Intellectual Disabilities Flashcards
A. Intellectual Disability
B. Global Developmental Delay
C. Unspecified Intellectual Disability
Introduction:
Previously called Mental Retardation, [DISORDER] refers to a disorder that starts during the developmental period (American Psychiatric Association, 2013). It consists of certain intellectual deficits and challenges handling aspects of daily life like school, work, home, social life, health, among other things. [DISORDER] is an explanatory phrase for sub standard intelligence that occurs below age eighteen, which is the developmental period.
While DSM-4 emphasized IQ scores, this is not so with DSM-5. Instead, no particular score is indicated to establish diagnosis, and the assessment is done based on the individual’s complete clinical presentation (American Psychiatric Association, 2013). The basis regarding this development was that this definition leaned more toward a conceptual rationale, and was not applicable to actual real-life cases. With the previous definition, an individual who met the cut off score could have adaptive issues in key areas of adaptive functioning which makes the individual’s actual functioning similar to that of people who have a much lower IQ score. Additionally, the previous term of mental retardation carried a huge social and affecting stigma, hence the adaptation of new terminology in DSM-5. While an estimated ten percent of children reportedly have some learning deficits, three percent have some form of [DISORDER].
According to DSM-5, there are three criteria that must be fulfilled in order for the diagnosis of [DISORDER] (American Psychiatric Association, 2013).
(A) Deficits in intellectual functions, such as reasoning, problem solving, planning, abstract thinking, judgment, academic learning, and learning from experience, confirmed by both clinical assessment and individualized, standardized intelligence testing.
(B) Deficits in adaptive functioning that result in failure to meet developmental and sociocultural standards for personal independence and social responsibility. Without ongoing support, the adaptive deficits limit functioning in one or more activities of daily life, such as communication, social participation, and independent living, across multiple environments, such as home, school, work, and community.
(C) Onset of intellectual and adaptive deficits during the developmental period.
Intellectual Disability
A. Intellectual Disability
B. Global Developmental Delay
C. Unspecified Intellectual Disability
Symptoms:
Some physical, neurologic and facial abnormalities may be seen with children have intellectual disability. This may be a head that is larger or smaller than normal, or deformities seen with the hands or feet. Some children may exhibit signs such as seizures, failure to thrive, or an unusual urine odor. In some cases, there may be a delay seen with motor skills, and the ability to roll, sit, and stand. Symptoms are a lot more evident at a younger age, especially when severely affected. One of the first signs that parents observe are language delays, this may be both expressive and receptive language abilities. These children experience delay with using words, assembling words together, and being able to formulate full sentences.
There are significant delays with dressing, feeding, and using the toilet. Memory problems, and challenges with problem solving and logical reasoning are evident. Children with [DISORDER]have slow social development, as a result of the deficits seen with language and cognitive abilities. Occasional behavioral disturbances can be seen, and may consist of inattention, hyperactivity, aggression, temper tantrums, heavy outbursts and self-injury (Gray, et al., 2011). This may be increased as result of the challenges with communication and difficulty with being able to control impulses. Additionally, comorbidities such as anxiety and depression are normal, especially from the children affected by the stigma seen with intellectual disability.
It is imperative to state that IQ or comparable standardized test scores must be part of an individual’s evaluation. In DSM-5, [DISORDER]is seen as being at least about two standard deviations or greater below the population, which is approximately an IQ score of 70 or less. Again the emphasis is not specifically on meeting any cutoff score, but rather on how the particular individual presents.
Intellectual Disability
A. Intellectual Disability
B. Global Developmental Delay
C. Unspecified Intellectual Disability
Treatment:
In order to get early intervention for those diagnosed with [DISORDER], the diagnosis should occur early. Early intervention has been shown to improve outcomes.
The basis of treatment involves the creation of a complete management plan for the individual. This plan consists of input from the multi disciplinary team of providers, which includes behavioral therapists, special education teachers, language therapists, community resources, among others.
