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Behavioural problem in a child ≥ 6 years

Emergency referrals

If any of the following are present or suspected, phone 000 to arrange immediate transfer to the emergency department or seek emergent medical advice if in a remote region.

It is proposed that the following conditions should be sent directly to emergency. This is not a list of all conditions that should be sent to the emergency department, it is intended as guidance for presentations that may otherwise have been directed to general paediatric outpatients:

  • Headaches
    • that wake at night or headaches immediately on wakening
    • new and severe headaches
    • associated with significant persisting change of personality or cognitive ability or deterioration in school performance
    • recent head injury or head trauma
    • any abnormalities on neurological examination, such as: focal weakness, gait disturbance, papilledema, diplopia
    • sudden onset headache reaching maximum intensity within 5 minutes  ( = explosive onset)
    • presence of an intracranial csf shunt
    • hypertension above 95th centile by age for systolic or diastolic
  • Seizures
    • all children with new onset of clinically obvious epileptic seizures should be referred to emergency for initial assessment, observation and consideration of emergency investigation or management.
    • any abnormalities on neurological examination, such as: focal weakness, gait disturbance, papilledema, diplopia
    • significant change in seizures for established epilepsy:
      • new onset of focal seizures or
      • a dramatic change in seizure frequency or duration
  • Faints syncope and funny turns
    • loss of consciousness in association with palpitations
    • sudden loss of consciousness during exercise
    • possible infantile spasms. this may be frequent brief episodes of head bobbing (with or without arm extension) in an infant less than 12 months old

  • Asthma, stridor and wheeze
    • infants who have apnoea or cyanosis during paroxysms of coughing
    • children with recurrent or persistent respiratory symptoms who have had an episode of choking
    • suggestive of a possible inhaled foreign body
    • recent onset or escalating stridor and respiratory distress
    • acute respiratory distress not responding to home management
    • acute respiratory symptoms causing inability to feed or sleep in an infant
  • Persistent and chronic cough
    • infants who have apnoea or cyanosis during paroxysms of coughing
    • children with recurrent or persistent respiratory symptoms who have had an episode of choking suggestive of a possible inhaled foreign body
    • prominent dyspnoea, especially at rest or at night
    • cough causing inability to feed or sleep in an infant

  • Chronic and Recurrent Abdominal Pain
    • severe pain not able to managed at home with simple analgesia
    • significant change in location or intensity of chronic abdominal pain suggestive of a new pathology
    • pain associated with vomiting where this has not occurred before
    • bile stained vomiting
  • Chronic Diarrhoea and/or Vomiting
    • vomiting or diarrhoea with weight loss in an infant <1 year
    • suspected pyloric stenosis
    • bile stained vomiting
    • acute onset abdominal distention
    • weight loss with cardiovascular instability, e.g. postural heart rate changes
    • new onset of blood in diarrhoea or vomitus
  • Constipation with or without soiling
    • severe abdominal pain or vomiting with pain

  • Urinary Incontinence and enuresis.
    • recent onset of polyuria/polydipsia that might suggest diabetes (mellitus or insipidus)
  • Recurrent Urinary Tract Infections (UTI)
    • acute infant  urinary tract infection presenting septicaemia or acutely unwell

  • Acute joint pain with fever
  • Acute joint pain unable to weight bear.

  • Infant <3 months with newly noted murmur and any of the following:
    • poor feeding
    • slow weight gain
    • weak or absent femoral pulses
    • post ductal (foot) oxygen saturation < 95%
    • respiratory signs (wheeze, recession or tachypnoea)

  • Anaphylaxis
  • Allergic reaction where there are any respiratory or cardiovascular symptoms or signs
  • Reaction to peanut or other nut should be referred to Emergency as these reactions can progress rapidly and should be observed and assessed in Emergency
  • Exposure to a known allergen with a previously identified potential for anaphylaxis in this patient even if the reaction appears currently mild
  • Severe angioedema of face

  • Faltering growth (failure to thrive in children < 6 years)
    • severe malnutrition
    • temperature instability
    • cardiovascular instability – postural heart rate change
  • Short stature
    • possible CNS signs (visual disturbance, morning headaches)

  • Suicidal or immediate danger of self-harm
  • Aggressive behaviour with immediate threatening risk to vulnerable family members

  • Fluctuating or altered conscious level – weak cry, not waking appropriately for feeds, lethargy, maternal concern of failure of normal interaction
  • Suspicion of harm or any unexplained bruising, especially in infant <3 months
  • Significant escalation in frequency or volume of vomiting
  • New onset of blood mixed in stool
  • Fever
  • Increased respiratory effort
  • Weak or absent femoral pulses in infant <3 months
  • Presence of newly noted heart murmur in infant <3 months

  • Inguinal hernia that cannot be reduced.
  • Painless firm neck swelling that is increasing in size.
  • White pupil or white instead of red reflex on eye examination.
  • Previously unrecognised intersex genitals (ambiguous as either virilised female or incomplete formation male eg bilateral absent testes).
  • Possible Infantile Spasms. This may be frequent brief episodes of head bobbing (with or without arm extension) in an infant less than 12 months old.
  • Absent femoral pulses.
  • Infant <3 months with newly noted murmur and any of the following:
    • poor feeding
    • slow weight gain
    • weak or absent femoral pulses
    • post ductal (foot) oxygen saturation < 95%
    • respiratory signs (wheeze, recession or tachypnoea)

  • New diagnosis of type 1 diabetes = polyuria and/or polydipsia and random BSL >11.0.
  • Ketoacidosis in a known diabetic with any of the following:
    • systemic symptoms (fever, lethargy)
    • vomiting
    • inability to eat (even if not vomiting)
    • abdominal pain
    • headache

Does your patient wish to be referred?

