Neurodevelopmental Disorders in Children Flashcards
What are the symptoms and features of ADHD?
- Present from childhood
- Persistent
- Impairing
- Pervasive
What causes ADHD?
-
Genetic
- 70-80% heritable
- Genes (dopaminergic pathways)
- Neurobiology
-
Risk factors
- Intrauterine: nicotine, alcohol.
- Perinatal: prematurity, low birth weight, hypoxia.
- Early life: emotional neglect, brain insult.
What is the impact of ADHD at the following stages:
- Preschool
- School age
- Adolescence
- College age
- Adulthood
What should be focussed on in the history when considering ADHD as a diagnosis?
-
Core symptoms:
- Onset and nature of difficulties
- Pervasiveness (home and school)
- Sleep, apetite and sensory issues
- Comorbidity
-
Areas to focus on:
- Family and history and functioning
- Education and peer relationships
- Obstetric history and development
Describe the management of ADHD.
- Approach
- Long-term
- Multimodal
- Multidisciplinary
- Psychosocial interventions
- Younger: behavioural parenting training
- Older: behaviour management programme for comorbidities (e.g. conduct disorder)
- Individualised school interventions
- Medication ± Behavioural intervention
- Psychostimulant > Atomoxetine > Other
What are the common side effects of ADHD medication?
- These side effects are often dose-related:
- Headache, nausea, appetite suppression, dizziness, insomnia, mood swings, hypertension, lack of ‘spontaneity’.
- Atomoxetine: increased suicidal ideation, liver damage.
- Dexamfetamine / Lisdexamfetamine: diarrhoea.
- Guanfacine: hypotension, sedation, increased weight gain.
What are the core features of Autism Spectrum Disorder?
And the other difficulties often seen?
-
Diagnostic criteria:
- Deficits in social communication and social interaction.
- Restricted, repetitive patterns of behaviour, interests or activities.
- PLUS:
- Must be present from early childhood
- Must limit and impair everyday function
-
Other difficulties often seen:
- Sensory
- Circadian rhythm
- Executive function e.g. planning, motivation
- Anxiety
Describe the aetiology of Autism Spectrum Disorder.
-
Genetic
- Heritability: 50%
- Multiple susceptibility genes acting synergistically
- Large number of candidate areas in the brain
-
Environmental
- Prenatal: rubella, ?cocaine, ?alcohol, ?valproic acid
- Perinatal: ?obstetric complications
- Postnatal: ?immunological abnormalities
- Genetic and environmental interaction
How is Autism Spectrum Disorder Assessed?
- Core assessments:
- Detailed developmental hx
- Information from school
- Observations in clinic / school
- Useful extras:
- Questionnaires e.g. social responsiveness scale
- RAADS for teenagers
- If inconclusive, can add in:
- Autism Diagnostic Observation Schedule (ADOS-2)
What are the interventions for ASD?
-
Make things easier:
- Psychoeducation, environment
- Alternative communication
- Routines: ‘Social stories’
-
Psychological:
- Behaviour therapy
- Modified CBT
-
Pharmacological:
- SSRIs (sertraline) for co-morbid anxiety or OCD
- Antipsychotics (risperidone) for aggression
- Melatonin for circadian dysregulation
What are the co-morbin presentations of ASD?
- Anxiety
- OCD
- ADHD
- Tic disorder
- Eating disorders
- Depression
What is the definition of a tic?
- Motor movement or vocalisation that is:
- Involuntary
- Sudden
- Rapid
- Reccurent / repetitive
- Non-rhythmic
- Short burtsts or series
- Various muscle groups
- Simple or complex
- Transient or chronic
- Premonitory urge
What is copropraxia?
Copropraxia is a tic consisting of involuntarily performing obscene or forbidden gestures, or inappropriate touching.
What is echopraxia?
Involuntary repitition or imitation of another person’s actions.
What is palilalia?
A speech disorder characterised by involuntary repetition of words, phrases, or sentences.
What are some of the common motor and vocal tics?
What are the characteristics of transient tic disorder?
- Symptoms less than 12 months
- Mostly school age
- Usually no specific symptoms
What are the characteristics of Tourette syndrome?
- Several motor tics
- At least 1 vocal tic
- Not at the same time
- Almost every day > 1 year
- Onset usually < 18 years
Describe the usual course of tic disorders.
- Onset 2-15 years
- Peak: 6-8 years
- Motor tic of face first
- Shoulders, torso, extremities after
- Vocal tics 2-4 years later
- Fluctuations every 6-12 weeks in location, complexity, type, intensity, frequency.
What are the indicators for poor prognosis in tic disorders?
- Familial history
- Existence of vocal or complex tics
- Comorbid hyperkinetic disorder
- Obsessive compulsive symptoms
- Aggressive behaviour vs self or others
What are the environmental factors which can have psychosocial effects on tic disorders?
- Can decrease during:
- Distraction
- High concentration job
- Cannabis use
- Alcohol use
- Intentional movements
- Can increase during:
- Stress
- Fear
- Emotional trauma
- Social presure
- Joy
- Tension
- Caffeine use
Describe the aetiology of tic disorders.
- Multifactorial: genetic, neurobiological, psychological, environmental.
- Dysregulation in cortico-striato-thalamo-cortical circuits.
- Deviations in dopaminergic and serotonergic systems.
- Increased dopamine activity in basal ganglia → deficient subcortical inhibition → impaired autonomic control of movement.
Describe the diagnosis of tic disorders.
- Detailed medical history
- Standardised questionnaires:
- Child behaviour checklist
- Strengths and difficulties questionnaire
- Interviews:
- Yale Global Tic severity scale
- Tourette’s Syndrome Severity Scale
- Parents / self rating scales
- Yale Tourette Syndrome Symptom List - Revised
- Physical and neurological exam
- EEG
What are the differential diagnoses of tic disorders?
Tic disorders have high comorbidity. Which other common disorders are associated with Tic disorders?
What are the cognitive behaviour methods of treatment for tic disorder?
- Habit reversal training
- Exposure response presention
- Mased (negative) practice
- Relaxation training
- Contingency management
- Family therapy
Describe the use of medication in the treatment of tic disorders.
- Most treatment is ‘off-label’
- Only when interfering with function or subjective discomfort
- Start slowly
- Only discontinue after a year
- Reduce in late adolescence
- Pre-medication work-up:
- FBC
- LFT
- Prolactin
- EEG
- ECG
- Physical / neurological exams
How would you treat tic disorder with comorbid ADHD?
- Psychostimulants (e.g. methylphenidate)
- Atomoxetine or clonidine for mild to moderate tics
- Addition of risperidone
How would you treat tic disorder and comorbid emotional disorders?
- SSRI
- SSRI & antipsychotic for moderate to severe tics
What are the alternative medicine treatments for tic disorders?
- Substantial anecdotal evidence for:
- Physical exercise
- Recreational activities in general
- No evidence for:
- Diet
- Vitamin or mineral supplementation
- Hypnosis
What are the features of foetal alcohol spectrum disorders?
