17 Neurodevelopmental Disorders

ROUTE MAP OF THE CHAPTER CH A PTER CU 1 !f'H

lMt...,..,~m bydo«(,bor,gU,,,.., i,,who:h

INm ir,g,1ot<11o<:ru.l....i~•• - ' " ' "' I "-' 1.. , .u•~ooa• ,
~¥l01h<t,rm>oologythat;..,,o,cio<«IW1tt,tho>t ~lt>w.:,~u ·_,.•,;,!'>c
d;qt,;t,tiff, Th<<~pt0<thonP<0<N<i1todd<\ll< IKIOr>
'l'°ffit«/with ffiO'~..tioiogy....d !rN,,....,I ']11'(C!F•;"" :,,
oi1h<,..-,oupsotd~-y11>K"''-"
""l~~(♦.g ,_;fw:_ol,.ac,;,,g.""il>-o<J 17.I ,i,rn,r(fU\lO'•'-',
..,.."'"'"'"""'' "'"),lo,tellt<tu>ldk,ol,ilill« ...... ,,,..11)
'"li<tk 5C>O<trumdfwrdo,-.

, •. '"·· ,,i;n,
,i,11:~•t. l97
- PSYCKOPATHOLOOY
'
t
'

W h.en yu~l rut-:.-e completed rhis dupte1' yo.u should be able to:

1. Disrnss. the d.ifl:erent ways in which learn ing and 5. Describe ,md evaluate the main forms of
dev--elopmentJ.l disJ.btlities are t~ategor:ize.d and intervention, care and support for intt"llecru al
bbelled. disabilities.
2. Describe and compare the various types of 6 • Describe the diagnostic criteria for autistic
spedfic learning disabilities, their aetiology and spectrum disorder.
treatment- 7. Compare and contrast theories of the aetiology
3. Describe the various forms of intellectual of autistic specrtum disorder.
disability. s. Describe and evaluate the main forms of
4. Compare and c01mast genetic, biological and intervention, care and support for individuals
environmental causes of intellectual disabilities. with autistic spectnim disorder.

3../-
: -••~--•••-••••~.--•-••- ••••••••••••• ••-•••.. •••••••os••••• ,- •- •• ••• ••••••••-•••• • ••••• • • .. • •• •• • • ..•••• • •• • .. •• • •• • •• •• •••• • .. ••• • • • ••• •• •• • • •• • ;- •• • .. ••• •• .. •• • •• • • • •• •• • •••• • • • • • •• • ••• •• • • ••••••••• • • ••• •"•" ••••• ....\

Outing chikl,hood, no-one knew what/ had. Jwast:onsi.dered 'crazy' by a doctor at age 1 because I had constant tantrums, which
1 ool,y.ended. one day; when my mothertook me to the beach during a holiday. My nerves suddenly were calmed down by the sight
and the soothing soonds of the sea. I was beginning to say my first words and ~tarted to make some progress.
Desp,te the progress, I stm
had strang~ behaviours, like spinning plastic lids, jars and coins. I rejected teddy bears that other
roddlers liked, but held on to other obj ects, like dice (which had a smooth surface and were pleasant to touch). I was terrorized by
everyday noises; like planes passing by, thunder, machinery, drills, balloo,ns bursting and any sudden noise.
Being the firstborn, my mother didn't take notice of behaviours like rocking back and forth, or spending time on a rocking
horse fn the-day care centre as a toddler instead of playing with other kids.
Despite socfa/izlng difficulties, my interest fo r reading and learning the alphabet pleased my mother. Instead of pointing out
pictures in a newspaper my mother was reading, I asked her what the letters were, and that prompted her to teach me to read
before starting school.
Socialty, i had problems thatwor(iedpeop/'e. I was 11ot able to recognize people easl/y, and was not able to decode nonverbal
cues. My mother complained about always having to spell things out to me. While my younger (non-autistic) brother seemed
to know instinctively when to bring up a subject, or when to say a joke, I was a nuisance, because I couldn't tell if somebody was
angry; sad, tired, and so on, jus t by looking at him/her. I took things literally and was terrorized by my mother's 'threats: which my
younger brother did not take seriously. Sile uttered threats like 'I will send you away' when we behaved badly. My brother was able
to understand that she never meant it; however, I was terrorized by them.
One thing that discouraged socializing was that most others did not like to talk about Insects, calculators, or space al/ the
time. Other people liked my subjects once in a while' but got angry if Jwent on and on. My mother constantly reminded me not to
ralk about the s.ame things over and over. Changing subjects was hard for me. I was fixated on certain subjects like entomofogy
and arachnology. Nobody cares to hear about the chelate pecjipalps of pseudoscorpions. I

