Spectrum Disorder Case Flashcards
what is meant by learning disability?
- A significantly reduced ability to understand new or complex information or learn new skills (impaired intelligence) with
- A reduced ability to cope independently (social function) which started before adulthood, with a lasting effect on development.
- Also called “special needs”
what is considered as having a mild learning disability?
85% of the LD population
Can generally learn reading, writing and maths.
May have jobs and live independently
what is considered as having a moderate learning disability?
10% of LD population
May be able to learn basic reading and writing.
Able to learn functional skills such as safety and self-help.
Require some type of supervision/oversight
what is considered as having a severe learning disability?
5% of LD population
Probably not able to read and write although may they may learn self-help and routines. Require supervision in their daily activities and living environment
what is considered as having a profound learning disability?
1% of LD population
Requires intensive support. May be able to communicate by verbal or other means. May have medical conditions that require ongoing nursing and therapy
what is not a learning disability?
• Problems with reading, writing or numeracy only = learning difficulty
• Emotional difficulties not linked
• Always linked to conditions like
– Attention Deficit Hyperactivity disorder (ADHD)
– Autism including Asperger’s syndrome
– what is a learning disability- Having a learning disability means that people find it harder to learn certain life skill eg DS
what is the definition of autism?
Autism spectrum disorder (ASD) is a lifelong developmental disability that affects how a person communicates with, and relates to, other people. It also affects how they make sense of the world around them.
They don’t interact with someone in the same way
why is autism known as spectrum?
• Autism is known as a “spectrum” disorder because there is wide variation in the type and severity of symptoms people experience. ASD occurs in all ethnic, racial, and economic groups. Occurs more in males than females
what is meant by high functioning autism spectrum?
requiring support, difficulty initiating social interactions, inflexibility of behaviour, difficulty switching activities. problems with organisation
what is characteristics of autism?
requiring substantial support. marked deficits with social interactions: inflexibility of behaviour . difficulty or distress coping with change. repetitive behaviours
what are the characteristic of severe autism?
requiring substantial support. marked deficits with social interactions: inflexibility of behaviour . extreme difficulty or distress coping with change. repetitive behaviours interfere with functioning
what are the causes of autism?
• NOT related to bad parenting, food allergies, vaccines or parents with high or low intelligence
• No one cause of autism has been identified
• Genetic influences are likely most important risk factor
– But not only cause (MZ twin studies < 100%)
• Cause is likely multifactorial- doesn’t know what it means
• Physiology and environment are ALWAYS interacting from day 1
• May be several types of autism with different causes
what are the characteristics of autism?
People with autism generally experience three main areas of difficulty: how you relate to other people
- Social Communication,
- Social Interaction
- Social Imagination
how does social communications affect people with autism?
Social communication is where people understand:
• Facial expressions
• Tone of voice
• Common gestures
• Eye contact
• Body language
People with autism may struggle with this
how does social interactions affect people with autism?
Social interaction is where people:
• Understand their own and other people’s feelings and emotions
• Social Intelligence test - Read the eyes
• Form relationships and making friends.
People with autism may struggle with this and can appear aloof, indifferent
and withdrawn.
how does social imagination affect people with autism?
. Social Imagination
Social imagination is the ability to comprehend:
• Abstract concepts and ideas
• People’s actions, emotions,
behaviours and consequences
• Solutions to life outside of their routines.
Those with autism may find this very difficult
what is meant by theory of mind?
- refers to the notion that many autistic individuals do not understand that other people have their own plans, thoughts, and points of view.
- A demonstration
- Questionnaire from University of Cambridge professor Simon Baron-Cohen
what is meant by adherence?
- Adherence has been defined as the “active, voluntary, and collaborative involvement of the patient in a mutually acceptable course of behaviour to produce a therapeutic result.”
- Compliance usually refers to whether patients take their medications as prescribed (eg, twice daily)
what is meant by non- adherence?
- estimated, in adults, to be between 30 and 50% for prescribed medication, depending on the disease and the health care system
- estimated, in children, to be between 4% and 92% and between 30-40% in chronic illness
- E.g. in patients with ADHD, it is estimated that most discontinue therapy after 4 months and approximately 20% stop after the first prescription.
what can we do to give medicine to children ?
- Manipulate adult formulations
- Liquid formulations
- Tablets
how can we manipulate adult formulations to give to children?
- Crushing tablets or opening capsules and mixing the content with food or drink
- Halving or quartering tablets
- Diluting concentrated liquid preparations
- Cutting or ‘halving’ suppositories
what are the problems with manipulating adult formulations?
