the transition of adolescents with diabetes from the children's health care service into the...

Review

The transition of adolescents with diabetes from the children’s

health care service into the adult health care service: a review

of the literature

ELIZABETH FLEMINGELIZABETH FLEMING BSc, RN

Research Student, Department of Nursing, University of Central Lancashire, Preston,

Lancashire, UK

BERNIE CARTERBERNIE CARTER BSc, PhD, PGCE, RSCN, SRN

Professor of Children’s Nursing, University of Central Lancashire, Lancashire, UK

WARREN GILLIBRANDWARREN GILLIBRAND MSc, RN

Lecturer, University of Central Lancashire, Lancashire, UK

Accepted for Publication 11 October 2001

Summary

• Adolescents with diabetes have unique health needs, which impact upon their

transition from children’s health care services into adult health care services.

• These health needs result from the precarious period in their lives, when

they have to cope with the stresses of being a maturing person. This

coincides with their move from the children’s into the adult health care

service. Whilst coping with these pressures they must also keep their diabetes

under control.

• The impact of emotional and physical demands upon the adolescent means

that they are more susceptible to non-adherence, which may result in reduced

diabetic control.

• This literature review identifies some of the many barriers erected to the

transition into the adult health care system; these barriers may be constructed by

any one of the parties involved: the children’s health care team, adult health care

team, the adolescent or their family.

• Principles of a successful transition are explored, along with the prerequisite

qualities required of health care providers and the health care service.

Correspondence to: Elizabeth Fleming, Department of Nursing, Uni-versity of Central Lancashire, Room 34, Harrington Building, Preston,Lancashire PR1 2HE, UK (tel.: +44 1772 893705; fax: +44 1772892998; e-mail: [email protected]).

Journal of Clinical Nursing 2002; 11: 560–567

560 � 2002 Blackwell Science Ltd

Keywords: adolescent, barriers, diabetes mellitus, health care, health needs,

transition.

Introduction

In developed countries diabetes is either the fourth or fifth

leading cause of death amongst the general population

(Amos et al., 1997). ‘Type 1 diabetes (IDDM) develops

when there is a severe lack of insulin in the body because

most or all of the cells in the pancreas that produce it have

been destroyed’ (Diabetes UK, 2000). A series of ran-

domized-controlled trials carried out by the Diabetes

Control and Complications Trial Research Group

(DCCT) found that insulin-dependent diabetes mellitus

(IDDM) responds well to intensive therapy and strict

control measures. This effectively delays the onset and

slows the progression of diabetic retinopathy, nephropathy

and neuropathy in patients with IDDM.

Advances in medical knowledge now mean that nearly

all children who have IDDM will survive into adult life.

Indeed, children affected by any one of many chronic

conditions often survive beyond adolescence (Blum et al.,

1993; Carles-Suris, 1995). In 1997, an estimated 124

million people globally had diabetes, or about 2.1% of the

world population, with a projection of 221 million

worldwide by 2010 (Amos et al., 1997). Estimates of the

prevalence of IDDM in people under the age of 20 years

are 0.14%, meaning that there are probably more than

20 000 young people with diabetes in the UK alone

(Mackinnon, 1998). Diabetes has become a major health

problem, with approximately 9% of acute NHS expendi-

ture being on diabetes care (Department of Health, 2001).

Adolescence is recognized as a stage when the young

person moves into a new and unfamiliar stage in their life.

They leave behind their childhood, taking on new

responsibilities and independence, striving to become an

autonomous adult. Adolescents and young persons with

diabetes face an additional challenge: the transition of their

care from the children’s health care team into the adult

health care team. Research shows that many people with

diabetes exhibit a marked deterioration in their metabolic

control during their teenage years (Ellemann et al., 1984;

Snorgaard et al., 1989; Thompson et al., 1995; Pound

et al., 1996). The transition period has the potential to

cause instability in the adolescent’s already vulnerable

position, and so it is the place of the health care team to

ensure that the transition process is a positive experience

for the adolescent, which builds and develops the person,

empowering them to become a well-balanced, independent

individual.

