Lectures 3 &4 : Developmental Psychopathology: MR, PDD, Autism,Aspergers and Learning Disorders

1. Lectures 3 &4 : Developmental Psychopathology: MR, PDD, Autism,Aspergers and Learning Disorders

2. Outline of Lecture • Part I: Mental Retardation and Associated Syndromes • Part II Pervasive Developmental Disorders • Autistic Disorder • Rett’s Syndrome • Childhood Disintegrative Disorder • Asperger’s Disorder • Part III: Learning Disabilities

3. Part I Mental Retardation (MR) “I am Sam” (2002) (clip) http://www.youtube.com/watch?v=gYPCTlnW-TA&feature=related

4. Mental Retardation: Diagnostic Features Significant subaverage IQ score (Criterion A) Significant Limitations in Adaptive Functioning in at least 2 skill areas (Criterion B)CommunicationSelf careHome livingSocial/interpersonal skillsUse of community resourcesSelf-directionFunctional academic skillsWork, leisure, health and safety Onset MUST occur before age 18 years (Criterion C)

5. Assessment of General Intellectual (IQ) functioning General Intellectual functioning is defined by the intelligence quotient (IQ or IQ equivalent) obtained by assessment with one or more of the standardized individually administered IQ tests (WISC-IV, Kaufman, DAS, etc) Significantly subaverage IQ is defined as an IQ of about 70 or below-approximately 2 standard deviations below the mean with a measurement error of approximately 5 points (e.g. WISC range of 65-75)

6. Mild Mental Retardation (85% of MR population) IQ level (50-55 to approximately 70) Preschoolers typically develop social and communication skills Mild MR not usually distinguishable from those without MR until after around age 5 or upon entering school; minimal impairment in sensorimotor skills By late teens most individuals with MR are able to acquire skills up to the sixth grade levels Minimum self-support needed; may need supervision guidance especially under stressful conditions (e.g. financial, social, physical, health-remember Axis IV)??? Can usually live independently or in supervised settings

7. Moderate MR (10% of MR population) IQ level (35-40 to 50 to 55) Profit from vocational training, moderate supervision required for personal care Benefit from training in social skills but unlikely to progress beyond a second grade level (e.g.- I am Sam) Often develop peer problems dues to problems in recognition in social conventions As adults unskilled and semiskilled work under supervision; also use of sheltered workshops Generally adapt well with supervision and when social support and environmental conditions are good

8. Severe MR (3-4% of MR population) IQ level: (20-25 to 35-40) In early childhood acquire little/no communication During school age years they can learn to talk and be trained in elementary self-care As adults they may perform simple tasks under closely supervised settings Adapt well to live in the community, group homes or living with supportive families However, if they have an associated physical handicap or other health condition they often require specialized consistent nursing care

9. Profound MR (1-2% of MR population) IQ level: (<20 or 25) Most diagnosed with Profound MR have identifiable neurological conditions During early childhood impairments in sensorimotor functioning Optimal development occurs in highly structured environment with constant supervision and individualized relationships with caregivers Some may perform simple tasks in closely supervised and sheltered settings.

10. MR Severity Unspecified This is coded when there is a strong presumption of MR but person cannot be tested by standardized IQ tests (e.g. if patient is too impaired, or uncooperative with testing due to behavioral/emotional problems Sometimes in infancy and early childhood it is difficult to yield accurate scores through IQ tests In general, during the younger ages it is more difficult to assess MR except in the case of Profound MR (Why?)

