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Niamh McNamara BA, PhD


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Transition from Child to Adult Mental Health Services in Ireland

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Niamh McNamara BA, PhD

  1. 1. Transition from Child to Adult Mental Health Services in Ireland Niamh McNamara BA, PhD School of Medicine & Medical Science University College Dublin The National Mental Healthcare Conference Thursday 27th September 2012
  2. 2. The importance of youth mental health
  3. 3. The ITRACK Project• Research team: University College Dublin, Trinity College Dublin, Lucena Clinic, Cluain Mhuire Services.• Collaborators: University of Warwick, University of Exeter, University of Limerick, University of Melbourne, NSUE, Bodywhys, HADD, SHINE.• Funded by the Health Research Board• Aims: To identify the barriers & enablers to effective transition for adolescents from CAMHS to adult services
  4. 4. Why focus on transition?• Transition will become increasingly important as Child & Adolescent Mental Health Services (CAMHS) begin to take on new presentations of 16 and 17 year olds• Reports place emphasis on developing & improving mental health services for young people – No focus on crucial link between CAMHS and adult services• Lack of information on transition process in Ireland – Likely issues found abroad will be mirrored here
  5. 5. ITRACK Studies• Study 1: Survey of transition policies & procedures in CAMHS and AMHS nationwide – Compare best practice for smooth transition with current clinical practice• Study 2: Semi-structured interviews with consultant psychiatrists, GPs, and staff from national youth organisations – Identify organisational facilitators and barriers to transition – Explore professionals’ experiences of service provision for older adolescents including transition
  6. 6. Best practice guidelines for transition• International transition policies & best practice recommendations: – Young people should receive the most suitable and effective care for their needs – Transitions should be seamless and user- centred – Should involve period of joint working between services
  7. 7. Study 1: An investigation of operationalpolicies for 16-18 year olds• Structured interviews with 57 consultant psychiatrists (32 CAMHS, 25 AMHS) – Based on mapping tool used in TRACK study (Singh et al., 2009)• Questions addressed key areas: – Transition boundaries & annual transition rates – Co-ordination of the transition process – Degree of collaboration between services – Involvement of young person in the transition process
  8. 8. Age Boundary• 84% CAMHS teams reported upper age limit of 18 – Typically refers to existing cases – Practice varies regarding re-referrals & new cases aged 16-18 – 34% accept new referrals aged 16-18• 52% AMHS teams reported lower age limit of 18 – 84% reported accepting cases between 16 -18
  9. 9. CAMHS Transition Numbers Mean SD Range NCases suitable for transfer to AMHS 7.73 9.86 1 – 50 25 per yearCases transferred to AMHS per year 4.50 3.33 1 – 10 20 Cases remaining in CAMHS past 5.46 6.37 0 – 21 26 transition boundary per year AMHS Transition Numbers Mean SD Range NCases referred for transfer to AMHS 4.63 3.52 0 – 10 19 per yearCases transferred to AMHS per year 4.82 3.54 0 – 10 17 * numbers represent clinician recall
  10. 10. Lost in Transition?• Most teams lack a structured process – 67% report lack of agreed, accessible & known transition care arrangements – 48% believe professionals unaware of their role in transition process and services each offers• Good information exchange – 93% report a comprehensive summary of notes is made available (with permission) to AMHS• Minimal interaction between services – 7% always hold professionals transfer meeting – 12% always hand-over care through meetings involving both services & the young person
  11. 11. Reminder: Best Practice Guidelines forTransition• Young people should receive the most suitable and effective care for their needs – Issue of access to services for 16-18 year olds• Transitions should be seamless and user-centred – Seems to be an administrative event rather than a process• Should involve a period of joint working between services – Limited interaction between services
  12. 12. Study 2: Qualitative study of professionals’ transition experiences• Face-to-face semi-structured interviews – Consultant Child & Adolescent Psychiatrists (n=8) – Consultant Adult Psychaitrists (n=8) – GPs (n=8) – Staff from national youth organisations (n=9)• Interview length ranged from 35 to 70 minutes• Questions addressed experiences providing mental health services to older adolescents and factors impacting on transition• Interview recordings transcribed verbatim & data analysed using thematic analysis
  13. 13. Questions for Today• Are young people receiving the most suitable and effective care for their needs?• What are the potential barriers to close dialogue and collaboration between child and adult mental health services?
  14. 14. Service Cultures• Respondents identified key differences between CAMHS and AMHS – Focus of service – Treatment model used – Working practices – Type of resources available• Service culture impacts on: – How service boundaries are defined – Level of inter-agency communication and collaboration
