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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
Inflamm Bowel Dis. Author manuscript; available in PMC 2012 June 16.
Published in final edited form as:
Inflamm Bowel Dis. 2011 October; 17(10): 2169–2173.
Published online 2010 December 16. doi:  10.1002/ibd.21576
PMCID: PMC3320668

Transitioning the Adolescent Inflammatory Bowel Disease Patient: Guidelines for the Adult and Pediatric Gastroenterologist


Twenty percent of inflammatory bowel disease (IBD) patients present in the pediatric years, with recent reports suggesting a rising incidence in the pediatric age group. This highlights the need for both pediatric and adult gastroenterologists to better understand issues related to the process of transition from pediatric to adult care. Research from other disciplines outside of IBD provide evidence that the transition period can be associated with poorer health outcomes and that a structured transition program may improve patient compliance and disease control. Recent data from the IBD literature support a need for transition clinics. The ideal model of a transition program has not been established. Controlled trials are not available to measure the impact of a structured transition program on clinically relevant endpoints such as disease control and hospital admissions. As local resources and availability of staffing and funding are highly variable, we have summarized some practical guidelines for the adult and pediatric gastroenterologist that can be used as an aid to help adolescents through the transition process even without the support of an established transition clinic.

Keywords: inflammatory bowel disease, pediatrics, transition process

Up to 25% of patients with inflammatory bowel disease (IBD) will first present in childhood or adolescence.1 Recent reports suggest that the incidence in pediatrics is rising. In a retrospective study from the United States over an 11-year period, the annual incidence of IBD in the pediatric population doubled from 1.1/100,000 to 2.4/100,000.2 In a U.S. population-based study the incidence of pediatric IBD was 7.05/100,000 with a 2-fold predominance in Crohn’s disease compared to ulcerative colitis.3 A European population-based study showed a rise in the incidence of pediatric Crohn’s disease over a 12-year period from 2.1/100,000 to 2.6/100,000.4 This growing cohort of patients will eventually move from pediatric to adult care, highlighting the need for both pediatric and adult gastroenterologists to better understand issues particular to the adolescent and the process of transition from pediatric to adult care. The purpose of this review is to highlight the need for a structured transition process based on evidence from other disciplines and the large gap in the IBD literature in addressing this patient population’s needs.

Transition is the purposeful, planned movement of adolescents and young adults with chronic physical and medical conditions from child-centered to adult-oriented healthcare systems.5 The transition of healthcare responsibilities from caregivers to patients encompasses more than the physical movement of a patient from the pediatric to the adult clinic or hospital.

Multiple guidelines have been proposed by national medical societies or experts in the field that provide consensus statements on transitioning adolescents and young adults with chronic illness,6,7 or specifically IBD.8,9 In 2002, a consensus statement on healthcare transition for young adults with special healthcare needs established a goal that by the year 2010 all physicians who provide care to young people with special healthcare needs 1) understand the rationale for transition from child-oriented to adult-oriented healthcare; 2) have the knowledge and skills to facilitate that process; and 3) know if, how, and when transfer of care is indicated.6 In the IBD community this goal has not been achieved. A nationwide survey of U.S. gastroenterologists reported 73% competence regarding medical aspects of adolescent care but only 46% competence with adolescent developmental and mental health issues.10

Transition to self-management involves gradual changes in knowledge, attitudes, and behavior.11 During this process, adolescents assume responsibility for all aspects of their own healthcare, become informed consumers of the adult healthcare system, and redefine their role in the self-management of their condition.12


Research regarding transitional care in IBD has been more sparse compared with other disciplines that also have a large proportion of pediatric patients with chronic disease, including cystic fibrosis,1317 rheumatological diseases,1826 diabetes mellitus (DM),2735 organ transplant,3642 and congenital heart disease.4355 Reports demonstrate that both adolescent and young adult liver transplant recipients are deficient in self-management of their healthcare.56 A qualitative study of solid organ transplant recipients found that the majority of subjects, despite indicating challenges in the transition process, preferred being treated as adults and being responsible for their own healthcare.57 In pediatric liver transplant recipients, the transition period was associated with poorer medical adherence.58 A further pilot study from the same authors found that a targeted education intervention for patients consisting of both education on their medical history and the process of transition improved medical adherence.59 Analysis of data from 115 renal transplant patients revealed that the period of transition was not associated with renal allograft loss. However, as patients over the age of 18 years had a lower admission rate for management of rejection or for biopsy compared with the younger age groups, the authors hypothesize that these patients were not receiving proper medical attention.41

