Assessments in Developmental and Behavioural Paediatrics
Introduction
When children present to the doctor with a developmental or behavioural problem, it is often complex, and due to a number of different causes. Rarely is there a single condition which explains all the child’s difficulties. The diagnostic process involves understanding the interplay of these various influences; developing a synthesis rather than a simple ‘diagnosis’. Consequently, each child must be approached as an individual. The assessment involves a careful and detailed history-taking in the first instance, and thereafter a physical examination, and perhaps investigations, including psychometric testing.
Psychometric and Developmental Testing
With time and feeding, children grow (ie they get bigger). They also develop (ie they become capable of ever more complex thinking and acting in the world). Research has documented the cognitive and behavioural capacities of children of differing ages and stages. This account of ‘normal’ development is called the psychometric approach (psycho – mental, metric – measure). An individual child’s development can be assessed by comparing it to ‘norms’ of development of children of the same age.
Below 4 years of age, developmental assessment is fraught with difficulties. The Griffith Mental Development Scales is the most widely used standard. The Wechsler Preschool and Primary Scale of Intelligence (WPPSI) is used to assess children between ages 4-7 years. The Wechsler Intelligence Scale for Children (WISC) is used to assess children between 6 and 16 years.
As well as measuring ‘thinking’ (reasoning, cognition), we can measure speech development, motor skills (eg handwriting), and vision and hearing. Academic performance in both literacy and numeracy can also be assessed (eg by the Weschler Individual Achievement Test WIAT).
Attention Deficit Hyperactivity Disorder (ADHD)
ADHD (aka ADD) is the most common medical condition contributing to behavioural problems in preschool children, and learning difficulties in school children. Of course, not all children with behavioural problems or learning difficulties have ADHD. Its recognition and diagnosis requires a careful history of development, behaviour and in school-aged children, of learning. School reports and the success (or otherwise) of support programs at school are important.
I use Connor’s Questionnaires, which are performed online and computerised, to assist in the diagnostic process. They are regarded widely as one of the best instruments for this purpose in the psychological and medical literature. Sometimes I will also have an academic assessment performed by a psychologist.
If the diagnosis of ADHD is made, I will present to you a plan of management, which will address all aspects of your child’s problems (not just the ADHD). This may include the use of medicine. The decision to use a medicine is a very significant one, and not be taken lightly. Should I make the diagnosis of ADHD, I will discuss at length with you the pros and cons of medication. Having answered your questions, I will give you my advice. The decision to use a medicine remains yours, and I will of course respect that decision.
The implementation of the plan of management will require ongoing monitoring (including liaison with the school), and I will see your child into the future, assessing his/her response to those interventions. And in this process, there is nothing preventing us from adjusting the management plan as we see fit, taking account of your child’s progress.
Autism Spectrum Disorder (Autism)
Autism is a serious developmental disorder, which is usually first recognised in the child in toddlerhood. Thankfully, it can now be treated, but the treatment is difficult and costly. The condition has lifelong implications.
Whilst Autism has been recognised for a long time, the development of effective treatment coincided with the recent remarkable increase in the rate of diagnosis. Many experienced in the field believe the condition is over-diagnosed at present. The Autism assessment is complex, and considering the implications for the child, it should be performed with great care.
The process involves independent assessment by three clinicians experienced in the field: a consultant paediatrician, a clinical psychologist, and a speech pathologist. Their assessments take account of the criteria published in the Diagnostic Statistical Manual of the American Psychiatry Association.
I caution parents about, ‘Getting a diagnosis’. It is an appalling phrase. It implies the diagnosis of autism is merely a means to an end. No reasonable person would wish the condition of autism on anyone. Yet providers of government funded autism therapy use the phrase often. So
As a parent, if you are referred to me you can be assured that I will approach the process of assessment with rigour and with care.