Transition from Child and Adolescent to Adult Mental Health Services: Analysis and Comparison of International Models

Research area: Psychological & psychiatric interventions

Duration: February 2025 - September 2025
Language: English (with German summary)

 

 

Background:
The transition from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS) is a critical period. However, the transition period remains fragmented, often leading to discontinuities in care through inadequate coordination and barriers to access [1]. Studies show that up to 45% of CAMHS patients require further care in adulthood [2], yet approximately half experience discontinuity in services, and only a small proportion experience an optimal transition [3-5].

Despite international efforts such as the MILESTONE project, which identified key components for successful transitions - including early planning, collaboration, service integration, and continuity of care [3]- implementation remains inconsistent. The MILESTONE survey of 28 countries found that in 2018, only two countries, Denmark and the UK, had national or regional transition guidelines, highlighting widespread policy and structural gaps in transitional psychiatry [1].

Existing research confirms these challenges in Austria: 98.8% of professionals rate the system as inadequate, and only 16.3% report having structured transition protocols at their workplace [2]. In addition, 70.9% feel that it is not easy for patients to cope with the transition [2]. Experts emphasise the importance of integrated care approaches, improved communication between CAMHS and AMHS, adequate resource allocation or generation and statutory guidelines [2, 6, 7]. Finally, a practitioner review published in 2024 highlights that there is still much to learn about making service transitions as effective and efficient as possible, with only preliminary evidence regarding the cost-effectiveness of transition protocols [8].

Project aim and research question:
The aim of this project is to systematically analyse and compare international strategies and models addressing transitional psychiatry for differences and similarities in structural processes, characteristics, implementation strategies, and resource allocation, as well as to identify factors that promote and hinder successful implementation. Based on this analysis, the project aims to derive recommendations for the implementation, evaluation and further development of transitional psychiatry in Austria.

The aim of this study is not to develop a detailed implementation plan or carry out an impact analysis for specific interventions or a budget-impact analysis. Instead, the study will focus on structural comparisons and provide a knowledge base for decision-making.

• Q1: What international and cross-national strategies and models of transitional psychiatry exist, and what are their similarities and differences?
• Q2: What are the particular challenges and considerations for transitioning young adults with specific mental health conditions?
• Q3: How does Austria’s current approach to transitional psychiatry compare with international models? What recommendations can be derived to harmonise Austria’s transitional psychiatry with these models and strategies?

Methods:
The following methods are used to answer the research questions:

• Q1: Country and cross-national organisations selection; structured hand search for international transitional psychiatric care models/strategies; adapted version of the AGREE II (Appraisal of Guidelines for Research & Evaluation) framework to assess the quality of the included reports; identification of experts (policymakers / healthcare professionals / researchers) through purposive sampling; expert consultations (oral or written) for further insights through (semi)-structured questionnaires; structured data extraction on key information (including basic model information, scope and target population, service integration and coordination, treatment approach, workforce and training requirements, implementation and governance, cost and resource allocation, and evaluation); thematic content analysis based on extracted data to identify patterns and gaps; narrative synthesis and data visualisation based on the identified themes
• Q2: Mental health condition selection; structured hand search for indication-specific models in the selected countries; expert identification and consultations (oral or written) for further insights through (semi)-structured questionnaires; data extraction on key information (including indication-specific transition challenges and considerations, existing policies, specialised transition services, gaps & limitations); thematic synthesis
• Q3: Needs assessment; structured hand search for overview of current care situation in Austria; expert identification and consultations (oral or written) for further insights through (semi)-structured questionnaires; data extraction; contextual comparative analysis (synthesised Q1 results) for structured policy mapping analysis (to define key policy dimensions and identify specific gaps); comparative table presentation; derivation of recommendations for every identified category to improve continuity of care and ensure sustainable personnel resources and qualifications, considering enabling and constraining factors and contextual conditions; structured framework to categorise recommendations; visualisation

Databases for Search Strategy (RQ 1-3): Google/Google Scholar, WHO MiNDbank, Europe's Encyclopedia of National Youth Policies, national websites of ministries of health, public health and guideline institutions, TRIP Database, Guidelines International Network, website resources of cross-national organisations