George's Story
•.._ •••• • ...• • - - •- • • • •• • • • n • • • • _ , • • • ·• • • . , -.., • • • • • • o • • • •• - • • • • .-, ••• • • ..-.~ - ,..., • •• • • • o • • • • • •• • •• • I • • o • • • • • • • ' • • • •· • • • • •• • • • • •• • • • • •• • • • • • • • , . ', , •• • • • • • • • ' • • •• O, o •• • • • • • • • • • •• • • ' • • • • • • • • • ' h • • •• • • • • 0 • • , ._ • • • • • • • • '< • • • • , -< • • • •• • • • • • • • • • • • • • • • • • o • • • • • •• ..

Introduction and may affect intellectual, social and motor develop-

ment, and a.s a consequence will have effects on academic
N eurodevelopmental disorders are a category of disor-
achievement, the development of social behaviours and
ders that rypic.ally begin to manifest in early development subsequent occupational functioning. hr this chapter,
 CHAPTER 17 NEUROOEVELOPMENTAL DISORDERS

_ will cover three categories of neurodevelopmental 17 .1 THE CATEGORIZATION

" - ~~ rder _ specific learning disorders , intellectual dis-
"1~ries and autistic spectrum disorder. Each of these AND LABELLING OF
. , ~,\:ii. • ories is ch aractenze . d b y· a spec1'fi c unpairment
· in
~- .-J,eg l ( 1
:~·rning or contro e .g . anguage or communication NEURODEVELOPMENTAL
';o1- rders such as dyslexia), or impairments that can
.,1150 ' . •
.-orer both mtellecrual and soC1al domams (e .g_ autistic
•
DISORDERS
·oectrurn disorder), or global impairments to intellec- ···· ··· ······· ······ ········ ···· ··
st 1, ,ocial and motor skills (e .g . intellectual disability). In this chapter learning disabilities are divided into three
nia , •
-.\ neurodevelopmental disorder can be considered as broad categories. These are (1) specific learning disabilities ,
· significant, lifelong condition that is usually present such as language and communication disabilities, (2) inteL-
3
frorn birth, but it may often not be recognized until the tectual disability , covering some of the more severe learn-
individual fails to reach important milestones in their ing difficulties, and (3) autistic spectrum disorder, which
development. Failing to sit up, to talk, to read, or attend covers a range of deficits in social communication, often
ro what is going on in the world are all possible signs with accompanying intellectual impairment_
of a learning disability if these activities do not appear There is considerable diversity across different areas of
as expected at normal developmental intervals. Most the world about how various learning disabilities should
neurodevelopmental disorders are permanent condi- be labelled. In the UK, Europe and much of Australasia
nons, but with suitable support and encouragement the term learning disability has often been used as an
many people with these conditions can acquire practical umbrella term to cover learning disability An umbrella term
and social skills even if this may take them longer than disorders across all three to cover specific learning disabilities,
normal. of the main categories intellectual disabilities and pervasive
George's story describes the early life of someone diag- described above - and it is developmental disorders.
nosed with autistic spectrum disorder. This involves diffi- especially used in this way
culties in interpreting nonverbal behaviour, impairment by health and social care For a video on learning and intellectual
disabilities go to
in communicating with others and a repetitive preoccu- services. In DSM-IV-TR,
www.wiley-psychopathology.com/
pation with individual objects, activities or topics. This the term mental retardation video/ch17
personal account provides a striking insight into how referred to a specific diag-
these disabilities can affect normal day-to-day living dur- nostic category of disorder defined as significantly below
, mg childhood. George prefers indulging in stereotyped average intellectual functioning, characterized by an IQ of
behaviours, such as rocking, to playing with other kids. 70 or below (DSM-IV-TR, p.49). However, the term mental
He is unable to understand both normal verbal innuendo retardation is now commonly frowned upon as stigmatiz-
and the nonverbal body language that most of us learn ing and demeaning and was replaced in DSM-5 by the label
to understand implicitly. This causes him t~ be ~een br 'intellectual disability' and in ICD-11 by 'intellectual devel-
others as 'difficult' , uncommunicative and a nmsance , opment disorder' - a change that was required by federal
all of which in turn causes him to feel more anxious and statute in the United States and was known as Rosa's Law.
distressed. Most neurodevelopmental disorders, no mat- There is as yet no genuine international consensus on the
ter how specific, cause problems across the whole range use of these categories and
of life activities, including educational, social and occu- labels, and even within coun- To read about Rosa's Law go to
\larional, but the degree to which sufferers have pro~- tries these terms can change http://tinyurl.com/pgyqk5n
th
lerns in these areas of ·functioning will depend on err quite frequently to reflect
background and family circumstances and the nature shifts in social attitudes towards individuals with learning
, and degree of the disability. . disabilities. Nevertheless, no matter how much we may
1'his chapter will look in detail at the vanous types believe that labels for such groups of people may be stig-
(if neurodevelopmental diso • · rd er,- t h err· aen·ology and
. the matizing, it would be difficult to understand the aetiology
v·ilnous
· treatment and caring options · h t are available of these disorders and to organize services and support if
t a
r(' 'h there were no way of defining their specific problem$.
' ,rt ese disabilities.

