Background:  Little is known regarding children of greatest concern with complex mental health problems. Method:  A one‐year prospective study of psychiatric diagnosis, psychosocial functioning, need status and service receipt in 60 children identified as most concerning. Results:  Thirty‐two (53%) had two or more disorders. The mean number of needs per child was five. One year later mean needs were unchanged but with considerable individual variation. Mean weekly costs were £1017 (€1627) (SD = £957 (€1531)). Higher costs related to social factors rather than diagnosis or need. Conclusions:  The mean annual cost of services to children with complex mental health problems is ten times that in other studies of children with mental health problems.

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