CHILD & ADOLESCENT PSYCHIATRY
K K K
Learningkobjectives:
1. Describekthekclinicalkfeatureskandkmanagementkofkautismkspectrumkdisorder.
2. DescribekthekclinicalkfeatureskandkmanagementkofkADHD.
3. DescribekthekclinicalkfeatureskandkmanagementkofkODD/conductkdisorder.
4. Describekthekclinicalkfeatureskandkmanagementkofkintellectualkdisabilitykandkcommonkgeneticksyndro
meskassociatedkwithkthis.
,AUTISM
Autismkiskcharacterisedkbykrepetitivekbehaviour,kcommunicationkdifficultykandkimpairmentkinksocialkinteractio
n.
ONSET
Onsetkiskbeforekthekfirstk3kyearskofklife.k70%kofkcaseskdoknotkhaveknormalkdevelopment.k30%kofkcaseskhavekakcl
eark‘setback’kinktheksecondkorkthirdkyearkofklife.
EPIDEMIOLOGY
WESTERN K COUNTRIES
• Prevalence:k7-28/10,000;kaccountskfork25-60%kofkallkautistickdisorders
• Genderkratio:kM:Fk=k4:1
• Socioeconomickstatus:kNokclearkassociation
SINGAPORE
• Gender:kBoysk>kgirls
• Birthkcomplications:kLowkincidencekinkautistickchildren
• Agekofkonset:k60%kdiagnosedkbeforekagekofk3kyears
• Caregiver:kHighkfrequencykofkcaregiverskofkautistickchildrenkwerekforeignkmaids
AETIOLOGY
Autismkhaskvariouskcauses;kthekaetiologykiskobscurekinkmostkinstances.
• GenetickCauses
▪ Heritability:k>90%,khigherkconcordancekinkmonozygoticktwins
▪ Recurrencekratekinksiblings:k3%kforknarrowlykdefinedkautism,k10-20%kforkmilderkvariant
▪ Loci:kChromosomek2qkandk7qkareksuspected
• EnvironmentalkCauses
▪ Perinatalkinjury:kModeratelykincreasedkinkautistickchildren
• MedicalkConditions
▪ Infective:kRubella,kcytomegalovirus
▪ Congenital:kFragilekXksyndrome,ktuberousksclerosis,kphenylketonuria,kneurofibromatosis,kinfantil
ekspasmsk(Westksyndrome)
THEORY K OF K MIND
Onekinfluentialktheoryksuggestskthatkthekprimarykdeficitkinkautismklieskinkthektheorykofkmind.kTheorykofkmindkrefe
rsktokthekcapacitykofkakpersonktokattributekindependentkmentalkstatesktokoneselfkandkotherskinkorderktokpredic
tkandkexplainkthekactionskofkothers.
,CLINICAL K FE ATURES
Figurek16.1:kClinicalkSignskofkAutism
ICD-10 K DIAGNOSTIC K CRITERIA
Thekpresencekofkabnormalkdevelopmentkiskmanifestedkbeforekthekagekofk3kyearskincludingkabnormalkrecepti
vekorkexpressiveklanguage,kabnormalkselectivekorkreciprocalksocialkinteraction,korkabnormalkfunctionalkorksym
bolickplay.
Abnormalkreciprocalksocialkinteractionskincludekfailurekinkeyekgazekandkbodyklanguage,kfailurekinkdevelopm
entkofkpeerkrelationship,klackkofksocio-
emotionalkreciprocitykandklackkofkspontaneousksharingkwithkotherkpeople.
Abnormalkcommunicationkincludesklackkofkdevelopmentkofkspokenklanguage,klackkofksocialkimitativekplay,kf
ailurektokinitiatekorksustainkconversationalkinterchange,kstereotypedkandkrepetitivekusekofklanguage.
Restricted,kstereotypedkandkrepetitivekbehaviourkincludeskpreoccupationkwithkstereotypedkinterest,kcompulsi
vekadherencektokrituals,kmotorkmannerisms,kpreoccupationkwithkpart-objectskorknon-
functionalkelementskofkplaykmaterials.
Otherknon-specifickproblemskincludekphobias,ksleepingkandkeatingkdisturbances,ktemperktantrumskandkself-
kdirectedkaggression.
