Ontwikkelings- En Gedragsstoornissen: Psychologische Diagnostiek
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ONTWIKKELINGS- EN GEDRAGSSTOORNISSEN: PSYCHOLOGISCHE DIAGNOSTIEK
Ontwikkelings- en gedragsstoornissen: psychologische diagnostiek ...................................................................... 1
Inleiding................................................................................................................................................................... 9
Ontwikkelingsstoornissen ................................................................................................................................... 9
DSM (sinds 1952) ............................................................................................................................................ 9
(Neurobiologische) ontwikkelingsstoornissen .................................................................................................... 9
Gedragsstoornissen........................................................................................................................................... 10
DSM ............................................................................................................................................................... 10
Ontwikkelings- en gedragsstoornissen in dit opleidingsonderdeel .................................................................. 10
structuur van de lessen/ opdeling per stoornis ................................................................................................ 11
diagnose: verschillende vormen ................................................................................................................... 11
Instrumenten ................................................................................................................................................ 11
Screeningsinstrumenten ........................................................................................................... 11
Sensitiviteit en specifiteit ...................................................................................................... 12
............................................................................................................................................... 13
Goed screeningsinstrument? ................................................................................................ 13
Informant............................................................................................................................... 13
Diagnostische instrumenten ..................................................................................................... 14
Assessment instrumenten ......................................................................................................... 15
Focus: onderkennende/ beschrijvende diagnostiek ..................................................................................... 15
Diagnostiek moet op verschillende niveaus gebeuren ............................................................. 16
Genetische of chromosale stoornis ~ gedragsmatig fenotype.................................................. 16
Intelligentie ....................................................................................................................................................... 17
Ontwikkelings- en intelligentietesting........................................................................................................... 17
CHC-model ................................................................................................................................. 17
Belangrijkste ontwikkelings- en intelligentietesten in het Nederlandse taalgebied (BFP, 2015)
................................................................................................................................................... 18
Invloeden op prestatie op intelligentietest ............................................................................... 18
Mentale retardatie DSM-IV-TR, verstandelijke beperking DSM-5 ................................................................ 18
Hoogbegaafdheid: meerfactorieel ............................................................................................ 19
Hoogbegaafdheid ≠ savantsyndroom ....................................................................................... 19
Autismespectrumstoornis ..................................................................................................................................... 20
DSM-5 Criteria → zie bijlage ............................................................................................................................. 20
DSM-5: specifiers .......................................................................................................................................... 20
DSM IV(-TR) (1994, 2000) .......................................................................................................... 20
DSM-5 (2013): van meer naar 1 en van 1 naar meer .................................................................................... 21
1
,Comorbiditeit .................................................................................................................................................... 21
Prevalentie ........................................................................................................................................................ 21
Autisme epidemie? ....................................................................................................................................... 22
Meisjes/ vrouwen met ASS ........................................................................................................................... 22
(een deel van) de geschiedenis van ASS............................................................................................................ 22
Leo Kanner .................................................................................................................................................... 22
Kanner en Eisenberg ..................................................................................................................................... 23
Hans Asperger (1906 – 1980) ........................................................................................................................ 23
DSM-IV-TR: desintegratiestoornis van de kindertijd ................................................................. 25
Andreas Rett.................................................................................................................................................. 25
DSM-Iv-RT: het syndroom van Rett ........................................................................................... 26
DSM-IV-TR: atypisch autisme (PDD-NOS).................................................................................. 26
DSM-5: AUtismespectrumstoornis ............................................................................................ 26
Voorbij het autisme spectrum – traits en BAP (genetisch verbonden familieleden vertonen ook enkele
kenmerken) ................................................................................................................................................... 27
Etiologie ............................................................................................................................................................ 27
Genetica ........................................................................................................................................................ 27
Broertjes en zusjes .................................................................................................................... 28
Neurobiologie (niveau van het brein) ........................................................................................................... 28
Groei brein................................................................................................................................. 28
Connectiviteit ............................................................................................................................ 29
Afwijkingen op diverse andere niveaus..................................................................................... 30
Conclusie genetica en neurobiologie ........................................................................................ 30
Omgeving (X genen) ...................................................................................................................................... 30
Etiologie samengevat .................................................................................................................................... 30
Psychologische verklaringsmodellen ................................................................................................................ 31
Neuropsychologische studies en psychologische verklaringsmodellen ........................................................ 31
