Specific Developmental

disorder
Specific reading disorder
 Defined by a reading age well below(usually
defined as 2 standard deviations below) the
level expected from the child’s age and IQ.
Clinical features
 Low intelligence
 Lack of opportunity to learn at home and
school
 Poor visual acuity
 Delay in learning to read
 Delayed acquisition of speech and language
 Writing and spelling are impaired
 Errors in reading and spelling include
omissions, substitution, or distortion of
words, slow reading, long hesitation, and
reversal of words or letters
 Poor comprehension
 Emotional problems
Aetiology

 Dyslexia
 There is subgroup of dyslexics with a
neuropsychological syndrome of poor
coordination, constructional difficulties and
left/right confusion.

 Genetic causes
 Occurrence of reading disorder in family
member
 Chromosomal abnormalities
 Neurological causes
 Children with cerebral palsy and epilepsy
 Disorder of brain maturation impair skill
required in reading

 Social factors
 If child brought up in an illiterate or
otherwise disadvantaged family, receives
little attention at school or changes school
frequently.
Assessment
 Identify the disorder early
 Assessment is carried out by an educational
or clinical psychologist using an individually
administered standardized test of reading
accuracy and comprehension
Treatment
 Educational approach to reawaken the
interest of a child with long experience of
failure.
 Start as early as possible before the child
has a sense of failure
 Parental interest and continued extra
teaching
 Behavioral problem need separate
attention.
Prognosis
 Among children with a mild problem in the
middle years of childhood, only about quarter
achieve normal reading skills by
adolescence.
 Very few with severe problems in mild
childhood overcome them by adolescence.
Specific arithmetic disorder
 Also known as mathematic disorder.
 Incidence about 1.3-6 per cent and
frequently occurs with specific reading
difficulties.
Clinical features
 Failure to understand simple mathematic
concept
 Failure to identify numerical symbol or
mathematical signs
 Difficulty in carrying out arithmetic
manipulation
 Inability to learn mathematical tables
 Can lead to secondary emotional
difficulties when the child is at school.
Aetiology
 Cognitive deficits involving working memory
 Assessment is based on arithmetic
subtests of the WISC and WAIS
 Treatment is by remedial teaching
 Prognosis not known.
 Motor skills Disorder
Also known as clumsy child syndrome
or specific motor dyspraxia
 Delayed motor development-clumsiness in
school work or play. E.g. dressing, walking,
feeding
 In ICD-10, this condition is called specific
developmental disorder of motor function.
 The children can carry out all normal
movements, but their coordination is poor.
 They tend to break things and are poor at
handicrafts and organised games.
 IQ testing usually shows good verbal but
poor performance scores.
 These children normally referred to
psychiatric because of secondary emotional
disorder.
 An explanation of the nature of the problem
should be given to the child, family and
teachers.
 Special teaching may improve their
confidence.
 There is usually some improvement with
time.
Communication Disorders
(developmental disorder of speech and
language)
• Half of children use words with meanings by
12.5 months and 97% do so by 21 months.
• Half form words into simple sentence by 23
months.
• Vocabulary and complexity of language develop
rapidly during the pre-school years.
• When children start schooling, 1% are seriously
retarded in speech, and 5% have difficulty in
making themselves understood by strangers.
• Process of language acquiring is complex-
not well understood.
• Language disorders are associated with
psychiatric:
i) the two may be an expression
of a common brain abnormality,
ii) language disorder impairs social
interaction and education.
Causes of speech and language
disorder
 No cause can be found in majority of children
with this disorder.
 The most common of these causes is
learning disability.
 Other important causes are deafness,
cerebral palsy, autism, and autistic spectrum
disorder.
 Social deprivation can also cause mild
delays.
Classification
 Differsin some ways between ICD-10 and
DSM-IV.
 ICD-10 uses title of ‘specific developmental
disorder of speech and language’,
 Whereas DSM-IV has the wider title of
‘communication disorder’.
3 disorders appear in both classification:
- phonological disorder (DSM-IV) or specific
speech articulation disorder (ICD-10).
- Specific developmental expressive
language disorder.
- Mixed receptive-expressive disorder
(DSM-IV); here ICD-10, specific
developmental receptive language disorder.
Phonological disorder (DSM-IV) or specific
speech articulation disorder (ICD-10).

