Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence

1
Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence

• RCS 6931
• 6/11/07
• Steven R. Pruett, Ph.D.

2
Many diagnoses in this section

• Mental Retardation
• Learning Disorders
• Motor Skills Disorder
• Communication Disorders
• PDDs
• Attention-Deficit Disruptive Behavior Disorders
• Feeding Eating Disorders
• Tic Disorders
• Elimination Disorders
• Other Disorders

3
Mental Retardation

• A behavioral syndrome related to low
  intelligence.
• Must begins before age 18
• IQ must be determined by a standard individual
  test and must be markedly below average.
• Note the criteria of an FSIQ 70 assumes a
  test mean of 100 with a SD of 15.

4
Mental Retardation

• Many behavioral problems are commonly associated
  with MR
• E.g. aggression, dependency, impulsivity,
  passivity, self-injury, low self-esteem,
  stubbornness, low frustration tolerance.
• Sometimes there are some comorbid affective
  disorders, psychotic disorders, and
  hyperactivity.
• Can be various physical manifestations given the
  cause of the MR.

5
Mental Retardation

• Etiology
• Genetics ( 5)
• Early Pregnancy factors ( 30)
• Later Pregnancy and Perinatal factors (10)
• Acquired Childhood Physical Conditions (5)
• Environmental Influences Mental Disorders
  (20)
• Unknown (30)

6
Mental Retardation

• Diagnostic Criteria
• Must have IQ 70 on a standardized test
• Functional problems in 2 or more
• Communicating
• Caring for self
• Living at home
• Relating to others
• Using community resources
• Directing self
• Academic functioning
• Working
• Using free time
• Health
• Safety
• Condition begins before age 18

7
Mental Retardation

• Types of MR
• Mild Mental Retardation 317
• IQ from 50-55 to 70
• Moderate Mental Retardation 318.0
• IQ from 35-40 to 50-55
• Severe Mental Retardation 318.1
• IQ from 20-25 to 35-40
• Profound Mental Retardation 318.2
• IQ less than 20-25
• Mental Retardation, Severity Unspecified 319
• Patient cannot be tested, but retardation seems
  highly likely.

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Mental Retardation

• Concerning infantsa diagnosing clinician must
  make a subjective decision on intellectual
  functioning.
• Mental Retardation MUST be noted in Axis II (this
  is NOT an Axis I disorder)
• Borderline Intellectual Functioning
• IQ in the 71-84 range
• V62.89 (p. 740 of DSM-IV-TR).
• Also coded under Axis II

9
Learning Disorders

• Always must be measured by a standardized test
  given to the individual alone (not in a group
  setting).
• Scores reflect a SIGNIFICANT deficiency in a
  learning ability given the individuals age,
  intelligence and education.
• Disorder materially impedes academic achievement
  or daily living.
• If there is also a sensory defect, the learning
  disorder is worse than would be expected from it.

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Learning Disorders

• Reading Disorder 315.00
• Difficulty with reading accuracy or comprehension
• Mathematics Disorder 315.1
• Disorder of Written Expression 315.2
• Difficulty in writing grammatically correct
  sentences original paragraphs
• Learning Disorder NOS 315.9
• Might include problems in all three areas that
  together significant impede academic acheivement

11
Motor Skills Disorder

• Developmental Coordination Disorder 315.4
• Marked impairment in the development of motor
  coordination
• Must interfere with academic achievement or ADLs
• Cannot have a general medical problem that causes
  motor skills delay (e.g., cerebral palsy)
• Must code any sensory deficit or general medical
  condition in Axis III

12
Developmental Coordination Disorder

• Can be given with MR
• But the motor difficulties must be in excess of
  those associated with mental retardation
• Occurs in as high of 6 of children (5-11 years
  of age).
• Variable course
• People with ADHD can be clumsy but this usually
  due to distractability and impulsiveness vs.
  motor impairment. These individuals should not be
  given this diagnosis

