Neurodevelopmental Disorders

Question 1

Intellectual Developmental Disorder Diagnostic Criteria

Answer 1

Includes both intellectual and adaptive functioning deficits in conceptual, social, and practical domains. Following 3 criteria must be met:
A. Deficits in intellectual functions (e.g., reasoning, problem-solving, plannign, abstract thinking, judgement, academic learning, learning from experience) confiemd by both clinical assessment and individualized, standardized intelligence testing.
B. Deficits in adaptive functioning result in failure to meet developmental and sociocultural standards for personal independence/social responsibility. Without ongoing support, adaptive deficits limint functioning in ≥1 iADLs
C. Onset of intellectual and adaptive deficits during development.

Question 2

Intellectual Developmental Disorder Specifiers

Answer 2

Evaluated based on domains (consult table in DSM-5-TR)
* Mild: Some support needed/impairment in conceptual tasks; social immaturity; independence in simple iADLs (feeding, self-care, simple jobs) but support needed for very complex/abstract ones (e.g., legal decisions, raising a family)
* Moderate: Marked delay in academic milestones/skills; marked differences in social behaviour and communication; similar iADL indepence to mild
* Severe: Limited attainment of conceptual skills; little understanding of the written language, speech limited and confined to simple/gestural social communication; support needed in all iADLs
* Profound: Abstraction/symobolic representation not comprehensible; limited understanding of symbolic communication; simple social communication; support needed in all aspects of daily care

Question 3

Key rule-outs/differential diagnoses for Intellectual Developmental Disorder

Answer 3

• Major/mild neurocognitive diosorders
• Communication disorders and specific LDs (multiple diagnoses can be made if full criteria are met)
• ASD: intellectual functioning usually impacted if at all by inability to express skills, rather than lack of skills

Question 4

Global Developmental Delay

Answer 4

• Reserved for children <5 years old, because clinical severity cannot yet be properly evaluated
• Individual fails to meet expected developmental milestones in several area of functioning
• Requires reassessment later on when the individual is able to complete standardized testing

Question 5

Unspecified Intellectual Developmental Disorder

Answer 5

• Reserved for childre >5 years old
• Assessment is imporssible because of sensory/physical impairments (e.g., blindness/prelingual deagness; locomotor disability, etc)
• Should only be used in exceptional circumstances and requires reassessment later on

Question 6

Language Disorder Diagnostic Criteria

Answer 6

A. Persistent difficulties in the acquisition/use of language across modalities due to difficulties in comprehension and production, including the following:
1. Reduced vocabulary (word knowledge and use)
2. Limited sentence structure
3. Impairments in discourse (ability to use vocab and connect sentences to explain/describe something or have a conversation)

B. Abilities are quantifiably below those expeted for age, resulting in functional limitations in communication, socializing, school, etc.
C. Onset early in developmental period
Not attributable to hearing or other sensory impairment, or physical/medical/neurological condition or explained by intellectual disability

Question 7

Language Disorder key rule-outs/differential diagnoses

Answer 7

• Normal variations in language ability
• Hearing or other sensory impairment
• Intellectual developmental disorder
• ASD
• Neurological disorder
• Language regression

Question 8

Speech Sound Disorder Diagnostic Criteria

Answer 8

A. Persistent difficulty with speech sound production that interferes with speech intelligibility or prevents verbal communication
B. Causes limitations in effective communication resulting in functional impairment
C. Onset early in developmental period
D. Not attributable to congenital or acquired medical/neurological conditions

Question 9

Speech Sound Disorder key rule-outs/differential diagnoses

Answer 9

• Normal variations in speech
• Hearing or other sensory impairments
• Structural deficits (e.g., cleft palate)
• Dysarthria
• Selective mutism

Question 10

Childhood-Onset Fluency Disorder (Stuttering) Diagnostic Criteria

Answer 10

A. Disturbances in the normal fluency and time patterning of speech that are inappropriate for age/language skills, persist over time and are characterized by frequent occurences of ≥1 of the following:
1. Sound and syllable repetitions
2. Sound prolongations of consonants as well as vowels.
3. Borken words (e.g., pauses within a word)
4. Audible or silent blocking
5. Circumlocutions
6. Words produced with excess of physical tension
7. Monosyllabic whole word repetitions

B. Causes anxiety about speaking or limitations in effective communication/functional impairment
C. Onset early in developmental period
D. Not attributable to speech motor or sensory deficit, dysfluency from a neurological condition, other medical condition/mental disorder

