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Tracto - Helping neurodivergent children thrive
I am confronted with child and adolescent patients on a daily basis where it is clear that the parents have lost control of the situation, be it a case of ADHD, anxiety, depression, Tourette Syndrome or autism. The family dynamics are often disrupted and even volatile which then culminate in a total chaotic situation where the children rule. They refuse to do their homework, often refuse to attend classes, refuse to perform any home chores and spend a long hours playing video or computer games.
Psychological support is effective to a point but can be expensive in the long run. More often than not, these children are referred for some form of pharmaceutical interventions which form part of the management of the underlying disorder. Despite this, the impact of the daily disruptive behaviour continues to have a negative impact on the family, the siblings as well as the relationship between the parents..
My plea is that there should be a return to a well structured family home program where each member has a specific role to play, responsibilities are understood by each individual and the parents accept responsibility for the physical and psychological wellbeing of the family. This could imply a total move away from the classical “come home, grab a snack, sit and watch TV till late and rush through the homework before slumping off to bed” style to a more structured week plan that includes going for a walk with the children and dogs, NO TV after 18h00, sit at a table for supper and talk about the experiences of each member whereafter the chores such as washing the dishes etc. are well understood and accepted. Rewards do not have to be attached to daily chores which are part of the weekly family program, but rather to some additional activities such as mowing the lawn of helping to paint a wall. It will be interesting to hear how one could organise families in a close community to decide on a specific program in order to avoid children comparing and using the differences to avoid their obligations. Of course this will also bring about some additional responsibilities where parents in such a community agree to adhere to the rules laid down by the broader or extended “family”.
I am part of a group that have started to tackle some of these critical issues and have developed an app that will assist parents with neurodiverse children to manage them more effectively.
Please have a look at Tracto that can be downloaded for free.
Download Tracto Application
Autism
Autism: now what?
If a combination of the following behaviours are being presented it might be a good idea to speak to a paediatrician about the possibility of autism.
Lack of eye contact
Not responding appropriately to their name
Not engaging in pretend play
Not playing peek-a-boo by eight months of age
Not babbling by 12 months
No pointing or waving
No imitative behaviour by 12 months
No words by 16 months
No meaningful two-word phrases by 24 months
Any loss of speech at any age
Preferring to play alone
Losing previously acquired skills at any age
No sharing of enjoyment or interest
Becoming distressed by minor changes in routine
Performing repetitive movements such as hand flapping or rocking
Playing with toys in unusual ways, such as spinning or lining them up
Exhibiting over sensitivity to sounds or textures
Being a picky eater
Experiencing plateaus or delays in skills development
Displaying challenging behaviours such as aggression, tantrums and self injury
Appearing to be in their own world
Not following any, or following too few, receptive instructions
Repetitive movements with objects or posturing of body, arms, hands or fingers
Being hyperactive
Being unable to sustain their attention compared to their peers.
Attention Deficit Hyperactivity Disorder (ADHD)
A brief review on pharmaceutical interventions in neuro-psychological disorders
Pieter Fourie (Dec 20)
Background
Sometimes children, especially during the school-going period from around 4 to 18 years, present with behavioural problems that will eventually be tied up to potentially three subgroups, i.e. attention, communication and/or emotional related issues. According to the international DSM V directive, these problems or issues are then again grouped in clinical diagnoses such as (i) attention deficit hyperactivity disorders with or without a number of co-morbidities (associated problems such as anxiety, oppositional defiant disorder and mood dysregulation), (ii) autistic spectrum disorders (including Asperger’s, Pathological Demand Avoidance and Pervasive Developmental Disorder not otherwise specified) and Tourette syndrome. Big names and often frightening to parents with children presenting with one of these entities. Be as it may, the pharmaceutical approach (medicine) does not necessarily distinguish between the clinical diagnoses, but rather focusses on the presenting behavioural problems, such as anxiety, communication deficits and concentration problems.
Pathophysiology
In order to communicate information effectively whether verbally or non-verbally, such as with writing, the brain activates a specific pathway, the so-called executive function network. By executing a task, the prefrontal cortex has to increase control over the decision making process (increasing attention whilst inhibiting other inputs such as sound, visual or tactile stimuli) followed by the execution of the task at hand. As an example, in order to perform a mathematical task, the prefrontal cortex has to initiate the process by activating the cortex problem solving system. Once the solution has been derived, the information is then transferred to the motor cortex that will give an order to the hand to write down the answer. The basal ganglia will modulate the hand movement thereby streamlining the information whilst feedback is given via the eyes to ascertain that the correct answer is written down neatly. The emotional center will guard over the whole process from beginning to end and once completed, will convey a feeling of satisfaction to the cortex.
