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NMSK Exam 1 > 13. Clinical Approach to Neurodevelopmental and ATN Disorders > Flashcards

13. Clinical Approach to Neurodevelopmental and ATN Disorders Flashcards

1
Q

When do neurodevelopmental disorders manifest?

A

Early in development, before the child starts going to school.

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2
Q

Neurodevelopmental Disorder:

Intellectual Disability (Intellectual Developmental Disorder)

A

Intellectual and adaptive functioning deficits in [conceptual, social and practical] domains that occur during developmental period

  1. Deficits in intellectual functions: executive functioning: reasoning, planning, problem solving, abstract thinking, academic learning and learning from experience that are confirmed clinically and by individualized, standard IQ test.
  2. Defcitis in adaptive functioning that do not meet development and sociocultural standards for personal independence and social responsibility. Limiting functioning in daily life => problems in education, employment, communication, socialization and independence.
  3. Onset of deficits in developmental period,
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3
Q

Deficits a child can experience in conceptual domain for adaptive functioning for Intellectual Developmental Disorder.

A
  1. Conceptual skills lags behind other kids
  2. For preschoolers: language and pre-academic skills develop slow.
  3. For school age: concepts lag behind peers.
  4. For adults: academic skills are at elementary level and support is needed to use them in work/personal life.
  5. Ongoing assisstance/caregivers are needed.
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4
Q

Deficits a child can experience in social domain for adaptive functioning for Intellectual Developmental Disorder.

A
  1. Hard time making friends same-age, because immature in social interactions
  2. Hard time perceiving social cues
  3. Communication, conversation and language are more concrete and less mature
  4. Peers notice pt has a hard time regulating emotion/behaviors
  5. Social judgement is immature for age => risk of being manipulated by others.
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5
Q

Deficits a child can experience in practical domain for adaptive functioning for Intellectual Developmental Disorder.

A
  1. Hard time with age-appropriate personal care.
  2. Hard time with complex daily living tasks: adults need help with grocery shopping, transportation,
  3. Hard time making good decisions about personal well-being and recreational activities.
  4. Jobs restircted to those that dont emphasize conceptual skills
  5. Need help making healthcare/ legal deicisons
  6. Need help raising a family.
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6
Q

What is Global Developmental Delay?

A

Dx for intellectual disability for those who cannot under systematic assessments of intellectual functioning:

    1. too young
  • 2. injured during developmental period
  • 3. severe head injury.
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7
Q

Autism Spectrum Disorder Diagnostic Criteria

A

A. ND disorder where person has deficits in social skills (communication/interaction) in multiple contexts, manfiested by all of the followingm seeling currently or prior:

  • Deficits in:
    • 1. Social-emotional recipricocity: failure of back-forth convo; reduced sharing of interest/emotions/affect; dec ability to initiate/respond to social interactions
    • 2. Non-verbal communication: eye contact, body language, facial expressions
    • 3. Developing, maintaining and understanding relationships: dif in imaginative play in making friends; no interest in firennds.

B.Restricted, repetitive patterns of behavior/interests or activities manifested by at least 2 of the following:

  1. Stereotyped/ repetitive movements:
  2. Insistence on sameness, adherence to routine, or ritualized patterns of verbal/nonverbal behavior:
  3. Preoccipation with certain/objects:
  4. Hyper or hyporeactive to sensory input or unsuual interests in sensory aspects of the environemnt:

C. Sx must be present in early developmental period (but may not become fully manifest until social demands > limited capacities, or may be masked by learning strategies.

D. Sx cause clinically significant impairment in [social, occupational or other important ares of functioning].

E. Not better explained by intellectual developmental disorder or global developmental delay. ID + ASD frequently co-occur. To make co-morbid dx: social communication should be below expected for general developmental level.

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8
Q

Give examples of the [restricted, repetitive INTENSE patterns of behavior, interests or activities] seen in ASD.