Inclusion criteria for country selection (Q1):

Criteria	Inclusion Criteria	Exclusion Criteria
1. Similar Healthcare System	Bismarck-based health systems with existing guidelines for transitional psychiatry	Countries with highly centralised or heterogeneous health systems (unless adopted a psychiatric transition policy at early stage (see criteria 2))
2. Established/Early Implemented Guidelines for Transitional Psychiatry	Countries with firmly established/early adopted national strategies/models on transitional psychiatry according to MILESTONE [1] or WHO report [9]	Countries without structured policies or transition frameworks
3. Research and Documentation	Countries with accessible data, published reports	Countries with limited or unavailable policy documentation
4. Population Size	Countries with a population over 5 million	Countries with a population under 5 million
5. Geography	European countries	Non-European countries unless they provide robust policy insights and were early adopting countries (e.g., Australia)
6. Human Development Index	Countries with an HDI equal to or higher than Austria’s (larger/smaller 0.926, 2022 [10])	Countries with an HDI below 0.926

The following countries are used for analysis: Australia, Belgium, Denmark, Germany, Netherlands, Switzerland and the United Kingdom.

The selected countries represent best practice models in transitional psychiatry due to their high Human Development Index (HDI), which ensures comparability of health system capacity, workforce availability, and overall socio-economic conditions, and their structural similarity to Austria's Bismarckian health system, which ensures policy relevance or their early introduction of structured strategies in transitional psychiatry, which provide long-standing, well-documented examples of transitional care. This selection ensures that the study results are applicable, implementable and informative for policy development in Austria.

Furthermore, as cross-national organisations, we included WHO, UNICEF and OECD because of their central role in shaping global (youth) mental health policies.

Inclusion criteria for the Selection of Mental Health Conditions (RQ2):

1. High Dropout Rates or Low Referral to AMHS, as reported by Reneses et al. [4] and/or Singh et al. [3, 11]
2. High Burden of Disease or Prevalence in Adolescents (15-19), according to the Global Burden of Disease Study (GBD) [12]
3. Emerging/Occurring Diseases during late adolescence Age, based on data from the Global Burden of Disease Study [12]

We will limit RQ2 to conditions that meet at least two of the above criteria. Therefore, we will focus on Anxiety Disorder, Attention Deficit and Hyperactivity Disorder (ADHD), Conduct Disorder, Depressive Disorders, Eating Disorders and Substance Abuse Disorder.

Inclusion criteria for relevant transitional psychiatry models (Q1):

Criterion	Inclusion	Exclusion
1. Type of Model	National or transnational strategies/models for transitional psychiatry, published by government bodies, health organisations, or academic institutions	Regional strategies or models (if national models exist), informal or unofficial policies
2. Scope of Transition	Covers transition from child and adolescent mental health services to adult mental health services	Policies addressing transitions in other sectors (e.g., school-to-work) or policies limited to children or adults only
3. Publication Language	Policies available in English, German, or national languages (if no official translation exists, neural machine translation will be applied for key policy documents)	Policies published only in languages, where neural machine translation is not feasible for interpretation
4. Publication Period	No restriction – all historical and current policies are included if they are still applicable	Policies that are outdated or replaced, unless they provide relevance for transitional psychiatry development
5. Model Characteristics (Preliminary)	Models must describe relevant characteristics (e.g. age range, target groups, treatment approaches, professional roles, service coordination and responsabilites, and implementation)	Policies that fail to specify key characteristics

This study prioritises national models where they are available. However, in cases where national frameworks are absent or insufficient, regional models will be considered to prevent (data) gaps. Regional models will only be included if no national model in the selected countries is found and will be identified through an unstructured hand search. These models will be subjected to the same inclusion criteria as national models to ensure consistency in analysis.

