Youth Experiences of Transition from Child Mental Health Services to Adult Mental Health Services: A Qualitative Thematic Synthesis

R E S E A R C H A R T I C L E Open Access
Youth experiences of transition from child
mental health services to adult mental
health services: a qualitative thematic
synthesis
Kathleen L. Broad 1 , Vijay K. Sandhu 2
, Nadiya Sunderji 3,4,5* and Alice Charach 6,7
Abstract
Background: Adolescence and young adulthood is a vulnerable time during which young people experience many
development milestones, as well as an increased incidence of mental illness. During this time, youth also transition
between Child and Adolescent Mental Health Services (CAMHS) to Adult Mental Health Services (AMHS). This transition
puts many youth at risk of disengagement from service use; however, our understanding of this transition from
the perspective of youth is limited. This systematic review aims to provide a more comprehensive understanding
of youth experiences of transition from CAMHS to AMHS, through a qualitative thematic synthesis of the extant
literature in this area.
Method: Published and unpublished literature was searched using keywords targeting three subject areas: Transition,
Age and Mental Health. Studies were included if they qualitatively explored the perceptions and experiences of youth
who received mental health services in both CAMHS and AMHS. There were no limitations on diagnosis or age of
youth. Studies examining youth with chronic physical health conditions were excluded.
Results: Eighteen studies, representing 14 datasets and the experiences of 253 unique service-users were included.
Youth experiences of moving from CAMHS and AMHS are influenced by concurrent life transitions and their individual
preferences regarding autonomy and independence. Youth identified preparation, flexible transition timing,
individualized transition plans, and informational continuity as positive factors during transition. Youth also valued
joint working and relational continuity between CAMHS and AMHS.
Conclusions: Youth experience a dramatic culture shift between CAMHS and AMHS, which can be mitigated by
individualized and flexible approaches to transition. Youth have valuable perspectives to guide the intelligent
design of mental health services and their perspectives should be used to inform tools to evaluate and incorporate
youth perspectives into transitional service improvement.
Trial registration: Clinical Trial or Systematic Review Registry: PROSPERO International Prospective Register of
Systematic Reviews CRD42014013799.
Keywords: Transition to adult care, Transitional programs, Health transition, Continuum of care, Adolescent, Young
adult, Child adolescent psychiatry, Adolescent health services, Mental disorders, Mental health services
* Correspondence: [e-mail]
3
Mental Health and Addictions Service, St. Michael’s Hospital, Toronto, ON,
Canada
4
Li Ka Shing Knowledge Institute, Toronto, ON, Canada
Full list of author information is available at the end of the article
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Broad et al. BMC Psychiatry (2017) 17:380
DOI 10.1186/s12888-017-1538-1

Background
At least 75% of mental health problems and illness have
onset in childhood, adolescence, or young adulthood [1].
However, this increased incidence of mental health condi-
tions in youth corresponds to a weak point in mental
health care provision [2]. The transition from Child and
Adolescent Mental Health Services (CAMHS) to Adult
Mental Health Services (AMHS) typically occurs between
18 and 21 years according to traditional age boundaries of
service provision organizations, a period that overlaps im-
portant development milestones for emerging adults [3].
This is a vulnerable period [4] during which service users
may disengage from utilizing mental health services at
higher rates than other age cohorts [5, 6].
Many factors may contribute to youth disengagement,
including disease-specific ambivalence or denial [7, 8]
and the potential for mental illness and/or addictions to
interfere with functioning and with acceptance of formal
supports [9, 10]. It has also been postulated that differ-
ences between CAMHS and AMHS services may
contribute to high disengagement rates [11]. However,
overall factors contributing to disengagement, especially
from the perspective of youth remain poorly understood.
Even when youth do receive care in AMHS, only 23%
report finding the service helpful [12]. Gaps and subopti-
mal care during this vulnerable time have the potential
for lasting functional impairment and development
derailment [13, 14]. Age-specific outpatient programs
have been shown to increase mental health service
utilization, compared to standard adult outpatient pro-
grams [15]; however, they lack consistent evidence of
effectiveness [16]. Given the vulnerability of this period
and the unique needs of transition-aged youth, it is cru-
cial to further understand youth experiences during the
transition from CAMHS to AMHS.
Previous systematic reviews have shown that young
people transitioning to adult health services experience
concern over a loss of familiar surroundings and relation-
ships [17] and want providers to be sensitive to their di-
verse needs [18]. Personal accounts from youth [19] and
stakeholders [20, 21] have emphasized the need to directly
involve young adults in the development of mental health
services. Existing literature reviews of service transitions
for youth with mental health concerns have identified gaps
in the provision of transitional care [22], however, few of
the included studies examined the experiences and
perspectives of youth [23–25]. Thus, the youth voice in
mental health planning and service delivery is under-
represented, and their subjective experiences of transition-
ing from CMHS to AMHS are insufficiently understood.
