Neurodevelopmental Disorders

It is often harder to diagnose psychiatric disorders in children due to limited communication, lacking abstract cognitive abilities, variable behaviors between age groups, and ego-syntonicity. It is common for etiologies and causes to be unknown, but there are contributing factors for neurodevelopmental disorders:

1. Social deprivation as well as deprivation of emotional care delays brain and cognitive development.
2. Genetic Disorders
   • Down Syndrome, also known as Trisomy 21, results from an extra chromosome 21 or rarely other genetic abnormalities. This results in characteristic features across clients with the disorder:
     • Short stature, abnormal fingerprints, heart defects, intellectual disability, epicanthal (eyelid) folds, palm prints, and poor muscle tone.
   • Fragile X Syndrome: a deficiency of a protein important for normal brain development and functioning. It is an X-linked disorder and therefore more common in men.
   • Rett’s Syndrome: also an X-linked disorder, it produces functional limitations that become apparent after approximately 5 months of normal functioning.
   • William’s Syndrome: a result of deletion of genetic material within chromosome 7.
3. Immune Dysfunction
   • Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infection (PANDAS) are immune reactions of both the mother and developing child that may result in neurodevelopmental disorders.
   • Sydenham’s Chorea, an autoimmune reaction triggered by GAHBS (and therefore paired with rheumatic fever) that attacks the brain (basal ganglia) which results in abnormal, purposeless movements that may resemble a dance, hence why this condition is also called St. Vitus Dance. Due to its nature, it has fewer psychological sequelae.
4. Infectious Diseases
   • Systemic Infections during infancy or childhood; not a type of primary neurodevelopmental disorder. This includes HIV, brain abscesses, meningitis, encephalitis, etc.
   • Congenital Infectious Diseases transmitted at or even before birth. These have also been linked to some cases of schizophrenia. This includes rubella (congenital rubella syndrome), zika virus, syphilis, etc.
5. Metabolic Disorders arising from either the mother or the child e.g. diabetes mellitus (DM) or phenylketonuria (PKU)
6. Nutrition disorders or deficits may result in neurodevelopmental disorders such as in spina bifida or anencephaly cases resulting from inadequate folic acid, iodine deficiency, or fetal alcohol syndrome.
7. Physical Trauma during birth (e.g. uncomplicated premature birth) or infancy/childhood (asphyxia, hypoxia) may result in developmental delays.

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Autism Spectrum Disorder

ASD (prev. autism, autistic disorder) is composed of various pervasive developmental disorders (PDD; Rett’s Disorder, Childhood Disintegrative Disorder, Asperger’s Syndrome) characterized by pervasive and often severe impairment of reciprocal social interaction skills, communication deviance (hard-to-follow forms of communication), and restricted stereotypical (repetitive) behavioral patterns.

• ASD is five times more prevalent in boys than girls. It is often identified by 18 months of age, no later than 3 years.
• 80% of children with autism experience early onset (<1 year), with the remaining 20% normally displaying routine development followed by regression during the 2nd to 3rd year of life.
• Autism has a genetic link, with many children having relatives with ASD or other autistic traits.

Children with ASD have persistent deficits in communication and social interaction accompanied by restricted and stereotyped patterns of behavior and interests/activities.

• These children minimally utilize communication techniques such as eye contact, facial expressions, and gestures. Intelligible speech may also be reduced.
• They may experience reduced spontaneous enjoyment and affect. They may not engage in play or in make-believe with toys.
• They may display stereotyped motor behaviors such as hand-flapping, body twisting, or head-banging.
• Deficits in communication due to ASD may improve, sometimes substantially, as the use of language and communication techniques develop. Behavior may deteriorate during adolescence due to hormonal changes. Complex social demands arise, leaving individuals dependent on others possibly until adulthood.

