Child Psychiatry Flashcards
What is ADHD?
A neurodevelopemental disorder associated with inattention, hyperactivity and impulsivity arising before the age of 6 years
What is the DSM-V diagnostic criteria for ADHD?
- At least 6 symptoms present for at least 6 months
- Must have started between age 6-12 years
- Must be present in 2 different settings (ie home and school)
- Must be an element of developmental delay
- Must exclude all other causes
5 symptoms if >17
What are the DSM-5 subtypes of ADHD?
- Inattentive type
- Hyperactive/impulsive type
- Both
Why do children with ADHD present to clinic?
- Poor school performance
- Disruptive behaviour
- Or both
What are the S/S of ADHD?
Inattention
Difficulty maintaining focus on particular topic/task
- Ignores instructions
- Easily distracted
- Avoids / can’t sustain tasks
- Lacks organisation
- Forgetful in daily activities
- Loses things
- Does not seem to listen when spoken to directly
Hyperactivity
High level of activity that makes it difficult to sit still / keep from acting impulsively
- Loud / talks excessively
- Energetic / runs around
- Doesn’t wait their turn easily
- Will spontaneously leave their seat when expected to sit
- Interruptive / intrusive
- Answers prematurely, before question has been finished
> Particularly pronounced in places like school
What is the aetiology/RFs for ADHD?
Cause unknown
- Boys > Girls (3: 1)
- FHx
- Sibling with ADHD
- problems during delivery - Prematurity, LBW, lack of oxygen
- Toxins during pregnancy - smoking, alcohol, heroine
- Conduct/mood disorder
- Autism Spectrum Disorder
- Learning disability
- Antisocial behaviour and depression
What are the investigations for ADHD?
- Do development assessment and full neurological screen
- Assess social/educational impact in context of age (i.e. making friends if young, dangerous driving if older)
- Rating scales – cannot provide a diagnosis
Conner’s Comprehensive Behaviour Rating Scale; age 6-18
Strengths and Difficulties questionnaire
What is the initial management of ADHD?
MDT-focussed
Paediatrician, psychiatrist, ADHD SNs, mental health and learning disability trusts, CAMHS, parent groups, social care workers, school/college and school nurses
1st line = following presentation, a period of watchful waiting for 10 weeks
- Self-help, simple behavioural management
- See if symptoms change or resolve over time
Refer to specialist if… severe symptoms, or >10w
What is the management for ADHD in children <5yrs?
[AFTER A 10w WATCH AND WAIT]
1st line: offer ADHD-focused group parent-training programme to parents and carers
- 10-16 meetings in a group of 10-12 participants
- Education on ADHD, parenting strategies, environmental changes
2nd line: specialist service referral
What is the management for ADHD in children >5yrs?
[AFTER A 10w WATCH AND WAIT]
1st line: ADHD-focused group parent-training programme to parents and carers
- 10-16 meetings in a group of 10-12 participants
- Education on ADHD, parenting strategies, environmental changes
2nd line: specialist service referral and medications if ADHD persists:
- 1st line = methylphenidate (trial for 6 weeks)
- 2nd line (monitor SEs) = lisdexamphetamine (3rd line if side effects)
- 3rd line = dexamphetamine
- 4th line = atomoxetine (NARI) or guanfacine
3rd line: CBT if problems in… social skills, self-control, active listening, dealing with expressing feelings
What other medications can be used in ADHD?
Clonidine > sleep disturbance, rages or tics
Antipsychotics > aggression and irritability
What is a SE of methylphenidate?
Stunted growth
What needs to be monitored during ADHD treatment?
Baseline:
Height, weight, HR, BP and ECG
Monitor:
- Response with symptom rating scales (e.g. Conner’s)
- Development of tics after taking stimulant medication
- Sexual dysfunction, seizures, sleep disturbance and worsening behaviour
- Measure weight every 3m (<10yo) or 6m (>10yo)
- Measure height, HR and BP every 6 months (may suppress appetite and cause growth impairment)
- Include plotting on a growth chart
- If interruptions to growth > referral and a planned break to allow catch-up growth
- Drugs cardiotoxic so refer to cardiologist if concerns
What dietary advice should be given to patients with ADHD?
n.b. no dietary interventions are particularly evidence-based
- Stress importance of balance diet and regular exercise
- Explore foods that seem to influence behaviour (recommend keeping a food diary)
- Dietician referral if relationship with certain foods is observed in the diary
What is the prognosis of ADHD?
