Outline of the Topic

1. Introduction

2. Definition

3. Classification- ICD10

DSM V

4.Neurodevelopmental Disorders

- Intellectual Disability

5. Autism Spectrum Disorders

- Autism

- Asperger Syndrome

- Rett’s disorder

6. Specific learning disorder

7.Communication Disorders

- Language disorders

- Speech disorder

- Childhood -onset fluency Disorder

- Social Communication Disorder

8. Habit Disorder

9. Conclusion

10. Reference

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Introduction:
Psychiatric problems are found not only in adult, but also in children. The risk factors for mental disorder in
childhood are genetic, biochemical pre and postnatal influences, individual temperament and personal
psychosocial development. As a child grows and develops, he develops certain competencies for coping up
with life. This may be in the form of communication, remembering, testing reality, solving problems and
controlling impulses and drives, developing a positive self-concept. Children who lack in any of these areas
are at a risk for developing mental disorder. Childhood mental disorders are very common with prevalence
rate of 10-20% in several community studies. Psychological disturbance in childhood is most useful defined
as an abnormality in at least one of three areas: emotion, behaviour or relationship.

Meaning of childhood psychiatric disorder:

Mental health disorders in children are generally defined as delays or disruptions in developing age-
appropriate thinking, behaviours, social skills or regulation of emotions. These problems are distressing to
children and disrupt their ability to function well at home, in school or in other social situations.

Classification of Childhood Disorders: According to ICD10 classification

F70-F79 – Mental retardation

F80-F89 – Disorders of psychological development
F80 Specific Developmental disorders of speech and language
F80.0 Specific speech articulation disorder
F80.1Expressive language disorder
F80.2 Receptive language disorder
F80.3 Acquired aphasia with epilepsy
F80.8 Other developmental disorders of speech and language
F80.9 Developmental disorder of speech and language, unspecified.

F81 Specific developmental disorders of scholastic skills

F81.0 Specific reading disorder
F81.1 Specific spelling disorder
F81.2 Specific disorder of arithmetical skills
F81.3 Mixed disorder of scholastic skills
F81.8 Other developmental disorders of scholastic skills
F81.9 Developmental disorder of scholastic skills, unspecified.

F82 Specific developmental disorder of motor skills

F83 Mixed specific developmental disorders

F84 Pervasive developmental disorders

F84.0 Childhood autism
F84.1 Atypical autism
F84.2 Rett’s syndrome
F84.3 Other childhood disintegrative disorder
F84.4 Overactive disorder associated with mental retardation and stereotyped movements
F84.5 Asperger’s syndrome
F84.8 Other pervasive developmental disorder
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 F84.9 Pervasive developmental disorder unspecified
F88 Other disorders of psychological development

F89 Unspecified disorder of psychological development

F90 - F98 – Behavioural and emotional disorders with onset usually occurring in childhood and
adolescence.
F90 Hyperkinetic disorder
F90.0 Disturbance of activity and attention
F90.1 Hyperkinetic conduct disorder
F90.8 Other hyperkinetic disorders
F90.9 Hyperkinetic disorder, unspecified.

F91 Conduct disorders

F91.0 Conduct disorder confined to the family context
F91.1 Unsocialized conduct disorder
F91.2 Socialized conduct disorder
F91.3 Oppositional defiant disorder
F91.8 Other conduct disorders
F91.9 Conduct disorder, unspecified

F92 Mixed disorders of conduct and emotions

F92.0 Depressive conduct disorder
F92.8 Other mixed disorders of conduct and emotions
F92.9 Mixed disorder of conduct and emotions, unspecified

F93 Emotional disorders with onset specific to childhood

F93.0 Separation anxiety disorder of childhood
F93.1 Phobic anxiety disorder of childhood
F93.2 Social anxiety disorder of childhood
F93.3 Sibling rivalry disorder
F93.8 Other childhood emotional disorders, Generalized anxiety disorder of childhood
F93.9 Childhood emotional disorder, unspecified

F94 Disorders of social functioning with onset specific to childhood and adolescence
F94.0 Elective mutism
F94.1 Reactive attachment disorder of childhood
F94.2 Disinhibited attachment disorder of childhood
F94.8 Other childhood disorders of social functioning
F94.9 Childhood disorder of social functioning, unspecified

F95 Tic disorders

F95.0 Transient tic disorders
F95.1 Chronic motor or vocal tic disorder
F95.2 Combined vocal and multiple motor tic disorder [de la Tourette's syndrome]
F95.8 Other tic disorders
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 F95.9 Tic disorder, unspecified

F98 Other behavioural and emotional disorders with onset usually occurring in childhood and
adolescence
F98.0 Nonorganic enuresis
.00 Nocturnal enuresis only
.01 Diurnal enuresis only
.02 Nocturnal and diurnal enuresis
F98.1 Nonorganic encopresis
.10 Failure to acquire physiological bowel control
.11 Adequate bowel control with normal faeces deposited in inappropriate places
.12 Soiling that is associated with excessively fluid faeces such as with retention with
overflow
F98.2 Feeding disorder of infancy and childhood
F98.3 Pica of infancy and childhood
F98.4 Stereotyped movement disorders
.40 Non-self-injurious
.41 Self-injurious
.42 Mixed
F98.5 Stuttering [stammering]
F98.6 Cluttering
F98.8 Other specified behavioural and emotional disorders with onset usually occurring in
childhood and adolescence
F98.9 Unspecified behavioural and emotional disorders with onset usually occurring in
childhood and adolescence
According to DSM 5
Neurodevelopmental Disorders
Intellectual Disabilities
319 Intellectual Disability (Intellectual Developmental Disorder) (33)
Specify current severity;
(F70) Mild
(F71) Moderate
(F72) Severe
(F73) Profound
315.8 (F88) Global Developmental Delay
319 (F79) Unspecified Intellectual Disability (Intellectual Developmental Disorder)
Communication Disorders
315.39 (F80.9) Language Disorder
315.39 (F80.0) Speech Sound Disorder
315.35 (F80.81) Childhood-Onset Fluency Disorder (Stuttering)
315.39 (F80.89) Social (Pragmatic) Communication Disorder
307.9 (F80.9) Unspecified Communication Disorder
Autism Spectrum Disorder
299.00 (F84.0) Autism Spectrum Disorder
Attention-Deficit/Hyperactivity Disorder

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 314.01 (F90.2) Combined presentation
314.00 (F90.0) Predominantly inattentive presentation
314.01 (F90.1) Predominantly hyperactive/impulsive presentation
314.01 (F90.8) Other Specified Attention-Deficit/Hyperactivity Disorder
314.01 (F90.9) Unspecified Attention-Deficit/Hyperactivity Disorder
Specific Learning Disorder
315.00 (F81.0) With impairment in reading (specify if with word reading
accuracy, reading rate or fluency, reading comprehension)
315.2 (F81.81) With impairment in written expression (specify if with spelling
accuracy, grammar and punctuation accuracy, clarity or organization of written
expression)
315.1 (F81.2) With impairment in mathematics (specify if with number sense, memorization of
arithmetic facts, accurate or fluent calculation, accurate math reasoning)
Motor Disorders
315.4 (F82) Developmental Coordination Disorder
307.3 (F98.4) Stereotypic Movement Disorder
Tic Disorders
307.23 (F95.2) Tourette's Disorder
307.22 (F95.1) Persistent (Chronic) Motor or Vocal Tic Disorder
307.21 (F95.0) Provisional Tic Disorder
307.20 (F95.8), Other Specified Tic Disorder
307.20 (F95.9) Unspecified Tic Disorder
Other Neurodevelopmental Disorders
315.8 (FSB) Other Specified Neurodevelopmental Disorder
315.9 (F89) Unspecified Neurodevelopmental Disorder

Neurodevelopmental Disorders
Neuro developmental disorders are a group of conditions with onset in the developmental period. The
disorders typically manifest early in development, often before the child enters grade school, and are
characterized by developmental deficits that produce impairments of personal, social, academic, or
occupational functioning. The range of developmental deficits varies from very specific limitations of
learning or control of executive functions to global impairments of social skills or intelligence. The
neurodevelopmental disorders frequently co-occur; for example, individuals with autism spectrum disorder
often have intellectual disability (intellectual developmental disorder), and many children with attention-
deficit/hyperactivity disorder (ADHD) also have a specific learning disorder. For some disorders, the
clinical presentation includes symptoms of excess as well as deficits and delays in achieving expected
milestones. For example, autism spectrum disorder is diagnosed only when the characteristic deficits of
social communication
are accompanied by excessively repetitive behaviours , restricted interests, and insistence on sameness.

