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