9.8 Continuity and transition into adult life

Homotypic and heterotypic continuity

• Homotypic continuity means the same disorder persists, as when childhood obsessive-compulsive disorder (OCD) carries on into adulthood.

• Heterotypic continuity links an earlier disorder to a different later presentation, through shared vulnerability, changing circumstances or classification, not proof that one problem has changed form.

• Childhood conduct problems can predict later antisocial behaviour without inevitably becoming personality disorder.

Dunedin birth cohort

• Dunedin followed just over 1,000 people with repeated assessments.

• About three quarters of those with an adult disorder at 26 had been diagnosed before 18.

• Childhood conduct, emotional and attentional disorders predicted several adult outcomes, some of them different diagnoses.

Group associations are not individual forecasts, so adult services should assess current needs rather than demand an identical diagnosis.

Course of each condition after 18

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Why the boundary does harm

• Eligibility differs because child and adolescent mental health services (CAMHS) and adult services use different thresholds and models.

• The TRACK study found transfer more likely with severe illness, medication or a previous admission, while some with neurodevelopmental or emotional needs were not referred or accepted.

• Children's services lean on the family, whereas adult care hands responsibility for appointments and medicines to the young person.

• Transfer often coincides with leaving school or home, changing GP, work or university, and adult ADHD and autism pathways can be hard to reach.

• Missed appointments may reflect executive difficulties, anxiety, transport or service barriers, so they call for engagement and a risk review, not automatic discharge.

Ineligibility is not absence of need, and turning 18 does not end useful family contact.

Planning

• National Institute for Health and Care Excellence (NICE) guideline NG43 starts planning by school year 9 (age 13 to 14), or promptly for later entrants, and covers young adults up to 25.

• Review at least annually, covering health, education, employment, relationships, housing and independence.

• A named worker coordinates and links services, ideally for at least six months either side of transfer.

• Agree a receiving counterpart and who holds responsibility, and involve primary care, above all where no adult specialist team accepts the referral.

• Ask regularly about family involvement and offer to talk privately.

Transfer versus transition

Transfer is an event that moves responsibility; transition is a process that prepares the young person and supports them afterwards.

• Joint appointments, a shared plan and continuity through the first adult appointments help.

• Handover passes on the developmental formulation, treatment response, communication needs, warning signs, safeguarding concerns and protective relationships, not a diagnosis list alone.

• NICE advises flexible timing during relative stability rather than a rigid birthday.

• England's Care Act continuity provisions protect specified children's social care support until adult arrangements are complete, but do not guarantee continued CAMHS care.

• The government response of March 2026 backed flexibility but did not mandate a universal 0 to 25 service.

Medication and monitoring

• NICE NG87 asks for ADHD treatment to be reviewed around school-leaving age, with adult transfer usually planned by 18, rather than stopping medication automatically.

• Specialists diagnose and titrate; stable prescribing can move to shared care, with a specialist-informed review at least yearly.

• Handover names the prescriber, the monitoring owner, the next review and outstanding results.

• Reassess diversion risk as circumstances change.

Adult life beyond the clinic

No single minimum stability period applies to every diagnosis and licence group.

Measuring a good outcome

• NICE quality standard QS140 covers early planning, annual review, a named worker, preparation with receiving professionals and active follow-up after missed appointments.

• In TRACK, 154 young people crossed the boundary, 90 transferred and only 4 met all four optimal criteria: information transfer, joint care, a planning meeting and continued care.

• MILESTONE studied managed transition at 40 CAMHS sites in eight countries with 793 participants; at 15 months, transition rose from 14.2% to 24.9% and appropriate transition from 16.4% to 32.3%.

• Planned discharge or non-statutory support can be the right outcome, so the number transferred does not measure success.