 Accuracy in the use of speech sound is below

the level appropriate for the child’s mental age
but language skills are normal.
 By the age of 7years, most speech sounds
should be normal.
 speech sounds may be omitted or distorted, or
other sounds substituted.
 In assessing speech production, appropriate
allowance should be made for regional accents
and dialects.
Prevalence: depends on the criteria used to
determine when speech production is
abnormal; a rate of 2-3 percent has been cited
among 6- to 7- years olds.

American Psychiatric Association, 1994a

 Specific developmental expressive language
disorder.

 The ability to use expressive spoken

language is markedly below the level
appropriate for the child’s mental age.
 Language development varies considerably
among normal children, but the absence of
single words by 2 years of age, and of two-
word phrases by 3 years of age signifies
abnormality.
 Signs at later ages include restricted
vocabulary, difficulties in selecting
appropriate words and immature
grammatical usage.
 Non-verbal communication, if impaired, is not
affected as severely as spoken language,
and the child makes efforts to communicate.
 Disorders of behavior are often present.
 Cluttering : some children speak
rapidly and with an erratic rhythm
such that the grouping of words does
not reflect the grammatical structure of
their speech.
 Prevalence: at rate of 3-5% of children has
been proposed (American Psychiatric
Association, 1994a).
 Prognosis: about ½ of the children
meeting DSM-IV criteria develop normal
speech by adult life, while the rest have
long lasting difficulties. Comorbid
condition, more severe the prognosis is.
 Treatment: special education.
Mixed receptive-expressive disorder (DSM-IV);
ICD-10, specific developmental receptive language
disorder.

 In this disorder the understanding of the language is

below the level appropriate to the child’s mental age.
 In almost all cases, Expressive language is also
disturbed.
 Failure to respond to familiar names, in the absence
of non-verbal cues, by the beginning of the second
year of age, or a failure to respond to simple
instructions by the end of the second year, are
significant signs suggesting receptive language
disorder- providing deafness, learning disability, and
pervasive developmental disorder have been
excluded.
 Prevalence: Up to 3% of school age children
has been suggested.
 Prognosis: poor with around 75% continuing
throughout childhood.
 Treatment: special education.
Acquired Epileptic Aphasia (Landau-
Kleffner syndrome)
 In ICD-10, 4th category.
 Rare disorder.
 Child whose language has so far develop
normally loses both receptive and expressive
language but retains general intelligence.
 Associated with EEG abnormalities.
 Child will develop seizures either before or
after the change in expressive language.
 Starts usually between 3 to 9 years of age.
 Aetiology: unknown
 Prognosis: variable; 2/3 of children are left
with a receptive language deficit, but the
other 1/3 recover completely.
 Treatment: Tx of seizures does not always
lead to improvement in language.
Assessment of speech and language
disorders
 Early investigation is essential.
 Exclude: mental retardation, deafness,
cerebral palsy, and pervasive developmental
disorder.
 The speech producing organs should be
examined.
 It is particularly important to detect deafness
at an early stage.
Pervasive
developmental
disorder
 Group of disorder characterized by
abnormalities in communication, social
interaction and by restricted repetitive
activities.
 Developmental abnormalities from infancy
or before the age of 5 years.

