Neurodevelopmental Disorders (Clinical Picture Only)
(12 Hours) Intellectual Developmental Disorder (Intellectual Disability)/
Specific Learning Disorder (Specific Learning Disabilities), - CAN LEAVE
Autism Spectrum Disorder, - MAJOR
Attention Deficit Hyperactivity Disorder - SHORT NOTE
ADHD
Neurodevelopmental disorders are a group of conditions characterized by: an early onset and
persistent course that are believed to be the result of disruptions to normal brain development
Neurodevelopmental disorders must have their onset during childhood.
Although neurodevelopmental disorders are heterogeneous in nature, they often overlap and
share common risk factors.
ADHD is
A persistent pattern of difficulties:
● sustaining attention and/or
● impulsiveness and
● excessive or exaggerated motor activity.
We all have had lapses in attention or periods of excess energy during childhood; however, in
order to meet criteria for ADHD these problems have to be numerous, persistent, and causing
impairment at home, school, or the workplace.
Comorbidity
Perhaps due partially to their behavioral problems, children with ADHD often score
approximately 7 to 15 points lower on intelligence quotient (IQ) tests (Barkley, 1997) and
show deficits on neuropsychological testing that are related to poor academic functioning
They often show specific learning disabilities such as difficulties in reading or learning other
basic school subjects.
Children and adolescents with ADHD also are at significantly higher risk of a range of school
problems including suspension and repeating a grade, and these effects appear to be due in
large part to disruptive behavior problems
In addition to academic problems, symptoms of ADHD also can lead to significant social
impairment. Hyperactive children often have great difficulty getting along with their parents
because they often fail to obey rules. Their behavior problems also can result in their being
viewed negatively by their peers
Prevalence
ADHD is fairly prevalent, occurring in approximately 9 percent of children and adolescents .
Although it is not the most prevalent disorder among U.S. children and adolescents (specific
phobia is seen in 19 percent of youth), it is the one that is most frequently diagnosed by
health professionals
WHY?
Bec: parents are much more likely to bring a child with ADHD in for treatment than they are a
child with a less disruptive disorder such as specific phobia.
The rate of ADHD is much higher in boys (13 percent) than in girls (4 percent) (Merikangas et
al., 2010) and is commonly comorbid with other externalizing disorders such as Oppositional
Defiant disorder and Conduct Disorder.
ADHD is seen in cultures all around the world.
For example, one study of 1,573 children from 10 European countries reported that ADHD
symptoms are similarly recognized across all countries studied and that the children have
significant impairments across a wide range of domains (Bauermeister et al., 2010).
Case study: Paul, a Student with ADHD
Paul was referred to a community clinic because of overactive, inattentive, and disruptive
behavior. His hyperactivity and uninhibited behavior caused problems for his teachers and for
other students. He would impulsively hit other children, knock things off their desks, erase
material on the blackboard, and damage books and other school property.
He seemed to be in perpetual motion, constantly talking and out of his seat. Although Paul was
determined to be above average intelligence, he was receiving failing grades due in large part to
his behavioral problems. Nevertheless, he often reported that he “felt stupid” and it was clear
that he had a seriously devalued self-image.
ADHD Beyond Adolescence
Approximately half of children with ADHD will continue to meet criteria in adulthood
Interestingly, however, most cases of adult ADHD are characterized by symptoms of
inattention (95 percent), whereas a much smaller percentage are characterized by
hyperactivity (35 percent) .
A systematic review revealed a high prevalence of adult ADHD ranging from 5.48 to 25.7%
among general and specific populations of India (Mishra et al, 2024).
It is estimated that approximately 4 percent of U.S. adults meet criteria for ADHD, with higher
rates among those who are male, divorced, and unemployed (Kessler, Adler, et al., 2006).
The association with unemployment may be due to trouble finding work, but may also be the
result of poor work performance or absenteeism.
One recent study showed that those with ADHD miss significantly more days of work
(approximately 22 more days each year) than those without ADHD highlighting the long-term
impairment associated with this disorder.
Causal Factors
The specific causes of ADHD have been widely debated.
Genetic AND Socio-environmental factors
● the brain develops differently in those with ADHD.
● Children with ADHD have smaller total brain volumes than those without ADHD
(Castellanos et al., 2002), and their brains appear to mature approx 3 years more slowly
than those without ADHD (Shaw et al., 2007)
● These maturational delays are most prominent in prefrontal brain regions involved in
attention and impulsiveness.
