9.3 Child and adolescent mental health services

Service models

• The four-tier model runs from universal support (tier 1) through targeted specialist work (tier 2) and multidisciplinary community care (tier 3) to highly specialised or inpatient care (tier 4).

• Organisation and terminology vary across the UK.

THRIVE is a needs-based framework from the Anna Freud Centre and the Tavistock and Portman NHS Foundation Trust. i-THRIVE supports its implementation, and many English services use it alongside other models.

The groupings are not a fixed ladder and not a map of particular buildings. School mental health support teams, community child and adolescent mental health services (CAMHS), crisis and home treatment, day programmes and inpatient units each do different work.

From referral to discharge

• Triage identifies urgency and immediate safety needs. An emergency needs an urgent clinical response, not a place on the waiting list.

• Assessment draws on the young person, carers, school and other professionals. When their accounts differ, the difference may point to a context-specific problem.

• A shared formulation links presenting difficulties, vulnerabilities, triggers, maintaining factors and strengths to evidence-based treatment options.

• Discharge needs an onward plan and a route back in.

• When a young person stops attending, ask about access, wishes and safeguarding rather than assume the need has gone.

The psychiatrist's role

• The psychiatrist brings medical diagnosis, physical and developmental assessment, treatment and legal expertise, such as capacity assessment and court reports.

• Intimate examination and pubertal staging are not required at every contact.

• Autism assessment is multidisciplinary. Attention deficit hyperactivity disorder (ADHD) can be diagnosed by a trained psychiatrist, paediatrician or other qualified professional.

• Off-label prescribing is common but needs a clear rationale and discussion.

• Stimulants need growth and cardiovascular monitoring. Antipsychotics need metabolic, movement and other relevant checks.

The multidisciplinary team

Whatever the discipline, development, family relationships and education are central, held together by a shared formulation and clear clinical responsibility.

The wider network

• In England, Children Act duties cover children in need, enquiries into significant harm and looked-after children. Other nations use their own frameworks.

• Youth justice and liaison and diversion services identify health and developmental needs.

• Neurodevelopmental and disability pathways may sit inside CAMHS or run separately.

Consent and competence

• Establish who holds parental responsibility, but do not assume parents make every decision for every under-18.

• Gillick competence turns on an under-16's understanding and intelligence for the particular treatment decision.

• The Fraser guidelines are narrower: they cover contraceptive advice or treatment given without parental involvement.

Fraser requires that:

1. The young person understands the advice.

2. They cannot be persuaded to involve their parents.

3. They are likely to continue sexual activity.

4. They would risk physical or mental harm without the advice or treatment.

5. Giving it without parental involvement is in their best interests.

England and Wales

• The Mental Capacity Act applies from 16. The Mental Health Act has no minimum age, but detention still needs its criteria and safeguards.

• Under section 131(4), parental consent cannot override a capacitous 16- or 17-year-old's refusal of informal psychiatric admission.

• Parental authority does not authorise every restrictive arrangement. Admission, treatment and deprivation of liberty each need the correct legal basis under current case law.

Confidentiality

• Children have their own confidentiality rights. Discuss what will be shared and seek agreement where you can.

• Parents do not automatically receive every detail because a child falls below a competence threshold.

• Share necessary information without consent where safeguarding or another lawful justification requires it, and explain this where it is safe.

Access, interfaces and transitions

• Eligibility, funding and records differ between health, education, social care and youth justice. When a referral or transition is unresolved, agree a responsible lead and an interim plan.

• England's eating disorder access standard is treatment within one week for urgent cases and four weeks for routine ones. Other standards differ by nation and pathway.

• Plan transition before the age boundary and name the receiving service.

• Looked-after and justice-involved children have high need, which calls for coordination rather than assuming one uniform presentation.

Outcome, experience and safety

• CYP IAPT in England, and CORC, have supported routine outcome monitoring.

• Outcome data should inform the clinical discussion, not replace it.

• Track safety during waiting, treatment and transitions, with clear routes for escalation.

• Co-production means young people and carers shape decisions from the outset, in service design and in individual care planning.