Childhood and adolescent mental health problems must be considered in terms of their long-term comorbidities, as they may operate as independent risk factors for adverse occurrences in adult life. Reference Broad1 Adolescents and young adults aged 16–24 years with chronic mental disorders experience development and maturation at different rates. However, the legal transition to adulthood occurs abruptly, potentially leading to negative outcomes. Recognising and addressing this transitional phase from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS) is essential to improve the quality of care provided to young individuals with psychiatric disorders as they move into adulthood. In this context, two key terms arise: transfer, which refers to the formal handover of care from CAMHS to AMHS as a discrete event; and transition, which describes a broader, more comprehensive process involving preparation, joint care, planning meetings and transfer of case notes to ensure continuity of care in AMHS. Reference Paul, Ford, Kramer, Islam, Harley and Singh2
Transfer process in Türkiye
In Türkiye, AMHS start accepting referrals when individuals are more than 18 years old, whereas CAMHS see those between 0 and 18 years old and can follow up a patient up to the age of 21 years. However, after the age of 18, CAMHS cannot issue official reports or complete most disability report procedures. CAMHS operate across various institutions, including university hospitals, training and research hospitals, public hospitals and private clinics. CAMHS provide follow-up care for patients with neurodevelopmental disorders (NDDs), regardless of the severity of their condition. All individuals with NDDs can be accepted by and receive care from AMHS if they are referred by CAHMS or if this is preferred by their parents. Although university hospitals may offer more consistent follow-up with the same doctor, as well as longer consultations and better engagement with families, public hospitals often provide quicker access to appointments owing to shorter waiting times. However, no single institution fully embodies the ideal transition process.
Challenges in transfer and/or transition from CAMHS to AMHS
For young individuals turning 18 while receiving treatment from CAMHS, the abrupt switch to AMHS may create a service gap. Research has shown significant differences between CAMHS and AMHS that can complicate the transition process. Whereas AMHS places greater emphasis on individual treatment and personal privacy, CAMHS frequently emphasises family support and involvement. Reference Mulvale, Nguyen, Miatello, Embrett, Wakefield and Randall3 Furthermore, communication difficulties and mistrust between the two departments lead to a lack of collaboration. Reference McLaren, Belling, Paul, Ford, Kramer and Weaver4 Moreover, the limited experience of AMHS in managing NDDs, which are predominantly diagnosed in childhood, Reference Swift, Sayal and Hollis5,Reference Young, Asherson, Lloyd, Absoud, Arif and Colley6 may result in inadequate treatment. Financial, organisational and procedural barriers have also been identified that pose a risk to continuity of care during the transition. Reference Anderson, Newlove-Delgado and Ford7
Factors influencing successful transfer and/or transition
A systematic review identified and compared different models of care for transition. The important factors found to positively influence the transition process were as follows: positive relationships with clinicians and the attributes of clinicians (determination, flexibility, instilling hope, providing support and reassurance, non-judgemental attitude and being a good listener), preparation (early provision of information about the transition) and involvement of the adolescent in the decision-making process. Reference Mulvale, Nguyen, Miatello, Embrett, Wakefield and Randall3 Factors including individualised planning, gradual transition, flexibility regarding the timing of transition, and ability to maintain continuity at the system level have been demonstrated to have a positive impact during the transition phase. After the transition phase, important factors include support by the healthcare team, autonomy and decisions regarding the extent to which families should be involved in treatment, and information exchange between the child and adult departments. Reference Hovish, Weaver, Islam, Paul and Singh8–Reference Lockertsen, Nilsen, Holm, Rø, Burger and Røssberg10
Transfer and/or transition process for patients with NDDs