DSM CRITERIA FOR ADHD
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: Six (or more) of the following symptoms have persisted for at least 6 months to
a degree that is inconsistent with developmental level and that negatively impacts directly
on social and academic/occupational activities:
a. Often fails to give close attention to details or makes careless mistakes in
schoolwork, at work, or during other activities (e.g., overlooks or misses details,
work is inaccurate).
b. Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty
remaining focused during lectures, conversations, or lengthy reading).
c. Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere,
even in the absence of any obvious distraction).
d. Often does not follow through on instructions and fails to finish schoolwork, chores,
or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily
sidetracked).
e. Often has difficulty organizing tasks and activities (e.g., difficulty managing
sequential tasks; difficulty keeping materials and belongings in order; messy,
disorganized work; has poor time management; fails to meet deadlines).
f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained
mental effort (e.g., schoolwork or homework; for older adolescents and adults,
preparing reports, completing forms, reviewing lengthy papers).
g. Often loses things necessary for tasks or activities (e.g., school materials, pencils,
books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
h. Is often easily distracted by extraneous stimuli (for older adolescents and adults,
may include unrelated thoughts).
i. Is often forgetful in daily activities (e.g., doing chores, running errands; for older
adolescents and adults, returning calls, paying bills, keeping appointments).
2. Hyperactivity and impulsivity: Six (or more) of the following symptoms have persisted for at
least 6 months to a degree that is inconsistent with developmental level and that negatively
impacts directly on social and academic/ occupational activities: (Slide 15)
a. Often fidgets with or taps hands or feet or squirms in seat.
b. 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).
c. Often runs about or climbs in situations where it is inappropriate. (Note: In
adolescents or adults, may be limited to feeling restless.)
d. Often unable to play or engage in leisure activities quietly.
e. 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).
f. Often talks excessively.
g. Often blurts out an answer before a question has been completed (e.g., completes
people’s sentences; cannot wait for turn in conversation).
h. Often has difficulty waiting his or her turn (e.g., while waiting in line).
i. 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 take over what others are doing).
B. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years.
C. Several inattentive or hyperactive-impulsive symptoms are present in two or more settings
(e.g., at home, school, or work; with friends or relatives; in other activities).
D. There is clear evidence that the symptoms interfere with, or reduce the quality of, social,
academic, or occupational functioning.
E. The symptoms do not occur exclusively during the course of schizophrenia or another
psychotic disorder and are not better explained by another mental disorder (e.g., mood
disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or
withdrawal).
ASD
Autism spectrum disorder (which we refer to as “autism”) is a neurodevelopmental disorder that
involves a wide range of problematic behaviors including:
● deficits in language and perceptual and motor development;
● Defective reality testing; and
● impairments in social communication.
Case study
Matthew is 5 years old. He rarely speaks to others and almost never makes direct and
sustained eye contact. Matthew’s parents began to notice 3 years ago that while other children
were starting to put words together into sentences and have back-and-forth conversations with
their parents, he never seemed to develop these abilities.
Matthew spends much of his time alone, often playing with his toys in his room. While doing so,
he frequently engages in repetitive movements over and over again, such as wheeling his toy
train back and forth hundreds of times in a row. Matthew doesn’t like to leave his home, which
his parents think has to do with him being overly sensitive to all of the sights and sounds
outside. He also struggles when things deviate from his normal daily routine, which leads him to
repeatedly scream at the top of his lungs several dozen times in a row.
Key Features: Derived from Case Study
● Lack of eye contact
● No conversational ability
● Prefers playing alone
● Repetitive movements
● Sensitivity to external sight and sound
● Frustration when there is deviance from routine
History
Autism was first described in 1943 BY Leo Kanner.
It afflicts tens of thousands of American children from all socioeconomic levels and is seemingly
on the increase—estimates range between 30 and 60 people in 10,000
A recent study by the Centers for Disease Control and Prevention (Baio, 2014) reported that the
rate of autism among children is about 1 in 68. This reported increase in autism in recent years
is likely due to methodological differences between studies and changes in diagnostic
practice and public and professional awareness in recent years rather than an increase in
prevalence
Autism is usually identified before a child is 30 months of age and diagnostic stability over the
childhood years is quite high.
Lord and colleagues (2006) report that children diagnosed with autism by age 2 tend to be
similarly diagnosed at age 9.
Recent research suggests that early signs of problems with social communication can be
detected in the first 6 months of an infant’s life (Jones & Klin, 2014).
When scanning the world around them, typically developing infants from 2 to 6 months of
age focus increasingly on the face and especially the eyes of others. This focus allows
infants to better understand those caring for them and helps facilitate later social interaction.
