ADHD and autism

Question 1

3 Core symptoms of ADHD?

Answer 1

1) Inattention
2) Hyperactivity
3) Impulsiveness

Question 2

RF and Ex of ADHD?

Answer 2

Ex:
- most common neurobehavioral disorder in children
- 3-5% of school aged children
- MALE > Female
RF:
- Genetically inherited
- Maternal smoking, alcohol, drugs
- Low birth weight

Question 3

Inattention symptoms:

Answer 3

1) Careless with detail
2) Fails to sustain attention
3) Fails to complete tasks
4) Does not appear to listen
5) Poor self-organisation
6) Loses things and forgetful
7) Easily distracted

Question 4

Hyperactivity symptoms:

Answer 4

1) Leaves seat in cless
2) Running/climbing about
3) Restless
4) Fidgeting with feet and hands

Question 5

Impulsiveness symptoms:

Answer 5

1) Blurts out answers
2) Talks excessively
3) Interrupts others
4) Poor road safety
5) Teenage pregnancy
6) Alcohol/substance misuse

Question 6

Presentation in primary school and adolescent children?

Answer 6

Primary school: MAINLY HYPERACTIVTY - distractibility, motor restlessness, specific learning disorders, aggressive behaviour, impaired family relationships, low self-esteem

Adolescents: Inattention - poor organisation, forgetful, loses things, aggressive/antisocial, alcohol and drugs.
As child ages the outward hyperactivity declines but remains inwards (restless and frustrated) - and increase in inattention and impulsivity.

Question 7

How do girls present with ADHD?

Answer 7

• Can be very overwhelmed and stressed, try to camouflage symptoms. Lots of effort but low performance in class.

Question 8

Comorbidity of ADHD?

Answer 8

• 50-80% of ADHD children have co-morbid disorder (rarely on its own) - specific learning disorder, autism spectrum disorder, anxiety, depression, bipolar

Question 9

Ddx of ADHD?

Answer 9

• Learning difficulty
• Hearing impairment
• Low/high IQ
• Behavioural disorder
• Anxiety disorder

Question 10

Dx of ADHD?

Answer 10

1) Developmental inappropriate levels
2) Be present across time and situations (school and home) for at least 6 months
3) ONSET BEFORE 7 YRS of AGE
4) Questionnaires and scales not diagnostic alone: CONNER’S RATING SCALE + SDQ (strengths and difficulties questionnaire)

Question 11

What situations do symptoms typically worsen?

Answer 11

1) Unstructured situations
2) Boring situations
3) Unsupervised
4) Repetitive activity
5) Lots of distraction
- Observing child via covert school nurses in varying contexts important to assess presence and severity of ADHD.

Question 12

Treatment of ADHD?

Answer 12

• By specialist (paeds or psych)
  1) Psycho-education: Patient + family educated about symptoms, typical course and potential treatments (1st line)
  2) Behavioural interventions: Encourage realistic expectations, positive reinforcement of desired behaviours, school intervention, treat co-morbidity.
  3) Pharmacological:
• METHYLPHENIDATE (CNS stimulant - amphetamine) - immediate release or modified release (longer lasting better + lasts school day)
• ATOMOXETINE (norepinephrine reuptake inhibitor - 2nd line) - only if methylphenidate doesn’t work + for substance misuse or anxiety problems - OD for 24-hour cover. Takes 6 weeks for full effect.
• DEXAMFETAMINE (treatment-resistant ADHD)

Question 13

Side-effects of methylphenidate and atomoxetine?

Answer 13

Methylphenidate - abdominal pain, anorexia, appetite suppression (growth suppression), nausea, vomiting, insomnia, RISK OF SUBSTANCE MISUSE
Atomoxetine - anorexia, dry mouth, nausea, vomiting

Question 14

Autism Spectrum Disorders brief:

Answer 14

• Group of lifelong developmental disorders characterised by:
  1) Impaired social interaction
  2) Speech and language disorders
  3) Rigidity, impaired imagination and routine/ritualistic behaviour
• Ranges from severe autism with or without severe learning difficulties to the older Asperger syndrome, to autistic features secondary to other clinical problems.

Question 15

Ex and RF for autism?

Answer 15

• MALE
• FH
• presents between 2 and 4 years when language and social skills usually rapidly expand.

Question 16

Impaired social interaction presentation?

Answer 16

1) Does not seek comfort, share pleasure or form close friendships
2) Prefers own company, in interest or ability in interactive with peers
3) Gaze avoidance
4) Socially and emotionally inappropriate behaviour
5) Lack of appreciation for social cues

Question 17

Speech and language disorder?

Answer 17

1) Developmental delay - could be severe
2) Lack of facial expressions and gestures, monotonous voice
3) Impaired comprehension and literal interpretation of speech
4) Echolalia (echoes questions)

Question 18

Rigidity/impaired imagination and routine/ritualistic behaviour?

Answer 18

1) Imposition of routine on others with violent temper tantrums if disrupted
2) Unusual stereotypical movements (hand flapping or tiptoe gait)
3) Poverty of imagination in play and general activities
4) Repetitive adherence and peculiar interests

Question 19

Co-morbidity with autism?

Answer 19

• Depression
• Anxiety
• Bipolar
• Learning disability
• Seizures

Question 20

Diagnosis of autism?

Answer 20

• RED FLAD - child starts learning words then 22 months later STOPS TALKING
• Observation of behaviour
• Diagnostic tools - Autistic diagnostic interview-revised (ADI-R), Diagnostic interview for social and communication disorders (DISCO)

Question 21

Treatment of autism?

Answer 21

• Education and information, ASD parenting workshop, school liaison/support.
• Adaptation of child’s environment, activities and routines (visual timetabling)
• Communication interventions: PECS (picture exchanging communication system)
• ABA (applied behavioural analysis) - best treatment approach but requires 25-30 hours of individual therapy each week - behaviour modification approach that helps reduce ritualistic behaviour, develop language, social skills and play)