neurodevelopmental disorders

NEURODEVELOPMENTAL DISORDERSPsychopathology and DiagnosisWaynesburg UniversityJames M. Hepburn, PhD

INTELLECTUAL (DEVELOPMENTAL) DISABILITYA move away from relying exclusively on IQ scores and toward using additional measures of adaptive functioning. DSM-IV criteria had required an IQ score of 70 as the cutoff for diagnosis; the new criteria recommend IQ testing and describe “deficits in adaptive functioning that result in failure to meet developmental and sociocultural standards for personal independence and social responsibility.”

DEFICITS IN GENERAL MENTAL ABILITY a. Reasoning b. Problem solving c. Planning d. Abstract thinking e. Judgment f. Academic learning g. Learning from experience

IMPAIRMENTS OF ADAPTIVE FUNCTIONING i. Conceptual ii. Social iii. Practical Deficits in Adaptive Functioning is met when

at least one domain of adaptive functioning requires ongoing support for the person to perform adequately in one or more life settings

CHANGES IN SEVERITY LEVELS OVER THE LIFESPAN Diagnostic assessments must determine

whether improved adaptive skills are the result of a stable, generalized new skill acquisition (in which case the diagnosis of intellectual disability may no longer be appropriate)

The improvement is contingent on the presence of supports and ongoing interventions (in which case the diagnosis of intellectual disability may still be appropriate.

GLOBAL DEVELOPMENTAL DELAY Reserved for individuals under the age of 5.

The child fails to meet expected developmental milestones in several areas of intellectual functioning and cannot be assessed.

UNSPECIFIED INTELLECTUAL DISABILITY This diagnosis is appropriate for individuals

over the age of 5, where formal assessment is compromised by physical disability such as blindness or loco-motor disabilities.

COMMUNICATION DISORDERS Communication Disorders include deficits in

language, speech and communication and includes the following: language disorder, speech sound disorder, childhood –onset fluency disorder, social (pragmatic) communication disorder, and other specified and unspecified communication disorders.

LANGUAGE DISORDER Difficulties in the acquisition and use of

language due to deficits in the comprehension or production of vocabulary sentence structure or discourse.

Usually affects vocabulary and grammar: i. First words and phrases are delayed; ii. Vocabulary size is smaller and less

varied iii. Sentences are shorter and less

complex

LANGUAGE DISORDER, CONTINUED Diagnosis is based on the synthesis of the

individual’s history, clinical observations in different contexts, and scores from standardized tests of language ability.

Language disorders emerge during the early developmental period. By age 4 individual differences in language ability are more stable and typically persist into adulthood.

When the child meets criteria for an intellectual disability, s separate diagnosis of Language Disorder is not given unless the language deficits are clearly in excess of the intellectual limitations.

SPEECH SOUND DISORDER: Difficulty with phonological knowledge of

speech sounds or the ability to coordinate movements for speech in varying degrees.

Diagnosed when speech sound production is not what would be expected based on the child’s age and developmental stage Not a result of physical, structural, neurological or

hearing impairment. Language disorder may co-occur with speech

sound disorder. The mastery of speech sound production should

result in mostly intelligible speech by age 3 years.

CHILDHOOD-ONSET FLUENCY DISORDER (STUTTERING) Disturbances in the normal fluency and time

patterning of speech as well as anxiety about speaking or limitations in effective communication and socialization.

Childhood fluency disorder occurs by age 6 for 80% of affected individuals. The severity of fluency disorder at age 8 years

predicts recovery or persistence into adolescence and beyond.

SOCIAL COMMUNICATION DISORDER Designed to capture children who have

severe deficits in social communication and interaction but who lack the restrictive and repetitive behavior patterns necessary for ASD. These children have typically been diagnosed with PDD-NOS.

SOCIAL (PRAGMATIC) COMMUNICATION DISORDER Difficulty with following rules for social

nuances in communication such as following social rules for discourse or inability to follow non-verbal cues.

A differential diagnosis of Autism should be based on the presence of restricted/repetitive patterns of behavior, interests or activities.

AUTISTIC SPECTRUM DISORDERS The most debated and anticipated change is

the consolidation of DSM-IV criteria for Autism—Asperger’s, childhood disintegrative disorder, and pervasive developmental disorder-not otherwise specific (PDD-NOS)—into one diagnostic category called autism spectrum disorder (ASD).

