Community Paediatrics Flashcards
Define autistic spectrum disorder (ASD)
Pervasive neurodevelopmental disorder which manifests before 3yrs of age characterised by triad of:
- Impairment in social interaction
- Impairment in communication
- Restricted stereotyped interests & behaviours
It is a spectrum hence there is a range of severities. On one end patients have normal intelligence and ability to function in everyday life but displaying difficulties with reading emotions and responding to others. This was previously known as Asperger’s syndrome. On the other end, patients can be severely affected and unable to function in normal environments.
Define autistic spectrum disorder (ASD)
Pervasive neurodevelopmental disorder which manifests before 3yrs of age characterised by triad of:
- Impairment in social interaction
- Impairment in communication
- Restricted stereotyped interests & behaviours
It is a spectrum hence there is a range of severities. On one end patients have normal intelligence and ability to function in everyday life but displaying difficulties with reading emotions and responding to others. This was previously known as Asperger’s syndrome. On the other end, patients can be severely affected and unable to function in normal environments.
What is the prevalence of ASD?
What is the male to female ratio for autism?
1-2%
More common in males (M:F is 4:1)
State some risk factors for Autistic Spectrum Disorder (structure as pre, ante and post natal)
Prenatal
- Genetics (number of chromosomes associated)
- FH of ASD or other psychiatric disorders
- Advancing parental age
- Drugs (e.g. sodium valporate in pregnancy)
- Infection (e.g. rubella)
Antenatal
- Obstetric complications e.g. hypoxia
- Prematurity
- Low birth weight
Postnatal
- Toxins e.g. lead, mercury
- Pesticide exposure
*
Autistic spectrum disorder is characterised by the triad of impairment in social interaction, impairment in communication & restricted stereotyped patterns of behaviour; state some features, which the child may display, for each of the 3 categories
Social Interaction
- Delay in social development e.g. smiling, waving, pointing
- Lack of eye contact
- Avoids physical contact
- Difficulty establishing friendships
- Lack of interest in others
- Unable to read non-verbal cues
Communication
- Delayed or absent speech
- Lack of appropriate non-verbal communication
- Repetitive use of words or phrases
Behaviour
- Repetitive behaviours
- Fixed/rigid routines and get upset if this changes
- Restricted stereotyped movements (may be self stimulating movements used to comfort themselves e.g. hand flapping, rocking)
- Obsessively pursued interests
- Greater interest in objects, numbers or patterns rather than people
- Lack of creativity
- Fascination with sensory aspect of environment
- Extremely restricted food preferences
Alongside features which can be grouped under social impairment, communication impairment and restricted, stereotyped behaviours children with autism often have other associated features; state some
- Fear/phobias
- Sleeping disturbances
- Temper tantrums
- Self injury (wrist biting common)
- Intellectual disability (if include all those on spectrum most won’t have)
State some other medical conditions associated with ASD
- Epileptic seizure (20%)
- Visual impairment
- Hearing impairment
- Pica
- Constipation
- Sleep disorders
- Underlying medical conditions e.g. fragile X, congenital reubella
- Psychiatric e.g. ADHD, depression, OCD
What screening questionnaire can be used to help identify autism in children aged 18 months to 3yrs?
CHAT (Checklist for Autism in Toddlers)
Discuss the management of Autistic Spectrum Disorder (structure as biopsychosocial)
Biological
- Treat co-existing disorders e.g. ADHD
- Melatonin for sleep disorders
- If have severe challenging behaviour that hasn’t responded to psychosocial interventions try antipsychotics
Psychological
- Psychoeducation for families, carers, schools etc…
- Behavioural therapies:
- ESDM (early start denver model. Based on ABA but done through play)
- ABA (applied behaviour analysis. Works on principle of operant conditioning)
- CBT (if child is older andhas verbal & cognitive ability to engage & is motivated)
Social
- Modification of environmental factors that initiate challenging behaviour or distress
- Social-communication intervention (play based strategies)
- Special schooling
- Direct towards charities for information & support e.g. National Autistic Society
Children with autism are managed by MDTs who aim to provide best environment and support for child & family. Who is involved in the MDT?
- Paediatrician
- CAMHs
- SALT
- Dietician
- Social workers
- Specially trained educators & special schools
- Charities e.g. National Autistic Society
What is ADHD?