- Increased risk of error
- Possible bioavailability issues. Higher bioavailability when there is a greater surface area and then may cause side effects
- Increased risk of ADRs
- Issues with supply – not licenced and the pharmacist will be held liable if things go wrong
- Child refusal
what considerations must be taken when giving liquid suspensions to children?
• Shaking the suspension- settles so the dosing is inaccurate if not shaken.
• Stability of medicine. Things in water is not stable as bacteria is a medium for bacteria growth.
• Transportation & Cost
• Accuracy of measuring device
• Volume – too small – inaccurate
too large – adherence problem
• Need for excipients – possible safety issues
• Taste masking but too nice overdose problem?
what considerations must be taken when giving tablets to children?
• What age can children take tablets? 6 yrs old
• Few studies show children around age 6 can swallow tablets
• By 11 year olds - 91% can take tablets
• Depends on:
– Size & shape tablet
– Taste of alternative
– Delayed in certain conditions
what is the links between fussy eaters and adherence to medication?
• Studies show fussy eaters have a higher rejection rate for all medications
what Psychological approach to dealing with fussy eaters
- Remain calm.
- Address the anxiety.
- Talk about it.
adherence to medication in older children
- Once a child can reason (from 7 onwards), adherence increases, then in adolescents some studies show it drops, why?
- Control medication moves to teenager
- Evidence of peer-pressure and fear of stigma
what other factors affects the adherence of taking medicines?
- Family factors
- Family size, parental marital status, general stress, and stability may be contributing factors to adherence in children.
- Parents’/Carers’ Beliefs about medicine
how does beliefs about medicines affect adherence
It is known that patients’ beliefs affect adherence rates. So there are 2 questions:
- What beliefs do patients have about medicines?
- What happens to your beliefs when it is not you taking the medicine but you are giving it to your child?
Beliefs about medicines…
• In General
– Harm
– Overuse
• Specific to prescribed medication
– Necessity
– Concerns
Comparison of beliefs about medicines - parents vs patients
• Views about medicines in general similar
• However, parent’s beliefs about a specific medicine differ
• More parents (approx. 25%) show negative beliefs about the medicine (concerns) which result in anxiety and possible non-adherence
how do parents get their children to take medicine?
• Masking in other foods/drinks • Force • Bribery – Offering biscuit or sweet drink after • Reasoning
How giving medication affects the carers psychologically
guilt
desperation
anxiety
what impact does giving medication on family life
- Need for a routine
- “Holidays can be very difficult as he has to take his melatonin more often”
- Problems in School
- “School refused to administer when my son was on a linctus as they did not want the responsibility of anything going wrong
Define ADHD
ADHD is a heterogeneous behavioural syndrome characterised by the core symptoms of hyperactivity, impulsivity and inattention. While these symptoms tend to cluster together, some people are predominantly hyperactive and impulsive, while others are principally inattentive.
what are the two main diagnostic criteria
the International Classification of Mental and Behavioural Disorders 11th (ICD-11) and the Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-V).
ICD-11 uses a narrower (more restrictive) diagnostic category, which includes people with more severe symptoms and impairment. ICD-11 was published early 2019, May 2019 presented to WHO congress – widespread use from January 2022.
DSM-V has a broader, more inclusive definition, which includes a number of different ADHD subtypes.
what comes under ICD-11- 6A05 Attention deficit hyperactivity disorder
Attention deficit hyperactivity disorder is characterized by a persistent pattern (at least 6 months) of inattention and/or hyperactivity-impulsivity, with onset during the developmental period, typically early to mid-childhood. The degree of inattention and hyperactivity-impulsivity is outside the limits of normal variation expected for age and level of intellectual functioning and significantly interferes with academic, occupational, or social functioning. Inattention refers to significant difficulty in sustaining attention to tasks that do not provide a high level of stimulation or frequent rewards, distractibility and problems with organization. Hyperactivity refers to excessive motor activity and difficulties with remaining still, most evident in structured situations that require behavioural self-control.
Impulsivity is a tendency to act in response to immediate stimuli, without deliberation or consideration of the risks and consequences.
The relative balance and the specific manifestations of inattentive and hyperactive-impulsive characteristics varies across individuals, and may change over the course of development. In order for a diagnosis of disorder the behaviour pattern must be clearly observable in more than one setting.
what is ADHD?
Attention deficit hyperactivity disorder is characterized by a persistent pattern (at least 6 months) of inattention and/or hyperactivity-impulsivity, with onset during the developmental period, typically early to mid-childhood.
what does inattention mean?
Inattention refers to significant difficulty in sustaining attention to tasks that do not provide a high level of stimulation or frequent rewards, distractibility and problems with organization.
what does hyperactivity mean?