13
Communications Disorders

• Expressive Language Disorder
• Mixed Receptive-Expressive Language Disorder
• Phonological Disorder
• Stuttering
• Communication Disorder NOS

14
Communication Disorders

• Common criteria
• Has to be measured by a standardized individually
  administered test.
• Disorders have to interfere with educational or
  occupational achievement or social communication.
• Cant be solely due to MR, environmental
  deprivation, or speech-motor or sensory deficit.
• If giving a comorbid dx, the communication
  disorder has to be worse than would be expected

15
Expressive Language Disorder 315.31

• Impairment in the development of expressive
  language
• Can be verbal as well as sign language
• Usually not recognized until around age 3
• Non-linguistic (performance) abilities are
  usually within normal limits
• Expressive Language delays can be either acquired
  or developmental.
• In acquired type the expressive language delay
  occurs after a period of normal development and
  is due to a general medical condition.

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Expressive Language Disorder

• Language delays are quite common in children
  (10-15). By the time they become school aged
  the range is 3-7.
• Diagnostic Criteria
• Morrison p. 509, DSM-IV-TR p. 61

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Mixed Receptive-Expressive Language Disorder
315.32

• Impairment in both receptive and expressive
  language development.
• E.g., difficulty in both following or
  understanding directions and asking questions
• Symptoms can vary depending on severity of
  disorder.
• Non-linguistic functioning is usually within
  normal limits.

18
Mixed Receptive-Expressive Language Disorder

• Not as common as Expressive Language Disorder
• May occur in 5 of preschool and up to 3 of
  school-aged children.
• Usually not detectable before age 4
• Diagnostic Criteria
• Morrison p. 509-510, DSM-IV-TR p. 64

19
Phonological Disorder 315.39

• Formerly known as Developmental Articulation
  Disorder
• Failure to use developmentally expected speech
  sounds that are appropriate to the individuals
  age AND dialect.
• Most frequent misarticulated sounds
• l, r, s, z, th, ch
• Lisping is probably the most common of the
  phonological disorders.

20
Phonological Disorder

• Prevalence approximately 2 of 6-7 year olds
  have a severe phonological disorder
• Only 0.5 of individuals age 17 have a severe
  phonological disorder.
• Usually children with mild to moderate
  Phonological Disorders do not have a general
  medical condition. About ¾ of these individuals
  spontaneously resolve.
• Usually individuals with severe Phonological
  Disorders have a significant medical condition
  (cleft palate, chronic otitis media, cerebral
  palsy)
• Diagnostic criteria
• Morrison p. 510, DSM-IV-TR p. 66

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Stuttering 307.0

• Disturbance of normal fluency and time patterning
  of speech that is inappropriate to the
  individuals age.
• Frequent repetitions or prolongations of sounds
  or syllables.

22
Stuttering

• Prevalence prepubertal children 1 and drops to
  0.8 in adolescence. Male to female ratio is 31
• Onset occurs before age 10 in 98 of cases.
  Usually insidious and episodic.
• Diagnostic criteria
• Morrison p. 510 DSM-IV-TR p. 69

23
Communication Disorder NOS 307.9

• Covers communication disorders not previously
  covered.
• Eg voice disorders
• Pitch
• Loudness
• Quality
• Tone
• Resonance

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Pervasive Developmental Disorders

• Severe pervasive impairment in several areas of
  development
• Reciprocal social interaction skills
• Communication skills
• Presence of stereotyped behavior, interests and
  activities
• Usually evident in 1st year of life
• Often associated with Mental Retardation

25
Pervasive Developmental Disorders

• Autistic Disorder
• Retts Disorder
• Childhood Disintegrative Disorder
• Aspergers Disorder
• PDD NOS

26
Autistic Disorder 299.0

• Markedly abnormal impairment in the development
  of social interaction and communication and a
  markedly restricted repertoire of activity and
  interests.
• Impaired social interaction is very significant
  and sustained.
• Lack of eye contact
• Facial expression
• Body postures
• Gestures

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Autistic Disorder

• Frequent have little to no interest in making
  friends when little.
• When older individuals with Autism do not know
  how to make social interactions.
• Obliviousness
• May have no concept of needs of others and may
  not notice others distress.

