DSM-5-TR Neurodevelopmental Disorders PDF

Lesson III: DSM 5 TR Neurodevelopmental Disorders Course Facilitator: Sarah Mae M. Dolot, RPm, RPsy  Neurodevelopmental Disorders The neurodevelopmental disorders are a...

Lesson III: DSM 5 TR Neurodevelopmental Disorders Course Facilitator: Sarah Mae M. Dolot, RPm, RPsy  Neurodevelopmental Disorders The neurodevelopmental disorders are a group of conditions with onset in the developmental period. typically manifest early in development, often before the child enters school, and are characterized by developmental deficits or differences in brain processes that produce impairments of personal, social, academic, or occupational functioning. The range of developmental deficits or differences varies from very specific limitations of learning or control of executive functions to global impairments of social skills or intellectual ability. more recent dimensional approaches to measurement of the symptoms demonstrate a range of severity, often without a very clear boundary with typical development. Diagnosis of a disorder thus requires the presence of both symptoms and impaired function 2  The neurodevelopmental disorders frequently co-occur with one another; for example, individuals with autism spectrum disorder often have intellectual developmental disorder (intellectual disability), and many children with attention- deficit/hyperactivity disorder (ADHD) also have a specific learning disorder. 3  TYPES OF NEURODEVELOPMENTAL DISORDERS ◇ Intellectual Development Disorder – characterized by deficits in general mental abilities, such as reasoning, problem solving, planning, abstract thinking, judgment, academic learning, and learning from experience. ◇ Communication Disorder - include language disorder, speech sound disorder, social (pragmatic) communication disorder, and childhood-onset fluency disorder (stuttering). ◇ Autism Spectrum Disorder - characterized by persistent deficits in social communication and social interaction across multiple contexts, including deficits in social reciprocity, nonverbal communicative behaviors used for social interaction, and skills in developing, maintaining, and understanding relationships. 4  TYPES OF NEURODEVELOPMENTAL DISORDERS ◇ Attention-Deficit/Hyperactivity Disorder (ADHD) - is a neurodevelopmental disorder defined by impairing levels of inattention, disorganization, and/or hyperactivity-impulsivity. ◇ Specific learning disorder - as the name implies, is diagnosed when there are specific deficits in an individual’s ability to perceive or process information for learning academic skills efficiently and accurately. ◇ Neurodevelopmental motor disorders - include developmental coordination disorder, stereotypic movement disorder, and tic disorders. Developmental coordination disorder is characterized by deficits in the acquisition and execution of coordinated motor skills and is manifested by clumsiness and slowness or inaccuracy of performance of 5  Intellectual Developmental Disorders (Intellectual Disability) 6  Intellectual Developmental Disorders (Intellectual Disability) “ 7 8  Severity levels for intellectual developmental disorder (intellectual disability) “ 9 10  “ 11 12  “ 13 14  Specifiers ◇ The various levels of severity are defined on the basis of adaptive functioning, and not IQ scores, because it is adaptive functioning that determines the level of supports required. Moreover, IQ measures are less valid in the lower end of the IQ range. Prevalence ◇ overall general population prevalence of approximately 10 per 1,000; however, the global prevalence varies by country and level of development, being approximately 16 per 1,000 in middle-income countries and 9 per 1,000 in high-income countries. The prevalence also varies by age, being higher in youth than in adults. In the United States, prevalence per 1,000 population does not vary significantly by ethnoracial groups. 15  Development and Course ◇ Onset of intellectual developmental disorder is in the developmental period. ◇ The age and characteristic features at onset depend on the etiology and severity of brain dysfunction. ◇ Delayed motor, language, and social milestones may be identifiable within the first 2 years of life among those with more severe intellectual developmental disorder, while mild levels may not be identifiable until school age when difficulty with academic learning becomes apparent. ◇ All criteria (including Criterion C) must be fulfilled by history or current presentation. ◇ Some children younger than 5 years whose presentation will eventually meet criteria for intellectual developmental disorder have deficits that meet criteria for global developmental delay. 16  Risk and Prognostic Factors ◇ Genetic and physiological. ◇ Prenatal etiologies include genetic syndromes (e.g., sequence variations or copy number variants involving one or more genes; chromosomal disorders), inborn errors of metabolism, brain malformations, maternal disease (including placental disease), and environmental influences (e.g., alcohol, other drugs, toxins, teratogens). ◇ Perinatal causes include a variety of labor and delivery–related events leading to neonatal encephalopathy. ◇ Postnatal causes include hypoxic ischemic injury, traumatic brain injury, infections, demyelinating disorders, seizure disorders (e.g., infantile spasms), severe and chronic social deprivation, and toxic metabolic syndromes and intoxications (e.g., lead, mercury). 17  Culture-Related Diagnostic Issues Intellectual developmental disorder occurs across ethnoracial groups. Prevalence differences across social and cultural contexts may be due to variation in environmental risks (e.g., perinatal injury, chronic social deprivation) for the disorder that are associated with socioeconomic status and access to quality health care. Sex- and Gender-Related Diagnostic Issues Overall, males are more likely than females to be diagnosed with both mild (average male:female ratio 1.6:1) and severe (average male:female ratio 1.2:1) forms of intellectual developmental disorder. 18  Association With Suicidal Thoughts or Behavior ◇ Individuals with intellectual developmental disorder can be at risk for suicide associated with comorbid mental disorder, higher intellectual and adaptive function, and immediate past stressors. ◇ Comorbid mental disorder may manifest atypically in intellectual developmental disorder; thus, recognizing comorbidity and screening for suicidal thoughts is important in the assessment process, with particular attention to change in behavior of the individual. 