Struggling at School Flashcards
(36 cards)
What questions do you want to ask about a child with behavioural issues?
- Specific aspects of behaviour - what are the parents main concerns
- Learning/schooling - attendance at school, what have the school reported regarding progress, is the child receiving any support
- Activities of daily living
- Attention and relationship with others
- Previous development
- If disabled - what disabilities at present, what additional support is in place?
What questions would you want to directly ask a child who is struggling at school?
- Any concerns about school/home? Likes/dislikes
- Ask about relationships with friends
- Anything they find easy or difficult
What is a red flag regarding development?
Any definite loss of skills may represent developmental regression - red flag for serious degenerative or destructive condition needing urgent investigation.
What are differentials for motor difficulties?
- Cerebral palsy - spastic diplegia
- Disorders of muscle have to be considered
What is Autism Spectrum Disorder?
ASDs are a range of developmental disorders that describe the abnormal social interactions, communication behaviours and patterns of thought and physical behaviour of some people. It includes severe autism of infancy through to the milder Asperger’s syndrome (autism spectrum).
Autism is a lifelong, developmental disability that affects how a person communicates with and relates to other people and how they experience the world around them. 4:1 boys : girls.
What medical disorders are associated with ASD?
- Fragile X syndrome more common
- Tuberous sclerosis - very common
- Williams syndrome
- Rubella and other congenital infections
- Co-existing conditions like intellectual disability, ADHD and OCD are common
What are key features of ASD?
- Difficulties in communication, social interaction and inflexible thinking
- At a younger age, children with autism have difficulties to communicate, leading to tantrums, frustration and being labelled as a difficult child. They are often very active and difficult to engage with.
- There may be difficulties with parent child bonding due to both parties being unable to understand each other
- As a child gets older, they may have difficulty making and maintaining friendships. They may isolate themselves, as they have difficulty understanding social cues. They may find it hard to take turns and may be on the edge of a group - look like he/she wants to join in but doesn’t know how to.
- Huge impact on families and education. Families often struggle to cope with the child failing to understand what is wrong and why a child behaves as he does. School may be unable to meet a child’s needs without extra support as the child is unable to engage to access the curriculum.
What are the clinical features of ASD?
- Impaired social skills: usually play alone, can’t understand social cues like eye gaze, facial expressions and gestures, struggle to maintain relationships
- Repetitive behaviours, interests and social activities: repetitive behaviour (stimming) e.g. tapping fingers on table, must have a routine or gets distressed
- Meltdowns - complete loss of emotional control
- ADHD in 35% and epilepsy in 18%
- History of speech delay: warning signs for true social communication disorder - lack of e.g. turn taking, following instructions
What is CAMHS role in managing ASD?
CAMHS are vital in helping families understand their child and put strategies in place to cope with their behaviour. The following can help:
- Create a profile of the child with the family
- Help the family identify the child’s strengths and difficulties
- Develop strategies in meeting the child’s needs in liasion with child psychologist/psychiatrist
What can paediatricians do to help manage ASD?
- Community paediatrician will look at other possible explanations/differentials for the child’s difficulties e.g. other LDs, specific language disability, and the health of the child in general (e.g. nutritional deficiencies due to restricted diet)
- Also they look at antenatal history, birth history, developmental and family history
What is the management of ASD?
- Goal is to increase ability to function independently and improve quality of life: learning and development, social skills, decreased disability and comorbidity
- Non-pharmacological therapy: early educational and behavioural interventions
- Pharmacological interventions: SSRIs can help relieve stress, anxiety, aggressions etc, antipsychotic drugs can reduce symptoms like aggression and self-injury, methylphenidate manages ADHD
- Family support and counselling
What are the effects on speech and language in ASD?
Speech delay is common in the general population, particularly in boys warning signs for a true social communication disorder are lack of the other building blocks of language such as turn taking (natural pause after a parent talks to an infant/child), showing understanding of language (following verbal instructions) and attempting to indicate need verbally or by pointing.
What repetitive behaviours are used in ASD children?
Repetitive play is typical with common reports of lining up the toys, repetitive noises or hand flapping. Echolalia is a specific kind of repetitive speech, words and phrases repeated often with specific intonation and without meaning.
