Lecture 3: Neurodevelopmental Disorders - I Flashcards
NDD overview (5 key characteristics)
- Abnormal development of the nervous system, impairing personal social academic and/or occupational functioning.
- Manifests early in development
- Frequently co-occur (i.e., ASD and ID; AD/HD and Learning disorder).
- Several influences but they are not all in the DSM criterion (e.g., perinatal, postnatal, environmental)
- May all be thought of as ‘developmental brain dysfunction’ rather than causally distinct disorders.
What are the 6 types of NDDs and the possible disorders within each category?
(I.C.A.A.S.M.)
Intellectual Disorders:
- Intellectual Developmental Disorder; Global Developmental Delay; Unspecified.
Communication:
Speech sound; Early childhood onset Fluency Disorder; Social (pragmatic) Communication Disorder, Language Disorder, Unspecified.
ASD
AD/HD
Predominantly Inattentive
Predominantly Impulsive/Hyperactive
Combined presentation
Other specified;Unspecified ADHD Disorder
Specific Learning Disorder
Motor Disorders:
DCD (Developmental Coordination Disorder)
Stereotypic motor disorder
Tic disorder
Intellectual Disability Characteristics
Characterised by:
- Intellectual and adaptive impairments
- IQ below 70
- Specified as mild to profound (85-90% are mild)
- Distinct from cog impairments later in life caused by ABI, HIV, Parkinsons, Alzheimers (neurocognitive disorders)
- Syndromic ID includes Down syndrome and Fragile X.
- Non-syndromic (deficits without abnormalities)
- Have full range of MH disorders but less likely to receive support for them.
ID Causes
- Genetic (Down syndrome 1/600; Fragile X 1/3000; Klinefelter 15/10,000; Prader-Willi 1/10,000).
- Pregnancy problems interfering with brain development (infection, drug use, malnutrition, preeclampsia)
- Birth problems - low weight, deprivation of oxygen
- Infections (meningitis, whooping cough, measles)
- Head injuries (near-drowning, malnutrition, exposure to toxins, neglect)
- Iodine deficiency (and goitre and cretinism)
- 2/3 of all children diagnosed with IDD have unknown cause.
What are the 8 Indicators/manifestations of ID?
- Apgar score
- Delayed dev milestones (rolling, sitting, crawling etc)
- Delayed speech
- Delays mastering potty training, dressing, independent feeding
- Difficulty remembering things
- Inability to connect actions with consequences
- Behaviour problems such as explosive tantrums
- Difficulty problem-solving/logical thinking
ASSESSMENT of ID
Medical (3)
Psychological (3)
Medical:
- Medical exam
- Genetic and neurological testing
- Perinatal / birth history
Psychological:
- Parent interviews (perinatal, birth, post-natal; Family; Developmental; and Educational history)
- Teacher interviews (Developmental; Educational)
- Standardised Cognitive Ax (WPPSI, WISC, SB) Universal Nonverbal Intelligence Test/Leiter International Performance Scale
And the Vineland Adaptive Behaviour Scale 3 (the leading instrument for supporting diagnosis of IDD), which provides info for developing tx plans.
IDD DIAGNOSIS (DSM-5)
What are the 3 criteria that must be met?
Specifier: Mild, Moderate, Severe, Profound
- Deficits in intellectual functions (reasoning, problem-solving, planning, abstract thinking, judgement, academic learning, and learning from experience). Confirmed by both clinical ax and individual standardised intelligence testing.
- Deficits in adaptive functioning (failure to meet expected levels of developmental and social cultural standards for personal independence and social responsibility). Without support, limits functioning across one or more activities of daily life (communication, independent living, and social participation - across home, school, work, community).
- Onset during developmental period
ID - GDD and Unspecified:
Global Developmental Delay:
- Diagnosis reserved for < age 5 years when severity cannot be reliably assessed during early childhood.
- Diagnosis for when individual fails to meet expected dev milestones in several areas of Intellectual functioning.
- Applies to individuals who can’t undergo systematic ax, including children who are too young to do stand testing. Requires ax after a period of time.
Unspecified Intellectual Disability
- Individuals > 5 years of age.
- When ax of ID is hard because of sensory/physical impairments (e.g., blindness, pre lingual deafness, locomotor disability; or presence of severe problem behaviours/co-occurring MD).
