Embedded Files
FM & PH – A child with behavioural challenges
In module Family Medicine and Public Health
Rory Sen, a 5-year-old boy, who is brought in by mum to the GP with unexplained bruising. Rory’s mum previously suffered domestic violence, before splitting from his Dad. Rory spends some weekends with his Dad.
MAIN CASE
Guidance and Resources – A child with behavioural challenges
Case Introduction – A child with behavioural challenges
Further Case Information – A child with behavioural challenges
Background Science – A child with behavioural challenges
Case Conclusion – A child with behavioural challenges
Formative Assessment – A child with behavioural challenges
CASE COMPONENT
Guidance and Resources – A child with behavioural challenges
In case FM & PH – A child with behavioural challenges
Learning Resources
Here is a list of useful links for your information or reminders about what you have already covered in relation to this case. They are listed here for ease of reference and you may wish to return to this page after you’ve worked through the case, but review of any of this material before you start the case is not compulsory.
You will be directed to specific information contained within some of these links as you work through this case, but can come back to this list if you want further information or are interested to know more.
Headache
1Med Learn Year 4, Case of ‘Headache’
NICE guidelines (2012) Headaches in over 12s: diagnosis and management
North West Headache Management Guideline for Adults
ADHD
NICE Guidance 2013 – Attention deficit hyperactivity disorder
Royal College of Psychiatrists – Attention Deficit Hyperactivity Disorder (ADHD)
Carer/ Health professional fact sheet: ADHD causes, symptoms, diagnosis, treatment including medication
General info ‘Background Information on ADHD’
Young minds – for children’s mental health. What is ADHD – Parent advice leaflet (optional to read)
Safeguarding
What to do if you’re worried a child is being abused (optional to read) – Advice for practitioners DFE March 15
This document tells you the duties of a health care worker (i.e. you) if they have concerns that a child has been abused or is at risk of harm. It also tells you about the roles of social services and the police in the process.
Working together to safeguard children – A guide to inter-agency working to safeguard and promote the welfare of children DFE March 2015
This document outlines:
The legislative requirements and expectations on individual services to safeguard and promote the welfare of children
A clear framework for Local Safeguarding Children Boards (LSCBs) to monitor the effectiveness of local services.
National Family Safety Program (KSA) ( optional to read)
Child maltreatment: when to suspect maltreatment in under 18s – NICE Clinical Guideline [CG89]: Pages 9- 27 (highlighted parts)
Forms Used in Registration and Notification of Suspected Case of Child Abuse (KSA)
Royal College of Psychiatrists Fact sheet – Child abuse and neglect – the emotional effects: the impact on children and adolescents: information for parents, carers and anyone who works with young people
45 min video – Lecture recorded by Dr Maggie Stegall on child safeguarding. Dr Stegall is one of the named consultants at CMFT with a lead role on child safeguarding
Case Introduction – A child with behavioural challenges
In case FM & PH – A child with behavioural challenges
Dr Alvaro Gonzalez is a Foundation Year doctor on placement in an inner city GP. His first patient is Julie Sen, a 25-year-old woman, and he decides to take a look at her medical records before calling her in.
Recent consultations
Headache
Significant Past
Post-natal visit
Contraception review
Medications
None
Allergies
None
No alerts
Julie is called in by Dr Gonzalez. She mentions to him that she has been suffering with terrible headaches for the past year. Julie is worried that she may be suffering with migraines. Her sister suffers with this badly and her symptoms are similar. She reports flashing lights happening before the headache on the right side of the head starts. There is also some numbness in the face with the headache. She also feels sick and tired during the episode, and wiped out after. The symptoms can last for several hours and then completely disappear.
What would be features that would suggest a diagnosis of migraine? (Select THREE)
· Headache worse in the morning
· Headache precipitated by physical exertion or Valsalva manoeuvre (e.g. coughing, laughing, straining)
· Numbness
· Aura before the onset of headache
· Fever
· Localised headache
· Headache worse in the morning
.
This would suggest raised intracranial pressure
· Headache precipitated by physical exertion or Valsalva manoeuvre (e.g. coughing, laughing, straining)
.
This is a red flag symptom. Red flags indicate possibility of serious intracranial pathology.
· Numbness
.
Correct answer.
This can be in the face or limbs
· Aura before the onset of headache
.
Correct answer.
· Fever
.
This is a red flag symptom. Red flags indicate possibility of serious intracranial pathology.
· Localised headache
.
Correct answer.
