Module 1: Classificatory Systems and Neurodevelopmental Disorders

Unit 1: Current classification systems: DSM 5 and ICD 11; Case history and MSE, Clinical
formulation.
Unit 2: Conceptualizing childhood psychopathology: Behavioural deficit and behavioural
excess,
Psychopathologies of timing, quantity versus quality distinction, equifinality and
multifinality, Interviewing and taking case history of children.
Unit 3: Intellectual Disabilities, Autism Spectrum Disorder, Specific Learning disorders and
Communication Disorders
Unit 4: Separation Anxiety disorder, School Phobia, Selective Mutism, Reactive Attachment
Disorder, ADHD,
Unit 5: Conduct Disorder, Oppositional Defiant Disorder, Tic Disorders, Elimination
disorders-
Encopresis and Enuresis, Eating Disorders- Pica, Anorexia Nervosa, Bulimia Nervosa,

Intellectual disability
Intellectual disability, formerly known as mental retardation, can be caused by a range of
environmental and genetic factors that lead to a combination of cognitive and social
impairments. The American Association on Intellectual and Developmental Disability
(AAIDD) defines intellectual disability as a disability characterized by significant limitations
in both intellectual functioning (reasoning, learning, and problem solving) and in adaptive
behavior (conceptual, social, and practical skills) that emerges before the age of 18 years.
In DSM 5, various levels of severity of intellectual disability are determined on the basis of
adaptive functioning, not on IQ scores.
DSM 5 criteria
Intellectual disability (intellectual development disorder) is a disorder with onset during the
developmental period that includes both intellectual and adaptive functioning deficits in
conceptual, social, and practical domains. The following three criteria must be met:
A. Deficits in intellectual functions, such as reasoning, problem solving, planning, abstract
thinking, judgment, academic learning, and learning from experience, confirmed by both
clinical assessment and individualized, standardized intelligence testing.
B. Deficits in adaptive functioning that result in failure to meet developmental and
sociocultural standards for personal independence and social responsibility. Without ongoing
support, the adaptive deficits limit functioning in one or more activities of daily life, such as
communication, social participation, and independent living, across multiple environments,
such as home, school, work, and community.
C. Onset of intellectual and adaptive deficits during the developmental period.

The severity levels of intellectual disability are expressed in DSM-5 as mild, moderate,
severe, and profound.
 Mild – IQ for this level of adaptive function may typically range from 50 to 70.
Can develop social and communication skills; minimal retardation in sensorimotor
areas; often not distinguished from normal until later age.

 Moderate - IQ for this level of adaptive function may typically range from 35 to 50.
Can talk or learn to communicate; poor social awareness; fair motor
development; profits from training in self-help; can be managed with moderate
supervision

 Severe - IQ in individuals with this level of adaptive function may typically range from
20 to 35.
Poor motor development; speech minimal; generally unable to profit from training in self-
help; little or no communication skills

 Profound - IQ in individuals with this level of adaptive function may typically be less
than 20.
Gross disability; minimal capacity for functioning in sensorimotor areas; needs nursing
care; constant aid and supervision required
Epidemiology
 The prevalence of intellectual disability at any one time is estimated to range from
1 to 3 percent of the population in Western societies.
 The incidence of intellectual disability is difficult to accurately calculate because
mild dis abilities may be unrecognized until middle childhood.
 The highest incidence of intellectual disability is reported in school age children,
with the peak at ages 10 to 14 years.
 Intellectual disability is about 1.5 times more common among males than females.

Comorbidity
 An epidemiological study found that 40.7 percent of intellectually disabled children
between 4 and 18 years of age met criteria for at least one additional psychiatric
disorder.
  An epidemiological study found that 40.7 percent of intellectually disabled children
between 4 and 18 years of age met criteria for at least one additional psychiatric
disorder
 Disruptive and conduct-disorder behaviors occurred more frequently in those
diagnosed with mild intellectual disability
 Comorbidity of psychiatric disorders with intellectual disability in children in this
study was not correlated with age or gender.
 Psychiatric disorders among persons with intellectual dis ability are varied, and
include mood disorders, schizophrenia, attention-deficit/hyperactivity disorder
(ADHD), and conduct disorder.
 Children diagnosed with severe intellectual disability have a particularly high rate of
comorbid autism spectrum disorder
 Frequent psychiatric symptoms that occur in children with intellectual disability,
outside the context of a full psychiatric disorder, include hyperactivity and short
attention span, self-injurious behaviors (e.g., head-banging and self-biting), and
repetitive stereotypical behaviors (hand-flapping and toe-walking).
 In children and adults with milder forms of intellectual disability, negative self-image,
low self-esteem, poor frustration tolerance, interpersonal dependence, and a rigid
problem-solving style are common.
Causal factors
Etiological factors in intellectual disability can be genetic, developmental, environmental, or
a combination.
Genetical
 One of the most well-known single gene causes of intellectually disability is found in
the FMRJ gene whose mutations cause fragile X syndrome.
 Abnormalities in autosomal chromosomes are frequently associated with intellectual
disability, whereas aberrations in sex chromosomes can result in characteristic
physical syndromes that do not include intellectual disability.
 Visible and Submicroscopic Chromosomal Causes of Intellectual Disability

