Cognitive-Perceptual Disorders: Attention-Deficit/Hyperactivity Disorder, Learning Problems, Sensory Processing Disorder, Autism Spectrum Disorder, Blindness, and Deafness

15 Cognitive-Perceptual Disorders


Attention-Deficit/Hyperactivity Disorder, Learning Problems, Sensory Processing Disorder, Autism Spectrum Disorder, Blindness, and Deafness



Cognitive development is the foundation for intelligence (Wilks et al, 2010), and cognition and perception affect a child’s ability to learn, comprehend and use information to understand and follow directions, retain information, make decisions, and solve problems. Cognition and general knowledge represent the accumulation and reorganization of experiences that result from participating in a rich learning setting with skilled and appropriate adult interventions. From these experiences children construct knowledge of patterns and relations, cause and effect, and methods of solving problems of everyday life.


Gordon (2010) describes the cognitive-perceptual functional health pattern to include the adequacy of sensory modes, such as vision, hearing, taste, touch, or smell, as well as the cognitive functional abilities such as language, memory, and decision-making. Sensory experiences such as pain (see Chapter 22) and altered sensory input may also be identified.


Piaget’s theory of cognitive development is probably the most classic (see Chapter 4). Newer theories and ideas related to the development of cognition and sensory awareness are emerging and being developed. Neurodevelopmental functioning of the brain uses a model of a tool kit full of basic instruments (functions) with different functions working in clusters (like tools) in different kinds of learning. The concept of multiple intelligences was introduced to describe different ways a child may be hard-wired to process information. Information processing looks at human learning with a computer as a model. Social cognition looks at the spectrum of social behaviors and affiliation with others.


Perception is the child’s ability to receive information from the internal and external environments through the senses: vision, hearing, touch, taste, and smell. Traditionally it was thought that learning occurs as a child receives visual or auditory input. The sensory processing theory, also referred to as sensory integration, refers to the way the nervous system responds to, processes, and organizes information through the senses in order for learning and physical and emotional development to occur. This theory expands sensory input to include vestibular and proprioception (Miller et al, 2009). Epigenetics provides a link between genetic and environmental factors affecting development. Wegner (2009) proposes a societal-familial-individual matrix as a clinical means of evaluating these factors.


Facilitating and monitoring cognitive-perceptual developmental progress as well as ensuring the maximum function of all the senses should be an integral part of primary care. Screening hearing and vision is a recognized standard of care. Following cognitive development in infancy and early childhood is primarily done by monitoring language and problem-solving domains integral to the other developmental parameters and should ideally be performed with standardized screening tools. As the child enters school, monitoring the adaptation to and performance in school becomes the key. Soliciting information about school performance from preschool through high school shows interest in the child’s mastery of educational tasks and managing academic challenges. Primary care providers may be consulted for guidance about appropriate timing and school placement for a child, performance more or less than expectations, problems, and the need for further assessment. As developmental experts, primary care providers need to be able to identify problems; advise, counsel, and educate parents; participate on interdisciplinary teams for diagnosis and management; and mediate and advocate for children and their learning needs.



image Standards for Care


Healthy People 2020: Health Promotion and Disease Prevention Objectives for the Year 2020 supports the need for visual and hearing screening in children (U.S. Department of Health and Human Services [USDHHS], 2010). New objectives for 2020 include “increase the proportion of children who are ready for school in all five domains of healthy development”; “increase educational achievement of adolescents and young adults”; and “increase the percentage of young children with autism spectrum disorder (ASD) and other developmental delays who are screened, evaluated, and enrolled in early intervention services in a timely manner” (USDHHS, 2010).


The U.S. Preventive Services Task Force’s (USPSTF) (2010) Child and Adolescent Recommendations for Development and Behavior states that there is “insufficient evidence to recommend for or against routine, brief, formal screening instruments in primary care to detect speech and language delays in children up to 5 years of age.”


Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents (Hagan et al, 2008) addresses health promotion to ensure physical, cognitive, and socioemotional health, supporting the healthy development of the child. This includes surveillance and screening for early identification and intervention of any problems. Specific cognitive skills in infancy, early childhood, middle childhood, and adolescence are identified in the Child Development section. Screening for vision and hearing is recommended and considered effective.



image Theories of Normal Cognitive-Perceptual Development



Piaget: Cognitive Development


Piaget’s learning model is discussed in detail in Chapter 4, but key concepts include assimilation (taking in information through any and all the senses), accommodation (taking one’s current abilities/understanding and modifying them to adjust to the new circumstance or challenge), schema (organizing this into a new mental structure or physical action), and equilibrium (a new level of cognition).



Neurodevelopmental Framework


A neurodevelopmental framework is a model of learning based on a synthesis of research from neuroscience, cognitive psychology, and child and adolescent development explaining how the brain functions and how these functions affect student learning and performance. Every person has strengths and weaknesses that influence learning, as well as particular affinities—subjects, ideas, and pursuits they’re drawn to. “Collectively, these strengths, weaknesses, and affinities shape both how we learn and what engages us—which, in turn, influence how much we actually learn and thrive in a given situation” (All Kinds of Minds, 2010).


There are eight constructs to the neurodevelopmental framework, which are listed in Table 15-1. Identifying a child’s strengths and weaknesses by using these constructs provides a method to describe, organize, and address individual students’ learning needs.


TABLE 15-1 Constructs of the Neurodevelopmental Framework



























Attention A series of control mechanisms through which the brain regulates learning and behavior. Components include:
Memory Organized storage and recall
Language
Spatial ordering
Temporal sequencing ordering
Neuromotor function
Higher-order cognition
Social cognition

CNS, Central nervous system; REM, rapid eye movement.







The Societal-Familial-Individual Matrix of School Achievement


Wegner (2009) proposes a matrix of societal, family, and individual elements that affect a child’s ability to achieve academically. Success can be defined as “successful attainment of skills commensurate with the child’s cognitive profile” and is often measured by passing all grades in school. This matrix offers a way to examine the interplay of a child’s individual profile, family factors, and community characteristics.


Individual characteristics affecting academic performance include: (1) cognition—often considered the predictor of academic success; (2) developmental skills—play a role in contributing to intelligence; (3) resilience—contributes to a child’s motivation to succeed or ability to persevere through failure; and (4) desire for education—a personal belief that education is important and contributes to the future.


Family factors that influence student educational achievement include: (1) community acceptance of varied types of family structures; (2) family values at odds with the larger community causing missed opportunities for the child; (3) performance expectations out of line with a child’s capabilities, either too high or too low; and (4) parental academic abilities that not only genetically influence a child’s capability but also affect the home support a child may receive.


Societal factors that influence educational systems include: (1) economic—the affluence of the community affects resources and experiences as well as, potentially, the quality of teachers attracted; (2) political—politicians may be hesitant to promote tax increases to provide needed resources for schools; (3) religious—a preponderance of a specific religious group may exert influence on a school’s curricula, policy, and procedures; and (4) cultural—as with religion, ethnic and cultural groups may exert pressure on a school.



image Effects of Cognitive-Perceptual Problems on the Child and Family


Although most children develop according to normal patterns, developmental delays, specific deficits, and alterations in cognitive-perceptual development sometimes occur. Delays from environmental deprivation or neglect are frequently reversible, once identified.


Feedback provides information to the child, positive reinforcement for correct responses to stimuli, and negative reinforcement for behaviors that are not appropriate. Parents, peers, and others provide important feedback to the child. For some children with perceptual problems, not only is the initial cue missed but also the feedback cues. This feedback is an essential component of the learning process.


Knafl and colleagues (1996, 2001) identified the following family management styles when a child has a chronic or disabling condition: thriving, accommodating, enduring, struggling, and floundering. Each management style described how parents perceived the child (normal, problematic, tragic), the parenting philosophy and view of illness, and their perception and approach to managing the illness. For example, parents who embraced a thriving family management style viewed the condition from a “life goes on” perspective and normalized the child’s illness as best they could. They had a parenting philosophy that was able to accommodate the condition into parenting activities and a confident mind-set, and they were proactive in their management approach.


