Neurodevelopmental

and Neurocognitive
Disorders
Learning Objectives

◦ Learn different neurodevelopmental and

neurocognitive disorders.
◦ Learn the DSM-5 criteria in diagnosing the following
disorders.
◦ Understand the biopsychosocial factors that
contribute to the development of the conditions.
◦ Get familiar with the different contemporary
treatment approaches to the specific mental
disorders.
Neurological Disorders

◦ Neurodevelopmental disorders – typically arise first

during childhood.
◦ Neurocognitive disorders – typically arise in old age.
Neurodevelopmental
Disorders
Attention-Deficit/Hyperactivity Disorder
• A persistent pattern of inattention and/or hyperactivity that
interferes with functioning or development as characterized by 1 or
2:
• Note: The symptoms are not solely a manifestation of oppositional
defiant behavior, defiance, hostility or failure to understand tasks or
instructions. For older adolescents and adults (age 17+) at least five
symptoms are required in inattention and hyperactivity/impulsivity
Attention-Deficit/Hyperactivity Disorder
• Inattention – Six or more of the following symptoms have persisted
for at least 6 months to a degree that is inconsistent with
developmental level and negatively impacts directly on social and
academic/occupational activities:
• Often fails to give close attention to details or makes careless mistakes in
school work, at work or during other activities.
• Often has difficulty sustaining attention in tasks or play activities.
• Often does not seem to listen when spoken to directly
• Often does not follow through on instruction and fails to finish school work,
chores or duties in the workplace
• Often has difficulty organizing tasks and activities
• Often avoids, dislikes or is reluctant to engage in tasks that require sustained
mental effort
• Often loses things necessary for tasks or activities
• Often easily distracted by extraneous stimuli
• Often forgetful in daily activities
Attention-Deficit/Hyperactivity Disorder
• Hyperactivity and impulsivity – 6 or more of the following symptoms
have persisted for at least 6 months to a degree that is inconsistent
with developmental level and that negatively impacts directly on
social and academic/occupational activities:
• Often fidgets with or taps hands or feet or squirms in seat
• Often leaves set in situations when remaining seated is expected
• Often runs about or climbs in situations where it is inappropriate
• Often unable to play or engage in leisure activities quietly
• Is often on the go acting as if driven by a motor
• Often talks excessively
• Often blurts out an answer before a question has been completed
• Often has difficulty waiting his or her turn
• Often interrupts or intrudes on others.
Attention-Deficit/Hyperactivity Disorder
• Several inattentive or hyperactive-impulsive symptoms were present
prior to age 12 years
• Several inattentive or hyperactive-impulsive symptoms are present in
two or more settings
• There is clear evidence that the symptoms interfere with or reduce
the quality of social, academic or occupational functioning
• The symptoms do not occur exclusively during the course of
schizophrenia, or another psychotic disorder and are not better
explained by another mental disorder.
Attention-Deficit/Hyperactivity
Disorder Subtypes

◦ Combined presentation – requires 6 or more

symptoms of inattention and 6 or more of
hyperactivity-impulsivity.
◦ Predominantly inattentive presentation – 6 or more
symptoms of inattention but less than 6 symptoms of
hyperactivity-impulsivity are present.
◦ Predominantly hyperactive/impulsive presentation –
6 or more symptoms of hyperactivity/impulsivity but
less than 6 symptoms of inattention.
Attention-Deficit/Hyperactivity
Disorder

◦ Boys are a little more than two times more likely than
girls to develop ADHD.
◦ Girls tend to present primarily inattentive features
and have less disruptive behavior than boys.
◦ ADHD is found across most cultures and ethnic
groups.
◦ Children with ADHD often do poorly in school.
◦ 20-25% of children with ADHD have a cooccurring
learning disorder
◦ Children with ADHD may have poor relationships with
other children.
◦ Adults diagnosed with ADHD as children are at
increased risk for antisocial personality disorder,
substance use disorder, mood and anxiety disorders.
Biological Factors

