Behavioural Disorders

Introduction

Autism Spectrum Disorder

Introduction

• It is a developmental disorder that is composed of persistent impairment in social communication and interaction and restricted, repetitive patterns of behavior or interests.
• Key features of autism include impairment in reciprocal social interactions, qualitative impairment in communication, and restrictive, repetitive stereotypical behaviors, interests, or activities.

 

Diagnostic Criteria

• Diagnosis is made before 3 years of age.
• At least 6 features ( at least 2 from social interaction deficit, and 1 from the other 2 parameters) to confirm diagnosis

 

Clinical features

• Social deficits with onset in early development
  • Difficulty sharing emotions or interests
  • Lack of nonverbal communication (eg, eye contact)
  • Difficulty developing/understanding relationships
• Restricted, repetitive behaviors & interests
  • Repetitive movements (eg, hand-flapping) or speech
  • Insistence on sameness/routines Intense, fixated interests
  • Adverse responses to sensory input (eg, foods, textures)
• ± Language delays & cognitive impairment

 

Screening

• The 2020 AAP guidelines on autism recommend universal autism screening with an autism-specific tool (e.g.,M-CHAT-R) at both the 18-month and 24-month visits, and whenever parental concerns are raised.
• Refer immediately for diagnostic evaluation if the initial M-CHAT-R score is 8-20.
  Risk factors for autism include: a sibling with an autism spectrum disorder, inconsistent hearing, unusual responsiveness, and concern by parent, other caregiver, and/or pediatric provider.
• Early Signs of Autism
  • Absence of a social smile at 6 months of age, limited eye contact
  • Absence of babbling by 9 months of age.
  • No response to name by 12 months of age.
  • No pointing or using other gestures to demonstrate interest by 14 months of age.
  • Not using single words by 16 months of age, or 2-word phrases by 24 months of age, or stereotypic use of language (including echolalia).
  • Lack of make-believe or symbolic play by 18 months.
  • Failure to develop age-appropriate peer relationships.
  • Lack of social-emotional reciprocity.
  • Restrictive interests, inflexible routines, preoccupation with words or objects.
  • Stereotypical movements such as hand-flapping, rocking, or excessive spinning.

 

Treatment

• Early diagnosis and intervention.
• Comprehensive, multimodal treatment (speech, behavioral therapy, educational services).
• Adjunctive pharmacotherapy for psychiatric comorbidities.
  • Risperdal is the drug of choice for aggressive behaviors in autism.
  • Mood stabilizers: e.g., Levetiracetam can be used too.

Attention Deficit Hyperactivity Disorder (ADHD)

Introduction

• ADHD is a behavioural disorder characterized by persistent patterns of inattention and/or hyperactivity-impulsivity that interfere with functioning or development.
  ADHD can be screened for using Vanderbilt Assessment Scales.

 

Diagnostic Criteria

1. Inattention
   Six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree inconsistent with developmental level and negatively impacts social, academic, or occupational functioning:
   • (For individuals 17 years or older, only five symptoms are required.)
   • Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
   • Often has difficulty sustaining attention in tasks or play activities.
   • Often does not seem to listen when spoken to directly.
   • Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace.
   • Often has difficulty organizing tasks and activities.
   • Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort.
   • Often loses things necessary for tasks or activities (e.g., school materials, keys, wallet).
   • Is often easily distracted by extraneous stimuli.
   • Is often forgetful in daily activities.
2. Hyperactivity and Impulsivity
   Six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree inconsistent with developmental level and negatively impacts social, academic, or occupational functioning:
   (For individuals 17 years or older, only five symptoms are required.)
   • Often fidgets with or taps hands or feet or squirms in their seat.
   • Often leaves the seat in situations when remaining seated is expected.
   • Often runs about or climbs in situations where it is inappropriate (in adolescents or adults, this may manifest as feelings of restlessness).
   • Often unable to play or engage in leisure activities quietly.
   • Is often “on the go,” acting as if “driven by a motor.”
   • Often talks excessively.
   • Often blurts out answers before a question has been completed.
   • Often has difficulty waiting their turn.
   • Often interrupts or intrudes on others (e.g., butts into conversations or games).
3. Several symptoms were present before the age of 12.
4. Several symptoms are present in two or more settings (e.g., at home, school, or work; with friends or relatives; in other activities).
5. Clear evidence that the symptoms interfere with or reduce the quality of social, academic, or occupational functioning.
6. Symptoms are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, personality disorder, substance intoxication, or withdrawal).

 

Clinical Features

• Inattentive &/or hyperactive/impulsive symptoms for ≥6 months
  • Inattentive symptoms: difficulty focusing, distractible, does not listen or follow instructions, disorganized, forgetful, loses/misplaces objects
  • Hyperactive/impulsive symptoms: fidgety, unable to sit still, "driven by a motor," hypertalkative, interrupts, blurts out answers
• Several symptoms present before age 12
• Symptoms occur in at least 2 settings (home, school) & cause functional impairment
• Subtypes: predominantly inattentive, predominantly hyperactive/impulsive, combined type

 

Subtypes of ADHD

Based on the symptom criteria:

• Predominantly Inattentive Presentation
  • (Symptoms primarily fall under the "inattention" category.)
• Predominantly Hyperactive-Impulsive Presentation
  • (Symptoms primarily fall under the "hyperactivity and impulsivity" category.)
• Combined Presentation
  • (Both inattention and hyperactivity-impulsivity criteria are met for the past six months.)

 

Treatment 

• Non-pharmacological: behavioral cognitive therapy. 
• Pharmacological: 
  • Stimulants: methylphenidates,amphetamines. 
    • Side effects include: Hypertension,Tachycardia, Insomnia, Decreased threshold for seizure, Reduced appetite, Addiction. 
  • Nonstiumelants: atomoxetine,alpha 2 adrenergic agonist.