Pediatric Clinical Practice Guidelines for Nurses in Primary
Care
Chapter 6 - Dysfunctional Problems of Childhood
Introduction
Common Dysfunctional Problems
Introduction
The topics discussed in this chapter include a variety of physiologic,
psychologic and social problems that may interfere with important
functions of daily living.
Assessment of these problems requires, above all, establishing
a good rapport with the family and the child. Usually, the initial
interview is lengthy; this is the session during which trust is
established. The history and physical examination vary with the
presenting complaint.
Common Dysfunctional Problems
Learning Disabilities
Definition
Inability to process language and its symbols or lack of arithmetic-related
skills at a level equal to peer group.
Affected children usually suffer from learning disability in a
specific area and are normal in all other areas of development.
Causes
Specific learning disabilities are generally thought to be biologic
in origin, although the exact mechanisms and biology have not yet
been determined.
Major psychiatric disturbances, social deprivation, or loss of
vision or hearing can also produce poor learning skills and must
be differentiated from specific disabilities.
History
- Current and past behavior and school performance (look for
specific patterns and for hyperactivity, which is often associated
with a learning disability)
- Perinatal history (perinatal asphyxia or intrauterine injury
may play a role in some cases), prematurity
- Family history (such disorders often run in families)
- Early development: recognition of risk factors such as delayed
language development
- Social, environmental, family and social factors, which may
aggravate the problem (e.g., constant derision may lead to low
self- esteem)
- History of meningitis, head trauma
Examination
Most aspects of the examination required to
define a specific learning disability are performed by a psychologist
and education specialists.
Perform a physical examination to rule out
the following conditions:
- Hearing and vision problems
- Medical problems
- Fetal alcohol syndrome (FAS)
- Abuse
- Iron deficiency anemia
- Neurologic abnormality
Differential Diagnosis
- Poor school performance (common)
- Poor motivation (family disorganization)
- Global developmental delay (mental retardation)
- Depression
- Sensory disorders (e.g., hearing loss secondary to otitis media)
- Cerebral palsy
Management
Nonpharmacologic Interventions
- Advocate for the child in the education system
- Support the child's self-esteem
- Support child and parents or caregiver with behavioral strategies
in conjunction with psychologic counseling and education
- Arrange for treatment by specialists
Monitoring and Follow-Up
- Follow up two or three times a year with the child and the
parents or caregiver to assess progress and provide support
- Liaise annually with the school (with parental consent)
Referral
- Most management of this problem should be done through the
education system.
- Refer the child to a physician for evaluation as soon as possible
(elective).
- A baseline assessment by a pediatrician
is indicated.
Fetal Alcohol Syndrome and Fetal Alcohol Effects
Introduction
Alcohol is a known teratogen that can cause birth defects by affecting
the growth and proper formation of the fetus's body and brain (Olson
et al 1992). Exposure to alcohol before birth can lead to long-term
developmental disabilities in the form of motor, speech or behavioral
problems. The range of disability varies, even for those with a
diagnosis of fetal alcohol syndrome (FAS).
There is no definitive information as to the quantity of alcohol
that may be safely consumed during pregnancy. Full-blown FAS is
more likely to occur if intake of alcohol during pregnancy is heavy
or continuous (Olsen 1992), but detrimental effects have also
been observed after intermittent or binge drinking. Children born
to mothers who consumed on average one or two drinks per day and
who may occasionally have consumed up to five or more drinks at
a time are at higher risk for learning disabilities and other cognitive
and behavioral problems.
Abnormalities related to prenatal exposure to alcohol occur along
a continuum. Many terms have been and are still used to describe
the severity of these alcohol-related abnormalities.
- Fetal alcohol syndrome (FAS): Medical diagnosis referring
to a set of alcohol-related disabilities associated with maternal
use of alcohol during pregnancy. Recognized in Canada as one
of the leading causes of preventable birth defects and developmental
delay in children.
- Fetal alcohol effects (FAE): Birth defects or developmental
abnormalities for which alcohol is being considered one of the
possible causes. Used to describe children with prenatal exposure
to alcohol, but only some of the characteristics of FAS, including
reduced or delayed growth, single birth defects, or developmental
learning and behavioral disorders that may not be noticed until
months or years after the child's birth.
- Alcohol-related birth defects (ARBD)
- Alcohol-related neurologic disorders (ARND)
The Canadian Paediatric Society (1997) advises healthcare professionals,
including family physicians, pediatricians and others to whom children
are referred, to increase their awareness of maternal alcohol use
during pregnancy, so as to identify the possible causes of birth
defects and other developmental disorders and to identify and prevent
risks for subsequent pregnancies.
High-Risk Populations
Women who drink and have the following characteristics:
- Low socioeconomic status
- Poverty
- Lack of education
- Smoker
- Use of other illicit drugs
- Poor health
Higher prevalence rates have been found in Manitoba and British
Columbia Aboriginal populations. Families with one or more children
affected by FAS are at much higher risk of recurrence.