, .,H - . ._.. disability, intellectual disability and a1,.1tisticspectrum disorder' defined?

· ow are the terms specific learnm9 .
~ . . "" . . '- ~ .
;
- PSYOtOPATKOLOG.V

SECTION SUMMARY ·---·-····· ·-·-···. ····-......................······.. ' ................................' ....................' ...............' ...., .... ..... ....' .. ,..... ............... ... -~
'

17~1 THE CATEGORIZATION ANO LABELLlNG Of LEARNING DISABILITIES

• The three mam categories of learning disabilities are (1) specific learning disabilities (e.g. specific learning diso rd er),
Q) mtP.Jte aoot disabi1ities, and {3} autistk spectrum disorder (ASD).
..•··
•.,__ - - - - ~ -••--•• - -- •----- • •-u~•-•-•- •u ..O • o-•-• • ..,.• •••••• ••,-••••• ••••••• ••• ••••••• • ••••• •• ••••••• .. •• ••• •• • ••• • • • ••• • •••• • • • • • •• • •• • •• •• ••••• • •• • • • H .. I• • •

understanding the meaning of what is read, difficulties

17.2 SPECIFIC LEARNING
D'ISABILITIES
DSM-5 ooides specific learning disabilities into two
~ood categones: ( 11 specific learning disorder, which cov-
ers ,Jillkulties in learning and using academic skills such
as reading and \.voting, and (2) communication disorders,
w-ruch .:ewers deficits in language, speech and communi-
G::tion generally.
11.2.1 Specific Learning Disorder
Spcctfk 1eammg disorder refers to a number of dis-
abilities that each affect the ind.i\.idual' s performance
on su.ruia:rdized teS,ts of academic abiJity such as read-
mg. mathematics or ~,:itten e.~ession. Individuals with
these disabilities show levels of achievement well below
v\-nat would be e.xpeaed for their age. schooling and level
of mtd,Hge.n£.e_ As we shall see. below. individuals v.ith
·~ !earning disorders can show deficits in perceptual
orgaruz:ari.on (o-rgamzing information), auditory and vis-
J.tl. perception. memory, and attention. Without special
remedial support. individuals with these disabilities will
oormalfy perlorm b,adly at school, be viewed as failures DSM·S SUMMARY TABLE 17 .1 Criteria for specme learning
by fnends and family, and as, a consequence exhibit low disorder
s,et::-eteem and motivation IBjoikland & Green, 1992).
5imibtly, sdiool d!op-out rates for children with specific • Impediments in learning and using academic skilis, marked
te.arning disabilities. are high and they will also experi-
e-n£:e· diffiruttltS m OCCl.lpational and social functioning.
Sp:c.ifu: learning disorder is diagnosed when there are
Jena.rs or impairments in the in&,,iduars ability to either
~ceive or piiocess infmmarion accurately, which will
euntUally manifest in academic orcumstances as difficul-
tta- h'l re;;.dmg, ,1rriting or in ;:narhematical ability. DSM-5
ba-s, mrorpot ,m:d a number of previously different disa-
&ifui-es , m.:b as dys!'..e·na and dysca:lculia}into a single spe-
cifu: learning dison'kr diagnostic category, and defines • The affected academic skills are substantially below what
,d:is;;IDihries b dus category as difficulties in learning and
~~~ ~i'toef..ie a t- using academic skills in
~ir'-<~~ e rs ~ 3S ~xla- one or more areas such
..,.~ ,.;,iir~nif.awi ~:so,~ as sfow reading, dilliculty
with spelling and written expression, difficulty mastering
number sense. and difficulties with mathematical reason-
ing. DSM-5 Summary Table 17.1 provides the diagn~sti c
criteria for specific learning disorder. Table 17 .1 descnbes
some of the specific disabilities covered under this diag-
nostic category and provides some examples.
Specific learning disabilities such as these are often
commonly comorbid with other childhood psychological
