education, specific interventions following initial consultation included medication (39, 64%), individual therapy (25, 41%) and parenting support (12, 20%).

Transition Pathways

  • Transition pathways were determined for each case in the sample that made the transition.
  • Of those with ‘MH need’, the majority were not referred.

Case Management around Transition

  • With respect to the 15 young people who were referred, there was documented evidence from the case notes that the young person consented to transition (n=6, 40%) and was prepared for the process (n=8, 53%).
  • There was written communication between CAMHS and AMHS with respect to transition in all cases, with a referral letter being consistently sent (n=14, 93%).
  • Less evident from the notes were the occurrence of planning (n=2, 13%), joint appointments (n=1, 6%) or telephone conversations (n=1, 6%) between corresponding clinicians.

Discussion:

  • At initial assessment, many of the children attending CAMHS had comorbid MH diagnosis and had family members with difficulties.
  • Less than a third of those with perceived MH need are in fact being referred, despite the fact that all but one of referrals made were accepted readily and within a short time frame by AMHS.
  • Prescribing rates amongst GPs in ADHD are known to precipitously drop after age 16, despite on-going impairment, even allowing for remission with developmental maturation, this suggests that many are not receiving appropriate care.
  • Young people (16-24) attending AMHS reported finding this stigmatising, believed the service catered for a much older cohort of patients, and excluded family and parents (Davis & Butler, 2002; Jivangee et al., 2009, Jivangee & Kruzich, 2011).
  • In their study, although not explored, these attitudes may well have explained the large numbers not consenting to referral.

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1
TITLE
Who is in the Transition Gap? Transition from CAMHS to AMHS in the Republic of Ireland
1,2, 3
McNicholas F,
1
Adamson M,
4
McNamara N,
2
Gavin B,
5
Paul M,
6
Ford T,
7
Barry S,
1
Dooley B,
8
Coyne I,
9
Cullen W,
4
Singh SP
1
University College Dublin, Ireland;
2
Lucena Clinic, Ireland;
3
Our Lady’s Hospital for Sick
Children, Crumlin,
4
University of Bedfordshire, UK;
5
University of Warwick, UK;
6
University
of Exeter Medical School, UK;
7
Cluain Mhuire Adult Mental Health Service, Ireland;
8
Trinity
College Dublin, Ireland;
9
University of Limerick, Ireland

2
ABSTRACT
Objective: The ITRACK study explored the process and predictors of transition between Child
and Adolescent Mental Health Services (CAMHS) and Adult Mental Health Services (AMHS) in
the Republic of Ireland.
Method: Following ethical approval, clinicians in each of Ireland's four Health Service
Executive (HSE) areas were contacted, informed about the study and invited to participate.
Clinicians identified all cases who had reached the transition boundary (i.e. upper age limit for
that CAMHS team) between January and December 2010. Data were collected on clinical and
socio-demographic details and factors that informed the decision to refer or not refer to AMHS
and case notes were scrutinised to ascertain the extent of information exchanged between
services during transition.
Results: Sixty-two service users were identified as having crossed the transition boundary from
nine CAMHS (HSE Dublin Mid-Leinster (n=40, 66%), HSE South (n=18, 30%), HSE West
(n=2, 3%), HSE Dublin North (n=1, 2%). The most common diagnoses were ADHD (n=19,
32%), mood disorders (n=16, 27%), psychosis (n=6, 10%) and eating disorders (n=5, 8%). Forty-
seven (76%) of those identified were perceived by the CAMHS clinician to have an ‘on-going
mental health service need’ and of these 15 (32%) were referred, 11(23%) young people refused
and 21(45%) were not referred with the majority (12, 57%) continuing with CAMHS more than
a year beyond the transition boundary. Young people with psychosis were more likely to be
referred (χ
2
(2, 46)= 8.96, p=.02) and those with ADHD less likely (χ
2
(2, 45)= 8.89, p=.01).
Being prescribed medication was not associated with referral (χ
2
(2, 45) = 4.515, p =0.11). In
referred cases (N=15), there was documented evidence of consent in 2 cases (13.3%), inferred in

3
another 4 (26.7%) and documented preparation for transition in 8 (53.3%). Excellent written
communication (100%) was not supported by face to face planning meetings (n=2, 13.3%), joint
appointments (n=1, 6.7%) or telephone conversations (n=1, 6.7%) between corresponding
clinicians.
Conclusions: Despite perceived on-going mental health need, many young people are not being
referred, or are refusing referral to AMHS, with those with ADHD being most affected. CAMHS
continue to offer on-going care past the transition boundary, which has resource implications.
Further qualitative research is warranted to understand, in spite of perceived mental health need,
the reason for non-referral by CAMHS clinicians and refusal by the young person.