Autism Disorders

1. Autism, also known as mindblindedness. A developmental disorder of variable severity ==characterized by difficulty in social interaction and communication and by restricted stereotyped thought and behavior==.
   • Onset, Incidence, and Etiology: often identified within the one year of age, and not later than 3 years. More common in boys than girls (5:1). Etiology is mostly unknown except for a genetic link and mechanical trauma during the birth process.
   • Characteristic: impairment of reciprocal interaction skills
   • Manifestations:
     • Difficulty in Social Interactions: unaffectionate, asocial, inappropriately attached to objects, lack of interest in the environment, inappropriate laughter or giggling, and avoidance of eye contact
     • Difficulty with Communication: underdevelopment of language; the use of gestures rather than language, and other difficulties in expression.
     • Stereotypical Behavior (SPAN)
       • Sustained repetitive motor movements e.g. spinning objects or the self, rocking, hand or finger flapping, body twisting, etc.
       • Preference of same-ness or having a routine: preoccupation with lights, moving objects, or parts of objects.
       • Apparent insensitivity to pain
       • No real fear of dangers
   • Diagnosis: assessment of any developmental delays in the first two years of life
     • 12 months: no babbling, pointing, or gesturing
     • 18 months: no single word spoken
     • 24 months: no two-word spontaneous expressions
   • Management:
     • Reduction of behavioral symptoms:
       • Temper tantrums, aggressiveness, self-injury, hyperactivity, and stereotyped behaviors: Haloperidol (Haldol), Risperidone (Risperdal)
       • Diminish self-injury and hyperactive and obsessive behaviors: Catapres (Clonidine), Anafranil (Clomipramine), and ReVia (Naltrexone).
     • Promote learning and development: special education focused on development of social skills, language, self-care, and academic performance.
     • Family Therapy: parental education
2. Rett’s Disorder: a ==regressive pattern of development== after a period of normal functioning from birth to 5 months of age.
   • Onset, Incidence, and Etiology: more common in girls (4:1). Etiology is unknown.
   • Characteristic: devolution of development from birth to five months of age.
   • Manifestations: stereotyped behavioral patterns (headbanging, tantrums, body twisting), loss of expressive (explaining) and receptive (understanding) language, and loss of interest in the social environment.
   • Differentials from Autism:
     • More common in girls rather than boys
     • Loss of previously acquired language rather than maldevelopment
     • Loss of hand function vs. preserved hand function
     • Presence of ataxia and seizures are common
     • Abnormal chewing ability
     • Delayed physical growth
3. Asperger’s Disorder: milder symptoms of autism; ==social challenges and unusual (stereotyped) behaviors or interests are still present, but problems with language or intellectual disability is absent==. Individuals may have normal IQ or even potentially exhibit exceptional skill or talents in specific areas.
   • Onset, Incidence, and Etiology: later onset, more common among boys, with an unknown but potentially genetic etiology.
   • Characteristic: severe impairment of social interactions with stereotyped behaviors. IQ may be preserved with exceptional talent in specific areas.
   • Manifestations: severe impairment in social interaction, and marked problems with empathizing and modulating social relationships.
   • Management: social skills training
4. Childhood Disintegrative Disorder, also known as Heller’s Syndrome and Dementia Infantialis. This involves ==marked regression in multiple areas of functioning after at least two years of normal growth and development==. Regression may be gradual or rapid (within 6 to 9 months).
   • Onset, Incidence, and Etiology: onset between 3 and 4 years of age, being more common in boys.
   • Manifestations:
     • Stereotyped behavioral patterns e.g. headbanging, tantrums, body twisting
     • Loss of previously acquired spoken language
     • Loss of previous acquired social skills
     • Loss of motor functions e.g. continence

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Attention-Deficit Hyperactivity Disorder

A neurodevelopmental type mental disorder characterized by difficulty in paying attention, excessive activity, and acting without regards to consequences, which are otherwise not appropriate for a person’s age i.e. hyperactivity, inattentiveness, distractibility and impulsivity. This condition is often identified and diagnosed at the beginning of preschool. Diagnosis is differentiated from other potentially similar disorders such as bipolar disorder or behaviorally acting out through its consistency across almost all times (behavior is displayed every day) and situations.

