014 Special Needs

What is meant by the term special needs, and what major categories are included?

Special needs is an umbrella term for children who require special attention and accommodations beyond those needed by most children. Categories include:

• Medical: cancer, cerebral palsy, cystic fibrosis

• Behavioral: ADHD, Oppositional Defiant Disorder (ODD)

• Developmental: Intellectual and Developmental Disabilities (IDD), Autism Spectrum Disorder (ASD)

• Learning: dyslexia

• Mental health: anxiety, bipolar disorder

What is ADHD, and what are its core features?

ADHD (Attention-Deficit/Hyperactivity Disorder) is a chronic condition characterized by:

• Persistent inattention

• Hyperactivity

• Impulsivity (may or may not be present)

Occurs in approximately 4-6% of the general population.

How can ADHD present differently in boys versus girls?

• Boys: More often show hyperactivity and impulsivity, leading to disruptive behavior.

• Girls: More often show inattentiveness rather than disruptive behavior, making diagnosis more difficult.

What is Oppositional Defiant Disorder (ODD)?

ODD is a behavioral disorder in which a child demonstrates a persistent pattern of:

• Uncooperative behavior

• Disobedience

• Defiance

• Hostility toward authority figures

What findings help distinguish ODD from normal childhood defiance?

• Symptoms persist for more than 6 months

• Behavior is not just a temporary phase

• Often begins around age 8, but may start as early as preschool

What factors contribute to ODD, and what serious outcome can result if it progresses?

• Believed to result from a combination of biological, psychological, and social factors

• Can progress to Conduct Disorder, a more severe behavioral disorder

How do ADHD and ODD differ?

• ADHD: Inattention, hyperactivity, and impulsivity.

• ODD: Defiant, hostile, and disobedient behavior toward authority figures lasting >6 months.

• ADHD primarily affects attention and self-regulation, whereas ODD primarily affects behavior toward others and authority.

What is Conduct Disorder, and how is it characterized?

Conduct Disorder is a repetitive, persistent pattern of behavior in which the basic rights of others or societal rules/norms are violated.

What 4 major categories of behaviors are used to diagnose Conduct Disorder?

Presence of 3 or more behaviors within the past 12 months:

1. Aggression toward people or animals

2. Destruction of property

3. Deceitfulness or theft

4. Serious violation of rules

When does Conduct Disorder typically present, and what disorder may precede it?

• Can begin during childhood or adolescence

• May develop from Oppositional Defiant Disorder (ODD)

What are Intellectual and Developmental Disabilities (IDD)?

IDD is a disability characterized by significant limitations in:

• Intellectual functioning (reasoning, learning, problem-solving)

• Adaptive behavior (everyday social and practical skills)

The condition begins before age 18.

What diagnostic features are commonly associated with IDD?

• Onset before 18 years of age

• IQ typically below 70-75

• Deficits in both intellectual functioning and adaptive behavior

What conditions fall under the umbrella of IDD?

Examples include:

• Down syndrome

• Autism Spectrum Disorder (ASD)

• Other developmental disabilities

How is the severity of Intellectual Disability commonly classified by IQ?

• Mild ID: IQ 55–70

• Moderate ID: IQ 35–55

• Severe ID: IQ 20–35

• Profound ID: IQ <20

How do ODD, Conduct Disorder, and IDD differ?

• ODD: Defiant, disobedient, hostile behavior toward authority figures lasting >6 months.

• Conduct Disorder: Violation of others' rights and major societal rules (aggression, theft, property destruction, rule-breaking).

• IDD: Deficits in intellectual functioning and adaptive behavior beginning before age 18.

What is Down syndrome, and what genetic abnormality causes it?

Down syndrome is a condition caused by a full or partial extra copy of chromosome 21.

What are the three genetic types of Down syndrome, and how common is each?

• Trisomy 21 (nondisjunction): ~95% of cases

• Translocation: ~4% of cases

  • Long arm of chromosome 21 attached to another chromosome (commonly chromosome 14)

• Mosaicism: ~1% of cases

  • Only some cells contain the extra chromosome

What key epidemiologic facts about Down syndrome are commonly tested?

• Most common chromosomal condition

• Approximately 1 in 661 births in the U.S.

• Risk increases with maternal age

What major medical conditions are associated with Down syndrome?

• Congenital heart defects

• Hirschsprung disease

• Hearing loss

• Thyroid disorders (hypothyroidism most common)

• Childhood leukemia

• Early-onset Alzheimer disease

What are two important long-term health concerns in individuals with Down syndrome?

• Alzheimer disease develops in approximately 50- 70% of individuals who reach age 60.

• Increased risk of thyroid disease, especially hypothyroidism.

How has life expectancy changed for individuals with Down syndrome?

• About 25 years in 1983

• Approximately 60 years today

What are the classic facial and physical features of Down syndrome?