4
Introduction:
Adolescence is a time of increased risk for many mental health (MH) disorders and the
importance of an effective and well managed transition between Child and Adolescent Mental
Health Services (CAMHS) and Adult Mental Health Services (AMHS) has been increasingly
recognised (Paul et al., 2013; McNamara et al., 2013; Singh et al., 2010). For many adolescents
the presentation of MH difficulties continue and persist into adulthood (Patton et al., 2012) and
as such they will frequently require long-term engagement with health services and require
transfer of care from CAMHS to AMHS. Continuity of care in MH services is therefore a key
aspect of service provision. Problems in transition typically disrupt continuity of care and may
have a serious impact on service users, on their carers and on the effectiveness of MH services in
providing quality care (Singh et al., 2010).
Shortcomings in transition have been highlighted in a UK report by the Health Select Committee
(House of Commons, 2000) and by Singh and colleagues (2010). These include arbitrarily drawn
service boundaries, poor communication between agencies, a shortage of in-patient units for
adolescents and the need for early intervention services. The findings of the CAMHS Report
(Health Service Executive, 2013) which audited all 60 CAMHS in Ireland reflects the lack of
standardised practice nationwide regarding service provision for 16 and 17 year olds. The report
indicated that only 19 teams nationwide accept all new cases up to and including 17. Thus while
a Vision for Change recommends that the upper age for CAMHS is 18, it is clear that the
transition boundary (i.e. the age boundary between CAMHS and AMHS) in reality varies
between 16 and 18 years. As a result some young people face difficulties accessing appropriate

5
services. At present there is limited information about the process of transition in Ireland
(McNamara et al., 2013).
Although mental health policy in Ireland, A Vision for Change: The Report of the Expert Group
on Mental Health Policy (Department of Health & Children, 2006) has emphasised the
importance of improving both the quality and continuity of treatment within MH services,
information on this area has so far been lacking. This Irish study of transition policy and practice,
ITRACK, is the first to explore the specific arrangements for transition between CAMHS and
AMHS. The critical gaps between operational practice and best practice guidelines have
previously been published (McNamara et al., 2013). In this paper, we describe the cohort of
young people reaching the transition boundary and their outcome.
Methods:
A comprehensive list of all consultant psychiatrists from child and adult MH services in urban
and rural areas throughout Ireland was generated from the HSE website and by making telephone
contact with each clinic. Ethical approval was received from the research ethics committee of
each participating clinical service. Clinicians were advised about the study and invited to
participate. Consenting child psychiatrists were asked to retrospectively identify all cases who
had reached the transition (age) boundary during January and December 2010. Specifically,
clinicians were asked to draw up a list of all young people whose cases were open when they
reached age X between January 1
st
and December 31
st
2010 (where X is the last chronological
year of age for which they should be seen by CAMHS as defined by that service/team).

Citations
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Journal ArticleDOI
TL;DR: Good transition should be a co-ordinated, purposeful, planned and patient-centred process that ensures continuity of care, optimizes health, minimizes adverse events, and ensures that the young person attains his/her maximum potential.
Abstract: Transition from child to adult health care is a common experience for young people with enduring health problems who reach the age boundary between services. Transition is distinct from transfer (1), since it is more than a discrete administrative event. Good transition should be a co-ordinated, purposeful, planned and patient-centred process that ensures continuity of care, optimizes health, minimizes adverse events, and ensures that the young person attains his/her maximum potential. It starts with preparing a service user to leave a child-centred health care setting and ends when that person is received in, and properly engaged with, the adult provider (2). In physical disorders, transition became a clinical and research priority as an increasing number of young people with previously life-threatening conditions survived into adulthood and needed ongoing care. Systematic and narrative reviews in cystic fibrosis (3), haemophilia (4), diabetes (5), congenital heart disease (6), cancer (7), cerebral palsy and spina bifida (8) and palliative care (9) have all identified transition as a risk period for disengagement and deterioration, but also a therapeutic opportunity for ensuring good outcomes into adult life. Three broad categories of interventions have been tried: those aimed at the patient (educational programmes, skills training); those aimed at the staff (named transition co-ordinators, joint clinics run by paediatric and adult physicians); and changes in service delivery (separate young adult clinics, out of hours phone support, enhanced follow-up) (10). Yet the clinical and cost evaluation of such transition programmes is inconsistent and there are no robust and validated transition-related outcome measures (11).

