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    12 views11 pages

    ADHD and Autism - 221125 - 211937

    Uploaded by

    Suhaila Ahmed

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    of 11
    ADHD Dr. SEN THOMAS PEDIATRICS. DUBAI HOSPITAL Definition + ADHD is a neuro-developmental disorder characterized by inattention, hyperactivity, and impulsivity It has a chronic course with symptoms ‘that begin in early childhood but often persist into adult life. + A key element of the definition is that symptoms manifest in two or more settings, for example in home and school, or home and work ADHD subtype + Depending upon the predominant symptoms, ADHD can be categorized into one of the three subtypes. + Predominantly inattentive -25 to 30% cases + Predominantly hyperactiveimpulsive ~ 8-10% + Combined - 60-70% EPIDEMIOLOGY * Prevalence: The prevalence in school-age children is estimated to be between 9 and 15 percent, making it one of the most common disorders of childhood * ADHD is more common in males than females * In the 2015 to 2016 National Health Interview Survey (NHIS), the prevalence was 14 percent in males and 6 percent in females Pathogenesis + The aetiology of ADHD is probably multifactorial and composed of + Genetic and environmental factors + A genetic imbalance of catecholamine metabolism in the cerebral cortex appears to play a primary role. + Environmental factors + Low birth weight and maternal smoking have the strongest evidence for association with ADHD. Other risk factors include poverty, lead exposure, iron deficiency, maternal alcohol drinking during pregnancy, and psychosocial adversity, pre-existing maternal psychiatric condition. Cen roan ee aed Inattention ‘Age of onset ‘Observed by 4 years of age ‘Observed by 8-9 years of age Peak Hyperactivity peaks by 7-8 years Persists throughout adulthood ‘and then declines, impulsivity persists through adulthood The Characteristics of symptoms of ADHD * Occur often + Be present in more than one setting (eg, school and home) + Persist for at least six months * Be present before the age of 12 years junction in academic, social, or occupational activities * Be excessive for the developmental level of the child CLINICAL FEATURES * Core symptoms: + hyperactivityimpulsivity and + inattention + Impaired functioning — To meet criteria for ADHD, core symptoms ‘must impair function in academic, social, or occupational activities. Symptoms of hyperactivity and impulsivity may include: + Excessive fdgeiness (eg. tapping the hands oft, squiing in seat) + Ocul remaining sated when sting is equred (eet schol work) + Felings of restlessres (m adcescets) or raporoprate running around or cimbing in younger hdr + Dict playing ity + Dif wo keep up with, seeming to abays be “on the go" + Excessive aking + Dic waiting urs + Blurtingout answers too quickly + Interruption or ints af ethers Symptoms of inattention may include: + oftezy marearng titn ily oo erhome een Fate trode dom arn deta aes aes + Flaw tow ugh at hc, hom) + oft ren asst nd ergs + Lec id fr rant ao bos, prs easome. + Ey dora year sim + Foren nom cote (a hwo re) Comorbid psychiatric disorders a * Oppositional defiant disorder (ODD), (50 - 80%) * Conduct disorder (1/3rd of cases) + Anxiety disorder, and Depression(1/3rd of cases) * Learning disabilities(20-60%) * Autism spectrum disorder + Sleep disorders Evaluation for ADHD + Initiated in children 24 years of age ‘+ Who have symptoms of inattention, hyperactivity, or impulsivity or who have complaints frequently associated with ADHD + (ee poor schoo! performance, dificulty making and keeping frends difficulty with team sports) HE, rcrensve medical, developmental, educational, and psychosocial ‘evaluation to confirm the presence & exclude other causes of core symptoms * Learning disablty, ASD, Language or communication disorder + To identify coexisting emotional, behavioral, and medical disorders (eg, anxiety, mood disorders, learning disabilities, sleep disorders) Comprehensive Assessment It is needed to minimize underdiagnosis and overdiagnosis of ADHD and it includes the following: 1 Developmental variations— © Oppostiona detent normal variation and low/high 1 a porionrce is [Nelrctplen cantons caution || sonar vorder—29% 3. Pervasiveness specttum disorder, learning @ Learning disability—70% 