Children who don’t fit in:

ADHD & Autism spectrum disorder

UMMP 3.2
SUBHASHINI JAYANATH
 SCOPE
PART A:
• Overview of ADHD
Definition & Features
• Diagnosis & Management
Criteria & Classification
http://www.uvm.edu/~psych/images/BTPC/ADHD.jpg

________________________________________________

PART B:
• Overview of Autism spectrum disorder
Definition & Features
• Diagnosis
Criteria & Classification
http://www.bbc.com/news/health-25184078
 PART A

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/adhd-dancing.jpg

ATTENTION DEFICIT HYPERACTIVITY

DISORDER (ADHD)
Overview of ADHD

http://www.heatherengland.com/2016/03/symptoms-of-adhd/
 What do we know?

• Maladaptively high levels of inattention,

impulsivity and hyperactivity
• Core symptoms – onset before the age of 7
• Can present to the clinician later than that
• Prevalence (UK):
• 0.5 per 1,000 -- 30 years ago
• Now > 3 per 1,000
 What do we know?
• Clinical diagnosis

• Spectrum

• Inattention without hyperactivity is

often misdiagnosed as a cognitive
impairment / a learning disorder
FEATURES
 INATTENTION

http://4.bp.blogspot.com

Disorganised Style
which
Prevents sustained effort
 IMPULSIVITY

Premature
&
Thoughtless
actions

http://4.bp.blogspot.com
 HYPERACTIVITY

Restlessness
&
Shifting
Excess of Movement
Diagnosis & Classification of
ADHD

http://prpsych.com/2016/05/the-adhd-conundrum/
 Diagnosis
• Diagnostic and Statistical Manual of Mental
Disorders, 5th Ed. @ DSM-5
vs.
• International Classification of Disease (ICD-10)
- ADHD as part of “hyperkinetic disorders”
- only combined type qualifies
- stricter criteria than DSM-5
(excludes co-morbidities)
 DSM-5 Diagnostic criteria
• Present before age 12 (DSM-IV: age 7)
• Chronicity: > 6 months
• F(x)l impairment across > 2 settings
• Clear evidence of significant impairment (social /
school / work)
• Inconsistent with developmental level
• Not due to other mental disorders (does not
exclude autism)

• Either INATTENTION / HYPERACTIVITY / BOTH

(6 out of 9 of either or both), for adults: 5/9
 TYPES

• INATTENTIVE

• HYPERACTIVE

• COMBINED
 Predominantly Inattentive Type
(ADHD-I)
[6/9 criteria]
• Careless / Fails to pay close attention to details
• Difficulty sustaining attention
• Does not follow through on instructions
• Does not listen
• Difficulty organising
• Avoids tasks requiring
sustained mental effort
• Forgetful
• Easily distracted
• Often loses things
 Predominantly Hyperactive Type
(ADHD-H)
[6/9 criteria]
Hyperactivity:
• Often fidgets / squirms
• Often leaves seat when expected to be seated
• Runs / climbs excessively when inappropriate
• Difficulty playing quietly
• On-the-go / driven by a motor
• Talks excessively
Impulsivity:
• Blurts out answers
• Difficulty awaiting turn
• Interrupts
 Combined Type
• 6 out of 9 of either / both inattention and
hyperactivity-impulsivity
 Differential Diagnoses
• Learning disorders
• Disorders of motor control
• ODD and Conduct disorder
• Tourette syndrome
• Bipolar disorder & Affective mood disorders
• Anxiety
• Depression
• Attachment disorder
• Autistic spectrum disorders
• Personality disorders (Borderline and Antisocial)
 Diagnosis … cont’d
Some tools:
• Conner’s Rating Scales (CRS)
• ADHD Rating Scale (ADHD-RS)

• Cornerstone  still the clinical interview and

assessment by a paediatrician or psychiatrist

• Cognitive impairment & learning disabilities

can be comorbidities / confounders  role of
clinical psychologist
 AETIOLOGY / ASSOCIATIONS
MULTIFACTORIAL
• Genetics – twin studies and family studies

