Case 5 - Autism and Personality Disorders Flashcards
How would you define Autism?
It is a lifelong (chronic), developmental disability that affects how a person communicates with and relates to other people + the world around them
Autism disorder is a social disability - what is the triad of autism in regard to this social disability?
Social communication:
- late to start talking or remain non-verbal
- difficulty initiating or sustaining conversation
- unusual / repetitive language
- not responding to name
- difficulty understanding non-verbal comms
Social interaction:
- difficulty recognising emotion in self + others
- ↓ eye contact
- unaware of appropriate social behaviour (share toys, take turns talking)
Social imagination: rigidity of thought, behaviour and play
- limited range of interests
- favour one specific toy (heavily)
- repetitive patterns of play / gestures
Autism is associated with ↑ occurrence of several mental health conditions - name some.
- Anxiety
- Depression / low mood (may be worse in adolescence)
- OCD (up to 30% of persons with autism)
- Sleep disturbance
- Gender dysmorphia
What are some known risk factors for autism?
- Males (~4x more likely)
- 1st degree relatives with ASD (high heritability)
- ↑ parental age (father > 50 and mother > 40)
- Exposure to specific chemicals / medications or infections during pregnancy
Review other side of card for Autism history taking / questions.
Language + communication:
- Can they hold a conversation?
- Voice: pitch? monotone? content of speech?
- Gestures when communicating?
- Meaningless repetition of speech?
Social + emotional interaction:
- Making + keeping friends?
0 Understand emotions of others + themselves?
- How is their eye contact?
- Ignoring social cues / behaviour appropriate for age?
- Narrowed interests? Unable to talk about other topics?
Flexibility / rigidity of thought?
- Repetitive play?
- How do they cope with change?
- Any obsessions? Routines Rituals?
Behaviour:
- Temper? Meltdowns?
- Obsessions, fears, phobias?
Sensory features:
- Problems with loud noises? textures? water?
- Sensory seeking? Sensory avoiding?
Birth History:
- Antenantal - Hx of alcohol, drugs, smoking, illness?
- Perinatal - delivery problems, ↓ birth weight?
- Postnatal issues
Developmental Hx:
- Motor development progressing?
- Hearing, speech and language progression? - speech regression = RED FLAG
- Development of social interaction and play?
Family Hx:
- Learning disabilities?
- Epilepsy / fits?
- Alcohol / drug abuse?
- Domestic violence or care leavers?
What tools can be used to screen for autism spectrum disorder (ASD)?
- CAST (childhood autism spectrum test)
- screen children 4-11yrs
- 39 yes/no questions
- ADOS-2 (autism diagnostic observation schedule)
- for diagnosing and assessing autism
- series of tasks involving
- interaction between examiner + patient
- observations of behaviour converted into quantitative score
- ADI-R (autism diagnostic interview-revised):
- structured interview with parents of individual (about the patient)
- examines; language / communication, social interaction, restricted, repetitive behaviours and interests
- min mental age of 24 months (2yrs)
- DISCO (diagnostic interview for social and communication disorders):
- semi-structured interview with parent/care giver
- 300 questions
- children + adults of any age
What medical conditions is ASD associated with?
progress test info
- Fragile X syndrome - trinucleotide repeat disorder
- male (females far less affected)
- autism is more common
- learning difficulties
- large low set ears, long thin face, high arched palate
- macroorchidism (large testes)
- hypotonia
- mitral valve prolapse
- Rett’s syndrome - non genetic, new mutation
- MECP2 gene
- female (males die after birth)
- autism like features: language, repetitive movements
- slower growth
- walking impairment
- smaller head size
- Complications: seizures, scoliosis, sleep disorders
- Congenital rubella (especially exposure during 1st trimester)
Is ADHD more common on males or females?
Males
~4x more than females
What are the 2 categories of features associated with ADHD?
1) Inattention and/or
2) Hyperactivity / Impulsivity
What features fall into the diagnostic categories 1) inattention 2) hyperactivity/impulsivity for ADHD?
INATTENTION:
- Doesn’t follow through on instructions
- Reluctant to engage in mentally-intense tasks
- Distracted
- Can’t sustain tasks
- Poor organisation of tasks/activities
- Forgets daily activities
- Often loses things necessary for tasks/activities
- Doesn’t listen when spoken to
HYPERACTIVITY / IMPULSIVITY:
- Unable to play quietly
- Talks excessively
- Doesn’t wait turn
- Spontaneously leave seat when expected to sit
- Often ‘on the go’
- Interruptive or intrusive to others
- Answer prematurely, before a question has been finished
- Run and climb in situations where it is not appropriate
What are the diagnostic criteria for ADHD?
Features from inattention and/or hyperactivity/impulsivity lists:
- If < 16yrs then 6 features
- If > 17yrs then 5 features
Symptoms cause significant functional impairment; socially, psychologically, educationally etc.
Pervasive - symptoms occur in 2 or more settings; social, home, school etc.
Onset < 7 yrs (DSM-V) < 6 yrs (ICD-10)
Persists for > 6/12 months
How is ADHD managed?
CONSERVATIVE:
- Education on ADHD impact
- Parenting strategies - involvement from both parents
- Liaison for school, college, university
- Behaviour management strategies
PHARMACOLOGICAL: - stimulants!!
5+ and young people
- 1st line = methylphenidate
- Low starting dose
- Titrate dose against behaviour + school work
- 2nd line = lisdexamfetamine
- If 6-week trial of methylphenidate at therapeutic dose did’t work
- Consider dexamfetamine IF responding to lisdexamfetamine but don’t tolerate long effect profile
Adults:
- 1st line = methylphenidate or lisdexamfetamine
- Try the other if the 1st didn’t work
- Consider dexamfetamine IF responding to lisdexamfetamine but don’t tolerate long effect profile
How is autism managed?
CONSERVATIVE:
Psychotherapy - both parents + patients:
- CBT
- Behaviour management programmes
- Applied behavioural analysis program - intense program (40hr a week for 3yrs) based on operant conditioning, imitation and reinforcement
Social - led by functional assessment:
- Carers
- Respite care
- Education of peers in school
- Learning support / special schools
PHARMACOLOGICAL:
2nd gen anti-psychotics = 1st line for children + adolescents with ASD
- Risperidone (only one liscenced in UK) - for aggressive, challenging behaviour in autistic children
SSRIs - low dose, used for restricted repetitive behaviours (evidence limited)
Melatonin - ↓ sleep latency (time taken to fall alseep)
What is ‘Conduct Disorder’?
DEFINITION:
- A repetitive and persistent pattern of behaviour in which either the basic rights of others or major age appropriate societal norms or rules are violated
- Lasting > 6/12
- Can occur in infancy, childhood or adolescence
FEATURES:
- aggressive / cruel behaviour; towards other people or animals
- frequent + severe temper tantrums for age
- deceitfulness / lies frequently
- thievery / breaking + entering
- frequent physical fights
- carrying / use of a weapon
- destruction of property
- violation of rules that is persistent and repetitive
- bullying
RISKS:
- risk of developing mental disorder
- retaliation from others due to behaviour
- substance misuse
- risk of harm to others (aggressive behaviour)
What would the management plan for a conduct disorder involve?
Multi-systemic therapy (MST)
- Identify problematic behaviours
- Interventions for each behaviour (tackle one at a time) and how to monitor progress
Work on any substance misuse
Continued assessment of mental state to monitor for development of mental health disorder
