Paediatric Mental Health

Question 1

What is ADHD?

Answer 1

Attention Deficit Hyperactivity Disorder is a neurodevelopmental disorder characterised by inattention, impulsivity and hyperactivity. Typically diagnosed in childhood with symptoms persisting into adulthood.

Question 2

What are the risk factors for ADHD?

Answer 2

Genetic Factors:
* Family history of first degree relatives with ADHD. Twin studies show heritability rate of 70 - 80%
* Certain genes associated with ADHD - DAT1, DRD4 and DRD5

Environmental Factors:
* Prenatal exposure to tobacco smoke, alcohol or drugs
* Premature birth and low birth weight
* Early childhood exposure to lead or other environmental toxins

Neurobiological abnormalities:
* MRI studies have shown structural brain differences in the prefrontal cortex, basal ganglia, corpus callosum and cerebellum
* Structural changes may result in altered connectivity between different brain regions
* Neurotransmitters dopamine and noradrenaline implicated in the pathophysiology of ADHD due to altered levels of functioning

Question 3

What is the clinical presentation of ADHD?

Answer 3

A child (typically male) presenting with hyperactivity, impulsivity and inattentiveness.

Question 4

How might hyperactivity present in children with ADHD?

Answer 4

• Patients appears to be in constant motion
• Fidgeting
• Inability to sit still
• Excessive talking
• Running about excessively when its not appropriate

Behaviours are typically more severe than those in peers at same age and developmental level

Question 5

How might impulsivity present in children with ADHD?

Answer 5

May manifest as hasty actions without forethought or regard for consequences. This may lead to risky behaviours or difficulties with social interactions.

Examples include:
* Interrupting conversations
* Intruding upon others activities
* Making decisions without considering potential outcomes

Question 6

How might inattentiveness present in a child with ADHD?

Answer 6

Patients with ADHD have difficulty sustaining attention during tasks or play activities.

Examples include:
* Not appearing to listen when spoken to directly
* Frequently losing items necessary for tasks
* Having trouble organising activities
* Avoiding or expressing dislike for tasks requiring sustained mental effort such as schoolwork or homework

Question 7

How can the clinical presentation of ADHD vary across age groups?

Answer 7

Childhood - classic triad of hyperactivity, impulsivity, and inattention is most evident at this stage

Adolescence - Hyperactive behaviours generally decrease but problems with attention and impulsivity may continue. May display more risk-taking behaviours

Adulthood - Inattentiveness often persists into adulthood, while hyperactivity tends to decrease further. Adults may experience difficulties with time management, goal setting, employment and relationships

Question 8

What other conditions are associated with ADHD?

Answer 8

• Intellectual disability
• Conduct disorders
• Anxiety disorders
• Depression
• Substance abuse

Question 9

What are the subtypes of ADHD?

Answer 9

1. Predominantly inattentive presentation
2. Predominately hyperactive-impulsive presentation
3. Combined presentation

Subtype depends on predominant symptom pattern for preceding 6 months

Question 10

How is ADHD diagnosed?

Answer 10

Accurate diagnosis requires comprehensive assessment including consideration of symptom severity, duration, impact on functioning and exclusion of other potential causes.

Includes developmental history, school performance, behaviour in different settings

Co-existing conditions should be identified

Question 11

What are the non-pharmacological interventions for ADHD?

Answer 11

• Parent-training/ education programmes as first line treatment in children <6 y/o
• School-based interventions such as individualised educational programmes or behavioural interventions

Question 12

What are the pharmacological interventions for ADHD?

Answer 12

• Methylphenidate is usually 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

Patients should have regular follow up to monitor effectiveness and side effects of medication

Question 13

What is Autism Spectrum Disorder?

Answer 13

Autism is a neurodevelopmental condition characterised by impairment in social interaction and communication, repetitive stereotyped behaviour, interests and activities.

Question 14

What are the risks factors for ASD?

Answer 14

• Genetic causes including gene defects and chromosomal anomalies
• Family history - sibling recurrence risk ~10% and concordance of 36-60% in monozygotic twins
• Advanced parental age - maternal age (>40 years) and paternal age (>50 years)
• Environmental factors e.g. toxin exposure, prenatal infections
• Genetic diagnoses e.g. Tuberous sclerosis, Fragile X syndrome, Chromosome 15q11-13 duplication syndrome, Angelman syndrome, Rett’s syndrome, Down syndrome

Question 15

What is the pathophysiology of ASD?

Answer 15

Pathophysiology is not well understood in this condition
* Genetic, perinatal and environmental factors seem to contribute
* May be related to abnormal function in hippocampal/amygdala regions
* May be related to altered cytokine levels on neuronal cell proliferation, neuron death, and synaptic pruninga (altered microglia on phagocytosis of neurons)

Question 16

How is the severity of ASD classified?

Answer 16

Diagnosis of ASD is qualified by 3 levels of severity rated seperately for social communication and restricted repetitive behaviours:
* Level 1 (requiring support)
* Level 2 (requiring substantial support)
* Level 3 (requiring very substantial support)

Question 17

What is the clinical presentation of ASD?

Answer 17

1. Impaired social communication and interaction
   * Children may play alone be relatively uninterested in other children
   * Fail to regulate social interaction with non-verbal cues such as eye gaze, facial expression and gestures
   * Fail to form and maintain appropriate relationships and become socially isolated
2. Repetitive behaviours, interests and activities
   * Stereotyped and repetitive motor mannerisms
   * Inflexible adherence to nonfunctional routines or rituals
   * Children have particular ways of going about everyday activities
3. May be associated with intellectual or language impairment
4. May be associated with ADHD or epilepsy
5. May have a higher head circumference to brain volume ratio

Question 18

What are the referral criteria for referral for ASD diagnosis in primary care?

