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 Access and Assessment hits sibling not attending school lines things up PMHW 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