ID Support/ Adaptions (7)
P S S M M L C
- Psychoeducation
- Skills training in managing challenging behaviours (school & home)
- Social skills training
- Management of grief process
- Modified educational programs
- Life skills training
- Coordination of care
COMMUNICATION DISORDERS (5)
Language
Speech Sound disorder
Social (pragmatic) Communication
Early Onset Fluency Disorder (stuttering)
Unspecified Communication Disorder
COMM DISORDER: Language Disorder - DSM Criteria
A. Persistent difficulties in acquisition and use of language (spoken, written, other) due to deficits in comprehension or production (limited vocab, limited sentence structure, impairments in discourse)
B. Language abilities substantially below what is expected for age. This results in functional limitations in communication, social participation, study/work etc.
C. Onset of symptoms in early developmental period
D. Difficulties not attributed to medical, sensory impairment, motor dysfunction, and not better explained by ID or GDD.
COMM DISORDERS: Speech Sound Disorder (DSM Criteria)
A. Persistent difficulty with speech sound production. Interferes with intelligibility or prevents verbal communication of messages.
B. Impairments interfere with social participation, academic achievement, and work performance.
C. Onset of symptoms in early developmental period
D. Difficulties not attributable to congenital or acquired conditions 9e.g., cerebral palsy, cleft palate, deafness, hearing loss, TBI, or other medical condition.
COMM DISORDER; Childhood-onset Fluency Disorder (DSM Criteria)
A. Disturbances in normal fluency and time patterning of speech inappropriate for age & language skills. Persist over time, and characterised by frequent and marked occurrences in 1 or more of:
- Sounds & syllable repetition
- Sound prolongations of consonants and vowels
- Broken words (pauses within a word)
- Circumlocutions (word substitutions to avoid problematic words)
- Excess of physical tension in word production
- Monosyllabic whole-word repetitions (I-I-I see him).
B. The disturbance causes anxiety about speaking or limitations in communication, social part, work/school performance.
C. The onset of symptoms in early developmental period
D. The disturbance is not attributable to speech-motor or sensory deficit, dysfluency associate with neurological insult (e.g., stroke, tumour, trauma), or other medical condition.
COMM DISORDERS: Social (Pragmatic) Communication Disorder (DSM-5)
A. Persistent difficulties in the social use of verbal/nv communication, manifested by ALL of:
- Deficits in using communication socially (greeting, sharing info, in appropriate manner to context)
- impairment in ability to exchange information to match context or needs of listener - speaking in classroom vs playground, talking differently to a child than to an adult, avoiding overly formal language).
- Difficulty following rules for conversation and storytelling (taking turns, rephrasing when misunderstood)
- Difficulties understanding what is not explicitly stated (e.g., making inferences), and nonliteral or ambiguous meanings of language (idioms, humour, metaphors, multiple meanings)
B. The deficits result in limitations in communication, social part, relationships, school/work etc
C. Symptom onset in early development (but may not manifest until social communication demands exceed capacity)
D. The symptoms are not attributable to medical / neurological condition or low abilities in domains of word structure/grammar. Not better explained by ASD, ID, GDD, or other MD.
COMMUNICATION DISORDERS: ASSESSMENT
Case history: Medical, Education, SES, Cultural, Linguistic background
Parent, client, teacher interviews
Review of auditory, visual, motor and cognitive status
Standardised / Non-standardised measures of speech, spoken and non-spoken, swallowing function (e.g., Clinical Evaluation of Language Fundamentals; CELF-5)
COMMUNICATION DISORDERS: INTERVENTION
- Generally intervention is by a speech pathologist.
- Individual therapy /modifications at home - Intervention for co-morbid disorders and difficulties associated with communication impairments.
AUTISIM SPECTRUM DISORDER
(Aetiology / Risk)
Biogenetic:
- Up to 90% have a genetic cause
- Polygenetic 90-95%
- Gut-brain link in ASD - new research
- Metabolic imbalance (mitochondrial dysfunction)
Brain-based factors
- fMRI multiple functional differences
- Majority of individuals show increased grey/white matter early childhood, with 10% increased brain size after birth (average size in adolescence/adult)
- Amygdala and fusiform less active
Psychosocial/Environmental factors
- Higher incidence of pre- and peri-natal problems, including prenatal viral infections/low birth weight.
