Neurodevelopmental Disorders

• Neurodevelopmental disorders were previously known as disorders first diagnosed in infancy or childhood.
• These disorders manifest early in development, often before children enter grade school.
• They involve impairments of the brain and/or central nervous system's growth and development.
• This term refers to disorders of brain function affecting emotion, learning ability, self-control, and memory.
• Neurodevelopmental disorders can feature sudden, rapid, recurrent, non-rhythmic, stereotyped motor movements or vocalizations.

Contributing Factors

• Social deprivation, or a lack of social and emotional care, can cause severe delays in brain and cognitive development.
• Genetic disorders may play a role.

Down Syndrome

• This is a genetically determined neurodevelopmental disorder also known as Trisomy 21.
• It commonly results from an extra chromosome 21.
• Less common instances relate to chromosomal abnormalities like translocation of genetic material.
• Down Syndrome is characterized by short stature and epicanthal folds.
• It includes abnormal fingerprints and palm prints.
• Heart defects and poor muscle tone are characteristics.
• Intellectual disabilities can result from developmental delays.

Immune Dysfunction

• Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infection, known as PANDAS, is a factor.
• Immune reactions during pregnancy may produce neurodevelopmental disorders in the developing child.

Infectious Diseases

• Systemic infections during infancy and childhood can result in neurodevelopmental consequences.
• System infections are not considered primary neurodevelopmental disorders.
• HIV, infections of the head and brain, brain abscesses, meningitis, and encephalitis can cause neurological issues.
• Infectious diseases can be transmitted congenitally and cause serious neurodevelopmental problems.
• Congenital infections include Rubella, Zika virus, and Treponema pallidum, which may progress to congenital syphilis.

Metabolic Disorders

• Metabolic disorders in either the mother or the child can cause neurodevelopmental disorders.
• Examples include diabetes mellitus and phenylketonuria.

Nutrition

• Nutrition disorders and nutritional deficits may cause neurodevelopmental disorders.
• Spina bifida and anencephaly are related to nutrition.
• Vitamin B and iodine deficiency are related.
• Fetal alcohol syndrome is also related.

Diagnosing Neurodevelopmental Disorders

• Neurodevelopmental examinations provide insights into a child's learning, growth, and development.
• Developmental tests assess motor, fine, and language skills, as well as emotional expression and attention.
• Neurologic examinations, brain imaging, and physical examinations can be useful.
• Laboratory tests analyze blood, urine, and other bodily fluids to gain insight into a child's health.

Mental Retardation Definition

• It refers to significantly sub-average general intellectual functioning.
• It results in or is associated with concurrent impairments in adaptive behavior.
• These impairments are manifested during the developmental period.

Levels of Mental Retardation

• Mild: IQ 50-70, educable
• Moderate: IQ 35-50, trainable
• Severe: IQ 20-35, needs custodial care
• Profound: IQ below 20, needs constant aid and supervision

Moderate Mental Retardation

• IQ range is 34-49%.
• Individuals in this range are trainable but are not fast learners.
• They have poor social awareness.
• Academic level is up to Grade 2.
• Individuals may contribute to self-support under close supervision.
• They may be able to do ADLs with supervision.

Severe Mental Retardation

• 20-34% demonstrates poor motor development and speech.
• May learn to talk in special schools and learn hygiene at special schools.
• A person is able to learn simple work tasks

Profound Mental Retardation

• Below 20% demonstrates minimal capacity for sensory motor functioning.
• They require very limited self-care.
• There is full assistance in ADL.

Learning Disorder

• Learning problems interfere with academic achievement and life activities requiring reading, math, or writing (APA, 2000).
• Reading Disorder: Dyslexia
• Mathematical Disorder: Dyscalculia
• Writing Disorder: Dysgraphia
• Low self-esteem and poor social skills are common

Motor Skills Disorder

• Has impairment in the development of motor coordination
• It is not due to general medical conditions like Cerebral Palsy or Muscular Dystrophy.
• Delays in motor milestones: walking, crawling, sitting, dropping things, clumsiness, poor performance in sports.

Communication Disorder

• Expressive Language Disorder: Difficulties with language interfere with academic, occupational or social aspects.
• Phonological Disorder: Failure to use developmentally-expected speech sounds appropriate for the individual’s age and dialect
• Stuttering: There is disturbance in the normal fluency and time patterning of speech that is inappropriate for the individual’s age.
• Frequent repetitions/ prolongations of sounds or syllables

Autism Spectrum Disorder

• Autism is characterized by difficulty in social interaction and communication.
• Restrictive or repetitive patterns of thought and behavior are noted.
• It is more common in boys.