Since lack of adequate exercise and obesity are seen in [DISORDER], it is important to develop programs that encourage healthy lifestyles (Bartlo & Klein, 2011). This may require the assistance of a dietitian or adjusting certain antipsychotics that increase the risk for obesity.
Many individuals with [DISORDER] experience intense bouts of pain, and it is important for this to be addressed in the treatment goal (Kankkunen, Janis, & Vehviläinen-Julkunen, 2010). This should be quick, and mild pain can be treated with NSAIDs or acetaminophen, while moderate pain can be treated with tramadol, and more severe pain with opioids. The use of written, verbal and illustrative methods of communication in addition to signs and demonstrations are beneficial for those with [DISORDER] to guarantee shared understanding and improve treatment compliance. Individuals with [DISORDER] tend to react differently to benzodiazepines and it is best to treat them using the smallest dose possible at all times.
Care should be taken to explore the possibility of sexual abuse in individuals with [DISORDER]. Given the low IQ levels, many may be prone to this, and this may influence the negative behaviors seen, such as heightened aggression.
Despite the known aspect of deficits seen with cognition, there is no main stay treatment. Limited research exist that show clear evidence of beneficial outcomes with medications.
Offering treatment is especially crucial in individuals with [DISORDER] who also have co-occurring mental disorders. This is as a result of the increased risk of suicide attempts (Ludi, Ballard, Greenbaum, Pao, & Bridge, 2012). It is quite important to include questions for suicidal screening while evaluating individuals diagnosed with [DISORDER].
Intellectual Disability
A. Intellectual Disability
B. Global Developmental Delay
C. Unspecified Intellectual Disability
Living with [DISORDER]:
One of the problems that individuals with [DISORDER] have is when they age out, and are no longer considered minors. No exceptions are made for these individuals, and those with a mild form of [DISORDER] are normally competent enough to make proper legal and medical decisions. It is important that they are adequately informed. It is normally up to the physicians to make sure the patient understands the treatment involved and is able to give proper medical consent. In cases where an individual with [DISORDER] is unable to have a firm understanding of the situation, then a family member may be granted a power of attorney which would allow the family member to consent on the patient’s behalf. In some cases, the ethics committees in the hospitals may be the best one to handle the more complex decisions, which may involve end of life care.
Patients with [DISORDER] face great stigma within the community at large, and children may face bullying both at school and at home. While it helps that the term has changed from mental retardation to [DISORDER], the stigma remains. It is important that family members offer great support, to assist with activities of daily living as needed. This is especially true when dealing with both legal and medical matters. As individuals with [DISORDER] are sometimes part of a larger vulnerable group prone to suicide attempts, communal support should be a priority. There should be consistent followup with the team, and the individual may not be able to control this with the cognitive deficits. Many individuals with [DISORDER] tend to develop dementia as they get older (Nagdee, 2011).
In some cases, patients with [DISORDER] also have a bigger medical condition, such as Down’s syndrome, Fragile X syndrome, or Klienfelter’s syndrome, which also require more extensive treatment. All of which should be considered when taking care of the [DISORDER] patient at home, and in the school setting.
Intellectual Disability
A. Intellectual Disability
B. Global Developmental Delay
C. Unspecified Intellectual Disability
Introduction:
Previously known in DSM-4 as “Mental Retardation, Severity Unspecified”, the term [DISORDER] in DSM-5 is used to explain developmental disability in children who are under five years of age (Thomaidis, et al., 2014). It refers to an important developmental milestone delay in regards to motor, speech and language; cognition; social functioning; and activities of daily living (Perna & Loughan, 2013). [DISORDER] is seen as a temporary diagnosis for children who are unable to undergo standardized IQ evaluation (American Psychiatric Association, 2013). Research has shown that a good number of children with [DISORDER] ultimately meet the diagnosis for Intellectual Disability once they reach school age. It is estimated that approximately five to ten percent of the pediatric population experience developmental delay (Thomaidis, et al., 2014). It remains hard to have an accurate estimate as [DISORDER] is affected by multiple factors such as age and socioeconomic status. This result in a higher number being reported in the developing world compared to westernized countries (Thomaidis, et al., 2014). [DISORDER] is seen in about fifteen percent of children below the age of five.
