MODULE 7

Neurodevelopmental disorders (NDs) are types of disorder that influence how

the brain functions and alters neurological development, causing difficulties in
social, cognitive, and emotional functioning.
The most common NDs are
 Autism spectrum disorder (ASD) and,
 Attention-deficit/hyperactive disorder (ADHD).
Many NDs are not as well known or widely studied.
Autism spectrum disorder (ASD)
Autism spectrum disorder (ASD) is a developmental disability caused by differences in the
brain.
People with ASD often have problems with social communication and interaction, and
restricted or repetitive behaviors or interests.
People with ASD may also have different ways of learning, moving, or paying attention.

Diagnostic Criteria For Autism Spectrum Disorder

To meet diagnostic criteria for ASD according to DSM-5, a child must have persistent deficits
in each of three areas of social communication and interaction (see A.1. through A.3. below)
plus at least two of four types of restricted, repetitive behaviors (see B.1. through B.4. below).

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):
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 stereotypes, 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).
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 co-occur; to make comorbid diagnoses of
autism spectrum disorder and intellectual disability, social communication should be
below that expected for general developmental level.

Specifiers

Specifier 1-

 Requiring very substantial support

 Requiring substantial support
 Requiring support

Specifier 2-

 With or without accompanying intellectual impairment

 With or without accompanying language impairment

Specifier 3-

 Associated with a known genetic or other medical condition or environmental factor

 Associated with a neurodevelopmental, mental, or behavioral problem

Specifier 4-

 With catatonia

Associated Features
 Many individuals with autism spectrum disorder also have intellectual impairment
and/or language impairment (e.g., slow to talk, language comprehension behind
production).
 Even those with average or high intelligence have an uneven profile of abilities.
 The gap between intellectual and adaptive functional skills is often large.
 Self-injury (e.g., head banging, biting the wrist) may occur, and disruptive/challenging
behaviors are more common in children and adolescents with autism spectrum
disorder.
 Adolescents and adults with autism spectrum disorder are prone to anxiety and
depression.
 Motor deficits like odd gait, clumsiness present,

Prevalence

• Across the US, 1-2% of population

• Non-US Countries- 1% of population
• Male:female ratio is 3:1
• Age of diagnosis is later in females, show accompanying IDs

Risk and Prognostic

 Environmental.
A variety of nonspecific risk factors, such as advanced parental age, low birth weight,
or fetal exposure to valproate, may contribute to risk of autism spectrum disorder.

 Genetic and physiological. Heritability estimates for autism spectrum disorder have
ranged from 37% - 90%, based on twin concordance rates.

Currently, as many as 15% of cases of autism spectrum disorder appear to be

associated with a known genetic mutation, with different de novo copy number
variants or de novo mutations in specific genes associated with the disorder in
different families. However, even when an autism spectrum disorder is associated
with a known genetic mutation, it does not appear to be fully penetrant. Risk for the
remainder of cases appears to be polygenic, with perhaps hundreds of genetic loci
making relatively small contributions.

Gender-Related Diagnostic Issues

Autism spectrum disorder is diagnosed four times more often in males than in
females. In clinic samples, females tend to be more likely to show accompanying
intellectual disability, suggesting that girls without accompanying intellectual
impairments or language delays may go unrecognized, perhaps because of subtler
manifestation of social and communication difficulties.

Comorbidity

• Autism spectrum disorder is frequently associated with intellectual impairment

and structural language disorder (i.e., an inability to comprehend and construct
sentences with proper grammar)
• Co-occur with ID, language disorders
• 70%- comorbid with one
• 40%- comorbid with two
 Treatment
• Applied Behavior Analysis (ABA)- Often used in schools, clinics to help child learn
positive behaviours, reduce negative ones.
• Discrete trial training (DTT) uses simple lessons and positive reinforcement.
• Pivotal response training (PRT) helps develop motivation to learn and
communicate.
• Early intensive behavioral intervention (EIBI) is best for children under age 5.
• Verbal behavior intervention (VBI) focuses on language skills.

• There is no cure for autism spectrum disorder, and there’s currently no

medication to treat it. But some medicines can help with related symptoms like
depression, seizures, insomnia, and trouble focusing.

ATTENTION DEFICIT/HYPERACTIVE DISORDER

ADHD is one of the most common neurodevelopmental disorders of childhood.

It is usually first diagnosed in childhood and often lasts into adulthood.

Children with ADHD may have trouble paying attention, controlling impulsive
behaviors (may act without thinking about what the result will be), or be overly
active.

DIAGNOSTIC CRITERIA

A. People with ADHD show a persistent pattern of inattention

and/or hyperactivity-impulsivity that interferes with the
functioning or development:

1. Inattention: Six or more symptoms of inattention for children

up to age 16 years, or five or more for adolescents age 17
years and older and adults; symptoms of inattention have
been present for at least 6 months, and they are
inappropriate for developmental level:
a) Often fails to give close attention to details or makes careless
mistakes in schoolwork, at work, or with other activities.
b) Often has trouble holding attention on tasks or play activities.
c) Often does not seem to listen when spoken to directly.
 d) Often does not follow through on instructions and fails to finish
schoolwork, chores, or duties in the workplace (e.g., loses focus,
side-tracked).
e) Often has trouble organizing tasks and activities.
f) Often avoids, dislikes, or is reluctant to do tasks that require
mental effort over a long period of time (such as schoolwork or
homework).
g) Often loses things necessary for tasks and activities (e.g. school
materials, pencils, books, tools, wallets, keys, paperwork,
eyeglasses, mobile telephones).
h) Is often easily distracted
i) Is often forgetful in daily activities.

