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Opinion & debate |
ETHOS Early Intervention Service, Department of Mental Health, St George’s Hospital Medical School, London, tel: 0208 725 3390, fax: 0208 725 3538, e-mail: s.singh{at}sghms.ac.uk
Newham Primary Care Trust
Barnet Early Intervention Service, Barnet Enfield and Haringey Mental Health Trust
North East London Mental Health Trust, London
Adolescents with mental health problems are poorly served by mental health services, since responsibility for care often falls between child and adult services. Within the UK, there is no consensus on how service boundaries should be delineated. Some services use an age cut-off at some point between 16 and 18 years, whereas others consider child services to be appropriate only for those in full-time education. The Audit Commission (1999) reported that nationally 29% of health authorities commissioned child and adolescent mental health services for young people before their 16th birthday only, although adult services were not considered suitable for those under 17 years old. The report highlighted the poor development of adolescent services and their inadequate links with other agencies, including adult mental health services.
Even though adolescence is a risk period for the emergence of serious mental illnesses such as schizophrenia, it has generally received only patchy attention from services (Reder et al, 2000). The Mental Health Foundation report Bright Futures suggested that young people generally have a poor image of adult services (Mental Health Foundation, 1999). Admitting young people to acute adult wards is particularly problematic and is likely to set them on a lifelong path of aversion to mental health care. Communication between child and adult services is notoriously poor. Although many young people experience transition to adult services, just under a quarter of services in the UK have specific arrangements for such transfer of care (Audit Commission, 1999).
There is considerable variation across the country in how well this transition is managed. A Select Committee on Health report on National Health Service mental healthcare identified several problems in the transition from child to adult services (Select Committee on Health, 2000). These problems included the failure of services to work together, the need for care management and planning to be led by a single practitioner who can coordinate care across all relevant agencies, the shortage of in-patient services for adolescents, the need for early intervention and the poor liaison between various agencies. In addition, access to psychotherapy is generally more difficult in adult services. There is therefore a serious risk of disruption in care provision for adolescents who are transferred to adult mental health services. A review of continuity in transition from child to adult services highlighted the paucity of high-quality research in this area (While et al, 2004).
In this paper we explore the conceptual and practical barriers that exist between child and adult services and recommend strategies for effectively managing this interface, especially in light of the development of specialist services such as early intervention in psychosis, which bridge the child-adult divide.
Barriers at the interface
The interface between child and adult services is influenced by how the services have evolved in their structure and function and how they differ in their conceptualisation and management of mental illnesses (Reder et al, 2000).
Evolution of services
Adult psychiatry has evolved under the successive influences of neurology,
phenomenology, psychology and sociology, and has developed treatment
strategies which were once entirely asylum-based but are now increasingly
provided in the community. The primary focus of adult psychiatry has been the
individual’s morbid mental state. Treatment strategies are aimed mainly
at ameliorating such states by biological and psychological therapies. Child
psychiatry, on the other hand, emerged later and primarily within a
sociological context, with concerns about vagrant, traumatised or delinquent
youth. It gradually broadened its horizons to include developmental concerns
and the role of systems such as the family. The assessment focus is therefore
on interactions between developmental and emotional processes, family
relations and social experiences, with treatments geared primarily towards
psychological and systems interventions.
Differing perspectives
These organisational and theoretical differences are most vivid at the
interface, where different perspectives collide, such as when a young person
with behavioural problems and an unstable family is referred to an adult
service that regards an absence of diagnostic phenomenology as a barrier to
offering help. The needs of a child envisioned within a family context allow
child services to offer help to the family unit; respect for the autonomy of
an adult prohibits adult services from intervening where an individual
declines help. Young people negotiating the developmental tasks of
adolescence, such as independence, sexuality, career and independent living,
are therefore caught between two very different services, one that considers
them and their problems as part of the family unit, and the other that
considers them as adult and autonomous. Concerns about confidentiality also
inhibit adult services from sharing findings and plans with family members,
unless the young person gives explicit consent. Families who wish to stay
involved in treatment plans are often left feeling isolated and removed from
major decisions made by adult services. All these heighten the risk of the
young person withdrawing from care at the point of transition.
Diagnostic uncertainty
Many young people have difficulty negotiating adolescence and can
experience a wide range of problems, which may persist into adult life if not
addressed early. The disturbances of conduct disorders, for instance, can
persist into adult life (Scott,
1998) and if such individuals get into trouble with the law or
misuse substances, they are likely to fall through the care net. The distress
of social problems such as domestic violence, homelessness, unemployment,
parental separation or parental mental illness can masquerade as
psychopathology, or be ignored as ‘reactive’ and hence perceived
as less serious than a diagnosable mental illness. The diagnostic uncertainty
caused by overlap between the ‘normal’ turmoil of adolescence and
the non-specific prodrome of serious mental disorders, combined with frequent
drug use in this age-group, is a further barrier to young people receiving
appropriate help from adult services.
Rigidity of boundaries
The developmental stage at which someone becomes an ‘adult’ is
impossible to define. Services that have clear age-related boundaries may have
explicit processes in place for managing the transition, but the rigidity of
the age cut-offs can hamper rather than facilitate the ability of services to
meet the needs of individuals astride these age bands. Tight demarcations and
referral criteria can be ploys to cope with budgetary restraints and managing
case-loads, rather than explicit attempts to target services
appropriately.
