Paediatric neuropsychiatry - ADHD, OCD & ASD

Question 1

Definition of neuropsychiatric disorders

Answer 1

abnormal behaviours and functional impairment. Categories are descriptive rather than aetiological. Biological, genetic and neurological factors are all important and clinical presentation is shaped by the developmental stage of the child

Question 2

Common Neuropsychiatric disorders

Answer 2

Hyperactivity, ADHD and hyperkinetic. Autism, autistic spectrum disorders and asbergers. Tourette’s syndrome
OCD. Specific learning disorders

Question 3

Hyperactivity

Answer 3

Disorders of attention and activity – ADHD (american) is getting stricter but currently up to 10% prevalence while Hyperkinetic disorder (european) is about 1-3%

Question 4

Diagnostic criteria for hyperactivity

Answer 4

Overactivity – figeting, lack of control etc. Inattention – forgetful, disorganised, distractable etc. Impulsivity – difficulty taking turns, risk taking, interrupting. Occur at two of home/school/clinic. Onset before 7yrs and for >6months Other causes excluded

Question 5

Epidemiology of hyperactivity

Answer 5

3:1, M/F – more common in inner cities/poor areas

Younger children

Question 6

Additional features commonly associated with hyperactivity

Answer 6

behavioural problems/conduct disorder/problems with relationships
Learning disabilities (10x), specific learning problems, soft neurological signs or developmental delay

Question 7

Soft neurological signs

Answer 7

clumsiness or neurodevelopmental immaturities

Question 8

Differential for hyperactive child (6)

Answer 8

May just be a naughty child – situational hyperactivity. Emotional disorders. Tics (tourettes), chorea/dyskineasia, Learning disability
Medical causes

Question 9

Causes of hyperactivity

Answer 9

Genetics – D4R, DA transporter, fragile X etc. Imaging indicates reduced function in the frontal lobes. Differential response to chemical stimulants suggests it may be a neurochemical imbalance
Psychosocial or diet related factors

Question 10

Treatment of hyperactivity disorders

Answer 10

Education – both of child, family and school. Behavioural management – ABC and positive reinforcement. Cognitive systems – ‘stop & think’ traffic lights, Medication – stimulants and neuroleptics
Diet (rarely)

Question 11

Medication to treat hyperactivity

Answer 11

1st line–> stimulants (methylphenidate/dexamphetamine). SEs: low appetite, insomnia, tearfulness, stereotypies/tics. Long term: height reduction. 2nd line –> atomoxetine (NRI), impramine or clonidine (a2 agonist). 3rd line –> Neuroleptics (low dose risperidone)

Question 12

Prognosis in hyperactivity

Answer 12

Usually wanes in adolescence — can lead to residual problems in adulthood, especially if educational attainment is poor
Can lead to ASPD and drug abuse in adulthood

Question 13

Epidemiology of autism

Answer 13

2/1000 in adult population of which 10-50% have childhood autism. ASD general prevalence 1%,
3:1 male to female ratio or greater
No relationship with socioeconomic status

Question 14

Characteristic features of autism/PDD

Answer 14

Social impairment,
Communication impairment
Restricted & repetitive activities or interests
Early onset

Question 15

Pervasive developmental disorders

Answer 15

a group of five disorders which impact general development

They include: PDD NOS, autism, asbergers, Rett syndrome and childhood dis-intergrative disorder

Question 16

Characteristic features of autism/PDD - social impairment

Answer 16

poor eye contact, lack in interest in people, affection/social interactions only on own terms

Question 17

Characteristic features of autism/PDD - communication impairment

Answer 17

some never acquire useful speech, way gain then lose speech or develop deviant speech

Question 18

Characteristic features of autism/PDD - Restricted/repetitive interests

Answer 18

Resistant to change, insistance on routines and rituals. Consuming preoccupations with certain subjects. Lack of make believe play
Stereotypies. Attachment to unusual objects or abnormal sensory interests

Question 19

Characteristic features of autism/PDD - Early onset

Answer 19

Usually have clear abnormalities during first year of life – minority are fine for first couple of years then develop a clear setback in the 2nd or 3rd year – should be before 3 years

Question 20

Associated features of PDDs

Answer 20

learning disability –> seizures in 1/3 of this group and 5% of normal IQ autistics
Hyperactivity common –> including aggression, self harm/dangerous behaviour, extreme food restrictions, fears and phobic avoidance

Question 21

Aspergers syndrome

Answer 21

Autistic features in the absence of clinically significant language delay – restricted/repeatative interests mostly evident in interests rather than behaviours

Question 22

Causes of autism/PDD

Answer 22

More likely in children with epilepsy, tuberose sclerosis, fragile X, PKU etc
Very large genetic component – 90% MZ concordance – sibling recurrence is only 5% but up to 20% for the broader syndrome

Question 23

Assessment of autism/PDD

Answer 23

Family, personal and developmental history is crucial

Genetic and standardised testing is used to verify the diagnosis

Question 24

Treatment/Management of autism/PDD

Answer 24

Appropriate school placement
Carer support and respite care
Behavioural programs and possible cognitive empathic training
Medication to treat symptoms can be used but not as a mainstay

Question 25

Autism in adolescence

Answer 25

Peak age of seizures is 11-14yrs
Early hyperactivity may be replaced by underactivity
10% will have a non-progressive lanaguage or cognitive loss phase
Increased agitation and aggression and inappropriate sexual behaviour

Question 26

Long term outcome in autism/PDD

Answer 26

20% good or very good outcomes but most remain dependent on familes/friends/support services – fewer have close friends or marry IQ and speech at 5 –> best predictor of adult independence. If performance IQ is under 60 - unlikely to be able to live independently

Question 27

Tourettes syndrome

Answer 27

Motor or vocal tics for >1yr before the age of 21yrs
1% incidence, male preponderance (3:1)
Coprolalia/copopraxia or echolalia/echopraxia may be present
Associated with OCD, autism, ADHD, LD, FH of OCD,

Question 28

Treatment of tourettes (4)

Answer 28

Clonidine or risperidone

Psychosocial support and special educational provision

Question 29

OCD

Answer 29

Obsessions and compulsions most days for 2 weeks. Irrational, recognisable & unpleasant. 0.5% prevalence in teens, 1/2 of adult cases onset in childhood. More males in childhood but even in adults.
Associated with other psychiatric disorders and treat with CBT/SSRIs

Question 30

Specific learning disorder

Answer 30

2 SD below the expected level of global intelligence

Dyslexia is specific reading and spelling disorder

Question 31

Aetiology of ASD/PDD

Answer 31

10% have a causal medical disorder (tuberous sclerosis, fragile X) - 90% idiopathic and polygenic –>but 90% heritable - 10% sibling risk