Our primary aim is to understand and describe the sub-
jective experiences of young people with mental health
problems as they transition from the child and adolescent
services to adult mental health services. This information
will be helpful in planning services to address the needs of
youth transitioning between service systems.
Methods
In this systematic review, we examined youth experi-
ences as they transition from CAMHS to AMHS. The
scope was international, and focused on qualitative
material because qualitative studies enable rich and
open-ended exploration of subjective experiences. Such
reviews have the advantage of providing a greater
breadth and depth of understanding by accessing a lar-
ger number and diversity of service users accounts and a
greater range of methodologies to elicit and analyze
these accounts [26]. This review was designed as a the-
matic synthesis [27], a method that adapts approaches
from both meta-ethnography and grounded theory and
has been used in several systematic reviews examining
people’s perspectives [26, 28]. Thematic synthesis allows
our analysis to “stay close” to the expressed views of
youth in the primary studies and retain particularities,
while also allowing development of higher level themes
occurring across multiple study populations to offer
both cumulative and novel interpretations of the find-
ings from primary studies as a whole [27]. Thus, by being
interpretative and not merely aggregative, this type of syn-
thesis can reduce uncertainty (e.g. in the case of recurrent
themes across studies) and also enhance complexity (e.g.
by highlighting differences and discrepancies) [29].
This review followed the “Enhancing Transparency in
Reporting the Synthesis of Qualitative Research”
(ENTREQ) guidelines [29] (See Additional file 1 for
ENTREQ checklist) and consisted of (1) a systematic lit-
erature search for relevant qualitative and mixed methods
research reports; (2) critical appraisal of included reports;
and (3) inductive and iterative analysis of included reports.
The protocol for this thematic synthesis was published a
priori with PROSPERO International prospective register
of systematic reviews (available online at http://
www.crd.york.ac.uk/prospero/display_record.asp?ID=CRD
42014013799; registration number CRD42014013799).
Search strategy
We searched both published and unpublished (“grey”)
literature. We identified published articles through sys-
tematic searches of the following electronic databases
for academic journals from inception to October 2014:
MEDLINE, EMBASE, PsycINFO, CINAHL, Social
Services Abstracts, Applied Social Sciences Indexes and
Abstracts (ASSIA); and of the following evidence-based
medicine databases: The Cochrane database of system-
atic reviews, EBM Reviews, The Campbell Collaboration,
and Centre for Reviews and Dissemination. A systematic
search strategy was developed with the assistance of a
Broad et al. BMC Psychiatry (2017) 17:380 Page 2 of 11

librarian, and peer-reviewed by a second librarian. Key-
words, their truncations and relevant database-specific
subject headings and MeSH terms were used, targeting
three subject areas: transition, age and mental health.
For an example search strategy see Additional file 2.
We identified additional published literature through
searches of reference lists of relevant articles (using
Science Citation Index and hand searching) and forward
citations of relevant articles (using Science Citation
Index or Google Scholar). We identified unpublished lit-
erature through Google searches with the same key-
words, and by contacting experts and key authors
identified in the search of published literature.
Inclusion and exclusion criteria
We included studies published in English that used a
qualitative methodology to (1) Describe the perceptions
and experiences of youth utilizing mental health services
and (2) Explore their experiences of receiving services or
care: (a) During the transition from CAMHS to AMHS
setting or (b) In both the CAMHS and AMHS settings.
We included all studies examining young adults who
have utilized mental health services, with no limitations
on diagnosis, age, ethnicity or geographic locale. We ex-
cluded studies examining youth with exclusively chronic
physical health conditions because young people utiliz-
ing mental health services have been much less studied
and may experience unique challenges compared to
young people with primarily physical disabilities [30].
All titles and abstracts were reviewed independently
by two research team members (KB and VS) using
DistillerSR, to organize the search, screen titles, and ab-
stracts and extract data. Any differences were resolved
by consensus amongst the two team members (KB and
VS), and, if necessary, a third team member (NS). Inter--
rater agreement for inclusion of studies was assessed
using the chance-corrected Kappa statistic. Agreement
for inclusion at the full text level ranged from Kappa
scores of 86% to 95%.
Quality assessment
We critically appraised all studies in duplicate (KB and
VS) using the Critical Appraisal Skills Programme
(CASP) Tool, which provides key criteria relevant to
critically appraising qualitative research studies (e.g.
appropriateness of research design, consideration of eth-
ical issues, rigour of data analysis) [31]. Any differences
were resolved by consensus amongst the two team
members. All studies were included in final analysis.