Some children are diagnosed under a year of age, while others become evident when the parents compare their children to others of the same age. Delays can show up as multiple issues and end in diverse prognosis with children. The research on early delays appears to be a bit unclear in regards to persistence of impairments or how they can progress to other disorders. Precise determination of the primary etiology symbolizes a vital step in handling young children with [DISORDER]. This can be hard to pin point as the actual determinants are very variable. These classifications can be labeled as prenatal, perinatal, and postnatal. They range from genetic abnormalities such as syndromes and anomalies to hypoischemic encephalopathy, to Central Nervous System (CNS) infections. Some research has shown that being diagnosed with [DISORDER] can result in an elevated risk of ensuing cognitive, behavioral, or academic issues (Perna & Loughan, 2013). Increasing amount of research implies that speech and language delays are frequently connected with consequent challenges with reading, writing, attention, and socialization.
As a result, early diagnosis of [DISORDER] is crucial, to ensure early intervention, especially in children with more severe delays. This is also needed to prevent future socio-behavioral problems, such as social anxiety, bipolar affective disorder, and psychotic depression (Moeschler & Shevell, 2014). Early diagnosis and intervention has been shown to decrease the risk of developing Attention Deficit Hyperactive Disorder (ADHD) in children (Perna & Loughan, 2013).
Global Developmental Delay
A. Intellectual Disability
B. Global Developmental Delay
C. Unspecified Intellectual Disability
Symptoms of [DISORDER]:
According to DSM-5, the [DISORDER] diagnosis is set aside for children under the age of 5 when clinical severity point cannot be consistently evaluated during early childhood (American Psychiatric Association, 2013). The diagnosis pertains to children who are unable to meet developmental targets in a number of areas of intellectual performance but who are not capable or too young to take part in methodical/standardized evaluations of intellectual functioning. This diagnosis involves reconsideration following a phase of time.
Global Developmental Delay
A. Intellectual Disability
B. Global Developmental Delay
C. Unspecified Intellectual Disability
Diagnosis of [DISORDER]:
There are multiple tests used in the diagnosis of [DISORDER]. These consist of the following below.
Genetic, molecular, and metabolic tests-These tests are usually conducted via urine or blood samples, and are able to detect hereditary types of [DISORDER] (American Academy of Neurology, 2014). In addition, blood and urine tests also allow for the evaluation of abnormalities in body chemistry, which can contribute to developmental delay. In children born to mothers with a history of alcoholism, tests can be conducted to check for fetal alcohol syndrome.
Chromosome testing- These tests help in inherited problems and genetic defects that can contribute to [DISORDER]. Some specific genetic testing can be done to evaluate certain rare disorders. One of the most common genetic causes of [DISORDER] is Fragile X, and conducting this test can eliminate this possible cause (Moeschler & Shevell, 2014). Rett syndrome is a high ranking cause of [DISORDER] among girls. The screening of girls for Rett Syndrome can be beneficial in eliminating this possibility of [DISORDER].
Children can be tested for other disorders. One such test is that of lead, which is quite toxic, and easily found in the environment. It can affect the nervous system, and has been associated with mental deficits. Older houses are linked with high lead exposure, and in children at risk for this exposure, a blood test can be conducted to check for elevated lead levels (American Academy of Neurology, 2014).
An important blood chemistry level that can contribute to [DISORDER] is the thyroid hormone. Decreased amounts of thyroid hormone levels can result in irregular growth and development, as well as slower mental ability. Normally new born babies are screened for this, but if this was not done at birth, it can be conducted in at risk children.
