For young people struggling with their mental health, being able to access child mental health services can be difficult enough. But what happens when they become too old and need to transition to adult services?
Each year, across the UK, more than 25,000 young adults move from child and adolescent mental health services (CAMHS) into adult mental health services. During this transition, around 50% of under-25s disengage and end the process.
Many of these may be discharged because they or the service decide that they are well enough to continue with alternative support. However, for others it can be a decision outside their control due to the inaccessibility of adult services.
Ageing out of CAMHS
There is no set age at which young people become too old for CAMHS. In some areas support can end at 16 years of age but most services end at 18.
"It all comes down to local planning of services so each area will differ and there isn't much accountability when it comes to local plans," says Charlotte Rainer, Policy Officer at The Children's Society. "Unfortunately, it is a common occurrence that young people fall off a cliff edge of support between child and adult services. This often means that they have to navigate a really challenging time of life without any support in place, putting their mental health at risk."
If young people who are currently accessing CAMHS become too old for the service, they may find that their mental health condition isn't considered severe enough to warrant adult support, she explains. "The thresholds for adult services are so much higher than they are for CAMHS that many young people won't actually be eligible to get any support from the service." Ideally, this gap should be covered by support in the community.
Knowing that your support is about to disappear or change can itself be a source of anxiety for many young people approaching adulthood, says Emily Dobson, Policy and Parliamentary Officer at YoungMinds. "If you're a seventeen-year-old, approaching your eighteenth birthday, and you've been with a counsellor or therapist for a number of years, knowing that that's about to change can be really daunting."
In some cases, young people who are approaching their eighteenth birthday are unable to access CAMHS at all because they are so close to transition age, making them too old for CAMHS and too young for adult services.
"Eighteen can be quite a vulnerable time for young people as there are lots of changes happening in their lives," she says. "They might be starting work for the first time or moving away from home. Their support networks might be changing as they're meeting new friends. It's important that they have continuity of care for their mental health whilst all those other changes are happening."
Whilst commissioning being done at a local level can lead to inconsistency in care across the country, it can also offer opportunities for innovation, explains Dobson.
"In Camden, they noticed they were having a particular issue with transitions between young people's mental health services and adult mental health services. Their local commissioners got together and developed a transitions team to address that and develop new policies," she says.
"One of them was called the 'No Bounce Rule' which means that if a young person is referred to your service then you have to ensure that either you provide some form of treatment to them, or one of the partner organisations does, to prevent that young person slipping through the gap."
Whilst care isn't always consistent across the board, there are NICE guidelines which set out the steps to be taken to ensure quality care for young people transitioning from child to adult services.
"The first is having a named worker to coordinate and particularly to help with planning for the transition. There should be a transition plan in place for young people at least six months before they are due to transition," says Dobson.
Key to this is an assessment to decide whether a young person still needs NHS mental health services or if support can be provided elsewhere in the community.
Part of good mental health care is continuous, informed support, Dobson explains. "There should be support provided throughout, before, during and after transition. Typically, that support should be meeting with the adult service they're going to transition to, ensuring that the young person is communicated with at every stage of the process and trying to improve the experience for them."
Transition is also about preparing a young person for the structural and cultural differences between CAMHS and adult services. "CAMHS and adult services are generally seen to have different cultures or different ways of doing things," says Dobson.
"It might include things like family involvement. For some young people in CAMHS, their parents are involved, maybe in arranging appointments or in sessions themselves. When they transition to adult services it's seen as their responsibility which can be quite challenging for young people."
When someone ages out of CAMHS but doesn't meet the requirements for adult support, there should be other services such as drop-in centres in place to help. Community support can also be used as a preventative tool to avoid young people requiring mental health support in the first place.
"The main motivation is to stop that young person's needs from escalating to the point where they do need to get help from CAMHS. There have been a few areas that have been developing early support to account for that," says Dobson.
The Children's Society are one of the organisations providing this community support for young people. "These hubs offer support to young people up until the age of 25 and provide a space where they can get the support they need, without an appointment, at a time that is right for them," says Rainer. "Support does vary in each area, though, and often young people have difficulty in finding out about alternative support."
The NHS Long Term Plan lays out a vision for CAMHS which would bring an end to some of the distress caused by disjointed services. This includes a plan to make CAMHS services available from birth to the age of 25 across England.
"What's really crucial for us is that the implementation of the Long Term Plan is developed with young people so that as they go through that transition, their needs are being met and they feel supported with their mental health," says Dobson.
A shift in the way that data is collected, processed and shared in mental health services would go a long way in improving care for young people, she suggests. "It would be beneficial to have much more robust data collection around the number of young people transitioning and the outcome because not all young people that need to transition end up receiving care from adult services. There isn't data routinely collected about their experiences."
As well as wider collection of information about young people, their individual experiences and cases could be more easily shared between services and clinicians through the medium of a mental health passport.
"It's a document, either physical or digital, young people can use to track their treatment and how they're feeling," says Dobson.
"It allows them to keep a record of the support they've received. Young people have told us that where they transition and they have different clinicians, they have to keep retelling the story. That can actually be quite damaging to them, particularly if they've experienced adversity or trauma. By having the mental health passport, they have ownership of their story but can show it to the clinician without having to relive the experience."