Otherkpervasivekdevelopmentkdisorders,ksocio-emotionalkproblems,kintellectualkdisabilitykandkschizophrenia-
likeksymptomskmustkbekabsent.
DSM-5 K DIAGNOSTIC K CRITERIA
AutismkSpectrumkDisorderkisknowkconsideredkaknewkDSM-5kterminologykwhichknowkcomprisesk4kpreviouskDSM-
IV-
TRkconditionsk(autistickdisorder,kAspergerkdisorder,kchildhoodkdisintegrativekdisorderkandkpervasivekdevelopm
entalkdisorderknotkotherwisekspecified).
AUTISM K SPECTRUM K DISORDER
Ankindividualkdiagnosedkwithkautismkspectrumkdisorderkwouldkhavekmarkedkdifficultieskinktermskofkcommunic
ationkandkengagementkwithkotherskacrosskmultipleksocialksituations.kThesekinclude:
1. Difficultieskwithkdemonstratingkappropriatekbehaviourskinksocialkcontexts,
2. Difficultieskassociatedkwithknon-verbalkcommunicationskusedkforksocialkinteractions,kand
3. Difficultieskassociatedkwithkfailurektokinitiatekorkadaptktoksocialkinteractions.
Inkaddition,kindividualskmustkalsokhavekcharacteristickrepetitivekbehaviouralkpatterns,ksuchkas
1. Repeatedkstereotypicalkmovementskor
2. Highlykritualizedkbehaviouralkpatterns
Thesekbehaviourskmustkhavekstartedksincekearlykdevelopmentkandkmustkhavekresultedkinkmarkedkimpairments
kinktermskofkfunctioning.kClinicianskshouldkdistinguishkbetweenkintellectualkdisabilitykandkautismkspectrumkbeh
aviour,kandknotekthatktherekareksituationskinkwhichkintellectualkdisabilitykandkautismkmightkco-occur.
, ASSESSMENT
MOHkguidelinesk(2010)krecommendkthatkchildrenkwithkonekorkmorekofkthekfollowingkclinicalkfeatureskbekreferr
edkpromptlykforkcomprehensivekdevelopmentalkevaluation:
1. Nokbabble,kpointingkorkotherkgestureskbyk12kmonths
2. Noksinglekwordskbyk18kmonths
3. Nokspontaneousk(non-echoed)k2-wordkphraseskbyk24kmonths
4. Anyklosskofklanguagekorksocialkskillskatkanykage
Diagnostickevaluationkofkakchildksuspectedktokhavekautismkshouldkbekcarriedkoutkbykakmulti-
disciplinarykteamkorkprofessionalkwhokisktrainedkandkexperiencedkwithkthekdiagnosiskofkautism.kEvaluationkincl
udes:
1. Ankautism-specifickdevelopmentalkhistory
2. Directkobservations
3. Obtainingkwiderkcontextualkandkfunctionalkinformation
INSTRUMENTS
1. AutismkDiagnostickObservationkSchedulek(ADOS)kforkpatientskandkAutismkDiagnostickInterviewk(ADI)kf
orkparents
2. ChildkBehaviourkChecklistk(CBCL):kAutismkSpectrumkDisorderkscalekconstructedkinkSingaporekbasedko
nk9kitemskfromkCBCL;khighkscoreskinkthekfollowingkcategories:kwithdrawn/depressed,ksocialkproblems,k
andkthoughtkproblemsksyndromesksignificantlykdiscriminatedkautismkchildrenkfromkotherkdisorders
3. IQktest:kPerformancekIQkbetterkthankverbalkIQ
INVESTIGATIONS
ChildrenkwithkASDkwithkthekfollowingkfeatureskshouldkhavekakgenetickevaluation:
1. Microcephalykorkmacrocephaly
2. Akpositivekfamilykhistoryk(ofkakgeneticksyndrome)
3. Dysmorphickfeatures
Electro-
encephalographyk(EEG)kisknotkroutinelykrecommendedkinkchildrenkwithkASDkbutkshouldkbekconsideredkifkanyk
ofkthekfollowingkarekpresent:
1. Clinicalkseizures
2. Symptomsksuggestivekofksub-clinicalkseizureske.g.kstaringkspells
3. Akhistorykofkdevelopmentalkregression
K K K
Learningkobjectives:
1. Describekthekclinicalkfeatureskandkmanagementkofkautismkspectrumkdisorder.
2. DescribekthekclinicalkfeatureskandkmanagementkofkADHD.
3. DescribekthekclinicalkfeatureskandkmanagementkofkODD/conductkdisorder.
4. Describekthekclinicalkfeatureskandkmanagementkofkintellectualkdisabilitykandkcommonkgeneticksyndro
meskassociatedkwithkthis.