85 citations


Cites background from "Who is in the transition gap? Trans..."

  • ..., only about 15% of young people with attention deficit hyperactivity disorder (ADHD) make a transition (16); the figure for Ireland is 7% (17)....

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TL;DR: The findings indicate that the age of onset of self-harm is decreasing, along with increases in highly lethal methods, indicate that targeted interventions in key transition stages for young people are warranted.
Abstract: Rates of hospital-treated self-harm are highest among young people. The current study examined trends in rates of self-harm among young people in Ireland over a 10-year period, as well as trends in self-harm methods. Data from the National Self-Harm Registry Ireland on presentations to hospital emergency departments (EDs) following self-harm by those aged 10–24 years during the period 2007–2016 were included. We calculated annual self-harm rates per 100,000 by age, gender and method of self-harm. Poisson regression models were used to examine trends in rates of self-harm. The average person-based rate of self-harm among 10–24-year-olds was 318 per 100,000. Peak rates were observed among 15–19-year-old females (564 per 100,000) and 20–24-year-old males (448 per 100,000). Between 2007 and 2016, rates of self-harm increased by 22%, with increases most pronounced for females and those aged 10–14 years. There were marked increases in specific methods of self-harm, including those associated with high lethality. The findings indicate that the age of onset of self-harm is decreasing. Increasing rates of self-harm, along with increases in highly lethal methods, indicate that targeted interventions in key transition stages for young people are warranted.

45 citations


Cites background from "Who is in the transition gap? Trans..."

  • ...In Ireland, there is limited formal interaction between child and adult services [29] and many young people who reach the upper age limit of CAMHS services are not referred to adult services, despite ongoing needs [30]....

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Journal ArticleDOI
Abstract: Transition-related discontinuity of care is a major socioeconomic and societal challenge for the EU. The current service configuration, with distinct Child and Adolescent Mental Health (CAMHS) and Adult Mental Health Services (AMHS), is considered a weak link where the care pathway needs to be most robust. Our aim was to delineate transitional policies and care across Europe and to highlight current gaps in care provision at the service interface. An online mapping survey was conducted across all 28 European Countries using a bespoke instrument: The Standardized Assessment Tool for Mental Health Transition (SATMEHT). The survey was directed at expert(s) in each of the 28 EU countries. The response rate was 100%. Country experts commonly (12/28) reported that between 25 and 49% of CAMHS service users will need transitioning to AMHS. Estimates of the percentage of AMHS users aged under 30 years who had has previous contact with CAMHS were most commonly in the region 20-30% (33% on average).Written policies for managing the interface were available in only four countries and half (14/28) indicated that no transition support services were available. This is the first survey of CAMHS transitional policies and care carried out at a European level. Policymaking on transitional care clearly needs special attention and further elaboration. The Milestone Study on transition should provide much needed data on transition processes and outcomes that could form the basis for improving policy and practice in transitional care.

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TL;DR: This review examined data from 87 peer-reviewed and non-academic documents to determine the characteristics that support the transition process and to identify opportunities for system and program improvement.
Abstract: The aim of this scoping review was to identify the core components of interventions that facilitate successful transition from child and adolescent mental health services to adult mental health services. In the absence of rigorous evaluations of transition program effectiveness for transitioning youth with mental health care needs, these core components can contribute to informed decisions about promising program and intervention strategies. This review examined data from 87 peer-reviewed and non-academic documents to determine the characteristics that support the transition process and to identify opportunities for system and program improvement. Data were extracted and synthesized using a descriptive analytic framework. A major finding of this review is a significant lack of measurable indicators in the academic and gray literature. This review did identify 26 core components organized within the framework of the six core elements of healthcare transitions. Policy makers, practitioners, and administrators can use the core components to guide decisions about transition program and intervention content. Confirmation of the impact of these core program components on youth outcomes awaits the conduct of rigorous randomized trials. Future research also needs to explicitly focus on the development of indicators to evaluate transition programs and interventions.

