Approach to Developmental

disorders in Children
DR KHANISA MD KHALID
GEN PEADS & CHILD HEALTH, HRPZ2 KOTA BHARU
What is developmental disorder?

 Any condition resulting from delayed/atypical growth and development

 Examples:
- Autism Spectrum Disorder
- ADHD
- Cerebral Palsy
- Down syndrome
- Intellectual disability
Introduction

 Aetiology- unclear
 Multifactorial- genetic vulnerability, environmental factors
Risk factors

 1. Advancing parental age

 2. prematurity : esp < 33 weeks
 3. neonatal encephalopathy : odds ratio 3- 5.99 for asd
 4. genetics: monozygotic twins, parents, siblings
Beneficial factors

 Use of folic acid: 4 weeks prior to conception until 8 weeks gestation

 Vaccination like mmr not associated with autism
Modified Checklist for Autism in Toddlers
(M-CHAT)

 A 23-itemquestionnaire on child behaviour &

development reported by parents for young
children
 Malay & Chinese versions for local use in
Malaysian healthcare facilities
 Training is required for interpretation of the
result.
 History

 Behavioural problems
 Medical history (prenatal & perinatal)
 Psychiatric history (co-existing mental disorders e.g. depression &
anxiety)
 Family history (any developmental disorders)
 Social history (school, home life, physical environment, social needs)
 Medication & allergy history
 Assessment

 History(ideally from the main caretaker & others who are

involved in the care of the child)

 Symptoms e.g. poor eye contact, lack of response to name,

impaired visual tracking of an object, poor social interaction,
poor reciprocal communication, repetitive behaviour, restricted
interests & limited ability to imitate

 Developmental history (including regression)

Eye contact in Autistic child
 Physical Examination

 General examination (any dysmorphism, detailed

neurological examination)
 Developmental assessment (for baseline developmental
age equivalent)
 Audiology (for hearing assessment)
 Visual
 Signs of physical abuse/self-harm
Syndromes associated with autism

 Williams
 Fragile x
 Angelman
 Landau kleffner
 Prader willi
 Rett
 Tardive dyskinesia
AUTISM SPECTRUM DISORDER
(ASD)
Restricted, Repetitive
Deficits in
Patterns of
Social Communication
Behaviour, Interests
& Social Interaction
& Activities

Autism
Spectrum
Disorder
 DSM-5 CRITERIA FOR ASD

 A. Persistent deficits in social

communication & social
interaction, as manifested by the
following, currently or by history:
1. Deficits in social - emotional reciprocity
2. Deficits in nonverbal communicative
behaviors used for social interaction
3. Deficits in developing, maintaining & understanding
relationships
 ASD Diagnostic Criteria

 B.Restricted, repetitive patterns of behavior,

interests or activities as manifested by at
least two of the following:
1. Stereotyped or repetitive motor movements, use of objects or speech
2. Insistence on sameness, inflexible adherence to routines or ritualized
patterns of verbal or nonverbal behavior
3. Highly restricted, fixated interests that are abnormal in intensity or focus
4. Hyper- or hyporeactivity to sensory input or unusual interest in sensory
aspects of the environment
 ASD Diagnostic Criteria

 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 or global developmental
delay.
 SEVERITY LEVELS FOR ASD
Severity level Social communication Restricted, repetitive behaviours
Level 3 Severe deficits in social communication skills, Inflexibility of behaviour, extreme difficulty coping
"Requiring very very limited initiation of social interactions & with change, or other restricted/repetitive
substantial support" minimal response to social overtures from behaviours markedly interfere with functioning in
others all spheres
Great distress/difficulty changing focus or action

Level 2 Marked deficits in social communication skills, Obvious interference with functioning in a variety
"Requiring substantial limited initiation of social interactions & of contexts Distress &/or difficulty changing focus
support" reduced or abnormal responses to social or action
overtures from others

Level 1 Without supports in place, deficits in social
"Requiring support" communication cause noticeable impairments
Difficulty initiating social interactions &
atypical responses to social overtures of others
Inflexibility of behaviour causes significant
interference with functioning in one or more
contexts
Difficulty switching between activities
Problems of organisation & planning hamper
independence
 ASD & COMORBIDITIES