What are the key features of ADHD?
- Usually affects children between age 3-7 years
- Inattention: short attention span with difficulty concentrating in class
- Hyperactivity: unable to sit still for short periods and constantly fidgeting
- Impulsiveness: unable to wait turn and little sense of danger
- Symptoms must be present for >6 months across at least 2 environments
How do you diagnose ADHD?
- Symptoms tend to be pervasive across all settings associated with difficulties in concentration and distractibility in order for diagnosis to be made
- Diagnosis is time consuming and requires information gathering from home and school usually via standardised questionnaires and procedures
- The inattention and distractibility cause difficulty in organisation and completion of tasks, leading to deterioration in academic performance unrelated to intellectual potential.
- To the combination of hyperactivity and inattention is added impulsivity. There is an association with risk taking particularly in adolescence e.g. crossing roads (green cross code is a methodical approach to gauge speed of oncoming vehicles and impulsive children often just set off).
What PMH is useful to know in ADHD?
- Pregnancy hx, any indication of infection or placental dysfunction, drug or alcohol use
- Birth history; prematurity or difficult delivery
- Postnatal health and progress
- Developmental history
What are the investigations for ADHD?
- Connor’s rating scale - questionnaire assessing academic, behavioural and social issues in young people (6-18 yrs)
- After consultation: 10 week wait and watch approach to observe whether symptoms change or resolve
- If symptoms persist - referral to specialist (usually paeds or CAMHS)
- Drug therapy should be last resort and only for those age 5 or above
What are the treatments for ADHD?
- Mild to moderate symptoms: often, parents going to training programmes suffices
- Severe:
1. 1st line: methylphenidate (dopamine re-uptake inhibitor) - give on 6 week trial basis. SEs: abdo pain, nausea, dyspepsia (monitor weight and height every 6 months)
2. 2nd line: lisdexamphetamine (LD) - can give dexamphetamine if LD works but SEs not tolerated - All these drugs can be cardiotoxic - do baseline ECG before treatment. Refer to cardiologist if PMH of heart disease in family.
What is school refusal vs truancy?
- In school refusal, the child will often miss school frequently due to medical symptoms or distress/anxiety - may be nausea, abdo pain and poor sleep. There may be underlying anxiety regarding separation from a parent or true school phobia may be present.
- Truancy often has a social component, something the child or young person would rather do - antisocial behaviour.
Why do you need to investigate poor school attendance?
- Poor attendance may be a sign of safeguarding issues - can range from the deliberate use of children as child labour to the hiding signs of physical abuse, to the absence from school due to child sexual exploitation or forced marriage.
- Exploration of events at home and school is an essential part of the assessment - bullying, specific learning difficulties such as dyslexia + dyspraxia and issues such as domestic violence may be precipitating factors.
What is global developmental delay?
A child has global developmental delay if they have a significant delay in milestones in 2 or more areas (2 or more SDs below the mean). If baby born premature (<37 weeks), then adjust milestone timelines accordingly, use 40 weeks as baseline i.e. if a child is born at 33 weeks gestation then add 7 weeks onto each milestone, so if they’re expected a pincer grip at 12 months, then a child born at 33 weeks would be expected around 14 months.
What are the main causes of profound disability?
- Chromosomal abnormalities: genetic factors including micro-duplications and deletions are being increasingly identified as important
- Cerebral palsy
- Inborn errors of metabolism
What may people with profound and multiple learning disabilities have?
- More than 1 disability
- Have profound LD
- Have great difficulty communicating
- Need high levels of support in all activities of daily living
- May have additional sensory (vision +/or hearing) needs
- May have inability to protect their airway and be at risk of recurrent chest infections
- May be unable to regulate their own intake and require gastrostomy, nasogastric or other interventions
- May have challenging behaviours and mental health difficulties
- Are at greater risk of other neurological disorders such as epilepsy and early puberty
What neuromuscular disorders are associated with learning difficulties?
With a history of mobility difficulties and tiptoe walking a neuromuscular disorder such as Duchenne or Becker muscular dystrophy is a possibility. Calf hypertrophy with proximal muscle weakness would be present with difficulty rising from sitting.