• Incidence: more common among boys
• Risk Factors: poor familial socioeconomic status, harmony, treatment (neglect, abuse), or parental deprivation; low birth weight; family history of ADHD
• Symptoms (mn. ADHD)
  • Academic Performance is poor
  • Development of Relationships is strained; behavior is disruptive and intrusive at home and during conversation, causing friction with family and peers.
  • Hyperactivity and Impulsivity: restlessness (can’t sit still, fidgets), excessive talking, running, and climbing, and being interruptive in conversation.
  • Difficulty sustaining attention and concentration
    • Not appearing to listen, missing details, easily distracted
    • Makes careless mistakes in school works, avoids mentally difficult tasks
    • Unable to organize and misplaces objects
    • Attention span can range from 2 to 3 minutes (mild) to 2 to 3 seconds (severe)

Treatment

1. Psychopharmacology (mn. CARDS)
   • Cylert (Pemoline): a stimulant, commonly causing insomnia, anorexia, weight loss, or failure to gain weight. It is hepatotoxic, and therefore the last drug to be prescribed.
   • Adderal (Amphetamine) is commonly used for ADHD cases.
   • Ritalin (Methyphenidine) is the most common drug used, effective in 70% to 80% ADHD cases.
   • Dexedrine (Dextroamphetamine): a stimulant, commonly causing insomnia, anorexia, weight loss, irritability, and risk for self-injury.
   • Strattera (Atomoxetine): a non-stimulant antidepressant (SSRI) drug. May cause anorexia, nausea and vomiting, fatigability, and abdominal distress.
2. Other Drugs
   • Tricyclic Antidepressants
   • Alpha-2 Agonists: Clonidine and Guanfacine
   • Traditional antipsychotic drugs may be used to manage severe impulsiveness

Nursing Assessment

1. Short attention span
2. High level of distractibility
3. Labile moods
4. Low frustration tolerance
5. Inability to complete tasks
6. Inability to sit still or fidgeting
7. Excessive talking
8. Inability to follow directions

Nursing Interventions

1. Ensure safety for the client and others: stop unsafe behaviors, provide supervision, and give clear instructions about acceptable and unacceptable behavior.
2. Improve role performance: Allow the client to accomplish tasks easier.
   • Modifying the environment: Identify and restrict stimuli that may aggravate the client. Interact with a one-to-one basis, and gradually increasing environmental stimuli may be implemented.
   • Gaining the child’s full attention: call the client’s name, establish eye contact, and allow the client to repeat given instructions.
   • Simplifying instructions and breaking complex tasks down into simpler tasks. State expectations for the task completion, and initially assist the client in the tasks. Gradually decrease assistance to prompting or reminding the client on performing tasks. Additionally, asking the client sequencing questions (“what happens next?”) can help with logical thought and decrease tangentiality. Reminders may also then be gradually decreased.
   • Allowing for breaks, especially for sedentary tasks where the client may feel restless.
   • Crucially, providing positive feedback for meeting expectations through each step and coming closer to completion conditions the client to perform.
3. Structured daily routine: establish a daily schedule and minimize changes. Children with ADHD do not readily adjust to changes and may fail to meet expectations for day-to-day tasks if they are done arbitrarily.
4. Client and family education and support:
   • Instruct the patients for implementing the same steps for improving role performance within the client’s home environment.
   • Listen to the parents’ feelings about frustration, anger, and guilt. They may blame themselves for the child’s problems. They should hear that neither they nor their child are at fault. Give the parents an opportunity to attend a support group.
   • Counsel the parents on giving the child positive feedback, focusing on the child’s strengths, and on how to build the child’s self-esteem, which may be impacted due to their behavioral tendencies. This may be done, for example, by counting the number of times the parents praise or criticize the child on a day-to-day basis.

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Related Neurodevelopmental Disorders

Tic Disorders

Tics are sudden, rapid, recurrent, non-rhythmic, stereotyped movement or vocalization. Tics can be suppressed but not indefinitely. These are exacerbated by stress and abated by focus. Tic disorders tend to run in families, with dopamine potentially being implicated in tic disorders ergo the use of atypical neuroleptics e.g. risperidone (Risperdal) and aripiprazole (Abilify) for treatment. Read also: Tourette’s Disorder

• Motor Tics: blinking, neck-jerking, shrugging, grimacing, and coughing.
• Complex Motor Tics: facial gestures, jumping, touching or smelling an object.
• Vocal Tics: clearing the throat, grunting, sniffing, and snorting.
• Complex Vocal Tics: coprolalia, socially unacceptable speech e.g. expletives, palilalia, repeating one’s own words or sounds, and echolalia, repeating others’ words or sounds.

