Conditions Exam 1 Study Guide

Week 1: Cerebral Palsy

• Developmental disability

• A groups of clinical syndromes resulting from an injury (or lesion) to an immature brain

• Brain conditions causing paralysis

• Strongest risk factor is premature birth and low birth weight

• 3.1-3.6 per 1000 live births

Characteristics:

• Non-progressive, Sensorimotor, Lifelong

• Can occur in the prenatal, perinatal or postnatal periods

Signs and Symptoms:

• Tone abnormalities

• Reflex abnormalities

• Atypical posture

• Delayed motor development

• Atypical motor performance

• • Spastic/paralysis

  • • Hemiplegia: one side

  • • Diplegia: one half of body

  • • Quadriplegia: all 4 extremities

  • • Monoplegia: 1 extremity

• • Athetoid: writhing movements

• • Decreased head and neck control

• • Dysarthria and drooling

• • Ataxia

  • • Wide-based, unsteady gait

  • • May have intention tremors

Types of brain injury that may occur

Periventricular leukomalacia (PVL): Damage to white matter adjacent to ventricles; results in necrosis or cysts, most often associated with births that occur before 32 weeks

Hypoxic ischemic encephalopathy (HIE): Brain not properly formed or not grown properly - can be caused by maternal infection or trauma

Intraventricular hemorrhage (IVH): Bleeding into ventricles most often occurs in preterm infants younger than 30 weeks gestation- blood vessels not fully developed and prone to bleeding - severe bleeding and clotting can cause blockage of ventricles, leading to hydrocephalus

• Grade 1-2 (mild bleeding)

• Grade 3-4 (severe bleeding)

Associated Disorders

• Cognitive impairment - Seizure disorder

• Visual and hearing impairments - Oral motor issues

• Gastrointestinal issues - Pulmonary complications

Medical Surgical Management

• Positioning

• Tone reducing medication

• Orthotics and splinting

• Tendon lengthening and tendon transfers

• Rhizotomy

• Deep brain stimulation

Occupational Therapy Interventions

• ROM/ stretching/ tone management

• Constraint Induced

• Adaptive devices/ compensation

• Academic performance focus, technology

• Caregiver education

Terms

Upper/lower motor neuron lesion:

Brain to spine UMN

Spine to muscles LMN

Hypertonicity: abnormal/excessive muscle tone

Hypotonicity: low muscle tone

Clonus: spasm/abnormal reflex response

Hyperreflexia: excess reflexes

Areflexia: absence of reflexes

Athetoid- dyskinetic, involuntary and uncontrolled movement- basal ganglia involvement, abrupt, jerky, distal movements

Ataxia:  unsteadiness and difficulty with balance (walking) - lesion of cerebellum or cerebellar pathways

Week 2: Autism Spectrum Disorder

Define ASD (DSM-5): impairment in social interaction and social communication

• Presence of restricted and repetitive behaviors

• Unusual responses to sensory information

• High sensitivity to changes in environment

• Dependent on routines

ASD Level 1: Those on this level will require some support to help with issues like inhibited social interaction and lack of organization and planning skills.

ASD Level 2: In this level, individuals require substantial support and have problems that are more readily obvious to others. These issues may be trouble with verbal communication, having very restricted interests, and exhibiting frequent, repetitive behaviors.

ASD Level 3: On the most severe end of the spectrum is Level 3 which requires very substantial support. Signs associated with both Level 1 and Level 2 are still present but are far more severe and accompanied by other complications as well. Individuals at this level will have limited ability to communicate and interact socially with others.

Restricted and repetitive behaviors (RRB): abnormal or intense preoccupation with routines or patterns

Sensory processing disorder: hypo or hyper reactivity to sensory information, or unusual preoccupation with the sensory aspects of the environment.

Theory of mind: Difficulty with theory of mind or perceiving another’s thoughts

Echolalia: echoing back of another’s behavior/scripting

Stimming: seeking repetitive stimulation to calm/organize

Diagnostic Process

• Referral for screening through provider

• Individual assessment through experienced clinician, covering:

• History (family, developmental milestones, other issues)

• Physical, neurological examination

• Parent interview

• Testing language, cognitive, development, sensory

• Observation: formal, informal

• Audiological testing

Signs and symptoms

• Difficulty with social communication and interaction

• Restricted and repetitive behaviors (RRBs): abnormal or intense preoccupation with routines or patterns

• Motor abnormalities

• Sensory processing disorder (auditory, oral, tactile, vestibular): hypo or hyper reactivity to sensory information, or unusual preoccupation with the sensory aspects of the environment.