 Incidence : 3 per 1000

Classification
DSM – IV ICD – 10

Autistic disorder Childhood autism

Rett’s syndrome Rett’s syndrome

Child disintegrative disorder Other childhood disintegrative disorder

Asperger’s disorder Overactive disorder with mental

retardation and stereotyped movement

Pervasive developmental disorder not Asperger’s syndrome

otherwise specified( including atypical
autism)

Atypical autism

Pervasive developmental disorder not

otherwise specified
Autistic Spectrum Disorder (ASD)

 This term is often used to denote the whole

range of pervasive developmental disorders.

 It recognizes that the boundaries between

the different syndromes are difficult to
decide.
Childhood autism
 This condition was described by Kanner
(1943) who suggested the name infantile
autism.

 Term childhood autism is used in ICD-10

(autistic disorder – DSM-IV)

 Prevalence: 1/1000 children

 4 : 1 ratio , more in boys
Aetiology
 The cause is unknown but the social,
language and behavioral problems in
autism suggest abnormalities in neural
system.

 1.Genetic factor
 Involvement of several genes

 50 times more frequent in the siblings of

affected persons than in general population
 Twin
studies: higher concordance about 90%
between monozygotic than diazygotic twins

 Cognitive
abnormalities are more frequent
among the siblings of autistic probands

 Autism has been linked to chromosome 2, 7 ,

15
2. Organic Brain Disorder
 larger brain volumes

 Functional MRI scanning provide information

about brain abnormalities

 Hypo-activation of amygdala, frontal and

temporal areas, suggesting malfunctioning in
social processing

 Hypo-activation of fusiform nucleus which is

involved in face processing
 3. Other evidence for biological cause

 1/3th of autistic children have HIGH

serotonin levels

 Also associated with fragile X syndrome

( Rett syndrome and tuberose sclerosis)

 10% of autistic children have co-morbid

medical condition
 4. Unsupported Theories

 Claims of an association with MMR vaccine

 Abnormal parenting (Kanner 1943)

- parents who were characterize as cold,
detached and obsessive.

- Kanner idea have not been substantiated

- Now, any psychological abnormalities in
parents may contribute in improper
brought
up.
- or, manifestation of parental genes

 There is no relationship between childhood

autism and schizophrenia
Clinical Feature
 Based on ICD-10 and DSM-IV,
- there are 3 kinds of abnormality are
required to make the diagnosis of autism:

1. Abnormalities of social development

(specific)
2. Abnormalities of communication
3. Restriction of interests and behavior
 Abnormalities development is apparent
before age of 3

- e.g -absence of babbling/ pointing by 12

months
-lack of imitation and oversensitivity
to sounds
1. Abnormalities of social
development
 Unable to make warm emotional relationship with
people ( autistic aloneness)

 Do not respond to their parents affectionate behavior

by smiling or cuddling

 They appear to dislike being picked up/kissed

 No more responsive to their parents than stranger

 Gaze avoidance ( the absence of eye to eye contact)

2. Abnormalities of Communication

 Delay in speech development

 Or develops normally until 2 years and then

disappears in part or completely

 Lack of speech is a manifestation of severe

cognitive defect

 Speech impartment such as misuse of pronouns

and the inappropriate repeating of words spoken
by others ( echolalia)
 Some autistic children are talkative but
repetitive monologue.

 Cognitive defect also affects non-verbal

communication and play:
- do not take part in the imitative games
of the first year of life

- later do not use toy in an appropriate

way
3. Restriction of interests and
behavior
(a) Obsessive desire for sameness
 Distress if there is any change in the environment

 E.g : same food repeatedly, on wearing the same

cloths

 Some are fascinated by spinning toys

(b)Odd behavior and mannerisms

 Odd motar behavior :

-whirling round and round, flapping their hands

4. Other Features
 May show sudden anger or fear without apparent
reason

 May be overactive and distractable

 Sleep badly or bed wetting

 Some injure themselves deliberately

 25% of them develop seizures (adolescence)

