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Genetics Flashcards

1
Q

What’s the genetic disorder?
Features: small brachycephalic head, epicanthal folds, flat nasal bridge, upward slanting palpebral fissures, brushfield spots, macroglossia, small ears, excess skin at nape of neck, single transverse palmar crease, short fifth fingers with clinodactyly, wide space between first and second toes

A

Trisomy 21

Key features: epicanthal folds and upstanting palpebral fissures, brushfield spots, clinodactyly

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2
Q

Genetic causes of Down syndrome

A

1) 95% presence of extra chromosome 21 as a result of non disjunction during meiosis
2) 3-4% translocation
3) 1-2% mosaicism

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3
Q

Risk factor for Down syndrome

A

Increasing maternal age

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4
Q

Prenatal screening for Down syndrome

A

First trimester: blood test (non invasive cell free DNA) and nuchal translucency

Second trimester: quad screen. Shows high Beta HCG, low unconjugated estriol, low AFP, and high inhibin

Diagnostic testing: amnio (after 15 weeks), CVS (10-14 weeks)

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5
Q

Down Syndrome systems and screening: cardiac

A

ASD, VSD, AV canal
All need an echo

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6
Q

Down syndrome systems and screening: GI

A

Classic associations: duodenal atresia (bilious emesis, double bubble sign), hirschprung (unable to pass meconium)

Reflux, constipation, feeding issues

Celiac: no universal screening, only if symptomatic

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7
Q

Down syndrome systems and screening: ophthalmology

A

**Cataracts, glaucoma, vision deficits, nystagmus, strabismus
Evals at birth to 2 mo, childhood q1-2 years and teens q3 years

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8
Q

Down syndrome systems and screening: endocrine

A

Hypothyroidism —> screen at birth, 6mo, 12 mo, then annually
Type 1 DM

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9
Q

Down syndrome systems and screening: heme/onc

A

Higher risk of leukemia
Transient myeloproliferative disorder at birth
Anemia, polycythemia, low WBC

CBC at newborn then annually (plus ferritin, iron studies, CRP)

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10
Q

Down syndrome systems and screening: orthopedic

A

Atlantoaxial (C1-C2) instability: no screening, XR if change in gait or use of arms and legs, bowel/bladder issues, neck pain, weakness. No high risk activities (football, heading in soccer, diving, gymnastics), backwards car seat, anesthesia precautions

Other ortho: hip displasia and dislocation, joint laxity, hypotonia, scoliosis

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11
Q

Down syndrome systems and screening: ENT, Pulm, audiology

A

Audiology testing at newborn, q6 months until ear specific at age 3, then annually
Anatomy —> increased risk of ear infections, sinusitits
Adenoid and tonsillar hypertrophy

OSA: sleep study between 3 and 5 years for all

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12
Q

What’s the genetic disorder?
-physical: microcephaly, low set or malformed ears, hypertelorism, palpebral and epicanthal folds, micropthalmia, cleft lip and palate, micrognathia, clenched hand posture, prominent calcani, scoliosis, hemivertebrae
-heart: VSD, PDA

A

Trisomy 18
Key features: clenched hand posture, prominent calcani (rocker bottom feet)
Most die because of central apnea

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13
Q

What’s the genetic disorder?
- orofacial cleft, abdominal wall defects (omphalocele), holoprosencephaly, aplasia cutis congenita, polydactyly, rocker bottom feet, VSD, microphthalmia

A

Trisomy 13

Key features: holoprosencephaly, cleft, abdominal wall

Median survival is 2.5 days

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14
Q

What’s the genetic disorder?
-features: short stature, low hairline, webbed neck, low set ears, high arched palate, wide space nipples
-primary ovarian insufficiency
-bicuspid aortic valve, coarctation
-slightly lower IQ, learning disabilities (math), ADHD, social emotional difficulties

A

Turner syndrome
-mosaicism may have less of these features
-hypergonadotropic hypogonadism
-key features: short stature, webbed neck, wide space nipples, bicuspid aortic valve and coarctation
-deficits in nonverbal

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15
Q

What’s the genetic disorder?
-tall stature
-subtle epicanthal folds, hypertelorism
-small penis, less facial hair, gynecomastia
-hypotonia, poor coordination
-cardiac septal defects
-speech delay, slightly lower IQ, learning disabilities,ADHD,ASD/social communication deficits