Classification (DSM-5)

1. Transient Motor or Vocal Tic Disorder: (1) at least one vocal or motor tics (but not both) (2) occurring every day, or nearly every day, for at least two weeks (3) that does not last longer than 12 consecutive months.
2. Motor or Vocal Tic Disorder: (1) rapid, recurrent, uncontrollable movements or vocal outbursts (but not both) (2) nearly every day for more than a year or every day for more than 3 months.
3. Tourette’s Disorder: (1) multiple motor tics and at least one vocal tic (2) occurring for multiple times a day, nearly every day, or intermittently for more than a year (3) that results in academic, social, and occupational functioning. The disorder is identified before 7 years of age, and is more common in boys.

Learning Disorders

An on-going problem in the areas of reading (dyslexia), mathematics (dyscalculia), or written expression (dysgraphia), performing below what is expected for the individual’s age, formal education, and intelligence (DSM-5).

• May result in low self-esteem and poor social skills, and problems with employment or social adjustment are experienced as adults.
• Management: early detection, special education, and intervention minimize difficulties and provide better outcomes.

1. Dyslexia is difficulty with reading and connecting letters to the sounds they make. Reading becomes slow, effort, and fails to become a fluent process.
2. Dysgraphia is difficulty with expressing one’s thoughts onto writing. This may include difficulty in spelling, grammar, punctuation, and handwriting.
3. Dyscalculia is difficulty in learning number-related concepts or using symbols and functions to perform calculations. Number sense, math-related memorization, mathematical reasoning, and mathematical problem-solving may be impacted.

Motor Skills Disorders

1. Developmental coordination disorder features impaired coordination severe enough to interfere with ADLs and academic achievement. The condition becomes evident when the child attempts to crawl, walk, manipulate toys and building blocks, or dress themselves. It may also accompany a communication disorder. This diagnosis is only made if it is not a part of general medical conditions such as cerebral palsy, muscular dystrophy, or other degenerative disorders (DSM-5).
   • Symptoms: unable to perform age-appropriate skills e.g. buttoning buttons, catching a ball, or an elementary school child struggling with writing or sports. Planning and memorization of motor patterns is impaired.
   • Management: special physical education (gym activities) for special needs promotes hand-eye coordination and motor development to improve specific skills.
2. Stereotypic movement disorder features rhythmic, repetitive, involuntary behaviors for a period no less than four weeks (DSM-5). Its onset begins prior to 3 years of age and continues into adolescence. This non-functional behavior may result in self-injury.
   • Handwaving, rocking, headbanging, biting fingernails or self for no apparent reason, or picking at the hair or skin like in trichotillomania and dermatillomania. Self-inflicted injuries are commonly associated with this disorder as pain fails to deter the behavior.
   • Comorbid conditions such as anxiety, ADHD, OCD, and Tourette’s/tics become the source of functional impairment more than the stereotypic behavior.
   • Behavioral therapy and cognitive behavioral therapy (CBT) may be used to help with stereotypic movement disorder.

Communication Disorders

Language consists of receptive (receiving and understanding language) and expressive (production of language) skills and ability. Difficulty in these speech, language, and communication may be a result of communication disorders. Diagnosed when deficits become severe enough to hinder development, academic achievement, or ADLs/socialization. Speech therapy is offered for individuals with these disorders.

1. Language disorders pertains to deficits in language production or comprehension across various linguistic modalities (spoken, written, sign language, etc.); (1) limited vocabulary, (2) inability to form sentences, and (3) impairment in discourse or conversation.
   • Expressive Language Disorder produces an inability to use verbal and non-verbal language for communication: limited speech, incomplete/incorrect use of words or sentences, and difficulty in learning new words (mn. LID)
   • Mixed Expressive-Receptive Language Disorder is characterized by the same problems with expressive language, with the addition of difficulty in understanding and determining the meanings of words and sentences. This may be developmental or acquired from neurologic or brain injury.
2. Speech sound disorder pertains to difficulty in producing intelligible speech not secondary to congenital or acquired conditions. This difficulty causes limitations in social, academic, and/or occupational performance.
   • A phonologic disorder causes difficulty in articulation sourced from the mind i.e. inability to understand the sounds of a language.
   • An articulation disorder causes difficulty in articulation due to the physical production of speech sounds.
3. Social (pragmatic) communication disorder involves the persistent difficulty in using verbal and nonverbal communication in social contexts; a diagnosis is made after observation of all of the following: (1) the inability to observe societal norms for conversation and context, (2) inability to tell a cohesive story, (2) not following rules of conversation such as taking turns talking and listening to others, and (3) inability to make inferences e.g. humor, figurative speech, double meanings, etc.
4. Stuttering pertains to a disturbance in fluency and patterning of speech with repetitions of sounds and syllables.

