Neurodevelopmental Disorders

Question 1

1.0

Intellectual Disability (intellectual developmental Dx)

DSM-5

Answer 1

1. No longer Axis II; all mental disorders are considered on a single axis and given equal weight.
2. Intellectual Disability are impairments of general mental abilities that impact adaptive functioing in three domains/areas:
   
   1. Conceptual Domain: language, reading, writing, math, reasoning, knowledge, and memory
   2. Social Domain: empahty, social judgement, interpersonal communication, friendships
   3. Practical Domain: self-management ADL, recreation, jobs, money.etc.
3. ID has no specific age requirement, but symptoms must begin during the developmental period and are diagnosed based on the severity of deficits in 3 adaptive functioning.
4. chronic
5. Removed IQ scores from the diagnostic criteria, with severity based on adaptive functioning.
6. IQ still included with 2SD below or 70 or below.

Assess intelligence across 3 domains (conceptual, social and practical)

• ETIOLOGY:
  
  • 30% early alterations in embryonic dvlopment (down’s, damage due to toxins).
  • 15-20% to environmental factors and other mental disorders (autism, lack of nurturance/stimulation)
  • 10% to pregnancy and perinatal problems
  • 5% to heredity (tay-sachs, fragile x, PKU)
  • 5% to general medical conditions during infancy/childhood (lead paint, encephalitis, malnutrition).
  • 30-40% unknown causes
• Down Syndrome: extra chomosome about 10-30% of ID cases. also heart lesions, respiratory/intestinal defects, cataracts, age faster, die early, and alzheimer’s

Question 2

2. 0
   * *Specific Learning Disorder**

no more discrepancy model

Answer 2

DSM 5 CHANGES TO SLD

1. 20-30% comorbid with ADHD, and higher risk for antisocial behavior and for arrest and conviction for antisocial bx
2. Reading Dx and otherSLD have LD throughout adolescence and adulthood, and 1/3 have problems as adults.
3. reading dx more common in boys
4. cerebellar-vestibular dysfunction (otitis media) incomplete dominance or other hemispheric abnormatilities, toxins, phonological processing is core problem for readind dx.
5. DSM 5: SPECIFIC LEARNING DX: combines diagnoses fo reading, math, and written expression disorder and LD NOS. all three commonly occure together.
   
   1. dyslexia and dyscalculia

The DSM-5 diagnostic criteria for SLD reflect two major changes,

1) one overarching category of SLD with ‘specifiers’ to characterize the specific manifestations of learning difficulties at the time of assessment in three major academic domains, namely reading, writing, mathematics (e.g., SLD With impairment in reading:

2) elimination of the IQ-achievement discrepancy requirement and its replacement with four criteria (A –
D), all of which must be met.

1. A refers to the key characteristics of SLD (at least one of six symptoms of learning difficulties that have persisted for at least 6 months despite the provision of extra help or targeted instruction).
2. Criterion B refers to measurement of those characteristics (the affected academic skills are substantially and quantifiably below those expected for age 5 and cause impairment in academic, occupational, or everyday activities, as confirmed by individually administered standardized achievement measures and comprehensive clinical assessment).
3. Criterion C refers to age at onset of problems (during the school-age years, although may not fully manifest until young adulthood in some individuals), and
4. Criterion D specifies which disorders (Intellectual Disabilities, uncorrected auditory or visual acuity problems, other mental or neurological disorders) or adverse conditions (psychosocial adversity, lack of proficiency in the language of instruction, inadequate instruction) must be ruled out before a diagnosis of SLD can be confirmed.

Question 3

3.0

Communication Disorders

Answer 3

DSM-5

1. Language disorder (combines expressive and mixed receptive-expressive dx),
2. speech sound disorder (was phonological dx) and
3. childhood-onset fluency dx (was stuttering).
   
   1. ages of 2-7, 3x common in males
   2. 60% of cases remits by 16yo
   3. reduce stress in home, cope with frustration, reduce demands
   4. regulated breathing, awareness training, social support, “habit reversal”.
4. Social (pragmatic) Communication Dx: new condition for persistent difficulties in the social uses of verbal and nonverbal communication (cannot be diagnosed w/components in ASD like restricted repetitive bx, interests, and activities).