A

Klinefelters XXY
-key features: tall, hypogonadism, hypotonia, speech delay

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16
Q

What’s the genetic disorder?
-tall stature, larger head size
-subtle epicanthal folds, hypertelorism
-cardiometabolic
-hypotonia, poor coordination
-mild speech delay, LDs

A

XYY

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17
Q

Cause of trisomy chromosome disorders

A

Non disjunction during meiosis

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18
Q

Fragile X mechanism and genetics

A

Trinucleotide repeat (CGG)
FMR1 gene
55-200 repeats is premutation
Anticipation: becomes larger one generation to the next

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19
Q

What’s the genetic disorder?
-large head, long face, large ears, high arched palate, hyper extensible joints, hypotonia
-macroorchidism
-developmental delays, ID, ADHD, anxiety/hyperarousal, repetitive behaviors

A

Fragile X
Key features: large head and ears, associations with ASD, anxiety, repetitive behaviors

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20
Q

Fragile X premutation associated disorders

A

Most are intellectually normal but can have prominent ears, hyperextensible joints
Fragile X associated tremor ataxia syndrome
Fragile X associated premature ovarian failure
Fragile X neuropsych disorders

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21
Q

Genetic testing for angelman and prader Willi
-gene involved and chromosome location
-genetic causes of each
-how to test

A

UBE3A gene on 15q11.2-q13

Angelman: absent maternal expression. Deletion of maternal copy, paternal uniparental disomy (both copies from dad), imprinting defect or mutation in maternal copy

Prader Willi: absent paternal expression. Deletion of paternal copy, maternal uniparental disomy (both copies from mom), imprinting defect or mutation in paternal copy

Test with: DNA methylation analysis for 80% of cases of angelman (can miss the mutation in the UBE3A) and almost all prader Willi. For the rest would do a microarray

Imprinting defect has highest recurrence risk
Most common cause is the deletion of the maternal (for angelman) and paternal (for prader Willi) copy

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22
Q

What’s the genetic disorder?
-Hypotonia, seizures, ataxia
-severe expressive language delay, motor delay
-microcephaly
-happy demeanor

A

Angelman syndrome
Key features: ataxia and happy demeanor, severe expressive language delay and motor delay

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23
Q

What’s the genetic disorder?
-At birth hypotonia. Motor and speech delay. Perseveration and rigidity.
-At 6-8 years, hyperphagia

A

Prader Willi
Key features: hypotonia and failure to thrive in infancy then hyperphagia and obesity in childhood

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24
Q

Genetic conditions involving imprinted region of 11p15.5

A

Beckwith Wiedeman: 85% sporadic and some autosomal dominant variable expressively

Russel Silver: hypomethylation 11p15.5 (or maternal uniparental disomy on chromosome 7)