Symptoms of Autism :

• Onset is identified usually by 12 months and not later than 3 years old
• There is impairment of reciprocal interaction skills
• Etiology is unknown but could be a genetic factor.
• Mechanical trauma of the birth process itself.
• Difficulty with social interactions:
• A person prefers to be alone.
• They may have inappropriate attachment to objects.
• There is a lack of interest in the environment, in appropriate laughing or giggling
• A person may avoid eye contact
• There is an inability to express needs.
• Unrelated responses to questions
• Delayed or absent of language development

Stereotyped Behavior (SPAN)

• S - sustained repetitive motor movements- spin objects or self, rocking hand or finger flapping, body twisting
• P - Prefer sameness - preoccupied usually with lights, moving objects or parts of objects
• A - Apparent insensitivity to pain.
• N - No real fear of dangers.

Diagnosing Autism Spectrum Disorders

• Children should be assessed for developmental delays within the first two years of life.
• By 12 months, there is no babbling, pointing, or gesturing and the child isn't responding to own name.
• By 14 months, there is no interest by pointing to object or people.
• By 18 months, there are no single words spoken and a child doesn't play pretend games.
• By 24 months, there are no two-word sentences but there is repeating words or sounds of others.
• There is no eye contact around 3-4 months.
• There is a loss of any language or social skills at any age.

Treatment and Management Considerations for Children with Autism

• Reduce behavioral symptoms like temper tantrums, aggressiveness, self-injury, hyperactivity, and stereotyped behavior.
• Haloperidol (Haldol) and Risperidone (Risperdal) can diminish self-injury, hyperactivity, and obsessive behaviors.
• Catapres (Clonidine) and Anafranil (Clomipramine) can be useful.
• Promote learning and development through behavior change programs and special education.
• Family therapy and parental education is an approach.

Rett’s Disorder

• It is a rare genetic neurological and developmental disorder.

Rett Syndrome

• This affects the way the brain develops, causing a progressive loss of motor skills and speech.
• Children normally develop until 6-18 months.
• Skills previously had are gone such as to crawl, walk, communicate, or use their hands.

Characteristic Features of Rett Syndrome

• Development of multiple deficits after a period of normal functioning from birth to 5 months.
• The incidence is more common in girls.
• Behavioral patterns include stereotyped behaviors.
• Communication: loss of expressive and receptive language.
• Social interaction: loss of interest in a social environment.

Asperger's Disorder

• Those affected usually have milder symptoms of autistic disorder.
• They might have social challenges as well as unusual behaviors and interests.
• Typically, there are no problems with language or intellectual disability.
• This is located on the mild end of the autism spectrum.

Symptoms

• Obsessive focus on a narrow topic of interest.
• A person has difficulty with social interaction.
• They engage in repetitive behavior.
• They focus on rules and routines.

Common Characteristics of Asperger's Syndrome

• Severe impairment in social interaction and stereotyped behaviors
• Normal IQ and many may exhibit exceptional skill/talent.
• Fascination with remembering trains, dates, colors, etc.
• There is no language/cognitive delays.
• Incidence is common among boys.
• Onset is later.
• There is a problem empathizing/modulating relationships, which gets noticeable at school.

Attention Deficit Hyperactive Disorders (ADHD)

• This disorder of the neurodevelopmental type is characterized by difficulty paying attention, excessive activity, and acting without regard to consequences.

Characteristics

• H – Hyperactivity
• I - Inattentiveness
• D – Distractibility and impulsivity
• Incidence: Common among boys
• Diagnosed when the child begins pre-school

Common Signs of ADHD

• Academic performance is poor due to a lack of concentration.
• Development of family and peer relationship is restrained.
• Disruptive and intrusive at home which can cause friction with siblings and parents.
• Hyperactive and impulsive behavior.
• Inability to sit still.
• Runs or climbs excessively.
• Fidgets and is often on the go.
• Talks excessively.
• Blurts out answers and interrupts conversation.
• Difficulty sustaining attention and concentration.

Further Characteristics

• Has difficulty with organization.
• He's easily distracted.
• He avoids tasks requiring mental effort.
• Often forgetful in daily activities.
• Often loses necessary things.
• Makes careless mistakes in school work

Attention Span with ADHD

• Severe: 2 to 3 seconds
• Mild: 2 to 3 minutes

ADHD Treatment

• Includes medication, behavioral interventions, special education and parental education

ADHD Psychopharmacology

• Stimulants (CARDS) are used to reduce hyperactivity, inattentiveness, impulsivity and lability of mood.
• Cylert (Pemoline) - Last drug to be prescribed due to its hepatotoxicity (liver damage)
• A – Adderall (Amphetamine)
• R – Ritalin (Methylphenidate)

