Neurodevelopmental Disorders

Question 1

What are the two main symptom groups in ADHD?

Answer 1

Inattention
Hyperactivity and impulsivity

Question 2

Describe the basic criteria for ADHD

Answer 2

Required that at least 6 of the 9 inattention and 6 of the 9 hyperactivity/impulsivity symptoms be present for at least 6 months and with the onset being before the age of 12 years

Question 3

What are the subtypes of ADHD

Answer 3

Predominently hyperactivity or inattention or mixed

Question 4

What is the “impairment” requirement for diagnosis of ADHD?

Answer 4

Impairment must be in two areas or more

Question 5

How does the diagnosis of ADHD change in those aged 17 or older

Answer 5

Only 5 symptoms of inattention and 5 symptoms of hyperactivity or impulsivity are required.

Question 6

Which gene has been linked to ADHD in genetic studies

Answer 6

Dopamine transporter gene

Question 7

Other than familial history, what are some other risk factors associated with ADHD?

Answer 7

maternal substance abuse, obstetric complications, malnutrition, exposure to toxins, viral infections

Question 8

Which areas of the brain are found to have abnormalities in children with ADHD?

Answer 8

Prefrontal cortex
Basal ganglia
Cerebellum

Question 9

Persistence of ADHD symptoms into adolescence and adulthood are predicted by which factors?

Answer 9

Family history of the disorder
Negative life events
Comorbidity with conduct symptoms, depression and anxiety disorders.

Question 10

What are some of the psychosocial interventions for ADHD?

Answer 10

Psychoeducation
Parent training - positive reinforcement, closely monitor the environment to minimize distractions
Behavior modification in the classroom and at home
CBT
Social skills training

Question 11

What is the basic MOA of methylphenidate?

Answer 11

Inhibits the reuptake of dopamine and norepinephrine in the brain which increases the activity of these two neurotransmitters

Question 12

What is the typical weight based dosing of methylphenidate?

Answer 12

0.3mg/kg before breakfast and lunch

Question 13

What is the typical dose increase increments for methylphenidate

Answer 13

Increase by 0.1mg/kg/week

Question 14

What is the maximum dosage of methylphenidate

Answer 14

2mg/kg or 60mg/day

Question 15

What are some contraindications of methylphenidate

Answer 15

Anxiety
Cardiac conditions
Motor tics
Tourettes
Glaucoma
Use with MAO inhibitor or use within 14 days of discontinuation of a MAO inhibitor

Question 16

What are some serious side effects of methylphenidate?

Answer 16

Tachycardia
Hypertension
Seizures
Thrombocytopenia
Arrythmias
Worsening of Tourette’s syndrome
Psychosis
Growth retardation
Dermatitis
Erythema multiforme

Question 17

Which groups of patients should methylphenidate be used with caution?

Answer 17

Hypertension
Diabetes
Seizure disorder
Cardiac disorders
Drug abuse
EEG abnormalities
Dementia

Question 18

What is some advice you would give to those using methylphenidate

Answer 18

Take the last dose with lunch to avoid insomnia
Do not mix with caffeine
Use OTC drugs with caution

Question 19

What are three other classes of drugs that can be used in the treatment of ADHD and examples of drugs in each class?

Answer 19

• Norepinephrine reuptake inhibitor (Atomoxetine)
• Alpha-agonist (Clonidine)
• Antidepressant (Bupropion)

Question 20

List the DSM 5 criteria for ADHD

Answer 20

A - a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development as characterized by (1) and/or (2)
(1) Inattention - 6 (or 5 in older children) or more of the the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impaccts directly on social and academic/occupational activities.
(2) Hyperactivity - same as above

B - several of the symptoms were present prior to the age of 12 years
C - several of the symptoms are present in two or more settings
D - clear evidence that they interfere with or reduce the quality of social, academic or occupational functioning
E - do not occur exclusively during the course of SCZ or another psychotic disorder and are not better explained by another psychiatric disorder.

Question 21

What are the 9 inattention symptoms?

