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Background To present clinical outcome data of the Adolescent Mentalization-based Integrative Treatment ( AMBIT)-trained NHS Lothian Tier 4 child and adolescent mental health service in the context of service utilization and engagement. Method Data were obtained for a 2-year period that included details of all face-to-face contacts between young people and clinicians along with routinely collected clinical outcomes data relating to anxiety, depression, symptoms of psychosis and quality of life. Results Improvements were observed in quality of life, symptoms and distress across the course of the intervention. Overall attendance rates were high (80%). Relative to those who were better engaged, the less well-engaged group received the same number of appointments but spent longer in the service (χ2(1) = 5.26, p = .022), had more professionals involved in their care (χ2(1) = 4.91, p = .027) and showed a nonsignificant trend to more inpatient admissions. Later engagement was not associated with distress or symptoms at entry into the service with the exception of negative symptoms in the Early Psychosis Support Service cohort. Age and two quality of life factors were associated with later engagement (p < .05). Conclusions Our AMBIT-trained Tier 4 CAMH service demonstrates change over the course of intervention consistent with the service model's theoretical expectations. Engagement with the service may be associated more with factors related to social circumstance and functioning than with key symptoms and distress. Less well-engaged young people utilize increased service resource. AMBIT's mentalizing focus may improve service provision for young people who are poorly engaged with mental health services. [ABSTRACT FROM AUTHOR]