Is an all-age service the answer to poor transitions for adolescents with eating disorders?

In a recent issue of the European Eating Disorders Review, Newell (2023) reports on the experiences of implementing an all-age eating disorder (ED) service. In our commentary of their work, we will begin with a summary, discuss what we consider to be the strengths, shortcomings, and obstacles of an all-age ED service, and conclude with alternative solutions. Before beginning, we would like to note that our perspective of ED transitions may introduce Canadian nuances to our commentary, given our differing healthcare systems.

The transition from child and adolescent (or paediatric) to adult ED services, that is often determined by turning 18-years-old, has been well-established as a distressing and problematic experience for patients, families, and healthcare providers alike. Newell (2023) presented various reasons for developing their all-age programme, including the long interruptions in ED care, uncertainty held by adolescents and parents about the upcoming change, and differences between services that were seen in their traditional paediatric and adult care systems.

In response to the current state of poor transitions for EDs, Newell (2023) developed an all-age ED service in Dorset, England. To do this, an interdisciplinary group of clinicians from an adult ED community service as well as the child and adolescent mental health service in Dorset were invited to join a ‘transitions’ team. Some staff were concerned that they did not have the appropriate skills to work with the other age group, or a wide age range, even if they had the proper training. This is why the invitation to join the ‘transitions’ team was voluntary. Members of this team joined because they felt confident and knowledgeable in applying the main modes of treatment [enhanced cognitive behavioural therapy (CBT-E) and family-based therapy (FBT)] across the age range. This core group was trained to provide care across both settings through regular clinical supervision by professionals, internal and external, with the required training. As the training progressed, the ‘transitions’ team reviewed new referrals and supported staff to continue providing care to existing patients who were approaching their 18^th birthday. The issue of how funding for the services would be split was addressed; there were separate budgets for each team, and flexibility was offered when needed. Over time, less and less supervision was needed because all members of the all-age ED team were competent in the main treatment modalities and the ‘transitions’ team disbanded.

Newell (2023) noted multiple facilitators that allowed for the implementation of their all-age ED service. Firstly, there was strong buy-in from both services, and a core team of individuals were willing to be the ‘transition’ experts. This format allowed those who felt more comfortable remaining in their original service could still do so. In addition, the change to an all-age ED service was well-received by Dorset's single mental health services commissioner and was well-managed administratively, as one person handled the merged identity of the new programme internally and externally.

The author describes the all-age service as a potential solution for transition issues moving forward. It is noted that these programs are starting to be supported in available literature (Newell, 2023). Another benefit of the all-age ED service is that the typical parameters for evidence-based treatments can be expanded to a wider age range (e.g., FBT for individuals who are over the age 18, and CBT for those under), thus meeting the unique needs of patients. In addition, current UK protocols for transition are quite costly in terms of time and effort, such as requiring adolescents to receive a 6-month period of parallel care. With an all-age ED service, there would be no duplication of effort from two teams as there would be no transition. Lastly, the author concluded that they now have a cohort of highly skilled staff who can treat a wider range of patients (Newell, 2023). To conclude, this paper highlighted the visible benefits of their new programme locally and discussed the potential advantages for an all-age service for this clinical population, while also underscoring that research is still needed to evaluate the impact of these programs.

To start, there is an undeniable need for a solution for the poor transitions experienced by transition-age youth with EDs. Arguably, this group requires a seamless transition more than other clinical populations due to the denial-based nature of EDs (Gregertsen et al., 2017). The cut-off age of 18 years may have been indicative of adulthood when it was established. But, in the present-day, this arbitrary threshold feels vestigial given the different nature of experiences faced by youth today. We also agree that the approach that will yield the most successful ED care is to tailor services to meet patient needs, rather than requiring patients to adapt to the care that is available.

That said, the implementation of an all-age ED service brings with it some obstacles. In Newell's report (2023), it was stated that members of the ‘transitions’ team would receive clinical supervision from internal and external transition experts. However, these providers were not originally trained to treat both age groups, further evidenced by the discomfort of some clinicians in the study to shift from their area of expertise. In some professions working with EDs, their registered college only allows professionals to work with the age group they were trained for (e.g., physicians, psychologists). Even among those for whom certification is not age-based (e.g., social workers, psychotherapists, dieticians), these professionals are typically expected to specialise with either children and adolescents or adults, as the skillsets to engage with these groups and rules of treatment vary widely. Further, it was stated that the ‘transitions’ team would support clinicians in either service to support a transition-age youth, meaning that some patient-facing therapists—especially those on the paediatric end—would be working with both age ranges. Lastly, the final concern pertaining to treatment delivery is that of fidelity; if some clinicians are now expected to treat a wider age range of patients, thus taking on new, complex treatment modalities, there may be a risk of reduced adherence to each model by virtue of there being multiple treatments they are expected to provide. The quantity of treatments that a clinician provides should not sacrifice the quality with which they deliver each of those treatments.