 1. INTELLECTUAL DISABILITIES
 About half of ASD children have ID
 Extreme autistic traits are significantly associated
with ID and poor academic performance
 COMORBIDITIES

2. Attention deficit hyperactivity disorder (ADHD)

 53% children with ASD have ADHD
 22% - hyperactivity/impulsivity
 46% - inattentive
 32% - combined
 Children with ASD who have ADHD
 are usually younger
 have a lower mean IQ
 COMORBIDITIES

3. Sleep problems
 44- 83% of school aged children with ASD have sleep
problems, supported by polysomnography;
at least one sleep problem
sleep onset problem
night waking
 COMORBIDITIES

4. Epilepsy
 The prevalence of epilepsy in ASD ranges from 7-46%.
 It increases with:
 symptomatic autism
 intellectual disability,
 age (median age 14 years)
 history of cognitive/developmental regression
 use of psychotropics medications
 abnormality of EEG
 associated psychiatric disorder
 COMORBIDITIES
5.Gastrointestinal problems
 Children with ASD 5 times more common to have feeding problems than those without ASD.
Type of problems:
 Food selectivity
 Food refusal
 Behavioural rigidity during meals
 Combination of above

 They tend to have a higher level of nutritional inadequacies with lower consumption of calcium and
protein.

 There is an increased incidence of constipation in these children.

 COMORBIDITIES

6. Psychiatric disorders
 70.8% have at least one current psychiatric disorder
 57% have multiple diagnosis:
 62.8% have ADHD, emotional & behavioural disorders
 24.7% have Tourette’s syndrome, chronic tics, etc.
 41.9% have anxiety or phobic disorder
 30% have oppositional or conduct problems
 1.4% have depressive disorder
 There is no substantial evidence on the prevalence of psychosis in children with ASD
 Investigations in ASD can be divided into:
 Audiological evaluation

 Other investigations
 36
AUDIOLOGY EVALUATION
 Aim: To rule out hearing impairment
 Electrophysiological test is preferably used in
children with ASD
 What hearing tests should be used?
o ABR/BSER (Auditory Brainstem Evoked Response) -
measures the hearing nerve’s response to sound
o TEOAE (Transient Evoked Otoacoustic emission) –
determine cochlear status
 Paediatric
Communication
Disorder

Paediatric
Feeding Acquired
Disorder Communication
Disorder

Swallowing Augmentative &

Disorder Alternative
Communication
(AAC)
Intervention

Voice
Disorder
Children with ASD may have problem with both speech &
nonverbal communication. They may also have problem to
interact socially.

Children with ASD may:

 not talk at all
 produce unintelligible words/‘jargon’
 use phrases inappropriately & out of context
 have difficulty with conversational skills which include eye contact &
gestures
 WHEN TO START SPEECH
THERAPY?

The earlier, the better!!!!!

Children with ASD who receive

therapy between 2-3 years old
showed improvement in
expressive language skills at 4
years old.1

1. Stone WL & Yoder, PJ. Autism, 2001, 5(4):341-361

 FAMILY INVOLVEMENT IN
THERAPY
 Parent participation is vital to a child’s
success.
 Involvement of family members in the
therapy helps
 increase the number of communication acts &
use of communication means2
 decrease autism behaviour & increase typical
communication3

2. Fernande FD, et al. Pro Fono Revista de Atualizacao Cientifica. 2008, 20(4):267-272
3. Tamanaha AC & Perissinoto J. J Soc Bras Fonoaudio. 2011, 2391): 8-12
 Aided Unaided
Require supplemental Nonverbal means of
materials communication -
Use of gestures &
Examples: manual signs
• Picture Exchange
Communication System Examples:
(PECS) • facial expression
• Speech Generating Device • body gestures
(SGD) • sign language
 Picture Exchange Communication
System (PECS)

A 6-phased aided AAC designed to facilitate

functional & spontaneous communication skill
 Picture Exchange Communication
System (PECS)