11. Associated Features & Disorders No specific personality and behavioral features are uniquely associated with MR Lack of communication skills may predispose to disruptive and aggressive behaviors that substitute for communicative language MR individuals may be vulnerable to exploitation by others (e.g. being physically and sexually abused-see Glen Ridge Rape Trial (1988-1989) Prevalence of COMORBID mental disorders that is estimated to be 3-4 times higher than in the general population Diagnosis of comorbid mental disorders is often complicated by the fact that the clinical presentation may be modified by the severity of MR and associated handicaps Deficits in communication skills may result in an ability to provide and adequate history (often in nonverbal adults, need to gestures, facial expressions,etc to make a diagnosis of mood/anxiety disorders, etc)

12. Associated Features and Disorders (cont) The most common associated mental disorders are ADHD, Mood Disorders, Pervasive Developmental Disorders, Stereotypic Movement Disorder and Mental Disorders due to a General Medical Condition (e.g Dementia due to Head Trauma) MR individuals due to Down syndrome may be at higher risk for developing Dementia to the Alzheimer’s Type Pathological changes in the brain associated with this disorder usually develop by the time these individuals are in their early 40’s Associations have been reported between specific etiological factors and certain comorbid symptoms and mental disorders. Example: Fragile X syndrome appears to increase the risk for ADHD; Social Phobia, Pervasive Developmental Disorders (esp. Autism) Example Individuals with Prader-Willi syndrome may exhibit hyperphagia and compulsivity

13. Predisposing Factors • Etiological factors may be primarily biological or primarily psychosocial or some combination of both • In approximately 30-40% of individuals seen in clinical settings, no clear etiology for MR can be determined despite extensive evaluation efforts. • Major Predisposing Factors Include: (DSM-IV p. 45) • Heredity • Early alterations of embryonic development • Environmental influences • Mental disorders • Pregnancy and perinatal problems • General medical conditions acquired in infancy or childhood

14. Specific Culture, Age, and Gender Features The prevalence of MR due to known biological factors is similar among children of upper and lower socioeconomic classes, except that certain etiological factors are linked to lower socioeconomic status (e.g. lead poisoning and premature births MR is more common among males, with male to female ration of approximately 1.5:1

15. Prevalence and Course of MR Prevalence is estimated at approximately 1% Age, mode of onset depend on the etiology and severity of MR; more severe MR associated with earlier recognition More severe MR resulting from an acquired condition, intellectual impairment will develop more abruptly Course of MR is influenced by the course of underlying general medical conditions and by environmental factors (e.g.-educational and other opportunities, environmental stimulation, and appropriateness of management( Individuals who had mild MR earlier in their lives manifested by failure in academic learning tasks, may with appropriate training and opportunities, develop good adaptive skills in other domains and may no longer have the level of impairment required for a diagnosis of MR

16. Differential Diagnosis No exclusion criteria, thus diagnosis should be made when the diagnostic criteria are met, regardless of and in addition to the presence of another disorder In Learning Disorders or Communication Disorders (unassociated with MR) dev’t is in a specific area (e.g.-reading, expressive language is impaired but there is no generalized impairment in intellectual developmental and adaptive functioning In PDD there is qualitative impairment in dev’t of reciprocal social interaction and in the dev’t of verbal and nonverbal social communication skills MR often accompanies PDD Generally, for individuals under 18, the diagnosis of dementia is made only when the condition is NOT characterized satisfactorily by the diagnosis of MR alone Distinguish between Borderline Intellectual Functioning

17. Borderline Intellectual Functioning Forrest Gump….. Borderline Intellectual Functioning (p. 740 DSM) describes an IQ range that is higher than that for MR (71-84) Possible to diagnose MR in individuals with 71-75 due to measurement errors if they have significant deficits in adaptive behavior that meet the criteria for MR Differentiation of Borderline Intellectual Functioning requires careful consideration of all available information Note this is a V code as is coded on Axis II (see pg. 740)

18. Examples: Praeder Willi Syndrome & Fragile X Syndrome Examples Prader Willi Syndrome- http://www.youtube.com/watch?v=v_YMx5H3xRA&feature=related Fragile X Syndrome http://www.cnn.com/video/#/video/health/2006/08/11/fortin.health.minute.fragile.x.affl?iref=videosearch

19. Part II: Pervasive Developmental Disorders • Pervasive Developmental Disorders are characterized by severe and pervasive impairment in several areas of development • Reciprocal social interaction skills • Communication skills • Stereotyped behavior, interests and activities • Includes: Autistic Disorder, Rett’s Disorder, Childhood Disintegrative Disorder, Asperger’s Disorder and PDD (NOS)

