Managing challenging behaviour in children with possible learning disability
BMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l1663 (Published 02 May 2019) Cite this as: BMJ 2019;365:l1663All rapid responses
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Professor Angela Hassiotis and colleagues list psychosocial and behavioural interventions and drug treatments for children with severe behaviour problems and intellectual disabilities [1]. It is disappointing that, although Professor Hassiotis is a professor of intellectual disabilities, they did not mention monitored repletion of common essential nutrient deficiencies, or the avoidance of colours and additives (which can be in some drug medications), or the importance of a high protein low allergy diet. In fact, children with psychiatric disorders and learning disabilities usually have biochemical abnormalities. [2-6]
References in PubMed for intellectual disability and nutrient deficiencies include -
254 for copper deficiency
97 for zinc deficiency
92 for folic acid deficiency
47 for vitamin B12 deficiency
41 for Vitamin B 6 deficiency
17 for magnesium deficiency
8 for manganese deficiency
6 for poly unsaturated fatty acid deficiencies
A normal copper/zinc ratio is important for normal superoxide dismutase function but excess zinc can cause copper deficiency.
We need less use of mind-bending drugs or just talking and more use of biochemistry. It is very important that the best preconception care, including state-of-the-art biochemistry, is available for all and children with problems need to be monitored frequently. In our study of children with dyslexia, sweat zinc levels were measured to parts per billion. All of the dyslexic children we tested were zinc deficient while their matched controls had normal range results. [3] Animal studies suggest that low zinc in early pregnancy can programme the child's brain to over react to stress and giving a predisposition to zinc deficiency. Dr John McLaren-Howard has also found that children with autism are more likely to have toxic DNA adducts (including cadmium and nickel) which can reduce with nutritional intervention. [4]
1 Grant ECG. www.bmj.com/rapid-response/2011/10/30/children-psychiatric-disorders-and... 5 April 2005
2 Capel ID, Grant ECG, et al. Comparison of concentrations of some trace, bulk and toxic metals in the hair of normal and dyslexic children. Clinical chemistry 1981; 27: 879-81.
3 Grant ECG, Howard JM, Davies S, Chasty H, Hornsby B, Galbraith J. Zinc deficiency in children with dyslexia: concentrations of zinc and other minerals in sweat and hair. BMJ 1988; 296: 607-609.
4 McLaren Howard J. The Detection of DNA Adducts (Risk Factors for DNA Damage). A Method for Genomic DNA, the Results and Some Effects of Nutritional Intervention. J Nutr Environ Med. 2002; 12: 19-31.
5 Grant ECG. McLaren-Howard. Re: The effects of toxic metals in autistic children. http://bmj.com/cgi/eletters/329/7466/588-b#74117, 13Sep 2004.
6 Bryan J, Osendarp S, Hughes D, Calvaresi E, Baghurst K, van Klinken JW. Nutrients for cognitive development in school-aged children. Nutr Rev. 2004 Aug;62(8):295-306. Review.
Competing interests: No competing interests
Please could the authors point me to some specific recent high quality evidence for medication. In the abstract of their own reference this is not present
(Conclusions
Antipsychotic medications appear to be effective for reducing challenging behaviour in the short-term among children with intellectual disabilities, but they carry a risk of significant side effects. Findings from this review must be interpreted with caution as studies were typically of low quality and most outcomes were based on a small number of studies. Further long-term, high-quality research is needed to determine the effectiveness and safety of psychotropic medication for reducing challenging behaviour.)
As a GP it is common to be asked about children's behaviour more so since the breakdown of health visiting services and increasingly being asked to prescribe potent medication off licence long term.. This is seemingly at odds with what we are encouraged to do in adults with behaviour challenges and learning difficulty where non pharmacological remedies are the norm (resources permitting)
It is probably no coincidence that sometimes these children are living in challenging domestic situations, but does this make the use of major tranquillisers ethical?
Competing interests: No competing interests
" Well she is quite obviously not behaving normally".
I don't remember much more of that first consultation we had with our GP when my daughter was 15 months old. We had had some concerns about her delayed development and behaviour but as our first born, with plenty of medical friends and family, who had been very reassuring, this was not the comment we were expecting.
I commend the authors of the article for their thorough and clear summary of the issues and proposed clinical pathway. What they fail to mention is the importance of kindness in this situation. That first consultation may be the first time the parents have had to face the possibility that their child will not go on to develop " normally". The first time that all their hopes and expectations for the future have to be readjusted. It is difficult to describe the emotions that follow this news.
The words of that GP resonate in my head ten years on and sadly I know we are not alone in having had this experience.
Competing interests: No competing interests
Re: Managing challenging behaviour in children with possible learning disability
May I add to the call for food additives to be considered as a cause?
This is at least easily considered, and easily avoided even if only for a test period. If avoiding additives proves to be effective, the relief for the family is enormous and their child can be regarded as "normal" again.
Competing interests: No competing interests