Volume 9 No 1 - January/February 2018 Paediatric Newsletter

Neuropsychiatric Issue

• The misuse of psychostimulants by adolescents and young adults who do not have a diagnosis of an attention deficit disorder (ADHD) • Drugs, alcohol and antisocial behaviour • Oppositional Defiant Disorder (ODD) • Obsessive Compulsive Disorder (OCD) • A perspective on

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Associate Professor Prakash Mohan Jeena Head of Paediatric Pulmonology and Critical Care University of KwaZulu Natal, Durban

he Life Esidimeni patient tragedy has highlighted the recognised and often mismanaged. We begin this edition with plight of mentally disturbed patients to the world. two major concerns in child health in South Africa today. Psy- The unnecessary deaths and the immeasurable chostimulants commonly prescribed for Attention Deficit- Hy suffering that is being portrayed by the families of peractivity Disorder are now being misused by students to assist the deceased at the current tribunal hearing are cramming before examinations and recreational use. The con- emotionally disturbing. And yet, politicians and senior health troversies in the ethics of this practice are magnificently articu- care providers hide behind the medical and legal rhetoric. lated in the article by Professor Venter. This subject matter ties Appropriate care for these patients could have been routinely well with the article that speaks to drug, alcohol and antisocial provided with insightful thinking. behaviour by Dr Holzapfel. The subsequent two manuscripts by Dr’s Belsham and Ladikos on Oppositional Defiant Disorder and Another similar tragedy is now waiting to unfold. Children, the Obsessive Compulsive Disorder respectively, provide insightful unspoken, the unheard and marginalised members of society are discourses on the recognition and diagnostic evaluation and being affected by a silent epidemic of psychiatric disorders that management of these conditions. Gone are the days where the is quietly progressing unnoticed, under the radar of more vocal diagnosis of childhood disorders is made on a mere noises of adults. The incidence of childhood psychiatric diseases has constellation of a few clinical features. This is clearly borne out increased substantially over the last decade. Part of this increase by the final excellent article on Autism, Pervasive Developmen- may be related to better diagnostic criteria as proposed by the tal Disorders and Disorders by Dr Benn where Diagnostic and Statistical Manual of Mental Disorders 5th edition, reference to the new classification, investigation and manage- greater awareness and recognition of these conditions by health ment is made. care professionals, better diagnostic tests, more psychological and psychiatric therapeutic options for these cases and a changing What makes this edition of the paediatric focus unique is epidemiology. Reasons for this observed increase in incidence the single-mindedness of looking at the psychological and may be related to transformation of society to a more liberal socio- psychiatric needs of children by health care professionals who cultural norm where it appears to be “cool” to use recreational are passionate guardians of these innocent souls. I feel indeed drugs, consume alcohol or smoke cigarettes at an early age. These honoured and blessed to be allowed to edit this newsletter social vices have heavily infiltrated the teenage and adolescent and I am sure that this edition will find its way as a reference population and its ill effects or ‘presumed benefits’ (cramming for document to many a doctor caring for children. examinations) is increasingly being seen. God Bless the world’s children to great . In this edition of the Paediatric Focus, we have a bonus of 5 ex- Professor PM Jeena citing articles on childhood psychiatric disorders that are poorly Editor

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2 Volume 9 No 1 - January/February 2018 Ethico-legal discourse: The misuse of psychostimulants by adolescents and young adults who do not have a diagnosis of an attention deficit disorder (ADHD)

Professor A Venter Department of Paediatrics and Child Health, University of the Free State, Bloemfontein

he misuse of psycho-stimulants refers to the The scope of the problem use of these medications for various reasons by In universities, especially, misuse of psycho-stimulants healthy individuals who do not have a diagnosis appears to be infrequent and the most common pattern of ADHD. involves times of stress, such as exams time. The general average misuse of psycho stimulants by college Definitions have become a bit confusing and nowa students was estimated to be at 4% originally, but is now distinction is being made between medical and non-medical probably closer to 10%. In the United States the misuse misuse, while “abuse” refers in a sense to . of methylphenidate gradually decreased between 2005 Medical misuse refers to the use of psycho-stimulants by and 2009, but has been countered with an increase in the persons for whom it has been described for ADHD, but use of amphetamines, which are not available in South they use it in ways that differ from what the prescribing Africa. It appears that stimulants are misused by college physician intended. Non-medical misuse is the use of students and students at universities, more often than not, psycho-stimulants for persons for whom the medication in medical and dental schools. was not prescribed, for cognitive enhancement, but also other reasons like, weight loss, recreation etc. This paper How they are obtained will refer to both these two scenarios, but will not include Psycho stimulants are usually obtained from students who the abuse of stimulants. have legal prescriptions. These students may give them to friends (diversion), sell them or in one study 33% of treated Why are stimulants misused? individuals had been robbed of their tablets. Sometimes they Studies have shown that cognition in non-sleep deprived are obtained from students without a legal prescription or healthy adults can be improved with a variety of psycho- via the internet. At least 20% are obtained frequently from stimulants including: Modafinil, atomoxetine and doctors by imitating the symptoms of ADHD and off course methylphenidate. It appears that at clinical relevant doses there is always the concern of street dealers who can provide which are usually not high, psycho stimulants improve a these psycho- stimulants, but for a fee. Of those students variety or processes that depend on the prefrontal cortex. who have ADHD, it was found that nearly a third of them The effects are mostly improved clarity memory and will divert their medication once in their life time. These possibly enhanced consolidation of memory. In single-dose students who divert their medication are also more likely to studies it has been shown that methylphenidate could use illicit drugs, have more childhood conduct problems, use improve working memory, speed of processing, attention prescribed medication less frequently and misuse stimulants. and vigilance, reasoning and problem solving, but has no In general it appears that a small number of prescribed users effect on visual learning and visual memory. There are also supply the majority of non-medical users. positive effects on response inhibition and self-regulation. With long term use there is a trend for stimulants to Which students are most likely to misuse enhance performance with longer delays. So it does psycho-stimulants? appear that stimulants enhance learning in ways that may Researchers have shown that those students who are be useful in the real world. most at risk to misuse psycho-stimulants are males who are attending institutions with competitive admissions Philosophically it has been stated that even if stimulants standards, usually Caucasian who belong to a fraternity or enhance cognition to a small degree, it may still beof sorority (which implies that they are from affluent families). relevance and practical use in the real world as success They have lower Grade Point Average (GPAs - an American often hinges on being at the top, not merely near the average value of accumulated final marks) with concerns top. Unfortunately the effects of neurotransmitter about their ability to succeed academically and they are enhancement on cognitive function follow an inverted engaged in substance use, risky behaviour and often are U-shaped curve, where deviations from the optimal level smokers and alcohol users. in either direction produce sub-optimal performance. Therefore some adolescents and young adults may find The misuse of psycho-stimulants may in fact reflect self- benefit, while others may remain unchanged or even be medication for undiagnosed ADHD in this population impaired. group. The findings of research on this issue is mixed, but