Question 4

4.0

Autism Spectrum Disorder

Answer 4

1. 4 previously separated dx into a singel condition with different levels of symptom severity in 2 core domains:
   
   1. autistic dx, asperger’s, childhood disintegrative dx, and PDD NOS all ASD now
2. Deficits in
   
   1. social communication and social interaction
   2. restricted repetitive behaviors, interests, and activities (RRBs)

Need both for ASD, but absent RRBs=Social Communication Dx

**ASD: **

1. oblivious to others, 50% remain mute for life or echolalia, pronoun reversals (you not I), 70% have IQ’s in the ID range.
2. lack of responsiveness to caregivers, baby refuse to cuddle, do not smile, do not respond to parent voices (not hearing loss).
3. Best outcome is the ability to communicate verbally by age 5-6 and IQ over 70 and a later onset of symtoms.
4. smaller-than-normal-cerebellum, enlarged ventricles, abnormal levels of norepinephrine, serotonin, dopamine.
5. huge genetic load: 50-100 times higher among biological siblings of autistic individuals than general population and identical twins higher than fraternal

interventions:

• enhancing ADLs, communication, and social skills, reducing undersirable bx.
• bx techniques most effective, shaping and discrimination training (Lovaas) improve communication skills.
• sheltered workshops and supported employment to help vocational skills.

Question 5

5.0

ADHD/ADD

Answer 5

DSM-5 changes

1. examples have been added for criterion items across the life span
2. cross-situational requirement has been strengthened to several symtoms in each setting
3. onset criterion has been changed from from before age 7 to ‘several inattentive or hyperactive-impulsive symptoms were present prior to age 12’.
4. subtypes have bee replaced with presentation specifiers that map directly to the prior subtypes
5. comorbid diagnosis with autism spectrum disorder is not allowed
6. cut off for ADHD for adults for 5 symptoms instead of 6 required for younger persons, both for inattention and for hyperactivity and impulsivity.
7. placed in the neurodevelopmental disorders chapter to reflect brain developmental correlates with ADHD and since the first chapter about disgnoses usually made in infancy, childhood, and adolescence cut out.

Question 6

5.5

ADHD/ADD

stats and facts.

Answer 6

ADHD:

1. two symptoms domains with 6 symptoms in one domain for atleast 6 months are required for diagnosis.
2. lower IQ, achievement delays, held back, suspended/expelled, drop out of high school.
3. social adjustment trouble w/ co-diagnosis with Conduct Disorder is common (30-90%). Also ODD, Anxiety and Major depression.
4. children frequency 3-7%, adults about 1-5%
5. 4-9 times more in boys, but ADD and adult ratio more equal.
6. atleast 60% continue as adults, more impatience, irritability, management of time/money, reckless driving, and impulsive sexuality.
7. inattention predominates majority of adults with adhd, executive functioning.
8. substance abuse among males, low ses, comorbid for disruptive bx dx.
9. genetic load, family members, identical twins.
10. Physiology: lower than normal activity in the caudate nucleaus, globus pallidus, and prefrontal cortex and smaller structures.

Question 7

5.8

ADHD continued

Answer 7

Fluctuation of symptoms in different settings. More symptomatic in familiar, repetitive, boring and structured situations.

**Behavioral Disinhibition Hypothesis: (Barkley): **core feature of ADHD is an inability to regulate bx to fit situational demands.

Inability to regulate attention, problems in inhibiting attention to nonrelevant stimuli and forcusing too intenseley on certain stimuli to the exclusion of others.

Treatment:

1. Methylphenidate (ritalin) beneficial for core symptoms in 75% of cases.
2. bx interventions are effective. Parent and teacher training to use positive reinforcement, time-out, and other bx interventions.

Mental Healthy Multimodal Treatment Study (MHA)

1. meds alone and combo of meds/bx treatment had a similar reduction in ADHD and were significantly better than the bx treatment alone or routine community care.
2. But combined treatment was superior for improving other areas of functioning like social skills, parent-child interactions, and academic performance.
3. Also, combined could use a lower dose than the those treated just with meds!
4. 36 month follow up: continuing meds alone or with bx trtment no longer had superior outcomes and that most children had sustained improvements in symptoms and functioning regardless of the type of treatment they received.