◦ Abnormal activity and immaturity in the prefrontal

cortex which controls cognition, motivation, and
behavior
◦ Abnormal function of dopamine and norepinephrine
who also play important roles in sustained attention,
inhibition of impulses, and processing of errors.
◦ Genetic factors play a role in the vulnerability to
ADHD, siblings of children with ADHD are3-4 times
more likely to develop the condition.
◦ ADHD is also associated with low birth weight,
premature delivery, difficult delivery leading to
oxygen deprivation, alcohol use, nicotine use, and
barbiturates use of mothers.
Psychosocial Factors

◦ Experience of frequent disruptions and in which the

parents are prone to aggressive and hostile behavior
and substance use.
◦ Family interaction patterns influence the course and
severity of ADHD.
Treatment for ADHD

◦ Pharmacotherapy – stimulants (Ritalin, Dexedrine,

and Adderall); norepinephrine reuptake inhibitors
(atomoxetine), alpha-2 agonists (clonidine,
guanfacine) – 56% reduction of symptoms
◦ Behavioral therapy – focus on reinforcing attentive,
goal-directed, and pro-social behaviors while
extinguishing impulsive and hyperactive behaviors. –
34% reduction of symptoms
◦ Combination – 68% reduction of symptoms
Autism Spectrum Disorder
• Persistent deficits in social communication and social
interactions across multiple contexts as manifested by the
following:
• Deficits in social-emotional reciprocity
• Deficits in nonverbal communicative behaviors
• Deficits in developing, maintaining and understanding relationships.
Autism Spectrum Disorder
• Restricted, repetitive patterns of behaviors, interests or activities as
manifested by at least two of the following:
• Stereotyped or repetitive motor movements, use of objects or
speech
• Insistence on sameness, inflexible adherence to routines, or
ritualized patterns of verbal and nonverbal behavior
• Highly restricted, fixated interests that are abnormal in intensity
or focus
• Hyper or hypo-reactivity to sensory input or unusual interest in
sensory aspects of the environment
Autism Spectrum Disorder
• 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)
• Symptoms cause clinically significant impairment in social,
occupational or other important areas of current
functioning.
Autism Spectrum Disorder

◦ Deficits in social interactions and communication may

first show in infants’ interaction with parents.
◦ Early symptoms include delayed language
development, no reaction to other people’s emotions,
preoccupation with one feature of a toy or an object.
◦ Routines and rituals are very important to children
with autism, and they perform stereotyped and
repetitive behaviors.
Contributors to Autism Spectrum
Disorder

◦ Genetics play a role in the development of the

disorder
◦ Siblings of children with autism spectrum disorder are
50 times more likely to have the disorder than are the
siblings of children without autism spectrum disorders.
◦ No single gene is responsible for autism spectrum
disorder, rather, abnormalities in several genes have
been associated with it.
◦ Disruption in the normal development of the brain
plays a role in the development of autism spectrum
disorder.
◦ Structural abnormalities in the brain including the
cerebellum, cerebrum, amygdala, and hippocampus
◦ Fusiform gyrus – area involved in facial perception.
Treatment for Autism Spectrum
Disorder

◦ Selective serotonin reuptake inhibitors reduce

repetitive behaviors and aggression, and improve
social interactions
◦ Atypical antipsychotic medication reduce obsessive
and repetitive behaviors
◦ Stimulants are used to improve attention
◦ Psychosocial therapies for autism spectrum disorders
combine behavioral techniques and structure
educational services.
Intellectual Disability
• Intellectual disability or intellectual developmental disorder is a
disorder with onset during the developmental period that
includes both intellectual and adaptive function deficits in
conceptual, social and practical domains.
• Deficits in intellectual functions such as reasoning, problem solving,
planning, abstract thinking, judgment, academic learning and learning
from experienced confirmed by both clinical assessment and
individualized, standardized intelligence testing.
• 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 ore or more activities of daily life, such as
communication, social participation, and independent living, across
multiple environments such as home, school, work or community.
• Onset of intellectual and adaptive deficits during the developmental
period.
Intellectual Disability