Volume 9 No 1 - January/February 2018 3 it is important to realise that in some studies, nearly 70% of Pillars of Ethics students who misuse the medication, fulfil the criteria for a diagnosis of ADHD. Beneficence Could there be an advantage to prescribing psycho- Why are psycho-stimulants then misused by stimulants to the normal population? Different arguments adolescents and young adults? have been made in this regard, especially that those • To improve cognition persons who do have ADHD would be inadvertently • To improve academic performance treated. It has also been shown that psycho-stimulants • To improve grades particularly improve the functioning of those with low • To help with concentration cognitive performance and may mitigate for adverse • To help alertness environmental effects, such as poverty. This philosophical • To help with studying reasoning is not that of the author, but of various authors • Increase reading comprehension who had written on this topic. We would be ignorant if • To reduce fatigue we did not take cognisance of the fact that healthy adults • To decrease psychological stress already use psycho-stimulants to counteract, for example, • To improve memory sleep deprivation, such as scientists, surgeons and air • To feel restless traffic controllers. Psycho-stimulants have been used to • For a general feeling of wellbeing boost cognition in soldiers, shift workers and pilots. • To get “high” • To lose weight In an extensive review, arguing that pharmachologisation of cognition would optimalise intellectual performance, benefits Side-effects of medication highlighted would create more productive individuals who In general those who misuse psycho-stimulants considered may make more discoveries that will be useful to everyone. them both physically harmless and morally acceptable. There would be a reduction in social inequality and it would be Appetite reduction, sleep difficulties and irritability are the as acceptable as “eating chocolate” (my analogy). It may also most common adverse events, but more than 74% of these enhance artistic and philosophical aims. Some philosophers youngsters feel that using the medication is justified and take this argument one step further and claim that psycho- therefore there is little incentive to stop using it. stimulants for these population groups should not only be permissible, but that it is morally praiseworthy. Since a doctor Ethico-Legal issues in cognitive enhancement or a health worker is responsible for the patient’s overall wellness and values, neuro-cognitive enhancement is known Before we can continue about the ethics of prescription to increase enjoyment of work, give energy drive and a sense of medication for cognitive enhancement rather than for of general well-being, among others. If this is the case then, persons with a diagnosis, it is important to ponder what the argument is made that there should be universal access ethically obligatory practices in medicine are. These are to stimulants for all who need them, as this will eliminate well identified: diversion, black market sales and poor quality drugs and • Prevent and diagnose disease enhance parent/child relationships. The counter argument • Cure or treat disease though is that educators may come to rely on pharmacological • Reduce suffering solutions to educational problems rather than correcting the • Educate patients underlying problems. The final question is this: Would this • Help patients die with dignity all be ethical? • Reassure the “worried well” Non-Maleficence It can be seen that the prescription of medication for cognitive The theoretical disadvantages of using medication is that enhancement would not be satisfied by the argument that the short-term benefits may be counteracted by long term it falls under “ethically obligatory practice”. But there are side effects and harm, but this argument is not strong as also ethically permissible practices, which include expert we already have data over many years of treating patients witness testimony and cosmetic surgery. It is clear that the with psycho-stimulants without any side-effects. The prescription of psycho-stimulants to healthy individuals argument that it may lead to drug abuse is a moot point could easily be placed under “ethical permissible practice”. and has generally been put to rest. There is the danger If that is true, it would not be unethical to prescribe these of the quality of illicit drugs being used by unsuspecting medications for adolescents or young adults who appear to students. The biggest disadvantage of psycho-stimulants require them for their educational success. There are ethical is that it can be used by persons without insight into their impermissible practices such as participating in execution or own health problems where there may be drug-drug torture or interrogation of detained persons and it is obvious interactions or where they may have medical conditions that the prescription of the psycho-stimulants does not fall that are contra-indicated. When taken orally, stimulants in this category. are seldom addictive. The problem is when Ritalin short

4 Volume 9 No 1 - January/February 2018 acting tablets are crushed and used intravenously or stimulants, especially during the examinations. It may sniffed. This is seldom the method of ingestion in the group even be necessary to have a tick-box on the questionnaire of adolescents and young adults discussed here. where the students have to indicate whether they have used stimulants or not. Off course if such processes are set Autonomy in place, universities should also take the responsibility to As it is, healthy people are already being coerced to use do random urine testing, just as it is done in sport. There psycho-stimulants and many “normal persons”, feel currently is no professional or societal consensus and this compelled to take them in order to meet the demands of is actually not a medical ethical issue. social and workplace demands, as we live in a very demanding society. These stimulants are often used to compensate for Although it is important to have a diagnosis of ADHD inadequate sleep or physical exhaustion. Unfortunately in confirmed and treated appropriately, many students will feign one review, a third of parents felt the pressure to give their symptoms to get hold of psycho-stimulants. Unfortunately children psycho-stimulants so that they can compete with the neuropsychological tests and objective measures of other children who use psycho-stimulants in the school. This inattention are not very effective in distinguishing the “real” is rather a sad state of affairs, but a reflexion of our “quick versus the “manufactured” ADHD student. QEEG has shown fix”, yet driven to perform, society. It is important to realise some promise as a diagnostic aid. that one’s autonomy to use the medication never supercedes other ethical principles. If a doctor is of the opinion that Universities will have to revise their policies to address giving psycho-stimulants would be harmful to the patient, he issues about misuse and diversion and there should be is allowed, ethically, to refuse to do so. A doctor may refuse safe places where students can lock up their medication. to treat a patient because of concerns that there is nota Students have to be educated about the dangers of non- diagnosis or a need, that the medication may be abused or medical use, especially with regard to alcohol and other sold, or there is an underlying medical condition that makes it substances. There is a perception amongst students that unsafe e.g. a cardiac condition, to mention some. when you take psycho-stimulants you can take more alcohol before the side-effects of the abuse is visible. In other words one would be able to drink more alcohol!

It is important for universities Conclusions and other secondary and tertiary It is not very satisfactory to have come to the conclusion that as far as ethics is concerned, the prescriptions of institutions to develop formal policies psycho-stimulants to healthy individuals can be considered about the use of psycho-stimulants, as ethically permissible, because they could potentially improve the wellbeing of the patients. The benefits especially during the examinations. It may outweigh the risks. It is clear that physicians have may even be necessary to have a tic- no obligation to prescribe these medications and may ethically refuse to do so. From a legal point of view the box on the questionnaire where the prescription of the medication is then used “off-label” and students have to indicate whether this is a common occurrence in medicine. Even so, the doctor still has an ethical and legal obligation to his patient they have used stimulants or not. and the doctor-patient relationship is still sacrosanct.

