Child and Adolescent Psychiatry and Mental Health Transitioning to Adult Mental Health Services for young people with ADHD: an Italian-based Survey on practices for Pediatric and Adult Services

Child and Adolescent Psychiatry and Mental Health Transitioning to Adult Mental Health Services for young people with ADHD: an Italian-based Survey on practices for Pediatric and Adult Services | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Child and Adolescent Psychiatry and Mental Health Transitioning to Adult Mental Health Services for young people with ADHD: an Italian-based Survey on practices for Pediatric and Adult Services Elisa Roberti, Francesca Scarpellini, Rita Campi, Michele Giardino, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2470407/v2 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 28 Nov, 2023 Read the published version in Child and Adolescent Psychiatry and Mental Health → Version 2 posted 5 You are reading this latest preprint version Show more versions Abstract Background . Supporting young ADHD patients in transition to adult services is essential. Yet, the low percentages of successful referrals and the issues reported by patients and clinicians stress the need for further attention to transitioning practices. The present study assessed the transitioning process of Attention-Deficit/Hyperactivity Disorder (ADHD) patients in Child and Adolescent Mental Health Services (CAMHS) and Adult Mental Health Services (AMHS) in the Italian territory. We asked child and adult psychiatrists to report the current state of services and their observations on limitations and possible future matters that must be addressed. Method . Seventy-seven centers (42 CAMHS, 35 AMHS) filled in a web-based survey in which they reported the number of ADHD patients, how many transitioning patients they had within the past year, and how they structured transition. Results. A fragmented picture emerged from the survey. Lack of resources, training, and communication between services hinder the transition process, and many adult patients remain under CAMHS' care. While some services have a protocol, there is no structured guidance that can help improve integration and continuity of treatment. Conclusion. The observed situation reflects a need for improvement and standard guidelines to enable a successful transition process, considering clinicians' and patients' necessities. Transition ADHD adult ADHD survey health services Figures Figure 1 Figure 2 Background Attention-Deficit/Hyperactivity Disorder (ADHD) is a common psychiatric disorder in childhood and adolescence, with an average prevalence of 5.9% based on symptoms criteria [ 1 , 2 ] and a prevalence of 2.9% in Italy [ 3 ]. While ADHD is a considered a neurodevelopmental syndrome that impacts children's daily life functioning [ 4 ], it affects adults as well, with a prevalence of around 2.2% [ 1 ]. Compared with childhood ADHD, adult symptomatology lacks validated diagnostic criteria and is relatively neglected in epidemiological studies [ 5 – 7 ]. Notably, while most symptoms that have their onset in the pediatric age continue to manifest throughout adolescence, they often persist (albeit with less impact) in adult life for up to two-thirds of the patients [ 8 ]. Yet, adolescents in care for ADHD often stop treatment altogether, and adults with ADHD frequently fall out of the care net when transitioning to adult age. Sometimes this happens because these individuals disengage with the care system, although they might resort to it again if their symptoms aggravate or after a life crisis [ 9 ]. Other common reasons why young people stop accessing treatment after transitioning to adult age are: increased perception of medications' adverse consequences, the idea of ADHD as a childhood disorder that does not require treatment for adults, changes in life circumstances leading to unintentional treatment cessation, lack of information and challenges in accessing services [ 10 , 11 ]. The difficulties in accessing services are particularly relevant as should be addressed, since care may not be guaranteed even for patients that require it the most. Supporting the transition phase is essential, as made evident by the low percentages of ADHD patients referred to adult services in many European countries [ 12 ]. A review that included eight studies (six from the UK, one from Hong Kong, and one from Italy) analyzed the commonalities in perceived transition issues [ 13 ]. The emerging themes were summarized in five categories. The first category comprised the lack of information, preparation, transition planning, parallel care of the services, and families' involvement. This domain also opened the question of the right transitioning age, with significant variations within and between studies. The second category was related to the lack of appropriate adult services and difficulties in identifying available services. The accessibility (i.e., long waiting lists and stigma associated with accessing a mental health service) and the high rates of unaccepted cases by adult services were also reported. The third category comprised the limited resources and competencies of adult services (i.e., need for more education, training, skill development, and adequate treatment individuation in clinicians of adult services). The fourth category described the inadequate care when pediatric clinicians held onto the patients beyond age boundaries or, conversely, the lack of supervision, leading to feelings of abandonment and perception of poor management of the condition. The fifth category considered the negative impact of a bad transitioning process on the patient's well-being. In attempting to overcome these issues, standard protocols and guidelines were designed in a few countries. In the UK, the National Institute for Clinical Excellence (NICE 2008, 2019) other than providing criteria for diagnosing and managing ADHD in children suggested a shared planning to organize the transition process [ 14 ]. One of the recommendations enclosed in these guidelines is that services " put in place systems of communication and protocols for information sharing among paediatric, child and adolescent, forensic, and adult mental health services for people with ADHD, including arrangements for transition between child and adult services ." Similar protocols exist in other countries, although their efficacy is not ensured. For instance, the TRACK study in England [ 15 , 16 ] and the IMPACT review in Northern Ireland [ 17 ] reported that very few patients receive optimal care in the transition process. The MILESTONE project [ 18 ] was the first to implement a new intervention applied in eight European countries to transitioning patients with several clinical diagnoses. The project showed that in the case of general mental disorders, a structured assessment of transition needs facilitates an appropriate planning process (shared between professionals, patients, and families). Nonetheless, this intervention was never specifically applied with neurodevelopmental disorders. More work is needed to inform clinicians and families on how the ADHD transitioning process can be successful and how to overcome the difficulties due to the so-called ' leaky pipelines' [ 19 ] through which patients disperse. Within the Italian National Health Service, to date there are no specific indications for and how to organize the transition to adult care. Just as there are no specific indications from the various scientific societies. With the present study, we aim to fill this gap by considering the opinion of professionals working with transitioning ADHD patients in the Italian territory. By collecting information on the available services, we assess the status of the ADHD transition process in the Italian territory. Moreover, by asking clinicians to report their observations on the transition process, we seek to evaluate whether their reported limitations are consistent with the five points highlighted by Price and colleagues (2019). Ideally, the collected evidence will be able to draw a picture of the current state of the procedures and design desirable future trajectories. Methods The TransiDEA (Transitioning in Diabetes, Epilepsy and ADHD patients) is an Italian project that aims to define and evaluate the feasibility of treatment programs for the transition from adolescence to adulthood in the ADHD, Epilepsy, and Diabetes pathological fields. It involves patients, parents, and clinicians as part of a collaborative and shared project. As a first step, the aim was to define the current situation concerning how adult and pediatric services manage the transition phase. The present work reports findings limited to the ADHD centers. The head of 89 national Child and Adolescent Mental Health Services (CAMHS) and 257 Adult Mental Health Services (AMHS) received a letter explaining the project's aims and the invitation to participate by completing the web-based questionnaire. It was also stated that the results would be reported and that they would be informed of the project's continuation. Three further reminders were sent to improve the recruitment rates. Two surveys were developed, one for pediatric and one for adult services. The two versions differed in questions about sending (pediatric services) or receiving (adult services) patients. The questions were adapted from previous surveys [ 20 , 21 ]. The structure of the surveys was as follows: An initial information screening on the centers: region, type of service, number of ADHD patients, presence of a specific service dedicated to ADHD patients, and pharmacological treatments administered; Questions on the transition process: number of patients in transition within the past year, sent to or coming from which services, for the services that formalize a preparation phase, starting from which age; Questions for centers that actively refer patients: Centers that refer to adult services (only for pediatric services): effective age at referral, criteria for referral (age, clinical characteristics, other aspects); Whether respondents feel that they received appropriate/sufficient information (only for adult services); Methods of the referral, or receiving, of the patients (e-mail, telephone, letters, information sheets, or other forms), the time required, whether an interview is also planned (with the patient, with the family, or between the services), professional figures involved (psychiatrists, psychologists, nurses, administrative officers, therapists, social workers, educators); Whether it is beneficial that both services have an active role in the transition phase, how long they believe that an optimal transition should be, in how many sessions, whether both specialists' teams should be present, and where it should be carried out (CAMHS, AMHS, a third facility, remotely, or if it does not matter); Whether services have a protocol, and whether it is specific for ADHD or generic; Whether services foresee a monitoring phase; Whether services also have disability care pathways; Questions on limitations, unmet needs, and desired changes in dealing with transitioning ADHD patients. The study was notified to the IRCCS "Carlo Besta" Foundation Ethics Committee (8 September 2021, protocol n. 87). The study was performed in accordance with the ethical standards of the 1964 Declaration of Helsinki and its later amendments. We followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. The analyses reported are descriptive. Data are reported as the number and percentage of responders, and continuous variables are summarized by reporting median values and interval ranges. Results Out of 89 the CAMHS and 257 AMHS contacted, 77 centers (22% of those 346 contacted initially) filled in the survey (47% CAMHS and 14% AMHS) between December 2021 and May 2022. Within the Italian National Health Service, the organizational structure and distribution of CAMHS and AMHS is based on the resident population by age, so although the response rate is low it is presumable that there are no marked differences between the responding and non-responding centers. A description of the services is reported in Table 1 . Table 1 Number and geographical distribution of the services that took part