28
Autistic Disorder

• Individuals with Autism may have different
  behavioral symptoms such as
• Hyperactivity
• Short attention span
• Impulsivity
• Aggressiveness
• Self-injurious behaviors
• Temper tantrums
• Rocking
• Sleep abnormalities
• Mood/affect abnormalities (e.g. inappropriate
  giggling)
• Lack of fear responses to real dangers

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Autistic Disorder

• Prevalence
• According to Newschaffer, Falb Gurney (2005)
  the number of autism cases per 10,000 have
  increased from 4.6 in a 1986 cohort to 24.1 in a
  1994 cohort
• Course
• By definition onset is before age 3 (difficult to
  ascertain before age 2 though).
• Language skills and IQ are strongest predictors
  of prognosis.

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Autistic Disorder

• Course cont.
• About 1/3 of cases will be able to achieve
  partial independence.
• Even highest functioning adults with Autistic
  Disorder will have problems with social
  interactions and communication.
• Interests and activities of adults with Autistic
  will be markedly limited.

31
Autistic Disorder

• Diagnostic Criteria
• Morrison p. 511-512 DSM-IV-TR p. 75
• Treatment
• In-home behavioral treatment
• SSRIs?

32
Retts Disorder 299.80

• Development of multiple specific deficit
  following a period of normal functioning after
  birth
• Developmental regression before the age of 4.
• Loss of skills persistent and progressive
• Usually results in Mental Retardation
• Recovery is usually very limited
• Communication and behavioral problems remain
  constant throughout life.

33
Retts Disorder

• Not as common as Autism
• Diagnostic Criteria
• Morrison p. 512-513, DSM-IV-TR p. 77.

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Childhood Disintegrative Disorder 299.10

• Marked regression in multiple areas of
  functioning following a period of at least 2
  years of apparently normal development (but no
  more than 10).
• Clinically significant loss of previously
  acquired skills in at least 2 areas language,
  social skills/adaptive behavior, bowel/bladder
  control, play, or motor skills.
• Most typically acquired skills are lost in almost
  all areas.

35
Childhood Disintegrative Disorder

• Fortunately this is very rare, but probably under
  diagnosed.
• Course Continuous degenerative course.
• (Occasionally coincides with a progressive
  neurological disorder.)
• Child will reach a plateau may have slight
  improvement. Duration is lifelong
• Diagnostic Criteria
• Morrison p. 513 DSM-IV-TR p. 79

36
Aspergers Disorder 299.8

• Severe and sustained impairment in social
  interaction and development of restricted
  repetitive patters of behavior, interests and
  activities.
• Early language cognitive skills are within
  limits (talking before walking).
• Mental Retardation is not usually seen in
  Aspergers Disorder
• Frequently are given an ADHD diagnosis before
  Aspergers Disorder diagnosis.

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Aspergers Disorder

• No good research on prevalence. Some increased
  frequency among family members\
• Course continuous and lifelong.
• Good verbal skills can mask disorder in children
• Prognosis is much better than Autistic Disorder
• Many individuals are capable of gaining
  employment and be personally self-sufficient.
• Five times more common in males than females.
• Diagnostic Criteria
• Morrison p. 299.8 DSM-IV-TR p. 84

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Pervasive Developmental Disability NOS 299.80

• Used when theres a severe/pervasive impairment
  in the development of reciprocal social
  interaction associated with impairment in either
  verbal or non-verbal communication skills or with
  the presence of stereotyped behavior etc.
• DSM-IV-TR suggests atypical autism

39
Attention-Deficit and Disruptive Behavior
Disorders

• Attention Deficit/Hyperactivity Disorder
• ADHD NOS
• Conduct Disorder
• Oppositional Defiant Disorder
• Disruptive Behavior Disorder NOS