Patients with congenital heart disease who believed that they should transfer care to an adult center rather than stay at the pediatric center are more likely to attend appointments after transition.60 In a large retrospective cohort study of 1507 young adults with DM followed until 20 years of age, physician continuity was a protective factor in DM-related hospitalization. Hospitalization related to diabetes rose from 7.6 to 9.5 cases in the 2 years after transition to adult care. Patients with no change in physician had a relative risk of 0.23 (95% confidence interval [CI] 0.05–0.79).32 Type 1 DM patients who transition under a structured process had improved clinic attendance and HbA1c levels compared with those referred to adult care by letter only.61 Similarly, a transition program involving a dedicated coordinator and an after-hour phone support system was associated with reduced hospital admissions for diabetic ketoacidosis.62

The majority of studies on transition tend to focus on descriptive data based on expert opinion or surveys of patient, family, and/or healthcare provider’s perceptions or experiences of the transition process. In contrast, McDonagh et al63 were able to construct a transition program based on a needs assessment of a group of patients with juvenile idiopathic arthritis. They measured quality of life at baseline and 6 and 12 months after the initiation of the transition program in 308 adolescents and found significant improvement reported by both patients and their families. Furthermore, the transition was designed to be developmentally age-appropriate, as the study recruited only 11-, 14-, and 17-year olds, each age reflecting a different stage of adolescent development.

In summary, the majority of the evidence from other disciplines supports the supposition that the transition period into adult care may be a vulnerable period and that having a structured transition program may have a positive effect on clinical and psychosocial outcomes.


To date, no large-scale study has compared outcomes of the transition process with or without a structured transition program for patients with IBD. A recent retrospective case–control study compared disease characteristics and compliance in 100 adolescents with adult controls matched for disease duration.64 All adolescents were seen at a biweekly transition clinic of IBD patients ages 16–24. Patient management was shared between a pediatric and adult gastroenterologist as well as an IBD nurse. A greater percentage of adolescents required hospital admission (46% compared to 14% of adults, P < 0.0001), azathioprine (46% compared with 17% of adults, P < 0.0001), and infliximab (20% compared with 6% of adults, P < 0.05). Adolescents missed a median number of 20% of their appointments compared with 0% in adults (P < 0.0001). Overall, these results support the need for a transition clinic, as adolescent patients may have more severe disease compared with adult patients with the same duration of disease and have lower rates of compliance to clinic follow-up. Furthermore, given that adult gastroenterologists will ultimately take over the care of these patients, it suggests that they should get involved early on in the care of these patients.

Hait et al9 published a review on the suggested protocol for the transition process. Since this publication, a study from the same authors found that there continued to be gaps in patient knowledge, as a survey of adult gastroenterologists revealed that deficits in patient knowledge of medical history and medications are the two most important perceived problems during transitioning to adult care.10 A medication adherence questionnaire study of 64 adolescents found that the most frequently reported barriers to taking medications appropriately were lack of time (33%), feeling well (16%), and belief that the medication was ineffective (14%) or had side effects (14%).65 Another study of 90 adolescents found that longer time since diagnosis, greater perceived disease severity, and lack of autonomous motivation to adhere predicted lower adherence to prescription medications.66

While a small study of patients and families who had undergone transition predominantly through the use of a joint visit attended by both adult and pediatric gastroenterologists reported the experience as positive,67 the literature remains relatively void of studies to answer the question of the impact of a structured transition program on patient outcomes.

Existing transition programs and clinics are highly variable, ranging from primarily educational didactic modules, joint visits with both pediatric and adult physicians, alternating visits between the pediatric and adult sites, or having a dedicated nurse transition coordinator. The ability to structure a transition program depends on local factors such as patterns of referral, funding, reimbursement, nursing and allied healthcare support, and distance from tertiary care centers for patient travel. No data exist on the most successful way to transition adolescents and young adults to adult care, and thus no consensus has been developed to provide an “ideal model.”


We hypothesize that young adults undergoing the transition process may face a variety of barriers, including 1) psychological distress,68,69 2) lack of cognitive understanding, 3) parents who continue to take the majority of responsibility,70 4) lack of trust in the adult medical team, 5) lack of understanding of how the adult healthcare system works, 6) negative perception of adult healthcare,71 and 7) loss of insurance. These factors may play a role in making the transition process more difficult and may consequently impact disease activity and complications.