NDDs are a major part of CAMHS and were introduced as a new category in the DSM-5. 11 In the ICD-11, NDDs gained even more prominence, becoming an integral part of the title of the chapter on psychiatry: ‘Mental, behavioral or neurodevelopmental disorders.’ 12 NDDs are defined as a group of conditions with onset in the early developmental period. Considering the significant impact of persisting symptoms of NDDs on adult life, it is crucial that young patients with NDDs can access care from mental health services as they become adults. Unfortunately, the likelihood of adolescents with attention-deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) transitioning to adult services has been shown to be lower compared with those without these disorders, and the additional transition needs of youth with NDDs has not been well established. Reference McNicholas, Tatlow-Golden, Gavin and Singh13,Reference Islam, Ford, Kramer, Paul, Parsons and Harley14 Recent studies have indicated that individuals with NDDs face significant challenges during the transition. For those with ADHD specifically, barriers include a lack of clear protocols, limited service availability, underrecognition and scepticism about ADHD as a chronic condition, as well as reluctance of adult clinicians to prescribe ADHD medications. Reference Price, Janssens, Woodley, Allwood and Ford15–Reference Adamo, Singh, Bölte, Coghill, Newcorn and Parlatini17 The CAMHS–AMHS gap disproportionately affects youth with ASD, who already struggle with social, emotional and relationship challenges. The absence of structured transition planning frequently forces emergency-based access to care, worsening long-term mental health outcomes in autistic individuals. Reference Merrick, King, McConachie, Parr and Le Couteur18
To the best of our knowledge, there has been no study investigating the transfer or transition process from CAMHS to AMHS in Türkiye. Therefore, our aim was to determine the transfer rate of patients diagnosed with NDDs from CAMHS to AMHS in a university hospital setting and to identify the barriers and challenges encountered during the transfer process and the factors that may facilitate it. We believe that our work will contribute to enhanced communication between CAMHS and AMHS clinics, improve the quality of healthcare in both service types, and provide important insights for future research, especially in settings with diverse institutional structures.
Method
Participants
The steps taken to form the study group are summarised in Fig. 1. Hacettepe University CAMHS hospital records between the years of 2008 and 2012 were screened to identify children aged between 6 and 10 years old who were followed up for NDDs. Diagnoses were defined according to the ICD-10 classification as follows: intellectual disabilities (F70, F71, F72 and F73), specific developmental disorders of speech and language (F80), specific developmental disorders of scholastic skills (F81), specific developmental disorder of motor function (F82), pervasive developmental disorders (F84), ADHD (F90) and tic disorders (F95). 19 Each patient was diagnosed through a minimum of two clinical examinations conducted by at least one resident and a senior CAMHS specialist, following neuropsychological assessments by clinical psychologists.
Fig. 1 Flowchart illustrating study design.
Children identified via these records as having had at least one visit each year until 2017–2018 made up the study sample, on the basis that they had been diagnosed with NDDs in childhood and continued to be followed up for at least 5 years. Individuals were excluded if they had a primary diagnosis of a chronic disabling neurological condition that causes moderate to severe mental retardation (cerebral palsy, neurometabolic disorders, etc.). Medical records were accessed for 224 patients, of which 13 were excluded owing to incomplete CAMHS follow-up data. The research sample of 211 patients with complete records was divided into two main categories. The first study group comprised patients who were aged 18 years and older in 2018 and had been examined at Hacettepe University AMHS and scheduled for at least one follow-up appointment between 2018 and 2019; this group were considered to have been diagnosed with neurodevelopmental disorders in childhood and undergone continued follow-up for at least 5 years with a transfer to AMHS. The second study group included patients who were not admitted to Hacettepe University AMHS after 2018, that is, those who had been diagnosed with neurodevelopmental disorders in childhood and underwent continued follow-up for at least 5 years but did not transfer to AMHS. The first group, which consisted of 81 patients, was denoted the ‘transferred’ group, whereas the second group, formed by 130 patients, was denoted ‘non-transferred’.
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2013. The study was approved by Hacettepe University Ethics Committee (approval number: GO 20/13, dated 12 February 2020).
Procedures
A standardised data extraction form was used to capture key variables, including ICD diagnosis codes, prescribed medications, number of follow-up visits, additional medical diagnoses and appointments with other departments. Each patient’s electronic records were then systematically reviewed. Data extraction was conducted by M.K.D. and Y.K.A. with support from the IT department.
Clinical features of the whole study sample (n = 211) were extracted from CAMHS files and compared between the transferred and the non-transferred groups. Additional comparisons were made between the ADHD and ASD groups in further analyses.
