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J R Soc Med. 2001 August; 94(8): 373–374.
PMCID: PMC1281628

Transition from the paediatric clinic to the adult service

T J David, Proceedings Editor, JRSM

What happens to the adolescent patient with a chronic disorder at the age of 16? At present the main options are transfer to adult services, long-term retention in the paediatric clinic or discharge from hospital supervision. Transfer of patients, when it occurs, is often done in a haphazard way. Reasons for transfer include leaving school, the patient's embarrassment at attending a paediatric clinic, and pregnancy. Probably the worst reason of all is non-adherence to treatment—the so-called punishment transfer, used as a weapon of last resort when dealing with the poorly cooperating teenager.

Simple transfer or discharge will seldom be the best option; what most patients need is an efficient and gradual transition from paediatric to adult services. To achieve effective transition, two principles must be recognized—first, that transition in healthcare is only one part of the wider evolution from dependent child to independent adult; second, that the change from paediatric to adult healthcare systems is difficult not only for those with chronic disease but even for normal young people. Many young adults neglect to register with a general practitioner and drop out of the healthcare system, seeking help only in crises that might sometimes have been avoided by regular contact and health promotion.

For this reason, special transition programmes have been set up for adolescents with a wide variety of chronic disorders such as diabetes, cystic fibrosis and arthritis. One barrier to effective transition is the reluctance of some paediatric professionals to ‘let go’ and trust either the independence of the adolescent or the skills of the adult services; and parents may be reluctant to let go for the very same reasons. These uncertainties are bound to undermine the adolescent's confidence in the competence and commitment of staff in adult services. A common obstacle to successful transition is the loss of respected and trusted paediatric carers who must now be traded for new and unknown carers in an adult service. Transfer to an adult service may also be seen as representing a step closer to disease complications and death, especially for teenagers with diabetes or cystic fibrosis1. Thus there is often little incentive for adolescents to abandon a service that has served them well for many years.

Commonly, adult services themselves present obstacles to successful transition. One of the biggest is the complete lack of an adult specialist service in the locality: for example, though paediatric services for cystic fibrosis are well provided, most districts in the UK do not offer a service for adults, and some patients must travel long distances to regional centres. Other obstacles to transition include a lack of interest by adult physicians in ‘paediatric’ diseases of adult life, busy clinics full of elderly sick patients, poor communications and contradictory advice.

What can be done to improve matters? In the UK a serious deficiency is the dearth of hospital facilities for adolescents—hence a sharp cut-off between paediatric and adult care at the age of 16. One effect of this forced transition at 16 is that a second transition may occur at 18 or 19 when the young adult moves away from home and goes to college or university. General principles of optimum transition are as follows:

  • The timing of transition should depend on the developmental readiness and health status of the adolescent
  • The healthcare services should make an effort to cater for adolescents, enabling transition to be delayed until the young person has completed the developmental tasks of adolescence (i.e. a transition target of 18-19, at the time of school leaving, may be better than 16)
  • Transition should not occur before the young person is able to manage his or her illness largely independent of parents and staff, and can function in an adult clinic. To achieve this, preparation (including education and taking responsibility for medication) must begin well before the anticipated transfer time
  • The transition should be a coordinated process, including receipt of an outline of the adult programme, a visit to the adult clinic, and one or more joint paediatric—adult clinic visits
  • A transition programme can only succeed with the active participation and interest of the staff in the adult clinic, who face the challenge of matching the level of family support and rapid staff response that are features of most paediatric services
  • Transition planning should involve the primary healthcare team2, who may provide the only medical continuity during a period of potential disruption. This is easier said than done, because young people with chronic illness often have little contact with their primary care health team1,3
  • Management links may need to be developed between the paediatric and adult centres, with detailed consultations on contracts and finance.

Transition to adult care is a major life event for young people with chronic illness. The lack of appropriate adolescent facilities—for example, adolescents being housed on paediatric wards in the company of young babies or on adult wards with very elderly patients—and the lack of healthcare staff skilled in meeting the needs of adolescents, are currently obstacles to efficient transition in the UK4. For the reader who wishes to explore the subject further, this topic is discussed in published papers from the most recent Section of Paediatrics symposium on cystic fibrosis5,6,7,8.

References

1. Viner R. Transition from paediatric to adult care. Bridging the gaps or passing the buck? Arch Dis Child 1999;81: 271-5 [PMC free article] [PubMed]
2. Fiorentino L, Datta D, Gentle S, et al. Transition from school to adult life for physically disabled young people. Arch Dis Child 1998;79: 306-11 [PMC free article] [PubMed]
3. Pennell SC, David TJ. The role of the general practitioner in cystic fibrosis. J R Soc Med 1999;92(suppl 37): 50-4 [PMC free article] [PubMed]
4. Sawyer SM, Bowes G. Adolescence on the health agenda. Lancet 1999;354(suppl 2): 31-4 [PubMed]
5. David TJ, ed. Transition to adult care: annual reviews and current clinical issues in children and adults with cystic fibrosis. J R Soc Med 2001;94(suppl 40)
6. Viner R. Barriers and good practice in transition from paediatric to adult care. J R Soc Med 2001;94(suppl 40): 2-4 [PMC free article] [PubMed]
7. Bryon S, Madge S. Transition from paediatric to adult care: psychological principles. J R Soc Med 2001;94(suppl 40): 5-7 [PMC free article] [PubMed]
8. Webb AK, Jones AW, Dodd ME. Transition from paediatric to adult care: problems that arise in the adult cystic fibrosis clinic. J R Soc Med 2001;94(suppl 40): 8-11 [PMC free article] [PubMed]

Articles from Journal of the Royal Society of Medicine are provided here courtesy of Royal Society of Medicine Press