Question 8

6.0

Conduct Disorder

Answer 8

1. persistent pattern of bx that violate the rights of others and/or age-appropriate social rules.
2. little concern for well-being of others, little or no remorse, ambiguous situations misinterpret actions of others as threatening.
3. at least 3 symptoms during the past 12 months
4. four catagories of symptoms: aggressive to people/animals, destruction of property, deceitfulness/theft, serious violation of rules.
5. Childhood Onset (prior to 10) and Adolescent Onset (10 and older)
6. Childhood onset: higher degree of aggressiveness and greater risk of eventual diagnosis of Antisocial Personality Dx and/or Substance-Related Dx.

Etiology:

Moffitt distinguishes between 2 types of Conduct Disorder that differ in terms of onset, symptom severity and etiology.

• Life-Course Persistent Type: by age 3, continues to adulthood, neurological impairments, a difficult temperament, and adverse environmental conditions.
• Adolescence limited Type: temprorary type of antisocial bx that reflects a maturity gap (biological maturation but lack of adult privileges/rewards), may be antisocial or steal with friends, but adhere to school rules.

Treatment:

• target preadolescents and include family interventions, parent management training, reward positive bx and replace physical punishment with time-out, cost response, similar techniques.

Question 9

7.0

ODD

oppositional defiant disorder

Answer 9

DSM 5 changes

1. three types of symtoms: angry/irritable mood, argumentative/defiant bx, vindictiveness
   
   1. both emotional and bx symtoms
2. exclusion criterion for Conduct Dx is removed
3. guidance on the frequency typically needed for bx to be considered symptomatic of the ODD (as many are developmentally appropriate at times).
4. severity rating has been added to the criteria to reflect research in degree of pervasiveness of symptoms across setting is an important indicator of severity.

Question 10

8.0

Intermittent Explosive Disorder

Answer 10

DSM 5

1. Physical aggression
2. verbal aggression
3. non-destructive/noninjurious physical aggression
4. aggressive outbursts are impulsive and/or anger based, cause marked distress, cause impariment in occupational or interpersonal functioning or be associeated with negative financial or legal consequences.
5. minimum age of 6years now required

Question 11

New DSM-5 Chapters

Answer 11

No more Disorders usually first diagnosed in infancy, childhood, and adolescence.

Neurodevelopmental disorders

1. ID (IDD)
2. Communication Dx
3. Autism Spectrum DX
4. AD/HD
5. Specific Learning Disorder
6. Motor Dx

Disruptive, Impulse-Control, and Conduct Disorders

1. ODD
2. Conduct Dx
3. Intermittent Explosive Disorder

problems in emotional and behavioral self-control

ADHD frequently comorbid but is listed as neurodevelopmental dx.

Question 12

9.0

Motor Disorders

Answer 12

DSM 5

• Developmental Coordination disorder
• Stereotypic Movement disorder
• Tourette’s dx
• Persistent (chronic) motor or vocal tic disorder
• provisional tic dx
• other specified tic dx
• unspecified tic dx
• (body-focused repetitive bx dx not in OCD chapter)

Question 13

Tourette’s Disorder

Answer 13

** TIC**

sudden, rapid, recurrent, nonrhythmic, sterotyped motor movement or vocalization that is expereinced as irresistible but can be suppressed varying lengths of time.

Motor TIC

eye blink, facial grimace, gestures, jumping, smelling objects, and echokinesis (imitating others movements)

Vocal TIC

grunting, snorting, barking, echolalia, coprolalia (cursing), palilalia (repeating one’s own sounds/words).

1. presence of at least one vocal tic and multiple motor tics that may appear simultaneously or at different times that begin prior to age 18.
2. average age of onset is 6-7 years and more common in males.
3. OCD is much higher for Touretters but also for bio relatives.
4. ADHD symptoms also prevalent and cause of high rate of school problems.
5. Higher-than-normal levels of dopamine and/or hypersensitivity of dopamine receptors in the caudate nucleus.

Treatment:

1. pharmacotherapy: antipsychotics haloperidol and pimozide effective in 80% of cases . but most find the side-effects intolerable
2. psychostimulants can increase tics
3. clonidine (hypertension) and desipramine (antidepress) are often used to treat the hyperactivity and inattention.
4. SSRI is useful for alleviating the OCD symptoms

Differential Diagnosis:

• Chronic Motor or Vocal Tic Dx: individual has motor or vocal tics but not both.
• Transient Tic Dx: they have one or both tic types for at least 4 weeks but no longer than 12 consecutive months.
• Specified Tic Dx: motor or vocal tics with onset after 18yo
• Unspecified Tic Dx: does not meet the above criteria