Neurodevelopmental Disorders

Question 1

What are neurodevelopmental disorders?

Answer 1

group of conditions with the onset in the developmental period

Question 2

When do neurodevelopmental disorders manifest?

Answer 2

often before the child enters primary school

Question 3

What are neurodevelopmental disorders characterized by

Answer 3

developmental deficits that produce impairments of personal, social, academic or occupational functioning

Question 4

Which developmental disorders occur together typically?

Answer 4

Autism and Intellectual disability, ADHD and Dyspraxia, Tic disorders and ADHD

Question 5

What are the types of neurodevelopmental disorders according to ICD-11 and DSM-5?

Answer 5

Intellectual Disabilities.

Communication Disorders: Language Disorder, Speech Sound Disorder, Childhood-Onset Fluency Disorder (Stuttering), Social (Pragmatic) Communication Disorder.

Autism Spectrum Disorder.

Attention-Deficit/Hyperactivity Disorder.

Specific Learning Disorder.

Motor Disorders: Developmental Coordination Disorder, Stereotypic Movement Disorder, Tic Disorders / Tourette.

Other Neurodevelopmental Disorders: traumatic brain injury, neurotoxicants, genetic syndromes.

Question 6

What is intellectual disability and types?

Answer 6

A combination of IQ and adaptive functioning

Mild, Moderate, Severe and profound

Global Developmental delay

Question 7

What are the types of specific learning disorders?

Answer 7

Impairment with Reading (dyslexia)

Impairment with written expression (dysgraphia)

Impairment with mathematics (dyscalculia)

Question 8

What are the types of communication disorders?

Answer 8

Language Disorder (Expressive, receptive, combined)

Speech Sound Disorder

Childhood-onset Fluency Disorder (Stuttering)

Social communication Disorder (Semantic Pragmatic language disorder)

Autism Spectrum Disorder

Question 9

What are the core features of ASD?

Answer 9

Communication deficits: Verbal and non-verbal

Deficits in social interaction or lack of reciprocal social interaction or deficits in socio-emotional reciprocity

Restricted/repetitive interests and behaviours

Question 10

How common is ASD?

Answer 10

Autism: 1 per 100 (DSM-5)

Considerable increase over older data? 1 in 67

4 times more common in boys than girls – but questions about females with ASD being under-diagnosed or missed

Question 11

What is the prevalence of other comorbid psychiatric disorders with ASD?

Answer 11

70 % had at least one co-morbid Psychiatric Disorder. 41 % had 2 or more psychiatric disorders.

(most common social anxiety, ADHD, oppositional defiant disorder)

Question 12

What are the mental health comorbidities in adults with ASD?

Answer 12

38% had co-morbid ADHD

7% had bipolar disorder with psychotic features

7.8% had Schizophrenia or another psychotic disorder

Question 13

What is ADHD?

Answer 13

(Attention Deficit Hyperactivity Disorder)
A persistent pattern of inattention and / or hyperactivity-impulsivity that interferes with functioning or development. Is it a disorder or variation – neurodiversity

Between 3 – 5 % of young people meet the criteria for a diagnosis

Gender ration M:F is 2:1

Question 14

What other developmental problems accompanies ADHD?

Answer 14

tics, motor co-ordination problems, sleep delay, enuresis, intellectual or specific learning problems, and Tics. As well as behavioural problems (ODD) and psychiatric problems such as anxiety and depression (in adolescence or later)

Question 15

What is inattention?

Answer 15

Often fails to give close attention to details or makes careless mistakes in school work at work or during other activities
Often has difficulty sustaining attention in tasks or play activities for example has difficulties remaining focused during lectures conversations or lengthy reading.
Often does not seem to listen when spoken to directly for example mine seems elsewhere even in the absence of any obvious distraction.
Often does not follow through on instructions and fails to finish school work chores or duties in the workplace for example starts tasks but quickly loses focus and it’s easily side-tracked.
Often has difficulty organising tasks and activities for example difficulty managing sequential tasks difficulty keeping materials and belongings in order; messy, dis organised work; has poor time-management; fails to meet deadlines.
Often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort for example school work or homework (for older adolescents and adults preparing reports, completing forms, reviewing lengthy papers).
Often loses things necessary for tasks or activities e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses and mobile-phones).
Is often easily distracted by extraneous stimuli (for older adolescents and adults may include unrelated thoughts).
Is often forgetful in daily activities for example doing chores running errands for older adolescents and adults returning calls being bills keeping appointments.