Intellectual Disability
Definition:
According to DSM-V-TR, Intellectual disability (intellectual developmental disorder) is characterized by
deficits in general mental abilities, such as reasoning, problem solving, planning, abstract thinking,
judgment, academic learning, and learning from experience. The deficits result in impairments of adaptive
functioning, such that the individual fails to meet standards of personal independence and social

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responsibility in one or more aspects of daily life, including communication, social participation, academic
or occupational functioning, and personal independence at home or in community settings. Global
developmental delay, as its name implies, is diagnosed when an individual fails to meet expected
developmental milestones in several areas of intellectual functioning. The diagnosis is used for individuals
who are unable to undergo systematic assessments of intellectual functioning, including children who are
too young to participate in standardized testing. Intellectual disability may result from an acquired insult
during the developmental period from, for example, a severe head injury, in which case a neurocognitive
disorder also may be diagnosed.

Incidence:
1to 2 % of the general population is with intellectual disability.

Etiology:
i) Perinatal cause
1.Prenatal factors:( Probably in 5% of cases)
 Infection (e.g) Rubella, syphilis, toxoplasmosis, AIDS.
 Maternal disease (e.g) DM, HTN, malnutrition, hypothyroidism, hypoparathyroidism.
 Drugs during first trimester (drugs, alcohol)
 Physical damage (e.g) Injury, radiation, hypoxia.
 Genetic
- Inborn errors of metabolism (e.g) Phenylketonuria, homocystinuria (amino acid)
- Sachs disease, Gaucher’s disease(lipid), Galactosemia, glycogen storage disease
(carbohydrates).
- Single gene disorder (eg) tuberous sclerosis.
- Cranial anomalies (eg) microcephaly.
2. Natal causes:
Premature birth, low birth weight, lack of respiration immediately after birth, hypoxia, birth
asphyxia, birth trauma, intrauterine growth retardation, kernicterus, placental abnormalities and
intraventricular haemorrhage.
3. Postnatal causes:
Infection (e.g) encephalitis, meningitis, malnutrition, cretinism, trauma (any brain injury)
and repeated fits.
ii) Sociocultural causes (probably in15% of cases)
Deprivation of Sociocultural stimulation.
iii) Psychiatric disorders (probably in 1-2% of cases)
Infantile autism
Childhood onset schizophrenia.

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 Diagnostic criteria
Intellectual disability (intellectual developmental disorder) is a disorder with onset during the developmental
period that includes both intellectual and adaptive functioning deficits in conceptual, social, and practical
domains. The following three criteria must be met:
A. Deficits in intellectual functions, such as reasoning, problem solving, planning, abstract thinking,
judgment, academic learning, and learning from experience, confirmed by both clinical assessment and
individualized, standardized intelligence testing.
B. Deficits in adaptive functioning that result in failure to meet developmental and sociocultural
standards for personal independence and social responsibility. Without ongoing support, the 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.
C. Onset of intellectual and adaptive deficits during the developmental period.

Developmental Characteristics of Intellectual Disability by Degree of Severity :

1. Mild (I.Q. range 50-70)
Ability to perform self-care activities: Capable of independently living, with assistance during times
of stress.
Cognitive/Educational capabilities: Capable of academic skills to sixth grade level. As adult can
achieve vocational skills for minimum self- support.
Social /Communication capabilities: Capable of developing social skills. Functions well in a
structured, sheltered setting
Psychomotor capabilities: Psychomotor skills usually not affected, although may have some slight
problems with coordination.
2. Moderate (I.Q. range 35-55)
Ability to perform self-care activities: Can perform some activities independently. Require
supervision.
Cognitive/Educational capabilities: Capable of academic skill to second grade level. As adult may
be able to contribute to own support in sheltered workshop.
Social /Communication capabilities: May experience some limitation in speech communication.
Difficulty adhering to social convention may interfere with
peer relationships.
Psychomotor capabilities: Motor development is fair. Vocational capabilities may be limited to
unskilled gross motor activities.
3. Severe (I.Q. range 20-35)

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 Ability to perform self-care activities: May be trained in elementary hygiene skills. Requires
complete supervision.
Cognitive/Educational capabilities: Unable to benefit from academic or vocational training. Profits
from systematic habit training.
Social /Communication capabilities: Minimal verbal skills and. Needs often communicated by
acting out behaviours.
Psychomotor capabilities: Poor psychometer development. Able to perform only simple task under
close supervision.
4.Profound (I.Q. level less than 20)
Ability to perform self-care activities: No capacity for independent functioning. Requires constant
aid and supervision.
Cognitive/Educational capabilities: Unable to profit from academic or vocational training. May
respond to minimal training in self-help if presented in the close
context of a one-to-one relationship.
Social /Communication capabilities: Little, if any, speech development. No capacity for socialisation
skill.
Psychomotor capabilities: Lack of ability for both fine and gross motor movement requires constant
supervision and care. May be associated with others physical disorders.

Management
Mental retardation is associated with various other psychiatric disorders. Therefore, the management
involves a multidisciplinary approach. The treatment of these patients should also be based on the social
and environmental needs and comorbidities. Management should look at the different level of
prevention.
Primary prevention.
i) Improvement in socio economic condition of society at large aiming at elimination of under
stimulation, prematurity and Perinatal factors.
ii) Education of lay public, aiming at removal of misconceptions about mentally retarded individuals.
iii) Medical measures for good perinatal medical care to prevent infection, trauma, excessive use of
medication, malnutrition, obstetric complication and disease of pregnancy.
iv) Facilitating research activities to study the cause of mental retardation. And their treatment.
v) Genetic counselling aim in at-risk parents, e.g Phenylketonuria, Down’s syndrome.
Secondary prevention.

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 i) Early detection and treatment of preventable disorders. E.g Phenylketonuria ( low phenylalanine diet)
Maple syrup urine disease (low branched amino acid diet) Hypothyroidism ( thyroxin).
ii) Early detection of handicaps in sensory, motor or behavioural areas with early remedial measures and
treatment.
iii) Early treatment of correctable disorders. e.g Infection- antibiotics.
iv) Early recognition of presence of mental retardation. A delay in diagnosis may cause unfortunate
delay in rehabilitation.
Tertiary prevention.
i) Treatment of psychological and behavioural problems.
ii) Behaviour modification.
iii) Rehabilitation in vocational physical and social areas.
iv) Parental counselling.
v) institutionalisation for individuals with profound mental retardation.
Somatic Management
Psychotropic drugs are used when the patient manifests psychotic symptoms as a comorbidity with
mental retardation. Anticonvulsant may be used in case of epilepsy. Antidepressant are used in case of
depression and anxiolytics in case of the anxiety.
Parental counselling.
The parents of mentally retarded children requires lifelong adjustment. Hence, the parents need guidance
and counselling, which is an important aspect of the management of the mentally retarded. This will
help the parents to understand and to accept the child’s problems and in making plans according to the
capacity of the mentally retarded person.
Counselling should focus on
 Giving information regarding the condition of the intellectual disabled child.
 Developing the right attitude towards the handicapped child.
 Educating the parents regarding their role in the training of the intellectual disabled child.
Contingency counselling:
Contingency management interventions are based on principles of basic behavioural analysis. A
behaviour that is reinforced in close temporal proximity to its occurrence will increase in frequency. Thus, if
you give a child a small toy or sticker each time he makes his bed, the child will start making his bed more
often. Behavioural principles of positive reinforcement are widely applied in everyday settings
(childrearing, employment, pet training), as well as clinical settings (autism, conduct disorder in
adolescents, intellectual disability).

