Children over the age of 11 years can still be referred to the school nurse for other health-related issues. Referrals for autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD) should be made directly to child and adolescent mental health services (CAMHS), provided by North East London NHS Foundation Trust (NELFT).

Outcomes

Improved understanding of a child’s developmental needs and the ability to implement effective strategies so that:

• young people are prepared for adulthood
• children have positive learning experiences
• children and young people can access community activities
• families feel supported and understand how best to help their child.

Stages along the pathway

1. identification of issues
2. support and referral
3. assessment
4. outcome of assessment
5. ongoing support, review and transition planning

Who may raise a concern with the school nurse?

• parents or carers notice a difference in their child compared with other children of a similar age
• schools raise concerns about learning difficulties or general development
• other professionals raise concerns, for example a speech and language therapist (SLT)
• families or schools report difficulty managing behaviours
• the child’s GP.

Stage 1 – Identification and request for help

Sources of support

• schools should implement Medway Core Standards or an equivalent programme, for example Elklan, Emotional Literacy Support Assistant (ELSA) provision or Language for Learning, for a minimum of three months
• schools should encourage parents and carers to use the same strategies at home
• schools should monitor and record the child’s progress
• families must be involved and participate in early intervention
• this may include supporting parents and carers to attend local positive parenting courses
• schools should signpost parents and carers to complete an online parenting course before considering a referral to the school nursing service
• once training has been completed, parents and carers should use the strategies learned for a minimum of six weeks
• parent training should include parental attention, containment, reciprocity and behaviour management
• consideration should be given to referral to Early Help or Family Solutions
• consideration should be given to referral to CAMHS
• safeguarding concerns should be considered and escalated where required
• child in need issues should be addressed and included in any referral
• looked-after children (LAC) should be assessed by the looked-after children nursing team, who can escalate concerns where required
• children with developmental regression should be directed immediately to their GP, who can refer directly to specialist children’s services.

Stage 2 – Support and referral

Once the school has completed a period of monitoring using Medway Core Standards, or an equivalent programme, and the child has not responded to intervention, concerns should be discussed with the named Special Educational Needs Co-ordinator (SENCO) at the six-weekly referral meeting.

The school nurse will liaise with the SLT if the child is known to the service.

The school and parents should be actively involved in the assessment process. Underlying medical conditions should be considered by the public health nurse (PHN), for example hearing, vision, sleep and emotional wellbeing.

During this period, the school and parents should continue to use all support strategies from Medway Core Standards.

The school nurse will complete a health needs assessment and, depending on the outcome, may:

• make referrals to other agencies in partnership with parents and carers
• provide advice and strategies to address identified concerns
• provide a package of care for behaviour, sleep or continence.

If, following assessment and intervention, the child still requires support, the school nurse or school staff nurse will consider referral to the Indigo Neurodiversity Pathway.

Learning disability nurses will support special schools that are considering a referral into the Indigo Neurodiversity Pathway.

Referral to specialist children’s services

Who can refer?

School-aged children should be referred by the school nurse in partnership with the school SENCO and the child’s parents or carers.

Other health professionals, for example SLTs and occupational therapists (OTs), can refer directly.

GPs are advised to contact the school nurse, who will consider the most appropriate stage of intervention for the child.

Who should be referred?

• children who present with behavioural and developmental difficulties that have not responded to intervention at school and at home
• children where there may be concerns about an underlying neurodevelopmental condition
• children whose difficulties have a moderate or severe impact on functioning and have been present for at least six months
• children from Year R until their 11th birthday who are registered with a Medway GP
• children over the age of 11 years should be referred to CAMHS through the NELFT referral process.

The role of the school nurse

• bring together all information collected over a minimum of three months through completion of a health needs assessment
• consider family circumstances that may affect behaviour
• ensure assessments and referrals are recorded on the RiO electronic patient record
• make an internal referral to specialist children’s services
• obtain consent for information sharing between Kent Community Health Foundation Trust (KCHFT), the school and the child’s GP
• explain the pathway to families.

The role of specialist children’s services

• provide immediate advice to the school nurse and SENCO where appropriate
• triage all referrals and identify the most appropriate pathway
• ensure families receive information about the next steps.

Stage 3 – Assessment

Neurodevelopmental conditions often coexist and overlap. Sometimes it is not immediately clear which pathway is the most appropriate.

We work with children and families to identify areas of need and determine whether a formal diagnosis should be considered.

Formal standardised testing may not take place if the child does not meet the criteria for diagnostic assessment. We use the DSM-5 and the ICD-10 when undertaking diagnostic assessments.