Neuroimaging tests such as CT and MRI can be conducted to evaluate any possible injury to the central nervous system and the brain. By looking at these detailed images, doctors can be provided insight regarding some children with [DISORDER]. While MRI offers more detailed images, CT brain scans are faster to do, and much cheaper for the patient.
Global Developmental Delay
A. Intellectual Disability
B. Global Developmental Delay
C. Unspecified Intellectual Disability
Treatment of [DISORDER]
To ensure early intervention for children diagnosed with [DISORDER], the diagnosis must take place early. Early intervention has been shown to improve outcomes in treatable causes of [DISORDER].
The treatment foundation would mean targeting the cause of the developmental delay. With children with speech delays, it would be imperative to seek the help of a speech pathologist. Children, who are experiencing delays in fine motor and daily living skills, will benefit from occupational therapy and physical therapy interventions. Those with hearing and vision delays, may benefit from the use of a hearing aid, correctional lenses/eye glasses.
In children with [DISORDER] due to metabolic causes, such as Phenylketonuria (PKU), dietary modification can help the children lead relatively normal lives. Behavioral and educational therapies can assist those with syndromes such as Fragile X, while extensive behavior modifications, parent training, and speech and language intervention, occupational and physical therapies may be indicated in a lifelong disability such as Down syndrome.
Global Developmental Delay
A. Intellectual Disability
B. Global Developmental Delay
C. Unspecified Intellectual Disability
Living with [DISORDER]:
It is important for children with [DISORDER] to be evaluated early, since some children ultimately end up with intellectual disability. Some children with [DISORDER] end up with a plethora of mental health issues such as ADHD, which can prove challenging if unidentified in school age children. On the other hand, some children with [DISORDER] may be remedied if the problem is identified. In some cases, some children with [DISORDER] were adopted from developing countries which lacked adequate individual attention, resulting in poor motor, language, social and cognitive skills. (Perna & Loughan, 2013) Once placed in an environment where this is encouraged, such deficits can be corrected before starting school.
School age children with [DISORDER] face great stigma within the community at large, and bullying may be an issue in school and even at home (Perna & Loughan, 2013). Family support is crucial to help these children with activities of daily living as needed. Older children with [DISORDER] can experience difficulty handling simple tasks such as eating, dressing, brushing their teeth or using the bathroom.
As individuals with [DISORDER] can be prone to develop Intellectual Disability, which is associated with increased suicide attempts, it is important for the community to be involved in the intervention. There should be continuity of treatment and collaboration between all medical professionals from the pediatrician or family physician, to the neurologist, speech pathologist and therapists.
As stated, some children with [DISORDER] may have a permanent lifelong medical condition, like Down’s syndrome, Fragile X syndrome, Prader-Willi syndrome, Angelman syndrome or Williams syndrome which would mean having a more comprehensive treatment plan. Most importantly each child with [DISORDER] regardless of cause should be seen as an individual, and personal needs should always be considered in helping maintain a normal life.
Global Developmental Delay
A. Intellectual Disability
B. Global Developmental Delay
C. Unspecified Intellectual Disability
Introduction:
[DISORDER] is a DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, fifth edition), diagnosis assigned to individuals who are experiencing symptoms of a neurodevelopmental disorder, but do not meet the full diagnostic criteria for one of the Neurodevelopmental disorders. The symptoms cause distress, and impair functioning in social, educational/occupational, or other major areas of functioning. The diagnosis can be assigned when the clinician decides not to specify the reason the diagnostic criteria are unmet, or if there is insufficient information available at the time of the evaluation to make a more specific diagnosis (American Psychiatric Association, 2013).