In contrast, children later diagnosed with autism show a significant decline in their focus on
the eyes of others from 2 to 6 months of age and this decline continues until 24
months—at which point it is approximately half the level of focus as that seen in typically
developing children (see Figure 15.6; Jones & Klin, 2014).
In contrast, while their attention to other people’s eyes decreases, infants later diagnosed with
autism show a significant increase in their focus on inanimate objects, which is double the level
of typically developing children by 24 months
Clinical Picture of ASD
Children with autism show varying degrees of impairments and capabilities. A cardinal and
typical sign is that a child seems apart or aloof from others, even in the earliest stages of life
(Hillman et al., 2007).
Mothers often remember such babies as not being cuddly, not reaching out when being
picked up, not smiling or looking at them while being fed, and not appearing to notice the
comings and goings of other people.
Issues are found across different domains of life like:
● Social deficit
● An absence of Speech
● Self stimulation
● Maintaining Sameness
Social deficit
Children with autism often do not show any need for affection or contact with others. Several
studies, however, have questioned the traditional view that children with autism are emotionally
flat. These studies have shown that children with autism do express emotions and should
not be considered as lacking emotional reactions (Jones et al., 2001). Instead, some have
characterized the seeming inability of children with autism to respond to others as a lack of
social understanding—a deficit in the ability to attend to social cues from others.
Indeed, neuroimaging studies have revealed that children with autism show decreased activity
in the medial prefrontal cortex, a region associated with understanding the mental states of
others, but increased activation in the ventral occipitotemporal regions involved in object
perception (Sigman et al., 2006).
Additionally, children with autism show deficits in attention and in locating and orienting to
sounds in their environment (Hillman et al., 2007). These children often show an aversion to
auditory stimuli, crying even at the sound of a parent’s voice. The pattern is not always
consistent, however; children with autism may at one moment be severely agitated or panicked
by a very soft sound and at another time be totally oblivious to a loud noise.
Absence of speech
Children with autism do not effectively learn by imitation (Smith & Bryson, 1994). This
dysfunction might explain their characteristic absence or severely limited use of speech. If
speech is present, it is almost never used to communicate except in the most rudimentary
fashion, such as by saying “yes” in answer to a question or by the use of echolalia—the
parrot-like repetition of a few words. Whereas the echoing of parents’ verbal behavior is
found to a small degree in normal children as they experiment with their ability to produce
articulate speech, persistent echolalia is found in about 75 percent of children with autism
(Prizant, 1983).
Self stimulation
Self-stimulation is often characteristic of children with autism.
It usually takes the form of such repetitive movements as head banging, spinning, and
rocking, which may continue by the hour.
Maintaining sameness
Many children with autism become preoccupied with and form strong attachments to unusual
objects such as rocks, light switches, or keys.
When their preoccupation with the object is disturbed—for example, by its removal or by
attempts to substitute something in its place—or when anything familiar in the environment is
altered even slightly, these children may have a violent temper tantrum or a crying spell
that continues until the familiar situation is restored. Thus children with autism are often said to
be “obsessed with the maintenance of sameness.”
Causal factors
Autism is a complex disorder and its precise causes are unknown.
Twin and sibling studies have shown that there is a very strong heritable component in
autism. For instance, 2 to 14 percent of siblings of children diagnosed with autism also have the
disorder, and approximately 20 percent have some symptoms of the disorder (Newschaffer et
al., 2007).
Although there is a clear heritable component, the exact mode of genetic transmission is not yet
understood. On one hand, recent research has shown that hundreds of different genes are
associated with increased risk of autism, suggesting that there are many different paths to
developing this disorder (Robinson et al., 2014; State & Šestan, 2012).
Research has shown that the same genetic variants are associated with multiple disorders. For
instance, some of the same genes that have been linked with an increased risk of autism also
increase the risk of ADHD, schizophrenia, bipolar disorder, and depression (Smoller et al.,
2013).
Researchers are trying to determine what portion of the genetic risk is inherited (52 percent)
and what portion is due to de novo genetic mutations (3 percent).
De novo mutations are those that occur in the egg or sperm and are passed on to every cell in
the child’s body, despite not appearing in the parents’ DNA.
It seems that much of the risk for autism is indeed inherited from one’s parents (Gaugler et al.,
2014).
However, a significant portion of risk also arises due to de novo mutations. This is important to
know, because as we learn about factors that increase the likelihood of genetic mutations, we
can take steps to try to decrease their occurrence. For instance, genetic mutations have been
reported to occur at higher rates in the sperm of older men, and there is now converging
evidence that older father age at a child’s birth is associated with increased risk of autism
(D’Onofrio et al., 2014). Findings like these do not explain how or why such mutations increase
the risk of autism, but can be useful for the purposes of family planning.
