Neurodevelopmental Disorders

Question 1

What are the two categories of brain dysfunction?

Answer 1

Two categories for brain dysfunction:

a) Neurodevelopmental disorders – onset in the developmental period
b) Neurocognitive disorders – onset in later life

Question 2

What are neurodevelopmental disorders ?

Answer 2

Onset in the developmental period
• Present during early childhood, typically before child enters grade school

• Characterized by developmental deficits producing impairment of personal,
social, academic or occupational functioning

• Range of disorders from specific limitations to global impairments

• In some disorders, the clinical presentation includes symptoms of excess as well as
deficits and delays in achieving expected milestones

• Not due to visual/auditory/neurological problems, lack of/inadequate academic instruction

Question 3

What are the types neurodevelopmental disorders?

Answer 3

1. Intellectual disability
2. Global developmental delay
3. Specific learning disorders
4. Communication disorders
   a) Language disorder
   b) Speech disorder
   c) Social (pragmatic) communication disorder
5. Autism spectrum disorder
6. Attention-deficit/hyperactivity disorder [ADHD]

Question 4

What are the diagnostic criteria of intellectual disability?

Answer 4

Diagnostic Criteria:
1. Deficits in intellectual functioning AND
• Confirmed using:
a) Clinical assessment
b) Standardized intelligence testing

2. Deficits in adaptive functioning that lead to
• Limitations in communication, social participation, independent living across
multiple environments (home, school, work, community). 

3. Begins before 18 years

Question 5

What is the normal area of intellectual ability of a normal person?

Answer 5

Standardized intellectual assessment:
➢ Wechsler intelligence tests (versions for adult and children)

• Neurotypical mean:
➢ 100 (SD = +/- 15)

• Intellectual Disability:
➢ An IQ score at least 2 SD BELOW
the mean

➢Score ≤ 70 +/- 5

Question 6

Describe the defects in adaptive functioning

Answer 6

Failure to achieve developmentally appropriate daily living skills in at least one of the
following domains:

 * Conceptual (e.g. academic skills)
 * Social (e.g. relational skills)
 * Practical (e.g. self management skills)

• Assessed using a standardized rating scale:
  
  • Vineland Adaptive Behavior Scales

Question 7

What are the mild intellectual disability features ?

Answer 7

About 85%

Can live independently with minimum levels of support

Immature social interactions

Question 8

What are the features of moderate intellectual disability?

Answer 8

About 10%

Varying degrees of support needed such as those available in group homes

• Limited communication and socialization skills
• Aware of their limitations

Question 9

What are the features of profound intellectual disability?

Answer 9

3-4%

Requires daily assistance with self-care activities and safety supervision

• Use simple speech & gestures
• Have maladaptive behaviour

Question 10

What are the features of Profound intellectual disability ?

Answer 10

1-2%

Requires 24-hour care

Nonverbal communication

Question 11

What is global developmental delay?

Answer 11

Child is less than 5 years old

• Has not met developmental milestones in several areas of functioning:
  * Learning to walk/talk
  * Social and emotional interactions
• Clinical severity level cannot be reliably assessed with standardized tests
• Will require reassessment later, if possible

Question 12

What are the types of neurodevelopmental disorders?

Answer 12

1. Intellectual disability
2. Global developmental delay
3. Specific learning disorders
4. Communication disorders
   a) Language disorder
   b) Speech disorder
   c) Social (pragmatic) communication disorder
5. Autism spectrum disorder
6. Attention-deficit/hyperactivity disorder [ADHD

Question 13

What are the types of Specific Learning Disorders?

Answer 13

1. Difficulty learning and using academic skills AND

2. Academic skills less than expected for age

Question 14

How do we diagnose difficulty in learning and using academic skills as. Part of “specific learning disorders”?