40
Attention Deficit/Hyperactivity Disorder

• Persistent pattern of inattention /or
  hyperactivity-impulsivity that is frequently
  displayed and more severe than is typically
  observed in individuals at a comparable level of
  development.
• Some symptoms must have been present before age
  7.
• Inattention must be seen in academic,
  occupational or social situations
• Work is often messy and carelessly performed.
• Frequent shift from one incomplete to task to the
  other.
• Often have difficulties with organization and
  plans

41
Attention Deficit/Hyperactivity Disorder

• Impairment must been seen in multiple contexts
  e.g home, school, work, social settings.
• Symptoms get worse in situations that require
  sustained attention or mental effort that lack
  intrinsic appeal or novelty.
• Signs of disorder may be absent with individual
  is receiving rewards for appropriate behavior,
  under close supervision or is in a novel setting.
• Symptoms are more likely to occur in group
  settings.

42
Attention Deficit/Hyperactivity Disorder

• Subtypes
• Attention-Deficit/Hyperactivity Disorder,
  Combined type 314.01
• 6 or more symptoms of inattention and 6 or more
  symptoms of hyperactivity-impulsivity have
  persisted for at least 6 months. Most common
  disorder.
• Attention-Deficit/Hyperactivity Disorder,
  Predominately Inattentive Type 314.00
• 6 or more symptoms of inattention and less than 6
  symptoms of hyperactivity-impulsivity have
  persisted for at least 6 months.

43
Attention Deficit/Hyperactivity Disorder

• Subtypes cont.
• Attention-Deficit/Hyperactivity Disorder,
  Predominately Hyperactive-Impulsive Type 314.01
• 6 or more symptoms of hyperactivity-impulsivity
  and less than 6 symptoms of inattention have
  persisted for at least 6 months.

44
Attention-Deficit/Hyperactivity Disorder

• Known to exist in various cultures (mostly
  Western)
• Difficult to establish diagnosis for children
  less than 4 or 5 years old.
• Prevalence 3 to 7 of school aged children.
  More often to be male
• 21 predominately inattentive
• 91 combined
• Course onset is usually during toddler years.
  Diagnosis is usually made during elementary
  school.
• Most individuals symptoms attenuate during late
  adolescence and adulthood.

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Attention-Deficit/Hyperactivity Disorder

• Diagnostic Criteria
• Morrison p. 516-517 DSM-IV-TR p. 92-93
• Treatment
• Psychopharmacology
• CNS stimulants
• Methylphenidate (Ritalin)
• Dextroamphetaime
• Amphetamine
• Pemoline
• SNRI
• Atomoxetine hydrochloride (Strattera)
• Therapy
• Behavioral

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Attention-Deficit/Hyperactivity Disorder

• Attention-Deficit/Hyperactivity Disorder NOS
  314.9
• Dont meet the diagnostic criteria for the 3
  variants of the ADHD
• E.g. age of onset is after age 7

47
Conduct Disorder

• Repetitive and persistent pattern of behavior in
  which the basic rights of others or major
  age-appropriate societal norms are violated.
• Aggressive conduct that causes harm or threatens
  physical harm to other people or animals
• Non-aggressive conduct that causes property loss
  or damage
• Deceitfulness or theft
• Serious violation of the rules
• Three or more of these behaviors must be present
  in last 12 months with at least 1 present in past
  6 months.

48
Conduct Disorder

• Prevalence More common in urban areas than
  rural. More frequent among males.
• General population rates vary from less than 1
  to 10.
• Conduct Disorder is one of the most frequent
  diagnosed conditions in outpt and inpt mental
  health facilities for children.
• Course Oppositional Defiant Disorder a common
  precursor to Conduct Disorder

49
Conduct Disorder

• Onset is rare after age 16. Variable course. In
  majority of individual the condition remits in
  adulthood. For those that persist it may evolve
  into Antisocial Personality Disorder.
• Early onset predicts a worse prognosis
• Subtypes
• Childhood-Onset type 312.81
• Starts before age 10
• Adolescent-Onset type 312.82
• Starts after age 10
• Unspecified Onset 312.89
• Age at onset is unknown

