Analysing the situation of mental health in children and adolescents in Spain is no easy task. In addition to the characteristics derived from being a field that has yet to be recognised as a speciality in Spain, we must add the uneven development of mental health care in the different regions of the country, as not every autonomous community has a full network of services differentiated from adult services.1 Nevertheless, child and adolescent psychology has grown at an astounding pace in recent year, attracting considerable interest in society at large as well as the health care field, and there has been a sustained increase in the resources allocated to care, research and education in different official strategic plans. The high prevalence of mental health problems in children and adolescents, combined with evidence that severe psychiatric disorders in adults emerge during childhood and consolidate during adolescence, is reason enough to justify and advocate for adequate mental health care in these early stages of life. Early diagnosis and effective treatment have an impact on outcomes, as they may change the course of disease.

The understanding of mental illness in childhood requires a developmental perspective, and it is necessary to understand developmental milestones in relation to chronological age to establish the clinical relevance or irrelevance of certain behaviours. In the first years of life, from birth to age 6 years, there is an exponential increase in the number of neural connections that will continue in subsequent years, although at a slower pace, with new networks being established and others that fall in disuse being eliminated, a neural pruning process that intensifies in adolescence. Thus, there are critical periods of vulnerability as well as windows of opportunity for intervention. These factors and environmental factors (family, social, educational) are intertwined to such degree that the circumstances and the symptoms with which a specific mental illness develops are not the same for different stages of development. Early intervention is essential in certain problems to prevent them from developing into full-blown disorders, and paediatricians play a key role in prevention through their privileged position of knowing children and families in depth.2 The approach to mental health care in children and adolescents should always be multidisciplinary with participation of professionals in different fields (psychiatrists, psychologists, paediatricians, nurses, social workers, teachers) working with families intensively and coordinating care through different institutions and organizations.

The history of child and adolescent psychiatry is relatively short. In the 18th century, the first orphanages and centres for children with special needs were created in Europe. In the first half of the 20th century, interest in mental health problems in children grew. In the 1950s the first professional associations emerged, and the Asociación Española de Psiquiatría del Niño y Adolescente (Spanish Association of Child and Adolescent Psychiatry) was founded in 1952. In the second half of the 20th century, psychoanalytic theories emphasised the importance of early life experiences, setting the foundations of attachment theory. The fields of behavioural therapy and family systems therapy developed theoretical frameworks and effective interventions.3 In the current 21st century, great advances in neurosciences are helping elucidate the aetiological mechanisms of these diseases. The development of new assessment instruments and advances in different treatment approaches (psychopharmacology and psychotherapy with different theoretical perspectives) along with telemental health services (so useful in the context of the current pandemic) have contributed to the improvement of care.

Addressing the comprehensive needs for mental health services and integral care of children and adolescents requires the presence of a complex care network, preferably in the framework of a community-based care model guaranteeing continuity of care. This network would be structured by levels of care specialization, with level 1 including primary care and the school and social environments, level 2 outpatient child and adolescent mental health treatment centres, and level 3 high-complexity or intensive care settings, such as partial hospitalization programmes, inpatient psychiatric care units or intermediate stay mental health units. The greatest disparities in the development of mental health services between autonomous communities corresponds to this third level, as levels 1 and 2 are more widely available.

The Department of Child and Adolescent Psychiatry and Psychology is located at the Hospital Infantil Niño Jesús in Madrid. The Section of Psychiatry and Psychology was instituted in the 1980s. With a biopsychosocial and family-centred approach, it integrates assessment and treatment models that have been proven efficacious and efficient in the management of mental health disorders in children, adolescents and families. In the framework of a continuity-of-care model, different services for care delivery have been organised into specific units and care programmes. At present, our institution offers a short stay unit for patients aged 4–17 years (31 beds); 3 day hospitals (Hospital de Día de Edad Infantil [early childhood]; Hospital de Día de Edad Escolar [school-age]; Hospital de Día de edad Adolescente [adolescence]); Intensive Outpatient Care; Post-Inpatient and Post-Day Hospital Discharge Outpatient Clinics; Outpatient Group and Family Services; Assessment, Diagnosis and Treatment Followup Clinics. The hospital also offers consultation-liaison services for management of emergent mental health problems in children and adolescents with complex mental illness and multiple disorders. We also ought to mention the 24-h urgent care centre, the only site offering urgent care specifically to the child and adolescent population in the entire Community of Madrid.

We would like to make a few comments in relation to the article published by Molina-Castillo et al. in the current issue of the journal.4 Law 1/1996 on the Legal Protection of the Minor specifies that the internment of minors will take place in a facility appropriate for age with management by providers with specialised training, and that it requires court authorization.

There is no longer any question that children need to be hospitalised in specialised units on account of the severity of certain disorders that may pose a risk to the patients themselves or to their environment. The main purpose of urgent hospitalization is to provide around-the-clock care to achieve medical and psychiatric stabilization in patients undergoing acute episodes of mental illness. The indication for elective hospitalization of children and adolescents is complex with mental illness requiring intensive observation, assessment and treatment.

The inpatient psychiatric unit of our hospital has 31 beds in 2 different rooms. This is the only psychiatric unit in Madrid that can admit children aged less than 12 years. Patients are managed by a multidisciplinary team according to individualised structured treatment plans. Parents are actively involved in the management, providing family support (unless contraindicated) as they do in any other hospital ward. Academic support from credentialed hospital school teachers and participation in recreational activities in hospital contribute to breaking the stigma associated with mental health. At present, there is a tendency toward shorter stays to reintegrate the minor to their usual environment as early as possible, and toward care delivery with a more social-ecological approach (hospital at home).5

Hospitalization is integrated in a continuum of care of increasing complexity, and coordination with other levels of care and institutions is of the essence. Ensuring the continuity of care after discharge is a must to prevent recurrent admissions that devalue a powerful care resource and cause frustration in patients and their families.

Important issues have yet to be resolved, like the lack of official recognition of the speciality, the disparities between autonomous communities and the need to increase the available resources to improve child and adolescent care through the establishment of transitional care units and additional residential and rehabilitation services, for there is no health without mental health, and without child and adolescent mental health, the future of Spain will be seriously compromised.