Next, the author underscored how this developmental period of young adulthood is associated with many other life changes, which is especially challenging for youth with psychiatric or ED concerns (Newell, 2023); this is also reflected in other research (Dimitropoulos et al., 2013). Although this could mean a healthcare transition should be avoided to alleviate some of this change, transitions are ultimately a normal part of life and would likely strengthen self-management skills to navigate healthcare systems as an adult and learn first-hand how to take their treatment into their own hands. The Society of Paediatric Nurses referred to healthcare transition services as ensuring that “adolescents and emerging adults learn the self-management knowledge and skills necessary to manage their daily treatment needs as independently as possible and become a literate health consumer” (Betz, 2017, p. 161). Even if paediatric patients with EDs were receiving their treatment from an all-age service, they may be experiencing life changes that may require them to move their care anyways (e.g., moving to a new city for post-secondary education). Individuals with EDs usually also experience comorbidities, such as medical or psychiatric (Erdur et al., 2012; Salbach-Andrae et al., 2008); unless transition is eliminated for the care they may receive for these other health concerns, it may be more confusing for them to undergo a healthcare transition for some of their needs, but not others. Although hard, we believe transitions to be necessary for development, as this allows young adults to progress through the natural and inevitable stress of developing their own healthcare management skills.

The intention behind and implementation of the author's all-age ED service was founded in strong feedback from stakeholders that a change was needed to avoid traumatic transitions (Newell, 2023). However, even the author noted how much of a role various facilitators played into the feasibility and success of their service, such as only having a single commissioner to set up this programme or strong buy-in among providers from both original services. In other contexts, however, there may be additional obstacles in place that may limit implementation success such as administrative red tape in larger regions, healthcare systems that may have a different structure for approval of new programs, insufficient provider buy-in, and the lack of funds or resources. This reality threatens the generalisability of such a service when applied to other sites.

Lastly, the article discussed the need for more research to evaluate this newly proposed solution and compare it to current transition procedures. It is possible that an all-age service is the ideal solution to remove the problem of transition, but additional evidence is needed to support this shift. Qualitative research may shed light upon new challenges and benefits experienced when an all-age ED service is implemented, while quantitative research, such as pre-post designs or comparative trials, can establish a difference in tangible outcomes (e.g., reductions in ED symptomology by age 19, self-management skills).

This example of a successful implementation of all-age ED service by Newell (2023) presents a strong, novel solution for current difficulties regarding ED transitions. There are understandably some concerns with this new solution, such as the ones we have presented above, but this approach may still be appropriate for some contexts. Until more research is dedicated to exploring the effectiveness of and experiences with an all-age ED service, we propose some alternate ways we can improve our current transition supports in the interim.

The first strategy we suggest for improving transition using the age-separated structures that are currently in place is for paediatric and adult ED programs to dissolve the strict age cut-off of 18 years and, instead, use a flexible age approach. This has been recommended for youth with complex healthcare needs more generally (Toulany et al., 2022) as well as for adolescents with EDs (Nadarajah et al., 2021). Logistically-speaking, extending the care of adolescents receiving paediatric care by asking their therapist to continue working with them would require a change in infrastructure, such as additional space and staff. Conversely, it is possible that it would be more feasible in some contexts for the adult programme to accept youth who are younger than 18 into their programme. To support either or both of these suggested changes, the overseeing administrative and funding bodies need to support this shift by offering the resources, finances, and personnel necessary to carry this out successfully.

Another suggested way transitions may be improved would be to facilitate long-standing relationships between paediatric and adult programs located in the same regions; this should also be encouraged and funded by the responsible governing healthcare administration bodies. Borrowing from Newell's (2023) process, paediatric and adult teams could create their own internal ‘transitions’ teams that communicate closely with both programs for a more seamless transfer of care. Depending upon what these unions decide, paediatric teams may agree to standardise the initiation of transition-related conversations with patients and parents to start much earlier (e.g., a notification in the medical record system to engage in this conversation with a patient upon turning 16 or 17 years old). If a transition is something that the adolescent-parent pair would like to consider, they could be placed on the waitlist of the desired adult ED care programme to counteract the reality of long waitlists and reduce the risk of a break in care for adolescents.

Lastly, there are a variety of suggested strategies offered in the literature that could be added to paediatric and adult programs to assist with transitions, such as incorporating a transition navigator, peer support for transitioning adolescents, peer support for parents, involvement of the family physician, and having a transition meeting with both providers (Nadarajah et al., 2021; Nicula et al., 2023).

In conclusion, the all-age ED solution proposed by Newell (2023) addresses some of the issues with transition; however, it may not be feasible in all settings. We acknowledge that our suggestion to improve existing transitions does not fully address this issue, but it has been posed here as an alternate to the all-age ED service. In the same way that Newell (2023) notes their service's intention to attend to the needs of the patients rather than asking them to adapt to the care offered, we suggest that each programme's approach—specifically, whether they take on an all-age ED service or enhance transitions within two separate programs—carefully consider many factors, such as the capacity, context, type of healthcare system or funding structure, and the nature of the patients and families they service.

The authors declare no conflicts of interest.