Behaviour Problems

Scope

Many behaviour problems are variations of an expected pattern of development, especially during the preschool period; parents may have unrealistic expectations of their child's performance or developmental needs/abilities. Parents can experience significant anxiety about whether their child's behaviour is 'normal' and may worry about how best to manage their child's difficulties effectively. More serious problems arise if there is developmental impairment, communication difficulties or social / safeguarding issues.

Most behaviour problems in preschool children can be managed by local universal services i.e. Health visitor, Children's Centres, local parenting programmes or referral Early Help.

Devon County Council Children's centres

Devon's family information service (DISC)

Devon Early help

Many behaviour problems in school-age children can be dealt with by schools, supported by the Devon Assessment Framework (DAF) process. School nurses and pastoral support staff can provide support to families. Some schools may have access to parent support workers.

The Community Child Health team at the RD&E are a team of consultants, speciality doctors and clinical nurse specialist. We carry out work in the following areas:

  • Developmental assessment, investigation and diagnosis in pre-school children
  • On-going medical management of neurodisability in children and young people up to the age of 16 years (or school leaving age if at special school)
    • E.g. Down Syndrome, Cerebral Palsy, Sensory Impairment, Neurofibromatosis, Tuberous sclerosis, Neuromuscular conditions and other congenital / inherited conditions in which health surveillance is required.
  • Medical input to multidisciplinary assessment of school age children in whom there are neurodevelopmental concerns, and on-going management of ADHD as clinically indicated.
  • Medical input as per statutory requirements - Children in Care, Safeguarding, SEND

Community Paediatricians work closely with other health professionals and other agencies, as part of the multidisciplinary team. Clinics are held in locations close to child's home or school. Special school clinics are vital in the on-going health surveillance and management of children and young people with complex needs by allowing easier access for parents / carers compared to a hospital based clinic, include all members of the multidisciplinary team and the child / young person does not miss school. In addition to scheduled clinic appointments, community paediatricians may attend 'Team Around the Child' (TAC) meetings or Annual Review meetings, if necessary, and carry out joint consultations with other health professionals.

Out of Scope

Assessment

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 toICS 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

Red Flags

  • 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

Investigations

  • 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

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

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 CCG - 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

Supporting Information

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 by the Eastern Locality on behalf of NEW Devon CCG.

Publication date: December 2016

 

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