This review critically evaluates publications relating to

the transition of young people from the children’s health

care service into the adult health care service. After

examining the unique health needs of adolescents, the

review then explores the barriers to the transition process

and the principles that should be adopted for a successful

transition.

LITERATURE SEARCHLITERATURE SEARCH

A search of the literature was undertaken using the key

words ‘adolescence’, ‘diabetes’ and ‘transition’. They were

entered into the CINAHL (Cumulative Index of Nursing

& Allied Health Literature, 1982–2001) and MEDLINE

(International Nursing Index & Index Medicus, 1966–

2001) databases. All literature accessed was available in the

English language. Reference lists of the papers obtained

from the databases were then manually searched, and the

relevant titles were included in the review. This included

those with one or more of the following terms in the title

‘adolescent’, ‘young person’, ‘youth’, ‘diabetes’ or ‘transi-

tion’. In addition, a small number of articles were selected

on the basis that the content of the original article made

relevant reference to an area in the literature review.

THE UNIQUE HEALTH NEEDS OF ADOLESCENTS WITHTHE UNIQUE HEALTH NEEDS OF ADOLESCENTS WITH

DIABETESDIABETES

The unique health needs of adolescents have been

identified by researchers and health care practitioners

(Gillies & Parry-Jones, 1992; House of Commons Select

Committee on Health, 1997; Viner & Keane, 1998).

Managing the health care needs of the maturing adolescent

within the adult setting is based on the premise that being

treated like an adult will promote both independence and

personal responsibility and this improves health outcomes

(Blum et al., 1993). It is inevitable that at some point an

individual will outgrow the services provided by the child

health care service, and their needs will be better

accommodated in the environment of the adult health

care system. The result is a period of transition and this

may be accompanied by a certain amount of sadness and

apprehension (Frank, 1992). A sense of loss may be felt

when they move from a trusted and known relationship to

a new service (Frank, 1992). Johnson (1995) has suggested

that these negative feelings towards the transition are

increased by the strong emotional attachments that often

The transition of adolescents with diabetes into the adult health care service 561

� 2002 Blackwell Science Ltd, Journal of Clinical Nursing, 11, 560–567

develop between patients and paediatricians. Transition

into the adult health care service comes at an often

already stressful and difficult time in the adolescent’s life

(Bradbury & Jenkinson, 1996; Saunders, 1998; Datta,

2001). They face radical changes in lifestyle, circum-

stances and personal relationships; these years are a time

of transition (Stockman & Bates, 1998). During this

stressful period, the adolescent must also find the time

and motivation to control their diabetes, as well as facing

their transition into the adult health care service.

Perhaps, then, it is not surprising that non-adherence

is an issue among adolescents with diabetes (La Greca

et al., 1995; Morris et al., 1997; Kyngas et al., 1998;

Werther & Court, 1998) as they are already predisposed

to factors that make non-adherence more likely (Frank,

1992). Werther & Court (1998) attribute non-adherence

to the major impact diabetes has on the adolescent’s life:

the management of diabetes involves life-long restrictions

and complicated treatment regimens that are associated

with undesirable side-effects.

Non-adherence resulting in poor glycaemic control is

likely to lead to further complications, such as microvasc-

ular and neurological complications (DCCT, 1993;

MacKinnon, 1998). The added pressures that diabetes

brings frequently lead the adolescent with diabetes to rebel

(Kinmonth, 1985; Ferguson, 1998). Manipulation of food

is an easy option for a rebelling adolescent with diabetes.

Many researchers have found a higher incidence of eating

disorders in female adolescents (Garner, 1980; Szmulker &

Russell, 1983; Steel et al., 1987; Peveler, 1996; Rydall

et al., 1997). Rydall et al. (1997) measured the prevalence

and persistence of disordered eating behaviour in 91

female adolescents on the basis of self-reporting. It was

concluded that this is both ‘common and persistent in

young women with IDDM, and is associated with

impaired metabolic control and a higher risk of diabetic

retinopathy’ (p. 1849).

