Paeds · mental-behavioural-and-psychosomatic
Collaborative care with child and adolescent mental-health services
Also known as Integrated paediatric behavioural health · Shared care with CAMHS · Child psychiatry access program · Collaborative care model in paediatrics · Stepped mental-health care for youth · Primary-care mental-health integration
Fellowship guide to collaborative care between the paediatrician and child and adolescent mental-health services (CAMHS): the four models of integration (referral, consultation-liaison / access programs, co-located, fully integrated), why the gap exists and how collaborative care closes it, the stepped-care tiers and who delivers each, multi-agency assessment and information-sharing, the acute-risk warm handoff, routine outcome monitoring, regional service architecture (ANZ Better Access and headspace, UK CAMHS tiers, US MCPAP and Project TEACH), and adaptation for Indigenous, refugee, rural and out-of-home-care youth — anchored by the AACAP 2023 collaborative-care clinical update, the Asarnow 2015 meta-analysis and the Massachusetts child psychiatry access program.
On this page
Study tools
Your progress
Saved on this device.
Practise this topic
Target exams
Red flags
- Active suicidal ideation, intent, plan or escalating self-harm — same-day crisis response and risk assessment with a CAMHS crisis team or emergency department, not a routine collaborative pathway
- Acutely psychotic, manic, or a danger to others — urgent specialist CAMHS or emergency mental-health assessment; do not manage in primary care alone
- Rapid weight loss, food refusal or bradycardia suggesting an eating disorder with medical instability — paediatric admission for medical stabilisation plus urgent CAMHS eating-disorders team
- Disclosed or suspected child maltreatment — mandatory reporting obligations and safeguarding procedures override routine referral; coordinate with child protection
- New neurological or cognitive change attributed to a mental-health presentation — exclude delirium, seizure, mass or metabolic disease before psychiatric framing
- Caregiver mental illness, substance use or family violence destabilising the child's environment — the collaborative plan must address the family system, not only the child
Life stages
Care settings
Clinical exam formats
Board mappings
- General and Community Paediatrics
- Behavioural and developmental paediatrics
- Adolescent medicine
- Renewed curriculum — Learning goal 5: Clinical assessment – essential general paediatrics
- Renewed curriculum — Learning goal 16: Mental health
- Developmental and behavioural paediatrics
- Adolescent and youth medicine
- Clinical Applications — mental and behavioural health presentations
- Long Cases
- Short Cases
- Communication stations
- 2. Professional skills and knowledge: Communication
- 3. Professional skills and knowledge: Leadership and team working
- 4. Professional skills and knowledge: Patient management
- 9. Mental health and behavioural presentations
- Foundation of Practice (FOP)
- Applied Knowledge in Practice (AKP)
- History
- Communication
- Management planning
- General Pediatrics Content Outline — Domain 5: Mental and Behavioral Health
- General Pediatrics Content Outline — Domain 6: Psychosocial Aspects
- Systems-Based Practice: Coordination of care
- Interpersonal and Communication Skills: Patient- and Family-Centered Communication
- Patient Care: Behavioral and mental health
- Collaborator
- Health Advocate
- Medical Expert
Integrated team with shared accountability · Stepped care matched to need · Loop of bidirectional consultation (paediatrician ↔ CAMHS) · Access widened (screening, warm handoff, telehealth) · Name a single care coordinator · Data-driven with routine outcome monitoring (ROMs). Get all six and the child stops falling between services. [1] [2]
Overview & Definition
Collaborative care, in this context, is the structured working partnership between paediatric primary care and specialist child and adolescent mental-health services that shares responsibility for a young person's mental health. It is not a referral and a handshake. The American Academy of Child and Adolescent Psychiatry's 2023 clinical update defines it as a team-based, measurement-guided model in which a behavioural-health clinician is integrated with the paediatric team, a consulting psychiatrist provides caseload oversight, and a care manager coordinates a stepped, registry-tracked plan. [1]
The model exists because of an unavoidable demographic fact: paediatric primary care is the de facto mental-health system for children and adolescents. Parents bring behavioural and emotional concerns to their general paediatrician or family doctor far more often than to a mental-health service, the presentations are often somatic, and the specialist CAMHS workforce is too small to see every affected child. Collaboration recognises this reality and redesigns care so that the front door is competent, supported and connected — rather than a place that simply mails a referral into a long queue. [2] [7]
Your role as a general paediatrician within collaborative care is therefore broader than "refer when severe". It is to recognise mental-health need early through routine surveillance and screening, stratify urgency and risk, start first-line evidence-based intervention in primary care when appropriate, consult specialist CAMHS for advice and shared management, and coordinate the plan across family, school and agencies so that no young person falls through a gap between services. [1] [9]
References12ShowHide
- [1]American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Collaborative and Integrated Care and AACAP Committee on Quality Issues. Clinical Update: Collaborative Mental Health Care for Children and Adolescents in Pediatric Primary Care. J Am Acad Child Adolesc Psychiatry, 2023.PMID 35779696
- [2]Campo JV, Geist R, Kolko DJ. Integration of Pediatric Behavioral Health Services in Primary Care: Improving Access and Outcomes with Collaborative Care. Can J Psychiatry, 2018.PMID 29673268
- [3]Asarnow JR, Rozenman M, Wiblin J, Zeltzer L. Integrated Medical-Behavioral Care Compared With Usual Primary Care for Child and Adolescent Behavioral Health: A Meta-analysis. JAMA Pediatr, 2015.PMID 26259143
- [4]Dvir Y, Ryan C, Straus JH, Sarvet B, Ahmed I, Gilstad-Hayden K. Comparison of Use of the Massachusetts Child Psychiatry Access Program and Patient Characteristics Before vs During the COVID-19 Pandemic. JAMA Netw Open, 2022.PMID 35107575
- [5]American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Telepsychiatry and AACAP Committee on Quality Issues. Clinical Update: Telepsychiatry With Children and Adolescents. J Am Acad Child Adolesc Psychiatry, 2017.PMID 28942810
- [6]Apple RW, Dickson CA, Cabral MDI. Integrated Behavioral Health in Pediatric Practice. Pediatr Clin North Am, 2021.PMID 34044996
- [7]Njoroge WFM, Hostutler CA, Schwartz BS, Mautone JA. Integrated Behavioral Health in Pediatric Primary Care. Curr Psychiatry Rep, 2016.PMID 27766533
- [8]Kodish I, Richardson L, Schlesinger A. Collaborative and Integrated Care for Adolescent Depression. Child Adolesc Psychiatr Clin N Am, 2019.PMID 31076110
- [9]Sengupta S. Engaging Pediatric Primary Care Clinicians in Collaborative and Integrated Care. Child Adolesc Psychiatr Clin N Am, 2021.PMID 34538447
- [10]Gloff NE, LeNoue SR, Novins DK, Myers K. Telemental health for children and adolescents. Int Rev Psychiatry, 2015.PMID 26540584
- [11]Cunningham NR, Ely SL, Barber Garcia BN, Bowden J. Addressing Pediatric Mental Health Using Telehealth During Coronavirus Disease-2019 and Beyond: A Narrative Review. Acad Pediatr, 2021.PMID 34118499
- [12]Kim-Cohen J, Caspi A, Moffitt TE, Harrington H, Milne BJ, Poulton R. Prior juvenile diagnoses in adults with mental disorder: developmental follow-back of a prospective-longitudinal cohort. Arch Gen Psychiatry, 2003.PMID 12860775