Community paediatrics Flashcards
ADHD, ASD, behavioural problems, developmental delay, non-accidental injury, learning difficulties, FII, abuse
What is ADHD?
A triad of inattention, hyperactivity (cannot regular activity according to situation) + impulsivity (disorganised, poorly regulated, difficulty taking turns, social disinhibition)
AKA hyperkinetic disorder
Early onset-usually by 5y
RF for ADHD
Male, genetics
Who diagnoses ADHD?
Community paediatrician
Psychiatrists are sometimes involved
Educational psychologist
How is ADHD managed?
- Adv parents + teachers to build concentration skills, encourage quiet self-occupation
- Moderation of extreme behaviour
- Increase self-esteem
- Behavioural: clear rules + expectations, consistent use of awards, consequences for unacceptable behaviour
- Diet: role controversial, omega 3 may improve concentration, some children do have clear behaviour to certain foods, avoid caffeine
- Severe cases + >6y try medication, may need to continue to adulthood, regular trials off medication to see if need to continue
What drugs are used for ADHD?
- Stimulants e.g. methylphenidate, dexamphetamine. Monitor weight (can cause anorexia) + BP/HR (can cause HTN/tachycardia)
- Non-stimulants e.g. atomoxetine. Often cause mood disorders or suicidal ideation
What is the DSM-5 criteria for ADHD?
Lasts 6 months+, onset <12y, noticeable in 2+ settings, impacts social/academic/occupational function, not better accounted for by another mental disorder
Involves inattention (lack of attention to details, doesn’t seem to listen, easily side-tracked, organisation difficulties, avoids sustained mental effort, misplaces objects, easily distracted) and hyperactivity/impulsivity (fidgeting, feeling restless, excessively loud, talks excessively, blurts out answers, acts without thinking, difficulty waiting turn)
What is ASD?
A developmental disorder with onset before 3y and the triad of features, over a continuum of behavioural states:
- Impaired social interaction e.g. no close friends, no interest/ability interacting with peers, gaze avoidance, social/emotionally inappropriate behaviour, doesn’t appreciate social cues, doesn’t appreciate that others have feelings
- Speech + language disorder: delayed development, limited use of gestures/facial expression, formal language, over-literal interpretation of speech, echoes questions, may be superficially good expressive speech (learnt)
- Ritualistic + repetitive behaviour: to self or others, concrete play, stereotyped movements, poverty of imagination in play, repetitive adherence to specific interests
What is Asperger syndrome?
The social + repetitive behavioural abnormalities without the delay in language/cognition development
Uncertain classification + validity
RF for ASD
Boys, genetics, may be some organic processes
NOT due to emotional trauma, poor parenting or MMR vaccine
How is ASD diagnosed?
Specific number of features in the ICD-10/DSM-5 from observation of behaviour
How is ASD managed?
- Parent support + education
- Applied behavioural analysis can help reduce ritualistic behaviour + develop social skills, but needs up to 30h therapy pw so costly + time consuming
- Appropriate education placement for the child so that they can incorporate this in their teaching
What are the causes of childhood behaviour problems?
