Week 11 - Neurodevelopmental Disorders (NDD’s) and Disorders in Children

Key considerations for pathology in children and adolescents

Specific nature of problems in childhood

  • Transactional Process: refers to how a child’s characteristics (biological, emotional, cognitive, and behavioural) and their environment (parents, schools, peers, culture) constantly influence and modify one another, shaping developmental outcomes in adaptive and maladaptive ways

  • Still Face Experiment demonstrates this, where it examines how infants respond to sudden disruption in caregiver emotional responsiveness. In the experiment, caregiver engages with child, then becomes unresponsiveness and “still-faced” then reengages. Infants can try and reengage when the disengagement occurs, but then resort to distress when this doesn’t work, and demonstrates how reciprocal emotional exchange is vital for infant regulation, and chronic cases like with long term parental responsiveness can cause dysregulation in infants developing self and emotional system

  • Behavioural Contextualism shown by the varying microsystems (immediate social spheres), mesosystems, exosystems and macrosystems (overarching cultural norms) can provide lens through which infant norms and development can both be understood and how it affects this development

Complicating role of typical developmental factors:

Cultural understanding of Disorders shown by

  • parenting varies across cultures and sub-cultures

  • Expectations of normal development have changed over time

  • Case of Disruptive Mood Dysregulation Disorder

Developmental roots of adult conditions

  • Adult mental disorders do not emerge De Novo, they are endpoints of developmental pathways shaped by biological, psychological, social experiences

  • Within-Child factors (relating the individual childs personality, cognition, emotions) can be demonstrated to influence development of conditions into adulthood, by examples such as how behavioural inhibition at 3 years of age predicts behavioural inhibition at 30 years of age

  • Trauma and neglect is shown to not only cause long lasting emotional and psychological effects in kids when they become adults, but actually change their neural architecture

Significance of early intervention and prevention

  • Possibility of influence on brain development, plasticity

  • Interrupting negative cycles can influence this

  • Reduction of long term costs associated with mental health treatment, easing burden on mental healthcare system

Changes in DSM-5 for Neurodevelopmental Disorders postulated from enhancement of developmental links, through reorganisation and regrouping of conditions - Lifespan approach employed that proposes how NDD’s emerge early in life but evolve and manifest differently across lifespan

ADHD can now be diagnosed later in life

New PTSD subtype for kids younger than 6

ASD (Autism Spectrum Disorder) subtypes removed and placed into ASD umbrella, can be diagnosed later and less severe forms qualify

Reactions to changes were mixed, critique was aimed heavily at potential reduction of unique developmental disorders, along with mixed reactions to ASD reclassification. Also said that Aspergers may have sufficient dissimilarities to argue against its inclusion under ASD umbrella

Brief overview of DSM disorders for children

Externalising Disorders:

  • Oppositional Defiant Disorder

  • Conduct Disorder

Internalising Disorders:

  • Anxiety

  • Mood and Somatic Disorders

Disorders of Basic Function:

  • Sleeping Disorders

  • Eating Disorders

  • Toileting Related

Neurodevelopmental Disorders:

  • Intellectual disabilities, ASD, ADHD

Disorders of Neglect:

  • Abuse

  • Trauma and Adjustment Disorder

Autism Spectrum Disorder (ASD):

Two main criteria

  • Social Communication and Interaction Deficit: Characterised by difficulty making and maintaining friendships, difficulty in developing theory of mind, lack of reciprocity in social interaction

  • Restricted and Repetitive Behaviours and Interests: Stereotyped behaviour patterns, routines, rituals, tics, OCD-like symptoms. Restricted interests and preoccupations, resistances to change

Other clinical features include

  • Unique cognitive profile

  • Language delay

  • Difficulty appreciating humour

  • 1/3 cases developing epilepsy

  • poor motor co-ordination

  • Hypo and Hyper sensitivity

Abbreviated Criteria for ASD:

A. Persistent deficits in social communication across multiple contexts, shown by:

  1. Deficits in social-emotional reciprocity, ranging form abnormal social approach to failure of engaging in normal back-forth conversation, to reduced sharing of interests, emotions or affect, to failure initiating or responding to social interactions

  2. Deficits in non-verbal communication, and misuse with abnormalities in eye contact or body language and deficits in understanding gestures

  3. Deficits in developing, managing, understanding relationships, with difficulty adjusting for social situations to difficulties in sharing imaginative play or making friends, or disinterest in doing do

B. Restricted and Repetitive behaviours

  1. Stereotyped or repetitive motor movements (stims)

  2. Insistence on sameness, inability to cope with routines/rituals that are not adhered to

  3. Highly restricted, fixated interets that can be “abnormal” in topic or intensity

  4. Hyper or Hypo Sensitivity to sensory input, all kinds

C. Symptoms be present in early development period, but may not become fully manifest until later social demans “exceed” capacities, or masked by learning strategies earlier in life

