Case 14: Disruptive Child. Expert comment by Dr Gil Myers

Thanks to everyone who contributed to the discussions about Elliot a 7 year old boy who had been behaving badly at school.

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You can see the highlights of the discussion on Twitter in the storify.

This week’s question setter was Laura Massey (Final Year Medical Student)  & expert was Dr Gil Myers, ST6 in Child & Adolescent Psychiatry. 

Information available at the start of the week:

Elliot is a seven year old boy who is causing his teachers difficulties due to his poor behaviour. He rarely seems to pay any attention to his teachers, is generally clumsy, and has few friends in his class. Elliot comes to clinic today accompanied by his mother and father.

Question 1: What information should you consider when coming up with a differential diagnosis list?

Further information released during the week:

Presenting complaint

Duration of symptoms

Elliot has always been described as “difficult to manage”. Probably since he could move about and crawl

ADHD symptomatology questions

Inattention

Elliot frequently fails to complete activities (school and home). He starts an activity but becomes sidetracked, leaving it unfinished

He is very forgetful. He forgets where he has left his toys in the house and often leaves clothes from his games kit at school.

In lessons he is easily distracted by other children or outside noises and doesn’t appear to listen. He often doesn’t finish tasks

Hyperactivity

Elliot struggles to sit still in class. He prefers to wander from his seat (at the back of the room) to the front to speak to the teacher directly.

When trying to complete tasks, he is much louder than his peers and tends to talk through the task.

Impulsive

He won’t take turns in “circle time” at school or during board games at home. He always wants to be first.

In class, he often interrupts other students to give answers and find it hard to put up his hand and wait to be picked.

Teachers and parents struggle to stop Elliot talking at inappropriate times, for example during a film.

Friendship groups

Elliot can make friends but other children find him too demanding. He quickly bounces between children so others don’t like to play with him

Full assessment of medical history

PMHx and PSHx

No significant past medical history of note.

No dysmorphic features, nothing to suggest chromosomal syndromes such as William’s

Neither the school nor the family are aware of any vocal or motor tics.

Drug history

None of note. Not currently taking any medication. No known drug allergies.

Family History

History of atopy in the family. No neurodevelopmental or significant psychiatric conditions.

Older sister (10 years old) has showed none of Elliot’s behaviours

Development

Term baby 39/40 weeks, spontaneous vaginal delivery, no SCIBU, no possibility of brain injury.

Mother smoked prenatally: approximately five cigarettes a day. Stopped during pregnancy.

No concerns raised by paediatricians, midwives, or health visitors regarding his development

Walked at 13/12 and spoke at 20/12, language below average for age. No SALT invovlement

Elliot has a tendency to drop things, and fell over more than his peers as a toddler. This is improving with age, and is not believed to be related to cerebral palsy or another neurological disorder.

Differential diagnosis

Stress/ anxiety/ depression

Home life described as generally good.

School: Elliot has a couple of close friends who are in the year below him. No signs that Elliot is being bullied, or bullying others.

Nothing to suggest stress, anxiety or depression is the cause of his current problems.

Problems with learning and attention due to physical disability

Eyesight and hearing within normal range on formal testing.

Elliot is bright and works well when given one-on-one attention; no evidence of any specific learning difficulties such as dyslexia.

Age appropriate behaviour

This could be considered immature but non-pathological behaviour but Elliot is very disruptive when compared to the rest of his classmates, particularly as Elliot was born in September so is one of the oldest in his class.

He appears to be aware of his behaviour and it’s implication but can’t stop himself from doing these things.

Conduct/ Oppositional Defiant Disorder

Elliot doesn’t like being told off, and can be very naughty on certain days.

He has not shown any particularly destructive behaviour. No excessive fighting or harm to others, or attempting to harm animals.

Autism Spectrum Disorder

Elliot engages in imaginative play and has varied interests: mainly sports, especially football and swimming, and painting

Elliot seems to benefit from a routine, especially in the morning before school. However he is not distressed by changes to these routines

He prefers not to play alone and will seek out friends (children his own age) to play with.

No hypersensitivity to sensory modalities have been noted.

Absence Seizures

No family history of note. EEG not consistent with absence seizures.

Q2. ADHD (Attention Deficit Hyperactivity Disorder) is suspected by Elliot’s teacher. How would you fully assess this in Elliot’s case?

ADHD, also known as hyperkinetic disorder in the UK, is a psychiatric disorder of the neurodevelopmental type

It should be assessed by someone trained in the diagnosis of ADHD either by: community paediatricians or child psychiatrists who will take a detailed history from parents and child preferably separately then together; talk to school teacher to ascertain their concerns.

Diagnosis rarely made before the age of seven years old, as difficult to differentiate ADHD with age appropriate behaviour.

Must include full developmental and psychiatric history; consider any physical issues such as eyesight and hearing.

Must show triad of symptoms:

  • Inattention
  • Hyperactivity
  • Impulsivity

These must be shown in more than one environment e.g. home/school/social.

School observation by a person not known to Elliot; observe him in both a lesson and at playtime. Focus on his behaviour and interactions with teachers and peers.

It was noted that Elliot was very disruptive in class always out of seat, walking around and shouting. Always had an excuse as to why he was standing up. Wouldn’t take turn in art class, instead of waiting for colouring pencils would snatch off his neighbours.

Parents second that this is the sort of behaviour they see with Elliot at home.

Conner’s rating scale one for each parent and one for the school. (Forms are different for both)

Long versions have 60-90 questions.

Score 0 not true → 3 very true/ frequently occurring.

Results show in graph measuring four categories:

  1. Hyperactivity
  2. Impulsivity
  3. Inattention
  4. ADHD symptomatology

Conner’s rating scales questionnaires should not form a strong basis for diagnosis by themselves, but is an important adjunct. Helps to highlight objective and subject concerns.

