Behavioral med Child Psychiatry

autism spectrum disorder (ASD)

neurodevelopmental disorder characterized by persistent deficits in social communication and interactions

restricted, repetitive, and inflexible behaviors, interests, and activities

what can affect outcomes of ASD

early diagnosis and intensive treatment

ASD DSM-5 criteria A

persistent deficits in social communication, social interactions - nonverbal behaviors, social reciprocity, and relationship skills

ASD DSM-5 criteria B

restricted, repetitive patterns of behavior, interests, or activities manifested by at least two of the following:

-repetitive motor movements, use of objects, or speech

-insistence on sameness, inflexible adherence to routines, ritualized paterns

-fixated interests abnormal in intensity or focus

-hypo/hyper-reactivity to sensory input

ASD DSM-5 criteria C

symptoms must be present in early development

ASD DSM-5 criteria D

symptoms must cause clinically significant impairment in important areas of functioning

ASD DSM-5 criteria E

not better explained by developmental delay or intellectual disability

early infantile autism

delayed speech, monotonous repetition of noises, excellent memory, dread of change, poor eye contact, awkward relationships

why has ASD prevalence increased since mid 1990's

possible reasons:

increased awareness

changes in he definition of ASD

earlier detection

more specialized developmental services

diagnostic substitutions

true increase in prevalence

ASD is 3-4x more common in

males

the ___ sibling is at greater risk for ASD

younger

up to 25% of ASD cases are associated with a

genetic cause

> genetic factors, epigenetic theory, increased rates in siblings, unequal sex distribution

ASD neurobiological factors

atypical neural connectivity seen on neuroimaging

increased head growth during infancy

increased brain size

gray and white matter volume

altered connectivity and processing

ASD prenatal/perinatal factors

prenatal- advanced parental age (>30-35), gestational diabetes/HTN/obesity

perinatal- toxin exposure, infections, low birth weight, meconium aspiration, pre-term delivery, low 5 minute apgar score

when does ASD present

first two years of life, may present in kindergarten or later

ASD clinical features

plateau of social skills after typical early development, lack of interest in socializing

absent or delayed speech

marked resistance to change

restricted interests

ASD is different from impairment in language development in that

the child may lack the intent to communicate

core symptom of ASD

sterotyped behaviors

hand/finger-flapping, rocking, toe-walking

lining up objects

echolalia

self-stimulating, self-injurious behaviors

ASD rituals and compulsions

eating food in specific order

always following same route from place-to-place

talks about the same topic or asks same questions repeatedly

lack of imaginative play/pantomime

rigid, repetitive play, exploratory play restricted

intolerance of deviation from expected rules

ASD restricted interests

strong attachment to one object

ASD atypical responses to stimuli

refusal to eat specific foods/textures

preoccupation w/ lights, colors, shiny objects

tactile resistance or defensiveness (light pressure bad deep pressure good)

indifference to pain

hypersensitivity to sound, lack of response to close sounds that would startle other children

ASD motor deficits

abnormal gait

clumsiness

toe walking

hypotonia

ASD physical finding

macrocephaly

ASD special skills

savant skills - calendar calculation, hyperlexia

ASD intellectual impairment

approx 30-45%

ranges in severity

impaired IQ in reasoning, verbal sequencing, and abstract skills, strengths in visuospatial and memory

ASD language impairment

common but not necessary for diagnosis

nonverbal

gestures only

single words or phrases

delayed language development

other neurodevelopmental conditions

ADHD, anxiety disorder, oppositional defiant disorder, depression, tic disorder, schizophrenia, learning difficulties

ASD keys for clinical practice

surveillance

screening

AAP recommends screening for ASD with

a screening test at 18-24 months

M-CHAT-R (modified checklist for autism in toddlers, revised)

role of PA in primary care

early identification

refer for comprehensive evaluation

refer for interventions

ASD intervention goals

maximize the ability of the individual to function in their environment

move the individual toward independence

improve the quality of life for the individual and family

ASD intervention modalities

behavioral and educational interventions

psychosocial interventions

psychopharmacologic interventions

complementary and alternative medicine (CAM)

ASD educational interventions

early education programs

IEP w measurable goals- minimum of 25 hrs/week x12 months per year

classroom placement guided by individual goals

applied behavioral analysis (ABA)

most widely used*

builds skills, decrease dysfunctional behaviors, teaches new skills, support use of learned skills at home, community, or school

targeted behavioral intervention

addresses specific behaviors- sleep disturbances, meltdowns, highly restrictive eating, elopement, aggression, or self-injurious behaviors

rule out other causes of these behaviors

starts w an assessment by a trained behaviorist

behavioral parent training

specialized parenting methods

promote skills development and adoption of daily living skills

prevent aggressive behaviors

reduce frequency of unsafe behaviors

can be part of ABA or separate intervention

psychosocial interventions

practice social, play, relationship skills, language skills

parents taught to be co-therapisets

guided practice on social interactions

CBT

psychopharmacological intervention for irritability

risperidone, aripoprazole

psychopharmacological intervention for hyperactivity/impulsivity

methylphenidate

psychopharmacological intervention for repetitive behaviors

SSRI, risperidone, valproate

CAM approaches in ASD

music therapy

pet therapy

yoga

melatonin

vitamin c, essential fatty acids, amino acids

ADHD

attention deficit hyperactivity disorder

neuropsychiatric condition characterized by inattention, impulsivity, and/or hyperactivity affecting preschoolers, children, adolescents, and adults