problems, and studies suggest that specific learning dis-
abilities can be diagnosed in 79 per cent of children with
bipolar disorder, 71 per cent with ADHD, 67 per cent
with autism, and slightly lower percentages \\ith anxi-
ety and depression (1 8-19 per cent) (Mayes & Calhoun,
2006). Literacy problems generally are associated vvith
increased risk for both externalizing and internalizing
disorders in childhood and this may be due either to the
stressors associated with academic failure (causing anxi-
ety and depression) or the fact that certain types of cogni-
tive deficit (such as attention deficits) may be common to
a number of different disorders, including specific learn-
ing disorders and disruptive behaviour disorders such as
ADHD (Maughan & Carroll. 2006).
by at least one of the following over a 6 month period:
• Inaccurate or slow and struggling reading
• Difficulty understanding t he meaning of read words
• Spelling difficulties
• Difficulties in expression through writing
• Difficulties underst anding numbers
• Difficulties with mathematical reasoning
would be expected for the patient's age
• The difficulties. are not better accounted for by inte!-
. lectuai disali)iliti~ vision or hearing diffic;:ulUes or other
mE!ntal or n~ijr1:)logicaldJsorders
 CHAPTER 17 NEURODEVELOPMENTAL DISORDERS -

rA-i:itE ·; 7. l Specific learning disabiUties

Problems with accurate or fluent word
recognition, poor decoding and poor
5pelling abilities (formerly classified
as dyslexia)
Problems with written expression
Difficulties mastering number sense
number facts or calculation (former!~
classified as dyscalculia)
Difficulties with verbal and written
expression
Description
Reading ach·ievement .1s substantially
.
~elow th e norm for chronological age,
intelligence and educational level
Writing skills are substantially below
th0 se expected for chronological
age, intelligence and educational
level
Mathematics ability is substantially below
norm for chronological age, intelligence
and educational level
Scores on tests of expressive language
development are substantially below
those for chronological age, intelligence
and educational level
Exampte symptoms
" Omit, <1dd or distort the sound of
words when reading
• Read slowly and with poor
comprehension
,. Regular errors in spelling, grammar or
punctuation
• Difficulty remembering arithmetic
facts (e.g. to 'carry' a number)
• Failure to understand arithmetic
concepts
~ Markedly limited vocabulary
• Making errors in tense
• Difficulty recalling the right word

Dyslexia even though children with impaired reading skills show

Dyslexia is a complex pattern of learning difficulties an improvement in reading ability with age , a gap in
associated with difficulties in word recognition while reading ability remains across time between children
reading, poor spelling and difficulties with written with reading impairments and those without . In it1di-
expression. Reading may be characterized by word viduals suffering dyslexic problems, writing skills fall
distortions, substitutions or omissions and is generally significantly below those expected for the child's chron-
slow, with the child having difficulty fully comprehend- ological age, IQ and educational history. The child will
ing what has been read. Between 3 and 17.5 per cent of have difficulty composing written text (Photo 17.1) and
school-age children have specifi.c developmental reading will exhibit grammatical errors, pw1cruation eITors,
problems (De.Fries, Fulker & LaBuda , 1987; Shaywitz, poor paragraph organization. spelling errors and poor
Shaywitz. Pugh, Fulbright et al. , 1998) and around