Recent research suggests women who have a college education or
are still students, who are unmarried, who smoke and who come from
households with an annual income of more than $50,000 are also
at risk of having a baby with FAS.
Diagnostic Criteria
Minimum criteria for diagnosis of FAS:
- History of maternal alcohol consumption during pregnancy
- Prenatal or postnatal growth retardation
- Involvement of CNS, such as neurologic abnormalities, developmental
delay, behavioral dysfunction, learning disabilities or other
intellectual impairments, and skull and brain malformations
- Characteristic facial features: short eye slits (palpebral
fissures), thin upper lip, flattened cheek bones and indistinct
groove between the upper lip and the nose (such characteristics
are not to be confused with the facial features that occur normally
in some ethnic groups)
Prevention Strategies
Pregnancy presents the healthcare professional with an excellent
opportunity to encourage behavioral change, as women are generally
receptive to suggestions about controlling their alcohol consumption
during pregnancy
According to the Canadian Paediatric Society (1997), prevention
efforts should target women before and during their childbearing
years, as well as those who influence such women, including their
partners, their families and the community. All efforts should
be family-centered and culturally sensitive; should address the
pregnant woman, her partner and her family in the context of their
community; and should be comprehensive, drawing on all services
appropriate to the often-complex social, economic and emotional
needs of these women
The CPS also recommends that healthcare professionals working
with members and leaders of communities must be consistent in advising
women and their partners that the prudent choice is not to drink
alcohol during pregnancy
Primary Prevention
Become involved in educating women, their partners and the community
in general about FAS and the adverse effects of alcohol on a fetus.
Goals of primary prevention:
- Early recognition of women who drink alcohol during pregnancy
- Appropriate counseling to reduce or eliminate alcohol use before
conception and during pregnancy
- Early recognition and intervention for any child born with
alcohol-related effects
Ask all female clients of childbearing age some basic questions
about alcohol consumption:
- Do you use alcohol?
- Has alcohol ever caused a problem for you or your family?
- Do you regularly use any other drugs or substances (e.g., illicit
drugs, prescription or OTC drugs)?
Discuss contraceptive methods with women and their partners and
enhance access to contraception.
Encourage awareness of and access to community resources for alcohol
abuse.
Be aware of, use and offer educational handouts on the effects
of alcohol in pregnancy.
Secondary Prevention
According to the Canadian Paediatric Society (1997), healthcare
professionals play an essential role in identifying women who drink
at levels that pose a risk to the fetus and to themselves. Screening
should be implemented to identify women at high risk for heavy
alcohol consumption before and during pregnancy. Similarly, healthcare
professionals have a responsibility to inform women at risk and
to initiate appropriate referrals and supportive interventions.
To identify any woman who is using alcohol during pregnancy, screen
all pregnant women with basic questions about their alcohol use (see "Primary
Prevention," above).
If the woman answers Yes to any of those questions, pose some
additional screening questions to assess her level of risk:
- In a typical week, on how many days do you drink?
- On those days, how many drinks do you usually have?
In addition, administer a standard screening test, such as the T-ACE questionnaire
- T for tolerance: How many drinks
does it take to make you feel high? (score 2 for more than 2
drinks, score 0 for 2 drinks or less)
- A for annoyance: Have people annoyed
you by criticizing you about your drinking? (score 1 for a Yes
response)
- C for cut down: Have you felt you
should cut down on your drinking? (score 1 for a Yes response)
- E for eye opener: Have you ever had
a drink first thing in the morning to get rid of a hangover or
to steady your nerves? (score 1 for a Yes response)
- Any score ≥2 indicates high risk
For women identified as being at high risk of having a child with
FAS, take the following steps:
- Ask such women why they drink
- Counsel pregnant women who are using alcohol about the effects
of alcohol on the fetus and their own health
- Counsel pregnant woman on the benefits of stopping or reducing
the use of alcohol at any time during the pregnancy
- Provide client with educational materials to facilitate behavioral
change
- Follow up closely, and provide support and encouragement
The Canadian Paediatric Society (1997) recommends that healthcare
professionals inform women who have occasionally consumed small
amounts of alcohol during pregnancy that the risk to the fetus
in most situations is likely minimal. They should also explain
that the risk is related to the amount of alcohol consumed, body
type, nutritional health and other lifestyle characteristics of
the expectant mother. If exposure has already occurred, healthcare
professionals should inform the mother that stopping consumption
of alcohol at any time will benefit both fetus and mother.
Tertiary Prevention
- Strategies should include early diagnosis of the condition
and programs designed specifically for children with FAS or FAE
and their parents or caregivers
- Refer women who are at high risk to appropriate treatment resources
for alcohol abuse
- Identify and treat women and their partners who already have
one FAS/FAE child and who plan to have more children
Management
Appropriate Consultation
Consult a physician as soon as possible about any child suspected
of suffering the effects of alcohol in utero.