19  DIFFERENTIAL DIAGNOSIS The diagnosis of intellectual developmental disorder should be made whenever Criteria A, B, and C are met. A diagnosis of intellectual developmental disorder should not be assumed because of a particular genetic or medical condition. A genetic syndrome linked to intellectual developmental disorder should be noted as a concurrent diagnosis with the intellectual developmental disorder. 20  ◇ Major and mild neurocognitive disorders Intellectual developmental disorder is categorized as a neurodevelopmental disorder and is distinct from the neurocognitive disorders, which are characterized by a loss of cognitive functioning “ ◇ Communication disorders and specific learning disorder Autism spectrum disorder. can be used if diagnostic criteria are met for intellectual developmental disorder. These neurodevelopmental disorders are specific to the communication and learning domains and do not show deficits in intellectual and adaptive behavior. They may co-occur with intellectual developmental disorder. 21  ◇ Autism spectrum disorder ￭ Intellectual developmental disorder is common among individuals with autism spectrum disorder. ￭ Assessment of intellectual ability may be complicated by social-communication and “ behavior deficits inherent to autism spectrum disorder, which may interfere with understanding and complying with test procedures. ￭ Appropriate assessment of intellectual functioning in autism spectrum disorder is essential, with reassessment across the developmental period, because IQ scores in autism spectrum disorder may be unstable, particularly in early childhood. 22  Comorbidity Co-occurring neurodevelopmental and other mental and medical conditions are frequent in intellectual developmental disorder, with rates of some conditions (e.g., mental disorders, cerebral palsy, and epilepsy) three to four times higher than in the general population. 23  GLOBAL DEVELOPMENTAL DELAY 24  Unspecified Intellectual Developmental Disorder (Intellectual Disability) 25  COMMUNICATION DISORDERS 26  COMMUNICATION DISORDERS Disorders of communication include deficits in language, speech, and communication. Speech is the expressive production of sounds and includes an individual’s articulation, fluency, voice, and resonance quality. Language includes the form, function, and use of a conventional system of symbols (i.e., spoken words, sign language, written words, pictures) in a 47 F80.2 rule-governed manner for communication. Communication includes any verbal or nonverbal behavior (whether intentional or unintentional) that has the potential to influence the behavior, ideas, or attitudes of another individual. Assessments of speech, language, and communication abilities must take into account the individual's cultural and language context, particularly for individuals growing up in bilingual environments. 27  Language Disorder 28  Development and Course ◇ Language acquisition is marked by changes from onset in toddlerhood to the adult level of competency that appears during adolescence. ◇ Changes appear across the dimensions of language (sounds, words, grammar, narratives/expository texts, and conversational skills) in age-graded increments and synchronies. ◇ Emerges during the early developmental period; however, there is considerable variation in early vocabulary acquisition and early word combinations. ◇ Individual differences in early childhood are not, as single indicators, highly predictive of later outcomes, although a late onset of language at age 24 months in a population based sample was the best predictor of outcomes at age 7 years 29  Risk and Prognostic Factors Environmental - Bilingualism does not cause or worsen a language disorder, but children who are bilingual may demonstrate delays or differences in language development. A language disorder in bilingual children will affect both languages; therefore, assessment across both languages is important to consider. Genetic and Physiological - Language disorders are highly heritable, and family members are more likely to have a history of language impairment. Population-based twin studies consistently report substantial heritability for Normal variations in language. Hearing or other sensory impairment. Intellectual developmental disorder (intellectual disability). Autism spectrum disorder. Neurological disorders. language disorder, and molecular studies suggest multiple genes interacting on causal pathways. 30  Differential Diagnosis ◇ Normal Variations in Language - Language disorder needs to be distinguished from normal developmental variations, and this distinction may be difficult to make before age 4 years. ◇ Hearing or other Sensory Impairment - Hearing impairment needs to be excluded as the primary cause of language difficulties. ◇ Intellectual developmental disorder (intellectual disability) - Language impairment is often the presenting feature of intellectual developmental disorder. However, the definitive diagnosis of intellectual developmental disorder may not be made until the child is able to complete standardized assessments. ◇ Autism spectrum disorder - Autism spectrum disorder frequently manifests with delayed language development. 31  Comorbidity Language disorder may be associated with other neurodevelopmental disorders in terms of specific learning disorder (literacy and numeracy), intellectual developmental disorder, attention-deficit/hyperactivity disorder, autism spectrum disorder, and developmental coordination disorder. It is also associated with social (pragmatic) communication disorder. 32  Speech Sound Disorder 33  Development and Course ◇ Learning to produce speech sounds clearly and accurately and learning to produce connected speech fluently are developmental skills. ◇ Articulation of speech sounds follows a developmental pattern, which is reflected in the age norms of standardized tests. ◇ It is not unusual for typically developing children to use developmental processes for shortening words and syllables as they are learning to talk, but their progression in mastering speech sound production should result in mostly intelligible speech by age 3 years. ◇ Children with speech sound disorder continue to use immature phonological simplification processes past the age when most children can produce words clearly. 34  Differential Diagnosis ◇ Normal variations in speech – Regional, social, or cultural/ethnic variations of speech should be considered before making the diagnosis. ◇ Hearing or other sensory impairment – Those who are deaf or hard of hearing may have speech sound production errors. ◇ Structural deficits – Speech impairment may be due to structural deficits (e.g., cleft palate). ◇ Dysarthria – Speech impairment may be attributable to a motor disorder, such as cerebral palsy. ◇ Selective mutism – Limited use of speech may be a sign of selective mutism, an anxiety disorder that is characterized by a lack of speech in one or more contexts or settings. 