Data analysis
We conducted an initial content analysis of individual
studies, followed by a thematic synthesis across all
studies [27], focusing only on content representing the
views of youth (typically, sections labelled “findings” or
“results”).
Three of the authors (KB, VS and NS) independently
read the text of three included studies and generated
“codes”, and then met over multiple sessions to develop
a consensus of codes and their meanings (i.e. a coding
dictionary). We then continued to analyze three more
studies independently, meeting regularly to triangulate
perspectives and revise the coding dictionary by adding,
merging, deleting, or modifying codes. Once the codes
were not changing, the remainder of the included stud-
ies were coded by the first author (KB). KB then led the
thematic analysis identifying over-arching themes emer-
ging from the results of the studies as a whole and com-
paring and contrasting findings across studies and
populations.
Results
Description of included studies
We identified a total of 3273 abstracts, primarily
through electronic databases with six articles identified
through the other search strategies (see Fig. 1 for
PRISMA diagram) [32]. Eighteen (18) articles, represent-
ing fourteen datasets met the inclusion criteria (see
Table 1). Three articles reported findings from the
TRACK Study: Singh [33], Singh et al. [6] and Hovish et
al. [24] Two other article pairs also reported findings
from the same datasets: (1) Munson et al. [34] and
Munson et al. [35]; and (2) Lindgren et al. [36] and
Lindgren [37]. Accounting for multiple reporting of
datasets, across the 18 included articles, the experiences
of 253 unique service-users were reported. Studies origi-
nated from the United Kingdom, United States, and
Sweden. The age of participants ranged from 16 to
27 years old, and represented both young men and
women, experiencing a range of diagnoses.
Quality assessment
Using the CASP tool, we identified issues with quality of
included studies (see Table 1 for CASP scores). Overall,
many articles scored lower in the areas of methodology.
Lower scoring articles were mainly from the grey litera-
ture [38–40] or conference abstracts [33, 41] and had
limited description of methodology. In other low scoring
articles, sampling and recruitment methods typically re-
lied on convenience sampling [23, 34, 35, 39, 42], limited
participation to those selected by their service providers
[24, 36, 38, 43–45], and/or did not consider the relation-
ship between researchers and participants [6, 23, 24, 33,
36–39, 41, 43, 44, 46, 47].
Other limitations were also identified. Four studies did
not operationalize the boundaries of transition from
Broad et al. BMC Psychiatry (2017) 17:380 Page 3 of 11

CAMHS to AMHS and the timing of interviews with
youth was often unclear [23, 38, 41, 42], making it un-
clear how much exposure youth had to AMHS. Further-
more, in studies that also examined parent, caregiver or
professional views, three studies linked parental and
youth views together in the discussion of themes [6, 24,
44]. To keep this thematic analysis in line with views of
youth, only findings indicated as originating from youth
were used in analysis.
Thematic foci
Three thematic foci emerged from the thematic synthe-
sis: (1) Complex Interplay of Multiple Concurrent
Transitions (2) Balancing Autonomy and the Need for
Supports and (3) Factors Impacting Youth Experiences
of Transition.
Complex interplay of multiple concurrent transitions
On the path to becoming an adult, young people experi-
ence multiple transitions in a variety of domains in
addition to the transition from CAMHS to AMHS, such
as change in level of parental involvement, life events,
and community agency involvement. For some youth,
these transitions were a major obstacle for continued
mental health service use, such as described by a youth
interviewed by Sakai et al.:
“I didn’t even get no Medicaid when I left foster care. I
had it but, it was never mailed to me. I didn’t even have
an address.” [43], p6.
In contrast, for some, life transitions, such as becom-
ing a parent, were a way for young people to become re-
engaged in mental health services as described in
Munson et al. [35]:
“...and shortly after she was born I had talked to the
doctor about postpartum depression... I’m like ‘...I don’t
want to get out of bed... I don’t want to do nothing’... He
was like ‘Well you could be having postpartum depres-
sion,’ and that’s when all of my childhood mental prob-
lems came up, because he had accessed my information
from my old doctor... he’s like ‘Well you know you need
to be on this medication...’” [pg 3].
As youth prepared to undergo major life transitions,
some voiced worries about the overlap of these
changes with their mental health care transition. The
interplay of these transitions made some feel more
vulnerable, especially as they sensed the impact of
diminishing supports:
“I turn 18 in like 2 weeks, and I want to move out and
live on my own, but it is going to be hard for me because
once I turn 18, the supports that I have, some of them
are going to disappear.. .. I am going to have to be able
to deal with my issues on my own and find other sup-
ports.” [23, p 11].
Fig. 1 PRISMA diagram
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