Other typologies have been described for families with children with other cognitive-perceptual problems. Kendall (1998) described four types of families of children with attention-deficit/hyperactivity disorder (ADHD) along a trajectory: the chaotic family, the ADHD-controlled family, the surviving family, and the reinvested family. Other studies of families living with ADHD indicate considerable disruption to family routines and an inability to achieve some sense of “normalcy.” Some families describe family life as a “nightmare,” despite outward indicators (intact marriage, stable residence, adequate income, resources to manage the ADHD, etc.) that the family is doing well (Shelton, 2001). Families of learning-disabled children have been described as healthy, split, chaotic, and blaming (Ziegler and Holden, 1988).



image Cognitive-Perceptual Development Problems and Primary Care



Assessment


Assessment of cognitive-perceptual development should be incorporated at every well-child visit from birth through young adulthood. Assessment of a child’s cognitive-perceptual development includes consideration of risk factors and current performance as elicited by history, actual assessment via screening tools, direct observation of the child and caregiver, as well as review of school data.




Screening


A developmental screening tool should be used consistently throughout the first 6 years of life to monitor children for any delay or lagging performance. Developmental screening is discussed in detail in Chapters 4 through 8. Cognitive red flags are listed in Box 15-1. Screening for autism using the M-CHAT is recommended at 18 and 24 months (see later section on Autism). Concerns about a child’s ability to deal with sensory input from either a learning or behavioral standpoint can be evaluated with a screening tool (see later section on Sensory Processing Disorder).



As the child enters school, screening for the acquisition of academic skills, school achievement, and the child’s ability in social interactions becomes important.



If any problems or concerns are identified, further evaluation should be undertaken. This is discussed later in the chapter.


Monitoring hearing and vision is the first step in assessment of perception. It is of note that children with cognitive-perceptual variations may achieve motor milestones on time, but experience delays in speech, social, and emotional areas of development.



Management Strategies


Children and families with problems in this domain generally need support in four areas: social and adaptive skills, education, family support, and multidisciplinary health care team consultations. Many families find this support lacking from their primary care providers. Satisfaction with primary care received by families of children with developmental disabilities including both physical and mental problems was studied by Liptak and colleagues (2006). They found that most families felt satisfied with physicians’ abilities to keep up with new aspects of care and with their sensitivity to the needs of the children. They indicated dissatisfaction with the ability of physicians to put them in touch with other parents, understand the effect of the condition on the family, answer questions about the condition, and provide information and guidance. They rated physicians’ knowledge about complementary and alternative medicine and their qualifications to manage children with developmental disabilities most negatively. Families with a child with autism rated primary care physicians worse on several factors than did other families.




Educational Strategies


Children with cognitive-perceptual problems are entitled to special education opportunities to maximize their learning potential. Infant stimulation opportunities are extremely important and early-intervention preschool programs are essential (see Chapter 4).


Two federal laws, the Americans with Disabilities Act (ADA), passed in 1990, and the Individuals with Disabilities Education Act (IDEA), reauthorized in 1997, provide mandates for reasonable accommodations that schools must provide to help children with disabilities to achieve meaningful, equal opportunity to benefit from educational services. Free and appropriate public education (FAPE) and least restrictive environment (LRE) are ideas that are built into the special education system. A response to intervention (RTI) approach is a tiered response to determining if a child has a disability and qualifies for special education. It is more effective in identifying students with learning disabilities than the traditional IQ discrepancy model. Once a child has been identified with special learning needs, an Individualized Education Plan (IEP) or a 504 plan are two means of delineating help for the child. Table 15-3 provides a differentiation of services.



TABLE 15-3 504 and Individualized Educational Plan (IEP) Evaluation and Educational Plans


























ADA/504 IDEA/IEP
Which is right?


Eligibility


Evaluation


Provisions



ADHD, Attention-deficit/hyperactivity disorder; IDEA, Individuals with Disabilities Education Act; IEP, Individualized Educational Plan.


