In 2013, DSM 5 has changed the classification of several well-known conditions. Attention deficit-hyperactivity disorder, Asperger’s syndrome, childhood disintegrative disorder and pervasive developmental disorder not otherwise specified are now under the heading of Autism spectrum disorder. This was because of lack of standardisation of application of diagnostic criteria. Individuals with one of the previous diagnoses should now fulfil the criteria for autism spectrum disorder instead.
Parents may visit the GPs concerned that their children may have ADHD or Asperger’s syndrome. Frequently, the school will have drawn attention to academic or behavioural issues the child is demonstrating and suggest medical review. To sort this out efficiently, the GP is then in for a long consultation and must keep an open mind about the diagnosis. Before referral to a child psychiatrist or paediatrician specialising in this area, many things should be done.
It is very important to speak to the child by him or herself, ideally with the parent’s permission and obviously, only if the child is also in agreement to this. This sheds light on the child’s ability to understand and communicate in the absence of parental influence. It also gives the child an opportunity to disclose things that are concerning him/her and allows the GP to ask screening questions to identify such problems. Common examples of these include parents having addiction disorders, unhappy marriages, bullying of the child or loneliness at school. More serious possibilities include domestic violence and childhood sexual abuse. The GP should take the opportunity to assess the child for depression and anxiety at this time.
It is important to ask the parents to obtain information from the school, such as academic reports over several years, to illustrate what the ability of the child has been over time. The parents should discuss their child’s situation with the teacher in detail. The GP must ask about major upheavals (such as bereavement or divorce) that could have contributed to behavioural and learning difficulties. It is surprising how many parents are significantly contributing to the cause of their children’s difficult behaviour in such scenarios, and yet are then assuming the child is the one who is causing problems for the family.
The pregnancy, delivery and development in early childhood needs to be reviewed by the GP. The child’s diet and sleeping patterns should be discussed with the parents and consideration given to testing for iron deficiency, lead poisoning and any medical conditions that could be contributing to the situation, such as sleep apnoea, undiagnosed coeliac disease or frequent bacterial infections. The effect of puberty on behaviour should be considered in older children, especially in the light of complicating factors such as period problems, friendship issues, peer groups, sexual activity and any drug and alcohol use.
Every child with learning and behavioural difficulties should have their vision tested by an optometrist and their hearing reviewed by an audiologist. If there is evidence of speech delay or language difficulties, the child should be reviewed by a speech pathologist. Educational issues, especially teachers suggesting impaired concentration or underperforming, should prompt psychometric testing by an educational psychologist. A general psychologist may help the child and/or parents cope with concerning behaviours, or management advice about issues raised (such as obsessional disorders, generalised anxiety, bullying). There is usually no need to wait for specialist medical review to commence these strategies and investigations.
1. Parry, T.S. Assessment of developmental learning and behavioural problems in children and young people. Medical Journal of Australia 2005; 183 (1): 43-48