Neurodevelopmental Disorders

• Abnormal Psychology by Pevi Mariz F. De Ocampo
• Abnormal Psychology studies the following topics:
  • Historical context
  • Integrative approach to psychopathology
  • Clinical assessment and diagnosis
  • Research methods
  • Trauma-, anxiety-, OCD related disorders
  • Somatic symptoms and dissociative disorders
  • Mood disorders and suicide
  • Schizophrenia and other psychotic disorders
  • Personality disorders
  • Substance use disorders
  • Childhood disorders
  • Disruptive and impulse control disorders
  • Eating disorders and obesity
  • Sexual dysfunctions
  • Gender dysphoria
  • Paraphilic disorders
  • Neurocognitive disorders
  • Psychological treatment
  • Societal and legal issues

Case 17: Temple Grandin

• Temple Grandin is a professor of animal sciences at Colorado State University
• She designed one-third of the livestock-handling facilities in the United States
• Grandin has published dozens of scientific papers and gives lectures throughout the world on safer and more humane animal handling.
• As a baby, Grandin didn't want to be held but was calm alone
• As a young child she lacked eye contact and seemed to lack interest in people, threw tantrums, rocked back and forth, spun around repeatedly, and could sit for hours watching sand trickle through her fingers.
• At age 2, she was labeled "brain-damaged" because doctors didn't understand autism spectrum disorder.
• Grandin's mother sought good teachers and ways to calm and engage her daughter and encourage her to speak.
• Grandin learned to speak by elementary school but had social interaction deficits
• At 12, Grandin scored 137 on an IQ test, falling in the very superior range
• Grandin was thrown out of regular school but went to college for a degree in psychology, and then graduate school for a PhD in animal sciences.
• Grandin has thrived in her career and personal life despite difficulty understanding emotions and social relationships.

Neurological Disorders

• Neurodevelopmental disorders typically arise first in childhood
• Neurocognitive disorders typically arise in older age

Neurodevelopmental Disorders

• Autism Spectrum Disorder
• Attention-Deficit/Hyperactivity Disorder
• Intellectual Disability
• Learning, Communication, and Motor disorders

Neurocognitive Disorders - Major and Mild

• Delirium

Autism Spectrum Disorder (ASD) Diagnostic Criteria

• Persistent deficits in social communication and interaction across multiple contexts, like: - Deficits in social-emotional reciprocity - Deficits in nonverbal communicative behaviors used for social interaction - Deficits in developing, maintaining, and understanding relationships
• Restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of the following: - Stereotyped or repetitive motor movements, use of objects, or speech - Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior - Highly restricted, fixated interests that are abnormal in intensity or focus - Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of environment
• Symptoms must be present in the early developmental period
• Symptoms cause clinically significant impairment in functioning
• Disturbances aren't better explained by intellectual disability/global developmental delay.

Autism Spectrum Disorder (ASD)

• Features impairment in two behavior domains - Deficits in social interactions and communications - Restricted, repetitive patterns of behaviors, interests, and activities

Pervasive Developmental Disorders (PDDs): DSM-IV TR Classification

• Autism: onset before age
• Asperger's Disorder: A high-functioning form of autism; often involving deficits in social interactions and restricted, repetitive behavior but no significant communication deficits.
• In the DSM-5, the PDD category has been dropped, and there is only one autism spectrum disorder.
• The single term "spectrum" captures the range of related but varied presentations considering symptom severity, developmental level, and age.
• Initial studies captured only about 50 to 60 percent of children who previously would have been diagnosed with Asperger's disorder.

Autism Spectrum Disorder (ASD): Additional symptoms

• Reciprocal Adoration: may not smile and coo in response to caregivers or initiate play with them
• Delayed Language Development: 50% don't develop useful speech; and those who do may use it differently.
• Echolalia: echoing what's heard, shows one-sided language and lacks social reciprocity
• Self-stimulatory behaviors: stereotyped and repetitive uses of one's body
• Routines and Rituals: changes to daily routine may cause distress.
• Lack of symbolic play: Preoccupation with one feature of a toy or object.
• Symptoms must have their onset in early childhood.
• Some children with ASD have abilities to play music without having been taught or to draw extremely well or have exceptional memory and math abilities, and are sometimes referred to as savants although such cases are quite rare.
• 30% of children with autism may develop seizure disorders by adolescence, suggesting neurological dysfunction.
• Abnormal brain function is observed in children with ASD when doing tasks that require facial expression perception, joint attention, empathy, or thinking about social situations.