handwriting.
60- 80 per cent of those diagnosed are likely to be bo~s
(Shaywitz, Shaywitz, Fletcher & Escobar, 19~0). This Dyscalculia
gender difference may be due to a number ot factors, The main feature of dyscakulia is that mathematical
including or arithmetical ability falls significantly short of that
expected for the child' s chronological age , IQ and edu-
1. higher referral rates in males b~ca~se th ey_ cational history. Individual skil1s that may be impaired in
may be m.ore disruptive than gu-1s m learning dyscalculia are ( 1) under-
clyscalculi• A specific learning
environments; standing or naming mathe- disability characterized bymathematkal
. ·a11y offset their reading matical terms, (2) decoding abitlty being substantially below norm
2. girls may at least parn ·
difficulties by enjoying reading more than boys problems into mathemati- (or 1;-hronologto-l age, Intelligence and
cal terms, (3) recognizing educatipnat level.
(Chiu & McBride-Chang, zoo6); and
and reading numerical symbols or arithmetical signs,
3. g. iris mav have more effective copin~ srrate~ies
· J . • . • h . ding difficulties (4) copying numbers or symbols correctly; ( 5) remem-
than boys for deahng wit rea bering to conduct ,eeirtain mathematical ope-r ations
(Ale,xander-Pa$e, 200 6 )- (such as ' carrying' figures when rpak.ing cak.ula:tlons),
. . d " - ggest that 'r eading prob- and (6) · foll.owing sequence,s of mathematical steps ·. in
Most longtrndma.l sru.. .1.es otsuan.... d ch ron1·c , which
. does the correct order. ft is estimated .that around 3-4 per
lems can often be pe,I"SlSt e · . al lag·, in reading c.enr of schqol-age children may suffer. from develop~
.. .. devdopment . .
no_t.sunp.ly _re,pr~sen~ a .· s e.cific learning disorder me.ntal ·dyscah::ulia, with the male to female ratio as
P . f ranu.,. .· -·"' Sh high as 4 :1 {Reigosa:-Crespo, Gonzale.z-Alemany, l,.eon.
ab1hty. but. .1s evidenL:-e
. .. for. ha 1990; ' · ....,-ywirz ,
(Bruck, 1992 ;_ Scarboroug' q _ For example, Torres & Mosquera , 201'.3 ).
1 961
Stuebing, Shayw1rz & Fletcher, -
_ , PSY.CffOJ>~THOlOGY
Will anrJ U"'11McTr1 1yr•lk1erK• , ourc• Na11oru,J Atidubon Sor.,oty (c,lltt.t1-0n!Ptw ro Rt'.eard>er1,
1,;~. F/J!µ,(J{)u<<J4 vmh pt1m;<ilfJf!.
PHOTO 17.1 Dyslexia includes deficils in spel/ing and
writing as well as reading. Other symptoms of dyslexia can
include poor comprehension, reversal of words or letters
while reading, and difficulty decoding syllables or single
words and associating them with specific sounds (phonics),
Here, a child with qy.slexla attempts to reproduce a teacher's
sentence.
17.2.2 Communication Disorders
Communication disorders include impairment5 in
language, speech and communication, and here we
will cover the DSM-5 diagnostic categories of language
disorder, speech sound disorder and chif.dhood-onset fluency
communk.a~ disor~1 Problems with disorder (otherwise known
theartkulaiionofsounds, as 'srutttring' J,
Language disorder
Language disorder concerns problems with language
acquisition and use as a result of problems in vocabu-
lary comprehension and
1-tngu.age disorder fl disablllty ,oncemed production, and in the
with problems fn •;ocabul.<1ry comprehttn· ·
construction of sentences,
sioo .and proouct~n.
'Ibis usually results in a sig-
nificantly t,m aller vocabulary size, with grammatic.:a) and
tenStl errors. These problems will appear during early
dcve1opmcnr and persist into adolescem:e and·adulthood
(OSM -5 Summary Table 17.2), General features of the
dootder include a limited amount of speech. limited
vocabulary. difficulty learning new words, difficulty find-
