Behaviour Concerns in Children Algorithm

Safety

Red Flags — Safeguarding, Risk and Neurological Causes

Done

Behaviour is communication. Before labelling it, ask whether the child is safe, unwell or in distress.

Safeguarding concern Disclosure, unexplained injuries, neglect, domestic abuse at home, sexualised behaviour beyond developmental norms, exploitation (county lines, online), missing from home → Same-day Follow local child-protection procedures; discuss with the safeguarding lead or children's social care

Self-harm or suicidal thoughts Young person with intent, a plan or unable to stay safe → Same-day CAMHS crisis or paediatric emergency assessment; 999 if overdose or serious injury

New behaviour change with neurological features Headache, vomiting, ataxia, visual change, seizures, personality change or reduced consciousness → Same-day Paediatric assessment; 999 if reduced consciousness or fitting

Loss of skills already acquired Language regression after age 3, or motor regression at any age → Urgent Paediatrician or paediatric neurologist; same day with focal signs or raised intracranial pressure features

Possible seizures Staring spells, unresponsiveness, unusual movements → Urgent Paediatrician with epilepsy expertise, seen within 2 weeks

Psychosis, severe agitation or intoxication Hallucinations, bizarre beliefs, drug or alcohol use → Same-day CAMHS crisis or paediatric assessment

Eating disorder features Food restriction, weight loss, purging with behaviour change → Same-day If medically unstable; otherwise urgent eating-disorder service

Behaviour change is a common way for abuse, neglect and exposure to domestic abuse to come to attention. A child's distress may be the only sign. Safeguarding responsibilities sit with every clinician (Working Together to Safeguard Children 2023). New behaviour change with neurological features or loss of skills needs a medical explanation, not a behavioural one.

Diagnose

History — From Parent, Child and School

Done

The behaviour

What exactly happens, how often, since when, triggers and what follows; where — home only, school only, or everywhere (pervasive)

Development

Pregnancy (alcohol, drugs), birth, milestones, speech and language, play, friendships, regression

Attention and activity

Inattention, hyperactivity, impulsivity in two or more settings, starting in childhood, with impairment (ADHD)

Social communication

Eye contact, shared attention, pretend play, rigid routines, intense interests, sensory differences, masking in girls (autism)

Emotions

Worry, fears, low mood, school refusal, tics, obsessions; meltdowns after school can reflect masking or anxiety

Learning

School progress, reading and writing difficulty, special educational needs support, EHC plan

Senses and sleep

Hearing (glue ear, missed newborn screen), vision, snoring and restless sleep, bedtime routine, screens

Family

Who lives at home, separation, bereavement, parental mental health, alcohol or drugs, domestic abuse, housing and money worries, young carer roles, siblings

Trauma and adversity

Looked-after or adopted, early neglect, bullying, online harm

Adolescents

Speak to the young person alone (HEADSS): home, education, activities, drugs, sex, suicide and mood; confidentiality and its limits

Medicines and health

Antiepileptics, antihistamines, salbutamol, steroids; constipation and soiling, enuresis, pain, thyroid symptoms

Whether behaviour is pervasive across settings or limited to one is the most useful discriminator: ADHD and autism show across settings, while behaviour confined to home or to one classroom points more to relationships, environment or a specific stressor.

Diagnose

Examination and Observation

Done

Growth

Height, weight and head circumference plotted on the centile chart — faltering growth, obesity or microcephaly change the picture

General

Dysmorphic features, neurocutaneous signs (café-au-lait macules, ash-leaf patches), injuries and their pattern, hygiene and signs of neglect

Neurological

Gait, coordination, tone, fundi if headache; tics

ENT

Large tonsils, mouth breathing (sleep-disordered breathing), ears for effusion

Observation

Interaction with parent and clinician, play, attention, language, sensory responses; parent–child relationship

Hearing and vision

Arrange audiology and an eye test if not adequately assessed — without delaying other referrals

Tests

Not routine. Bloods only for a specific indication (for example TSH, FBC, ferritin); genetic testing and EEG are specialist-led

A behaviourally normal child in a 10-minute consultation does not exclude ADHD or autism — information from home and school matters more than clinic observation. Hearing loss and sleep-disordered breathing can both present as inattention or hyperactivity.

Diagnose

Differentials

Done

ADHD

Two or more settings

Inattention and/or hyperactivity–impulsivity from early childhood with impairment at home and school (NICE NG87)

Autism

Social communication + restricted patterns

Differences in both domains; may be verbal and academically able; girls often mask (NICE CG128)

Anxiety

Avoidance, clinginess, anger

Separation anxiety, school refusal, social anxiety, OCD; anger can be the visible sign

Conduct problems / ODD

Defiance, aggression

Persistent defiance, temper, rule-breaking, aggression to people or animals (NICE CG158)

Learning difficulty or disability

Struggling to keep up

Global or specific (dyslexia, developmental language disorder); frustration shows as behaviour

Hearing or vision impairment

Missed input

Glue ear, unrecognised refractive error

Sleep problems

Tired child

Short sleep, sleep-disordered breathing, late screens — overactivity and irritability by day

Family stress and parenting

Context

Separation, parental illness, domestic abuse, inconsistent boundaries; often behaviour at home only

Trauma and attachment

Adversity

Looked-after or adopted children, abuse, bereavement; hypervigilance can look like ADHD

Other

Consider

Depression, tics or Tourette syndrome, absence seizures, fetal alcohol spectrum disorder, medicine side effects, hyperthyroidism

Conditions frequently coexist — for example ADHD with autism, anxiety or learning difficulty — and adversity can mimic or worsen any of them. The aim in primary care is a safe working differential and the right route, not a final diagnosis.