• Feeding disorders

• Co-occurring medical disorders (seizures, GI problems)

• Strong need for routines

• Difficulty with theory of mind or perceiving another’s thoughts

• Auditory Processing

• Echolalia: echoing back of another’s behavior/scripting

• Stimming: seeking repetitive stimulation to calm/organize

• Motor issues related to use of sensation to plan, guide, and execute movement

• Sleep disturbances

Etiology

• No clear etiologic factor

• Likely originates in utero with abnormalities in brain development

• Increased evidence for genetic etiology

• Growing research suggests complex combination of biology, genetics and environmental factors

Etiology & Brain Development

• Abnormalities in brain volume

• Differences in eye contact (around 2 mos.)

• Increased evidence for genetic etiology

• Loss of brain connectivity (brain white matter, especially corpus callosum)

Etiology & the environment

• Age of parents

• Exposure to toxins prenatally, during pregnancy

• Nutrition

• Fevers during pregnancy (3rd trimester)

• Prenatal vitamins/folic acid can reduce risk

Incidence and Prevalence

• 1% of world’s population

• 3.5 million Americans

• Increase in diagnosis to 1 in 68 (2014)

• Boys 5 x more likely

Prognosis

• Many children improve

• Some individuals have residual issues throughout lifetime

• IQ, language strong predictors of lifespan functional issues

Medical management

• Early identification is key: 0-3 years most effective

• Interventions primarily behavior based with focus on language, sensory, motor, cognitive skills

• Limited pharmacological interventions for hyperactivity, irritability, anxiety, perseveration

• ◦ Pharmacology- stimulant medications (Ritalin, Adderall, Concerta, Dexedrine)

• ◦ Behavioral: counseling, specific skill training, coping skills, sensory motor

• ◦ Education: parent, teacher, child

Occupational Therapy Intervention

• Highly individualised - Sensory integration

• ADL/IADL retraining - Behavioral intervention

• Family education

Week 3: ADHD and Sensory Processing Disorder

Description and definition: ADHD = Attention-deficit/hyperactivity disorder

• A chronic condition characterized by attention limitation, over activity and impulsive behaviors

ADHD Diagnostic Criteria

• inattention, hyperactivity, impulsivity

• symptoms must be present before age 12   (5-6 symptoms)

• symptoms must impact function in more than one setting

Etiology: Not a single known cause

• mix of genetics and environmental factors

• ADHD is likely to be passed on by family members

• low birth weight, stress or toxins during pregnancy

• Nutritional deficiencies, Allergies, Immunizations

• Brain structure or neurotransmitter disruptions

Incidence and Prevalence: 

• In the U.S. children ages 3-17, 7 million or 11.4% have been diagnosed with ADHD

• Boys are more likely than girls to have ADHD

• 6 in 10 children with adhd reported that it is moderate or severe

Signs and Symptoms:

• inattention, lack of concentration, hyperactivity, forgetfulness, and impulsivity

• trouble controlling emotions, interrupting others, risk behavior

• sleep problems, low self esteem, decreased school performance

Complications: Adhd can cause disruptions and struggles in a person’s everyday life because it makes it more difficult for them to get things done and stay focused on one thing at a time. This can be a problem with school, work or other important things that require attention. Their impulsivity can lead to a higher risk of injuries or social and family issues. 

Medical Management: 

Medication: 

• Simulants (methylphenidate (Ritalin), dextroamphetamine (Dexedrine)) can increase dopamine and norepinephrine levels which can improve concentration. 

• Atomoxetine (Strattera): not a stimulant but improves adhd symptoms

• Antidepressants: some can help improve adhd symptoms

Counseling: can help them deal with the symptoms and stress

Education: learn about how to manage and improve the symptoms by changing habits and mindset

CBT: cognitive behavioral therapy

Impact on Occupational Performance:

• makes it difficult to stay focused and get tasks done quickly

• can be easily distracted

• boredom or lose engagement in activities

• memory

• organization skills

• impulse control

Notes from Class

ADHD Inattentive: List Four Symptoms

• In school challenged by close details, sustaining attention,

•  Struggles with listening

•  Difficulties with following through, gets sidetracked easily

•  Poor organizational skills, managing sequential tasks

•  Loses necessary items frequently

•  Easily distracted, forgetful

ADHD Predominantly Hyperactive-Impulsive Defined: restless, movement, talking

ADHD Hyperactive-Impulsive: List Three Symptoms:

