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PPT - Mental Retardation

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									  Motor Skills Disorder
Communication Disorders
          Psy 610A
      Gary S. Katz, Ph.D.
       Developmental Coordination
             Disorder (315.4)
A.   Performance in daily activities that require motor coordination
     is substantially below that expected given the person’s
     chronological age and measured intelligence. This may be
     manifested by marked delays in achieving motor milestones
     (e.g., walking, crawling, sitting), dropping things, “clumsiness”,
     poor performance in sports, or poor handwriting.
B.   The disturbance in (A) significantly interferes with academic
     achievement or activities of daily living.
C.   The disturbance is not due to a general medical condition (e.g.,
     cerebral palsy) and does not meet criteria for a Pervasive
     Developmental Disorder.
D.   If Mental Retardation is present, the motor difficulties are in
     excess of those usually associated with it.

Note: If a general medical (e.g., neurological) condition or sensory
    deficit is present, code the condition on Axis III.
         Developmental Coordination
               Disorder (315.4)
   Manifestations of this disorder may vary by age
       Younger children may have difficulty with crawling, walking,
        zipping pants.
       Older children may have trouble with handwriting,
        assembling puzzles.
   Commonly seen with delays in other nonmotor (e.g.,
    language) milestones
       Phonological Disorder, Expressive Language Disorder,
        Mixed Receptive-Expressive Language Disorder
   May be as high as 6% of children aged 5-11yrs
   Usually noticed when the child first attempts gross or
    fine motor tasks.
         Developmental Coordination
               Disorder (315.4)
   Problems with motor coordination may be due to a
    range of neurological problems.
       These are not DCC; they are motor impairment due to a
        general medical condition.
   If MR is present, motor impairment must be beyond
    what would be expected for that individual.
   If a PDD Diagnosis is given, cannot diagnose DCC.
   ADHD kids tend to knock things over, fall down, end
    up in the ER – but this is due to impulsivity and
    inattention, not motor impairment.
       If both conditions are present, can diagnose both.
Expressive Language Disorder (315.31)
A.   The scores obtained from standardized individually administered measures
     of expressive language development are substantially below those obtained
     from standardized measures of both nonverbal intellectual capacity and
     receptive language development. The disturbance may be manifest
     clinically by symptoms that include having a markedly limited vocabulary,
     making errors in tense, or having difficulty recalling words or producing
     sentences with developmentally appropriate length or complexity.
B.   The difficulties with expressive language interfere with academic or
     occupational achievement or social communication.
C.   Criteria are not met for Mixed Receptive-Expressive Language Disorder or
     a Pervasive Developmental Disorder.
D.   If Mental Retardation, a speech-motor or sensory deficit, or environmental
     deprivation is present, the language difficulties are in excess of those usually
     associated with these problems.

Note: If a speech-motor or sensory deficit or a neurological condition is present,
    code the condition on Axis III.
Expressive Language Disorder (315.31)
   Linguistic features vary depending on its severity and
    the age of the child.
       Can see limited amount of speech, limited vocabulary, a
        variety of gramamtical errors
   ELD can be acquired or developmental.
       Acquired – occurs after a period of normal development
        (usually due to insult, accident, or injury)
       Developmental – impairment not associated with postnatal
        neurological insult of known origin.
   Children with ELD often begin speaking late and
    progress more slowly.
Expressive Language Disorder (315.31)
   ELD is often accompanied by Phonological Disorder
    and dysfluencies (e.g., cluttering, rapid speech)
   Often have associated Learning Disorders
   Can have some receptive language problems as well
    (but if significant, Dd: Mixed Receptive-Expressive
    Language Disorder)
   Also see Developmental Coordination Disorder (with
    motor delays) and Enuresis
   Social withdrawal, ADHD also common in ELD.
Expressive Language Disorder (315.31)
   Need to make sure assessment tools are
    culturally & linguistically appropriate (not always
    possible).
   Advisable to consult with / refer to
    Speech/Language Pathologist.
   Prevalence
     Under age 3, relatively common: 10-15% of all
      children
     By school age, prevalence drops to 3-7% of all
      children
Expressive Language Disorder (315.31)
   Usually recognized by 3yrs of age but milder forms may
    not be identified until later adolescence when language
    becomes more complex.
   Acquired type is more sudden, and outcome is linked to
    the severity of the trauma.
   Outcome of developmental type is more variable. Most
    children improve substantially with intervention; a
    smaller proportion have difficulties persisting into
    adulthood.
Expressive Language Disorder (315.31)
   Some family aggregation seen in the developmental
    type; not so in the acquired type.

