ADHD + Learning disabilities Flashcards

Question

What did the Russell Barkley Milwaukee Study of 2008 show about people with ADHD and workplace, driving and substances?

Answer 1

Workplace Fired 2-4xmore 18 x more disciplinary actions 22 days more absenteeism Monthly income 20-40% less Driving 2-4x more likely in car crash 2-4x banned from driving Substances 2-3x more likely abuse tobacco 3-8x more likely abuse alcohol 8x more likely drug dependence

Answer 2

Relationships 10x risk of unwanted pregnancy 4x risk more risk of std’s Fewer close friends Higher risk extra marital affairs Education 30-40% SEN Lower reported grades below C 50% of adults need additional tutoring 3.5x less likely to enter college

Answer 3

Meet full criteria for ADHD ADHD...Significant impact In at Least One Domain of Everyday Life After Environmental Modification Stress Importance of Balanced Diet/Regular Exercise Mental Health Educational enivronment Social circumstances Neurodevelopment co morbidity

Answer 4

Underage pregnancy Detentions Self harm Bing eating Poor organisation Hyperfocus Meltdowns Social rejections Cyberbullying Zoning out Overwhelmed

Answer 5

Sleep difficult Giggles Fidgets Bites nails Hair play Not achieving full academic potential Friendship difficulties Talks too much Moody Meltdowns Looses it

Answer 6

Hyperkinetic disorder is diagnosed by specialists and treatment depends on whether the patient is pre-school, school-age or adult, as well as the severity of symptoms. Support for parents and teachers is crucial. Support groups include add+up and ADDISS. If there is a clear link between food or drink consumed and behaviour, parents should be advised to keep a food diary and a referral to a dietician can be made if appropriate.

Answer 7

Parent-training and education programmes (psychoeducation) are first-line. Parent-training is behavioural with parents being helped to reinforce positive behaviour and to find alternative ways of managing disruptive behaviour. Drug treatments are not recommended.

Answer 8

Psychoeducation and CBT (and/or social skills training) should be provided. 209 In severe hyperkinetic disorder in school-age children, drug treatment is first-line with the CNS stimulant methylphenidate (Ritalin) being the usual choice. Atomoxetine (and if this fails, dexamfetamine) is the alternative when methylphenidate has been ineffective. Side effects should be monitored for. Side effects of CNS stimulants include headache, insomnia, loss of appetite and weight loss. Recent studies show no clear link between extended stimulant use and growth retardation.

Answer 9

Ritalin Elvanse Strattera Intuniv

Answer 10

Learning disability (LD) is a state of arrested or incomplete development of the mind. It is characterized by impairment of skills manifested during the developmental period, and skills that contribute to the overall level of intelligence. ICD-10 divides LD into four categories depending on the severity (see ICD-10 box). A triad must exist to constitute a learning disability. This includes (1) Low intellectual performance (IQ below 70). (2) Onset at birth or during early childhood. (3) Wide range of functional impairment including social handicap due to reduced ability to acquire adaptive skills (activities of daily living).

Answer 11

Mild → IQ = 50–70 (Mental age = 9–12) Moderate → IQ = 35–49 (Mental age = 6–9) Severe → IQ = 20–34 (Mental age = 3–6) Profound → IQ = <20 (Mental age <3 years)

Answer 12

Perinatal: Birth asphyxia, intraventricular haemorrhage, neonatal sepsis. Neonatal: Hypoglycaemia, meningitis, neonatal infections, kernicterus. Postnatal Infection (e.g. meningitis, encephalitis), anoxia, metabolic (e.g. hypothyroidism, hypernatraemia), cerebral palsy. Environmental: Neglect/non-accidental injury, malnutrition, socioeconomically deprived. Psychiatric: Autism, Rett’s syndrome. Antenatal: Congenital infection (rubella, CMV, toxoplasmosis), nutritional deficiency, intoxication (alcohol, cocaine, lead), endocrine disorders etc Genetic: Down’s syndrome, fragile X syndrome, Cri du chat, Prader–Willi etc

Answer 13

The prevalence of LD is 2%: 85% of these are mild, 10% moderate and 5% severe or profound. The ♂ to ♀ ratio is 3:2. The most common risk factor is a positive family history of LD.