• Environment – prenatal exposure to cigarette

smoke & alcohol ?, preschool exposure to lead

• Traumatic brain injury (but only some children

with ADHD have had TBI)

• Prematurity – cerebral ischaemia could

contribute to persistent deficient dopaminergic
neurotransmission
 AETIOLOGY / ASSOCIATIONS
• Delayed brain maturation –
Frontal cortex areas (higher-order
executive functions – impulse control,
focusing, memory, work for reward) peak
in thickness later in adolescence than for
those without ADHD
• Difficulty in switching off the default mode
network (DMN) – require greater incentives
Motivation, Inhibition and Development in ADHD
Study (MIDAS) group at the University of
Nottingham
 CHALLENGES

- Extent
- Context
- Constitution

• Age-dependant patterns: http://www.sleepsolutionsnw.com/adhd-misdiagnosis/

 Extreme activity (early childhood)

 Inability to sit still (later childhood)
 Fidgetiness (adolescence)
 Inner restlessness (adulthood)
 CO-MORBIDITIES

http://www.milestonemom.com
kiwicommons.com
http://www.lanc.org.uk/
 Common Associations – but NOT part
of DIAGNOSTIC Criteria
• Disobedience
• Sleep disturbance
• Temper tantrums
• Mood swings
• Aggression
• Unpopularity
• Clumsiness
• Learning disability
MANAGEMENT & FOLLOW UP

http://img199.imageshack.us/

http://www.google.com.my/imgres?q=adhd
 NON-PHARMACOLOGICAL
MANAGEMENT
• Psychotherapy
- Behavioural Therapy
- Positive and Negative Reinforcement
• Social Skills Training
• Parenting Skills Training
• Organisation & Structure
– Schedules, organisation of items, lists
(organisation of tasks)

Child Group Therapy & Parent Group Therapy

PHARMACOLOGICAL MANAGEMENT
-- if behavioural therapy is not
enough...
STIMULANTS vs. NON-STMULANTS

www.theodysseyonline.com/25-things-that-really-confuse-me
 PHARMACOLOGICAL MANAGEMENT

• STIMULANTS
Concerta – extended release
Ritalin – short acting methylphenidate
methylphenidate
• In children - NO EVIDENCE for the use of:

• Dexamphetamine
and limited evidence in adults
 PHARMACOLOGICAL MANAGEMENT
• NON-STIMULANTS

Atomoxetine

- precise mechanism unclear

- selective inhibition of pre-synaptic NAd transporter
 NAd reuptake inhibition
- less effect on brain regions associated with motivation
& reward (vs. stimulants)  no dependancy
- OD or divided into BD
 Atomoxetine
• Side effects
– abdominal pain, nausea, vomiting
- anorexia, weight loss
- tachycardia, hypertension (mild)
- dizziness

Rarely: hepatotoxicity, seizures, suicidal ideation

• NO EVIDENCE for the use of:

• TCAs (tricyclic antidepressants)

• SSRIs (selective serotonin reuptake inhibitors)
• SNRIs (serotonin & NAd reuptake inhibitors)
• Atypical antipsychotics (e.g. risperidone)
• Nicotine patches
 CAUTION in medicating children
with…

Autism – can worsen ritualistic

behaviour & sterotypies

Medical co-morbidities – seizures,

Tourette syndrome, tic disorders
 PROGNOSIS
• ADHD often persists throughout life
• But, many “self-adjust” during young adulthood
• Good prognostic factors:
- absence of conduct disorder / antisocial
behaviour / other mental illnesses
- good family & social support
- constructive leisure activities
- appropriate & timely treatment
 ADULT ADHD

http://newhopemedical.org

http://img2.timeinc.net
 PART B

AUTISM SPECTRUM DISORDER

Overview of Autism
 DEFINITION of Autism

A neurodevelopmental disorder
that impairs a child's ability to
communicate and interact with
others. It includes restricted
repetitive behaviour, interests
and activities. These issues cause
significant impairment in social,
occupational and other areas of
functioning.

