Childhood and adolescent disorders

Question 1

What is the DSM criteria for Autism Spectrum Disorder?

Answer 1

DSM-V criteria: child must have persistent deficits in each of 3 areas of social communication and interaction plus at least 2/4 types of restricted, repetitive behaviours
A. Persistent deficits in social communication and social interaction across multiple contexts
1. Deficits in social-emotional reciprocity
2. Deficits in nonverbal communicative behaviours used for social interaction
3. Deficits in developing, maintaining, and understand relationships
B. Restricted, repetitive patterns of behaviour, interests, or activities
1. Stereotyped or repetitive motor movements
2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behaviour
3. Highly restricted, fixated interests that are abnormal in intensity
4. Hyper- or hyporeactivity to sensory input
C. Symptoms must be present in the early developmental period
D. Symptoms cause clinically significant impairment in functioning
E. Not better explained by intellectual disability or global developmental delay

Question 2

List some comorbidities of ASD?

Answer 2

Co-morbidities: ID (40% of ASD children also have ID), AHDH, OCD, behaviour disorders, psychotic disorders

Question 3

Describe the pathophysiology of ASD?

Answer 3

• Aetiology unknown, but genetic aetiology likely
• Possibly linked to elevated serotonin levels
• MRIs show increased cortical thickness
• fMRIs show less activation in the prefrontal regions, indicating a dysfunction of the frontostriatal networks
• Abnormal glutamate/glutamine physiology has been seen, particularly in the limbic areas.

Question 4

Describe the treatment of ASD?

Answer 4

• Multisystemic: family education, behaviour shaping, speech therapy, occupational therapy, educational planning
• Pharmacotherapy: no specific medications
o Low-dose Risperidone shows some promise
o Aripiprazole shows some benefit for symptoms if irritability

Question 5

What is the DSM criteria for ADHD?

Answer 5

DSM-V criteria:
A. Children must have at least 6 symptoms of either (or both) inattention or hyperactivity/ impulsivity, while older adolescents and adults (>17yo) must have at least 5.
- Inattention symptoms: making careless mistakes, difficulty focusing one’s attention, often seeming not to listen, often failing to follow directions, difficulty organising tasks, avoiding tasks requiring sustained mental effort, often losing things, easily distracted by other stimuli, forgetful
- Hyperactivity symptoms: fidgeting/squirming, often leaving one’s seat, running/climbing excessively or inappropriately, difficulty playing quietly, often being “on the go”, talking excessively
- Impulsivity symptoms: blurting out an answer before the question is completed, difficulty waiting for one’s turn, often interrupting others
B. Evidence several of these symptoms were present <12yo
C. Impairment is present in two or more settings
D. Clinically significant impairment

Question 6

List some DDx of ADHD.

Answer 6

DDx: early-onset bipolar disorder (restless, distractable but also affective component), lead intoxication, petit mal seizures (poor attention, brief periods of being unaware of surroundings, lost time)

Question 7

Describe the treatment of ADHD?

Answer 7

Pharm:
• First line: Stimulant (methylphenidate or amphetamine preparations) or atomoxetine
• Second-line medication: Clonidine and guanfacine
• Third-line medications:
- Bupropion; contraindicated in seizure disorders, exacerbates tics (dopaminergic action)
- Imipramine; prolongs QT
Non-pharm: Behavioural therapy: once mediation has controlled symptoms

Question 8

What is the DSM criteria of bipolar disorder?

Answer 8

DSM-V:
A. A distinct period of abnormally and persistently elevated, expansive or irritable mood AND persistent increased energy lasting at least 1 week (or any duration if hospitalised).
B. Three or more of the following symptoms during the period of mood disturbance and increased energy:
- Inflated self-esteem or grandiosity
- Decreased need for sleep
- Greater talkativeness than usual or pressure to keep talking
- Flight of ideas or subjective experience that thoughts are racing
- Distractibility
- Increase in goal-directed activity or psychomotor agitation
- Excessive involvement in pleasurable activities with a high potential for painful consequences (buying sprees, sexual activity, foolish investments)
C. Criteria for mixed episode are not met
D. Impairment must be severe enough to cause impaired functioning, hospitalisation OR psychotic features are present
E. Disturbance is severe enough to cause impairment in normal functioning
F. Symptoms are not caused by the effect of a substance or medical condition

Question 9

Distinguish between subtypes of bipolar disorder?