  15. 15. Defining Service Boundaries: Age• As seen in Study 1, considerable variation in age boundaries• Issue of who is responsible for 16-18 year old age group impacts on quality of relationships between services• Resources used as justification for setting age boundaries in both services “As a service we’re a bit rigid about the 18 year old mark and that comes from, the managementteam are very strict about it, it’s partly a resourceissue because we’re on an extremely tight budgetand we don’t , you know, we need to be careful aboutthat but we get clear instruction you cannot takesomebody under 18” AMHS05 consultant
  16. 16. CAMHS02 Each sector has found its own unsatisfactory way of dealing with it so for us if you’re unlucky enough to have been vulnerable enough before you were sixteen you’ll still get a service from us but if you were lucky enough to be resilient enough until after you were sixteen you won’t get a service from us you’ll go straight to adult so it’s not right but that’s where it is […..]Int And is the lower age for adult 16 years or is it 18?CAMHS02 Em well we work off the em the kind of the agreement that if they’re as I said earlier if they’re it they’ve been here before they were 16 we’ll take them if they’re coming in cold at 16 we don’t take them they go to adultInt And are adult happy to [take them]?CAMHS02 NoInt But will they take them?CAMHS02 yeah, yeah
  17. 17. Defining service boundaries: Clinical Presentation“I mean you’re set up to meet needs I suppose, you know, and the needs weaddress are, you know, from adult up to the age of 65, is major mental illnessem that’s that’s what that’s the need that needs to be met and that’s whatwe’re good at”AMHS04 Consultant“….I suppose my logic on it was that if it was a child who was say psychoticand was going to be requiring probably inpatient treatment at some point[and] definitely going to be graduating to adult psych services I thought thatwas less clearly ours whereas obviously a young person with difficulties withina family setting, I thought that maybe we could do an intervention morequickly and maybe discharge”CAMHS05 Consultant“…I think general adult psychiatrists are totally at sea with ADHD, withAsperger’s syndrome, Autism, I think the, you know, our level of knowledge isatrocious and I feel really sorry for people who are leaving child and adolescentservices and they have to face into that gulf of knowledge and servicesavailable….”AMHS01 consultant
  18. 18. Some flexibility around age dependingon clinical need“There is a limited flexibility around it….traditionally thisarea has had [a CAMH] service that did provide input upto the age of 18 and that persists occasionally there arepeople who kind of exceed the capacity of a child andadolescent service….for example we have somebodywho’s under 18 attending who’s prescribed clozapine and[the CAMHS] isn’t able to provide a clozapine servicebecause the infrequency with which it’s prescribed sothere is a kind of shared care arrangement there in placeso in circumstances where you know a case is made forsomebody under 18 that they have a particular needwhich we can best meet we would try to come to somekind of shared care arrangement”AMHS05 consultant
  19. 19. Collaboration and communication“….The reality is that there’s very little communication orliaison between child psychiatry and adult services, theyare quite different, you know we don’t have in my viewwe don’t have enough joint working, we don’t do thingstogether, and there’s very much a….I mean there’s verymuch a bit of a fight really you know, it’s always maybethe only time when there’s any discussion is about thiscontroversial 16 to 18 year and there’s a lot ofresentment on both sides I would say about that, so Ithink that’s a real difficulty, you know once people gointo training, you know we might have trainees they gointo child psychiatry and that’s it, and child psychiatry asI say we rarely meet if ever, I don’t know if we evermeet”AMHS03 Consultant
  20. 20. Study 2: Conclusion• Variation in level of contact and quality of relationships between child & adult mental health services – Underpinned by differing service cultures and working practices – Limited resources place constraints on what can be achieved• Urgent need to resolve issue of responsibility of care for 16-18 year old group
  21. 21. Summary• Study 1: Transition process is under-developed in Ireland• Study 2: Difficult to separate transition from wider issue of mental health service provision for 16-18 year olds• Need to encourage close dialogue and collaboration between child and adult mental health services• Currently collecting data on transition experiences of young people and parents/carers
  22. 22. Questions?• Research team: – Prof Fiona McNicholas (Principal Investigator) – Dr Niamh McNamara (UCD), Dr Blanaid Gavin (Lucena Clinic), Dr Siobhan Barry (Cluain Mhuire Services), Dr Barbara Dooley (UCD), Prof Imelda Coyne (TCD), Prof Swaran Singh (University of Warwick), Dr Moli Paul (University of Warwick), Dr Tamsin Ford (Peninsula College of Medicine), Prof Walter Cullen (UL) – Dr Karen O’Connor, Dr Nicolas Ramperti – Ms Cliana Doyle, Ms Erin Brennan (Lucena Clinic)• Contact details: Dr Niamh McNamara –