20. Autistic Disorder: Diagnostic Criteria (p. 75) • A) A total of 6 or more items from (1), (2), and (3) with at least two from (1), and one each from (2) and (3) • 1) Qualitative Impairment in social interaction as manifested by at least (2) of the following • Marked impairment in the use of multiple nonverbal behaviors such as eye to eye gaze, facial expression, body postures, and gestures to regulate social interaction • Failure to develop peer relationships appropriate to developmental level • A lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g. by a lack of showing, bringing or pointing out objects of interests • Lack of social reciprocity • 2) Qualititative impairments in communication as manifested by at least one of the following • Delay in or total lack of the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime) • In individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others • Stereotyped and repetitive use of language or idiosyncratic language • Lack of varied spontaneous make believe play or social imitative play appropriate to developmental level • 3) Restricted repetitive and stereotyped patterns of behavior, interests and activities, as manifested by at least one of the following • Encompassing preoccupation with one or more stereotyped and restricted patterns of interests that is abnormal either in intensity or focus • Apparently inflexible adherence to specific, nonfunctional routines or rituals • Stereotyped and repetitive motor mannerisms (e.g. hand or finger flapping or twisting, or complex whole body movements • Persistent preoccupation with parts of objects

21. Autistic Disorder: Diagnostic Criteria Cont. (P. 75) • B) Delays in Abnormal Functioning in at LEAST one of the following areas, with onset prior to 3 years old • 1) social interaction • 2) language as used in social communication, or • 3) persistent preoccupation with parts of objects • C) The disturbance is not better accounted for by Rett’s Disorder or Childhood Disintegrative Disorder

22. Specific Age and Gender Related Features In infancy there may be a failure to cuddle; indifference or aversion to affection or physical contact; a lack of eye contact, facial responsiveness, or socially directed smiles and a failure to respond to their parents voices Over the course of dev’t child may become more interested in social interaction; but have difficulty interacting appropriately or with reciprocity Rates of the disorder are 4-5 times higher in males than in females. Females with the disorder are more likely to exhibit more severe MR

23. Prevalence & Course Estimated at least 5/10,000 with reported rates ranging from 2 to 20 cases per 10,000 individuals. However, most recent estimates are higher some as high as 6/1000 live births Onset is prior to age 3 In infancy often lack of interest in social interaction Follows a continuous course: In school age children and adolescents, developmental gains in some areas are common Some individuals deteriorate behaviorally during adolescence, whereas others improve Language skills and overall intellectual functioning are the strongest factors related to ultimate prognosis Only a small percentage of individuals with the disorder go on as adults to live and work independently

24. Familial Pattern Increased risk of Autistic disorder among siblings of individuals with the disorder Approximately 5% of siblings also exhibit conditions; rates among MZ twins very high concordance (in some studies up to 95% or higher) Also risk for various developmental difficulties in affected siblings

25. Differential Diagnosis See Pg. 74 of DSM-IV Rett’s Disorder differs from Autistic disorder in its characteristic sex ratio and pattern of deficits Childhood Disintegrative Disorder Has a distinctive pattern of severe developmental regression in multiple areas of functioning following at least two years of normal development Asperger’s Disorder can be distinguished from Autistic disorder by the lack of delay or deviance in early language development. Asperger’s Disorder is NOT diagnosed if criteria are met for Autistic disorder For other differential diagnoses (see p. 74)

26. Rett’s Disorder: Diagnostic Criteria (p.77) • A) All of the following • 1) apparently normal prenatal and perinatal development • 2) apparently normal psychomotor development through the first five months after birth • 3) normal head circumference at birth • B) Onset of all of the following after the period of normal development • 1) deceleration of head growth between ages 5 and 48 months • 2) loss of previously acquired purposeful hand skills between ages 5-30 months with the subsequent development of stereotyped hand movements (e.g., hand wringing or hand washing) • 3) loss of social engagement early in the course although often social interaction develops later • 4) appearance of poorly coordinated gait or trunk movements • 5) severely impaired expressive and receptive language development with severe psychomotor retardation