Elimination Disorders

Children with elimination disorders are often continent by adolescence. Only 1% of cases persist into adulthood. Associated impairment depends on limitation of social activity due to the condition, effects on self-esteem, ostracism by peers, and punishment or angry responses of caregivers or parents.

1. Encopresis is the repeated passage of feces inappropriately e.g. in bed, in pants, on the floor by a child at least 4 years of developmental or chronological age. This may either be involuntary (often associated with psychological constipation) or intentional (often associated with oppositional defiant disorder or conduct disorder).
2. Enuresis is the repeated voiding of urine inappropriately during the day or at night by a child at least 5 years of developmental or chronological age. This is most often involuntary, but can be voluntary (related to disruptive behavior disorder). It is usually unaccompanied by other mental disorders. 75% of children with enuresis have a first-degree relative who have had enuresis.

Treatment

• Enuresis: imipramine (Tofranil), an antidepressant with urinary retention as a side effect. Desmopressin (Nocdurna, DDAVP), an antidiuretic hormone, may also be used.
• Elimination disorders related to disruptive behavior disorders may be resolved with psychological treatment of the disorder. Both forms of elimination disorders respond to behavioral approaches e.g. pads with warning bells and positive reinforcement for continence.

Intellectual Disability Disorders

Intellectual disability, also known as mental retardation, is characterized by below-average intelligence or mental ability and a lack of skills necessary for day-to-day living. There are two areas affected by these disorders: Intellectual Functioning, also known as IQ, referring to the ability to learn, and Adaptive Behaviors, skills necessary for day-to-day life such as being able to communicate effectively, interact with others, and take care of oneself.

• The Intelligence Quotient (IQ) is measured via a test, with an IQ of 100 being the average. An IQ of 70 or less is considered to be intellectually disabled.
• Symptoms may appear during infancy, or may not be noticeable until school age, depending on severity.
  • Delays in being able to roll over, sit up, crawl, or walk
  • Delays in being able to talk
  • Delays in mastering tasks such as toilet training, dressing, and self-feeding.
  • Difficulty in remembering things
  • Inability to connect actions with consequences; impaired judgment
  • Behavior problems: explosive temper tantrums
  • Difficulty with problem-solving or logical thinking (cognitive impairment)

Classifications

1. Mild to Moderate Intellectual Disability: the most common classification is Mild ID. These individuals are still able to learn practical life skills and function in ordinary life with minimal levels of support. Moderate ID requires moderate support.
2. Severe Intellectual Disability: manifesting major delays in development, individuals often retain receptive language but struggles with expressive language. Simple daily routines and self-care can still be learned, but supervision is required in social settings. They are often situated in supervised home environments such as a group home.
3. Profound Intellectual Disability: often stemming from congenital syndromes, individuals are unable to live independently and require close supervision and aid with self-care activities. Associated medical conditions such as language and physical limitations are common.

Classification	IQ	Characteristic
Mild; Moron	70 to 50	Educable
Moderate; Imbecile	50 to 35	Trainable
Severe; Idiot	35 to 20	Requires Close Supervision
Profound	20 or less	Requires Custodial Care

Treatment and Management

1. Principles of Care: repetition, role modeling, and restructuring the environment.
   • Nursing care for clients with cognitive impairment (CI) involve limit-setting (establishing discipline), providing a means of communication (speech therapy, sign language), and encouraging socialization
2. Address underlying causes of ID such as restricting phenylalanine for phenylketonuria, etc.
3. Treat comorbid physical and mental disorders to improve functioning and life skills e.g. targeted pharmacologic treatments of behavioral disorders among children with Fragile X syndrome.
4. Early behavioral and cognitive interventions, special education, habilitation, and psychosocial supports.