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Primary care management and referral guideline Primary care management and referral guideline

Behavioural Concerns in Children Under 6 Years – Management and referral guideline

See also:

Red flags

  • Child abuse or neglect
  • Severe distress within the individual or family

Purpose

Primary care management and referral guidelines contain condition-based information for GPs about when to refer a patient, assessment and management measures that should be taken prior to submitting a referral, and what should be included in a referral to the relevant outpatient department or specialist service.

Introduction

  • Behavioural problems in children are common. Approximately 12% of Australian children aged 4 to 12 years experience:
    • externalising behavioural problems e.g., aggression, hyperactivity.
    • internalising problems such as anxiety and depression.
  • The first 5 years of life involve growth and development at a greater rate than any other time in a person’s life. Language and communication develop, motor skills advance, thinking becomes more complex, and the child begins to understand their own feelings and recognise the needs of others. This development happens in the context of the environment in which children are raised. Family dynamics, life events, and care settings all have a bearing on a child’s behaviour.
  • The child’s behaviour is a form of communicating their internal world and exploring the wider context of family and school pressures and influences. The cause of behavioural problems is rarely isolated within the child.
  • In most cases, behavioural difficulties are temporary, and occur as children strive to achieve developmental milestones.
  • Toddlers (aged ≤ 3 years) typically test parental authority. Common behavioural problems include:
    • separation anxiety.
    • oppositional behaviour (refusing to comply with requests).
    • aggression (kicking, biting, and fighting).
    • temper tantrums (explosions of frustration).

Assessment

Consider assessing the child’s behaviour:

  • at childhood vaccination encounters.
    Childhood vaccination encounters
    For each planned visit, check the Personal Health Record (Red Book) for a brief description of what parents should expect from their child (Milestones on page 5) and topics for discussion.Parents of infants can check Your Guide to the First 12 Months for additional information.

  • opportunistically during unplanned visits.
  • to address concerns raised by parents or carers.

Take a history and ask about:

  • concerning behaviour, and consider whether it is abnormal.
    Concerning behaviour
    Common behavioural problems in children aged <6 years include:

    • whining.
    • tantrums.
    • bedtime resistance.
    • fighting e.g., with parents, other children, siblings.
    • biting.
    • kicking.
    • swearing.

    Check:

    • when the behaviour started.
    • for a precipitating event (if any) e.g., entering daycare or kindergarten, birth of sibling, parental separation, death of grandparent.
    • where the behaviour occurs – home, educational, or social setting.
    • mood (e.g., anxious, happy, sad), self‑esteem.
    • attention in general, not just towards interests.
    • truthfulness.
    • compliance or opposition.
    • for episodes of anger (disruptive, destructive, violent).
    Abnormal behaviour
    The behaviour is likely to be abnormal if it is:

    • prolonged.
    • extreme.
    • potentially harmful or dangerous.
    • occurring in at least 2 different settings e.g., home, preschool or school, social situations.
  • perinatal history.

    Perinatal history

    • Complications during pregnancy or delivery e.g., growth restriction, prematurity
    • Perinatal infections (TORCH)
    • Exposure to medications, drugs, or alcohol in utero
    • Serious illness or major surgery early in life e.g., congenital heart disease, sepsis
  • medical history.
    Medical history
    Check for symptoms of underlying medical problems:

    • Malnutrition or specific nutritional deficiencies e.g., iron deficiency
    • Sleep disturbances e.g., obstructive sleep apnoea (OSA)
    • Problems with vision or hearing
    • Chronic constipation
    • Dysmorphic syndrome
  • family history.

    Family history

    • Developmental or behavioural problems in parents and siblings
    • Mental health
  • development – see Developmental Concerns in Children Aged < 6 Years.

Assess the child’s environment and put the behaviour into context – consider:

Assessing the child’s environment

  • Seek collateral history whenever possible e.g., letter from childcare or kindergarten detailing behaviour and learning history.
  • Assess behaviour in all environments (e.g., home, childcare, kindergarten, prep, with grandparents or babysitter), as children with intrinsic behavioural disorders will have problems in more than one setting.
  • child factors.

    Child factors

    • Temperament
    • History of trauma
    • Sleeping patterns e.g., adequate sleep, snoring
    • Eating habits and nutrition
    • Underlying medical problems e.g., constipation, eczema, glue ear, absence seizures
    • Developmental delay
    • Mood or anxiety disorder
  • family relationships and parental factors.
    Family relationships and parental factors
    Assess interaction between the child and parent, and whether family relationships could be affecting the child’s behaviour.Check for:

    • poor parent‑child attachment or bonding.
    • marital conflict or single parenthood.
    • children on access arrangements.
    • parental mental illness (linked with poorer attendance at behaviour management courses) – consider whether parent’s mental state needs to be assessed.
    • drug or alcohol abuse.
    • large family size.
    • aggressive behaviour of parents and siblings.
    • poor quality and quantity of maternal social contacts with relatives or friends outside the home (influences mother‑child interaction within home).