- Bio: genetics, prematurity, alcohol in utero, serious illness in infancy, epilepsy
- Psycho: low self esteem (restricts development of coping skills, or attention seeking), cognitive style
- Social: lack of positive early relationships + attachment, separation anxiety, adversities in the family, poor resilience (e.g. not spending time as a family ,poor sleep and exercise habits), bullying
Meal refusal
Try giving child frequent smaller snack
Food diary
Monitor growth
Sleep problems
Melatonin released from pineal gland main controller of the circadian rhythm
- Difficulty going to sleep-mostly separation anxiety in toddlers, create a routine
- Waking at night-normal but some times can’t settle
- Nightmares-bad dreams recalled by child, reassure the child, if recurrent/frequent may be a morbid preoccupation for some reason
- Night/sleep terrors-high arousal, child sitting up in bed disorientated + distressed, unresponsive for a few minutes, no recollection the next day
Disobedience + tantrums
V common-toddlers realise world not orientated around them
Analyse using Antecedents (triggers), Behaviour and Consequences
May be provoked by GDD< language issues, hearing impairment, certain meds
M: affection + attention pre-tantrum, distraction, ignoring (not surrender), time out, hold child firmly if putting self/others in danger
Aggressive behaviour in little child
Learned behaviour - keep calm, follow the 1-2-3 principle (1=stop, 2= warn, 3=go to room), actively manage
Enuresis
Can be at day or night
Causes: genetic delay in sphincter competence, stress, rarely organic thing like a UTI or severe faecal retention or osmotic diuresis
Dip urine if in daytime or sx of DM
M: normal up to 5y, then explain to parent + child that is beyond conscious control and can help with star chart, enuresis alarm, desmopressin (synthetic ADH in >7y if alarm nt working or need short term relief)
Faecal soiling
Abnormal >4y
Causes: faecal retention due to constipation/pain/fear of toilet, or no retention (uncommon, urgency for unknown reasons or a neuropathic bowel from a spinal problem or general LD or intentional)
Child loses awareness once rectum dilates so stool may seep out uncontrolled
M:
*disimpact with a stool softener (macrogol e.g. movicol) then stimulant laxative (may need an enema if severe), then maintenance laxative therapy + encourage regular use of toilet
Somatisation
Communication of emotional distress through bodily symptoms
Commonly recurrent abdomen pain (sharp central colicky pain [in general the further from umbilicus the more likely it is organic]), headaches, in older children limb pain/aching muscles/neuro sx
Tics
A quick sudden coordinated movement, recurs in same part of child’s body, can be suppressed to some extent. Mostly occur when child inactive and go when concentrate
Most around head like grunting, sniffing, throat clearing
Usually resolve by adulthood
*Tourette’s syndrome: multiple motor + vocal tics e.g. grunitng/coughing/squeaking (The swearing [coprolalia] is uncommon), M-CBT or if severe clonidine/risperidone
Antisocial behaviour
Due to lack fo social skills, chronic anger, emotional issues, ADHD/depression, poor supervision by adults
Conduct disorder - severe form with coercive relationships etc
M: parent training programmes (need motivation to attend)
Anxiety
Rarely say they are anxious but c/o pains/nausea or behave in apparently manipulative ways to cope with/avoid feared situation
If irrational may benefit from CBT with graded exposure, for general anxiety may be from an event or disproportionate and should respond to parental comfort
School refusal
Unable to attend school due to overwhelming anxiety - may have physical sx like nausea/headache/hyperventilation
Reason may be rational like bullying/underachievement , or disproportionate to stresses when it is school refusal
Usually cos of anxiety + personality issues, or in primary school separation anxiety (provoked by bereavement, house move etc)
M: adv + support, treat underlying emotional disorder, graded return to school, address bullying/education issues
Educational underachievement
Chronic: vision/hearing issue, dyslexia, hyperactivity, chaotic family BG
Recent onset: preoccupations e.g. parental divorce, fatigue, abuse, brain conditions (rare)
Eating disorders
Anorexia nervosa - brady, amenorrhoea, slow relaxing tendon reflexes, low T3, low LH+FSH
Bulimia - binge + purge. Can cause hypokalaemia, alkalosis
Chronic fatigue syndrome
Persisting fatigue with rapid exhaustion on minimal physical/mental exhaustion
Debate over how much physical vs psychological
Often recommended graded exercise, CBT, support to achieve a normal life
Depression in adolescents
Low mood that also affects motivation/judgement/ability to experience pleasure/guilt; more common in kids to have apathy/boredom, separation anxiety, irritable mood (rather than depressed like in adults)
M: guided self help, 2-3m refer to CAMHS/psych, if having SSRI then fluoxetine licensed
Deliberate self harm
Common
Causes: coping with negative feelings, feeling more in control, physical pain to distract from emotional issues
Methods: cutting, burning, biting, bruising, ligatures, punching walls
Normalise the problem when asking about it
Drug misuse in adolescents
Area-dependent
- Glue/aerosol sniffing - arrhythmias, BM suppression, renal failure
- Alcohol-falls, RTAs
- LSD + cannabis-anxiety, psychosis
- Ecstasy-hyperthermia, dehydration, death
- legal highs depends on type, unregulated, depressant or stimulant
Psychosis
A breakdown in perception, understanding of reality + lack of insight
Not common in children, exclude drug causes e.g. steroids and medical e.g. infection/thyroid/seizures
How is child mental health managed?