Question 16

What is hyperactivity and impulsivity?

Answer 16

Often fidgets with or taps hands or feet or squirms in seat.
Often leaves seat in situations when remaining seated is expected (e.g. leaves his or her place in the classroom, in the office or other workplace or in other situations that require remaining in place).
Often runs about or climbs in situations where it is inappropriate (note: in adolescents or adults may be limited to feeling restless).
Often unable to play or engage in leisure activities quietly.
Is often “on the go” acting as if “driven by a motor” (e.g. is unable to be or uncomfortable being still for extended time; as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with).
Often talks excessively.
Often blurts out an answer before a question has been completed (e.g. completes people sentences; cannot wait for turn in conversation).
Often has difficulty waiting his or her turn (e.g. while waiting in line).
Often interrupts or intrudes on others (e.g. butts into conversations, games or activities; may start using other people’s things without asking or receiving permission; for adolescents and adults may intrude into or takeover what others are doing).

Question 17

What is dsyfunctional in ADHD

Answer 17

anterior cingulate cortex

Question 18

What is the neuroanatomy of ADHD?

Answer 18

smaller brain 4%
right frontal lobe 8%
smaller basal ganglia 6%-> normalisation 18years
smaller cerebellum 12%-> more pronounced 18yrs

Question 19

What are the volumetric differences in ADHD

Answer 19

manifest early (6 years), correlate with ADHD severity, irrespective of medication status and comorbidities

Question 20

What are the comorbidities of ADHD

Answer 20

Children with ADHD w/o ASD or LD even have high rates of psychiatric comorbidities:

20-40 % have an Anxiety Disorder
5-20 % have a mood disorder
30 % have a disruptive behaviour disorder (ODD/CD)

Question 21

What are the types of neurodevelopmental motor disorders?

Answer 21

Tic Disorders

Stereotypic Movement Disorder

Developmental Coordination Disorder

Question 22

What are tics?

Answer 22

sudden, rapid, repetitive, non-rhythmic, inapposite, irresistible, muscle movements or vocalizations, which can be classified as simple or complex (Cath et al 2001, Singer 2011).

Motor / Vocal (phonic)
Simple vs complex

Question 23

How is Tourette Syndrome classified according to DSM-5?

Answer 23

: Both multiple motor AND one or more vocal tics have been present at some time during the illness although not necessarily concurrently.
B: The tics may wax and wane during in frequency but have persisted for more than 1 yr since the first tic onset.
C: Onset is before the age of 18.
D: The disturbance is not attributable to physicoogical effects of a substance (e.g. cocaine) or another medical condition (e.g. Huntington’s disease, or post-viral encephalitis)

Chronic Tic Disorder
Provisional (transient) Tic Disorder

Question 24

What is the course and prognosis of tic disorders?

Answer 24

55-60 % tic disorders disappear by late teens/ early adulthood

20-25 % becomes minor or occasional

20 % tics stay as they are

Co-morbidities predict functioning and affect quality of life more than tics themselves

Question 25

Why is Tourette Syndrome more than just a movement disorder?

Answer 25

The whole complex of symptoms in a Tic disorder are better understood as a complex neurobehavioural or a neuropsychiatric condition.

There is a general presence of impulse control difficulties, subtle differences in neuropsychological and motor functioning.

As well as a very high rate of psychiatric /developmental co-morbidities.

Question 26

What are the comorbidities of tourettes?