A study involving 40 children and adolescents (age

range 7–17 years) with IDDM carried out by La Greca

et al. (1990) also found a link between poor adherence and

manipulation of food. Items significantly related to poor

adherence in older adolescents (aged 12–17 years) were

‘eating proper foods’, ‘sticking to the prescribed diet’ and

‘carrying sugar to treat reactions’. A study in Tayside,

Scotland, involving 89 teenage patients showed that 28%

were under-using their prescribed insulin (Morris et al.,

1997). The results indicated direct links with under-usage

and poor glycaemic control. In addition to the problems

identified regarding adherence to treatment regimens,

higher rates of non-attendance at clinic appointments have

been reported after transition into the adult health care

service (Wilson & Greenhalgh, 1999). They found that

40% (62 people) of young persons (aged 16–25) registered

at the young person’s clinic, in the north of England, were

not attending the clinic.

Smooth, uneventful transition into the adult health care

system is extremely important for an adolescent’s short-

and long-term welfare. When this is abrupt or the

adolescent and their family lack the necessary skills to

cope with the change, regular clinic attendance and

adherence may come under threat, ultimately compromi-

sing metabolic control. Successful transition of the care of

adolescents from the children’s health care service into the

adult health care service can be very challenging (Savage &

Besser, 1997). This has been attributed to the unpredict-

able and insecure nature of adolescence which does not fit

well with the behaviour changes required to manage

diabetes (Werther & Court, 1998).

In ‘The St Vincent Declaration: a charter for change’,

devised by the British Diabetic Association (BDA, 1995),

the targets include:

• Sustained improvement in health experience and a life

approaching normal expectations in quality and quan-

tity.

• To promote independence, equity and self-sufficiency

for all people with diabetes – children, adolescents,

adults and older people.

Maturing into an adult provokes pressures that impact

upon an adolescent’s management of their diabetes,

providing the potential to become non-adherent with

treatment regimes. As health care practitioners, this

provides us with a challenge if the targets laid down in

the St Vincent Declaration (1995) are to be achieved, and

adolescents with diabetes are to receive a standard of health

care that will facilitate their full potential. In addition to

this, the UK Diabetes National Service Framework

(Department of Health, 2001), due to be implemented in

2003 will lay down specific goals for services providing care

for adolescents with diabetes. The advent of National

Service Frameworks (NSF) involves implementing

national standards, against which measurement of progress

can be done, putting health care providers under additional

pressure to provide a quality service.

THE TRANSITION FROM THE CHILDREN’S HEALTHTHE TRANSITION FROM THE CHILDREN’S HEALTH

CARE SERVICE INTO THE ADULT HEALTH CARECARE SERVICE INTO THE ADULT HEALTH CARE

SERVICESERVICE

The adolescent’s transition into the adult health care

system is virtually inevitable, the only exceptions being

those who refuse the transition and those who do not

survive to reach this stage. Poor transition into the adult


562 E. Fleming et al.

health care system may lead to the mismanagement of the

adolescent’s diabetes, resulting in microvascular and

neurological complications, which are major causes of

morbidity and mortality in IDDM (DCCT, 1993, 1996).

This transition involves a move between two very

different health care systems. The approach of children’s

health care places far greater emphasis on the family.