4, Functional complications —__—_ disability, seizure disorder, @ Autism spectrum Neurodevelopmental syndromes _ disorder Sere eee, (fragile X and fetal alcohol), @ Anxiety, depression eal eater communication disorders @ Ticsand obsessive @ Parcotandteacherrating ® Emotional disorders—depression, compulsive disorder reece anxiety, mood, oppositional a defiant disorder, conduct disorder, bipolar, and obsessive Sencar, compulsive disorder Psychosocial problems—child ‘abuse, neglect, and bullying % Medical conditions—hearing/ vision impairment, sleep disorder, anemia, substance abuse, and thyroid disorders Management * Plan under the guidance of + Developmental petatcan + Pediatric neurlogst + Pediatric payehiatrit + Principles of management + Early diagnosis and appropriate multdscipinary interertion wil improve prograsis + Aim to improve functional outcomes, eg, decrease activity level, improve social and academic functioning + Management of comorbid conditions Modalities of Management * Behavioral interventions — + The first-line treatment for preschool chidren (below 6 years) with ADHD ; + Medication— + With or without behavioral interventions are the first-line therapy for school-aged children (26 years) and adolescents who meet the diagnostic criteria for ADHD ; * Educational interventions + Combination of the above Prognosis + Persistence of ADHD at age 25 years: + ‘+ Meeting full criteria for ADHD: ~15% + + ADHD in partial remission: ~65% + Symptoms of inattention persist more and show slower decline. Always. Lintgue Totally Interesting Sometimes Mysterious Dr. Sen Thomas SSR, Pediatrics Dubai Hospital Case history #1 * A 3-year-old boy presents because his parents have concerns about his language development. He started using ‘single words at age 18 months but still doesn't use two words together. He stopped using words he had previously learnt between 18 and 24 months, but has now regained most of these words. He also seems uninterested in ‘engaging with other children. He occasionally engages with his parents but less than they think he should. He doesn't tend to look at them much and he has difficulty maintaining eye contact with them. When he wants something he pulls them to where the object is and screams; he doesn't point like other children. His parents have also noticed that he does not play in the same way as other children of his age; he tends to line toys up, or plays with certain aspects ‘of them, such as the car doors. He doesn't use the toys in the imaginative way that other children do. When his toys ‘are moved he becomes very upset. He tends to become distressed when he thinks there is change around the house. In contrast, he is not concerned when either of his parents leaves the house. He tends to flap his hands at times and his parents report him staring at the ceiling lights for 10 to 20 minutes at a time. He is a fussy eater and hates being messy, AUTISM * Leo Kanner, a child psychiatrist, in 1943 first coined the term ‘autism’ + 11 children described who demonstrated : a profound lack of social engagement, failed to use language to communicate, had an obsessive need for sameness. + Autism is now recognized as a + Neurodevelopmental disorder & neurobehavioral disorder. + Autism occurs due to underlying disorder of brain development. WHAT IS AUTISM? * Autism is a complex neurodevelopmental disorder characterized by: * Qualitative impairments in social interaction, * Qualitative impairments in communication, and + Restricted, repetitive, stereotyped patterns of behavior, interests and activities. SOME FACTS ABOUT AUTISM + Autism is NOT a single disorder. *+ Autistic symptoms occur along a wide spectrum. + Sensory hypo sensitivities or hyper sensitivities to the environment often noted. ‘+ Symptoms may vary in the same autistic child and change over time. DIAGNOSIS OF AUTISM + Diagnosis based entirely on clinical findings. + Ascertain whether the child's specific behaviors meet the Diagnostic and Statistical Manual of Mental Disorders - V -Revised (DSM -V) criteria + Observe child in several settings as symptoms may unfold over time. Epidemiology * One report from the US Centers for Disease Control estimated that 1 in 46 children aged 8 years has ASD, + And that ASD was 4.2 times more prevalent in boys than girs. + Reference + Macnner MJ, Shaw