Usually frontal or temporal
Her main worry is that she is getting these headaches three times a week now and each time she has to go and lie in bed, leaving her 5 year old son, Rory, alone watching DVDs. The headaches started after her partner, Carl, left her. However, she doesn’t feel that life is more stressful than other people’s lives. She is hoping that the GP will give her medications to help her.
Julie works as a British Gas customer services adviser in a call centre. She finds the work boring but relieved she has a job to pay the bills. Work is flexible and it allows her to pick up Rory from the out of school club. Julie is originally from Sheffield and her dad still lives there. She manages to visit him every couple of weeks.
She split from Carl due to arguments over money. This ended up in him hitting Julie. He regretted the act but Julie did not want him back. Carl now lives in his dad’s flat, as his dad currently lives abroad. Carl pays Julie’s rent and Julie allows Rory to visit him on the weekends. She has no concerns with letting Rory stay there as they both get on well.
What should the GP examine to determine the diagnosis?
BP
Pulse
Neurological examination (however experienced GPs may do BP, pulse and perform a focused neurological examination)
The focused exam would include checking the fundi
The history and examination suggest a migraine picture. Dr Gonzalez outlines why he thinks this, in terms of her symptoms and examination findings which are normal.
He advises that migraleve could be used to relieve the symptoms and preventative medication such as a beta blocker (propranolol) could be tried to reduce the number of episodes.
Dr Gonzalez notices that Julie doesn’t seem happy with the diagnosis. There is a pause and then Julie mentions that she actually feels her migraines are due to worries about Rory.
She thinks he is a bright child but is really struggling at school. He isn’t able to concentrate and just runs around the classroom. The school suggested he visits the GP to explore the worries with them. She is worried as Rory is “so like his dad.” Carl was hyperactive at school and was often excluded due to his behaviour. Julie had high hopes to become a school teacher, as she loved biology and chemistry, but she was not able to get good grades at GCSE. She regrets that she wasn’t able to pursue her dream.
Dr Gonzalez checks with Julie if she feels at risk of domestic violence, or risk of harm from Carl now when she sees him. She is certain that she is not. Dr Gonzalez advises her that there is help available if ever she felt at risk herself, or if any concerns about Rory going there. She says that there isn’t currently, but thanked the doctor for his concern.
Dr Gonzalez suggests that Julie returns with Rory, to look into this further.
GP visit 2
Julie visits Dr Gonzalez again after three weeks. She describes she is struggling to cope with Rory’s behaviour at home. He has a short attention span for daily tasks, play and home learning activities . These problems have worsened since her partner left and she had to begin work at the call centre. Julie reports that he flits from thing to thing, doesn’t finish what he should be doing, doesn’t listen properly to instructions and rushes into things without seeing the consequence. This regularly makes them late out of the house in the morning. Julie says Rory’s impetuous behaviour means he’s always covered in bruises due to bumping into furniture at home and playing out at his dad’s.
The class teacher speaks to Julie on a weekly basis about similar problems in school.
These are as follows:
· Difficulty concentrating in whole class activities
· Fidgeting and distracting other children
· Unable to complete tasks
· He is unable to keep up with activities
· He is disrupting others’ learning
When Rory was in nursery, Julie reported that he:
· Was a handful
· Always on the go
· Climbing everywhere
· Had no awareness of danger
Nursery staff and Julie had put his behaviour down to the busy and chaotic lifestyle. Rory is now known to the school Special Educational Needs Coordinator (SENCO) .
His class teacher is supported by the SENCO to use strategies in the classroom to help Rory’s concentration.
What is the role of a SENCO? (Select FOUR)
· Co-ordinates provision in school for pupils with special educational needs (SEN)
· Liaises with other healthcare professionals to co-ordinate support for children with SEN
· Works closely with the headteacher to develop the school’s SEN policy
·Liases with parents/carers for a consistent approach at home and school to meet a child’s needs
· Is responsible for carrying out 1-1 additional teaching support with children with SEN
· Co-ordinates provision in school for pupils with special educational needs (SEN)
.
Correct answer.
· Liaises with other healthcare professionals to co-ordinate support for children with SEN
.
Correct answer.
· Works closely with the headteacher to develop the school’s SEN policy
.
Correct answer.
· Liases with parents/carers for a consistent approach at home and school to meet a child’s needs
.
Correct answer.
· Is responsible for carrying out 1-1 additional teaching support with children with SEN
.
Further information can be found at the Autism education trust
The teacher has set positive interventions to improve his behaviour, including setting clear boundaries, a visual timetable and small group work with a classroom assistant.
Julie is also worried that Rory has no friends at school. He never gets invited to parties or play dates, and she doesn’t know any of the mums due to her busy schedule.
