Neurodevelopmental and Attention Disorders - Cooley Flashcards
this diagnosis is used for individuals who are unable to undergo systematic assessments of intellectual functioning:
- children who are too young to participate in standardized testing
- acquired insult during the developmental period
- severe head injury
global developmental delay
what are the three criteria that must be must to diagnose an intellectual disability?
- deficits in intellectual functions (reasoning/problem solving)
- deficits in adaptive functioning that result in failure to meet developmental/sociocultural standards
- onset of intellectual and adaptive deficits during the developmental period
what are examples of adaptive functioning deficits in the conceptual domain?
- conceptual skills lag markedly behind those of peers
- for preschoolers, language and pre-academic skills develop slowly
- for school-age, progress in reading/writing/math/money lags behind peers
- for adults, academic skill is typically at elementary level
- ongoing assistance may be needed for conceptual tasks of day-day life
what are examples of adaptive functioning deficits in the social domain?
- difficulty developing age-mates, immature in social interactions
- difficulty accurately perceiving peer’s social cues
- communication, conversation, language are more concrete, less mature
- difficulties regulating emotion and behavior are noticed by peers
- social judgement is immature for age, person at risk for being manipulated
what are examples of adaptive functioning deficits in the practical domain?
- difficult with age-appropriate personal care
- difficult with complex daily living tasks in comparison to peers
- difficult making good decisions about personal well-being
- competitive employment restricted to jobs that do not emphasize conceptual skills
- individuals generally need support
this disorder is characterized by disturbances of the normal fluency and motor production of speech, including repetitive sounds or syllables, prolongation of consonants or vowel sounds, broken words, blocking, or words produced with an excess of physical tension
childhood-onset fluency disorder
- persistent difficulties in the acquisition of language across modalities d/t deficits in comprehension or production
- reduced vocabulary
- limited sentence structure
- impairments in discourse - language abilities below those for expected age
- onset in early developmental period
- difficulties not attributable for hearing or other sensory impairment
language disorder
- persistent difficulty with speech sound production
- the disturbance causes limitations in effective communication
- onset in early dvlpmental period
- difficulties not attributable to congenital/acquired conditions like cerebral palsy, cleft palate, deafness
speech sound disorder
- disturbances in the normal fluency and time patterning of speech that are inappropriate for the individual’s age and language skills
- sound/syllable repetition
- broken words
- sound prolongation - disturbance causes anxiety about speaking or limitations in effective communication, social participation, or academic or occupational performance
- onset in early dvlpmental period
- disturbance not attributable to speech-motor or sensory deficit
childhod-onset fluency disorder
- stuttering/broken words
- persistent difficulties in the social use of verbal/nonverbal communication
- deficits in using communication for social purposes
- impairment of the ability to change communication to match context
- difficulties following rules for conversation
- difficulties understanding what is not explicitly stated - deficits result in functional limitations in effective communication, social participation, social relationships, academic achievement, etc
- onset in early dvlpmental period
- sx not attributable to another medical/neurologic condition
social (pragmatic) communication disorder
- language skills ok, lacking communication skills
- primary difficulty with the social use of language and communication
- most common associated feature is the delay in reaching language milestones
- milder forms may not become apparent until early adolescence, when language and social interactions become more complex
- deficits in social communication and social interaction across multiple contexts:
- social-emotional reciprocity
- nonverbal communicative behaviors
- developing, maintaining, and understanding relationships - restricted, repetitive patterns of behavior, interests or activities by at least two of the following:
- repetitive motor movements, use of objects or speech
- insistence on sameness, inflexible adherence to routines
- highly restricted, fixated interests that are abnormal in intensity/focus
- hyper or hypo-reactivity to sensory input
autism spectrum disorder
- disturbances are not better explained by intellectual disability (intellectual development disorder) or global development delay
- frequently co-occurs with intellectual developmental disorder
what factors do you need to specify with autism?
