Diagnosis in developmental-behavioural paediatrics: the art of diagnostic formulation

Child and adolescent mental health multiaxial classification: A useful biopsychosocial framework for paediatrics?

In child and adolescent psychiatry, the multiaxial classification approach has been developed over some decades and remains very relevant as it encapsulates the biopsychosocial approach, an approach which is also central to paediatric practice. There is considerable overlap between developmental-behavioural paediatrics and child and adolescent mental health, including presenting clinical problems, diagnoses, multidisciplinary and holistic approach to assessment and management, and similar use of pharmacological agents and psychosocial interventions. Multiaxial classification can be of use to paediatricians in a variety of ways, both in clinical practice and for teaching purposes. It can improve communication between the two disciplines and promotes a more holistic diagnostic representation in a structured and consistent format. Presented here are a number of practical ways in which the multiaxial biopsychosocial framework can be used, including case description, formulation, timeline and interventions, training and teaching.

Innovations in practice: Adaptation of developmental and behavioral pediatric service in a tertiary center in Singapore during the COVID-19 pandemic

BACKGROUND

As the coronavirus 2019 pandemic continues, healthcare services need to adapt to continue providing optimal and safe services for patients. We detail our adaptive framework as a large Developmental and Behavioral Pediatrics service in a tertiary academic institution in Singapore.

METHODS

The multidisciplinary team at our unit implemented various adaptations and workflow processes during this evolving pandemic in providing continued clinical care tailored to the challenges specific to our patient population. Services were continued via teleconsultation mode during the 'Circuit Breaker' (enhanced movement restriction) period. Specific workflow processes, IT infrastructure, and staff training were put in place to support smooth running of this service. Segregation of services into two teams based at two separate sites and implementation of stringent infection control measures surrounding the clinic visit by providers, patients and their families were incorporated to ensure safety. Measures were also taken to ensure providers' mental wellbeing.

RESULTS

The clinical service was continued for the majority of our patients with a lowest reduction in patient consultations to half of baseline during the 'Circuit Breaker' period. We received positive feedback from families for teleconsultation services provided.

CONCLUSION

We have been able to continue services in our DBP clinics due to our dynamic reassessment of workflow processes and their prompt implementation in conjunction with the hospital and national public health response to the pandemic. Given that this pandemic is likely to be long drawn, our unit remains ready to constantly adjust these workflows and make adaptations as we go along, together with the support for mental health of patients, parents and staff. Continual improvements in workflows will be helpful even beyond the pandemic to ensure good continuity of care for our patients and families.

The complexity of early diagnostic decision making: A follow-up study of young children with language difficulties

Background & aims

Due to the complexity of early diagnostic decision making, we examined the predictive value of an early diagnostic classification and early abilities on later best estimate diagnosis for 22 clinically referred children with language difficulties.

Methods and procedures

Four years after initial evaluation (Time 1), the clinical files of these children were reviewed. A best-estimate (BE) diagnosis of language disorder (LD), intellectual disability (ID), or autism spectrum disorder (ASD) was established, with ASD being most common.

Outcomes and results

Early clinical classifications were relatively unstable or difficult to establish at a young age. The magnitude of children's cognitive and receptive language delay was a significant predictor of a later BE diagnosis of ID and LD respectively. A BE diagnosis of ASD, by contrast, could not be predicted from children's early social communication problems nor the presence of restricted and repetitive behaviors and interests.

Conclusions

Taken together, the results of this study suggest that language difficulties can be an early marker of a neurodevelopmental disorder which is often not identified at the age of first referral.

Implications

Eligibility for treatment should, therefore, be based on biopsychosocial case formulation rather than DSM or ICD diagnostic classification.

What this paper adds?

In this study a dimensional approach was used to characterize the abilities of young children referred with mild to profound receptive and/or expressive language difficulties. Later on, a categorical approach was adopted to establish best estimate diagnoses. Our clinical, broadly defined sample reflects the heterogeneous intake of young children referred for diagnostic assessment. Other studies on diagnostic stability often only focus on one diagnostic category (and are explicitly excluding children with specific other diagnoses), not taking into account the difficulties of early differential diagnostic decision making and stability across different categories over time. Investigations of differential diagnosis within a clinical group, instead of only differentiating children with a specific diagnosis from typically developing children, may be more informative for clinicians.

Neurodevelopmental-behavioural paediatrics

PURPOSE OF REVIEW

Neurodevelopmental-behavioural paediatrics (NBP) is a field of medical practice that has arisen in response to recent changes in child health epidemiology. This review considers how the profession of NBP is addressing clinical need, and discusses possibilities for future development of the field.

