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At the heart of general practice since 1960

Five-minute Practitioner: August 2007

Only got five minutes? Then just read these key points on: QRISK, respiratory problems in children, neuropsychiatric disorders and autism spectrum disorders

Only got five minutes? Then just read these key points on: QRISK, respiratory problems in children, neuropsychiatric disorders and autism spectrum disorders

QRISK

The novel risk score QRISK performs better for the UK population than the Framingham or ASSIGN models and could be a more accurate tool for GPs to calculate CVD risk and populate risk registers, which are likely to come to the fore in the near future.

The algorithm could be embedded in clinical systems to provide a rapid and contemporaneous risk score for patients.

Respiratory problems

Preschool children with respiratory problems will typically present with abnormal features that the parents have observed (signs) rather than the subjective feelings of distress an older child or adult might present with (symptoms).

Most respiratory illnesses in children are short-lived and self-limiting, and are secondary to acute respiratory tract infections (RTIs). Most parents recognise this and will present when the symptoms are more severe or last longer than they expect.

The primary question in the diagnosis of a young child with wheeze is whether the child has atopic asthma or viral wheezing. Most young children with wheeze will have viral wheezing.

There is a natural reluctance to label children with wheeze who may outgrow their symptoms as having asthma. However, it is reasonable to consider a diagnosis of asthma even in young children if there is evidence of allergic sensitisation and recurrent wheezing (particularly if wheezing has occurred without an obvious viral infection).

Neuropsychiatric disorders

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. These figures probably underestimate true prevalence.

Early intervention gives the best chance of success because presymptomatic children are more likely to be amenable to change than children with entrenched pathology and damaged social relationships.

The key feature that usually leads to the recognition of child psychiatric disorders is parental concern. Early language delay is a powerful indicator of child psychopathology. ‘Clumsiness' and tics can also be important indicators.

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 diagnosis.

Autism spectrum disorders

Autism spectrum disorders (ASD) is the current term used to describe a group of complex neurodevelopmental disorders that includes autism, atypical autism and Asperger syndrome. It is now recognised that around 50% of children and young people with ASD have normal intellectual functioning.

ASD is a triad of impairment:

• Social impairment: delayed or atypical social, interpersonal development

• Impairment of language and communication: impaired verbal and non-verbal communication

• Impaired thinking and behaviour: rigidity of thought and behaviour; repetitive, ritualised behaviour; impoverished imaginative play.

By the time the child reaches 2-3 years healthcare professionals can reliably recognise features of ASD.

The Checklist for Autism in Toddlers (CHAT) and modified CHAT (M-CHAT) are both designed for use with children in the 18-24 months age range.

Since they occur more commonly, there are some health problems that should be ruled out in all children and young people with ASD. They include: hearing and visual impairments; sleep problems; mental ill health, particularly attention deficit hyperactivity disorder (ADHD), anxiety and depression and epilepsy.

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