To obtain parental views about the transfer process, a telephone survey questionnaire form was prepared by the research team in alignment with the research objectives and the relevant literature (Supplementary Material 1 available at https://doi.org/10.1192/bjo.2025.59). Telephone interviews were conducted with one of the parents of each patient. The recruitment process included all individuals whose telephone numbers were recorded in the hospital system. Cases in which telephone numbers were inactive or calls went unanswered were excluded. After patients’ verbal consent had been obtained and formally recorded, a survey questionnaire was administered. Through the questionnaire, the experiences of all patients regarding the transfer process were explored, and patients who had not made the transfer were asked whether they had continued their follow-up in an adult clinic of a different centre. Telephone interviews were concluded within a time frame ranging from 10 to 15 min. Telephone interviews were conducted with 31 parents from the transferred and 33 from the non-transferred group.
Statistical analysis
SPSS software was used to compare the two groups. The normal distribution of variables was assessed using both visual methods (histograms and probability graphs) and analytical methods (Kolmogorov–Smirnov and Shapiro–Wilk tests). P < 0.05 was determined as the limit of significance. Pearson’s chi-squared test was used to examine categorical variables between the transferred and non-transferred groups. Within the transferred group, CAMHS and AMHS categorical data were compared using McNemar’s test. In cases where sample sizes were insufficient, Fisher’s exact test was employed for comparisons. Owing to the non-normal distribution of continuous variables such as age and follow-up years, Mann–Whitney U test was used for comparisons. The factors predicting the transfer to AMHS were assessed using logistic regression models.
Results
Clinical characteristics of the transferred and non-transferred groups
Our sample included a total of 211 patients, with 81 (38.4%) in the transferred group and 130 (61.6%) in the non-transferred group (Table 1). The mean age at first visit for the entire group was 7.7 years (7.3 years in the transferred group and 7.9 years in the non-transferred group). There were 55 female patients (26%) and 156 male patients (74%) (Supplementary Table 1). ADHD was the most prevalent primary diagnosis, affecting 155 individuals (73.5%) overall. The next most common diagnosis was ASD, which was present in 40 patients (19%), followed by intellectual disability in ten patients (4.7%). Regarding medical treatments, ADHD medications were administered to 132 patients (64.1%), antipsychotics to 72 (35%) and selective serotonin reuptake inhibitors to 43 (20.3%). A small proportion of patients (1.9%) received mood stabilisers. The prevalence of multiple psychiatric diagnoses was high, with 103 patients (48.8%) having more than one diagnosis. Intellectual disability, which was diagnosed in 40 patients (19%), was the most common comorbid condition, followed by specific developmental disorders of scholastic skills (20 patients, 9.5%) and anxiety disorders (19 patients, 9%). Other comorbidities included obsessive compulsive spectrum disorders (ten patients, 4.7%), oppositional defiant disorder (eight patients, 3.8%) and major depression (five patients, 2.4%). Regarding other chronic medical diagnoses, 47 patients (22.3%) had at least one, and 24 patients (11.3%) transferred from paediatric to adult services (Table 1).
Table 1 Comparison of clinical characteristics of the transferred and non-transferred groups according to CAMHS records
ADHD, attention-deficit hyperactivity disorder; ASD, autism spectrum disorder; SSRI, selective serotonin reuptake inhibitor; CAMHS, child and adolescent mental health services.
a. Methylphenidate and atomoxetine.
b. List of disorders according to ICD diagnosis and codes:
ADHD (F90); intellectual disabilities (F70–F79, categorised by severity); learning disorder (F81, specific developmental disorders of scholastic skills); phobic and other anxiety disorders (F40–F41); obsessive–compulsive disorder (F42) and trichotillomania (F63.3); oppositional defiant disorder (F91.3) ASD (F84, pervasive developmental disorders); borderline intellectual functioning (R41.83, measured full scale IQ 70–80); major depression (F32, depressive episode; F33, recurrent depressive disorder); substance misuse disorder (F10–F19, mental and behavioural disorders due to psychoactive substance use, categorised by substance type); tic disorders (F95, including Tourette syndrome); speech disorder (F80.0–F80.9, specific developmental disorders of speech and language); bipolar affective disorder (F31); psychotic disorder (F20–F29, schizophrenia, schizotypal and delusional disorders); encopresis (F98.1, nonorganic encopresis).
c. From paediatric neurology, cardiology, rheumatology, nephrology, gastroenterology, allergy/immunology, pulmonology or endocrinology/metabolism to adult neurology, cardiology, rheumatology, nephrology, gastroenterology, pulmonology or endocrinology.
d. Fisher’s exact test was used.
