School Problems and the Family physician - Part I

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Approach to a child with ADHD



A. History
  • Determine signs of early childhood developmental delay
  • Problems of growth and development
  • Sleep disorders
  • Difficulty in toilet training
  • Hospitalization
    and therapies
  • Description of present and past behaviour and learning difficulties
B. Physical Examination
  • Dysmorphic facies
  • Coordination problems
  • Soft neurological
    signs:
    Right and left dissociation,
    Inability to do alternating
    movements of hands and fingers (Dysdiadochokinesia)
    Inability of Tandem walking (characteristic of ADHD) along with clumsiness and awkwardness.
C. School report
  • Obtain information about the achievement (Report card)
  • Description of the child’s behaviour in school; and attendance record.
  • Information about peer relationship.
D. Assessment of behaviour
  • Note any discrepancy in behaviour at school as per the report and the behaviour at home. Symptoms of ADHD can be present alone or in combination with other behavioural problem. Occasionally a child referred for behaviour problems does not have behaviour problems at school. There is a discrepancy between reports obtained from the school and complaints brought forth by the family, which reflects disturbance at home. A good rule of the thumb is that if symptoms of ADHD do not occur at school, the problem is not ADHD (new criteria for ADHD include symptoms in at least 2 settings eg. Home and school).
E. Assess for core symptoms of ADHD. (Ref. Table-1)
F. Assessment of IQ is necessary and compared with the school achievement. Gross discrepancy is noted in ADHD.
G.An evaluation of the educational programme and background: This is required whenever a discrepancy in IQ and achievement is noted even when the core symptoms of ADHD are present. If the educational programme and background of the child appear to be inadequate the final assessment of behaviour problems should be delayed until adequate education evaluation is completed and child is enrolled in an appropriate programme.
H.Treatment : Often children with ADHD need individual or family therapy as well as medications and educational programme. Referral of these patients to psychological services, before introducing medication helps ensure that the emotional problems are not overlooked.
I. Medications : - Refer Table-2

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