35  Comorbidity Speech may be differentially impaired in certain genetic conditions (e.g., Down syndrome, 22q deletion, FoxP2 gene mutation). If present, these should also be coded. 36  Childhood-Onset Fluency Disorder (Stuttering) 37 38  Development and Course ◇ Genetic and physiological. ◇ Sensory deficits. ◇ Childhood-onset fluency disorder, or developmental stuttering, occurs by age 6 for 80%–90% of affected individuals, with age at onset ranging from 2 to 7 years. ◇ The onset can be insidious or more sudden. Typically, dysfluencies start gradually, with repetition of initial consonants, first words of a phrase, or long words. ◇ The child may not be aware of dysfluencies. 39  Risk and Prognostic Factors Genetic and physiological The risk of stuttering among first-degree biological relatives of individuals with childhood-onset fluency disorder is more than three times the risk in the general population. To date, mutations of four genes that underlie some cases of stuttering have been identified. 40  Functional Consequences of Childhood-Onset Fluency Disorder (Stuttering) ◇ In addition to being features of the condition, stress and anxiety can exacerbate dysfluency. ◇ Impairment of social functioning may result from this anxiety. ◇ Negative communication attitudes may be a functional consequence of stuttering starting in the preschool years and increasing with age 41  Differential Diagnosis Sensory Deficits - Dysfluencies of speech may be associated with a hearing impairment or other sensory deficit or a speech-motor deficit. When the speech dysfluencies are in excess of those usually associated with these problems, a diagnosis of childhood-onset fluency disorder may be made. Normal speech dysfluencies - Dysfluencies of speech may be associated with a hearing impairment or other sensory deficit or a speech-motor deficit. When the speech dysfluencies are in excess of those usually associated with these problems, a diagnosis of childhood- onset fluency disorder may be made. Specific learning disorder, with impairment in reading - Children who have dysfluencies when they read aloud may be diagnosed mistakenly as having a reading disorder. 42  Bilingualism - it is necessary to distinguish between dysfluencies resulting from attempts to learn a new language and dysfluencies that indicate a fluency disorder, which typically appear in both languages. Medication side effects - Stuttering may occur as a side effect of medication and may be detected by a temporal relationship with exposure to the medication. Adult-onset dysfluencies - If onset of dysfluencies is during or after adolescence, it is an “adult-onset dysfluency” rather than a neurodevelopmental disorder. Adult-onset dysfluencies are associated with specific neurological insults and a variety of medical conditions and mental disorders and may be specified with them, but they are not a DSM-5 diagnosis. Tourette’s disorder – Vocal tics and repetitive vocalizations of Tourette’s disorder should be distinguishable from the repetitive sounds of childhood-onset fluency disorder by their nature and timing. 43  Comorbidity Childhood-onset fluency disorder can co-occur with other disorders, such as attention- deficit/hyperactivity disorder, autism spectrum disorder, intellectual developmental 54 F80.82 disorder (intellectual disability), language disorder or specific learning disorder, seizure disorders, social anxiety disorder, speech sound disorder, and other developmental disorders. 44  Social (Pragmatic) Communication Disorder 45 46 Development and Course Because social (pragmatic) communication depends on adequate developmental progress in speech and language, diagnosis of social (pragmatic) communication disorder is rare among children younger than 4 years. By age 4 or 5 years, most children should possess adequate speech and language abilities to permit identification of specific deficits in social communication. Milder forms of the disorder may not become apparent until early adolescence, when language and social interactions become more complex. Risk and Prognostic Factors Genetic and physiological - A family history of autism spectrum disorder, communication disorders, or specific learning disorder appears to increase the risk for social (pragmatic) communication disorder; this includes siblings of children with these disorders who may present with early symptoms of social (pragmatic) communication disorder. Differential Diagnosis Autism spectrum disorder - Autism spectrum disorder is the primary diagnostic consideration for individuals presenting with social communication deficits. The two disorders can be differentiated by the presence in autism spectrum disorder of restricted/repetitive patterns of behavior, interests, or activities and their absence in social (pragmatic) communication disorder. Attention-deficit/hyperactivity disorder - Primary deficits of ADHD may cause impairments in social communication and functional limitations of effective communication, social participation, or academic achievement. Social Anxiety Disorder - The symptoms of social (pragmatic) communication disorder overlap with those of social anxiety disorder. The differentiating feature is the timing of the onset of symptoms. Intellectual developmental disorder (intellectual disability) and global developmental delay - Social communication skills may be deficient among individuals with global developmental delay or intellectual developmental disorder, but a separate diagnosis is not given unless the social communication deficits are clearly in excess of the intellectual limitations. Unspecified Communication Disorder Autism Spectrum Disorder  Autism Spectrum Disorder Diagnostic Criteria A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by all of 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 stereotypies, 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 same route or eat 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 hyporeactivity 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). 54  ◇ D. 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). ◇ “ E. These disturbances are not better explained by intellectual developmental disorder (intellectual disability) or global developmental delay. Intellectual developmental disorder and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual developmental disorder, social communication should be below that expected for general developmental level. 55  Note: ◇ Individuals with a well-established DSM-IV diagnosis of autistic disorder, Asperger’s disorder, or pervasive developmental disorder not otherwise specified should be given the “ diagnosis of autism spectrum disorder. ◇ Individuals who have marked deficits in social communication, but whose symptoms do not otherwise meet criteria for autism spectrum disorder, should be evaluated for social (pragmatic) communication disorder. 