The amygdala is the brain structure most frequently implicated in NDD, which would include [DISORDER]. A sub-cortical structure regulates our response to potentially dangerous environmental stimuli. Sensory input goes to the orbito-frontal cortex, and to the amygdala for processing on an ongoing basis. If the sensory input is deemed non-threatening, we note it and attend to the next incoming sensory stimuli. If the sensory input is recognized as a threat by the amygdala, the fight/flight/freeze response of the parasympathetic nervous system begins to activate. The amygdala acts much faster than the orbito-frontal cortex. The right frontal lobe is specifically involved with executive function- e.g., decision making- and inhibition, but processes information slowly relative to the amygdala. A threat to survival is often best dealt with urgently, which is the function of the amygdala- recognize threats, and prepare the body to engage, or withdraw, or sometimes, neuromuscular lock- e.g. - the freeze response- can be conducive to survival. Individuals with disorders along the NDD spectrum, including [DISORDER], have dysregulation in the amygdala, which results in inappropriate response to stimuli. An underactive amygdala can result in high-risk behavior, and inappropriate social behavior. An overactive amygdala can produce excessive anxiety and risk aversion, as well as avoidance of social interaction (Schumann, Bauman, and Amaral, 2011).
Unspecified Intellectual Disability
A. Intellectual Disability
B. Global Developmental Delay
C. Unspecified Intellectual Disability
Symptoms of [DISORDER]:
According to the DSM-5, (American Psychiatric Association, 2013), NDD consists of a range of disorders first apparent in childhood including:
• Autism spectrum disorder
• CP (Cerebral palsy).
• Epilepsy
• Schizophrenia
• Bi-polar Disorder
• AD/HD (Attention Deficit/ Hyperactivity Disorder).
• OCD (Obsessive Compulsive Disorder).
• Disorders of communication, speech, and language.
• Tic Disorders, including Tourette’s Disorder
• FAS/FAE (Fetal Alcohol Syndrome/Fetal Alcohol Effects)
• FXS (Fragile X Syndrome)
• Rett Syndrome
• William’s Syndrome
• Down syndrome
There are vast quantities of symptoms for the NDD spectrum, and the symptoms of each individual disorder on the spectrum may be unique, or overlap, which can contribute to diagnostic ambiguity. There is commonality in that symptoms are manifested as disruption in physical, intellectual, emotional, behavioral, and cognitive functioning, typically first apparent in early childhood ((American Psychiatric Association, 2013; Elsevier Ltd., 2013). The debatable exceptions are Schizophrenia, and bipolar disorder. Schizophrenia does not typically manifest until the late teens-early twenties. The increasingly prominent view of Bi-polar disorder it cannot be reliably diagnosed until adulthood. However, the apparent age of emergence of these two disorders may be a result of failure to recognize early predictors. Infants can present what are termed soft neurological signs that are predictive of schizophrenia later in life. The signs include:
• Lack of eye contact with their care-giver
• Emotional flatness/lack of affect
• Failure to meet developmental milestones for coordination
These signs are not definitive, as they can be indicative of other neurodevelopmental disorders, such as Autism Spectrum, or sensory deficits, such as hearing impairment.
Most psychological disorders are diagnosed based on the presence of symptoms, which are self-reported by the patient or their family or associates, or observed by the clinician. The symptoms of disorders indicative of [DISORDER] are not always clearly defined, and could include:
• Failure to reach expected developmental milestones for walking and speech.
• Inability to interact appropriately with peers.
• Poor academic performance.
• Overreaction to frustration compared to peers.
• Emotionally labile in comparison to peers.
Some of the disorders in this category have markers that are more objective:
• Physical features associated with conditions such as Down syndrome, CP, or FSX.
• Objective measures such as EEG (Electroencephalogram) confirmation of Epilepsy.
• Objective measures such as the presence of the genetic markers for FSX.
Post-mortem studies also indicate there are anomalies in neuronal structures, including the soma, dendrites, axons, and at synaptic connections. An example of this is the presence of spine-like structures on the dendrites of cortical neurons in individuals with FXS (Zoghbi & Bear, 2012).
