Psychosocial issues

Adolescents are making the transition to adulthood and need to achieve independence from their parents as well as to plan their future vocation. In partnership with this, the young adult must take over responsibility for their chronic illness from their carers.

The psychosocial aspects of adolescence include our observation of educational attainment, occupational status, marital status, social relationships, and living away from the parental home, as well as recognition of an increased risk of psychiatric disturbance. Families with experience of chronic childhood illness often have complex family dynamics. Moving from a paediatric setting -- which often has a parent-focused approach -- to an adult, patient-focused setting can lead to parental anxiety. A parent’s inherent desire to protect their child could impair the development of an independent young adult. The process of transition should, therefore, be gradual to minimise anxieties to all parties.

A study by Reynolds et al(3), found that, compared with their healthy counterparts, young adults diagnosed with end-stage renal failure in childhood had a higher lifetime risk of a psychiatric disorder and lower self-esteem. Young adults with childhood end-stage renal failure had a lower level of educational attainment with increased unemployment: 53% of subjects being in full-time employment compared with 75% of the controls.

Young adults with end-stage renal failure had a higher likelihood of being single or living with their parents; there was a gender difference here, 46% of females were married compared with no males. An early age of illness onset and persistent physical-health problems were associated with a poorer social outcome.

Managing transition effectively
Effective transition of an adolescent to adult services should encompass appropriate management of their renal disease while enabling them to achieve their developmental potential and maintain quality of life. The timing of this transition should be on an individual basis depending on age, maturity, family dynamics, the complexity of disease and the availability of appropriate adult nephrological services.

Written policies on transition should be agreed between local paediatric and adult renal services.

Several factors can be incorporated to facilitate transition(4).

		The paediatric unit should foster independence.
		Care should be taken to inform and involve young patients and their parents in all discussions.
		Transfer to the adult unit should be a positive part of a long-term plan discussed and agreed with the adolescent.
		Early personal contact with members of staff from the adult unit while still under paediatric care should be routine.
		Site/clinic visits with information well in advance should also be routine.
		Joint adult-paediatric clinics and joint adolescent-inpatient facilities should be available.
		Policies on management should be agreed in advance.
		Extra initial support in the adult unit should be provided.
		Feedback from young adults who have undergone transition should be sought.
		As part of routine training, paediatric nephrologists should spend some time in adult renal units, and vice versa.

Audit and research of modes of transition can support the optimal goal of an uninterrupted, co-ordinated service that meets the physical and psychosocial needs of the adolescent.