56  Specifiers Specify current severity: ◇ Based on social communication impairments and restricted, repetitive patterns of behavior ◇ Requiring very substantial support “ ◇ Requiring substantial support ◇ Requiring support Specify if: ◇ With or without accompanying intellectual impairment ◇ With or without accompanying language impairment 57  Specify if: ◇ Associated with a known genetic or other medical condition or “ environmental factor (Coding note: Use additional code to identify the associated genetic or other medical condition.) ◇ Associated with a neurodevelopmental, mental, or behavioral problem 58  Specify if: ◇ With catatonia (refer to the criteria for catatonia associated with another “ mental disorder, p. 135, for definition) (Coding note: Use additional code F06.1 catatonia associated with autism spectrum disorder to indicate the presence of the comorbid catatonia.) 59  “ 60  “ 61  “ 62  Prevalence ◇ Frequencies for autism spectrum disorder across the United States have been reported to be between 1% and 2% of the population, with similar estimates in child and adult ◇ “ Prevalence across non-U.S. countries has approached 1% of the population (0.62% median global prevalence), without substantial variation based on geographic region or ethnicity and across child and adult samples. ◇ Globally, the male:female ratio in well-ascertained epidemiological samples appears to be 3:1, with concerns about underrecognition of autism spectrum disorder in women and girls. 63  Development and Course ◇ The age and pattern of onset also should be noted for autism spectrum disorder. ◇ The behavioral features of autism spectrum disorder “ first become evident in early childhood, with some cases presenting a lack of interest in social interaction in the first year of life. ◇ Symptoms are typically recognized during the second year of life (age 12–24 months) but may be seen earlier than 12 months if developmental delays are severe, or noted later than 24 months if symptoms are more subtle. 64  Risk and Prognostic Factors Environmental ◇ A variety of risk factors for neurodevelopmental disorders, such as advanced parental age, “ extreme prematurity, or in utero exposures to certain drugs or teratogens like valproic acid, may broadly contribute to risk of autism spectrum disorder. Genetic and physiological ◇ Heritability estimates for autism spectrum disorder have ranged from 37% to higher than 90%, based on twin concordance rates, and a more recent five-country cohort estimated heritability at 80%. 65 Differential Diagnosis Intellectual developmental disorder (intellectual disability) without autism spectrum disorder Language disorders and social (pragmatic) communication disorder Selective mutism Stereotypic movement disorder Rett syndrome Symptoms of anxiety Obsessive-compulsive disorder Schizophrenia Personality disorder Comorbidity Autism spectrum disorder is frequently associated with intellectual developmental disorder and language disorder (i.e., an inability to comprehend and construct sentences with proper grammar). Specific learning difficulties (literacy and numeracy) are common, as is developmental coordination disorder. Attention-Deficit/Hyperactivity Disorder (ADHD)  Attention-Deficit/Hyperactivity Disorder Diagnostic Criteria 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: ◇ Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required. 69  1. 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). 2. Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading). 3. “ Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction). 4. 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). 5. 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). 70  6. 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). 7. Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, “ paperwork, eyeglasses, mobile telephones). 8. Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts). 9. Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments). 71  ◇ 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: 72  ◇ Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or a failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required. “ 1. Often fidgets with or taps hands or feet or squirms in seat. 2. 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). 3. Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless.) 4. Often unable to play or engage in leisure activities quietly. 73  5. 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). 6. Often talks excessively. 7. Often blurts out an answer before a question has been “ completed (e.g., completes people’s sentences; cannot wait for turn in conversation). 8. Often has difficulty waiting his or her turn (e.g., while waiting in line). 9. 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). 74  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). 75  Specify whether: ◇ F90.2 Combined presentation: If both Criterion A1 (inattention) and Criterion A2 (hyperactivity- impulsivity) are met for the past 6 months. ◇ F90.0 Predominantly inattentive presentation: If “ Criterion A1 (inattention) is met but Criterion A2 (hyperactivity- impulsivity) is not met for the past 6 months. ◇ F90.1 Predominantly hyperactive/impulsive presentation: If Criterion A2 (hyperactivity- impulsivity) is met and Criterion A1 (inattention) is not met for the past 6 months. 76  Specify if: ◇ In partial remission: When full criteria were previously met, fewer than the full criteria have been met for the past 6 months, and the symptoms still result in impairment in social, academic, or occupational functioning. Specify current severity: “ ◇ Mild: Few, if any, symptoms in excess of those required to make the diagnosis are present, and symptoms result in no more than minor impairments in social or occupational functioning. ◇ Moderate: Symptoms or functional impairment between “mild” and “severe” are present. ◇ Severe: Many symptoms in excess of those required to make the diagnosis, or several symptoms that are particularly severe, are present, or the symptoms result in marked impairment in social or occupational functioning. 77  Prevalence ◇ Population surveys suggest that ADHD occurs worldwide in about 7.2% of children; however, cross-national prevalence ranges widely, from 0.1% “ to 10.2% of children and adolescents. ◇ Prevalence is higher in special populations such as foster children or correctional settings. In a cross- national meta-analysis, ADHD occurred in 2.5% of adults. 