[Posted on 7 May, 2018 by Anne-Katrin Kantzer]
The longer I work in child and adolescent psychiatry, the stranger I feel it is that we draw a line at the age of 18 when it comes to responsibility for our patients. As an old Chinese proverb tells us, grass won’t grow any faster by pulling on it. “Things” must be allowed to grow and mature at their own pace, and that pace is not the same for all individuals.
In my everyday clinical work, I see many patients with developmental disorders, quite a few of them have autism. Changes – whether big or small – can present a challenge for people with ESSENCE symptoms, and especially for individuals with autism. It is therefore very important that we follow up our patients throughout childhood and adolescence. Transitions like starting school or moving from primary to secondary school are high-risk ages/periods for crises. That is when we need to be there and help prepare, and to pick up on early signs of psychiatric burdens like anxiety or depression.
Turning 18 is a major milestone in our society. I remember my own sense of both dread and delight as I looked forward to my 18th birthday: being an adult, getting to make my own decisions. All the rights I would finally have. Getting my driver’s licence. No signature from one’s parent or guardian when failing an exam. Having a drink at a party. Moving out. Getting to vote in national elections. A big moment. And kind of a scary one, too.
There are mainly two groups among my patients that I worry about when they start inching closer to that crucial 18th birthday:
One group is looking forward to the day when they can finally make their own decisions. When no one can tell them what to do anymore. They might have completely unrealistic fantasies about the new freedom that awaits them. My job as a child and adolescent psychiatrist is to support the parents and to prepare the adolescent for this transition well ahead of time. Intellectual functions like consequential thinking and nuanced reasoning usually only mature in a person’s late teens and early adult years, and this occurs even later for adolescents with weak central coherence and theory of mind. The fact that our society defines adulthood based on biological age is problematic, as the cognitive functions required to handle adult responsibilities mature at vastly different rates.
Another group I encounter is made up of young people who end up in a life crisis. Their 18th birthday is like a wall staring back at them, and no matter how you try to help and prepare them for this transition, their theory of mind is simply not up to the task. Their fear of change takes over. Many young adults also become more aware of the potential difficulties that await them. Differences compared to age peers in terms of independence and social integration become more pronounced. Becoming an adult starts to feel like an insurmountable mission, a project that requires all one’s energy and that also creates identification issues. I have met many patients for whom the near-term prospect of turning 18 has caused them to develop severe depression, or escalated anxiety and sleeping problems. These patients must first be stabilised before they can move on.
The issue is not that adult psychiatric services are incapable of taking on young patients; some of our patients simply aren’t ready to take the step into adulthood. The leap is too great, there are too many changes to deal with all at once. These patients need to remain within child and adolescent psychiatric services past the magical legal age limit of 18 and eventually, at a somewhat later date, carefully be transferred to adult psychiatric services. With all the knowledge available concerning developmental psychology and the field of ESSENCE, it is high time for us to change our routines. I wish there would be more flexibility in my everyday clinical work. I would like to be able to provide care tailored to the patient’s individual needs, desires and capabilities all the way until the age of 25. Let our patients mature at their own pace and feel ready for the leap into adulthood rather than shoving them over the threshold! Let the grass grow tall, or you’ll risk ripping off its tips when you pull on it.