• Learning disability
• Neuromuscular problem
• Attention-deficit hyperactivity disorder
• Specific speech and language delay
• Visual problem
• Cerebral palsy
• Brain tumour
Assessment
In the pre-school child initial assessment is usually by a paediatrician to exclude other pathologies, including general developmental delay. The school-age child is usually assessed by a paediatrician, but information should also be obtained from the school about the child’s difficulties and overall progress. In addition, often a speech and language assessment and occupational therapy assessment are required.
The occupational therapist examines:
• fine- and gross-motor developmental levels
• visual motor integration (e.g. doing puzzles or copying shapes)
• visual perception
• balance and posture
• responses to sensory stimulation
• bilateral coordination
• motor planning
Management
DCD is not curable but the child often improves in some areas with maturity. Liaison of education, health professionals and the child and parents is crucial to help the child within the classroom and the home environment. The school’s special educational needs coordinator (SENCO) and school nurse can play an important role in the communication between health and education. Speech and language therapists and occupational therapists give advice to the school to help with difficulties in the
classroom. Sometimes group and individual therapy can help, e.g. a phonology course for articulation difficulties. Advice for parents to help with home activities is also important.
7. ATTENTION DEFICIT HYPERACTIVITY DISORDER
It is estimated that up to 3% of school-age children meet the diagnostic criteria for attention deficit hyperactivity disorder (ADHD). It is more common in boys.
Diagnosis
Problems occur in three areas:
• Inattention
• Hyperactivity
• Impulsiveness
It is possible to have one of these features without the others, e.g. marked inattention without the hyperactivity or hyperactivity without inattention.
In addition:
• The behaviour should have persisted for at least 6 months
• The behaviour should be inconsistent with the child’s developmental age
• There must be clinically significant impairment in social or academic development
• The symptoms should occur in two or more settings including social, familial, educational and/or occupational settings
• There should be no other explanation for the symptoms, e.g. psychiatric illness
Diagnosis requires detailed history and information gathering from parents, school and other professionals. Structured questionnaires, e.g. Conner Scales, are used to screen and diagnosis ADHD.
Examination to exclude other differential diagnoses is important.
Children with ADHD develop emotional and social problems, poor school performance and problems within the home because of the difficult behaviour. It is associated with unemployment, substance abuse and crime in adulthood.
Differential diagnosis
• Inappropriate expectations
• Language/communication disorder
• Social problem
• Specific learning difficulty
• Chronic illness, e.g. asthma
• Epilepsy
• DCD
• Drugs
Management
Management involves a comprehensive treatment programme. There needs to be multiprofessional collaboration of the parents, the child, the school and other professionals. In some areas children with ADHD are managed by child psychiatrists and in others community paediatricians take on this role.
Assessment
This should include assessment of:
• an individual’s needs
• coexisting conditions
• physical health
• social, familial and educational/occupational circumstances
Treatment
• Psychological/behavioural interventions; range of interventions from support groups through to psychotherapy can help including parent training/education programme (first line in pre-school age)
• Educational support: close communication with school is vital with the development of an
individual education plan if necessary. Simple changes such as working in smaller groups, reward systems and moving the child nearer the teacher can help
• Social services – support if necessary
• Drug treatment; for older children and young people with severe ADHD, drug treatment should be offered as a first-line treatment but should always form part of a comprehensive treatment plan Stimulant medications, e.g. methylphenidate (Ritalin), are used for the treatment of ADHD. They are usually given twice a day, morning and lunchtime. An evening dose is usually avoided because of difficulties with sleep. A drug holiday is recommended once a year. Side effects include weight and growth retardation and hypertension. Treatment should be started and monitored by child psychiatrists or paediatricians with expertise in ADHD. Height, weight, pulse and blood pressure should be
monitored at least 6-monthly. Drug treatment does not cure ADHD. It improves the symptoms to allow the other interventions an opportunity to take effect.
• Methylphenidate can be used as part of a comprehensive treatment programme for children with severe ADHD as can atomoxetine and dexamfetamine
• Not licensed for those under 6 years
• Diagnosis should be made by a psychiatrist or paediatrician with expertise in ADHD
• The clinical expert should supervise the medication – GPs may agree to ‘share care’
• Treatment should be stopped if there is no benefit
• Treatment should also include advice and support to parents and teachers
• Children should be regularly monitored
• Transition to adult care requires careful planning
• A balanced diet, good nutrition and regular exercise are recommended
8. SPECIAL EDUCATIONAL NEEDS AND THE EDUCATIONAL STATEMENT
Many children have special educational needs, but only a small percentage (approximately 2%) need statements because their difficulties are such that they require provision additional to or different from that normally available to children.
• With the pre-school child it is often health that first becomes aware of the special educational needs, e.g. global developmental delay, Down syndrome, cerebral palsy
• Some medical conditions may have significant impact on the child’s academic attainment and the ability to participate fully in the curriculum. Some of the most common medical conditions are congenital heart disease, epilepsy, cystic fibrosis, haemophilia and childhood cancers