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25
What’s the genetic disorder? -prematurity, polyhydramnios, neonatal hypoglycemia -overgrowth: macrosomia, macroglossia, asymmetrical growth -omphalocele, renal anomalies, ear anomalies -tumors in 4-7% (wilms, adrenal, gonadoblastoma, hepatoblastoma) -increased risk of neurodevelopmental diagnoses (ADHD)
Beckwith Wiedeman Key features: neonatal hypoglycemia, overgrowth, omphalocele, tumors
26
What’s the genetic disorder? -SGA, postnatal growth failure, relative macrocephaly, neonatal hypoglycemia -frontal bossing, triangular facies, micrognathia -motor and cognitive delays, LDs
Russell Silver Key features: SGA/growth failure/short stature. Triangular facies. Neonatal hypoglycemia.
27
What’s the genetic disorder? -arched eyebrows, long eyelashes, long palpebral fissures, flat nose, large ears -short stature, hypotonia, scoliosis, seizures, nystagmus, strabismus -mild to moderate ID, language deficits, ADHD
Kabuki Syndrome KMTD2 or KDM6A Key features: arched eyebrows, long eyelashes, long palpebral fissures
28
What’s the genetic disorder? -long narrow face with high forehead, prominent jaw, pointed chin, down slanting eyes -overgrowth (tall, macrocephaly, large hands and feet), advanced bone age, cardiac and renal anomalies, seizures, hyperextensible joints, hypotonia, scoliosis, seizures -developmental delay, moderate to severe ID, ASD
Sotos Syndrome NSD1 Key features: overgrowth, long narrow face, moderate to severe ID
29
What’s the genetic disorder? -short stature, broad and angulated thumbs -down slanting eyes, low set ears, ocular anomalies -heart and kidney defects -moderate to severe ID, ADHD features, stereotypic behaviors
Rubinstein Taybi Key features: thumbs and ID
30
What’s the genetic disorder? -failure to thrive and childhood onset obesity -broad square face, heavy brows, deep set eyes -difficulty sleeping and excessive daytime sleepiness -mild to moderate ID, stereotypic and self injurious behavior, sensory issues
Smith Magenis RAI1 Key features: sleeping problems, stereotypic and self injurious movements, FTT and childhood obesity, coarse features
31
What’s the genetic disorder? -developmental stagnation at 6-18 mo -repetitive and stereotyped behaviors, fits of crying, apnea -ataxia, tremors, seizures, abnormal tone -prolonged QT -severe ID
Rett Syndrome MECP2 Key features: developmental stagnation, repetitive and stereotyped behaviors (hand movements), severe ID and neuro symptoms
32
The features and gene of CHARGE syndrome
CHD7 Coloboma (gap in iris) Heart disease Atresia choanae Retracted growth and development Genital hypoplasia Ear anomalies + seizures, cleft, hypothyroidism, FTT, tracheoesophageal abnormalities, neurodevelopment (ADHD, ASD, OCD)
33
Clinical criteria to diagnose NF1 (need 2 out of the 7) and ages they appear/approximate timeline
1) cafe au lait spots (infancy) 2) axillary or inguinal freckling (age 3) 3) optic glioma (age 4) 4) lisch nodules (hamartomatous tufts of pigment on iris) adolescence 5) skin neurofibromas adolescence 6)bony pseudoarthroses, 7) first degree relative with NF1
34
Genetics of neurofibromatosis type 1
NF1 gene, neurofibrin, 17q11.2 50% autosomal dominant, 50% sporadic Complete penetrance with variable expressivity Diagnosis is clinical! Don’t need to test unless 1) young child with suspected dx and sub threshold criteria particularly if no parent affected 2) nerve sheath tumor without other criteria or 3) for purposes of prenatal/preimplantation
35
Genetics of tuberous sclerosis
TSC1: hamartin, 9q34 TSC2: tuberin, 16p13.3 These are both tumor suppressor genes Autosomal dominant though most sporadic TSC2 more severe
36
Skin findings in neurofibromatosis and tuberous sclerosis
NF: cafe au lait spots (pigmented light to dark brown spots), axillary or inguinal freckling TSC: ash leaf spots (hypopigmented macular), shagreen patches (thick leathery orange peel patches), angiofibromas (reddish brown spots on nose and cheeks), unguarded fibromas
37
Tumors and growths in neurofibromatosis and tuberous sclerosis
NF1: optic gliomas, lisch nodules (growth in iris), neurofibromas (soft fleshy bumps on skin) TSC: cortical tubers, subependymal nodules, rhabdomyosarcoma
38
What’s the genetic disorder? -short stature, webbed neck, pectus -pulmonary valve stenosis (or other cardiac) -mild ID, LD, motor delays (hypotonia, hyperextensible, DCD)
Noonan Syndrome Key features: short stature and webbed neck with ID and right sided heart
39