78  Development and Course ◇ Many parents first observe excessive motor activity when the child is a toddler, but symptoms are difficult to distinguish from highly variable normative behaviors before age 4 years. ◇ ADHD is most often identified during elementary school years “ when inattention becomes more prominent and impairing. ◇ The disorder is relatively stable through early adolescence, but some individuals have a worsened course with development of antisocial behaviors. ◇ In most individuals with ADHD, symptoms of motoric hyperactivity become less obvious in adolescence and adulthood, but difficulties with restlessness, inattention, poor planning, and impulsivity persist. ◇ A substantial proportion of children with ADHD remain relatively impaired into adulthood. 79  Risk and Prognostic Factors Temperamental ◇ ADHD is associated with reduced behavioral inhibition, effortful control, or constraint; negative emotionality; and/or elevated novelty seeking. These traits may predispose some children to ADHD but are not specific to the disorder. Environmental ◇ Very low birth weight and degree of prematurity convey a greater risk for ADHD; the “ more extreme the low weight, the greater the risk. Prenatal exposure to smoking is associated with ADHD even after controlling for parental psychiatric history and socioeconomic status. A minority of cases may be related to reactions to aspects of diet. Neurotoxin exposure (e.g., lead), infections (e.g., encephalitis), and alcohol exposure in utero have been correlated with subsequent ADHD, but it is not known whether these associations are causal. Genetic and physiological ◇ The heritability of ADHD is approximately 74%. Large-scale genome-wide association studies (GWAS) have identified a number of loci enriched in evolutionarily constrained genomic regions and loss-of-function genes as well as around brain-expressed regulatory regions. There is no single gene for ADHD. Course modifiers ◇ Family interaction patterns in early childhood are unlikely to cause ADHD but may influence its course or contribute to secondary development of conduct problems. 80  Differential Diagnosis ◇ Oppositional Defiant Disorder ◇ Intermittent Explosive Disorder ◇ Other NDDS ◇ Specific Learning Disorders ◇ Intellectual Developmental Disorder “ ◇ Autism Spectrum Disorder ◇ Reactive Attachment Disorder ◇ Anxiety Disorders ◇ Posttraumatic Stress Disorder (PTSD) ◇ Depressive Disorders ◇ Bipolar Disorder ◇ Disruptive Mood Dysregulation Disorder ◇ Personality Disorders ◇ And Others… 81  Association with Suicidal Thoughts or Behavior ◇ ADHD is a risk factor for suicidal ideation and behavior in children. Similarly, in adulthood, ADHD is associated “ with an increased risk of suicide attempt, when comorbid with mood, conduct, or substance use disorders, even after controlling for comorbidity. 82 ◇ Suicidal thoughts are also more common in ADHD populations than in non-ADHD control subjects. ADHD predicted persistence of suicidal thoughts in U.S. Army soldiers.  Comorbidity ◇ Although ADHD is more common in males, females with ADHD have “ higher rates of a number of comorbid disorders, particularly oppositional defiant disorder, autism spectrum disorder, and personality and substance use disorders. 83  Other Specified Attention Deficit/Hyperactivity Disorder ◇ This category applies to presentations in which symptoms characteristic of attention-deficit/hyperactivity disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet “ the full criteria for attention-deficit/hyperactivity disorder or any of the disorders in the neurodevelopmental disorders diagnostic class. ◇ The other specified attention-deficit/hyperactivity disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for attention-deficit/hyperactivity disorder or any specific neurodevelopmental disorder. ◇ This is done by recording “other specified attention- deficit/hyperactivity disorder” followed by the specific reason (e.g., “with insufficient inattention symptoms”). 84  Unspecified Attention-Deficit/Hyperactivity Disorder ◇ This category applies to presentations in which symptoms characteristic of attention-deficit/hyperactivity disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning “ predominate but do not meet the full criteria for attention- deficit/hyperactivity disorder or any of the disorders in the neurodevelopmental disorders diagnostic class. ◇ The unspecified attention-deficit/hyperactivity disorder category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for attention-deficit/hyperactivity disorder or for a specific neurodevelopmental disorder, and includes presentations in which there is insufficient information to make a more specific diagnosis. 85  Specific Learning Disorder 86  Specific Learning Disorder Diagnostic Criteria A. Difficulties learning and using academic skills, as indicated by the presence of at least one of the following symptoms that have persisted for at least 6 months, despite the provision of interventions “ that target those difficulties: 1. Inaccurate or slow and effortful word reading (e.g., reads single words aloud incorrectly or slowly and hesitantly, frequently guesses words, has difficulty sounding out words). 2. Difficulty understanding the meaning of what is read (e.g., may read text accurately but not understand the sequence, relationships, inferences, or deeper meanings of what is read). 3. Difficulties with spelling (e.g., may add, omit, or substitute vowels or consonants). 87  4. Difficulties with written expression (e.g., makes multiple grammatical or punctuation errors within sentences; employs poor paragraph organization; written expression of ideas lacks clarity). 5. Difficulties mastering number sense, number facts, or calculation (e.g., has poor understanding of “ numbers, their magnitude, and relationships; counts on fingers to add single-digit numbers instead of recalling the math fact as peers do; gets lost in the midst of arithmetic computation and may switch procedures). 6. Difficulties with mathematical reasoning (e.g., has severe difficulty applying mathematical concepts, facts, or procedures to solve quantitative problems). 88  ◇ B. The affected academic skills are substantially and quantifiably below those expected for the individual’s chronological age, and cause significant interference with academic or occupational performance, or with activities of daily living, as confirmed by individually administered standardized achievement measures and comprehensive clinical assessment. For individuals age 17 years and older, a documented history of impairing learning “ difficulties may be substituted for the standardized assessment. ◇ C. The learning difficulties begin during school-age years but may not become fully manifest until the demands for those affected academic skills exceed the individual’s limited capacities (e.g., as in timed tests, reading or writing lengthy complex reports for a tight deadline, excessively heavy academic loads). 