Answer 14

Mild LD: Usually identified at a later age when the child starts school. They have adequate language abilities, social skills and self-care. There may be difficulties in academic work. Most live independently but may need some support in housing and employment. Moderate LD: Able to communicate but language is limited. May need supervision for self-care but able to do simple work. Severe LD: There is a marked degree of motor impairment. Little or no speech in early childhood but may eventually use simple communication. May be able to perform simple tasks under supervision. They may have associated physical disorders. Profound LD: Severe motor impairment and severe difficulties in communication. Have little or no self-care. Frequently have physical disorders and require residential care.

Answer 15

Common physical disorders include motor disabilities (e.g. ataxia, spasticity), epilepsy, impaired hearing and/or vision and incontinence (faecal and urinary). Specific causes are uncommon in mild LD whereas they are usually identifiable in severe or profound LD.

Answer 16

Down’s syndrome: A genetic disorder (trisomy 21) characterized by LD, dysmorphic facial features and multiple structural abnormalities. It is the commonest cause of LD.

Answer 17

PROBLEMS Palpebral fissure (up slanting), Round face, Occipital + nasal flattening, Brushfield spots (pigmented spots on iris)/Brachycephaly, Low-set small ears, Epicanthic folds, Mouth open + protruding tongue, Strabismus (squint)/Sandal gap deformity/Single palmar (Simian) crease

Answer 18

heart defects (ventricular and atrial septal defects, ToF), hearing loss, visual disturbance (cataracts, strabismus, keratoconus), GI problems (oesophageal/duodenal atresia, Hirschsprung’s, coeliac), hypothyroidism and haematological 212 malignancies (AML, ALL), increased incidence of Alzheimer’s

Answer 19

The second most common cause of LD. A sex-linked disorder with developmental, physical and behavioural problems. Physical features: Large, protruding ears, long face, high arched palate, flat feet, soft skin, lax joints. Medical problems: Mitral valve prolapse.

Answer 20

Due to a deletion of part of chromosome 15. Characterized by hypotonia and developmental delay as an infant, and obesity, hypogonadism and behavioural problems (compulsive eating, disruptive behaviour) in later years

Answer 21

: Caused by a partial deletion of chromosome 5. Those affected have a high-pitched cry like a cat. Low birth weight and feeding difficulties are also characteristic.

Answer 22

‘Did you have any issues during your pregnancy?’, ‘Were all of the antenatal scans normal?’, ‘Was the baby premature?’, ‘Were there any complications during the delivery?’, ‘What was the condition of the baby when he/she was born?’ (pregnancy related factors) ‘Is there any history of conditions, specifically learning disability, which run in the family?’, ‘Do you and your partner have any mutual relatives?’ (family related factors) Depending on age: ‘How does your child cope with daily activities?’, ‘Did they reach their milestones at the proper time, for instance at what age did they start walking?’, ‘Do they have any known medical problems?’ (clinical features) Ask about associated medical problems and screen for co-morbid psychiatric problems.

Answer 23

Appearance will vary depending on the cause of learning disability, for example the type of genetic disorder (see Key facts 1). The extent of behaviour problems is determined by the level of LD. In more severe cases there may be motor impairment. There is often speech disturbance and mood can be low or normal.

Answer 24

Cardiovascular, respiratory, neurological (cranial nerves and peripheral), weight/height/head circumference, developmental assessment.

Answer 25

Early-onset Alzheimer’s disease, schizophrenia, anxiety and depressive disorders, autism, hyperkinetic disorder, eating disorders, personality disorders.