When children reach school age, decisions are made collaboratively between parents and school personnel about the best placement of the child (mainstream classroom, special classroom, or combination of settings). A wealth of information about these legal rights and provisions can be found on the Internet.





image Cognitive-Perceptual Problems of Children



Attention-Deficit/Hyperactivity Disorder



Description


ADHD is one of the most commonly diagnosed behavioral disorders in childhood. It is considered a neurobiologic condition because it has a clear neurologically based etiology with symptoms that profoundly affect the behavior of individuals across many settings in their lives (Pliszka and American Academy of Child and Adolescent Psychiatry [AACAP], 2007). The symptoms of ADHD can affect cognitive, educational, behavioral, emotional, and social functioning in individuals with ADHD.


The core symptoms of ADHD are inattention, hyperactivity, and impulsivity. In ADHD these symptoms occur at a developmentally inappropriate level. There is a range of severity of symptoms from one individual to the next. Also, the scope and severity of behaviors may change within an individual as maturation occurs. The criteria defining ADHD were established by the American Psychiatric Association (APA) in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) (APA, 2000) (Table 15-4).


TABLE 15-4 DSM-IV-TR Criteria for Attention-Deficit/Hyperactivity Disorder



















































Domain Criteria
Essential features

Six or more of the following symptoms of inattention:









Hyperactivity/Impulsivity traits Six or more of the following symptoms of hyperactivity-impulsivity:










From American Psychiatric Association: Diagnostic and statistical manual of mental disorders, fourth edition, text revision, Arlington, VA, 2000, American Psychiatric Association.


ADHD has three different diagnostic subtypes depending on the number of positive symptoms in each category (Box 15-2).



ADHD is now understood to be a chronic condition with persistence in many individuals into adolescence and adulthood (Van Cleave and Leslie, 2008). Approximately 60% to 85% of children with ADHD continue to have symptoms into adolescence (Pliszka and AACAP, 2007). Factors that increase the risk of ADHD persisting into adolescence and adulthood include a strong family history of ADHD and the comorbidities of aggression and other conduct problems. Multiple studies cited by Spencer and colleagues (2007) show that untreated adults with ADHD struggle with a great many social difficulties including higher rates of marital discord and divorce, lower socioeconomic status, higher unemployment rates, higher rates of substance abuse, poor self-esteem, and higher rates of traffic violations and motor vehicle accidents.



Etiology




Cross-Cultural Considerations


In the U.S. the incidence of ADHD in Hispanic children is 5.6%, compared with 10.5% among non-Hispanic children (CDC, 2010a). Those most to least likely to be diagnosed with ADHD are multiracial, African-American, and Caucasian. ADHD has been well documented outside of the U.S. Studies show a similar range of rates of ADHD incidence occurring in children internationally (Buitelaar et al, 2006; Faraone et al, 2003). Although there is agreement across cultures about the presence of ADHD, perceptions often vary by culture, with a paucity of ADHD research from developing countries.


Although ADHD is a condition with a proven neurobiologic basis, it occurs within a sociocultural framework. This is an important consideration for providers in giving sensitive care to families. Perceptions about parenting and childrearing, beliefs about medication and the health care system in general, family and social networking roles in managing child behavior problems, and parents’ own experiences with school are all factors that shape the approach to seeking care, diagnosis, and treatment. Families may have differing understandings of what constitutes behavior problems. Studies show that providers who are most sensitive and successful in working with families are open and honest in the discussion of diagnoses and all treatment options, include key family members in collaborative decision making, and strive to become more aware of the community and cultural values of the populations with which they work (Olaniyan et al, 2007).



Effect on Individuals, Families, and Communities


Because ADHD symptoms cross over so many settings and are chronic, often into adulthood, this condition has a major effect on the individual as well as on his or her family and community. Table 15-5 summarizes impairments across the life span. In families in which ADHD is present, significantly higher levels of stress (than in the general population) are reported. Individuals with ADHD (with and without comorbid conditions) have six times greater difficulty in the areas of friendship with peers, and emotional, and conduct problems than their nonaffected peers. There is a nine times greater likelihood of family stress; problems with classroom learning and conduct; and difficulties with leisure activities (e.g., playing with friends or participating on a sports team) (Strine et al, 2006).