89  ◇ D. The learning difficulties are not better accounted for by intellectual disabilities, uncorrected visual or auditory acuity, other mental or neurological disorders, psychosocial adversity, lack of proficiency in the language of academic instruction, or inadequate educational instruction. ◇ Note: The four diagnostic criteria are to be met based on a clinical synthesis of the individual’s history (developmental, medical, family, “ educational), school reports, and psychoeducational assessment. ◇ Coding note: Specify all academic domains and subskills that are impaired. When more than one domain is impaired, each one should be coded individually according to the following specifiers. Specify if: ◇ F81.0 With impairment in reading: ￮ Word reading accuracy ￮ Reading rate or fluency ￮ Reading comprehension 90  ◇ Note: Dyslexia is an alternative term used to refer to a pattern of learning difficulties characterized by problems with accurate or fluent word recognition, poor decoding, and poor spelling abilities. If dyslexia is used to specify this particular pattern of difficulties, it is important also to specify any additional difficulties that are present, such as difficulties with reading comprehension or math reasoning. ◇ “ F81.81 With impairment in written expression: ￮ Spelling accuracy ￮ Grammar and punctuation accuracy 91 ￮ Clarity or organization of written expression ◇ F81.2 With impairment in mathematics: ￮ Number sense ￮ Memorization of arithmetic facts ￮ Accurate or fluent calculation ￮ Accurate math reasoning  ◇ Note: Dyscalculia is an alternative term used to refer to a pattern of difficulties characterized by problems processing numerical information, learning arithmetic facts, and performing “ accurate or fluent calculations. ◇ If dyscalculia is used to specify this particular pattern of mathematic difficulties, it is important also to specify any additional difficulties that are present, such as difficulties with math reasoning or word reasoning accuracy. 92  Specify current severity: ◇ Mild: Some difficulties learning skills in one or two academic domains, but of mild enough severity that the individual may be able to compensate or function well when provided with appropriate accommodations or support services, especially during the school years. ◇ Moderate: Marked difficulties learning skills in one or more academic domains, so that the individual is unlikely to become proficient without “ some intervals of intensive and specialized teaching during the school years. Some accommodations or supportive services at least part of the day at school, in the workplace, or at home may be needed to complete activities accurately and efficiently. ◇ Severe: Severe difficulties learning skills, affecting several academic domains, so that the individual is unlikely to learn those skills without ongoing intensive individualized and specialized teaching for most of the school years. Even with an array of appropriate accommodations or services at home, at school, or in the workplace, the individual may not be able to complete all activities efficiently. 93  Prevalence ◇ The prevalence of specific learning disorder “ across the academic domains of reading, writing, and mathematics is 5%–15% among school-age children in Brazil, Northern Ireland, and the United States. Prevalence in adults is unknown. 94  Development and Course ◇ Onset, recognition, and diagnosis of specific learning disorder usually occur during the “ elementary school years when children are required to learn to read, spell, write, and learn mathematics. However, precursors such as language delays or deficits, difficulties in rhyming or counting, or difficulties with fine motor skills required for writing commonly occur in early childhood before the start 95 of formal schooling.  Risk and Prognostic Factors Environmental ◇ Environmental factors, including socioeconomic conditions (e.g., low socioeconomic status) and exposure to neurotoxicants, increase the risk for specific learning disorder or difficulties in reading and mathematics. Risks for specific learning disorder or difficulties in reading and mathematics include prenatal or early-life exposure to any of the following: air pollution, nicotine, polybrominated diphenyl ethers or polychlorinated biphenyls (flame retardants), lead, or manganese. “ Genetic and physiological ◇ Specific learning disorder appears to aggregate in families, particularly when affecting reading, mathematics and spelling. The relative risk of specific learning disorder in reading or mathematics is substantially higher (e.g., 4–8 times and 5–10 times higher, respectively) in first-degree relatives of individuals with these learning difficulties compared with those without them. Notably, rates vary depending on method of ascertainment (objective testing or self-report) of parent diagnostic status. Family history of reading difficulties (dyslexia) and parental literacy skills predict literacy problems or specific learning disorder in offspring, indicating the combined role of genetic and environmental factors. There is high heritability for both reading ability and reading disability in alphabetic and nonalphabetic languages 96  Differential Diagnosis ◇ Normal Variations in Academic Attainment ◇ Intellectual Developmental Disorder “ ◇ Learning Difficulties due to Neurological or Sensory Disorders ◇ Neurodegenerative Cognitive Disorders ◇ ADHD ◇ Schizophrenia or other Psychotic Disorders 97  Comorbidity ◇ The different types of specific learning disorder commonly co-occur with one another (e.g., specific “ learning disorder with impairment in mathematics and with impairment in reading) and with other neurodevelopmental disorders (e.g., ADHD, communication disorders, developmental coordination disorder, autism spectrum disorder) or other mental disorders (e.g., anxiety and depressive disorders) or behavioral problems. 98  Motor Disorders 99  Motor Disorders Diagnostic Criteria A. The acquisition and execution of coordinated motor skills is substantially below that expected given the individual’s chronological age and opportunity for skill learning and use. “ Difficulties are manifested as clumsiness (e.g., dropping or bumping into objects) as well as slowness and inaccuracy of 100 performance of motor skills (e.g., catching an object, using scissors or cutlery, handwriting, riding a bike, or participating in sports). B. The motor skills deficit in Criterion A significantly and persistently interferes with activities of daily living appropriate to chronological age (e.g., self-care and self-maintenance) and impacts academic/school productivity, prevocational and vocational activities, leisure, and play.  