Timetable/Milestones:

Period	Tasks
February – March 2025	Scoping and project setup; Hand search; Literature selection and acquisition; Document analysis;
April – May 2025	Document analysis; Planning and preparation of expert consultations (identification of participants, development of interview guide); Expert consultations; Data extraction;
June – July 2025	Expert consultations; Thematic and comparative analysis of international models (RQ1 & RQ2); Structured analysis of policy mapping and derivation of recommendations (RQ3); Draft report;
August – October 2025	Analysis of results/development of policy recommendations (Q3); Visualisations, internal and external review; Revision; Finalisation;

References:
[1]  Signorini G., Singh S. P., Marsanic V. B., Dieleman G., Dodig-Curkovic K., Franic T., et al. The interface between child/adolescent and adult mental health services: results from a European 28-country survey. European Child & Adolescent Psychiatry. 2018;27(4):501-511. Epub 20180124. DOI: 10.1007/s00787-018-1112-5.
[2]  Pollak E., Kapusta N. D., Diehm R., Plener P. L. and Skala K. Transitional and Adolescent Psychiatry in Austria: A Pilot Study on the Attitudes of Experts. Kinder- und Jugendpsychiatrie und Psychotherapie. 2018;46(4):325-335. Epub 20171204. Transitions- und Adoleszenzpsychiatrie in Osterreich: Eine Pilotuntersuchung zur Sicht von Expert(innen). DOI: 10.1024/1422-4917/a000559.
[3]   Singh S. P., Paul M., Ford T., Kramer T., Weaver T., McLaren S., et al. Process, outcome and experience of transition from child to adult mental healthcare: multiperspective study. The British Journal of Psychiatry. 2010;197(4):305-312. DOI: 10.1192/bjp.bp.109.075135.
[4]  Reneses B., Escudero A., Tur N., Aguera-Ortiz L., Moreno D. M., Saiz-Ruiz J., et al. The black hole of the transition process: dropout of care before transition age in adolescents. European Child & Adolescent Psychiatry. 2023;32:1285-1295. Epub 20220120. DOI: 10.1007/s00787-021-01939-8.
[5]  Paul M., Ford T., Kramer T., Islam Z., Harley K. and Singh S. P. Transfers and transitions between child and adult mental health services. The British Journal of Psychiatry. 2013;54:s36-40. DOI: 10.1192/bjp.bp.112.119198.
[6]  Trabi T., Purtscher-Penz K. and Plener P. The transition of psychiatric ill adolescents from child and adolescent psychiatric care to adult psychiatric care. neuropsychiatrie. 2023;37(1):26-32. Epub 20221121. Versorgung psychisch kranker Jugendlicher im Prozess der Transition vom Jugend- ins Erwachsenenalter. DOI: 10.1007/s40211-022-00441-0.
[7]   Neumann M., Dürr A., Gonzalez-Martin A., Urban M., Manoharan N., Surikova V., et al. Mind the gap – Forderungen für eine verbesserte transitionspsychiatrische Versorgung aus Expert:innenperspektive. psychopraxis neuropraxis. 2024;27(4):245-250. DOI: 10.1007/s00739-024-01017-z.
[8]   Adamo N., Singh S. P., Bolte S., Coghill D., Newcorn J. H., Parlatini V., et al. Practitioner Review: Continuity of mental health care from childhood to adulthood for youths with ADHD - who, how and when? The Journal of Child Psychology and Psychiatry. 2024;65(11):1526-1537. Epub 20240716. DOI: 10.1111/jcpp.14036.
[9]  World Health Organization [WHO]. World mental health report: transforming mental health for all. Geneva: World Health Organization, 2022  [cited 10.02.2025]. Available from: https://iris.who.int/bitstream/handle/10665/356119/9789240049338-eng.pdf?sequence=1.
[10]  United Nations Development Programme [UNDP]. Human Development Index (HDI). 2022.
[11]  Singh S. P., Paul M., Ford T., Kramer T. and Weaver T. Transitions of care from Child and Adolescent Mental Health Services to Adult Mental Health Services (TRACK Study): a study of protocols in Greater London. BMC Health Services Research. 2008;8:135. Epub 20080623. DOI: 10.1186/1472-6963-8-135.
[12]  Kieling C., Buchweitz C., Caye A., Silvani J., Ameis S. H., Brunoni A. R., et al. Worldwide Prevalence and Disability From Mental Disorders Across Childhood and Adolescence: Evidence From the Global Burden of Disease Study. JAMA Psychiatry. 2024;81(4):347-356. DOI: 10.1001/jamapsychiatry.2023.5051.