Community Flashcards
What is ADHD characterised by?
Hyperactivity, inattention, impulsivity
Why are more boys diagnosed with ADHD than girls?
Girls tend to have less disruptive forms of ADHD so less noticeable
Features of ADHD
Impaired attention Hyperactivity Impulsivity Easily distracted/disruptive Can't adhere to social norms Fidgety
What is the ICD-10 criteria for ADHD?
Early onset of symptoms (<6 years), which are present in 2 or more settings.
Two main features for diagnosis are impaired attention and over-activity.
What is the DSM-V Criteria for ADHD?
Three subtypes of ADHD - combined, predominantly inattentive type, predominantly hyperactive/impulsive type.
Diagnosis made when at least 6 of criteria from either inattention category or hyperactivity/impulsivity category are met and have been present from before age of 12 for at least 6 months.
Investigations of ADHD?
Conner’s questionnaire (objective assessment).
School observation and reports.
Information obtained from school, home and other regularly visited environments.
If any doubt, rule out other differentials eg epilepsy, fragile X or global developmental delay.
If learning difficulties, consider bloods - FBC, U&Es, LFT, TFT, Calcium, Iron, glucose
Consider karyotyping and MRI brain.
Management of ADHD?
If medication considered - take FHx and ECG if positive FH of serious cardiac disease or sudden death.
Preschool:
- Medication NOT recommended.
- Offer parents training/education programme.
Mild/moderate ADHD in school-age children with moderate impairment:
- First line - behavioural strategies, in form of parent education sessions.
- CBT, social skills training can be used.
- Teachers should be trained on behavioural strategies in classroom
- If behavioural strategies are ineffective -> consider medication.
Severe ADHD in school-age children with severe impairment:
- first line - medication
- if medication refused, offer group parent training/education programme.
Medications used in ADHD?
Methylphenidate:
- stimulant
Atomoxetine:
- Used when methylphenidate not effective, if there is associated tic disorder or anxiety disorder, or if there is a risk of stimulant medication being abused or redirected.
Lisdexamfetamine:
- newer stimulant, used when methylphenidate not effective at maximum doses.
Guanfacine:
- non-stimulant medication.
- Used when stimulant medication not suitable, not tolerated or ineffective.
Antipsychotics:
- should not be used in children with ADHD.
Side effects of ADHD medication?
Raised BP Palpitations Disturbed sleep Impaired growth and appetite suppression There can be problems with aggression or child becoming more emotional, anxious or depressed.
Risk factors of Autism spectrum disorder?
- More common in males
- Prematurity
- Perinatal hypoxia
- Increased maternal/paternal age
Features of autism?
- Abnormal social interaction
- Impaired social communication (eg echolalia)
- Restrictive or repetitive activities
Others - sensory issues, may not eat certain foods, may not tolerate loud noises, may self-harm, may not tolerate haircuts or brushing teeth.
Examination of autism patient?
Skin stigmata or neurofibromatosis or tuberous sclerosis using a Wood’s light.
Signs of injury, for example self-harm or child maltreatment.
Congenital anomalies and dysmorphic features including macrocephaly or microcephaly.
Diagnosis of autism?
At least one features from all 3 categories and one of the following present before age of 3:
- lack of social attachments
- abnormal/delayed receptive or expressive speech development
- abnormal or lack of symbolic play
Investigations of autism?
Clinical diagnosis
Symptoms should be consistent at home and at school.
Diagnosis made through MDT, consisting of educational psychologist and speech therapist, as well as either a Community Paediatritcian or Child Psychiatrist.
Management of autism?
Behavioural management strategies - visual timetables, preparation and explanation for changes in routine.
Educational measures - special educational measures put in place to access mainstream schooling through Educational Health Care Plan (EHCP) or to attend a special school.
Melatonin for sleep can aid child’s behaviour and education.
Treat co-morbid conditions such as ADHD, sleep disorders, learning difficulty, and mental health problems such as anxiety and depression.