On the other hand, ethically, it appears that there are strong Justice arguments that it would be quite in order to prescribe Here the argument for universal access becomes psycho-stimulants to healthy individuals if the doctor’s important, because it could not be ethically justified if only opinion is that it would be beneficial, but the question the wealthy had access. Is it also not justified to use them then is, is this morally acceptable? The answer does not lie during the exams where certain students will get unfair within medical ethics, it lies within social ethics. advantage over equally capable non-medicated students? The use of psycho-stimulants may have outdated human Stimulants are used to obtain better marks and are used virtues, like hard work, and students will be unable to take purely for cramming purposes. If it is considered unethical credit for their achievements. and immoral for individuals to use the medications as cognitive enhancers by society, then we should “declare General considerations war”, exactly the same way as enhancers are pursued in Universities have been grappling with the problem of the sport arena. At this time this is unlikely, because of the medical misuse for quite some time. It is important for pressures for adolescents and young adults to perform in universities and other secondary and tertiary institutions every aspect of their lives, especially academically. to develop formal policies about the use of psycho- Bibliography available on request.

Volume 9 No 1 - January/February 2018 5 Drugs, alcohol and antisocial behaviour

Dr Eleanor Holzapfel Psychiatrist, Akeso Crescent Clinic Bromhof, Randburg

iterature reports the frequent co-occurrence and as- and (angry irritable mood, argumentative sociation of substance use and antisocial behaviour.1 and defiant behaviour and vindictiveness) in the DSM- However, it is difficult to determine whether antiso- 5 (Table 2).7 Serious antisocial behaviour that persists cial behaviour happens before or after substance into adulthood is referred to adult antisocial personality use.2 Substance use is a symptom of childhood, ado- disorder in the DSM-5 (Table 3)7 Antisocial behaviour that lescent and adult antisocial behaviour and research has does not meet the criteria for a disorder is included in the shown these behaviours tend to be genetically linked.3,4 Oth- DSM-5 under the V codes.7 These V codes refer to child er studies illustrate that substance use is one of the causes of or adolescent antisocial behaviour and adult antisocial antisocial behaviour.1,2 It is clear however that the risk and the behaviour which can be a focus of clinical attention.7 protective factors are shared by both these two behaviours.1 Prevention and treatment programmes for these behaviours Continuity of antisocial behaviour from therefore need to be cognoscente of this association.1 childhood to adulthood Not all children who start with antisocial behaviour in early Definitions of antisocial behaviour childhood progress on to the later, more severe forms. The term antisocial behaviour incorporates a range of Only about half continue from those in early childhood to behaviours from minor offensive or harmful acts, to more those in middle childhood, and of those children in middle serious criminal activity.5 childhood only a smaller number will progress to show antisocial behaviours in adolescence and adulthood.8,9 Moffitt These acts violate social rules, cause or are likely to cause distinguished between adolescents who engage in antisocial harassment, alarm or distress to one or more people.6 The behaviour for a short period of time (adolescent limited), most prevalent types of antisocial behaviour in younger and those who persist with antisocial behaviours from early children include aggression, hyperactivity and oppositional childhood through to adulthood (life course persistent).5 defiant behaviour, in early adolescence include fighting, alcohol use, theft and property damage.5 Youth who develop childhood onset conduct disorder often have long-standing problems related to attention-deficit These behaviours continue into mid-adolescence, along hyperactivity disorder and oppositional defiant disorder that with high rates of cigarette use and skipping school.5 In late present prior to their development of antisocial behaviour.10 adolescence, alcohol use, skipping school, cigarette use, These children have risk factors and developmental factors fighting, property damage, marijuana use and driving a car that are linked to the presence of the disorder (Figure 1).10-12 without permission are the most common types of antisocial In contrast, adolescent onset conduct disorder may be as a behaviour.5 Males are significantly more likely to engage in result of rebellious adolescents who are poorly monitored almost all types of antisocial behaviour, particularly violent by their parents and who engage with antisocial peers.10 behaviour.5 There are, however, no differences in the The antisocial behaviour may not be as severe.10 In early prevalence of substance use between males and females.5 onset conduct disorder (before the age of 10 years), about half have greater and more serious problems that persist Antisocial behaviour threatens the establishment and into adulthood.6 Of those with adolescent onset, the maintenance of a safe and secure community.5 Individuals majority (over 85%) stop their antisocial behaviour by their who participate in antisocial behaviour are at risk of being early twenties. However, they may continue to experience excluded from essential support networks such as school, functional impairments in certain areas of adult life.6 community facilities and service providers as well as their 5 families. They are also at risk of being involved with the Early Childhood Middle Childhood Late Childhood criminal justice system.5 and Adolescence

Rejection by normal peers In the Diagnostic and Statistical Manual of Mental Disorders Poor parental Child Commitment 5th edition (DSM-5), substance use disorders and antisocial discipline and conduct to deviant Delinquency monitoring problems 7 peer group behavioural disorders are classified as separate disorders. Academic These disorders however have risk and protective factors in failure 5 common (Table 1). Serious antisocial behaviour in childhood Figure 1: A developmental progression of antisocial behaviour.12 and adolescence is referred to oppositional defiant disorder Adapted from Patterson GR; DeBaryshe BD; Ramsey E. A developmental perspective on antisocial behaviour. Am Psychol. 1989 Feb; 44(2):329-35

6 Volume 9 No 1 - January/February 2018 Escape % of all children 1/5 15% 1/5 4/5 1/5 Oppositional and 4/5 1/5 10% defiant Gets into fights 4/5 Hard to control 4/5 Blamed by parents Rejected by peers Stealing and truanting Poor school Career offender achievement Deviant peer group 5% Low self-esteem Unemployed Disliked by siblings Blames others Anti-social attitude Drug misuse 10% 10% 10% 10% 0% 5 years 8 years 11 years 14 years 17 years