A
  1. Stereotyped or repetitive motor movements:
    1. lining up toys,
    2. idiosyncratic phrases
    3. Echolalia
  2. Insist on everything being the same, no changes in routine, or ritualized patterns of verbal/nonverbal behavior:
    1. extreme distress at small changes,
    2. problems with transitions,
    3. rigid thinking patterns,
    4. same greeting rituals;
    5. same routnies, eat same food
  3. Interests that are highly restricted, intense and fixated:
    1. strong attachment to or preoccupation with unsual objects
  4. Hyper or hyporeactive to sensory input or unsual interests in sensory aspects of the environemnt:
    1. indiff to pain/temp,
    2. adverse response to specific sounds/textrues
    3. excessive smelling or touching of objects
    4. visual facination with lights or movemeents.
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9
Q

Autism Spectrum Disorder typically co-occurs with what?

How is the co-morbid diagnosis made?

A

Typically co-occurs with [Intellectual Disability].

To make co-morbid dx: social communication must be below that for general developmental level.

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10
Q

Specifications for Autism Spectrum Disorder

A
  1. W or WO intellectual impairment
  2. W or WO language impairment
  3. Assc with a known medical, genetic or environmental factor
  4. Assc with another neurodevelopmental, mental or behavioral disorder
  5. W catatonia
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11
Q

Severity of ASD

A

When diagnosing ASD, you must ID a severity, based on social communication impairments and restricted, repetitive patterns of behavior.

  1. Level 3 => requiring very substantial support
  2. Level 2 => requiring substantial support
  3. Level 1 => requiring support
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12
Q

Research shows that what BEST differentiates people with ASD and ID?

A

Restricted interests/repetitive behaviors: rocking, talking about 1 topic only

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13
Q

What is language like in those with ASD?

A

Formal language skills are intact, but the USE of language for reciprocal communication is impaired.

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14
Q

How do adults witth ASD that have compensation strategies for some social challenges react in new/unsupported situations?

A

Struggle: support from effort and anxiety of consciously calculating what is socially intuitive for most people

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15
Q

Most consistently useful behavioral intervention for patients with ASD?

A

Key = early intevention with behaviorial management

  1. Education and support for parents, siblings, teachers and caregivers.
  2. Learning about “parellel process” and how it can be useful for behavioral managment: allowing them to listen to some music at low noise
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16
Q

Medications for ASD

A

No tx for autism, only sx. Only 2 FDA approved meds for [irritability and agitation] associated with Autism

  1. Risperidone
  2. Aripiprazole
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17
Q

What other medications have off-label uses for Autism?

A
  1. Valproic acid
  2. Gabapentin
  3. Stimulants
  4. Alpha AGO
  5. Antidepressants
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18
Q

What have been associated with Autism?

A
  1. Advanced age of dad (paternal)
  2. Valproic acid (used for epilepsy) in pregnancy.
  3. Genes
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19
Q

Who is more likely to be dianogsed with ADHD?

Why do we think this is?

A

4x common in M (most cases in children 6 - 12 YO); girls are less likely to have disorder recognized.

  • This is because F are more likely to present with inattentive subtype than boys => less disruptive behavior => referral bias causing under ID and lack of treatment for G.
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20
Q

Who is less likely to receive consistent ADHD treatment?

A

Poorest children

21
Q

Adult ADHD has comorbidities with what psychiatric disorders, in order of MC => LC?

A
  1. Mood disorders
  2. Anxiety disorders
  3. Substance disorders
  4. Intermittant explosive disorders
22
Q

A significantly higher proportion of ______ than ____ with adult ADHD received treatment for co-morbid mental/substance problem in the prior 12 months.

A

F > M

23
Q

TEST Q = what are the most common co-morbidities in chidren with ADHD?