Dsm 5
Autism Spectrum Disorder
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.
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; see text):
1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple
motor stereotypes, lining up toys or flipping objects, echolalia, idiosyncratic phrases).
2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of
verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulties with
transitions, rigid thinking patterns, greeting rituals, need to take the same route or eat the
same food every day).
3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong
attachment to or preoccupation with unusual objects, excessively circumscribed or
perseverative interests).
4. Hyper- or hypo reactivity to sensory input or unusual interest in sensory aspects
of the environment (e.g., apparent indifference to pain/temperature, adverse response
to specific sounds or textures, excessive smelling or touching of objects, visual
fascination with lights or movement).
C. Symptoms must be present in the early developmental period (but may not become fully
manifest until social demands exceed limited capacities, or may be 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 (intellectual
developmental disorder) or global developmental delay. Intellectual disability and autism
spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum
disorder and intellectual disability, social communication should be below that expected for
general developmental level.
TREATMENTS AND OUTCOMES OF AUTISM
The treatment prognosis for many children with autism is poor in part because so many people
with autism are insufficiently treated (Moldin & Rubenstein, 2006).
Use of a range of fads and “novel” approaches that have little to no support for their
effectiveness.
Intensive behavioral treatments have proven to be effective for many people diagnosed with
autism.
Behavioral treatment
Initially, it was believed that no effective way to treat people diagnosed with autism, exists.
Ivar Lovaas (1987) reported an intensive behavioral intervention administered via
one-on-one meetings with the child for over 40 hours per week for 2 years resulted in extremely
positive results.
The intervention was based on both discrimination training strategies (reinforcement) and
contingent aversive techniques (punishment).
The treatment plan typically enlists parents in the process and emphasizes teaching children to
learn from and interact with “normal” peers in real-world situations.
Results: 47 percent achieved normal intellectual and educational functioning, compared with
only 2 percent of children in the untreated control condition.
Dawson and colleagues (2010) recently showed that toddlers (18–30 months old) with autism
who were randomly assigned to receive the Early Start Denver Model (ESDM) intervention
showed significant improvements in IQ (an average of a 17-point increase), language, and
adaptive behavior as well as a decrease in symptoms of autism.
EDSM Includes 20 hours per week of intensive behavioral work with the child and parent(s)
focused on interpersonal exchanges, verbal and nonverbal communication, and adult
sensitivity to children’s cues.
Results: Greater cortical activation when viewing other people’s faces (compared to
objects), which in turn was correlated with greater improvements in the children’s social
communication (Dawson et al., 2012).
Although treatments like this one are extremely time consuming, their powerful results suggest
that behavioral interventions can cause improvements in people diagnosed with autism. See the
Developments in Practice box for other novel approaches to treating autism.
Adhd
For Inattention (FOCUS NOW):
F - Fails to give attention to details or makes careless mistakes.
O - Often loses focus during tasks or play.
C - Can't seem to listen when spoken to directly.
U - Unfinished tasks, failing to follow instructions.
S - Struggles to organize tasks and activities.
N - Neglects tasks requiring sustained effort.
O - Often misplaces important items.
W - Wandered focus due to distractions.
For Hyperactivity/Impulsivity (RUN FAST):
R - Restless, fidgeting, or squirming.
U - Up and out of seat when expected to stay seated.
N - Noisy, running, or climbing inappropriately.
F - Fails to play quietly.
A - Active as if "driven by a motor."
S - Speaks excessively.
T - Talks over others or blurts out answers.
Autism
For Social Communication Deficits: "RECIPROCAL NONVERBAL
RELATIONS."
1. R - Reciprocity deficits (e.g., failure in back-and-forth conversation, reduced sharing of
emotions or interests).
2. N - Nonverbal communication issues (e.g., poor eye contact, body language, gestures,
or facial expressions).
3. R - Relationship challenges (e.g., difficulty making friends, adjusting to social contexts,
lack of interest in peers).
For Restricted and Repetitive Behaviors: "MOVEMENT ROUTINE FOCUS
SENSES."
1. M - Movement or speech patterns (e.g., repetitive motor movements, echolalia, lining up
objects).
2. R - Routine rigidity (e.g., inflexible adherence to routines or distress at changes).
3. F - Fixated interests (e.g., abnormally intense or focused interests).
4. S - Sensory reactivity (e.g., hypersensitivity to sounds or textures, fascination with lights
or movement).