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Background: High rejection rates for referrals to child and adolescent mental health services (CAMHS) are common. The most cited reasons for rejection are that the child does not have a clinical need for assessment and poor quality of the referrals. However, studies of interventions aimed at improving appropriateness of referrals are sparse. Methods: In this randomized feasibility trial, we tested if the Development and Well-Being Assessment (DAWBA) as an adjunct to referral letters could improve accuracy of referral decisions made by CAMHS. The primary outcome of the study was the proportion of "correct" referral decisions. Results: The study included 160 children referred to CAMHS. Almost all (95.6%) participants fulfilled criteria for a mental disorder and 82.1% also reported high impact of symptoms. Compared to the group who did not complete the DAWBA, referral decisions for the DAWBA group showed higher sensitivity (0.63 vs. 0.83), specificity (0.30 vs. 0.42), and negative predictive value (0.14 vs. 0.36) as well as slightly higher positive predictive value (0.81 vs. 0.86). Conclusions: The use of the DAWBA as an adjunct to standard referral letters could lead to more correct referral decisions and reduce the proportion of wrongful rejection referrals to CAMHS.

Aim: To investigate parental help-seeking patterns prior to referral to outpatient child and adolescent mental health services (CAMHS), and whether type of symptoms or duration of mental health problems prior to referral influence help-seeking., Setting: Child mental health services in Denmark involve several sectors collaborating based on stepped-care principles. Access to CAMHS is free of charge but requires a formal referral., Methods: In this cross-sectional observational study, parents of 250 children were interviewed about pathways to outpatient CAMHS using the Children's Services Interview., Results: The median parent-reported duration of mental health problems prior to referral to CAMHS was 6.0 (IQR 3.4-8.5) years for children referred for neurodevelopmental disorders compared to 2.8 (IQR 1.0-6.5) years for children referred for emotional disorders. Educational services were the first help-seeking contact for the majority (57.5%) but referrals to CAMHS were most frequently from healthcare services (56.4%), predominantly general practitioners. Educational services played a greater part in help-seeking pathways for children referred for neurodevelopmental disorders., Conclusion: The majority of children referred to CAMHS have mental health problems for years before referral. The delay in time-to-referral was most pronounced for children referred for neurodevelopmental disorders. Help-seeking pathways differ by symptom duration and type of symptoms.