Rory was born slightly early at 36 weeks. He spent one night in neonatal intensive care unit (NICU) for observation but has been OK since.
What differential diagnoses could explain Rory’s behaviour? (Select THREE most likely)
· Glue ear
. Hyperthyroidism
· Child neglect
· Developmental delay
· Higher than average intelligence with boredom
· ADHD
· Glue ear
. Hyperthyroidism
· Child neglect
.Correct answer.
Bruising due to poor supervision, child in distress and lack of boundaries
· Developmental delay
.Correct answer.
Prematurity can be associated with behavioural problems
· Higher than average intelligence with boredom
· ADHD
Correct answer.
Attention difficulties, possible family history, school involvement
· Victim of bullying
Dr Gonzalez checks Rory’s height and weight. As he does this, he notices a bruise on Rory’s right wrist.
Dr Gonzalez asks Julie about the bruising. Julie thinks it’s because he’s playing out a lot with older kids when at dad’s house. She knows he has late nights with dad, and his behaviour and concentration is definitely worse after he has been at dad’s place. She is adamant that Carl would never hit him.
Dr Gonzalez asks Rory if anyone has ever done anything to him which he hasn’t liked, which Rory doesn’t answer. Dr Gonzalez does not push the issue, and instead asks if he has any other bruises. Rory lifts his top to show Dr Gonzalez bruises of different ages on his arms, shoulders and chest, and also shows him bruises of his shins and knees with some grazes.
What would the GP be worried about?
The main concern is whether there is a safeguarding issue, given the apparent non-accidental bruising.
Dr Gonzalez explains to Julie that given the findings, he has some safeguarding concerns which he needs to raise with the Safeguarding Lead at the practice and the local area team. Julie understands as she cannot be sure about the cause of all the bruises.
What should Dr Gonzalez do now?
· Nothing
· Safeguarding referral
· Admit to A&E
· Safeguarding referral
.Correct answer.
If there are grounds for concern such as suspicious bruising, the referral should be made to allow further investigation. There are no immediate risks at present that require a paediatric assessment immediately.
Resources that will help with your answer:
· GMC – safeguarding children – please see the case study ‘sharing information about a child without the consent of a parent’.
Dr Gonzalez also suspects that Rory may have ADHD (Attention Deficit Hyperactivity Disorder) and refers him to the CAMHS (Child and adolescent mental health) team for assessment.
Can you summarise the problems that Rory is having that may make you suspect ADHD?
· Difficulty concentrating in whole class activities
· Fidgeting and distracting other children
· Unable to complete tasks
· He is unable to keep up with activities
· He is disrupting others learning
IN PRACTICE:
Can you find out how safeguarding referrals are handled in the practice? Does your practice have a safeguarding lead who you could speak to?
CASE COMPONENT
Further Case Information – A child with behavioural challenges
In case FM & PH – A child with behavioural challenges
GP visit: 3 months later
Julie brings Rory back to review his behaviour with Dr Gonzalez.
The safeguarding concerns were explored and there were no concerns identified.
He has been seen by CAMHS and ADHD has been diagnosed . Julie was relieved initially that it wasn’t just bad behaviour after all. Rory is due for a CAMHS review in 2 months but mum would like this expedited, as he was not progressing at school and still getting in trouble. Dr Gonzalez agrees.to write to CAMHS
CAMHS agree to see Rory sooner and start him on Methylphenidate (Equasym XL) 5mg OD.
Methylphenidate is a central nervous system stimulant that is structurally related to amphetamine.
Rory has a good response with this dose. The school initially reported significant improvement in concentration and level of work, and felt he was well prepared now for year 2. The hospital will provide the prescription initially, and then request the GP prescribe using a ‘Shared Care Protocol’.
What is a shared care protocol?
This is an agreement between primary and secondary care to share responsibility for managing a medication prescribed to a patient. Clinical responsibility remains with the consultant, but the medication is issued by the GP. GPs are not obliged to agree to this if they cannot perform the tasks for issuing, such as monitoring bloods etc.
What are the legal requirements of writing a FP10 for methyl phenidate?
Methyl phenidate is a controlled drug. This means that prescriptions are issued differently.
Background Science – A child with behavioural challenges
In case FM & PH – A child with behavioural challenges
· 1MedLearn Year 4, Case of ‘Headache’
· CASE COMPONENT
· Case Conclusion – A child with behavioural challenges
· Case Conclusion – A child with behavioural challenges
· In case FM & PH – A child with behavioural challenges
· Rory’s symptoms improved with the methylphenidate and he did not have any side effects. Julie felt that her migraines had settled and felt better in herself. She was happy that Dr Gonzalez had picked up on and looked into her concerns about Rory’s behaviour.
