behavioural disorders Flashcards
define adhd according to icd10?
classic triad but:
- inattention and or 2/3
- hyperactive
- impulsive
these INTERFERE with functioning or development
- > start b4 age 6/7 and last more than 6 months
- > must happen in 2+ settings ! key for diagnosis
- > cant be explained by mental/psych disorder
demonstrated across 2 or more settings (such as home and school)
aetiology of adhd?
genetics
dopamine and noradrenaline deficiencies and
frontal lobe abnormalities are implicated
apart from the hyperactive impulsive side, list some sx of the innatention side of adhd?
lose things easily eg. phone
cant give close attention to task
cant follow instructions
easily distracted
forgetfulness
difficulty with peer interactions
Labile mood
Identify the possible complications of attention deficit hyperactivity disorder and its management
risky behaviour - poor road safety, clumsy, accident prone
eiak of substance missuse
list some ivx for adhd?
conners rating scales
- academic, social, behavioural etc issues
- Tscores above 60
classroom observation
educational psychology assessment
lecture:
wisconsin card sorting and stroop test (colours) - measures of distractibility
management for adhd in kids and young people?
- Family: education on ADHD; advice on parenting
and boundaries. eg info leaflets. - Behavioural management. -> Parent skills training!!
- Support for teachers: appropriate schooling placement.
- Family therapy. parents may want to discuss diet of child; some evidence.
- Stimulant medication (methylphenidate - 1st line drug NICE - severe cases)
lisdexamphetamine - 2nd line drug if methylphenidate not working well
dexamphetamine - if lisdex was good but intolerable side effects
3rd line drug - Atomoxetine - non-stimulant medication
- 1st line if tics
others;
clonidine - 1st line if comorbid tics - tertiary adhd service must advise.
Concerta XL - long acting methylphenidate for 1x daily use
This increases monoamine pathway activity, improving concentration and allowing learning and maturation.
how to monitor kid on drugs for adhd?
give drug holiday to prevent growth retardation
monitor;
BP and HR
Height every 6m
weight after month 3+6 then every 6m
prognosis for adhd?
90% get conduct disorder
hyperactivity and imipulsivity improves with age
15% get ADHD as adults.
may suffer low self-esteem, peer
rejection, educational under-achievement, and harsh
parenting. Although symptoms often improve in adolescence,
up to 50% of adults have ongoing problems
Untreated ADHD is a risk factor for later dissocial personality disorder, criminality, and substance abuse.
icd10 definition for conduct disorder?
need to have 3+ out of 15 behaviours for more than 6m:
Aggression to people and animals
Destruction of property
Deceitfulness or theft
Serious violation of rules
- truancy before 13. runaway more than 2x. bully, break
in
behaviours frequent and persistent
risk factors for conduct disorder?
individual characteristics, risks within family, risks outside
male
lower than average intelligence
urban upbringing, deprivation, parental criminality,
harsh and inconsistent parenting,
maternal depression, and a family
history of substance misuse. Antisocial behaviour is
often learned from parental or societal models/ hoodlum group
differentials for conduct disorder?
Oppositional defiant disorder
ADHD, ASD
Depression, BPAD, Psychosis
Adjustment disorder
How is conduct disorder managed?
Treat any psychiatric disorders eg adhd
Address modifiable risk factors
- NICE Psychosocial intervention
- parent training program 3-11y/o
- child focussed program 9-14yo
- multimodal intervention 11-17 yo - refer to CAMHS if severe or mental health issue or
learning disorder
-> educational support, anger management etc
prognosis of conduct disorder?
50% develop subtacne misuse problems OR
Antisocail/Dissocial personality disorder as adults
become juvenile delinquents as teens
passed on to kids.
what is the presentation of tic disorders?
repetitive, involuntary and purposeless movements or vocal utterances
simple = blinking, throat clearing complex = self hitting , swearing
can reduce when mind is focussed on something else
aetiology of tic disorders?
Fhx including of OCD!!
precipitating factors
stress
stimulant medications
management of tic disorders?
stress management
reassurance
Clonidine - adrenergic agonist
Haloperidol - antipsychotic
what are the characteristics of gilles de la tourette syndrome?
Multiple motor tics
- copropraxia: involuntary performing of obscene or
forbidden gestures. innapropriate motor tics
One vocal tic
- can include coprolalia: involuntary and repetitive use
of obscene language
worsens in teens
list some side effects of methylphenidate?
postural hypotension
insomnia
palpitations
tics
a boy with adhd has his sx well controlled on methylphenidate. he develops tics. should you continue the medication?
methyphenidate is a stimulant so causes tics
dont continue. give non-stimulant instead i.e. atomoxitine
what is lisdexamphetamine?