NEW CRITERIA For ASD, the new criteria identify two major

categories of symptoms for the diagnosis of ASD, rather than three from the DSM-IV.

a. deficits in social communication and social interaction;

b. restrictive and repetitive behavior patterns.

LEVELS OF SEVERITY Three levels of severity for both principal

symptoms indicate the level of supportive services required by an individual patient. The three levels are:

a. “requiring support,” b. “requiring substantial support,” and c. “requiring very substantial support.”

SPECIFIERS Specifiers include

a. Severity b. With or without accompanying

intellectual impairment c. With or without accompanying

language impairment d. Associated with known medical or

genetic condition or environmental factors.

INCLUSIVE CATEGORY Autism spectrum disorder encompasses

disorders previously referred to as early infantile autism, pervasive developmental disorder NOS, childhood disintegrative disorder, and Asperger’s disorder.

Impairments in communication and social interaction are pervasive and sustained.

ASD & COMMUNICATION DEFICITS Language deficits range from complete lack

of speech through language delays, echoed speech, or overly literal language.

The use of language for reciprocal social communication is impaired in ASD.

Deficits in nonverbal communication include absent, reduced, or atypical use of eye contact, gestures, facial expressions, body orientation or speech intonation.

INTERPERSONAL RELATIONSHIP DEFICITS Deficits in interpersonal relationships should

be judged against norms for age, gender, and culture.

a. In young children there is often a lack of shared social play and insistence on

playing by very fixed rules. b. Difficulties in understanding irony,

metaphors, and white lies. c. Sometimes a preference for relating to

people much older or much younger than them.

STEREOTYPY Stereotyped or repetitive behaviors include

simple motor behaviors such as hand flapping or spinning coins, and repetitive speech.

Resistance to change and ritualized behavior.

Many adults with ASD without intellectual or language disabilities learn to suppress repetitive behavior in public, and childhood history of such may need to be evaluated.

DIAGNOSTIC INDICATORS OF ASD Symptoms are typically recognized during the

second year of life.

a. Look for early developmental delays or any losses of social or language skills.

b. A “red flag” for ASD is the deterioration in social behaviors or use of language during the first 2 years of life for some individuals.

c. First symptoms of ASD involve delayed language development and/or lack of social interest or unusual social interactions

DEVELOPMENTAL PROGRESSIONS ASD is not a degenerative disorder—

Developmental gains are typical in later childhood.

Only a minority of individuals with ASD live and work independently in adulthood, and those who do tend to have superior language or intellectual abilities.

DIFFERENTIAL DIAGNOSIS OF ASD ASD is 4x more prevalent in males than females When an individual shows impairment in social

communication but not restrictive and repetitive behavior or interests, R/O social (pragmatic) communication Disorder.

Intellectual disability is the appropriate diagnosis when there is no apparent discrepancy between the level of social-communicative skills and other intellectual skills.

ADHD should be considered when ADHD symptoms exceeds that typically seen in individuals of comparable mental age

ATTENTION-DEFICIT/HYPERACTIVITY DISORDER A persistent pattern of inattention and/or

hyperactivity-impulsivity

Hyperactivity refers to excessive motor activity; Impulsivity refers to actions that occur without forethought and result in a high potential for harm. Impulsive behaviors may manifest as social intrusiveness.

DIAGNOSTIC CRITERIA & ASSOCIATED FEATURES ADHD begins in childhood, and symptoms

must be present before age 12. Symptoms must be present in more than one

setting. Typically symptoms vary depending on context within a given setting.

Mild delays in language, motor, or social development often co-occur with ADHD.

Associated features may include low frustration tolerance, irritability, or mood lability.

ADHD PREVALENCE ADHD occurs in most cultures in about 5% of

children and about 2.5% of adults.

It is 2x more prevalent in males than females. Females are more likely than males to present primarily with inattentive features.

DEVELOPMENTAL PATTERNS Most often first identified in elementary age

children. The disorder is relatively stable through adolescence, but some develop symptoms of conduct disorder.

In adulthood, along with inattention and restlessness, impulsivity may remain problematic even when hyperactivity has diminished.