 Nurses Role
Prevention of intellectual disability
 Give genetic counselling to the couple if there is history of MR in the family.
 Prevent the mother from having any type of infection during pregnancy.
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  Encourage abortion if the mother had Rubella infection.
 Enrol the mother for irregular antenatal checkup.
 Educate the couple for delivery in a good hospital with adequate facilities.
 To take the infant from any type of infection.
 Explain the mother about the growth and development of the child. It will help to identify the
delay developmental milestone.
Put up exhibitions in antenatal clinic and community health centre on prevention of mental retardation.
Assessment of degree of intellectual disability
 Encourage parents to bring the child to a well-baby clinic regularly.
 Check for the milestones and teach the mother. Ensure any physiological handicap before informing
or creating doubt in parents about MR especially is deafness.
 Help handling anxiety of parents.
Psychosocial support
i. Acceptance of child
 Encourage parents to talk about the report.
 Listen patiently and with supportive attitude
 Educate parents that home environment is safe for the child psychologically and physically.
 Encourage mother to clarify her doubts at each stage of child development.
 Explain that they don't have to be ashamed of having a intellectual disabled child at home.
ii. Help parents in developmental changes
 Prepare parents to accept the physical growth of the child
 Train and care for the female child during her menstruation.
 Do not leave a young girl alone at home with a male intellectual disabled client.
 Control and punish the impulsive behaviour of the child.
 Do not over protect.
iii. Help in communication
 Help parents to use simple names and ask the child to repeat Dad, Mom, Names of toys, dolls etc.
 Call my name at home.
 Give reward when the client tries to call a correct name.
iv. Improve attention and concentration
 To help the client to familiarize and learn about things in his nearby environment.
 Explain to parents to give one activity at a time like taking out water with a mug from one bucket
till it empty.
 Encourage the client to repeat these activities.
v. Help in fostering group behaviour (Group will motivate the child to learn some activities)
 Allow the child to attend group activities.
 Help the child to learn behaviour which is accepted in the group such as not throwing things here
and there.
 Be quiet when guest have come.

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vi. Help coping with physical stimulation of senses
Goal:- stimulation of senses that in eye, ear, skin and nose. They will also help the client to start
identifying things.
 Put the bed near the window so that the client can see a variety of things.
 Use bright colours.
 Name the colour repeatedly.
 Allow the child to listen to music and sound.
 Put the child over a blanket, smooth cloth, rough cloth.
 Show a picture of dog repeatedly, then show the real dog and say 'Dog'.
Physical need
i. Train the child for personal hygiene (care of skin and teeth)
Goal:- To help the client to learn self care.
 Take a brush and hold it in your hand
 Tell the child to hold it in a similar manner
 Put paste on your brush and the child's brush
 Take near your mouth
 Make the child repeat it
 Open your mouth, put teeth together and brush
 'Step by step see the child repeats
 Take the child to the bathroom
 Demonstrate bathing procedure step by step like brushing
 Repeat activities for several days/weeks
 Show happiness at each positive act of the child
ii. Helping in dressing
 Demonstrate buttoning and unbuttoning of the shirt without wearing it.
 Explain to the parents to give clothes with big holes of buttons. No back buttons. Use press
buttons.
 Provides clothes with zips.
 Demonstrate repeated opening and closing of the zip.
 Get bright coloured clothes for the child with a picture of them.
 Give this to the child and tell them this belongs to him or her.
iii. Helping in Toilet training
Goal:- To develop regular habits.
 Ask children to pass urine in the toilet in front of the MR child.
 Till the child to repeat the same act.
 Demonstrate to the child how to sit in the toilet.
 Show washing after passing stool.
 Allow the child to repeat.
 Reward the child.
iv. Training in eating
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  Take a slice of bread and hold it in your fingers.
 Tell the child to repeat the same.
 Help in putting the bread slices in his or her fingers.
 Open your mouth and bite a small piece.
 Now ask the child to repeat the same.
 Chew slowly.
 Ask the child to chew.
 Swallow it in front of the child.
 Ask the child to do the same.
Recreational activities
Goal :- To help the client join the group in play to attain pleasure.
 Provide simple craft activity like folding paper in two.
 Playing with mud and making small toys.
 Colouring a toy with one or two colours.
 Providing the child to paint what he or she likes.
Rehabilitation of children
Goal:- To help the child to be occupied
 Allow the child to do small activities at home.
 Health parents to St the child to a day-care centre halfway homes.

AUTISM SPECTRUM DISORDERS

Autism spectrum disorder is 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.
In addition to the social communication deficits, the diagnosis of autism spectrum disorder requires the
presence of restricted, repetitive patterns of behavior, interests, or activities. Because symptoms change with
development and may be masked by compensatory mechanisms, the diagnostic criteria may be met based on
historical information, although the current presentation must cause significant impairment.
Within the diagnosis of autism spectrum disorder, individual clinical characteristics are noted through
the use of specifiers (with or without accompanying intellectual impairment; with or without accompanying
structural language impairment; associated with a known medical/genetic or environmental/acquired
condition; associated with another neurodevelopmental, mental, or behavioral disorder), as well as specifiers
that describe the autistic symptoms (age at first concern; with or without loss of established skills; severity).
These specifiers provide clinicians with an opportunity to individualize the diagnosis and communicate a
richer clinical description of the affected individuals. For example, many individuals previously diagnosed
with Asperger's disorder would now receive a diagnosis of autism spectrum disorder without language or

intellectual impairment.

Diagnostic criteria
A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested
by the following, currently or by history (examples are illustrative, not exhaustive; see text):

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 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:
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 hypo reactivity to sensory input or unusual interest in sensory aspects of the environment
(e.g.,
apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive
smelling or touching of objects, visual fascination with lights or movement).
C. Symptoms must be present in the early developmental period (but may not become
fully manifest until social demands exceed limited capacities, or may be masked by
learned strategies in later life).
D. Symptoms cause clinically significant impairment in social, occupational, or other important
areas of current functioning.
E. These disturbances are not better explained by intellectual disability (intellectual developmental
disorder) or global developmental delay. Intellectual disability and autism
spectrum disorder frequently cooccur; to make comorbid diagnoses of autism spectrum
disorder and intellectual disability, social communication should be below that expected
for general developmental level.
AUTISM
Autism is a developmental disorder that is characterized by impaired development in communication, social
interaction and behavior.

Autism is a spectrum disorder. In other words, the symptoms and characteristics of autism can present in a
wide variety of combinations, from mild to severe. Two children, both with the same diagnosis, can act very
differently from one another and have varying skills.

Incidence
Autism is not a rare disorder, being the third most common developmental disorder. The prevalence in the
United States is about 11.3 per, 1000 children. It occurs about 4.5 times more often in boys than in girls.

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Onset of the disorder occurs in early childhood and in most cases, it runs, a chronic course with symptoms
persisting into adulthood.
Typically, the onset occurs before the age of 2 1/2 years. In some cases, the onset may occur later in
childhood. Such cases are called as childhood onset autism.

Predisposing factors
Neurological implications: Imaging studies have revealed a number of alterations in major brain
structures of individuals with ASD. In one recent study, the investigators found a disproportionate
enlargement in temporal lobe white matter and an increase in surface area in a temporal, frontal and
parieto-occipital lobe.
Other imaging studies have revealed an overall impairment in brain connectivity networks associated with
attention, consciousness and self- awareness. The role of neurotransmitter, such as serotonin dopamine
and epinephrine, is currently under investigation.
Psychological implications: Ursano, Kartheiser and Barnhill(2008) listed a number of medical conditions
that may be implicated in the predisposition of ASD. This includes tuberous sclerosis, fragile X syndrome,
maternal rubella, congenital hypothyroidism, phenylketonuria, Down syndrome, neurofibromatosis, and
Angelman syndrome.
Genetics: Research has reveals strong evidence that genetic factors play a significant role in the etiology
of ASD. Study have shown that parents who have one child with ASD at increased risk for having more
than one child with the disorder. Other studies with both monozygotic and dizygotic twin also have
provided evidence of genetic involvement. Research into how genetic factors influence the development
of ASD is ongoing. A number of linkage studies have implicated areas on several chromosomes.
Chromosomes in the development of the disorder. Most notably, chromosomes 2,7,15, 16 and 17.
Perinatal influences: In a study by researcher at Kaiser Permanente in Oakland, California, it was found
that women who suffered from asthma and allergies around the time of pregnancy were at increased risk
of having a child affected by ASD. Women with asthma and allergies recorded during the second
trimester had a greater than twofold elevated risk of having a child affected by the disorder. The
researcher have postulated that this may be due to maternal immune response during pregnancy and/or
that asthma and allergy may shear environmental risk factors with ASD.