Psychological > pharmacological
Counselling, parenting groups, behavioural therapy (young children,, alters environmental factor that trigger behaviour), family therapy (alter dysfunctional relationships), cognitive therapy (how ways of thinking affect feelings + behaviour), individual/group dynamic psychotherapy
Inpatient if suicidal or child protection
What is developmental delay?
Delay-slow acquisition of all (global) or some (specific) skills, especially in 0-5y
Can also have regression
Global developmental delay
Delayed acquisition of all skill fields usually picked up by age 2y
When child older they the individual difficulties more distinguished
Delayed motor skills
Usually presents between 3m-2y (when motor development most rapid)
May be due to a central issue like CP, congenital myopathy, SC lesion e.g. SB, GDD, or a normal variant of walking development
Signs may include: at 3m can’t lift head, at 6m floppy trunk, at 9m rounded back + poor arm use, at 13m not weight bearing, at 18m excessive tip toe gait/using just 1 hand
Delay in S+L
Delay may be due to hearing loss, GDD, cleft palate (anatomical), cerebral palsy (incoordination), environmental deprivation, or a normal familial pattern of later speaking
Disorders include comprehension issues, of expression (know what to say but cant produce it well), production issues like dysfluency (stammer)/verbal dyspraxia/pragmatics/semantics, social/communication issue like ASD
Do hearing test, SALT assessment
Strabisumus
Misalignment of the visual axes.
Transient is common up to 3m/marked epicanthic folds may make it look like squint, if >3m refer, and always check red reflexes (to exclude retinoblastoma)
Non-paralytic type most common - refractive error in one/both eyes usually causing an eye to turn out (convergent)
Paralytic type rare and varies with gaze direction cos of a motor nerve issue, more a/w sinister pathologies
Test with corneal light test, cover test
Refractive errors
- Hypermetropia - commonest in young children, accommodation usually helps them see but can correct with convex lenses
- Myopia - usually starts in adolescence unlesss preterm, concave lenses help
- Astigmatism - abnormal corneal curvature, common but if u/l can cause amblyopia
- Amblyopia - potentially permanent reduction in VA in an eye that hasn’t received a clear image during development (up to about age 7). E.g. squint, refractive errors, cataracts. Need to do patching to force ‘lazy; eye to work. Main target for preschool vision screening
Severe visual impairment
In UK usually hereditary (e.g. cataract, albinism, retinal dystrophy, retinoblastoma) or cerebral pathology (congenital infection, HIE, post natal infection)
What investigations might you request in developmental delay?
- Cytogenetics - genomic studies, karyotyping, FISH for specific chromosomal deletions
- Metabolic: TFT, LFT, bone profile, U+E, blood film, CK, ammonia, ferritin, vitamin B12
- Infection: TORCH screen
- Imaging: cranial US in newborn, CT/MRI, skeletal surgery for bone age
- Neurophysiology: EEG, nerve conduction studies
- Pathology: nerve/skin/muscle biopsy
- Vision + hearing check
- Behavioural + cognitive assessment by educational psychologist
- Therapy assessments PT/OT/SALT
How can you assess clinically for a developmental problem?
- History - keep confidence by starting at a level below what a child of that age is likely to be able to do
- Observation of child, make fun for them, formulate developmental picture of the different fields
- Adjust for prematurity
- Examination: growth (H, W, HC), dysmorphic features, HS, skin injuries/cleaniless, CNS like wasting/tone + power/reflexes, vision function, hearing (was newborn screening normal, any issues), patterns of mobility, hand dominance, dexterity, general behaviour + cognition
What are the indicators of neurodevelopmental delay?