Attention-Deficit/Hyperactivity Disorder

• A major focus of socialization is helping children learn to pay attention, control impulses, and organize behaviors for long-term goals.

DSM-5 Criteria for Inattention/Hyperactivity Disorder

• A persistent pattern of inattention and/or hyperactivity that interferes with functioning or development, as characterized by (1) and/or (2) - Inattention: - Six or more symptoms for at least 6 months, inconsistent with developmental level, negatively impacts activities

            - Fails to give close attention to details, makes careless mistakes
            - Difficulty sustaining attention
            - Does not seem to listen when spoken to directly
            - Does not follow through on instructions, fails to finish tasks
            - Difficulty organizing tasks and activities
            - Avoids tasks requiring sustained mental effort
            - Loses things necessary for tasks/activities
            - Easily distracted by extraneous stimuli
            - Forgetful in daily activities
    - Hyperactivity & Impulsivity:
      - Six or more symptoms for at least 6 months
  
            - Fidgets, taps hands/feet, squirms in seat
            - Leaves seat when remaining seated is expected
            - Runs about/climbs in inappropriate situations
            - Unable to play/engage in leisure activities quietly
            - "On the go," acting as if "driven by a motor"
            - Talks excessively
            - Blurts out answers before question completed
            - Difficulty waiting turn
            - Interrupts or intrudes on others' activities
  

• Inattentive or hyperactive-impulsive symptoms were present prior to age 12.

• Symptoms present in two or more settings

• Symptoms interfere with or reduce the quality of functioning

• Symptoms don't occur exclusively during schizophrenia or another psychotic disorder

Specify presentation, based on the predominant cluster of symptoms, which is diagnosed with varying criteria:

• Combined Presentation: Inattention & Hyperactivity met for the past 6 months.

• Predominantly Inattentive Presentation: Inattention (A1) met, but Hyperactivity not met for the past 6 months.

• Predominantly Hyperactive/Impulsive Presentation: Hyperactivity met, but Inattention not met for the past 6 months.

• The combined presentation requires six or more symptoms of inattention and six or more symptoms of hyperactivity-impulsivity.

• A predominantly inattentive presentation is diagnosed if 6+ symptoms of inattention but less than 6 symptoms of hyperactivity-impulsivity are present.

• A predominantly hyperactive/impulsive presentation is diagnosed if 6+ symptoms of hyperactivity/impulsivity but less than 6 symptoms of inattention are present.

• ADHD begins by definition in childhood

• In the DSM-5 the age limit for the onset of symptoms was raised from 7 years to 12 years

• ADHD children with the combined presentation are more likely to have behaviors that worsen over time, and become severe enough to be diagnosed as a conduct disorder.

• Abnormal activity has been seen in: - The prefrontal cortex, which is vital to the control of cognition, motivation, and behavior. - The striatum, which is involved in working memory and planning - Cerebellum, which is involved in motor behaviors.

• The cerebral cortex is smaller in volume in children, and there is less connectivity between frontal areas of the cortex and areas of the brain that influence motor behavior, memory and attention, and emotional reactions

Neurodevelopmental Disorders:

• Autism Spectrum Disorder
• Attention-Deficit/Hyperactivity Disorder
• Intellectual Disability
• Learning, Communication, and Motor disorders

Neurocognitive Disorders:

• Major and mild neurocognitive disorders
• Delirium

Intellectual Disability (ID)

• Is also known as intellectual developmental disorder
• It was formerly referred to as mental retardation
• Significant deficits exist in multiple areas:
  • Intellectual Functioning: - Abstract thinking, reasoning, learning problem solving, and planning
  • Life Functioning: - Conceptual, social, and practical domains

Diagnostic and Statistical Manual of Mental Disorders (DSM–5) criteria for intellectual disability (ID)

• ID disorder with an onset during the developmental period that includes both intellectual and adaptive functioning deficits in conceptual, social, and practical domains, under the following conditions:
  • Deficits in intellectual functions such as reasoning, problem-solving, planning, abstract thinking, judgment, academic learning, and learning from experience are confirmed by both clinical assessment and individualized, standardized intelligence testing.
  • Deficits in adaptive functioning that result in failure to meet developmental and sociocultural standards for personal independence and social responsibility exist and without ongoing support, these 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.
  • Onset of intellectual and adaptive deficits must have begun during the developmental period
  • The severity is classified as mild, moderate, severe, or profound, on the basis of adaptive function and the level of supports required.