,AUTISM
Autismkiskcharacterisedkbykrepetitivekbehaviour,kcommunicationkdifficultykandkimpairmentkinksocialkinteractio
n.
ONSET
Onsetkiskbeforekthekfirstk3kyearskofklife.k70%kofkcaseskdoknotkhaveknormalkdevelopment.k30%kofkcaseskhavekakcl
eark‘setback’kinktheksecondkorkthirdkyearkofklife.
EPIDEMIOLOGY
WESTERN K COUNTRIES
• Prevalence:k7-28/10,000;kaccountskfork25-60%kofkallkautistickdisorders
• Genderkratio:kM:Fk=k4:1
• Socioeconomickstatus:kNokclearkassociation
SINGAPORE
• Gender:kBoysk>kgirls
• Birthkcomplications:kLowkincidencekinkautistickchildren
• Agekofkonset:k60%kdiagnosedkbeforekagekofk3kyears
• Caregiver:kHighkfrequencykofkcaregiverskofkautistickchildrenkwerekforeignkmaids
AETIOLOGY
Autismkhaskvariouskcauses;kthekaetiologykiskobscurekinkmostkinstances.
• GenetickCauses
▪ Heritability:k>90%,khigherkconcordancekinkmonozygoticktwins
▪ Recurrencekratekinksiblings:k3%kforknarrowlykdefinedkautism,k10-20%kforkmilderkvariant
▪ Loci:kChromosomek2qkandk7qkareksuspected
• EnvironmentalkCauses
▪ Perinatalkinjury:kModeratelykincreasedkinkautistickchildren
• MedicalkConditions
▪ Infective:kRubella,kcytomegalovirus
▪ Congenital:kFragilekXksyndrome,ktuberousksclerosis,kphenylketonuria,kneurofibromatosis,kinfantil
ekspasmsk(Westksyndrome)
THEORY K OF K MIND
Onekinfluentialktheoryksuggestskthatkthekprimarykdeficitkinkautismklieskinkthektheorykofkmind.kTheorykofkmindkrefe
rsktokthekcapacitykofkakpersonktokattributekindependentkmentalkstatesktokoneselfkandkotherskinkorderktokpredic
tkandkexplainkthekactionskofkothers.
,CLINICAL K FE ATURES
Figurek16.1:kClinicalkSignskofkAutism
ICD-10 K DIAGNOSTIC K CRITERIA
Thekpresencekofkabnormalkdevelopmentkiskmanifestedkbeforekthekagekofk3kyearskincludingkabnormalkrecepti
vekorkexpressiveklanguage,kabnormalkselectivekorkreciprocalksocialkinteraction,korkabnormalkfunctionalkorksym
bolickplay.
Abnormalkreciprocalksocialkinteractionskincludekfailurekinkeyekgazekandkbodyklanguage,kfailurekinkdevelopm
entkofkpeerkrelationship,klackkofksocio-
emotionalkreciprocitykandklackkofkspontaneousksharingkwithkotherkpeople.
Abnormalkcommunicationkincludesklackkofkdevelopmentkofkspokenklanguage,klackkofksocialkimitativekplay,kf
ailurektokinitiatekorksustainkconversationalkinterchange,kstereotypedkandkrepetitivekusekofklanguage.
Restricted,kstereotypedkandkrepetitivekbehaviourkincludeskpreoccupationkwithkstereotypedkinterest,kcompulsi
vekadherencektokrituals,kmotorkmannerisms,kpreoccupationkwithkpart-objectskorknon-
functionalkelementskofkplaykmaterials.
Otherknon-specifickproblemskincludekphobias,ksleepingkandkeatingkdisturbances,ktemperktantrumskandkself-
kdirectedkaggression.