Significance levels of p < 0.05 are shown in bold.
The clinical characteristics of patients in CAHMS follow-up were compared between the transferred and non-transferred groups (Table 1). The transferred group consisted of 18 female (22.2%) and 63 male (77.8%) patients, and the non-transferred group consisted of 37 female (28.5%) and 93 male (71.5%) patients. There was no significant difference between the two groups with respect to gender (P = 0.315) or primary diagnosis (P = 0.095). However, individuals in the transferred group were significantly more likely to have one or more comorbidities (P < 0.001) and to have intellectual disability as a comorbidity (P < 0.001). There were no significant differences between the transferred and non-transferred groups for other comorbidities, although antipsychotic use in CAMHS was more common in the transferred group compared with the non-transferred group. (P = 0.006). The groups were similar regarding other chronic medical diagnoses (P = 0.920).
Differences between CAMHS and AMHS were examined in terms of the clinical characteristics of patients who were transferred (Table 2). The primary diagnosis of ADHD changed to other disorders after transfer from CAMHS to AMHS (P = 0.002). Two of the patients with ADHD were primarily diagnosed with major depression, six were diagnosed with intellectual disability and two were diagnosed with schizophrenia after transfer to AMHS. Although there was no statistically significant difference in primary diagnoses among ASD patients, five patients were primarily diagnosed with intellectual disabilities in AMHS; these had already been noted as comorbidities in CAMHS. Medication choices for the transferred group in childhood were also different in AMHS compared with CAMHS (P = 0.012), with methylphenidate and atomoxetine more often used in CAMHS. In addition, the comorbidity rate in the CAMHS period was higher than that in the AMHS period (P = 0.001). Regarding comorbidities, there were no patients with substance misuse in CAMHS; however, one patient was diagnosed with substance misuse disorder in AMHS. There were three patients with a diagnosis of brief psychotic disorder in CAMHS. After transfer, symptoms of two of these patients resolved; however, one patient met the diagnostic criteria for schizophrenia.
Table 2 Clinical characteristics of the transferred group
ADHD, attention-deficit hyperactivity disorder; ASD, autism spectrum disorder; SSRI, selective serotonin reuptake inhibitor; CAMHS, child and adolescent mental health services; AMHS, adult mental health services.
a. Comparison of ADHD versus ASD versus others yielded a significant difference: χ 2 = 12.36; P = 0.002 (McNemar’s test followed by Bonferroni correction, significance level was accepted at P < 0.017 for all three groups).
b. Methylphenidate and atomoxetine.
c. Fisher’s exact test was used, and significance levels of p < 0.05 are shown in bold.
CAMHS and AMHS follow-up durations and frequencies of visits were examined for all patients, as well as for the subgroups with ADHD and ASD diagnoses, along with age at transfer to AMHS and the transfer duration (Table 3). The mean ages at first diagnosis in CAMHS were 7.3 and 7.9 years for the transferred and non-transferred groups, respectively. The duration of follow-up in CAMHS was higher in the transferred group (P = 0.01). Age at referral did not differ between the transferred and non-transferred groups for any disorder. The mean age at referral to AMHS was 18.6 years. Comparison of follow-up numbers and rates did not show differences that reached the significance level for any disorder. The mean duration of transfer to AMHS was 7.9 months for ADHD patients and 8.4 months for ASD patients.
Table 3 Follow-up information for the sample
ADHD, attention-deficit hyperactivity disorder; ASD, autism spectrum disorder; CAMHS, child and adolescent mental health services; AMHS, adult mental health services.
Significance levels of p < 0.05 are shown in bold.