Hyperactivity refers to excessive motor activity and difficulties with remaining still, most evident in structured situations that require behavioural self-control.
what does impulsivity?
is a tendency to act in response to immediate stimuli, without deliberation or consideration of the risks and consequences.
what common co-existing conditions exist in children who have ADHD?
are disorders of mood, conduct, learning, motor control and communication, and anxiety disorders.
In adults they include personality disorders, bipolar disorder, obsessive compulsive disorder and substance misuse.
why cant ADHD be considered a categorical diagnosis?
A categorical approach to a diagnosis results in labelling each subject as either having (D+) or not having (D) a disorder. The DSM-V categorises a patient as being depressed or not depressed. A dimensional approach results in labelling each subject with an ordinal score (D), with higher scores a stronger indicator of the presence of the disorder. Higher scores on the Hamilton depression scale are associated with a stronger likelihood of ‘‘being depressed’’ as well, perhaps, of greater impairment, or greater resistance to treatment
what is the DSM-V diagnosis of ADHD?
Extremes of the triad symptoms of inattention, impulsivity and hyperactive behaviour. These are
• Pervasive
• Of early onset
• Unexplained by other disorders
• Resulting in impairment and disability.
what symptoms is required in the ICD-11 hyperkinetic disorder?
• The ICD-11 ‘hyperkinetic disorder is more restrictive and requires symptoms to be more:
Pervasive
•Impairing
what is the diagnostic criteria for ICD-11
• Inattention • Overactivity • Impulsiveness, have all been present: 1. From an early age 2. Persist in more than 1 setting 3. Impair; social function, learning and ‘normal’ development.
How is ADHD diagnosed?
- The diagnosis is based on very specific symptoms, which must be present in more than one setting.
- Children should have at least 6 attention deficit symptoms and / or 6 hyperactivity/impulsivity symptoms, with some symptoms presenting before age 7.
- The symptoms must be present for at least 6 months, seen in two or more settings, and not caused by another problem.
- The symptoms must be severe enough to cause significant difficulties in many settings, including home, school, and in relationships with peers.
what are the inattentive symptoms in ADHD?
- Fails to give close attention to details or makes careless mistakes in schoolwork
- Has difficulty keeping attention during tasks or play
- Does not seem to listen when spoken to directly
- Does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace
- Has difficulty organising tasks and activities
- Avoids or dislikes tasks that require sustained mental effort (such as schoolwork)
- Often loses toys, assignments, pencils, books, or tools needed for tasks or activities
- Is easily distracted
- Is often forgetful in daily activities
what are the hyperactivity symptoms in ADHD?
- Fidgets with hands or feet or squirms in seat
- Leaves seat when remaining seated is expected
- Runs about or climbs in inappropriate situations
- Has difficulty playing quietly
- Is often “on the go,” acts as if “driven by a motor,” talks excessively.
what are the Impulsivity symptoms in ADHD?
- Blurts out answers before questions have been completed
- Has difficulty awaiting turn
- Interrupts or intrudes on others (butts into conversations or games)
what is the Epidemiology of ADHD>
Inattention and hyperactive / impulsive symptoms are commonly seen in practice with up to 6% of children meeting criteria for ADHD.
Up to 78% continue to exhibit symptoms at 10 yr follow-up, and inattentive symptoms are more likely to persist into adulthood.
ADHD accounts for 30-50% of mental health referrals among children
3 – 4 times more likely in boys than girls.(However, refer to later slide.)
High co-morbidity ~ conduct disorder most common.
what type of people may have increased prevalence of ADHD compared to the general population?
- people born preterm
- looked-after children and young people (i.e. in the ‘care’ system)
- children and young people diagnosed with oppositional defiant disorder or conduct disorder
- children and young people with mood disorders (for example, anxiety and depression)
- people with a close family member diagnosed with ADHD
- people with epilepsy
- people with neurodevelopmental disorders (for example, autism spectrum disorder, tic disorders, learning disability [intellectual disability] and specific learning difficulties)
- adults with a mental health condition
- people with a history of substance misuse
- people known to the Youth Justice System or Adult Criminal Justice System
- people with acquired brain injury.
what are the long term effects that can occur in ADHD?
ADHD is a chronic condition:
Commonly continues through adolescence and then into adulthood (with consequent high co-morbidity ~ depression, anxiety.
If untreated associated with:
Educational, Employment Difficulties, relationship problems. High incidence of substance misuse (Most common is Alcohol and / or Cannabis)
what is the initial management of ADHD?
Diagnosis must follow extensive and comprehensive mental health assessment by a specialist clinician;
Paediatrician
Child Psychiatrist
In addition the diagnosis should follow a full assessment by an:
• Educational + / or a Clinical Psychologist
onset of ADHD?