• Fidgets with hands, taps feet, squirms in chair

•  Struggles with staying seated

•  Restless, constantly moving

•  Talks excessively

•  Blurts out answers before question asked

•  Difficulty waiting, taking turn

ADHD Combined Defined: Both inattentive and hyperactive symptoms

ADHD Unspecified Defined: have some symptoms but does not meet diagnostic criteria

ADHD Co-morbidities Examples:

• As many as 80% at risk of having: learning, coordination, depression, anxiety, oppositional behavior disorders

•  Motor disorders in 40-60% of individuals with ADHD

•  Close association with sensory processing disorders: low sensory registration pattern, over sensitivity across various sensory domains

• Strong association with substance abuse, PTSD, OCD, Bipolar in older adolescents and adults

ADHD Occupational Therapy Treatment:

• Sensory integration - ADL/IADL retraining

• gross/fine motor/ proprioceptive - behavioral interventions

• family education

Description and definition: Sensory Processing Disorder (SPD)

• A neurological disorder that affects the brain’s ability to organize sensory stimuli from the environment. 

• includes senses like touch, sight, sound, taste, smell, or movement

• Can be overly sensitive or under sensitive

Etiology: not a single known cause

• combination of genetics and environment

• can be inherited

• premature birth, low birth weight, drugs or alcohol

• birth complications

• postnatal restrictions/ lack of sensory exposure

Incidence and Prevalence: 

• affects 5%-16% of school aged children

• more common in children with autism or adhd

Signs and Symptoms:

• overly or under sensitive to sensory stimuli

• constant movement

• stimming (hand flapping)

• abnormally high or low pain tolerance

• not understanding personal space

• difficulty with social interactions

Complications:

• Behavioral issues (constant movement, stimming, outbursts)

• poor school performance

• decreased social participation

• difficulty communicating

• can also be linked to other conditions like autism and adhd

Medical Management:

• Therapy: OT, PT, speech-language therapy

• assistive devices: weighted blanket, compression garments

• sensory friendly activities, sensory integration

• no medication is used to treat SPD

Impact on Occupational Performance:

• SPD can make it more difficult and less enjoyable to participate in certain activities because they can become easily over stimulated

• can make things like going to the grocery store or sitting in class a difficult task

• impacts motor development and completion of ADLs and self care

SPD Occupational Therapy Interventions:

• sensory integration

• adaptations/strategies

• motor tasks

• family education

Sensory Processing Disorder (SPD) terms and concepts to know

SPD Signs and Symptoms Pattern 1

Involves 3 subtypes:

Subtype 1: Over-responsivity:  

• More intense, or longer than typical, exaggerated flight or fight response

• Characteristic of autism, fragile X syndrome, ADHD, mood disorders

Subtype 2: Under-responsivity: 

• Slow or limited response to incoming stimuli

• Often mistaken for lazy, uninvolved, Less exploration of the environment, May lack sustained attention

Subtype 3: Sensory Craving: Seek input in an erratic, disorganized manner

• May appear impulsive, unsafe, May be considered fearless, thrill seeker

•  May have behavioral issues due to sensory seeking

• Disorganized activity

SPD Signs and Symptoms Pattern 2

Made of up two subtypes: postural disorders, dyspraxia

Subtype 1: Postural Disorders

• Due to inefficient processing vestibular/kinesthetic inputs

• May have issues around muscle tone, posture

• Smooth movement, endurance may be compromised

• Oculomotor control may be compromised

• Balance, weight shifting, trunk mobility challenging

Subtype 2: Dyspraxia

• Difficulty with motor planning

• Clumsy, awkward, maladaptive response

• Unsure where their body is in space

• Balance, weight shifting, trunk mobility challenging

SPD Signs and Symptoms Pattern 3 Defined

• Sensory Discrimination

• Visual discrimination involves pattern recognition (shapes), visual-spatial analysis (simple puzzles)

• Auditory discrimination involves differentiating sounds

• Tactile discrimination, ex: ID coin in pocket

• Somatosensory issues with body scheme, motor planning

Week 4: Substance Abuse and Intellectual Disability

Intellectual Disabilities

Intellectual Disability (ID) defined: 

• Limitations in intellectual functioning and adaptive behavior. Diagnosed before age 18, standardized assessments. 