ADHD DSM-5 criteria A

persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by:

6 or more symptoms of inattention for at least 6 months, and negatively impact social/academic/occupational activities

and/or

6 or more symptoms for at least 6 months of hyperactivity-impulsivity with functional impairment

ADHD DSM-5 criteria B

several symptoms were present before age 12

ADHD DSM-5 criteria C

several symptoms are present in 2 or more settings

ADHD DSM-5 criteria D

clear evidence of functional impairment

ADHD DSM-5 criteria E

not related to another mental/psychiatric disorder

poor attention to detail, poor follow-through, difficulty with organization, easily distracted, and forgetful in daily activities are examples of

inattention

fidgeting, squirming, unable to play quietly, and talking excessively are examples of

hyperactivity

blurts out answers before question is completed, difficulty waiting their turn, interrupting others are examples of

impulsivity

ADHD predominant type

combination, inattentive, hyperactive-impulsive

ADHD partial remission

fewer than full criteria met for past 6 months with functional impairment

ADHD is more prevalent in

males

symptoms of ADHD present by

age 3

typically not diagnosed until school-age

ADHD genetic factors

approx 75% heritability

increased rate in males

ADHD neurochemical factors

structural brain differences, neurotransmitter imbalance (increased NE and decreased dopamine)

ADHD environmental factors

diet, food sensitivities, sleep deficiency may exacerbate symptoms

prenatal tobacco/alcohol exposure

premature/low birth weight

head trauma in young children

ADHD clinical features

hyperactivity, short attention span, distractability, perseveration, failure to finish tasks, inattention, poor concentration, impulsivity, emotional lability, aggression and defiance

ADHD diagnosis

comprehensive medical and psychiatric hx

direct observation of the child

school hx

teacher's report

assessment of social relationships

symptoms in at least 2 settings

ADHD differentials

anxiety disorder, bipolar I disorder, oppositional defiant disorder, learning disorder, hearing and visual impairment, absence seizure disorder

ADHD treatment

behavioral/psychological interventions

pharmacotherapy

criteria for ADHD pharmacotherapy

comprehensive CV-focused patient hx, family hx, physical examination

screening for bipolar

baseline height, weight, BP, HR

screening for substance abuse

first line treatment for ADHD

stimulants- methylphenidate, dextroamphetamine, dextroamphetamine/amphetamine salt

stimulants contraindications

known cardiac risk/abnormalities

non-stimulants for ADHD

good for those with hx of substance abuse or who respond poorly to stimulants

atomoxtine, alpha agonists (clonidine, guanfacine)

adverse effects of stimulants

decreased appetite, poor growth, dizziness, nightmares/insomnia, tics, suicidality/psychosis, diversion/miuse

drug holiday

d/c of stimulant medication on weekends or during summer

not routinely recommended and not for non-stimulants

ADHD psychosocial interventions

academic organization skills, parental training, behavior modification in school/home, CBT

oppositional defiant disorder (ODD)

enduring patterns of negativistic disobedient and hostile behavior toward authority figures

inability to take responsibility for mistakes

ODD generally [do/do not] resort to physical aggression or significant destructive behavior

do not

ODD clinical characteristics

losing temper, arguing with adults, refusing to comply with rules, deliberately annoying people, blaming others, angry, resentful, easily annoyed

ODD DSM-5 criteria

at least 6 months of 3 components:

angry/irritable modd

argumentative/defiant behavior

vindictiveness (at least twice in 6 months)

ODD is typically noted by

8yo

ODD comorbidities

pediatric bipolar disorder, anxiety disorder, ADHD

ODD risk factors

childhood physical or sexual abuse

overly harsh parenting

pattern of behavior seen in parents

unresolved conflicts from childhood fueling defiant behavior

other mental health diagnosis

ODD treatment

family intervention (primary treatment)

CBT

individual psychotherapy

conduct disorder

set of behaviors in a child or adolescent that deviate from age-appropriate norms

violation of the rights of others

social and academic difficulties

4 categories of behaviors in conduct disorder

physical aggression or threats of harm to others/animals

destruction of property

deceitfulness

frequent violation of rules

conduct disorder DSM-5 criteria

3 persistent specific behaviors over the past 12 months, with at least 1 of them present in the past 6 months

conduct disorder symptoms

bullying, physical fights, use of weapons, forces sexual activity, fire setting, breaking and entering, lies to obtain things, stays out past curfew, runs away overnight at least twice, truant from school before age 13

conduct disorder is MC in

males (4-12x more likely)

greater freq in children of parents with antisocial personality disorder and alcohol dependence

conduct disorder comorbidities

antisocial personality disorder, pediatric bipolar disorder, anxiety disorder, other learning differences, ADHD, OCD

parental factors of conduct disorder

harsh, punitive parents w severe physical and verbal aggression, chaotic home conditions, parental psychiatric disorders

sociocultural factors of conduct disorder

lack of supportive social network

increase exposure to substance use

chronic exposure to violence, physical, or sexual abuse and neglect

conduct disorder treatment

CBT to develop problem solving

psychopharmacologic interventions of conduct disorder

antipsychotics to reduce aggression- haloperidol, risperidone, olanzapine, quetiapine (atypicals better tolerated)

SSRIs target symptoms of impulsivity, irritability, mood lability