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Abstract: Medical Management of Eating Disorders Birmingham CL, Beumont PJ, eds. 275 pages. New York: Cambridge Univ Pr; 2004. $55.00. ISBN: 0521546621. Order at www.cambridge.org. Field of medicine: Internal medicine. Format: Softcover book. Audience: General practitioners, psychiatrists, internists, pediatricians, health care professionals, nursing staff, dietitians, family caregivers, and patients. Purpose: To provide a general clinical overview of eating disorders. Content: The book has 5 sections (medical perspective, treatment, patients with specific diseases, psychiatric and psychological perspectives, and areas of special interest) divided into 95 chapters. Each section includes a comprehensive clinical outline and information for patients. In addition, the text contains many useful tables summarizing relevant issues and diagnostic color photographs of important physical manifestations related to eating disorders. Highlights: The book gives a comprehensive and original approach to eating disorders whose prevalence and incidence are dramatically increasing over the world. The short chapters, covering a wide range of topics, outline the current state of knowledge on the subject, including issues such as integrated medical and psychiatric intervention, the role of the dietitian, and important information for the family. All chapters are clearly and professionally written. Furthermore, many case reports and clinical examples have been included with pertinent discussion. The book is easy to read, progressing logically through clinical presentation, therapy, and psychiatric and psychological examination. The text will be useful for clinicians (such as nurses and primary care physicians) who are faced with patients with eating disorders and need initial guidance. Limitations: As with many medical handbooks, most of the contents are concise and limited by the need for access to up-to-date information. Although the book provides an approach to differential diagnosis of common symptoms, it lacks sufficient detail to provide the insight needed to resolve the diagnostic dilemmas. The well-chosen references are listed according to topic at the end of the book, but they are not cited in the text. Related reading: Another book on eating disorders is Brewerton's Clinical Handbook of Eating Disorders: An Integrated Approach (Marcel Dekker, 2004). Reviewer: Gerardo Nardone, MD, Department of Clinical and Experimental Medicine, University of Naples Federico II, Naples, Italy.

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Abstract: Attention deficit hyperactivity disorder (ADHD) is among the most common psychiatric disorders of childhood that persists into adulthood in the majority of cases. The evidence on persistence poses several difficulties for adult psychiatry considering the lack of expertise for diagnostic assessment, limited treatment options and patient facilities across Europe. The European Network Adult ADHD, founded in 2003, aims to increase awareness of this disorder and improve knowledge and patient care for adults with ADHD across Europe. This Consensus Statement is one of the actions taken by the European Network Adult ADHD in order to support the clinician with research evidence and clinical experience from 18 European countries in which ADHD in adults is recognised and treated. Besides information on the genetics and neurobiology of ADHD, three major questions are addressed in this statement: (1) What is the clinical picture of ADHD in adults? (2) How can ADHD in adults be properly diagnosed? (3) How should ADHD in adults be effectively treated? ADHD often presents as an impairing lifelong condition in adults, yet it is currently underdiagnosed and treated in many European countries, leading to ineffective treatment and higher costs of illness. Expertise in diagnostic assessment and treatment of ADHD in adults must increase in psychiatry. Instruments for screening and diagnosis of ADHD in adults are available and appropriate treatments exist, although more research is needed in this age group.

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TL;DR: It is suggested that adult ADHD is a common disorder associated with impaired functioning and having ADHD is associated with lower levels of education and employment status.
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468 citations


"Who is in the transition gap? Trans..." refers background in this paper

  • ...Given that up to 60% of children with ADHD continue to meet the diagnostic criteria in adulthood (Faraone & Biederman, 2005), there is an urgent need to develop adult ADHD services....

    [...]


