Twitchers, Klutzes, Scamps and Geeks: A GPs guide to neurodevelopmental disorders in childhood

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Twitchers, Klutzes, Scamps and GeeksA GPs
guide to neurodevelopmental disorders in
childhood

• Dr Gordon Bates
• Child Neuropsychiatrist
• Parkview Clinic, Birmingham

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Ticquers, Whizzkids, Aspies and the
coordinationally challengedA GPs guide to
neurodevelopmental disorders in childhood

• Dr Gordon Bates
• Child Neuropsychiatrist
• Parkview Clinic, Birmingham

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Overview

• Context
• Definitions
• Overlaps
• Case Examples
• Assessment
• Management
• Role of Primary care

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Context

• Neurodevelopmental conditions
• Include ADHD, Autistic spectrum disorder,
  dyspraxia, dyslexia and tic disorder
• Are common affecting 1in 10 children boys more
  than girls up to 5 of visits
• Cluster together, comorbidity is the rule
• Are being increasingly recognised by parents and
  teachers (who will contact you!)
• Cause significant short and long term morbidity
  for children and their families

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Attention Deficit Hyperactivity Disorder

• Characterised by pervasive overactivity,
  inattention and impulsiveness
• Prevalence of 5 internationally
• Different presentations at different ages
• Hyperactivity and aggression in Junior school
• Academic failure and poor organization at Senior
  level
• Risk factor for substance misuse, delinquency,
  antisocial personality disorder

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Autistic Spectrum Disorder

• Characterised by impaired social skills, language
  and need for sameness
• Prevalence of 1-2
• Wide range of severity
• no verbal language and learning disability
• Trainspotters, collectors, IT consultants
• Risk factor for depression, substance misuse and
  treatment resistant schizophrenia

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D Y S P R A X I
A
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Dyspraxia (DCD)

• Clinical diagnosis based on severe coordination
  or visuoperceptual problems
• Clinically 3 subtypes Gross, fine motor and
  kinaesthetic with overlap
• Other features
• Language problems esp. preposition
• Poor attention
• Social clumsiness
• Poor sequencing and learning problems

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Tic Spectrum

• Transient tic disorder
• Chronic Motor tic disorder
• Chronic Vocal tic disorder
• Tourettes syndrome

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Tic Disorder

• Rapid stereotyped movements or noises usually
  experienced as compulsive and worsened by stress
• Far more common than previously thought
• Prevalence of Tourettes around 1
• Coprolalia not essential feature
• Very strong heredity (looks autosomal dominant)
• Worsening severity linked to other conditions

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ADHD and Tourettes severityComings and Comings
(1987)
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Neurodevelopmental Disorders
ASD
Dyspraxia
Autistic Spectrum
ADHD
TS
Tourettes Syndrome
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Clustering

• Up to 80 of children with one neurodevelopmental
  disorder have another
• Each disorder shares some prefrontal cortex
  pathology but mostly distinct systems for e.g.
  attention, reading, coordination
• All these systems start development at the same
  time and evolve over many years
• Possible environmental trigger with clear genetic
  vulnerability

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Case Example A

• TD 8 years Australian Male
• Birth History full term NVD Lanugo
• Poor sleeper Good feeder
• Developmental Slow to talk Slow to dress
• History Speech indistinct
• Behaviour always on the go Unable to settle
• bumps into everything ignores you
• Poor with knife and fork Aggressive
• Major temper tantrums

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Case Example B

• BS 12 years American male
• Birth History Premature 30/40 NVD Neonatal
  jaundice
• Fussy eater Poor sleeper
• Developmental H Normal milestones
• Family History Paternal alcohol misuse
• No limit-setting
• School History Low academic performance overall
• Concentration problems Attitude
• Behaviour Oppositional Delinquency
• Short term goals Short term goals

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Primary Care Interventions

• Assessment
• Useful questions, request school info, Hearing
• Information
• Basic psychoeducation, support group, books and
  websites
• Diets
• Fashionable treatments
• Referral

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Assessment

• Screening Questions
• Can you take them shopping?
• Do they have road sense?
• Will anyone else look after them?
• Do they climb?
• Have they ever been lost?
• Do they spend a lot of time in Casualty?
• Can all their friends do their shoelaces?

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Assessment contd.

• Consider if
• Academic failure
• Problems start below age 5
• Pervasive problems
• Overactive or tics in front of you
• All other interventions fail or temporary
• Other children in family dissimilar or similar
• School exclusion
• Rapid turnover of friends or none

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Assessment contd

• Do not exclude if
• Well behaved and still in front of you
• Punitive or ineffective parenting style
• Good sleep pattern
• History of domestic violence
• History of adoption or multiple placements
• Good concentration for video games or cartoons
• Average academic performance
• Ok in small structured groups

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Dietary Advice

• No evidence for food allergies causing
  behavioural problems
• Usually placebo or Hawthorn effect
• Exclusion diet sometimes helpful
• Ask about caffeine
• Specialist diets require paediatric dietician
• ADHD Feingold diet (tartrazine)
• Autism Milk and Wheat protein-free

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Fashionable Therapies

• ADHD Omega fish oils, IQ /-
• Zinc, magavitamins Care
• Autism Separate MMR -
• Secretin -
• Facilitated learning -
• Dyspraxia Sensory integration /-
• Tics Mass practice -

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Referral Routes