◦ The severity of intellectual disability can be classified

as mild, moderate, severe or profound, on the basis of
adaptive functioning (and not IQ alone) and the levels
of supports required.
◦ Individually administered intelligence tests are used to
assess the level of intellectual functioning of a person
suspected of having intellectual disability
◦ Have a score of two standard deviations below the
mean IQ score – 70 (± 5, 65-75)
◦ 1-3% of the population has intellectual development
disorder.
Severity of Intellectual Disability

◦ Mild – may be able to care for themselves reasonably

well except in complex situations like making legal or
health decisions.
◦ Moderate – with extensive training, they can learn to
care for their personal needs.
◦ Severe – require support for all aspects of daily living.
◦ Profound – maladaptive behavior may be present,
individual is fully dependent on others for all aspects
of daily living, including physical care, health and
safety
Biological Causes of Intellectual
Disorder

◦ 300 genes affecting brain development and

functioning have been implicated in the development
of intellectual disability.
◦ Phenylketonuria – children with PKU are unable to
metabolize phenylalanine, an amino acid. Buildup of
the amino acid causes brain damage.
◦ Tay-Sachs disease – carried by a recessive gene
causing progressive degeneration of the nervous
system between 3-6 months old, children die before
age 6.
◦ Down syndrome – occurs when chromosome 21
comes in triplicate
◦ Fragile X syndrome – caused when a tip of the X
chromosome breaks off.
Biological Causes of Intellectual
Disorder

◦ Brain damage during gestation and early life can

cause intellectual disability
◦ Exposure to German measles, herpes or syphilis of
pregnant mothers pose a greater risk of damage to
the fetus causing intellectual disability.
◦ Fetal alcohol syndrome – children have below
average IQ of 68
◦ Shaken baby syndrome – when a baby is shaken, it
leads to intracranial injury and retinal hemorrhage.
◦ Exposure to toxic substances like lead, arsenic and
mercury can also cause brain damage.
Sociocultural Factors of Intellectual
Disorder

◦ Children with intellectual disability are more likely to

come from low socioeconomic backgrounds.
◦ Social disadvantages of being poor also contribute to
lower-than-average intellectual development.
◦ These sociocultural factors may directly affect the
biological condition that impede a child’s cognitive
development
Treatments for Intellectual Disability

◦ Drug therapy – medications are used to reduce seizures,

control aggressive and self-injurious behaviors, and
improve mood.
◦ Behavioral strategies – enhances children’s positive
behaviors and reduces negative behaviors, social and
communication skills are taught, aiming to improve total
functioning
◦ Early intervention programs – includes intensive one-on-one
interventions to enhance basic skills and efforts to reduce
social conditions that interfere with the child’s development.
◦ Mainstreaming – children are put in regular classrooms
instead of special education classes.
◦ Group homes – adults with intellectual disability live
together and receive assistance in performing daily tasks,
and training in vocational and social skills.
◦ Institutionalization
Specific Learning Disorder
• 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 or
interventions that target those difficulties:
• Inaccurate or slow and effortful word reading
• Difficulty understanding the meaning of what is read
• Difficulties with spelling
• Difficulties with written expression
• Difficulties mastering number sense, number facts or calculation
• Difficulties with mathematical reasoning
Specific Learning Disorder
• 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+, a documented history of
impairing learning difficulties may be substituted for the standardized
assessment.
• 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.
• 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.
Specific Learning Disorder