Acquired and developmental factors

Prenatal period:
 Maternal chronic illnesses and conditions affecting the normal development of the
fetus's CNS include uncontrolled diabetes, anaemia, emphysema, hypertension, and
long-term use of alcohol and narcotic substances.
 Maternal infections during pregnancy, especially viral infections, have been known to
cause fetal damage and intellectual disability.
HIV (Human immunodeficiencey virus):
  Cognitive impairments are well known to be associated with transmission of HIV
from mothers to their babies.
 HIV may have both direct and indirect influences on the developing brain.
Complications of Pregnancy:
 Toxemia of pregnancy and uncontrolled maternal diabetes present hazards to the fetus
and can potentially result in intellectual disability
Perinatal Period:
 Some evidence indicates that premature infants and infants with low birth weight are
at high risk for neurological and subtle intellectual impairments that may not be
apparent until their school years.
Acquired Childhood disorders like infection, Head trauma, Asphyxia and Long-term
exposure to Lead and chemotherapy can also adversely affect brain function.
Environmental and Sociocultural Factors
Mild intellectual disability has been associated with significant deprivation of nutrition and
nurturance. Children who have endured these conditions are at risk for a host of psychiatric
disorders including mood disorders, posttraumatic stress disorder, and attentional and anxiety
disorders. Prenatal environment compromised by poor medical care and poor maternal
nutrition may be contributing factors in the development of mild intellectual disability.
Teenage pregnancies are at risk for mild intellectual disability in the baby due to the increased
risk of obstetrical complications, prematurity, and low birth weight. Poor postnatal medical
care, malnutrition, exposure to toxic substances such as lead, and potential physical trauma
are additional risk factors for mild intellectual disabilities. Child neglect and inadequate
caretaking may deprive an infant of both physical and emotional nurturance, leading to
failure to thrive syndromes.
Diagnosis
The diagnosis of intellectual disability can be made after the history is obtained, using
information from a standardized intellectual assessment, and a standardized measure of
adaptive function indicating that a child is significantly below the expected level in both
areas. The severity of the intellectual disability will be determined on the basis of the level of
adaptive function.
Clinical features
 Mild intellectual disability may not be recognized or diagnosed in a child until school
challenges the child's social and communication skills.
 Cognitive deficits include poor ability to abstract and egocentric thinking, both of
which become more easily evident as a child reaches middle childhood.
 Communication deficits, poor self-esteem, and dependence may further contribute to
a relative lack of social spontaneity.
  Moderate levels of intellectual disability are significantly more likely to be observed
at a younger age, since communication skills develop more slowly and social isolation
may ensue in the elementary school years.
 They continue to require a relatively high level of supervision but can become
competent at occupational tasks in supportive settings.
 Severe intellectual disability is typically obvious in the preschool years; affected
children have minimal speech and impaired motor development.
 Behavioral approaches are useful means to promote some self-care, although those
with severe intellectual disability generally need extensive supervision.
 Children with profound intellectual disability require constant supervision and are
severely limited in both communication and motor skills.
 By adulthood, some speech development may be present, and simple self-help skills
may be acquired.
OR
Clinical features frequently observed in populations with intellectual dis ability either in
isolation or as part of a mental disorder, include hyperactivity, low frustration tolerance,
aggression, affective instability, repetitive and stereotypic motor behaviors, and self-injurious
behaviors. Self-injurious behaviors occur more frequently and with greater intensity in more
severe intellectual disability.
Course and prognosis
 Although the underlying intellectual impairment does not improve, in most cases of
intellectual disability, level of adaptation increases with age and can be influenced
positively by an enriched and supportive environment.
 In general, persons with mild and moderate mental intellectual disabilities have the
most flexibility in adapting to various environmental conditions.
 Comorbid psychiatric disorders negatively impact overall prognosis.
 When psychiatric disorders are superimposed on intellectual disability, standard
treatments for the comorbid mental disorders are often beneficial
Differential diagnosis
 Sensory deficits
 Expressive and receptive speech disorders
 failure to read (alexia), failure to write (agraphia), or failure to communicate (aphasia)
Treatments
Interventions for children and adolescents with intellectual disability are based on an
assessment of social, educational, psychiatric, and environmental needs. Intellectual disability
is associated with a variety of comorbid psychiatric disorders that often require specific
treatment, in addition to psychosocial support.
Primary prevention comprises actions taken to eliminate or reduce the conditions that lead to
development of intellectual disability, as well as associated disorders.
Secondary and tertiary prevention includes:
 educational interventions
 Behavioural and cognitive-behavioural interventions
 Family education
 Social intervention
 Psychopharmacologic interventions


Autism spectrum disorder

One of the most disabling of the childhood disorders is autistic disorder, which is often
referred to as autism, childhood autism, or, in the DSM-5, autism spectrum disorder. It is a
developmental disorder that involves a wide range of problematic behaviors including
deficits in language and perceptual and motor development; defective reality testing; and an
inability to function in social situations. Autistic disorder was characterized by impairments
in three domains: social communication, restricted and repetitive behaviors, and aberrant
language development and usage. Children with autism show varying degrees of impairments
and capabilities.

DSM 5 Criteria
A. Persistent deficits in social communication and social interaction across multiple
contexts, as manifested by the following, currently or by history.

1. Deficits in social-emotional reciprocity, ranging, for example, from abnormal social

approach and failure of normal back-and-forth conversation; to reduced sharing of
interests, emotions, or affect; to failure to initiate or respond to social interactions.
2. Deficits in nonverbal communicative behaviors used for social interaction, ranging,
for example, from poorly integrated verbal and nonverbal communication; to
abnormalities in eye contact and body language or deficits in understanding and use
of gestures; to a total lack of facial expressions and nonverbal communication.
3. Deficits in developing, maintaining, and understanding relationships, ranging, for
example, from difficulties adjusting behavior to suit various social contexts; to
difficulties in sharing imaginative play or in making friends; to absence of interest in
peers.
B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least
two of the following, currently or by history
 1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple
motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases).