in the web-based survey. The table also reports the number of ADHD patients, the number of services that currently have ADHD patients, and the number of services that have a dedicated ADHD unit. CAMHS AMHS Number of services 42 35 Area North 33 23 Center 4 7 South 5 5 Number of total ADHD patients Minors 7262 - Adults 210 (3% of all ADHD patients) 656 min 2 - max 250 Services that currently have adult ADHD patients 17 (40%) 23 (66%) Services with a dedicated ADHD unit 33 (79%) 10 with specialists' teams since 2017 (min 2012 - max 2021) The transition process Seventy-four percent of the CAMHS (all with a dedicated service) reported cases of transition (n = 31), for a total of 206 patients, while 43% of the AMHS (8 with a dedicated team of specialists) had transitioning patients in the past year (n = 15), for a total of 167 patients. The majority of the CAMHS referred their patients primarily to a private psychiatrist (80%, n = 34) and then to an AMHS (38%, n = 16), while most AMHS reported that patients were coming from the CAMHS (40%, n = 14). Twenty-three CAMHS (55%) have a formalized preparation phase, ideally taking place at 17 years of age (range: 16–19). Eighty-three percent of the CAMHS (n = 35) prescribed methylphenidate and atomoxetine, while only 54.3% (n = 19) of the AMHS prescribed these drugs. Services that referred patients During the year preceding the survey, 36 CAMHS (85%) were involved in the transition process of 15 to 21 year-old patients (Median = 18 years). The median transitioning age corresponded to the age criteria for referral, which was also 18 years. Nonetheless, the intended window for transitioning was narrower, ranging from a minimum of 17 years of age to a maximum of 19 years. The most frequent criteria that CAMHS used for patients' selection for transitioning were age (83%) and clinical features (comorbidities, severe symptoms, and drug treatment) (31%). Eight of the 11 AMHS who received ADHD patients in transition received appropriate and sufficient information about the patients. Figure 1 summarizes the methods, the time required, the interviews planned, and the professional figures involved in the transition process. The main differences between child and adult services were that adult services reported involving nurses and other professional figures more than CAMHS, as well as the use of information sheets. CAMHS, on the other hand, favored different information and communication channels, such as e-mail, phone, and letters. Figure 1. Methods, time required, interviews planned, and professional figures involved in the transition process for both CAMHS and AMHS. Compilers were given the opportunity to provide multiple responses. Services' role in the transition Sixty-nine percent of the CAMHS (n = 29) and 91% of the AMHS (n = 32) considered it beneficial that both services have an active role in the transition phase (11 of the AMHS and 22 of the CAMHS who received or sent ADHD patients in the previous year). CAMHS consider that an optimal transition should take two meetings (range: 1–6) in a nine-week window, while AMHS indicated seven meetings (range: 1–50). 15 of the CAMHS (36%) and 21 of the AMHS (91% of the 23 with ADHD patients) report that both specialists' teams should be present when discussing the case of a transitioning patient. Both types of services would prefer that meetings were carried out in their facilities (Table 2 ). Table 2 CAMHS and AMHS responses to where meetings regarding transitioning ADHD patients should be carried out. Where should the meetings with transitioning patients take place? CAMHS AMHS CAMHS 7 4 AMHS 5 8 A third facility 0 2 Remotely 1 1 It does not matter 2 6 Protocol, monitoring phase, and disability care pathways Ten CAMHS (24% of all centers, 39% of those who sent patients in the previous year) and 11 AMHS reported having a transition protocol (32% of all centers, 50% of the centers with ADHD patients). Of these, only 3 CAMHS and 2 AMHS had a protocol specific to ADHD patients. Only 4 of the participating CAMHS (9%) and 5 of the AMHS (15%) reported foreseeing a monitoring phase. 22 of the CAMS (52%) and 5 of the AMHS (15%) plan disability care pathways. Limitations, unmet needs, and desired changes in dealing with transitioning ADHD patients Twenty-seven CAMHS (64%) reported limitations, and 30 (71%) desired changes, while 19 AMHS (54%) reported limitations, 25 (71%) unmet needs, and 31 (89%) desired changes. Those who answered positively could write down what they perceived as a limitation or what they envisioned as a future possibility. As for limitations, some emerging common themes pertained to the integration amongst services, communication issues, lack of resources, organizational problems, and lack of treatment continuity. CAMHS workers also described the lack of AMHS psychiatrists' training as highly problematic, the lack of shared training, and the absence of reliable protocols. Moreover, AMHS reported the need to potentiate services, rehabilitation pathways, and ease-of-access to pharmacological treatments. The difficulty in dealing with diagnoses and disorders and issues in communicating with the families were also reported. Regarding future desired changes, both CAMHS and AMHS, again, reported working on the lack of resources and organizational problems, adding the implementation of strategies to better deal with the diagnostic process, and with the improvement of psychiatrists' training. AMHS services added the need to work on services' integration and communication, and CAMHS services listed the need to design standard protocols and shared training. AMHS centers did not foresee any functional changes in dealing with the families, although they perceived this as an issue. These themes are summarized in Fig. 2. Figure 2. Limitations and desired changes in the future as reported by both CAMHS and AMHS. Some observations are shared (centered), others are limited to CAMHS (left side) or AMHS (right side). Discussion The transitioning process entails many changes and difficulties of which clinicians, patients, and families can be more or less aware. Although some guidelines exist in many countries (e.g., the NICE guidelines in the UK), their efficacy and generalizability have not yet been accurately evaluated. In Italy, only two studies have assessed the situation, one at the single province level (i.e., Modena) [ 22 ], and one at the regional level for the Lombardy Region [ 21 ]. The latter involved a total of 18 services in an exploratory study investigating the health care management and continuity for young adults with ADHD. In this region, regional ADHD territorial services are accredited in regional hospitals, and therefore linked to CAMHS, and often deal with the transition process of ADHD patients towards a shift in care by AMHS. Nonetheless, what emerged from Reale and colleagues is that in 2018, out of these 18 centers, only four reported having a protocol to manage the transition process, and none of those protocols were specific for ADHD patients [ 21 ]. Moreover, while it seems that previously hospitalized adolescents have a 50% chance of being successfully transferred to an AMHS and that higher engagement was witnessed within the first two years [ 23 ], this rate was limited to a narrow territory (i.e., the Province of Modena). No studies considered the professionals' opinion, nor did they cover the whole national territory. Additionally, the factors contributing to a successful transition process in the country are unknown. The present study aimed to draw a picture of the current state of the transitioning process in Italy. We asked the professional figures involved (i.e., CAMHS and AMHS workers) how the transitioning process happens and to describe the issues they perceive as problematic, along with their needs. From the clinicians' point of view it is essential to delineate the services' functioning and guarantee the availability of adequate services that are sensitive to patients' needs. We achieved an acceptable geographical representation, with a total of seventy-seven respondents (42 working in CAMHS and 35 in AMHS) from 18 of the 20 Italian regions. The analysis of the survey responses drew an interesting picture. While 74% of the CAMHS reported following transitioning patients in the previous year, only 43% of the AMHS stated the same. This means that many patients still get lost in the process. Some of these patients are sent to private psychiatrists or psychologists, falling out of the public health system nonetheless. In other cases, adult patients continue to be treated by CAMHS (in our sample, this happened for 210 patients, distributed in 40% of the CAMHS). Moreover, the ideal age range for transitioning would be between 17 and 19 years of age, while the time window actually needed is wider, involving patients between 15 and 21 years of age. Even when the transition is completed by the 18 years of age mark, the gap with what would be defined by protocols is considerable. While these data suggest that organizational problems affect day-to-day transition process management, many more factors that hinder a successful transition are consciously reported as unmet needs or desired changes. Such observations largely overlap with the first three dimensions reported by Price and colleagues [ 13 ]. First , the lack of professionals' preparation, transition planning, protocols, and parallel care of the services. In this domain, we also included the absence of training and competencies in adult services. Secondly , the lack of appropriate adult services. The AMHS are aware of the need to potentiate the services they provide, such as rehabilitation pathways, and access to pharmacological treatment. Third , the limitations due to the lack of resources and organizational problems. Both CAMHS and AMHS professionals strongly felt this theme. Interestingly, what was highlighted in this domain is the need to develop strategies to efficiently follow the transition with the available resources rather than to increase the resources. Only one AMHS raised the issue of communicating with the families. When describing how they arranged the meetings between services, only 21 AMHS and 28 CAMHS declared that they involve the patients' families in the process. The families had, on the other hand, a central role in other studies [ 13 , 24 ]. The scarce consideration of families in the Italian transition organization may contribute to the lack of a smooth passage, given that these patients are still vastly dependent on their parents' support. Moreover, a theme that often emerged was the lack of adequate training for professionals working in the AMHS. Once again, from the opposite viewpoint, more than half of those same professionals reported that they did not receive enough adequate information (only 48% said that they did). Another observation in this respect is that only 61% of the CAMHS that sent patients to AMHS in the previous year think it would be helpful to actively involve both services in the transition phase. Having formal guidelines to smooth the communication between the two parties in the process might also help improve communication and outcomes. This observation sheds attention on the need for specific protocols to address the needs of the ADHD population in the transition phase. We asked the 21 services that reported having a protocol whether they could send it to us to investigate whether guidelines already exist, need improvement, or if there is a complete lack of efficient protocols. Notably, while in 2018, in the Lombardy region [ 21 ], no pediatric centers were reported to have a specific protocol for one of the neurodevelopmental disorders, from our survey, it emerged that three pediatric centers do (2 within the same region). Nonetheless, they regard Autism Spectrum Disorder, Schizophrenia, and Behavioral Disorders, while no protocol specific to ADHD exists. Many more centers have a non-specific protocol (n = 10 CAMHS, n = 11 AMHS) or do not have a protocol (76% of CAMHS, 78% of AMHS). We received the full version of six protocols, four from CAMHS and two from AMHS. All were characterized by the working group's definition, the number of meetings and the corresponding figures involved (i.e., patients, CAMHS, and AMHS specialists), and the criteria to select patients, including the age window. One protocol also included the possibility of defining personalized trajectories based on specific needs. With the available resources, defining individual care paths does not emerge as a priority, as confirmed by the fact that no respondent listed individual needs in future directions. Instead, it would be desirable to have flexible enough guidelines to allow for a certain degree of customization, considering the available assets. In our survey, only when provided space to write notes on the transition process did eight clinicians report more psychological considerations, such as the importance of paying attention to individuality, culture, and personal experiences concerning the care process. While most of these essential points were shared, the degree of detail differed widely. Suffice it to say that some protocols are only 2 to 5 pages long, while others are up to 25 pages long. In the future, the need for a standard protocol should be addressed. We believe that it should fall somewhere in between the existing ones: while short protocols are not detailed enough, excessively long protocols may be complicated to use daily in a reality of scarse resources. A limitation of this study is the reduced sample size. Although the included services are not expected to differ from the ones that did not participate, reaching a wider number of professionals would have ensured a better representation on the practices adopted at a national level. Moreover, most of the services that took part in the survey are located in large cities, mostly in northern Italy. A limitation that this survey and the results obtained could-should help to overcome. Nonetheless, we think that the merits of this survey's observations are several. First, it constitutes the first attempt to draw a picture of the transitioning patients from the professionals' point of view. It collects practical information and allows a highlighting of needs and desired changes. Moreover, it stands as the starting point for future work. As future steps of the TransiDEA project, the collected protocols will be analyzed in depth. Individual pathways of patients and their clinicians will then be analyzed, leading to the definition of standardized guidelines. To do so, individual stakeholders from across Italy, including patients, parents or caregivers, clinicians from CAMHS and AMHS, and possibly general practitioners [ 24 ] will be involved. Conclusions A successful transition process is crucial for the future of ADHD patients. However, as reflected by this survey conducted in Italy, there are currently many difficulties hindering this process. The priority in the near future must be the definition of standard guidelines that can facilitate a successful transition. Abbreviations ADHD Attention-Deficit/Hyperactivity Disorder TransiDEA Transitioning in Diabetes, Epilepsy and ADHD CAMHS Child and Adolescent Mental Health Services AMHS Adult Mental Health Services NICE National Institute for Clinical Excellence Declarations Ethics approval and consent to participate: The study "Transition care between adolescent and adult services for young people with chronic health needs in Italy", (RF-2019-12371228) was conducted in accordance with the Declaration of Helsinki, and approved by the IRCCS "Carlo Besta" Ethics Committee (ethics committee of reference for the Mario Negri IRCCS Institute) (8 September 2021, protocol n. 87). No data concerning single individuals were analyzed. Therefore, no anonymization was necessary, and no informed consent to participate was required. Consent for publication: Not applicable. The article does not contain personal medical information about any identifiable living individual. No data concerning single individuals were analyzed. Therefore, no explicit consent for publication was required. Availability of data and materials: The data and the materials presented in this study are available on request from the corresponding author. Competing interests: The authors have no conflicts of interest relevant to this article to disclose. The authors have no relevant financial or non-financial interests to disclose. All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript. Funding: The study is part of the project ""Transition care between adolescent and adult services for young people with chronic health needs in Italy"", funded by the Italian Ministry of Health (RF-2019-12371228) Authors' contributions: MB coordinated the study with the help of the TransiDEA Group. MB, ER, FS, RC, MG, and AC analyzed the data and prepared the results. MB, ER, and A.C. wrote the first draft of the manuscript. MB and AC participated in the design and execution of the study. All authors edited the manuscript. All participants of the TransiDEA group discussed and approved the final version. MB is the guarantor. Acknowledgements: The authors would like to acknowledge Chiara Pandolfini for language editing. Moreover the authors would like to thank the centers that took part in the survey: "Papa Giovanni XXIII" Hospital, Bergamo (Dr. Patrizia Stoppa); "A. Manzoni" Hospital, Lecco (Dr. Ottaviano Martinelli); “ASST Lod” Hospital, Lodi (Dr. Paola Morosini); "Carlo Poma" Hospital, Mantova (Dr. Giuseppe Capovilla); “IRCCS Cà Granda Ospedale Maggiore Policlinico Foundation”, Milano (Dr. Maria Antonella Costantino); "G. Salvini" Hospital, Garbagnate Milanese (Dr. Federico Raviglione); "S. Anna" Hospital, Como (Dr. Patrizia Conti); "Del Ponte" Hospital, Varese (Dr. Giorgio Rossi); “ASST Cremona” Hospital, Cremona (Dr. Maria Teresa Giarelli); “Spedali Civili Presidio Ospedale dei Bambini” Hospital, Brescia (Prof. Elisa Maria Fazzi); "ASST Valtellina e Alto Lario" Hospital, Sondrio (Dr. Marialuisa Carpanelli); “ASST Santi Paolo e Carlo” Hospital, Milano (Prof. Maria Paola Canevini); “ASST Vallecamonica”, Sebino, Brescia (Dr. Francesco Rinaldi); “IRCCS Eugenio Medea - Associazione La Nostra Famiglia”, Lecco (Dr. Massimo Molteni); “Niguarda Cà Granda” Hospital, Milano (Prof. Aglaia Vignoli); “IRCCS Mondino Foundation”, Pavia (Prof. Renato Borgatti, Dr. Laura Farinotti); “Comprensorio sanitario di Merano Azienda Sanitaria dell’Alto Adige”, Merano (Dr. Donatella Arcangeli); CAMHS “ASL Liguria 2”, Savona (Dr. Paola Bona); CAMHS “ASL Liguria 5”, La Spezia (Dr. Franco Giovannoni); CAMHS “AV3 ASUR”, Macerata (Dr. Maurizio Pincherle); CAMHS, Firenze; “Azienda ospedaliero-universitaria Senese” Hospital, Siena (Dr. Roberto Canitano); CAMHS, Pescara (Dr. Elena Gennaro); “Ospedale Civile Giuseppe Mazzini” Hospital, Teramo (Dr. Chiara Caucci), “Federico II” Hospital, Napoli (Prof. Carmela Bravaccio); “AOU Sassari, Divisione Neuropsichiatria Infantile” (Prof. Stefano Sotgiu); “Centro di Riferimento per l'ADHD-Asp”, Catania (Dr. Giancarlo Costanza); “AO S. Croce e Carle”, Cuneo (Dr. Eleonora Briatore); “Ospedale Infantile Regina Margherita” Hospital, Torino (Dr. Benedetto Vitiello); “Azienda Sanitaria Universitaria Integrata”, Udine (Dr. Giuseppe Zappulla); “Ospedale Santo Spirito”, Bra (Dr. Elisa Colombi); “Asst- Valle Olona”, Gallarate (Dr. Mariarosa Ferrario); “Associazione La Nostra Famiglia”, Treviso (Dr. Malida Franzoi); “Associazione La Nostra Famiglia” San Donà di Piave and Conegliano (Dr. Federica Martinez); “ASL Novara”, Borgomanero; “Ospedale Beauregard Azienda USL Valle d’Aosta”, Aosta (Dr. Laure Obino); “IRCCS Burlo Garofalo”, Trieste (Dr. Marco Carrozzi); “Dipartimento Salute Mentale e delle Dipendenze”, ASST Melegnano e della Martesana (Dr. Federico Durbano); AMHS “Assisano Media Valle del Tevere”, Assisi (Dr. Marco Grignani); AMHS, Perugia (Dr. Marco Grignani); “ASL Roma 1”, Roma (Dr. Alessandro Antonucci); AMHS, S. Giovanni Valdarno; AMHS, Foligno (Dr. Angelo Rella); AMHS “D5 Casilina”, Roma (Dr. Pietro Di Paolo); AMHS, Salerno (Dr. Germano Fiore); AMHS, Soverato; AMHS, Lecce; AMHS, Cerignola - Orta Nova (Dr. Gianluca Piemontese); “Struttura Complessa di Psichiatria Mantova 1”, Castiglione delle Steviere (Dr. Giulio De Nicola); “Azienda Sanitaria dell'Alto Adige”, Bolzano (Dr. Andres Conca); “Struttura Complessa Di Psichiatria, Dsmd Asst”, Monza; AMHS, Mugnano (Dr. Angelo Cucciniello); CPS - Treviglio (Dr. Moro Anna Rosa); AMHS, Rozzano; “ASST Valtellina e Alto Lario”, Sondrio (Dr. Giorgio Francobandiera; Dr. Maria Carla Moraca); “Dipartimento Salute Mentale ASL TO4 Piemonte”, Ivrea; AMHS, Brescia (Dr. Paola Corsini); “Servizi di salute mentale 3 distretto asl Roma 1”, Roma (Dr. Alessandro Antonucci); “ASST Papa Giovanni”, Bergamo (Dr. Emi Bondi); AMHS “Mantova 1”, Mantova; AMHS, Voghera, Stradella (Dr. Luisa Aroasio); AMHS, Chiavari; AMHS, Verona (Dr. Giuseppe Imperadore); AMHS, Genova (Dr. Daniela Malagamba); AMHS, Varese (Prof. Camilla Callegari); “ASST Rhodense”, Garbagnate Milanese (Dr. Marco Toscano); AMHS, San Daniele del Friuli; AMHS “ASL Roma 1”, Roma (Dr. Gialuigi Di Cesare); AMHS, Piacenza (Dr. Corrado Cappa); “Azienda Ulss 8 Berica”, Vicenza (Dr. Francesco Gardellin); AMHS “ASL CN2”, Bra (Dr. Elio Laudani). TransiDEA group members : Coordinating and Managing Group: Maurizio Bonati, Antonio Clavenna, Nicoletta Raschitelli, Francesca Scarpellini, Elisa Roberti, Rita Campi, Michele Giardino, Michele Zanetti, Massimo Cartabia; Diabetes (D): Vanna Graziani, Federico Marchetti, Tosca Suprani, Paolo Di Bartolo; Epilepsy (E): Maria Paola Canevini, Ilaria Viganò; ADHD (A): Ilaria Costantino, Valeria Tessarollo; Scientific technical committee (CTS): Giampaolo Ruffoni. References Faraone SV, Banaschewski T, Coghill D, Zheng Y, Biederman J, Bellgrove MA, et al. The World Federation of ADHD International Consensus Statement: 208 Evidence-based conclusions about the disorder. Neurosci Biobehav Rev. 2021;128:789–818. https://doi.org/10.1016/j.neubiorev.2021.01.022 . Polanczyk GV, Willcutt EG, Salum GA, Kieling C, Rohde LA. ADHD prevalence estimates across three decades: an updated systematic review and meta-regression analysis. Int J Epidemiol. 2014;43:434–42. https://doi.org/10.1093/ije/dyt261 . Reale L, Bonati M. ADHD prevalence estimates in Italian children and adolescents: a methodological issue. Ital J Pediatr. 2018;44:108. https://doi.org/10.1186/s13052-018-0545-2 . Reale L, Bartoli B, Cartabia M, Zanetti M, Costantino MA, Canevini MP, et al. Comorbidity prevalence and treatment outcome in children and adolescents with ADHD. Eur Child Adolesc Psychiatry. 2017;26:1443–57. https://doi.org/10.1007/s00787-017-1005-z . McGough JJ, Barkley RA. Diagnostic Controversies in Adult Attention Deficit Hyperactivity Disorder. Am J Psychiatry. 2004;161:1948–56. https://doi.org/10.1176/appi.ajp.161.11.1948 . Sibley MH, Mitchell JT, Becker SP. Method of adult diagnosis influences estimated persistence of childhood ADHD: a systematic review of longitudinal studies. Lancet Psychiatry. 2016;3:1157–65. https://doi.org/10.1016/S2215-0366(16)30190-0 . Song P, Zha M, Yang Q, Zhang Y, Li X, Rudan I. The prevalence of adult attention-deficit hyperactivity disorder: A global systematic review and meta-analysis. J Glob Health. 2021;11:04009. https://doi.org/10.7189/jogh.11.04009 . Faraone SV, Biederman J, Mick E. The age-dependent decline of attention deficit hyperactivity disorder: a meta-analysis of follow-up studies. Psychol Med. 2006;36:159–65. https://doi.org/10.1017/S003329170500471X . Young S, Murphy CM, Coghill D. Avoiding the twilight zone: recommendations for the transition of services from adolescence to adulthood for young people with ADHD. BMC Psychiatry. 2011;11:174. https://doi.org/10.1186/1471-244X-11-174 . Titheradge D, Godfrey J, Eke H, Price A, Ford T, Janssens A. Why young people stop taking their attention deficit hyperactivity disorder medication: A thematic analysis of interviews with young people. Child Care Health Dev. 2022;cch12978. https://doi.org/10.1111/cch.12978 . Hansen AS, Telléus GK, Mohr-Jensen C, Lauritsen MB. Parent-perceived barriers to accessing services for their child’s mental health problems. Child Adolesc Psychiatry Ment Health. 2021;15:4. https://doi.org/10.1186/s13034-021-00357-7 . Kooij SJ, Bejerot S, Blackwell A, Caci H, Casas-Brugué M, Carpentier PJ, et al. European consensus statement on diagnosis and treatment of adult ADHD: The European Network Adult ADHD. BMC Psychiatry. 