D. Causes clinically significant impairment

E. Not better explained but intellectual developmental disorders or global developmental delay in populations child is in

“Treatment” of ASD:

  • Psychoeducation

  • Family-based approach to management

  • Structured teaching

  • Behaviour support

  • Functional behavioural analysis + positive behaviour plans

  • Planning ahead for life transitions

  • Psychopharmacological treatment

Ineffective treatments include

  • Sensory integration training

  • Facilitated communication

  • Gluten and Casein free diets

  • Vitamins and Minerals

  • Rejection of vaccination

Selected Evaluated psychosocial programs for Indigenous Australins with ASD:

  • Aboriginal and Torres Strait Islander Peoples psychoeducation and support: targeted for teachers and carers

  • Alert Program Study: School based delivery teaching strategies to manage focus and emotional regulation, particular research focus on outcomes for students with FASD

Neuroaffirming Practices and Interventions (NAI’s):

paradigm that re-conceptualises ASD from a deficit-focused approach to seeing autism as a heterogenous constellation of varying strengths and weaknesses

Alternate Therapies for Adults:

Interpersonal/Relational Therapy trialled, teaching them to make up for deficits in more behaviourally oriented modalities by improving relationships to relieve own mental health symptoms.

Raises some moral questions with its goals, changing neurodivergent behaviour to appease others?

Attentional Deficit/Hyperactivity Disorder (ADHD):

Recently a increase in number of diagnoses

DSM-5 lowered threshold, and studies have concluded this criteria change may have a role in the increase. Extra vigilance is recommended to prevent misdiagnoses

System Factors in adult ADHD diagnoses relate to how increase in availability of such a diagnosis as well as supporting treatments may have made people less reluctant to get one

Two main criteria for diagnosing ADHD

A. Inattention

  • Difficulties sustaining attention across contexts

  • Overlooking details

  • Does not seem to listen when spoken to directly

  • Difficulties following instructions

  • Planning and organisational difficulties

B. Hyperactivity/Impulsivity

  • Fidgeting and Squirming

  • Leaving seats, running and climbing when they are expected to stay still

  • Talking excessively, interrupting

Other clinical features:

  • Poor time estimation

  • Poor planning skills

  • Difficulty internalising routines, skills, rules

  • Delay in motor development and clumsiness

  • Low frustration tolerance and anger

Prognosis of ADHD:

  • Language delay

  • Learning difficulty

  • Conflictual relationships with parents

  • Excessive high-risk taking in adolescence

  • Accidental injuries and obesity

  • Low self esteem and depression

  • Possible conduct problems

Treatment for ADHD:

  • Psychoeducation

  • Medicaiton

  • Family intervention

  • School intervention

  • Child-focused intervention

  • Artificial food colour (AFC) elimination

While AFC’s are not a major cause of ADHD, they affect children regardless of whether they have ADHD or not

Non-pharmacological interventions for ADHD:

CBT is heavily utilised and targets cognitive, emotional and behavioural difficulties by teaching techniques to help with attention, impulsivity, emotional regulation

Adult ADHD:

Process of being diagnosed has been described by individuals as laborious and misdiagnosis is frequent

Diagnosis commonly caused feelings of relief as well as identity change, including acceptance and emotional turmoil

People wish they had been diagnosed sooner

Symptomatology is similar, with inattention, impulsivity, hyperactivity, chaotic schedules and lifestyles, lack of structure, emotional dysregulation being common

Coping skills are often adapted such as organisation strategies, environmental modifications, physical activity, and stimulant medications which help achieve goals and increase productivity

Outside support through workplace and educational accomodation helpful, alongside therapies that teach aforementioned skills

Substance abuse can be prominent with impulsivity and self medication being common

Stigma of legitimacy of adult ADHD is real, people feeling they did not feel comfortable to disclose their diagnoses to others

Underachievement in education is common, with medication and accomodation being seen as helpful

Accessing services can be difficult and often required heavy self-advocacy

Anxiety disorders in Children:

Similar to Anxiety, fear is still an adaptive response to danger, normal adaptive fears become maladaptive if there is an inaccurate appraisal to the threat to well-being. These maladaptive fears are referred to as anxiety

Phobias are most common anxiety disorders in children

Prognosis:

Shows to be more common among girls, with a high risk of co-morbidity and risk of social isolation, educational underachievement and mood disorders in adulthood

Treatment options:

  • Psychoeducation

  • Monitoring

  • Exposure

  • Relaxation training

  • Cognitive restructuring

  • Modelling and rehearsal

  • Reward system

  • Medications (SSRI’s)

Under investigation is school and outside-school based programs targeting anxiety disorders in children, with extra elements needing to be considered such as involving parents. Systemic issues such as appropriate staffing and funding and training need to also be considered, and flexibility and personalisation at scale needed