Child Psych Flashcards
What is autism spectrum disorder (ASD)?
Characterized by impairments in social communication/interaction & restrictive, repetitive behaviors/interests
Combines 4 previously separate disorders (autistic, Asperger’s, childhood disintegrative, pervasive development disorder)
Diagnosis of ASD
Severity depends on degree of impairment:
- Mild
- Moderate
- Severe (severe RBRs)
DEFICITS IN SOCIAL COMMUNICATION & INTERACTION:
Impaired social/emotional reciprocity:
- Can’t hold a conversation (unidirectional)
- Not share (interests, emotions)
- Not check on other person interest
- Lack empathy / understanding
- Screener: understand others emotions?
Deficits in nonverbal communication:
- Eye contact, facial expressions, gestures, body
Relationship / interpersonal challenges:
- Lack of interest in peers
- Not adjust behavior to situation
- Not sharing imaginative play
RESTRICTED, REPETITIVE BEHAVIORS, INTERESTS, & ACTIVITIES (RBRs): Stereotyped repetitive mannerisms (self-stimulating things):
- Motor (hand flapping, circling)
- Speech (No inflection at the right point, breathes at wrong times, emphasis on the wrong part of the syllable, etc.)
Inflexible rituals / routines (rigid thought patterns, sameness):
- Screener questions: trouble w/ transitions (plan to go to dinner, but then decide not to –> outburst)
Intense / peculiar interest:
- Fixated w/ abnormal intensity / focus
Hyper/hypo-reactivity to sensory input:
- Increased (or decreased) - textures, light, sound, pain
If there are no RBRs, it is SOCIAL (PRAGMATIC) COMMUNICATION DISORDER:
- Social use of verbal & nonverbal communication
Not better accounted for by ID or global developmental delay
- When ID & ASD co-occur, social communication is below expectation based on developmental level
Red flags for ASD
Rapid deterioration of social &/or language skills during first 2 years of life
If skills are lost after age 2 or more expansive losses occur (e.g. self-care, motor skills), an extensive medical workup needs to be initiated
Epidemiology of ASD
Recent increase in prevalence: 1% of population
- Could be related to expansion of diagnostic classification and/or increased awareness/recognition
Males to females ratio is 4:1
Symptoms typically recognized between 12-24 months old, but varies based on severity
Etiology of ASD
Multifactorial:
- Prenatal neurological insults:
- Infections
- Drugs
- Advanced paternal age
- Low birth weight
- 15% of cases are associated w/ known genetic mutation:
- Fragile X syndrome (most common known single gene cause of ASD)
- Down’s syndrome
- Rett syndrome
- Tuberous sclerosis
- High comorbidity w/ ID
- Association w/ epilepsy
Known not to cause:
- Maternal temperament & mental illness
- Immunizations
Prognosis of ASD
It is a chronic condition
- Prognosis is variable, but 2 most important predictors of adult outcome:
- Level of intellectual functioning
- Language impairment
- Only minority of patients able to live & work independently in adulthood
No cure, but various treatments are used to help manage symptoms & improve basic social, communicative, & cognitive skills
Treatment of ASD
Early intervention
Remedial education
Behavioral therapy
- Applied Behavioral Analysis
Psychoeducation
Meds:
- Used to reduce disruptive behavior / irritability / aggression associated w/ ASD:
- Low-dose atypical antipsychotic:
- Risperidone (Risperdal)
- Aripiprazole (Abilify)
- Low-dose atypical antipsychotic:
What is intellectual disability (ID)?