C. Onset of symptoms is in the early developmental period. D. The motor skills deficits are not better explained by “ intellectual developmental disorder (intellectual disability) or visual impairment and are not attributable to a neurological condition affecting movement (e.g., cerebral palsy, muscular dystrophy, degenerative disorder). 101  Prevalence ◇ The prevalence of developmental coordination disorder in children ages 5– 11 years ranges from “ 5% to 8% cross-nationally (in the United Kingdom, 1.8% of children age 7 years are diagnosed with severe developmental coordination disorder and 3% with probable developmental coordination disorder); and 7%–8% in Canada, Sweden, and Taiwan. Males are more often affected than females, with a male:female ratio between 2:1 and 7:1. 10  Development and Course ◇ The course of developmental coordination disorder is variable but stable at least to 1-year and 2-year follow-up. ◇ Although there may be improvement in the longer term, problems with coordinated movements continue through adolescence in an estimated 50%– 70% of children. ◇ Onset is in early childhood. Delayed motor milestones may be the first signs, or “ the disorder is first recognized when the child attempts tasks such as holding a knife and fork, buttoning clothes, or playing ball games. ◇ In middle childhood, there are difficulties with motor aspects of assembling puzzles, building models, playing ball, and handwriting, as well as with organizing belongings, when motor sequencing and coordination are required. ◇ In early adulthood, there is continuing difficulty in learning new tasks involving complex/automatic motor skills, including driving and using tools. Inability to take notes and handwrite quickly may affect performance in the workplace. ◇ Co-occurrence with other disorders (see the section “Comorbidity” for this disorder) has an additional impact on presentation, course, and outcome. 103  Risk and Prognostic Factors Environmental ◇ Developmental coordination disorder is associated with prematurity and low birth weight and with prenatal exposure to alcohol. “ Genetic and physiological ◇ Impairments in underlying neurodevelopmental processes have been found in visual-motor skills, including both visual- 104 motor perception and spatial mentalizing. Cerebellar dysfunction, which affects the ability to make rapid motoric adjustments as the complexity of the required movements increases, may also be involved. However, the precise neural basis of developmental coordination disorder remains unclear.  Comorbidity ◇ Disorders that commonly co-occur with developmental coordination disorder include “ communication disorders; specific learning disorder (especially reading and writing); problems of inattention, including ADHD (the most frequent coexisting condition, with about 50% co- 105 occurrence); autism spectrum disorder; disruptive and emotional behavior problems; and joint hypermobility syndrome.  Stereotypic Movement Disorder Diagnostic Criteria (F98.4) A. Repetitive, seemingly driven, and apparently purposeless motor behavior (e.g., hand shaking or waving, body rocking, head banging, self-biting, hitting own body). B. The repetitive motor behavior interferes with social, academic, or other “ activities and may result in self-injury. C. Onset is in the early developmental period. D. The repetitive motor behavior is not attributable to the physiological effects of a substance or neurological condition and is not better explained by another neurodevelopmental or mental disorder (e.g., trichotillomania [hair-pulling disorder], obsessive-compulsive disorder). Specify if: ◇ With self-injurious behavior (or behavior that would result in an injury if preventive measures were not used) ◇ Without self-injurious behavior 106  Specify if: ◇ Associated with a known genetic or other medical condition, neurodevelopmental disorder, or environmental factor (e.g., Lesch-Nyhan syndrome, intellectual developmental disorder [intellectual disability], intrauterine alcohol exposure) ◇ Coding note: Use additional code to identify the associated “ genetic or other medical condition, neurodevelopmental disorder, or environmental factor. Specify current severity: ◇ Mild: Symptoms are easily suppressed by sensory stimulus or distraction. ◇ Moderate: Symptoms require explicit protective measures and behavioral modification. ◇ Severe: Continuous monitoring and protective measures are required to prevent serious injury. 107  Development and Course ◇ Stereotypic movements typically begin within the first 3 years of life. ◇ Simple stereotypic movements are common in infancy and may be involved in acquisition of motor mastery. ◇ “ In children who develop complex motor stereotypies, approximately 80% exhibit symptoms before age 24 months, 12% between 24 and 35 months, and 8% at 36 months or older. ◇ In most typically developing children, the severity and frequency of stereotyped movements diminish over time. ◇ Onset of complex motor stereotypies may be in infancy or later in the developmental period. ◇ Among individuals with intellectual developmental disorder, the stereotyped, self-injurious behaviors may persist for years, even though the typography or pattern of self-injury may change. 108  Tic Disorders Note: A tic is a sudden, rapid, recurrent, nonrhythmic motor movement or vocalization.  Tourette’s Disorder Diagnostic Criteria A. Both multiple motor and one or more vocal tics have been present at some time during the illness, although “ not necessarily concurrently. B. The tics may wax and wane in frequency but have persisted for more than 1 year since first tic onset. C. Onset is before age 18 years. D. The disturbance is not attributable to the physiological effects of a substance (e.g., cocaine) or another medical condition (e.g., Huntington’s disease, postviral encephalitis) 110  Persistent (Chronic) Motor or Vocal Tic Disorder Diagnostic Criteria A. Single or multiple motor or vocal tics have been present during the illness, but not both motor and vocal. B. The tics may wax and wane in frequency but have persisted “ for more than 1 year since first tic onset. C. Onset is before age 18 years. D. The disturbance is not attributable to the physiological effects of a substance (e.g., cocaine) or another medical condition (e.g., Huntington’s disease, postviral encephalitis). E. Criteria have never been met for Tourette’s disorder. Specify if: ￭ With motor tics only ￭ With vocal tics only 111  Provisional Tic Disorder DIAGNOSTIC CRITERIA A. Single or multiple motor and/or vocal tics. B. The tics have been present for less than 1 year since “ first tic onset. C. Onset is before age 18 years. D. The disturbance is not attributable to the physiological effects of a substance (e.g., cocaine) or another medical condition (e.g., Huntington’s disease, postviral encephalitis). E. Criteria have never been met for Tourette’s disorder or persistent (chronic) motor or vocal tic disorder. 