RECENT FINDINGS

Research publications relevant to NBP clinical practice focus primarily on cause (e.g. biology, imaging, neuropsychology), early detection, diagnostic methodologies and initial treatment strategies, with emphasis on psychotropic medication. Translation of this research implies that NBP clinical services should be undertaken using algorithmic methodologies, and evaluated against treatment attributable outcomes. These strategies and outcomes potentially define the central purpose of the profession; however, they may not be sufficient to best help the children seen.

SUMMARY

Two sets of information inform and extend consideration of NBP purpose and strategy. Firstly, longitudinal and adult studies indicate that even with treatment, problems persist in adult life for a significant proportion of children with neurodevelopmental-behavioural disorders. Secondly, NBP clinical practice deals with significant, irreducible complexity and uncertainty, arising from both child-diagnostic and contextual factors. Complexity limits the extent to which evidence-based clinical algorithms are able to inform care. Suggestions for how to address both challenges are offered.

Child with multiple problems: Clinical complexity and uncertainty

When practising neurodevelopmental-behavioural paediatrics, responsibility rests with the individual clinician to interpret research evidence in their daily work. This is not necessarily an easy task. Children do not usually present with single, easily definable problems. Complexity and uncertainty are present from the outset due to heterogeneity inherent in the diagnoses available, patterns of comorbid problems and the unique challenges of each child's social context. This article examines the resulting clinical challenge and offers potential responses. Rather than striving to eliminate uncertainty with strategies such as extensive assessment, the goal is to work effectively and efficiently within the limits of what can be readily known. Suggested strategies address complexity by considering the components of what is going on (biological, developmental, transactional) as hypotheses shared within each child's system of care. These hypotheses can then be tested and revised systematically as further information arises along the journey of treatment and longitudinal care.

Quality of Diagnosis and Treatment Plans After Using the 'Diagnostic Guideline for Anxiety and Challenging Behaviours' in People with Intellectual Disabilities: A Comparative Multiple Case Study Design

BACKGROUND

People with intellectual disabilities often have a multitude of concurrent problems due to the combination of cognitive impairments, psychiatric disorders (particularly anxiety) and related challenging behaviours. Diagnoses in people with intellectual disabilities are complicated. This study evaluates the quality of the diagnoses and treatment plans after using a guideline that was developed to support professionals in their diagnostic tasks.

MATERIALS AND METHODS

A comparative multiple case study with an experimental and control condition, applying deductive analyses of diagnoses and treatment plans.

RESULTS

The analyses revealed that the number of diagnostic statements and planned treatment actions in the experimental group was significantly larger and more differentiated than in the control condition. In the control group, consequential harm and protective factors were hardly mentioned in diagnoses and treatment plans.

CONCLUSIONS

Working with the 'Diagnostic Guideline for Anxiety and CB' leads to improved diagnoses and treatment plans compared with care as usual.

Prevalence and outcomes of breast milk expressing in women with healthy term infants: a systematic review

BACKGROUND

Expressing breast milk has become increasingly prevalent, particularly in some developed countries. Concurrently, breast pumps have evolved to be more sophisticated and aesthetically appealing, adapted for domestic use, and have become more readily available. In the past, expressed breast milk feeding was predominantly for those infants who were premature, small or unwell; however it has become increasingly common for healthy term infants. The aim of this paper is to systematically explore the literature related to breast milk expressing by women who have healthy term infants, including the prevalence of breast milk expressing, reported reasons for, methods of, and outcomes related to, expressing.

METHODS

Databases (Medline, CINAHL, JSTOR, ProQuest Central, PsycINFO, PubMed and the Cochrane library) were searched using the keywords milk expression, breast milk expression, breast milk pumping, prevalence, outcomes, statistics and data, with no limit on year of publication. Reference lists of identified papers were also examined. A hand-search was conducted at the Australian Breastfeeding Association Lactation Resource Centre. Only English language papers were included. All papers about expressing breast milk for healthy term infants were considered for inclusion, with a focus on the prevalence, methods, reasons for and outcomes of breast milk expression.

RESULTS

A total of twenty two papers were relevant to breast milk expression, but only seven papers reported the prevalence and/or outcomes of expressing amongst mothers of well term infants; all of the identified papers were published between 1999 and 2012. Many were descriptive rather than analytical and some were commentaries which included calls for more research, more dialogue and clearer definitions of breastfeeding. While some studies found an association between expressing and the success and duration of breastfeeding, others found the opposite. In some cases these inconsistencies were compounded by imprecise definitions of breastfeeding and breast milk feeding.

CONCLUSIONS

There is limited evidence about the prevalence and outcomes of expressing breast milk amongst mothers of healthy term infants. The practice of expressing breast milk has increased along with the commercial availability of a range of infant feeding equipment. The reasons for expressing have become more complex while the outcomes, when they have been examined, are contradictory.