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Published by European Society of Child and Adolescent Psychiatry (ESCAP)
The guidance outlines practices, procedures, and service environments to promote appropriate, safe, and timely transitions of young people from child and adolescent mental health services to adult mental health services or alternative care settings across Europe.
Key Takeaways
Start early: Allow sufficient time for information sharing, preparation and a gradual transition process. Initiate planning at approximately 6 months before the service boundary for those in care over 12 months.
Multidisciplinary approach: If available and feasible, engage a multidisciplinary team of care providers with knowledge of a broad range of services and opportunities in the transition planning process.
Involve young people: Actively involve young people throughout the transition planning process, seeking their input, preferences and perspectives to promote shared decision-making.
Include parents/caregivers: With the young person’s consent, involve parents/caregivers in transition planning.
Evaluate ongoing treatment needs: Assess symptom severity, functional impairment, disorder progression, and comorbidities... to determine the most appropriate care setting.
Comprehensive transition need and readiness evaluation: Assess the young person’s readiness and need for transition using a validated standardised tool such as the Transition Readiness and Appropriateness Measure (TRAM).
Consider severity or impairment over diagnosis: Assessments should focus on the overall level of impairment, risk and treatment needs, rather than solely on the diagnosis.
Prioritise transition to AMHS for severe mental illness: Young people with severe conditions like psychosis, bipolar disorder, severe symptoms of depression, anxiety or PTSD, personality disorder, eating disorder... should be prioritised for transition to AMHS.
Comprehensive preparation: Develop and implement comprehensive transition preparation to help young people feel ready and address any feelings of uncertainty.
Therapeutic relationships: Recognise the value of existing relationships and support continuity by involving CAMHS clinicians in introductory meetings, joint meetings, or engaging a key worker.
Enhance communication and coordination: Foster collaboration among CAMHS, AMHS, primary care and/or other relevant services... to ensure seamless transition and consistent care.
Provide step-down services: For those who show improvement in their mental health but may still need some level of care, consider organising less intensive support during the initial transition period.
Enhanced support: Ensure the young people has attended at least one AMHS appointment before CAMHS discharge. AMHS should follow up with young people who do not engage... within the first three months.
Comprehensive assessment and care planning: Conduct a thorough assessment to identify the young person’s ongoing mental health needs, strengths, functional impairments and required community supports.
Community service/resource linkage: Identify and actively support the young person to connect with appropriate community-based resources, such as peer support groups, counselling services, vocational training, or social services.
Follow-up and monitoring: Ensure a system is in place for structured follow-up and monitoring, either through primary care or community-based services, to track the young person’s progress.
Allocate sufficient budget and resources: Ensure appropriate funding and resources for transition activities, e.g., for transition coordinators, joint working time or clinics, and evaluation tools.
Establish shared responsibility and ownership for transition: Promote shared responsibility between CAMHS and AMHS for transition outcomes through genuine inter-service collaboration.
Pre-transition monitoring and planning: Establish a systematic process to identify young people approaching the service age limit at least 6–12 months in advance.
Clinical Topic
Youth mental health service transition
Objectives
To support transitional care at the CAMHS and AMHS boundary across Europe, providing guidance regarding practices and procedures, and services and environments designed to promote appropriate, safe and timely passage of service users.
Target Patient Population
Young people transitioning from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS) or other care settings.
Target Providers
Therapeutic Area
Mental HealthGuideline Scope
Care Settings
Special Populations
Monitoring Guidance
Ensure a system is in place for structured follow-up and monitoring through primary care or community-based services to track progress and identify emerging concerns after discharge from CAMHS.
Difficulty
intermediate
Learning Paths