Comparison of clinical characteristics of the transferred and non-transferred groups in relation to ADHD and ASD diagnoses
In our comparison of clinical characteristics of the transferred and non-transferred groups extracted from CAMHS medical records (Table 4), patients who transferred to AMHS with a primary diagnosis of ADHD were prescribed significantly more antipsychotics than the non-transferred group (P = 0.010). There was a higher comorbidity rate for both ADHD and ASD in the transferred group (P = 0.001 and P = 0.049, respectively). Comorbidity of intellectual disability was significantly higher for the transferred group among ADHD patients (P < 0.001). When we did not consider transfer status, there was no difference between patients with ADHD and ASD regarding other chronic medical diagnoses (χ 2 = 2.4, P = 0.120). However, other chronic medical diagnoses were more common in patients with ASD compared with patients with ADHD in the transferred group (χ 2 = 7.4, P = 0.007). No such difference was found between ASD and ADHD patients in the non-transferred group (χ 2 = 0.9, P = 0.350). Among patients with ASD, this rate was higher for those who could transfer to AMHS (p = 0.016) compared with those who did not transfer, and some of these patients also could manage the transfer to the other adult departments related to their chronic physical diagnoses.
Table 4 Clinical characteristics of ADHD and ASD patients by transfer status
ADHD, attention-deficit hyperactivity disorder; ASD, autism spectrum disorder; SSRI, selective serotonin reuptake inhibitor.
a. Methylphenidate and atomoxetine.
b. Fisher’s exact test was used.
c. From paediatric neurology, cardiology, rheumatology, nephrology, gastroenterology, allergy/immunology, pulmonology or endocrinology/metabolism to adult neurology, cardiology, rheumatology, nephrology, gastroenterology, pulmonology or endocrinology.
Significance levels of p < 0.05 are shown in bold.
Results of the telephone surveys
Similar numbers of individuals were available via telephone in the two groups (n = 31 in the transferred group, n = 33 in the non-transferred group). However, comparison of the telephone contact rates between the two groups showed that individuals in the transferred group had a significantly higher availability rate (χ 2 = 4.59, P = 0.030).
According to the results of the telephone surveys (Table 5), the psychiatric disorder comorbidity rate was higher in the transferred group. The prevalence of intellectual disability was also higher in the transferred group (P = 0.140). There was no significant difference in medication choices for CAMHS between the groups. However, owing to the small sample size, it was not possible to compare differences in clinical characteristics among the primary diagnoses.
Table 5 Differences between transferred and non-transferred groups in the telephone survey
CAMHS, child and adolescent mental health services; AMHS, adult mental health services.
a. Fisher’s exact test.
Significance levels of p < 0.05 are shown in bold.
When child psychiatrists opted for transfer, the transfer rate to AMHS significantly increased (P < 0.001), as confirmed by asking the patients’ parents during telephone calls whether they had been previously informed by their doctors about the transfer process. Among the patients who transferred, the initial appointments in the AMHS were primarily arranged by the patients’ families. Ten of the patients in the non-transferred group sought treatment in other centres after being unsuccessful in transferring to AMHS within the same hospital. However, four of them were unable to continue follow-up anywhere, despite requiring it. Nineteen patients’ parents reported that their child did not continue with any AMHS treatment because of symptom relief or decreased severity. The primary diagnosis of 18 of these patients was ADHD, and one patient’s primary diagnosis was mild intellectual disability. When these 19 patients were excluded, the perceived difficulty during the transfer period was more significant for those who were unable to transfer to AMHS within the same hospital.
We established a separate group comprising individuals in the transferred group (n = 31) and those in the non-transferred group who were able to transfer to another hospital (n = 10) and investigated differences in clinical characteristics between this group and individuals who did not make the transfer (n = 23) (Supplementary Table 2). The most significant differences observed between patients who were able to continue with AMHS (n = 41) and those who were not were related to comorbidities and the decision to transfer. Patients who were able to transfer to AMHS exhibited a higher prevalence of psychiatric comorbidities (P = 0.040) and were more likely to have been informed by their child psychiatrists about the necessity of the transfer beforehand (P < 0.001). Conversely, there were no significant differences in clinical characteristics (other diagnoses and medication choices) during the CAMHS period between these patient groups (all P > 0.05).