Factors causing behavioural problems?
Genetics Gender (boys more likely that girls) Intellectual ability Development Temperament Chronic illness
Family - early attachment, divorce, family structure, parental stratus, parental mental health.
Environment - social class, neighbourhoods, physical abuse, neglect, sexual abuse, schools, day care facilities.
Examples of sleep related problems?
Refusal to go to bed at night - separation anxiety, fear of darkness and silence, erratic bedtime routine.
Waking at night
Nightmares and night terrors
Management of sleep related problems?
Sleep diary, sleep hygiene, positive bedtime routine, melatonin.
Management of food refusal?
Social reinforcement Avoid forcing Avoid snacking between main meals Keep regular family meal times Do not prolong mealtimes Avoid using preferred food as reward Rejection of new foods can be overcome by repeated exposure.
Causes of delayed motor skills?
Central motor deficit (cerebral palsy)
Congenital myopathy, primary muscle disease
Spinal cord lesions (spina bifida)
Global developmental delay
Features, assessment and management of delayed motor skills?
Hand dominance before age of 1 is abnormal so needs investigating.
Assessment by neurodevelopmental paediatrician and physiotherapist.
Management - ongoing physiotherapy and subsequent OT involvement is likely to be needed.
Reasons for delay in speech?
Hearing loss Global developmental delay Difficulty in speech production from anatomical defect - eg cleft palate. Environmental deprivation/lack of opportunity for social interaction. Normal variant (family pattern).
Reasons for speech and language disorders?
Language comprehension disorder
Language expression disorder
Problems with phonation and speech production (eg stammering)
Difficulty with grammar and construction of sentences
Social and communication skills problem (eg autism)
Investigations and management for delay in speech?
Hearing test, SALT assessment.
Neurodevelopmental paediatrician and paediatric audiological physician involved.
SALT therapy
Special schooling
Investigations for global developmental delay?
Cytogenetics - karyotyping, fragile X, DNA FISH analysis.
Metabolic - TFTs, CK, lactate, LFTs, bone chemistry, U&Es, plasma amino acids, gases.
Infection - congenital infection screen
Imaging - cranial USS in newborn, CT and MRI brain scan, skeletal survey, bone age.
Neurophysiology - EEG
Nerve and muscle biopsies
Other - hearing, vision, clinical genetics, cognitive assessment, child psychiatry, physiotherapy, occupational therapy, SALT, dietician, nursery/school reports.
Features of learning difficulties?
IQ 70-80 - borderline and mild learning disability.
IQ 50-70 - moderate learning difficulties.
IQ 35-50 - severe learning disabilities
IQ <35 - profound learning difficulties.
Management of learning difficulties?
Borderline/mild - supported by learning support assistants in mainstream schools
Moderate/severe - special schools. Tend to be lower socioeconomic classes.
Severe/profound - apparent from infancy and irrespective of social class.
What is dyspraxia? Features? Management?
Disorder of motor planning and/or execution with no significant findings on standard neurological examination.
Problems with handwriting, dressing, cutting food, drawing, often messy eating.
Assessment and advice is primarily from occupational therapist.
What is dyslexia?
Disorder of reading skills disproportionate to child’s IQ.
Reasons for school absence?
Illness
Parents may keep child off school
Truancy
What is school refusal?
Inability to attend school due to overwhelming anxiety.
May not complain of anxiety, however suffer with physical consequences.
Somatic symptoms - nausea, headache, hyperventilation.
Reasons for school refusal?
Bullying
Educational underachievement - visual or hearing problems, dyslexia, learning difficulties, ADHD, chaotic family background.
School refusal based on separation anxiety - house move or death in family.
True school phobia - older, anxious children who are uncommunicative and stubborn.
Management of school refusal?
Advise and support parents and school about condition
Treat underlying emotional disorder
Plan and facilitate an early and graded return to school
Make it more rewarding for child to go to school than stay at home.
Address bullying or educational difficulties if present