• Epicanthal folds

• Upward-slanting eyes

• Flat nasal bridge

• Flat, broad face

• Short neck

• Small chin

• Small mouth with relatively large tongue

What are the classic facial and physical features of Down syndrome?

• Epicanthal folds

• Upward-slanting eyes

• Flat nasal bridge

• Flat, broad face

• Short neck

• Small chin

• Small mouth with relatively large tongue

What musculoskeletal and extremity findings are commonly seen in Down syndrome?

• Excessive joint flexibility (hypermobility)

• Single deep palmar crease

• Short stature

• Short fingers

Why can the large tongue seen in Down syndrome be clinically significant?

A relatively large tongue can contribute to obstructive sleep apnea.

What is the typical cognitive profile of individuals with Down syndrome?

• Average IQ is approximately 50

• Can range from:

  • Mild ID: IQ 55–70

  • Severe ID: IQ 20–35

• Individuals with mosaic Down syndrome often have IQ scores 10-30 points higher than those with standard Trisomy 21.

How does language development typically present in Down syndrome?

• Receptive language (understanding) is usually stronger than expressive language (speaking).

• Many individuals exhibit:

  • Stuttering

  • Rapid or irregular speech patterns

What are the most common visual problems seen in Down syndrome?

• Significant refractive error (RE) occurs in about 80%

• Astigmatism (>1 diopter) occurs in approximately 67- 74%

• Failure of normal emmetropization (development toward normal vision)

How does visual acuity in children with Down syndrome compare with typically developing children?

• Under age 2: Similar to typically developing children

• Over age 2: Generally worse visual acuity than typically developing peers

What ocular disorders are commonly associated with Down syndrome?

• Accommodative insufficiency

• Strabismus

• Amblyopia

• Nystagmus

What is accommodative insufficiency, and how common is it in Down syndrome?

• Reduced ability to focus on near objects

• About 55% have an accommodative lag >1 diopter

• About 92% have accommodative amplitude <10 D

How common are strabismus and amblyopia in individuals with Down syndrome?

• Strabismus: 19–34%

• Amblyopia: ~17%

What are Brushfield spots, and how are they related to Down syndrome?

• Brushfield spots are small white or gray speckles on the iris

• Caused by focal areas of iris stromal connective tissue hyperplasia surrounded by relative hypoplasia

• More commonly seen in individuals with light-colored irides

• Classic ocular finding associated with Down syndrome

What eyelid and anterior segment abnormalities are commonly seen in Down syndrome?

• Prominent epicanthal folds

• Blepharitis (~33%)

  • Chronic, treatment-resistant inflammation

  • Can lead to excessive eye rubbing

What optic nerve abnormalities may be seen in Down syndrome?

• Increased number of vessels at the disc margin

• Spoke-like vessel pattern

• Optic nerve hypoplasia

What corneal disorder is associated with Down syndrome?

• Keratoconus (1–8%)

• Progressive thinning and steepening of the cornea

• Can cause:

  • Irregular astigmatism

  • Progressive visual decline

What is Autism Spectrum Disorder (ASD)?

ASD is a group of neurodevelopmental disorders characterized by:

• Difficulties with social interaction

• Impaired verbal and nonverbal communication

• Repetitive/restricted behaviors

What conditions were historically included under the autism spectrum?

• Autistic disorder

• PDD-NOS (Pervasive Developmental Disorder–Not Otherwise Specified)

• Asperger syndrome

What are the key epidemiologic features of ASD?

• Approximately 1 in 68 children affected (per slide)

• Prevalence has increased substantially over recent decades

• 4–5 times more common in boys than girls

• Signs and symptoms typically emerge between 2–3 years of age

What causes Autism Spectrum Disorder?

• No single identifiable cause

• Likely results from a combination of:

  • Genetic susceptibility

  • Environmental influences affecting early brain development

What risk factors have been associated with ASD?

Potential risk factors include:

• Advanced maternal or paternal age

• Maternal illness during pregnancy

• Oxygen deprivation during birth

What prenatal factor may help reduce ASD risk according to this slide?

Maternal use of prenatal vitamins containing folic acid before conception and during pregnancy may reduce risk.

What developmental milestones are considered early red flags for Autism Spectrum Disorder?

• No big smiles or joyful expressions by 6 months

• No back-and-forth social interaction (smiles, sounds, facial expressions) by 9 months

• No babbling by 12 months

• No pointing, showing, reaching, or waving by 12 months

• No words by 16 months

• No meaningful two-word phrases by 24 months

What developmental regression should raise immediate concern for ASD?

Any loss of:

• Speech

• Babbling

• Social skills

at any age is a major red flag.

What screening tool is commonly used for early autism screening in toddlers?

M-CHAT (Modified Checklist for Autism in Toddlers)

• Screening tool for ASD

• Consists of 20 parent-completed questions

• Provides a risk assessment for autism

How is a diagnosis of Autism Spectrum Disorder typically made?