The evidence from other disciplines suggests that medical compliance is poor during the period of adolescence and transition. Recent studies of IBD adolescents show multiple barriers to medical compliance including perceived lack of time, duration of disease, and belief in the efficacy of medical therapy.65,66 It is essential to understand the needs of patients and their families during the transition process. Studies are needed to measure medical compliance and disease course pre- and posttransition. Controlled trials are necessary to determine the efficacy of a structured transition process with clinically relevant endpoints such as disease control, hospital admission and surgery, disease- and drug-related complications, and quality of life. With the rising incidence of childhood IBD this is an area that demands systematic investigation. As reimbursement may be an issue in the U.S., documenting that particular transition models are of benefit in improving outcomes and reducing hospitalizations and surgeries will be important to fund proper transition.

The ideal model for the transition process of patients with IBD has not been established and likely will depend on institutional and local resources. General guidelines have been proposed by both Canadian and U.S. pediatric societies for the transition to adult care for youth with special health-care needs that have now been adapted for IBD patients.6,7 Tables 1 and and22 provide summary guidelines for IBD programs to aid patients through the transition process.

Recommendations for Pediatric Gastroenterologists
Recommendations for Adult Gastroenterologists
  1. Healthcare providers need to recognize that pediatric-and adult-oriented healthcare represent two different cultures. Pediatric IBD care is family-focused, with significant parental involvement within a multidisciplinary team, including a nutritionist, social worker, and psychologist/psychiatrist if needed. Adult healthcare is focused on individual healthcare often without the resources for a multidisciplinary team.
  2. Asking patients and families about their expectations and fears of transition is important. In academic centers this may serve as a formal needs assessment to base future transition care programs. In community and individual practices this may be informal in the form of questions during follow-up visits, but may serve to acknowledge that healthcare providers recognize that the transition process can be a time of stress for patients and families.
  3. Adolescent patients and their families should be educated on the differences between pediatric and adult healthcare.
  4. Although it may not be feasible to identify the specific adult gastroenterologist that will be taking over care, we suggest providing a written healthcare transition plan (which can be updated regularly) by ages 16–23 that identifies the following:
    1. who will take over care (individual physician or IBD center);
    2. the tasks that the adolescent will need to master before entering the adult healthcare system (Table 3);
      TABLE 3
      Suggested Knowledge and Tasks that Adolescents Should Master by the Time They Attend an Adult Care Clinic
    3. how the care will be financed, as patients and their families may be unprepared for possible changes in health insurance when patients are no longer considered dependent children.
  5. The actual provision of transition services will be highly dependent on local funding and resources but may include: individual education by a physician, nurse clinician, psychologist, or social worker; educational groups; written materials including checklists for patients and parents; joint transition clinics; and Web-based tools.


