Referral letters to child and adolescent mental health services

In the face of substantial demand, many out-patient child and adolescent mental health services (CAMHS) triage referrals on the basis of referral letter information. The validity of this procedure is uncertain; it is often asserted that referral letters provide a poor guide to clinical status. Using routinely collected data from one CAMHS team, we investigated the congruence between the main problem highlighted in the referral letter, and the subsequent specialist assessment diagnosis.

Among 98 children whose main problem in the referral letter was a behaviour problem, there were various diagnoses at assessment: hyperkinetic disorders formed the single largest group (23%), with almost as many emotional (17%) or conduct disorders (17%). Hyperactivity/inattention was the main problem in 39 referral letters: 51% of these children subsequently received a diagnosis of hyperkinetic disorder. Four of the eight children whose main problem in the referral letter was an eating problem received a diagnosis of anorexia or bulimia. The greatest specificity was from the 83 letters highlighting emotional symptoms as the main problem: 67% received a diagnosis of an emotional disorder (two combined with conduct disorder). Thus, letters identifying emotional problems or hyperactivity/inattention often provided a guide to clinical diagnosis.

However, children referred with ‘behaviour problems’ could be found to have any of a number of clinical diagnoses at assessment. This suggests that such referrals cannot be reliably triaged before assessment without considering additional information. This presents a serious problem for services with substantial assessment waiting lists. Other factors that might also influence triage, such as the child’s functional impairment, problem severity, or risk behaviour, need similar investigation.