No past anti-social behaviour

Figure 2: Continuity of anti social behaviour from age 5-17.9 Adapted from Drugs, alcohol and youth crime: Counting the cost - Mentor UK.Available from: https://www. mentoruk.org.uk/wp- content/uploads/sites/3/2017/07/thinking-crime-jan2013.pdf. Table 1. Risk and protective factors for antisocial Table 2. DSM-5 Conduct disorder.7 5 behaviour and substance use A repetitive and persistent pattern of behaviour in which the basic rights of others or major age-appropriate societal norms or rules are violated, as Context Risk Factors Protective Factors manifested by the presence of at least three of the following 15 criteria in the • Prenatal and postnatal past 12 months from any of the categories below, with at least one criterion present in the past 6 months: difficulties Aggression to People and Animals • Antisocial personality • Social competence and 1. Often bullies, threatens or intimidates others including impulsiveness, good social skills 2. Often initiates physical fights belief system & attitudes • Attachment to family 3. Has used a weapon that can cause serious physical harm to others (e.g. a bat, which favour deviancy, Individual • Problem solving skills and brick, broken bottle, knife, gun) restlessness, risk-taking, good coping style 4. Has been physically cruel to people aggressive behaviour • Internal locus of control 5. Has been physically cruel to animals • Early signs of antisocial 6. Has stolen while confronting a victim (e.g. mugging, purse snatching, extortion, • Moral beliefs and values behaviour, including displays armed robbery). of aggression 7. Has forced someone into sexual activity. • Alcohol and drug use Destruction of property 8. Has deliberately engaged in fire setting with the intention of causing serious • Parental criminality damage. • Poor family management • Supportive, caring parents 9. Has deliberatly destroyed others’ property (other than by fire setting). practices (i.e. lack of • Family harmony Deceitfulness or Theft supervision, harsh/ • Responsibility for chores or 10. Has broken into someone else’s house, building or car. inconsistent discipline) required helpfulness Family 11. Often lies to obtain goods or favours or to avoid obligations (i.e. cons others • High levels of family conflict • Secure and stable family 12. Has stolen items of nontrivial value without confronting a victim (e.g. • Lack of parental • Small family size shoplifting, but without breaking and entering, forgery). involvement (neglect, low • Strong family norms and Serious violations of rules parental warmth) morality 13. Often stays out at night despite parental prohibitions, beginning before age • Economic stressors 13 years. 14. Has run away from home overnight at least twice while living in the parental • Positive school climate surrogate home or once without returning for a lengthy period. • School achievement 15. Is often truant from school, beginning before age 13 years. • Academic failure • Responsibility and required The disturbance in behaviour causes clinically significant impairment in social, • Truancy and low helpfulness academic, or occupation functioning. If the individual is 18 years or older, criteria commitment to schooling • Sense of belonging and are not met for antisocial personality disorder. School • Frequent school changes bonding 312.82 (F91.2) Adolescent-onset type: Individuals show no symptom characteristic of • Expulsion or suspension • Opportunities for success conduct disorder prior to age 10 years. from school at school and recognition 312.89 (F91.9) Unspecified onset: Criteria for a diagnosis of conduct disorder are met • Bullying of achievement but there is not enough information available to determine whether the onset of the • School norms around first symptom was before or after the age of 10 years. violence 7 • Pro-social peer group Table 3. Antisocial Personality Disorder • Poor social ties (few social • Friends and peers with Diagnostic Criteria 301.7 (F60.2) activities, low popularity) positive moral beliefs and • Mixing with delinquent A. A pervasive pattern of disregard for and violation of the rights of others, Peers attitudes siblings and peers occurring since age 15 years, as indicated by three (or more of the following): • Participates in social • Gang membership 1. Failure to conform to social norms with respect to lawful behaviours, as activities or sporting • Peer rejection indicated by repeatedly performing acts that are grounds for arrest. events 2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure. • Low socioeconomic areas 3. Impulsivity or failure to plan ahead. • Community disorganisation • Access to support services 4. Irritability and aggressiveness, as indicated by repeated physical fights or • Availability of firearms and • Community networking assaults. drugs • Attachment to community 5. Reckless disregard for safety of self or others Community • Exposure to violence and • Participation in church or 6. Consistent irresponsibility, as indicated by repeated failure to sustain or neigh- crime within the community other community group consistent work behaviour or honor financial obligations. bourhood • Urban area • Community and cultural 7. Lack of remorse as indicated by being indifferent to or rationalising having • Media portrayal of violence norms against violence hurt, mistreated, or stolen from another. • Lack of support services • Strong cultural and ethnic B. The individual is at least age 18 years. • Social or cultural pride C. There is evidence of conduct disorder with onsest before age 15 years. D. The occurence of antisocial behaviour is not exclusively during the course of discrimination or .

Volume 9 No 1 - January/February 2018 7 Personality disorders are understood to be persistent and faster onset of substance use disorders as well as poorer pervasive. However, the presence of antisocial behaviour in psychosocial and treatment outcomes.8 Adolescent and adults without a history of conduct disorder in childhood or adult antisocial behaviour without conduct disorder are also adolescence suggests that these behaviours were acquired often diagnosed in patients with substance use disorders.8 in adulthood and may be more responsive to treatment.6 Children living with parents in treatment for substance use Studies are investigating the proportion of adult-onset disorders have higher rates of substance use and antisocial antisocial behaviours in individuals with substance use behaviour.16 disorders and their ability to change.6 Management Associations of substance use and antisocial It is evident from the literature that a correlated relationship behaviour exists between substance use and antisocial behaviour. Drug use at an early age is an important predictor of Managing the one problem will lead to a positive influence development of a substance use disorder later. Tobacco, on the other problem.1 It is also seen from the literature alcohol, and marijuana are the first addictive substances most that treatment programmes able to identify and target risk people try.13 Research has shown that 13% of individuals with factors as well as protective factors in young age can prevent a substance use disorder started using marijuana by the age the development of antisocial behaviour and substance use of fourteen.13 Adolescents may experiment with substances in adolescence and adulthood.9 as part of their developmental phase of risk-taking, novelty- seeking, self-identity and peer pressure.13 Population-based Aspects of management9 epidemiologic surveys of adolescents have demonstrated • Identify the individual and family at risk. that by 12th grade, 71%, 42%, 43%, and 25% have tried • Make a thorough assessment of the individual and family alcohol, cigarettes, marijuana, or other illicit substances or including differential diagnosis and comorbidity. another illicit substance respectively during their lifetime.14 • Target treatment plan and individualise care according to Unfortunately the use of substances may have very serious the needs of the individual and family. long term consequences.13 • Refer to members of the multi-disciplinary team which can include: Psychiatrist, psychologist, councillors, Studies looking at adolescents between 11-17 years have community nurses, social workers, occupational shown adolescents who started earlier with criminal therapists, teachers and community services/networks. behaviour also developed substance use disorders at a • Specific focus: younger age.2 Studies have also shown drug use more -- parenting and childcare programmes. common in adolescents who have committed offences.2 The -- health visitors and family support services. use of drugs introduces the individual to antisocial behaviour -- family-centred programmes. such as use of an illegal substance, offences committed with -- children and adolescent education about drugs and the purpose of obtaining drugs, association with peers who alcohol. reinforce illegal behaviours and drug induced behavioural -- children and adolescents learn to explore concepts of inhibition which increases the risk of impulsive and antisocial attitudes, values and morals. behaviour.2 -- children and adolescents develop personal, life, social and communication skills. There is strong evidence that alcohol and binge drinking -- engaging children and adolescents in the classroom. increase risk taking and impair decision making.15 Drinking -- involving children and adolescents in youth is linked to unsafe sex, aggression, criminal activity such community projects; youth will then interact with as vandalism, graffiti and shop lifting as well as disorderly healthy and supportive adult role models as well as behaviour.15 Adolescents who drink are at risk of using explore their identity in a safe place, problem solve other substances such as marijuana and cocaine.15 When and build self-confidence. adolescents do drink they are more likely to binge drink.15 Binge drinking is defined as four to five drinks at one Conclusion time.15 The prevalence rates of drinking for boys and girls Antisocial behaviour and substance use often occur in the younger age groups are similar. In older adolescents, together.1 This link is due to developmental, genetic and however, more males engage in frequent and heavy drinking, environmental factors (family, school, peers, community).3 and drinking problems are more common.15 Individuals at risk can be identified from a young age.9 Management programmes and treatment policies must Antisocial personality disorder and its developmental therefore work with the youth and their families from early precursor conduct disorder may be classified separately on, with a focus on targeted prevention of antisocial and from substance use disorders in the DSM-5. However, substance use behaviours in adolescents and adults.9 these disorders are significantly associated. A diagnosis of conduct disorder and antisocial personality disorder, References available on request. is associated with polysubstance use, an earlier and