Answer 9

1. Bipolar Type I: A syndrome with complex manic symptoms
2. Bipolar Type II: depression and hypomania
   - Hypomania: elevated, expansive or irritable mood, and increased activity/energy that do not meet the full criteria for mania. Usually no psychotic symptoms, racing thoughts or marked psychomotor agitation.
3. Rapid cycling bipolar disorder: at least 4 mood episodes (depression or hypomania/mania) in a year, separated by full/partial remission of at least 2 months or full switch from one pole to the other.

Question 10

List some DDx of bipolar disorder in children?

Answer 10

• ADHD; similar due to the psychomotor agitation. ADHD involves distractibility, impulsivity and hyperactivity present daily with onset <7yo.
• Oppositional Defiance Disorder (ODD); defiant opposition of others’ wishes, breaks minor rules. Frequent comorbid diagnosis in ADHD.
• Conduct Disorder (CD); defiantly breaks major social rules. Frequent comorbid diagnosis in ADHD
• Disruptive Mood Dysregulation Disorder (DMDD); irritable all the time, temper outburst at least 3/week over a year. Prior to DSM-V these children were classified as bipolar disordered.
• Mood disorders; consider if depressive episode
• Adjustment disorder with depressed mood
• Mood disorders related to substance intoxication
• Anxiety disorders
• Medication side-effects
• General medical condition

Question 11

Outline the treatment of bipolar disorder in children?

Answer 11

Pharm:
• First line: Monotherapy with mood stabilisers or atypical antipsychotics if NO psychosis
- Divalproex: used for childhood seizure disorders, well-established safety and risk profile. Used in children <12yo. Monitor platelets, LFTs, PCOS development.
- Lithium: used in children >12yo. Monitor TFT, UEC.
• Atypical antipsychotics; have been used as monotherapy for controlling mania
• Antidepressants (e.g. SSRIs and bupropion); can be used during bipolar-depression phase but must be used with CAUTION as they can trigger manic symptoms.
Non-pharm:
• Cognitive therapy; reducing negative thoughts and building self-esteem
• Family therapy; improve any contribution family dynamics

Question 12

What is the DSM definition of enuresis?

Answer 12

DSM-V criteria:
• Inappropriate elimination of urine into bed or clothes.
• Either frequency of at least 2/week for at least 3 months, OR clinically significant distress/impairment.
• Chronological or developmental age > 5yo.
• Not caused by substance or medical condition.
• Specify if nocturnal, diurnal or both.

Question 13

Distinguish between primary and secondary enuresis.

Answer 13

1. Primary enuresis: failure to establish bladder control by 5yo
2. Secondary enuresis: loss of continence after previously achieved (usually 6 months)
   - Typically occurs 5-8yo
   - Often attributed to a period of stress (e.g. divorce of parents), must screen for trauma/neglect delaying development

Question 14

List some DDx of enuresis.

Answer 14

DDx:
• Substances use; diuretics, antipsychotics, SSRIs, neuroepileptics
• Medical conditions; spina bifida, diabetes (DM and DI), seizure disorders, neurogenic, thyroid disorder, bladder, UTI, constipation in children (can cause urinary incontinence)
• Symptoms suggestive of a noneuretic cause; presence of other symptoms, altered frequency, urgency, straining, weak stream, genital or lower urinary tract pain

Question 15

Describe the treatment of enuresis.

Answer 15

Only initiate treatment if symptoms cause pt distress/impairment
Non-pharm:
- Psychoeducation; high rate of spontaneous resolution, avoid punishment, not voluntary, explore stressors, family therapy
- Bell and Pad Training; 6-16 weeks, sensor detects fluid in underwear/mattress and alarm goes off, pt taken to bathroom to void
Pharm:
- For short-term use, if pt fails to respond to behavioural modifications, should NOT be considered prior to 7yo
- First line: Desmopressin acetate (DDAVP)
- Second line; Imipramine (danger in overdose), oxybutynin chloride, tolterodine

Question 16

What is the DSM-V criteria for gender dysphoria in children?