Usually before aged 3 yrs ~ often some symptoms arise in infancy .
Duration:
6 months and to a maladaptive level inconsistent with ‘normal development.’
Severity:
Clinically significant severity in at least 2 different settings
what non- Pharmacological interventions can be carried out for people with ADHD?
• Psycho-educational measures~ education + advice should be the base / basis of any treatment offered.
• Parent training and Family-Centred Behavioural Therapy. Effectiveness shown in RCT’s
• Behavioural Interventions (school or pre-school):
Effective in reducing hyperactive behaviour and promoting social adjustment.
No single scheme has been shown to be superior to others.
what Pharmacological Treatment is used for people with ADHD?
Increasingly, medication is used for symptoms rather than syndromal control.
Experimental studies are difficult both ethically + practically
P’kinetics +P’dynamics have been extrapolated from adult studies, therefore:
• Off-Licence, beyond terms of licence.
• Must discuss openly and fully with carers (pts if appropriate)
• Obtain informed consent
why should we not assume that drugs are not necessarily more hazardous at younger end of the age spectrum
Bioavailability is often lower in children due to:
• Rapid metabolism
• Distribution in a relatively larger ECF
Conversely, drugs cross the Blood Brain Barrier more readily.
Prescribing and subsequent titration should be on a mg/kg dosing range.
what are the ideal properties of medication used in the treatment of ADHD?
• Longer duration of action
• Not potentially addictive
• Ease of administration
• Absence of ‘rebound’ effects
• No effect on appetite, growth
• Rapid onset of action
• Effective in treating associated symptoms
~ depression, anxiety etc
• Dissipates rapidly - hence will not induce insomniawhat things should healthcare professionals be aware of before initiating medication for ADHD?
- be familiar with the pharmacokinetic profiles of all the short- and long-acting preparations available for ADHD
- ensure that treatment is tailored effectively to the individual needs of the child, young person or adult
- take account of variations in bioavailability or pharmacokinetic profiles of different preparations to avoid reduced effect or excessive adverse effects.
what does the baseline assessment contain for the initial diagnosis of ADHD?
• a review to confirm they continue to meet the criteria for ADHD and need treatment
• A review of mental health and social circumstances, including:
1. presence of coexisting mental health and neurodevelopmental conditions
2. current educational or employment circumstances
3. risk assessment for substance misuse and drug diversion
4. care needs
what review of physical health include in the assessment for ADHD?
- a medical history, taking into account conditions that may be contraindications for specific medicines
- current medication
- height and weight (measured and recorded against the normal range for age, height and sex)
- baseline pulse and blood pressure (measured with an appropriately sized cuff and compared with the normal range for age)
- a cardiovascular assessment
- an electrocardiogram (ECG) if the treatment may affect the QT interval.
what medication should be offered for children aged 5 and over and young people?
• Offer methylphenidate (either short or long acting) as the first line pharmacological treatment for children aged 5 years and over and young people with ADHD.
• Consider switching to lisdexamfetamine for children aged 5 years and over and young people who have had a 6 week trial of methylphenidate at an adequate dose and not derived enough benefit in terms of reduced ADHD symptoms and associated impairment.
• Consider dexamfetamine for children aged 5 years and over and young people whose ADHD symptoms are responding to lisdexamfetamine but who cannot tolerate the longer effect profile.
• Offer atomoxetine or guanfacine to children aged 5 years and over and young people if:
1. they cannot tolerate methylphenidate or lisdexamfetamine or
2. their symptoms have not responded to separate 6 week trials of lisdexamfetamine and methylphenidate, having considered alternative preparations and adequate doses.
name psychostimulants
Methylphenidate, Lisdexamfetamine, Dexamfetamine
Centrally-acting sympathomimetics ~ Atomoxetine
should only be used after:
• Specialist assessment
And as part of a Care Package that includes:
• Educational
• Psychological
• Behavioural assessment + intervention.
stimulants
Stimulants are effective in at least 70% of hyperactive children
{Swanson et al, 1991}.
Dysfunctional dopamine pathways (decreased Dopaminergic activity) in the fronto-basal ganglia are thought to be responsible for the Clinical Symptoms of ADHD.
Frontal lobes of affected children have been shown to be 10% smaller compared to control children.
what does stimulants improve?
Stimulants are more effective in treating hyperactivity than inattention. However: • Over-activity • Attention span • Impulsivity • Aggression • Social Interaction Should all improve Social skills and general academic achievement may not improve.
Methylphenidate:
- Licensed for ADHD as part of a comprehensive treatment programme.
- Reserved for when remedial interventions have not been effective / proved sub-optimal.
- Patient must be under specialist supervision.
- Not licensed in children under 6 yrs.
