Neurodevelopmental Disorders

[page 174-178]

The neurodevelopmental disorders are a group of conditions with onset in the

developmental period. The disorders typically manifest early in development, often before the
child enters school, and are characterized by developmental deficits or differences in brain
processes that produce impairments of personal, social, academic, or occupational functioning.
The range of developmental deficits or differences varies from very specific limitations of learning
or control of executive functions to global impairments of social skills or intellectual ability. Once
thought to be categorically defined, more recent dimensional approaches to measurement of the
symptoms demonstrate a range of severity, often without a very clear boundary with typical
development. Diagnosis of a disorder thus requires the presence of both symptoms and impaired
function.
The neurodevelopmental disorders frequently co-occur with one another; for example,
individuals with autism spectrum disorder often have intellectual developmental disorder
(intellectual disability), and many children with attention-deficit/hyperactivity disorder (ADHD)
also have a specific learning disorder. The neurodevelopmental disorders also frequently co-
occur with other mental and behavioral disorders with onset in childhood (e.g., communication
disorders and autism spectrum disorder may be associated with anxiety disorders; ADHD with
oppositional defiant disorder; tics with obsessive-compulsive disorder). For some
neurodevelopmental disorders, the clinical presentation includes behaviors that are more
frequent or intense when compared with those of normal children of the same developmental
age and gender, as well as deficits and delays in achieving expected milestones. For example,
autism spectrum disorder is diagnosed only when the characteristic deficits of social
communication are accompanied by excessively repetitive behaviors, restricted interests, and
insistence on sameness.
Intellectual developmental disorder is characterized by deficits in general mental abilities,
such as reasoning, problem solving, planning, abstract thinking, judgment, academic learning,
and learning from experience. The deficits result in impairments of adaptive functioning, such
that the individual fails to meet standards of personal independence and social responsibility in
one or more aspects of daily life, including communication, social participation, academic or
occupational functioning, and personal independence at home or in community settings. Global
developmental delay, as its name implies, is diagnosed when an individual fails to meet expected
developmental milestones in several areas of intellectual functioning. The diagnosis is used for
individuals younger than 5 years who are unable to undergo systematic assessments of
intellectual functioning, and thus the clinical severity level cannot be reliably assessed.
Intellectual developmental disorder may result from an acquired insult during the developmental
period from, for example, a severe head injury, in which case a neurocognitive disorder also may
be diagnosed.
The communication disorders include language disorder, speech sound disorder, social
(pragmatic) communication disorder, and childhood-onset fluency disorder (stuttering). The first
three disorders are characterized by deficits in the development and use of language, speech,
and social communication, respectively. Social communication disorder is characterized by
deficits in both verbal and nonverbal communication skills that result in social impairment and
are not better explained by low abilities in structural language, intellectual developmental
disorder, or autism spectrum disorder. Childhood-onset fluency disorder is characterized by
disturbances of the normal fluency and motor production of speech, including repetitive sounds
or syllables, prolongation of consonants or vowel sounds, broken words, blocking, or words
produced with an excess of physical tension. Like other neurodevelopmental disorders,
communication disorders begin early in life and may produce lifelong functional impairments.
Autism spectrum disorder is characterized by persistent deficits in social communication
and social interaction across multiple contexts, including deficits in social reciprocity, nonverbal
communicative behaviors used for social interaction, and skills in developing, maintaining, and
understanding relationships. In addition to the social communication deficits, the diagnosis of
autism spectrum disorder requires the presence of restricted, repetitive patterns of behavior,
interests, or activities. Because symptoms change with development and may be masked by
compensatory mechanisms, the diagnostic criteria may be met based on historical information,
although the current presentation must cause significant impairment.
Within the diagnosis of autism spectrum disorder, individual clinical characteristics are
noted through the use of specifiers (with or without accompanying intellectual impairment; with
or without accompanying structural language impairment; associated with a known genetic or
other medical condition or environmental factor; associated with a neurodevelopmental, mental,
or behavioral problem), as well as specifiers that describe the severity of autistic symptoms.
These specifiers provide clinicians with an opportunity to individualize the diagnosis and
communicate a richer clinical description of the affected individuals. For example, many
individuals previously diagnosed with Asperger’s disorder would now receive a diagnosis of
autism spectrum disorder without language or intellectual impairment.
ADHD is a neurodevelopmental disorder defined by impairing levels of inattention,
disorganization, and/or hyperactivity-impulsivity. Inattention and disorganization entail inability
to stay on task, seeming not to listen, and losing materials necessary for tasks, at levels that are
inconsistent with age or developmental level. Hyperactivity-impulsivity entails overactivity,
fidgeting, inability to stay seated, intruding into other people’s activities, and inability to wait—
symptoms that are excessive for age or developmental level. In childhood, ADHD frequently
overlaps with disorders that are often considered to be “externalizing disorders,” such as
oppositional defiant disorder and conduct disorder. ADHD often persists into adulthood, with
resultant impairments of social, academic, and occupational functioning.
Specific learning disorder, as the name implies, is diagnosed when there are specific
deficits in an individual’s ability to perceive or process information for learning academic skills
efficiently and accurately. This neurodevelopmental disorder first manifests during the years of
formal schooling and is characterized by persistent and impairing difficulties with learning
foundational academic skills in reading, writing, and/or math. The individual’s performance of the
affected academic skills is well below average for age, or acceptable performance levels are
achieved only with extraordinary effort. Specific learning disorder may occur in individuals
identified as intellectually gifted and manifest only when the learning demands or assessment
procedures (e.g., timed tests) pose barriers that cannot be overcome by their innate intelligence
and compensatory strategies. For all individuals, specific learning disorder can produce lifelong
impairments in activities dependent on the skills, including occupational performance.
The neurodevelopmental motor disorders include developmental coordination disorder,
stereotypic movement disorder, and tic disorders. Developmental coordination disorder is
characterized by deficits in the acquisition and execution of coordinated motor skills and is
manifested by clumsiness and slowness or inaccuracy of performance of motor skills that cause
interference with activities of daily living. Stereotypic movement disorder is diagnosed when an
individual has repetitive, seemingly driven, and apparently purposeless motor behaviors, such
as hand flapping, body rocking, head banging, self-biting, or hitting. The movements interfere
with social, academic, or other activities. If the behaviors cause self-injury, this should be
specified as part of the diagnostic description. Tic disorders are characterized by the presence
of motor or vocal tics, which are sudden, rapid, recurrent, nonrhythmic, stereotyped motor
movements or vocalizations. The duration, presumed etiology, and clinical presentation define
the specific tic disorder that is diagnosed: Tourette’s disorder, persistent (chronic) motor or vocal
tic disorder, provisional tic disorder, other specified tic disorder, and unspecified tic disorder.
Tourette’s disorder is diagnosed when the individual has multiple motor and vocal tics that have
been present for at least 1 year and that have a waxing-waning symptom course.
The use of specifiers for the neurodevelopmental disorder diagnoses enriches the clinical
description of the individual’s clinical course and current symptomatology. These include the
following: Severity specifiers are available for intellectual developmental disorder, autism
spectrum disorder, ADHD, specific learning disorder, and stereotypic movement disorder.
Specifiers indicative of current symptomatology are available for ADHD, specific learning
disorder, and persistent motor or vocal tic disorder. Autism spectrum disorder and stereotypic
movement disorder also include the specifier “associated with a known genetic or other medical
condition or environmental factor.” This specifier gives clinicians an opportunity to document
factors that may have played a role in the etiology of the disorder, as well as those that might
affect the clinical course.