- Manifestation of ADHD will change as the child gets older
- Hyperactivity tends to become less of a problem
- Inattention becomes more pronounced as the tasks they face become more complex
Outcome:
- Some may grow out of it
- 90% get conduct disorder if untreated
- 15% have ADHD as an adult
What is autism spectrum disorder (ASD)?
A neurodevelopmental condition characterised by deficits in… (evident when <3yo):
- Verbal and non-verbal communication
- Reciprocal social interaction
- Restrictive or repetitive behaviours/interests
What is the epidemiology of ASD?
- Presents at 2-4yo (when language and social skills normally rapidly expand)
- Most have decreased IQ (savant syndrome is very rare)
- May occur in association with any level of general intellectual/learning disability
- Ranges from subtle problems of understanding and impaired social function to severe disabilities
- M > F
What are the RFs for ASD?
- Genetics (chromosomal abnormalities e.g. Down’s / gene defects e.g. Fragile X)
- M > F (75% - 25%)
- Sibling with ASD
- Birth CNS defect
- Premature
- Parental psychotic/affective disorder
- Sodium valproate
- Learning disability
- ADHD
- HIE
- Older parents
What is the diagnostic criteria for ASD?
(A) Abnormal / impaired development evident ≤3yrs
- Receptive or expressive language
- Development of selective social attachments or of reciprocal social interaction
- Functional or symbolic play
(B) ≥6 symptoms:
(1) Impairment in social interaction (≥2)
- Failure adequately to use eye-to-eye gaze
- Failure to develop peer relationships
- Lack of socio-emotional reciprocity
- Lack of spontaneous seeking to share enjoyment, interests, etc. with other people
(2) Abnormalities in communication (≥1); e.g.
- Delay in or total lack of, development of spoken language (no attempt to compensate)
- Relative failure to initiate or sustain conversation
- Stereotyped and repetitive use of language or idiosyncratic use of words or phrases;
- Lack of varied spontaneous make-believe play
- Echolalia
(3) Restricted, repetitive, and stereotyped patterns of behaviour, interests, and activities (≥1); e.g.
- Preoccupation with stereotyped and restricted patterns of interest
- Apparently compulsive adherence to specific routines or rituals e.g. same meal each day
- Repetitive motor mannerisms involving hand, finger flapping and whole-body movements
- Preoccupations with non-functional elements of play materials (such as their odour)
(C) The clinical picture is not better described by other medical disorder
What are the investigations for ASD?
Specialist diagnosis required > Refer to specialist (CAMHS, developmental paediatrician)
- History from parent
- History from nursery
- Physical exam to exclude physical causes and establish baseline
Autism diagnosis and assessment – GOLD-STANDARD
- ADI-R (Autism Diagnostic Inventory – Revised)
- ADOS (Autism Diagnostic Observation Schedule)
- Childhood Autism Rating Scale (CARS)
Learning difficulties assessment:
- Wechsler Intelligence Scale for Children (WISC) or Wechsler Preschool and Primary Scale of Intelligence (WPPSI)
- Conner’s rating scale (6-18yrs)
What is the management for ASD?
MDT / Patient-Centred care is key
- A spectrum, so everyone is different > individualise management plan
- MDT: paediatrician, child, adolescent psychiatrist, educational or clinical psychologist, SALT, OT, specialist health visitor / social worker, specialist nurse (SN)
Early education and behavioural interventions:
- Applied behavioural analysis (ABA) - therapy that helps kids with autism lessen problematic behaviour
- Early Start Denver Model (ESDM) - play based therapy for kids aged 12-48 months to help develop communication skills, play skills, language skills
- More Than Words - for parents to learn techniques how to encourage kids to communicate
- Adjust the social and physical environment to suit the child (i.e. lighting, noise levels, visual support)
Family Interventions:
- Support
- Parental education
- Involving parents in therapy plan
- Discuss need for education, health and care (EHC) plan assessment with nursery/school/GP/community paeditrician