Clinical and follow-up characteristics predictive of the transfer
Logistic regression analysis was employed with transfer as the dependent variable. The results indicated that the CAMHS doctor providing information about transfer (B = 2.46, s.e. = 0.68, P < 0.001) and the presence of psychiatric comorbidities (B = 1.572, s.e. = 0.71, P = 0.260) were positively associated with the likelihood of the transfer. However, no significant associations were observed for age at first CAMHS visit, number of CAMHS visits, follow-up time in CAMHS and primary diagnosis in CAMHS.
Discussion
To the best of our knowledge, this is the first study to examine the transfer process of young individuals with NDDs from CAMHS to AMHS in Türkiye. Our findings indicate that the transferred group had a higher prevalence of comorbidities, particularly intellectual disability, and a greater frequency of antipsychotic prescriptions in CAMHS. In addition, individuals in the transferred group experienced longer follow-up durations in CAMHS and were more often informed by child psychiatrists about the transfer process to AMHS.
Although primary diagnoses were similar between the two groups, the higher prevalence of comorbidities and higher rate of antipsychotic prescriptions in the transferred group may point to a more complex clinical profile. This complexity, possibly linked to greater behavioural challenges, may have contributed to the higher likelihood of transfer to AMHS in this group. Research indicates that individuals with subaverage IQ and ADHD are at greater risk of disruptive behaviour problems and aggression, often necessitating longer-term antipsychotic treatment. Reference Aman, Binder and Turgay20–Reference Pringsheim, Hirsch, Gardner and Gorman22 Furthermore, the use of antipsychotic medication might contribute to the perception of a greater necessity for follow-up in AMHS. Another reason could involve the social and economic benefits associated with a disability report, as some patients might visit AMHS primarily for this purpose, even in the absence of a subjective need for ongoing treatment. As our study was retrospective in nature, we were unable to evaluate the impact of the symptom severity of the primary diagnoses and comorbidities on the transfer process. However, it could be considered that adolescents with comorbid mental disorders experienced more severe mental health problems and, although they may not have found support for the transfer process in the hospital they were treated in, they may have attempted to engage with the system through other healthcare centres in some way. The need for young individuals and their families in this group to remain within the system to continue benefiting from social and economic support with their education and employment may also have been a factor. Thus, ensuring continuity with AMHS remains essential for this age group.
Another notable finding was the longer follow-up duration in CAMHS for the transferred group. This may reflect greater treatment and follow-up needs of individuals in this group, as well as a higher degree of cooperation and willingness to maintain regular appointments. The familiarity and trust developed with the system during this extended period might have also facilitated a smoother transfer to AMHS, making it easier to navigate the process of scheduling appointments. This would be consistent with our finding that when child psychiatrists actively guided the transfer process, the transfer rate to AMHS significantly increased. Strong engagement with both the system and the treating psychiatrist, as well as the psychiatrist’s proactive role in encouraging the transition, is likely to have contributed to the continuation of care into adulthood.
We found that the time from the last appointment in CAMHS to the first appointment in AMHS was 7.9 months for the ADHD group and 8.4 months for the ASD group. In Türkiye, referral times to AMHS are considerably longer in university hospitals compared with public hospitals, consistent with the mean transition duration of 8 months observed in our study. This extended waiting period, coupled with the risk of appointment rejection, raises significant concerns regarding timely access to care. Similarly, international studies have reported challenges. In Australia, a study found that many adolescents referred by CAMHS were not accepted by AMHS despite evident psychiatric needs. Reference Cosgrave, Yung, Killackey, Buckby, Godfrey and Stanford23 The TRACK study of transition from CAMHS to AMHS found that 5.5% of patients who successfully transitioned did not have an appointment within the first 3 months, and 7.8% had only one appointment, although no data were provided for mean waiting times. Reference Singh, Paul, Islam and Weaver24 By contrast, structured transition support programmes, such as the Youth Transition Project in Ottawa, Canada, have demonstrated promising outcomes. Following the introduction of a transition coordinator to assess adolescents and enhance communication between services, the mean waiting time for transition decreased to 68.62 ± 52.03 days in 2013, compared to 134.12 ± 99.90 days in 2011. Reference Cappelli, Davidson, Racek, Leon, Vloet and Tataryn25 Taken together, our findings and previous evidence indicate that a structured transition approach is necessary to address delays and improve continuity of care.
