Neurodevelopmental Conditions Flashcards
What is ADHD?
Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental condition characterised by an abnormally high activity level and an inability to concentrate.
ADHD affects a person’s development and ability to carry out everyday tasks. It primarily affects children but can be diagnosed at any age. Importantly, features must be present before the age of seven and be consistent across at least two settings.
ADHD is estimated to have a global prevalence of 5% (3-4% in the UK) and a male to female ratio of 3:1. However, it is thought to be under-recognised and diagnosed in girls.
Prior to what age must symptoms have been present to diagnose ADHD?
Age 7, and be consistent amongst at least 2 settings
Risk factors for ADHD
Prematurity
Low birth weight
Low paternal education
Prenatal smoking
Maternal depression
Typical features of ADHD?
Short attention span
Quickly losing interest in tasks
Constantly fidgeting or unable to sit still
Impulsive behaviour
Described as disruptive
Poor organisational skills
Acting without thinking
Differential diagnoses for ADHD
Anxiety (can present with inattention)
Depression (can present with poor concentration)
Autism (may have poor impulse control)
Childhood trauma (can cause children to perform less well in school, appear inattentive and disruptive. The history should sensitively enquire about any precipitating events to new behaviours)
Less common: Personality disorders (defiant disorder, conduct disorder), epilepsy, learning disability
Why is autism a potential differential for ?ADHD
Children with autism spectrum conditions often have poor impulse control and may be described as disruptive due their rigidity of thought. Parents should be asked about the child’s development in communication, social skills, and imaginative play.
How can anxiety present similarly to ADHD and how do the two differ in presentation?
Anxiety can often present with inattention due to excessive worry and rumination.7 Patients may report difficulty concentrating, forgetfulness and being easily distracted. Features more suggestive of anxiety include worry, palpitations and feeling like something awful might happen.
How many symptoms are required for a diagnosis of ADHD and under what conditions must they occur?
Children up to the age of 16: there must be six or more symptoms of inattention and six or more symptoms of hyperactivity and impulsivity.
For those aged 17 and over: only five or more symptoms are required from each category.
The symptoms must occur in multiple settings (e.g. at home and school), have been present for at least six months and are not better explained by another disorder.
For example, if a child only displays these behaviours at school but is calm at home it suggests that the cause may be environmental. If the behaviours only continue for two weeks, then they may be better explained by a situational caus
DSM-5 criteria doe ADHD: symptoms of inattention
Failing to pay close attention to detail or making careless mistakes
Difficulty concentrating on activity
Appearing not to listen without apparent distraction
Not finishing tasks (not due to lack of understanding)
Poor organisation skills
Disliking tasks requiring sustained concentration
Easily distracted
Repeatedly losing items for tasks
Forgetfulness
DSM-5 criteria doe ADHD: symptoms of hyperactivity and impulsivity
Fidgeting or struggling to remain still when seated
Leaving one’s seat when sitting is expected
Running around or climbing in inappropriate situations
Inability to play quietly
Talking excessively
Blurting put answers before questions are complete
Difficulty waiting their turn
Interrupting or intruding on others
Being ‘on the go’ - others may describe them as difficult to keep up with
How might impulsivity in adults with ADHD be reflected
Note that impulsivity in adults may be reflected in drug or alcohol use, forensic history and employment history
Primary care management of ADHD in children
Watchful waiting for up to 10 weeks and encouraged self help and simple behavioural management
Establishing healthy diet and regular exercise
For parents or carers offer referal to group based ADHD focussed support program
Simple behavioural management: reward charts, lsotifie redirections
If symptoms severe or issues persist after simple self help measures refer to CAMHS or specialist paediatrician
Secondary care management of ADHD in children
First line: ADHD focused group parent training program
Second line: medication (methylphenidate) and CBT
Issues with medicating ADHD in children and how this is managed
Methylphenidate is, counterintuitively, a central nervous system stimulant.
It can cause growth retardation, weight loss, tachycardia, and hypertension.
As such, children taking this medication need to have their height, weight, heart rate and blood pressure measured every six months.
Complications of ADHD symptoms persisting into adulthood
Lower educational and employment attainment
Poor self-esteem
Criminal behaviour
Relationship issues
Sleep disturbance
Substance abuse
Road traffic accidents
Self-harm
What is autism
Autism spectrum disorder (ASD) is a neuro-developmental disorder characterised by abnormal social interaction, communication and restricted, repetitive behaviours. ASD is four times more prevalent in boys than girls.1 In the UK, 1 in 100 people are considered to be on the autistic spectrum.2
What is the characteristic features of what was formally known as Asperger’s
absence of intellectual impairment and/or impairment of functional language.
