Neurology: ADHD; Autism; Depression Flashcards
Describe the aetiology for ADHD [3]
Genetic Factors
- FHx
Environmental Influences
* Prenatal exposure to tobacco smoke, alcohol or drugs increases the risk of developing ADHD.
* Premature birth and low birth weight
* Early childhood exposure to lead or other environmental toxins
Neurobiological Abnormalities:
- Areas implicated include prefrontal cortex, basal ganglia, corpus callosum and cerebellum, where functional imaging studies suggest that these structural changes may result in altered connectivity between different brain regions.
Describe the clinical features of ADHD
Hyperactivity
- constant motion, exhibiting behaviours such as fidgeting, inability to sit still, excessive talking or running about excessively when it’s not appropriate.
Impulsivity:
- hasty actions without forethought or regard for consequences.
- This can lead to risky behaviours or difficulties with social interactions.
- e.g. interrupting conversations, intruding upon others’ activities and making decisions without considering potential outcomes.
Inattentiveness
- difficulty sustaining attention during tasks or play activities.
- They may appear not to listen when spoken to directly, frequently lose items necessary for tasks and have trouble organising activities.
NB: Features should be consistent across various settings. When a child displays these features only at school but is calm and well behaved at home, this is suggestive of an environmental problem rather than an underlying diagnosis.
How does ADHD present differently from childhood to adolescence to adulthood [3]
Childhood: The classic triad of hyperactivity, impulsivity and inattention is most evident at this stage.
Adolescence: While hyperactive behaviours generally decrease during adolescence, problems with attention and impulsivity may continue. Adolescents may also display risk-taking behaviours.
Adulthood: Inattentiveness often persists into adulthood, while hyperactivity tends to decrease. Adults may experience difficulties with time management, goal setting, employment and relationships.
What are the three recognised subtype of ADHD? [3]
There are three recognised subtypes of ADHD:
* predominantly inattentive presentation;
* predominantly hyperactive-impulsive presentation;
* combined presentation.
The subtype diagnosis depends on the predominant symptom pattern for the past six months.
Describe how you manage ADHD
Assessment:
- Comprehensive assessment should be conducted including developmental history, school performance and behaviour in different settings.
- Co-existing conditions such as learning difficulties, anxiety disorders or autism spectrum disorder should be identified.
Non-pharmacological intervention:
* Offer parent-training/education programmes as first-line treatment for parents or carers of children under 6 years with ADHD.
* Establishing a healthy diet and exercise can offer significant improvement in symptoms. Keeping a food diary may suggest a link between certain foods, such as food colourings, and behaviour. Elimination of these triggers should be done with the assistance of a dietician
* School-based interventions such as individualised educational programmes or behavioural interventions may be beneficial.
Pharmacological intervention:
- Methylphenidate is usually the first-line medication for children and young people. Dexamfetamine or atomoxetine can be considered if response to methylphenidate is inadequate.
- Lisdexamfetamine or atomoxetine could be used as first line treatment in adults with ADHD.
Monitoring:
- Patient should have regular follow-up to monitor effectiveness and side-effects of medication along with ongoing need for other support.
What are the pharmacological interventions for ADHD?
- in children [3]
- in adults [2]
Methylphenidate is usually the first-line medication for children and young people. Dexamfetamine or atomoxetine can be considered if response to methylphenidate is inadequate.
Lisdexamfetamine or atomoxetine could be used as first line treatment in adults with ADHD.
Which drug is aka Ritalin? [1]
Methylphenidate
Which genetic conditions are associated with ASD? [5]
Tuberous sclerosis complex
Fragile X syndrome
Chromosome 15q11-13 duplication syndrome
Angelman syndrome
Rett’s syndrome
Down syndrome
Describe the classification of autism spectrum disorder is [2]
The classification of autistic spectrum disorder was introduced in the diagnostic and statistical manual of mental disorders fifth edition (DSM-5), introduced in 2013.
This took previous diagnoses such as Aspergers syndrome and autistic disorder and grouped them into one spectrum disorder, suggesting that the same disorder was responsible for the features of the condition and those affected fall somewhere along the spectrum.
The autistic spectrum has a significant range. On one end patients have normal intelligence and ability to function in everyday life but displaying difficulties with reading emotions and responding to others. This was previously known as Asperger syndrome. On the other end, patients can be severely affected and unable to function in normal environments.
The diagnosis of ASD is qualified by three levels of severity rated separately for social communication and restricted, repetitive behaviours.
What are they? [3]
Severity is assessed separately for each domain as:
Level 1 (requiring support)
Level 2 (requiring substantial support), and
Level 3 (requiring very substantial support).
Describe the clinical features of ASD
Impaired social communication and interaction:
- Children frequently play alone and maybe relatively uninterested in being with other children.
- They may fail to regulate social interaction with nonverbal cues like eye gaze, facial expression, and gestures.
- Fail to form and maintain appropriate relationships and become socially isolated.
- Delay in smiling
- Unable to read non-verbal cues
- Lack of eye contact
Communication
* Delay, absence or regression in language development
* Lack of appropriate non-verbal communication such as smiling, eye contact, responding to others and sharing interest
* Difficulty with imaginative or imitative behaviour
* Repetitive use of words or phrases
Repetitive behaviours, interests, and activities:
* Stereotyped and repetitive motor mannerisms, inflexible adherence to nonfunctional routines or rituals are often seen.