8 Volume 9 No 1 - January/February 2018 Oppositional Defiant Disorder (ODD)

Dr Brendan Belsham Child psychiatrist and writer. His book, What’s the fuss about ADHD? Robindale, Randburg, Johannesburg

our-year-old James was brought to me by his an oppositional temperament may progress to the full- parents for ongoing behavioural difficulties. They blown disorder. The quality of mother-infant attachment were finding him increasingly difficult to discipline, is possibly the most crucial early environmental risk and he was constantly defying everyday requests. factor. Insecure attachment resulting from emotionally He was often in trouble for provoking and annoying or physically unavailable or erratic early parenting is his younger brother. His parents dreaded taking him out for associated with ODD and a host of other emotional and fear of his tantrums and anger outbursts. His preschool neurodevelopmental sequelae. It seems likely that in teacher complained of similar behaviour; he was highly many cases, the condition arises from a ‘poor fit’ between impulsive in the classroom, with very low frustration the child’s temperament and early parenting practices. tolerance and repeated lashing out at his peers, who had ostracised him as a result. As a younger child he experienced the ‘terrible twos,’ but unlike his siblings, his defiance didn’t settle with age; on the contrary it seemed to be worsening. ODD is commonly comorbid with other conditions. There is a well- Oppositional Defiant Disorder (ODD) is a childhood condition comprising, as its name suggests, a pervasive described association between pattern of negativistic, hostile and defiant behaviour. Attention Deficit Hyperactivity The average prevalence is around 3% and boys are more commonly affected than girls. There are eight symptoms, Disorder (ADHD) and Oppositional which are divided into three clusters or dimensions, Defiant Disorder (ODD); in fact, namely irritable (frequent temper outbursts, often easily annoyed, angry and resentful), headstrong (often around 40% of boys with ADHD argues with adults, frequent rule violations, purposefully meet criteria for ODD. annoying others, blaming others for his/her mistakes) and hurtful (spiteful, vindictive). The diagnosis requires four of these eight symptoms, which should have been present for at least six months. An important caveat is that the ODD is commonly comorbid with other conditions. symptoms are beyond what might be expected for the There is a well-described association between Attention developmental stage of the child, as in the ‘terrible twos’ Deficit Hyperactivity Disorder (ADHD) and Oppositional and early adolescence. Another important differential Defiant Disorder (ODD); in fact, around 40% of boys diagnosis is that of , in which a child with ADHD meet criteria for ODD. Anxiety disorders are presents with behavioural or emotional symptoms in the also commonly seen in children with ODD, as are mood aftermath of a specific psychosocial stressor, such asa disorders. severe illness or a bereavement. In adjustment disorders, once the stressor has terminated, the symptoms should The differential diagnosis of ODD includes adjustment resolve. disorder, anxiety disorders and mood disorders. Some anxious children present with inflexibility, avoidance As with most psychiatric disorders, the condition is and stubbornness, all of which may be misconstrued as thought to arise from a complex interplay between defiance. Emotional dysregulation is implicit in several genetic and environmental risk factors. At least in certain of the diagnostic criteria for ODD, the irritable cluster individuals, the genetic vulnerability may not be for in particular. It is therefore not surprising that mood ODD per se but rather for associated conditions such disorders such as depression, childhood bipolar disorder as depression or anxiety, which may manifest in early or disruptive mood dysregulation disorder are other childhood as ODD before the other condition becomes important differential diagnoses to consider. apparent. The temperament of the child may be another important risk factor. Some children are more compliant Before considering the management of ODD itself, it is by nature, and others are born with a tendency to be more important to identify and treat comorbid conditions, oppositional. These traits exist on a normal spectrum, which may themselves present with defiant behaviour as but in the presence of other risk factors, a child with discussed earlier. Associated conditions such as ADHD,

Volume 9 No 1 - January/February 2018 9 anxiety disorders, depression and learning disorders all is often possible due to the simultaneous introduction of have evidence-based treatments and once adequately more appropriate parenting strategies. Viewed in this way, addressed, the ODD symptoms often improve. For there is often a synergistic partnership between the effect example, the medications used for ADHD have been shown of the medication and the implementation of psychosocial to improve not only the core symptoms of inattentiveness, interventions, which may be less effective and less likely to impulsivity and hyperactivity, but also associated gain traction when used alone. This may be an important symptoms such as defiance and irritability, and to improve consideration when parents have become demoralised by a social interactions. succession of failed therapies, and on the brink of giving up on mental health services altogether. Medication may thus Given the importance of the parent-child relationship and provide a window of opportunity for families to experience parenting style as risk factors for the development of ODD, it success with improved interactional patterns, which may is incumbent on the treating physician to identify and treat themselves become self-sustaining. in one or both parents where relevant. Some parents are resistant to being made the focus of The long-term course and prognosis of ADHD is highly clinical attention and will not accept such an approach, at variable. Broadly, there are are three possible outcomes. least not initially, but with time and the development of In some children the symptoms gradually resolve and rapport between the family and clinician, this will usually normal development ensues. This could be related to be possible at a later date. With successful treatment timeous implementation of improved parenting strategies of parental psychopathology it is not uncommon for or other treatment, but may also be due to natural children’s symptoms to improve significantly, sometimes maturation of the child’s frustration tolerance and self- to sub-threshold levels which no longer require specific regulatory capacities. A significant percentage of children management. Furthermore, psychotropic medications are with ODD develop mood disorders in subsequent years, generally well-researched in adults, whereas in children and in such cases ODD may be viewed as a developmental they are often used in an off-label manner. precursor to depression or bipolar disorder. The gravest potential outcome is the emergence of conduct disorder, The treatment of Oppositional Defiant Disorder must be a severe behavioral disorder in which societal norms and individualised as the condition is heterogeneous and the the rights of others are repeatedly violated. Conduct perpetuating factors are varied. Psychosocial interventions disorder is itself predictive of antisocial personality are generally regarded as first-line treatment, and might disorder which confers a massive burden and cost to involve parent management training, family therapy, families and to society in general. Genetic vulnerability individual therapy for the child or some combination of plays a major role in determining the trajectory of ODD, these approaches. but there is emerging evidence that parenting factors, maternal warmth in particular, are important pathway Parent management training is an evidence-based moderators in the prognosis of the condition. treatment which involves education and guidance for parents and caregivers, specifically targeting children’s There is some interesting longitudinal research on the challenging behaviours. It is often conducted in a group three dimensions of ODD. It seems that these clusters setting which is not only more cost-effective but also of symptoms are stable across time and are also confers the therapeutic advantage of sharing one’s prognostically important. Specifically, the irritable type experiences with fellow parents in similar predicaments. is predictive of depression in the teenage years, and Again, many parents are unfortunately not prepared to headstrong with conduct disorder in later adolescence. invest the time and effort required to amend their daily Separate research has flagged the co-occurrence of child-rearing practices. ADHD, ODD/conduct disorder and anxiety/depression at the age of six as being highly predictive of depression and As a last resort, if other interventions have failed, suicidal behaviour in later life. psychopharmacological treatment may be considered. This typically involves the dopamine antagonists (antipsychotics) Oppositional Defiant Disorder is a common behavioral such as risperidone (Risperdal) or aripiprazole (Abilify). disorder of childhood which is associated with significant Mood stabilisers such as lamotrigine (Lamictin) may also distress to both affected individuals and their families. be considered. Parents should be warned of potential side- Recognition of the condition is thus important as isan effects such as weight gain with the antipsychotics, and the understanding of the disorders commonly associated development of a rash with lamotrigine. There is also the with it. Timeous intervention is essential to improve the potential risk of tardive dyskinesia (a potentially irreversible outcome of the condition and where possible avert the ) with the antipsychotics, which should development of more severe sequelae such as mood thus ideally not be used long-term. Every six to twelve months disorders and conduct disorder. consideration should be given to a trial off medication, or even reducing the dosage where possible. In practice this References available on request.