Mayo Clinic. http://www.mayoclinic.org/diseases-

conditions/autism-spectrum-
disorder/basics/definition/con-20021148
 .

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http://hub.rockyview.ab.ca/pluginfile.php/493/mod_book/chapter/264/autism_symptoms.jpg
Diagnosis & Classification of Autism
Spectrum Disorder

http://www.friendshipcircle.org/blog/2013/07/15
 CRUCIAL POINTS IN THE HISTORY:
• HEARING – any concerns?
– normal / otherwise?
– ever assessed?
• LANGUAGE DELAY – expressive?
– receptive?
– both?
• OTHER ASPECTS OF DEVELOPMENT
– any delay?
– any regression?
ADDITIONALLY: Complete paediatric history and specific
history related to traits of autism (DSM-5)
 DSM-5 Criteria – MAINSTAY for the
diagnosis of autism spectrum disorder

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BASIC REQUIREMENTS FOR DIAGNOSIS

Items present:

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• must cause functional impairment

• cannot be solely due to global developmental delay
(GDD) / other DSM-5 diagnoses
• are / were present in early childhood (age < 8),
but may not be fully manifest till later
 IMPORTANT CONSIDERATIONS
• 2 CORE DOMAINS:
(A) SOCIAL COMMUNICATION / INTERACTION DEFICITS
A1, A2, A3
(B) RESTRICTED, REPETITIVE PATTERNS OF BEHAVIOUR,
INTERESTS OR ACTIVITIES (RRBs)
B1, B2, B3, B4

• CHECKLIST:
• >5 items (currently present / present in history) with:
• all three (3) items from (A), and
• at least 2 (> 2) items from (B)
(A) SOCIAL COMMUNICATION /
INTERACTION DEFICITS

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 (A) SOCIAL COMMUNICATION /
INTERACTION DEFICITS
(A1) Lack of social / emotional reciprocity
• sharing interests, seeking attention, empathy, turn-taking, social
initiations, conversation, imitation

(A2) Marked impairment in non-verbal communication

• eye contact, gestures, facial expression, posture, speech
production, pointing, gaze-tracking

(A3) Severe problems developing and maintaining

relationships appropriate to level
• interest in peers, relationships, play
 (B) RRBs
(B1) Stereotyped and repetitive speech, motor
mannerisms or use of objects
• stereotypies, unusual gait, tiptoeing, echolalia, copied accents, repetitive
vocalisations or use of objects

(B2) Inflexible adherence to non-functional routines,

ritualised verbal / non-verbal behaviour, or
excessive resistance to change

(B3) Highly restricted patterns of interests, abnormal in

intensity or focus
• predictable activities, unusual attachment to objects

(B4) Unusual interest in sensory aspects of environment,

or hyper- / hypo-reactivity to sensory input
• over-awareness, sensory-seeking, sensory-defensiveness
 References
• ADD ADHD Information Library Copyright 1996-2012.
http://newideas.net/adhd/neurology.

• Attention Deficit / Hyperactivity Disorder, DSM-5, Information Sheet. American

Psychiatric Asociation. 2013.
http://www.dsm5.org/Documents/ADHD%20Fact%20Sheet.pdf

• ADHD. National Institute of Mental Health. U.S. Dept. of Health and Human Services.

• Attention-deficit hyperactivity disorder and hyperkinetic disorder: information for

parents, carers and anyone working with young people, Royal College of Psychiatrists.
http://www.rcpsych.ac.uk

• The NICE guideline on the diagnosis and management of ADHD in children, young
people and adults, National Collaborating Centre for Mental Health, 2009.

• Autism spectrum disorder. Mayo Clinic. http://www.mayoclinic.org/diseases-

conditions/autism-spectrum-disorder/basics/definition/con-20021148.

• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental

disorders (DSM-5®). American Psychiatric Pub.