    Ask about:

    • parenting practices:
      • Warm or harsh
      • Engaged versus disengaged or neglectful
      • Whether boundaries are set
      • Consistent parenting
      • Whether parents agree in their approach
      • Signs of abuse or neglect
    • parent’s expectations of the child’s behaviour.
  • cultural factors.

    Cultural factors

    • Differences in parenting styles
    • Acceptance of behaviour
    • Cultural beliefs and traditions
    • Exposure to trauma
  • social factors.
    Social factors
    Socioeconomic disadvantage is a risk factor for behavioural disorders.

    • Check for:
      • parental unemployment.
      • financial stress.
      • lack of stable housing.
      • lack of support from friends or extended family.
    • Consider whether support services are, or have been, involved with the family, and how they engaged with these services.
  • school factors.

    School factors

    • Friendship problems
    • Bullying – as either victim or perpetrator
    • Learning difficulties

    Sometimes a child is anxious at school because they are worried about their parent(s) at home.

Determine severity.

Severity
Consider severe behavioural problem if:

  • developmental regression or significant delay.
  • significant child distress.
  • social impairment e.g., school refusal.
  • severe aggression towards others e.g., classmates, siblings.
  • self‑harming behaviours e.g., head banging, hair pulling, punching self.
  • sexualised behaviours.
  • parental mental illness, drug or alcohol use, or severe distress.

Ask about the family’s goals and expectations, along with their capacity to implement behavioural management strategies.

Family’s goals and expectations
Consider whether:

  • this is a low‑risk family and social environment where the parents simply want reassurance their child is normal.
  • the parents are looking for specific behavioural management strategies.
  • there is a particular concern about a disorder such as autism spectrum disorder or ADHD.

Examine the child.

Examination
Check:

  • height, weight, and head circumference, and plot in the appropriate growth chart – available in most patient record software.
  • nutritional status e.g., pallor, dentition.
  • response to visual and auditory stimuli.
  • communication – verbal and non‑verbal (pointing, showing, eye contact).
  • skin, including under arms, torso, limbs, and base of spine – look for:
    • skin manifestations of neurological conditions e.g., neurofibromas, café-au-lait spots (can occur under the armpit in middle childhood), hypopigmentation.
    • chronic skin conditions (e.g., eczema).
  • head and neck – tympanic membrane (e.g., glue ear), submucous cleft palate, dysmorphic features (e.g., atypical face), eyes (e.g., range of movement, squint).
  • central nervous system – check face symmetry, reflexes, power, tone, plantar response, and gait, looking for evidence of neurological conditions such as spina bifida and cerebral palsy.
  • abdomen e.g., for organomegaly, faecal loading.
  • muscles – check for atrophy, hypertrophy, asymmetry.
  • for signs of injury or trauma (inflicted or accidental) e.g., bruises, burns.

Arrange formal hearing or vision testing, if indicated.

Decide whether the behaviour is primarily:

  • reactionary with no underlying medical problem (i.e., a neurodevelopmentally normal child in an abnormal environment), or
  • due to an intrinsic medical problem or neurodevelopmental or mental health disorder.

    Intrinsic medical problems

    Neurodevelopmental or mental health disorders
    Neurodevelopmental and mental health disorders are uncommon in this population. They include:

    • ADHD (rarely diagnosed in this age group) – suspect if developmentally inappropriate degrees of inattention, impulsiveness, and/or hyperactivity. See ADHD in Children and Youth.
    • autism spectrum disorder (ASD) – suspect if disordered communication or social understanding, need for sameness, and sensory modulation difficulties. See Autism Spectrum Disorder.
    • conduct disorder – suspect if persistent pattern of conduct that violates rights of others and age‑appropriate societal norms e.g., aggression to people and animals, destruction of property, deceitfulness or theft.
    • oppositional defiant disorder – suspect if pattern of negative, hostile, and defiant behaviour without more serious violations of the basic rights of others e.g., deliberately annoying others, frequently defying or arguing with adults, losing temper, spite or resentfulness, blaming others for their behaviour.
    • intermittent explosive disorder.
    • adjustment disorders.
    • mood or anxiety disorders.

    Discuss with the parents in terms of behavioural difficulties and avoid using diagnostic labels.

Management

Always engage family support services
Children with behavioural problems and no medical or developmental problems should be managed by family support services and behaviour specialists, and generally do not need to be seen by a paediatrician.

If suspected child neglect or abuse, ensure the child’s safety.

Ensure the child’s safety

  • Contact child safety services immediately and manage according to their advice.
  • If signs of physical abuse (inflicted injury), or child at imminent risk of harm, consider transfer by ambulance to your nearest ED.
  • Clearly document the event.

If developmental concerns, follow the Developmental Concerns in Children Aged < 6 Years guideline.

If intrinsic medical problems are found, manage according to appropriate guidelines or refer to your local General Paediatrics service.

Intrinsic medical problems

If severe or complex behavioural problems, refer to the Child Development Program if available, or refer to your local General Paediatrics service and mark your request as urgent.

If suspected autism spectrum disorder (ASD), manage according to the Autism Spectrum Disorder.