Answer 26

Before birth: Amniocentesis, chorionic villus sampling, genetic testing and karyotyping. For Down’s syndrome: Two methods, (1) Serum screening (β-hCG and pregnancy-associated plasma protein A) + nuchal translucency; (2) Quad test (β-hCG, α-fetoprotein, inhibin A, estriol). After birth: Bloods: FBC (infection), TFTs (hypothyroidism), glucose (hypoglycaemia), serology (ToRCH infections). 213 Brain imaging: CT head and/or

Answer 27

A multidisciplinary approach is vital. Care is provided by a variety of health care professionals including a psychiatrist, speech and language therapist, specialist nurses, psychologist, occupational therapist, social worker and even teachers (for educational support). The GP must be involved in the care of the individual as physical health problems are common. Treatment of co-morbid medical conditions and psychiatric problems is vital. Antipsychotics can be used for challenging behaviour but are overused. Behavioural techniques such as applied behavioural analysis, and positive behaviour support, as well as CBT can be used. Psychiatrists, mental health nurses and psychologists can support carers with these strategies. Family education is essential and support should be offered through educational programmes and voluntary organizations. Prevention can be attempted through genetic counselling and antenatal diagnosis.

Answer 28

Autism is a pervasive developmental disorder characterized by a triad of impairment in social interaction, impairment in communication, and restricted, stereotyped interests and behaviours.

Answer 29

Genetics: There is a complex polygenic relationship, with a number of chromosomes implicated, such as chromosome 7. There is a significantly increased risk of autism associated with genetic syndromes such as fragile X syndrome and tuberous sclerosis. Parental age: A study found that women who are 40 years old have a 50% greater chance of having a child with autism as compared with women aged 20–29 years. Drugs: Babies who have been exposed to certain medications in the womb have a greater risk of developing autism. These include sodium valproate in particular. Infection: Prenatal viral infections (e.g. rubella) increase the risk of autism.

Answer 30

Obstetric complications such as hypoxia during childbirth, ↓ gestational age at birth, as well as very low birthweight offer increased risk of autism.

Answer 31

Toxins such as lead and mercury may increase the risk of autism. Pesticide exposure may affect those genetically predisposed to autism

Answer 32

Male Males are 4 × more likely to be affected than females. Genetics/Family history There is an 88% concordance rate in monozygotic twins, indicating a strong genetic component. Advancing parental age Recent studies have suggested that advancing parental age is a significant risk factor for ASD. Parental psychiatric disorders Evidence suggests a link between parental psychiatric disorders such as schizophrenia and the child having autism. Prematurity Born before 35 weeks’ gestation. Maternal medication use ↑ with mothers receiving sodium valproate during pregnancy.

Answer 33

Struggle to access healthcare 9x higher risk of death by suicide than general pop 70% have co-morbidity 1 in 4 are non-speakers, prefer AAC Affects 1 in 54 people

Answer 34

At 3 months babies babble ‘conversation’ with mother Eager demand for social interaction Second year of life Development of speech Development of imagination with pretend games Act out thoughts and actions of other persons These are impaired in autism : organic damage, environmental factors Kanner’s Autism---------------Asperger’s Syndrome Autism Spectrum Disorder - 1% of childhood population (Baird et al, 2006)

Answer 35

DSM IV had 4 subcategories of pervasive developmental disorder which have all been combined into ASD - Autistic Disorder, Asperger’s Disorder, Pervasive Developmental Disorder, Not Otherwise Specified (PDD-NOS), and Childhood Disintegrative Disorder (CDD). These were removed in recognition of the difficulty in distinguishing them and different clinician interpretation.

Answer 36

The two categories of social impairment and language impairment have been simplified into one; persistent deficits in social communication/interaction Sensory issues has been added as a symptom under the restricted/repetitive behavior category. A severity assessment scale (levels 1-3) based on level of support needed for daily function has been added although there is a variation in its usage New diagnosis of social communication disorder, for disabilities in social communication without repetitive, restricted behaviors.