2010;10:67. https://doi.org/10.1186/1471-244X-10-67 . Price A, Janssens A, Woodley AL, Allwood M, Ford T, Review. Experiences of healthcare transitions for young people with attention deficit hyperactivity disorder: a systematic review of qualitative research. Child Adolesc Ment Health. 2019;24:113–22. https://doi.org/10.1111/camh.12297 . National Institute for Health & Care Excellence. NICE Clinical Guideline [CG177] Osteoarthritis: Care and Management in Adults. London: National Institute for Health & Care Excellence; 2019. Islam Z, Ford T, Kramer T, Paul M, Parsons H, Harley K, et al. Mind how you cross the gap! Outcomes for young people who failed to make the transition from child to adult services: the TRACK study. BJPsych Bull. 2016;40:142–8. https://doi.org/10.1192/pb.bp.115.050690 . Singh SP, Paul M, Ford T, Kramer T, Weaver T, McLaren S, et al. Process, outcome and experience of transition from child to adult mental healthcare: multiperspective study. Br J Psychiatry. 2010;197:305–12. https://doi.org/10.1192/bjp.bp.109.075135 . Leavey G, McGrellis S, Forbes T, Thampi A, Davidson G, Rosato M, et al. Improving mental health pathways and care for adolescents in transition to adult services (IMPACT): a retrospective case note review of social and clinical determinants of transition. Soc Psychiatry Psychiatr Epidemiol. 2019;54:955–63. https://doi.org/10.1007/s00127-019-01684-z . Singh SP, Tuomainen H, Bouliotis G, Canaway A, De Girolamo G, Dieleman GC et al. Effect of managed transition on mental health outcomes for young people at the child–adult mental health service boundary: a randomised clinical trial. Psychol Med 2021:1–12. https://doi.org/10.1017/S0033291721003901 . Anderson JK, Newlove-Delgado T, Ford TJ. Annual Research Review: A systematic review of mental health services for emerging adults – moulding a precipice into a smooth passage. J Child Psychol Psychiatry. 2022;63:447–62. https://doi.org/10.1111/jcpp.13561 . Reale L, Frassica S, Gollner A, Bonati M. Transition to adult mental health services for young people with attention deficit hyperactivity disorder in Italy: Parents’ and clinicians’ experiences. Postgrad Med. 2015;127:671–6. https://doi.org/10.1080/00325481.2015.1070658 . Reale L, Costantino MA, Sequi M, Bonati M. Transition to Adult Mental Health Services for Young People With ADHD. J Atten Disord. 2018;22:601–8. https://doi.org/10.1177/1087054714560823 . Pontoni G, Di Pietro E, Neri T, Mattei G, Longo F, Neviani V, et al. Factors associated with the transition of adolescent inpatients from an intensive residential ward to adult mental health services. Eur Child Adolesc Psychiatry. 2022;31:805–18. https://doi.org/10.1007/s00787-020-01717-y . Pontoni G, Di Pietro E, Neri T, Mattei G, Longo F, Neviani V, et al. Factors associated with the transition of adolescent inpatients from an intensive residential ward to adult mental health services. Eur Child Adolesc Psychiatry. 2022;31:805–18. https://doi.org/10.1007/s00787-020-01717-y . Price A, Mitchell S, Janssens A, Eke H, Ford T, Newlove-Delgado T. In transition with attention deficit hyperactivity disorder (ADHD): children’s services clinicians’ perspectives on the role of information in healthcare transitions for young people with ADHD. BMC Psychiatry. 2022;22:251. https://doi.org/10.1186/s12888-022-03813-6 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 28 Nov, 2023 Read the published version in Child and Adolescent Psychiatry and Mental Health → Version 2 posted Reviewers agreed at journal 26 Sep, 2023 Reviewers invited by journal 26 Sep, 2023 Editor assigned by journal 21 Sep, 2023 Submission checks completed at journal 21 Sep, 2023 First submitted to journal 20 Sep, 2023 You are reading this latest preprint version Show more versions Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2470407","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[{"code":1,"date":"2023-01-16 15:46:06","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":236744287,"identity":"4ec71291-423e-41bd-9697-47dd137b55eb","order_by":0,"name":"Elisa Roberti","email":"","orcid":"","institution":"Istituto di Ricerche Farmacologiche Mario Negri IRCCS","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Elisa","middleName":"","lastName":"Roberti","suffix":""},{"id":236744288,"identity":"e7b089d2-0c5f-4472-8dd9-d752b0a9bc78","order_by":1,"name":"Francesca Scarpellini","email":"","orcid":"","institution":"Istituto di Ricerche Farmacologiche Mario Negri IRCCS","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Francesca","middleName":"","lastName":"Scarpellini","suffix":""},{"id":236744289,"identity":"321b4fc9-f385-40f8-9ab7-7768fad8570b","order_by":2,"name":"Rita Campi","email":"","orcid":"","institution":"Istituto di Ricerche Farmacologiche Mario Negri IRCCS","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Rita","middleName":"","lastName":"Campi","suffix":""},{"id":236744290,"identity":"54cb2983-4c6f-4a62-90ee-17d3d61ba4e7","order_by":3,"name":"Michele Giardino","email":"","orcid":"","institution":"Istituto di Ricerche Farmacologiche Mario Negri IRCCS","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Michele","middleName":"","lastName":"Giardino","suffix":""},{"id":236744291,"identity":"99aa16f1-dd15-4f45-ab17-a467240da78a","order_by":4,"name":"Antonio Clavenna","email":"","orcid":"","institution":"Istituto di Ricerche Farmacologiche Mario Negri IRCCS","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Antonio","middleName":"","lastName":"Clavenna","suffix":""},{"id":236744292,"identity":"5c8c6c7f-d073-43c2-b551-0ce42735c6ca","order_by":5,"name":"Maurizio Bonati","email":"data:image/png;base64,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","orcid":"","institution":"Istituto di Ricerche Farmacologiche Mario Negri IRCCS","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Maurizio","middleName":"","lastName":"Bonati","suffix":""}],"badges":[],"createdAt":"2023-01-12 09:29:26","currentVersionCode":2,"declarations":"","doi":"10.21203/rs.3.rs-2470407/v2","doiUrl":"https://doi.org/10.21203/rs.3.rs-2470407/v2","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13034-023-00678-9","type":"published","date":"2023-11-28T15:01:56+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":43849082,"identity":"a2aa1b4e-fc87-4c5d-9f7d-6b0daa9bfe2e","added_by":"auto","created_at":"2023-09-27 21:56:30","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":81961,"visible":true,"origin":"","legend":"\u003cp\u003eMethods, time required, interviews planned, and professional figures involved in the transition process for both CAMHS and AMHS. Compilers were given the opportunity to provide multiple responses.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3372131/v1/3613e3b7eed86c170e32fb2e.jpg"},{"id":43849086,"identity":"82c2256a-da43-40e3-b007-f9e26b2aedb5","added_by":"auto","created_at":"2023-09-27 21:56:30","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":115313,"visible":true,"origin":"","legend":"\u003cp\u003eLimitations and desired changes in the future as reported by both CAMHS and AMHS. Some observations are shared (centered), others are limited to CAMHS (left side) or AMHS (right side).\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3372131/v1/093cbec7a8df57e32e60efd8.jpg"},{"id":47561402,"identity":"abbcfb09-ab01-4385-89b7-b0f202d54523","added_by":"auto","created_at":"2023-12-04 15:11:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":552950,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2470407/v2/3afd40c0-6ec5-44d6-a5fe-518fe4aa1cdd.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Child and Adolescent Psychiatry and Mental Health Transitioning to Adult Mental Health Services for young people with ADHD: an Italian-based Survey on practices for Pediatric and Adult Services","fulltext":[{"header":"Background","content":"\u003cp\u003eAttention-Deficit/Hyperactivity Disorder (ADHD) is a common psychiatric disorder in childhood and adolescence, with an average prevalence of 5.9% based on symptoms criteria [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] and a prevalence of 2.9% in Italy [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. While ADHD is a considered a neurodevelopmental syndrome that impacts children's daily life functioning [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], it affects adults as well, with a prevalence of around 2.2% [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Compared with childhood ADHD, adult symptomatology lacks validated diagnostic criteria and is relatively neglected in epidemiological studies [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Notably, while most symptoms that have their onset in the pediatric age continue to manifest throughout adolescence, they often persist (albeit with less impact) in adult life for up to two-thirds of the patients [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Yet, adolescents in care for ADHD often stop treatment altogether, and adults with ADHD frequently fall out of the care net when transitioning to adult age. Sometimes this happens because these individuals disengage with the care system, although they might resort to it again if their symptoms aggravate or after a life crisis [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Other common reasons why young people stop accessing treatment after transitioning to adult age are: increased perception of medications' adverse consequences, the idea of ADHD as a childhood disorder that does not require treatment for adults, changes in life circumstances leading to unintentional treatment cessation, lack of information and challenges in accessing services [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The difficulties in accessing services are particularly relevant as should be addressed, since care may not be guaranteed even for patients that require it the most.\u003c/p\u003e \u003cp\u003eSupporting the transition phase is essential, as made evident by the low percentages of ADHD patients referred to adult services in many European countries [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. A review that included eight studies (six from the UK, one from Hong Kong, and one from Italy) analyzed the commonalities in perceived transition issues [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The emerging themes were summarized in five categories. The \u003cb\u003efirst category\u003c/b\u003e comprised the lack of information, preparation, transition planning, parallel care of the services, and families' involvement. This domain also opened the question of the right transitioning age, with significant variations within and between studies. The \u003cb\u003esecond category\u003c/b\u003e was related to the lack of appropriate adult services and difficulties in identifying available services. The accessibility (i.e., long waiting lists and stigma associated with accessing a mental health service) and the high rates of unaccepted cases by adult services were also reported. The \u003cb\u003ethird category\u003c/b\u003e comprised the limited resources and competencies of adult services (i.e., need for more education, training, skill development, and adequate treatment individuation in clinicians of adult services). The \u003cb\u003efourth category\u003c/b\u003e described the inadequate care when pediatric clinicians held onto the patients beyond age boundaries or, conversely, the lack of supervision, leading to feelings of abandonment and perception of poor management of the condition. The \u003cb\u003efifth category\u003c/b\u003e considered the negative impact of a bad transitioning process on the patient's well-being.\u003c/p\u003e \u003cp\u003e In attempting to overcome these issues, standard protocols and guidelines were designed in a few countries. In the UK, the National Institute for Clinical Excellence (NICE 2008, 2019) other than providing criteria for diagnosing and managing ADHD in children suggested a shared planning to organize the transition process [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. One of the recommendations enclosed in these guidelines is that services \"\u003cem\u003eput in place systems of communication and protocols for information sharing among paediatric, child and adolescent, forensic, and adult mental health services for people with ADHD, including arrangements for transition between child and adult services\u003c/em\u003e.