Availability of services
Child services generally have more in the way of individual and family
psychotherapy provision, whereas access to local in-patient and day-patient
facilities is often limited and is sometimes non-existent. The converse is
true of adult services. This can lead to an abrupt disjunction when a young
person who has been in psychotherapy, possibly for some years, is abruptly
transferred to an adult service where the only readily available
non-pharmacological treatment option may be admission to a local day service
populated largely by older patients with very different needs.
Lack of a common language
The structural and functional differences between services have also
introduced concepts that may be alien to all but those who are directly
involved in providing a service. Adult services struggle to understand exactly
what is meant, for example, by tiers 1, 2, 3 and 4, or the differences between
primary child and adolescent mental health workers and primary care mental
health workers. Workers in child services may struggle to understand the
differences between case management, care programme approach and the
differences between the standard and enhanced care programme approach.
Managing the interface
How is the interface between child and adult services best managed? Given the barriers identified above, there can be no clear-cut and easy answer, which could be implemented overnight. Several strategies could be considered, dependent upon local needs and priorities, including the following.
Specialist services
Giving evidence to the Select Committee on Health, several organisations
such as Young Minds, Sainsbury Centre, Rethink, the Royal College of
Psychiatrists and the Royal College of Nursing recommended the setting up of
specialist services for young people aged 16-25 years. Despite the obvious
advantages of such specialised services, it is unlikely that these will appear
nationally in the near future. One interesting area of opportunity is the
emerging early intervention services, which are clearly astride child and
adult services, and are meant to provide care for young people aged 14-35
years who are experiencing psychosis. 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.
Liaison models
Maitra & Jolley (2000)
have described a liaison project in the London Borough of Hammersmith and
Fulham in which child and adult psychiatrists routinely attend each
other’s meetings to discuss cases involving children: either child
patients who have a carer with potential mental health problems or children of
adult patients who are actually suffering or at potential risk of mental
health problems. The authors note several benefits of such liaison, including
a higher profile for children within adult services, shaping of the process of
referrals across services, improved scope for prophylactic work, possibilities
of joint working and the availability of a forum for formal and informal
discussions. Given the resource implications of such models, an audit of the
process and outcomes would be very useful in helping other services develop
similar working patterns.
Joint working
The dilemmas and dichotomies of different perspectives - a child within a
family system, as opposed to an adult with a distinct mental health problem -
can be effectively dealt with by child and adult services working jointly in
individual cases. Child services bring the important understanding of
developmental processes in the assessment and management of young people;
adult services are usually better equipped to provide diagnostic precision and
appropriate pharmacological treatments. This approach also facilitates
interdisciplinary learning and fosters therapeutic skills in both child and
adult services. However, lines of responsibility and accountability must be
clear, lest in the hope that the ‘other side’ is responsible,
neither service delivers.
Specialised workers astride service
Specialised workers who are members of both child and adult services can
potentially harvest the advantages of both liaison models and joint working.
However, there is a paucity of such trained staff. There may also be concerns
about clinical responsibilities, supervision, fragmentation of working
practice and divided loyalties across teams.
Protocols and guidelines
At the very least, all child and adult services should have written
protocols for managing the interface. These should include:
Training and research
The bodies responsible for training professionals to work in the mental
health field should consider the development of a course for specialist
workers to enable such staff to work with children from the age of 14 years or
so up to young adulthood. This would require adult services to adopt a more
family-based and systems approach, and child services to improve their
phenomenological and diagnostic skills. Priority should also be given to
research into interface issues, problems of transition and effectiveness of
different models of joint working and managing the interface.
Conclusion
Desite a number of recent reports on this topic, there has been little progress in improving the interface between child and adult mental health services. Change will require both a ‘top down’ and a ‘bottom up’ approach. Regional offices responsible for delivery of both types of service in their area should become central in the development of better interfaces. National bodies should take the lead in developing training for joint workers. On the ground, clinical and managerial professionals from child and adult services need to begin working together to develop protocols to facilitate transition. This is also a fertile area for research, which should be pursued both at local and national level.
References
AUDIT COMMISSION (1999) Children in Mind. London: Audit Commission.
MAITRA, B. & JOLLEY, A. (2000) Liaison between child and adult psychiatric services. In Family Matters: Interface Between Child and Adult Mental Health (eds P. Reder, M. McClure & A. Jolley), pp. 285-302. London: Routledge.
MENTAL HEALTH FOUNDATION (1999) Bright Futures. Promoting Children and Young People’s Mental Health. London Mental Health Foundation.
REDER, P., MCCLURE, M. & JOLLEY, A. (2000) Interface between child and adult mental health. In Family Matters: Interface Between Child and Adult Mental Health (eds P. Reder, M. McClure & A. Jolley), pp. 3 -20. London: Routledge.
SCOTT, S. (1998) Aggressive behaviour in childhood.
BMJ, 316, 202
-206.
SELECT COMMITTEE ON HEALTH (2000) Transitions between child/adolescent and adult services. In Fourth Report. Provision of NHS Mental Health Services. London: Stationery Office (available at http://www.parliament.the-stationery-office.co.uk/pa/cml99900/cmselect/cmhealth/373/37312.htm).
WHILE, A., FORBES, R., ULLMAN, S., et al (2004) Good practices that address continuity driving transition from child to adult care: synthesis of the evidence. Child Care Health and Development, 30, 439 -452.[CrossRef][Medline]
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| British Journal of Psychiatry | Advances in Psychiatric Treatment | All RCPsych Journals |
