Paeds - Development and CAMHS

Question 1

Attention Deficit Hyperactivity Disorder (ADHD)

Pathophysiology
Clinical Features
Investigations
Management

Answer 1

1. ) Pathophysiology - neurobehavioural disorder that is characterised by hyperactivity, inattention, impulsivity
   - often runs in families, more common in boys
   - up to 50% have a co-morbid condition: ASD, learning difficulties, oppositional defiance disorder, depression, anxiety, tics/Tourette’s
2. ) Clinical Features
   - inattention: easily distracted, forgetful in daily activities, difficulty sustaining attention in tasks or play
   - hyperactivity: fidgety, talks excessively, motor
   - impulsivity: difficulty waiting for turns, bursts out answers before questions have been completed
   - other features: disinhibition, disruptive behaviour, recklessness, lack of adherence to social norms
   - symptoms must be early-onset (<6yrs old), present in 2 or more settings, and out of context of their age/IQ
3. ) Investigations
   - questionnaires such as Conner’s questionnaire
   - QBtest is a diagnostic screening tool
   - information should be obtained from the school, home or any other regularly visited environment
4. ) Management
   - 1°conservative: behavioural strategies for parents, CBT and social skills training for the child
   - 2°medication: first line if there is severe impairment
   - methylphenidate (stimulant) is the first line, available in different preparations, titrate dose to response
   - Atomoxetine (non-stimulant) if methylphenidate is ineffective or cannot be used due to side effects
   - others: lisdexamfetamine, guanfacine
   - side effects: ↑BP, palpitations/arrhythmias, ↓appetite and stunted growth, disturbed sleep, emotional dysregulation (aggression, depression, anxiety)

Question 2

Autism Spectrum Disorder

Diagnostic Features of Autism
Other Features of Autism
Management
Co-Morbid Conditions

Answer 2

1. ) Diagnostic Features of Autism - all 3 categories must be present with at least 1 present before the age of 3
   - abnormality of social interaction: poor eye contact, struggles to make friends, poor empathy
   - impaired social communication: delayed speech, abnormal use of language e.g. echolalia
   - restrictive/repetitive activities: preoccupations with unusual subjects, need for routine, rituals, repetitive motor mannerisms (e.g. hand flapping)
   - non-medical professionals involved in the diagnosis:
   - nurses: CPN, CAHMS nurse, ASD nurse
   - SALT, OT, educational/clinical psychologist, teachers
2. ) Other Features of Autism
   - sensory issues: can impact their health and or QoL
   - severely restricted diet: may only eat certain foods
   - dislike hair being cut or teeth being brushed
   - high pain threshold, may not tolerate loud noises
3. ) Management - no cure or medications
   - mild: diagnosis alone can be sufficient to explain the child’s behaviour and allow people to meet their needs
   - behavioural management strategies
   - education, health and care plan (EHCP) details the needs of the child and how the school can meet them
   - some may require a special school for support
   - poor prognostic factors: IQ <50, no communicative speech before the age of 5
4. ) Co-Morbid Conditions - will also require treating
   - ADHD, dyspraxia, visual/hearing impairment,
   - anxiety, epilepsy, tuberous sclerosis, fragile X

Question 3

Developmental Milestones

General Information
Gross Motor Development
Vision and Fine Motor Development
Hearing, Speech and Language Development
Social, Emotional and Behavioural Development

Answer 3

General Information
- median age: average age the activity is done
- limit age: where further investigations are required
- developmental delay is in one domain
- global developmental delay is on 2 or more domain

1. ) Gross Motor Development
   - sits up without support: 6-8mths, limit age is 12mths
   - crawling: 8-9 months
   - walking: 12mths, limit age is 18 months
2. ) Vision and Fine Motor Development
   - follows moving object by turning head: 6wks, limit age is 3 months
   - palmar grasp: 4-6 months
   - mature pincer grip: 10 months, limit age is 12 months
   - hand preference before 12 months is a red flag
   - brick building: tower of 3 = 18mths, 6 = 2 years
3. ) Hearing, Speech and Language Development
   - polysyllabic babble (bababa, lalalala): 7 months
   - Dada Mama: 10 months
   - not knowing 2-6 words by 18mths is a red flag
   - joining words: 2 words = 2 years, 3 words = 3 years
4. ) Social, Emotional and Behavioural Development
   - smiles responsively: 6 weeks, limit age is 10 weeks
   - symbolic play: 18-24mths, limit age is 2-2.5 years
   - parallel play: 2.5-3 years
5. ) Investigations and Management
   - bloods: FBC, U+Es (RF), LFTs (metabolic), TFTs (hypo), haematinics, CK (DMD) vit D
   - hearing tests, karyotyping or DNA analysis, more detailed metabolic screens, MRI and EEG
   - detailed developmental assessment using tools such as ‘Schedule of Growing Skills’