Journal ArticleDOI
TL;DR: A series of steps are proposed that include better coordination and use of data collected across countries, greater harmonisation of school-based surveys, further development of strategies for socially marginalised youth, targeted research into the validity anduse of these health indicators, and advocating for adolescent-health information within new global health initiatives.
Abstract: Adolescence and young adulthood offer opportunities for health gains both through prevention and early clinical intervention. Yet development of health information systems to support this work has been weak and so far lagged behind those for early childhood and adulthood. With falls in the number of deaths in earlier childhood in many countries and a shifting emphasis to non-communicable disease risks, injuries, and mental health, there are good reasons to assess the present sources of health information for young people. We derive indicators from the conceptual framework for the Series on adolescent health and assess the available data to describe them. We selected indicators for their public health importance and their coverage of major health outcomes in young people, health risk behaviours and states, risk and protective factors, social role transitions relevant to health, and health service inputs. We then specify definitions that maximise international comparability. Even with this optimisation of data usage, only seven of the 25 indicators, covered at least 50% of the world's adolescents. The worst adolescent health profiles are in sub-Saharan Africa, with persisting high mortality from maternal and infectious causes. Risks for non-communicable diseases are spreading rapidly, with the highest rates of tobacco use and overweight, and lowest rates of physical activity, predominantly in adolescents living in low-income and middle-income countries. Even for present global health agendas, such as HIV infection and maternal mortality, data sources are incomplete for adolescents. We propose a series of steps that include better coordination and use of data collected across countries, greater harmonisation of school-based surveys, further development of strategies for socially marginalised youth, targeted research into the validity and use of these health indicators, advocating for adolescent-health information within new global health initiatives, and a recommendation that every country produce a regular report on the health of its adolescents.

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"Who is in the transition gap? Trans..." refers background in this paper

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    [...]


Journal ArticleDOI
TL;DR: Adolescents sit poorly between the family centred, developmentally focused, paediatric paradigm (which frequently ignores their growing independence and increasingly adult behaviour) and the adult medical culture, which acknowledges patient autonomy, reproduction, and employment issues but neglects growth, development, and family concerns.
Abstract: The fate of older adolescent patients in paediatric clinics is either one of transfer to adult services, long term retention in the paediatric clinic, or discharge from medical supervision, either voluntarily or by neglect. Neither simple transfer to adult doctors nor allowing adolescents to “drop out” of medical care is now acceptable quality care for young people with chronic illness. Arranging efficient and caring transfer for adolescents from paediatric to adult care is one of the great challenges facing paediatrics—and indeed the health services—in the coming century.1 Many illnesses once considered to be confined to childhood, such as cystic fibrosis and metabolic conditions, must now be thought of as diseases that begin in childhood but continue into adult life. Paediatric and adult medicine differ greatly in their approach to issues of growth, development, patient agency, and involvement of the family—differences that may become more noticeable with the recent separation of paediatricians from the Royal College of Physicians in the UK. Adolescents sit poorly between the family centred, developmentally focused, paediatric paradigm (which frequently ignores their growing independence and increasingly adult behaviour) and the adult medical culture, which acknowledges patient autonomy, reproduction, and employment issues but neglects growth, development, and family concerns.2 The simple matter of transferring care to adult physicians has been challenged in the past decade by the notion of “transition”, emphasising the need for the change to adult care to be a guided educational and therapeutic process, rather than an administrative event.3 To achieve effective transition, it must be recognised that transition in health care is but one part of the wider transition from dependent child to independent adult and that, in moving from child centred to adult health services, young people undergo a change that is systemic and cultural, as well as clinical.2 …

302 citations


"Who is in the transition gap? Trans..." refers background in this paper

  • ...Young people express anxiety and negative opinions of adult medical services including concerns over lack of familiarity with the new service and the necessity to start over with a new team, in addition to beliefs that they will be more formal, less friendly and have a broad-age range of other patients (Viner, 1999; Soanes & Timmons, 2004; Tuchman et al., 2008)....

    [...]

  • ...…services, including concerns over lack of familiarity with the new service and the necessity to start over with a new team, in addition to beliefs that they will be more formal, less friendly and have a broad age range of other patients (Viner, 1999; Soanes & Timmons, 2004; Tuchman et al. 2008)....

    [...]