Question 11

Childhood-Onset Fluency Disorder key rule-outs/differential diagnoses

Answer 11

• Sensory deficits (e.g., hearing impariment or speech-motor deficit)
• Normal speech dysfluencies (e.g., phrase repetitions in young children)
• Specific LD with impairment in reading (e.g., slower reading aloud)
• Bilingualism
• Medication side-effects
• Adult-onset dysfluencies
• Tourette’s disorder (distinguished by nature and timing of the repetitive sounds)

Question 12

Social (Pragmatic) Communication Disorder Diagnostic Criteria

Answer 12

A. Persistent difficulties in the social use of verbal and nonverbal communication as manifested by all of the following:
1. Deficits in communication for social purposes (e.g., greeting, sharing information)
2. Impairment of ability to change communication to match context/needs of the listener (e.g., speaking differently in the classroom than on the playground)
3. Difficulties following rules for conversation and storytelling (e.g., turn-taking, rephrasing, using nonverbal/verbal cues to regulate the interaction)
4. Difficulties understanding what it not explicitly stated and nonliteral/ambiguous meanings

B. Results in functional limitations/impairment
C. Onset early in developmental period, but may not become fully manifest until social communication demands exceed capacity
D. Not attributable to another medical or neurological condition, low abilities in grammar/vocab skills, or another mental disorder

Question 13

Social Communication Disorder key rule-outs/differential diagnoses

Answer 13

• ASD: Differentiated by presence of restricted interests/repetitive behaviours
• ADHD
• Social anxiety disorder
• Intellectual developmental disorder

Question 14

Autism Spectrum Disorder Diagnostic Criteria

Answer 14

A. Persistent deficits in social communication and interaction across multiple contexts, manifested by all of the following (currently or historically):
1. Deficits in social-emotional reciprocity (abnormal social approach, normal back-and-forth conversations, reduced sharing of interests/emotions/affect; failure to initiate or response to social interaction)
2. Deficits in nonverbal communicative behaviours for social interaction (e.g., maintaining eye contact, reading facial expressions)
3. Deficits in developing, maintaining, and understanding relationships (e.g., adjusting behaviour to suit contexts; lack of interest in peers)

B. Restricted, repetitive patterns of behaviour, interests, or activities, manifested by ≥2 of the following (currently or historically)
1. Stereotyped/repetitive movements, use of obsject, or speech
2. Insistence on sameness, inflexible adherence to routines, ritualized patterns of verbal/nonverbal behaviour
3. Highly restriced, fixated interests that are abnormal in intensity or focus
4. Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment

C. Symptoms must be present in the early developmental period (but may only become fully manifest later in life)
D. Causes clinically significant distress/functional impairment
E. Not better explained by intellectual developmetnal disorder (but may co-occur with it)

Question 15

Autism Spectrum Disorder Specifiers

Answer 15

Severity:
* Requiring very substantial support
* Requiring substantial support
* Requiring support

Accompanying impairments:
* With/without accompanying intellectual impairment
* With/without accompanying language impairment

Aetiology:
* Associated with known genetic/medical condition or environmental factor
* Associated with a neurodevelopmental, mental, or behavioural problem

Other features:
* With catatonia

Question 16

Autism Spectrum Disorder Key Rule-Outs/differential diagnoses

Answer 16

• ADHD: Presence of repetitive behaviours/restricted interests can be a key differentiator (both diagnoses can be given if hyperactivity exceeds account solely due to ASD)
• Intellectual developmental disorder without ASD
• Language disorders and social communication disorder
• Selective mutism
• Stereotypic movement disorder
• Rett syndrome: most individuals with Rett improve their social communication after age 4
• Anxiety disorders
• OCD
• Schizophrenia
• Personality disorders: early developmental symptoms of ASD (lack of imaginitive play, restricted/repetitive behaviour, sensory sensitivity) can be helpful to distinguish presentations

Question 17

Attention-Deficit/Hyperactivity Disorder Diagnostic Criteria

Answer 17

A. Persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by ≥1 of:
1. Inattention: ≥6 of the following symptoms (≥5 if 17 or older) have persisted for ≥6 months to a degree that is incosistent with developmental level and negatively impacts directly on social and academic/occupational activities:
* Often fails to give close attention to details or makes careless mistakes in schoowork, at work, or during other activities
* Often has difficulty sustaining attention in tasks or play activities
* Often does not seem to listen when spoken to directly, even in absence of an obvious distraction
* Often does not follow through on instructions and failrs to finish schoolwork, chores, other duties (e.g., starts but loses focus/gets sidetrackede easily)
* Avoids, dislikes, is reluctant to engage in tasks requiring sustained mental effort
* Often has difficulty organizing tasks and activities
* Often loses things necessary for activities
* Is often easily distracted by extraneous stimuli
* Is often forgetful in daily activities