How ID is defined for intellectual functioning: 

• Ability to reason, plan, problem solve and think abstractly. Need to be 2 standard deviations below the mean for IQ. 

How ID is defined for adaptive behavior:

•  Delay in adaptive behavior, learned conceptual skills, social skills needed for everyday functioning.

6 symptoms of ID: 

• Gross, fine motor, language, memory, poor awareness of social rules, issues with problem solving. 

ID mild defined:  

• Difficulty with academic skills, abstract thinking, executive functioning, short term memory, emotional regulation, can perform basic ADLS and possibly work.

ID moderate defined: 

• significant difficulty with academic skills, abstract thinking, executive functioning, short term memory, emotional regulation. Need assistance with some ADLS and vocational skills. 

ID severe defined: 

• Only understand simple speech, gestures, limited conceptual skills, language= simple phrases only, need assist for all ADLS.

ID profound defined:

•  Loss of function, minimal understanding, enjoy established relationships, basic recreational activities, dependent for all ADLs, co-occurring motor/sensory issues is common. 

Comorbidities of ID: ADHD, depression, bipolar, anxiety, ASD, CP, Epilepsy, Mental illness

Medical management of ID: 

• No surgical or drug treatment used directly for ID treatment. 

• Medications used to treat co-occurring conditions, such as seizures. 

3 common issues with individuals with Down’s syndrome and ID: 

• Issues around muscle tone (low tone)

• Comorbidities such as cardiac issues 

• Hearing loss (as much as 75%)

Common OT interventions for ID: 

• Fine and gross motor skills, handwriting, sensory processing, core/muscle tone management, academic adaptation/strategies.

Substance use:

Substance disorders 4 Criteria for diagnosing:

1. Impaired control

2. social impairment

3. risky use

4. pharmacological criteria 

• Irreversible damage 

• alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedatives, hypnotics, anxiolytics, stimulants, tobacco, gambling.

Substance-induced disorders: Include cluster of substance related symptoms: intoxication, med-induced mental disorders, sleep problems, sexual dysfunction, delirium, dementia.

• usually reversible

• Usually consists of changes in perception, wakefulness, attention, thinking, judgement, psychomotor behavior and interpersonal behavior.

Cause = genetics, biological, childhood trauma, age cohorts

Protective factors: supportive family, child’s temperament, positive family rituals

• Impacts neurological pathways involved in the dopamine reward pathway and the prefrontal cortex

Brain Centers and Addiction: 

Intoxication stage = basal ganglia

Withdrawal stage = amygdala

Anticipation stage = prefrontal cortex

• variety of genes make an individual vulnerable to this disease

• Onset as an adult primary related to ACE score and trauma

• Greater risk if you grew up in household with substance use disorder

Incidence and prevalence:

• 51% adults 12 and older drink alcohol

• 24% reported binge drinkers

• 6.1% defined as heavy drinkers

• 5.4% adults 12 and older have substance use disorder

• most common illicit drug is marijana and prescription pain relievers

• alcohol dependency is 2 times more in males than females

Drinking Risk 

High risk Males = 5 or more drinks per day, 15 or more drinks per week

High risk Females = 4 or more drinks per day, 8 or more drinks per week

Signs and symptoms:

• Poor academic performance - money problems

• violent outbursts - trouble with the law

• excessive or lack sleeping - withdraw from friends and family

• drastic weight changes

Medical management

• medications with counseling

• self-help groups

• detox

• Opioids: methadone, Sub Oxone

• CBT, Dialectical behavior therapy

OT interventions

• Assessment (cognitive, perception, community skills)

• Stress management strategies

• Coping skills

Week 5: Mood and anxiety Disorders

Condition: Mood Disorders

Description and definition: 

• Extreme levels of emotions

• Can either be depression or mania

• Major Depressive Disorder (MDD): severely impacts function for at least two weeks

• Bipolar Disorder (BD): 2 types, extreme mood swings that impact functioning

Etiology:

• Not a known definite cause

• Combination of biological, genetic and psychosocial factors

• Can be triggered by substance use, childbirth, seasonal changes and medical conditions.

Incidence and Prevalence:

• 16% of the population is diagnosed yearly with MDD

• 5% yearly with BD

• Women more likely to have MDD than men

• African Americans more likely than white americans to have MDD

• Low socioeconomic status associated

Signs and Symptoms:

MDD: depressed mood, feeling hopeless, sad, change in weight, altered sleep, fatigue, impaired cognition, suicide thoughts.