Answer 37

Asocial Few social gestures, e.g. waving, nodding and pointing at objects. Lack of: Eye contact (gaze avoidance), social smile, response to name, interest in others, emotional expression, sustained relationships and awareness of social rules. Behaviour restricted Restricted, repetitive and stereotyped behaviour, e.g. rocking and twisting. Upset at any change in daily routine. May prefer the same foods, insist on the same clothes and play the same games. Obsessively pursued interests. Fascination with sensory aspects of environment. Communication impaired Distorted and delayed speech (often the first sign which is noticed). Echolalia (repetition of words). Sensory Hyper/Hypo Reactivity

Answer 38

To reach the threshold of a diagnosis, patients must meet all criteria A and at least 2 of B in the presence of C,D and E. Persistent deficits in social communication and social interaction Restricted, repetitive patterns of behaviour, interests, or activities Symptoms must be present in the early developmental period Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay.

Answer 39

Core Autism features Developmental history Functioning: home/education/employment Physical, mental & behavioural disorders Neuro-developmental disorders Sensory sensitivities Attention to detail Direct observation of Core features Social situations

Answer 40

Social-emotional reciprocity info dumping, direct answers to questions, literal interpretation, abstract language difficult to interpret, alexithymia. Written asynchronous communication often preferred Nonverbal communicative behaviours used for social interaction facial expressions mis-match, eye gaze differences, hand gestures Developing, maintaining, and understand relationships communicate well with autistic people, auditory processing speed and working memory, authenticity, justice over relationship, doesn’t follow society’s expectations

Answer 41

Stereotyped or repetitive motor movements, use of objects or speech. Toe-walking, spinning, flapping, tics, tapping, intense attachment to objects Highly restricted, fixated interests that are abnormal in intensity or focus. Special interests that bring joy, wide-range of interest. Range from single, to short intense interests (can be people) often open the world, used for comfort at times of stress Preference for sameness, and strong adherence to routines, or ritualised patterns of verbal or nonverbal behaviour Anxiety response. Autistic inertia makes seemingly simple transitions difficult Restricted eating patterns Hyper- or hypo-reactivity to sensory input. Neurological differences in perception. Sound, touch, proprioception, vision, olfactory, taste Interoception

Answer 42

Category C - not acquired, (e.g.not TBI or anxiety/mood disorder etc). Can be hard if childhood trauma, attachment. Acknowledgement that might not present until demand exceeds capacity Category D - significant impairment (adults are usually diagnosed at a period of breaking point) Category E - not better explained by something else

Answer 43

Anxiety – 90% including social anxiety Sleep difficulties Auditory processing speed, working memory Hypermobility EDS, POTs over-represented Difficulty advocating and expressing needs Alexithymia – Difficulty recognising feelings Stress makes things worse in Autism/ADHD as can't mask Overwhelm – Autistic Burnout

Answer 44

50% of parents have cause for concern by 12–18 months of age. The onset of autism is before the age of 3 years. There is also a diagnosis of atypical autism after the age of 3

Answer 45

Epileptic seizures: ~20% develop this. Visual impairment. Hearing impairment. Infections. Pica: Eating inedible objects. Constipation. Sleep disorders. Underlying medical conditions: PKU, fragile X, tuberous sclerosis, congenital rubella, CMV or toxoplasmosis. Psychiatric: Hyperkinetic disorder, depression, bipolar affective disorder, anxiety, psychosis, OCD, DSH.