50
Conduct Disorder

• Diagnostic Criteria
• Morrison p. 520 DSM-IV-TR p. 98-99
• Treatment
• Stimulants (ADHD meds)
• Parent Management Training
• Family Therapy

51
Oppositional Defiant Disorder 313.81

• Recurrent pattern of negativistic, disobedient,
  and hostile behavior toward authority figures
  that persists for at least 6 months. At least 4
  of the following
• Losing temper
• Arguing with adults
• Actively defying or refusing to comply with a
  request or rule of an adult
• Deliberately doing things that will annoy other
  people
• Blaming others for his/her own mistakes or
  misbehavior
• Being touchy or easily annoyed by others
• Being angry and resentful
• Being spiteful or vindictive

52
Oppositional Defiant Disorder

• Frequently comorbid with ADHD, learning
  disabilities and communication disorders
• Disorder is more prevalent in males than females
  before puberty. After puberty the rates are
  about equal.
• More common in families where at least one parent
  has a history of a mood disorder, ODD, ADHD,
  ASPD, or Substance-Related disorder.
• Mothers with a Depressive Disorder
• More common in families where there is serious
  martial discord.

53
Oppositional Defiant Disorder

• Disruptive behaviors are less severe than those
  individuals with a Conduct Disorder
• Diagnostic Criteria
• Morrison p. 521-522 DSM-IV-TR p. 102.
• Treatment
• Family Therapy
• Parent Management Training
• ADHD meds
• Antidepressants

54
Disruptive Behavior Disorder NOS 312.9

• Clinical presentations that do not meet the
  diagnostic criteria for either ODD or CD. Still
  must have a clinically significant impairment.

55
Feeding Eating Disorders of Infancy or Early
Childhood

• Pica 307.52
• Morrison p. 522 DSM-IV-TR p. 105
• Rumination Disorder
• Morrison p. 523 DSM-IV-TR p. 106
• Feeding Disorder of Infancy or Childhood
• Morrison p. 523 DSM-IV-TR p. 108

56
Tic Disorders

• Tics are a sudden, rapid, recurrent, nonrhythmic
  stereotyped motor movement or vocalization.
• Tourettes Disorder 307.23
• Multiple motor tics and one or more vocal tics
• Rare, but more common in males than females
• May involve swearing
• Gordon Whitmore - Morrison p. 525
• Diagnostic criteria
• Morrison p. 524 DSM-IV-TR p. 114

57
Chronic Motor or Vocal Tic Disorder 307.22

• Doesnt have both the Motor and Vocal Tic as in
  Tourettes (just one)
• Tics have occurred for over a year with no
  tic-free period longer than 3 consecutive months.
• Diagnostic Criteria
• Morrison p. 526-527 DSM-IV-TR p. 115

58
Transient Tic Disorder 307.21

• Tic disorder has not lasted longer than 12
  months.
• Occurs every day for at least 4 weeks
• Diagnostic Criteria
• Morrison p. 527 DSM-IV-TR p. 116.
• Tic Disorder NOS 307.20
• Tic disorder that doesnt meet the criteria for
  other tic disorders

59
Elimination Disorders

• Encopresis
• Repeated passage of feces into inappropriate
  places
• With constipation 787.6
• Without constipation 307.7
• Diagnostic Criteria
• Morrison p. 528 DSM-IV-TR p. 118

60
Enuresis 307.6

• Repeated passage of urine into inappropriate
  places
• Not due to a medical condition
• Nocturnal or diurnal or both
• Diagnostic Criteria
• Morrison p. 528 DSM-IV-TR p. 121

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Other Disorders

• Separation Anxiety Disorder 309.21
• Selective Mutism 313.23
• Reactive Attachment Disorder of Infancy or Early
  Childhood 313.89
• Stereotypic Movement Disorder 307.3
• Disorder of Infancy, Childhood or Adolscence NOS
  313.9