DIFFERENTIAL DIAGNOSIS OF ADHD With Oppositional Defiant Disorder (ODD) can be

complicated, because some individuals with ADHD develop secondary oppositional attitudes toward tasks that are challenging and require attention and sustained activity.

Intermittent Explosive Disorder reflects serious aggression toward others, which is not a feature of ADHD.

Children with ADHD may show significant changes in mood within the same day; such lability is distinct from a manic episode, which must last 4 or more days. Bipolar disorder is rare in preadolescents, even when severe irritability and anger are prominent.

Children with ADHD may also be diagnosed with Disruptive mood dysregulation disorder.

SPECIFIC LEARNING DISORDER The consolidation of separate learning

disorders that had appeared in DSM-IV—reading disorder, mathematics disorder, and disorder of written expression—into one diagnosis called specific learning disorder

SPECIFIC LEARNING DISORDER Difficulties learning and using academic skills

in reading, writing, and mathematics. It can include deficits in recognition, comprehension and fluency.

Learning disorders cannot be better accounted for by intellectual disability, visual or auditory deficits, neurological impairments or inadequate educational opportunities

SPECIFIERS Each academic area that is impaired should

be specified.

Severity (Mild, Moderate, Severe) should also be specified for each impaired domain.

It is a neurodevelopmental disorder with a biological origin that is the basis for abnormalities at a cognitive level.

DIAGNOSTIC CONSIDERATIONS OF SPECIFIC LEARNING DISORDERS It is not simply a consequence of the lack of

opportunity or inadequate instruction. The individual’s performance of the affected

academic skills is well below average for age. They are typically readily apparent in the early school years.

Specific learning disorder affects learning in individuals who otherwise demonstrate normal levels of intellectual functioning, and can occur in intellectually “gifted”

The diagnosis is made on the basis of medical, developmental, educational and family history.

An uneven profile of academic abilities is common.

PREVALENCE & PROGNOSIS Learning disorders affect 5-15% of school-

age children; Prevalence in adults is 4%. It is more common in males than in females (2:1-3:1).

Specific learning disorder is lifelong. Comorbidity with ADHD is predictive of worse

mental health outcome than that associated without ADHD.

Individualized instruction may improve or ameliorate the learning difficulties in some individuals.

MOTOR DISORDERS Developmental Coordination Disorder

Stereotypic Movement Disorder

Tic Disorders

DEVELOPMENTAL COORDINATION DISORDER Impaired skills requiring motor coordination,

significantly interfering with performance of daily activities (dressing, eating, use of specific tools, sports, etc.); can affect both gross and fine motor skills.

Typically not diagnosed before the age of 5 years.

COMORBIDITIES If intellectual disability is present, the motor

difficulties are in excess of those expected for the mental age.

Both ADHD and ASD can be diagnosed with Developmental Coordination Disorder if coordination problems are not better attributable to lack of attention or impulsiveness.

STEREOTYPIC MOVEMENT DISORDER Repetitive, seemingly driven, and

purposeless motor behavior. Specify with or without self-injurious behavior; Specify with a known medical condition,

neurodevelopmental disorder or environmental factor;

Specify if mild, moderate, or severe.

DIFFERENTIAL DIAGNOSIS When ASD is present, stereotypic movement

disorder is diagnosed only when there is self-injury or when the stereotypic behaviors are a focus of treatment.

Stereotypies have an earlier age of onset (before 3 years) than do tics, which have a mean age of 5-7 years).

They are more consistent and fixed in their pattern compared with tics.

TIC DISORDER a. Tourette’s Disorder b. Persistent (Chronic) Motor or Vocal Tic

Disorder c. Provisional Tic Disorder

Diagnosis for any tic disorder is based on the presence of motor and/or vocal tics.

DIFFERENTIAL DIAGNOSIS Tic symptoms cannot be attributable to the

physiological effects of a substance or another medical condition.

Having previously met diagnostic criteria for Tourette’s disorder negates a possible diagnosis of persistent tic or vocal tic disorder.

Differentiating tics from OCD behaviors can be difficult, but OCD often have cognitive-based drive and require repeated behaviors equally on both sides of the body. The behaviors appear more goal directed and complex than tics.