2. Hyperactivity and impulsivity: ≥6 of the following thath ave persisted for ≥6 months to a degree that is inconsistent with developmental level and that negatively impacts social and academic/occupational activities:
   
   • Often fidgets or taps hands or feet or squirms in seat.
   • Often leaves seat in situations when remaining seated is expected
   • Often runs about or climbs in situations where it is inappropriate (may be only feelings of restlessness in teens/adults)
   • Often unable to play or engage in leisurely activities quietly
   • Is often “on the go” as if “driven by a motor”
   • Often talks excessively
   • Often blurts out an answer before a question has been completed
   • Often has difficulty waiting their turn
   • Often interrupts or intrudes on others

B. Several symptoms were present before age 12
C. Several symptoms are present in ≥2 settings
D. Clear evidence that symptoms interfere with or reduce quality of functioning in important domains
E. Does not occur exclusively during schizophrenia or another psychotic disorder; not better explained by another mental disorder

Question 18

ADHD Specifiers

Answer 18

Presentation:
* Combined presentation: Criteria for inattention and hyperactivity are met
* Predominantly inattentive presentation: Criteria met for inattention but not for hyperactivity for the past 6 months
* Predominantly hyperactive presentation: Vice-versa

Course:
* In partial remission: Full criteria were previously met; now fewer than full criteria are met for the past 6 months, but still result in significant functional impairment

Severity:
* Mild: Few, if any, symptoms in excess of those needed for a dx. Results in some impairment but is manageable.
* Moderate: Between mild and severe
* Severe: Severe symptoms, well in excess of those needed for a dx. Result in severe functional impairment.

Question 19

Key differentials/rule-outs for ADHD

Answer 19

• ODD
• Intermittent explosive disorder
• Other neurodevelopmental disorders
• Specific learning disorder
• Intellectual developmental disorder
• ASD
• Reactive attachment disorder
• Anxiety disorders
• PTSD
• Depressive disorders
• Bipolar disorder
• Disruptive mood dyregulation disorder
• Substance use disorders
• Personality disorders
• Psychotic disorders
• Medication-induced symptoms of ADHD
• Neurocognitive disorders

Question 20

Specific Learning Disorder

Answer 20

A. Difficulties learning and using academic skills, as indicated by the presence of ≥1 of the following symptoms that have persisted for ≥6 months, despite the provision of interventions targetting those abilities:
1. Inaccurate or slow, effortful word reading
2. Difficulty understanding the meaning of what is read (e.g., may read text accurately but not understand the sequence, relationships, inferences, or deeper meanings)
3. Difficulties with spelling (e.g., may add, omit, or substitute vowels or consonants)
4. Difficulties with written expression (e.g., makes multiple grammar or punctuation errors within sentences; employs poor paragraph organizationl written expression of ideas lacks clarity)
5. Difficulties mastering number sense, number facts, or calculation (e.g., has poor understanding of numbers, their magnitude, and relationships; counts on fingers to add single-digit numbers instead of recalling the math fact as peer so; gets lost in arithmetic computation and may switch procedures.
6. Difficulties with mathematical reasoning (e.g., has severe difficulty applying concepts, facts, or procedures to solve quantitative problems)

B. The affected academic skills are substantially and quantifiably below those expected for the individual’s age and cause significant interference with academic/occupational performance, or iADLs, as confirmed by individually administered standardized achievement measures and comprehensive clinical assessment (or hisgtory of impaired learning for individuals >17 years old)
C. Difficulties begin in school-age years but may not become fully manifest until later in life.
D. Not better accounted for by intellectual disabilities, uncorrected visual/auditory acuity, other mental/neurological disorders, psychosocial adversity, lack of proficiency in the language of instruction, or inadequate education

Question 21

Specific Learning Disorder Specifiers

Answer 21

Specify all academic domains and subskills that are impaired:
* With impairment in reading:
* Word reading accuracy
* Reading rate or fluency
* Reading comprehension
* With impairment in written expression:
* Spelling accuracy
* Grammar and punctuation accuracy
* Clarity or organization of written expression
* With impairment in mathematics
* Number sense
* Memorization of arithmetic facts
* Accurate or fluent calculation
* Accurate math reasoning

Severity:
* Mild: Some difficulties learning skills in 1-2 acadmic domains, but of mild enough severity that the individual may compensate or function well when provided with appropriate accommodations and support
* Moderate: Marked difficulties learning skills in ≥1 academic domains so that the individual is unlikely to become proficient without intervals of intensive and specialized teaching during school years. Some accommodations/support needed at least part of the day at school, in the workplace, or at home to complete activities.
* Severe: Severe difficulties learning skills, affecting several academic domains, so that the individual is unlikely to learn them without ongoing intensive individualized and specialized teaching for most of school years. Even an array of accommodations/support services at home/work/school may not allow the individual to complete all activities efficiently.

