Neurodevelopmental Disorders in Children

Question 1

What are the symptoms and features of ADHD?

Answer 1

• Present from childhood
• Persistent
• Impairing
• Pervasive

Question 2

What causes ADHD?

Answer 2

• 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.

Question 3

What is the impact of ADHD at the following stages:

• Preschool
• School age
• Adolescence
• College age
• Adulthood

Answer 3

Question 4

What should be focussed on in the history when considering ADHD as a diagnosis?

Answer 4

• 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

Question 5

Describe the management of ADHD.

Answer 5

• 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

Question 6

What are the common side effects of ADHD medication?

Answer 6

• 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.

Question 7

What are the core features of Autism Spectrum Disorder?

And the other difficulties often seen?

Answer 7

• 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

Question 8

Describe the aetiology of Autism Spectrum Disorder.

Answer 8

• 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

Question 9

How is Autism Spectrum Disorder Assessed?

Answer 9

• 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)

Question 10

What are the interventions for ASD?

Answer 10

• 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

Question 11

What are the co-morbin presentations of ASD?

Answer 11

• Anxiety
• OCD
• ADHD
• Tic disorder
• Eating disorders
• Depression

Question 12

What is the definition of a tic?

Answer 12

• 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

Question 13

What is copropraxia?

Answer 13

Copropraxia is a tic consisting of involuntarily performing obscene or forbidden gestures, or inappropriate touching.

Question 14

What is echopraxia?

Answer 14

Involuntary repitition or imitation of another person’s actions.

Question 15

What is palilalia?

Answer 15

A speech disorder characterised by involuntary repetition of words, phrases, or sentences.

Question 16

What are some of the common motor and vocal tics?

Answer 16

Question 17

What are the characteristics of transient tic disorder?

Answer 17

• Symptoms less than 12 months
• Mostly school age
• Usually no specific symptoms

Question 18

What are the characteristics of Tourette syndrome?

Answer 18

• Several motor tics
• At least 1 vocal tic
• Not at the same time
• Almost every day > 1 year
• Onset usually < 18 years

Question 19

Describe the usual course of tic disorders.

Answer 19

• 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.

Question 20

What are the indicators for poor prognosis in tic disorders?

Answer 20

• Familial history
• Existence of vocal or complex tics
• Comorbid hyperkinetic disorder
• Obsessive compulsive symptoms
• Aggressive behaviour vs self or others

Question 21

What are the environmental factors which can have psychosocial effects on tic disorders?

Answer 21

• 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

Question 22

Describe the aetiology of tic disorders.

Answer 22

• 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.

Question 23

Describe the diagnosis of tic disorders.

Answer 23

• 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

Question 24

What are the differential diagnoses of tic disorders?

Answer 24

Question 25

Tic disorders have high comorbidity. Which other common disorders are associated with Tic disorders?

Answer 25

Question 26

What are the cognitive behaviour methods of treatment for tic disorder?

Answer 26

* Habit reversal training * Exposure response presention * Mased (negative) practice * Relaxation training * Contingency management * Family therapy

Question 27

Describe the use of medication in the treatment of tic disorders.

Answer 27

* 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

Question 28

How would you treat tic disorder with comorbid ADHD?

Answer 28

* Psychostimulants (e.g. methylphenidate) * Atomoxetine or clonidine for mild to moderate tics * Addition of risperidone

Question 29

How would you treat tic disorder and comorbid emotional disorders?

Answer 29

* SSRI * SSRI & antipsychotic for moderate to severe tics

Question 30

What are the alternative medicine treatments for tic disorders?

Answer 30

* Substantial anecdotal evidence for: * Physical exercise * Recreational activities in general * No evidence for: * Diet * Vitamin or mineral supplementation * Hypnosis

Question 31

What are the features of foetal alcohol spectrum disorders?

Answer 31