TABLE 15-5 Summary of ADHD Impairments Across the Life Span















Life Stage Impairment
Childhood
Adolescence
Adulthood

ADHD, Attention-deficit/hyperactivity disorder.


Adapted from Pliszka S, American Academy of Child and Adolescent Psychiatry (AACAP) Work Group on Quality Issues: Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder, J Am Acad Child Adolesc Psychiatry 46(7):894-921, 2007; Spencer TJ, Biederrman J, Mick E: Attention-deficit/hyperactivity disorder: diagnosis, lifespan, comorbidities and neurobiology, Ambul Pediatr 7(3):73-81, 2007.


The injury rates among children with ADHD are higher than in the general population. Emergency department admissions rates for children and teens with ADHD are 81% compared with 74% in the general population. Serious accidents such as motor vehicle accidents occur at a higher rate for individuals with ADHD. Adolescents with ADHD also have a greater incidence of traffic violations and driving while under the influence of drugs or alcohol (CDC, 2010a).


ADHD is a chronic health condition and has significant direct and indirect costs at all levels of society. On an individual level ADHD significantly affects self-esteem, peer relationships, educational achievement, and prospective employment possibilities. ADHD, primarily the combined and hyperactive/impulsive subtypes, are predictors of substance abuse, criminal behaviors, marital difficulties, and divorce. Thus the condition can be seen as having indirect costs to society and the legal and criminal justice systems.


ADHD is also a significant cause of family stress and financial burden. Parents of children with ADHD report days of missed work due to the child’s school and medical appointments. Many of the services required for adequate evaluation and treatment of ADHD are not covered by health insurance (e.g., psychological testing, mental health care, or educational testing beyond that done at the school). The average annual direct health care costs for an individual with ADHD are $1,574 compared with $541 for a matched control without ADHD (CDC, 2010a).



Pathophysiology


ADHD is an extremely heterogeneous disorder, meaning there is a wide spectrum of symptoms and severity. Increasingly, neurobiologic research provides strong evidence that ADHD is primarily a genetic, inheritable disorder. There also appears to be a number of environmental factors that may play into the disorder by modulating (i.e., increasing or decreasing) one’s predisposition to underlying biochemical vulnerability (Krull, 2010a; Singh, 2008).


Complex neurobiologic activity that takes place in the prefrontal cortex (PFC) is called “executive functioning.” The PFC is a highly specialized region where organization and regulation of information and stimuli occur. Executive functioning refers to the interwoven processes continually occurring in the PFC: organizing and making sense of input received, sustaining focus on relevant stimuli, suppressing irrelevant stimuli (distractions), drawing on memory to understand stimuli, planning and organizing for future goals and consequences of actions, and regulating emotional and behavioral responses. The PFC in turn transmits information to, and receives input from, other brain areas such as the sensory cortices, basal ganglia, and cerebellum (for attention regulation and motor response) and to the amygdala, hypothalamus, and brainstem nuclei (where emotions and attention/arousal maintenance are regulated) (Arnsten, 2009; Krull, 2010a; National Resource Center on ADHD, 2009).



Genetics and Neurobiologic Pathophysiology


ADHD appears to be caused by deletions or duplications in a number of genes. The genes that are affected are those that regulate the manufacturing of the catecholamine (noradrenergic) neurotransmitters noradrenaline and dopamine in the brain (Arnsten, 2009). The net result of the genetic irregularities is that these neurotransmitters are less available in certain brain regions in individuals with ADHD. Both dopamine and noradrenaline (dopamine more strongly in ADHD) are known to be essential for healthy brain function, especially for alerting to and maintaining attention, maintaining an appropriate level of internal arousal, and inhibiting external distraction. Attention is a complex and multilayered neurologic activity requiring the function and interconnection of a number of different areas of the brain.


Brain imaging shows structural and chemical differences in the temporal and parietal cortices and the PFC in individuals with ADHD compared with those without this condition. The temporal and parietal regions of the brain are responsible for sensory awareness—recognizing and perceiving incoming information, orienting in time and space. Structurally, imaging has shown the brains of individuals with ADHD have smaller prefrontal cortical volumes. Neurochemically, there is also reduced catecholamine activity, particularly in the areas of the basal ganglia and the PFC. It is now felt that these “under-activated” brain regions and the pathways interconnecting them account for the symptoms of ADHD.