Formerly mental retardation (this is illegal)
- De-emphasizing IQ scores
- Destigmatize
Characterized by severely impaired cognitive & adaptive/social functioning
- Severity level is based on adaptive functioning, indicating degree of support required
- Single IQ score does not adequately capture this & is no longer used solely to determine ID severity
Diagnosis of ID
FUNCTIONAL DEFICITS Intellectual: - Reasoning - Problem solving - Planning - Abstract thinking - Judgment - Learning (academic & experience) - Confirmed by clinical assessment & standardized intelligence testing (scores at least 2 SDs below the population mean) Adaptive: - Communication - Social participation - Independent living - Require ongoing support in multiple environments
Deficits affect 3 domains:
- Conceptual
- Social
- Practical (being able to live alone)
Onset in developmental period
Severity levels (based on need for support):
- Mild
- Moderate
- Severe
- Profound
Epidemiology of ID
Overall: 1% of population
Etiology of ID
GENETIC:
Down Syndrome (trisomy 21) (most common chromosomal disorder, #1 identifiable cause)
- Epicanthic folds, flat nasal bridge, palmar crease
Fragile X syndrome (FMR-1 gene mutation) (#1 inheritable cause, #2 identifiable cause)
- Macrocephaly, joint hyperlaxity, macroorchidism in post-pubertal males
- Males > females
Others:
- Phenylketonuria
- Familial mental retardation
- Prader-Willi
- Williams
- Angelman
- Tuberous sclerosis
PRENATAL:
TORCH infections
- Toxoplasmosis
- Other (syphilis, HIV/AIDS, alcohol/illicit drugs)
- Fetal alcohol syndrome (FAS) = leading preventable cause of birth defects & ID
- 3 features:
- Growth retardation
- CNS involvement (structural, neurologic, functional)
- Facial dysmorphology (smooth philtrum, short palpebral fissures, thin vermillion border)
- May cause range of developmental disabilities, including ID
- Rubella
- CMV
- HSV
PERINATAL:
- Birth trauma
- Anoxia
- Premature
- Meningitis
- Hyperbilirubinemia
POSTNATAL:
- Hypothyroidism
- Malnutrition
- Toxin exposure
- Trauma
- Psychosocial causes
Idiopathic / unknown = 50%
What is global developmental delay?
Failure to meet expected developmental milestones in several areas of intellectual functioning
Diagnosis reserved for patients <5 years old when severity level can’t be reliably assessed via standardized testing
Patients will need to be reevaluated to clarify the diagnosis at a later time
What are specific learning disorders?
Characterized by delayed cognitive development in a particular academic domain (with normal IQ - it is difficult to say someone has a learning disorder if he/she is not expected to be at a higher level)
- Challenges w/ reading, writing, & arithmetic often co-occur
- Frequently occurs w/ ADHD which can worsen the prognosis
Diagnosis of specific learning disorders
Significantly impaired academic skills which are below expected for chronological age
- Interfere w/ schooling, occupation, or activities of daily living (ADLs)
Begins during school-age, but may become more impairing as demands increase
Affected areas:
- Reading (dyslexia)
- Learning difficulty with accurate/fluent word recognition, poor decoding, & poor spelling
- Writing
- Arithmetic (dyscalculia)
Not better accounted for by ID, visual/auditory deficits, language barriers, or subpar education
Always rule out sensory deficits before diagnosing a specific learning disorder
Epidemiology of specific learning disorders
Prevalence in school-age children: 5-15%
Males > females
Etiology of specific learning disorders
ENVIRONMENTAL:
Increased risk w/ prematurity, very low birth weight, prenatal nicotine use
GENETIC:
Increased risk in first-degree relatives of affected individuals
Comorbidity of specific learning disorders
Commonly co-occurs w/ other neurodevelopmental disorders (e.g. ADHD, communication disorders, developmental coordination disorders, ASD)
Comorbid w/ other mental disorders (e.g. anxiety, depressive, & bipolar disorders)
Treatment of specific learning disorders
Work w/ school
- Develop Individualized Education Plan (IEP) vs. 504 plan
- IEP:
- Have to make sure there are adjustments/accommodations for that particular person so that he/she is able to show that he/she can do that specific thing (give calculator, allow longer time, etc.)
- 504 Plan:
- Only requires “equal access”
- It is a structural thing (ramp access, large doors, allowed to go to school, etc.)
- IEP:
Accommodations:
- Regular classroom
- Special education
Behavioral techniques may be used to improve learning skills
What are communication disorders?
Encompass impaired speech, language, or social communication that are below those expected for chronological age
Begin in the early developmental period
Lead to academic or adaptive issues
What are the types of communication disorders?