Otherkpervasivekdevelopmentkdisorders,ksocio-emotionalkproblems,kintellectualkdisabilitykandkschizophrenia-
likeksymptomskmustkbekabsent.
DSM-5 K DIAGNOSTIC K CRITERIA
AutismkSpectrumkDisorderkisknowkconsideredkaknewkDSM-5kterminologykwhichknowkcomprisesk4kpreviouskDSM-
IV-
TRkconditionsk(autistickdisorder,kAspergerkdisorder,kchildhoodkdisintegrativekdisorderkandkpervasivekdevelopm
entalkdisorderknotkotherwisekspecified).
AUTISM K SPECTRUM K DISORDER
Ankindividualkdiagnosedkwithkautismkspectrumkdisorderkwouldkhavekmarkedkdifficultieskinktermskofkcommunic
ationkandkengagementkwithkotherskacrosskmultipleksocialksituations.kThesekinclude:
1. Difficultieskwithkdemonstratingkappropriatekbehaviourskinksocialkcontexts,
2. Difficultieskassociatedkwithknon-verbalkcommunicationskusedkforksocialkinteractions,kand
3. Difficultieskassociatedkwithkfailurektokinitiatekorkadaptktoksocialkinteractions.
Inkaddition,kindividualskmustkalsokhavekcharacteristickrepetitivekbehaviouralkpatterns,ksuchkas
1. Repeatedkstereotypicalkmovementskor
2. Highlykritualizedkbehaviouralkpatterns
Thesekbehaviourskmustkhavekstartedksincekearlykdevelopmentkandkmustkhavekresultedkinkmarkedkimpairments
kinktermskofkfunctioning.kClinicianskshouldkdistinguishkbetweenkintellectualkdisabilitykandkautismkspectrumkbeh
aviour,kandknotekthatktherekareksituationskinkwhichkintellectualkdisabilitykandkautismkmightkco-occur.
, ASSESSMENT
MOHkguidelinesk(2010)krecommendkthatkchildrenkwithkonekorkmorekofkthekfollowingkclinicalkfeatureskbekreferr
edkpromptlykforkcomprehensivekdevelopmentalkevaluation:
1. Nokbabble,kpointingkorkotherkgestureskbyk12kmonths
2. Noksinglekwordskbyk18kmonths
3. Nokspontaneousk(non-echoed)k2-wordkphraseskbyk24kmonths
4. Anyklosskofklanguagekorksocialkskillskatkanykage
Diagnostickevaluationkofkakchildksuspectedktokhavekautismkshouldkbekcarriedkoutkbykakmulti-
disciplinarykteamkorkprofessionalkwhokisktrainedkandkexperiencedkwithkthekdiagnosiskofkautism.kEvaluationkincl
udes:
1. Ankautism-specifickdevelopmentalkhistory
2. Directkobservations
3. Obtainingkwiderkcontextualkandkfunctionalkinformation
INSTRUMENTS
1. AutismkDiagnostickObservationkSchedulek(ADOS)kforkpatientskandkAutismkDiagnostickInterviewk(ADI)kf
orkparents
2. ChildkBehaviourkChecklistk(CBCL):kAutismkSpectrumkDisorderkscalekconstructedkinkSingaporekbasedko
nk9kitemskfromkCBCL;khighkscoreskinkthekfollowingkcategories:kwithdrawn/depressed,ksocialkproblems,k
andkthoughtkproblemsksyndromesksignificantlykdiscriminatedkautismkchildrenkfromkotherkdisorders
3. IQktest:kPerformancekIQkbetterkthankverbalkIQ
INVESTIGATIONS
ChildrenkwithkASDkwithkthekfollowingkfeatureskshouldkhavekakgenetickevaluation:
1. Microcephalykorkmacrocephaly
2. Akpositivekfamilykhistoryk(ofkakgeneticksyndrome)
3. Dysmorphickfeatures
Electro-
encephalographyk(EEG)kisknotkroutinelykrecommendedkinkchildrenkwithkASDkbutkshouldkbekconsideredkifkanyk
ofkthekfollowingkarekpresent:
1. Clinicalkseizures
2. Symptomsksuggestivekofksub-clinicalkseizureske.g.kstaringkspells
3. Akhistorykofkdevelopmentalkregression
