Reasoning GP · Algorithm · 1-page summary
Behaviour concerns — children and young people
For: children and young people under 18 whose parents, carers or school raise behaviour concerns. Not for: adults. Sleep as the main problem: sleep problems in children algorithm. Children's doses: BNFC.
Core rule: behaviour is communication — safeguarding first, then ask whether it is pervasive across settings; gather school information without delaying a referral, and start support before any diagnosis.
0Stop — call 999 now — before any history
- Overdose or serious self-injury → 999
- Reduced consciousness or a fit with new behaviour change → 999
1Triage — where does it happen?
| Pattern | Think |
|---|---|
| Home and school | ADHD, autism, learning difficulty, hearing or vision |
| Home only | Family stress, parenting, relationships, sleep |
| School only | Learning difficulty, bullying, anxiety, masking |
| Sudden change | Trauma, abuse, bereavement, illness, drugs |
| Loss of skills | Neurological cause — block 2 |
2Screen — one row is enough
- Safeguarding concern: disclosure, injuries, neglect, domestic abuse, exploitation → child-protection procedures Same-day
- Self-harm or suicidal thoughts with intent or a plan → CAMHS crisis Same-day
- Neurological features: headache, vomiting, ataxia, seizures, personality change → paediatrics Same-day
- Regression: language after age 3, motor at any age → paediatrician or neurologist Urgent
- Possible seizures → epilepsy-experienced paediatrician within 2 weeks
- Psychosis, intoxication, eating-disorder features → Same-day if unstable
3Assess — home, school and the child
☐ Behaviour, settings, onset, triggers ☐ Development, speech, play, friendships ☐ Family, adversity, parental wellbeing ☐ Adolescents seen alone (HEADSS) ☐ Growth plotted; dysmorphic and neurocutaneous signs; injuries ☐ Hearing and vision checked ☐ School information with consent (SDQ)
Bloods, genetics and EEG are not routine in primary care.
4Classify — only if the screen is negative
- ADHD — two or more settings, from early childhood → specialist ADHD service if impairment persists.
- Autism — social communication + restricted patterns → autism team on reasonable concern.
- Anxiety or low mood → CAMHS or school support.
- Conduct problems → group parent training (ages 3–11).
- Learning, hearing, vision, sleep, family stress, trauma → address the cause.
- Uncertain — gather school information; review in 4–10 weeks.
5Treat today — doses: NICE/SPC, BNF, local formulary
- Listen and plan: explain that diagnosis needs information from more than one setting.
- Parenting: praise, routines, calm boundaries; refer to a group parent-training programme. ADHD features: consider watchful waiting of up to 10 weeks with ADHD-focused parent support.
- School: liaison letter with consent; SEN support needs no diagnosis.
- Do not start ADHD medication, antipsychotics or melatonin in primary care.
6Refer routinely
- Reasonable concern about autism → autism team (check hearing in parallel).
- Persistent ADHD symptoms with impairment → specialist ADHD service.
- Developmental concerns → community paediatrics; emotional difficulties → CAMHS.
- Audiology, optometry, speech and language therapy, Early Help.
7Never reassure by
- A calm child in clinic.
- A verbal, academically able child (autism).
- Behaviour at home only, without asking about the home.
- Waiting for school agreement before referring.
- Labelling hypervigilance after trauma as ADHD without asking.
- A normal newborn hearing screen years ago.
8Safety-net — say it, then document it
999 “Call 999 for an overdose or serious injury, a fit lasting more than 5 minutes, or if your child is very drowsy or hard to wake.” Same-day “Contact us today if your child talks about suicide or self-harm, gets new severe headaches or vomiting, loses skills, changes suddenly, or you worry they are being harmed.”
Follow-up: 4–10 weeks — school information, parenting programme, hearing and vision; keep reviewing while waiting.
✓Safe to leave primary care only if — all five, documented
No block 0–2 row applies
Safeguarding considered and recorded
Growth, hearing and vision checked
School information requested with consent
Referral route and review agreed
Summary of the full Reasoning GP behaviour concerns in children algorithm, which holds the detail, examination, investigations and evidence. Sources: NICE NG87, CG128, CG170, CG158, NG225, NG76; Working Together to Safeguard Children 2023; SEND Code of Practice. Clinical reference — follow local pathways and check doses in the current SPC, BNF and local formulary.