USE OF AN IMPAIRMENT CARD FOR DEVELOPMENTAL/PSYCHIATRIC PAEDS IN THE OFFICE SETTING

BACKGROUND: In my Community Paediatrics Office, I am asked daily: Is my child or teen’s behaviour abnormal? When do we need to do something about it? Or there may be some disagreement betweem caregivers about a diagnosis and its significance. How often do we hear a story when one parent thinks that the child DOES have ADHD and the other parent disagrees? The answer is in the DSM V when we speak about impairment. Is the behaviour causing “significant impairment” most of the time, almost every day? We do not have a blood test nor a scan to diagnose developmental, behavioural and psychiatric disorders. What we have is subjective criteria per the DSM V. And so, I developed an Impairment Card (printed on Business Card Stock paper) that I can pull out and hand to the parents and child/teen to get a sense of impairment. This card has allowed me to dialogue with parents, children/teens and teachers about their challenges. It allows us to consider a “diagnose” or “disorder” and inform families about the need to DO something about the behaviour (whether it’s the need to obtain an assessment, get the child/family into therapy or consider trying or changing a medication). My hope is present the idea of an Impairment Card that would be used in the office setting. At the CPS Conference, I intend to hand out the card(s) to any CPS delegate who inquires about the use of the Impairment Card. OBJECTIVES: I developed the card to use in my office to try and generate conversation about the question of when a behaviour or mood is considered normal vs abnormal. The card states: Is there a sense that your child/teen’s emotions, behaviour and/or inattention is significantly affecting: a) School / Academics / Learning? b) Self-Esteem? c) Friendships? d) The Environment? - Home. - School. - Job. I wanted to know if such a card would be helpful to children, their parents and teachers in giving common/easy language to complex behavioural and psychiatric diagnoses. DESIGN/METHODS: The card is used to direct conversation at every visit. Let me provide you with two examples: A 7 year old child is sent to my office with a “strong will” and features of ADHD. Or a 12 year old has features of Anxiety. When do we give a diagnosis of ADHD or ODD? When is it called an Anxiety Disorder? We have DSM V criteria of ADHD, ODD and Anxiety: a) I would walk through the diagnostic criteria with the parents and/or child. b) I would ask them to complete rating scales. c) But an final question relates to HOW impairing is their inattention, hyperactivity, impulsivity, defiance or anxiety. I might ask questions / invite commentary such as: a) All of us have features of inattention or anxiety and some anger. But if it is impairing our tasks of daily living (school, self-esteem, friends, our environment), then we have a problem that we need to acknowledge. b) Is the inattention, hyperactivity, anxiety, defiance happening most of the time, almost every day? c) Is the child’s Anxiety impairing them academically? Is there hyperactivity/inattention impairing their ability to learn? d) Is their self-esteem falling because of their anxiety or inattention? e) Is their Anxiety and/or Hyperactivity/Anger affecting their ability to develop friendships? f) Is their child’s Anxiety and/or Hyperactivity/Anger affecting their home life? Are they driving their parents crazy? Are they driving the teachers crazy? This is actually not dissimilar to when we complain of our knee or shoulder hurting. Our own sense of impairment is going to drive our plans to take time off work and present to the doctor or the ER. It’s the same with behavioural and psychiatric issues. Impairment drives what we do. RESULTS: The information/feedback I’ve received from parents, children/teens and teachers has made me aware how valuable the Impairment Card is in my office: a) The card is VERY simple to use. There is no need for big/complex/onerous forms to complete. b) The parents can take it away in their wallet and pull it out at the parent-teacher interview to invite dialogue at school from the teachers about impairment at school. c) The card invites parents to talk between themselves about the sense of impairment and how we all have our own subjective sense of how bad (or good) the sitaution is. Impairment also varies with time and context. d) I’ve had teachers ask me to send them cards so that they can pull it out at the P-T interviews. e) Commentary about “impairment” now comes out at every visit (first visit and every follow up visit). And I have a stamp in my EMR to routinely bring the subject up. f) Parents very much appreciate the statement that a child’s behaviour can be very impairming for their own (mom/dad’s) mental health and the “health” of the household. CONCLUSION: The Impairment Card is VERY easy to use and hand out in an office setting. The Card invites conversation about impairment. I ask the parents to go home and talk regularly with their spouses, teachers and the kids about how “impairing” their child’s behaviour is. It has become an immensely useful tool in my office to help me explain when a behaviour becomes a “disorder”. And more important, it help drive understanding and change.(Fig 1)

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