10 Volume 9 No 1 - January/February 2018 Obsessive Compulsive Disorder

Dr Androula Ladikos Child Psychiatrist Pretoria

Abstract items. Significant distress is seen when having to get rid Obsessive Compulsive Disorder (OCD) is common in children of them leading to , often in living areas to the and if not diagnosed and treated, can lead to substantial point where the area can no longer be used for what it was functional impairment in a young person in all areas of intended. Symptoms include excessive collecting, buying, his/her life, as well as that of their family. It seldom occurs even stealing items for which there is really no need or space. on its own. A particularly early onset of the condition I have encountered this in a family where one could hardly appears to carry a familial load. This is more often seen in move in the room of the child and attempting to move or get boys than in girls and may be co-morbid with tic disorders. rid of even one item, triggered a huge emotional meltdown. Basal ganglia dysfunction is thought to be involved in the pathology of the condition. Treatment options, which An early onset of the condition is defined by an onset include medication and Cognitive Behavioural Therapy between the ages of 10 and 17 years.4 The age at onset (CBT) are available to alleviate and minimise this suffering should be viewed as an ongoing variable, the value of as well as improve their quality of life. distinguishing between an early versus a later onset, being unclear. Some studies have reported a poorer prognosis and aediatric Obsessive Compulsive Disorder is a poor treatment response in the early onset group, but common in children. In 1903 Janet described a this has not been substantiated. Three studies looking at case of paediatric OCD.1 Early in the 1970’s age of onset of OCD and CBT (Cognitive Behaviour Therapy) serious research began in young persons with response revealed no difference in response to selective OCD following work done by Judith Rappaport. serotonin reuptake inhibitor treatment or behaviour therapy This condition has a negative impact in all aspects of a young in individuals who had an early (before 12 years) or late person’s life. It is chronic and debilitating. Geller reports a onset (15 years and onwards) OCD. Both groups improved prevalence rate of paediatric OCD between 2% to 4 % and a and had significantly less symptoms during CBT. The latter mean age of onset, between 7.5 years and 12.5 years.2 There needs to be tailored to a child’s developmental level. is an equal distribution of male to female patient in adults, with a 3:2 boy: girl ratio in children. Spontaneous remission Paediatric OCD is becoming an acknowledged developmental can occur. The diagnosis is made clinically following DSM 5 sub-type of the disorder with a higher prevalence in boys, an criteria.3 increasing familial load, and co-occurring with tic disorders. Their OCD symptoms often involve repeating and ordering/ Clinical presentation re-arranging. Parents of children in the very early onset The condition is characterised by obsessions, which are group report a higher level of psychosocial difficulties, recurrent and persistent thoughts, images or impulses possibly due to the longer duration of the illness. OCD often incapacitating and senseless, as well as compulsions. symptoms in very young children are often mistaken as a Compulsions are repetitive, purposeful behaviours, usually normal developmental phase. performed to counteract, neutralise and supress these obsessive thoughts. They comprise observable behaviours The core symptoms of OCD are similar in juveniles and such as hand washing, or covert mental acts such as adults. The DSM 5 in its description of symptoms of OCD, has counting, ordering, checking, praying, and repeating words replaced the word ‘impulses’ with ‘urges’. It has also added silently. These are usually performed according to certain a tic-related specifier as well as specifiers relating to insight rules or in a stereotypical fashion. These rituals can take up such as good or fair insight, with poor insight and with a substantial amount of a young person’s time and often absent insight/delusional beliefs, where the individual is interferes with their daily functioning (academic work, social totally convinced that the OCD beliefs are true. Poor insight skills) causing marked distress. Negative emotions include has been associated with poor prognosis. Children are less doubting, a fear of contamination, harm to self and others, insightful than adults. catastrophic thoughts, symmetry urges as well as hoarding. Comorbidity Multiple obsessions and compulsions can occur. Hoarding is OCD often co-occurring with other psychiatric conditions often seen in paediatric OCD and is defined as a persistent in young persons, leads to treatment challenges. Geller difficulty in getting rid of or parting with possessions, reports 39% of children and 62% of adolescents have clinical irrespective of their actual value and a need to save the symptoms of depression during their course of OCD while

