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Question 1

What is ADHD characterised by?

Answer 1

Hyperactivity, inattention, impulsivity

Question 2

Why are more boys diagnosed with ADHD than girls?

Answer 2

Girls tend to have less disruptive forms of ADHD so less noticeable

Question 3

Features of ADHD

Answer 3

Impaired attention
Hyperactivity
Impulsivity
Easily distracted/disruptive
Can't adhere to social norms
Fidgety

Question 4

What is the ICD-10 criteria for ADHD?

Answer 4

Early onset of symptoms (<6 years), which are present in 2 or more settings.
Two main features for diagnosis are impaired attention and over-activity.

Question 5

What is the DSM-V Criteria for ADHD?

Answer 5

Three subtypes of ADHD - combined, predominantly inattentive type, predominantly hyperactive/impulsive type.

Diagnosis made when at least 6 of criteria from either inattention category or hyperactivity/impulsivity category are met and have been present from before age of 12 for at least 6 months.

Question 6

Investigations of ADHD?

Answer 6

Conner’s questionnaire (objective assessment).
School observation and reports.
Information obtained from school, home and other regularly visited environments.
If any doubt, rule out other differentials eg epilepsy, fragile X or global developmental delay.
If learning difficulties, consider bloods - FBC, U&Es, LFT, TFT, Calcium, Iron, glucose
Consider karyotyping and MRI brain.

Question 7

Management of ADHD?

Answer 7

If medication considered - take FHx and ECG if positive FH of serious cardiac disease or sudden death.

Preschool:

• Medication NOT recommended.
• Offer parents training/education programme.

Mild/moderate ADHD in school-age children with moderate impairment:

• First line - behavioural strategies, in form of parent education sessions.
• CBT, social skills training can be used.
• Teachers should be trained on behavioural strategies in classroom
• If behavioural strategies are ineffective -> consider medication.

Severe ADHD in school-age children with severe impairment:

• first line - medication
• if medication refused, offer group parent training/education programme.

Question 8

Medications used in ADHD?

Answer 8

Methylphenidate:
- stimulant

Atomoxetine:
- Used when methylphenidate not effective, if there is associated tic disorder or anxiety disorder, or if there is a risk of stimulant medication being abused or redirected.

Lisdexamfetamine:
- newer stimulant, used when methylphenidate not effective at maximum doses.

Guanfacine:

• non-stimulant medication.
• Used when stimulant medication not suitable, not tolerated or ineffective.

Antipsychotics:
- should not be used in children with ADHD.

Question 9

Side effects of ADHD medication?

Answer 9

Raised BP
Palpitations
Disturbed sleep
Impaired growth and appetite suppression
There can be problems with aggression or child becoming more emotional, anxious or depressed.

Question 10

Risk factors of Autism spectrum disorder?

Answer 10

• More common in males
• Prematurity
• Perinatal hypoxia
• Increased maternal/paternal age

Question 11

Features of autism?

Answer 11

• Abnormal social interaction
• Impaired social communication (eg echolalia)
• Restrictive or repetitive activities
  Others - sensory issues, may not eat certain foods, may not tolerate loud noises, may self-harm, may not tolerate haircuts or brushing teeth.

Question 12

Examination of autism patient?

Answer 12

Skin stigmata or neurofibromatosis or tuberous sclerosis using a Wood’s light.
Signs of injury, for example self-harm or child maltreatment.
Congenital anomalies and dysmorphic features including macrocephaly or microcephaly.

Question 13

Diagnosis of autism?

Answer 13

At least one features from all 3 categories and one of the following present before age of 3:

• lack of social attachments
• abnormal/delayed receptive or expressive speech development
• abnormal or lack of symbolic play

Question 14

Investigations of autism?

Answer 14

Clinical diagnosis
Symptoms should be consistent at home and at school.
Diagnosis made through MDT, consisting of educational psychologist and speech therapist, as well as either a Community Paediatritcian or Child Psychiatrist.

Question 15

Management of autism?

Answer 15

Behavioural management strategies - visual timetables, preparation and explanation for changes in routine.

Educational measures - special educational measures put in place to access mainstream schooling through Educational Health Care Plan (EHCP) or to attend a special school.

Melatonin for sleep can aid child’s behaviour and education.

Treat co-morbid conditions such as ADHD, sleep disorders, learning difficulty, and mental health problems such as anxiety and depression.

Question 16

Factors causing behavioural problems?