* Children are noted to have particular ways of going about everyday activities.
* Stereotypical repetitive movements. There may be self-stimulating movements that are used to comfort themselves, such as hand-flapping or rocking.
* Extremely restricted food preferences
ASD is often associated with intellectual impairment or language impairment.
ASD is also associated with a higher head circumference to the brain volume ratio.
Which conditions are associated with ASD? [2]
Attention deficit hyperactivity disorder (35%) and epilepsy (18%) are also commonly seen in children with ASD.
What are indications for specialist referral for further assessment (NICE, 2011) for ASD? [4]
- Refer children younger than 3 years if there is a regression in language or social skills.
- Consider referring children and young people if you are concerned about possible ASD based on reported or observed signs and/or symptoms.
- Factors associated with an increased prevalence of ASD.
- The likelihood of an alternative diagnosis.
There are two major sets of diagnostic criteria for ASD:
- The Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Disease Classification (ICD).
Describe what characterises each [+]
Asperger’s disorder (formally known as a syndrome) is now part of ASD rather than a separate entity.
Describe how people with Asperger’s typically present [2]
Typically have a normal or above-average intelligence without learning disabilities.
Learning disability is common amongst people with autism. Overall, they usually have fewer or no problems with speech and language.
Pulsenotes:
Describe the dx for ASD [+]
Persistent deficits in social communication and social interaction in multiple settings (evidenced by deficits in all 3 of the following):
* Social-emotional reciprocity
* Nonverbal communicative behaviours
* Developing, maintaining and understanding relationships
Restricted, repetitive patterns of behaviour, interests, or activities (evidence by ≥2 of the following):
* Stereotyped or repetitive movements, use of objects, or speech
* Insistence on sameness, unwavering adherence to routines, or ritualised patterns of verbal or nonverbal behaviour
* Highly restricted, fixated interests that are abnormal in strength or focus
* Increased or decreased response to sensory input or unusual interest in sensory aspects of the environment
Children and young adults with ASD may require specific treatment interventions depending on their personal needs. These can include: [5]
Behavioural & educational interventions (e.g. high staff-to-student ratio, highly supportive teaching environment, predictability and structure)
Psychosocial interventions (e.g. be appropriate for the child or young person’s developmental level and sensitive and responsive to their patterns of communication and interaction, include techniques to expand communication, interactive play and social routines)
Interventions for life skills (e.g. coping strategies for leisure activities, public transport and employment)
Interventions for speech and language problems (e.g. involvement of speech and language team)
Intervention for sleep disorders
PM:
Early identification and subsequent intervention of ASD improves outcomes significantly.
While specific interventions might vary based on the individual, core principles of structure, routine, and visual aids underpin most strategies.
What are three early intervention techniques used? [3]
Applied Behaviour Analysis (ABA):
- A teaching approach that rewards positive behaviour and diminishes inappropriate or self-harming behaviours.
TEACCH (Treatment and Education of Autistic and related Communication-handicapped Children):
- Focuses on individualised schedules and work systems.
Early Intensive Behavioural Intervention (EIBI):
- Rooted in the principles of applied behaviour analysis (ABA), EIBI targets various areas of child development, providing intensive support.
What occupational therapy [2] and communication enhancement [2[ can be used for ASD people?
Communication Enhancement:
* Speech and Language Therapy: Assists with language development and communicative function.
* Picture Exchange Communication System (PECS): A visual-based system to initiate communication for non-verbal or minimally verbal individuals.
Occupational Therapy:
* Sensory Integration Therapy: Aims to manage and integrate sensory information to allow an individual to respond appropriately to environmental demands.
* Adaptive Skills Training: Helps in developing skills required for daily living.
NICE recommend referral to CAMHS for children with moderate to severe depression. CAMHS can then initiate what treatment plan [5]?
Psychological therapy as the first line treatment with cognitive behavioural therapy, non-directive supportive therapy, interpersonal therapy and family therapy
Pharmacological treatment:
- Fluoxetine is the first line antidepressant in children, starting at 10mg and increasing to a maximum of 20mg
- Sertraline and citalopram are second line antidepressants
- When the child responds to medical treatment, it should continue 6 months after remission is achieved
When they do not respond to medical treatment they may require intensive psychological therapy
Describe the clinical features of depression
Persistent low mood
Anhedonia, or the loss of interest or pleasure in almost all activities once enjoyed, is another key feature
- Individuals may show noticeably diminished interest in hobbies, social interactions, sexual activity and other sources of potential enjoyment.
Another common symptom is decreased energy levels or increased fatigue.
Cognitive changes
- Difficulties in concentration and decision-making are frequently reported.
- Patients may also exhibit negative patterns of thinking such as excessive guilt or feelings of worthlessness.
Insomnia
Appetite changes
- +/- appetitie
Suicidal ideation
How do you dx depression?
Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
* Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
* Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).
* Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)
* Insomnia or hypersomnia nearly every day.
* Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
* Fatigue or loss of energy nearly every day.
* Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
* Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
* Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
Which two questions can be used to screen for depression? [2]
- ‘During the last month, have you often been bothered by feeling down, depressed or hopeless?’
- ‘During the last month, have you often been bothered by having little interest or pleasure in doing things?’
A ‘yes’ answer to either of the above should prompt a more in depth assessment.