\" Similar protocols exist in other countries, although their efficacy is not ensured. For instance, the TRACK study in England [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] and the IMPACT review in Northern Ireland [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] reported that very few patients receive optimal care in the transition process. The MILESTONE project [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] was the first to implement a new intervention applied in eight European countries to transitioning patients with several clinical diagnoses. The project showed that in the case of general mental disorders, a structured assessment of transition needs facilitates an appropriate planning process (shared between professionals, patients, and families). Nonetheless, this intervention was never specifically applied with neurodevelopmental disorders.\u003c/p\u003e \u003cp\u003eMore work is needed to inform clinicians and families on how the ADHD transitioning process can be successful and how to overcome the difficulties due to the so-called '\u003cem\u003eleaky pipelines'\u003c/em\u003e [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] through which patients disperse. Within the Italian National Health Service, to date there are no specific indications for and how to organize the transition to adult care. Just as there are no specific indications from the various scientific societies.\u003c/p\u003e \u003cp\u003eWith the present study, we aim to fill this gap by considering the opinion of professionals working with transitioning ADHD patients in the Italian territory. By collecting information on the available services, we assess the status of the ADHD transition process in the Italian territory. Moreover, by asking clinicians to report their observations on the transition process, we seek to evaluate whether their reported limitations are consistent with the five points highlighted by Price and colleagues (2019). Ideally, the collected evidence will be able to draw a picture of the current state of the procedures and design desirable future trajectories.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe TransiDEA (Transitioning in Diabetes, Epilepsy and ADHD patients) is an Italian project that aims to define and evaluate the feasibility of treatment programs for the transition from adolescence to adulthood in the ADHD, Epilepsy, and Diabetes pathological fields. It involves patients, parents, and clinicians as part of a collaborative and shared project. As a first step, the aim was to define the current situation concerning how adult and pediatric services manage the transition phase. The present work reports findings limited to the ADHD centers. The head of 89 national Child and Adolescent Mental Health Services (CAMHS) and 257 Adult Mental Health Services (AMHS) received a letter explaining the project's aims and the invitation to participate by completing the web-based questionnaire. It was also stated that the results would be reported and that they would be informed of the project's continuation. Three further reminders were sent to improve the recruitment rates.\u003c/p\u003e \u003cp\u003eTwo surveys were developed, one for pediatric and one for adult services. The two versions differed in questions about sending (pediatric services) or receiving (adult services) patients. The questions were adapted from previous surveys [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The structure of the surveys was as follows:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eAn initial information screening on the centers: region, type of service, number of ADHD patients, presence of a specific service dedicated to ADHD patients, and pharmacological treatments administered;\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eQuestions on the transition process: number of patients in transition within the past year, sent to or coming from which services, for the services that formalize a preparation phase, starting from which age;\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eQuestions for centers that actively refer patients:\u003c/p\u003e \u003cp\u003e \u003col style=\"list-style-type: lower-alpha;\"\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eCenters that refer to adult services (only for pediatric services): effective age at referral, criteria for referral (age, clinical characteristics, other aspects);\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhether respondents feel that they received appropriate/sufficient information (only for adult services);\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eMethods of the referral, or receiving, of the patients (e-mail, telephone, letters, information sheets, or other forms), the time required, whether an interview is also planned (with the patient, with the family, or between the services), professional figures involved (psychiatrists, psychologists, nurses, administrative officers, therapists, social workers, educators);\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eWhether it is beneficial that both services have an active role in the transition phase, how long they believe that an optimal transition should be, in how many sessions, whether both specialists' teams should be present, and where it should be carried out (CAMHS, AMHS, a third facility, remotely, or if it does not matter);\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eWhether services have a protocol, and whether it is specific for ADHD or generic;\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eWhether services foresee a monitoring phase;\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eWhether services also have disability care pathways;\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eQuestions on limitations, unmet needs, and desired changes in dealing with transitioning ADHD patients.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e The study was notified to the IRCCS \"Carlo Besta\" Foundation Ethics Committee (8 September 2021, protocol n. 87). The study was performed in accordance with the ethical standards of the 1964 Declaration of Helsinki and its later amendments. We followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. The analyses reported are descriptive. Data are reported as the number and percentage of responders, and continuous variables are summarized by reporting median values and interval ranges.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOut of 89 the CAMHS and 257 AMHS contacted, 77 centers (22% of those 346 contacted initially) filled in the survey (47% CAMHS and 14% AMHS) between December 2021 and May 2022. Within the Italian National Health Service, the organizational structure and distribution of CAMHS and AMHS is based on the resident population by age, so although the response rate is low it is presumable that there are no marked differences between the responding and non-responding centers. A description of the services is reported in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eNumber and geographical distribution of the services that took part in the web-based survey. The table also reports the number of ADHD patients, the number of services that currently have ADHD patients, and the number of services that have a dedicated ADHD unit.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eCAMHS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c7\" namest=\"c4\"\u003e \u003cp\u003eAMHS\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNumber of services\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c7\" namest=\"c4\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eArea\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNorth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c7\" namest=\"c4\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCenter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c7\" namest=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSouth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c7\" namest=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNumber of total ADHD patients\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMinors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e7262\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c7\" namest=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdults\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e210\u003c/p\u003e \u003cp\u003e(3% of all ADHD patients)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c7\" namest=\"c4\"\u003e \u003cp\u003e656\u003c/p\u003e \u003cp\u003emin 2 - max 250\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eServices that currently have adult ADHD patients\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e17 (40%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c7\" namest=\"c4\"\u003e \u003cp\u003e23 (66%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eServices with a dedicated ADHD unit\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e33 (79%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c7\" namest=\"c4\"\u003e \u003cp\u003e10 with specialists' teams\u003c/p\u003e \u003cp\u003esince 2017 (min 2012 - max 2021)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eThe transition process\u003c/h2\u003e \u003cp\u003eSeventy-four percent of the CAMHS (all with a dedicated service) reported cases of transition (n\u0026thinsp;=\u0026thinsp;31), for a total of 206 patients, while 43% of the AMHS (8 with a dedicated team of specialists) had transitioning patients in the past year (n\u0026thinsp;=\u0026thinsp;15), for a total of 167 patients. The majority of the CAMHS referred their patients primarily to a private psychiatrist (80%, n\u0026thinsp;=\u0026thinsp;34) and then to an AMHS (38%, n\u0026thinsp;=\u0026thinsp;16), while most AMHS reported that patients were coming from the CAMHS (40%, n\u0026thinsp;=\u0026thinsp;14). Twenty-three CAMHS (55%) have a formalized preparation phase, ideally taking place at 17 years of age (range: 16\u0026ndash;19). Eighty-three percent of the CAMHS (n\u0026thinsp;=\u0026thinsp;35) prescribed methylphenidate and atomoxetine, while only 54.3% (n\u0026thinsp;=\u0026thinsp;19) of the AMHS prescribed these drugs.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eServices that referred patients\u003c/h2\u003e \u003cp\u003eDuring the year preceding the survey, 36 CAMHS (85%) were involved in the transition process of 15 to 21 year-old patients (Median\u0026thinsp;=\u0026thinsp;18 years). The median transitioning age corresponded to the age criteria for referral, which was also 18 years. Nonetheless, the intended window for transitioning was narrower, ranging from a minimum of 17 years of age to a maximum of 19 years. The most frequent criteria that CAMHS used for patients' selection for transitioning were age (83%) and clinical features (comorbidities, severe symptoms, and drug treatment) (31%). Eight of the 11 AMHS who received ADHD patients in transition received appropriate and sufficient information about the patients. Figure\u0026nbsp;1 summarizes the methods, the time required, the interviews planned, and the professional figures involved in the transition process. The main differences between child and adult services were that adult services reported involving nurses and other professional figures more than CAMHS, as well as the use of information sheets. CAMHS, on the other hand, favored different information and communication channels, such as e-mail, phone, and letters.\u003c/p\u003e \u003cp\u003eFigure 1. Methods, time required, interviews planned, and professional figures involved in the transition process for both CAMHS and AMHS. Compilers were given the opportunity to provide multiple responses.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eServices' role in the transition\u003c/h2\u003e \u003cp\u003eSixty-nine percent of the CAMHS (n\u0026thinsp;=\u0026thinsp;29) and 91% of the AMHS (n\u0026thinsp;=\u0026thinsp;32) considered it beneficial that both services have an active role in the transition phase (11 of the AMHS and 22 of the CAMHS who received or sent ADHD patients in the previous year). CAMHS consider that an optimal transition should take two meetings (range: 1\u0026ndash;6) in a nine-week window, while AMHS indicated seven meetings (range: 1\u0026ndash;50). 