Answer 16

Genetics
Gender (boys more likely that girls)
Intellectual ability 
Development
Temperament
Chronic illness

Family - early attachment, divorce, family structure, parental stratus, parental mental health.

Environment - social class, neighbourhoods, physical abuse, neglect, sexual abuse, schools, day care facilities.

Question 17

Examples of sleep related problems?

Answer 17

Refusal to go to bed at night - separation anxiety, fear of darkness and silence, erratic bedtime routine.
Waking at night
Nightmares and night terrors

Question 18

Management of sleep related problems?

Answer 18

Sleep diary, sleep hygiene, positive bedtime routine, melatonin.

Question 19

Management of food refusal?

Answer 19

Social reinforcement
Avoid forcing
Avoid snacking between main meals
Keep regular family meal times
Do not prolong mealtimes
Avoid using preferred food as reward
Rejection of new foods can be overcome by repeated exposure.

Question 20

Causes of delayed motor skills?

Answer 20

Central motor deficit (cerebral palsy)
Congenital myopathy, primary muscle disease
Spinal cord lesions (spina bifida)
Global developmental delay

Question 21

Features, assessment and management of delayed motor skills?

Answer 21

Hand dominance before age of 1 is abnormal so needs investigating.

Assessment by neurodevelopmental paediatrician and physiotherapist.

Management - ongoing physiotherapy and subsequent OT involvement is likely to be needed.

Question 22

Reasons for delay in speech?

Answer 22

Hearing loss
Global developmental delay
Difficulty in speech production from anatomical defect - eg cleft palate.
Environmental deprivation/lack of opportunity for social interaction.
Normal variant (family pattern).

Question 23

Reasons for speech and language disorders?

Answer 23

Language comprehension disorder
Language expression disorder
Problems with phonation and speech production (eg stammering)
Difficulty with grammar and construction of sentences
Social and communication skills problem (eg autism)

Question 24

Investigations and management for delay in speech?

Answer 24

Hearing test, SALT assessment.

Neurodevelopmental paediatrician and paediatric audiological physician involved.
SALT therapy
Special schooling

Question 25

Investigations for global developmental delay?

Answer 25

Cytogenetics - karyotyping, fragile X, DNA FISH analysis.
Metabolic - TFTs, CK, lactate, LFTs, bone chemistry, U&Es, plasma amino acids, gases.
Infection - congenital infection screen
Imaging - cranial USS in newborn, CT and MRI brain scan, skeletal survey, bone age.
Neurophysiology - EEG
Nerve and muscle biopsies
Other - hearing, vision, clinical genetics, cognitive assessment, child psychiatry, physiotherapy, occupational therapy, SALT, dietician, nursery/school reports.

Question 26

Features of learning difficulties?

Answer 26

IQ 70-80 - borderline and mild learning disability.

IQ 50-70 - moderate learning difficulties.

IQ 35-50 - severe learning disabilities

IQ <35 - profound learning difficulties.

Question 27

Management of learning difficulties?

Answer 27

Borderline/mild - supported by learning support assistants in mainstream schools

Moderate/severe - special schools. Tend to be lower socioeconomic classes.

Severe/profound - apparent from infancy and irrespective of social class.

Question 28

What is dyspraxia? Features? Management?

Answer 28

Disorder of motor planning and/or execution with no significant findings on standard neurological examination.
Problems with handwriting, dressing, cutting food, drawing, often messy eating.

Assessment and advice is primarily from occupational therapist.

Question 29

What is dyslexia?

Answer 29

Disorder of reading skills disproportionate to child’s IQ.

Question 30

Reasons for school absence?

Answer 30

Illness
Parents may keep child off school
Truancy

Question 31

What is school refusal?

Answer 31

Inability to attend school due to overwhelming anxiety.
May not complain of anxiety, however suffer with physical consequences.

Somatic symptoms - nausea, headache, hyperventilation.

Question 32

Reasons for school refusal?

Answer 32

Bullying

Educational underachievement - visual or hearing problems, dyslexia, learning difficulties, ADHD, chaotic family background.

School refusal based on separation anxiety - house move or death in family.

True school phobia - older, anxious children who are uncommunicative and stubborn.

Question 33

Management of school refusal?

Answer 33

Advise and support parents and school about condition
Treat underlying emotional disorder
Plan and facilitate an early and graded return to school
Make it more rewarding for child to go to school than stay at home.
Address bullying or educational difficulties if present