   Differential Diagnoses:
       ELD from Mixed Receptive-Expressive Language Disorder
        (impairment in receptive language as well).
       PDD or Autism = no diagnosis of ELD
       MR, sensory deficit: need to have more extreme ELD than
        expected with deficits.
       Disorder of Written Expression (problem is with writing; can
        have both).
       Selective Mutism (will see normal language in some settings)
Mixed Receptive-Expressive Language
         Disorder (315.32)
A.   The scores obtained from standardized individually administered measures
     of both receptive and expressive language development are substantially
     below those obtained from standardized measures of both nonverbal
     intellectual capacity. Symptoms include those for Expressive Language
     Disorder as well as difficulty understanding words, sentences, or specific
     types of words such as spatial terms.
B.   The difficulties with receptive and expressive language interfere with
     academic or occupational achievement or social communication.
C.   Criteria are not met for a Pervasive Developmental Disorder.
D.   If Mental Retardation, a speech-motor or sensory deficit, or environmental
     deprivation is present, the language difficulties are in excess of those usually
     associated with these problems.

Note: If a speech-motor or sensory deficit or a neurological condition is present,
    code the condition on Axis III.
        Mixed Receptive-Expressive
        Language Disorder (315.32)
   Why no “Receptive Language Disorder?”
     Because development of expressive language relies
      on the acquisition of receptive skills, difficulties in
      receptive skills leads to difficulties in expressive
      skills.
     Can have more severe receptive than expressive; but
      quite rare.
   Problems seen in both aspects of speech
   Exists in acquired and developmental types
         Mixed Receptive-Expressive
         Language Disorder (315.32)
   Child may be exceptionally quiet or have
    difficulty following commands, give tangential
    responses to questions.
   Conversational skills are quite poor.
   Often see deficits in auditory processing as well.
       Difficulties with arbitrary sound-symbol associations
        used in language.
   Also seen with Phonological Disorder, Laerning
    Disorders, ADHD, Developmental
    Coordination Disorder, Enuresis.
        Mixed Receptive-Expressive
        Language Disorder (315.32)
   Need to have culturally and linguistic relevant
    testing tools.
     Hard to find.
     Best to consult with / refer to a Speech/Language
      Pathologist
   Prevalence:
     5% of preschoolers
     3% of school-age children

     Probably less common than Expressive Language
      Disorder
        Mixed Receptive-Expressive
        Language Disorder (315.32)
   Course:
     Usually undetectable before 4yrs of age
     Severe forms detectable by 2yrs of age

     Milder forms not noticeable until elementary school.

   Prognosis generally worse than ELD alone
   Developmental type responds well to intensive
    early intervention; acquired type depends upon
    severity of insult.
   Familial aggregation among 1st-degree relatives
    for developmental type.
     Phonological Disorder (315.39)
A.   Failure to use developmentally expected speech sounds that
     are appropriate for age and dialect (e.g., errors in sound
     production, use, representation, or organization such as, but
     not limited to, substitutions of one sound for another [use of
     /t/ for target /k/ sound] or omissions of sounds such as final
     consonants.
B.   The difficulties in speech sound production interfere with
     academic or occupational achievement or with social
     communication.
C.   If Mental Retardation, a speech-motor or sensory deficit, or
     environmental deprivation is present, the speech difficulties
     are in excess of those usually associated with these problems.

Note: If a speech-motor or sensory deficit or a neurological
    condition is present, code the condition on Axis III.
    Phonological Disorder (315.39)
   Includes phonological production (articulation) errors, errors in
    sorting appropriate sounds for language from non-language
    sounds, omissions, substitutions, and distortions.
        Omissions: “Cah” for “Cat”
        Substitutions: “Fwend” for “Friend”
        Distortions: Bostonian “Cah” for “Car”
   Associated with history of chronic ear infections (shapes the way
    sounds are “stored” developmentally)
   Also seen in structural abnormalities of the oral cavity (e.g., cleft
    palate)
   Need to consider culture in assessing – consult!
   More prevalent in males.
    Phonological Disorder (315.39)
   2% of 6-7 year old children present with moderate to
    severe Phonological Disorder, milder forms have
    higher prevalence.
   Prevalence = 0.5% by 17yrs of age
   Identifiable usually when child enters preschool and
    teachers identify the speech struggles. More severe
    problems seen when family cannot understand child.
   Responds well to early intervention.
   Evidences a familial pattern.
                     Stuttering (307.0)
A.    Disturbance in the normal fluency and time patterning of speech
      (inappropriate for the individual’s age), characterized by frequent
      occurrences of one or more of the following:
     1.   Sound and syllable repetitions
     2.   Sound prolongations
     3.   Interjections
     4.   Broken words (e.g., pauses within a word)
     5.   Audible or silent blocking (filled or unfilled pauses in speech)
     6.   Circumlocutions (word substitutions to avoid problematic words)
     7.   Words produced with an excess of physical tension
     8.   Monosyllabic whole-word repetitions (e.g., “I-I-I-I see him”)
B.    The disturbance in fluency interferes with academic or occupational
      achievement or with social communication.
C.    If a sensory-motor or sensory deficit is present, the difficulties are in excess
      of those usually associated with these problems.