1. Sawczenko A, Sandhu BK, Logan RF, et al. Prospective survey of childhood inflammatory bowel disease in the British Isles. Lancet. 2001;357:1093–1094. [PubMed]
2. Malaty HM, Fan X, Opekun AR, et al. Rising incidence of inflammatory bowel disease among children: a 12-year study. J Pediatr Gastroenterol Nutr. 2010;50:27–31. [PubMed]
3. Kugathasan S, Judd RH, Hoffmann RG, et al. Epidemiologic and clinical characteristics of children with newly diagnosed inflammatory bowel disease in Wisconsin: a statewide population-based study. J Pediatr. 2003;143:525–531. [PubMed]
4. Auvin S, Molinie F, Gower-Rousseau C, et al. Incidence, clinical presentation and location at diagnosis of pediatric inflammatory bowel disease: a prospective population-based study in northern France (1988–1999) J Pediatr Gastroenterol Nutr. 2005;41:49–55. [PubMed]
5. Blum RW, Garell D, Hodgman CH, et al. Transition from child-centered to adult health-care systems for adolescents with chronic conditions. A position paper of the Society for Adolescent Medicine. J Adolesc Health. 1993;14:570–576. [PubMed]
6. A consensus statement on health care transitions for young adults with special health care needs. Pediatrics. 2002;110(6 Pt 2):1304–1306. [PubMed]
7. Transition to adult care for youth with special health care needs. Paediatr Child Health. 2007;12:785–793. [No authors listed.] [PMC free article] [PubMed]
8. Baldassano R, Ferry G, Griffiths A, et al. Transition of the patient with inflammatory bowel disease from pediatric to adult care: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr. 2002;34:245–248. [PubMed]
9. Hait E, Arnold JH, Fishman LN. Educate, communicate, anticipate-practical recommendations for transitioning adolescents with IBD to adult health care. Inflamm Bowel Dis. 2006;12:70–73. [PubMed]
10. Hait EJ, Barendse RM, Arnold JH, et al. Transition of adolescents with inflammatory bowel disease from pediatric to adult care: a survey of adult gastroenterologists. J Pediatr Gastroenterol Nutr. 2009;48:61–65. [PubMed]
11. Giarelli E, Bernhardt BA, Mack R, et al. Adolescents’ transition to self-management of a chronic genetic disorder. Qual Health Res. 2008;18:441–457. [PubMed]
12. Rosen DS. Transition of young people with respiratory diseases to adult health care. Paediatr Respir Rev. 2004;5:124–131. [PubMed]
13. Dugueperoux I, Tamalet A, Sermet-Gaudelus I, et al. Clinical changes of patients with cystic fibrosis during transition from pediatric to adult care. J Adolesc Health. 2008;43:459–465. [PubMed]
14. McLaughlin SE, Diener-West M, Indurkhya A, et al. Improving transition from pediatric to adult cystic fibrosis care: lessons from a national survey of current practices. Pediatrics. 2008;121:e1160–1166. [PubMed]
15. Okumura MJ, Heisler M, Davis MM, et al. Comfort of general internists and general pediatricians in providing care for young adults with chronic illnesses of childhood. J Gen Intern Med. 2008;23:1621–1627. [PMC free article] [PubMed]
16. Tuchman LK, Schwartz LA, Sawicki GS, et al. Cystic fibrosis and transition to adult medical care. Pediatrics. 2010;125:566–573. [PubMed]
17. Tuchman LK, Slap GB, Britto MT. Transition to adult care: experiences and expectations of adolescents with a chronic illness. Child Care Health Dev. 2008;34:557–563. [PubMed]
18. van Pelt PA, Kruize AA, Goren SS, et al. Transition of rheumatologic care, from teenager to adult: which health assessment questionnaire can be best used? Clin Exp Rheumatol. 2010;28:281–286. [PubMed]
19. McDonagh JE. Transition of care from paediatric to adult rheumatology. Arch Dis Child. 2007;92:802–807. [PMC free article] [PubMed]
20. McDonagh JE, Southwood TR, Shaw KL. Unmet education and training needs of rheumatology health professionals in adolescent health and transitional care. Rheumatology (Oxford) 2004;43:737–743. [PubMed]
21. Robertson L. When should young people with chronic rheumatic disease move from paediatric to adult-centred care? Best Pract Res Clin Rheumatol. 2006;20:387–397. [PubMed]
22. Shaw KL, Southwood TR, McDonagh JE. Development and preliminary validation of the ‘Mind the Gap’ scale to assess satisfaction with transitional health care among adolescents with juvenile idiopathic arthritis. Child Care Health Dev. 2007;33:380–388. [PubMed]
23. Shaw KL, Southwood TR, McDonagh JE. Young people’s satisfaction of transitional care in adolescent rheumatology in the UK. Child Care Health Dev. 2007;33:368–379. [PubMed]