Unspecified Intellectual Disability
A. Intellectual Disability
B. Global Developmental Delay
C. Unspecified Intellectual Disability
Risk Factors for [DISORDER]:
The DSM -5 does not specify risk factors for [DISORDER] (American Psychiatric Association, 2013). The risk factors for [DISORDER] will vary, as they will for NDD, depending on the exact type. Risk factors can include a multitude of genetic and environmental variables, encompassing pre-natal, peri-natal, and post-natal events, including chromosomal aberrations, or hypoxia during labor. Maternal use of ethanol during pregnancy has been identified as a major preventable contributor to NDD spectrum disorders. Including AD/HD, Developmental Coordination disorder, and MR (Mental Retardation) (Landgren, Svensson, Strömland, and Grönlund, 2010). The most obvious potential consequence of maternal use of ethanol is FAS spectrum disorders. It is noted that in the early developmental years, psychosocial factors such as the quality of adult caregiver interaction can have enduring effects, either mitigating or worsening genetic influences (Bale, Baram, Brown, Goldstein, Insel, McCarthy, Nemeroff, Reyes, Simerly, Susser, and Nestler 2010). Metabolic conditions during pregnancy, specifically maternal obesity, and two common obesity related disorders, hypertension, and diabetes, can increase risk of two specific disorders along the NDD spectrum specifically Autism spectrum disorders, and Developmental disability (Krakowiak, Walker, C.K., Baker, Ozonoff, Hansen, and Hertz-Picciotto, 2012).
Unspecified Intellectual Disability
A. Intellectual Disability
B. Global Developmental Delay
C. Unspecified Intellectual Disability
Onset of [DISORDER]:
According to the DSM-5, [DISORDER], as well as the full spectrum of NDD disorders, are first apparent in early childhood (American Psychiatric Association, 2013). There are also gender differences in the onset of symptoms, e.g., boys tend to present with OCD symptoms about age five, while girls may not have symptoms until the mid-teens.
Unspecified Intellectual Disability
A. Intellectual Disability
B. Global Developmental Delay
C. Unspecified Intellectual Disability
Differential Diagnosis in [DISORDER]:
The differential diagnosis will vary depending on the segment of the NDD spectrum that is the focus of clinical attention. The DSM -5 notes that if the clinician suspects a NDD spectrum disorder, it is important to recognize co-morbid conditions in the NDD spectrum- e.g., AD/HD with Intellectual Disability (American Psychiatric Association, 2013).
The context of the clinical presentation must be considered. The clinician must be conscientious about not pathologizing WNL (Within Normal Limits) behaviors that are better accounted for by developmental variations, or environmental stressors such as maltreatment by family or peers. The latter can produce behaviors that can be misconstrued as [DISORDER]. A child that has been subjected to peer abuse or familial abuse may become withdrawn, excessively emotionally labile and reactive for their age, and distracted. However, the direction of causality can be complex, as the literature notes that psychosocial factors can contribute to the etiology of [DISORDER] (Bale, Baram, Brown, Goldstein, Insel, McCarthy, Nemeroff, et al, 2010).
Unspecified Intellectual Disability
A. Intellectual Disability
B. Global Developmental Delay
C. Unspecified Intellectual Disability
Treatment of [DISORDER]:
The DSM-5 does not specify treatment for [DISORDER] (American Psychiatric Association, 2013). Treatment will be dictated by diagnostic clarification, though there are overlapping treatment consideration across the spectrum of NDD/[DISORDER]. The amygdala is noted as a common target for pharmacological interventions, given the commonality of amygdalary involvement in NDD Spectrum disorders (Schumann, Bauman, and Amaral, 2011). It could be postulated that behavioral interventions using CBT (Cognitive Behavioral Therapy) could also be beneficial by modulating anxiety in social situations. Family therapy may be indicated as the diagnostic picture clarifies. The long-term stressors associated with caring for a child with NDD/[DISORDER] can strain a marriage or sibling relationships. The parents and siblings can also learn how to best support the NDD/[DISORDER] child. Family therapy may also reveal conflicts and stressors that have led to a clinical presentation misinterpreted as [DISORDER].
Unspecified Intellectual Disability