2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of

verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulties with
transitions, rigid thinking patterns, greeting rituals, need to take same route or eat
same food every day)

3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g.,
strong attachment to or preoccupation with unusual objects, excessively
circumscribed or perseverative interests).

4. Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of

the environment (e.g., apparent indifference to pain/temperature, adverse response to
specific sounds or textures, excessive smelling or touching of objects, visual
fascination with lights or movement).

C. Symptoms must be present in the early developmental period (but may not become fully
manifest until social demands exceed limited capacities, or may be masked by learned
strategies in later life).
D. Symptoms cause clinically significant impairment in social, occupational, or other
important areas of current functioning.
E. These disturbances are not better explained by intellectual disability (intellectual
developmental disorder) or global developmental delay. Intellectual disability and autism
spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum
disorder and intellectual disability, social communication should be below that expected for
general developmental level.

Prevalence
In recent years, reported frequencies for autism spectrum disorder across U.S. and non-U.S.
countries have approached 1% of the population, with similar estimates in child and adult
samples. Autism spectrum disorder is diagnosed four times more often in boys than in girls.
In clinical samples, girls with autism spectrum disorder more often exhibit intellectual
disability than boys. One potential explanation for this is that girls with autism spectrum
disorder without intellectual disability may be less likely to be identified, referred clinically,
and diagnosed.
Associated features
 Many individuals also have intellectual impairment and/or language impairment (e.g.,
slow to talk, language comprehension behind production).
  Motor deficits are often present, including odd gait, clumsiness, and other abnormal
motor signs (e.g., walking on tiptoes).
 injury (e.g., head banging, biting the wrist) may occur, and disruptive/challenging
behaviors are more common in children and adolescents with autism spectrum
disorder than other disorders, including intellectual disability
 Adolescents and adults with autism spectrum disorder are prone to anxiety and
depression.
 Some individuals develop catatonic-like motor behavior (slowing and “freezing” mid-
action),

Development and Course

Autism spectrum disorder is typically evident during the second year of life, and in severe
cases, a lack of developmentally appropriate interest in social interactions may be noted even
in the first year. Some studies suggest that a decline in social interaction may ensue between
the first and second years of life. In up to 25 percent of cases of autism spectrum disorder,
some language develops and is subsequently lost. Autism spectrum disorder in children with
normal intellectual function and mild impairment in language function may not be identified
until middle childhood when both academic and social demands are increased. Some children
experience developmental regression, with a gradual or relatively rapid deterioration in social
behaviors or use of language, often during the first 2 years of life. Deafness may be suspected
but is typically ruled out. The clinical distinction is based on the type, frequency, and
intensity of the behavior (e.g., a child who daily lines up objects for hours and is very
distressed if any item is moved). Symptoms are often most marked in early childhood and
early school years, with developmental gains typical in later childhood in at least some areas
(e.g., increased interest in social interaction). A small proportion of individuals deteriorate
behaviorally during adolescence, whereas most others improve. Many adults report using
compensation strategies and coping mechanisms to mask their difficulties in public but suffer
from the stress and effort of maintaining a socially acceptable facade. Scarcely anything is
known about old age in autism spectrum disorder.

Causal factors
Genetic Factors
Family studies have demonstrated increased rates of autism spectrum disorder in siblings of
an index child, as high as 50 percent in some families with two or more children with autism
spectrum disorder. Siblings of a child with autism spectrum disorder are also at increased risk
for a variety of developmental impairments in communication and social skills, even when
they do not meet criteria for autism spectrum disorder. Studies indicate that both an increase
and decrease in certain genetic patterns may be risk factors for autism spectrum disorder. In
addition to specific genetic factors, gender plays a strong role in the expression of autism
spectrum disorder. Currently, as many as 15% of cases of autism spectrum disorder appear to
be associated with a known genetic mutation, with different de novo copy number variants or
de novo mutations in specific genes associated with the disorder in different families.
 The most significant prenatal factors associated with autism spectrum disorder in the
offspring are advanced maternal and paternal age at birth, maternal gestational
bleeding, gestational diabetes, and first-born baby
 Perinatal risk factors for autism spectrum disorder include umbilical cord
complications, birth trauma, fetal distress, small for gestational age, low birth weight,
low 5-minute Apgar score, congenital malformation etc.

Differential diagnosis
 Social (pragmatic) communication disorder
 Childhood Onset Schizophrenia
 Intellectual Disability with Behavioral Symptoms
 Language Disorder
 Congenital Deafness or Hearing Impairment

