Background <p>Child and adolescent mental health is increasingly recognized as a major public health concern worldwide. However, access to timely and coordinated mental health care remains uneven, particularly for children experiencing psychosocial, developmental or learning difficulties. Fragmentation across health, social care and education systems often contributes to discontinuous care pathways, especially in resource-constrained and rural settings. While a substantial body of literature on child mental health services originates from high-income countries, the organization of services differs significantly across national systems. In France, Child and Adolescent Medico-Social Centres (Centres Médico-Psycho-Pédagogiques, CMPP) are publicly funded outpatient services operating at the interface of healthcare, disability support and education sectors. Despite their central role in organizing care pathways, little is known about how these pathways are shaped and sustained in everyday practice.</p> Methods <p>This qualitative study adopted an interpretive case study design within a French CMPP located in a predominantly rural territory. Data were collected as part of a collaborative action-research project and included 50 semi-structured interviews with families, CMPP professionals and territorial partners, as well as approximately 250&#xa0;h of participant and non-participant observations. Data were analyzed using an abductive thematic approach supported by the qualitative coding software Taguette. Coding and interpretation were conducted collaboratively within an interdisciplinary research team combining perspectives from public health and management sciences. Regular analytic meetings were recorded and documented, enabling the research team to retrace the iterative development of codes and themes and to compare insights across interviews, observations and reflexive notes.</p> Results <p>Ten main themes were identified, highlighting organizational, relational and territorial mechanisms shaping child mental health care pathways over time. Results show that pathways are rarely linear and are marked by delays, uncertainty and discontinuities, particularly in contexts of limited resources. Families play a central role in sustaining continuity of care through coordination, information sharing and engagement, often compensating for systemic fragmentation. Professional practices rely on situated adjustments and informal coordination to manage constraints, while territorial characteristics such as rurality influence access to specialized resources and intensify reliance on local networks.</p> Conclusions <p>This study provides an empirically grounded analysis of child mental health care pathways within a French medico-social service. The findings highlight how organizational constraints, territorial characteristics and intersectoral coordination practices shape care trajectories in practice. By examining pathways as lived and negotiated processes, the study contributes to health services research on care coordination and equity in child mental health systems, while highlighting the specific role of medico-social organizations such as CMPPs within the French context.</p>