Psychologische theorie.................................................................................................................................. 31
aanvankelijk: Zoektocht naar primair deficit............................................................................. 32
Theory of mind (TOM) ................................................................................................................................... 32
2
, Theory of mind bij de mens....................................................................................................... 32
TOM deficit bij kinderen met autisme (Baron-Cohen et al) ...................................................... 33
False belief taak zelf een probleem? ......................................................................................... 34
Advanced TOM taken ................................................................................................................ 34
Wat voor 4 jaar? ............................................................................................................................................ 36
Mogelijke voorlopers van ToM ..................................................................................................................... 36
ASS en imitatie........................................................................................................................... 36
ASS en spiegeleuronen .............................................................................................................. 36
Spiegelneuronen bij mensen ................................................................................................. 37
ASS en joint attention................................................................................................................ 37
Gerapporteerde deficieten.................................................................................................... 37
ASS en symbolisch spel .............................................................................................................. 38
Doen alsof spel – symbolisch spel ......................................................................................... 38
Terug naar ToM ............................................................................................................................................. 39
Tom 2.0 hypothese: spontane TOM deficit ............................................................................... 39
Recente evidentie ...................................................................................................................... 39
Conclusies ASs en TOM ............................................................................................................. 40
TOM: implicaties voor praktijk .................................................................................................. 40
Executieve functies (EF) deficit ..................................................................................................................... 41
Onderzochte EF-domeinen........................................................................................................ 41
Evidentie .................................................................................................................................... 41
EF en ASS-symptomen ............................................................................................................... 41
Implicaties voor de praktijk ....................................................................................................... 42
Verminderde centrale coherentie ............................................................................................. 42
Evidentie .................................................................................................................................... 43
Conclusies verklaringsmodellen .................................................................................................................... 43
Predictive coding ....................................................................................................................... 44
ASS: sterkten ................................................................................................................................................. 44
Diagnostiek........................................................................................................................................................ 44
Minimaal diagnostisch protocol .................................................................................................................... 44
Differentiaaldiagnose ........................................................................................................................................ 47
Aandachtsdeficiëntie-/ hyperactiviteitsstoornis (ADHD) ...................................................................................... 48
DSM-5................................................................................................................................................................ 48
DSM-5 ADHD specifiers ................................................................................................................................. 49
Ontwikkelingsdimensie ................................................................................................................................. 49
ADHD+ (comorbiditeit)...................................................................................................................................... 50
3
, ADHD en/ of ODD/ CD ................................................................................................................................... 52
ADHD en/ of angst- en stemmingsstoornissen ............................................................................................. 52
ADHD en/ of ticstoornissen ........................................................................................................................... 52
ADHD en/ of leerstoornissen ........................................................................................................................ 52
ADHD en/ of taalstoornissen......................................................................................................................... 52
ADHD of? ....................................................................................................................................................... 53
ADHD+ ........................................................................................................................................................... 53
Dalsgaard et al. 2015, mortaliteit.................................................................................................................. 53
Maar ook … ................................................................................................................................................... 53
Een blik in het verleden ..................................................................................................................................... 54
Melchior Adam Weikard (1755) .................................................................................................................... 54
Heinrich Hoffman, 1845 (Zappel-Phillipp) ..................................................................................................... 54
Johnny head in air ......................................................................................................................................... 55
Sir George Frederic Still (1902) ..................................................................................................................... 55
Prevalentie ........................................................................................................................................................ 55
ADHD epidemie? ........................................................................................................................................... 55
Wat zegt onderzoek? .................................................................................................................................... 56
advies van de hoge gezondheidsraad (herkenning, diagnose & behandeling ADHD) .................................. 57
...................................................................................................................................................................... 57
Stepped diagnosis en care ............................................................................................................................ 57
Etiologie ............................................................................................................................................................ 58
Genetische component ................................................................................................................................. 58
Mogelijke omgevingsfactoren ....................................................................................................................... 58
