DSM CHAPTER 12 DEVELOPMENTAL MILESTONES • Milestones are recognizable skills or abilities that have an expected range and order of appearance, such as a child taking his first step around the time of his first birthday. Identifying any significant variations from expected patterns, such as a child taking that first step near his second birthday, is a key task for any practitioner. Knowing when a significant variation in development has occurred improves diagnostic accuracy because DSM -5 specifically requires consideration of developmental stages • Five different milestone skill areas should be evaluated: gross/fine motor, visual motor problem solving, speech and language, social/emotional, and adaptive skills • Gross motor skills are the most obvious to recognize because they involve crawling, walking, running, and throwing • Visual motor problem solving describes a child’s physical interactions with the world. Fine motor skills (using one’s hands and fingers) rely on visual input and generally progress at a slower pace than gross motor skills. If the development of these milestones is delayed, it may be because of impairments in cognitive, sensory, or motor abilities. • To be able to communicate, a person first must be able to receive input (proc ess what is seen and heard), understand the meaning of that input, then generate an expression of his thoughts (translate thoughts into words, then express fluently). Delays in expressive language milestones may be more apparent than receptive language del ays, which may be more subtle but when present may worsen an expressive language impairment • Social/emotional skills are the core elements of psychiatric functioning. Social skill development is interactive and thus reliant on the presence of a responsive c aregiver. A child’s temperamental traits influence how he responds to routine activities, which influences how his caregivers respond. Developing shared joint attention with another person by approximately age 1 year is a key social milestone. Normal socia l and emotional development is most closely linked with speech and language skills. • When you evaluate for the presence of an intellectual disability, adaptive milestones need to be investigated. Standardized intelligence testing is no longer considered th e sole basis for diagnosing intellectual disability. Adaptive skills include infants learning to feed themselves or dress themselves. For older kids, it involves self -protection and self -direction. • A child may acquire all his skills in the usual sequence but at a slower rate (a delay), may acquire his skills at differential rates in different areas (a dissociation), or may achieve milestones out of the usual order of acquisition (a deviation). Growth and development will follow recognizable patterns, but i t is not an exact script. It is our task to consider what would constitute normal -
range development. • Table 12 -2 in the book shows normal -range developmental milestones and developmental red flags that should trigger specialized assessments • ************** *************************************************************** NRNP 6665 FINAL EXAM REVIEW(WALDEN UNIVERSITY) RUTTER’S CHILD AND ADOLESCENT PSYCHIATRY CHAPTER 51 AUTISM SPECTRUM DISORDER • ASD is characterized by impairments in reciprocal social communication and a tendency to engage in repetitive stereotyped patterns of behaviors, interests, and activities. It arises from atypical brain development. The etiology is likely multifactorial. • The clinical presentation can change over time, often in response to the demands of the environment or in the presence of co -occurring conditions. • Many individuals with ASD have an early history of regression or a period of lack of progress of language, of cognition more generally, or social behavior in the early preschool period • The clinical presentation of ASD is remarkably diverse usually with a combination of some delayed/immature behaviors together with the emergence of more unusual behavioral profiles . Some of the earliest social communication symptoms represent difficulties in joint attention, eye contact, lack of social intention to communicate with others, lack of social imitative play and fascination with sensory stimuli. Some symptoms of ASD are a n exaggeration of delays observed in typical development (lack of useful speech, limited symbolic, and imaginative play skills) whereas other symptoms are quite distinct and are rarely (or only very transiently) observed in the development of typical child ren (delayed echolalia and neologisms). • Cognitive difficulties are very common in individuals with ASD but with the broadening of the diagnostic criteria for ASD, the proportion of individuals with intellectual disability has declined • “Hyperlexia,” a rema rkable ability to read but with little comprehension of content, is sometimes observed in severely disabled individuals • Children with moderate to severe cognitive impairment at earlier developmental stages in the preschool years often present with little o r no speech and poor nonverbal communication. They also tend to engage in repetitive play with sensory stimuli and can become quite upset by stimuli from the environment such as the texture of certain clothes, some everyday noises, and particular foods • With higher functioning or older individuals, speech and language are often present, grammar and vocabulary may be age appropriate, but there remain difficulties in the social use of communication. In addition to the sensory interests, higher functioning chil dren and adolescents with ASD often develop intense circumscribed interests that are observed in typically developing children but are pursued in a solitary, non -social, manner • AS referred to individuals with characteristics of autism but without clinically significant cognitive or language delay. PDDNOS referred to individuals with characteristics of autism but not enough to qualify for a diagnosis of either autism or AS. Rett syn drome was a type of PDD that was characterized by a period of normal development and then a very specific set of signs and symptoms (e.g., hand wringing) with developmental regression. Disintegrative disorder was a subtype of PDD characterized by normal de velopment past 36 months of age at which point the clinical presentation of autism would emerge • DSM -5 has revised the diagnostic criteria for ASD replacing a triad of impairments with two behavioral domains —social communication and repetitive stereotyped b ehaviors. • Although delays in language acquisition are common in ASD, they are nonspecific and so have been removed from the diagnostic criteria. Each domain includes different groups of symptoms or sub -domains and can be represented dimensionally dependin g on the need for intervention and support. • DSM -5 includes stereotyped and repetitive speech within the restricted/repetitive