CHILD PSYCH OVERVIEW
Autism Spectrum Disorder. The word Autism comes from the Greek word “auto” which means “self.” These guys are trapped within themselves. Read A Curious Incident of the Dog in the Nighttime for an entertaining and casual introduction to Autism. Autism begins at birth, although it may take a few years for the symptoms to fully flesh out. The buzzwords of Autism include social awkwardness, an inability to hold a conversation, poor language skills, inability to make friends, motor stereotypies (hand flapping, rocking), need for sameness, unusual interests of abnormal intensity (subway maps) and they overreact to certain physical stimuli (very bothered by particular textures). Many, if not most, of Autistic people also have ID, although their brain size is paradoxically increased and they have high serotonin levels! 80% are male. The DSM-5 breaks Autism down into three levels. Level 1 is mild (awkward but high functioning). Level 2 is moderate. Level 3 is severe (nonverbal). There is a 20% overlap with epilepsy. Treatment begins with instilling structure and routine into their lives. Early treatment portends a better outcome (kindling theory). Tics, anxiety and obsessions are treated with SSRIs. Impulsivity and aggression are treated with atypical antipsychotics, alpha-2 agonists or mood stabilizers.
ASD without Intellectual Disability and Without Structural Language Impairment is the convoluted new name given to Asperger’s Syndrome. This is a variant of Autism that is higher functioning. It’s typically diagnosed later in life than regular ASD because of their preserved language skills. They often have intense, narrow ranges of interests that are pretty wacky to most folks (train schedules, astronomy), but their knowledge outside of that particular field is often subpar. Individuals who are especially intelligent, but only in a single domain, are called savants. Despite their intelligence, they are socially awkward. They may crave social interactions, but they can’t understand other’s points of views, and can’t wrap their heads around the fact that they themselves are weird and off-putting (remember, they’re trapped within themselves). Often depressed as they get older because they’re just odd enough to alienate others, but they’re intelligent enough to understand it. Treatment is similar to ASD. The “rain man” or savant autism characterized by an abnormally high IQ is a very rare variant.
Attention Deficit Hyperactivity Disorder (ADHD) is both common and treatable. ADHD is broken into two categories. To better understand this, let’s break down the name. There’s an “Attention Deficit” component involving poor attention skills (common in girls and adults). And there’s the “Hyperactive” component that involves being spazzy (common in boys). Inattentive patients will seem disorganized, spacey and won’t be able to finish tasks like homework. Hyperactive patients will seem fidgety, annoying and will interrupt others. Some patients are AD, others are H, but most are AD and H.
Inattentive patients may be confused for absence seizures, but those with ADHD will be aware of their spacing-out episodes. Hyperactive patients may be confused with manic behavior, but they won’t stay up for days on end or have grandiose fantasies.
Importantly, ADHD symptoms are present 24 / 7. A kid who is disruptive during class, but an angel at home, might be acting out because they have a learning disability and that makes school very upsetting to them. But an ADHD kid will be symptomatic in more than one area of their life.
ADHD is very responsive to treatment. Treatment consists of stimulants. It may seem counterintuitive to give a stimulant to a hyperactive child, but it makes a little more sense when you understand the neurochemistry of ADHD. Their brains have underfunctioning dopamine pathways, including the mesolimbic pathway that’s involved in rewards and Schizophrenia. Patients with ADHD have to work extra hard to earn reward signals. Hyperactive patients are constantly looking for more stimuli in order to activate that path, while Inattentive patients go through life sadly accustomed to being under-rewarded.
1st Line - Behavioral therapy
2nd Line - Stimulants. Methylphenidate (Ritalin), Amphetamines (Adderall) and Lisdexamfetamine (Vyvanse). The MOA of these drugs is largely similar -- they increase Dopamine levels in the synapse. They also increase Norepinephrine levels, activating the sympathetic nervous system, and accounting for the tachycardia that is commonly seen in patients. Although tachycardia is concerning, studies have shown that stimulants are quite safe overall, and that getting an EKG isn’t necessary before initiating therapy; however, stimulants are unsafe in people who have structural heart defects. Other side effects include poor appetite and difficulty falling asleep. They can be addicting (because they modulate Dopamine), and they have value on the streets.
3rd Line - Alpha-2 Agonists. Clonidine is a short acting A2A. It’s an old-school drug that I saw being used in the ER to rapidly lower BP, but it turns out to have some calming effects on the brain. Weird! A2 receptors are found on the presynaptic neurons in the PNS, and are closely associated with blood vessels (hence the hypotensive effects). But the A2 receptors in the brain are found on the postsynaptic neurons. The exact MOA is complicated. However, Clonidine is really sedating, so chemists came up with a new and improved version called Guanfacine.
Last Line - The other non-stimulants. Bupropion is helpful if they have ADHD plus depression. Atomoxetine works like an SNRI, although Dr. Smith says it’s rarely effective in his experience. It can cause rare hepatotoxicity. Atomoxetine is non-addicting.
Disruptive Mood Dysregulation Disorder - temper tantrums, and angry in between
Intermittent Explosive Disorder - temper tantrums
Oppositional Defiance Disorder - defiant kid
Conduct Disorder - defiant AND evil. They start fires, torture animals, fight kids and bully others. If they don’t grow out of it by the time they turn 18 years old, the diagnosis is changed to Antisocial Personality Disorder.