NEUROPSYCHIATRIC CONDITIONS IN CHILDHOOD Hen’s teeth.... Or not?? Dr Kirsty Yates Community 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!”

What else do you want to know??

Behaviour Aggressive Repetitive Spits Restless On the go Changes in routine Yelps Awareness of difference Movements Since 3-4yr Daily Grimace Blink Flap hands R arm stretches Increase when anxious Education Not learning Kept back in nursery Going to ARC Poor conc Reasurrance Seek cuddles Copies speech/phrases

What are your initial thoughts?? a)I’m not worried – reassure mum b)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 Gross motor Fine Motor & vision Hearing CommunicationCognitive Concerns Poor handwriting Help dressing Delayed speech Persisting echolalia Needed SALT 1 yr Delayed learning History of soiling Sleep difficulties Play 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 LAC Dad recently detained HMP CSC involved Financial difficulties

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 TicsRestInatt n Agg n RepEduc n Peers Speech / / /

BiologicalPsychologicalSocial 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 AttachmentPoor engagement ?Parenting Lack social network Protective Physically healthy Twin is “normal” Relationship with twin Father/Mat GM supportive Multiple agencies Attends school

Causes of wiggles and squiggles PDD ADHD LD Anxiety Disruptive Beh. Depression Bipolar disorder Personality disorder Tics/TS Abuse/neglect Age(4-7 years) at assessment Age of child

Tics Sudden, rapid, repetitive, involuntary, stereotyped purposeless movements Vocal or motor Simple 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/Aspergers Huntingtons disease Wilsons disease Fragile X Hallervorden-Spatz Causes of TICS

Chorea Choreoathetosis Dystonia Tremor Myoclonus Stereotypies Compulsions Perserveration SIB 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 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 Echophenomenon Coprolalia/ Copropraxia Paliphenomena 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 TICS OCDADHD Sleep LD

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. 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?