Answer 14

1. Difficulty learning and using academic skills

• At least one symptom for at least 6 months

a) Slow/inaccurate/effortful word reading
b) Difficulty understanding meaning of what is read
c) Difficulty spelling
d) Difficulty with written expression
e) Difficulty with numbers/calculation
f) Difficulty with mathematical reasoning

Question 15

How do we diagnose “Academic skills less than expected for age” for a specific learning disorder?

Answer 15

2. Academic skills less than expected for age
   a) Causes significant interference with academics/occupation/daily living
   b) Confirmed with standardized tests & clinical assessment
   c) Present during school age when demands > capacity

Question 16

What are the specifiers of specific learning disorders?

Answer 16

Impairment in reading (dyslexia)

Impairment in written expression

Impairment in mathematics (dyscalculia)

Severity:
Mild: Mild difficulties; may learn to function well with initial support services

Moderate: Marked difficulties; needs accommodations/support to complete tasks

Severe: Severe difficulties; needs intensive and individualized teaching

Question 17

What are the requirements in communication?

Answer 17

Children must have a mastery of multiple aspects of language:
• Receptive (receiving and understanding) and expressive (production of verbal or gestures) language skills

  • Express themselves in vernacular language

Question 18

What are the types of communication disorders?

Answer 18

1. Language disorder
2. Speech disorder
   a) Speech sound disorder
   b) Childhood-onset fluency disorder
3. Social (pragmatic) communication disorder

Question 19

What are the diagnostic criteria of language disorder?

Answer 19

Diagnostic Criteria:
A. Persistent difficulty in acquisition and use of language across modalities (speaking,
reading, writing, signing, etc.)

There is:
1. Decreased vocabulary
2. Limited sentence structure
3. Impairments in conversing (limited vocabulary, cannot connect sentences)
AND

B. Language ability below expectations for age (typically present before 4 years)

Question 20

What is Speech sound disorder?

Answer 20

Persistent difficulty with speech sound production that interferes with speech
intelligibility or prevents verbal communication • Blue→bu
• Rabbit→wabbit
• School→coo
• Play→puhlay • Radio→wadio

• Speech should be intelligible by age 3-4
• Milder cases spontaneously recover by age 8
• With speech therapy, almost all cases completely recover

Question 21

What are the diagnostic criteria of Fluency Disorder?

Answer 21

Diagnostic Criteria:

A. Persistent disturbances in the normal fluency and time patterning of speech that
are inappropriate for age and level of language skill

1. Sound and syllable repetitions
2. Sound prolongations of consonants and vowels
3. Broken words
4. Blocking – pauses in speech
5. Words produced with excessive tension
6. Monosyllabic whole-word repetitions (e.g., “I-I-I-I see him”)
   AND

B. The disturbance causes anxiety about speaking or limits effective communication

Question 22

What is the epidemiology of Childhood onset Fluency Disorder?

Answer 22

Usually diagnosed by age 6

• May not be present during oral reading, singing or talking to inanimate
objects

• 80% recover without intervention before age 16

Question 23

What are the diagnostic criteria of social (pragmatic) communication disorder?

Answer 23

Diagnostic Criteria:
1.Persistent difficulties in the social use of verbal and nonverbal communication (all of the following):

➢ Deficits in using communication for social purposes (greeting, sharing info) ➢ Impairment in ability to change communication to match context
➢ Difficulty following the rules for communication
➢ Difficulty understanding implicit meanings
AND

2. The deficits result in functional limitations in effective communication that

• Diagnosis rarely made before age 4-5

Question 24

What are the diagnostic criteria of Autism Spectrum Disorder?

Answer 24

1. Persistent deficits in social communication and social interaction across multiple contexts
   AND
2. Restricted, repetitive patterns of behavior (RRBs), interests, or activities
3. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by:

A. Deficits in social-emotional reciprocity
• Limited back-and-forth conversation
• Failure to initiate or respond to social interactions • Does not share experiences/emotions
B. Deficits in nonverbal communicative behaviours
• Limited eye contact, use of gestures, facial expressions
• Limited understanding of body language & facial expressions

C. Deficits in developing, maintaining, and understanding relationships (problems with sharing, imaginative play, making friends)

Question 25

What are the autism specifiers?

