Behavioural problem in a child ≥ 6 years

Emergency department referrals

All urgent cases must be discussed with the on-call Registrar to obtain appropriate prioritisation and treatment.

Contact through:

Caboolture Hospital (07) 5433 8888
Redcliffe Hospital (07) 3883 7777
Royal Brisbane and Women's Hospital (07) 3646 8111

Urgent cases accepted via phone must be accompanied with a written referral and a copy faxed immediately to the Central Patient Intake Unit: 1300 364 952.

If any of the following are present or suspected, refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region.

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

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

Child in Department of Child Safety supervised out of home care with imminent threat of breakdown of current foster placement due to behaviour.

Category 2

Appointment within 90 days is desirable

Primary school child needing a medical assessment due to behaviour that has resulted in being expelled or repeatedly suspended from school or is unable to attend due to their behavioural challenges
Child presenting with moderate-severe behavioural concerns i.e. putting themselves or others at risk of harm, that have associated moderate-severe developmental / learning concerns.
Sudden change in behaviour with a suspected medical or underlying developmental comorbidity as a possible cause.
Sudden change in behaviour in a child who has previously been diagnosed with a developmental condition i.e. FASD, ASD, Intellectual Impairment) Children with significant anxiety or other behavioural concerns who have been seen by mental health or psychology services and have ongoing significant difficulty requiring medical (health) assessment
A child currently in out of home care (OOHC) or at risk of entering or leaving OOHC, where they have previously been on a waiting list for this problem and were removed without receiving a service
Children with significant behavioural concerns, that have been seen by mental health or psychology services, that are requesting specialist paediatrician review for diagnostic purposes

Category 3

Appointment within 365 days is desirable

Most other referrals for behavioural problems in children > 6 years
Child must be concurrently supported / referred to external behavioural services

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 HealthPathways for assessment and management information if available
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
Consider the potential impact of parental mental health on a child’s behaviour. If this is an issue, then referral of the parent to address their own mental health / wellbeing may be more appropriate in the first instance.
In the majority of cases it is thought inappropriate for children to wait more than 6 months for an outpatient initial appointment
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: Department of Children, Youth Justice and Multicultural Affairs
Clinical urgency is the dominant consideration in the prioritisation of a referral for a child currently in out of home care (OOHC), or at risk of entering or leaving OOHC.

Referral requirements

A referral may be rejected without the following information.

Essential referral information

History and Examination

Description of the behaviours of concern
If educational setting concerns are present, then a letter from the educational setting must be included in a GP referral. In the absence of a letter from the educational institution provided with the referral, the referral will be categorised Cat 3 unless they meet other non-educational criteria.
Children with behavioural concerns should be concurrently referred to appropriate behaviour specialist (either a psychologist, individual positive parenting program counsellor or other community behavioural support program) The service or practitioner they have seen should be identified in the referral. The specialist assessing this referral may waive this requirement in circumstances where primary care services are inaccessible.
Report presence or absence of concerning features
- 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?
- Information on family violence / exposure to adverse childhood events (psycho-social trauma)
Confirmation of OOHC (where appropriate)

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 parent’s 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.

Clinical Modifiers (where relevant)

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

Reason for Referral (essential)

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

Clinical Information (essential)

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