112  Specifiers ◇ The “motor tics only” or “vocal tics only” specifier is only required for persistent (chronic) motor or vocal tic disorder. Prevalence ◇ “ Tics are common in childhood but transient in most cases. A national survey in the United States estimated 3 per 1,000 for the prevalence of clinically identified cases. The frequency of identified cases was lower among African Americans and Latinx individuals, which may be related to differences in access to care. The estimated prevalence of Tourette’s disorder in Canada ranges from 3 to 9 per 1,000 in school-age children. Globally, males are more commonly affected than females, with the ratio varying from 2:1 to 4:1. Epidemiological studies have shown tics to be present in children from all continents, but exact prevalence rates are influenced by methodological differences in research. 113  DIAGNOSTIC FEATURES ◇ Tics are classically categorized as either simple or complex. ◇ Simple motor tics are characterized by the limited involvement of specific muscle groups, often are of short duration, and can include eye blinks, facial grimaces, shoulder shrugs, or extension of the extremities. ◇ Simple vocal tics include throat clearing, sniffs, chirps, barks, or grunting often caused by contraction of the diaphragm or muscles of the oropharynx. ◇ Complex motor tics are of longer duration and often include a combination of “ simple tics such as simultaneous head turning and shoulder shrugging. Complex tics can appear purposeful, such as head gestures or torso movements. They can also include imitations of someone else’s movements (echopraxia) or sexual or taboo gestures (copropraxia). ◇ complex vocal tics have linguistic meaning (words or partial words) ◇ Palilalia - can include repeating one’s own sounds or words (), repeating the ◇ Echolalia - last-heard word or phrase or uttering socially unacceptable words, including obscenities, or ethnic, racial, or religious slurs (coprolalia). ◇ coprolalia is an abrupt, sharp bark or grunt utterance and lacks the prosody of similar inappropriate speech observed in human interactions. 114  Development and Course ◇ First onset of tics is typically between ages 4 and 6 years. ◇ Eye blinking is highly characteristic as an initial symptom. “ ◇ Peak severity occurs between ages 10 and 12 years, with a decline in severity during adolescence. ◇ Many adults with tic disorders experience diminished symptoms. ◇ However, a percentage of individuals will have persistently severe or worsening symptoms in adulthood. 115  Risk and Prognostic Factors Environmental ◇ Early in brain development, a number of environmental risk factors have been identified, “ including advanced paternal age as well as pre- and perinatal adverse events (e.g., impaired fetal growth, maternal intrapartum fever, maternal smoking, severe maternal psychosocial stress, preterm birth, breech presentation, and cesarean delivery). 116  Genetic and physiological ◇ Genetic factors influence tic expression and severity. The heritability of tic disorders is estimated to be 70%–85%, and there are no differences in familial risk or heritability between males and females. “ ◇ Important risk for Tourette’s disorder and rare genetic variants in families with tic disorders have been identified. ◇ Common genetic variants have also been identified. They are shared across tic disorders in a graded fashion that 117 correlates with disease severity. ◇ tic disorders likely exist along a continuous developmental spectrum, based on both their phenomenology and their genetic background.  Other Specified Tic Disorder (F95.8) ◇ This category applies to presentations in which symptoms characteristic of a tic disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet “ the full criteria for a tic disorder or any of the disorders in the neurodevelopmental disorders diagnostic class. ◇ The other specified tic disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for a tic disorder or any specific neurodevelopmental disorder. This is done by recording “other specified tic disorder” followed by the specific reason (e.g., “with onset after age 18 years”). 118  Unspecified Tic Disorder (F95.9) ◇ This category applies to presentations in which symptoms characteristic of a tic disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning “ predominate but do not meet the full criteria for a tic disorder or for any of the disorders in the neurodevelopmental disorders diagnostic class. ◇ The unspecified tic disorder category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for a tic disorder or for a specific neurodevelopmental disorder and includes presentations in which there is insufficient information to make a more specific diagnosis. 119  Other Neurodevelopmental Disorders (F88) ◇ This category applies to presentations in which symptoms characteristic of a neurodevelopmental disorder that cause impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the neurodevelopmental disorders diagnostic class. The other specified neurodevelopmental disorder category is used in situations in which the “ clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific neurodevelopmental disorder. This is done by recording “other specified neurodevelopmental disorder” followed by the specific reason (e.g., “neurodevelopmental disorder associated with prenatal alcohol exposure”). An example of a presentation that can be specified using the “other specified” designation is the following: ◇ Neurodevelopmental disorder associated with prenatal alcohol exposure: Neurodevelopmental disorder associated with prenatal alcohol exposure is characterized by a range of developmental disabilities following exposure to alcohol in utero. 120  Unspecified Neurodevelopmental Disorder (F89) ◇ This category applies to presentations in which symptoms characteristic of a neurodevelopmental disorder that cause impairment in social, occupational, or other important areas of functioning predominate but do not “ meet the full criteria for any of the disorders in the neurodevelopmental disorders diagnostic class. ◇ The unspecified neurodevelopmental disorder category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for a specific neurodevelopmental disorder and includes presentations in which there is insufficient information to make a more specific diagnosis (e.g., in emergency room settings). 121  END OF “ NEURODEVELOPMENTAL DISORDERS 122