- with or without accompanying intellectual impairment
- with/without accompanying language impairment
- associated with a known medical or genetic condition or environmental factor
- associated with another neurodevelopmental, mental, or behavioral disorder
- with catatonia
what is level 3 autistic?
requiring very substantial support
what is level 2 autistic?
requiring substantial support
what is level 1 autistic?
requiring support
what are the most useful behavioral interventions for autistic pts?
education and support for parents, siblings, teachers, caregivers
- learning about “parallel process” and learning how to use it for behavioral management
what are the only 2 meds that are FDA approved for the irritability and agitation associated with autism?
risperidone and aripiprazole
females with ADHD present more commonly with what subtype than boys?
inattentive subtype
NOTE: less disruptive behavior in females with ADHD may contribute to referral bias causing under identification and lack of treatment
- childhood onset of multiple motor and vocal tics lasting more than one year
- neuropsychiatric spectrum disorder associated with:
- OCD sx that do not always meet full dx criteria
- disturbances of attention that do not always meet ADHD full criteria
tourette syndrome
NOTE: evidence suggests that boys are more likely to have tics and ADHD, whereas girls more likely to have OCD
what is considered the “clinical triad” of tourette’s?
tics, ADHD, OCD
tic behaviors that can be subtle, may not meet criteria for diagnosis, intermittently in remission, or merely absent during assessment for ADHD
chronic tic disorder
OCD is associated with what part of the brain?
prefrontal lobe
- allows for perception of behavior
ADHD is associated with what part of the brain?
supplemental motor area connects with dorsal anterior midcingulate cortex (daMCC)
- ability to assess a situation
- prioritizing what is relevant vs. irrelevant
- filtering out extraneous information
- make a plan how to act
- execute the plan
- assess effect of action in a fluid manner
- information processing dysfunction within the PREFRONTAL CORTEX
- primarily d/t deficiency of DA and NE
executive functioning
what areas of the brain experience decreased activation in patients with ADHD?
- right inferior prefrontal cortex (IFC) extending into the insula
- in a cluster comprising the supplementary motor area (SMA)
- cognitive division of anterior cingulate cortex (ACC)
- left caudate extending into putamen and insula, and the right mid-thalamus
what is the DSM-V diagnostic criteria for ADHD in children?
they should have six or more symptoms of the disorder
what is the DSM-V diagnostic criteria for ADHD in people 17+
they should have at least five symptoms
- fails to give close attention to details or makes careless mistakes
- has difficulty sustaining attention
- does not appear to listen
- struggles to follow through on instructions
- has difficulty with organization
- avoids/dislikes tasks requiring a lot of thinking
- loses things
- easily distracted
- forgetful in daily activites
inattentive ADHD
- fidgets with hands/feet or squirms in chair
- has difficulty remaining seated
- runs around/climb excessively in children, extreme restlessness in adults
- difficulty engaging in activities quietly
- acts as if driven by a motor
- talks excessively
- blurts out answers before question have been completed
- difficulty waiting/taking turns
hyperactive ADHD
- custom designed hardware precisely measures reaction times
- language and culture-free testing
- extensively normed by gender for ages 4-80
- embedded performance validity to flag unusual performance
- immediately available
- any personnel can be trained to administer
- shorter test for young children
test of variable of attention (TOVA)
- a task-oriented computerized assessment of attention-related problems in individuals aged 8 years +
- by indexing the respondent’s performance in areas of inattentiveness, impulsivity, sustained attention, and vigilance
- administered on a computer/laptop, 15 minutes
conners continuous performance test
what are the American Academy Pediatrics (AAP_ clinical practice guidelines for preschool-aged children (4-5 years)? KNOW this
- prescribe evidence-based parent and/or teach-administered behavior therapy as first line tx
- prescribe methylphenidate if the behavior therapy does not provide significant improvement and the child continues to have moderate to severe sx
what are the American Academy Pediatrics (AAP_ clinical practice guidelines for elementary-aged children (6-11 years)? KNOW this
prescribe FDA approved meds for ADHD and/or evidence-based parent/teacher-administered behavior therapy as treatment for ADHD
- preferably meds and behavior therapy should be used together
what are the American Academy Pediatrics (AAP_ clinical practice guidelines for adolescents (12-18 years)? KNOW this
- prescribe FDA approved medications for ADHD with the assent of the adolescent
- may prescribe behavior therapy as treatment for ADHD, although preferably both medication and behavior therapy should be used together
which alpha-2 adrenergic agonists are alternatives to stimulants based on their ability to modulate noradrenergic tone in the prefrontal cortex?
