ADHD and Autism (and everything else in between) Dr Ankit Mathur – Consultant Community Paediatrician
Objectives
• Community Paediatric service – pathways
• Importance of these conditions
• Case studies
• Differential diagnosis and co-morbidities
• Gaps in service – Intervention
Community Paediatric Service
• Four consultant paediatricians – 2 part time
• One staff grade in community paediatrics
• Staff grade and audiology lead
• 2 part time ADHD nurses
• “limited psychology service”
ADHD
• All cases seen by paediatrics until November 2007
• ADHD pathway now fully commissioned by CAMHS
• Active caseload in paediatrics of 210 children
• We do see ADHD as part of other neurodevelopmental problems
Why are these conditions important? • ADHD - Prevalence of 5%
• ASD - Prevalence of 1.1%
• In Suffolk – 8380 children with ADHD, severe 1676
• Impacts on individuals, families, education, social care and health wellbeing
Impact?
• Lack of recognition / treatment increases costs
Increased risks of trauma, substance misuse
Increased mental health difficulties – increased burden on adult psychiatry services
Reduced school attendance
Increased youth offending, prison population
Increased teenage pregnancy
Learning Disability
• 33 times more likely to have ASD than the general population
• 8 times more likely to have ADHD
• 6 times more likely to have a conduct disorder
• 4 times more likely to have an emotional disorder
• 1.7 times more likely to have a depressive disorder
Recognition and Treatment
• Reduces stigma as known genetic condition
• Help adaptive child functioning, improve self esteem, reduce anxiety
• Can improve compliance
• Improve school attendance
• Improve parental relationships
Paediatric Clinic
• Developmental History, Examination, School observation, School questionnaires
• Assess impact on functioning
• Diagnosis with support information
• Education to schools – nursing role
• Behavioural advice – nursing role
• Medication
Paediatric Clinic
• Medication monitoring 6 monthly
• BP, HR, Growth monitoring
• Symptom review
• School feedback
• Recognition of co-morbidities
• Review whilst in full time education
• Transition to GP / adult services
Other causes of attention, concentration and socio-communication difficulties
• Medical
Genetic syndromes – Neurofibromatosis, Tuberous Sclerosis, Fragile X, intellectual disability
Prematurity
Auditory processing difficulties, poor working memory
• Environmental
Fetal Alcohol Spectrum Disorder
Neglect, Domestic Violence, Abuse, Attachment, Acquired Brain Injury (infection, trauma, tumour)
Case study - JH
• Adopted
• Known myoclonic epilepsy, learning difficulties, socio-communication difficulties
• Investigated medically
• Treated and monitored with anticonvulsants
• Concerns raised regarding ADHD
• Observed by ADHD nurse at school
• Diagnosed with ADHD, advice and support given
• Parents met ADHD nurse to discuss behavioural support and strategies
Case Study - JH
• Medication commenced in ADHD clinic
• Remained with Paediatrician to manage epilepsy and ADHD
• Encountering growth difficulties on medication
• Working closely with school to help support him whilst off medication
• Likely to remain within our service until 16-18yrs
Summary - ADHD
• All New referrals to CAMHS
• We retain children with other neurodevelopmental needs who also have ADHD
• Do not refer under 5 years
• 80% have other co-morbidities so my cross different services
Interface with CAMHS
• Co-morbidities eg low mood, significant anxiety, socio-communication difficulties, conduct disorder, tic disorder
• Difficult to transfer accountability
• Cost improvement is affecting clinical management eg telephone triage, access and assessment
Autism Spectrum
• ?Traits of Autism – used very loosely in referrals
• Higher functioning Autism
• Asperger Syndrome
• Socio-communication disorder
• Semantic pragmatic disorder
• Pervasive developmental disorder
• Increasing referral rates from GPs, schools, TAC meetings, CAMHS
Helpful Referral Information
• Longstanding difficulties with social skills
• Difficulties raised at school and home
• Examples of difficulties with communication and reciprocal social interaction
• Rigidity
• Many children line up cars!
• Need triad of impairments
Pathways
Pre-school
• Seen by paediatrician – developmental history and examination
• Observed ? Home / nursery
• Multidisciplinary Assessment
• Feedback and disclosure of diagnosis
• Support and intervention
School aged (>5years – 11yrs)
• Send questionnaires to school and parents
• MDT panel meeting (including education)
• Plan pathway for each child
• Seen by paediatrician
• Often observed in school –specialist SALT
• Formal assessments (ADOS /DISCO)
• Feedback and diagnosis
• Post diagnostic support, services available
Intervention
• Limited support for those with anxiety / significant sensory difficulties
• Need wider support – county inclusive resource
• Anxiety issues not necessarily recognised as “A mental health problem”
Referral loops!
Aggressive behaviour CAF/TAC
No mental health problem PMHW
hits sibling
not attending school
Access and Assessment lines things up
Paediatrics Anxiety, good reciprocal conversation, poor family relationships ,
difficulty regulating emotions
CAMHS
Case Study
• 6yr old referred 2010 – difficult behaviour, mother has MS, family pressures
• Previously seen by CAMHS – ADHD excluded
• Investigated for learning difficulties, no ASD
• Child in Need Plan in place
• Re-referred to CAMHS – to reassess ADHD
• Social services withdrew support
Case study
• No ADHD, anxiety driven presentation
• Parenting course suggested
• Difficulties with sibling relationships
• Referred for a CAF /TAC plan –financial advice offered
• Behavioural problems continued
• Jan ‘13 – writing, maths difficulties
Case study
• Struggling at home with behaviour
• Father given up work to care for wife
• Violent – broke TV
• Referred March 2013 - ?Autism
• September 2013 – Access/ assessment team
• Inattention, no remorse, refuses to sleep alone
• “recommend referral to paediatrics” – not Mental health
Case Study
• Father angry at rejected referral
• Phone review by paediatrician – no active interventional strategy to help move forwards, combination of LD, poor social skills, low self esteem, concerns about maternal health, poor working memory
• Parents focussed on diagnosis
• Liaised with CAMHS, seen jointly, for more practical support ?who delivers it
Case study
• Younger sibling referred – similar concerns re violence
• CAMHS felt we needed to exclude ASD before we see
• 2014 – no further forwards, CAMHS wanting to refer back to paediatrics for ASD assessment!!!
Gaps in Service
• Support for children’s emotional well being
• Practical intervention strategies for family with close follow up
• Lack of co-ordination
• Lack of wider support
• Child should be reviewed in context of family
• No Liaison Psychiatry services
Liaison Child Psychiatry
• Dr Wesblatt – Peterborough
• National standards
• Supports children with emotional difficulties stemming from all medical problems eg neurobehavioural , CBT
• Supports areas not accessible by CAMHS
Summary
• We see children with neurodevelopmental problems, developmental delay, Intellectual disability – not just behavioural difficulties
• ADHD and Autism cross services – need more joint working
• Early detection and support can prevent / reduce long term morbidity
• Multiagency early intervention is required