Treatments
Pharmacotherapy
The drugs most often used in the treatment of autism are antidepressant, antipsychotic
medication, and stimulants; but the data on their effectiveness do not support their use unless
a child’s behavior is unmanageable by other means.
Behavioral treatment
Behavior therapy in an institutional setting has been used successfully in the elimination of
self-injurious behavior, the mastery of the fundamentals of social behavior, and the
development of some language skills. Some studies show that intensive behavioral treatment
of children with autism, requiring a significant investment of time and energy on the part of
therapist and parents, can bring about improvement, particularly if this treatment continues at
home rather than in an institution.
CBT
There are at least two published studies in which CBT was used to treat repetitive behavior in
individuals with autism spectrum disorder.
Communication Disorders
Disorders of communication include deficits in language, speech, and communication.
Speech is the expressive production of sounds and includes an individual’s articulation,
fluency, voice, and resonance quality. Language includes the form, function, and use of a
conventional system of symbols (i.e., spoken words, sign language, written words, pictures in
a rule governed manner for communication. Communication includes any verbal or
nonverbal behavior that influences the behavior, ideas, or attitudes of another individual.
According to DSM 5, Language Disorder includes both expressive and mixed receptive-
expressive problems, speech disorders include Speech Sound Disorder (formerly known as
Phonological Disorder) and Childhood Onset Fluency Disorder (stuttering). There also social
(pragmatic) communication disorder, and other specified and unspecified communication
disorders.
Language Disorder
Language disorder consists of difficulties in the acquisition and use of language across many
modalities, including spoken and written, due to deficits in comprehension or production
based on both expressive and receptive skills. These deficits include reduced vocabulary,
limited abilities in forming sentences using the rules of grammar, and impairments in
conversing based on difficulties using vocabulary to connect sentences in descriptive ways.
DSM 5 CRITERIA
A. Persistent difficulties in the acquisition and use of language across modalities (i.e., spoken,
written, sign language, or other) due to deficits in comprehension or production that include
the following:
1. Reduced vocabulary (word knowledge and use)
2. Limited sentence structure (ability to put words and word endings together to form
sentences based on the rules of grammar and morphology).
3. Impairments in discourse (ability to use vocabulary and connect sentences to explain or
describe a topic or series of events or have a conversation)
B. Language abilities are substantially and quantifiably below those expected for age,
resulting in functional limitations in effective communication, social participation, academic
achievement, or occupational performance, individually or in any combination.
C. Onset of symptoms is in the early developmental period.
D. The difficulties are not attributable to hearing or other sensory impairment, motor
dysfunction, or another medical or neurological condition and are not better explained by
intellectual disability (intellectual developmental disorder) or global developmental delay.
Associated features supporting Diagnosis
 A positive family history of language disorders is often present.
 Individuals, even children, can be adept at accommodating to their limited language.
They may appear to be shy or reticent to talk.
 Affected individuals may prefer to communicate only with family members or other
familiar individuals.
 Although these social indicators are not diagnostic of a language disorder, if they are
notable and persistent, they warrant referral for a full language assessment. Language
disorder, particularly expressive deficits, may co-occur with speech sound disorder.
Development and course
 Language acquisition is marked by changes from onset in toddlerhood to the adult
level of competency that appears during adolescence.
 Changes appear across the dimensions of language (sounds, words, grammar,
narratives/expository texts, and conversational skills) in age graded increments and
synchronies.
 Language disorder emerges during the early developmental period; however, there is
considerable variation in early vocabulary acquisition and early word combinations.
 By age 4 years, individual differences in language ability are more stable, with better
measurement accuracy, and are highly predictive of later outcomes.
 Language disorder diagnosed from 4 years of age is likely to be stable over time and
typically persists into adulthood, although the particular profile of language strengths
and deficits is likely to change over the course of development.
Risk factors
• Children with receptive language impairments have a poorer prognosis than those with
predominantly expressive impairments.
• They are more resistant to treatment, and difficulties with reading comprehension are
frequently seen.
• Genetics and physiological: Language disorders are highly heritable, and family members
are more likely to have a history of language impairment.

Differential Diagnosis
Normal variations in language:
• Language disorder needs to be distinguished from normal developmental variations.
• distinction may be difficult to make before 4 years of age.
• Regional, social, or cultural/ethnic variations of language (e.g., dialects) must be considered
when an individual is being assessed for language impairment
Hearing impairment
• needs to be excluded as the primary cause of language difficulties.
• Language deficits may be associated with a hearing impairment, other sensory deficit, or a
speech-motor deficit.
• When language deficits are in excess of those usually associated with these problems, a
diagnosis of language disorder may be made.
Intellectual disability (intellectual developmental disorder).
• Language delay is often the presenting feature of intellectual disability, and
• the definitive diagnosis may not be made until the child is able to complete standardized
assessments.
• A separate diagnosis is not given unless the language deficits are clearly in excess of the
intellectual limitations.
Neurological disorders:
• Language disorder can be acquired in association with neurological disorders, including
epilepsy (e.g., acquired aphasia or Landau Kleffner syndrome).
Language regression:
• Loss of speech and language in a child younger than 3 years may be a sign of autism
spectrum disorder (with developmental regression) or a specific neurological condition, such
as Landau-Kleffner syndrome.
• Among children older than 3 years, language loss may be a symptom of seizures, and a
diagnostic assessment is necessary to exclude the presence of epilepsy (e.g., routine and sleep
electroencephalogram).
Comorbidity
•Language disorder is strongly associated with other neurodevelopmental disorders in terms
of
• specific learning disorder (literacy and numeracy),
• attention-deficit/hyperactivity disorder,
• autism spectrum disorder, and
• developmental coordination disorder.
• It is also associated with social (pragmatic) communication disorder.
• A positive family history of speech or language disorders is often present.