Answer 21

1 - often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during activities
2 - often has difficulty sustaining attention in tasks or play activities
3 - often does not seem to listen when spoken to directly
4 - often does not follow-through on instructions and fails to finish tasks
5 - often has difficulty organizing tasks and activities
6 - often avoids dislikes or is reluctant to engage in tasks that require sustained mental effort
7 - often loses things necessary for tasks or activities
8 - often is easily distracted by extraneous stimuli
9 - often forgetful in daily activities

Question 22

What are the 9 hyperactivity symptoms of ADHD?

Answer 22

1 - often fidgets or taps hands/feet or squirms in seat
2 - often leaves seat in situations where remaining in seat is expected
3 - often runs about or climbs in situations where it is inappropriate
4 - often unable to play or engage in leisure activities quietly
5 - is often “on the go” or acting as if “driven by a motor”
6 - often talks excessively
7 - often blurts out the answer before a question has been completed
8 - often has difficulty waiting his or her turn
9 - often interrupts or intrudes on others

Question 23

What are the specifiers for ADHD?

Answer 23

• combined presentation
• predominantly inattentive presentation
• predominantly hyperactive/impulsive presentation
• in partial remission
• mild
• moderate
• severe

Question 24

What are some differentials for ADHD?

Answer 24

Conduct disorder
Oppositional defiant disorder
Disruptive Mood dysregulation disorder
IDD
Intermittent explosive disorder

Question 25

What are some common side effects of Ritalin?

Answer 25

Insomnia
Loss of appetite
Headaches
GI upset
Anxiety
Irritability
Raised BP and pulse rate
Growth deceleration

Question 26

What is the basic MOA of Buproprion

Answer 26

Dopamine and Norepinephrine reuptake inhibitor

Question 27

What are two alternative stimulants to methylphenidate?

Answer 27

Dexamphetamine
Lisdexamphetamine (prodrug)

Question 28

What is the basic MOA of lisdexamphetamine?

Answer 28

This is dexamphetamine that has been complexed with lysine to make an inactive form and this is gradually broken down into the active forms inside red blood cells which acts similar to the extended release forms of methylphenidate

Question 29

In which situations would atomoxetine be an appropriate choice?
What warning should you give to parents?

Answer 29

Children who do not respond to stimulants
Where there are dopaminergic adverse effects such as tics, anxiety and stereotypies.
Suicidal thoughts and liver disease.

Question 30

What are the DSM 5 criteria for Autism Spectrum Disorder?

Answer 30

A - persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive; see text):

1 - Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.

2 - Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication, to abnormalities in eye contact and body language or deficits in understanding and use of gestures, to a total lack of facial expressions and nonverbal communication.

3 - Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.

SPECIFY Severity - based on social communication impairments and restricted, repetitive patterns of behavior.

(B) Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive):

1 - Stereotyped or repetitive motor movements, use of objects, or speech

2 - Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal and non-verbal behavior

3 - Highly restricted, fixated interests that are abnormal in intensity or focus

4 - Hyper- or hypo-reactivity to sensory input or unusual interest in sensory aspects of the environment.

SPECIFY severity based on social communication impairments and restricted, repetitive patterns of behavior.

C - Symptoms must be present in the early developmental period (may not become fully manifested until social demands exceed limited capacities, or may by masked by learned strategies in later life)

D - Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.

E - These disturbances are not better explained by intellectual disability or global developmental delay. ID and ASD frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and ID, social communication should be below that of expected for general developmental level.

Question 31

Quick and easy summary of the DSM5 criteria for ASD?

Answer 31

A - Deficits social communication and social interaction multiple contexts

1 - Social-emotional reciprocity
2 - Nonverbal communicative behaviors used for social interaction
3 - Developing, maintaining and understanding relationships

B - Restrictive, repetitive patterns of behavior, interests or activities

1 - Stereotyped or repetitive motor movements, use of objects or speech
2 - Sameness, routines, patterns
3 - Fixated interests
4 - Hyper or hyporeactivity to sensory input

C - present since early developmental period
D - clinically significant impairment
E - not better explained by ID or global developmental delay

Question 32

What are the autism specifiers?

