Behavioral Neurology
What to know
ADHD requires developmentally inappropriate inattention and/or hyperactivity, at least six symptoms, onset before age 12, involvement in more than one setting, and functional impairment. Stimulants are first line; atomoxetine and alpha-2 agonists are alternatives. Monitor growth, blood pressure, and sleep.
Autism spectrum disorder requires deficits in social communication plus restricted, repetitive behaviors; screen with the M-CHAT at 18 and 24 months, refer early for behavioral intervention, and evaluate hearing. Regression between 15 and 24 months is common in ASD; regression after age 2 with loss of language and hand-wringing in a girl suggests Rett syndrome (MECP2). Comorbid epilepsy occurs in about a quarter.
Tourette syndrome requires multiple motor tics and at least one vocal tic for more than a year; comorbid ADHD and OCD are the rule. Behavioral therapy (CBIT) is first line, with alpha-2 agonists or antipsychotics for severe impairment. Do not withhold stimulants solely because of tics.
Intellectual disability requires IQ below 70 with adaptive deficits; first-tier workup includes chromosomal microarray and fragile X testing, with thyroid and lead studies as indicated. Learning disabilities are specific (dyslexia, dyscalculia).
Traps
"Stimulants cause tics" is weak evidence, and questions punish reflex avoidance of stimulants. Rett syndrome and childhood disintegrative disorder are distinct from ASD. Do not attribute regression to autism without considering neurodegenerative and epileptic (Landau-Kleffner) causes.
Rule of thumb
In Tourette syndrome with ADHD, treat the ADHD first - it usually causes more impairment than the tics.
Headache, Sleep, and Neurotrauma
What to know
Headache: distinguish primary from secondary using red flags - thunderclap onset, fever, nocturnal vomiting, neurologic deficit, papilledema, age under 5, and change in established pattern. Pediatric migraine is shorter (2–72 hours), often bilateral frontal, with GI symptoms and relief with sleep; treat with NSAIDs and triptans, and consider topiramate, amitriptyline, propranolol, or cognitive behavioral therapy for prevention. Idiopathic intracranial hypertension presents with headache, papilledema, and obesity; treat with acetazolamide and weight management. Medication overuse headache is common.
Sleep: obstructive sleep apnea from adenotonsillar hypertrophy causes snoring, enuresis, and daytime inattention. Narcolepsy with cataplexy is diagnosed by multiple sleep latency test; HLA-DQB1*0602 is supportive. Non-REM parasomnias (sleep terrors, sleepwalking) are benign and arise from slow-wave sleep; REM behavior disorder is rare in children. Restless legs syndrome warrants ferritin testing.
Neurotrauma: concussion is a functional injury with headache, dizziness, and cognitive slowing; management is rest followed by graded return to learning and then play, with no same-day return. Epidural hematoma shows a lucid interval and a biconvex shape; subdural hematoma is crescentic from bridging veins; diffuse axonal injury involves the gray-white junction. Abusive head trauma classically shows subdural hemorrhage, retinal hemorrhages, and encephalopathy.
Traps
Do not clear an athlete for same-day return. A normal CT does not exclude concussion. Young children with headache need careful funduscopy.
Rule of thumb
Lucid interval followed by rapid deterioration equals epidural hematoma - a neurosurgical emergency.