Answer 46

Does your child ever engage in pretend play alone or with others?’, ‘Does your child struggle to interact with others and make friends?’ (social interaction poor) ‘Have you noticed any patterns in their behaviour?’, ‘Does your child insist on the same toys, activities or foods?’, ‘Have you noticed them making any abnormal movements such as flapping their hands or walking on tiptoes?’ (repetitive, stereotypical behaviour) ‘Do they struggle to communicate with you?’, ‘Have you noticed that their speech is monotonous or repetitive?’ (impaired communication) ‘What sort of games does your child play and with what toys?’ (unimaginative play) ‘Do you have any concerns about your child’s development?’ (developmental history)

Answer 47

A. Presence of abnormal or impaired development before the age of three. B. Qualitative abnormalities in social interaction. C. Qualitative abnormalities in communication. D. Restrictive, repetitive and stereotyped patterns of behaviour, interests and activities. E. The clinical picture is not attributable to other varieties of pervasive developmental disorder

Answer 48

Appearance & Behaviour Ritualized, stereotyped behaviour, e.g. clapping, rocking. Poor eye contact, detached. Lack of facial expression and gestures. May attach to unusual items. Speech Delayed speech. Difficulty initiating and maintaining conversation. Repetitive language. May have unusual rate, rhythm and volume. Mood Normal or have erratic mood changes (can appear to have a labile mood). Thought Obsessions and compulsions. Intense preoccupation with special interests. Perception May be very sensitive to noise, touch or smell. Cognition Impaired attention but may also be able to concentrate on special interests. Insight May be poor but they may be distressed if aware they are different/don’t fit in.

Answer 49

Full developmental assessment including family history, pregnancy, birth, medical history, developmental milestones, daily living skills and assessment of communication, social interaction and stereotyped behaviours (see OSCE tips). Hearing tests if required. Screening tools including CHAT (CHecklist for Autism in Toddlers).

Answer 50

Asperger’s syndrome* Rett’s syndrome* Childhood disintegrative disorder* Learning disability Deafness Childhood schizophrenia

Answer 51

Asperger’s syndrome: Similar to autism with abnormalities in social interaction and restricted, stereotyped, repetitive interests and behaviours. However, unlike autism, there is no impairment in language, cognition or intelligence (IQ normal). It is more prevalent in boys.

Answer 52

Severe, progressive disorder starting in early life. Results in language impairment, repetitive stereotyped hand movements, loss of fine motor skills, irregular breathing and seizures. Almost exclusively seen in girls. The MECP2 gene’s role in Rett’s syndrome has been identified.

Answer 53

Characterized by two years of normal development followed by loss of previously learned skills (language, social and motor). Also associated with repetitive, stereotyped interests and behaviours as well as cognitive deterioration.

Answer 54

A full developmental assessment is essential in any child with suspected autism, paying particular attention to communication and social interaction. SPEECH and HEARING developmental milestones: 3 months → turns towards sound, quietens to parent’s voice. 6 months → double syllables e.g. ‘adah’. 9 months → says ‘mama’ and ‘dada’. 12 months → knows and responds to own name. 12–15 months → knows about 2–6 words, understands simple commands. 2 years → combines two words. 3 years → talks in short sentences (e.g. 3–5 words), asks ‘what?’ and ‘who?’ questions. 4 years → asks ‘when?’, ‘how?’ and ‘why?’ questions. SOCIAL BEHAVIOUR developmental milestones: 6 weeks → smiles (refer at 10 weeks if not smiling). 6 months → enjoys interaction. 1 year → waves bye-bye. 2 years → interested in other children. 3 years → make believe play. 4 years → plays with other children

Answer 55

Diagnosis should be by a specialist and can be reliably made at age 3. Local autism teams (community-based multidisciplinary teams including paediatricians, psychiatrists, educational psychologists, speech and language therapists and occupational therapists) should ensure that all those diagnosed with autism have a key worker to manage and coordinate treatment. CBT can be used if the child has the verbal and cognitive ability to engage and is motivated. Interventions for life skills include support developing their daily living skills, their coping strategies and enabling access to education and community facilities such as those related to leisure and sports. Ensure all physical health, mental health and behavioural issues are addressed (Key facts 1). Families and carers should also be offered personal, social and emotional support. Self-help groups such as the National Autistic Society (NAS) are available. Special schooling may be considered. Melatonin may be considered for sleep disorders that persist despite behavioural interventions.

