Child Psychiatry - ADHD, ASD, Conduct disorder Flashcards
ADHD
Epidemiology
- Prevalence 5% in children, 2.5% in adults
- M:F = 3:1 in HK
- Familial, ~25% risk in siblings
- Heritability is 0.7-0.8 (equivalent to Schizophrenia and Bipolar)
ADHD
Comorbidities
ADHD
Pathology
- Hyperactivity - Impulsivity: Poor inhibition in Motor, Verbal, Cognition, Motivation, Emotion
- Inattention: Sustain attention, distractible, poor task re-engagement, poor working memory
ADHD
Examples of attention deficit
- Careless errors
- Can’t sustain attention, fails to finish tasks
- Easily distracted, don’t seem to listen
- Don’t follow instructions
- Can’t organise tasks
- DIslike sustained mental effort
- Procrastination
- Slow, inefficient, disorganised
ADHD
Examples of hyperactivity
- Fidgets
- Leaves seat and runs about when inappropriate
- Cannot do leisure activities quiet;y
- Talks excessively
- On the go/ driven by motor
- Workaholic/ over-scheduled
- Self-select very active jobs
ADHD
Examples of impulsivity
- Canot wait in line
- Complete other’s sentences
- Interrupts or intrudes on others
- Make important decisions without consideration
- Short temper, impulsive behavior
- Irritable
- Labile mood
ADHD
Diagnosis
A. 6 or more symptoms (5 or more in over 17yo) - DISTRACTED FIDGET CAT
- Inattention
- Hyperactivity-impulsivity
- inconsistent with developmental level
- at least 6 months
- Not due to conduct disorder (oppositional/ defiance/ hostility)
B. Symptoms preent by 12yo
C. Symptoms Present in 2 or more settings
D. Clear evidence that interfere/ reduce quality of social/ occupational activities
E. Not schizophrenia or other mental disorders
Compare ADHD with other ddx
ADHD
Management
Prognosis
Meds = more effective than psycho-social treatment
Medication:
- Psychostimulants: Methylphenidate (Ritalin)
- Noradrenergic reuptake inhibitor: Atomoxetine (Strattera)
- S/E for both: Anorexia, Mood swings, Abdominal pain +/- motor tics/ tacycardia for Ritalin
Behavioral therapy:
- Parent Management Training (PMT): reward system, time out…etc
- Special schooling: reduce inattention and disruptive behavior
Prognosis: 50% persist into adulthood
Comorbid with conduct disorders: antisocial/ criminal/ substance abuse
Higher risk fo suicide in early adulthood
ASD
Epidemiology
More common in boys/ male predominance
Not cultural difference
5/10,000
MZ twin - 40-95%
DZ - up to 30%
One sibling - 18%
Heritability >0.9
ASD
Risk factors
Old parental ages
Premature/ LBW
Sibling with ASD (18%)
Down syndrome, Fragile X, Tuberous Sclerosis
Antenatal Valproate
Association: 50% average/ above-average intellegence, 50% below average
ASD
Diagnosis
3 pillars: Social, Speech, Behavior
Dx: at least 6 symptoms with at least 2 social symptoms and 1 from two other categories
Persistent deficit in social communication and social interactions
- Deficient non-verbal communicative behavior
- Deficits in developing, maintaining, and understanding relationships
- Deficient socio-emotion reciprocity
Speech:
- Speech delay (one word by 2, phrase by 3)
- Impaired conversation
- Odd language
- No imaginative play
Restrictive, repetitive patterns of behaviour, interests, or activities
- Highly restricted, fixated interests that are abnormal in intensity or focus
- Insistence on sameness, inflexible adherence to routines, or ritualised patterns of verbal or nonverbal behaviour
- Hyper- or Hypo-reactivity to sensory input or unusual interest in sensory aspects of the environment
- Stereotyped or repetitive motor movements, use of objects, or speech
Symptoms must be present in early development
Must cause clinically significant impairment (social, occupational or other)
Not due to intellectual disability, global developmental delay
Isolated social communication deficit = evaluate for social communication disorder
Aspergers vs ASD
Asperger’s vs ASD
Key Differences:
Language Development:
Asperger’s = normal language development
ASD = delays in language acquisition.
Cognitive Ability:
Asperger’s = average or above-average intelligence
ASD = intellectual disability to average or above-average intelligence
Social Skills:
Both groups may struggle with social interactions
Asperger’s = aware of their social = desire to engage socially
ASD = hard to understand social cues and may not express a desire to engage socially.
ASD
Workup
Clinical interview:
- Day hospital assessment by MDT
- Standard questionnaires: e.g. Childhood Autism Rating Scale (CARS), Autism Diagnostic Interview – Revised (ADI-R), Autism Spectrum Quotient (AQ)
- Educational Assessment, IQ Test, OT assessment, ST assessment
Theory of mind test
1st order/ Sally Anne test: +ve cannot differentiate self/ others, will say Sally will look into the box
2nd order: +ve cannot read the mind of a mind reader, will say The church
3rd order
ASD
Management
Prognosis
Main treatment: Psycho-education, counselling and training of parent
No medication specifically
Supportive meds:
- Antipsychotics for aggression
- Seizure medications
- Anti-depressants for control of obsession
Prognosis
- IQ scoring and language assessment at 5 years old
- 1/3 independence
- 1/5 seizure at teenage
Conduct disorder
Spectrum