Levels of Intellectual Disability

• MILD: IQ scores ranging from 50-55 to roughly 70. It's the most commonly diagnosed case - considered educable; intellectual levels in adulthood compare w/ 8-11yo - approximates that of adolescents but lack normal adolescents' judgment - generally don't show signs of brain pathology or physical anomalies, but require some supervision to foresee consequences of their actions.
• MODERATE: IQ scores ranging from 35-40 to 50-55 - some can be taught to read and write a little, and may achieve fair command of spoken language. - can achieve partial independence in daily self-care, acceptable behavior, and economic sustenance in a family or other sheltered environment. - rate of learning is slow, and their level of conceptualizing is extremely limited.
• SEVERE: IQ scores ranging from 20-25 to 35-40 - commonly suffer from impaired speech development, sensory defects, and motor handicaps. - can develop limited levels of personal hygiene and self-help skill, requiring supervision but can perform simple occupational tasks under it.
• PROFOUND: IQ scores are below 20-25 - deficient in adaptive behavior and can't master more than the simplest tasks; speech, if functional at all, is rudimentary. - They are diagnosed in infancy due to obvious physical malformations or grossly delayed development. - Severe physical deformities, CNS pathology and retarded growth are typical. - Convulsive seizures, mutism, deafness and other physical anomalies are common.

Communication Disorders

• Language Disorder - persistent difficulties in the acquisition and use of language in speech or sign language due to deficits in comprehension or production of vocabulary, sentence structure, or discourse.
• Speech Sound Disorder - persistent difficulty with speech sound production; interfering with speech intelligibility or preventing verbal communication; deficit in phonological knowledge of speech sounds + difficulty coordinating jaw, tongue or lips for speech
• Childhood-Onset Fluency Disorder (Stuttering) - disturbance in the normal fluency and time patterning of speech; sound syllable repetitions, sound prolongations of consonants/vowels, and pauses within words.
• Social (Pragmatic) Communication Disorder - persistent difficulties with pragmatics or the social use of language, affects social relationships and participation; not better explained by autism, intellectual disability, or low abilities in domains of word structure/grammar or general cognitive ability.

Motor disorders

• Tourette's Disorder requires both multiple motor + one or more vocal tics during the illness (not necessarily concurrently).
• Persistent Motor or Vocal Tic Disorder has single motor/vocal tics, lasting for at least 1yr, with onset before 18yo.

Elimination Disorders

• ENURESIS: Habitual involuntary discharge of urine, usually at night, after the age of expected continence (age 5); bed-wetting isn't organically caused - Primary functional enuresis = never been continent. - Secondary functional enuresis = been continent for at least a year but have regressed.
• ENCOPRESIS: symptom disorder of children who have not learned appropriate toileting for bowel movements after age 4. - a third of children w/ encopresis are also enuretic - is six times more common in boys than girls

Neurocognitive Disorders

• Neurodevelopmental Disorders include: - Autism Spectrum Disorder - Attention-Deficit/Hyperactivity Disorder - Intellectual Disability - Learning, Communication, and Motor disorders
• Neurocognitive Disorders include: - Major and mild neurocognitive disorders - Delirium

DSM-5 Criteria include:

• Evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains: complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition.
• Cognitive deficits interfere with the person's independence in everyday activities.
• Deficits do not occur exclusively in context of a delirium.
• Deficits are not better explained by another mental disorder.
• Major neurocognitive disorder is commonly known as dementia when referring to older adults with degenerative disorders like Alzheimer's disease

Alzheimer's disease

• Is a progressive and fatal neurodegenerative disorder including:

• Clear evidence of a decline in learning and memory

• Begins with mild memory loss and progresses to profound memory loss and disorientation quickly

• Neurons in the brain secrete a sticky protein substance, beta-amyloid, faster than it can be broken down, which then accumulates into amyloid plaques.