Note: If a speech-motor or sensory deficit or a neurological condition is present,
      code the condition on Axis III
                Stuttering (307.0)
   Extent of the disturbance varies, often more severe
    when there is pressure to communicate.
   Often absent during oral reading, singing, or talking to
    inanimate objects or pets.
   At onset, speaker may not notice stuttering; however
    fearful anticipation may develop later.
   Stuttering may be accompanied by motor movements
    (jerking of head, eyeblinks)
   Impairment in social functioning may contribute to
    anxiety, frustration, low self-esteem.
                    Stuttering (307.0)
   Prevalence
       1% in prepubertal children
       0.8% in adolescence
       Male:Female ratio 3:1
   Onset
       typically between 2 and 7yrs; peak at 5yrs
       Before 10yrs in 98% of cases
   Familial pattern
       First-degree biological relatives = 3x risk of gen population.
       For men with a history of stuttering, 10% of their daughters and 20% of
        their sons will stutter.
   Differential Dx
       Hearing impairment, speech-motor deficit, normal dysfluencies that occur
        in young children
Communication Disorder NOS (307.9)
   Disorders of communication that do not meet
    criteria for any specific Communication
    Disorder
       e.g., Voice Disorder - Abnormality of pitch,
        loudness, quality, tone, or resonance.
                   Case Material
   Ed – 8yr old male
   Previous DX of ADHD
       Taking Concerta (methylphenidate) 45mgs
   Struggles with engaging in appropriate peer play
    (often plays the class clown)
       Will crawl under tables to make other students laugh
                 Case Material
   Unremarkable pregnancy & birth history
   Some lack of weight gain early in infancy
   Developmental milestones somewhat late
     Walking at 12mos
     1st words at 18mos

     Clustering words at 24mos

     Rec’d SP/L services at 3yrs of age

     Some infrequent enuresis when hyperfocused
                    Case Material
   Some continuing difficulty expressing himself
    verbally & in written expression
     Speaks very rapidly, appears to stutter
     Reverses written letters
     Observations:
         Repeats final sounds of a word: (“The cat is on the wall
          …all …all …all.”)
         Repeats initial words of a sentence: (“The thing… the
          thing… the thing that….”)
         Phoneme substitutions (“Brudder” for “Brother”,
          “Afross” for “Across”)
                   Case Material
          Wechsler Intelligence Scale for Children – 4th Edition

   Verbal Comprehension Subtests          Perceptual Reasoning Subtests
Similarities              9          Block Design                 14
Vocabulary               10          Picture Concepts             10
Comprehension            10          Matrix Reasoning             14
(Information)            (9)         (Picture Completion)         (9)
(Word Reasoning)        (NA)

      Working Memory Subtests              Processing Speed Subtests
Digit Span               5           Coding                       4
Letter-Numbr Seq.        9           Symbol Search                8
(Arithmetic)            (8)          (Cancellation)              (9)

  Verbal Comprehension Index                          98
  Perceptual Reasoning Index                          117
  Working Memory Index                                83
  Processing Speed Index                              78
  Full Scale IQ                                       94
               Case Material
   Woodcock-Johnson Tests of Achievement, Form A - Continued
                   (norms based on age 8yrs, 1mos)
                                 Grade Equivalent Standard Score
Oral Language (Ext)                      2.1            95
Oral Expression                          3.0           104
Listening Comprehension                  1.6            91
Total Achievement                        2.5            96
Broad Reading                            2.3            92
Broad Math                               3.1           108
Broad Written Language                   2.4            95
Basic Reading Skills                     2.3            94
Reading Comprehension                    2.1            94
Math Calculation Skills                  2.6            99
Basic Writing Skills                     2.1            92
Written Expression                       2.9           103
Academic Skills                          2.4            95
Academic Fluency                         2.6            98
Academic Applications                    2.6            99
Phon/Graph Knowledge                     1.3            80
Diagnoses?
                             Diagnoses
Axis I:     Phonological Disorder
            Disorder of Written Expression
            Mathematics Disorder
            Reading Disorder
            Academic Problem
            Attention-Deficit Hyperactivity Disorder, Combined Type (by history)
            Stuttering (by history)
            Adjustment Disorder with Mixed Disturbance of Emotions and Conduct (by history)

Axis II:    Deferred

Axis III:   Deferred

Axis IV:    Problems with the school environment.
            Problems with the peer group.

Axis V:     Current estimated GAF: 75
            Highest GAF in past year: 75

								
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