If suspected ADHD, manage accordingly

If suspected mental health disorder:

  • refer to your local child and youth mental health service for assessment if eligible (need to add link to CYMHS eligibility criteria
  • in a child aged ≤ 4 years, consider requesting mental health assessment through the Zero to Four Child and Youth Mental Health Service
  • discuss and complete a mental health care plan (if eligible), and refer to a private paediatric psychologist for assessment if available (this can be done while awaiting specialist assessment).
  • consider referring to a private psychiatrist for assessment if available.

For all patients:

  • provide behaviour management advice.
    Behaviour management advice
    Advise parents:

    • that warm, consistent parenting with clear rules is optimal for a child’s development.
    • to stay calm and use strategies appropriate for the child’s developmental stage.
    • to reward desirable behaviour and set clear consequences for undesirable behaviour.

    The Raising Children Network website provides excellent parenting advice, including tips for encouraging good behaviour.

  • strengthen parental supports.

    Parental supports

    • Recommend the Raising Children Network for excellent parenting support and advice.
    • Identify and manage any parental mental illness. Consider a GP Mental Health Care Plan where eligible.
    • Help parents access appropriate community-based parenting programs.
  • address school related issues.
    School related issues
    Encourage the parent to liaise with the school to address:

    • possible triggers e.g., bullying.
    • strategies for managing the behaviour.
    • referral to the school counsellor or learning support team.
  • arrange regular follow up and reassess behaviour, parental engagement with support services, and response to interventions.

    Reassess behaviour

    • If behaviour improving, reinforce advice and continue engagement of support services as needed.
    • If behaviour not improving, or worsening, consider:
      • asking about non‑compliance with parenting support or other intervention – look for reasons why.
      • reassessing working diagnosis.
      • referring to your local General Paediatrics service.

When to refer

  • If suspected child neglect or abuse:
    • contact child safety services immediately.
    • and signs of physical abuse (inflicted injury), or child at imminent risk of harm, consider transfer by ambulance to your nearest ED.
  • If intrinsic medical conditions are found, consider referring to your local General Paediatrics service
  • If severe or complex behavioural problems, refer to Child Development Program if available, or refer to your local General Paediatrics service and mark your request as urgent.
  • If suspected mental health disorder:
    • Refer to your local child and youth mental health service for assessment if eligible
    • in a child aged ≤ 4 years, consider requesting mental health assessment through the Zero to Four Child and Youth Mental Health Service
    • consider referring to a private paediatric psychologist for assessment while awaiting specialist assessment.
    • consider referring to a private psychiatrist for assessment if available.
  • Consider requesting appropriate community-based parenting programs.
  • If behaviour not improving, or worsening, consider referring to your local General Paediatrics service.

Referring to your local Paediatric services

Public

Check the patient’s catchment area before requesting assessment. When services are available in the patient’s local area, refer the patient to the local hospital.

Queensland Children’s Hospital

1. Referral can be made by either:

  • GP Smart Referral via BP or Medical Director
  • Secure messaging
    Secure messaging
    Send a written request to the Referral Centre via eReferral
    (Medical Objects ID: RQ402900084, HealthLink ID: qldrchld):

    • To download templates, see Referral Forms.
    • If unable to attach investigations or use secure messaging, fax to 1300 407 281.

    For more information, contact the Referral Centre:
    P.O. Box 3474, South Brisbane QLD 4101
    Phone 1300 762 831
    Fax 1300 407 281

2. Check the minimum referral criteria and insert the required information into referral.

Private

Search for a provider via the National Health Services Directory.

Guideline approval and disclaimer

Guideline approval history
Version no. 1.0 Approval date 09/05/2019 Review date 01/05/2022

Disclaimer

The information contained in this GP referral and management guideline is intended for information purposes only. The information has been prepared using a multidisciplinary approach with reference to the best information and evidence available at the time of preparation. No assurance is given that the information is entirely complete, current, or accurate in every respect.
This guideline is not a substitute for clinical judgement, knowledge and expertise, or medical advice. Variation from this guideline, taking into account individual circumstances may be appropriate.
This guideline does not address all elements of standard practice and accepts that individual clinicians are responsible for the following:
  • ●  Providing care within the context of locally available resources, expertise, and scope of practice.
  • ●  Supporting consumer rights and informed decision making in partnership with healthcare practitioners including the right to decline intervention or ongoing management.
  • ●  Advising consumers of their choices in an environment that is culturally appropriate and which enables comfortable and confidential discussion. This includes the use of interpreter services where necessary.
  • ●  Ensuring informed consent is obtained prior to delivering care.
  • ●  Meeting all legislative requirements and professional standards.
  • ●  Applying standard precautions, and additional precautions as necessary, when delivering care.
  • ●  Documenting all care in accordance with mandatory and local requirements.
Children’s Health Queensland disclaims, to the maximum extent permitted by law, all responsibility and all liability (including without limitation, liability in negligence) for all expenses, losses, damages and costs incurred for any reason associated with the use of this guideline, including the materials within or referred to throughout this document being in any way inaccurate, out of context, incomplete or unavailable.

Resources

For health professionals
Education

Further information

For families

Contact details

Hospital Switchboard
(Ask for the General Paediatric Registrar)
t: 07 3068 1111

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