Answer 26

ADHD 30 - 50%
Compulsions /CB 30 - 40%
Obsessive Compulsive Disorder 5 %
Anxiety disorders 25% - 30%
Conduct & ODD 10-30%
ASD 5 % (broader phenotype 20%)
Mood Disorder 10%

Self injury
Migraine and other headaches
Sleep disorders
Teeth grinding/ bruxism
Restless leg syndrome

Question 27

How many % with Tourettes have Coprolalia

Answer 27

8%

Question 28

How is Stereotypic Movement Disorder classified according to DSM-5?

Answer 28

A: Repetitive, seemingly driven, and apparently purposeless motor behaviour.

B: Interferes with social, academic, other activity, or self-injury

C: Onset in early developmental period

D: RMB is not better explained by another neurodevelopmental condition or mental health condition (Trichotillomania / OCD) and is not attributable to physiological effects of a substance or a neurological condition

Question 29

What do undiagnosed neurodevelopmental conditions typically explain?

Answer 29

Often explain school refusal

Explain medically unexplained or functional symptoms such as tummy pain or loss of function of legs

Explains depression and bullying

Can also explain certain medical conditions / sleep problems / eating problems etc

Hence always important to consider to remember neurodevelopmental conditions / profile when doing general psychiatric and paediatric assessments

Question 30

Michael Rutter showed rates of mental illness much higher in children with

Answer 30

Learning disability
Epilepsy
Cerebral palsy

More recent national estimates suggest that 35-40% of children and young people with a learning disability are likely to have a mental health issue (Emerson 2003)

Question 31

What are the implications of physical health in children with LD/ASD?

Answer 31

Higher rates of physical health problems in LD/ ASD
Some have identified syndromes- encompass multisystem problems (e.g. 22q11 del)

Selective eating leads to nutritional deficiencies, dental problems and constipation
Sensory sensitivities – refusal to brush teeth
Sleep delay and problems common in ASD
Pain communicated differently in children with LD/ASD

Question 32

What are the challenges in detecting mental illness in ASD/LD

Answer 32

Communication difficulties makes it difficult for children to express their thoughts and feelings.

Children’s behaviour is difficult to interpret because of aspects of their functioning are at a much younger age than their chronological age.

The signs and symptoms of particular mental illness in developmental conditions may be atypical, and most research on common psychiatric disorders is based on typically developing children.

Co-morbidities can create further difficulties.

Aggressive behaviour may indicate anxiety or depression but at the same time headache, toothache or tummy ache!

Question 33

What are the challenges in managing mental health problems?

Answer 33

Children with Autism are much more likely to experience side-effects with psychotropic medication.

Prescribing medication is complicated due to interactions with other medication that the child is taking for co-morbid medical conditions.

Presence of epilepsy makes prescribing more complicated due to risk of lowering of seizure threshold.

Lack of good evidence for medication use due to lack of large trials means off-license prescribing

Engagement with therapies may be difficult and availability of therapies vary. Therapy may require a degree of cognitive and/or language ability and motivation. Therapeutic approaches often require modification.

Question 34

What family/parenting style (factors) are associated with neurodevelopmental presentations?

Answer 34

Shared genetics

Parents coping style once they know their child has chronic disability

Parental stress and anxiety

Differences between 2 parents’ view and approach to managing the problem

Question 35

What are the questions in a case formulation?

Answer 35

What is the presenting problem

What precipitated this problems

What are the predisposing (pre-existing factors)

What are the perpetuation (or maintaining factors)

What are protective factors

Question 36

Other useful tips when assessing children with developmental disorders

Answer 36

Young people with Neurodev conditions can experience high levels of stress and anxiety particularly when in highly stimulating and demanding environment (Hospital or a clinic)

Ask parents: “what age do you think your child is functioning at?” (rough measure of ability)
Think: what behaviours is the child communicating? (Pain or anxiety through diff behaviour)

Consider (where suitable):
Simple fact-based discussions with clear timelines (with visual support)
Balance involving child in treatment decisions– helps ‘not being in control feeling’
Advance preparation, gradual steps towards toleration
Contract, rules for behaviour

For clinicians and paediatric / medical teams:
Who should be involved (including community services)?
What environmental factors and adaptations do we need to consider (home / school / clinics)
How do we prepare for and manage admissions, procedures & emergency events?