Is seven-year-old's behaviour cause for concern?
Dr Tanvir Jamil discusses a common consultation
Dr Tanvir Jamil discusses a common consultation
Joanne, a single mum, brings along her seven-year-old son, Jensen. She is at the end of her tether. Jensen does not sleep, is always shouting and cannot seem to do anything for more than a few minutes. He is an only child and is now getting into trouble at school. She asks you for some tablets for his 'hyperactivity'.
What sorts of childhood behavioural problems can I expect to see in general practice?
Generally you can divide up child behavioural problems into those that occur in the under-fives and those in the over-fives. In the former you can expect to see temper tantrums, sleep problems, food refusal and bowel problems. In the latter group problems are more extensive and complex and include hyperactivity, aggression, autism, dyslexia, dyspraxia, somatising, school refusal and problems secondary to hearing loss.
How do you define 'hyperactivity' in a child?
This can be difficult as any parent will tell you all children seem to have a limitless supply of energy. The medical definition of hyperactivity can vary from country to country and there have been issues over the use of methylphenidate (Ritalin) and the role of food additives. In general the main features of hyperactivity are listed in the box overleaf together with their typical behaviours.
Problems in a single area make up attention deficit hyperactivity disorder (ADHD). If a child has problems in all three areas the diagnosis is hyperkinetic disorder (HKD). To make a diagnosis of ADHD the symptoms must have started before the child was seven, the child must have been behaving like this for at least six months and the behaviour must be causing problems in at least two places, such as at home and at school. If a child can play computer games for hours on end then ADHD is unlikely – he is probably just badly behaved.
How common are hyperactive disorders?
The prevalence of ADHD is 3-5%, HKD is 0.5-1%. Having said that, many teachers and parents think ADHD is much more common than we think. The risk of finding ADHD in a first-degree relative is 25%. In monozygotic twins the incidence has been shown to be between 59% and 81%.
Children with HKD are at significant risk of developmental delay and have higher-than-average rates of motor and language delay. In almost half of children there is also another psychological or physical problem. Severe HKD can continue into adolescence and adulthood and sufferers may go on to develop antisocial conduct disorders. However, between half and two-thirds of children grow out of HKD or ADHD by their teenage years. The pathophysiology for this condition is unclear but studies indicate that decreased activity of certain brain regions in the frontal lobe may be responsible.
What are the mainstays of treatment?
You will need to get a specialist involved and they will want to see the child and the whole family together, including other siblings. Behaviour modification and special education are paramount. Some children may benefit from dietary modification, not just simply the exclusion of food additives.
Nothing has been significantly proven, but some researchers think foods containing salicylates – prunes, raisins, raspberries, almonds, apricots, canned cherries, blackcurrants, oranges – may cause adverse effects in children, whereas a diet high in zinc, magnesium and omega-3 fats may help. Foods that can cause 'allergies' in children such as peanuts, shellfish and wheat may also contribute to behavioural problems. If parents notice that specific foods worsen hyperactivity, these may be avoided.
What about the use of medication?
Methylphenidate is a central nervous system (CNS) stimulant – it is structurally related to amphetamine but has milder central nervous system stimulant properties. It has been advocated as part of a comprehensive treatment programme for children with severe ADHD and HKD.
Dexamfetamine is another CNS stimulant related to amphetamine that is occasionally used in ADHD. Both are 'controlled drugs' and are given to those children who fail to respond to psychotherapy and behaviour modification. Given over the long term, these drugs can improve symptoms within four to eight weeks. Atomoxetine is not a CNS stimulant or an amphetamine derivative but it has been shown to reduce the signs and symptoms of ADHD. Even though not licensed, some specialists have used tricyclic antidepressants –for example, imipramine for ADHD.
How long can children take methylphenidate?
Those children who respond to medication should take it up to about 10 years of age. After this therapy should be withdrawn gradually, once every year to determine if it is still necessary. Some patients may need the drug into their late teens or adulthood.
What kind of behaviour modification and educational techniques can this mother expect for her son?
Long-term treatment programmes are carried out in collaboration with parents, specialists and teachers. The care plan includes setting specific attainable goals, such as increasing independence, decreasing disruptive behaviour, improving academic performance, and improving relationships with family members, teachers and peers.
Positive reinforcement, such as rewards or privileges – and negative consequences including withdrawal of privileges – reinforce appropriate behaviour. Small class size, structured work, stimulating schoolwork and appropriate seating can also be helpful.
What does the future hold for this child?
With help, most children will have settled down by their mid-teens. They will have been able to catch up with their learning, improve their school performance, make friends and function well in adulthood.
The remaining minority will continue with problems of inattention and impulsivity. Long-term sequelae include poor relationships, poor fine motor control and increased risk of accidents.
Dr Tanvir Jamil is a GP in Burnham, Buckinghamshire