Question 22

Key rule-outs/differentials for Specific LDs

Answer 22

• Normal variations in academic attainment: can be distinguished if external factors preventing attainment are corrected and difficulties persist
• Intellectual developmental disorder: In LD, difficulties present in the context of normal intellectual functioning. Both can be diagnosed if LD difficulties are in excess of what is explained by IDD.
• Learning difficulties due to neurological or sensory disorders
• Neuocognitive disorders
• ADHD
• Psychotic disorders: Reading ability is usually preserved in cases of schizophrenia presenting with cognitive impairment

Question 23

Developmental Coordination Disorder Diagnostic Criteria

Answer 23

A. Acquisition and execution of coordinated motor skills is substantially lower than expected for one’s age and opportunity for skill learning and use. Difficulties manifest as clumsiness (dropping things, bumping into things), as well as slowness and inaccuracy of performance of motor skills (catching, using scissors/cutlery, handwriting, riding a bike, sports)
B. Criterion A significantly and persistently interferes with iADLs appropriate to one’s age and impacts schools productivitiy, prevocational/vocational activities, leisure, and play.
C. Onset in the early developmental period.
D. Not better explained by intellectual developmental disorder or visual impairment; not attributable to a neurological condition affecting movement

Question 24

Key rule-outs/differentials for Developmental Coordination Disorder

Answer 24

• Motor impairments due to another medical condition
• Intellectual developmental disorder
• ADHD
• ASD
• Joint hypermobility syndrome

Question 25

Stereotypic Movement Disorder Diagnostic Criteria

Answer 25

A. Repetitive, seemingly driven, and apparently purposeless motor behaviour (e.g., hand shaking/waving, body rocking, head banging, self-biting, hitting own body)
B. Interferes with social/academic/other activities, may cause self-injury
C. Onset in early developmental period
D. Not attributable to substances/neurological condition; not better explained by another neudevelopmental condition/mental disorder.

Question 26

Stereotypic Movement Disorder Diagnostic Criteria

Answer 26

• With self-injurious behaviour
• Without self-injurioous behaviour
• Associated with a known genetic or other medical condition, neurodevelopmental disorder, or environmental factor

Severity:
* Mild: Symptoms easily suppressed by sensory stimulus or distraction
* Moderate: Symptoms require explicit protective measures and behavioural modification
* Severe: Continuous monitoring and protective measures are required to prevent serious injury.

Question 27

Key differentials/rule-outs for Stereotypic Movement Disorder

Answer 27

• Normal development: Simple stereotypies may occur in normal development. More complex ones which cannot be suppressed easily likely warrant a SMD diagnosis
• ASD: Look for other key features of ASD to differentiate
• Tic Disorders: Stereotypies have earlier onset; tics are more variable in their presentations and typically involve the face, eyes, head and shoulders, while stereotypies involve limbs; Tics are usually ego-dystonic (unlike stereotypies)
• OCD: Distinguished by presence/absence of obsessions
• Other neurological and medical conditions
• Substance-induced repetitive behaviours
• Functional (conversion) stereotypies: Distinguished by sudden onset and coexistence of other conversion disorder symptoms

Question 28

Tic Disorders Diagnostic Criteria

Answer 28

Note: A tic is a sudden, rapid, recurrent, nonrhythmic motor movement or vocalization

Tourette’s Disorder
A. Both multiple motor and ≥1 vocal tics have been present at some time, although not necessarily concurrently
B. Tics may wax and wane in frequency but have persisted for >1 year since first tic onset
C. Onset before age 18
D. Not attributable to substances or another medical condition

Persistent (Chronic) Motor or Vocal Tic Disorder
A. ≥1 motor OR vocal tics (but not both) have been present
B. Tics may wax and wane in frequency but have persisted for >1 year since first tic onset
C. Onset before age 18
D. Not attributable to substances or another medical condition
E. Criteria have never been met for Tourette’s

Specify if:
* With motor tics only
* With vocal tics only

Provisional Tic Disorder
A. Single or multiple vocal and/or motor tics.
B. Tics have been present for <1 year since first onset
C. Onset before age 18
D. Not attributable to substances or another medical condition.
E. Criteria have never been met for either of the other tic disorders.

Question 29

Key rule-outs/differentials for tic disorders

Answer 29

• Abnormal movements accompanying other disorders
• Paroxysmal dyskinesias
• Myoclonus: more rapid, less suppressible, lacks premonitory sensation or urge
• OCD
• Functional tic disorder: Individual presents with “tic attacks” that last 15 minutes to several hours