What features distinguish turner and noonan? What features do they have in common?
Both have short stature and webbed neck and cubitus valgus Noonan has higher incidence of ID Cardiac: turner is left sided (coarctation of aorta, bicuspid aortic valve); Noonan is right sided (Pulm stenosis) and HCM
40
What’s the genetic disorder? -long narrow face -pectus, hyperextensible joints, scoliosis -aortic dissection -lens dislocation up -normal cognition and population rates of ASD and ADHD
Marfan syndrome Fibrillin 1 FBN1 AD Key features: tall, upward lens dislocation, aortic dissection, cognitively normal
41
What features differentiate Marfan and homocystinuria
Marfan: up lens dislocation, normal IQ, hyperextensible joints Homocystinuria: down lens dislocation, low IQ, rigid joints
42
Features of Ehlers Danlos
Skin fragility, hypermobile joints GI problems, allergy problems, pain Symptoms lead to mental health issues
43
What’s the genetic disorder? -frontal bossing, macrocephaly, flat nasal bridge -short stature, rhizometric shortening of limbs, hyperextensible joints, trident fingers -motor milestone delay (catch up by age 4), no cognitive delay
Achondroplasia FGFR3, AD Key features: short stature, frontal bossing, trident fingers
44
What’s the genetic disorder? -hypoplastic nares, boxy nose, eyelid hooding, short palpebral fissures, prominent ears, low set ears -cleft lip/palate -immunodeficiency, hypocalcemia -tetrology of fallot -borderline IQ with higher verbal, -ADHD anxiety poor social/ASD
Di George 22q11.2
45
What’s the genetic disorder? -broad forehead, shortened upturned nose, flat nasal bridge, long philtrum, downturned lip, wide mouth -stellate iris pattern -heart murmur -hypercalcemia -friendly personality, ID, sound sensitivity -ADHD and anxiety -joint laxity and short stature
Williams Syndrome 7q11.23 Elastin gene The heart murmur=supravalvular aortic stenosis Key features: friendly personality, stellate iris pattern, hypercalcemia
46
What are the features of digeorge? What is the affected gene?
Cardiac defects (tetrology of fallot most common; also interrupted aortic arch, VSD, truncus arteriosis) Abnormal facies (boxy nose, hypoplastic nares, hooded eyelids, prominent ears) Thymic hypoplasia (immunodeficiency) Cleft lip/palate Hypocalcemia 22q11.2 Plus: developmental delay, LD, ID, behavioral and mental health
47
Which genetic disorder is associated with low calcium? And which one is high calcium? And what genes are they associated with?
Low = DiGeorge (22q11.2) High = Williams (7q11.23, elastin)
48
3 Genetic disorders associated with childhood onset abdominal obesity
Prader willi Rubinstein Taybi Smith Magenis
49
2 disorders associated with repetitive movements
Rett Smith Magenis
50
What’s the genetic disorder? -broad square face with heavy brow, deep set eyes, depressed nose (coarse features) -hypotonia, speech impairment, mild to moderate ID -self injurious behavior, self hugging, sensory behavior, ADHD, anxiety -sleep issues (inverted circadian rhythm of melatonin) -eye issues -childhood onset abdominal obesity
Smith Magenis 17p11.2 Key features: self hugging/self injurious, sleep issues, sensory, coarse feature
51
What’s the genetic disorder? -hypertelorism, micrognathia, round face, low set ears, microcephaly -intellectual disability -high pitch cry
Cri du Chat 5p- Key features: microcephaly, high pitch cry, ID
52
What’s the genetic disorder? -arched eyebrows that meet, long eyelashes, small upturned nose, low set ears, small chin -slow growth, short stature -mild LD to severe ID, behavior problems
Cornelia de Lange Cohesin complex Most common gene = NIPBL (autosomal dominant, most cases sporadic) Key features: arched eyebrows that meet, short stature
53
What two disorders present with arched eyebrows and slow growth? How do they differ?
Kabuki: arched eyebrows with sparse lateral thirds, long eyelashes, depressed nasal tip Cornelia de Lange: arched eyebrows that meet, long palpebral fissures, upturned nose Cornelia de Lange has more limb issues and worse cognitive Cornelia de Lange neonatal growth retardation. Kabuki born normal growth parameters and retardation occurs afterwards
54
4 disorders with self injurious behavior
Lesch Nyhan Smith Magenis Smith Lemli Opitz Rett
55
Historical feature and associated disorder: avoidance of protein
Urea cycle disorders
56
Historical feature and associated disorder: episodic regression with illness
Mitochondrial disorders
57
Historical feature and associated disorder: episodic encephalopathy