More Information about Medications

• D – Dexedrine (Dextroamphetamine) SE: insomnia, loss of appetite, weight loss, irritability & increase self-injury during the highest dose
• S – Strattera (Atomoxetine) - Non-stimulant drug approved in 2002
• Helps to increase the ability to pay attention, concentrate, stay focused, and stop fidgeting.
• Antidepressant, selective norepinephrine reuptake inhibitor.
• SE: loss of appetite. N/V, fatigability, abdominal distress

Psychotherapy and psychosocial interventions

• Behavioral therapy aims to help the child change his/her behavior
• Cognitive behavioral therapy aims to teach the child mindfulness techniques to improve focus and concentration.
• Specific behavioral classroom management interventions aim to help the child manage his/her symptoms and improve his/her functioning at school and with peers
• Support groups connect with others who have similar problems

Parenting Education

• Family and marital therapy aims to help family members and spouses
• Find better ways to handle disruptive behaviors, to encourage behavior changes, and improve interactions with the patient.
• Parenting skills training aims to teach parents the skills needed to encourage and reward positive behaviors in their children.

Causes of ADHD

• Brain anatomy and function: A lower level of activity in the parts of the brain that control attention and activity level may be associated with ADHD.
• Genes and heredity: ADHD frequently runs in families.
• Prematurity increases the risk of developing ADHD.
• Prenatal exposures: Alcohol or nicotine from smoking increase the risk of developing ADHD.
• Toxins in the environment cause rare cases but may lead to ADHD.

Nursing Interventions for ADHD

• Ensure safety of the client, prevent unsafe behavior, and provide close supervision.
• Give clear directions about acceptable and unacceptable behavior.
• Give positive feedback for meeting expectations, improve role performance.
• Simplify instructions/directions and get the child’s full attention.
• Break complex tasks into small steps.
• Focus on structured daily routine.
• Establish a daily schedule, minimize changes.
• Listen to parent feelings and frustrations.

Nursing Actions

• Ensure the education and support of the client/family and listen to parents.

Tic Disorders

• Characterized by a sudden, rapid, recurrent, non-rhythmic, stereotyped motor movement or vocalization.
• Examples of motor tics include blinking, neck jerking, grimacing, shoulder shrugging, and coughing.
• Examples of vocal tics include clearing of the throat, grunting, sniffing, and snorting.
• Coprolalia is the involuntary parrot-like repetition of a word or sentence just spoken by another person.
• Palilalia is a speech disorder characterized by involuntary repetition of words and phrases during verbal output.
• Echolalia is the repetition of words of others.

There are different types of tic disorders:

• Provisional Tic Disorder/Transient Tic Disorder is characterized by single or multiple vocal or motor tics, but for no longer than 12 months.
• Tics start before age 18 years
• Provisional tics go away by themselves in less than a year, but may get worse with anxiety, tiredness, and some medications.
• They affect up to 10 % of children during the early school years.

Motor or Vocal Tic Disorder

• Is characterized by rapid, recurrent, uncontrollable movements or vocal outburst (but not both)

Affecting Less Than 1% of Children

• May be related to a more complex tic disorder called Tourette's disorder.
• The child has had the tics nearly every day for more than a year.
• There has been no tic-free day longer than 3 months.
• To be diagnosed with a persistent tic disorder, a person must:
• Have one or more motor or vocal tics, starting before age 18 years.
• Tics occur many times a day nearly every day or on and off throughout a period of more than a year.

Tourette Disorder

• Multiple motor tics and one or more vocal tics are present.
• Tics occur numerous times a day for more than one year.
• Often, there are significant impairment in academic, social and occupational functions.
• Often more common in boys but rare.
• The disorder is identified by 7 years of age.

May Have Lifelong Problems

• Some may have lifelong problems; others have no symptoms after early adulthood.
• The average onset occurs between aged 2 and 15, with the average at 6 years of age.
• Is more common in males; about 3-4x more common.

Diagnostic Criteria

• Have two or more motor tics and at least one vocal tic
• Tics happen at the same time.
• Have had tics for at least a year.
• The tics can occur many times a day.

Exclusion Criteria

• Symptoms are not due to medicines or another medical condition.

Elimination Disorders

• Elimination disorders all involve the inappropriate elimination of urine or feces, usually first diagnosed in childhood or adolescence.
• It is characterized by inappropriate elimination of urine or feces
• Onset is usually first diagnosed in childhood or adolescence which includes enuresis and encopresis.

Enuresis

• A repeated voiding during the day or night into clothing or bed by a child
• Must be at least 5 years of age
• Known as bedwetting
• Characterized by repeated voiding of urine into inappropriate places

Key Facts about Nocturnal Enuresis

• Bedwetting at night is the most common type of elimination disorder.
• Diurnal enuresis is daytime wetting when the child is +5 years or older
• Medical conditions, stress, developmental delays cause.
• Treatment can include urine alarm, bladder training and reward.