Clinical Features
Impairment in social interaction:
 Does not respond to name by 12 months of age
 Avoids eye contact
 Prefers to play alone
 Does not share interests with others
 Only interacts to achieve a desired goal
 Flat or inappropriate facial expressions
 Does not understand personal space boundaries.
 Avoids physical contact
 Has trouble understanding other people's feelings or talking about own feelings
Impaired in communication:
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  Delayed speech and language skill.
 Repeated words or phrases over and over (Echolalia)
 Reverse pronounces. e. g say ‘me’ instead of ‘I’.
 Give unrelated answers to questions
 Does no point or respond to pointing
 Uses few or no gestures.
 Does not understand jokes, or teasing

Impairment in behavior:
 Plays with toys the same way every time
 Likes parts of objects
 Gets upset by minor changes
 Has obsessive interests
 Has to follow certain routines
 Stereotype behavior like head banging, body spinning making sounds etc
 Compulsive behaviour like arranging objects in stracks or lines.
 Resistance to even the slightest change in the environment.
 Restricted behavior is limited in focus, interest or activity such as preoccupation with a single
television program, toy or game.

4. Other symptoms
 Hyperactivity
 Impulsivity (acting without thinking)
 Short attention span
 Aggression
 Causing self-injury
 Temper tantrums
 Unusual eating and sleeping habits
 Unusual mood or emotional reactions
 Lack of fear or more fear than expected
 Unusual reactions to the way things sound, smell, taste, look or feel

Treatment
There is no single best treatment for all children with autism. However, well planned, structured teaching
of specific skills is very important. Some children respond well to one type of treatment while other have a
negative response or no response at all to the same treatment.

1. Pharmacotherapy
Drug treatment is used for the treatment of autism and for the treatment of associated
epilepsy.
 Fenfluramine decreases 5-HT levels in brain. It has been reported to be helpful in
increasing IQ and decreasing behavioral symptoms
 Haloperidol decreases dopamine level in brain. It is believed to decrease
hyperactivity and abnormal behavioral symptoms.
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  Anti-epileptic medication is used for generalized or other seizures.

2. Psychotherapy is not effective in treatment of autism. However, parental counselling and supportive
therapy are useful is allaying parental anxiety and Guilt, and ensuring their active involvement in therapy.

3. Behavior and communication approaches

 Applied behavior analysis (ABA)
ABA encourages positive behaviours and discourages negative behaviours in order to improve a
variety of skills.
For example a teacher might ask a child put his toys away. If the child puts his toys away, the teacher will
praise the child. If the child does not put the toys away, the teacher might guide the child's hand or withhold
a reward until the child puts the toys away.
ABA methods are used to
 Teach new skills
 Increase new positive behaviours
 Continue positive behaviours
 Cut down on behaviours that interferes with learning
 Occupational therapy: Occupational therapy teaches skills that help the person live as
independently as possible. Skills might include dressing, eating, bathing and relating to people.
 Sensory integration therapy: Sensory integration therapy helps the person deal with
sensory information like sight, sounds and smells.
 Speech therapy: It helps to improve the person's communication skills. Some people are able to
learn verbal communication skills.
4. Dance Movement Therapy
Dance Movement therapy can help people with autism in varied ways and in all the areas of
impairment the person suffers from in autism. The benefits experienced are as follows:
 It helps in improving attention and concentration and thus helps in furthering education.
 Dance as a way of expression of emotion enables autistic people to express through movements.
 It helps autistic people in forming better relation.
 Due to liking towards repetitive movements, a therapist can repeat a movement pattern which the
patient needs to learn and when they start imitating the movement vocabulary develops.
 This helps them in learning different patterns of movements required for daily life activities
 Group sessions in dance movement therapy enables in developing social skills and communications
of autistic person
 Doing a choreographed dance movement sequence in a series of sessions in a row helps in
improving memory and recapitulation skills.
 Touch therapy helps in developing trust on others well as helps in reducing sensitivity to physical
contact and touch.
 Dance movement therapy helps in improving body image of an autistic person.
 It helps in developing body awareness and improves general well-being
 Many a times usage of proper movements on the different planes of motion can stimulate verbal
communication skills

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  It helps in stopping the repetitive movements as they learn varied movements in the session
 Since it's a movement therapy, the motor skills develop including the gross and fine motor skills As
the social skills develop, it promotes understanding the feeling and emotions of others and thus
develop empathy
 Dance movement therapy helps an autistic person in better adaption to different situations.
The main focus of a dance movement therapy session with autistic people is to promote expression of
emotion, breaking the withdrawal symptoms and engaging with others, increasing interpersonal bonding
and communication, recognizing, associating and responding to others, increasing eye contact, participate in
group activities and promote socialization and increasing shared focus, learning through mirroring, and
developing trust.
With the vast range of benefits and the varied focus that a dance movement therapy session includes, it is
sure to benefit anyone taking the session. Howeve r. the earlier it is starts, the improvements are much more
and even the impairments would not be so drastic. As for a child with autism, an early diagnosis with a
good intervention including dance movement therapy could help the child in developing properly in the
cognitive, social, emotional and motor developments at the pace and help them lead a better life.

ASPERGER'S SYNDROME
Asperger's syndrome is neurological condition characterized by delay in the development of motor skills,
extreme difficulty in social interactions, abnormal fixation with routines, portraying a marked tendency to
perform repetitive tasks. Asperger's syndrome is more common is males than females. It may represent a
milder form of autism and the child may possess normal intelligence, language development and cognitive
skills.

Asperger syndrome (AS), also known as Asperger's, is a neurodevelopmental condition characterized by

significant difficulties in social interaction and nonverbal communication, along with restricted and
repetitive patterns of behaviour and interests. The syndrome is no longer recognised as a diagnosis in itself,
having been merged with other conditions into autism spectrum disorder (ASD). It was considered[15] to
differ from other diagnoses that were merged into ASD by relatively unimpaired spoken
language and intelligence.

Clinical features
As a pervasive developmental disorder, Asperger syndrome is distinguished by a pattern of symptoms rather
than a single symptom. It is characterized by qualitative impairment in social interaction, by stereotyped and
restricted patterns of behavior, activities, and interests, and by no clinically significant delay in cognitive
development or general delay in language. Intense preoccupation with a narrow subject, one sided verbosity,
restricted prosody, and physical clumsiness are typical of the condition, but are not required for
diagnosis. Suicidal behavior appears to occur at rates similar to those without ASD.
Social interaction
A lack of demonstrated empathy affects aspects of social relatability for persons with Asperger
syndrome. Individuals with Asperger syndrome experience difficulties in basic elements of social
interaction, which may include a failure to develop friendships or to seek shared enjoyments or
achievements with others (e.g., showing others objects of interest); a lack of social or emotional reciprocity;
and impaired nonverbal behaviors in areas such as eye contact, facial expression, posture, and gesture.

