Included national strategies

We included twelve relevant documents [8,9,10,11,12,13,14,15,16,17,18,19] from seven countries, published between 2013 and 2022, for our analysis of CAMH strategies and models. Table 1 gives an overview of included documents per selected countries.

Table 1 Overview of selected documents per countryKey principles

All included documents stated key principles on which CAMH services should be based. While these varied broadly across countries, most often mentioned key principles were to increase the focus on prevention, early detection/intervention (including efforts to improve mental health literacy), improved coordination and that CAMH services should be evidence-based including the need for more mental health services research. Additional key principles were to strengthen participation, to take special treatment needs into account, and to establish low-threshold services that are culturally sensitive and needs-based.

The general style of the documents differed in some regards. While some documents were rather strategic (Czechia, Germany, Spain), others were describing concrete models (Australia, Norway, United Kingdom) or a combination of both (Switzerland). Some documents explicitly provided an evidence base for each recommendation (e.g., Czechia, Norway), while others gave more jurisdictional context (Switzerland, Germany). One document in particular followed a thorough participatory approach, with the foreword of the document directed at children and adolescents in easy-to-understand language (United Kingdom).

Topic areas in included documents

The majority, but not all of the 14 topic areas were described in each of the included documents. The document from Czechia addressed the fewest number of topic areas, while Australia and Spain were the only countries addressing all topic areas. Table 2 gives an overview which topic areas were described in the included documents.

Table 2 Topic areas in selected documentsInformation activities, prevention/promotion, detection

All countries recommend information and awareness raising activities to increase health literacy and reduce stigma. Several distribution channels (traditional and social media), targeting children, adolescents, carers, and less often professionals, are recommended. For strengthening mental health promotion and illness prevention, the focus is on increasing early help-seeking, and improving interpersonal relationships (e.g., reducing violence and improving respectfulness). One key target group of these activities are parents with a mental illness, as there is rising awareness of the negative impact parental mental illness can have on children. One recommendation in this area is to introduce specialised programmes aimed at developing parenting skills, especially for families under psychosocial stress, in order to reduce the risk of traumatisation of children. Another recommendation is to increase care for these affected families, to counteract the existing disadvantages. The key setting of promotion and prevention activities is within schools. Similarly, the recommended core setting for screening and early detection in the documents is the school environment, involving different professionals (e.g., school health nurses).

Treatment, telemedicine, care pathways, transitional psychiatry

Regarding treatment, the necessity to broaden the range of settings is highlighted, ranging from home-treatment, inpatient-equivalent treatment and other outreach approaches, to inpatient treatment. To allow family-focused care, alternatives to hospital care are described as important. As for medication, the need to improve safety by installing measures to reduce the wide off-label use is emphasised. Suggestions on the mode of care delivery include telehealth and face-to-face approaches in single- and/or group settings. The increased use of digital applications is mainly recommended for detection, self-care, and better system navigation. Australia has defined the expansion of telehealth tools as a priority activity, however, with funding extensive evaluation research alongside.

Suggestions on care pathways and integrated care play a prominent role aiming at integrating services across different sectors, such as health and education. A key suggestion is to establish a single point of access and to provide a coordinator for each patient/family. The pathways to access hospital care should be clearly defined and linked to quality indicators monitoring waiting times or “no shows”. The care pathways are recommended to be in line with the different developmental stages throughout child and adolescence, e.g., which service networks and interventions are required at each stage of development. For better management of transitional phases (e.g., when entering schools, or from adolescent to adult psychiatry), a shared recommendation is to move away from age thresholds to needs-based transitions depending on developmental stages, including extending ages for transition into adult mental health care up to 25 years.

Vulnerable patient groups, user participation, infrastructure

A broad number of especially vulnerable groups, at greater risk for developing a mental illness and often requiring complex care arrangements, have been identified across all documents. These include culturally and linguistically diverse groups. Measures to better and routinely detect circumstances that make a child vulnerable and installing a lead professional for case management (shifting the responsibility for coordination from the family to the professionals) are recommended. Further, an additional re-distributing of resources to better care for these vulnerable children and adolescents are suggested. These resources are recommended to cover interpreter services, additional time, personnel, and material resources, developing social and emotional wellbeing services for diverse populations, and appropriate referrals to specialist mental health services. Another topic described across most documents is strengthened user participation. The aim is to provide more tailored care and better navigation in care pathways, by involving users in both individual care planning but also in the systemic design processes of the services.

Regarding infrastructure and resources, the countries recommend infrastructure to be accessible and culturally safe. For financing, an increase in budget is required for interprofessional collaboration, psychotherapy and psychoeducational programmes, and for policies aimed at preventing inequality in youth. Examples are ring-fenced budgets jointly provided by the health, social and educational ministry. Additionally, new reimbursement mechanisms for providers are suggested to fund a combination of outpatient services for children with complex needs.

Workforce development, implementation, digital tools, data acquisition/research

The workforce qualification and professional development is another topic area described across most documents. Most countries suggest broadening the traditional health workforce with additional workers (e.g., allied health specialists, family therapists, diverse and LGBTIQ + health workers, peer support workers). A specific highlight is put on developing the competences of school teaching staff (led by mental health specialists), as well as implementing a designated wellbeing staff member in all schools. For the implementation strategy and process, some countries created inter-ministerial/cross-sectional committees, with individual responsibilities from managers of health centers, school health services and municipalities. To guide implementation, it is recommended to identify what is working in some regions and rolling it out to the whole country, with phases of implementation described as an establishment phase, an embedding phase, and a full operational phase.

Almost all countries recommend increasing data acquisition and research with the aim of monitoring changes in mental disorder prevalence and effects of interventions. A broad range of specific research topics and study designs are listed, including (cross-sectoral) mental health service research allowing benchmarking of services (e.g., waiting times and user satisfaction). Several countries are in the process of implementing national mental health services datasets for data acquisition and sharing across relevant sectors. Most countries further suggest increasing the availability of digital tools for case management (e.g., tools to facilitate clinical decision making and cross-sector video conferences) and documentation (e.g., continued development of trans-organisational electronic patient record systems).

Establishing a child and adolescent mental health strategy

Drawing inspiration from the recommendations in international CAMH strategies and models, the following Fig. 2 may serve as a starting point for health policy discussions on establishing and further adapting a stand-alone CAMH strategy. In this guiding principle, the importance of a participatory design approach is emphasised. Further, health services research plays a central role for the depicted components (current status analysis, development of a mental health strategy, operationalisation, implementation, and evaluation).

Fig. 2

Guiding principles for a stand-alone child and adolescent mental health strategy

Quality assessment

The assessment of the overall quality of the documents ranged from 62 to 95%. Reasons for lower ratings were, among others: the views and preferences of the target population were not always included, the target users of the documents were not always clearly defined, and no application of systematic methods to search for evidence, and the recommendations were not always explicitly linked to supporting evidence (see Table 3).

Table 3 Quality assessment of the included documents