Improves communication skills in individual with ASD

in terms of:
non-imitative spoken communication acts7
number of different non-imitative words7
functional communication8
challenging behaviour8
socialisation8
 requesting
7.Flippin M et al.skills
Am 9J Speech lang Pathol. 2010, 19(2):178-195
8.Ganz JB et al. Res Dev Disabil. 2012, 3392):406-418
9.Schlosser RW & Wendt O. Am J Speech Lang Pathol. 2008, 17(3):212-230
 Speech Generating Device (SGD)

 Anelectronic device that

produces speech for the user

 SGD with enhanced milieu

teaching & signing improves
requesting skills.9

9.Schlosser RW & Wendt O. Am J Speech Lang Pathol. 2008, 17(3):212-230

 Video self-modelling

 Individuals observe themselves

performing the targeted behaviours &
imitating the behaviours

 Videoself-modelling improves social

communication skills, functional skills
& behavioural functioning.10

10.Bellini S & Akullian J. Exceptional children. 2007, 73:264-287

 Occupational therapy provides assessment &
intervention to promote skill development &
optimise independence in daily activities.

 Occupational therapy may combine a variety of

strategies/approaches.
SOCIAL SKILLs & SELP-HELP SKILLs

 Improve deficits in the skills in children with ASD6

 Social skill intervention - improvement in overall social competence & friendship quality 7

Self-help Skills Social Skills

6. Flynn L, Healy O. Res in Autism Spectr Disord. 2012, 6 (1):431-441
7. Reichow B, Steiner AM, Volkmar F. Cochrane Database Syst Rev. 2012 7:CD008511
SENSORY INTEGRATION THERAPY
 SOCIAL stories

 Help children with ASD to understand the nuances of interpersonal

communication for effective & appropriate interaction

 Conducted by:
 trained occupational therapists
 speech-language therapists
 psychologists
 teachers or caregivers
Take home message

 Monitoring & transition for adolescents to adulthood is crucial to

enable them to achieve independent living & full potential in all
aspects of life.
 Care for children & adolescents with ASD should be continued
into adult health services.
 Children with ASD who are registered as OKU can benefit from
the social welfare service.
CASE PRESENTATION

 A mother brings her 8 year old son for evaluation after he is

suspended from school for jumping on his seat, teasing other
children, and not following instructions. He spends two to three
hours a night doing homework which he never successfully
completed. His mother wants to know what is wrong with her
child.

 The boy might be having….

DSM 5 criteria for ADHD

 1. INATTENTION:
 Six or more symptoms of inattention for children up to age 16, or five or
more for adolescents 17 and older and adults; symptoms of inattention have
been present for at least 6 months, and they are inappropriate for
developmental level:
 Often fails to give close attention to details or makes
careless mistakes in schoolwork, at work, or with other
activities.
 Often has trouble holding attention on tasks or play
activities.
 Often does not seem to listen when spoken to directly.

Often does not follow through on instructions and fails
to finish schoolwork, chores, or duties in the
workplace (e.g., loses focus, side-tracked).
 Often has trouble organizing tasks and activities
 Often has trouble organizing tasks and activities.
 Often avoids, dislikes, or is reluctant to do tasks that
require mental effort over a long period of time (such
as schoolwork or homework).
 Often loses things necessary for tasks and activities
(e.g. school materials, pencils, books, tools, wallets,
keys, paperwork, eyeglasses, mobile telephones).
 Is often easily distracted
 Is often forgetful in daily activities
 2.HYPERACTIVITY AND IMPULSIVITY:
 Six or more symptoms of hyperactivity-impulsivity for children up to age
16, or five or more for adolescents 17 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
 Often fidgets with or taps hands or feet, or  Is often “on the go” acting as if “driven by a motor”.
squirms in seat.  Often talks excessively.
 Often leaves seat in situations when remaining  Often blurts out an answer before a question has
seated is expected.
been completed.
 Often runs about or climbs in situations where it  Often has trouble waiting his/her turn.
is not appropriate (adolescents or adults may be
limited to feeling restless).  Often interrupts or intrudes on others (e.g., butts into
 conversations or games)
Often unable to play or take part in leisure
activities quietly.
Prevalence

 3-4: 1

Prevalence 7.5%

Mental health referrals: 30-50%

Persists in 40-70% adolescent, up to 50% adult

Comorbidities