17
People with Asperger syndrome may not be as withdrawn around others, compared with those with other
forms of autism; they approach others, even if awkwardly. For example, a person with Asperger syndrome
may engage in a one-sided, long-winded speech about a favourite topic, while misunderstanding or not
recognizing the listener's feelings or reactions, such as a wish to change the topic of talk or end the
interaction. This social awkwardness has been called "active but odd". Such failures to react appropriately to
social interaction may appear as disregard for other people's feelings and may come across as rude or
insensitive. However, not all individuals with Asperger syndrome will approach others. Some may even
display selective mutism, not speaking at all to most people and excessively to specific others. Some may
choose only to talk to people they like.
The cognitive ability of children with AS often allows them to articulate social norms in a laboratory
context, where they may be able to show a theoretical understanding of other people's emotions; however,
they typically have difficulty acting on this knowledge in fluid, real-life situations. People with AS may
analyze and distill their observations of social interaction into rigid behavioral guidelines and apply these
rules in awkward ways, such as forced eye contact, resulting in a demeanour that appears rigid or socially
naïve. Childhood desire for companionship can become numbed through a history of failed social
encounters.
Violent or criminal behavior
The hypothesis that individuals with AS are predisposed to violent or criminal behavior has been
investigated but is not supported by data. More evidence suggests that children diagnosed with Asperger
syndrome are more likely to be victims, rather than offenders.
A 2008 review found that an overwhelming number of reported violent criminals with Asperger syndrome
also had other coexisting psychotic psychiatric disorders such as schizoaffective disorder. This coexistence
of psychotic disorders is referred to as comorbid disorders. Comorbid disorders can be completely
independent of one another or can have overlap in symptoms and how they express themselves.
Empathy
People with an Asperger profile might not be recognized for their empathetic qualities, due to variation in
the ways empathy is felt and expressed. Some people feel deep empathy, but do not outwardly communicate
these sentiments through facial expressions or language. Some people come to empathy through intellectual
processes, using logic and reasoning to arrive at the feelings. It is also important to keep in mind that many
people with Asperger profiles have been bullied or excluded by peers in the past and might therefore be
guarded around people, which could appear as lack of empathy. People with Asperger profiles can be and
are extremely caring individuals; in fact, it is particularly common for those with the profile to feel and
exhibit deep concern for human welfare, animal rights, environmental protection, and other global and
humanitarian causes.
Evidence suggests that in the "double empathy problem model, autistic people have a unique interaction
style which is significantly more readable by other autistic people, compared to non-autistic people."
Restricted and repetitive interests and behavior
People with Asperger syndrome can display behavior, interests, and activities that are restricted and
repetitive and are sometimes abnormally intense or focused. They may stick to inflexible routines, move
in stereotyped and repetitive ways, preoccupy themselves with parts of objects, or engage in compulsive
behaviors like lining objects up to form patterns.

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The pursuit of specific and narrow areas of interest is one of the most striking among possible features of
AS. Individuals with AS may collect volumes of detailed information on a relatively narrow topic such as
weather data or star names without necessarily having a genuine understanding of the broader topic. For
example, a child might memorize camera model numbers while caring little about photography. This
behavior is usually apparent by age five or six. Although these special interests may change from time to
time, they typically become more unusual and narrowly focused and often dominate social interaction so
much that the entire family may become immersed. Because narrow topics often capture the interest of
children, this symptom may go unrecognized.
Stereotyped and repetitive motor behaviors are a core part of the diagnosis of AS and other ASDs. They
include hand movements such as flapping or twisting, and complex whole-body movements. These are
typically repeated in longer bursts and look more voluntary or ritualistic than tics, which are usually faster,
less rhythmical, and less often symmetrical. However, in addition to this, various studies have reported a
consistent comorbidity between AS and Tourette syndrome in the range of 8–20%, with one figure as high
as 80% for tics of some kind or another, for which several explanations have been put forward, including
common genetic factors and dopamine, glutamate, or serotonin abnormalities.
According to the Adult Asperger Assessment (AAA) diagnostic test, a lack of interest in fiction and a
positive preference towards non-fiction is common among adults with AS.
Speech and language
Although individuals with Asperger syndrome acquire language skills without significant general delay and
their speech typically lacks significant abnormalities, language acquisition and use is often
atypical. Abnormalities include verbosity; abrupt transitions; literal interpretations and miscomprehension
of nuance; use of metaphor meaningful only to the speaker; auditory perception deficits;
unusually pedantic, formal, or idiosyncratic speech; and oddities in loudness, pitch, intonation, prosody, and
rhythm. Echolalia has also been observed in individuals with AS.
Three aspects of communication patterns are of clinical interest: poor prosody, tangential and circumstantial
speech, and marked verbosity. Although inflection and intonation may be less rigid or monotonic than in
classic autism, people with AS often have a limited range of intonation: speech may be unusually fast, jerky,
or loud. Speech may convey a sense of incoherence; the conversational style often includes monologues
about topics that bore the listener, fails to provide context for comments, or fails to suppress internal
thoughts. Individuals with AS may fail to detect whether the listener is interested or engaged in the
conversation. The speaker's conclusion or point may never be made, and attempts by the listener to elaborate
on the speech's content or logic, or to shift to related topics, are often unsuccessful.
Children with AS may have a sophisticated vocabulary at a young age and such children have often been
colloquially called "little professors" but have difficulty understanding figurative language and tend to use
language literally. Children with AS appear to have particular weaknesses in areas of nonliteral language
that include humor, irony, teasing, and sarcasm. Although individuals with AS usually understand the
cognitive basis of humor, they seem to lack understanding of the intent of humor to share the enjoyment
with others. Despite strong evidence of impaired humor appreciation, anecdotal reports of humor in
individuals with AS seem to challenge some psychological theories of AS and autism.

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Motor and sensory perception
Individuals with Asperger syndrome may have signs or symptoms that are independent of the diagnosis but
can affect the individual or the family. These include differences in perception and problems with motor
skills, sleep, and emotions.
Individuals with AS often have excellent auditory and visual perception. Children with ASD often
demonstrate enhanced perception of small changes in patterns such as arrangements of objects or well-
known images; typically this is domain-specific and involves processing of fine-grained
features. Conversely, compared with individuals with high-functioning autism, individuals with AS have
deficits in some tasks involving visual-spatial perception, auditory perception, or visual memory. Many
accounts of individuals with AS and ASD report other unusual sensory and perceptual skills and
experiences. They may be unusually sensitive or insensitive to sound, light, and other stimuli; these sensory
responses are found in other developmental disorders and are not specific to AS or to ASD. There is little
support for increased fight-or-flight response or failure of habituation in autism; there is more evidence of
decreased responsiveness to sensory stimuli, although several studies show no differences.
Hans Asperger's initial accounts and other diagnostic schemes include descriptions of physical clumsiness.
Children with AS may be delayed in acquiring skills requiring dexterity, such as riding a bicycle or opening
a jar, and may seem to move awkwardly or feel "uncomfortable in their own skin". They may be poorly
coordinated or have an odd or bouncy gait or posture, poor handwriting, or problems with motor
coordination. They may show problems with proprioception (sensation of body position) on measures
of developmental coordination disorder (motor planning disorder), balance, tandem gait, and finger-thumb
apposition. There is no evidence that these motor skills problems differentiate AS from other high-
functioning ASDs.
Children with AS are more likely to have sleep problems, including difficulty in falling asleep,
frequent nocturnal awakenings, and early morning awakenings. AS is also associated with high levels
of alexithymia, which is difficulty in identifying and describing one's emotions. Although AS, lower sleep
quality, and alexithymia are associated with each other, their causal relationship is unclear.
Management of Asperger's syndrome
Therapies
Managing AS ideally involves multiple therapies that address core symptoms of the disorder. While most
professionals agree that the earlier the intervention, the better, there is no treatment combination that is
recommended above others. AS treatment resembles that of other high-functioning ASDs, except that it
takes into account the linguistic capabilities, verbal strengths, and nonverbal vulnerabilities of individuals
with AS. A typical program generally includes:

 Applied behavior analysis (ABA) procedures, including positive behavior support (PBS)—or

training and support of parents and school faculty in behavior management strategies to use in
the home and school, and social skills training for more effective interpersonal interactions;
 Cognitive behavioral therapy to improve stress management relating to anxiety or explosive
emotions and to help reduce obsessive interests and repetitive routines;
 Medication for coexisting conditions such as major depressive disorder and anxiety disorders;
 Occupational or physical therapy to assist with poor sensory processing and motor coordination;
and,

20
  Social communication intervention, which is specialized speech therapy to help with
the pragmatics and give-and-take of normal conversation.
Of the many studies on behavior-based early intervention programs, most are case reports of up to five
participants and typically examine a few problem behaviors such as self-injury, aggression,
noncompliance, stereotypies, or spontaneous language; unintended side effects are largely ignored. Despite
the popularity of social skills training, its effectiveness is not firmly established. A randomized controlled
study of a model for training parents in problem behaviors in their children with AS showed that parents
attending a one-day workshop or six individual lessons reported fewer behavioral problems, while parents
receiving the individual lessons reported less intense behavioral problems in their AS children. Vocational
training is important to teach job interview etiquette and workplace behavior to older children and adults
with AS, and organization software and personal data assistants can improve the work and life management
of people with AS.
Medications: -
Atypical neuroleptic medication-risperidone, olanzapine SSRI- fluoxetine, fluvoxamine

RETT'S DISORDER
The diagnostic criteria for Rett's disorder include the following
 A period of apparently normal development before six to 18 months of age.
 A normal sized head at birth followed by slowing of head growth between five months and four
years.
 Severe impairment in the use of language and loss of purposeful hand motion
 Repetitive hand movement that include one or more of the following hand washing, hand wringing
or hand clapping.
 Shaking of the chest particularly when the child is agitated or upset.
 In children able to walk, an unsteady, stiff legged, wide based gait.
Management of Rett's syndrome
Management of gastrointestional (reflux, constipation) and nutritional (poor weight gain) issues.
Increasing the patient's communication skills especially with augmentative communication strategies
Parental counselling
Modifying social medication
Sleep aids
SSRI
Anti-psychotics (for self-harming behaviours)
Occupational therapy
Speech therapy
Physical therapy.