Approach
To simplify matters, a very limited description is presented here. When evaluating a patient, attention is specifically given to five target domains namely:
hyperactivity and inattention
These symptoms usually arise from a decrease of certain neurotransmitters i.e. dopamine and/or noradrenaline in the prefrontal cortex
behavioural issues (aggression, self-harming, tantrums)
Poor inhibitory control of emotions due to low dopamine in the central areas of the brain
communication (dyspraxia, dyslexia, poor eye contact and emotional avoidance)
Poor or incomplete neural integration between pathways connecting important centres such as the prefrontal cortex, cortex and basal ganglia
sleep disturbance
Usually a result of a shift in the circadian rhythm leading to wakefulness till around 23h00
mood disorders including anxiety
Insufficient levels of serotonin in the emotional area
Medication options
Although there are a multitude of options, the following are a few medications that are often prescribed.
hyperactivity and inattention
Clonidine: an antihypertensive drug that is very effective in improving concentration
Methylphenidate: e.g. Ritalin(4 or LA:8hours), Concerta(12hours) or Contramyl(12hours)
Atomoxetine: e.g. Strattera or Inir
Tricyclic antidepressant: Ethipramine
behavioural issues (aggression, self-harming, tantrums)
Clonidine: see above
Antipsychotics: e.g. respiridone (given twice daily) or aripiprazole
Anti-convulsants: ac e.g. sodium valproate, lamotrigene or carbamazipine
Lithium: stabilises neural activity
communication (dyspraxia, dyslexia, poor eye contact and emotional avoidance)
Antipsychotics: see above
SSRI: e.g. sertraline, fluoxetine or escitalopram
Both in combination
sleep disturbance
Circadian rhythm modifiers: e.g. melatonin or Circadin
SSRI: see above
Mirtazapine: a new antidepressant
mood disorders including anxiety
SSRI: see above
Anticonvulsants: see above
Both in combination
Monitoring
Monitoring the response of the different medications, either alone or in combination is absolutely essential, therefore feedback from the caretaker or patient on a regular basis will help to identify any side-effects, determine efficacy as well as optimal dosage through incremental increasing of the dose.
Tourette Syndrome
Understanding Tourette Syndrome
Pieter Fourie
Introduction
Tourette syndrome is considered to be neither a psychological nor a psychiatric problem. In layman’s terms it is defined as a highly talented and intelligent brain that is held captive by a body that it has not yet come to terms with. It is possibly one of the the most common neurological disorders known, although no genetic test is readily available. Most research indicate that the genetic transmission is autosomal dominant, however, it is probably more complex.
There is no cure for Tourette syndrome and therefore it is a lifelong condition. Treating Tourette syndrome symptoms effectively leads to a dramatic improvement of the manner in which the patient will manage the problems he/she experiences and the syndrome will “burn out”. Boys are more affected than girls. These children often slept poorly as infants, refused specific foods and often do not tolerate loud sounds or rough clothing materials
1. Clinical presentation
Ticks and involuntary movement of body parts, are the most common symptoms that will occur around the ages 7 to 11. These will include the following.
Blinking of eyes
Throat clearing
Feet tapping
Shoulders pulling
Facial grimacing
Sniffing
Hands clapping
Biting nails, clothes and licking of lips.
Shouting
Profanity
Lying: primarily to avoid punishment
Stealing: trying to impress friends or purely on the spur of the moment.
Inappropriate sexual touching
Low self esteem due to poor performance at school
Poor interpersonal relationships
Argumentative: always trying to win the argument
Does not demonstrate remorse
Poor response to punishment
Has a high sense of what is right or wrong and will expect others to comply, although often fails to comply themselves
Manipulative: will especially try and set up parents against each other
Likes to tease others but do not tolerate to be ridiculed
A strong association with obsessive compulsion has been demonstrated
2. Management
Understanding the underlying pathology is essential for effective management. Parents needs to be educated that there is hope and if treated well, the outcome will often be very good.
Children with Tourette syndrome are more comfortable operating in an environment where they have well structured guidelines and expectations.
Rather than punishment, negotiations concerning expectations are often more effective.
Attention must be paid to the specific educational requirements that will support the patient’s specific needs and capabilities.
Therapeutic support
Because the brain is highly neuroplastic up to the age of twenty, the sooner medication is instituted, the more effective it can support the central nervous system to optimise neural pruning as well as neural integration.
Never commence with stimulants such as methylphenidate first and only add them once the patient is more receptive.
Because these patients suffer from a high level of anxiety, a SSRI should be prescribed as early as possible.
Poor neural communication should be supported with an antipsychotic such as risperidone, aripiprazole or equivalent.
Clonidine often will control mood swings and improve concentration.
Psychological support, especially to educate the parents/caregiver is often very helpful with specific focus and supplying them with management tools to cope with all the aspects mentioned above.
3. Future outcome
Although the underlying pathology is poorly understood and the symptomatology extremely complex and difficult to manage, the outcome will often be surprisingly positive provided:
Therapeutic interventions are commenced as early as possible
Parents are psychologically supported to cope with these children
Educational support is specifically structured around the needs of the individual patient
Educating teachers and caregivers to identify children with Tourette syndrome as early as possible.