A

Tourette Syndrome Triad: Majority of TS patients have the following comorbidities

Tics + ADHD + OCS (obsessive compulsive syndrome)

24
Q

Tourette Syndrome Triad; go into more detail

A
  1. Tics: Chronic motor/vocal tics that develop in childhood (before 18 YO) that last >1 year
  2. OCS: OC symptoms that do not meet full criteria for OCD
  3. ADHD: Disturbance of attention that does NOT meet full criteria for ADHD
25
Q

Boys are more likely to have _______;

Girls are more likely to have _______.

A
  • Boys = tics and ADHD
  • Girls = OCD
26
Q

What do clinicians need to consider in the intitial assessment and ongoing management of patients with ADHD?

A

Chronic Tic Disorder

27
Q

Those who committed childhood suicide more often had _________; less often had ______.

A
  • more often = ADHD
  • less often = depression and dysthymia
28
Q

What functions is prefrontal CTX responsible for?

A

Executive Functioning

  1. Assessing situations
  2. Prioritizing what is relevant vs. irrelevant
  3. Filtering out extenous information
  4. Making plans on how to act
  5. Executing plans
  6. Assessing effect of action in a fluid manner
29
Q

What is the proposed neurological problem in patients with ADHD?

A
  • Dysfunction with processing information in the prefrontal CTX, particularly the daNCC (dorsal anterior midcingulate cortex)due to a deficiency in DA and NE.
30
Q

What area has ↓ activation in both ADHD and Tics Disorder?

A

SMA (Supplementary motor area)

31
Q

ADHD Inattentive Type

Diagnostic Criteria

A

Children: 6 or more of following sx; 17 and older: at least 5 sx in multiple settings

  1. Hard time sustaining attention
  2. Does not seem to listen
  3. Easily distracted
  4. Struggles to follow instructions
  5. Fails pay attention to detail/makes careless mistakes
  6. Hard time being organized
  7. Avoids/dislikes tasks the require alot of thinking
  8. Loses things
  9. Forgetful in daily activities
32
Q

ADHD Hyperactive Type

Diagnostic Criteria

A

Children: 6 or more of following sx; 17 and older: at least 5 sx in multiple settings

  • 1. Fidgets with hands or feet or squirms in chair
  • Difficulty
    • 2. Remaining seated
    • 3. Engaging in activities quietly
    • 4. Waiting or taking turns
    1. Children = Runs about or climbs excessively; adults = extreme restlessness
    1. Acts as if driven by a motor
    1. Talks excessively
    1. Blurts out answers before questions have been completed
33
Q

What diagnostic tests can be used to diagnose ADHD?

A
  1. TOVA (Tests of Variable Attention)
  2. Conners Continuous Performance Test
34
Q

Strengths and Weakness of TOVA, to dx ADHD.

A
  • Strength:
      1. Language and culture-free testing (in 8 langages)
      1. Normed by gender
      1. Performance validity to flag unusual performance
      1. Immediately available, easy to read report
      1. Has txs for home and school success strategies
      1. Anyone can be trained to give test
    • 7. Shorter test for young children
  • Weakness
    • ​1. Long time to measure vigilance
35
Q

Strengths and Weakness of Conners Continuous Performance Test, to dx ADHD.

A

Task-oriented computerized test of attention related problems in ppl 8 YO or older.

  1. Administration: 15 minutes (1 minute practice test + 14 minute test time)
  2. Use a laptop
36
Q

1st line of treatment for ADHD in

  • 1. Preschool children (4-5 YO)
  • 2. Elementary children (6-11 YO)
    1. Adolescents (12- 18 YO)
A
  • 1. Preschool children (4-5 YO)
      1. Evidence-based behavior therapy to parent and/or teacher
    • If no improvement and child has mod-severe sx => methylphenidate
  • 2. Elementary children (6-11 YO)
      1. Preferred: meds + behavior therapy
    • FDA approved meds for ADHD and/or evidence-based behavior therapy to parent and/or evidence-based behavior therapy to teacher
  • 3. Adolescents (12- 18 YO)
      1. Meds
      1. May give behavior therapy.
    • Preferred to give both.
37
Q

MOA of Alpha 2 AGO in treatment of ADHD

A
  • Guanfacine and clonidine = non-stimulants/anti-HTN that modulate noradrenergic tone in PFC
  • MOA:
    1. Enhanced noradrenergic input from locus coeruleus
    2. Direct POST-synaptic stimulation alpha2-R (resp to NE) on neuron in prefrontal CTX
38
Q

Bupropion, an anti-depressant with mixed catecholiminergic effect, should not be taken in what patients with ADHD?