Answer 32

1. With or without accompanying intellectual impairment
2. With or without accompanying language impairment
3. Associated with a known medical or genetic condition or environmental factor
4. Associated with another neurodevelopmental, mental or behavioral disorder
5. With catatonia
6. Severity for both criterion A and B

Question 33

What are the severity specifier levels for ASD?

Answer 33

Level 1 - Requiring support
Level 2 - Requiring substantial support
Level 3 - Requiring very substantial support

Question 34

Which disorders from the DSM IV are now grouped under the single diagnosis of ASD?

Answer 34

Autistic disorder
Asperger’s disorder
Childhood disintegrative disorder
Pervasive developmental disorder

Question 35

Comment on epidemiology and risk factors for ASD

Answer 35

Prevalence is about 1-2%
Risk factors:

Environmental: advanced parental age, extreme prematurity, in utero exposure to certain drugs or teratogens, low birth weight

Genetic: 15% of cases of ASD appear to be associated with genetic mutation. Majority of these cases appear to be polygenic with hundreds of genetic loci making relatively small contributions

Prognostic: presence or absence of associated intellectual developmental disorder and language impairment and mental health problems affects the prognosis.

More common in boys than girls in a ratio of about 4:1

Question 36

What are some features associated with ASD but are not strictly part of the DSM V criteria?

Answer 36

Intellectual and language impairment
Theory-of-mind deficits (difficulty seeing the world from another’s perspective)
Executive function deficits
Difficulty with central coherence - inability to understand context, overfocus on the details
Motor deficits (odd gait, clumsiness, walking on tip toes)
Self injury - head banging, biting the wrist

Question 37

What are some differentials for ASD?

Answer 37

ADHD
IDD
Language and communication disorders
Selective mutism
Stereotypic movement disorder
Retts Syndrome
Anxiety disorders
Personality disorders
OCD
SCZ

Question 38

Co-morbidities with ASD

Answer 38

IDD
Language disorders
Anxiety, depression, ADHD
Restrictive food intake disorder
Epilepsy
Constipation

Question 39

Comment on the treatment of ASD

Answer 39

Varied according to age, level of impairment, co-morbidities, family, social situation
Goal is to increase the patient’s ability to function
Speech therapy and OT
Special school placement or grants (SW)
Behavior and communication therapy
Establishing a clear and consistent routine
Family support and counseling

Pharmacotherapy only indicated for certain reasons.
Antipsychotics may be used in aggressive behavior or self-harming activity
SSRIs can be used for motor stereotypies and anxiety
Mood stabilizers such as Epilim, Carbamazepine can be used to limit troublesome behaviors. Referral to a subspecialist in Child or Adolescent Psychiatry is recommended in cases where management has proved difficult

Question 40

What are some red flags for ASD in the early developmental period?

Answer 40

Deficits in eye tracking
Lack of response to their name
Milestone regression or plateau from approximately 17 months

Question 41

Comment on the epidemiology of IDD

Answer 41

• more common in boys than girls
• prevalence is approximately 1% of the general population
• children with mild disorder represent the majority of cases constituting approximately 85%
• children with moderate disorder constitute roughly 10% of those identified `

Question 42

What is IQ?

Answer 42

Intelligence Quotient: score on a test that rates the person’s intellectual function, or cognitive ability, as compared to the general population. IQ tests, for example the Wechsler Intelligence Scale for Children or the Wechsler Adult Intelligence Scales, use a standardized scale normed for particular populations, with a mean score of 100. On most tests, a score between 85 and 115 indicates average intelligence. An intellectual disability may be diagnosed when the IQ score is 2 or more standard deviations below the population mean, including a margin of error of measurement of 5 points. IQ score of 65-75.

Question 42

Define IDD (Intellectual Developmental Disorder)

Answer 42

Characterized by deficits in general mental abilities and impairment in everyday adaptive functioning, with overall onset in early developmental period.