Minimum referral criteria

Does your patient meet the minimum referral criteria?

Category 1

Appointment within 30 days is desirable

  • Primary school child needing a medical assessment due to a recent change in behaviour  that has resulted in being expelled or repeatedly suspended from school for more than 50%of the last 3 months
  • Sudden change in behaviour with a suspected medical comorbidity as a possible cause
  • Children with significant anxiety who have been seen by mental health or psychology services and have ongoing significant difficulty requiring medical assessment

Category 2

Appointment within 90 days is desirable

  • Primary school child needing a medical assessment due to a recent change in behaviour  that has resulted in being expelled or repeatedly suspended from school for more than 50%of the last 3 months
  • Sudden change in behaviour with a suspected medical comorbidity as a possible cause
  • Children with significant anxiety who have been seen by mental health or psychology services and have ongoing significant difficulty requiring medical assessment

Category 3

Appointment within 365 days is desirable

  • Most other referrals for behavioural problems in children > 6 years

If your patient does not meet the minimum referral criteria

Consider other treatment pathways or an alternative diagnosis.

If you still need to refer your patient:

  • Please explain why (e.g. warning signs or symptoms, clinical modifiers, uncertain about diagnosis, etc.)
  • Please note that your referral may not be accepted or may be redirected to another service

Other important information for referring practitioners

Not an exhaustive list

  • Refer to local care pathway
  • The following children should be directed to Child and Youth Mental Health Services
    • children who may be at risk of self-harm
    • aggressive behaviour with high risk of significant injury to vulnerable family members
    • primary school child with significant school refusal due to anxiety
  • Raising children network www.raisingchildren.net.au
  • If you have a reason to suspect a child in Queensland is experiencing harm, or is at risk of experiencing harm, you need to contact Child Safety Services: https://www.communities.qld.gov.au/
  • In the majority of cases it is thought inappropriate for children to wait more than 6 months for an outpatient initial appointment

Referral requirements

A referral may be rejected without the following information.

Essential referral information

  • General referral information
  • Description of the behaviours of concern
  • A letter from the school outlining behaviours of concern is required if school based behaviours are the primary reason for the referral.
  • Report presence or abscence of red flags

Presence or abscence of red flags

  • Is physical aggression placing family members (e.g. much younger siblings) at risk of injury? If so, provide details outlining which family members and why they may be at risk of injury. Consider referral to Child Youth Mental Health service as per other useful information
  • Is the child expected to be in out of home care supervised by the department of child safety for more than 6 months?. If so, do you consider that the child’s foster placement is at risk of breaking down due to the child’s behaviour?

Highly desirable information – may change triage category

  • Brief comment on current school educational attainments (good, average, poor, very poor (>2 years behind))
  • Guidance officer assessment or other information from the school.
  • Information about school attendance, expulsion or suspension.
    • estimate number of days suspended in the previous 3 months.
    • estimate number of days missed because of school refusal.
  • Previous medications or therapies used.
  • Significant psychosocial risk factors (especially parents mental health, family violence, housing and financial stress, department of child safety involvement)
  • Previous services accessed (other paediatricians, mental health services, allied health services, etc.)
  • Family history, including family members affected with ASD, ADHD, learning difficulty or mental illness.
  • Copies of previous of speech, occupational therapy, physiotherapy or cognitive assessments if available.
  • Audiometry
  • If the child is in foster care please provide the name and regional office for the Child Safety Officer who is the responsible case manager.

Desirable information — will assist at consultation

  • Pregnancy and birth history
  • Other past medical history
  • Immunisation history
  • Developmental history
  • Medication history
  • Height/weight/head circumference and growth charts with prior measurements if available.
  • Other physical examination findings inclusive of CNS, birth marks or dysmorphology

Out of catchment!

Metro North Health is responsible for providing public health services to the people who reside within its boundaries. Special consideration is made for patients requiring tertiary care or services that are not provided by their local Hospital and Health Service. If your patient lives outside the Metro North Health area and you wish to refer them to one of our services, inclusion of information regarding their particular medical and social factors will assist with the triaging of your referral.

  • Impact on employment
  • Impact on education
  • Impact on home
  • Impact on activities of daily living
  • Impact on ability to care for others
  • Impact on personal frailty or safety
  • Identifies as Aboriginal and/or Torres Strait Islander

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can’t order, or the patient can’t afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

  • Presenting symptoms (evolution and duration)
  • Physical findings
  • Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
  • Body mass index (BMI)
  • Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
  • Current medications and dosages
  • Drug allergies
  • Alcohol, tobacco and other drugs use

  • Full name (including aliases)
  • Date of birth
  • Residential and postal address
  • Telephone contact number/s – home, mobile and alternative
  • Medicare number (where eligible)
  • Name of the parent or caregiver (if appropriate)
  • Preferred language and interpreter requirements
  • Identifies as Aboriginal and/or Torres Strait Islander

  • Full name
  • Full address
  • Contact details – telephone, fax, email
  • Provider number
  • Date of referral
  • Signature

  • Willingness to have surgery (where surgery is a likely intervention)
  • Choice to be treated as a public or private patient
  • Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)
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