- modulation is a consequence of both enhanced noradrenergic input from the locus coeruleus and direct postsynaptic stimulation of a-2A receptros
guanfacine and clonidine
antidepressant with mixed catecholaminergic effects
- found to have higher response rate and a greater reduction in inattentive and overall ADHD symptoms
- advantages include the lack of abuse liability, single daily dosing, and efficacy for co-occurring anxiety and depression
buproprion
NOTE: may increase the risk of SEIZURE
inhibits presynaptic NE reuptake, resulting in increased synaptic NE and DA
- SA include dry mouth, insomnia, nausea, decreased appetite, constipation, decreased libido, ED, urinary hesitancy, dizziness, sweating
- can produce QT prolongation! use with caution in pt with CV risk
atomoxetine
med for adults ONLY
- binds to DA transporter, inhibiting DA reuptake
- appears to improve the core sx of ADHD
- assoc with serious dermatologic and psychiatric reactions
modafinil
effectively reduces sx of inattention, hyperactivity, and impulsivity in up to 80% of children with ADHD
- increases extracellular DA levels in the brain by blocking the DA transporters in the synapse
- in children, may cause neurochemical imprinting
- tx during a specific period of maturation alters the CBF response, likely reflecting increased DA NT d/t neurochemical imprinting by methylphenidate
methylphenidate (ritalyn)
- the acquisition and execution of coordinated motor skills is substantially below that expected, given individuals chronological age and opportunity for skill learning and use
- difficulties manifest as clumsiness, slowness - motor skills interfere with activities of daily living appropriate to chronological age
- motor skills deficits are not better explained by intellectual disability
developmental coordination disorder
- repetitive, seemingly driven, and apparently purposeless motor behavior
- repetitive motor behavior interferes with social, academic, or other activities and may result in self-injury
- repetitive motor behavior not attributable to the physiological effects of a substance or neurological condition
stereotypic movement disorder
what must be specified with a stereotypic movement disorder?
- with/without self-injurious behavior
- associated with a known medical or genetic condition, neurodevelopmental disorder, or environmental factor
what is considered a mild stereotypic movement disorder?
symptoms are easily suppressed by sensory stimulus or distraction
what is considered a moderate stereotypic movement disorder?
symptoms require explicit protective measures and behavioral modification
what is considered a severe stereotypic movement disorder?
continuous monitoring and protective measures are required to prevent serious injury
- both multiple motor tics and 1+ phonic tics must be present at some time during the illness, although not necessarily concurrent
- tics must occur many times a day, nearly every day, or intermittently throughout a period >1 year
- anatomical location, number, frequency, type, complexity, or severity of tics must change over time
- onset of tics before age 21
- involuntary movements and noises must not be explained by another medical condition
Tourette’s disorder
what are the comorbidities seen with Tourette’s?
- ADHD
- OCD
- anxiety disorders
- mood disorders and risk of suicide
- disruptive behaviors
- learning disabilities and poor school performance
- sleep disorders
what are the medications used for Tourette’s?
- antidopaminergic drugs (haloperidol, pimozide, aripiprazole)
- DA depleters (inhibit VMAT)
- antipsychotics
- a-adrenergic agonists
- botulinum toxin injection
- anticonvulsants
- single or multiple motor or vocal tics have been present during the illness, but not both motor and vocal
- the tics may wax/wane in frequency but have persisted for more than 1 year since tic onset
- onset before age 18
- disturbance not attributable to the effects of medications or another medical condition
persistent (chronic) motor or vocal tic disorder
what must you specify with persistent motor/vocal tic disorder?
- with motor tics only
- with vocal tics only