24. Tattersall R, McDonagh JE. Transition: a rheumatology perspective. Br J Hosp Med (Lond) 9(71):315–319. [PubMed]
25. Tucker LB, Cabral DA. Transition of the adolescent patient with rheumatic disease: issues to consider. Pediatr Clin North Am. 2005;52:641–652. viii. [PubMed]
26. Tucker LB, Cabral DA. Transition of the adolescent patient with rheumatic disease: issues to consider. Rheum Dis Clin North Am. 2007;33:661–672. [PubMed]
27. Allen D, Gregory J. The transition from children’s to adult diabetes services: understanding the ‘problem’ Diabet Med. 2009;26:162–166. [PubMed]
28. Bobo N, Butler S. The transition from pediatric to adult diabetes health care. NASN Sch Nurse. 2010;25:114–115. [PubMed]
29. de Beaufort C, Jarosz-Chobot P, Frank M, et al. Transition from pediatric to adult diabetes care: smooth or slippery? Pediatr Diabetes. 2010;11:24–27. [PubMed]
30. Jones SE, Hamilton S. The missing link: paediatric to adult transition in diabetes services. Br J Nurs. 2008;17:842–847. [PubMed]
31. Lundin CS. Living with diabetes during transition to adult life — relationships, support of self-management, diabetes control and diabetes care. Int J Integr Care. 2008;8:e71. [PMC free article] [PubMed]
32. Nakhla M, Daneman D, To T, et al. Transition to adult care for youths with diabetes mellitus: findings from a Universal Health Care System. Pediatrics. 2009;124:e1134–1141. [PubMed]
33. Neu A, Losch-Binder M, Ehehalt S, et al. Follow-up of adolescents with diabetes after transition from paediatric to adult care: results of a 10-year prospective study. Exp Clin Endocrinol Diabetes. 2010;118:353–355. [PubMed]
34. Owen P, Beskine D. Factors affecting transition of young people with diabetes. Paediatr Nurs. 2008;20:33–38. [PubMed]
35. Parfitt G. Proving young person’s experience transition: lessons from Wales. Paediatr Nurs. 2008;20:27–30. [PubMed]
36. McDonagh JE, Kelly DA. The challenges and opportunities for transitional care research. Pediatr Transplant. 2010;14:688–700. [PubMed]
37. Bell LE, Bartosh SM, Davis CL, et al. Adolescent transition to adult care in solid organ transplantation: a consensus conference report. Am J Transplant. 2008;8:2230–2242. [PubMed]
38. Bell LE, Sawyer SM. Transition of care to adult services for pediatric solid-organ transplant recipients. Pediatr Clin North Am. 2010;57:593–610. [PubMed]
39. Chaturvedi S, Jones CL, Walker RG, et al. The transition of kidney transplant recipients: a work in progress. Pediatr Nephrol. 2009;24:1055–1060. [PubMed]
40. Fredericks EM. Nonadherence and the transition to adulthood. Liver Transpl. 2009;15(suppl 2):S63–69. [PubMed]
41. Koshy SM, Hebert D, Lam K, et al. Renal allograft loss during transition to adult healthcare services among pediatric renal transplant patients. Transplantation. 2009;87:1733–1736. [PubMed]
42. Paone MC, Wigle M, Saewyc E. The ON TRAC model for transitional care of adolescents. Prog Transplant. 2006;16:291–302. [PubMed]
43. Berg SK, Hertz PG. Outpatient nursing clinic for congenital heart disease patients: Copenhagen Transition Program. J Cardiovasc Nurs. 2007;22:488–492. [PubMed]
44. Gurvitz MZ, Inkelas M, Lee M, et al. Changes in hospitalization patterns among patients with congenital heart disease during the transition from adolescence to adulthood. J Am Coll Cardiol. 2007;49:875–882. [PubMed]
45. Hilderson D, Saidi AS, Van Deyk K, et al. Attitude toward and current practice of transfer and transition of adolescents with congenital heart disease in the United States of America and Europe. Pediatr Cardiol. 2009;30:786–793. [PubMed]
46. Hudsmith LE, Thorne SA. Transition of care from paediatric to adult services in cardiology. Arch Dis Child. 2007;92:927–930. [PMC free article] [PubMed]
47. Knauth A, Verstappen A, Reiss J, et al. Transition and transfer from pediatric to adult care of the young adult with complex congenital heart disease. Cardiol Clin. 2006;24:619–629. vi. [PubMed]
48. Knauth Meadows A, Bosco V, Tong E, et al. Transition and transfer from pediatric to adult care of young adults with complex congenital heart disease. Curr Cardiol Rep. 2009;11:291–297. [PubMed]
49. Lyon ME, Kuehl K, McCarter R. Transition to adulthood in congenital heart disease: missed adolescent milestones. J Adolesc Health. 2006;39:121–124. [PubMed]
50. Moons P, Hilderson D, Van Deyk K. Implementation of transition programs can prevent another lost generation of patients with congenital heart disease. Eur J Cardiovasc Nurs. 2008;7:259–263. [PubMed]
