3.2 Transitions #2 - Australian ADHD Clinical Practice Guideline

3. Treatment and Support

3.2 Transitions

Clinical Questions

For which people with ADHD should a transition to further services take place (preschool to school, primary to secondary school, school to adulthood, older adults)?

Clinical practice gaps, uncertainties and need for guidance

ADHD is a lifelong condition and treatment and support needs may vary over one’s life. Well-managed transitions between services at key developmental stages throughout the lifespan of people with ADHD are important to ensure continuity of care but are absent in many services (Ford, 2020; Paul et al., 2013). Many individuals drop out of services at these transition points, particularly during adolescence and early adulthood (Montano & Young, 2012), resulting in increased anxieties for people with ADHD and their families during this period (Shanahan, Ollis, Balla, Patel, & Long, 2020).

Poor transition contributes to long-term negative health and social outcomes for people with ADHD (Appleton, Elahi, Tuomainen, Canaway, & Singh, 2021; Young, Asherson, et al., 2021) and potentially death (Dalsgaard, Østergaard, Leckman, Mortensen, & Pedersen, 2015) if left untreated.

Even when paediatric (or child and adolescent mental health) services recognise the need to refer people to other services, there are barriers that may prevent effective transfer of care (Marcer, Finlay, & Baverstock, 2008). These barriers include inadequate ADHD education in primary care (Montano & Young, 2012), lack of expert services to which adults with ADHD can be referred (Coghill, 2017; Hall et al., 2013), lack of planning, differences in service delivery models between adult and mental health services (Ford, 2020), gaps in communication between child and adult services (Hall et al., 2013), and perceived unhelpful attitudes of some healthcare professionals experienced by people with ADHD (Matheson et al., 2013; Tatlow-Golden, Prihodova, Gavin, Cullen, & McNicholas, 2016). There is a strong need to ensure clear guidance on clinical transitions for people with ADHD, to prevent these negative outcomes and overcome the identified transition barriers.

Summary of narrative review

Transition here refers to the transfer of care of a person with ADHD from one service to another. It includes a referral from the existing service, transfer of appropriate information, and acceptance by the accepting agency, with subsequent care and responsibility for future transfers. Disruption in care or discontinuation of care can occur due to the barriers listed above. Transitions are particularly important for people in high-risk groups.

For example, those with severe symptoms or co-occurring symptoms require early identification to allow sufficient planning. The major transition is between child and adult services, but transitions between one service and another must also be supported. Comprehensive information exchange is key to the continuity of care.

From the time of diagnosis onward, future transition points should be anticipated and comprehensively planned. Transition should be a shared responsibility among treating clinicians. All are responsible both for initiating discussion and engaging in planning.

The process should be managed through collaboration between referring and receiving services (for example, paediatric and adult specialists), and should involve primary care and people with ADHD and their families. Individualised transition plans help guide the planning of transition support and transfer of care arrangements. These plans should also identify risk factors and management strategies, especially for higher-risk populations.

Identifying a transition lead or leads would help people with ADHD and their families coordinate this complex process, and this practice can bring key stakeholders together to enable optimal transition and handover. The lead role may be fulfilled by a paediatrician, general practitioner, psychiatrist, psychologist, allied health professional, or a dedicated transition lead.

Adolescents transitioning to adulthood and to adult services need education, support and preparation before and during the process. These should be provided in tandem with education and support for parents and carers who have a key role in enabling a successful transition as advocates, navigators and care coordinators.

Recommendations

Clinical considerations for implementation of the recommendations

The feasibility of implementing optimal transition practices may depend on a range of factors, including geographic location, existing linkages to relevant supports in the community, availability of and access to appropriate services, and availability of dedicated time, resources and personnel. Due to a lack of public adult ADHD services, most adults with ADHD receive care in the private sector, resulting in significant cost to themselves.

The absence of an identified transition lead during key points of transition may lead to disjointed care, anxiety and stress for people with ADHD and their families, and gaps in care, all of which can result in poorer health outcomes. Whilst transition leads are often available in paediatric services, this may not be the case in adult settings. Transition lead roles should be included in economic evaluations assessing cost benefits of effective transition between services for those with ADHD.

See Technical Report, section 10.9 for further details