Specialist children’s services will work with families to identify their greatest challenges. These may include:

• sleep difficulties
• continence issues
• behaviour management
• sensory processing difficulties
• motor coordination difficulties.

These difficulties should be addressed before formal assessment because they can affect diagnostic outcomes.

Specialist children’s services will ensure records are available on RiO so that the school nurse can keep the school informed of progress through the pathway.

Schools and families may be asked to complete monitoring and recording activities before decisions are made about next steps.

Families will be encouraged to take part in community activities. The family engagement officer can help identify suitable opportunities.

Supporting children at school, at home and in the community is important for wellbeing and self-confidence.

The pathway focuses on the child’s needs rather than a single diagnosis. Families should understand this before referral to the Indigo Neurodiversity Pathway.

Our clinical team includes:

• specialist nurses
• SLTs
• OTs
• physiotherapists
• paediatricians
• podiatrists
• dietitians.

Children will see the most appropriate professional based on their individual needs.

Stage 4 – Outcome of assessment

Regardless of the outcome, children and families may require ongoing support to manage identified difficulties.

A lack of formal diagnosis should not be seen as a barrier to receiving support at home, school or in the community. The focus is on impact and functioning.

We will seek consent from the family before sharing information.

Schools should be aware that if consent is not provided, information cannot be shared. However, families may choose for key findings to be shared, such as:

• diagnosis
• medication
• ongoing support.

Families may invite other professionals to attend the diagnostic feedback session where appropriate, including the school nurse or a member of school staff.

The clinical evaluation report will be shared with the family and GP. Any onward referrals will be included within the report.

Typical neurodevelopmental conditions considered include:

• autism spectrum disorder
• attention deficit hyperactivity disorder
• sensory processing disorder
• motor coordination disorder.

Some children present with difficulties across more than one area. Clinicians will complete a thorough assessment before making any diagnosis.

A formal diagnosis may not always be made. This does not mean that difficulties are not present, and advice and support will continue throughout the pathway.

Stage 5 – Ongoing support, review and transition planning

Schools are expected to continue the support outlined within the assessment.

At times of change, the school nurse can review the situation and make referrals to other services where appropriate.

Appendix 1

Medway services for behaviour support

Programme or service	Description	Referral information
Triple P ADHD	A five-week programme for parents providing information about attention deficit hyperactivity disorder (ADHD) and parenting strategies for children aged five to 11 years	Referrals can be made by professionals through Early Help. Self-referrals are not accepted
Triple P - Teen Parenting Programme	A five-week programme for parents providing information about teenage development and parenting strategies for children aged 11 to 17 years	Professionals can refer through Early Help. Parents and carers can self-refer
Non-Violent Resistance (NVR)	A 10-week programme for parents of children aged five to 17 years who display aggression or violence towards parents and carers	Professionals can refer through Early Help or the Youth Offending Team (YOT). Parents and carers can self-refer
Incredible Years School Age Parenting Programme (IY)	A 12-week programme designed to promote emotional and social competence and reduce behavioural and emotional difficulties in children aged five to 12 years	Professionals can refer through Early Help. Parents and carers can self-refer
Domestic Abuse Recovering Together (DART)	A 10-week programme helping families talk about domestic abuse, improve communication and rebuild relationships	Referrals can be made directly through participating National Society for the Prevention of Cruelty to Children (NSPCC) service centres
Positive Pathways	An NSPCC programme for children and young people aged seven to 18 years that helps build confidence, resilience and coping skills	Referrals can be made through participating NSPCC service centres
Salvation Army parent drop-in	Advice and support for parents with concerns about child behaviour for children aged nought to 10 years	Fridays, 9 to 11am. Telephone: 01634 851224
Salvation Army Parent-Talk	A 10-week parenting programme for parents of children aged nought to 10 years. A free crèche is available	Parents and carers can self-refer by contacting the Salvation Army in Gillingham. Telephone: 01634 851224
Family Action Digital Parent Support Service	Telephone, text and email support for parenting issues, with support from befrienders and counsellors	Helpline: 0808 802 0222. Text: 07537 404282. Email: NDPSS@familyaction.org.uk
Medway Early Help and Family Solutions	Support with education, relationships, health, wellbeing, housing, finances, domestic abuse and anti-social behaviour	Chatham All Saints Children and Family Hub: 01634 338833. Gillingham Children and Family Hub: 01634 338877. Strood Children and Family Hub: 01634 335533 Wayfield Children and Family Hub: 01634 337733. Email: ehsupport@medway.gov.uk