A
  • Hx of seizures => increases risks of seizures!
39
Q

Atomoxetine MOA

A
  1. Non-stimulant used to tx ADHD
  2. SSNR (selective NE re-uptake inhibitor); bc no effect on DA => no euphoria => no abuse potential
  3. Less insomnia and loss of appetite.
40
Q

What ADHD med should ONLY be used in adults?

A

Modafinil: binds to DA transporter and inhibits DA-reuptake

41
Q

Motor Disorders

A
  1. Developmental Coordination Disorder
  2. Stereotypic Movement Disorder
  3. Tic Disorder
42
Q

Stereotypic Movement Disorder

A
  • A. Repetitive, seemingly driven, and apparently purposeless motor behavior(e.g., hand shaking or waving, body rocking, head banging, self-biting, hitting own body).
  • B. The repetitive motor behavior interferes with social, academic, or other activities and may result in self-injury.
  • C. Onset is in the early developmental period.
  • D. The repetitive motor behavior is not attributable substance/ neurological condition and is not better explained by another neurodevelopmental or mental disorder
43
Q

Specifications of Stereotypic Movement Disorder

A
  1. With self-injurious behavior (or behavior that would result in an injury if preventive measures were not used)
  2. Without self-injurious behavior
  3. Associated with a known medical or genetic condition, neurodevelopmental disorder, or environmental factor (e.g., Lesch-Nyhan syndrome, intellectual disability [intellectual developmental disorder], intrauterine alcohol exposure)

Specify current severity:

  1. Mild: Symptoms are easily suppressed by sensory stimulus or distraction.
  2. Moderate: Symptoms require explicit protective measures and behavioral modification.
  3. Severe: Continuous monitoring and protective measures are required to prevent serious injury.
44
Q

What is a tic?

A

sudden, rapid, recurrent, nonrhythmic motor movement/vocalization

45
Q

Tourettes Disorder Diagnostic Criteria

A
  1. Multiple motor AND one or more vocal tic that occur before 18 YO and persist for > 1 year.
    1. Tics must occur MANY time a day, nearly everyday or interittently thoughout a period of more than 1 year
    2. Anatomic location, number, frequency, type, complexity and severity of tic MUST change over time
    3. Not explained by another medical condition or effects of substances
    4. Must be witnessed by a reliable examiner at some point during illness OR videotaped.
46
Q

What comorbities, in order of MC, occur with Tourettes?

A
  1. ADHD
  2. OCD
  3. Anxiety disorder
  4. Mood disorder and risk of suicide
  5. Disruptive behavior
  6. Learning disabilities and poor school performance
  7. Sleep disorders
47
Q

Only approved drugs for tx of Tourettes?

SE?

A
  1. Antidopaminergic drugs:
    1. Haloperidol
    2. Pimozide
    3. Aripiprazole
  2. May cause Tardive Dyskinesia
48
Q

Other drugs for tx of Tourettes

A
  1. DA depleter (Tetrabenazine): deplete DA by inhibiting VMAT2 in presynaptic neuron => block uptake of DA synaptic vesicles and less DA storage and release (as effective as typical neuroleptics, but dont cause TD)***
  2. A2 AGO: guanfacine/clonidine
  3. Antipsychotics: fluphenazine and risperidone
  4. Botox injections
  5. Anticonvulsants: topiramate, valproic acid and gabapentin
49
Q
A

NMSK Exam 1 (22 decks)

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