Download Psychotic Disorders in Children: How Do We Distinguish Them?

Autism Spectrum Disorder and
Attention-Deficit/Hyperactivity Disorder
Rob Nicolson, M.D.
Department of Psychiatry,
Western University
I have not had in the past 2 years a financial interest or
arrangement or affiliation with one or more organizations that
could be perceived as a direct or indirect conflict of interest in
the content of the subject of this or any other program
Learning Objectives
By the end of this session you will :
• Have a greater understanding of the challenges
associated with Autism Spectrum Disorder (ASD)
and Atttention-Deficit/Hyperactivity Disorder
(ADHD)
• Be familiar with current important issues
pertinent to ASD and ADHD
Autism Spectrum Disorder
Case: Connor
• 5 year old male
• Does not speak or communicate using gestures
• Seems disinterested in playing with peers at daycare; wiggles
fingers in front of eyes; often looks our of corner of eyes at objects
• Significant tantrums with aggression and self-injurious behaviour
• Parents recently separated and don’t have formal parenting
agreement
– Lives with mother, sees dad on weekends
– Very different approaches to his tantrums; doctor has expressed
concerns about the inconsistency in parental approaches
• Diagnosis
• Epidemiology
• Etiology
• Treatment
Diagnosis of (ASD):
Social Interaction and Communication
• Persistent deficits in social communication and social
interaction, manifested by all three of the following:
– Deficits in social-emotional reciprocity
– Deficits in nonverbal communicative behaviors used
for social interaction
– Deficits in developing, maintaining, and
understanding relationships appropriate to
developmental level
Diagnosis of (ASD):
Repetitive Behaviour
• Restricted, repetitive patterns of behaviour,
interests, or activities, as manifested by at least
two of the following:
– Stereotyped or repetitive motor movements, use of objects,
or speech.
– Insistence on sameness, inflexible adherence to routines,
or ritualized patterns of verbal or nonverbal behaviour.
– Highly restricted, fixated interests that are abnormal in
intensity or focus
– Hyper- or hyporeactivity to sensory input or unusual
interest in sensory aspects of the environment
Diagnosis of ASD
• Must have all three social-communication symptoms and
at least 2 of the repetitive behaviour symptoms
• Symptoms must be inconsistent with the person’s
developmental level
• Symptoms must be present in early childhood
• Symptoms together limit and impair everyday
functioning
• Diagnosis
• Epidemiology
• Etiology
• Treatment
Epidemiology of
Autism Spectrum Disorder
• Prevalence among 8 year olds: 1.47% (1/68)
• Male:female ratio: 4.5:1
• Intellectual Disability occurs in 31%
• 20% have seizures, typically beginning early in life or in
adolescence
• Diagnosis
• Epidemiology
• Etiology
– Neurobiology
– Environmental Factors
• Treatment
Neurobiology of ASD
• Considered a “neurodevelopmental disorder” (i.e., caused
by abnormal development of the brain rather than
degeneration or specific lesion)
• 5-10% of patients have detectable chromosome
abnormalities
• Sibling recurrence rate is 5-10%
• Heritability about 90%
• “Unaffected” relatives have increased rates of social,
language, and behavioural problems
Environmental Factors in ASD
• Much has been written in recent years about vaccinations
being a “cause” of autism, either directly from MMR
vaccine or from mercury being used as preservative
• Epidemiological studies indicate that there is absolutely
no relationship between autism and vaccinations
• Diagnosis
• Epidemiology
• Etiology
• Treatment
– Intensive Behavioural Intervention
– Pharmacotherapy
Intensive Behavioural Intervention (IBI)
• An intensive intervention (at least 20 hours per week)
for children with ASD
• Goal of IBI is to increase children's developmental
trajectories, or rate of learning, and to prepare them
to learn in other, more natural, environments
• Several studies indicate that IBI can be beneficial for
a group of children with ASD
Pharmacotherapy of ASD
• There are no pharmacological treatments for ASD per se
• Treatment therefore aimed at reduction of behaviours
which interfere with daily functioning (typically
aggression and hyperactivity/inattention)
• Goal of medication should be to enhance other treatments
(behaviour modification, education, speech therapy,…)
• Some medications have been shown to reduce interfering
behaviours but should be used judiciously and in
conjunction with other interventions
Case: Connor
• After assessment, diagnosed with ASD
– Eligible for provincial-funded IBI program (waiting list about 1 year)
• Mom:
– Quit work to be able to care for John
– Wants him in privately funded, home-based IBI program
– Feels medication is necessary to reduce aggression and self-injury
• Dad:
– Wants John to receive IBI program through provincial-funded
program and to attend daycare until IBI funding is available
– Often unable to attend parenting seminars
– Is strongly against the use of any medications
Attention-Deficit/Hyperactivity Disorder
Case: Spencer
• 7 year old male, just finishing grade 1
• Parents divorced two years ago and have joint custody of he and
younger sister
• Since JK, teachers have commented that he:
– Does not listen or follow directions, doesn’t seem to pay attention
– Restless, frequently out of his seat, speaks out of turn and interrupts often
– Disruptive, defiant, frequent fights (sent home numerous times)
• Mother (who had problems with attention when she was a child)
reports he is “exhausting”: argumentative, difficult to manage due
to tantrums, needs constant supervision
• Dad denies similar problems at his house
• Diagnosis
• Epidemiology
• Etiology
• Treatment
Diagnosis of ADHD
• The essential feature of ADHD is a persistent pattern of
inattention and/or hyperactivity–impulsivity which is
inconsistent with the individual’s developmental level
• Clear evidence of significant impairment in social or
academic functioning in at least two settings
• Must have at least 6 inattentive symptoms AND/OR at
least 6 hyperactive symptoms
• Some symptoms must be present before the age of 12
Inattentive Symptoms
1.