Volume 9 No 1 - January/February 2018 11 Tourette’s Disorder occurs in about 25% of children and Disorders Associated with Streptococcal Infection (PANDAS). 9% of teenagers. Disruptive disorders are uncommon in This is usually suspected when the onset of OCD symptoms adult OCD while in children with OCD, high rates of ADHD is sudden, with an episodic course with an abrupt relapse (attention deficit hyperactivity disorder) and oppositional and remission of symptoms. There is no specific test for defiant disorder are seen. Co-occurring non-OCD anxiety PANDAS but the presence of OCD and/or a , disorders are common (e.g. separation anxiety) and around ADHD symptoms or oppositional behaviours should serve 5% of patients with pervasive also as an index of suspicion, especially post streptococcal have substantial OCD symptomatology. infection, and where there are choreiform movements. GABHS evidenced by either a positive throat culture for Coercion streptococcus or positive streptococcus serology (ASOT or Families of children who have OCD have heightened stress AntiDNAse-B) confirms the condition levels. Some children inflict high levels of coercive behaviours at home5 by attempting to force rules and prohibitions on Treatment others. This coercion can include the accommodation of Treatment should follow a bio-psycho-social intervention rituals or forced participation in them. The primary target is model. CBT is an evidence-based, proven and effective usually the mother in 95% of cases, father in 57% and siblings psychotherapeutic tool that needs to be offered to all in 49%. Peers are sometimes roped in. Contamination and juveniles with OCD. It is important to involve parents in the washing are two coercive behaviours that are commonly therapeutic process to help them deal with the rituals and seen. One needs to bear coercion in mind when dealing obsessions at home. with families who have a child or adolescent with OCD. Continually accommodating the coercion will lead to poorer There is extensive evidence that serotonin re-uptake response results and parents need tools to know how to inhibitors (SSRI’s) offer effective treatment for adult OCD. deal with this. Research in children is limited. Clomipramine, which is a tricyclic agent used in paediatric studies, and shown to The role of neuropsychological tests be superior to placebo, is no longer in widespread use, Neuropsychological test performance in the adult due to uncomfortable cholinergic side effects. Fluoxetine literature on OCD showed an under performance on has shown efficacy in children with OCD and is usually neuropsychological tests, pertaining to nonverbal memory, well tolerated. The initial dose should be low and titrated planning and processing speed.6 There is limited research on gradually to the lowest effect dose to minimise gastro- neuropsychological testing in children with OCD compared intestinal upset and central nervous system symptoms such to adults. Existing studies have revealed conflicting results as insomnia.7 Sertraline has demonstrated efficacy in a 12- with some OCD children outperforming healthy children and week multi-centre double-blind, placebo controlled, parallel vice versa, depending on the type of neuropsychological test group, randomised trial conducted in children with OCD and the domain tested. Some authors conclude that youth from the ages 6 years to 17 years, in addressing the OCD in the early stages of OCD do not display impairment, so symptoms, (although some remained mildly ill) with minimal more research is needed in this area. side-effects at doses often used in adults.8 The medication should be combined with CBT. Causality A glutamate transported gene may be associated with early Patients believed to have PANDAS should have treatment onset OCD through linkage studies. There appears to be a for the underlying neuropsychiatric symptoms along with familial risk, as the disorder is seen in children of parents timely antibiotics for known streptococcal infections. diagnosed with OCD. Course and Prognosis Neuroimaging studies implicate the cortico-striatal Symptom improvement and remission has been -thalamic circuits in paediatric OCD. Structural differences demonstrated using serotonergic medication in combination in the brain of some young OCD persons in neuroimaging with CBT. Family dysfunction and high symptom severity are studies include a greater volume of the cingulate gyrus, a associated with a poorer response to treatment. There are a diminished striatum, diminished grey matter density in the group of unresponsive patients who may need augmentation orbito-frontal cortex and a larger corpus callosum. of their SSRI therapy with additional medication.

Increased OCD symptoms in Tourette’s Disorder sufferers In summary OCD can occur in young persons and can be supports the concept of basal ganglia dysfunction. An treated effectively. High rates of co-morbid conditions in this inflammatory reaction in the basal ganglia after infections group can caused significant impairment and poor quality of with Group A beta haemolytic streptococcus (GABHS) in life if undetected and not managed. which anti-GABHS antibodies cross react with neurons in the basal ganglia, is another proposed aetiology leading to References available on request. what is known as Paediatric Autoimmune Neuropsychiatric

12 Volume 9 No 1 - January/February 2018 A perspective on Autism

Dr David Benn MBBCh DCH (SA), MMed (Psych) Child Psychiatrist Blairgowrie, Johannesburg

utism was first clearly described and named individuals the non-verbal means of communication (such by Leo Canner of John’s Hopkins Hospital in as gesture, appropriate facial expression or spontaneous 1944. His first paper on this subject physical affection) are intact. described ‘Autistic aloneness’ and ‘insistence on sameness’. These are still regarded as This has led to the development of more formal diagnostic core features of Autistic Disorder. However, the term instruments such as the ADOS (Autism Diagnostic autism was first used by Eugene Bleuler in 1910 to Observational Schedule). The ADOS uses both observation describe some of the negative symptoms of schizophrenia. and interaction with a child. Other diagnostic instruments In 1938 Hanz Asperger of the Vienna University Hospital, include the Autism Diagnostic Interview Revised, the also made use of this term in a lecture on child psychology. Diagnostic Interview Social (the Unfortunately, this led to Autism being described as one DISCO) and the Childhood Autism Rating Scales or CARS. of the childhood psychoses () The latter is used mainly to assess the severity of autism. which is highly misleading because it is not a classical . The diagnosis should not be made after a single consultation or without assessments of other professionals. While it Diagnosis and diagnostic criteria is usually the paediatrician, or perhaps child psychiatrist In 1980 with the advent of DSM III, classical autism was who is the first medical professional to be involved in clearly differentiated from childhood schizophrenia. In assessment and diagnosis, commonly the children have 1987 the DSM III R provided the first widely accepted been seen by other professionals particularly speech and diagnostic criteria for autism. language therapists and occupational therapists by the time they reach the medical profession. In May 2013, DSM V was released. This document contained an updated classification for Pervasive Most children with Autistic Spectrum Disorder have a Developmental Disorders. DSM V groups these disorders history of general developmental delay from an early as Autism Spectrum Disorders (ASDs) and includes Classic age. There is, however, a group of children who show Autism, Pervasive Developmental Disorder not otherwise regression in development after a clearly documented specified, Asperger's Syndrome, Rhett Syndrome and period of normal development. This is usually referred Childhood Disintegrative Disorder. The latter 3 terms to as Regressive Autism and is extremely distressing to have now been officially removed and replaced with a parents and professionals. general term, Autism Spectrum Disorders. A family history of autism in first degree relatives is It is also important to note that DSM V specifies that relatively uncommon because the very nature of the the diagnosis of autism does not exclude the diagnosis disorder mitigates against developing the relationships Attention Deficit Hyperactivity Disorder. The diagnostic needed for normal procreation. Individuals with autism system recognises a triad of symptom groups: seldom marry. • impaired social interaction, • impaired ability to communicate The child presents with delayed language development, • and stereotypical or narrow interests. impaired social interaction and stereotypical interests such as spinning an object. In severe autism, there is a These do exist in a continuum with normal and, particularly profound failure of the ability to communicate which is a in high functioning autism, involves the subjective cause of great frustration and anxiety. In Autism Spectrum perception of the diagnosing clinician. What, exactly Disorders such as high functioning autism, these same constitutes “stereotypical or narrow interests”? History symptoms occur but in far less severe form. For example, is full of individuals who’s dogged and obsessive interest some individuals with high functioning autism (previously in a particular area of research or endeavour, has resulted Asperger's Disorder) may at some level have an excellent in significant scientific and technological breakthroughs, command of verbal language but may be verbose and not to mention wonderful art. In young children, isolated pedantic in their speech. They often lack an understanding delayed language development (with or without deafness) of the subtleties of language and will for example take can resemble autism or autism spectrum disorder. In these figures of speech literally.