Question 43

What is adaptive functioning?

Answer 43

The ability to adapt to the needs of everyday living and required conceptual, social and practical skills.

Question 44

What are the DSM V criteria for IDD?

Answer 44

Intellectual disability (intellectual developmental disorder) is a disorder with onset during
the developmental period that includes both intellectual and adaptive functioning deficits
in conceptual, social, and practical domains.

The following three criteria must be met:

A. Deficits in intellectual functions, such as reasoning, problem solving, planning, abstract
thinking, judgment, academic learning, and learning from experience, confirmed by
both clinical assessment and individualized, standardized intelligence testing.

B. Deficits in adaptive functioning that result in failure to meet developmental and sociocultural standards for personal independence and social responsibility. Without ongoing support, the adaptive deficits limit functioning in one or more activities of daily life,
such as communication, social participation, and independent living, across multiple
environments, such as home, school, work, and community.

C. Onset of intellectual and adaptive deficits during the developmental period.

Question 45

What are the specifiers for IDD?

Answer 45

Mild
Moderate
Severe
Profound

These are graded in each of 3 domains:
- conceptual
- social
- practical

Question 46

What are some of the intellectual functions that are affected in IDD?

Answer 46

Reasoning
Problems solving
Planning
Abstract thinking
Judgement
Academic learning
Learning from experience

Question 47

What are some of the adaptive functions affected in IDD?

Answer 47

Failure to meet developmental and socio-cultural standards
Limitation of activities of daily living such as:
Communication
Social participation
Independent living skills

Question 48

Describe the conceptual (academic) domain

Answer 48

Competence in memory
language
reading
writing
mathematic reasoning
acquisition of practical knowledge
problem solving
judgement in novel situations

Question 49

Describe the social domain

Answer 49

Awareness of other’s thoughts, feelings, and experiences, empathy, interpersonal communication skills, friendship abilities, and social judgement.

Question 50

Describe the practical domain

Answer 50

Involves learning and self-management across life settings, including personal care, job responsibilities, money management, recreation, self-management of behavior, and school and work task organization, among others.

Question 51

What are some genetic risk factors for IDD?

Answer 51

Autosomal abnormalities such as down syndrome
Sex chromosome abnormalities such as Kleinfelter’s syndrome
Other genetic abnormalities such as fragile X syndrome, prader-willi syndrome, phenyketonuria, retts disorder, neurofibromatosis, tuberous sclerosis, lesch-nyhan synndrome.

Question 52

What are some prenatal acquired causes of IDD?

Answer 52

Infections - HIV, syphilis, rubella
Toxins - FASD, prescribed medications
Maternal illness (HPT, DM, HIV)
Metabolic disorders

Question 53

What are some perinatal causes of IDD?

Answer 53

Birth trauma/asphyxia
Infections (HIV, gonorrhea)
Enddocrine disorders
Kernicterus
Neonatal disorders
Preterm or very low birth weight

Question 54

What are some post-natal causes of IDD

Answer 54

Infections - TBM
Head injury/trauma
Seizure disorders
Toxins
Malnutrition
Neurodegenerative disorders

Some sociocultural factors:
- poverty, social deprivation, lack of environmental stimulations, lack of opportunities to learn or practice skills

Question 55

Which psychometric tests are most commonly used in SA for the assessment of IDD?

Answer 55

Grover Counter Test
Vineland Adaptive Behavior Scales

Question 56

What are the physical facial features of FAS?

Answer 56

Small head
Small eye opening
Low nasal bridge
Flat midface
Smooth philtrum
Thin upper lip

Question 57

What are some other features of FASD?

Answer 57

Low body weight
Short height
Sleep and sucking difficultiies
Vision and hearing problems
Delayed speech and language development
Difficulty concentrating and short attention span
Hyperactivity
Learning disabilities
Low IQ
Poor coordination
Poor reasoning and judgement
Poor school performance
Poor short-term memory