ADHD & ASD

Question 1

Define ADHD

Answer 1

A condition incorporating features relating to inattention and/or hyperactivity/impulsivity that are persistent.

Question 2

How many diagnostic features must be present for a diagnosis of ADHD in children up to 16 y/o?

Answer 2

6

Question 3

How many diagnostic features must be present for a diagnosis of ADHD in children aged ≥17 y/o?

Answer 3

5

Question 4

What are the 3 cardinal features of ADHD?

Answer 4

1) Hyperactivity
2) Inattention
3) Impulsivity

Question 5

Give some examples of inattention criteria for ADHD

Answer 5

• Easily distracted by extraneous stimuli
• Forgetful in daily activities
• Often has difficulty sustaining attention in tasks or play activities

Question 6

Give some examples of hyperactivity criteria for ADHD

Answer 6

• Often fidgets with hands or feet or squirms in seat
• Often talks excessively
• Is often on the go or often acts as if driven by a motor

Question 7

Give some examples of impulsivity criteria for ADHD

Answer 7

• Often has difficulty waiting turn
• Aften bursts out answers before questions have been completed

Question 8

What is required for diagnosis of ADHD?

Answer 8

• 5 or 6 diagnostic features (depending on age)
• Present for at least 6 months
• Impairment must be present in MORE THAN ONE setting

Question 9

What are 3 differentials for ADHD

Answer 9

1) Auditory processing disorder

2) Oppositional-Defiant Disorder

3) Conduct Disorders

Question 10

What is auditory processing disorder?

Answer 10

This is a disorder in which the brain has difficulty interpreting sounds and the information heard (may coexist with ADHD).

Can present as children having trouble concentrating and following instructions, particularly in the presence of background noise.

Question 11

Oppositional-defiant disorder and conduct disorders vs ADHD?

Answer 11

Conduct disorder: there are marked features of aggression (not usually a feature of ADHD).

Oppositional-defiant disorder: there are features of anger, vindictiveness and being argumentative.

Children with ADHD tend to not want to get in trouble but can’t help themselves, often getting carried away.

Question 12

NICE guidelines differentiate management for ADHD into what 3 groups?

Answer 12

1) Preschool children

2) Mild-moderate ADHD in school-age children with moderate impairment

3) Severe ADHD in school-age children with severe impairment

Question 13

What is the management of ADHD in preschool children?

Answer 13

Medication is NOT recommended.

Parents should be offered a parent training/education programme.

Nursery/pre-school teachers should be informed of the child’s diagnosis, severity of impairment, care plan and special educational needs.

Question 14

Management of mild-moderate ADHD in school-age children with moderate impairment?

Answer 14

1st line –> behavioural strategies e.g. parent education sessions, CBT, social skills training.

2nd line –> medication

Question 15

Management of severe ADHD in school-age children with severe impairment?

Answer 15

1st line –> medication

Question 16

What are the 4 medications lisenced for ADHD?

Answer 16

1) Methyphenidate

2) Atomoxetine

3) Lisdexamfetamine

4) Guanfacine

Question 17

What is the 1st line ADHD medication in children?

Answer 17

Methylphenidate (initially given on a six-week trial basis).

Question 18

What is methylphenidate?

Answer 18

A CNS stimulant (which primarily acts as a dopamine/norepinephrine reuptake inhibitor).

Question 19

Side effects of methylphenidate?

Answer 19

• abdo pain
• nausea
• dyspepsia

Question 20

What monitoring is required in children taking methylphenidate?

Answer 20

Weight and height monitoring every 6 months

Question 21

If there is an inadequate response to methylphenidate in ADHD, what is 2nd line?

Answer 21

lisdexamfetamine

Question 22

What medication can be started in those who have benefited from lisdexamfetamine, but who can’t tolerate its side effects?

Answer 22

Dexamfetamine

Question 23

What are the 2 first line medications for ADHD in adults?

Answer 23

Methylphenidate or lisdexamfetamine.

Switch between these drugs if no benefit is seen after a trial of the other.

Question 24

What is a key side effects of ADHD medications?