- Prenatal - FH, Tay-Sachs (more common in Jewish), antenatal screening results
- Perinatal - asphyxia, IVH/PVL, abnormal neurology
- Infancy - developmental delay (GDD, motor), vision/hearing concerns, neurocutaneosu/dysmorpic features
- Preschool - S+L delay, abnormal gait + motor skills, poor social communication, inattention
- School age - balance + coordination problems, LD, hyperactive, specific learning difficulties, social communication issues
- Any age - acquired brain injury causing regression
What conditions can lead to abnormal development and LD?
- Genetic - chromosomal disorders, cerebral dysgenesis, neuronal migration disorders
- Brain: neonatal stroke, IVH/PVL, HIE
- Metabolic: congenital hypothyroidism, PKU, symptomatic neonatal hypoglycaemia, neonatal jaundice
- Teratogens in utero
- Congenital infection
- Neurocutaneous syndromes like tuberous sclerosis and neurofibromatosis
- Infections
- Anoxia - suffocation, near-drowning, seizures
- Trauma
- chronic illness, neglect
What are the different types of non-accidental injuries?
- Fractures: # in non-mobile child (unless OI), rib #, multiple #, # of different ages
- Bruises: in shape of a hand/object, around neck/wrists/ankles, to buttocks if <2y, to trunk with vague history (on shins of mobile are v normal)
- Burns: any if not mobile, in shape of something like a cigarette, glove + stocking (forced immersion) (splash marks/pulling drink onto self-may be neglect from poor supervision)
- Bites
General learning disability
A slow acquisition of cognitive skills. If borderline/mild usually just additional help in mainstream school, if more severe usually need a special school
Severe/profound usually begins with GDD early, whereas less severe emerge as start school
Most profound LD has an organic cause
Specific learning difficulties
A skill is more delayed than expected for the child’s level of cognitive ability
- Dyspraxia - developmental coordination disorder of motor planning/execution without neuro findings due to a problem with higher cortical processes. CF: problems of perception, use of language, putting thoughts together (can affect education + self esteem) e.g. messy handwriting, difficulty dressing, cutting up food, drawing, oro-motor dyspraxia
- Dyslexia: disorder of reading disproportionate to IQ, often when reading age is >2y behind chronological age
- Dyscalculia (calculation) + dysgraphia (writing)
- Disorders of executive function from acquired brain injury like organisation, cognitive flexibility, problem solving. May affect mood, concentration, eating, social skills
What medical problems are more common in kids with developmental issues?
- Hearing impairment, strabismus, visual field defects
- ADHD, sensory processing disorder, conduct disorders, OCD
- GI: GORD, oromotor incoordination, aspiration constipation
- Ortho: hip dislocation: contractures, painful spasms, osteoporosis
- Urogenital: UTI, delayed continence, VUR
- Resp infections
- Neuro: epilepsy, microcephaly, hydrocephalus, cerebral palsy
What are the members of community MDTs?
Specialist health visitors Dieticians Social workers Psychologists - educational + clinical Paediatricians SALT OT PT Specialist neurodisability services for rehab Transition to adult services which are quite poor cf children's
What is developmental regression?
Acute regression following acute brian injury with a slow resolution, or slow regression in neurodegenerative disorders
Fabricated or induced illness
Used to be Munchausen by proxy
Usually the mother - harms child to fulfil their own need
- Verbal fabrication: invent signs/sx, medical staff harm child by unnecessary intervention
- Induction of illness: e.g. giving noxious substance, excessive/unnecessary administration of normal things like salt or medication
Common co-morbidities in ASD?
Generalised learning difficulties
Seizures
Affective disorders like anxiety, sleep disturbance
MH disorders like ADHD
NAI head trauma
Commonest fatal form of NAI, most commonly <6m babies. 1/3 die, 1/3 permanent disability
CF: poor feeding, lethargy, seizures, respiratory problem, sudden death
Shaken baby syndrome - retinal haemorrhages, subdural haematoma, encephalopathy