15 of the CAMHS (36%) and 21 of the AMHS (91% of the 23 with ADHD patients) report that both specialists' teams should be present when discussing the case of a transitioning patient. Both types of services would prefer that meetings were carried out in their facilities (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCAMHS and AMHS responses to where meetings regarding transitioning ADHD patients should be carried out.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cem\u003eWhere should the meetings with transitioning patients take place?\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eCAMHS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eAMHS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCAMHS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAMHS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA third facility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRemotely\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIt does not matter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eProtocol, monitoring phase, and disability care pathways\u003c/h2\u003e \u003cp\u003eTen CAMHS (24% of all centers, 39% of those who sent patients in the previous year) and 11 AMHS reported having a transition protocol (32% of all centers, 50% of the centers with ADHD patients). Of these, only 3 CAMHS and 2 AMHS had a protocol specific to ADHD patients. Only 4 of the participating CAMHS (9%) and 5 of the AMHS (15%) reported foreseeing a monitoring phase. 22 of the CAMS (52%) and 5 of the AMHS (15%) plan disability care pathways.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eLimitations, unmet needs, and desired changes in dealing with transitioning ADHD patients\u003c/h2\u003e \u003cp\u003eTwenty-seven CAMHS (64%) reported limitations, and 30 (71%) desired changes, while 19 AMHS (54%) reported limitations, 25 (71%) unmet needs, and 31 (89%) desired changes. Those who answered positively could write down what they perceived as a limitation or what they envisioned as a future possibility.\u003c/p\u003e \u003cp\u003eAs for limitations, some emerging common themes pertained to the integration amongst services, communication issues, lack of resources, organizational problems, and lack of treatment continuity. CAMHS workers also described the lack of AMHS psychiatrists' training as highly problematic, the lack of shared training, and the absence of reliable protocols. Moreover, AMHS reported the need to potentiate services, rehabilitation pathways, and ease-of-access to pharmacological treatments. The difficulty in dealing with diagnoses and disorders and issues in communicating with the families were also reported.\u003c/p\u003e \u003cp\u003eRegarding future desired changes, both CAMHS and AMHS, again, reported working on the lack of resources and organizational problems, adding the implementation of strategies to better deal with the diagnostic process, and with the improvement of psychiatrists' training. AMHS services added the need to work on services' integration and communication, and CAMHS services listed the need to design standard protocols and shared training. AMHS centers did not foresee any functional changes in dealing with the families, although they perceived this as an issue. These themes are summarized in Fig.\u0026nbsp;2.\u003c/p\u003e \u003cp\u003eFigure 2. Limitations and desired changes in the future as reported by both CAMHS and AMHS. Some observations are shared (centered), others are limited to CAMHS (left side) or AMHS (right side).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe transitioning process entails many changes and difficulties of which clinicians, patients, and families can be more or less aware. Although some guidelines exist in many countries (e.g., the NICE guidelines in the UK), their efficacy and generalizability have not yet been accurately evaluated. In Italy, only two studies have assessed the situation, one at the single province level (i.e., Modena) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], and one at the regional level for the Lombardy Region [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The latter involved a total of 18 services in an exploratory study investigating the health care management and continuity for young adults with ADHD. In this region, regional ADHD territorial services are accredited in regional hospitals, and therefore linked to CAMHS, and often deal with the transition process of ADHD patients towards a shift in care by AMHS. Nonetheless, what emerged from Reale and colleagues is that in 2018, out of these 18 centers, only four reported having a protocol to manage the transition process, and none of those protocols were specific for ADHD patients [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Moreover, while it seems that previously hospitalized adolescents have a 50% chance of being successfully transferred to an AMHS and that higher engagement was witnessed within the first two years [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], this rate was limited to a narrow territory (i.e., the Province of Modena). No studies considered the professionals' opinion, nor did they cover the whole national territory. Additionally, the factors contributing to a successful transition process in the country are unknown.\u003c/p\u003e \u003cp\u003eThe present study aimed to draw a picture of the current state of the transitioning process in Italy. We asked the professional figures involved (i.e., CAMHS and AMHS workers) how the transitioning process happens and to describe the issues they perceive as problematic, along with their needs. From the clinicians' point of view it is essential to delineate the services' functioning and guarantee the availability of adequate services that are sensitive to patients' needs. We achieved an acceptable geographical representation, with a total of seventy-seven respondents (42 working in CAMHS and 35 in AMHS) from 18 of the 20 Italian regions.\u003c/p\u003e \u003cp\u003eThe analysis of the survey responses drew an interesting picture. While 74% of the CAMHS reported following transitioning patients in the previous year, only 43% of the AMHS stated the same. This means that many patients still get lost in the process. Some of these patients are sent to private psychiatrists or psychologists, falling out of the public health system nonetheless. In other cases, adult patients continue to be treated by CAMHS (in our sample, this happened for 210 patients, distributed in 40% of the CAMHS). Moreover, the ideal age range for transitioning would be between 17 and 19 years of age, while the time window actually needed is wider, involving patients between 15 and 21 years of age. Even when the transition is completed by the 18 years of age mark, the gap with what would be defined by protocols is considerable.\u003c/p\u003e \u003cp\u003eWhile these data suggest that organizational problems affect day-to-day transition process management, many more factors that hinder a successful transition are consciously reported as unmet needs or desired changes. Such observations largely overlap with the first three dimensions reported by Price and colleagues [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. \u003cb\u003eFirst\u003c/b\u003e, the lack of professionals' preparation, transition planning, protocols, and parallel care of the services. In this domain, we also included the absence of training and competencies in adult services. \u003cb\u003eSecondly\u003c/b\u003e, the lack of appropriate adult services. The AMHS are aware of the need to potentiate the services they provide, such as rehabilitation pathways, and access to pharmacological treatment. \u003cb\u003eThird\u003c/b\u003e, the limitations due to the lack of resources and organizational problems. Both CAMHS and AMHS professionals strongly felt this theme. Interestingly, what was highlighted in this domain is the need to develop strategies to efficiently follow the transition with the available resources rather than to increase the resources.\u003c/p\u003e \u003cp\u003eOnly one AMHS raised the issue of communicating with the families. When describing how they arranged the meetings between services, only 21 AMHS and 28 CAMHS declared that they involve the patients' families in the process. The families had, on the other hand, a central role in other studies [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The scarce consideration of families in the Italian transition organization may contribute to the lack of a smooth passage, given that these patients are still vastly dependent on their parents' support.\u003c/p\u003e \u003cp\u003eMoreover, a theme that often emerged was the lack of adequate training for professionals working in the AMHS. Once again, from the opposite viewpoint, more than half of those same professionals reported that they did not receive enough adequate information (only 48% said that they did). Another observation in this respect is that only 61% of the CAMHS that sent patients to AMHS in the previous year think it would be helpful to actively involve both services in the transition phase. Having formal guidelines to smooth the communication between the two parties in the process might also help improve communication and outcomes.\u003c/p\u003e \u003cp\u003eThis observation sheds attention on the need for specific protocols to address the needs of the ADHD population in the transition phase. We asked the 21 services that reported having a protocol whether they could send it to us to investigate whether guidelines already exist, need improvement, or if there is a complete lack of efficient protocols. Notably, while in 2018, in the Lombardy region [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], no pediatric centers were reported to have a specific protocol for one of the neurodevelopmental disorders, from our survey, it emerged that three pediatric centers do (2 within the same region). Nonetheless, they regard Autism Spectrum Disorder, Schizophrenia, and Behavioral Disorders, while no protocol specific to ADHD exists. Many more centers have a non-specific protocol (n\u0026thinsp;=\u0026thinsp;10 CAMHS, n\u0026thinsp;=\u0026thinsp;11 AMHS) or do not have a protocol (76% of CAMHS, 78% of AMHS).\u003c/p\u003e \u003cp\u003eWe received the full version of six protocols, four from CAMHS and two from AMHS. All were characterized by the working group's definition, the number of meetings and the corresponding figures involved (i.e., patients, CAMHS, and AMHS specialists), and the criteria to select patients, including the age window. One protocol also included the possibility of defining personalized trajectories based on specific needs. With the available resources, defining individual care paths does not emerge as a priority, as confirmed by the fact that no respondent listed individual needs in future directions. Instead, it would be desirable to have flexible enough guidelines to allow for a certain degree of customization, considering the available assets. In our survey, only when provided space to write notes on the transition process did eight clinicians report more psychological considerations, such as the importance of paying attention to individuality, culture, and personal experiences concerning the care process. While most of these essential points were shared, the degree of detail differed widely. Suffice it to say that some protocols are only 2 to 5 pages long, while others are up to 25 pages long. In the future, the need for a standard protocol should be addressed. We believe that it should fall somewhere in between the existing ones: while short protocols are not detailed enough, excessively long protocols may be complicated to use daily in a reality of scarse resources.