• Cells lose their dendrites

• Neurofibrillary tangles are webs of abnormal filaments within nerve cells, made of tau proteins

• In a normal brain, tau acts like scaffolding, supporting a tube inside neurons to conduct impulses.

• In the disease, tau is misshapened and tangled, collapsing the neuron tube.

• Parkinson's disease is characterized by resting tremors or rigid movements with underlying cause of loss of dopamine neurons in the substantia; might involve depression, anxiety, apathy, cognitive problems, hallucinations and delusions.

• Huntington's is a rare degenerative disease involving a chronic, progressive chorea of the central nervous system: rare; afflicts 1 in 10,000 people; caused by Huntington gene on chromosome 4, a dominant gene- has a 50% chance of developing the disease if a parent has the disease.

• Major neurocognitive disorder is characterized by decline in cognitive functioning that interferes with daily living.

  • APHASIA: deterioration of language; can't produce names of objects or people
  • APRAXIA: can't execute common actions like waving good-bye or putting on a shirt
  • AGNOSIA: failure to recognize objects/people.

• People may not be able to identify common objects, such as chairs or tables

Delirium

• Characterized by disorientation, recent memory loss, and a clouding of attention; difficulty focusing, sustaining, or shifting attention.
• It develops rapidly within hours or days.
• Early phase may include mild symptoms such as fatigue, decreased concentration, irritability, restlessness, or depression; even visual hallucinations.
• As it worsens, the person's orientation becomes disrupted; it's characterized by symptoms sundowning and/or worsening at night

"DSM-5 Criteria for Delirium

• A disturbance in attention and orientation to the environment
• The disturbance develops over a short period of time representing a change from baseline attention and awareness that fluctuates in severity
• Additional disturbance in cognition, such as memory deficit, disorientation, language, visuospatial ability, or perception.
• Disturbances aren't better explained by another preexisting, established, or evolving neurocognitive disorder
• Disturbance is a direct physiological consequence of medical condition, substance intoxication/withdrawal, or exposure to toxin/multiple etiologies

Eating disorders

• Anorexia Nervosa Restricting Type
• Anorexia Nervosa Binge/Purge Type
• Bulimia Nervosa
• Binge-eating disorder

Anorexia Nervosa

• Literally means "lack of appetite induced by nervousness,”.
• Driven by relentless pursuit of thinness involving behaviors that result in significantly low body weight.

DSM-5 Criteria for Anorexia Nervosa

• Restriction of energy intake relative to requirements for sig. low body weight given age, sex, developmental trajectory, physical health (defined as weight that is less than minimally normal / less than minimally expected).
• Intense fear of gaining weight/becoming fat that interferes w/ weight gain, even at sig. low weight.
• Disturbance in the way which body weight/shape is experienced, undue influence of body weight/shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.
• Specify restricting or binging sub-type
• Amenorrhea is no longer a requirement for the anorexia diagnosis

Subtypes

• restricting type simply refuse to eat or do excessive exercise to prevent weight gain.
• binge/purge periodically engage in binge eating or purging behaviors
• Many patients with anorexia deny having any problems.

Bulimia Nervosa

• Recurrent episodes of binge eating - Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food larger than most people would eat during a similar period under similar circumstances. - A sense of lack of control over eating during episode Recurrent inappropriate compensatory behaviors to prevent weight gain (i.e., self-induced vomiting, misuse of laxatives, diuretics, meds; fasting or excessive exercise).
• Binge eating and compensatory behaviors both occur for 3 months
• Self-evaluation based on body shape and weight.
• Disturbance does not occur exclusively during episodes of anorexia nervosa.
• People with binge/purge type anorexia nervosa continue to be substantially below a healthy body weight, while those with bulimia nervosa are more likely to be at normal weight or overweight.

Binge Eating

• eating in large quantities
• even small food consumption can feel "binged" and be purged.