Speech Sound Disorder

Children with speech sound disorder have difficulty pronouncing speech sounds correctly due
to omissions of sounds, distortions of sounds, or atypical pronunciation. Formerly called
phonological disorder, typical speech disturbances in speech sound disorder include omitting
the last sounds of the word (e.g., saying mou for mouse or drin for drink), or substituting one
sound for another (saying bwu instead of blue or tup for cup). Speech sound errors can also
occur in patterns because a child has an interrupted airflow instead of a steady airflow
preventing their words to be pronounced (e.g., pat for pass or bacuum for vacuum).
• Speech sound production describes the clear articulation of the phonemes (i.e., individual
sounds) that in combination make up spoken word
• Speech sound production requires both the phonological knowledge of speech sounds and
the ability to coordinate the movements of the articulators (i.e., the jaw, tongue, and lips,)
with breathing and vocalizing for speech
• Speech sound disorder is thus heterogeneous in its underlying mechanisms and includes
phonological disorder and articulation disorder.
• diagnosed when speech sound production is not what would be expected based on the
child’s age and developmental stage and when the deficits are not the result of a physical,
structural, neurological, or hearing impairment.
• Among typically developing children at age 4 years, overall speech should be intelligible,
whereas at age 2 years, only 50% may be understandable.
DSM 5 criteria
A. Persistent difficulty with speech sound production that interferes with speech intelligibility
or prevents verbal communication of messages.
B. The disturbance causes limitations in effective communication that interfere with social
participation, academic achievement, or occupational performance, individually or in any
combination
C. Onset of symptoms is in the early developmental period
D. The difficulties are not attributable to congenital or acquired conditions, such as cerebral
palsy, cleft palate, deafness or hearing loss, traumatic brain injury, or other medical or
neurological conditions.

Associated features
Language disorder, particularly expressive deficits, may be found to co-occur with speech
sound disorder.
 A positive family history of speech or language disorders is often present.  If the ability to
rapidly coordinate the articulators is a particular aspect of difficulty, there may be a history of
delay or incoordination in acquiring skills that also utilize the articulators and related facial
musculature; among others, these skills include chewing, maintaining mouth closure, and
blowing the nose.
Other areas of motor coordination may be impaired as in developmental coordination
disorder.
• Verbal dyspraxia is a term also used for speech production problems.
• Speech may be differentially impaired in certain genetic conditions (e.g., Down syndrome,
22q deletion, Fox P2 gene mutation). If present, these should also be coded.
Development and course
• Developmental skills - learning to produce speech sounds clearly and accurately and
learning to produce connected speech fluently.
• Articulation of speech sounds follows a developmental pattern
• Children with this disorder continue to use immature phonological simplification processes
past the age when most children can produce words clearly.
• Most speech sounds should be produced clearly and most words should be pronounced
accurately according to age and community norms by age 7 years.
• The most frequently misarticulated sounds also tend to be learned later, leading them to be
called the “late eight” (l, r, s, z, th, ch, dzh, and zh).
• Misarticulation of any of these sounds by itself could be considered within normal limits up
to age 8 years.
• When multiple sounds are involved, it may be appropriate to target some of those sounds as
part of a plan to improve intelligibility prior to the age at which almost all children can
produce them accurately.
• Lisping (i.e., misarticulating sibilants) is particularly common and may involve frontal or
lateral patterns of airstream direction. It may be associated with an abnormal tongue-thrust
swallowing pattern.
• Most children with speech sound disorder respond well to treatment, and speech difficulties
improve over time, and thus the disorder may not be lifelong.
• However, when a language disorder is also present, the speech disorder has a poorer
prognosis and may be associated with specific learning disorders.

Differential diagnosis
 Normal variations in speech: Regional, social, or cultural/ethnic variations of speech
should be considered before making the diagnosis.
 Hearing or other sensory impairment:
▪ Hearing impairment or deafness may result in abnormalities of speech.
 ▪ Deficits of speech sound production may be associated with a hearing impairment,
other sensory deficit, or a speech-motor deficit.
▪ When speech deficits are in excess of those usually associated with these problems,
a diagnosis of speech sound disorder may be made.
 Structural deficits: Speech impairment may be due to structural deficits (e.g., cleft
palate).
 Dysarthria:

• Speech impairment may be attributable to a motor disorder, such as cerebral palsy.

• Neurological signs, as well as distinctive features of voice, differentiate dysarthria

from speech sound disorder, although in young children (under 3 years) differentiation
may be difficult, particularly when there is no or minimal general body motor
involvement (as in, e.g., Worster-Drought syndrome).
 Selective Mutism:
▪ Limited use of speech may be a sign of selective mutism, an anxiety disorder that is
characterized by a lack of speech in one or more contexts or settings.
▪ Selective mutism may develop in children with a speech disorder because of
embarrassment about their impairments,
▪ but many children with selective mutism exhibit normal speech in “safe” settings,
such as at home or with close friends.
Comorbidity
 Speech sound disorders (SSD) are often comorbid with other disorders, including:
• Language impairment (LI): 11–15% of children with SSD also have LI at age 6.
• Reading disorders (RD): 18% of children with SSD-only and 75% of children with SSD+LI
have RD at school age.
• Attention deficit-hyperactivity disorder (ADHD): Children with SSD and SLI have higher
rates of inattentive ADHD symptoms.
• Intellectual disability (ID): ID has a significant effect on global functioning in SSD.

