In every diagnostic and evaluative process of a child suffering from a mental disorder, it is necessary to take into account the possibility that an organic condition exists that is causing or exacerbating the disorder. A physical examination must be performed, including a full neurological examination and routine blood tests. In every case where there is a suspicion of physical illness, experts from other fields must be consulted and supplementary tests performed, such as imaging procedures. Overlooking a physiological factor and delaying treatment of it is liable to be fatal or lead to irreparable damage, therefore a high suspicion index and a rapid response on the part of the psychiatrist are essential.
Several physical disorders may produce psychiatric symptoms: they include tumours, intoxications, nutritional deficiencies and metabolic disorders. Unusual mental symptoms, positive results in physiological or neurological examinations or laboratory tests, signs of cognitive impairment or a family history of hereditary physical illness must all arouse suspicion and stimulate further investigation.
An additional significant element is the high risk of comorbidity between ''difficult child'' syndromes and a secondary organic disorder due to physical injury. For example, children suffering from ADHD tend to bruise more easily, suffer from injuries demanding hospitalization and from head injuries and develop organic residua. In a study by DiScala et al. , the characteristics of injuries suffered by ADHD children were compared to those of children not suffering from this disorder. It was found that children suffering from ADHD are more likely to be injured as pedestrians or cyclists and to suffer from self-inflicted injuries. In addition, they are more likely to suffer from multiple physical injuries, head injuries and more severe injuries. The time they spent in hospital was longer, and they were referred to the intensive care unit more frequently. In this study, 53% of the cases resulted in long-term injury or disability, as opposed to 48% in non-ADHD children. As a result, they were also referred more often to rehabilitation wards. Another study , conducted in children who suffered closed head injuries, showed a high prevalence of ADHD prior to the injury. In addition, many children developed ADHD after the injury.
The possible development of a vicious circle, in which ADHD or behaviour disorder will expose the child to physical injury, and the physical injury will lead to a deterioration of behaviour, should be considered.
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