Case Studies of Mental Health in General Practice(19)——Childhood Mental Health

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Affiliation：Monash University,Victoria 3806,Australia(Bruce Tonge,Leon Piterman,Hui Yang);University of Melbourne,Victoria 3010,Australia(Fiona Judd,Grant Blashki)

Attention deficit hyperactivity disorder;Childhood;Mental health;General practice

Compared to adults,children,particularly boys,are often relatively inattentive,impulsive and busy(hyperactive).If these behaviours are much more excessive and pervasive than expected in a child of the same developmental age,and cause impairment in the child′s social life and learning,then the child has the neurodevelopmental condition of Attention Deficit Hyperactivity Disorder(ADHD)[1].Prevalence estimates vary because of differing diagnostic criteria and cultural and social factors from about 1.5% of 6-12 year olds in Europe,to 5% in the USA[1].In China,estimates vary widely from 1%-14%[2]and about 6% in Hong Kong[3].There are only several hundred specialist clinicians available in mainland China with expertise in ADHD therefore the condition is greatly underdiagnosed and undertreated,usually with herbal remedies.Under diagnosis might also be influenced by the stigma associated with mental illness in children[2].ADHD is twice as common in boys.

The General Practitioner plays a central role in assessment and management because they understand the family,social and cultural environment of the child.The GP can assess whether the behaviour is developmentally excessive,and if services are available,refer on for assessment to a specialist paediatrician or psychiatrist.The GP can then follow up and monitor treatment and link the family into local support services and liaise with the school[4].

1　History

Anthony L is the 8 year old son of Chinese parents currently living in Australia for business and study reasons.Anthony attends a local primary school.In class he cannot sit still,interrupts the teacher,runs out of the room,keeps touching other children on the head and is unable to complete any schoolwork.He is friendly but cannot persist in games.He has difficulty writing and reading even though he speaks English well.At home he is constantly moving.He is unable to focus on a game,sit still to eat a meal,or watch the TV.He cannot complete tasks such as dressing himself.He has difficulty settling to sleep but is then up early and does not stop all day.He interrupts the conversation of his parents and visitors.His parents love him but are upset and stressed by his constant demanding behaviour and school failure.Recently he has been refusing to get ready for school,complaining of stomach pains and is distressed when his parents take him to school but he does settle quickly after they leave him.On questioning regarding Anthony′s family history it was discovered that a paternal uncle and young adult male cousin have a history of learning difficulties,impulsive antisocial behaviour and unstable employment.

2　Developmental history

The pregnancy was normal although Anthony′s mother smoked cigarettes heavily,a habit she has now ceased.Delivery was at full term but labour was precipitous(1.5 hours).Anthony was born blue requiring suction and oxygen with Apgar score of 2 at one minute and 6 at five minutes.Anthony has remained relatively small for his weight and height(5th percentile).He was an irritable and restless baby who had difficulty settling to breast feeding and slept poorly.He walked at 12 months but was delayed in the development of his fine motor skills and handedness.He still does not have a clear hand preference.A developmental assessment revealed a scatter of abilities in the low normal range but with delay in short term auditory memory and fine motor skills.

3　Examination

Throughout the consultation,Anthony was on the move from one toy to another without completing an activity such as assembling a toy train track.He often interrupted his parents with irrelevant comments but was friendly and made good eye contact.When asked to draw a person he was easily distracted for example by a faint noise outside the room.He needed prompting to complete the drawing which lacked detail and was immature for a child his age.When asked to draw a person he used a clumsy pencil grasp.When asked to write his name and a simple sentence,the letters were uneven in size and spacing with some omission and the spelling was incorrect.

On physical examination his vital signs were normal,including abdominal and neurological examination,which were both unremarkable.

4　Questions

4.1Question 1:What is the most likely psychological diagnosis?

4.2Question 2:What are the associated psychological or neurodevelopmental problems and differential diagnoses to consider?

4.3Question 3:What further assessment and investigations should be considered?

4.4Question 4:What causes ADHD?

4.5Question 5:What non-pharmacological intervention should be considered?

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4.6Question 6:What medical management would be the appropriate for Anthony?

5　Answers

5.1Answer 1:What is the most likely psychological diagnosis?The likely diagnosis is Hyperkinetic Disorder(ICD-10) or ADHD(DSM-IV) of the combined inattentive hyperactive type[1,4-5].He has developmentally excessive:inattention,hyperactivity,impulsiveness and disorganisation.

These symptoms severely interfere with his school work,social interactions,play and family life.The symptoms commenced before the age of seven,have persisted for more than six months,and are pervasive(occur in more than one setting).

5.2Answer 2:What are the associated psychological or neurodevelopmental problems and differential diagnoses to consider?Children with ADHD often have a range of other associated cognitive and emotional and behavioural problems.The most frequent of these which can be diagnosed according to the ICD-10 are:(1)Specific developmental disorders of scholastic skills(for example with reading,spelling or arithmetic) or Motor Function or Speech and Language.(2)Conduct Disorders,such as Oppositional Defiant Disorder.(3)Emotional Disorders of childhood such as Separation,Phobic or Social Anxiety Disorder perhaps with somatic symptoms.(4)Mood Disorder such as a Depressive episode.(5)Tic Disorders.(6)Non-Organic Sleep Disorders.(7)Pervasive Developmental Disorder such as Childhood Autism.(8)Mental Retardation(Intellectual Disability).