Childhood-Onset Fluency Disorder (Stuttering)

Child-onset fluency disorder (stuttering) usually begins during the first years of life and is
characterized by disruptions in the normal flow of speech by involuntary speech motor
events. Stuttering can include a variety of specific disruptions of fluency, including sound or
syllable repetitions, sound prolongations, dysrhythmic phonations, and complete blocking or
unusual pauses between sounds and syllables of words. In severe cases, the stuttering may be
accompanied by accessory or secondary attempts to compensate such as respiratory,
abnormal voice phonations, or tongue clicks. Associated behaviors, such as eye blinks, facial
grimacing, head jerks, and abnormal body movements, may be observed before or during the
disrupted speech.
DSM 5 criteria
A. Disturbances in the normal fluency and time patterning of speech that are inappropriate for
the individual’s age and language skills, persist over time, and are characterized by frequent
and marked occurrences of one (or more) of the following:
1. Sound and syllable repetitions.
2. Sound prolongations of consonants as well as vowels.
3. Broken words (e.g., pauses within a word).
4. Audible or silent blocking (filled or unfilled pauses in speech).
5. Circumlocutions (word substitutions to avoid problematic words).
6. Words produced with an excess of physical tension.
7. Monosyllabic whole-word repetitions (e.g., “I-I-I-I see him”).
B. The disturbance causes anxiety about speaking or limitations in effective communication,
social participation, or academic or occupational performance, individually or in any
combination.
C. The onset of symptoms is in the early developmental period. (Note: Later-onset cases are
diagnosed as 307.0 [F98.5] adult-onset fluency disorder.)
D. The disturbance is not attributable to a speech-motor or sensory deficit, dysfluency
associated with neurological insult (e.g., stroke, tumor, trauma), or another medical condition
and is not better explained by another mental disorder.
Associated Features Supporting Diagnosis
 Fearful anticipation of the problem may develop.
 Attempt to avoid dysfluencies by
1. linguistic mechanisms (e.g., altering the rate of speech, avoiding certain words or
sounds) or
2. avoiding certain speech situations, such as telephoning or public speaking.  stress
and anxiety have been shown to exacerbate dysfluency.
 Accompanied by motor movements (e.g., eye blinks, tics, tremors of the lips or face,
jerking of the head, breathing movements, fist clenching).
 Children with fluency disorder show a range of language abilities, and the relationship
between fluency disorder and language abilities is unclear
Development and Course
 Childhood-onset fluency disorder, or developmental stuttering, occurs by age 6 for
80% 90% of affected individuals, with age at onset ranging from 2 to 7 years.
 The onset can be insidious or more sudden.
  Typically, dysfluencies start gradually, with repetition of initial consonants, first
words of a phrase, or long words.
 The child may not be aware of dysfluencies.
 As the disorder progresses, the dysfluencies become more frequent and
interfering, occurring on the most meaningful words or phrases in the utterance.
 As the child becomes aware of the speech difficulty, he or she may develop
mechanisms for avoiding the dysfluencies and emotional responses, including
avoidance of public speaking and use of short and simple utterances.
 Longitudinal research shows that 65%–85% of children recover from the
dysfluency, with severity of fluency disorder at age 8 years predicting recovery or
persistence into adolescence and beyond.

Risk and Prognostic Factors

Genetic and physiological factors: The risk of stuttering among first-degree biological
relatives of individuals with childhood-onset fluency disorder is more than three times the
risk in the general population

Differential Diagnosis
 Sensory deficits: Dysfluencies of speech may be associated with a hearing impairment
or other sensory deficit or a speech-motor deficit. When the speech dysfluencies are in
excess of those usually associated with these problems, a diagnosis of childhood-onset
fluency disorder may be made.
 Normal speech dysfluencies: The disorder must be distinguished from normal
dysfluencies that occur frequently in young children, which include whole-word or
phrase repetitions (e.g., “I want, I want ice cream”), incomplete phrases, interjections,
unfilled pauses, and parenthetical remarks.
If these difficulties increase in frequency or complexity as the child grows older, a
diagnosis of childhood-onset fluency disorder is appropriate.
• Medication side effects: Stuttering may occur as a side effect of medication and may be
detected by a temporal relationship with exposure to the medication.
• Adult-onset dysfluencies: If onset of dysfluencies is during or after adolescence, it is an
“adult-onset dysfluency” rather than a neurodevelopmental disorder. Adult onset
dysfluencies are associated with specific neurological insults and a variety of medical
conditions and mental disorders and may be specified with them, but they are not a DSM-
5 diagnosis.
• Tourette’s disorder: Vocal tics and repetitive vocalizations of Tourette’s disorder should
be distinguishable from the repetitive sounds of childhood-onset fluency disorder by their
nature and timing.
Social (Pragmatic) Communication Disorder
A. Persistent difficulties in the social use of verbal and nonverbal communication as
manifested by all of the following:
1.Deficits in using communication for social purposes, such as greeting and sharing
information, in a manner that is appropriate for the social context.
2. Impairment of the ability to change communication to match context or the needs of the
listener, such as speaking differently in a classroom than on a playground, talking differently
to a child than to an adult, and avoiding use of overly formal language.
3. Difficulties following rules for conversation and storytelling, such as
• taking turns in conversation,
• rephrasing when misunderstood, and
• knowing how to use verbal and nonverbal signals to regulate interaction.
4. Difficulties understanding what is not explicitly stated (e.g., making inferences) and
nonliteral or ambiguous meanings of language (e.g., idioms, humor, metaphors, multiple
meanings that depend on the context for interpretation).
B. The deficits result in functional limitations in effective communication, social
participation, social relationships, academic achievement, or occupational performance,
individually or in combination.
C. The onset of the symptoms is in the early developmental period.
D. The symptoms are not attributable to another medical or neurological condition or to low
abilities in the domains of word structure and grammar, and are not better explained by
autism spectrum disorder, intellectual disability (intellectual developmental disorder), global
developmental delay, or another mental disorder.
Associated Features Supporting Diagnosis
 The most common associated feature is language impairment, which is characterized
by a history of delay in reaching language milestones.
 Individuals with social communication deficits may avoid social interactions.
 Attention-deficit/hyperactivity disorder (ADHD), behavioral problems, and specific
learning disorders are also more common among affected individuals.