Answer 24

Cardiotoxicity

Question 25

What investigation is required for a baseline before starting ADHD medications?

Answer 25

ECG

Question 26

Side effects of ADHD meds?

Answer 26

- Raised BP - Palpitations (representing potentially dangerous arrhythmias) - Disturbed sleep - Impaired growth and appetite suppression (common and can be severe enough to stop the child eating and gaining weight) - Can be problems with aggression or the child becoming more emotional, anxious or depressed§

Question 27

What adverse outcomes can ADHD be associated with?

Answer 27

- substance abuse - more criminal convictions - lower educational attainment - unemployment

Question 28

What is methylphenidate also known as?

Answer 28

Ritalin

Question 29

What is the prevalence of autism spectrum disorder (ASD) in the UK?

Answer 29

1%

Question 30

Risk factors for ASD?

Answer 30

1) Genetic causes e.g. gene defects and chromosomal anomalies (25%) 2) FH 3) Advanced parental age (maternal ≥40 and paternal ≥50) 4) Environmental factors e.g. toxin exposure, prenatal infections

Question 31

What are some genetic diagnoses commonly associated with ASD?

Answer 31

1) Tuberous sclerosis complex 2) Fragile X syndrome 3) Chromosome 15q11-13 duplication syndrome 4) Angelman syndrome 5) Rett's syndrome 6) Down syndrome

Question 32

What is the sibling recurrence risk of ASD?

Answer 32

10%

Question 33

What is the ASD concordance risk in monozygotic twins?

Answer 33

36-60%

Question 34

What are the 3 levels of ASD?

Answer 34

Level 1 (requiring support) Level 2 (requiring substantial support), and Level 3 (requiring very substantial support).

Question 35

What are the key clinical features of ASD?

Answer 35

1) Impaired social communication 2) Abnormality of social interaction 3) Repetitive or restrictive behaviours, interests, and activities Others: - Sensory issues - Restrictive diet - May not tolerate their hair being cut or their teeth being brushed - May not tolerate loud noises - High pain threshold - Self harm e.g. head banging or hitting themselves - Motor mannerisms e.g. pinching themselves

Question 36

What 2 conditions are commonly seen in children with ASD?

Answer 36

ADHD (35%) and epilepsy (18%)

Question 37

How may abnormality of social interaction present in children with ASD?

Answer 37

- Poor eye contact - Failure to use facial expression or body language during social interactions (particularly with strangers) - Problems making friends with peers - Difficulty in reading social situations (such as failing to pick up on others emotions)

Question 38

How may impaired social communication present in children with ASD?

Answer 38

- Delay or failure to develop either spoken language or sign language to communicate with others - Failure to initiate or continue conversations - Abnormal use of language, either with idiosyncrasy or stereotyped language (e.g. echolalia), abnormal intonation, pitch, rate or rhythm of speech.

Question 39

How may restrictive or repetitive present in children with ASD?

Answer 39

- Preoccupations with unusual subjects e.g. traffic lights - Need for routine, with great upset if this is disrupted e.g. certain rituals - Abnormal preoccupations with toys and other materials e.g. spinning wheels on cars for the vibration it makes, or licking metal objects. - “Motor mannerisms” with the classical hand-flapping or other such repetitive and compulsive movements, which can occur more when the child is excited or upset

Question 40

Indications for specialist referral for further assessment of ASD:

Answer 40

1) Refer children younger than 3 years if there is a regression in language or social skills. 2) Concerned about possible ASD based on reported or observed signs and/or symptoms. 3) Factors associated with an increased prevalence of ASD. 4) The likelihood of an alternative diagnosis.

Question 41

Give 4 differentials for ASD

Answer 41

1) ADHD 2) Global developmental delay/intellectual disability 3) Developmental language disorder 4) Social (pragmatic) communication disorder

Question 42

How is social attachment affected in ASD?

Answer 42

A lack of social attachment

Question 43

How is receptive or expressive speech development affected in ASD?

Answer 43

Abnormal/delayed

Question 44

How is symbolic play affected in ASD (e.g. having a pretend tea party)?

Answer 44

Abnormal or lack of symbolic play