Always be reminded that these patients are often very talented and highly intelligent and with the right support the final outcome will improve dramatically.
Anxiety & Depression
There is a Silent Tragedy in Our Homes
Written by Psychiatrist Luis Rojas Marcos
There is a silent tragedy that is developing today in our homes and affecting our most beloved ones: our children. Our children are in a devastating emotional state! Over the last 15 years, researchers have given us more and more news about the epidemics:
• 1 in 5 children with mental health problems;
• 43% ADHD increase observed;
• 37% increase in adolescent depression;
• 200% increase in suicide rate in children aged 10 to 14 years.
What is happening and what are we doing wrong?
Children today are being stimulated with material objects, but they are deprived of the basic concepts of a healthy childhood, such as:
• emotionally available parents;
• clearly defined limits;
• responsibilities;
• balanced nutrition and adequate sleep;
• movement in general, but especially in open air;
• creative play, social interaction, unstructured gaming opportunities, and boredom spaces.
Excessive Demand Avoidance (EDA)
Understanding Excessive Demand Avoidance (EDA)
Blog post by PRIORY - Education and Children’s Services
What is EDA?
Excessive Demand Avoidance previously know as Pathological Demand Avoidance (PDA) is a developmental disorder which is distinct from autism but falls under the spectrum. It is a pervasive developmental disorder (meaning it affects all areas of development) and was first identified by Elizabeth Newson in 2003, although it is still not currently recognised in many tools used for diagnosing autism. It is a complex, challenging and misunderstood condition that is often ignored or not even recognised by many professionals. It is worth noting that strategies which are helpful for learners with autistic spectrum disorder may not be useful in cases of EDA.
Core features of EDA are:
• A need to resist normal, everyday demands made by others
• This resistance appears to be a way of managing acute anxiety
• Unlike those with autism, learners with EDA may use social skills to manipulate; these skills are, however, at a functional and logical level rather than at a deeper emotional level.
General/Other
Say NO!
Pieter Fourie
Dear parents, mothers, fathers, teachers and caretakers - Please say NO!
Toddlers
Say no when throwing a tantrum.
When touching something dangerous
When wanting something in the shop
When refusing to go to bed
When taking things off a counter
When refusing to get out of the bath
Preschool
Say no to walking around while eating
Watching television all day long
Demanding food thats not on the table
Demanding a toy or sweets in the shop
Refusing to tidy up room
Playing in a dangerous area
Primary school
Say no to extra screen time
To sleep out with friends whose parents you do not know
Say no to late night playing outside
Say no to violent video games
High heel shoes and risky skirts
Say no to swearing and bad jokes
High school
Say no to tattoos and belly rings
To ripped jeans and risky tops
Say no to smoking and drugs
Say no to alcoholic drinks
Say no to under age videos
Open parties and bars
College/University
Say no to too much pocket money
Weekends with friends you do not trust
Driving without a license
Drinking and driving
Say no to travelling alone late night
Say no to bribes and cheating
Let your “NO” come from your mind - but motivated by your heart.
Religion and parenthood
Something has happened over the past 50 years, that has accelerated exponentially, especially since the introduction of the internet. Somehow, as a world population, we have started to move away from religion and attached ourselves to the internet as the ultimate guideline to direct our thoughts and behaviour. This has had a dramatic effect on our psychological wellbeing. Whereas before, an individual would have sourced her/his emotional strength for her/his religious directives, the internet presents the individual with an unlimited array of psychological support options, such as mindfulness, self realisation and mental strength guidelines to name a few.
Parents with children, especially in the pre-teen and teen group, will probably agree that it is one of the most challenging phases in their lives to find meaning and self-worth. This is clear from the large numbers of young children ending up taking antidepressants to lessen anxiety and support their daily emotional fluctuations. The Covid pandemic has escalated the increased anxiety and confidence and self worth are at an all time low. I see this daily in my practice and the parents are relatively lost to guide them as they themselves struggle with the same issues.
Combining the loss of religious directives with what we are experiencing here, it is highly suggestive that the absence of a higher power, where one could have gone to for guidance and strength, trickles down to our inability to direct our children. The psychological support offered by the internet is mostly self directed and in itself questionable so that it fails to act as a guidance law that can support our decisions and child rearing.
The original concept of an omnipotent god directing our moral and social lifestyles to which we owe allegiance gave us as parents a very stable reference point which was supposed to be handed down from one generation to another. As always, the younger generation, especially during the pre-teen and teenage phase, will question our moral and disciplinary actions, but in time will come to some form of acknowledgment that it is required to protect and guide their own thoughts and actions.
My plea therefore is to reinvestigate our decision to divorce ourselves from a religious source. Ultimately it is the only form of psychological and emotional support that has withstood the test of time and has not been watered down to some senseless self-directed technique. If we do not reorganise our guidance priorities we will increasingly experience a disruption of the family dynamics to the point of complete psychological apathy.