Lisdexamfetamine is a prodrug of dexamfetamine.
used in treatment of adhd
name a non-stimulant medication that can be used for the treatment of adhd?
atomoxetine
given when they cannot tolerate lisdexamfetamine or methylphenidate
management of adhd in adults?
lisdexamfetamine or methylphenidate - 1st line drugs
what to do here:
For children aged 5 years and over, young people and adults with ADHD experiencing an acute psychotic or manic episode?
stop adhd meds
CASE: an 11y/o girl presents with behavioural and social difficulties. she is shy in school and was selectively mute for 1 year of primary school.
at home, she is aggressive towards her mother including kicking. she has loud violent outbursts intermittently. she displays no empathy or remorse and cant read other peoplee emotions well.
she doesnt seek comfort and is solitary. she doeesnt understand sarcasm and has a high pain threshold. her diet is limited to 10 foods.
she does not display repetitive behaviours and has gestures when speaking.
she is coping well with education and is going to secondary school now.
what is your differential and why? what is the most likely diagnosis?
differential;
ASD - because; doesnt seek comfort, solitary. doesnt understand sarcasm, restricted diet. violence - can result from breaking of restricted routine/interests. no empathy. can’t read others.
ADHD - violent outbursts maybe due to;
paying little attention to normal social conventions +
disobedience due to through impulsivity rather than
deliberate naughtiness.
Aspergers - similar sx to autism without laguage problems.
most likely diagnosis - ASD
CASE: an 11y/o girl presents with behavioural and social difficulties. she is shy in school and was selectively mute for 1 year of primary school.
at home, she is aggressive towards her mother including kicking. she has loud violent outbursts intermittently. she displays no empathy or remorse and cant read other peoplee emotions well.
she doesnt seek comfort and is solitary. she doeesnt understand sarcasm and has a high pain threshold. her diet is limited to 10 foods.
she does not display repetitive behaviours and has gestures when speaking.
she is coping well with education and is going to secondary school now.
what is your differential and why? what is the most likely diagnosis?
how would you treat this patient?
differential;
ASD - because; doesnt seek comfort, solitary. doesnt understand sarcasm, restricted diet. violence - can result from breaking of restricted routine/interests. no empathy. can’t read others.
ADHD - violent outbursts maybe due to;
paying little attention to normal social conventions +
disobedience due to through impulsivity rather than
deliberate naughtiness. Behvaiour problems only in 1 setting. not presenting before 6y/o
Aspergers - similar sx to autism without laguage problems.
most likely diagnosis - ASD
treatment - behaviour therapy -> behavior and reward intervention, because she can behave in school! no iissues with speech so no S&L therapy needed.
7 y/o boy, is disruptive at school, talks a lot and blurts out answers quick, doesnt finish his school, he moves around the class a lot
- He is not stimulated enough because he is very smart and finishes work early
- He may have learning difficulties and doesnt understand; dyspraxia, dyslexia etc
consider all these BEFORE a medical/mental health condition;
- ADHD
GP has referred 12 y/o girl. this is the 18th presentation in 3 months coming with physical pain of different origion. she worries about school work and is missing lots of school. all tests done by paeds = negative
Somatisation of :
- things wrong at home: abuse, domestic violence of parent. grooming?
- things wrong at school; bullying, difficulty coping
a 16 year old boy is always hanging out with gangs, he has been charged with arson. he cant control his actions of violence espeecially when he is drunk and angry
- Conduct disorder
- ADHD : 1/4 of adhd patients have conduct disorder. some have elements of conduct disorder. and also learning disability. this leads to vicious cycle of poor academic performance then hanging out with similar students/ deliquent friends.
- Grooming by gang members? neglect at home so he feels a sense of family from these? perhaps he had difficulty fitting in elsewhere
define psychiatriic disorder
Abnormal; behaviours eemotions relationship
causing IMPAIRMENT
which anxiety disorders are most and least prevalent in young?
specific phobias 5%
panic disorders 5%
OCD 2%
what domains can we look at to assess childhood development?
lecture
cognitive
behaviuoral
emotional
social
list some behavioural disorder treatments?
lecture
positive reinforcement for good behaviour
no attention for bad behaviour
meds = last resort
prognosis = good if addressed early.
what development features define adolescence?
lecture
physical: growth spurt
moral : consider their choices
emotional: turmoil
cognitive: abstract thinking / formal operational
behavioural: close friendships. sexuality. drug/alcohol experimentation
whats the difference between school refusal and truancy?
lecture
refusal;
kids
related anxiety, somatisation
parents aware kid is home. academically capable
truancy;
adolescent, parents unaware
poor academic ability
what is heritability of autism, adhd, schizo?
lecture
autism 90%
schizo 80%
adhd 60-90%
aetiology of adhd?
lecture
dopamine - …
prefrontal cortex dysfunction most implicated
size reduced - mri
blood flow reduced - functional imaging
hence why diifficulty planning, impulsivity, innapropriate actions common in adhd kids.
non genetic;
very low birth weight, food additives….
parental criticism, maltreatment, maternal depression
how do stimulant meds eg methylphenidate work?
lecture
Block pre-synaptic DAT - dopamine transporter
Agonist at post-synaptic DRD4 – dopamine receptor 4