CHILDHOOD DISINTEGRATIVE DISORDER

Children with this rare condition begin their development normally in all areas, physical and mental. At
some point, usually between 2 and 10 years of age, a child with this illness loses many of the skills he or
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she has developed. In addition to the loss of social and language skill, a child with disintegrative disorder
may lose control of other functions including bowel and bladder control

SPECIFIC LEARNING DISORDERS

SLD, also known as specific learning disability, is the diagnosis a doctor may give to children (and some
adults) who have trouble understanding or learning information. It’s a type of neurodevelopmental disorder.
They may have significant challenges with math, reading, or writing. This may be problematic, as these are
the building blocks and core competencies for many future career paths that might be that person’s strength.
SLD interferes with how children take in and process information. If they have issues with incorrect or
incomplete schoolwork, it isn’t because they “aren’t focusing” or “not trying hard enough” — it’s a result of
SLD. SLD is different from attention deficit hyperactivity disorder (ADHD), in which children have trouble
sitting still or staying on task in school.

According to recent statistics, an estimated 5% to 15% of those children in homeroom experience some
form of learning disorder. Without proper treatment, this can cause them to fall behind in school and
potentially harm their mental health.

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).
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).
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).
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.
22
Specific learning disability characteristics

 slow reading speed for the child’s grade level.

 trouble understanding the meaning of what they’re reading.
 struggling to clearly write out thoughts without grammatical errors.
 marked difficulty with spelling.
 particular trouble with mathematical concepts like addition, subtraction, multiplication, and division.
 difficulty completing math problems or knowing how or when to apply the concepts.
Risk and Prognostic Factors
 Environmental. Prematurity or very low birth weight increases the risk for specific learning
disorder, as does prenatal exposure to nicotine.
 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. 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, including high heritability for most manifestations of
learning abilities and disabilities (e.g., heritability estimate values greater than 0.6). Covariation
between various manifestations of learning difficulties is high, suggesting that genes related to one
presentation are highly correlated with genes related to another manifestation.
 Course modifiers. Marked problems with inattentive behavior in preschool years is predictive of
later difficulties in reading and mathematics (but not necessarily specific learning disorder) and
nonresponse to effective academic interventions. Delay or disorders in speech or language, or
impaired cognitive processing (e.g., phonological awareness, working memory, rapid serial naming)
in preschool years, predicts later specific learning disorder in reading and written expression.
Comorbidity with ADHD is predictive of worse mental health outcome than that associated with
specific learning disorder without ADHD. Systematic, intensive, individualized instruction, using
evidence-based interventions, may improve or ameliorate the learning difficulties in some
individuals or promote the use of compensatory strategies in others, thereby mitigating the otherwise
poor outcomes.
Types of SLD
There are three main types of SLD that can better describe what your child is having trouble learning.It can
be confusing to hear the terms and acronyms thrown around the developmental psychology and academic
genre, so here’s a key to the terms based on what you’re seeing.

Their reading is very slow, and the letters

on the page seem to move around and get Dyslexia difficulty with reading and comprehension
mixed up.

23
 Writing and putting their thoughts down illegible handwriting, often with spelling
Dysgraphia
on paper is super frustrating. and grammatical errors

Telling the time on a clock is hard.

They don’t seem to understand math

assignments and how or when to use the difficulty understanding mathematical
concepts. Dyscalculia concepts and how to apply them to math
problems
It’s really hard to visually see if one group
is numerically larger or smaller than
another.

Treatment of SLD
When it comes to treating SLD, early intervention is key to your child’s overall success in school.
Since there is currently no way to cure SLD, helping your child understand their learning disorder and
giving them the tools they need to overcome their obstacles is the best way to set them up for success.
Treatment often involves a personalized approach for each child. It can include multimodal teaching that
utilizes the five senses.
For example, a recommended treatment for dyslexiaTrusted Source involves:
 focusing on the sounds that letters make
 phoneme awareness, which refers to hearing each individual sound in a word and how the sounds all
work together
 combining letters and phonemes by writing it out by hand
Supplementing treatment
There are a lot of resources available for parents and caregivers looking to help their child with a learning
disorder.
The Individuals with Disabilities Education Act (IDEA) guarantees free and appropriate public education, a
free evaluation for your kid if their teacher suspects that they might have a learning disorder, and the
creation of an Individualized Education Program.
“Individualized Education Programs (IEPs) [are] personalized educational plan[s] to set specific goals for
the student and the steps the school will take to help the student achieve these goals,” explains Dr. Myszak.
There are also 504 plans, so-called for Section 504 of the 1973 Rehabilitation Act. These allow for
customizations of the learning environment for someone who’s in developmental need.

COMMUNICATION DISORDERS
The communication disorders include language disorder, speech sound disorder, social (pragmatic)
communication disorder, and childhood-onset fluency disorder (stuttering). The first three disorders are
characterized by deficits in the development and use of language, speech, and social communication,
respectively. Childhood-onset fluency disorder is characterized by disturbances of the normal fluency and
motor production of speech, including repetitive sounds or syllables, prolongation of consonants or vowel
sounds, broken words, blocking, or words produced with an excess of physical tension. Like other
neurodevelopmental disorders, communication disorders begin early in life and may produce lifelong
functional impairments
24
 Language disorders
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 rule-governed manner for communication.

Diagnostic criteria
A. Persistent difficulties in the acquisition and use of language across modalities (i.e.,
spoken, written, sign language, or other) due to deficits in comprehension or production
that include the following:
1. Reduced vocabulary (word knowledge and use).
2. Limited sentence structure (ability to put words and word endings together to form
sentences based on the rules of grammar and morphology).
3. Impairments in discourse (ability to use vocabulary and connect sentences to explain
or describe a topic or series of events or have a conversation).
B. Language abilities are substantially and quantifiably below those expected for age, resulting
in functional limitations in effective communication, social participation, academic
achievement, or occupational performance, individually or in any combination.
C. Onset of symptoms is in the early developmental period.
D. The difficulties are not attributable to hearing or other sensory impairment, motor dysfunction,
or another medical or neurological condition and are not better explained by intellectual
disability (intellectual developmental disorder) or global developmental delay
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. Language
disorder emerges during the early developmental period; however, there is considerable variation in early
vocabulary acquisition and early word combinations, and individual differences are not, as single
indicators, highly predictive of later outcomes. By age 4 years, individual differences in language ability are
more stable, with better measurement accuracy, and are highly predictive of later outcomes. Language
disorder diagnosed from 4 years of age is likely to be stable over time and typically persists into adulthood,
although the particular profile of language strengths and deficits is likely to change over the course of
development.
Risk and Prognostic Factors
Children with receptive language impairments have a poorer prognosis than those with
predominantly expressive impairments. They are more resistant to treatment, and difficulties with reading
comprehension are frequently seen.
Genetic and physiological. Language disorders are highly heritable, and family members are more likely to
have a history of language impairment.

Speech Sound Disorder

Diagnostic criteria
A. Persistent difficulty with speech sound production that interferes with speech intelligibility or prevents
verbal communication of messages.
25
B. The disturbance causes limitations in effective communication that interfere with social participation,
academic achievement, or occupational performance, individually or in any combination.
C. Onset of symptoms is in the early developmental period.
D. The difficulties are not attributable to congenital or acquired conditions, such as cerebral palsy, cleft
palate, deafness or hearing loss, traumatic brain injury, or other medical or neurological conditions.