- Exposure to toxins
- Born to older parents
- History of viral infections
Culture and Gender
- Diagnosis age varies to SES / geography
- Minority ch diagnosed 1yr later than white
- 4:1 Male to female
- Females diagnosed later in life
- Non-hetero and trans -> increased prevalence
ASD Assessment
- Developmental and family history markers:
- Behavioural regression/ loss of language skills
- Lack of cooing; babbling, other socially meaningful gestures by 12mths
- No single word speech by 16mths
- Lack of 2-word spontaneous phrase speech by 2yrs - Semi-structured interview with teacher
- Classroom observations
- Screening
-> social communication questionnaire
-> social responsiveness scale-2 - Assessment by other professionals: Speech path; Genetics (differential - speech/language disorders or Fragile X)
- Cognitive Ax and Ax of Adaptive behaviour
- Structured, standardised Ax such as ADOS (Autism Diagnosis Observ Schedule) and ABAS-3rd Ed (Adaptive Behaviour Ax System)
-> ADOS: Semi-structured ax of communication, social interaction and play.
-> ABAS: Assesses adaptive skills across a lifespan 0-89 years. Used for ID and AD/HD too. Rate individual’s observed adaptive skills on 4-point scale. Completed by parent/teacher/self-report.
ASD Diagnosis (DSM-5)
A. Persistent deficits in social communication and interaction across multiple contexts, manifested by:
- deficits in social-emotional reciprocity
- deficits in nonverbal communication behaviours
- deficits in developing, maintaining and understanding relationships
B. Restricted, repetitive patterns of behaviour, interests, or activities as manifested by at least TWO of the following (currently or historically):
- Stereotyped or repetitive motor movements
- Insistence on routines or sameness
- High restricted, fixated interests
- Hyper- or hypo reactivity to sensory input
C. Symptoms in early dev
D. Symptoms cause significant impairment
E. Not better explained by another disorder (e.g., social (pragmatic))
ASD Co-morbidity
I) Often present with co-occurring conditions, including epilepsy, depression, anxiety, OCD, eating disorder.
ii) > 1 in 2 adults with ASD have minimum 1 additional psychiatric disorders (usually mood/anxiety - and usually social anxiety)
iii) Intellectual function varies widely -ranging from superior to profound.
iv) 50% of individuals with ASD show symptoms consistent with ADHD
ASD - Treatment / Adaptations
Manifestion: Individuals often present for support for non-core symptoms (e.g., anxiety, depression, irritability, aggression). Research still needed for non-core symptoms.
Pharmacological:
- No meds show efficacy
- Meds target non-core symptoms
- Risperidone and aripiprazole to reduce irritability
- Repetitive behaviour (SSRIs)
- Oxytocin for social behaviour..?
Behavioural/Cognitive:
- Applied behaviour analysis (ABA) - intensive. Recommended for ch < 4yrs.
- Behaviour Therapy and CBT for non-core symptoms
- Parent training (deliver consistent consequences and use visual schedules)
- Environmental modifications (reduce noise)
Skills Training
- Social skills - individual and group
- Peer interventionist and tutor models
- Social stories
- Computer-based training games
- Video-modelling
Educational and School-based therapies
- Adaptations in the environment based on functional ax.
- Antecedent based (visual cues, chaining)
Parent training - ID function of child’s behaviour and modify antecedents/ consequences
Other disciplines - OT and speech therapy.
ADHD Aetiology/ Risk
- Rates higher in biological relatives
- Twin studies show AD/HD is 60-90% heritable - 1 of most heritable disorders
- Genes DRS4, DRD5, DAT1 (also associated with temperament factors - Cloningers Novelty Seeking)
- Neuroimaging studies show structural and functional abnormalities: structures underpinning executive functioning, planning, and following through.
- Brain volume reduced around 5%
- Less grey matter ni: Left anterior cingulate cortex; left and right hippocampus-amygdala complexes, occipital cortex, and widespread cerebellar regions.
- Primarily the combined type show: dysfunction in prefrontal-striatum circuity to parietal cortical connections
- Low DNA methylation (regulate gene expression) associated with with dopamine receptors and serotonin
- Environmental factors 10-40% of variance -> neurological damage pre- and peri-natal period (maternal stress, substance use, low heartbeat in delivery, small head circumference, low birth weight).