ing the right word (e.g. unable to ·come up with ihe. word
car when pointing to a car). shortened sentt'flC'es, ~impl:e
grammatical strocmres {e.g, use of relatively few verb
forms,1. omission of critical parts of sentences,
word order and slow language development generally.
Language' disorder is often c0tnorbid-in younger children
' with speech sound disorder (see below), reflectmg a gei~-
eraJ impairment in th e fluidity of language and erratic
speech rhythms, Language di5order can. be ~den:lficd as
early as age 2- 3 years (Eisenwort, Marschik, Fladerer,
Motl et aL , 2004), but milder forms may n ot becom.e
apparent until early adolescence,
Speech sound disorder ,_
lrus is a disorder characteriz1:d by persistent d1ffa:ulry
with speech sound production and to be diagnosed with
speech sound di1order rhese impairments must be prob~
lems in effective communi-
speech sound disorder Per1lstent dtf·
cation that interfere with ficulty with speech sound prod(.Jctlon that
social, academic or occupa• interfere~ with ~peech mtelhgibility or pre-
tional achievement (DSM-5 venb verbal communication of me"!,sage,.
Summary Table 17.3 J, l 'be
disorder includes errors of sound production (e.g. using
a t sound co represent the letter k) and the omissions of
sounds - especially from the ends of words. Sufferers will
also be unable to categorize speech sounds and will be
unable to decipher which sounds in rhc language make a
difference in meaning, The most severely misarticulared
sounds are those learnt later in the developmental process,
such as /, r, s. z, th and ch , and lisping is particularly com-
mon (e.g, saying wabbit in..c;read of rabbit). Speech S<Jund
disorder may often be associated with physical causes,
such as a hearing impairment, deft palate, neurological
limitations such as cerebral palsy, and ear, nose and throat
problems (Fox, Dodd & H oward, 2002 ), but at least 3 per
cent of pre-school children are diagnosed with a speech
sound disorder of unknown origin. Prt.'Valence rate of
similar or related speech sound disorders is around 2 per
cent in 6- 7-year-olds falling to 0.5 per cent by age 17 years
(DSM-lVTR, p.66 ).
DSM-5 SUMMARY TABLE 17,2 Criteria for language
disorder
• Ongoing difficulties lo the attainment and use of f;m-
9uage (including spoken and written}, due to d!ffkul~
ties in understanding and emitting that include the
following:
• Reduced vocabulary
• limited sentence structure ability
• Dlfficµlties in di~logue
• Abilities ·,m~ substantially below what would be expected
for thei'patient's age
• _Symptoms start in early devel.oprntmt
unusual • The difficulties are ncit better ac:courrte.d for by vision or
hearing difficuities, motor dysfuntf)on or other rnentaJ or
neuro!ogkal dlso,ders

otNH SUMM'AltV TAB Lt 11 il Cr/tw/o {1}1' tporeh ~ownd
dNndW
t o~qolng dlff1t1Jlty wm{ $(}f'i(h liotrnd protl;J~h;lt\ t t\rrt
undor1;t.indlt1rl ()r pr1.\v _ ,
- r.i'l1W¼ 1'.lh'.)bl~m~ with l P!:1\lCh
\f(Jl'l'J~I t b11,muri!Ct1Uon " ~Ill..
• 11W dtfhfl.llty Cl'IU'i<'~ llmlhltl(u1~ 111 l~ffor;llV(• cCl ti1fl\ \it"11{~
\l('Hi~inrerforlt'l9 with S.t1cl.1l p,11 ttdi:>Mlr.m, 11t uefornlt. nr
unqpl\llQrW>I oe, fon-nh.r1c:1:
I. Sympt()IY1j Slijft ln \',ltly tluwtoprnQnt
• Olfht.ultlt'l "> dr~r nQt bHwr , o(f0Yt\lt:rl f\) 1 hy C'.C>li(JNilt
, " l or
.,,
ll~Q!J Irr < eMc11\.h) n•; 1r,dodhi~J r.creb,ol palw, ctt,~f-MM or
othot 1m;c,ll\.t)I c.01,cilt:\Ol)S -
Childhood-onset fluency dlsotder (stuttering)
'1'~11~ ls ,, probhm~ with the fluency ,,nd 1·in1c,pnt1trning
0t speech wh_k h 11w<,lvcs (1) frequunr rcperiliOJ's or pro-
