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At the heart of general practice since 1960

August 2007: Recognising childhood neuropsychiatric disorders

How should childhood neuropsychiatric disorders be classified?

How can early diagnosis be made?

What are the therapeutic options?

How should childhood neuropsychiatric disorders be classified?

How can early diagnosis be made?

What are the therapeutic options?

In the most recent comprehensive survey of the mental health of children in the UK, psychiatric diagnoses were present in 7.7% of boys and 5.1% of girls aged five to ten years.1 These figures do not include some important disorders (for example of motor function) that overlap and merge with the psychiatric conditions, so they probably underestimate true prevalence. Egger and Angold2 reported that 12.1% of preschool children aged two to five years in the US had a psychiatric diagnosis associated with functional impairment.

The neuropsychiatric conditions GPs are most likely to see among preschool children are:

• Conduct disorder

• Oppositional-defiant disorder

• Attention deficit hyperactivity disorder (ADHD)

• Autism spectrum disorders

• Overlapping motor disorders such as tic disorders and dyspraxia.

There has been much debate among child psychiatrists about diagnostic classification systems; in particular whether to use case definitions from the US Diagnostic and Statistical Manual (DSM-IV) or the International Classification of Diseases (ICD-10). These arguments are of more than academic interest, since the application of DSM-IV criteria for ADHD gives a prevalence of 8-12%, while the much more restrictive ICD-10 criteria for hyperkinetic disorder leads to prevalence estimates of 1-2%.3

Summaries of the clinical features of each of the diagnoses are presented in table 1, attached.

Epidemiological studies have established that each of the conditions mentioned above is determined by both genetic and environmental components to varying degrees (see table 2, attached).

The conditions should not be thought of as discrete and easily identifiable, but as a collection of syndromes that overlap and merge with both a number of other early onset problems and with normality.5 The level of overlap between the diagnoses is very high and it is uncommon to see a ‘pure' case of any condition without some features of others. Conduct disorder affects 90% of all boys with any psychiatric diagnosis under 11 years old.

Early detection

There is now robust evidence that psychiatric symptoms and disorders begin early in life and can be chronic and protracted.6 Children with these problems, whether caused by nature, nurture or both, are likely to have profound difficulties in developing relationships with their family, peers, school and wider society.

Conduct disorder is remarkably persistent from the preschool years and has major costs to society,7 as well as an impact on general health and mortality.

Around one-third of patients with ADHD continue to meet the DSM-IV diagnostic criteria in adulthood, with two-thirds continuing to suffer from ADHD-related disabilities.8

Autism spectrum disorders can be identified before the age of two.9 They persist throughout life.

All these conditions have a major public health impact throughout the lifespan of the patient.

There is a lack of robust evidence from trials that early intervention is more effective than late intervention. This is largely because of a lack of good epidemiology – proving that early intervention works best requires robust methods of case identification and trial design can be difficult. Nevertheless, early intervention gives the best chance of either cure or a significant reduction in behavioural problems because presymptomatic children are more likely to be amenable to change than children with entrenched pathology and damaged social relationships.

Parents of children with neuropsychiatric problems are also likely to benefit from obtaining an early diagnosis. As well as providing an explanation for their difficulties in parenting it can allow access to help from health, educational and social services and the voluntary sector.

In a recent survey, many GPs in Scotland stated that the care offered to young people with mental health problems was ‘too little, too late'.10

Diagnosis

The key feature that usually leads to the recognition of child psychiatric disorders is parental concern. This increases the likelihood of a GP recognising a neuropsychiatric disorder from 26% to 88%, but, understandably, also increases the number of false-negative diagnoses.11

Early language delay is a powerful indicator of child psychopathology.

A recent Swedish cohort study demonstrated that 70% of children with language delay at 30 months had major psychiatric diagnoses at seven years.12 Language delay was indicated by any of:

• Fewer than 50 single words

• No two-word utterances

• Poor cooperation or verbal comprehension.

The population prevalence of this degree of language delay is about 6%, so many children with significant neuropsychiatric conditions should be identifiable using this simple language assessment at 30 months.

‘Clumsiness' and tics can also be important indicators of neuropsychiatric problems.

At least 20% of children with developmental coordination disorder have ADHD and 92% of children with Tourette syndrome have psychiatric comorbidity. Children with these conditions are also likely to have evidence of other learning and language disorders.

Differential diagnoses

Sensory impairments can sometimes mimic the communication difficulties in autism; it is not uncommon for parents of children with autism to consult for the first time with concerns about possible visual or hearing problems.

In children with known learning and communication difficulties, pain is a common cause of agitation and behavioural problems. Ruling out chronic physical problems such as dental pain and reflux oesophagitis is crucial in such cases.