2.
3.
4.
5.
6.
7.
8.
9.
Lack of attention to details or makes careless errors
Difficulty sustaining attention
Does not seem to listen
Difficulty following instructions
Difficulty organizing tasks
Avoids work requiring sustained attention
Often loses things
Easily distracted
Often forgetful
Hyperactive/Impulsive Symptoms
1.
2.
3.
4.
5.
6.
7.
8.
9.
Often fidgets or squirms
Often leaves seat in class
Runs or climbs excessively
Difficulty playing quietly
Often “on the go”
Talks excessively
“Blurts” out answers
Difficulty awaiting turn
Often interrupts
Disorders Comorbid with ADHD
•
Up to 65% of patients with ADHD have a comorbid
psychiatric disorder
1. Disruptive behaviour disorders (oppositional defiant
disorder or conduct disorder): 50%
2. Anxiety disorders: 25%
3. Learning disorders: 25%
4. Mood disorders: 20%
5. Tourette Syndrome: 7%
• Diagnosis
• Epidemiology
• Etiology
• Treatment
Epidemiology of ADHD
• Prevalence about 3% to 5% of school aged children
• Male:female ratio about 4:1 (9:1 in clinical samples)
– Females less likely to have problems with hyperactivity and
impulsivity
• 10% of behaviour problems seen in general pediatrics are
due to ADHD
• Children with ADHD account for up to 50% of referrals
to child psychiatrists
Epidemiology of ADHD
• For most, persists into adulthood, although overt
hyperactivity may decrease
• In long-term follow-up, people with ADHD have:
– Increased school difficulties
– Increased social and relationship difficulties
– Increased substance use problems
– Increased job difficulties and unemployment
– Increased arrests and incarceration
– Increased serious car accidents
• Diagnosis
• Epidemiology
• Etiology
– Neurobiology
– Environmental Factors
• Treatment
Neurobiology of ADHD
• Patients with ADHD (on average) have reductions of:
brain volume, particularly in the frontal lobes
– Changes are independent of medication treatment
– Long-term stimulant treatment appears not to change
developmental trajectory
• Genetics seems to play a very significant role
– Relatives of children with ADHD have higher rates of ADHD
than relatives of control subjects
– Heritability about 70%
Environmental Factors in ADHD
• Obstetrical complications
– Tend to be complications leading to chronic low oxygen
• Maternal cigarette smoking during pregnancy
• Psychosocial adversity
– Low SES, low maternal education, single parenthood, chronic
family conflict, reduced family cohesion
• Diagnosis
• Epidemiology
• Etiology
• Treatment
Treatment of ADHD
•
Behavioural interventions
– Education about ADHD and associated difficulties
– Training in behavioural change strategies (reward
positive behaviour, ignore unacceptable behaviour)
– Parent stress management
– Generally dependent upon appropriate medication to
be of value, particularly in more severely affected
children
Pharmacological Treatment of ADHD
• Stimulants
– methylphenidate (Ritalin, Concerta, Biphentin),
dextroamphetamine (Dexedrine, Vyvanse), mixed amphetamine
salts (Adderall)
– First line medications for ADHD in the vast majority of cases
– Can be extraordinarily effective, with 70% - 80% of
participants in clinical trials showing significant improvement
– Abuse liability with oral formulations is low and tolerance does
not typically develop to cognitive effects
Pharmacological Treatment of ADHD
• Atomoxetine (Strattera)
– Second line (or perhaps 1a) treatment
– Non-stimulant
– May help with comorbid anxiety
• Alpha Agonists
– guanfacine (Intuniv), clonidine (Catapress)
– Third line treatment
– Effective in treatment of tics
• Other Treatments
Case: Spencer
• Diagnosed with attention-deficit/hyperactivity disorder and
learning disorder (reading)
• Parents and school have collaboratively started a behavioural
program in all three environments, although consistency in parental
homes is uncertain
• Mother would like to start him on Biphentin as she has seen it work
in other children
• Father would like to wait until he’s older as “he’s just being a kid”
and wants to see if school improves with behaviour program
Conclusion
• ASD and ADHD are common and present in diverse ways
• For many people, both conditions result in lifelong challenges
and disabilities
• Having a child with ASD or ADHD can be very challenging
and stressful for families
• Informed parenting approaches and involvement are critical for
optimal outcome