Neurobiologische bevindingen ..................................................................................................................... 59
, Event rate manipulaties ............................................................................................................ 65
Evidentie .................................................................................................................................... 66
Ander motivationeel functioneren (bij mensen met ADHD) ......................................................................... 67
Delay aversion hypothese (Sonuga-Barke)................................................................................ 67
1. Delay aversion en impulsiviteit - studie ........................................................................ 68
Delay aversion: opdeling naar subtypes – studie .................................................................. 68
Shortened reward delay gradient ......................................................................................... 69
Van shortened reward delay gradient naar delay aversion .................................................. 69
Contextgevoeligheid van symptomen ............................................................................................................... 70
Multifactoriële modellen .................................................................................................................................. 70
Van een kerndeficit (EF deficit)… naar multifactorieel ................................................................................. 70
Conclusies.......................................................................................................................................................... 71
Implicaties ......................................................................................................................................................... 71
Diagnostiek........................................................................................................................................................ 71
Diferentiaaldiagnose ..................................................................................................................................... 72
Multimodale assessment .............................................................................................................................. 72
Interview: ouder als informant ................................................................................................. 73
Interview: leerkracht als informant ........................................................................................... 73
Interview: kind als informant .................................................................................................... 73
Vragenlijsten ................................................................................................................................................. 74
Intelligentie onderzoek → waarom intelligentie onderzoek? ...................................................................... 74
Neuropsychologisch onderzoek .................................................................................................................... 74
Bourdon-VOS ............................................................................................................................. 75
Continuous performance task (CPT) ......................................................................................... 75
Test of everyday attention fot children (TEA-CH) ..................................................................... 76
Neuropsychologisch onderzoek: vaststellingen ............................................................................................ 76
Groepsverschillen versus individuele classificatie..................................................................... 77
Verdere vaststellingen met betrekking tot neuropsychologisch onderzoek ............................ 77
Conclusies met betrekking tot neuropsychologisch onderzoek................................................ 77
Observatie ..................................................................................................................................................... 77
Observatiesystemen .................................................................................................................. 78
Extra aandachtspunten volwassenen ........................................................................................................... 78
NLD ........................................................................................................................................................................ 79
Definitie Rourke ................................................................................................................................................ 79
Model Goldberg en costa .............................................................................................................................. 79
Rourke: kernproblematiek NLD ..................................................................................................................... 80
5
, NLD: tekorten .................................................................................................................................................... 80
Problemen met NLD .......................................................................................................................................... 81
Diagnostiek moet op verschillende niveaus gebeuren ..................................................................................... 81
Overlap ASS ................................................................................................................................................... 82
NLD – ASS verschillend neurologisch profiel? ........................................................................... 82
Visuospatiële leerstoornis (VSLD) ................................................................................................................. 82
Conclusies.......................................................................................................................................................... 83
Gedragsstoornissen............................................................................................................................................... 84
Inleiding ............................................................................................................................................................. 84
Ontwikkelingsverloop van ‘normaal’ probleemgedrag ................................................................................. 84
Oppositioneel opstandige stoornis (ODD) ............................................................................................................ 85
DSM-5................................................................................................................................................................ 85
Wijzigingen ten opzichte van DSM-IV TR ...................................................................................................... 86
Prevalentie en verloop ...................................................................................................................................... 86
Normoverschrijdend-gedragsstoornis (CD)........................................................................................................... 87
specifiers ........................................................................................................................................................... 87
Wijzigingen ten opzichte van DSM-IV TR ...................................................................................................... 88
Prevalentie ........................................................................................................................................................ 88
Aanvang in de kindertijd ............................................................................................................................... 88
Aanvang in de adolescentie .......................................................................................................................... 89
Beperkte prosociale emoties ........................................................................................................................ 89
ODD en CD: Verloop, bijkomende problemen, comorbiditeiten ...................................................................... 89
Diagnostiek........................................................................................................................................................ 90
Vragenlijsten ................................................................................................................................................. 90
Interview ....................................................................................................................................................... 91