Intelligence Level
 There is intellectual impairment

 Whereby 3/4th of IQ score is in the

‘retarted’ range

 They have restricted power of memory

and mathematical skills.
Psychopathology

Theory of mind in autism

 By age of 4 years, normal children are
able to form an idea of what others are
thinking
 An autistic child tends to lack this ability.
 Its cause is not known.
Differential Diagnosis
 Deafness
 Communication disorder
 Learning disability
Prognosis
 10-20% of children with childhood austism begin to
improve between the ages of about 4-6 years
 Further 10-20% can live at home but cannot work,
need to attend a special school/training centre and
remain dependent on their family members
 60% improve little and are unable to lead an
independent life; may need long term residential
care.
 Those who improve may continue to show
language problems, emotional coldness and odd
behaviours.
 Few develop epilepsy in adolescence.

Pointers to better prognosis:

 Communicative speech by the age of about 6
years
 Higher IQ

Outcome is highly variable even within the normal

IQ range.
Assessment
 Cognitive level
 Language ability
 Communication skills, social skills and
play
 Repetitive or otherwise abnormal
behaviour
 Stage of social development in relation to
age, mental age and stage of language
development
Management
In absence of any specific treatment, management has 3
main aspects:

1) Management of abnormal behaviour

- contingency management may control some of the

abnormal behaviours
- providing rewards for desired behaviours and
removing reinforcement from undesired behaviours
- often carried out at home by parents, instructed and
supervised by a clinical psychologist
2) Education and social services

- Most require special schooling

- If condition is so severe, then residential
schooling is necessary
- special care is needed to avoid an
institutional atmosphere, since this can
increase social withdrawal
- adolescents may need vocational training
3) Help for the family

- parents need continuing support as well as

support for their effort to help the child
themselves and obtain help from educational
and social services.
- some need genetic counseling since the risk of
a further autistic child is about 3 %
- help parents join voluntary organization in
which they can meet other parents of autistic
children and discuss common problems.
Rett’s disorder
 It’s a rare X-linked condition, occurs exclusively in girls

 Disorder is associated with sporadic mutation in the

MECP2 gene, located on the X-chromosome. (MECP2
regualates expression of genes involved in brain
development)

 Reported prevalence: 8 per 100,000 girls

 After 1st month of life, head growth slows

 Over the next 2 years, there is arrest of cognitive

development and loss of purposive skilled hand
movements.
 Stereotyped movements develop with hand-clapping and
hand-wringing movements

 Ataxia of the legs and trunk may develop

 Interest in the social environment diminishes in the first

few years of the disorder.

 Expressive and receptive language development is

impaired severely

 There is psychomotor retardation

 Some develop severe learning disability

Childhood Disintegrative Disorder
Also known as Heller’s disease
 Begins after a period of normal development lasting for
more than 2 years.

 Resembles childhood autism:

- marked loss of cognitive functions,
- abnormalities of social behaviours and communication
and unfavorable outcome

 Differs from childhood autism:

- loss of motor skills and of bowel and bladder control

 Condition may arrest after a time or progress to a severe

neurological condition
Asperger’s Syndrome
Asperger’s syndrome
 Was 1st describe by Asperger (1944)

 This condition has also referred to as autistic

psychopathy

 More common male

 Prevalence : 39/10000

 Develop normally at 1st but by the 3rd year begin to

lack in their relationships
 Marked abnormalities of social behavior

 Stereotyped and repetitive activities

 form of intense but narrow interest and rather
motor mannerism

 There is no delay of cognitive development

 Speech may be stilted and intonation – more of

repetitive monologue, eccentric,and solitary

 Do not share interests with others or without

friends
 The cause of asperger’s syndrome is
unknown

It is also uncertain whether this condition is

milder variant of childhood autism

Prognosis: the abnormalities persist up to adult

life. Most of them able to work but

few successful relationship or
marriage
Atypical Autism
Atypical Autism
 ICD-10
 Not otherwise specified NOS (DSM-IV)

 Resemble autism but do not meet the

diagnostic criteria.

 Prevalence : varies according to the criteria

adopted.