Environmental Factors


In many areas the research on environmental factors that contribute to ADHD is inconclusive. Some of the areas that have been or are being researched include:



Prenatal maternal tobacco use. Prenatal maternal tobacco use is associated with a 2.4-fold increased risk of ADHD (Froehlich et al, 2009).


Prenatal alcohol use. Direct association with ADHD is not as well established in the literature (DynaMed Database, 2010).


Lead exposure. Froehlich and associates (2009) report a direct correlation between early lead exposure and later ADHD diagnosis even with low lead levels (<10 mcg/dL).


Prematurity and low birthweight. Prematurity and low birthweight increase ADHD risk by 2.64-fold (DynaMed Database, 2010).


Food additives (artificial colors and flavors). There have been a number of studies in this area and none have shown a causal connection between food additives and ADHD. Elimination of food additives is not a recommended part of any ADHD practice guidelines (Krull, 2010b).


Refined sugar. Although some children respond to excessive sugar with an increased activity level, reviews of many studies fail to show an association with sugar and ADHD (Krull, 2010b).


Essential fatty acids (omega 3 and omega 6). These nutrients are integral in the development and functioning of neuronal membranes. Three studies showed no benefit to fatty acid supplementation for children with ADHD, although benefits were found in one study (Krull, 2010b).


Iron deficiency. Low serum ferritin is associated with learning difficulties. One study showed that children with ADHD had lower serum ferritin levels than matched non-ADHD children. Another study (Krull, 2010b) showed that iron supplementation in children with low serum ferritin levels improved ADHD symptoms.


Zinc. Limited research has demonstrated zinc deficiency in children with ADHD and/or a benefit from zinc supplementation on ADHD symptoms (Krull, 2010b).


Environmental factors such as family adversity and stress, violence in the home, parenting style, and poverty have been studied with regard to how they may contribute to the etiology of ADHD. There is no clear evidence about these factors causing ADHD. However, any of these factors can be seen as modifying or modulating ADHD, as well as other childhood psychiatric conditions (Spencer et al, 2007).




Assessment


The diagnosis and management of ADHD can be made in the primary care pediatric office, but involves working with the child’s school and other domains where the child regularly spends time (e.g., after-school or childcare programs, sports activities, etc.). There is no “one” assessment tool to diagnose ADHD though there are a number of tools and evidence-based practice guidelines that are available to help clinicians develop an organized, efficient, and safe practice in assessing, diagnosing, and caring for children and adolescents with ADHD. Table 15-6 provides resource information for the four main guidelines.


TABLE 15-6 Clinical Tools and Evidence-Based Guidelines for ADHD Assessment and Treatment























Name of Tool or Guideline Age Applicable What Is Included
National Initiative for Children’s Healthcare Quality (NICHQ) and American Academy of Pediatrics (AAP): Caring for children with ADHD: a resource toolkit for clinicians (www.nichq.org/resources/ADHD_toolkit.html) School-age children and adolescents Materials for ADHD diagnosis and management based on the DSM-IV criteria for school-age children and adolescents; Vanderbilt ADHD assessment tool and scoring information

Ages 6 to 12 years Algorithm and practice recommendations for assessment, diagnosis, and treatment

Ages 3 through 17 years Recommendations about assessment, diagnosis and treatment
Institute for Clinical Systems Improvement (ICSI) Health care guideline: Diagnosis and management of attention-deficit/hyperactivity disorder in primary care for school-age children and adolescents, March 2010 (www.icsi.org) School-age children and adolescents Algorithms for diagnosis and treatment, background on ADHD, tables about ADHD medications, table of the full DSM-IV-TR diagnostic criteria

ADHD, Attention-deficit/hyperactivity disorder; DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, fourth edition.


The components of the ADHD assessment include:




History


Table 15-7 outlines many of the areas for assessment and suggested topics to explore in taking a history when evaluating for ADHD.


