Neurodevelopmental Disorders

Neurodevelopmental disorders (NDD)

Neurodevelopmental disorders are disabilities associated primarily with the functioning of the neurological system and brain

- onset of NDD occur often in childhood and adolescent years

Developmental deficits

- A group of conditions due to an impairment in physical, learning, language, or behavior areas

- These conditions begin during the developmental period, may impact day-to-day functioning, and usually last throughout a person's lifetime.

Erikson's theory of development

If the conflict during each respective stage is not resolved, the person may struggle with the future sense of self and development

Difficulty in determining NDD

- Children, specifically from birth to age 5, often lack the abstract cognitive abilities and vocabulary to effectively describe what they are experiencing

- Children frequently cannot distinguish which manifestations are unwanted or abnormal

- Behaviors that are common in one developmental stage in a person without an intellectual disability may be cause for great concern in another

NDD barriers to early identification

- Lack of consistency and consensus in screening

- Lack of interprofessional collaboration and coordination

- Lack of community-based resources

- Long waiting lists or lack of available services

- Inconsistent or lack of communication with professionals

- Costs and low reimbursements

- Feelings of stigma

- Lack of native-language speaker or cultural differences

5 types of NDD

- ADHD

- Language communication disorders

- ASD

- ID

- Motor and tic disorders

Comorbidities with NDD

- Seizures

- Depression

- Anxiety

- OCD

- Drug abuse

- Sleep disorders

- PTSD

- Psychoses

- Obesity

- Aggression

ADHD manifestations

Inattention → A person wanders off task, lacks persistence, has difficulty sustaining focus, and is disorganized

Hyperactivity → A person seems to move about constantly, including in situations in which it is not appropriate, or excessively fidgets, taps, or talks.

Impulsivity → Acting immediately in response to stimuli on a momentary basis without a plan or consideration of outcomes, difficulty establishing and following plans, a sense of urgency, and self-harming behavior under emotional distress

Inattention

- Unable to concentrate, easily distracted, short attention span

- Unable to follow instructions

- Difficulty with organization

Hyperactivity

- Unable to sit still

- Fidgeting

- Excessive physical movement, talking, or interrupting

Impulsivity

- Acting without thinking

- Lack of regard for consequences

- No sense of danger, frequently getting injured

ADHD etiology

Studies have suggested that it is hereditary, and strong evidence supports that low birth weight and prenatal exposure to alcohol and tobacco are identified risk factors

ADHD prevalence

- The prevalence of either ADHD or learning disabilities was reported to be approximately 14% of children

- Hispanic children were less likely than non-Hispanic Black and white children to have these disorders

- Younger non-Hispanic Black children had these diagnoses more frequently than younger Hispanic and non-Hispanic White children, and the percentage of children with these diagnoses decreased in all racial and ethnic groups, as income increased

ADHD comorbidities

- Learning disabilities (most common)

- Epilepsy

- Children (oppositional defiant disorder (ODD), conduct disorder (CD) are the most common)

- Adolescence and adulthood (substance use disorders, sleep disorders, anxiety disorders, somatic conditions)

ADHD diagnosis

- Family and academic professionals may be the first to identify these behaviors and seek help from clinical professionals

- Academic institutions can assist by completing a developmental assessment and documenting objective information

- Adolescents and adults may present with anxiety, depression, and personality changes

ADHD DSM-5 Criteria

A persistent pattern (for at least six months) of inattention and/or hyperactivity-impulsivity that interferes with functioning, development, social activities, or other academic or occupational activities.

Examples include:

- Inattention to details

- Difficulty maintaining attention span

- Appears not to listen when spoken to directly

- Shows a lack of follow-through with instructions, organization, or other tasks

- Easily loses necessary items

- Easily distracted

- Forgetful in daily activities

- Dislikes tasks that require concentration

Manifestations are present in two or more settings and are apparent before the age of 12, and interfere with, or reduce the quality of, social, academic, or occupational functioning. The manifestations are not better explained by other mental disorder, including psychotic disorders, such as schizophrenia.

Learning Disorders general

- Difficulties learning and using academic skills, with at least one of the following difficulties having persisted for at least 6 months despite interventions

- Academic skills are below those expected for age or grade level and interfere with academic or occupational performance or with activities of daily living

What are learning disorders identified?