2. Hyperactivity and Impulsivity: Six or more symptoms of

hyperactivity-impulsivity for children up to age 16 years, or
five or more for adolescents age 17 years and older and
adults; symptoms of hyperactivity-impulsivity have been
present for at least 6 months to an extent that is disruptive
and inappropriate for the person’s developmental level:

a) Often fidgets with or taps hands or feet, or squirms in seat.

b) Often leaves seat in situations when remaining seated is expected.
c) Often runs about or climbs in situations where it is not
appropriate (adolescents or adults may be limited to feeling
restless).
d) Often unable to play or take part in leisure activities quietly.
e) Is often “on the go” acting as if “driven by a motor”.
f) Often talks excessively.
g) Often blurts out an answer before a question has been
completed.
h) Often has trouble waiting their turn.
i) Often interrupts or intrudes on others (e.g., butts into
conversations or games)
In addition, the following conditions must be met:

B. Several inattentive or hyperactive-impulsive symptoms were present

before age 12 years.
C. Several symptoms are present in two or more settings, (such as 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, school, or work functioning.
E. The symptoms are not better explained by another mental disorder
(such as a mood disorder, anxiety disorder, dissociative disorder, or a
personality disorder). The symptoms do not happen only during the
course of schizophrenia or another psychotic disorder.
Based on the types of symptoms, three kinds (presentations) of ADHD can occur:

1. Combined Presentation: if enough symptoms of both criteria inattention

and hyperactivity-impulsivity were present for the past 6 months
2. Predominantly Inattentive Presentation: if enough symptoms of
inattention, but not hyperactivity-impulsivity, were present for the past
six months
3. Predominantly Hyperactive-Impulsive Presentation: if enough symptoms
of hyperactivity-impulsivity, but not inattention, were present for the
past six months.
Because symptoms can change over time, the presentation may change over
time as well.

Associated Features

Prevalence

• 7.2% of children
• Higher in special populations like foster children, those in
correctional settings
• 2.5% of adults
• More frequent in males than females(2:1 in children and 1.6:1 in
adults)
• Females primarily present with inattentive features

RISK 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 (less than 1,500 grams) conveys a two- to threefold risk for
ADHD, but most children with low birth weight do not develop ADHD. Although ADHD is correlated
with smoking during pregnancy, some of this association reflects common genetic risk. A minority of
cases may be related to reactions to aspects of diet. There may be a history of child abuse, neglect,
multiple foster placements, neurotoxin exposure (e.g., lead), infections (e.g., encephalitis), or alcohol
exposure in utero. Exposure to environmental toxicants has been correlated with subsequent ADHD,
but it is not known whether these associations are causal.
Genetic and physiological. ADHD is elevated in the first-degree biological relatives of individuals
with ADHD. The heritability of ADHD is substantial. While specific genes have been correlated with
ADHD, they are neither necessary nor sufficient causal factors. Visual and hearing impairments,
metabolic abnormalities, sleep disorders, nutritional deficiencies, and epilepsy should be considered
as possible influences on ADHD symptoms

Comorbidity
• ODD, ASD, Personality, Substance use disorders are common
• Conduct disorder occurs in quarter of children
• Anxiety disorders, MDD disorders, OCD occur in minority
• Comorbid sleep disorders are associated with daytime impairments in cognition

Treatments • Medications like stimulants that boost levels of brain chemicals and nonstimulants and
antidepressants can help • CBT • Family Therapy

INTELLETUAL DISABILITY

Intellectual disability is characterized by deficits in general mental abilities, such as reasoning,

problem solving, planning, abstract thinking, judgement, academic learning, and learning from
experience.

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.
Specifiers • Various severity levels based on adaptive functioning not IQ scores, since scores matter
very little in the lower ranges.

Associated Features Supporting Diagnosis

• Intellectual disability is a heterogeneous condition with multiple causes.

• There may be associated difficulties with social judgment; assessment of risk; self-
management of behavior, emotions, or interpersonal relationships; or motivation in school
or work environments. Lack of communication skills may predispose to disruptive and
aggressive behaviors.
• Due to lack of risk awareness, accidental injury risks are increased

Prevalence

• Approximately 10 per 1000

• Middle-income countries- 16 per 1000
• High-income countries- 9 per 1000
• Higher in youths than adults
• In US, prevalence does not vary by ethnoracial groups
• Males more likely to be diagnosed with mild and severe ID.

Risk and Prognostic Factors

Genetic and physiological.

• Prenatal etiologies include genetic syndromes, inborn errors of metabolism, brain

malformations, maternal disease, and environmental influences.
• Postnatal causes include hypoxic ischemic injury, traumatic brain injury, infections,
demyelinating disorders, seizure disorders , severe and chronic social deprivation, and toxic
metabolic syndromes and intoxications.

Comorbidity

• Most treatment plans for intellectual disability focus on the person’s strengths, needs,
support needed to function, additional conditions
• Supportive services include early intervention, special education, transition services,
vocational programs, housing options, rehabilitation counselling
• Family members, caregivers, friends, co-workers, and community members can also provide
additional support to people with intellectual disability. Treatments
• Neurodevelopmental, medical, mental disorders are 3-4x more common
• Knowledgeable informants essential to help identify symptoms
• Most common disorders are ADHD, ASD, Impulse-control disorders