CASE COMPONENT
Formative Assessment – A child with behavioural challenges
Which of the following situations may prompt a safeguarding referral?
· Grace Evans is a 6 year old girl. Mum has brought her in to the GP with an unexplained vaginal discharge. She doesn’t want to be examined, and even screams when her abdomen is felt. She has recently been visiting her estranged dad and the problems started after seeing him. She is also very recluse, when she was previously very sociable even with strangers.
· Home visit – family new to area – baby + 6 and 7 year old boys - Broken dining table and coffee table stacked up at side of the room . Kitchen knives and other kitchen equipment stored out on draining board .Route to toilet impeded by stack of baby’s nappies , wipes and baby walker, resulting in boys not being able to access the toilet – boy’s clothes and carpet heavily soiled.
· Lily Powers is a 2 year old girl who comes with her mum to her mum’s appointment. The GP notices that her hair is full of headlice. She is also very thin, with poorly fitting and dirty clothes.
· Child – 18 months - left alone in the house, asleep in the cot, when mum at work, for 2 evenings per week . House locked when mum leaves . Bottles of milk left in the cot should the child wakes. Mum works at the pub round the corner Friday and Saturday night.
· Young Mum – 3 preschool children and expecting fourth. Children have no thick coat in winter. No socks and soles of feet very dirty. Children are overweight – all still have full fat milk in bottles with each meal and between on request. Mum describes them as fussy eaters.
· Children 3 and 5. Parents both have alcohol problems. Children attend nursery + school (but often arrive late). Various carers organised to pick up – neighbours, friends and grandparents all known to teachers but children never seem to know who they are going home with. Children slight in build and staff notice they are ravenous - the 6 yr old reports their tea is cereal and milk which he fixes for himself and sister
· Donny Hilton is a 7 year old boy who burnt his hand 2 weeks ago. His parents didn’t seek medical assistance until now, and the GP notices a second degree burn that is now infected.
· Grace Evans is a 6 year old girl. Mum has brought her in to the GP with an unexplained vaginal discharge. She doesn’t want to be examined, and even screams when her abdomen is felt. She has recently been visiting her estranged dad and the problems started after seeing him. She is also very recluse, when she was previously very sociable even with strangers.
.Correct answer.
There are concerns about underlying sexual abuse.
· Home visit – family new to area – baby + 6 and 7 year old boys - Broken dining table and coffee table stacked up at side of the room . Kitchen knives and other kitchen equipment stored out on draining board .Route to toilet impeded by stack of baby’s nappies , wipes and baby walker, resulting in boys not being able to access the toilet – boy’s clothes and carpet heavily soiled.
.Correct answer.
This is neglect. Hazards are present for the boys and difficulty for them to access basic needs such as the toilet.
· Lily Powers is a 2 year old girl who comes with her mum to her mum’s appointment. The GP notices that her hair is full of headlice. She is also very thin, with poorly fitting and dirty clothes.
.Correct answer.
There is clear evidence of neglect here, mainly due to Lily’s appearance.
· Child – 18 months - left alone in the house, asleep in the cot, when mum at work, for 2 evenings per week . House locked when mum leaves . Bottles of milk left in the cot should the child wakes. Mum works at the pub round the corner Friday and Saturday night.
.
Correct answer.
Mum could mention this to GP as an aside. This is a clear case of neglect, whereby there is a clear and imminent danger of the baby being left unsupported at home.
· Young Mum – 3 preschool children and expecting fourth. Children have no thick coat in winter. No socks and soles of feet very dirty. Children are overweight – all still have full fat milk in bottles with each meal and between on request. Mum describes them as fussy eaters.
.
Correct answer.
There is evidence of neglect here, with evidence of no socks or thick coat in winter. Diet is also poor.
· Children 3 and 5. Parents both have alcohol problems. Children attend nursery + school (but often arrive late). Various carers organised to pick up – neighbours, friends and grandparents all known to teachers but children never seem to know who they are going home with. Children slight in build and staff notice they are ravenous - the 6 yr old reports their tea is cereal and milk which he fixes for himself and sister
.
Correct answer.
There is evidence of neglect here, with a poor diet, parents having alcohol dependence and no structured plan for school drop offs and pick ups.
· Donny Hilton is a 7 year old boy who burnt his hand 2 weeks ago. His parents didn’t seek medical assistance until now, and the GP notices a second degree burn that is now infected.
.Correct answer.
This is a concern with neglect as parents have delayed bringing their child to seek medical assistance.
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