Community - ADHD

Question 1

what is ADHD

Answer 1

characterized by impaired attention or hyperactivity or impulsivity

Should be evident in more than 1 situation (eg. school and at home)
Should be present for at least 6 months

Question 2

DSM5 criteria of ADHD

Answer 2

Persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning/development

6 or more symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level (symtpoms are not solely a manifestation of oppositional behavior, defiance, hostility, or failure to understand tasks)
>17yrs, only 5 symptoms required

Several inattentive or hyperactive-impulsive symptoms were present before age of 12 yrs

Several inattentive or hyperactive-impulsive symptoms are present in 2 or more settings (eg. home, school, work, friends)

There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic or occupational functioning

The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder (e.g. mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal)

Question 3

Pharmacological management of ADHD

Answer 3

CNS stimulants - methylphenidate (ritalin) and dexamphetamine
Highly effective for 3/4 children. Produce increased concentration and academic efficiency.

Antidepressants and some antipsychotics are second line.

Question 4

Psychotherapy in ADHD. Prognosis

Answer 4

Behavioral modification and family education are important

Permissive parents are not helpful in this situation

Remission of symptoms usually 12-20yrs age
Unstable family dynamics and coexisting conduct disorder are associated with a worse prognosis

15% of patients have symptoms in adulthood

Question 5

At what age should urinary continence be achieved (daytime)

Answer 5

Age 3-5yrss

Question 6

Causes of daytime enuresis

Answer 6

Lack of bladder control:
Lack of attention to bladder sensation with detrusor instability

Bladder neck weakness

Neuropathic bladder (spina bifida - bladder is enlarged and fails to empty properly)

UTI

Constipation

Ectopic ureter (constant dribbling)

Question 7

Examination in daytime enuresis

Answer 7

There may be a distended bladder (neuropathic)

Abnormal perineal sensation and anal tone or abnormal leg reflexes and gait (also sensory loss in S2,3,4) - SPINA BIFIDA

Ultrasound can show incomplete emptying

Question 8

Management of daytime enuresis

Answer 8

If no neurological cause:

Bladder training and pelvic floor exercises

Treat constipation

Anticholinergic drugs may help

Question 9

Causes of secondary enuresis. Investigations?

Answer 9

Emotional upset
UTI
Polyuria

test urine for protein, nitrites, and protein

Glucose levels

Ultrasound of renal tract

Question 10

History in nocturnal enuresis (aetiology)

Answer 10

2/3 have a 1st degree family member

Young children need to be free from stress to learn night time continence

Organic causes uncommon.. UTI, faecal retention which causes bladder neckdysfunction, polyuria due to DM or renal concentrating disorders

Question 11

Urine test in nocturnal enuresis

Answer 11

Glucose
Protein
Infection

Question 12

Management of nocturnal enuresis

Answer 12

Triad trying to tackle all 3 pathophysiologies:

Decreased ADH - diurnal rhythm - desmopressin (analogue - only short-term)

Unstable bladder - keep urine dilute and increased toilet use - oxybutynin to relax bladder

Development of bladder control - bed wetting alarm or star charts for motivation

Management is straighforward, but painstaking

Explanation is crucial:
to both the child and parent that the problem is common and beyond conscious control. Stop punishing child

Question 13

At what age is management for nocturnal enuresis usually undertaken?

Answer 13

Not before 6yrs of age.

5% resolve spontaneously after the age of 4yrs

Question 14

Classify learning difficulties by severity

Answer 14

Mild (70-80)
Moderate (50-70)
Severe (35-50)
Profound (<35)

Severe and profound are usually apparent from infancy

Moderate only emerges as a delay in speech and language. Mild may only be noticable in school

Question 15

Organic prenatal causes of learning difficulties (most causes are organic)

Answer 15

Genetic - Down’s, fragile X, microcephaly, hydrocephalus

Vascular - Occlusions, haemorrhage

Metabolic - hypothyroidism, PKU

Teratogenic - alcohol and drug abuse

Congenital infections - (TORCH) toxoplasmosis, rubella, CMV, HIV

Neurocutaneous syndrmes (tuberous sclerosis, neurofibromatosis)

Question 16

Perinatal causes of learning difficulties

Answer 16

Extreme prematurity
Birth asphyxia
Metabolic - symptomatic hypoglycaemia

Question 17

Postnatal causes of learning difficulties

Answer 17

Infection - meningitis, encephalitis

Anoxia - suffocation, seizures

Trauma - head injury

Metabolic - hypoglycaemia, inborn errors of metbolism

Vascular - stroke

Question 18

Diagnostic criteria of dyspraxia

Answer 18

“chronic and usually permanent condition characterised by impairment of both functional performance and quality of movement that is not explicable in terms of intellect, or by any other diagnosable neurological or psychiatric features.

Motor performance that is substantially below expected levels, given the person’s chronologic age and previous opportunities for skill acquisition. The poor motor performance may manifest as coordination problems, poor balance, clumsiness, dropping or bumping into things; marked delays in achieving developmental motor milestones (e.g., walking, crawling, sitting) or in the acquisition of basic motor skills (e.g., catching, throwing, kicking, running, jumping, hopping, cutting, colouring, printing, writing).

This significantly interferes with daily living/ academic achievement

Onset of symptoms is in early developmental period

Motor symptoms are not better explained by intellectual developmental disorder or visual impairment and are not attributable to a neurological condition affecting movement (eg. CP, muscular dystrophy)