Transitioning from child and adolescent psychiatry to follow-up care: a concept mapping study

Youth with severe and enduring mental health problems often require follow-up care after treatment in child and adolescent psychiatry (CAP). In this study, follow-up care is defined as services beyond CAP, including basic mental health support, primary mental health care, and practical or parenting support delivered by community-based teams. However, transitions to such care are often fragmented, poorly coordinated, and experienced as abrupt. This study explores perspectives of CAP clinicians, follow-up care providers, parents, and youth to identify factors considered both important and feasible for improving care transitions. Using Group Concept Mapping (GCM), a participatory mixed-methods approach, participants (n = 55) generated, sorted, and rated statements perceived as important and feasible in transitions from CAP to follow-up care. Data were analyzed using multidimensional scaling, hierarchical cluster analysis and Go-Zone analysis. Participants generated 56 statements, thematically grouped into nine clusters: (1) Care coordination, (2) Integrated care networks, (3) Care organization, (4) Family-centered care, (5) Follow-up care, (6) Shared decision-making, (7) Handover, (8) Accessible services, and (9) Empowerment and recovery. The findings suggest that transitioning from CAP to follow-up care is multifaceted and requires more than a timely handover between care providers. Particularly, shared decision-making, recovery orientation, and family involvement emerged as central themes across clusters. Our study indicates that improving transitions may benefit from coordinated, relational, and tailored approaches that promote continuity and empower youth and families throughout the process.