lo!lg;tti<ms ol St11.mds, (2) pm.1sts within words, (3) filled
11r t,mf\llud prnuc$ In spc!crh, (4) word sublitltutfons to
avc\ld pronouncing problematic word,~. (~) words pro•
tlun·d with tm (rxcess nf' physicol tension, and (6) mon-
osyllabic word repetitions (1~.g. ·go-go•t~o-go out of thl:
ro<1111') (DSM., 5 Sumrnnry Tahl<: 17.4). Pcarful. unridpu-
\ion of srutterlog may ch•wlop in many sufferers and this
may m:\k.c s\u ttel'ing won;e in st:rc-stiful shuations, such
as when giving u speech or
1\u\terlng Ad1stu1b,mt1.1 ln thu norm,,I
11u~r,~y ;ind time pntternlnq of ~pccc:h tht1t
at an interview, Sumerlng
may be acc:o mponied by
1; mnpp1oprl.1te for th~ 1ndlvklunl•~ a9c.
physical symµton, s suc:h
as eye blinks, tics, n·cmor!l, j<:·rk.ii1 g of the hcnd and
rll•nching fists. As tan be envisaged, snmedng can also
havt highly detrimti\tal effeccs on sori.'1 and ot cupn•
rlonal fui1ctio11lng, On~n t)f sn1rtering rypka lly ocl.'. urs
betWel'n Z and 7 years of age, with a peak onset around
5 year~. The unset i~ usual'ty insidious and in.itially the
(hiki may be L1nawnrt.> or stutteriJ1g. However, as nwan··
ne~s in(·rctu;~s. the child will develop compensatory
stt·att~ies Jot-avoiding words nnd situations that cause
~tutt~!ring. Ce>JT'tf\ll.111ity studies estim.ate prev.ilcnce
!'ates of childhood-onset
lhlldhood•OnHt fluenty c;ll!'order
litutt1rlng) A problem with tho fhJl'nry fluency disorder (stutter•
:ndlhnt'-Pt1t\umlng of speoch which log) for all indivldu.1ls at
11 1VQlv{!-5 fr1•quMt ,~petition, 01 pmlon
() ,7 per cent, rising to 1.4
1au0ns of ~ound,, f'ill,N '~ within wQrd~, per c~nt in yoi111g children
- llllu'I')~ In w•eQth, wc.ird sul>stl\ut lom,
V.'O rtt~mod1.1.t;E;d with i)n c-xcPs, of pt 1ysl1:ul and dmpping to 0.5 per
ll'l'\11011, ,,r,cl monosyll11blt worri rnpotltlo,,&. cent in ,1llolcscents (Craig,
Haucock, 'lT'.an, Craig &
Pi:rers. 20()2). 1--k ,wcwr. the prognosis fol' tlttltterinv; i!i
good, with al'Ot1nd 40 per cent of sufferers ovel'coming
the proble111-brfore tht>y start, school nrld super cent over-
eo111itig- it before udolescenC'e (C<.>\!tln-e & Guirnr, 1993).
CHAPTER 17 NIUkODllVELOPMENTAL l)tSORDlifiS -
0$M•5 SUMMARYTABLE 17,4 Ulterla for d,lldhoocl•onsM
fhH•ncy dl~Mtll'f Mut/t• 1/11rJ)
• O1,~jolh:g dl~lllrbMcei ti( riortiiu l 01wnc.. y ancl tirmt
~ioHornnIn sr;i<-~ch, lm)pproptlate to the rt1tlet'lt's oq~,
11nu 1111,guttgc> skAI~, J~ mnt~t:d by ill l('i\St orio of the
fOll tiwlno: .
• Sou-n(J Md -syllt1bl0 repotltlont,
• SQltnd prolongiltloil _of conson~nts ond voweb
• liroken words
• f illed 01 unf\ll~d p11uses in speech
• Word sub~tltlltlo11 to avoid dlfftcult word!.
• Word pronw,clall9n with excE>sslva physical tension
• Mo11osyllablr whole.,worct repetitions
•- lho disturbance cau\cs anxiety about speaking or lhnlta,
tlon In effectlvn comrnunlra tlon
• Symptoms stort In early development
• Dlfficultles t1re not potter accountl!d-for by speech•mot,,r
or sensory deficit or other n,edlcal condition
Stuttcrlng is more i.:nrnmon in niaks rhan foma lrs, with
n mak-10,fo malc t'Ul'iu of 4: l u1 adolescents and 2.3: 1
in both y<Jungcr rhilclnm and adulrs. Of those children
diagnosed with stuttering, 12,7 per cent also have speech
sound disorder, l 'i .2 per rent have another learning dis-
ability and 5' .9 per cent have ADHI) (Blood, Ridenour,
Qualls & Hammer, 2003) .
17,2.3 The Aetiology of
Specific Learning Disabilities
In the fo llowing section we will disruss the ae tiol-
ogy and c,rnst•s of some of the more co mmon of the
specif-le lcl\rning disnbili tics we have desrribc·<l in this
settion .
Dyslexia
As mentioned earlier, dyslexia is a condition that