For Anthony the GP should consider Specific Developmental Disorders with hand writing,reading,fine-motor skills(necessary to manipulate and hold a pencil) and language(short term auditory memory problems).He is unable to retain and work on verbal instructions which together with his distractibility mean that he often does not know what he is meant to be doing in class and is disorganised.

The GP should also consider Separation and Social Anxiety Disorders with school refusal and somatic symptoms of stomach pain.There are multiple underlying reasons for Anthony′s anxiety about going to school including his increasing learning and social difficulties as well as the criticism of his behaviour and school failure by the teacher and his parents.

School report findings can be very helpful.Cognitive assessment for example IQ and learning ability tests may help get a more in depth picture of the child.Specialised tests such as EEG brain scan or even a Chromosome analysis maybe useful if a genetic disorder is suspected.

5.4Answer 4:What causes ADHD? For some children with ADHD,the symptoms are the result of a specific brain disorder due to a condition such as Foetal Alcohol Syndrome or an acquired brain injury,or a genetic disorder such as Fragile X Syndrome.For most children,ADHD will be the result of an interaction of biological(genetic and familial influences),psychological(e.g.delay in the development of short term auditory memory) and social(family conflict and parenting difficulties) factors.Most children with ADHD also have other developmental and behavioural problems such as anxiety and school refusal,oppositional and defiant behaviour,tics,depression and irritability,learning difficulties(spelling,reading,numeracy) and problems with coordination and speech[1,4-5].

In Anthony′s case,the development of ADHD may be due in part to the neonatal effects on his brain of maternal tobacco use and a precipitous delivery and perinatal hypoxia.There may also be some paternal genetic influences given the family history of learning and behaviour problems.

Symptoms of ADHD usually improve as children mature.The majority will not qualify for a diagnosis of ADHD when they reach adulthood but many will still continue to have some symptomatic impairment in their daily life[4-5].Subsequent mental health and behavioural problems in adult life include difficulties with relationships,employment,and alcohol and substance abuse[4-5].The emergence of Conduct Disorder in adolescence can develop into criminal behaviour and Personality Disorder.Associated anxiety might develop into Obsessive Compulsive Disorder.Depression is an increasing risk during adolescence and suicidal behaviour can be a consequence of impulsiveness.If a reliable childhood developmental history is unavailable then differentiating ADHD from Bipolar Mood Disorder in adults can be difficult.

5.5Answer 5:What non-pharmacological intervention should be considered? Parent education about the condition and advice on managing difficult behaviour,perhaps using an online or printed parenting programme can be helpful[5].Special educational techniques at school such as breaking tasks into simple steps,modifying the environment to reduce distractions and rewarding small achievements are helpful.The use of written checklists to help the child to be better organised can be very helpful,for example lists to guide dressing and school bag packing,and a clear timetable for daily activities.Psychological treatment for the associated anxiety might be indicated such as the use of relaxation exercises and participation in a social skills training group[5].There is insufficient evidence on the benefits of diets to recommend their use,although some food additives such as tartrazine(yellow colouring) can adversely stimulate behaviour[5].

5.6Answer 6:What medical management would be the appropriate for Anthony? There is extensive evidence that stimulant drugs[4-5](methylphenidate and dexamphetamine sulfate) reduce symptoms of ADHD,improve learning,family and social problems for up to three years.To date there is no clear evidence of longer term benefits.Stimulant drugs are short acting(2-6 hours) and are usually given 2-3 times a day but not in the evening to avoid disturbing sleep.Common side effects include appetite suppression(with delay in pubertal maturation),headaches,anxiety and irritability,tics and initial insomnia(but this is also a symptom of ADHD).More rarely palpitations and minor increases in blood pressure(which need monitoring) and psychotic symptoms might occur.

Drug treatments should be initiated by a specialist but can be monitored weekly by the GP until a therapeutic response is established,then monthly.Occasionally illegal use of the drug by child or parent might occur.

The GP should monitor blood pressure,pulse,height,weight,sleep,appetite,tics and mood.Slow release forms of stimulant drugs might also be available if a more even level of medication is required over ten hours or if compliance and administration of the drug by the teacher is a problem.Second line drug treatments include atomoxetine or perhaps imipramine or clonidine.Neuroleptics such as risperidone have no clear benefit on symptoms of ADHD but might be used by a specialist for aggression or unstable mood.The use of a symptom checklist is the best way to monitor response to treatment.

1Tonge B,Rinehart N.Autism and attention deficit/hyperactivity disorder[M]// Schapira A.Neurology and clinical neuroscience.Philadelphia:Mosby Elsevier,2007:129-139.

2Hinshaw S.International variation in treatment procedures for ADHD:Social context and current trends[J].Psychiatric Services,2011,52(5):459-464.

3Lam H,Ho T.Early adolescent outcome of ADHD in a Chinese population:5 year follow up study[J].Hong Kong Medical Journal,2010,16(4):257-264.

4National Institute of Clinical Excellence(NICE).Attention deficit hyperactivity disorder:Diagnosis and management of ADHD in children,young people and adults.National clinical practice guideline number 72.London:The British Psychological Society and the Royal College of Psychiatrists[EB/OL].http://www.nice.org.uk/CG72.

5National Health and Medical Research Council.Clinical Practice Points on the diagnosis,assessment and management of attention deficit hyperactivity disorder in children and adolescents.Commonwealth of Australia [EB/OL].http://www.nhmrc.gov.au/ _files_nhmrc/publications/attachments/mh26_adhd_cpp_2012_120903.pdf.