Casey (1988) developed the notion of ‘family-centred

care’, and that has become fundamental to the care for

children. It centres on the partnership of the child and

family with the children’s nurse, this being adjusted

according to the nursing needs of the child. At consul-

tations the child is almost always seen alongside a family

member and so to a certain extent this can, unless

appropriately handled, remove pressure from the growing

child to become independent and self-caring of their

health. The adult health care system is much more

directive and formal. Consultations without the presence

of a parent will often be encouraged. It is often taken for

granted that the patient has the necessary cognitive skills

to manage their own care. A study by Eiser et al. (1993)

evaluated the perceptions of 69 patients of a diabetic clinic

in Exeter, UK, for under 25 years olds. Paediatricians

were perceived to emphasize family and social life, school

or work progress, whereas adult physicians tended to

emphasize the risk of long-term complications, importance

of exercise and need to maintain strict levels of glycaemic

control. Although this evaluation was limited to one clinic,

some credence can be given to the findings as others have

also suggested that differences in service provision exist

between children’s and adult services (Schidlow & Fiel,

1990; Rosen, 1994). The differences between modes of

service are illustrated in Table 1. It is apparent that the

transition must be carefully managed, so that the adoles-

cent does not need to make an abrupt adaptation in their

move from an environment that is very supportive and

helpful in managing their health to one where they are

expected to be independent, with the necessary knowledge

to manage their own health, with minimal intervention

from others.

BARRIERS TO THE TRANSITION FROM THE CHILDREN’SBARRIERS TO THE TRANSITION FROM THE CHILDREN’S

HEALTH CARE SERVICE INTO THE ADULT HEALTHHEALTH CARE SERVICE INTO THE ADULT HEALTH

CARE SERVICECARE SERVICE

The literature identifies certain parental emotions as

barriers to the transition process. Rosen (1994, p. 243)

suggests that parents may be ‘particularly suspicious’ of

adult health care providers as they are more likely to

promote an environment that fosters the independence

of the adolescent, leaving parents feeling excluded.

Adolescents and parents may view transition into the

adult health care system as a ‘step closer to disease

complications and death’ (Viner, 1999, p. 272). Parental

anxiety has been identified as a factor that may impede the

transition (Blum et al., 1993). This may intensify as the

adolescent faces a move into the adult world, with a new

health care system and a more independent life (Blum

et al., 1993). These anxieties reflect the usual anxieties

many parents experience as they gradually have to

relinquish decision-making for their children. Thorough

planning and preparation will help to alleviate some

parental anxieties and it is important that the transition

programme incorporates the adjustment of all family

members (Betts et al., 1996; Viner, 1999).

In addition to barriers erected by adolescents and their

family, physicians may display their own resistance to the

transition. Blum (1991) proposes that many childhood

conditions are relatively unknown to adult physicians and,

whilst they are knowledgeable about diabetes itself, they

may be less aware of some of the emotional turmoil that

adolescents may be experiencing. This may create reluct-

ance on the part of adult physicians to accept responsi-

bility for care of the adolescents as they may find them

‘medically challenging, emotionally demanding and finan-

cially draining’ (Rosen, 1994, p. 243). It may be that the

characteristics displayed by some adolescents make adult

physicians view them as problematic or ‘unpopular’

patients (Stockwell, 1972).

Paediatricians, in some respects, are ‘like parents –

highly protective of their young patients and possibly

fearful of ‘‘letting go’’ of their care’ (Sawyer et al., 1997,

p. 88). This fear of ‘letting go’ may be furthered by

suspicions about adult physicians’ lack of appropriate

knowledge and experience. Schidlow & Fiel (1990) believe

that this fear is heightened as many paediatricians feel that

they have the necessary skills to care for adults within the

paediatric environment.

ADOLESCENTS’ PERCEPTIONS OF THE TRANSITIONADOLESCENTS’ PERCEPTIONS OF THE TRANSITION

INTO THE ADULT HEALTH CARE SYSTEMINTO THE ADULT HEALTH CARE SYSTEM

Attempts have been made to measure adolescents’ views of

service provision. Newton (1987) made an informal

Table 1 The differences between the two modes of service

Children’s health care service Adult health care service

Family centred Person centred

Socially orientated Disease orientated

Informal and relaxed Formal and direct

School and life progress Diet, exercise and compliance



attempt to explore the attitudes and concerns of 70 (39

females and 31 males, age range 15–26 years) adolescents

and young adults with diabetes, through the use of a

questionnaire. The origins and validity of the tool are not

stated. Sixty-three per cent of the participants agreed that

they had gone through a period when they felt they could

no longer cope with their diabetes. Parents, friends and

other diabetics (15, 20 and 22 respectively) were reported

as helping the adolescent to cope during this period.