Answer 56

Treat co-existing disorders (eg methylphenidate for hyperkinetic disorder) Antipsychotics for behaviour that challenges Melatonin

Answer 57

Modification of environmental factors Social-communication intervention Self-help groups such as National Autistic Society Special Schooling

Answer 58

Psychoeducation for families or carers Full assessment of the functions of behaviour to understand the child fully CBT

Answer 59

Social-communication intervention (e.g. play-based strategies). Do not use pharmacological agents such as antipsychotics, antidepressants or exclusion diets.

Answer 60

Auditory sensitivity avoid some sounds listening to music to camouflage auditory integrating training – NICE recommends not to use it minimise the background noise consider use of ear plugs Tactile sensitivity buy duplicates of tolerated garments sensory integration therapy areas can be desensitised Sensitivity to taste and texture only lick or taste new foods Visual sensitivity avoid bright light use sunglasses Sensitivity to pain look for behavioural indicators of pain encourage to report pain minor discomfort might indicate significant illness

Answer 61

Treat co-existing physical disorders (e.g. epilepsy and constipation) and mental health (e.g. anxiety, depression) and behavioural problems (e.g. hyperkinetic disorder). Modification of environmental factors which initiate or maintain challenging behaviour, are the first line in management (e.g. lighting, noise, social circumstances and inadvertent reinforcement of challenging behaviour). Antipsychotics (e.g. risperidone) should be considered for behaviour that challenges, when psychosocial interventions are insufficient or if the features are severe. This requires careful consideration as there are significant side effects, and metabolic monitoring is required.

Answer 62

individuals whose neurology differs substantially from dominant norms are neurodivergent

Answer 63

The social dynamics around neurodiversity are similar to the dynamics that manifest around other forms of human diversity. These dynamics include unequal distribution of social power; conversely, when embraced, diversity can act as a source of creative potential.

Answer 64

High functioning Low functioning Symptoms Treatment Disorder Deficits Tantrums

Answer 65

Characteristics Difficulties Challenges Autistic person Abilities Strengths Meltdowns

Answer 66

Impairment is problem - should cure her or give her prosthetics - medieval Stairs are the problem - build a ramp - social model of disability

Answer 67

Social communication: Sarcasm Social media Keep up with adolescent talk Abstract Wordplay Understand negotiation Switch language style to situation Fit in right group Organisation: Independent travel On time Pack school bag Not loose possessions Letters home Travel between lessons Right equipment/PE kit Learning: Lecture style learning Concentrate 1hr+ Teamwork Sarcasm from teachers

Answer 68

Angry Self harm Irritable Compulsive shopping Concentration issues Substance/ alcohol misuse Underachieving in education or occupation Criminjal justice system involvement Overhwelmed Oppositional Mind wandering Conficlict with peers, partners and family

Answer 69

Meet full criteria for ADHD ADHD...Significant impact In at Least One Domain of Everyday Life After Environmental Modification Stress Importance of Balanced Diet/Regular Exercise Mental Health Educational environment Social circumstances Neurodevelopment co morbidity

Answer 70

Break big chunks of info into bite sized pieces Use checklists for tasks with multiple steps Develop routines Practice working memory skills Experiment with various ways of remembering information Reduce multitasking

Answer 71

Difficulty with planning, problem solving, organisation focus, instruction Broad condition that differs from ADHD and affects attention, learning and social, organisation and time -management skills Work around area problems and CBT

Answer 72

Under or oversensitivity to: Touch, movement, body position, sound, taste, sight, smell Difficult paying attention Fluctuating from one activity to another Accident prone when feeling overwhelmed OT - sensory assessment and sensory integration therapy