KA, Bakian AV, et a. Prevalence and characteristics of autism spectrum disorder among children aged 8 years - autism and developmental disabilities monitoring network, 11 Sites, United States, 2018. MMWR Surveill Summ, 2021 Dec 3,70(11)1-16. Epidemiology + Rate in siblings — The estimated prevalence of ASD in siblings of a child with ASD who does not have an associated medical condition or syndrome is approximately 10 percent (range 4 to 14 percent), * However, in some studies, the prevalence of ASD in siblings of children with ASD is as high as 20 percent Associated conditions and syndromes in ASD + Intellectual disability(ID) - 33-45% + Attention deficit hyperactivity disorder ~ 50%, * Epilepsy: 30% * Up to 25 percent of cases of ASD are associated with a genetic cause + These conditions include tuberous sclerosis complex fragile X syndrome, chromosome 115q11-13 duplication syndrome, Angelman syndrome, Rett syndrome, Down syndrome a WHAT CAUSES AUTISM? + Pathogenesis ~ The pathogenesis of ASD is incompletely understood. * The general consensus is that ASD is caused by genetic factors that alter brain development resulting in the neurobehavioral phenotype. + Environmental and perinatal factors account for few cases of ASD but may modulate underlying genetic factors. + Majority of epidemiologic evidence does not support an association between immunizations and ASD. ALERTING SIGNALS IN CHILDREN 2 - 3 YRS. OF AGE + Social impairments + Does not imitate actions (eg, clapping) + Does not show toys to other people. * Lac iterest in other chien (eq, does not sme ator touch face of another +s indifferent to other people's happiness or distress (eg, not distressed when ‘mother cries) + Prefers to be alone (does not want cuddling or act cuddly) + Has litle or no eye contact. + Prefers solitary play activities, ‘+ Has odd relationships with adults (too friendly or ignores). + Develops loss of any socal skills ALERTING SIGNALS IN CHILDREN 2 - 3 YRS. OF AGE + Communication impairments, * Does not babble, point by 12 months + Does not speak single words by 18 months. + Does not speak two word spontaneous (non- echoed) phrases by 24 months. + Has poor response to name (may seem tobe dea). + Has delayed language development, especially comprehension. + Has unusual use of language (eg, repeats words or phrases in place of normal responsive language). + Has deficient non-verbal communication (eg, no gestures with hands while talking) + Does not participate in shared imaginary games (eg cannot ply ring ~a~ring roses or other nursery games). * Develops oss of any language sil ALERTING SIGNALS IN CHILDREN 2 - 3 YRS. OF AGE + Repetitive and stereotyped behavior patterns + Resists changes in routine (eg. iid and limited dietary habits) + Inappropriate attachment to objects (eg. carries teddy bear al day long) * Unable to cope with change, especially in unstructured setting (eg. uncontrollable crying when taken frst time to beach) + Has repeated motor mannerisms (eg, hand flapping. rocking) + Plays oddly and repetitively with toys (eg, lines up objects, spins objects) + Turns light switches on and off, regardless of scolding + ls over -sensitive to sound or touch (eg. frequently wakes up at night) & + Bites hits, aggressive to peers + Laughs, cries or shows distress for reasons not apparent to others AUTISM SCREENING TOOLS ‘+ M-CHAT (Modified Checklist for Autism in Toddlers) + PDDBI (Pervasive Developmental Disorders Behavior Inventory) + ADI-R (Autism Diagnostic Interview Revised) + ADOS (Autism Diagnostic Observation Schedule) + CARS (Childhood Autism Rating Scale) MANAGEMENT OF AUTISM + Amultidscpinary team of professionals trained and specialized in autism is necessary. + The team should include + Developrrtal pediatric, + Oh payors, + Occipstona (behavra heaps, + Spmech therapist, + Paha + Speci teacher and INTERVENTION STRATEGIES FOR AUTISM + The goals of treatment are to maximize functioning, move the child toward independence, and improve the quality of life. + focuses on behavioral and educational interventions that target the core symptoms + Pharmacotherapy interventions may be used as an adjunct to address medical or psychiatric comorbidities + Ongoing family education and suppor, screen for coexisting medical conditions, and

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