Nurses, doctors and dieticians were considered a major

source of support to 18% of adolescents. Perceived

support offered by physicians, nurses, parents and friends

has been shown to influence compliance with self-care

among adolescents (Kyngas et al., 1998). Cross-tabulation

showed that better compliance was associated with the

actions of physicians, nurses and parents described as

‘motivating’ and when parental actions were perceived as

‘accepting’. Caution needs to be applied to these results

as they were not tested for statistical significance.

Court is one of the few authors who has questioned

adolescents and young adults about transition into the

adult service. In the first study (Court, 1991), question-

naires were delivered to 100 adolescents and young

persons who had left the diabetes service of the Royal

Children’s Hospital, Melbourne, between 1 and 5 years

previously (response rate 70%; age range 17–27 years;

mean age 20.5 years). The author does not indicate the

origins of the questionnaire, or if it had been validated.

For the majority (53%) the ideal age for transition was 17–

20; although an age of up to 25 was felt to be appropriate

by 35%, no rationale for this was provided in the paper.

Individuals prioritized privacy and confidentiality, short

waiting times and an informal atmosphere. Qualities of the

physician rated as very or quite important included ‘one

you like and can talk to’ (96%) and ‘one you can see

regularly and get to know’ (90%). In his further study,

also carried out at the Royal Children’s Hospital,

Melbourne, Court (1993) found very similar results (105

respondents, 69% response rate, aged range 15–18 years).

Almost all adolescents anticipated the most appropriate

time for transfer as between 17 and 25 years. They

valued continuity of care by a physician whom they

trusted. They also expected confidentiality, privacy and a

degree of informality. Again the origins of the question-

naire, along with its reliability and validity, are not

indicated.

Eiser et al. (1993) also questioned adolescents specific-

ally about the transition process. The study involved

evaluation of patients’ perceptions of a diabetic clinic for

under 25 years olds (n¼ 69, 41 females and 28 males; 74%

response rate; age range 12–20 years) in Exeter, UK, and

an assessment of experiences in transferring from a

paediatric clinic. Patients were asked to answer questions

by giving a rating on a five-point scale (1¼ not important

at all, 5¼ very important indeed) and the means are given

below. Staff in the under-25 clinic were perceived as

placing a great deal of importance on ‘avoiding long-term

complications’ (4.9), ‘blood glucose levels’ (4.8), ‘insulin

management’ (4.5) and ‘exercise’ (4.3). They were per-

ceived to assign a lesser importance to ‘school progress’

(2.6), ‘family relations’ (2.9) and ‘patients’ privacy’ (3.0).

A series of questions was directed only at those who had

experience of transferring from the paediatric clinic to

adult clinic (n¼ 41). These patients felt that it would have

been helpful if they had been able to ‘visit the under-25

clinic before transfer’ (3.4), and there had been ‘greater

co-ordination between paediatricians and physicians’ (3.4).

‘Nurses from the under-25 clinic visiting the paediatric

clinic’ (3.1) or ‘adult patients visiting the paediatric clinic’

(2.2) were thought to be slightly less helpful. ‘School

progress’ and ‘family relations’ were emphasized by

paediatric staff (P < 0.05), whilst the adult staff empha-

sized the importance of ‘exercise’ and ‘blood glucose

levels’ (P < 0.05).