Development and Course

  Diagnosis of social (pragmatic) communication disorder is rare among children
younger than 4 years. Because of social (pragmatic) communication depends on
adequate developmental progress in speech and language,
 By age 4 or 5 years, most children should possess adequate speech and language
abilities to permit identification of specific deficits in social communication.
 Milder forms of the disorder may not become apparent until early adolescence,
 The outcome of social (pragmatic) communication disorder is variable, with some
children improving substantially over time and others continuing to have difficulties
persisting into adulthood.
 Even among those who have significant improvements, the early deficits in
pragmatics may cause lasting impairments in social relationships and behavior and
also in acquisition of other related skills, such as written expression.
Differential Diagnosis
➢ autism spectrum disorder:

• It is the primary diagnostic consideration for individuals presenting with social

communication deficits.
• The two disorders can be differentiated by the presence in autism spectrum disorder of
restricted/ repetitive patterns of behavior, interests, or activities and their absence in social
(pragmatic) communication disorder.
• comprehensive history should be obtained – because individuals with autism spectrum
disorder may only display the restricted/repetitive patterns of behavior, interests, and
activities during the early developmental period.
• Current absence of symptoms would not preclude a diagnosis of autism spectrum disorder,
if the restricted interests and repetitive behaviors were present in the past.
• A diagnosis of social (pragmatic) communication disorder should be considered only if the
developmental history fails to reveal any evidence of restricted/repetitive patterns of
behavior, interests, or activities.
➢ Attention-deficit/hyperactivity disorder:

• Primary deficits of ADHD may cause impairments in social communication and functional
limitations of effective communication, social participation, or academic achievement.
➢ Social anxiety disorder (social phobia):

• The symptoms of social communication disorder overlap with those of social anxiety
disorder. • The differentiating feature is the timing of the onset of symptoms.
• In social (pragmatic) communication disorder, the individual has never had effective social
communication.
• in social anxiety disorder, the social communication skills developed appropriately but are
not utilized because of anxiety, fear, or distress about social interactions.
➢ Intellectual disability (intellectual developmental disorder) and global developmental
delay: • Social communication skills may be deficient among individuals with global
developmental delay or intellectual disability.
• but a separate diagnosis is not given unless the social communication deficits are clearly in
excess of the intellectual limitations.

Unspecified Communication Disorder

 This category applies to presentations in which symptoms characteristic of
communication disorder that cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning predominate but do not
meet the full criteria for communication disorder or for any of the disorders in the
neurodevelopmental disorders diagnostic class.
 The unspecified communication disorder category is used in situations in which the
clinician chooses not to specify the reason that the criteria are not met for
communication disorder or for a specific neurodevelopmental disorder, and includes
presentations in which there is insufficient information to make a more specific
diagnosis.

Treatment
Individualized Treatment Plan
 Therapy is usually provided individually. In some cases, group therapy is most
beneficial for the child.
 Target the specific difficulties that the child is experiencing.
 The model of therapy (individual or group) and the frequency of therapy are always
determined by considering the specific needs of the child and the family.
 In each therapy session, the goal is to help the child perform a certain task or tasks.
 Once the child is able to perform the task, frequent practice at home is essential.
 Therefore, parents are important members of the child’s treatment team.
Speech Therapy
 Speech-language pathologist gathers additional information from family members,
observes the child’s communication interactions, and administers standardized formal
tests.
 speech therapy exercises that focus on building familiarity with certain words or
sounds

