Paediatric neuropsychiatry - ADHD, OCD & ASD Flashcards
Definition of neuropsychiatric disorders
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
Common Neuropsychiatric disorders
Hyperactivity, ADHD and hyperkinetic. Autism, autistic spectrum disorders and asbergers. Tourette’s syndrome
OCD. Specific learning disorders
Hyperactivity
Disorders of attention and activity – ADHD (american) is getting stricter but currently up to 10% prevalence while Hyperkinetic disorder (european) is about 1-3%
Diagnostic criteria for hyperactivity
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
Epidemiology of hyperactivity
3:1, M/F – more common in inner cities/poor areas
Younger children
Additional features commonly associated with hyperactivity
behavioural problems/conduct disorder/problems with relationships Learning disabilities (10x), specific learning problems, soft neurological signs or developmental delay
Soft neurological signs
clumsiness or neurodevelopmental immaturities
Differential for hyperactive child (6)
May just be a naughty child – situational hyperactivity. Emotional disorders. Tics (tourettes), chorea/dyskineasia, Learning disability
Medical causes
Causes of hyperactivity
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
Treatment of hyperactivity disorders
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)
Medication to treat hyperactivity
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)
Prognosis in hyperactivity
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
Epidemiology of autism
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
Characteristic features of autism/PDD
Social impairment,
Communication impairment
Restricted & repetitive activities or interests
Early onset
Pervasive developmental disorders
a group of five disorders which impact general development
They include: PDD NOS, autism, asbergers, Rett syndrome and childhood dis-intergrative disorder
Characteristic features of autism/PDD - social impairment
poor eye contact, lack in interest in people, affection/social interactions only on own terms
Characteristic features of autism/PDD - communication impairment
some never acquire useful speech, way gain then lose speech or develop deviant speech
Characteristic features of autism/PDD - Restricted/repetitive interests
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
Characteristic features of autism/PDD - Early onset
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
Associated features of PDDs
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
Aspergers syndrome
Autistic features in the absence of clinically significant language delay – restricted/repeatative interests mostly evident in interests rather than behaviours
Causes of autism/PDD
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
Assessment of autism/PDD
Family, personal and developmental history is crucial
Genetic and standardised testing is used to verify the diagnosis
Treatment/Management of autism/PDD
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
Autism in adolescence
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
Long term outcome in autism/PDD
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
Tourettes syndrome
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,
Treatment of tourettes (4)
Clonidine or risperidone
Psychosocial support and special educational provision
OCD
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
Specific learning disorder
2 SD below the expected level of global intelligence
Dyslexia is specific reading and spelling disorder
Aetiology of ASD/PDD
10% have a causal medical disorder (tuberous sclerosis, fragile X) - 90% idiopathic and polygenic –>but 90% heritable - 10% sibling risk