Postal questionnaires were used in a study carried out

by Pacaud et al. (1996) (n¼ 135). Fifty per cent of the

participants expressed having either difficulties or a delay

or loss of regular follow-up through transition from the

children’s into the adult health care service. The ideal age

for transition was identified as significantly higher for

those who had problems than those who did not

(19.9 ± 0.6 vs. 18.4 ± 0.2 years, P < 0.05). Some caution

needs to be applied to these results because of the low and

possibly biased response rate (36%), and because the

origins of the questionnaire are not provided, or whether it

has been tested for validity and reliability. A section was

provided on the questionnaire for participants to elaborate

on their personal experiences and perceptions. One

summed up their feelings as follows:

Insecurity, no explanations on how follow-ups are

organized, less information, less interest, but a more

efficient blood sampling centre (Pacaud et al., 1996,

p. 18).

There is a distinct lack of research exploring adoles-

cents’ perceptions of their transition into the adult service.

The research available is scant, often with a limited target

population, and at times lacks robust methodology. This

aside, the data do display some common themes. Adoles-

cents felt that the ideal time for transition into the adult

service was late in their teenage years or early in their

twenties (Court, 1991, 1993; Pacaud et al., 1996). They

emphasized the need for health care workers to possess



effective interpersonal and communication skills. These

should be used in relations between patients and health

care workers and between health care workers and other

staff. In particular, they should be used to reduce gaps and

promote continuity between the children’s and adult

service (Court, 1991; Eiser et al., 1993). The qualitative

responses in Pacaud’s (1996) study identify that after

experiencing transition, young persons can identify dif-

ferences between children’s and adult services. This is

supported by the study by Eiser et al. (1993), which found

that adolescents report significant differences between the

services (P < 0.05).

Transition programmes have been designed and models

of care developed in order to try and overcome some of

these difficulties. This review suggests that certain factors

are fundamental to successful transition.

PRINCIPLES OF A SUCCESSFUL TRANSITIONPRINCIPLES OF A SUCCESSFUL TRANSITION

Frank (1992) states that the goal for health professionals,

when concerned with the transition of adolescents with

diabetes from the children’s into the adult health care

service, should be a ‘gradual preparation of the youth and

their parents for the change’ (p. 87). She believes that the

strategies implemented should not aim to eliminate

differences between the approaches taken by the children’s

and adult health care services, but rather should ease the

transition.

There is some debate over the most appropriate time to

introduce the concept of transition into the adult service

and the most appropriate time for the transition to take

place. Rosen (1993), in his review of the transition of

adolescents with cancer into the adult health care system,

highlighted the most important factor as being the premise

that transition will eventually occur. The principles should

be explained beforehand, allowing the adolescent and

family sufficient time to familiarize themselves with the

idea that care will be delivered in a different setting and by

a different team at some point in the future. This idea,

that the transition should be planned and co-ordinated, is

supported by others (Blum, 1991; Sawyer et al., 1997).

Rosen (1991) advocates the introduction of transition in

childhood, and Sawyer et al. (1997) support anticipation

of the physical transfer of care from as early as the time of

diagnosis. The most appropriate time to introduce the

concept is debatable, but what is clear is that its

introduction at an early stage allows adequate time for

preparation such as health education and promotion of

independence.

The timing of the transition forms another key area

in the literature. Frank (1992) identified through his

literature review that age alone is an insufficient criterion.

It is perhaps obvious that age alone could not be a deciding

factor for the timing of the transition, as it would be nearly

impossible to predict each adolescent’s level of maturity

and dependent behaviour by just their age. According to a

report for the British Diabetic Association (Betts et al.,

1996), the timing of transfer should take into account an

adolescent’s physical development and emotional matur-

ity. In addition to this, the working relationship between

the paediatrician and the adult diabetologist, and the

provision of an adolescent and young adult clinic should

be considered.

Authors and researchers share the consensus that the

promotion of independence for chronically ill adolescents

plays a key role in ensuring a successful transition. As

adolescents become cognitively and socially mature, they

must be encouraged and allowed to play a more active role

in their health care (Rettig & Athreya, 1991; Blum et al.,

1993; Rosen, 1993, 1994). Adolescents’ desire for more

information was highlighted in Court’s survey (1993).