Urea cycle disorders
58
Historical feature and associated disorder: developmental regression in a previously neurotypical preschool or school age child
X linked adrenoleukodystrophy
59
Historical feature and associated disorder: diurnal symptoms or fluctuates with time of day
GLUT1
60
What’s the genetic disorder? -Anemia and low absolute neutrophil count -abdominal bloating and greasy foul, smelling stools -skeletal abnormalities, short stature, heart defects -developmental delay, lower IQ, language and perceptual reasoning problems
Shwachman Diamond Key features: bone marrow failures/cytopenias, pancreatic insufficiency/malabsorption, skeletal
61
What’s the genetic disorder? -triangular faces, broad forehead, narrow chin, long nose -liver disease (jaundice, cholestasis) -pulmonary valve stenosis and peripheral pulmonic stenosis -butterfly vertebrae
Alagille Syndrome 20p12 JAG1, autosomal dominant Key features: jaundice, pulmonary valve disease, butterfly vertebrae
62
What’s the genetic disorder? -microcephaly, broad/flat nasal bridge and prominent glabella, high forehead, widely spaced large eyes -delayed growth and feeding issues -seizures, hypotonia, ID
Wolf Hirschhorn Deletion 4p16.3 Key features: widely spaced eyes, prominent glabella, seizures
63
Labs for and symptoms of urea cycle disorders
High ammonia respiratory alkalosis Vomiting, poor feeding, tachypnea Developmental delay with episodic changes in behavior
64
Labs to order for suspected amino acid disorder
Plasma amino acids and urine organic acids, elevated anion gap metabolic acidosis with ketonuria PKU Homocystinuria Nonketotic hyperglycemia Maple syrup urine disease Glutaric acidemia type 1
65
Disorders associated with the following -increased phenylalanine and low tyrosine -increased homocysteine -increased glycine -increased leucine, isoleucine, valine -decreased carnitine
PKU Homocystinuria Nonketotic hyperglycemia Maple syrup urine disease Glutaric acidemia type 1
66
What’s the genetic disorder? Vomiting, eczematoid rash, odor, fair skin and hair
PKU (Treat with restricted phe diet and prevent severe ID)
67
What’s the genetic disorder? -Tall stature, skeletal abnormalities, pectus, rigid joints -ID, developmental delay -downward lens dislocation -increased risk of thromboembolism
Homocystinuria
68
What’s the genetic disorder? Intractable seizures in first 24 hours of life, variable cognitive. No dietary treatment
Nonketotic hyperglycemia
69
What’s the genetic disorder? Presents at 3-5 days with feeding difficulties and respiratory distress, hypoglycemia, seizures, rigidity
Maple syrup urine disease (Treated with diet)
70
What’s the genetic disorder? Failure to thrive, poor, feeding, vomiting, hypotonia, liver failure, E. coli sepsis Mild ID, delayed speech, difficult difficulties with visual motor
Galactosemia Treat with no galactose (soy formula)
71
What’s the genetic disorder? Ptosis, ophthalmoplegia, ragged red fiber myopathy,diabetes,ataxia, deafness
Kearns Sayre and chronic progressive external ophthalmoplegia syndromes (Mitochondrial)
72
What’s the genetic disorder? Epilepsy, cerebellar ataxia, ragged red fiber, myopathy, myoclonic jerks
Myoclonic epilepsy and ragged red fibers (MERRF) (Mitochondrial disorder)
73
What’s the genetic disorder? Myopathy, ataxia, cardiomyopathy, deafness, diabetes, stroke
Mitochondrial encephalopathy, lactic acidosis, stroke-like episodes (Mitochondrial)
74
Mucopolysaccharidoses most commonly presenting with developmental findings
Hurler (MPS2) and Sanfilippo (MPS3)
75
What’s the genetic disorder? Developmental delay at 18 to 24 months, plateau, behavior issues (hyperactivity, and aggression) at 3 to 5 years Hearing loss
Hurler (MPS2) Mucopolysaccharidosis, lysosomal storage
76
What’s the genetic disorder? Regression from 2 to 6 years Cognitive regression First speech, then fine motor, then adaptive, then gross motor Hyperactivity and aggression
Sanfilippo (MPS3) Mucopolysaccharidoses, lysosomal storage
77
What’s the genetic disorder? Clumsiness to ataxia, poor fine motor, Supranuclear gaze palsy, dystonia, seizures
Nieman Pick Type C Sphingolipidoses, lysosomal storage Key features: supranuclear gaze palsy
78
What’s the genetic disorder? Enhanced startle , progressive loss of motor skills, axial, hypotonia, extremity hypertonia, hyperreflexia, macrocephaly, seizures
Tay Sachs *cherry red spot on macula (Spingolipidoses, lysosomal storage)
79