TABLE 15-7 Attention-Deficit/Hyperactivity Disorder History























































































































































Assessment Area Suggested Topics to Explore
Chief complaint and history of present problem Major areas of concern
First awareness of problem
Beliefs about causation of problem
Previous evaluations and results
Medication history for behavioral, emotional, or learning problems
Birth history* Prenatal history; maternal health; use of medications, recreational drugs, alcohol, and tobacco during pregnancy
Prematurity, low birthweight or IUGR
Birth and postpartum complications, anoxia, difficult delivery, birth defects
Neonatal behavior: feeding, sleep, temperament problems
Medical history Chronic diseases, ongoing medications
Hospitalizations, prolonged illness
Trauma history (head injury, frequent injuries)
Poisoning or lead or environmental exposures
Neurologic status, seizures, tics, habit spasms, uncontrolled twitches, outbursts of uncontrollable sounds or words
Environmental allergies
Cardiovascular history (see section about cardiovascular risks with stimulants)
General health* Vision, hearing
ADHD history Attention: paying attention, sustaining attention, listening, following through, organization, reluctant to engage in activities that need sustained attention, loses things, distracted, forgetful
Activity: fidgets, leaves seat, runs or climbs when inappropriate, has difficulty with quiet games, talks excessively, has problems waiting turn, interrupts, “on the go”
Developmental history* Milestones: motor, personal-social, language, cognitive
Strengths (e.g., personality, activities, friendliness)
Weaknesses
Behavioral history* Frequency with which child complies when told to do something
Methods used at home to improve behavior and effectiveness
Parenting skills and style, cultural beliefs
Parental agreement about child management
Counseling history for child or family (or both)
Academic history Child’s progress at each grade level (strengths seen)
Adjustment problems at school, child’s history with peers, friendships
Difficulties with specific skills: reading, writing, spelling, math, concepts
Performance problems: attention, grades, participation, excessive talking, disturbing others, fighting, bullying, teasing, abusive language, not completing work
School assistance: tutoring, counseling, special help
Functional Health Patterns
Feeding Not able to sit through a complete meal
Messy and clumsy with utensils, dishes, and glasses
Inadequate caloric intake can be result of symptoms and further exacerbated by medications used to treat ADHD
Gastric distress may be a side effect of stimulant medication
Elimination Enuresis, encopresis
Sleeping Difficulty falling asleep, night waking, needs less sleep than other family members
Complains about fatigue interfering with completion of tasks
Activity Difficulty maintaining routines for activities of daily living
Cognitive Level of performance is below potential for achievement
Tends to miss the point of conversations and activities
Often does things the hard way in absence of established routines
Self-concept Struggles with low self-esteem, moodiness
Role relationships Births, deaths, deployment
Marriage and family transitions: separation, divorce, remarriage
Violence: domestic, current or past abuse of parent or child; problems with the law; weapons in the home
Inadequate social and relational skills
Lies, steals, plays with fire, hurts animals, is aggressive with other children, talks back to adults
Coping and stress tolerance Family stress and coping patterns
Stressors: parent job loss or change, financial problems
Outbursts of temper, low tolerance for frustration
Moody, worried, sad, quiet, destructive, fearful or fearless, self-deprecating
Somatic complaints
Social and environmental history* General family relationships (child and parents/siblings)
Home, daycare, and school environments
Family social risk factors: recent moves, financial stress, parental job losses, births, deaths, divorces, remarriages, alcohol and drug use, involvement with law enforcement, weapons in the home
Family history* ADHD, neurologic problems, learning difficulties
Mental health history of close family members, health or behavior problems in other family members
Genetic disorders: cognitive disabilities, growth disorders, neurofibromatosis
Drug or alcohol abuse (current and/or past)
Teacher history Obtain information from school about child’s problems, strengths, weaknesses, academic management of issues

ADHD, Attention-deficit/hyperactivity disorder; IUGR, intrauterine growth retardation.


* These must be included in the assessment.

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Jul 24, 2016 | Posted by in PEDIATRICS | Comments Off on Cognitive-Perceptual Disorders: Attention-Deficit/Hyperactivity Disorder, Learning Problems, Sensory Processing Disorder, Autism Spectrum Disorder, Blindness, and Deafness

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