Primary diagnosis showed the most significant change between CAMHS and AMHS in the transferred group in our study. Specifically, ADHD, as a primary diagnosis, often changed upon transition to AMHS, probably contributing to the decreased use of ADHD medications in adult services. There could be several reasons for this gap. First, ADHD is a developmental disorder, with approximately one-third of cases resolving in adulthood. Reference Hinshaw26–Reference Hamed, Kauer and Stevens28 Consequently, some patients may no longer require ADHD treatment as they age. Prognostic factors associated with the persistence of ADHD into adulthood include severity of symptoms, necessity for pharmacological treatment, and co-occurring depressive or behavioural symptoms. Reference Caye, Spadini, Karam, Grevet, Rovaris and Bau29 Similarly, Girela-Serrano et al reported that severe hyperactivity, impulsivity and emotional dysregulation were related to transfer and continued follow-up in AMHS. Reference Girela-Serrano, Miguélez, Porras-Segovia, Díaz, Moreno and Peñuelas-Calvo30 Despite this, ADHD remains underdiagnosed and undertreated in adulthood, reflecting discrepancies in recognition and treatment of ADHD between CAMHS and AMHS. Reference Targum and Adler31,Reference Ginsberg, Beusterien, Amos, Jousselin and Asherson32 A recent review reported that only a small proportion of young people with ADHD transition to AMHS globally. Reference Adamo, Singh, Bölte, Coghill, Newcorn and Parlatini17 The prevalence of diagnosed adult ADHD is consistently lower than expected on the basis of population estimates, leaving many adults undiagnosed and untreated. Therefore, low administrative rates of ADHD in adulthood might falsely suggest a limited demand for services. Even among those who successfully transition to AMHS, the frequency of appointments for ADHD patients tends to decline. Reference Appleton, Elahi, Tuomainen, Canaway and Singh33 In addition, health professionals are often hesitant to prescribe stimulants to young adults, owing to concerns about misuse. Reference Loskutova, Waterman, Callen, Staton, Bullard and Knowledge34 Furthermore, a lack of specialist expertise in ADHD and limited provision of services for adults with the condition contribute to underrecognition in AMHS. Reference Asherson, Leaver, Adamou, Arif, Askey and Butler35 Our findings align with the literature reporting systemic challenges in addressing gaps in care for adults with ADHD.
We conducted a telephone survey to investigate parental perspectives on the transfer process, including parents of individuals from both the transferred and non-transferred groups. Parents in the transferred group were more accessible via telephone and reported a significantly higher rate of being informed in advance about the transfer process by CAMHS. This proactive guidance by child psychiatrists may have resulted in a greater engagement through informed decision-making. It appears to be important to enhance the education and knowledge of child psychiatrists in this regard, to provide them with access to appropriate tools and enable them to apply these in collaboration with the family and the adolescent. Collaborative efforts with families and adolescents are essential to determine the timing and necessity of the transfer process. In this context, the Transition Readiness and Appropriateness Measure (TRAM), developed within European CAMHS practices through the MILESTONE Study, serves as a valuable tool. Reference Santosh, Singh, Adams, Mastroianni, Heaney and Lievesley36,Reference Singh, Tuomainen, Bouliotis, Canaway, De Girolamo and Dieleman37 The Transition Readiness and Appropriateness Measure evaluates various factors, including symptom frequency and severity, illness impact, risk factors, barriers to functioning and systemic issues, many of which were identified as relevant in our study. On the other hand, the perception that follow-up care was no longer necessary after symptom remission might have influenced some responses. However, parents in the non-transferred group reported greater challenges during the transfer period, with these challenges becoming even more pronounced when patients who no longer required follow-up care were excluded. These findings for both individuals and families emphasise the multifaceted nature of mental healthcare trajectories and the need for customised transition support mechanisms.