27. Rett’s Disorder Prevalence, Course and Associated Features and Disorders • Prevalence: Rett’s disorder is much less common than Autistic Disorder, has been reported ONLY IN FEMALES • Course: Pattern of developmental regression is highly distinctive; onset prior to age 4 (usually in 1st-2nd year of life) • Lifelong duration • Loss of skills is persistent and progressive • Recovery is limited • Modest gains in social interaction in later childhood and adolescence • Communicative and behavioral difficulties usually remain relatively constant throughout life • Associated Features/Disorders • Severe/Profound MR (Code on Axis II) • Some increased frequency of EEG abnormalities and seizure disorder • Data suggest that a genetic mutation is the cause of some cases in Rett’s disorder

28. Childhood Disintegrative Disorder: Diagnostic Criteria (p. 79) • A) Apparently normal development for at least the first two years after birth as manifested by the presence of age-appropriate verbal and nonverbal communication, social relationships, play and adaptive behavior • B) Clinically significant loss of previously acquired skills (before 10 years) in at least two of the following areas • Expressive or receptive language • Social skills or adaptive behavior • Bowel or bladder control • Play • Motor skills • C) Abnormalities of functioning in at least two of the following areas • Qualitative impairment in social interaction (e.g. impairment in nonverbal behaviors, failure to develop peer relationships, lack of social or emotional reciprocity • Qualitative impairments in communication (e.g., delay or lack of spoken language, inability to initiate or sustain a conversation, stereotyped and repetitive use of language, lack of varied make believe play • Restricted, repetitive and stereotyped patterns of behavior, interests, and activities, including motor stereotypies and mannerisms • D) The disturbance is NOT better accounted for by another specific PDD or by Schizophrenia

29. Childhood Disintegrative Disorder: Associated Features, Prevalence and Course • Associated Features and Disorders • Usually associated with severe MR • Increased frequency of EEG abnormalities and seizure disorders • Occasionally observed in association with a general medical condition (Axis III) • Prevalence-very rare and much less common than autistic disorder; condition is likely under diagnosed • Course • Can only be diagnosed if the symptoms are preceded by at least 2 years of normal development and the onset is prior to age 10 • In most cases onset is between 3-4 yrs old and may be insidious or abrupt • Signs may include increased activity levels, irritability, and anxiety followed by a loss of speech and other skills; child may also lose interest in the environment • Disorder follows a continuous course, and in the majority of cases the duration is lifelong • Social, communicative, and behavioral difficulties remain relatively constant throughout life

30. Journal Activity: “Rainman” Watch the following clips from “Rainman” and respond/reflect on some of the features he has that are associated with Autistic Disorder or possibly Asperger’s Disorder? How would you go about making the proper DSM-IV Differential Diagnosis.. Is there evidence of MR-if so what severity level and why? http://www.youtube.com/watch?v=kJZQkslDBjM http://www.youtube.com/watch?v=vqbXPfaN_VM http://www.youtube.com/watch?v=AeITXkW0ITs

31. Autism: Prevalence and Trends • Current Prevalence Rate: Estimated at 10-16/10,000 • Prevalence for Broader PDD spectrum (excluding Rett’s and Childhood Disintegrative Disorder is 60/10,000 • The number of students being served under the IDEA category of Autism has risen sharply from 15,580 in 1992 to 192,643 in 2005! (US Department of Education, 2007) • What are the Reasons for such a huge rise in number of students?

