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European Society of Child and Adolescent PsychiatryChild and Adolescent Psychiatry2026intermediate

European Society of Child and Adolescent Psychiatry (ESCAP) practical guidance for clinicians and mental health services regarding child to adult mental health service transitions and managed discharge at the service boundary.

Published by European Society of Child and Adolescent Psychiatry (ESCAP)

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Summary

AI-generated

The guidance outlines practices, procedures, and service environments to promote appropriate, safe, and timely transitions of young people from child and adolescent mental health services to adult mental health services or alternative care settings across Europe.

youth mental healthservice transitionchild and adolescent psychiatryESCAPCAMHSAMHSmanaged dischargeguidelines

Key Takeaways

  • 1
    Initiate transition planning at approximately 6 months prior to the CAMHS-AMHS boundary.
  • 2
    Actively involve young people and their parents/caregivers in shared decision-making throughout the process.
  • 3
    Conduct comprehensive transition need and readiness evaluations using standardized tools like TRAM.
  • 4
    Prioritise transition to AMHS for those with severe mental illness or impairment rather than solely focusing on diagnosis.
  • 5
    Ensure continuity of care through therapeutic relationships, shared key workers, and effective information sharing across services.
  • 6
    For those not transitioning to AMHS, implement structured managed discharge with clear step-down services, community linkage, and follow-up.

Key Recommendations

Transition planning

  • 1

    Start early: Allow sufficient time for information sharing, preparation and a gradual transition process. Initiate planning at approximately 6 months before the service boundary for those in care over 12 months.

    Process
  • 2

    Multidisciplinary approach: If available and feasible, engage a multidisciplinary team of care providers with knowledge of a broad range of services and opportunities in the transition planning process.

    Process
  • 3

    Involve young people: Actively involve young people throughout the transition planning process, seeking their input, preferences and perspectives to promote shared decision-making.

    Clinical Practice
  • 4

    Include parents/caregivers: With the young person’s consent, involve parents/caregivers in transition planning.

    Clinical Practice

Transition decision-making

  • 12

    Evaluate ongoing treatment needs: Assess symptom severity, functional impairment, disorder progression, and comorbidities... to determine the most appropriate care setting.

    Assessment
  • 13

    Comprehensive transition need and readiness evaluation: Assess the young person’s readiness and need for transition using a validated standardised tool such as the Transition Readiness and Appropriateness Measure (TRAM).

    Assessment
  • 16

    Consider severity or impairment over diagnosis: Assessments should focus on the overall level of impairment, risk and treatment needs, rather than solely on the diagnosis.

    Assessment
  • 17

    Prioritise transition to AMHS for severe mental illness: Young people with severe conditions like psychosis, bipolar disorder, severe symptoms of depression, anxiety or PTSD, personality disorder, eating disorder... should be prioritised for transition to AMHS.

    Clinical Practice

Transition preparation

  • 20

    Comprehensive preparation: Develop and implement comprehensive transition preparation to help young people feel ready and address any feelings of uncertainty.

    Process

Continuity of care and service collaboration

  • 27

    Therapeutic relationships: Recognise the value of existing relationships and support continuity by involving CAMHS clinicians in introductory meetings, joint meetings, or engaging a key worker.

    Process
  • 29

    Enhance communication and coordination: Foster collaboration among CAMHS, AMHS, primary care and/or other relevant services... to ensure seamless transition and consistent care.

    Process
  • 31

    Provide step-down services: For those who show improvement in their mental health but may still need some level of care, consider organising less intensive support during the initial transition period.

    Clinical Practice

Care after transition to AMHS

  • 32

    Enhanced support: Ensure the young people has attended at least one AMHS appointment before CAMHS discharge. AMHS should follow up with young people who do not engage... within the first three months.

    Process

Managed discharge and follow-up

  • 38

    Comprehensive assessment and care planning: Conduct a thorough assessment to identify the young person’s ongoing mental health needs, strengths, functional impairments and required community supports.

    Assessment
  • 42

    Community service/resource linkage: Identify and actively support the young person to connect with appropriate community-based resources, such as peer support groups, counselling services, vocational training, or social services.

    Process
  • 44

    Follow-up and monitoring: Ensure a system is in place for structured follow-up and monitoring, either through primary care or community-based services, to track the young person’s progress.

    Process

Service improvement and advocacy

  • 47

    Allocate sufficient budget and resources: Ensure appropriate funding and resources for transition activities, e.g., for transition coordinators, joint working time or clinics, and evaluation tools.

    Administrative
  • 49

    Establish shared responsibility and ownership for transition: Promote shared responsibility between CAMHS and AMHS for transition outcomes through genuine inter-service collaboration.

    Administrative
  • 51

    Pre-transition monitoring and planning: Establish a systematic process to identify young people approaching the service age limit at least 6–12 months in advance.

    Administrative

Scope & Objectives

Clinical Topic

Youth mental health service transition

Objectives

To support transitional care at the CAMHS and AMHS boundary across Europe, providing guidance regarding practices and procedures, and services and environments designed to promote appropriate, safe and timely passage of service users.

Target Patient Population

Young people transitioning from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS) or other care settings.

Target Providers

Health care practitioners (clinicians) in CAMHS and AMHSMental health care leadersManagersService providers

Patient Criteria & Setting

Therapeutic Area

Mental Health

Guideline Scope

Transition of careDischarge management

Care Settings

Child and adolescent mental health services (CAMHS)Adult mental health services (AMHS)Primary careCommunity-based services

Special Populations

Young people with severe mental illnessYoung people with developmental disorders (e.g., intellectual disability, Autism Spectrum Disorder)Young people with co-morbid chronic physical health conditions

Safety & Contraindications

Monitoring Guidance

Ensure a system is in place for structured follow-up and monitoring through primary care or community-based services to track progress and identify emerging concerns after discharge from CAMHS.

Authors & Contributors

Helena TuomainenRebecca AppletonGail AsherGwendolyn C. DielemanTomislav FranićGiovanni de GirolamoEllie JacksonEniko KissAthanasios MarasSimone MarchiniFiona McNicholasMathilde M. OverbeekDiane Purper-OuakilAnne Marie Råberg ChristensenParamala SantoshUlrike M.E. SchulzeCathy StreetLeanne WalkerDieter WolkeSwaran P. Singh

Guideline Features

Flowcharts includedBased on systematic reviewMultidisciplinaryPatient involvement

Learning Context

Difficulty

intermediate

Learning Paths

Transition planningCAMHS to AMHS transitionManaged dischargeYouth mental healthService collaboration