Bipolar: persistent elevated mood, minimal need for sleep, excessive talking, racing thoughts, distractibility, impulsivity. 

Complications:

• Medications can have significant side effects

• substance abuse

• suicidal thoughts

Medical Management:

• SSRIs and SNRIs commonly prescribed for MDD

• Lithium used as mood stabilizer for BD

• ECT: common used when medications don’t work

• Repetitive transcranial magnetic stimulation: magnetic field that facilitates brain electrical currents to help reduce symptoms

Impact on Occupational Performance:

• Personal hygiene, sexual activity, Nutrition, sleep, health management, school performance, social participation

• Affect: display of emotion, especially facial

• Anhedonia: lack of interest

• Avolition: lack of drive

• Dysphoria: depressed state

• Flight of ideas: rapidly changing, disconnected thoughts

• Grandiosity: inflated importance

• Hypomania: elevated mood, less than full mania

• Psychomotor: increased movement

Psycho Retardation: decreased movement

• Psychosis: delusions/hallucinations without insight

Condition: Anxiety Disorders

Description and definition: 

• Fear and anxiety

• anticipating danger or threats

• Anxiety disorders, obsessive compulsive disorders, trauma and stress related disorders

• Panic disorders, phobias, social anxiety disorder, agoraphobia

Etiology:

• Combination of biology, genetic, psychosocial factors, cognitive/emotional influences and stress.

Incidence and Prevalence:

• 40 million people in the US have an anxiety disorder in a year time frame

• 2x more likely in women than men

• Panic disorder: 5 million yearly

• Phobia: most common mental disorder, 19 million yearly

• Social Anxiety: 15 million

• Generalized anxiety: 6.8 million

Signs and Symptoms:

• Generalized: restless, on edge, easily fatigued, difficulty concentrating, irritable, muscle tension, difficulty sleeping.

• Panic: sudden attacks of fear, fear of losing control, panic attacks (heart racing, shortness of breath, chest tightness, light headed, nausea)

• Phobia: sweating, increased heart rate, trembling

• Social anxiety: Sweating, increased heart rate, trembling that impacts performance, cognition, increasing cycle of anxiety

• Separation Anxiety Disorder: excessive and recurrent distress around anticipation or actual separation from someone, fear that something bad will happen to an individual, fear of being alone, refuse to be away from home

Complications:

• Mental health conditions

• physical health conditions

• social problems

• suicide, substance use, depression

Medical Management:

• Medications = antilyotics and antidepressants (zoloft, Paxil Prozac Lyrica, Xanax, Klonopin)

• Behavioral

• Psychosocial

Impact on Occupational Performance:

• ADL, IADL - Health management

• rest and sleep - education

• Work - play and leisure

• social participation

Week 6: Schizophrenia 

Key symptoms: abnormal interpretation of reality (delusions, hallucinations), and or disorganized thinking

Positive Symptoms: Easily observed, such as: delusions, hallucinations, disorganized speech,

disorganized behavior

Negative Symptoms: Experienced internally, maybe less visible, such as: flat affect, lack of volition

Diagnosis: Made through clinical assessment of behaviors, psychiatric history, mental status exam, system clusters

Two positive or negative symptoms (or clusters of symptoms), one of which must be delusions,

hallucinations, or disorganized speech, for at least one month, impacting ability to work or relationships (APA, DSM-5)

Cultural differences: Disease defined differently in different cultures (medical versus spiritual). US has high rate for a western country

Avolition: Lack of motivation

Alogia: Diminished speech

Anhedonia: Inability to experience pleasure

Asociality: Lack of interest in social interactions

Schizophreniform Disorder: Differs in duration, no more than 6 months

Schizoaffective Disorder: Major mood disorders along with schizophrenic symptoms, may not impact function

Catatonia abnormal movement

Medical Management:

• Antipsychotic medication targeting dopamine

• Skills Training

• Family psychoeducation

• ECT: Electrical stimulation to the brain to relieve symptoms

• Cognitive Behavioral Therapy (CBT) Helps people change their thinking and behavior to manage mental health issues

Tardive dyskinesia: involuntary movements, side effect from medications

Impact on occupational performance key areas:

• ADL, IADL: Personal hygiene

• Health Management: taking medications

• Rest and Sleep: struggle with sleep

• Social isolation

Occupational therapy interventions: 

• Skilled assessment (ability to manage medications, live in community independently)

• Coping strategies

• Behavioral strategies

• Community re-integration

• Healthy occupations

• Medication Compliance