What’s the genetic disorder? -Microcephaly, 2-3 toe syndactyly, postaxial polydactyly, hypertelorism, ptosis, broad nasal tip, anteverted nares, low set ears, cleft palate, epicanthal folds, -Cardiac, GI, GU -ID moderate to severe, ASD, sensory hypersensitivity, language, impairment, sleep issues, self injurious
Smith Lemli Opitz 7 dehydrocholesterol predicate (AR) Cholesterol metabolism
80
What’s the genetic disorder? -typical early development. Onset 3 to 10 years. Then behavioral cognitive and neurological changes. Rapidly progressive central demyelination
X linked adrenoleukodystrophy Elevated VLCFA
81
What’s the genetic disorder? Typical at birth. At 3 to 6 months failure to thrive, hypotonia, irritability. At 18 months abnormal posturing. (dystonia, choreoathetosis), spasticity, hyperreflexia, no walking. At 2 to 3 years self mutilation.
Lesch Nyhan X linked HGPRT 1 Increased uric acid Key features: hypotonia, posturing, self mutilation (lip picking/biting)
82
Differences between XXY and XYY in presentation
Both have tall stature and similar facial features XXY has hypogonadism and gynecomastia XXY has more speech delay; XYY has more executive function and social difficulties
83
What’s the genetic disorder? -tall stature, pectus, hypotonia, fifth finger clinodactyly -increased risk of seizures -lower than avg IQ and LDs -risk of ADHD, anxiety, depression
Trisomy X Key desires: tall stature, risk of seizures Most have no clinical signs or features
84
Malformation
Structural defect arising from intrinsically abnormal developmental process during embryogenesis (neural tube defect)
85
Deformation
Abnormal structure resulting from nondisruptive mechanical forces applied to once formed normal part (eg club foot, amniotic band)
86
Dysplasia
Result of altered cellular constitution, tissue organization, or function within either a specific organ or tissue type
87
Williams syndrome neurocognitive profile
ID in 75% Challenges in visual spatial skills are common Stronger expressive than receptive language, notable strengths in verbal short term memory
88
Fragile X neuro cognitive profile
Learning disability in any area (most commonly math) EF deficits ASD ADHD Anxiety Variable intelligence, severe ID to average, most boys mild to moderate. Relative weakness in visual spatial and strength in verbal
89
Diagnosis of TSC: major and minor features
Major: hypomelanotic macules, angiofibromas, ungual fibromas, shagreen patch, retinal hamartomas, multiple cortical tubers, subpendymal nodules, cardiac rhabdomyomas, lymphangioleiomyomatosis, angiomyolipomas Minor: confetti skin lesions, dental enamel pits, intraoral fibromas, retinal achromatic patch, multiple renal cysts, nonrenal hamartomas, sclerotic bone lesions 2 major or 1 major with 2 minor Don’t need genetic test positive to diagnose. Can diagnose if have mutation without these features
90
Neurodevelopmental and TSC
Nearly all have some challenge in behavior, academic, cognitive or psychosocial Psychiatric: ADHD, anxiety, depression Cognitive: profound ID in 30% though most have normal IQ. Risk of ID increases with seizures and ASD ASD: more frequent than in general population
91
What’s the cognitive, developmental and behavioral profile with 22q11.2?
Overall borderline Higher verbal than nonverbal Strengths: memory, reading decoding, spelling Deficits: spatial, attention, working memory, visual memory, VMI Math LD common ADHD, ASD, anxiety, poor social interaction, oppositionality Higher rates of psychosis
92
Klinefelters cognitive, developmental, behavioral profile
Learning disability (most often dyslexia) Math and visual spatial abilities usually normal (higher nonverbal than verbal skills) Expressive and receptive language deficits IQ on average 10 points lower Behaviorally, ADHD, ODD, OCD, anxiety, ASD
93
Heart defect most common in -fragile X -22q11 -Williams -Noonan -turner -downs -Rett
-fragile X : mitral valve prolapse -22q11 : conotruncal like tetrology of fallot, truncus arteriosis, interrupted aortic arch -Williams: supravalvular aortic stenosis -Noonan: peripheral pulmonic stenosis -turner: bicuspid aortic valve, coarctation -Downs: AV canal defects, ASD -Rett prolonged QT
94
Trofinetide
Approved in 2023 as the only specific treatment for Rett syndrome Synthetic terminal tripeptide of insulin like growth factor 1
95
What’s the genetic disorder? Girl with Tall stature, hypotonia, pectus, increased seizure risk Mean IQ a little lower (85-90), LD usually affecting verbal Higher rates of ADHD, depression, anxiety
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