32. Autism: Associated Features • Mental Retardation (MR) • Rate of MR in autism is around 70% • Seizures • Age of appearance of seizures is BIMODAL, peaks in early childhood and another in adolescence • Greater proportion of affected males (4:1 ratio) • Comorbidity with other genetic syndromes • Fragile X Syndrome • Tuberous Sclerosis

33. Autism: Etiology-Genetics • Genetics • Twin studies: MEDIAN concordance rate is about 60% for MZ twins; in some studies up to 90% • Chromosome 15 & Chromosome 7 most commonly affected • Reviews of genome wide scans have revealed at least one positive genetic linkage on almost every chromosome

34. Autism Etiology: Neurological Correlates • Unusual serotonin levels and synthesis patterns • Unusual brain size and growth patterns • Autistic children tend to go through a prior of accelerated head and brain growth soon after birth, which subsides before 24 mos/unusually large brain size • Once completed, this period is followed by a time of unusually slow brain growth relative to same age non-autistic peers so that by adolescence average overall brain volume is not substantially different • Cerebellum abnormalities • Amygdala abnormalities

35. Diagnosis and Assessment of Autism • Most children with autistic disorder will be identified before they reach school age; higher functioning (e.g-Aspergers may be later) • Comprehensive Assessment is required to be eligible to receive special education services under the classification of “Autistic” Assessments usually include many but not necessarily all of the following tests • Psychological • Genetic • Audiological • Speech/language • Occupational Therapy (O/T) evaluation • Physical Therapy (P/T) evaluation • Educational • Adaptive Functioning • Psychiatric • Neurological/Neurodevelopmental

36. Diagnostic Tools for School Psychologists when assessing for Autism • Standardized Intelligence Tests • Standardized educational Tests (in some cases) • Adaptive Functioning Measures • Social/Emotional Functioning; Social History • Specialized Assessment Tools • The Autism Diagnostic Interview Revised (ADI-R; Rutter, Le Conteour, & Lord, 2003) • administered in semistructured interviews to parents/caregivers • The Autism Diagnostic Observation Schedule (ADOS; Lord, Rutter, DiLavore & Risi, 1999) • Standardized behavioral observation and coding system • Both are considered the "The Gold Standard "consistent with DSM-IV-TR criteria; maximum diagnostic utility is obtained when both scales are used together

37. Autistic Disorder: Diagnostic Criteria (DSM-IV-TR- P. 75) A) A total of 6 (or more) items from (1), (2) and (3) with at least 2 from (1) and one each from (2) and (3) • (1) Qualitative impairment in social interaction as manifested by at least 2 symptoms (see pg. 75) (e.g.- lack of eye contact, lack of social initiation, lack of social or emotional reciprocity • (2) Qualitative impairments in communication (e.g.-lack of speech, inadequate speech, stereotyped or repetitive speed, lack or varied, spontaneous/imitative play) • (3) Restricted repetitive and stereotyped patterns of behavior, interests and activities (e.g.- preoccupation with abnormal patterns, inflexibility, adherence to rigid routines, stereotyped and repetitive motor mannerisms, persistent preoccupation with parts of objects

38. Autistic Disorder: Diagnostic Criteria (DSM-IV-TR- P. 75)-cont • Delays in abnormal functioning in at least one of the following areas with onset prior to age 3 • 1) social interaction • 2) language as used in social communication • 3) persistent preoccupation with parts of objects • The disturbance is not better accounted for by Rett’s Disorder or Childhood Disintegrative Disorder

39. Aspergers Syndrome: A Special Case • “Rainman” (1989) • http://www.youtube.com/watch?v=AeITXkW0ITs&feature=related • “Mozart and the Whale” (2006) • http://www.youtube.com/watch?v=qlOMimp9KDY

40. Diagnostic Criteria (DSM-IV-TR) P. 84 • A) Qualitative impairment in social interaction (see p. 84)-need at least 2 • B) Restricted repetitive and stereotyped patterns of behavior, interests and activities (see p. 84)-need at least 1 • C) Disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning • D) No clinically significant general delay in language (e.g. single words used by 2 years old, communicative phrases used by 3 yrs) • E) No clinically significant delay in cognitive development, or in the development of age-appropriate self-help skills, adaptive behavior (other than in social interaction) and in curiosity about the environment in childhood • F) Criteria are NOT met for another specific Pervasive Developmental Disorder