\u003c/p\u003e \u003cp\u003eA limitation of this study is the reduced sample size. Although the included services are not expected to differ from the ones that did not participate, reaching a wider number of professionals would have ensured a better representation on the practices adopted at a national level. Moreover, most of the services that took part in the survey are located in large cities, mostly in northern Italy. A limitation that this survey and the results obtained could-should help to overcome. Nonetheless, we think that the merits of this survey's observations are several. First, it constitutes the first attempt to draw a picture of the transitioning patients from the professionals' point of view. It collects practical information and allows a highlighting of needs and desired changes. Moreover, it stands as the starting point for future work. As future steps of the TransiDEA project, the collected protocols will be analyzed in depth. Individual pathways of patients and their clinicians will then be analyzed, leading to the definition of standardized guidelines. To do so, individual stakeholders from across Italy, including patients, parents or caregivers, clinicians from CAMHS and AMHS, and possibly general practitioners [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] will be involved.\u003c/p\u003e"},{"header":"Conclusions","content":" \u003cp\u003e A successful transition process is crucial for the future of ADHD patients. However, as reflected by this survey conducted in Italy, there are currently many difficulties hindering this process. The priority in the near future must be the definition of standard guidelines that can facilitate a successful transition.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eADHD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAttention-Deficit/Hyperactivity Disorder\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTransiDEA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTransitioning in Diabetes, Epilepsy and ADHD\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCAMHS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eChild and Adolescent Mental Health Services\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAMHS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAdult Mental Health Services\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNICE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e\u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNational Institute for Clinical Excellence\u003c/div\u003e \u003cdiv class=\"Description\"\u003e\u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eThe study \u0026quot;Transition care between adolescent and adult services for young people with chronic health needs in Italy\u0026quot;, (RF-2019-12371228) was conducted in accordance with the Declaration of Helsinki, and approved by the IRCCS \u0026quot;Carlo Besta\u0026quot; Ethics Committee (ethics committee of reference for the Mario Negri IRCCS Institute) (8 September 2021, protocol n. 87). No data concerning single individuals were analyzed. Therefore, no anonymization was necessary, and no informed consent to participate was required.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable. The article does not contain personal medical information about any identifiable living individual. No data concerning single individuals were analyzed. Therefore, no explicit consent for publication was required.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe data and the materials presented in this study are available on request from the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors have no conflicts of interest relevant to this article to disclose. The authors have no relevant financial or non-financial interests to disclose. All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThe study is part of the project \u0026quot;\u0026quot;Transition care between adolescent and adult services for young people with chronic health needs in Italy\u0026quot;\u0026quot;, funded by the Italian Ministry of Health (RF-2019-12371228)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u003c/strong\u003e MB coordinated the study with the help of the TransiDEA Group. MB, ER, FS, RC, MG, and AC analyzed the data and prepared the results. MB, ER, and A.C. wrote the first draft of the manuscript. MB and AC participated in the design and execution of the study. All authors edited the manuscript. All participants of the TransiDEA group discussed and approved the final version. MB is the guarantor.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eThe authors would like to acknowledge Chiara Pandolfini for language editing.\u0026nbsp;Moreover the authors would like to thank the centers that took part in the survey: \u0026quot;Papa Giovanni XXIII\u0026quot; Hospital, Bergamo (Dr. Patrizia Stoppa); \u0026quot;A. Manzoni\u0026quot; Hospital, Lecco (Dr. Ottaviano Martinelli); \u0026ldquo;ASST Lod\u0026rdquo; Hospital, Lodi (Dr. Paola Morosini); \u0026quot;Carlo Poma\u0026quot; Hospital, Mantova (Dr. Giuseppe Capovilla); \u0026ldquo;IRCCS C\u0026agrave; Granda Ospedale Maggiore Policlinico Foundation\u0026rdquo;, Milano (Dr. Maria Antonella Costantino); \u0026quot;G. Salvini\u0026quot; Hospital, Garbagnate Milanese (Dr. Federico Raviglione); \u0026quot;S. Anna\u0026quot; Hospital, Como (Dr. Patrizia Conti); \u0026quot;Del Ponte\u0026quot; Hospital, Varese (Dr. Giorgio Rossi); \u0026ldquo;ASST Cremona\u0026rdquo; Hospital, Cremona (Dr. Maria Teresa Giarelli); \u0026ldquo;Spedali Civili Presidio Ospedale dei Bambini\u0026rdquo; Hospital, Brescia (Prof. Elisa Maria Fazzi); \u0026quot;ASST Valtellina e Alto Lario\u0026quot; Hospital, Sondrio (Dr. Marialuisa Carpanelli); \u0026ldquo;ASST Santi Paolo e Carlo\u0026rdquo; Hospital, Milano (Prof. Maria Paola Canevini); \u0026ldquo;ASST Vallecamonica\u0026rdquo;, Sebino, Brescia (Dr. Francesco Rinaldi); \u0026ldquo;IRCCS Eugenio Medea - Associazione La Nostra Famiglia\u0026rdquo;, Lecco (Dr. Massimo Molteni); \u0026ldquo;Niguarda C\u0026agrave; Granda\u0026rdquo; Hospital, Milano (Prof. Aglaia Vignoli); \u0026ldquo;IRCCS Mondino Foundation\u0026rdquo;, Pavia (Prof. Renato Borgatti, Dr. Laura Farinotti); \u0026ldquo;Comprensorio sanitario di Merano Azienda Sanitaria dell\u0026rsquo;Alto Adige\u0026rdquo;, Merano (Dr. Donatella Arcangeli); CAMHS \u0026ldquo;ASL Liguria 2\u0026rdquo;, Savona (Dr. Paola Bona); CAMHS \u0026ldquo;ASL Liguria 5\u0026rdquo;, La Spezia (Dr. Franco Giovannoni); CAMHS \u0026ldquo;AV3 ASUR\u0026rdquo;, Macerata (Dr. Maurizio Pincherle); CAMHS, Firenze; \u0026ldquo;Azienda ospedaliero-universitaria Senese\u0026rdquo; Hospital, Siena (Dr. Roberto Canitano); CAMHS, Pescara (Dr. Elena Gennaro); \u0026ldquo;Ospedale Civile Giuseppe Mazzini\u0026rdquo; Hospital, Teramo (Dr. Chiara Caucci), \u0026ldquo;Federico II\u0026rdquo; Hospital, Napoli (Prof. Carmela Bravaccio); \u0026ldquo;AOU Sassari, Divisione Neuropsichiatria Infantile\u0026rdquo; (Prof. Stefano Sotgiu); \u0026ldquo;Centro di Riferimento per l\u0026apos;ADHD-Asp\u0026rdquo;, Catania (Dr. Giancarlo Costanza); \u0026ldquo;AO S. Croce e Carle\u0026rdquo;, Cuneo (Dr. Eleonora Briatore); \u0026ldquo;Ospedale Infantile Regina Margherita\u0026rdquo; Hospital, Torino (Dr. Benedetto Vitiello); \u0026ldquo;Azienda Sanitaria Universitaria Integrata\u0026rdquo;, Udine (Dr. Giuseppe Zappulla); \u0026ldquo;Ospedale Santo Spirito\u0026rdquo;, Bra (Dr. Elisa Colombi); \u0026ldquo;Asst- Valle Olona\u0026rdquo;, Gallarate (Dr. Mariarosa Ferrario); \u0026ldquo;Associazione La Nostra Famiglia\u0026rdquo;, Treviso (Dr. Malida Franzoi); \u0026ldquo;Associazione La Nostra Famiglia\u0026rdquo; San Don\u0026agrave; di Piave and Conegliano (Dr. Federica Martinez); \u0026ldquo;ASL Novara\u0026rdquo;, Borgomanero; \u0026ldquo;Ospedale Beauregard Azienda USL Valle d\u0026rsquo;Aosta\u0026rdquo;, Aosta (Dr. Laure Obino); \u0026ldquo;IRCCS Burlo Garofalo\u0026rdquo;, Trieste (Dr. Marco Carrozzi); \u0026ldquo;Dipartimento Salute Mentale e delle Dipendenze\u0026rdquo;, ASST Melegnano e della Martesana (Dr. Federico Durbano); AMHS \u0026ldquo;Assisano Media Valle del Tevere\u0026rdquo;, Assisi (Dr. Marco Grignani); AMHS, Perugia (Dr. Marco Grignani); \u0026ldquo;ASL Roma 1\u0026rdquo;, Roma (Dr. Alessandro Antonucci); AMHS, S. Giovanni Valdarno; AMHS, Foligno (Dr. Angelo Rella); AMHS \u0026ldquo;D5 Casilina\u0026rdquo;, Roma (Dr. Pietro Di Paolo); AMHS, Salerno (Dr. Germano Fiore); AMHS, Soverato; AMHS, Lecce; AMHS, Cerignola - Orta Nova (Dr. Gianluca Piemontese); \u0026ldquo;Struttura Complessa di Psichiatria Mantova 1\u0026rdquo;, Castiglione delle Steviere (Dr. Giulio De Nicola); \u0026ldquo;Azienda Sanitaria dell\u0026apos;Alto Adige\u0026rdquo;, Bolzano (Dr. Andres Conca); \u0026ldquo;Struttura Complessa Di Psichiatria, Dsmd Asst\u0026rdquo;, Monza; AMHS, \u0026nbsp;Mugnano\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;(Dr. Angelo Cucciniello); CPS - Treviglio\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;(Dr. Moro Anna Rosa); AMHS, Rozzano; \u0026ldquo;ASST Valtellina e Alto Lario\u0026rdquo;, Sondrio (Dr. Giorgio Francobandiera; Dr. Maria Carla Moraca); \u0026ldquo;Dipartimento Salute Mentale ASL TO4 Piemonte\u0026rdquo;, Ivrea; AMHS, Brescia (Dr. Paola Corsini); \u0026ldquo;Servizi di salute mentale 3 distretto asl Roma 1\u0026rdquo;, Roma (Dr. Alessandro Antonucci); \u0026ldquo;ASST Papa Giovanni\u0026rdquo;, Bergamo (Dr. Emi Bondi); \u0026nbsp;AMHS \u0026ldquo;Mantova 1\u0026rdquo;, Mantova; AMHS, Voghera, Stradella (Dr. Luisa Aroasio); AMHS, Chiavari; AMHS, Verona (Dr. Giuseppe Imperadore); AMHS, Genova (Dr. Daniela Malagamba); AMHS, \u0026nbsp;Varese (Prof. Camilla Callegari); \u0026ldquo;ASST Rhodense\u0026rdquo;, Garbagnate Milanese (Dr. Marco Toscano); AMHS, San Daniele del Friuli; AMHS \u0026ldquo;ASL Roma 1\u0026rdquo;, Roma (Dr. Gialuigi Di Cesare); AMHS, Piacenza (Dr. Corrado Cappa); \u0026ldquo;Azienda Ulss 8 Berica\u0026rdquo;, Vicenza (Dr. Francesco Gardellin); AMHS \u0026ldquo;ASL CN2\u0026rdquo;, Bra (Dr. Elio Laudani).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTransiDEA group members\u003c/strong\u003e: Coordinating and Managing Group: Maurizio Bonati, Antonio Clavenna, Nicoletta Raschitelli, Francesca Scarpellini, Elisa Roberti, Rita Campi, Michele Giardino, Michele Zanetti, Massimo Cartabia; Diabetes (D): Vanna Graziani, Federico Marchetti, Tosca Suprani, Paolo Di Bartolo; Epilepsy (E): Maria Paola Canevini, Ilaria Vigan\u0026ograve;; ADHD (A): Ilaria Costantino, Valeria Tessarollo; Scientific technical committee (CTS): Giampaolo Ruffoni.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFaraone SV, Banaschewski T, Coghill D, Zheng Y, Biederman J, Bellgrove MA, et al. The World Federation of ADHD International Consensus Statement: 208 Evidence-based conclusions about the disorder. Neurosci Biobehav Rev. 2021;128:789\u0026ndash;818. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.neubiorev.2021.01.022\u003c/span\u003e\u003cspan address=\"10.1016/j.neubiorev.2021.01.022\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePolanczyk GV, Willcutt EG, Salum GA, Kieling C, Rohde LA. ADHD prevalence estimates across three decades: an updated systematic review and meta-regression analysis. Int J Epidemiol. 2014;43:434\u0026ndash;42. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/ije/dyt261\u003c/span\u003e\u003cspan address=\"10.1093/ije/dyt261\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReale L, Bonati M. ADHD prevalence estimates in Italian children and adolescents: a methodological issue. Ital J Pediatr. 2018;44:108. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s13052-018-0545-2\u003c/span\u003e\u003cspan address=\"10.1186/s13052-018-0545-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReale L, Bartoli B, Cartabia M, Zanetti M, Costantino MA, Canevini MP, et al. Comorbidity prevalence and treatment outcome in children and adolescents with ADHD. Eur Child Adolesc Psychiatry. 2017;26:1443\u0026ndash;57. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00787-017-1005-z\u003c/span\u003e\u003cspan address=\"10.1007/s00787-017-1005-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcGough JJ, Barkley RA. Diagnostic Controversies in Adult Attention Deficit Hyperactivity Disorder. Am J Psychiatry. 2004;161:1948\u0026ndash;56. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1176/appi.ajp.161.11.1948\u003c/span\u003e\u003cspan address=\"10.1176/appi.ajp.161.11.1948\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSibley MH, Mitchell JT, Becker SP. Method of adult diagnosis influences estimated persistence of childhood ADHD: a systematic review of longitudinal studies. Lancet Psychiatry. 2016;3:1157\u0026ndash;65. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S2215-0366(16)30190-0\u003c/span\u003e\u003cspan address=\"10.1016/S2215-0366(16)30190-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSong P, Zha M, Yang Q, Zhang Y, Li X, Rudan I. The prevalence of adult attention-deficit hyperactivity disorder: A global systematic review and meta-analysis. J Glob Health. 2021;11:04009. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.7189/jogh.11.04009\u003c/span\u003e\u003cspan address=\"10.7189/jogh.11.04009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFaraone SV, Biederman J, Mick E. The age-dependent decline of attention deficit hyperactivity disorder: a meta-analysis of follow-up studies. Psychol Med. 2006;36:159\u0026ndash;65. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1017/S003329170500471X\u003c/span\u003e\u003cspan address=\"10.1017/S003329170500471X\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYoung S, Murphy CM, Coghill D. Avoiding the twilight zone: recommendations for the transition of services from adolescence to adulthood for young people with ADHD. BMC Psychiatry. 2011;11:174. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/1471-244X-11-174\u003c/span\u003e\u003cspan address=\"10.1186/1471-244X-11-174\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTitheradge D, Godfrey J, Eke H, Price A, Ford T, Janssens A. Why young people stop taking their attention deficit hyperactivity disorder medication: A thematic analysis of interviews with young people. Child Care Health Dev. 2022;cch12978. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/cch.12978\u003c/span\u003e\u003cspan address=\"10.1111/cch.12978\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHansen AS, Tell\u0026eacute;us GK, Mohr-Jensen C, Lauritsen MB. Parent-perceived barriers to accessing services for their child\u0026rsquo;s mental health problems. Child Adolesc Psychiatry Ment Health. 2021;15:4. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s13034-021-00357-7\u003c/span\u003e\u003cspan address=\"10.1186/s13034-021-00357-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKooij SJ, Bejerot S, Blackwell A, Caci H, Casas-Brugu\u0026eacute; M, Carpentier PJ, et al. European consensus statement on diagnosis and treatment of adult ADHD: The European Network Adult ADHD. BMC Psychiatry. 2010;10:67. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/1471-244X-10-67\u003c/span\u003e\u003cspan address=\"10.1186/1471-244X-10-67\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrice A, Janssens A, Woodley AL, Allwood M, Ford T, Review. Experiences of healthcare transitions for young people with attention deficit hyperactivity disorder: a systematic review of qualitative research. Child Adolesc Ment Health. 2019;24:113\u0026ndash;22. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/camh.12297\u003c/span\u003e\u003cspan address=\"10.1111/camh.12297\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNational Institute for Health \u0026amp; Care Excellence. NICE Clinical Guideline [CG177] Osteoarthritis: Care and Management in Adults. London: National Institute for Health \u0026amp; Care Excellence; 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIslam Z, Ford T, Kramer T, Paul M, Parsons H, Harley K, et al. Mind how you cross the gap! Outcomes for young people who failed to make the transition from child to adult services: the TRACK study. BJPsych Bull. 2016;40:142\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1192/pb.bp.115.050690\u003c/span\u003e\u003cspan address=\"10.1192/pb.bp.115.050690\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSingh SP, Paul M, Ford T, Kramer T, Weaver T, McLaren S, et al. Process, outcome and experience of transition from child to adult mental healthcare: multiperspective study. Br J Psychiatry. 2010;197:305\u0026ndash;12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1192/bjp.bp.109.075135\u003c/span\u003e\u003cspan address=\"10.1192/bjp.bp.109.075135\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeavey G, McGrellis S, Forbes T, Thampi A, Davidson G, Rosato M, et al. Improving mental health pathways and care for adolescents in transition to adult services (IMPACT): a retrospective case note review of social and clinical determinants of transition. Soc Psychiatry Psychiatr Epidemiol. 2019;54:955\u0026ndash;63. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00127-019-01684-z\u003c/span\u003e\u003cspan address=\"10.1007/s00127-019-01684-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSingh SP, Tuomainen H, Bouliotis G, Canaway A, De Girolamo G, Dieleman GC et al. Effect of managed transition on mental health outcomes for young people at the child\u0026ndash;adult mental health service boundary: a randomised clinical trial. Psychol Med 2021:1\u0026ndash;12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1017/S0033291721003901\u003c/span\u003e\u003cspan address=\"10.1017/S0033291721003901\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnderson JK, Newlove-Delgado T, Ford TJ. Annual Research Review: A systematic review of mental health services for emerging adults \u0026ndash; moulding a precipice into a smooth passage. J Child Psychol Psychiatry. 2022;63:447\u0026ndash;62. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/jcpp.13561\u003c/span\u003e\u003cspan address=\"10.1111/jcpp.13561\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReale L, Frassica S, Gollner A, Bonati M. Transition to adult mental health services for young people with attention deficit hyperactivity disorder in Italy: Parents\u0026rsquo; and clinicians\u0026rsquo; experiences. Postgrad Med. 2015;127:671\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/00325481.2015.1070658\u003c/span\u003e\u003cspan address=\"10.1080/00325481.2015.1070658\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReale L, Costantino MA, Sequi M, Bonati M. Transition to Adult Mental Health Services for Young People With ADHD. J Atten Disord. 2018;22:601\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1087054714560823\u003c/span\u003e\u003cspan address=\"10.1177/1087054714560823\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePontoni G, Di Pietro E, Neri T, Mattei G, Longo F, Neviani V, et al. Factors associated with the transition of adolescent inpatients from an intensive residential ward to adult mental health services. Eur Child Adolesc Psychiatry. 2022;31:805\u0026ndash;18. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00787-020-01717-y\u003c/span\u003e\u003cspan address=\"10.1007/s00787-020-01717-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePontoni G, Di Pietro E, Neri T, Mattei G, Longo F, Neviani V, et al. Factors associated with the transition of adolescent inpatients from an intensive residential ward to adult mental health services. Eur Child Adolesc Psychiatry. 2022;31:805\u0026ndash;18. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00787-020-01717-y\u003c/span\u003e\u003cspan address=\"10.1007/s00787-020-01717-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrice A, Mitchell S, Janssens A, Eke H, Ford T, Newlove-Delgado T. In transition with attention deficit hyperactivity disorder (ADHD): children\u0026rsquo;s services clinicians\u0026rsquo; perspectives on the role of information in healthcare transitions for young people with ADHD. BMC Psychiatry. 2022;22:251. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12888-022-03813-6\u003c/span\u003e\u003cspan address=\"10.1186/s12888-022-03813-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"child-and-adolescent-psychiatry-and-mental-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"caph","sideBox":"Learn more about [Child and Adolescent Psychiatry and Mental Health](http://capmh.biomedcentral.com)","snPcode":"13034","submissionUrl":"https://submission.nature.com/new-submission/13034/3","title":"Child and Adolescent Psychiatry and Mental Health","twitterHandle":"@IACAPAP","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Transition, ADHD, adult ADHD, survey, health services","lastPublishedDoi":"10.21203/rs.3.rs-2470407/v2","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2470407/v2","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e \u003cem\u003eBackground\u003c/em\u003e. Supporting young ADHD patients in transition to adult services is essential. Yet, the low percentages of successful referrals and the issues reported by patients and clinicians stress the need for further attention to transitioning practices. The present study assessed the transitioning process of Attention-Deficit/Hyperactivity Disorder (ADHD) patients in Child and Adolescent Mental Health Services (CAMHS) and Adult Mental Health Services (AMHS) in the Italian territory. We asked child and adult psychiatrists to report the current state of services and their observations on limitations and possible future matters that must be addressed.\u003c/p\u003e \u003cp\u003e \u003cem\u003eMethod\u003c/em\u003e. Seventy-seven centers (42 CAMHS, 35 AMHS) filled in a web-based survey in which they reported the number of ADHD patients, how many transitioning patients they had within the past year, and how they structured transition.\u003c/p\u003e \u003cp\u003e \u003cem\u003eResults.\u003c/em\u003e A fragmented picture emerged from the survey. Lack of resources, training, and communication between services hinder the transition process, and many adult patients remain under CAMHS' care. While some services have a protocol, there is no structured guidance that can help improve integration and continuity of treatment.\u003c/p\u003e \u003cp\u003e\u003cem\u003eConclusion.\u003c/em\u003e The observed situation reflects a need for improvement and standard guidelines to enable a successful transition process, considering clinicians' and patients' necessities.\u003c/p\u003e","manuscriptTitle":"Child and Adolescent Psychiatry and Mental Health Transitioning to Adult Mental Health Services for young people with ADHD: an Italian-based Survey on practices for Pediatric and Adult Services","msid":"","msnumber":"","nonDraftVersions":[{"code":2,"date":"2023-09-27 21:56:26","doi":"10.21203/rs.3.rs-2470407/v2","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"87d5e156-b97d-4cdb-8cd4-a6e9657f268f","date":"2023-09-26T14:06:56+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-09-26T13:52:17+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-09-22T02:14:54+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-09-21T07:00:44+00:00","index":"","fulltext":""},{"type":"submitted","content":"Child and Adolescent Psychiatry and Mental Health","date":"2023-09-20T09:12:55+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"child-and-adolescent-psychiatry-and-mental-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"caph","sideBox":"Learn more about [Child and Adolescent Psychiatry and Mental Health](http://capmh.biomedcentral.com)","snPcode":"13034","submissionUrl":"https://submission.nature.com/new-submission/13034/3","title":"Child and Adolescent Psychiatry and Mental Health","twitterHandle":"@IACAPAP","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cb18eb65-78ae-479b-8959-3f53fc75f77f","owner":[],"postedDate":"September 27th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-12-04T15:08:07+00:00","versionOfRecord":{"articleIdentity":"rs-2470407","link":"https://doi.org/10.1186/s13034-023-00678-9","journal":{"identity":"child-and-adolescent-psychiatry-and-mental-health","isVorOnly":false,"title":"Child and Adolescent Psychiatry and Mental Health"},"publishedOn":"2023-11-28 15:01:56","publishedOnDateReadable":"November 28th, 2023"},"versionCreatedAt":"2023-09-27 21:56:26","video":"","vorDoi":"10.1186/s13034-023-00678-9","vorDoiUrl":"https://doi.org/10.1186/s13034-023-00678-9","workflowStages":[]},"version":"v2","identity":"rs-2470407","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2470407","identity":"rs-2470407","version":["v2"]},"buildId":"FbvkV6FR0MCFSLy54lSbu","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}