Language activities
  Involves playing and talking with the child while using pictures, books, and objects to
stimulate language development.
 The SLP may also demonstrate correct pronunciation and use repetition exercises to
help increase the child’s language skills.
Articulation activities
 These will involve the SLP working closely with a child to help them with their
pronunciation.
 The SLP will demonstrate how to make specific sounds, often during play activities
Exercises:
 The SLP may use a number of tongue, lip, and jaw exercises, alongside facial
massage
 to help strengthen the muscles around the mouth.
 This can help them with future speech and communication.
Contrast therapy
 Contrast therapy involves saying word pairs that contain one or more different speech
sounds. An example word pair might be “beat” and “feet” or “dough” and “show.
Oral-motor therapy
 The oral-motor therapy approach focuses on improving muscle strength,  motor
control, and breath control.
 These exercises can help people develop fluency, which produces smoother speech
that sounds more natural.
Therapies For Stuttering
 Fluency shaping therapy
 Fluency shaping therapy involves teaching a person to stretch vowels and
consonants. This can help a person speak at higher speeds and use longer
sentences and phrases.
 One technique involves practicing smooth, fluent speech at a very slow speed,
using short sentences and phrases
 Stuttering modification therapy
 This therapy does not aim to eliminate the stutter.
 Instead, it aims to modify the stuttering to require less effort, making it easier for
someone to manage.
 This therapy works on the principle that if anxiety makes stuttering worse,
reducing the effort needed will alleviate the stuttering.
 Electronic fluency devices
 These devices use the so-called altered auditory feedback effect.  The person
wears an earpiece that echoes the speaker’s voice so that they feel they are talking
in unison with someone else.  Some people respond well to this treatment, but
others do not.
  Parent-implemented language interventions
 This approach involves a parent or caregiver using routines and activities to help
children develop their language skills.
 One study looked at parent-implemented language interventions with young
children between 18–60 months of age.
 The results showed that parents who implemented communication and language
interventions had a significant, positive impact on the language skills of children
with and without intellectual disabilities.
Specific Learning Disorders
Specific learning disorder in youth is a neurodevelopmental disorder produced by the
interactions of heritable and environmental factors that influence the brain's ability to
efficiently perceive or process verbal and nonverbal information. The inadequate
development found in learning disorders, a term that refers to delayed development, may be
manifested in language, speech, mathematical, or motor skills, and it is not necessarily due to
any demonstrable physical or neurological defect. Severe specific learning disorder may
make it agonizing for a child to succeed in school, often leading to demoralization, low self-
esteem, chronic frustration, and compromised peer relationships.
 An estimated 4 to 8 percent of youth in the United States have been identified with
dyslexia, encompassing a variety of reading, spelling, and comprehension deficits.
DSM 5 criteria
A. Difficulties learning and using academic skills, as indicated by the presence of at least
one of the following symptoms that have persisted for at least 6 months, despite the
provision of interventions that target those difficulties:
1. Inaccurate or slow and effortful word reading (e.g., reads single words aloud
incorrectly or slowly and hesitantly, frequently guesses words, has difficulty sounding
out words).
2. Difficulty understanding the meaning of what is read (e.g., may read text accurately
but not understand the sequence, relationships, inferences, or deeper meanings of what is
read). 3.Difficulties with spelling (e.g., may add, omit, or substitute vowels or
consonants).
4. Difficulties with written expression (e.g., makes multiple grammatical or punctuation
errors within sentences; employs poor paragraph organization; written expression of
ideas lacks clarity).
5. Difficulties mastering number sense, number facts, or calculation (e.g., has poor
understanding of numbers, their magnitude, and relationships; counts on fingers to add
single-digit numbers instead of recalling the math fact as peers do; gets lost in the midst
of arithmetic computation and may switch procedures).
6. Difficulties with mathematical reasoning (e.g., has severe difficulty applying
mathematical concepts, facts, or procedures to solve quantitative problems).
B. The affected academic skills are substantially and quantifiably below those expected for
the individual's chronological age, and cause significant interference with academic or
occupational performance, or with activities of daily living, as confirmed by individually
administered standardized achievement measures and comprehensive clinical assessment. For
individuals age 17 years and older, a documented history of impairing learning difficulties
may be substituted for the standardized assessment.
C. The learning difficulties begin during school-age years but may not become fully manifest
until the demands for those affected academic skills exceed the individual's limited capacities
(e.g., as in timed tests, reading or writing lengthy complex reports for a tight deadline,
excessively heavy academic loads).
D. The learning difficulties are not better accounted for by intellectual disabilities,
uncorrected visual or auditory acuity, other mental or neurological disorders, psychosocial
adversity, lack of proficiency in the language of academic instruction, or inadequate
educational instruction.

Course and prognosis

Children with reading disability may gain knowledge of printed language during their first 2
years in grade school, without remedial assistance. In severe cases and depending on the
pattern of deficits and strengths, remediation may be continued into the middle and high
school years.
Treatments
 Individual education program (IEP)
 Another approach teaches children with reading disorders to recognize whole words
through the use of visual aids and bypasses the sounding-out process.

Unit 4; Separation Anxiety disorder, School Phobia, Selective Mutism, Reactive

Attachment Disorder, ADHD

Separation anxiety disorder

Children with separation anxiety disorder exhibit unrealistic fears, oversensitivity, self-
consciousness, nightmares, and chronic anxiety. They lack self-confidence, are
apprehensive in new situations, and tend to be immature for their age. Such children are
described by their parents as shy, sensitive, nervous, submissive, easily discouraged,
worried, and frequently moved to tears. Typically, they are overly dependent, particularly
on their parents. The essential feature in the clinical picture of this disorder is excessive
anxiety about separation from major attachment figures, such as their mother, and from
familiar home surroundings.

DSM 5 criteria
A. Developmentally inappropriate and excessive fear or anxiety concerning separation
from those to whom the individual is attached, as evidenced by at least three of the
following:
1. Recurrent excessive distress when anticipating or experiencing separation from home
or from major attachment figures.
2. Persistent and excessive worry about losing major attachment figures or about possible
harm to them, such as illness, injury, disasters, or death.
3. Persistent and excessive worry about experiencing an untoward event (e.g., getting lost,
being kidnapped, having an accident, becoming ill) that causes separation from a major
attachment figure.
4. Persistent reluctance or refusal to go out, away from home, to school, to work, or
elsewhere because of fear of separation.
5. Persistent and excessive fear of or reluctance about being alone or without major
attachment figures at home or in other settings.
6. Persistent reluctance or refusal to sleep away from home or to go to sleep without
being near a major attachment figure.
7. Repeated nightmares involving the theme of separation. 8. Repeated complaints of
physical symptoms (e.g., headaches, stomach aches, nausea, vomiting) when separation
from major attachment figures occurs or is anticipated.
B. The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and
adolescents and typically 6 months or more in adults.
C. The disturbance causes clinically significant distress or impairment in social,
academic, occupational, or other important areas of functioning.
D. The disturbance is not better explained by another mental disorder, such as refusing to
leave home because of excessive resistance to change in autism spectrum disorder;
delusions or hallucinations concerning separation in psychotic disorders; refusal to go
outside without a trusted companion in agoraphobia; worries about ill health or other
harm befalling significant others in generalized anxiety disorder; or concerns about
having an illness in illness anxiety disorder.

 When children with separation anxiety disorder are actually separated from their
attachment figures, they typically become preoccupied with morbid fears, such as the
worry that their parents are going to become ill or die.
 They cling helplessly to adults, have difficulty sleeping, and become intensely
demanding.
 Separation anxiety is more common in girls