41. Course and Prognosis • Continuous and lifelong disorder • In school age children, good verbal abilities mask other symptoms (social dysfunction • In adolescence, interest in forming social relationships may increase but may lack understanding of conventional rules/reciprocity, etc • Often abnormal expression of sexualized behavior may be present (e.g.-excessive and inappropriate staring, touching, inappropriate comments)

42. Aspergers Syndrome: Prevalence and Trends • 5 times more common in males • Prognosis is significantly better than in Autistic Disorder and most adults are capable of employment and personal independence

43. Associated Features • In contrast to Autistic Disorder, MR is usually Not present in Aspersers, occasionally mild MR • Variability in cognitive functioning • Strengths in verbal ability (vocabulary, rote memory) • Weaknesses in nonverbal areas (visual-motor, visual spatial skills) • Comorbidity of ADHD diagnosis; symptoms of overactivity and inattention • Depressive Disorders also common especially in adolescence • Obsessive Compulsive Disorder and features also often present

44. Interventions for Autism & Aspergers • Multidisciplinary approach when planning psychological and educational interventions for individuals with Autism and Aspergers • Generally, a behavioral approach has been recommended when setting therapy/counseling goals • Goals are different depending on • Levels of cognitive functioning • Levels of social functioning • Levels of adaptive functioning • Individual’s other co-existing psychological and medical history • Family dynamics • Social context

45. Behavioral Interventions • Applied Behavioral Analysis • 1:1 intensive • Pivotal Response Training • Incidental Teaching • Positive Behavior Support • Strength based approach • DRO (Differential Reinforcement for Other Behaviors) • Reinforcing alternative behaviors- ex) if student constantly kicks his desk; he is given positive reinforcement when he engages in sitting appropriately • Behavioral Interventions-often developed using a combination of FBA (Functional Behavioral Assessment) and subsequently developing a BIP (Behavior Intervention Plan) • These interventions are not limited to Aspergers and Autism and can be applied to many different disorders.

46. Therapeutic Interventions • Limited success with individual therapy that involves verbal communication in low functioning Autistics • In higher functioning students (e.g-Aspergers) social skills groups, individual training in social skills; anger management are useful (CBT approach mainly used) • Family therapy/counseling often a necessary component to help parents, siblings deal with and follow through with school-based interventions

47. Psychopharmacology Interventions • Used to treat associated features and syndromes (but caution b/c of side effects) • Stimulants (ADHD and features of hyperactivity and inattention (e.g. Ritalin, Concerta, Adderrall) • SSRI’s (Prozac, Zoloft, etc) to help with repetitive behaviors, resistance to change, anxiety and OCD type behavior • Atypical Antipsychotics (Risperidal, Olanzapine) to help with aggression, self-injury, severe tantrums, property destruction • Lamictal and Depakote-two mood stabilizers have often been successful in treating seizures and associated mood disorders in those with Aspergers/Autism

48. Journal Activity • Watch the following clips from the movie “Rainman” (1989) • http://www.youtube.com/watch?v=RW1qHA5Hqwc • http://www.youtube.com/watch?v=vqbXPfaN_VM&feature=related • http://www.youtube.com/watch?v=kJZQkslDBjM Identify some of the features you observe which resemble Aspergers/Autism and/or other associated conditions discussed • Reflect on the challenges that Raymond’s brother had to deal with when working with him….and how he coped with the everyday life of “Rainman”

49. Part III: Learning Disabilities • Diagnostic Features • Diagnosed when person’s achievement on an individually administered, standardized tests in reading, math, or written expression is substantially below that for age, schooling and level of intelligence • Learning problems significantly interfere with academic achievement or activities of daily living requiring these skills • What is “substantially below”-usually 2 standard deviations, higher IQ, with much lower achievement in one or more specific academic areas (sometimes 1.5 SD difference is used)

50. Risk Factors for Development of Learning Disabilities • Family History of Learning and or Psychiatric Disorders • Poverty • Low SES • Minority groups are over-represented; especially those with limited English proficiency; why? • Other risk factors???