◦ Dyslexia – severe difficulties in reading

◦ Dyscalculia – severe difficulties in mathematics
◦ Children with learning disorders often struggle with low
academic performance or have to put forth extraordinarily
high levels of effort to achieve average grades
◦ They can become demoralized or disruptive in class.
◦ 40% never finish school
◦ As adults, they may have problems getting and keeping a
good job, often avoiding work activities that require
reading, arithmetic and writing.
Communication Disorders
Language Disorder
Speech Sound Disorder
Childhood-Onset Fluency Disorder
(Stuttering)
Social (Pragmatic) Communication
Disorder
Persistent difficulties in the acquisition and use of
language in speech, written or sign language due to
deficits in the comprehension or production of
vocabulary, sentence structure, or discourse.
Persistent difficulty with speech sound production
that interferes with speech intelligibility or prevents
verbal communication of messages. Includes
deficits in the phonological knowledge of speech
sounds and/or difficulty coordinating movements
of the jaw, tongue, or lips for clear with breathing
and vocalizing for speech.
A disturbance in the normal fluency and time
patterning of speech (sound syllable repetitions,
sound prolongation of consonants and vowels,
pauses within words.
Persistent difficulties with pragmatics or the social
use of language and nonverbal communication in
naturalistic contexts, which affects the development
of social relationships and social participation.
Symptoms are not better accounted for by autism
spectrum disorder, intellectual disability, or low
abilities in the domains of word structure and
grammar or general cognitive ability.
Causes of Communication Disorders

• Certain genetic abnormalities may account for a

number of different learning disorders.
• Abnormalities in brain structure and functioning
cause learning disorders.
• Broca’s area – ability to articulate and analyze words
• Low activities in parietotemporal and occipitotemporal regions
• Lead poisoning, birth defects, sensory deprivation
and low socioeconomic status are related to
communication disorders.
Treatment of Communication
Disorders

◦ Involves therapies designed to build missing skills

◦ Specialized instruction to overcome skills deficits
actually change brain functioning
◦ Studies support neural effects of specialized training
to overcome learning problems.
Motor Disorders
Tourette’s Disorder
Persistent Motor or Vocal Tic
Disorder
Stereotypic Movement Disorder
Developmental Coordination
Disorder
Both multiple motor and one or more vocal
tics that have been present at some time
during the illness, although not necessarily
concurrently.
Single motor or vocal tics, persistent for at
least 1 year, and with onset before age 18.
Repetitive, seemingly driven, and
apparently purposeless motor behavior
(hand shaking, waving, body rocking, head
banging, self biting) that cause clinically
significant distress or functional
impairment
Motor performance that is substantially
below expected levels, given the person’s
chronologic age and previous opportunities
for skill acquisition (e.g. poor balance,
clumsiness, dropping or bumping into
things, marked delays in acquiring basic
motor skills such as walking, crawling,
sitting, catching, throwing, cutting, coloring
or printing)
Motor Disorders

◦ Tics – sudden, rapid, recurrent, nonrhythmic motor

movements or vocalizations. E.G. jerking of the head,
arm, leg, eye blinking, facial grimacing, neck
stretching, throat clearing, sniffing, and grunting.
◦ Habit reversal therapy – trigger for and signs of
impending tics or stereotypic behaviors are identified
and clients are taught to engage in competing
behaviors with positive results.
◦ Occupational therapy and physical therapy are used
to treat developmental coordination disorder.
Neurocognitive Disorders
Neurocognitive Domains

• Complex attention – sustained attention, divided attention, selective

attention, processing speed.
• Executive function – planning, decision making, working memory,
responding to feedback, error correction, overriding habits,
inhibition, mental flexibility
• Learning and memory – immediate memory, recent memory, long
term memory
• Language – expressive language and receptive language
• Perceptual motor – visual perception, visuo-construction, perceptual
motor, praxis and gnosis
• Social cognition – recognition of emotions, theory of mind
Major Neurocognitive Disorder
• Evidence of significant cognitive decline from a previous level of
performance in one or more cognitive domains based on:
• Concern of the individual, a knowledgeable informant, or the clinician that
there has been a significant decline in cognitive function
• A substantial impairment in cognitive performance, preferable documented
by standardized neuropsychological testing, or another qualified clinical
assessment
• The cognitive deficits interfere with independence in everyday
activities
• The cognitive deficits do not occur exclusively in the context of
delirium
• The cognitive deficits are not better explained by another mental
disorder
Mild Neurocognitive Disorder
• Evidence of modest cognitive decline from a previous level of
performance in one or more cognitive domains based on:
• Concern of the individual, a knowledgeable informant, or the clinician that
there has been a mild decline in cognitive function
• A modest impairment in cognitive performance, preferable documented by
standardized neuropsychological testing, or another qualified clinical
assessment
• The cognitive deficits do not interfere with capacity for
independence in everyday activities
• The cognitive deficits do not occur exclusively in the context of
delirium
• The cognitive deficits are not better explained by another mental
disorder
Major Neurocognitive Disorder

