ADHD definition
Neuro-developmental disorder characterised by inattention, hyperactivity + impulsivity.
Chronic: starts in childhood, continues.
Symptoms have to manifest in 2 or more settings to be defined as ADHD (e.g. at home and school, not just at school)
ADHD RFx
- FHx
- MALE
- Low birth weight
- EPILEPSY
- Maternal Antenatal NICOTINE use
- TIC DISORDERS
Psychoscoial adversity
Traumatic brain injury
Severe early deprivation
Lead exposure and Iron deficiency
ADHD presention
- Failure to pay close attention to tasks
- Difficulty maintaining sustained mental effort
- Difficulty organising tasks
- Easily distracted by extraneous stimuli
- Forgetful in daily activities/remembering objects
- Trouble remaining still
- As if ‘Driven by a motor’
- Difficulty being patient (e.g. turn-taking)
Other common Sx:
- Mild mood Sx (dysphoria, mood, irritable, boredom)
- Difficulty in peer interactions
- Low self-esteem
- Impaired working memory
- Impaired processing speed
ADHD Dx
From clinical Hx - taken from multiple sources (parents, teachers, carers etc)
- Behaviour rating scales used to aid (ADHD rating scale, Conner rating scales - 3 forms; most widely accepted)
Can do neuropsychological testing to differentiate from learning disabilities (ADHD kids will have normal cognitive + academic ability but impaired executive function)
ADHD treatment
Ages 4-6:
- Parent Training in Behaviour Management and/or Behavioural classroom intervention + Psychoeduction
- Consider methyphenidate if not responsive/severe
6-18:
- STIMULANT (methylphenidate or amfetamine)
- NON-STIMULANTS (Guanfacine, Clonidine or Atomoxetine) if tic disorder or substance misuse
+ Psychoeduction
Also HEALTHY DIET + EXCERCISE
Asutism Spectrum Disorder
Neurodevelopmental condition characterised by persistantly impaired social interaction and restricted, repetitive and stereotyped patterns of behaviours
Ie impaired social interaction, communication and flexibility of behaviour
When can features of ASD typically be observed by?
3 y/o
Features of ASD relating to social interaction
- Lack of eye contact
- Delay in smiling
- Avoids physical contact
- Unable to read non-verbal cues
- Difficulty establishing friendships
- Not displaying a desire to share attention (i.e. not playing with others)
ASD features relating to communication
- Delay, absence or regression in language development
- Lack of appropriate non-verbal communication such as smiling, eye contact, responding to others and sharing interest
- Difficulty with imaginative or imitative behaviour
- Repetitive use of words or phrases
ASD features relating to behaviour
- Greater interest in objects, numbers or patterns than people
- Stereotypical repetitive movements - self-stimulating movements
- Intensive and deep interests that are persistent and rigid
- Repetitive behaviour and fixed routines
- Anxiety and distress with experiences outside their normal routine - Extremely restricted food preferences
Diagnosis of ASD
Clinical diagnosis by specialist - scoring tools to assist (CAST, CARS, Social Communication Questionnaire)
Rule out differentials if suspected
- genetic testing may be offered in general as ASD is associated with a number of genetic variations. (Fragile X syndrome)
ASD Tx
12 months - 5 years (equivalent developmental age)
- Behavioural and Parent-mediated interventions for core features
- Input from early educational services
- Family support + eductaion
Same for older but with additional support for other mental health conditions as required
Requires MDT management:
- CAHMS
- SALT
- Dieticians
- Pediatricians
- Social Workers
- Specially trained educators and school environments
- Charity help potentially
OCD
A disorder characterised by the presence of obsessions and compulsions
These are not something the person enjoys/willingly does. They impact on other areas of life e.g. school, social life
Obsessions
Unwanted, uncontrolled thoughts and images that are difficult to ignore. (intrusive)
E.g. overwhelming fear of contamination, violent/explicit images
Compulsions
Repetitive actions the individual feels they must do, generating anxiety if not done.
Often a way to handle compulsions
In young people particularly, compulsions usually involve family members. May not be able to articulate the resoning behind them.
What is the cycle of repetitive behaviour in OCD
The obsessions lead to anxiety, which leads to the compulsive behaviour, which leads to a temporary improvement in the anxiety. Shortly after the temporary improvement in anxiety the obsession reappears, leading to further anxiety, further compulsive behaviour with a temporary relief. This cycle continues and each time gets more engrained in the person’s behaviour.
Person feels they can’t get relief from anxiety if they don’t do compulsions
RFx for OCD
- FHx - esp 1st degree relatives (genetics plays a role as monozygotic twins more likely to exhibit in both)
- AGE (peak onset between 10-21 years)
- Environmental factors like strep infections (PANDAS - aediatric autoimmune neuropsychiatric disorders associated with streptococcal infection)
- PREG + POSTNATAL PERIOD (more likely to experience OCD in postpartum than general populace - relating to baby)
Oft associated with psychiatric co-morbidity (Anxiety, Depression, Eating disordes, ASD, phobias, tic disorder)
OCD Dx
Clinical - based on DSM-5
- supported by scoring sytems/interviews
- Particularly CY-BOCS (Children’s Yale-Brown Obsessive Compulsive scale (Y-BOCS = adult one))
Sx need to have lasted 2 weeks to be diagnosed OCD
OCD Tx
1st line = CBT or Pharmacotherapy (SSRI or Tri-cyclic (clomipramine))
- give BOTH if severe/comorbid personality disorder/dissociative symptoms
2nd line = increased dose/combination therapy
3rd = diff drug
4th = specialist evaluation
Seperation anxiety
Normal in < 3 y/o - disorder typically diagnosed between 7-9 y/o
- more common if insecure attachment; if parent ill etc
Crying, nausea, stay while falling asleep, may refuse to go to classes, exacessive worrying about caregivers, nightmares
- typically harder to calm child than in younger kids
Can lead to agrophibia, panic disorder later
Need to differentiate if it is a specific phobia or seperation anxiety
School phobia consists of
- SIgnificant anxiety
- Fear of specific aspect of school
- Avoidance
Selective mutism Dx
Must be mostly mute for most days over the course of at least 6 months
Organic causes to exclude for anxiety
- Hyperthyroid
- Arrhythmias
- Epilepsy
- Phaeochromocytoma
- Asthma
- Non-prescription drugs
Anxiety Mx
- Assess for co-morb (e.g. ASD)
- Anxiety management techniques
- Graded exposure
- CBT
- Identify/’capture’ scary thought; challange it; re-write it; distract; change behaviour (focus on reality + rationality)
- Thought shifting (e.g. do it scared)
- Worry monster
- Group work
- Medication (SSRIs - Fluoxitine)
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