- Begin during school-age years but may not become fully apparent until later years or with standardized testing

- No evidence of intellectual disabilities, uncorrected visual/auditory acuity, other mental/neurological disorders, psychological adversity, lack of proficiency in the language of academic instruction, or inadequate educational instruction

Behavioral Signs of a Learning Disability

- Not wanting to go to school

- Complaining about the teacher

- Reluctance to engage in reading/writing activities

- Saying the work is too hard

- Not wanting to schoolwork

- Avoiding assignments/homework

- Saying negative things about his or her academic performance, such as "I'm dumb"

- Disobeying teacher's directions

- Frequent misreading/misinterpretation of information

- Cutting class and skipping school (in adolescents and teens)

- Bullying

Dyslexia difficulties at preschool age

- Recognizing letters and sounds

- Word pronunciation

- Learning new vocabulary

- Learning the alphabet

- Learning days of the week

- Rhyming

Dyslexia difficulties at school age

- Spelling rules and letter placement

- Remembering facts or numbers

- Handwriting

- Learning new skills

- Reading

- Following sequences

Dyslexia difficulties adolescent and adult

- Reading at grade level

- Understanding jokes, idioms, or expressions

- Organizing and time management

- Learning a foreign language

- Memorization

- Summarizing a story

Cognitive Disabilities

Confirmation by both clinical assessment and individualized, standardized intelligence testing of deficiencies in intellectual functions

- Reasoning

- Problem solving

- Planning

- Abstract thinking

- Judgement

- Academic learning

- Learning from experiences

Deficiencies of adaptive functioning that do not meet developmental and sociocultural standards of daily function and social responsibility

Cognitive signs of a learning disability

- Often spelling the same word differently in a single assignment

- Trouble with open-ended questions on tests

- Poor reading and language comprehension

- Weak memory skills

- Difficulty in adapting skills from one setting to another

- Slow work pace

- Difficulty grasping abstract concepts

- Inattention to details

- Excessive focus on details

- Frequent misreading/misinterpretation of information

- Trouble filling out applications or forms

- Easily confused by instructions

- Poor organizational skills

- Mental health problems like depression or anxiety

Levels of Intellectual Disability

Mild: 85% of identified cases. Individuals can learn to read, write, and perform math skills at a 3rd to 6th grade level

Moderate: Individuals are usually able to learn to read and write at a basic level, as well as perform basic life skills. Often requires assistance working or living independently.

Severe: It is likely individuals are not able to read or write, but are able to perform some basic living skills.

Profound: Individuals are usually able to communicate verbally or non-verbally to some degree.

Intellectual Disabilities

- Disorder with onset during the developmental period that includes both intellectual and adaptive functioning deficits in conceptual, social, and practical domains (intellectual, social, and daily)

- May be mild, moderate, severe, or profound

Intellectual Disabilities DSM 5

- Deficits in intellectual functions such as reasoning, problem solving, planning, abstract thinking, judgement, academic learning, and learning from experience confirmed by both clinical assessment and individualized, standardized intelligence testing.

- 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.

- Onset of intellectual and adaptive deficits during the developmental period

Intellectual Disabilities Etiology

- Genetic disorders (fragile X, down's syndrome, genetic mutations)

- Environmental factors (pre/postnatal infections, exposure to toxins, nutritional deficiencies)

Intellectual Disabilities Comorbidities

- Epilepsy

- Gastroesophageal reflex disease (GERD)

- Constipation

- Sensory impairments

- Injuries/falls

- Aspiration and choking

- May lead to comorbidities (may worsen with age)

Autism Spectrum Disorder (ASD)

- Marked by significant social, communication, and behavioral deficits

- Autism spectrum disorders (ASDs) are a group of developmental disabilities ranging from very mild to very severe

- Hallmark signs include rocking, flapping hands, spinning

ASD Level 1

Needs some support

- Sometimes appears just awkward or anti-social

- Change is difficult, thrives with a good routine

- Fidgets and can be seen as "quirky" or "annoying" to others

- Sometimes perceived as "lazy" or "insecure"

ASD Level 2

Needs more support

- Most people can tell there is a disability

- Doesn't engage socially

- Doesn't handle change well

- Has repetitive behaviors that are noticeable

- Is developmentally delayed

ASD Level 3

Needs the most support

- Everyone can tell there is a disability

- Doesn't communicate, except when necessary

- Any change to routine is nearly impossible

- Repetitive behavior helps client stay calm

- Major developmental delays or missed milestones are present

ASD Etiology

Genetics

- linked to specific inherited genes

- De novo mutations (not inherited)

Environment

- advanced parental age

- claims related to immunizations not supported by evidence

ASD Comorbidities

- ADHD

- Epilepsy

- Psychiatric/behavioral complaints

- Gastrointestinal disorders

- Depression

ASD DSM-5 Criteria

Deficiencies in social communication and social interaction across multiple contexts, which may be characterized by:

- Social-emotional reciprocity, ranging 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

- Nonverbal communicative behaviors used for social interaction, ranging 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

- Developing, maintaining, and understanding relationships, ranging 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

Engaging in restricted, repetitive patterns of behavior, interests, or activities

Inabilities are not better explained by intellectual disability

Receptive Communication Disorders

- The individual has a hard time comprehending what others say and has a difficult time applying information and following instructions