Q3. ADHD is confirmed. Elliot’s parents are not keen on medication. What other options are available to help manage Elliot’s difficulties?

Consider the option of watchful waiting. This allows you to see how Elliot behaves over a further 12 weeks before reassessing. Problems may be due to acute disruptions, settling in or other things which resolve without intervention.

Large focus on parent training which NICE recommend. These can start even before diagnosis is fully known. For example, The Triple P Positive Parenting Program or Webster Stratten.

These interventions promote positive parent-child relationship with a focus on playing with the child, rewarding positive behaviour, and consistent consequences for negative behaviour.

Practical tips for managing ADHD such as set routines to help with forgetfulness e.g. always putting items back in the same place, and breaking down instructions into stages, such as single instructions instead of a long list of commands.

Encourage balanced diet and regular exercise to help with high energy levels.

Tips for teachers and school:

  • Move Elliot to the front, so close to the teacher.
  • Avoid distraction e.g. not sat next to the window
  • Break up instructions into staging, learn in chunks.
  • Classroom assistant to help keep Elliot on task with one-on-one attention
  • Clear goals with regular positive feedback

Additives are not linked to “bad behaviour” according to evidence, so immediately removing from diet is not recommended by NICE. If suspected family could try food diary to see if links between food and drink with poor behaviour. If a link is found, Elliot’s care team should involve a dietician.

Group psychological treatment

These have a role in social skills training – how to react to people’s emotions, how to behave in certain situations. Some cognitive behavioural training or individual psychological treatment may be appropriate but these are more suited to older children and in mixed presentations.

Comorbities

Co-morbidities are common in ADHD and should also be managed in conjuncture with the ADHD.

Co morbidities include: depression and anxiety, tic disorders, conduct disorders, learning and language disabilities. However, Elliot has not shown to have any of these.

Q4. Elliot hasn’t responded to his current management plan. What medication should you prescribe? What advice would you give to the family?

Elliot has shown little improvement with non-pharmacological therapy so first line medication is now considered: the stimulant methylphendiate, and second line atomextine.

Methylphenidate

  • Positive effects seen in 70% of children
  •  Start with low dose and titrate against symptoms and side effects for the first four to six weeks, until the optimum dose is found.
  • Consider immediate vs modified release?
  • Immediate 2 to 3 doses a day, would have to be given out at school, but easier to titrate in the first few weeks.
  • Modified – one tablet a day, better adherence, no need for school to give medication as normally given with breakfast in mornings.
  • Before treatment need to enquire about family history of cardiac disease, along with an examination of the cardiovascular system.
  • Record current weight and height on age appropriate chart, along with heart rate and blood pressure on centile chart. Methylphenidate is known to increase heart rate and blood pressure.
  • Heart rate and blood pressure recorded every three months on the centile chart.
  • Height must be plotted on chart every six months, as methylphenidate causes growth suppression on average 2.5cm for those on treatment.

This can be managed with drug holidays i.e. only give treatment on school days to allow for catch up growth on weekends or school holidays.

Weight – monitor at the first three and six months of starting treatment, then six monthly.

◦      Methylphenidate causes appetite suppression.

◦      If weight loss occurs extra dietary advice – encourage taking tablet with or after food and not before.

◦      Additional snacks early mornings and late evenings.

◦      Nutritional high calorie snacks at these times to prevent further weight loss.

May also cause other side effects (usually during titration period):

◦      Headache

◦      Sleep problems (insomnia)

◦      Emotional outbursts and irritability

◦      Stomach upsets

Atomoxetine

Selective noradrenaline reuptake inhibitor, with a slower onset of action compared to methylphenidate. – four to six weeks before effect apparent.

Symptom control is often more sustained, often used in those that fail to improve with methylphenidate.

Side effects: sedation, loss of appetite and stomach upsets.

Expert Comment

Key points:

1. Not all badly behaved children have ADHD. There are many other diagnoses to consider, including non-psychiatric or medical concerns.

2. Assessment must show triad of symptoms in at least two different contexts.

3. Emphasise that non-pharmacological treatment is key in the management of ADHD.

4. Know that methylphenidate has a large range of side effects, and possible strategies to reduce them.

Resources:

Dr Gil Myers says:

Concerns raised by parents and teachers about young people’s behaviour make up a large part of the workload of a community CAMHS psychiatrist. Having a good understanding of the range of issues to consider for these referrals is important as a professional assessment can set the focus for managing these difficulties appropriately – whether they are psychological, sociological or medical. There will always be a debate about the validity of an ADHD diagnosis – arguments against say that it is pathologising normal childhood behaviours and medicating non-conformity.

While I can see that these are valid concerns, in my experience there are certain children who are unable to achieve their full potential because they cannot moderate their impulsive, hyperactive behaviour due, in part, to their brain biochemistry. Without help they will not be able to form appropriate peer relationships or learn what they need to in order to live fulfilled lives. Non-pharmaceutical interventions with additional medication where appropriate can alter these downward trajectories. This to me is as important as ensuring a child is physically healthy.

Because of the stigma of a young person having a psychiatric label, it is important that every assessment is objective and thorough.  This means talking to the child, parents and school to ensure that all three share the concerns and present a similar picture of difficulties. Using impartial, evidence-based rating scales and strict criteria for inclusion are essential as psychiatry doesn’t have the benefit of specific blood levels or imaging. When these standards are met, it is important to act quickly and safely but also to monitor for the side effects of these interventions. We should also be reflective in our practice and open to the idea that young people who had problems can improve and learn to manage their own difficulties – which can mean reducing or stopping medication when needed.

When managed properly, ADHD doesn’t need to limit a child, their parents or their teachers. It’s crucial that we embrace this message and promote positive recovery for everyone.

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