Answer 16

DSM-V criteria for children:
A. A marked incongruence between one’s experienced/expressed gender and assigned gender of at least 6 months duration. As manifested by at least 6 of the following (one of which must be A1):
1. A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from that assigned)
2. In boys (assigned gender), a strong preference for cross-dressing or simulating female attire. In girls (assigned gender), a strong preference for wearing only typically masculine clothing.
3. A strong preference for cross-gender roles in make-believe play.
4. A strong preference for the toys/games/activities stereotypically used by the other gender
5. A strong preference for playmates of the other gender
6. In boys (assigned gender), a strong rejection of typically masculine toys/games/activities and avoidance of rough-and-tumble play. In girls (assigned gender), a strong rejection of typically feminine toys/games/activities.
7. Strong dislike of one’s sexual anatomy.
8. A strong desire for the primary and/or secondary sex characteristics to match one’s experienced gender.
B. The condition is associated with clinical significant distress/impairment.

Question 17

List some DDx of gender dysphoria.

Answer 17

DDx:
• Simple non-conformity with stereotypic sex role behaviour (e.g. tomboy); gender dysphoria goes much further and involves profound disturbance in pt’s sense of identity
• Transvestic fetishism; cross-dressing in the clothes of another sex, to create sexual excitement, generally do not have other symptoms of gender identity disorder, gender identity matches their assigned sex
• Schizophrenia; delusions can include believing they are a member of the other sex (not that they feel like one or want to be one)
• Other psychotic disorders (e.g. psychotic depression, mania) can cause gender confusion

Question 18

Describe the treatment of gender dysphoria.

Answer 18

• First step should be assessment for psychological trauma or co-occurring psychopathology
• Real life experience living in the community as the desired gender is recommended; >3 months prior to hormonal reassignment, >12 months prior to surgical reassignment
• Staged transition is recommended:
• -> First fully reversible steps; presenting as desired gender, suppressing puberty
• -> Then partially reversible steps; administration of hormones to bring out desired sex characteristics
• -> The irreversible steps; sex reassignment surgery

Question 19

What is the DSM criteria for conduct disorders?

Answer 19

DSM-V criteria:
A. Persistent, repetitive pattern of behaviour that infringes on the basis rights of others or violates major age-appropriate societal norms. This pattern is manifested by the presents of at least 3 of the following symptoms in the last 12 months (with at least one in the last 6 months):
–> Aggression towards people or animals (7 symptoms in category)
–> Destruction of property (2 symptoms in category)
–> Deceitfulness or theft (3 symptoms in category)
–> A serious rule violation (3 symptoms in category)
(The personal can have more than one symptom in a category)
- The disturbance causes clinically significant impairment.
- If the pt is older than 18, the criteria for antisocial personality disorder are not met

Question 20

List some DDx of CD?

Answer 20

• Oppositional Defiance Disorder (ODD); also has negative behaviour pattern BUT offenses do not typically cause significant harm to others or involve violations of major societal norms.
• Adjustment disorder with disturbance of conduct; in relation to a stressor
• Mania
• MDD; irritable and conduct problems BUT also marked mood symptoms
• Disruptive Mood Dysregulation Disorder (DMDD); new DSM-V diagnosis to describe primary-school aged children with chronic negative mood and temper outbursts. Diagnosed instead of ODD when particularly severe and negative mood predominated. Controversial diagnosis, could represent a extreme form of ODD.
• Intermittent explosive disorder; impulsive outbursts of anger and aggression (uncommon in ODD)
• Antisocial personality disorder; if symptoms appear after 18yo
• ADHD; hyperactive and impulsive BUT does not violate societal norms or the rights of others (as in CD)

Question 21

Describe the treatment of CD?

Answer 21

• Multisystemic treatment approach; involving pt, parents and teachers
• Parental training; help relationship between the pt and caregiver, teach caregiver new skills at home
• Teach classroom social skills
• Treat comorbid psychiatric disorders first (e.g. depression)
• Behavioural and cognitive behavioural group- based parenting interventions; effective and cost-effective
• Atypical neuroepileptics (e.g. Risperidone, olanzapine, quetiapine, aripiprazole) for aggression