DSM-5 Criteria for Binge Eating

• Eating, in a discrete period of time (2hr period), an amount of food that is definitely larger than most people would eat during similar time under circumstances AND a sense of lack of control over eating during the episodes.
• Binge-eating episodes occur with 3+ of the following
  • Is eating is more rapidly than normal
  • Is eating occurs until feeling uncomfortably full
  • Is eating involves large amounts of food when not feeling physically hungry
  • Is eating occurs alone due to embarrassed feelings
  • Is followed by disgust with oneself, depression, or feelings of guilt
• Marked distress happens with binge events
• It occurs, on average, at least once a week for three months.
• Binge-eating is not associated with recurrent inappropriate behavior/does not occur during the course of bulimia or Anorexia.
• Binge eating disorder is similar to bulimia nervosa, except that a person with it does not regularly take purging, fasting, or excessive exercise to compensate for binges.
• Some eating disorder presentations include:
  • Atypical anorexia nervosa: all criteria for anorexia nervosa are met, BUT the individual's weight is within/above the normal range, despite significant weight loss.
  • Bulimia nervosa of low frequency and/or limited duration: all criteria for bulimia nervosa are met, BUT binge eating and inappropriate compensatory behaviors is only less than once a week and/or for less than 3 months
• People with BED are often significantly overweight and feel disgusted with their body/ashamed of their bingeing

Sexual dysfunctions

Dysfunctions include issues in males/females, gender dysphoria, and paraphilic disorders Sexual Dysfunction: impairs both in their desire for sexual gratification or in the ability to achieve it with varied degrees- and it's grouped according to Desire & arousal and Orgasm and sexual pain

• normal arousal cycle features desire phase with fantasies of sexual activity/a sense of wanting sexual activity.
• arousal phase: by a subjective sense of sexual pleasure in addition to physiological changes like penile erection in males and vaginal lubrication/clitoral enlargement.
• The orgasm phase involves the release of sexual tension/peaking of pleasure, while the last phase is resolution in which the person is in relaxation, well-being
• Female Sexual Interest/Arousal Disorder involves persistent lack/significantly reduced sexual activity and/or a lack of arousal response
• Male Hypoactive Desire Disorder entails persistent absence/deficient sexual fantasies or desire
• Erectile Disorder is recurrent inability to attain/maintain an erection/a marked decrease in erection

Disorders of Orgasm or Sexual Pain

• Female Orgasmic Disorder has reduced intensity/recurrent delay/or absence of orgasms during sex.
• Early Ejaculation involves it within one min of sex when it's not desired
  • Delayed Ejaculation has marked delay in its frequency, or the lack of ejaculation. -Genito-Pelvic Pain can have vaginal penetration problems, discomfort/tightening of pelvic floor when there is penetration. - Gender Dysphoria is when the individual feels the gender they truly identify with does not match their assigned sex Criteria for Gender Dysphoria in Children include marked incongruence of their gender between their experienced/expressed gender, which must continue for 6 months.
    • must show a strong desire to be treated in their desired identity, and for primary and/or secondary sex characteristics as well.
• A Paraphilic Disorder contains atypical sexual urges or behavior. Paraphilias are Greek for "love beyond normal or unusual”

Features include

• atypical sexual preferences - divided into those that involve consent vs non-consent when it comes other parties - contact versus no contact when it comes to others in these activities
• occurs currently to the individual due to distress/impairment in their ability to function or is associated with personal dangers and entails the potential of harm to others.

The paraphilic disorders involve atypical

• Recurrent
• Intense sexually arousing fantasies, sexual urges, or behaviors
• These must cause individual sign. distress/impairment, or harm to others/risk of harm.
• Fetishistic disorder: Nonliving objects/nongenital body parts
• Transvestic disorder: Cross-dressing
• Sexual sadism disorder: Acts of physical or psych. suffering
• Sexual masochism disorder: of being humiliated, or made into submission
• Voyeuristic disorder: observing a naked, undressing, or in the process of activity
• Exhibitionistic disorder: genitals to an unsuspecting member
• Frotteuristic disorder: Touching/rubbing vs a nonconsenting member
• Pedophilic disorder: with the prepubescent child or children

Test your knowledge of neurodevelopmental disorders, intellectual disabilities, and Autism Spectrum Disorder (ASD). Explore the characteristics, diagnostic criteria, and affected domains of life functioning associated with these conditions.