In Türkiye, being more than 18 years old is sufficient for the decision to transfer from CAMHS to AMHS to be made. However, the progression of the transfer process is mainly left to the discretion of the child psychiatrist, the family and the young individual, without a structured transition plan in place. As a result, the process is often abrupt, leading to service gaps that can have negative consequences for the young person’s mental healthcare. The absence of a transition clinic, lack of communication between CAMHS and AMHS, lack of a common consensus regarding transition age and systemic difficulties related to scheduling appointments may represent challenges in providing an appropriate mental health service for this age group in our country. To transform the transfer into a more effective transition, it will be essential to implement a structured plan that supports the young individual through this critical period. This should involve early preparation, ensuring a gradual and individualised approach to the transition and enhancing communication between CAMHS and AMHS. Development of such a structured transition framework would mean that patients would benefit from a smoother progression into adult care, maintaining continuity in their treatment and reducing the risk of care disruption. A successful transition process can also promote the young individual’s autonomy, provide clear expectations for the future, and offer ongoing support to both patients and their families, ultimately leading to better mental health outcomes.
Our study had several limitations. First, it was a retrospective study that involved a small sample from a single hospital and lacked information about the severity of symptoms related to diagnoses, which may have restricted our ability to fully understand the factors influencing the transfer process. In addition, a lack of detailed information from old hospital records on confounding factors such as socioeconomic status and symptom severity may have influenced transfer outcomes. Second, our focus was primarily on clinical characteristics of patients and transfer process, rather than on long-term functional outcomes. Examining functional outcomes in long-term follow-up of patients transferring from CAMHS to AMHS would be a valuable direction for future research. Third, we acknowledge that the university hospital population in this study may not fully represent CAMHS services across Türkiye. Nevertheless, this study serves as pioneering work for Türkiye, and we hope it will inspire future research, including multi-institutional studies in various healthcare settings. Furthermore, we were unable to investigate referrals to private clinics, as our data on individuals who did not attend were limited to telephone records. Although we had some limited information regarding follow-up from other institutions, this could not be included in the overall analysis owing to our inability to contact all individuals by telephone. In addition, the higher rate of telephone contact with the transferred group made it challenging to comprehend the difficulties faced by the non-transferred group. The higher contact rate with the transferred group may have been related to their greater involvement in the healthcare system. Nevertheless, the difference in the response rate could represent a limitation due to response bias.
The main problems that studies should address in the future are inadequate planning of the transfer process, a lack of standardised outcome assessments, inconsistent involvement of adolescents and their families, limited interdisciplinary cooperation between CAMHS and AMHS, and a lack of clear national policies. Reference Hendrickx, De Roeck, Maras, Dieleman, Gerritsen and Purper-Ouakil38–Reference Signorini, Singh, Boricevic-Marsanic, Dieleman, Dodig-Ćurković and Franic40 Young individuals with NDDs are at particular risk in this regard. Reference Signorini, Singh, Boricevic-Marsanic, Dieleman, Dodig-Ćurković and Franic40 In the present study, we examined the follow-up and transfer processes, as well as the clinical characteristics of young individuals with NDDs in a university hospital sample. It was evident that implementation of a structured transition framework and further research are required to improve mental health services during this age period, when there is a greater need for psychiatric support.
Supplementary material
The supplementary material is available online at https://doi.org/10.1192/bjo.2025.59
Data availability
The data that support the findings of this study are available on request from the corresponding author, M.I.Y., upon reasonable request.
Author contributions
M.K.D.: conceptualisation, study design, literature search, development of telephone interview questions, conducting telephone interviews, data collection, data handling and analysis and writing the manuscript. Y.K.A.: conceptualisation, study design, literature search, development of telephone interview questions, conducting telephone interviews, data collection, data handling and analysis and writing the manuscript. Ş.K.: conceptualisation, study design, development of telephone interview questions, data handling and analysis, ethical guidance and writing the manuscript. H.T.Ç.E.: conceptualisation, study design, literature search, development of telephone interview questions, supervision of data collection process, data handling and analysis and writing the manuscript. M.I.Y.: conceptualisation, study design, literature search, development of telephone interview questions, supervision of data collection process, data handling and analysis and writing the manuscript.
Funding
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Declaration of interest
None.
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