Neuropsychiatric conditions in childhood

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Hens teeth .... Or not??

• Neuropsychiatric conditions in childhood

Dr Kirsty Yates Community Paediatrics, GNCH
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The problem 5 year old boy
His behaviour is terrible. He makes these weird
movements all the time . He doesnt seem to be
learning at school and theyre also complaining
about his behaviour!
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• What else do you want to know??

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(No Transcript)
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What are your initial thoughts??

1. Im not worried reassure mum
2. I would like some more information

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Family History
Past Medical History
Examination
Social History
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Background

• Ex prem Twin II 344 wk C/S
• Maternal methadone and diazepam
• SCBU vomiting ºNAS
• Physically healthy
• Seen for child protection medical 3y 1m. GDD
  follow up

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Development
Poor handwriting Help dressing
Concerns
Delayed speech Persisting echolalia Needed SALT 1
yr
Delayed learning History of soiling Sleep
difficulties Play with others Activity and
inattention
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Family history

• Both parents drug users
• Hep B and C positive
• Dad Plummer court
• Chronic hepatitis and ?trophoblastic disease
• Maternal hx depression inpatient.
• No history of movement disorder in family

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Social History

• Limited support mum previously a LAC
• Dad recently detained HMP
• CSC involved
• Financial difficulties

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13
5
20
23
25
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Examination

• Normal
• Observation
• Active, poor concentration, alert to noises in
  surroundings
• Tics Vocal and motor
• Screeching, grunting, blinking, grimacing,
  posturing
• Echolalia
• Pretend play - bus driver, plastic food
• Poor eye contact

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• What is the differential diagnosis?

• Summary of Main symptoms
• Tics, restless, inattention, aggression,
  repetitive
• behaviours, learning, speech, peer
  relationships
• Significant psychosocial difficulties

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Differential at this point??

• TS
• ASD
• ADHD
• LD
• Attachment disorder
• Environmental

Tics Rest Inattn Aggn Rep Educn Peers Speech
/- /-

/- /-
/- /-
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Biological Psychological Social
Predisposing Prematurity Drugs in Utero Developmental delay Temperament Mat depression Parents drug users Separated Financial difficulties
Precipitating Learning difficulties SAL delay ?other condition Maternal health problems Separation from mum Understanding of social relationships In LAC Maternal absence
Perpetuating Learning difficulties SAL delay Maternal health problems Attachment Poor engagement ?Parenting Lack social network
Protective Physically healthy Twin is normal Relationship with twin Father/Mat GM supportive Multiple agencies Attends school
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Causes of wiggles and squiggles
Personality disorder
Bipolar disorder
Depression
Disruptive Beh.
Anxiety
Age of child
LD
Tics/TS
ADHD
Age(4-7 years) at assessment
PDD
Abuse/neglect
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Tics

• Sudden, rapid, repetitive, involuntary,
  stereotyped purposeless movements
• Vocal or motor
• Simple or complex
• Common
• 10 lt10yrs age 25 all childhood
• All races and cultural groups
• 4x more common boys
• Higher in special schools

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Causes of TICS

• Idiopathic
• Familial
• TS
• Acquired
• Carbon monoxide poisoning
• Drugs
• Trauma/Tumour

• ASD/Aspergers
• Huntingtons disease
• Wilsons disease
• Fragile X
• Hallervorden-Spatz

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Differential diagnosis of Repetitive behaviours

• Chorea
• Choreoathetosis
• Dystonia
• Tremor
• Myoclonus

• Stereotypies
• Compulsions
• Perserveration
• SIB

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Categories of Tic disorders

• DSM IV
• Transient tic disorder
• Chronic motor or vocal tic disorder
• Combined motor and vocal tic disorder (Tourette)

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What is Tourette Syndrome?

• Neuropsychiatric condition
• Gille de la Tourette - 1885
• Spectrum of severity
• 1 in 100 childhood population
• Childhood onset

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Diagnosis

• Multiple motor tics one or more vocal tics at
  some point
• gt1 year duration
• Periods of remission lt2 months
• Tics change over time in location, frequency,
  type, complexity severity.
• lt18yrs onset
• Not explainable by other medical conditions

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Clinical Characteristics

• Mean age onset 7 yrs (2-18y)
• Tics
• Echophenomenon
• Coprolalia/ Copropraxia
• Paliphenomena
• Other stuff....

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Tic Progression
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Aetiology

• Precise location in brain unknown ?basal
  ganglia/frontal cortex dopamine transport,
  release uptake
• Biological , genetic (concordance in twins)
• PANDAS
• Exacerbations by environmental factors

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What does it feel like?
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Difficulties and Misconceptions

• Coprolalia RARE! 1-3/10 adults
• Suppressing tics/Hiding Tics
• Often improve when absorbed in a task
• Co-morbidities may be the presentation

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What should you say?

• Its not their fault,
• Acceptance and understanding essential
• Tics can change Course can wax and wane
• Tics be suppressed, but often payback
• Exacerbations at times of stress, boredom,
  excitement and illness

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Tics and the other stuff

• Physical, educational, economical and social
  consequences
• 12 have tics only
• Often Tics not the main problems. Tics as a
  marker

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Common Co-morbidites
Sleep LD
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Famous people with Tourette Syndrome
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Treatment

• Drug treatment available for Tics but often side
  effects with sedation and weight gain,
  extra-pyramidal side effects
• Should be started monitored by specialist.
• Strategies
• Ignoring the tics
• CBT OCD element
• Behavioural analysis
• Competing response, relaxation, massed negative
• Future ?DBS, ?Immunological therapies

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Further Information

• Tourette syndrome association uk.
• www.tourettes-action.org.uk
• www.tsa.org
• Books
• Why do you do that? A Book about Tourette
  Syndrome for Children and Young People Uttom
  Chowdhury and Mary Robertson.
• Hi, Im Adam A Childs Book about Tourette
  Syndrome Adam Buehrens
• Tics and Tourette syndrome. A Handbook for
  Parents and Professionals. Uttom Chowdhury

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Take home messages

1. Tics are common
2. Tourettes has a spectrum of severity and is more
   common than we think
3. Tics as a symptom on their own do not necessarily
   require treatment but parental education and
   understanding paramount.
4. Tics/TS can be a marker for other neurobiological
   conditions that have worse consequences

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Questions?