When asked what, in addition to health care, they would

like to receive from a health service, the most important

needs identified by more than a one-third of the subjects

were information about their condition and new develop-

ments, along with provision of emergency care and

telephone advice. Provision of information has also been

highlighted by Betts et al. (1996), who argue that under-

standing the complications of diabetes is important, so that

informed decisions on lifestyle are possible.

As well as considering maturity and dependency of the

adolescent the transition should occur at a time of relative

stability in their health, and be co-ordinated with other life

transitions (Eiser et al., 1993; Rosen, 1994). Transition

during a period of good health allows the team to assess

baseline health, and avoids a situation where the adoles-

cent and their family attribute the period of instability to

the transition. Co-ordinating with other lifestyle transi-

tions that have brought about independence allows a

logical process to follow.

Discussion

The literature highlights the need for collaboration

between children’s and adult health care services, which

will assist the structured care of adolescents. It is accepted,

and necessary, that children’s teams take a more family-

centred approach, whilst adult teams place greater

emphasis on individual independence and autonomy.

These two differing approaches are necessary for adoles-

cents’ development. They should not be seen as rivals to

one another. Rather, they are both equally important, both



making their essential contributions to the adolescents’

development. Implementation of a transition programme

can complement the two approaches: facilitating a seam-

less transition, whilst aiding cognitive, emotional and

intellectual capabilities of the adolescent. The Diabetes

NSF, due to be implemented in 2003 in the UK, will

result in the introduction of national standards and

definitive service models with recommendations specific-

ally for adolescents with diabetes. Preliminary findings,

from a study carried out by us, suggest that there is

significant disparity between the services provided for

adolescents with diabetes, in the north-west region of

England. This is despite the fact that the transition of

adolescents with chronic illness has previously been

identified as requiring priority through national docu-

ments such as ‘Government Response to the Reports of

the Health Committee on Health Services for Children

and Young People, 1997’ and ‘Youth Matters: Evidence

Based Best Practice for the Care of Young People in

Hospital’ (Viner & Keane, 1998). We anticipate that the

findings of our study will be published early in 2003.

Included in the goals of the Diabetes NSF is to ‘reduce

unacceptable variations in the quality of services for

people with diabetes’. This should result in a reduction in

the disparity of service which still appears to exist.

‘Improvement of health outcomes of people with diabetes’

is highlighted as a further goal of the Diabetes NSF.

Caution should be exercised when interpreting the term

‘health outcome’. As health care practitioners it is easy to

impose our values on the people for whom we are

providing care, assuming that both parties hold the same

values. However, what an adolescent defines as a ‘health

outcome’ may bear no relation to the ‘health outcomes’

defined by health care professionals. The paucity of

research addressing what adolescents identify as needs

during their transition into the adult health care service

has been highlighted. Therefore, interpretation of ‘health

outcome’ from adolescents’ perspectives may prove diffi-

cult. Identification of what adolescents prioritize in their

lives and care of their diabetes should be done through

further studies.

Conclusion

When the transition of adolescents with diabetes into

adult services is managed effectively, it has the capacity

to provide the attributes necessary for a self-sufficient

person capable of living an independent lifestyle.

Individuals will become independent in their health

care, and in addition will be able to transfer these skills

into other aspects of their life. This review identifies,

from a conceptual basis, some of the problems and

pitfalls of transition. In reality, implementation of a

successful transition programme relies on more than the

results of rigorous research and unification of expert

opinion. Members of the healthcare team who interact

with patients on a daily basis often find themselves in

the frustrating position of being unable to deliver the

highest quality healthcare because of constraints of the

UK NHS infrastructure. It is this that dictates and

limits to whom resources will be available. The future

will see the implementation of the Diabetes NSF, which

will stand by the promise to ‘improve health outcomes

of people with diabetes’ and ‘reduce unacceptable

variations in the quality of services for people with

diabetes’ (Department of Health, 2001).

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