Predisposing medical conditions to autism
Infantile spasms
Congenital rubella
Tuberous sclerosis
Fragile X syndrome
ASD risk factors
Male sex
Family history
Genetic variants such as PTEN, MeCP and several submicroscopic copy number variants (CNV)
Chromosomal abnormalities
Typical features of ASD can be classed into which three categories?
social interaction,
communication
restricted, repetitive behaviours.
Social interaction features of autism
Lack of response to other people’s emotions
Unable to interpret social cues
Inability to form social attachments
Avoidance of physical contact
Lack of eye contact
Young children: delay in smiling, not displaying a desire to share attention
Communication features of autism
Usually delayed or minimal expressive speech
Impairment in make-believe or fantasy play
Lack of social gestures
Conversational skills tend to be one-way (monologues, endless questions etc…)
Delay absence or regression of language development
Lack of appropriate non verbal communication
Use of repetitive words or phrases
What restricted or repetitive behaviours may feature in autism
The tendency to resist change with a rigid daily routine
Preoccupations with specific interests like dates or timetables
Inability to adapt to new environments
Stereotypical moments (hand flapping or rocking)
Intensive deep interest that are persistent and rigid
Extremely restricted food preferences
Comorbidities which have an increased prevalence amongst patients with autism
ADHD
Epilepsy
Bowel disorders
Schizophrenia
Down syndrome
Sleep disorders
Characteristics of features of autism required for diagnosis
A diagnosis of ASD is based on clinical assessment with deficits occurring across all social, behavioural and communication domains.
These features must be observable in all environments that are sufficient to cause impairment in functional capacity.
They should have been present from early childhood but may not be fully evident until later when social demands exceed capabilities.
Differential diagnosis for ASD
Global developmental delay: delay occurring in all areas of development, not just social/communication
ADHD: difficulties with hyperactivity, attention, and impulse control.
Diagnostic tools for ASD
Diagnostic Interview for Social and Communication Disorders (DISCO)
Autism Diagnostic Observation Schedule (ADOS)
Potential non pharmacological support for autism
Specialist education (adjust curriculum, routine and structure)
Occupational therapy
Speech therapy
Clinical psychology, psychoeducation
Sleep hygiene
Care agencies
Dieticians
Specially trained educators or schools
Charities such as the national autistic society
Social stories
Environmental adjustments e.g. dim lit rooms, sensory soothing
Manage co existing mental or physical conditions
Potential pharmacological support for autism
There are no specific medications for ASD; however, patients with symptoms of depression and/or anxiety may benefit from behavioural and pharmacological intervention (e.g. SSRIs).
In addition, children with sleep difficulties which may benefit from a trial of melatonin if behavioural management/sleep hygiene proved to be unsuccessful.
Practical tips for approaching autistic patients in hospital/appointments
Find out in advance how patient communicates
Avoid large volumes of people in room
Use clear, direct literal language without any turns of phrase or sarcasm that may be misconstrued.
Enable company of people patient trusts
Complications of autism
There are several ‘complications’ or challenges that patients with ASD may face personally and interpersonally, including:
Social isolation
Bullying and victimisation
Problems in education
Problems with employment
Inability to live independently
Diagnostic tools for ADHD
Primary care physicians with the appropriate training may use the strengths and difficulties questionnaire or the Conners’ rating scale to aid their assessment.3,6,8 In adults, assessment can be aided by the Diagnostic Interview for ADHD in Adults (DIVA) questionnaire.9
ADHD medication
The drugs used in the management of ADHD all act to increase levels of noradrenaline, principally through inhibition of the reuptake of the neurotransmitter. Methylphenidate, lisdexamfetamine and atomoxetine are all stimulant drugs that work via this mechanism, and these have been shown to improve concentration, cognition and short-term memory in those with ADHD. Care must be taken with the medications due to their mechanism of action; reduced appetite, increased blood pressure and insomnia are all common side effects. Regular monitoring of height, weight, pulse and blood pressure is required.
First line drug for ADHD in children and also adults
Methylphenidate
Third line drug for ADHD
Atomoxetine
Third line drug for adhd
Dexamfetamine
Associated conditions with ASD
Sodium valproate use during pregnancy
ADHD
Tuberous sclerosis
Cerebral palsy
IBD
Coeliac disease
Chronic diarrhoea
Constipation
Heterogenous mental health conditions
Epilepsy
Autism assesment tools
ADOS (autistic diagnostic observation schedule looks at current behaviour and skills, not developmental data)
DISCO (diagnostic interview for social and communication disorders)
ADI-R (autistim diagnostic interview revised)
3DI (developmental dimensional and diagnostic interview)
What term is used to describe a phenomenon in which the patient has a fascination with repetitive mechanical tasks or with the ordering of objects?
Punding
This is associated with Parkinson’s disease medication or with those taking methamphetamin