Diagnostic Features
Speech sound production describes the clear articulation of the phonemes (i.e., individual sounds) that in
combination make up spoken words. Speech sound production requires both the phonological knowledge of
speech sounds and the ability to coordinate the movements of the articulators (i.e., the jaw, tongue, and
lips,) with breathing and vocalizing for speech. Children with speech production difficulties may experience
difficulty with phonological knowledge of speech sounds or the ability to coordinate movements for speech
in varying degrees. Speech sound disorder is thus heterogeneous in its underlying mechanisms and includes
phonological disorder and articulation disorder. A speech sound disorder is diagnosed when speech sound
production is not what would be expected based on the child's age and developmental stage and when the
deficits are not the result of a physical, structural, neurological, or hearing impairment. Among typically
developing children at age 4 years, overall speech should be intelligible, whereas at age 2 years, only 50%
may be understandable.
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. Most speech sounds should be produced clearly
and most words should be pronounced accurately according to age and community norms by age 7 years.
The most frequently misarticulated sounds also tend to be learned later, leading them to be called the ''late
eight" (/, r, s, z, th, ch, dzh, and zh). Misarticulation of any of these sounds by itself could be considered
within normal limits up to age 8 years. When multiple sounds are involved, it may be appropriate to target
some of those sounds as part of a plan to improve intelligibility prior to the age at which almost all children
can produce them accurately. Lisping (i.e., misarticulating sibilants) is particularly common and may
involve frontal or lateral patterns of airstream direction. It may be associated with an abnormal tongue-thrust
swallowing pattern. Most children with speech sound disorder respond well to treatment, and speech
difficulties improve over time, and thus the disorder may not be lifelong. However, when a language
disorder is also present, the speech disorder has a poorer prognosis and may be associated with specific
learning disorders.

Childhood-Onset Fluency Disorder (Stuttering)

Diagnostic criteria
A. Disturbances in the normal fluency and time patterning of speech that are inappropriate for the
individual’s age and language skills, persist over time, and are characterized by frequent and marked
occurrences of one (or more) of the following:
26
 1. Sound and syllable repetitions.
2. Sound prolongations of consonants as well as vowels.
3. Broken words (e.g., pauses within a word).
4. Audible or silent blocking (filled or unfilled pauses in speech).
5. Circumlocutions (word substitutions to avoid problematic words).
6. Words produced with an excess of physical tension.
7. Monosyllabic whole-word repetitions (e.g., “I-I-I-I see him”).
B. The disturbance causes anxiety about speaking or limitations in effective communication,
social participation, or academic or occupational performance, individually or in
any combination.
C. The onset of symptoms is in the early developmental period. (Note: Later-onset cases
are diagnosed as 307.0 [F98.5] adult-onset fluency disorder.)
D. The disturbance is not attributable to a speech-motor or sensory deficit, dysfluency associated
with neurological insult (e.g., stroke, tumor, trauma), or another medical condition
and is not better explained by another mental disorder.

Development and Course

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. As the disorder progresses, the dysfluencies become
more frequent and interfering, occurring on the most meaningful words or phrases in the utterance. As the
child becomes aware of the speech difficulty, he or she may develop mechanisms for avoiding the
dysfluencies and emotional responses, including avoidance of public speaking and use of short and simple
utterances. Longitudinal research shows that 65%-85% of children recover from the dysfluency, with
severity of fluency disorder at age 8 years predicting recovery or persistence into adolescence and beyond.
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.

Social (Pragmatic) Communication Disorder

Diagnostic Criteria
A. Persistent difficulties in the social use of verbal and nonverbal communication as manifested
by all of the following:
1. Deficits in using communication for social purposes, such as greeting and sharing information, in a
manner that is appropriate for the social context.
2. Impairment of the ability to change communication to match context or the needs of the listener, such
as speaking differently in a classroom than on a playground, talking differently to a child than to an adult,
and avoiding use of overly formal language.
3. Difficulties following rules for conversation and storytelling, such as taking turns in conversation,
rephrasing when misunderstood, and knowing how to use verbal and nonverbal signals to regulate
interaction.

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 4. Difficulties understanding what is not explicitly stated (e.g., making inferences) and nonliteral or
ambiguous meanings of language (e.g., idioms, humor, metaphors, multiple meanings that depend on the
context for interpretation).
B. The deficits result in functional limitations in effective communication, social participation, social
relationships, academic achievement, or occupational performance, individually or in combination.
C. The onset of the symptoms is in the early developmental period (but deficits may not become fully
manifest until social communication demands exceed limited capacities).
D. The symptoms are not attributable to another medical or neurological condition or to low abilities in the
domains of word structure and grammar, and are not better explained by autism spectrum disorder,
intellectual disability (intellectual developmental disorder), global developmental delay, or another mental
disorder.
Clinical Features
Social (pragmatic) communication disorder is characterized by a primary difficulty with pragmatics, or the
social use of language and communication, as manifested by deficits in understanding and following social
rules of verbal and nonverbal communication in naturalistic contexts, changing language according to the
needs of the listener or situation, and following rules for conversations and storytelling. The deficits in
social communication result in functional limitations in effective communication, social participation,
development of social relationships, academic achievement, or occupational performance. The deficits are
not better explained by low abilities in the domains of structural language or cognitive ability.
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. The
outcome of social (pragmatic) communication disorder is variable, with some children improving
substantially over time and others continuing to have difficulties persisting into adulthood. Even among
those who have significant improvements, the early deficits in pragmatics may cause lasting impairments in
social relationships and behavior and also in acquisition of other related skills, such as written expression.
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.

Management of Communication disorders

The speech treatment plan developed for your child will vary depending on the subtype of communication
disorder that he or she has, as well as on other factors such as your child's intellectual ability, behavior, and
personality.
There are essentially three main goals for communication disorder treatments: 1) to help children to develop
and improve their communication abilities, 2) to help children develop coping strategies and alternative
communication options enabling them to compensate for times when their communications abilities are
insufficient, and 3) to help children get used to using and practicing their communication skills and coping
strategies in real-world environments such as home, at school, and with friends.

Communications treatment may include one or more of the following types of interventions:
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  Speech Therapy to help children learn new vocabulary, organize their thoughts and beliefs, and
correct grammatical or word errors
 Behavior Therapy designed to increase children's use of desirable communication behaviors,
decrease their unwanted problem behaviors and use of maladaptive coping strategies, and to promote
their development of useful interpersonal skills. Changes occur via a program of systematic reward
and reinforcement. For example, children may be encouraged to use mnemonic strategies (adaptive
coping behavior) to help them remember facts relevant to their school performance. Remembering
the word "HOMES" can trigger the names of the five great lakes: Huron, Ontario, Michigan, Erie,
and Superior.
 Some clinicians may also recommend the use of Stimulant Medications as a treatment for any
impulsivity or hyperactivity symptoms that may be present. This is a variation on a common
intervention typically used for treating ADHD, which you may read about more in our ADHD topic
center.
 Environmental Modification can also be an important part of treatment for communication
disorders. For example, children with communication disorders can be given extra time during
school-based discussions or oral test situations to more adequately formulate responses.

HABIT DISORDER

TEMPER TANTRUM
Temper tantrum is a sudden outburst or violent display anger, frustration and bad temper as physical
aggression or resistance such as, rigid body, biting, kicking, throwing objects, hitting, crying, rolling on
floor, screaming loudly, banging limbs etc.
Information about Temper tantrums
 Temper Tantrums or "acting-out" behaviours are natural during early childhood. It is normal for
children to want to be independent as they learn they are separate people from their parents.
 This desire for control often shows up as saying "no" Often and having tantrums. Tantrums are
worsened by the fact that the child may not have the vocabulary to express his or her feelings.
 Tantrums usually begin in children 12 to 1 8 months old. They get worse between age 2 to 3, then
decrease until age 4. After age 4, they rarely occur. Being tired, hungry, or sick, can make
tantrums worse or more frequent.

Causes of Temper Tantrum

 Emotional insecurity
 Lack of sleep
 Fatigue
 Limitation
 Frustration
 Unmet needs
 Attention seeking

Management
 Professional help from child guidance clinic.