Observatie ..................................................................................................................................................... 91
Sociometrie ................................................................................................................................................... 91
Ouder-kind interacties en gezinsprocessen .................................................................................................. 91
Ruimere context ............................................................................................................................................ 91
Ruimer functioneren ..................................................................................................................................... 92
Gevalideerde vragenlijst ............................................................................................................................... 92
Etiologie ............................................................................................................................................................ 92
Genetica ........................................................................................................................................................ 92
Omgevingsfactoren ....................................................................................................................................... 92
Opvoedingsstijl .............................................................................................................................................. 92
Neurobiologie................................................................................................................................................ 93
Neuropsychologie ......................................................................................................................................... 93
6
, ODD/ CD: conclusies ......................................................................................................................................... 94
Coördinatieontwikkelingsstoornis (DCD) .............................................................................................................. 95
DCD of ook wel .................................................................................................................................................. 95
DSM5: DCD ........................................................................................................................................................ 95
Prevalentie ........................................................................................................................................................ 95
Comorbiditeit .................................................................................................................................................... 96
Impact ............................................................................................................................................................... 96
etiologie ............................................................................................................................................................ 96
Neurobiologie en neuropsychologie ............................................................................................................. 96
Diagnostiek........................................................................................................................................................ 97
Communicatiestoornissen .................................................................................................................................... 98
DSM5 ................................................................................................................................................................. 98
Taalontwikkeling ............................................................................................................................................... 98
Taalstoornis ................................................................................................................................................... 98
Taal(ontwikkelings)stoornissen: subtypering................................................................................................ 99
Gemengd receptief/ expressieve taalstoornis .......................................................................... 99
Expressieve taalstoornis ............................................................................................................ 99
Pragmatiek ........................................................................................................................................................ 99
‘hogere orde stoornissen’ ........................................................................................................................... 100
Differentiaaldiagnostiek en comorbiditeit ...................................................................................................... 100
Etiologie communicatiestoornissen ................................................................................................................ 100
Enkele veelgebruikte testen ............................................................................................................................ 100
Nieuw in DSM5: Sociale (pragmatische) communicatiestoornis .................................................................... 101
Hoe verhoudt dit zich tot ASS?.................................................................................................................... 101
Het nut van sociale (pragmatische) communicatiestoornis? ...................................................................... 102
ASS en taalstoornis? .................................................................................................................................... 102
Gilles de la tourette ............................................................................................................................................. 103
DSM-5.............................................................................................................................................................. 103
Historiek .......................................................................................................................................................... 103
1e casus........................................................................................................................................................ 103
Georges Gilles de la tourette ...................................................................................................................... 104
Tics (zie WC) .................................................................................................................................................... 104
enkele begrippen ............................................................................................................................................ 104
Prevalentie ...................................................................................................................................................... 105
Verloop ............................................................................................................................................................ 105
Premonitory urges .......................................................................................................................................... 106
Etiologie .......................................................................................................................................................... 106
- Mentale retardatie
- Pervasieve ontwikkelingsstoornissen (diep doordringend, waarbij bepaalde basisfuncties verstoord zijn
zoals sociale interactie bij communicatie (nu ass))
- Specifieke ontwikkelingsstoornissen (op 1 bepaald gebied, bv motoriek)
DSM-IV (1994) * DSM-IV-TR (2000)
- Term ‘ontwikkelingsstoornissen’ wordt niet meer gebruikt (“disorders usually first diagnosed in infancy,
childhood, or adolescence”)
- TR = tekst revision (enkel de tekst is veranderd)
ICD-10 (1992)
- F80 - F89: stoornissen in de psychologische ontwikkeling
- International Classification of Diseases and related health problems
DSM- 5 (mei 2013, NL 2014)
- Neurobiologische ontwikkelingsstoornissen (Neurodevelopmental disorders) → nu nadruk op het
neurobiologische (zie afbeeldingen slides les 1) aka extra nadruk op de hersenen
- Meer overkoepelende termen (subtypes verdwenen) → nu één categorie
- Meer dimensioneel
DSM (SINDS 1952)
De Diagnostic and Statistical Manual of Mental Disorders (DSM) is een classificatiesysteem waarin internationale
afspraken zijn gemaakt over welke criteria van toepassing zijn op een bepaalde psychische stoornis op basis van
(nieuwe) wetenschappelijke inzichten. Het is niet enkel een lijst van symptomen, er zijn ook andere criteria.