Referral
The care of a child with FAS, FAE, ARBD or ARND requires a coordinated,
multidisciplinary, team approach to maximize the child's potential
for good quality of life.
There is a small window of opportunity, up to age 10 or 12, to
achieve the greatest benefit for a child affected by alcohol in
utero. This is the period when the greatest development of fixed
neural pathways occurs, and thus when it is easiest to develop
alternative coping pathways to work around damaged areas of the
brain.
Attention Deficit Hyperactivity Disorder (ADHD)
Definition
A cluster of behavioral symptoms:
- Poor attention span
- Impulsivenes
- Hyperactivity
Not all children with the disorder will exhibit
all three behaviors. For example, some very quiet children have
a poor attention span.
Causes
Genetic Syndromes
- Fragile X syndrome
- Phenylketonuria (PKU)
- Gilles de la Tourette syndrome
Intrauterine or Prenatal Damage
- Fetal alcohol exposure
- Intrauterine anoxia
Postnatal Factors
- Prematurity
- Meningitis
- Significant head injuries
May be familial without a specific cause.
In most affected children, there is no obvious contributing cause.
History
- Prenatal: pregnancy, exposure to drugs or alcohol
- Perinatal: delivery, asphyxia, illnesses
- Family history: ADHD, related behavioral disorders
- Past medical history: illnesses such as meningitis, injuries,
hospital admissions
- History of school progress and behavior (talk with teacher)
- Symptoms (see Table 6-1) usually present
before child enters school
The diagnosis is usually established by the presence of at least
8 of 14 possible characteristics over a period of at least 6 months
(Table 6-1).
Table 6-1. Diagnostic Criteria
for Attention Deficit Hyperactivity Disorder
A disturbance of at least 6 months' duration during which at least
8 of the following are present
- Often fidgets with hands or feet or squirms in seat (in adolescents,
may be limited to subjective feelings of restlessness)
- Has difficulty remaining seated when required to do so
- Is easily distracted by extraneous stimuli
- Has difficulty awaiting turn in games or group situations
- Often blurts out answers to questions before they havebeen
completed
- Has difficulty following instructions from others, but not
because of oppositional behavior or failure of comprehension
(e.g., fails to finish chores)
- Has difficulty sustaining attention in tasks or play activities
- Often shifts from one uncompleted activity to another
- Has difficulty playing quietly
- Often talks excessively
- Often interrupts or intrudes on others (e.g., butts into other
children's games)
- Often does not seem to listen to what is being said to him
or her
- Often loses items necessary for tasks or activities at school
or at home (e.g., pencils, toys, books, assignments)
- Often engages in physically dangerous activities without considering
possible consequences, but not for the purpose of thrill-seeking
(e.g., runs into street without looking)
Other characteristics
- Onset before the age of 7 years
- Does not meet the criteria for a pervasive developmental disorder
Adapted, with permission, from Green, M.; Haggerty, R.J. 1990.
Ambulatory Paediatrics IV. W.B. Saunders Ltd., Baltimore, MD.
Physical Examination
- Complete general examination: look for dysmorphic features
of genetic conditions, FAS
- Examine ears and check hearing
- Examine eyes and check vision
- "Soft neurologic signs" often present (e.g., increased
reflexes, poor coordination, poor balance)
- Educational evaluation done through the school system
Differential Diagnosis
- Acting-out behavior disorders
- Reaction to a highly stressful environment
- Deafness
- Pervasive developmental disorder (e.g., autism)
Management
Goals of Treatment
- Improve academic achievement
- Improve attention span
- Control hyperactivity (behavior)
Appropriate management includes the involvement of a multidisciplinary
team, of which educational specialists are the mainstay. Many specific
methods can be used to overcome the child's weaknesses and take
advantage of his or her strengths.
The medical role involves advocacy and sometimes the administration
of medication. The school and the parents or caregiver should monitor
for desired effects and side effects (e.g., impaired growth or
tic).
Nonpharmacologic Interventions
- Support for the family
- Advocacy within the educational system and within the community
- Monitor medication use, dosage, side effects
Client Education
- Explain nature, course and treatment modalities of the disorder
- Stress importance of regular follow-up
- Counsel parents or caregiver about medication: appropriate
use, dosage and side effects
Behavioral Strategies
Counsel parents or caregiver about behavioral strategies:
- Decrease environmental stimuli
- Focus on the child's positive traits to increase self-esteem
- Give simple directions
- Make eye contact with the child
- Use "time out" as a disciplinary tactic
Pharmacologic Interventions
Drug of choice:
methylphenidate (Ritalin) (B class drug), starting
dose 0.2-0.5 mg/kg daily in two doses, morning and noon; the dose
can be increased by 0.15 mg/kg each day
This drug is not recommended for children < 6
years of age.
This drug can improve concentration and, in
higher doses, reduce hyperactivity. Its use is still controversial,
and it should be prescribed only by a physician after full evaluation.
Drug-free periods during school holidays will result in catch-up
growth.
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