51. Moons P, Pinxten S, Dedroog D, et al. Expectations and experiences of adolescents with congenital heart disease on being transferred from pediatric cardiology to an adult congenital heart disease program. J Adolesc Health. 2009;44:316–322. [PubMed]
52. Murphy DJ, Jr, Foster E. ACCF/AHA/AAP recommendations for training in pediatric cardiology. Task force 6: training in transition of adolescent care and care of the adult with congenital heart disease. J Am Coll Cardiol. 2005;46:1399–1401. [PubMed]
53. Ross HM, Fleck D. Clinical considerations for allied professionals: issues in transition to adult congenital heart disease programs. Heart Rhythm. 2007;4:811–813. [PubMed]
54. Wray J, Maynard L. Specialist cardiac services: what do young people want? Cardiol Young. 2008;18:569–574. [PubMed]
55. Yeung E, Kay J, Roosevelt GE, et al. Lapse of care as a predictor for morbidity in adults with congenital heart disease. Int J Cardiol. 2008;125:62–65. [PubMed]
56. Annunziato RA, Parkar S, Dugan CA, et al. Brief report: deficits in health care management skills among adolescent and young adult liver transplant recipients transitioning to adult care settings. J Pediatr Psychol. 2009 [Epub ahead of print] [PubMed]
57. Stabile L, Rosser L, Porterfield KM, et al. Transfer versus transition: success in pediatric transplantation brings the welcome challenge of transition. Prog Transplant. 2005;15:363–370. [PubMed]
58. Annunziato RA, Emre S, Shneider B, et al. Adherence and medical outcomes in pediatric liver transplant recipients who transition to adult services. Pediatr Transplant. 2007;11:608–614. [PubMed]
59. Annunziato RA, Emre S, Shneider BL, et al. Transitioning health care responsibility from caregivers to patient: a pilot study aiming to facilitate medication adherence during this process. Pediatr Transplant. 2008;12:309–315. [PubMed]
60. Reid GJ, Irvine MJ, McCrindle BW, et al. Prevalence and correlates of successful transfer from pediatric to adult health care among a cohort of young adults with complex congenital heart defects. Pediatrics. 2004;113(3 Pt 1):e197–205. [PubMed]
61. Cadario F, Prodam F, Bellone S, et al. Transition process of patients with type 1 diabetes (T1DM) from paediatric to the adult health care service: a hospital-based approach. Clin Endocrinol (Oxf) 2009;71:346–350. [PubMed]
62. Holmes-Walker DJ, Llewellyn AC, Farrell K. A transition care programme which improves diabetes control and reduces hospital admission rates in young adults with Type 1 diabetes aged 15–25 years. Diabet Med. 2007;24:764–769. [PubMed]
63. McDonagh JE, Southwood TR, Shaw KL. The impact of a coordinated transitional care programme on adolescents with juvenile idiopathic arthritis. Rheumatology (Oxford) 2007;46:161–168. [PubMed]
64. Goodhand J, Dawson R, Hefferon M, et al. Inflammatory bowel disease in young people: the case for transitional clinics. Inflamm Bowel Dis. 2010;16:947–952. [PubMed]
65. Greenley RN, Stephens M, Doughty A, et al. Barriers to adherence among adolescents with inflammatory bowel disease. Inflamm Bowel Dis. 2010;16:36–41. [PubMed]
66. Reed-Knight B, Lewis JD, Blount RL. Association of disease, adolescent, and family factors with medication adherence in pediatric inflammatory bowel disease. J Pediatr Psychol. 2010 [Epub ahead of print] [PubMed]
67. Dabadie A, Troadec F, Heresbach D, et al. Transition of patients with inflammatory bowel disease from pediatric to adult care. Gastroenterol Clin Biol. 2008;32(5 Pt 1):451–459. [PubMed]
68. Mackner LM, Crandall WV. Long-term psychosocial outcomes reported by children and adolescents with inflammatory bowel disease. Am J Gastroenterol. 2005;100:1386–1392. [PubMed]
69. Engstrom I. Mental health and psychological functioning in children and adolescents with inflammatory bowel disease: a comparison with children having other chronic illnesses and with healthy children. J Child Psychol Psychiatry. 1992;33:563–582. [PubMed]
70. Clarizia NA, Chahal N, Manlhiot C, et al. Transition to adult health care for adolescents and young adults with congenital heart disease: perspectives of the patient, parent and health care provider. Can J Cardiol. 2009;25:e317–322. [PMC free article] [PubMed]
71. Anthony SJ, Martin K, Drabble A, et al. Perceptions of transitional care needs and experiences in pediatric heart transplant recipients. Am J Transplant. 2009;9:614–619. [PubMed]