(NEUROBIOLOGISCHE) ONTWIKKELINGSSTOORNISSEN
- Neurobiologisch: oorsprong in andere hersenontwikkeling
- Aanvang in (vroege) kinderjaren (verstoring/vertraging op één of meerdere levensdomeinen)
- Verstoorde en/of vertraagde verwerving van taal, communicatieve, cognitieve, motorische of sociale
vaardigheden (of een combinatie hiervan)
- Klinische presentatie (= hoe het beeld zich laat zien) omvat ook “excessieve” symptomen (niet enkel
tekorten = deficieten, maar een teveel van iets = excessief)
o Teveel: hyperactief gedrag bij kind met ADHD, buitensporige agressie
o Tekort: geen initiatief nemen om sociaal contact aan te gaan
- Tamelijk stabiel verloop met progressieve verbetering (maar vaak blijven symptomen en problemen in
volwassenheid – soms afvlakking of andere uiting maar verdwijnt niet)
o Vroeger dacht met dat ADHD en ASS enkel bij kinderen was
o Kan wel ander beeld vertonen in volwassenheid (ADHD: opvallende hyperactiviteit neemt af, wel
meer sociale onrust)
9
, - Leidt tot (vaak levenslange) beperkingen in persoonlijk, sociaal, schools of beroepsmatig functioneren
>> criteria om te spreken van een ontwikkelingsstoornis (niet zomaar de kenmerken ervan kunnen
afvinken) = impairment-criterium (er moet sprake zijn van een beperking)
- Meestal hogere prevalentie bij jongens, vaak niet zo goed herkend bij meisjes (maar eerder mss meer
oog voor de jongens vb. erkenning van meisjes met autisme) → geen eenduidige oorzaak
- Etiologie vaak onbekend (= complex, meerdere factoren die bepalen dat die stoornis ontstaat), vaak
sterke genetische factor (en interactie met omgevingsfactoren)
o <-> genetische stoornissen zoals syndroom van Down
GEDRAGSSTOORNISSEN
Problemen in de zelfcontrole van emoties en gedrag, leiden tot:
- Schending van de rechten van anderen (vb. agressie, eigendom vernielen)
- En/of ernstig conflict met maatschappelijke normen of (personen met) autoriteit
- Externaliserende problematiek: naar buiten gericht (<-> internaliserende vb. depressie, angst)
Symptomen komen in beperktere mate ook voor bij normaal/typisch ontwikkelende personen (belang van
frequentie, intensiteit, hardnekkigheid, pervasiviteit over situaties, beperking) → afweging maken: wanneer
spreek je van een stoornis
- Vaak complexe problematiek waarbij ook leerstoornissen, sociale problemen en gezinsproblemen
voorkomen
- Vrij hoge prevalentie (gemiddeld 3-5%), meer bij jongens
- Slechte prognose, zeker bij aanvang in (vroege) kindertijd → best om zo vroeg mogelijk bij te zijn
- Etiologie is grotendeels onbekend, samenspel van biologische en omgevingsfactoren (waarbij die laatste
wellicht wat meer doorwegen dan bij ontwikkelingsstoornissen, dit lijdt tot complexe problematiek)
- Neurobiologische ontwikkelingsstoornissen: ADHD (geen gedragsstoornis meer)
- Disruptieve, impulsbeheersings- en andere gedragsstoornissen: ODD, CD (ODD: oppositioneel-
opstandige stoornis; CD: normoverschrijdend-gedragsstoornis)
o CD andere term dan in DSM-III & DSM-IV
ONTWIKKELINGS- EN GEDRAGSSTOORNISSEN IN DIT OPLEIDINGSONDERDEEL
- (Genetische stoornissen), beperkt behandeld
- Autismespectrumstoornis (ASS)
- ADHD
- ODD/CD
- Stoornis van Gilles de la Tourette
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