behaviors domain and for the first -time sensory reactivity to aspects of the individual’s environment has also been included • For a n individual to meet criteria for a DSM -5 diagnosis of ASD, evidence of symptoms in all three of the social -communication sub -domains and any two (or more) of the four restricted and repetitive behavior sub -domains is required. For individuals who meet cri teria for impaired Social Communication in the absence of restricted and repetitive behaviors, a new diagnostic category of Social Communication Disorder has been included in DSM -5. Impaired Social Communication - non-verbal communication, developing and ma intaining relationships, and social -emotional reciprocity. Repetitive/Restrictive patterns of behavior - restricted and fixated interests, excessive adherence to routine, stereotyped repetitive speech/motor/use of object, hyper or hypo -reactivity to sensory input. • In the USA, a rapid increase in the number of children receiving a diagnosis occurred once legislation for special schooling was introduced for autistic children • Parents often become concerned about the development of their children at 12 –18 months of age but children most commonly do not receive a diagnosis until 4 or 5 years of age. the American Academy of Pediatrics (AAP) and the UK National Screening Committee do not recommend universal screening. The AAP does suggest that surveillance for ASD should take place at well baby visits at 6, 12, 18, and 24 months • No screening instrument currently available has sufficient sensitivity and specificity to be used as a diagnostic instrument • Among all mental disorders, health care spending in the Unit ed States is the highest for individuals with ASD, who had higher physician and outpatient visits as well as greater prescribed medication use when compared to the non ASD pediatric population • Zaroff and Uhm (2012) have reported higher rates of ASD among w hite Americans compared to Hispanic individuals. Likewise, according to Bernier et al. (2010), white Americans receive a diagnosis approximately a year and a half before African American children and two and a half years before Latino children • The ToM (The ory of Mind) deficit may help our understanding of some of the behavioral features of ASD including a lack of ability to generalize learned responses across settings and the presence of repetitive and stereotyped behaviors. The “ToM” deficit focuses on asp ects of the social communication impairments and the inability to impute mental states either to oneself or to others. • The WCC (Weak Central Coherence) Theory was formulated by Frith arguing that individuals with autism demonstrated a local processing bia s (and thus a WCC). The weak central coherence theory attempts to explain how some people diagnosed with autism can show remarkable ability in subjects like mathematics and engineering , yet have trouble with language skills and tend to live in an isolated social world. These perceptual abilities might also account for the extreme distress experienced by some c hildren with ASD at small changes in the environment. • Overall, for many individuals, there is a gradual reduction in autistic symptoms and an improvement in adaptive abilities over time, but it is the variability in individual outcomes that is most strikin g. The major predictors of better long -term outcome appear to be higher IQ and the presence of useful speech before 5 years of age • Individuals with ASD appear to have higher rates than the general population of ADHD, mood and anxiety disorders, obsessive compulsive disorder (OCD), Tourette’s Syndrome, Disruptive Behavior Disorders/Oppositional Defiant Disorder. ADHD and anxiety disord ers are probably the two most common comorbid disorders • Recent family studies have used the baby sibling design, in which infant siblings of an older child with autism are followed from birth. A combined analysis of many different samples reported that th e sibling recurrence risk is around 19% in siblings followed prospectively from birth. A number of twin and family studies have also reported that sub -threshold autistic like traits occur in the relatives of individuals with ASD more commonly than expected • ASD has a profound effect on fertility as people with ASD generally do not reproduce • The most common abnormalities involve chromosome 7q and 15q but given that there are so many brain expressed genes it is not surprising that ASD can be associated with a bnormalities at many different loci. The well -replicated finding that between 5% and 15% of individuals with ASD have either a single gene disorder or a chromosomal abnormality highlights the importance of general medical screening and genetic testing as p art of the diagnostic assessment. Many of the genes associated with ASD are involved in maintaining the integrity of the synapse and DNA structure within neurons. This provides some evidence that the genes involved in ASD are likely to be part of one or mo re common pathways. • Many obstetric complications have been studied as possibly associated with autism. These include extreme prematurity, hypoxia, bleeding during pregnancy, Caesarean delivery, maternal gestational diabetes, medication use (valproate), bre ech presentation and neonatal encephalopathy. • A systematic review by De Cook et al. (2012) evaluated the role of endocrine disruptors such as bisphenol A (BPA), phthalates, pesticides, and hazardous air pollutants (HAPs) in the environment. The authors co ncluded that there was possibly a positive relationship between exposure to pesticides in the atmosphere and the prevalence of ASD in that region. It appears that individuals who were exposed to thalidomide prenatally were 50 times more likely to have a child with ASD than mothers in the general population. VPA, an anti -epileptic drug, is another teratogen and has been shown to increase the prevalence among those exposed by 8 –18 times compared to the general population • Out of the four studies that were revi ewed, three reported an increased risk of autism in children from mothers with a different ethnic origin, with one study indicating a greater risk for immigrant mothers from East Asia • Four reviews suggest that both advanced maternal and paternal age are ri sk factors for autism, with paternal age perhaps playing a more significant role. Fathers over the age of 50 have the greatest risk of having an offspring with autism compared to fathers below 30 years of age • The most consistent and well -replicated finding has been that 25 –50% of children and adolescents with autism have elevated serotonin levels in blood and platelets • OT and arginine vasopressin (AVP) are important regulators of complex social behaviors. There have been some reports of differences in level s of peripheral OT and AVP in children with autism compared to age -matched controls.