LANGUAGE DISORDER
Difficulty acquiring & using language due to expressive and/or receptive impairment:
- Reduced vocabulary
- Limited sentence structure
- Impairments in discourse
Increased risk in families of affected individuals
SPEECH SOUND DISORDER (phonological disorder)
Difficulty producing articulate, intelligible speech
CHILDHOOD-ONSET FLUENCY DISORDER (stuttering)
Dysfluency & speech motor production issues
Increased risk of stuttering in first-degree relatives of affected individuals
SOCIAL (pragmatic) COMMUNICATION DISORDER
Challenges w/ social use of verbal & nonverbal communication
If restricted/repetitive behaviors, activities, or interests are present –> diagnose ASD
Increased risk w/ family history of communication disorders, ASD, or specific learning disorder
Treatment of specific learning disorders
Speech & language therapy
Family counseling
Tailor education to meet individual’s needs
What is ADHD?
Characterized by persistent inattention, hyperactivity, & impulsivity inconsistent w/ patient’s developmental stage
3 subcategories:
- Predominantly inattentive type
- Predominantly hyperactive/impulsive type
- Combined type
Diagnosis of ADHD
2 symptom domains: inattentiveness & hyperactivity/impulsivity
INATTENTION (at least 6):
- Fails to give close attention to details or makes careless mistakes
- Doesn’t seem to listen when spoken to directly
- Does not follow through on instructions & can’t finish tasks
- Difficulty organizing tasks
- Avoids, dislikes, or reluctant to engage in tasks requiring sustained mental effort
- Distractible
- Loses things needed for tasks
- Forgetful in daily activities
HYPERACTIVITY/ IMPULSIVITY (at least 6):
- Fidgets w/ hands or feet or squirms in chair
- Runs/climbs in inappropriate situations
- Out of seat constantly in situations where remaining seated is expected
- Difficulty playing quietly
- “On the go” or “driven by a motor”
- Talks excessively
- Difficulty awaiting turn
- Interrupts or intrudes upon others
- Blurts out answers before questions have been completed
Symptom onset before age 12, but can be diagnosed retrospectively in adulthood
- 6+ symptoms for more than 6 months present in AT LEAST 2 settings:
- Get collateral info from teachers at school
- Rating scale: Conner’s, Vanderbilt, etc.
- Sources: parents, teacher, student
- Compare progress before & after treatment & before/after changes in meds & dosages
- Symptoms interfere w/ or reduce quality of social/academic/occupational functioning
- Symptoms not due to another mental disorder
Differential diagnosis of ADHD
MEDICAL DISORDERS:
- Vision / hearing impairments
- Seizure disorders
- Lead poisoning
- Iron deficiency anemia
- Thyroid disorders
- Sleep disorder
MEDICATIONS:
- Prescribed medications (e.g. albuterol, steroids)
- Drugs of abuse (e.g. cocaine)
EMOTIONAL / BEHAVIORAL DISORDERS:
- Depression / mood disorders
- Anxiety disorders
ENVIRONMENTAL DISORDERS:
- Child abuse / neglect
- Inadequate parenting
- Inappropriate educational setting
- Stressful home environment
Epidemiology of ADHD
Prevalence:
- 5% of children
- 2.5% of adults
Males to females is 2:1
- Females present more often w/ inattentive symptoms
Etiology of ADHD
Etiology of ADHD is multifactorial:
GENETIC FACTORS:
- Increased rate in first-degree relatives of affected individuals
ENVIRONMENTAL FACTORS:
- Low birth weight
- Smoking during pregnancy
- Childhood abuse/neglect
- Neurotoxin/alcohol exposure
Course/prognosis of ADHD
Stable through adolescence
Many continue to have symptoms as adults (inattentive > hyperactive)
High incidence of comorbid ODD, CD, & specific learning disorder
Treatment of ADHD
Multimodal treatment of ADHD:
- Meds are most effective treatment for decreasing core symptoms, but should be used in conjunction w/ educational & behavioral interactions
MEDS:
- 1st line: stimulants (response rate 94% if both are tried)
- Methylphenidates (Ritalin, Concerta, Focalin)
- Amphetamines (Adderall, Vyvanse, Dexedrine)
- Nonstimulants
- 2nd line: atomoxetine (SSRI)
- Alpha agonists (Guanfacine, Clonidine)
- Other meds
- Bupropion + TCA
THERAPY:
- Behavioral therapy (modification techniques & social skills training)
- Educational interventions (i.e. classroom modifications)
- Parent psychoeducation