Answer 25

• With or without accompanying intellectual impairment
  • With or without accompanying language impairment
  • In the old DSM-IV, there was a classification – “Asperger’s disorder”

  • However, in the new DSM-5, persons would be diagnosed as Autism Spectrum Disorder without language impairment and without intellectual impairment.

Question 26

What are the diagnostic criteria of ADHD?

Answer 26

Affects preschoolers, children, adolescents, adults

• Symptoms that result in impairment are present before age 12 years
• 6 or more specific symptoms of inattention AND/OR
• 6 or more specific symptoms hyperactivity-impulsivity AND
• Persisted for at least six months

Question 27

What are the inattention symptoms of ADHD?

Answer 27

A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by (1) or (2)

1. Inattention: 6 or more specific symptoms of inattention have persisted for at least six months to a degree that is inconsistent with developmental level, and that negatively impacts directly on social and academic/occupational activities:

a) Lack of attention to details
b) Difficulty in remaining focused
c) May seem not to be listening
d) Lack of follow through
e) Difficulty organizing tasks
f) Avoids tasks that require sustained effort
g) Loses things
h) Easily distracted
i) Forgetful

Question 28

What are the hyperactive and impulsive symptoms for ADHD?

Answer 28

A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by (1) or (2):

Hyperactivity and Impulsivity: 6 or more specific symptoms of hyperactivity- impulsivity have persisted for at least six months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational functioning:

a) Fidgets, squirms in seat
b) Leaves seat, when being seated is expected
c) Runs about, inappropriately (adult may feel restless)
d) Unable to remain quiet while at play or leisure
e) On-the-go; motor driven
f) Talks excessively

The above are hyperactive symptoms

g) Blurts out
h) Cannot wait for turn
i) Interrupts, intrudes

The above are impulsive symptoms

Question 29

What are the types of ADHD types?

Answer 29

1. ADHD,
   Presentation [inattention and hyperactivity-impulsivity] Both Criteria 1 and 2 are met for the past 6 months
   6 or more symptoms of inattention AND 6. Or more symptoms of hyperactivity-impulsivity
2. Predominantly Inattentive
   Criteria 1 met for the past 6 months
   ≥6 symptoms of Inattention BUT <6 symptoms of hyperactivity-impulsivity
3. Predominantly hyperactive-impulsive
   Criteria 2 met for the past 6 months
   6 or more symptoms of Hyperactivity-8mpulsivity BUT less than 6 symptoms of inattention

Question 30

What is the stimulant treatment for ADHD?

Answer 30

A combination of medication and behavioral psychotherapy are recommended
✓(if child <6 years old, then behavioral interventions are first-line)

1. Stimulant
   • Drugs affecting catecholamines
   • Amphetamine (Adderall), methylphenidate (Ritalin)
   • Mechanism: increases dopamine and norepinephrine in prefrontal cortex
   • Adverse effects: appetite loss, insomnia, edginess, GI upset • Blackbox warning: potential for abuse

Question 31

What is the Non-stimulant treatment for ADHD?

Answer 31

Non-stimulant
• Drugs selectively inhibiting norepinephrine reuptake
• Atomoxetine (Strattera)
• [AT-oh-MOX-ih-teen]
• Mechanism: selectively inhibits norepinephrine reuptake in the
prefrontal cortex
• Used in stimulant failures or if there are contraindications for using stimulants (e.g. coexisting anxiety, tics, abuse liability

Non-stimulant
• Drugs selectively inhibiting norepinephrine reuptake
• Viloxazine
• Received FDA approval in 2021 for use in Paediatric patients • Contraindications: monoamine oxidase inhibitors
• Warning: higher rates of suicide thoughts and behaviors