- Familial factors: Parent-child conflict; marital discord, parental stress, and social isolation can exacerbate.
ADHD ASSESSMENT
What are the domains of ax for ADHD?
- MEDICAL
- Observations
- Interviews with parents
- Questionnaires and rating scales
- Trials of medication - PSYCHOLOGICAL
- Observations across several settings
- Interviews with parents, relatives, teachers, the individual
- Questionnaries and rating scales
- Ax of comorbid disorders **
2A. Psychometric Assessments:
i) Connors Rating Scale (6-18).
- Measures hyper/emotional distress, aggressive behaviour, academic difficulties, social probs, separation fears, perfectionism, compulsive behaviour, violence potential, physical symptoms
- Forms for parents, teacher and self-report
- 20 mins
ii) Vinelands Adaptive Behaviour Scales
- Birth to 90 yrs
- Communication, Daily living skills, socialisation, motor skills, maladaptive behaviour domains.
- Interview & parent/teacher forms
iii) Behaviour Assessment System for Children (BASC)
- 2-21 yrs
- Behavioural and emotional symptoms, externalising, internalising, adaptive skills, school probs.
- Forms for Teacher, parent, self-report.
Observation of student; Dev history
iv) Achenbach Child Behaviour Checklist
- 6-18 years
Various scales including depressive symptoms, anxiety problems, somatic problems, ADHD, oppositional defiant problems, conduct problems
- Forms for parent/teacher/youth
Possibly OT and Speech path
ADHD (DSM Diagnosis)
A. Persistent pattern of inattention and/or hyperactivity-impulsivity characterised by (1) and/or (2)
1. Inattention (6 or more)
2. Hyper/impulsive (6 or more)
B. Several symptoms present prior to age 12 yrs.
C. Several symptoms present in 2 + settings
D. Symptoms interfere with/reduce quality of social, academic, work functioning.
E. Symptoms don’t occur only during the course of another psychotic disorder/not better explained by another MD (e.g., mood, anxiety, dissociative, PD, substance).
Specifiers.
Other specified ADHD
Unspecified ADHD
Diagnostic limitations
ADHD can be reliably identified and treated in preschoolers.
Needs clear behaviour indicators of preschool ADHD to facilitate differentiation from normative preschool behaviours.
Needs sex-specific criteria to improve accuracy of diagnosis
Subtype accuracy issues (most children transition between subtypes over time)
ADHD Comorbidity
i) Approximately 50% of children with ADHD have a co-occuring CONDUCT problem diagnosis
ii) Between 65% to 90% of children with either ODD or CD are diagnosed with ADHD (ch with ADHD and CDs who a persistent course of ADHD)
iii) ADHD & CD/OCD at heightened risk of smoking, drinking, illicit drug use as adolescents
iv) Inattention overlaps with ASD, motor coordination, and reading problems
v) 1/8 children with ADHD meet diagnosis for ASD
vi) 30-50% have significant academic problems
vii) 30-50% diagnosed with anxiety or depression - unclear if common causes, or are secondary)
viii) Bipolar comorbid.
ADHD Intervention
Medication and behaviour therapy is most supported.
- Behav therapy = structured behaviour management in school/home
Presence of comorbidity influences which tx is best
Other I/v include:
- Psychoeducation
- Family intervention to promote rule-following at home
- Child-focused social skills training
-Dietary ax and iv
SPECIFIC LEARNING DISORDER
COMMON LEARNING DIFFICULTIES
SLD - ASSESSMENT
SLD - INTERVENTION
MOTOR DISORDERS
3 types
Motor Disorders - Ax and intervention, and diagnosis in children;
Ax (4 types)
Intervention (5 types)
Diagnosis in children look for 8 things in CI
OT or physio:
- Peabody Dev Motor Scales
- Dev Coordination Scale
- Movement Ax Battery for Ch (MABC-2)
- Daily functioning (self-care, leisure, play, etc)
Intervention
- Goal setting
- Educating parents
- Skill dev (balance and coordination, strength and endurance, attention and alertness, body awareness, movement planning)
- Build confidence
- Improve sensory awareness
AX and Diagnosis in Children:
- Temperament
- Attachment
- parenting styles
- Exposure to abuse/trauma
- Social experiences
- cultural contexts
- sleeping
- Eating
(On each dimension, what is considered ‘average’) - how do they combine together in the current presentation?