◦ Also known as dementia, which typically occurs in

late life.
◦ Memory deficits are prominent
◦ Aphasia or deterioration of language
◦ Echolalia or repeating what they hear
◦ Palilalia or repeating sounds or words over and over
◦ Apraxia or impairment of the ability to execute
common actions such as waving goodbye or putting
on a shirt
◦ Agnosia or failure to recognize objects or people
◦ Executive functions – brain functions that involve the
ability to plan, initiate, monitor, and stop complex
behaviors.
Alzheimer’s Disease

◦ Shows clear evidence of decline in learning and

memory.
◦ First described by Alois Alzheimer in 1906 where he
discovered filaments within nerve cells were twisted
and tangled called neurofibrillary tangles;
◦ Plaques or deposits of proteins called beta-amyloid
that are neurotoxic and accumulate in the spaces
between cells of the brain critical to memory and
cognition were also discovered.
◦ There is extensive cell death in the cortex of
Alzheimer patients resulting in shrinking of the cortex
and entanglement of the ventricles of the brain.
◦ Seem to be caused by the apolipoprotein E gene
(ApoE) which is in chromosome 19.
Other Causes of Neurocognitive
Disorders

◦ Cerebrovascular disease
◦ Traumatic brain injury
◦ Parkinson’s Disease – degenerative brain disorder
resulting from the death of brain cells producing
dopamine.
◦ Lewy Body Disease – caused by abnormal round
structures that develop in the brain
◦ HIV infection – human immunodeficiency virus
◦ Huntington’s disease – develops chorea, irregular
jerks, grimaces, and twitches; transmitted by a single
dominant gene on chromosome 4.
◦ Prion disease – mental and physical abilities
deteriorate and many tiny holes appear in the cortex
causing it to appear like a sponge.
Treatment and Prevention of
Neurocognitive Disorder

◦ Pharmacotherapy – prevent the breakdown of the

neurotransmitter acetylcholine (used at neuro-
muscular junction) creating a positive effect on
symptoms; regulates the activity of glutamate which
plays an essential role in learning, and memory
◦ Antidepressants and antianxiety
◦ Behavioral therapies – used to manage patient’s
angry outbursts and emotional instability.
◦ Aerobic exercise and mental activity are protective
factors.
Delirium
• Disturbance in attention (reduced ability to direct, focus, sustain, and
shift attention) and awareness (reduced orientation to the environment)
• The disturbance develops over a short period of time (usually hours to a
few days), represents a change from baseline attention and awareness,
and tends to fluctuate in severity during the course of the day
• An additional disturbance in cognition (memory deficit, disorientations,
language, visuospatial ability and perception)
• The disturbances in criteria A and C are not better explained by another
preexisting, established, or evolving neurocognitive disorder and do not
occur in the context of a severely reduced level of arousal such as coma.
• There is evidence from the history, physical examination, or laboratory
findings that the disturbance is a direct physiological consequence of
another medical condition, substance intoxication or withdrawal, or
exposure to a toxin, or is due to multiple etiologies.
Causes of Delirium

◦ Medical disorders – stroke, congestive heart failure,

infectious disease, HIV infection
◦ Intoxication of illicit substances and withdrawal from
these drugs or prescription medications
◦ Older people experience delirium following surgery,
resulting from the medical condition itself or effects
of the medication.
Treatments for Delirium

◦ Treating the underlying medical disorder

◦ Keeping the patient safe until the symptoms subside
◦ Substances that contribute to the delirium must be
discontinued
◦ Antipsychotic medication sometimes are used to
treat the person’s confusion.