By a multidisciplinary team, often including:

• Psychologist

• Pediatrician

• Speech-language pathologist

• Occupational therapist

How do sensory processing abnormalities commonly present in Autism Spectrum Disorder?

Individuals with ASD may have:

• Hypersensitivity (too much sensory input)

• Hyposensitivity (too little sensory input)

Sensory information may be processed differently across multiple sensory systems.

What are common examples of sensory sensitivities in ASD?

• Sight: bright lights, bright colors, sunlight

• Touch: clothing textures, tags/labels

• Taste: strong flavors (e.g., onions, olives)

• Sound: noisy environments

• Temperature: unusual responses to hot/cold (e.g., wearing shorts in winter)

• Pain: may ignore injuries or overreact to minor stimuli

What are the key components of early intervention for Autism Spectrum Disorder?

• Multidisciplinary treatment team

• Approximately 25 hours/week of structured therapeutic activities

• Early, intensive intervention

What developmental areas are targeted during ASD treatment?

Focus on:

• Social skills

• Language and communication

• Imitation skills

• Play skills

• Daily living skills

• Motor skills

What family and peer factors improve outcomes in ASD intervention programs?

• Interaction with typically developing peers

• Active parent involvement in treatment planning and intervention

What ocular abnormalities are more common in children with Autism Spectrum Disorder?

• Significant refractive error: ~27–29%

• Amblyopia: ~10–11% (vs ~3% in general population)

• Strabismus: ~21–41% (vs ~3% in general population)

How common are ocular abnormalities in children with ASD?

Studies cited on the slide found that approximately 40-52% of children with ASD have at least one ocular abnormality.

What are key examination strategies when evaluating a patient with ASD?

• Ask about sensory sensitivities beforehand

• Avoid overstimulating environments

• Use supports and modifications to improve cooperation

How should instructions be given to children with ASD during an eye exam?

Offer choices between acceptable behaviors, rather than a yes/no option.

Example:
✅ “Would you like to put on the glasses, or would you like me to help you put them on?”
❌ “Do you want to wear the glasses?”

Pearl: Avoid giving the option of simply saying "no."

What is "shaping" and how is it used during examination of patients with ASD?

Shaping = reinforcing successive approximations toward a desired behavior.

Example:
BIO light:

1. Shine on leg

2. Then shoulder

3. Then face

4. Finally into eyes

The patient is gradually reinforced for tolerating each step.

What is the High-Probability/Low-Probability Request strategy?

A behavioral technique in which:

1. The patient first completes an easy task they are likely to do (high-probability request)

2. Followed by a more difficult task (low-probability request)

Purpose: build momentum and compliance.

What is the most effective general approach when examining a child with ASD?

Reduce sensory overload, use predictable routines, provide controlled choices, and gradually reinforce desired behaviors using shaping and high-probability request techniques.

What are the hallmark features of Asperger syndrome (historically considered the high-functioning end of ASD)?

• Difficulty with social interactions

• Restricted interests

• Repetitive behaviors

• Often normal to above-average intelligence

Common findings:

• Robotic or unusual speech

• Poor eye contact

• Awkward movements/mannerisms

• Difficulty understanding social/emotional cues

• Obsession with specific topics

How do language and cognitive development in Asperger syndrome differ from classic autism?

• Typically no significant delay in language development

• Typically no significant cognitive delay

• Many individuals have average to above-average vocabulary and intelligence

• Most do not have intellectual disability

What developmental area may still be delayed in Asperger syndrome despite normal intelligence?

Motor development may be delayed, resulting in clumsiness or awkward movements.

What is cerebral palsy, and what is the underlying mechanism?

Cerebral palsy is a nonprogressive neurologic disorder caused by brain injury occurring during infancy or early childhood that permanently affects:

• Movement

• Posture

• Muscle coordination

What are common causes of the brain injury that leads to cerebral palsy?

• Fetal or neonatal ischemic stroke

• Birth trauma

• Hypoxia/oxygen deprivation

• Bacterial meningitis

• Viral encephalitis

• Traumatic brain injury (MVA or falls)

• Child abuse

What epidemiologic and cognitive findings are associated with cerebral palsy?

• Occurs in approximately 1.5- 4 per 1,000 live births

• Intellectual impairment is present in about 40% of individuals

How do Asperger syndrome and cerebral palsy differ?

Asperger Syndrome

• Autism spectrum condition

• Social communication deficits

• Restricted interests/repetitive behaviors

• Usually normal language and intelligence

• May have motor clumsiness

Cerebral Palsy

• Nonprogressive brain injury disorder

• Primarily affects motor control and coordination

• Caused by early brain damage

• May be associated with intellectual impairment

What is the key distinguishing feature of cerebral palsy?

A nonprogressive motor disorder caused by early brain injury that permanently affects movement and muscle coordination.