1. Preschool children

• Consider behaviour in context of developmental level (to include social, emotional, cognitive and communication abilities) If concerns regarding milestones, request developmental assessment from health visitor.
• Consider social and parenting environment. Where appropriate, address adult mental health concerns and refer for additional support.
• Request input from health visitor who may refer to local parenting programme.
• Children under the age 6yrs are rarely diagnosed with ADHD
• If developmental delay highlighted by health visitor screening (Ages and Stages or Schedule of Growing Skills), refer to ICS Single Point of Access

2. School Age

• Significant pervasive behaviour difficulties may be due to an underlying neurodevelopmental disorder i.e. Autism Spectrum Disorder (ASD) or Attention Deficit Hyperactivity Disorder (ADHD)
• Referrals for possible ASD should be sent to ICS SPA
• Concerns regarding possible ADHD without comorbid mental health issues should be sent to community paediatrics at RD&E
• Concerns regarding ADHD with co-morbid mental health issues should be sent to CAMHS via ICS SPA. Comorbidity is more likely in the school-age group.
• Consider behaviour in the context of the child's social and emotional experience at school. Consider referral to school pastoral support team where there is evidence of issues within setting (e.g. bullying; unaddressed learning needs)
• Consider behaviour in the context of social, emotional or psychological difficulties. Children experiencing significant psychological distress may present with behavioural difficulties. Where there is evidence of self-harm, at risk behaviours and/or evidence of significant mental health difficulties refer to MASH and/or CAMHS as appropriate

Attention Deficit Hyperactivity Disorder (ADHD)

Diagnostic criteria (Diagnostic and Statistical Manual of Mental Disorders (DSM))

ADHD is the persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, has symptoms presenting in two or more settings (e.g. at home, school, or work; with friends or relatives; in other activities), and negatively impacts directly on social, academic or occupational functioning. Several symptoms must have been present before age 12 years.

Diagnostic tools allow assessment from age 6 years.

Children and young people accepted for assessment by community paediatrician will undergo the following:

• Initial information gathering
• Parent interview and school observation by Clinical Nurse Specialist (CNS)
• Connor's questionnaires to be completed by parents and teachers
• Medical assessment by paediatrician in clinic

Differential diagnoses of behaviour problem

• Normal variant
• Parenting issue
• Specific learning difficulty
• Developmental impairment / learning disability
• Neurodevelopmental disorder – ASD, ADHD
• Speech and language disorder
• Mental health issues
• Attachment disorder
• Social disadvantage – abuse / neglect
• Parental learning difficulty / disability

• Loss of developmental skills in preschool child – refer directly to community paediatrics
• Sudden change in behaviour in child with epilepsy – alert managing consultant or epilepsy specialist nurse
• Sudden change in behaviour in child or young person with severe learning disability – may indicate physical problem – assess for causes of pain
• Any change in behaviour related to possible abuse / neglect / risk to others– refer to MASH

• Developmental screening assessment in preschool child by health visitor
• Information gathering for school-aged child to provide evidence of pervasive problem
  • Devon Assessment Framework (DAF) paperwork if done
  • School report
  • Educational psychology assessment if done
  • Reports from other professionals involved

Management of the behaviour problem will depend on the underlying diagnosis.

Community paediatricians manage children with ADHD without mental health co-morbidities.

Management of ADHD will include the following:

• Parent education via Living with ADHD course (run by CAMHS) and written information.
• Share information with school so adjustments can be made in the classroom.
• Consider medication if behaviour management alone not enough and symptoms moderate / severe as per NICE guidelines.

Referral Criteria

• Referrals for ADHD (without comorbid mental health issues) can be sent directly to community paediatrics
  • Please include the information to provide evidence that problems exist both at home & school and reports from any professionals already involved to inform assessment
• Referrals for preschool children with behaviour concerns likely to be due to underlying developmental issues should be sent to ICS SPA
• A Devon Assessment Framework (DAF) is required for most services within ICS. This should be carried out by whoever is most involved with the family e.g. school Special Educational Needs Co-ordinator, health visitor / school nurse, children's centre worker. A DAF is not required for direct referral to community paediatrics.
• If you have concerns regarding a medical condition as a cause for the behaviour requiring paediatric input, please refer directly to Community Paediatrics

Referral to Community Paediatrics

e-Referral Service Selection

• Specialty: Children's & Adolescent Services
• Clinic Type: Community Paediatrics
• Service: DRSS-Eastern-Child & Adolescent Services-Devon ICB  - 15N

Referral to Integrated Children Services

Complete Request for Services Form, available on Children & Family Health Devon website and send with supporting documentation to:

• Email: VCL.DevonSpa@nhs.net
• Post: Integrated Children's Services, Single Point of Access Team, Virgin Care Limited, 1a Capital Court, Bittern Way, Sowton Industrial Estate, Exeter EX2 7FW
• For support on making a referral telephone: 0330 0245 321

Referral Forms

DRSS Referral Form

ICS request form

Patient Information

General advice on behaviour management

Contact a family for families with disabled children

Young Minds

ADHD information

NHS choices - ADHD

ADDiSS

Evidence

NICE guidance – assessment and management of ADHD

NICE – assessment of autism

Pathway Group

This guideline has been signed off on behalf of NHS Devon.

Publication date: December 2016