Almost all the individual components of the neuropsychiatric disorders are seen in normal children, so normality is the most important differential diagnosis. It is the extent and pattern of the findings that defines the diagnoses.

History

Most neuropsychiatric conditions have a substantial genetic component, so taking a good family history is important. The developmental history is also crucial; this should cover the pregnancy and birth, motor and linguistic milestones, social development and temperament.

Lack of pretend play and limited capacity for imagination in children over two years are important indicators of autism spectrum disorders.

The 6-item M-CHAT parent questionnaire (see table 3,attached)13 can be useful in determining which toddlers at risk of autism need further evaluation. The M-CHAT questionnaire is not appropriate for children over the age of two.

Physical disorders are also important: epilepsy and other neurological problems greatly increase the risk of neuropsychiatric conditions.

Examination

A great deal of information can be elicited very rapidly in a normal consultation:

• Be alert for dysmorphic features, which are often associated with neuropsychiatric conditions.

• Briefly assess gross and fine motor function and look for unusual stereotyped movements.

• Attempt to assess the use of language – in infants note the use of babble.

• Note the level of engagement of the child, both with the parent and with you. Pay particular attention to features such as direction of gaze, capacity for mimicry and whether the child tries to elicit adult attention.

• Try to establish whether the child has the capacity for sustained attention, for example to a toy or book, and whether there is disruptive behaviour.

• Try to observe the way the child is parented – for example whether there is warmth, consistency, empathy and child-centredness.

Referral

In many areas, health visitors offer structured parenting programmes that will help families dealing with disruptive behaviour.14 However, the availability of such skills is very variable.

There is wide variation in the pattern of services in the UK. Sadly, some psychiatrists refuse to see children with conduct disorder despite the fact that many affected children, particularly those with early-onset problems, have other significant diagnoses. In some areas a child health ‘one stop shop' might offer the best referral option.

Referral of children with language delay to speech and language therapy services is helpful if these are clearly linked with neurodevelopmental assessment services.

Treatment

Conduct disorder

There is now robust randomised trial evidence that parenting programmes help children aged three to five years with behavioural symptoms that indicate a high risk of developing conduct disorder.14 A recent NICE guideline supports the use of such programmes.15

Families with children who have more deeply entrenched problems require specialist assessment and more comprehensive treatment programmes.

ADHD

The behaviour of children with ADHD challenges parents and evokes negative parenting. Parenting programmes increase treatment adherence and are recommended as a routine intervention in the SIGN guideline on ADHD.16

In older children, school-based interventions are also of value. Treatment with stimulants, such as methylphenidate, or with the noradrenaline reuptake inhibitor atomoxetine should rarely, if ever, be offered without psychosocial intervention. Decisions to prescribe and modify prescribing regimens should only be made by clinicians with expertise in the field.

Pharmacotherapy is used less commonly in the preschool age group than in older children, partly because the risk of side effects is higher. In many parts of the UK shared care protocols for ADHD prescribing clarify the roles and responsibilities of primary and secondary care.

Autism spectrum disorders

The recently published SIGN guideline on autism17 describes the evidence base for a range of interventions to promote communication in autism.

Pharmacotherapy is rarely used in young children, although risperidone and methylphenidate can be useful in some circumstances. Melatonin can be used for sleep problems unresponsive to behavioural interventions, but can promote seizures in children with, or at risk of, epilepsy.

Conclusion

GPs should be alert to the possibility of a child having a neuropsychiatric disorder. Parental concerns should be taken seriously. For example, most parents of children with autism believe that there was something in infancy that differentiated their child from others,18 but often find it difficult to communicate their concerns clearly.

Health visitors play a key role in supporting families with a child who has a neuropsychiatric disorder. As well as providing a link to social and educational services, they are likely to provide, or have access to, behaviour management programmes.

The stress of living in a family with a child who has neurodevelopmental problems should not be underestimated. The practice team must be accessible for support and act as a conduit to appropriate services.

Acknowledgments

I would like to thank Professor Christopher Gillberg for his helpful advice. The author holds a primary care research career award in infant mental health from the Scottish Executive Health Department Chief Scientist Office.

Author

Dr Philip Wilson
DPhil MRCP MRCPCH FRCGP
GP and senior research fellow, University of Glasgow

Key points Summary of DSM-IV/ICD-10 diagnostic criteria for the common neuropsychiatric conditions of early childhood Table 1: Summary of DSM-IV/ICD-10 diagnostic criteria for the common neuropsychiatric conditions of early childhood Table 2: Neuropsychiatric disorders most likely to be seen among young children in primary care MCHAT Table 3: Checklist for Autism in Toddlers - Modified (for use at 18 months)

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