- Have challenges understanding and processing verbal and nonverbal information from others

Social Communication Disorders

The individual has a hard time relating to others resulting in isolation and feeling misunderstood

- Individuals who have a social language disorder have difficulty using appropriate verbal and nonverbal gestures, making it challenging to connect and relate to other people

Expressive Communication Disorders

The individual has a hard time communicating thoughts, concepts, and ideas, as well as relating to others

- Individuals who have an expressive language disorder have challenges with forming sentences and using appropriate words and body gestures to communicate their ideas

Types of motor movement disorders

Developmental coordinatization disorder (DCD)

- Lack of appropriate motor skills

Stereotypic movement disorder

- Repetitive nonpurposeful movement

Tic disorder

- Movement disorder characterized by fast, unanticipated, nonrhythmic movement or vocalizations

- Motor and vocal

Motor tic

Shaking, copying others' movements, obscene gestures, blinking

Vocal Tic

Throat clearing, echolalia (repeating words or phrases of others), pallia (repeating self constantly), copropraxia (use of curse words)

Provisional Tic Disorder

One or more motor and or vocal tics for less than 1 year and present prior to 18 years old

- The client experiences one or more motor tics.

- The motor tics are present for fewer than 12 months in a row.

- The client experiences tics prior to the age of 18.

- The symptoms are not caused by side effects of prescription medications, drugs, or medical conditions such as Huntington's disease.

- The client does not have a prior diagnosis of Tourette syndrome or a persistent (chronic) tic disorder (motor or vocal)​​​​​​​.

Persistent Motor Tic Disorder

Have a single or multiple motor and vocal tic; must be persist for one year and present before 18 years old

- Either one or more motor tics are present or one or more vocal tics are present, not both.

- Tics occur several times each day or off and on throughout a period of greater than 12 months.

- The client experiences tics prior to the age of 18.

- The symptoms are not caused by adverse effects of prescription medications, drugs, or medical conditions.

- The client does not have a prior diagnosis of Tourette syndrome.

Tourette Syndrome

Most severe tic disorder; must have multiple motor tics and a vocal tic; must persist for one year and must be present prior to age 18

- The client experiences two or more motor tics and at least one vocal tic; these may not always occur simultaneously.

- Tics are present for greater than 12 months.

- Tics occur several times during the day, nearly every day, or off and on.

- The client experiences tics prior to the age of 18.

- The symptoms are not caused by adverse effects of prescription medications, drugs, or medical conditions.

Developmental Coordination Disorder DSM-5 Criteria

- Clumsiness, slowness, and inaccurate performance of motor skills related to coordinated motor skills is substantially below expectations.

- Deficiency of motor skills affects everyday function and basic life skills.

- Onset occurs in the child's early developmental period.

- There is no evidence of intellectual disability, visual impairment, or other neurological condition.

Stereotypic Movement Disorder DSM-5 Criteria

- Movements that are repetitive, driven, and seemingly without purpose.

- Behavior interferes with social, academic, occupational, or other functions and possibly results in self-injury.

- Onset occurs in the child's early developmental period.

- No evidence of substance use, a neurological condition, or other disorder that may cause similar symptoms.

Speech Language Pathologist

Identifies speech and language deficits; works with client to develop compensatory strategies and prevent further deterioration

Occupational Therapy

Assess client’s ability to perform activities of daily living; teaches and guides the client in performing competing behaviors (i.e., control tics)

Physical Therapy

Assess client's status; teaches and guides the client in performing competing behaviors (i.e., control tics)

NDD comprehensive assessment

- Standardized developmental screenings at well child visits

- Autism screening at 18 months and 24 months

- Observations of mental, behavioral, physical performance

- History of head injury, trauma, or severe emotional stress

NDD role of the nurse

Intellectual/learning → cognitive-based communication, focus on strengths

Communication → focus on creative alternatives to communicate so they receive the information

Autism spectrum disorder → early screening, liaisons to community resources

ADHD → advocacy

Tic disorders → maintain integrity, dignity, educate family and public

Generate solutions for NDD

- Individualized

- Developmentally appropriate

- Involve parents

- Behavioral interventions vs. medical interventions

Managing disruptive behaviors

- Verbal warning

- Time out

- Quiet room

- Medication

- Seclusion and restraint

Tourette Syndrome Care plan

- Teach child and parents behavioral techniques to reduce tics

- Family therapy to improve stress management

- Pharmacological intervention with a second-generation antipsychotic medication, such as risperidone, to treat unresolved tics

ASD Care plan

- Refer to an early intervention program at school

- Educate parents to provide structure and consistent expectations

- Use behavior management with a reward system

- Physical, occupational, and speech therapy as needed

- Pharmacological intervention with a stimulant medication, such as methylphenidate, to treat unresolved signs of hyperactivity and impulsivity