Review of the evidence for the management of co-morbid Tic disorders in children and adolescents with attention deficit hyperactivity disorder

Attention deficit hyperactivity disorder(ADHD) is the most common neurodevelopmental disorder in children and adolescents, with prevalence ranging between 5% and 12% in the developed countries. Tic disorders(TD) are common co-morbidities in paediatric ADHD patients with or without pharmacotherapy treatment. There has been conflicting evidence of the role of psychostimulants in either precipitating or exacerbating TDs in ADHD patients. We carried out a literature review relating to the management of TDs in children and adolescents with ADHD through a comprehensive search of MEDLINE, EMBASE, CINAHL and Cochrane databases. No quantitative synthesis(meta-analysis) was deemed appropriate. Metaanalysis of controlled trials does not support an association between new onset or worsening of tics and normal doses of psychostimulant use. Supratherapeutic doses of dextroamphetamine have been shown to exacerbate TD. Most tics are mild or moderate and respond to psychoeducation and behavioural management. Level A evidence support the use of alpha adrenergic agonists, including Clonidine and Guanfacine, reuptake noradrenenaline inhibitors(Atomoxetine) and stimulants(Methylphenidate and Dexamphetamines) for the treatment of Tics and comorbid ADHD. Priority should be given to the management of co-morbid Tourette's syndrome(TS) or severely disabling tics in children and adolescents with ADHD. Severe TDs may require antipsychotic treatment. Antipsychotics, especially Aripiprazole, are safe and effective treatment for TS or severe Tics, but they only moderately control the co-occurring ADHD symptomatology. Short vignettes of different common clinical scenarios are presented to help clinicians determine the most appropriate treatment to consider in each patient presenting with ADHD and co-morbid TDs.

Behavioural and emotional disorders in childhood: A brief overview for paediatricians

Mental health problems in children and adolescents include several types of emotional and behavioural disorders, including disruptive, depression, anxiety and pervasive developmental(autism) disorders, characterized as either internalizing or externalizing problems. Disruptive behavioural problems such as temper tantrums, attention deficit hyperactivity disorder, oppositional, defiant or conduct disorders are the commonest behavioural problems in preschool and school age children. The routine Paediatric clinic or Family Medicine/General Practitioner surgery presents with several desirable characteristics that make them ideal for providing effective mental health services to children and adolescents. DSM-5 and ICD-10 are the universally accepted standard criteria for the classification of mental and behaviour disorders in childhood and adults. The age and gender prevalence estimation of various childhood behavioural disorders are variable and difficult to compare worldwide. A review of relevant published literature was conducted, including published metaanalyses and national guidelines. We searched for articles indexed by Ovid, Pub Med, Pub Med Medical Central, CINAHL, EMBASE, Database of Abstracts and Reviews, and the Cochrane Database of Systematic reviews and other online sources. The searches were conducted using a combination of search expressions including "childhood", "behaviour", "disorders" or "problems". Childhood behaviour and emotional problems with their related disorders have significant negative impacts on the individual, the family and the society. They are commonly associated with poor academic, occupational, and psychosocial functioning. It is important for all healthcare professionals, especially the Paediatricians to be aware of the range of presentation, prevention and management of the common mental health problems in children and adolescents.

Classification,prevalence and integrated care for neurodevelopmental and child mental health disorders:A brief overview for paediatricians

‘Neurodevelopmental disorders’comprise a group of congenital or acquired longterm conditions that are attributed to disturbance of the brain and or neuromuscular system and create functional limitations,including autism spectrum disorder,attention deficit/hyperactivity disorder,tic disorder/Tourette’s syndrome,developmental language disorders and intellectual disability.Cerebral palsy and epilepsy are often associated with these conditions within the broader framework of paediatric neurodisability.Co-occurrence with each other and with other mental health disorders including anxiety and mood disorders and behavioural disturbance is often the norm.Together these are referred to as neurodevelopmental,emotional,behavioural,and intellectual disorders(NDEBIDs)in this paper.Varying prevalence rates for NDEBID have been reported in developed countries,up to 15%,based on varying methodologies and definitions.NDEBIDs are commonly managed by either child health paediatricians or child/adolescent mental health(CAMH)professionals,working within multidisciplinary teams alongside social care,education,allied healthcare practitioners and voluntary sector.Fragmented services are common problems for children and young people with multi-morbidity,and often complicated by subthreshold diagnoses.Despite repeated reviews,limited consensus among clinicians about classification of the various NDEBIDs may hamper service improvement based upon research.The recently developed“Mental,Behavioural and Neurodevelopmental disorder”chapter of the International Classification of Diseases-11 offers a way forward.In this narrative review we search the extant literature and discussed a brief overview of the aetiology and prevalence of NDEBID,enumerate common problems associated with current classification systems and provide recommendations for a more integrated approach to the nosology and clinical care of these related conditions.

Management of sleep disorders among children and adolescents with neurodevelopmental disorders: A practical guide for clinicians

There is a complex relationship between sleep disorders and childhood neurodevelopmental,emotional,behavioral and intellectual disorders(NDEBID).NDEBID include several conditions such as attention deficit/hyperactivity disorder,autism spectrum disorder,cerebral palsy,epilepsy and learning(intellectual)disorders.Up to 75%of children and young people(CYP)with NDEBID are known to experience different types of insomnia,compared to 3%to 36%in normally developing population.Sleep disorders affect 15%to 19%of adolescents with no disability,in comparison with 26%to 36%among CYP with moderate learning disability(LD)and 44%among those with severe LD.Chronic sleep deprivation is associated with significant risks of behavioural problems,impaired cognitive development and learning abilities,poor memory,mood disorders and school problems.It also increases the risk of other health outcomes,such as obesity and metabolic consequences,significantly impacting on the wellbeing of other family members.This narrative review of the extant literature provides a brief overview of sleep physiology,aetiology,classification and prevalence of sleep disorders among CYP with NDEBIDs.It outlines various strategies for the management,including parenting training/psychoeducation,use of cognitive-behavioral strategies and pharmacotherapy.Practical management including assessment,investigations,care plan formulation and follow-up are outlined in a flow chart.