Answer 18

• Indications for specialist referral for further assessment (NICE 2011):

1. Refer first to a paediatrician or paediatric neurologist (who can refer to the autism team if necessary) children and young people:
   * older than 3 years with regression in language
   * of any age with regression in motor skills.
2. Consider referring children and young people to the autism team if you are concerned about possible autism on the basis of reported or observed features suggesting possible autism. Take into account:
   * the severity and duration of the features suggesting possible autism
   * the extent to which the features suggesting possible autism are present across different settings (for example, home and school)
   * the impact of the features suggesting possible autism on the child or young person and on their family
   * the level of parental or carer concern and, if appropriate, the concerns of the child or young person
   * factors associated with an increased prevalence of autism
   * the likelihood of an alternative diagnosis

Question 19

What are the DSM-5 diagnostic criteria for ASD?

Answer 19

1. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history:
   * Deficits in social-emotional reciprocity including verbal interaction or sharing interests
   * Deficits in non-verbal communicative behaviours used for social interaction.
   * Deficits in developing and understanding relationships.
2. Restricted, repetitive patterns of behaviour, interests, or activities, as manifested by at least 2 of the following, currently or by history:
   * Stereotyped or repetitive motor movements, use of objects or speech
   * Insistence on sameness, inflexible adherence to routines, or ritualised patterns of verbal or non-verbal behaviour
   * Highly restricted, fixated interests that are abnormal in intensity or focus
   * Hyper- or hypo-reactivity to sensory input
3. Unusual interest in sensory aspects of the environment
4. Symptoms must be present in the early developmental period
5. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.
6. These disturbances are not better explained by intellectual disability (intellectual development disorder) or global developmental delay. Intellectual disability and ASD frequently co-occur; to make comorbid diagnoses of ASD and intellectual disability, social communication should be below that expected for the general developmental level.

Question 20

What are the ICD-10 diagnostic criteria for ASD?

Answer 20

ICD-10 criteria for the diagnosis of pervasive developmental disorders is also based on atypical social communication and interaction and restricted, repetitive patterns of behaviour, activities, and interests.

• Typical: a pervasive developmental disorder defined by the presence of abnormal and/or impaired development that is manifest before the age of 3 years, and by the characteristic type of abnormal functioning in all 3 areas of psychopathology: reciprocal social interaction, communication, and restricted, repetitive behaviour.
• Atypical: A pervasive developmental disorder that differs from autism in terms either of age of onset or of failure to fulfil all 3 sets of diagnostic criteria. More common in people with severe learning disabilities and those with a severe specific developmental disorder of receptive language.

Question 21

What differential diagnoses should be considered when assessing for ASD and what are the similarities and differences when compared with ASD?

Answer 21

1. ADHD
   * Similarities - social communication difficulties
   * Differences - normal pragmatic language skills, nonverbal social behaviour, and imaginative play. Lack of restrictive, repetitive patterns of behaviour, interests and activities
2. Social (pragmatic) communication disorder
   * Similarities - impairment in social communication and social interaction
   * Differences - absence of restricted, repetitive patterns of behaviour, interests or activities
3. Global developmental delay/intellectual disability
   * Similarities - language delay, may show reptitive behaviours
   * Differences - social responsiveness and communication appropriate for the developmental level
4. Developmental language disorder
   * Similarities - social communication difficulties
   * Differences - normal reciprocal social interactions, and normal desire and intent to communicate. Appropriate imaginative play

Question 22

How is ASD managed?

Answer 22

1. MDT Approach - input from professional including paediatricians, psychologists, speech and language therapists, occupational therapists, educational professionals, and social care workers
2. Early interventions
   * Applied Behaviour Analysis (ABA) - A teaching approach rewarding positive behaviour and diminishing 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) - targets various areas of child development, providing intensive support
3. Communication Enhancement
   * Speech and Language Therapy - Assist with language development and communicative function
   * Picture Exchange Communication System (PECS) - a visual system to initiate communication for non-verbal or minimally verbal individuals
4. Social Skills Training
   * Structured teaching of social norms and behaviours to help navigate social situations more effectively
5. Occupational therapy
   * Sensory Integration Therapy - to manage and integrate sensory information to allow appropriate response to environmental demands
   * Adaptive Skills Training - helps in developing skills required for daily living

Question 23

What pharmacological management is available for ASD?

Answer 23

Kind of a trick question because no drug treats the core symptoms of ASD but medications can be helpful for associated comorbidities:

• ADHD - Methylphenidate, atomoxetine or guanfacine
• Anxiety and OCD - SSRIs may have a role

Question 24

What support may be available for families of those with ASD?

Answer 24

• Parent-managed behavioural interventions - Equips parents with skills to manage behavioural challenges
• Support groups - offering parents and caregivers peer support
• Respite care - provides temporary care relief for families, ensuring their well-being

Question 25

How can individuals with ASD be supported as they transition to adulthood?

Answer 25

• Transition planning - starting in adolescence, focussing on life skills, further education, employment and independent living
• Mental Health Support - for coexisting mental health conditions including psychological and pharmacological interventions
• Employment and vocational training - tailored support to enable meaningful employment
• Housing and independent living - consideration of supported living environments may be necessary for some