Diagnose

Gather Information — School Liaison and Watchful Waiting

Done

School liaison

With consent, ask the school (class teacher or SENCO) for a description of behaviour, learning and peer relationships; a Strengths and Difficulties Questionnaire (SDQ) from parent and teacher can help

Support without diagnosis

School can start SEN support, adjustments and a support plan without a diagnosis; ask about an Early Help assessment for family support

ADHD features with impact

Consider a period of watchful waiting of up to 10 weeks and a referral to group-based ADHD-focused parent support (NICE NG87); if impairment is persistent and at least moderate, refer — do not hold the referral back for a questionnaire

Possible autism

Refer to the autism team on reasonable concern — do not wait for speech, school agreement or a screening-tool result; check hearing in parallel (NICE CG128)

Conduct problems

Offer a group parent-training programme for parents of children aged 3–11 (NICE CG158); child-focused problem-solving groups for 9–14; multimodal interventions for older teenagers via specialist services

NICE NG87 and CG128 both place weight on information from more than one setting. School information strengthens a referral but should not delay one when concern and impairment are clear.

Refer

Referral — Who, Where and How Fast

Done

999 / Same-day

Safeguarding concern (child-protection procedures); self-harm with risk; psychosis; new neurological features; medically unstable eating disorder

Urgent

Regression (language after 3, motor at any age) → paediatrician or paediatric neurologist; possible seizures → epilepsy-experienced paediatrician within 2 weeks

Autism team

Reasonable concern about autism, via the local single point of access (often community paediatrics or CAMHS by age)

Specialist ADHD service

Persistent ADHD symptoms with impairment in two or more settings — community paediatrics, CAMHS or a specialist paediatric ADHD team per local criteria. Under 5s: ADHD-focused parent training first-line

CAMHS

Anxiety, depression, OCD, trauma, self-harm, severe or persistent conduct problems with emotional difficulty

Community paediatrics

Developmental concerns, suspected learning disability, younger children with neurodevelopmental features, faltering growth or medical features

Other

Audiology, optometry or orthoptics, speech and language therapy, educational psychology (via school), Early Help and parenting programmes, school nurse, young carers' services

Referral routes vary between areas — know the local single point of access. Include impairment across settings, school information where available, growth, hearing status and any safeguarding context in the referral letter.

Treat

Management at This Consultation

Done

All families

Listen, explain, plan Today

Take concerns seriously; explain that a diagnosis needs information from more than one setting; agree what will happen next and when

Behaviour at home

Parenting strategies

Praise specific good behaviour, consistent routines and calm boundaries, clear short instructions, planned consequences; refer to a group parent-training programme

School

Liaison letter

With consent, write to school or the SENCO asking for observations and support

Treatable contributors

Fix what you can

Hearing and vision checks, constipation and soiling, enuresis, sleep (see sleep problems in children), anaemia or thyroid if indicated

Do notStart ADHD medication in primary care — diagnosis and initiation are specialist; the GP may later continue it under a shared-care agreement

Do notRoutinely use medicines to manage conduct problems or behaviour in autism (NICE CG158, CG170); no antipsychotics or melatonin started in primary care

CarersAsk about parental wellbeing, offer support for the parent's own mental health, signpost parent support organisations and carers' assessments

RecordWho has parental responsibility, consent for information sharing, safeguarding context and the plan

Next steps: see ADHD · Autism · Constipation in children · Nocturnal enuresis

NICE NG87 recommends ADHD-focused parent training first-line in under-5s and parental support alongside environmental modifications at all ages; medication is specialist-initiated. NICE CG158 recommends group parent-training programmes for conduct problems and advises against routine medication. Much of the effective support begins before any diagnosis.

Lifestyle

Home and Self-Care

Done

Sleep Regular bedtime routine, no screens in the hour before bed, devices out of the bedroom

Activity Daily physical activity and outdoor play; structured activities and clubs

Routine and structure Visual timetables, warnings before transitions, predictable days

Food and drink Regular meals, limit caffeine and energy drinks in teenagers; no evidence for exclusion diets in primary care

Family wellbeing Time for each child, sibling support, parent's own support and respite

Support organisations Young Minds parents helpline, National Autistic Society, ADHD Foundation, Contact (families with disabled children)

Structure, sleep and activity help most children whatever the eventual diagnosis, and parental wellbeing strongly influences child outcomes.

Safety

Follow-Up and Safety-Netting

Done

4–10 weeks

Review school information, parenting programme uptake, hearing and vision results; refer if impairment persists

While waiting

Waits for neurodevelopmental assessment can be long — review periodically, keep school support going, revisit safeguarding and family stress

Safety-net 999

Overdose or serious self-injury, a fit lasting more than 5 minutes, child very drowsy or hard to wake

Safety-net same-day

Talk of suicide or self-harm, new severe headaches or vomiting, loss of skills, sudden marked change in behaviour, any worry that the child is being harmed

Planned review keeps the child from being lost between services while waiting, and gives repeated opportunities to notice safeguarding concerns or new medical features.

🧒 Behaviour Concerns in Children and Young People

Red Flags — Safeguarding, Risk and Neurological Causes

History — From Parent, Child and School

Examination and Observation

Differentials

Gather Information — School Liaison and Watchful Waiting

Referral — Who, Where and How Fast

Management at This Consultation

Home and Self-Care

Follow-Up and Safety-Netting