Volume 9 No 1 - January/February 2018 13 The symptoms of autism are usually first noted during the Disorder and learning disabilities. With this in mind, one time when children are being vaccinated. This is probably the of the conceptualisations of autism is that it may reason for the belief that vaccines such as the MMR cause the extreme end of the spectrum of specific learning autism although this association is completely discredited. disabilities. It is interesting to note that while classic autism is rarely seen in more than one sibling in a family, there is a Ultimately the diagnoses of autism and autism spectrum high association between classic autism and the presence disorder is a clinical diagnosis and a careful history is very of specific learning disabilities in siblings. Most children important. Special investigations are usually undertaken with specific learning disabilities show more subtle to eliminate conditions that may mimic autism. Impaired impairments of language development and particularly of motor coordination is a common finding in autistic written language. children. Delayed cognitive development is seen in up to 70% of children. This is very difficult for parents to While it is well accepted that Autistic Spectrum Disorders accept and some parents actually seek an alternate are associated with children born of older mothers, older diagnosis. Genetic testing is sometimes undertaken fathers may actually be even more important in the in ‘syndromic’ children and the most frequent genetic aetiology. Disorders commonly associated with the Autistic diagnosis associated with autism is . Spectrum Disorder diagnosis include genetic disorders (up Interestingly, maternal rubella accounts for just under 1% to 15%), delayed cognitive development, epilepsy, anxiety of children with autism. disorders and metabolic disorders.

In the diagnostic process, speech and language therapists Pathology provide precise inputs on the exact language delays and Pathophysiology and associated neuro-cognitive dysfunc- are important in the therapy. Assessment and treatment tions that underlie autism are poorly understood. These by occupational therapist are essential. Their concepts may involve overgrowth of neurons, impairments of synap- of Sensory Integration Disorder provides a sound basis tic development and functions, as well as disturbances in for their therapeutic interventions. What the sensory the development of the mirror neurone areas of the brain. integration occupational therapists see may be autism seen from a different point of view. As this group of The factors that cause autism appear to act on a large disorders is extremely complex, a combination of set of systems within the brain. The pathophysiology is assessments and therapies are appropriate. therefore highly complex. Neuro-anatomical studies have demonstrated that, following birth, the brains of autistic children appear to grow faster than usual and this is Epidemiological studies have, in followed by a period of relatively normal growth velocity. As a result, the excessive neurones may cause over activity recent years, shown a marked in important brain regions. The organisation of the brain increase in the incidence and involves neural pruning and babies are born with far more neurons and neuronal connections and they end up prevalence of autistic spectrum with this as adults. In addition, there may be abnormal disorders, partly due to a loosening formation of synapses and/or poor regulation ofthe of the diagnostic criteria. synthesis of neurotransmitters. The immune system may also have an important role in the aetiology and increases of pro-inflammatory kinins have Have ASDs become more common? been demonstrated in the brain of autistic individuals. Epidemiological studies have, in recent years, shown While the role of neurotransmitters in Attention Deficit a marked increase in the incidence and prevalence of Hyperactivity Disorder is relatively well understood, the autistic spectrum disorders, partly due to a loosening of role of these molecules in autistic spectrum disorders is the diagnostic criteria. Autistic Spectrum Disorders affects poorly understood. about 11 in 1000 internationally. The mirror neurone theory of autism is fascinating. Mirror The prevalence of classic autism, on the other hand, is in neurones are activated in mammals when one mammal the region of 1 to 2 in a 1000 of the general population. observes another performing a task. The neuronal activity The male/female ratio for classic autism is around 4:1. in the observer exactly mirrors the neuronal activity of the individual performing the act. Autistic and Autistic It is also likely that in South Africa, diagnosis in the private Spectrum individuals show poorly developed theory of healthcare sector has increased partly because children mind i.e the ability to attribute thoughts and feelings to with autistic spectrum disorders receive better medical aid other people, as well as showing empathy. This could benefits than those with Attention Deficit Hyperactivity be due to impairment of the mirror neurone system.

14 Volume 9 No 1 - January/February 2018 The Mirror Neurone System was first discovered in the and is very expensive. The provinces in South Africa that frontal lobes of macaque monkeys by Risolatti et al at the are best served with both dedicated autistic schools and University of Parma. special schools with autistic wings are Gauteng, Eastern Cape and Western Cape. The ABA approach is often Table 1. Screening for Autism and ASDs integrated into these educational programmes.

• No babbling by 12 months Medication • No gesturing by 12 months (e.g. pointing and waving) While there are no drugs that treat the core symptoms • No single words by 16 months of autism, about half of children with autism and • No spontaneous two-word phrases by 24 months autism spectrum disorders in North America are taking (No echolalia) psychoactive drugs. • Any loss of language or social skills during development. Source: Child Psychology and Psychiatriy: An Introduction, David H Most commonly prescribed are antipsychotics such as Skuse, 2003. risperidone, but antidepressants and anticonvulsants are also used. I believe that the use of antipsychotic drugs should be very carefully considered as children in the Management autistic spectrum are more likely to have atypical responses. The main goals of management are to minimise the These include serious and even fatal adverse events such as effects of the associated deficits, to minimise family acute dystonic reactions, neuroleptic malignant syndrome distress and to optimise and encourage the development and neutropenia. Some induce gynecomastia in both of independence. ASD individuals with higher cognitive genders and Tardive Dyskinesia, while relatively rare, may abilities and better language acquisition show more be irreversible. This group of drugs has the potential to favourable treatment outcomes. cause permanent neurological damage. Having said this, there are a large number of autistic children that benefit Generally, a multi-pronged treatment approach is needed. from these drugs. I think that antidepressants may be This includes supplying accurate information and support underused. What these drugs do best in ASDs is reduce for the family. By the nature of these interventions, their levels of anxiety. efficacies are difficult to measure objectively. There is, however, evidence that almost any sensible intervention Autism and autistic spectrum disorders are very distressing is better than none, but the core of therapy usually and anxiety provoking for the individual sufferers. When involves intensive behavioural therapy. These are usually there is co-morbid Attention Deficit Hyperactivity Disorder undertaken by occupational therapists, speech and the use of stimulants may be appropriate. Once again, language therapists, psychologists and sometimes neuro- children with autism are more likely to develop adverse developmental physiotherapists. reactions to these drugs as well.

Applied behaviour analysis (ABA) is one of the best known Autism and Autistic Spectrum Disorders are complex, interventional approaches and this is usually combined multi-faceted disorders that require multiple treatment with speech and language therapy, occupational therapy, and therapeutic inputs. They are managed in the context teaching at the appropriate cognitive level for the child and of a multi-disciplinary team which is often not practical sometimes social skills therapy. ABA draws in the family in a private practice setting. However modern means of and particularly the parents into active therapy. It is usually communication make it relatively easy for members of a intensive, emotionally and physically draining and can also multi-disciplinary team to stay in contact with each other. be very costly. The schooling required by autistic children is highly specialised requiring a very low teacher/pupil ratio References available on request.

Volume 9 No 1 - January/February 2018 15 Footprints and colours do not correspond to pneumococcal disease prevalence, Prevenar 13 (R) approval or use