NEUROPSYCHIATRIC CONDITIONS IN

CHILDHOOD

Hen’s teeth .... Or not??

Dr Kirsty YatesCommunity Paediatrics,

GNCH

The problem: 5 year old boy

“His behaviour is terrible. He makes these weird movements all the time . He doesn’t seem to be learning at school and they’re also complaining about his behaviour!”

“His behaviour is terrible. He makes these weird movements all the time . He doesn’t seem to be learning at school and they’re also complaining about his behaviour!”

What else do you want to know??

What are your initial thoughts??

a)I’m not worried – reassure mumb)I would like some more information

Family History

Past Medical History

Social History

Examination

Background

Ex prem: Twin II 34+4 wk C/S

Maternal methadone and diazepam

SCBU – vomiting –ºNAS

Physically healthy

Seen for child protection medical 3y 1m. GDD – follow up

Development

Concerns

Poor handwritingHelp dressing

Delayed speechPersisting echolalia

Needed SALT 1 yr

Delayed learningHistory of soilingSleep difficultiesPlay with others

Activity and inattention

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

Social History

Limited support – mum previously a LACDad recently detained HMPCSC involvedFinancial difficulties

52023 13525

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

WHAT IS THE DIFFERENTIAL DIAGNOSIS?

Summary of Main symptoms

•Tics, restless, inattention, aggression, repetitive behaviours, learning, speech, peer relationships

•Significant psychosocial difficulties

Differential at this point??

TS

ASD

ADHD

LD

Attachment disorder

Environmental

Tics Rest Inattn Aggn Rep Educn

Peers Speech

+++ + + +/- +/- + + +

+ + + + ++ + ++ ++

+/- ++ ++ ++ + + +/-

+ + + + +/- + +/- +

Biological Psychological Social

PredisposingPrematurity

Drugs in UteroDevelopmental

delay

TemperamentMat depression

Parents drug users

SeparatedFinancial

difficulties

Precipitating

Learning difficultiesSAL delay

?other conditionMaternal health

problems

Separation from mum

Understanding of social

relationships

In LACMaternal absence

PerpetuatingLearning

difficultiesSAL delay

Maternal health problems

Attachment Poor engagement?ParentingLack social

network

ProtectivePhysically healthyTwin is “normal”

Relationship with twin

Father/Mat GM supportive

Multiple agenciesAttends school

Causes of wiggles and squiggles

PDDADHD

LD

Anxiety

Disruptive Beh.

Depression

Bipolar disorder

Personality disorder

Tics/TS

Abuse/neglect

Age(4-7 years)at assessment

Ag

e o

f ch

ild

Tics

Sudden, rapid, repetitive, involuntary, stereotyped purposeless movements

Vocal or motorSimple or complex

Common 10% <10yrs age 25% all childhood All races and cultural groups 4x more common boys Higher in special schools

Idiopathic

Familial TS

Acquired Carbon monoxide

poisoning Drugs Trauma/Tumour

ASD/AspergersHuntingtons diseaseWilsons diseaseFragile XHallervorden-Spatz

Causes of TICS

ChoreaChoreoathetosisDystoniaTremorMyoclonus

StereotypiesCompulsionsPerserverationSIB

Differential diagnosis of Repetitive behaviours

Categories of Tic disorders

DSM IV

Transient tic disorder

Chronic motor or vocal tic disorder

Combined motor and vocal tic disorder (Tourette)

What is Tourette Syndrome?

Neuropsychiatric condition

Gille de la Tourette - 1885

Spectrum of severity

1 in 100 childhood population

Childhood onset

Diagnosis

Multiple motor tics + one or more vocal tics at some point

>1 year duration

Periods of remission <2 months

Tics change over time in location, frequency, type, complexity & severity.

<18yrs onset

Not explainable by other medical conditions

Mean age onset 7 yrs (2-18y)

Tics

EchophenomenonCoprolalia/ CopropraxiaPaliphenomena

Other stuff....

Clinical Characteristics

Tic Progression

Aetiology

Precise location in brain unknown ?basal ganglia/frontal cortex – dopamine transport, release & uptake

Biological , genetic (concordance in twins)

PANDAS

Exacerbations by environmental factors

What does it feel like?

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

What should you say?

1. It’s not their fault,

2. Acceptance and understanding essential

3. Tics can change; Course can wax and wane

4. Tics be suppressed, but often payback

5. Exacerbations at times of stress, boredom, excitement and illness

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

Common Co-morbidites

SleepLD

Famous people with Tourette Syndrome

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

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, I’m Adam: A Child’s Book about Tourette Syndrome” Adam Buehrens

Tics and Tourette syndrome. A Handbook for Parents and Professionals. Uttom Chowdhury

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

Questions?