Attention Deficit Hyperactivity Disorder is characterised by a persistent pattern of inattention, hyperactivity & impulsivity consistent across various settings. The behaviour is more severe and frequent than in other individuals at comparable stage of development.
If features of ADHD are not present in various settings, what may this suggest?
Environmental problem
What is the prevalence of ADHD?
What is the male to female ratio?
What is the average age of onset?
- 3%
- M:F is 3:1
- Age of onset 3-7yrs
State some risk factors for ADHD
*Highlight the 2 most commonly associated ENVIRONMENTAL risk factors according to NICE
- Family history
- Epilepsy
- Male
- Alcohol use during pregnancy
- Cannabis use during pregnancy
- Low birth weight
- Prematurity
- Low socioeconomic class
Three core features of ADHD are inattention, hyperactivity & impulsivity; state some features/behaviours that demonstrate each of the core feautres
Inattention
- Not listening when spoken to
- Highly distractible (moving from one activity to another, quickly lose interest)
- Reluctant to engage in mentally challenging tasks e.g. school work
- Forgetting or losing belongings
Hyperactivity
- Constantly moving or fidgeting
- Running & jumping around in appropriate places
- Excessive talking or noisiness
Impulsivity
- Difficulty waiting their turn
- Interrupting others
- Will prematurely blurt out answers to questions
- Temper tantrums
- Aggression
- Disobedient
- Running out into street without looking
Collateral information from who is important in assessment of ADHD?
School
Many people with ADHD have comorbid conditions; state some
- Learning difficulties
- Conduct disorder (50% pts with ADHD)
- Oppositional defiant disorder
- Tourette’s syndrome
- Mood disorders
- Anxiety disorders
- Dyspraxia
Discuss the management of ADHD
General Management for All
- Psychoeducation for both parent, child & school
- Healthy diet with avoidance of foods that trigger symptoms
- Support groups e.g. ADDISS
Psychotherapy/training programmes
- Parent training (helps parents reinforce positive behaviour & find alternative ways of managing disruptive behaviour)
- CBT and/or social skills training in older children
Pharmacological
NOTE: drug therapy should be last resort is only available to those aged 5yrs or more if other options haven’t worked and ADHD is severe:
- First line= methylphenidate
- If fails other options include= lisdexamfetamine, dexamfetamine & atomoxetine
What is the mechanism of action of methylphenidate?
Dopamine/noradrenaline reuptake inhibitor
State some side effects of methyphenidate
- GI upset (abdo pain, nausea/vomiting, diarrhoea, dry mouth)
- Anorexia
- Palpitations
- Headache
- Insomnia
- Drowsiness
- Dizziness
Drugs used for ADHD are cardiotoxic therefore a baseline ECG is required before initiation; true or false?
True
What monitoring is required for ADHD pts taking medication?
- Weight (every 3 months if 10yrs and younger, after first 3 months then 6 monthly if >10yrs)
- Height (every 6 months)
- BP and HR: routinely every 6 months,before & after each dose change,
Discuss the DSM-V criteria for ADHD
What is cerebral palsy?
Disorder of movement & posture due to a non-progressive lesion of the motor pathways in the developing brain.
It is the most common cause of major motor impairment. Huge variation in severity & type of symptoms; may be wheelchair bound and dependent or a para-olympic athelete with minor problems with coordination or mobility.
State some potential causes of cerebral palsy; structure your answer as antenatal, perinatal & post-natal
Antenatal
- Maternal infections (e.g. rubella, CMV, toxoplasmosis)
- Trauma
- Chorionamnionitis
Perinatal
- Birth asphyxia (lack of blood flow or gas exchange to or from fetus in period immediately before, during or after birth e.g. children with hypoxic-ischaemic-encephalopathy)
- Pre-term birth
Postnatal
- Meningitis
- Intraventricular haemorrhage
- Severe neonatal jaundice
- Head injury
State some conditions associated with cerebral palsy
- Learning disability (60%)
- Epilepsy (30%)
- Hearing impairment (20%)
- Squints (30%)
- Visual impairment
- Gastroesophageal reflux
- Kyphoscoliosis
- Muscle contractures