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 Parent should be made aware about the beginning of temper tantrum and when the child loses control.
Parent should provide alternate activity at that time. Nobody should make fun and tease the child about
the unacceptable behavior.
 Parent should explain the child that the angry feeling is normal but controlling anger is an important
aspect of growing up.
 The child should be protected from self-injury or from doing Injury to others.
 The child's tension can be released by energetic exercise and physical activities.
 Parents must be firm and consistent in behavior.

How to Avoid a Temper Tantrum

 The temper tantrum is probably one of the most challenging parts of parenting.
 When child is flailing on the ground, it's hard not to feel powerless, overwhelmed, and fearful of hat
other people might be thinking of you and your child
 Spend Quality Time Together
 Set Clear Expectations
 Healthy Food and Drink
 Give Choices
 Reinforce Positive Behaviours

 Stay Calm

THUMB SUCKING
Thumb sucking is defined as non-nutritive sucking of fingers or thumb
Consequently thumb sucking often continues through the childhood, with an incidence of about 25
% in under 2 years and 15% under 5 years.
Thumb sucking is a socially accepted behavior among infants and toddlers. The professionals
discourage parents to prevent thumb sucking in children up to 3 years of age.
Etiology
 Parent —Overprotection, Neglect, Strictness, Disharmony, Over jealous mother
 Teacher — Strictness, Excessive punitive attitude

 Siblings and friends — Separation from class siblings, Excessive competition

 Child himself— Boredom, Loneliness, Excessive burden of household work, Separation from attached
parents

Management
Parents and family members need to support and to be advised not to become irritable, anxious and
tense.
Praising and encouraging child for breaking the habit are very useful.
Distraction during the bored time or engaging the thumb or finger for other activity, keep the hand
busy.
The child should not be scolded for the habit.
Consultation with dentist or speech therapist
Put gloves on child's hands or wrap the thumb with a cloth or bandage.
Hygienic measures to be followed and infections to be treated promptly.
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Complication
Malalignment of teeth
Deformity of jaw
Facial distortion / deformity
Speech difficulties
GI infection
If the child develop thumb sucking at the age of 7-8 years, it is a sign of stress.

NAIL BITING

Nail biting is a bad oral habit of biting the nails Nail biting can be a temporary, relatively non-destructive
behavior. Nail biting, also known as onychophagy or onychophagia (or even erroneously onychophagia),
is an oral compulsive habit.
It is sometimes described as a parafunctional activity, the common use of the mouth for an activity other
than speaking, eating, or drinking.
This habit reaches peak by 13— 15years.
40% to 50% of the children are nail biters at the age of 13-15 yr. half of them give up the habit by the
age of 16 years in response to disapproved by peers or parents.

Etiology
 Nail biting is a sign of tension and self-punishment
 Feeling to insecurity
 Conflict and hostility
 Due to pressure at school or home
 Parent neglect or separation
 Stress of examination
 Excessive fear
 Overprotected parents.

Associated behavioral problems

 Motor restlessness
 Disturbance in sleep
 Thumb sucking
 Hair pulling
 Bedwetting
 Soiling
 Abnormal oral activity
Management
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 Identify the cause of nail biting with the help of a psychologist and the steps to be taken to remove the
habit.

 The child should be praised for well-kept hand by breaking the habit to maintain the self-confidence.

 The child's hands to be kept busy with creative activities or play

 Punishment to be avoided
 Parents need reassurance to accept situations and the child to overcome the problem

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PICA
Pica is a psychological disorder characterized by an appetite for substances that are largely non- nutritive.
Pica is an eating disorder that involves eating items that are not typically thought of as food and that do not
contain significant nutritional value, such as hair, dirt, and paint chips. People with pica frequently want and
eat non-food items such as:
 Dust
 Clay
 Paint chips
 plaster
 Chalk
 Cornstarch
 Laundry starch
 Baking soda
 Coffee grounds
 Cigarette ashes
 Burnt match heads
 Cigarette butts
 Feces
 Ice
 Glue
 Hair
 Buttons
 Paper
 Sand
 Toothpaste
 Soap etc.
Etiology
 The specific causes of pica are unknown, but certain conditions and situations can increase a person's
risk:
 Nutritional deficiencies, such as iron or zinc, that may trigger specific cravings (however, the non-food
items craved usually don't supply the minerals lacking in the person's body)
 Dieting — people who diet may attempt to ease hunger by eating non-food substances to get a feeling of
fullness
 Malnutrition, especially in developing countries, where people with pica most commonly eat soil or clay
 Cultural factors in families, religions, or groups in which eating non-food substances is a learned
practice
 Parental neglect, lack of supervision, or food deprivation
 Often seen in children living in poverty
 Developmental problems, such as autism, other developmental disabilities, or brain abnormalities —
mental health conditions, such as obsessive-compulsive disorder (OCD) and schizophrenia

Type
 Acuphagia (sharp objects)
 Amylophagia (starch)

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  Cautopyreiophagia (burnt matches)
 Coniophagia (dust)
 Coprophagia (feces)
 Emetophagia (vomit)
 Geomelophagia (raw potatoes)
 Geophagia (dirt, soil, clay)
 Hyalophagia (glass)
 Lithophagia (stones)
 Mucophagia (mucus)
 Pagophagia (ice)
 Plumbophagia (lead)
 Trichophagia (hair, wool, and other fibers)
 Urophagia (urine)
 Hematophagia (Vampirism) (blood)
 Xylophagia (wood, or derivates of wood such as paper)

Diagnostic evaluation
▪ complete medical history and
▪ physical examination- — a medical evaluation is important to assess for possible anaemia intestinal
blockages, or potential toxicity from ingested substances.
▪ X-rays and
▪ Blood test
Management
 Psychotherapy of the child and parents.
 Associated problems should be treated with specific management.
 The first-line treatment for pica involves testing for mineral or nutrient deficiencies and correcting
those.
 Discrimination training between edible and non-edible items.
 Make meal time pleasure
 Meet the emotional need of child.
 Do not leave the child alone.
 Keep the child busy in activity.

Complication
A child who continues to consume non-food items may be at risk for serious health problems, including:
 Lead poisoning (from eating lead-based paint chips or dirt contaminated with lead) constipation or
diarrhoea (from consuming indigestible substances like hair, cloth, etc.)
 Intestinal obstruction or perforation (from eating objects that could block or injure the intestines)
 Tooth or mouth injuries (from eating hard substances that could harm the teeth)

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  Parasitic and other infections (from eating dirt, feces, or other infected substances)

Conclusion
As a child, grows and develops, he develop certain competencies for coping up with life.
This may be in the form of communication, remembering, testing reality, solving problem and controlling
impulses and drives. Developing a positive self-concept. Children who lack in any of these areas are at a risk
for developing mental disorder. The epidemiology also showed that most disorders go untreated. And only.
Minority of these children are in contact with specialized mental health services.

References
1. Townsend M.C. Psychiatric Mental Health Nursing Concepts of Care of Evidence-Based
Practice. Ninth edition. New Delhi: Jaypee Brothers Medical Publishers P(Ltd); Page no 704-
740.

2. KP Neeraja, Essentials of Mental Health and Psychiatric Nursing. 1 st edition. New Delhi: Jaypee
Brothers Medical Publishers P(Ltd); Page no 342-353.

3. Barker Phil. Psychiatric and Mental Health Nursing The craft of caring. Second edition.
HODDER ARNOLD PART OF HACHETTE LIVRE UK; Page no 540-560.

4. Theodore Dorothy D. Textbook Of Mental Health Nursing. New Delhi: Reed Elsevier India
Private Limited; Page no 2-82.
5. Niraj Ahuja. A Short Textbook of Psychiatry, Seventh edition. JAYPEE Publication; Page no162-
172.
6. T.Anbu, Text Book of Psychiatric Nursing.3 rd edition. EMMESS Medical Publishers. Page no
301-330.

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 CLASS PRESENTATION
ON
DISORDERS OF INFANCY,
CHILDHOOD AND ADOLESCENCE

SUBMITTED TO SUBMITTED BY
Madam Barnali Suparna Singh Ghosh
Mukherjee
M.Sc. Nursing 2nd Year
Professor Student
36
Govt. College of Govt. College of Nursing
Nursing
BMCH, Purba Bardhaman