r1ffccts both reading and written cxpn·ssion, and is a
pcrsistcnt, chronic con-
dition in which !'t>ading dysl1ltl1 A persistent, chronic learning
ability h,A~ behind that of dls11bllity In which there 1Jre developmental
deficits lnspclllng, reading and writing
non-impaired l.ndivi\'.iuals abllitles.
fo r the conrse of most of
their lifetim.e, The development of dysh!:xia can be pre•
dieted by a number of risk facto rs, i_\1duding dif11culty
recognizing rhymti•s at ~ge 4 years (Bradley & Bl'yanr,
- flS\'(:HOPATttOLOG.Y
.• • . • • .· ..1 , t f other abilities, such as
Jchot ts qum· mdepenuen · 0 .d f
1Q~1) , diffit-ub:y n,nning t>wryd3y o-bjt-.::ts ,H age 5 ye~u·s •. g vocabulary an use o
,ieneral intelligence. reasonm ·
. h
•. k il C
~. Shan ~we er. ram ,
·
"Wolf, Ually & Mnni~, 1QSt,) an.d dift1.culry karnmg ~
'-)'TltaX (Share & Stanovic · 199 ;i' .
synt..1t'tk ruks at ,1,gc .?-J ye:rrs ,sc,: rburough, 1:90). - ) 5-,1 . ;vitz & Shavw1tz (2005 ,
Katz Fowler et aL , 1995 · l.l)'V • . .
Hnwe,aer, thi• nhun c..'l.uses ot dys.le..\'1~• nuw appc.~r to ·· . .
p.1302 ) charactenze the expenenc
, · -e of the dysle.xic m
·
,. ,
bie hknu:tie,~,.1
,ts ab.norm.a l'mrs.
· m • , ,,-ti~·'-, a1·ea~
· spt:l,. • · · ot
· the
the following way:
bra.it'l :mch as ,he t~·tnpnropal'iet,tl r~gion \Shaywitz &
Shavwi~, ZOO'i \ These abnormalities m,l)' be the result
... that the affected
. .reader
_ cannot use
of itnttk fano-ts and they m:1y give ri:,e t0 the difticnl - Th e probl t>m 1s , .
. b l . her order lin~nusuc skills to access
ti~ th,ll sufferers have in de\'.oding and comprehend: I11s o r er 11g · o .

ing writlen m :\te.riaL Wt: will revie,1,: these theo~es ot t h e meamng . . the printed word
m ltt'l _ has first been
the at•tiolog:y of dy~~h by looking in turn at ev1deJ1ce decoded and identified. Suppose. tor example, an
refoted to geot:tic inheritance. 1.:ognitiYe impairments individual knows the precise meaning of the spoken
and brain abnormulitit' S. won.1.1 , appan•ri·on'·, howeYer, she will not be able to,
use her knowledge of the meaning of the word until
Genetic faciors As ea.rlv as 1950. Hallgren reported she can decode and identify the printed word on the
that rnore. th ...m 80 per ce~r of children \vith dyslexia page and it will appear that she does not know
also h,1d mher fa.rnily members with the disability, \\rith the word's meaning.
1110ft' recent studies su~>esting that between 23 and 65
per cent of children with dyslexia have a parent with
the disorder (,_Scarborough, 1990). In addition, 40 per Bra in abnormalities Associated with problems
cent of the siblings of sufferers will also exhibit symp- in relating written letters to corresponding sounds are
toms of dyslexia tPennington & Gilger. 1996). This sug- deficits in brain functioning in dyslexia - especially in
gests th«t dyslexia runs in families and so may have an the temporoparietal areas of the brain. Post-mortem
imporrnm genetic component , and evidence for this studies of the brains of dyslexia sufferers suggest abnor-
genetic component is supported by studies suggest- malities in the temporoparietal brain region (Galaburda,
ing that dyslexia c:onc.ordance rates are significantly Sherman, Rosen, Ahoitiz et al. , 1985) and the number
highe.r in MZ than in DZ twins (Stevenson. Graham. and organization of neurones in the posterior language
Fred.man & Mcloughlin, 1987). Using genetic mark- area of the cortex (Galaburda, 1993). Nevertheless, these
ers for dyslexia, linkage studies have implicated genes abnormalities found in post-mortem studies might sim-
on a number of chromosomes in the aetiology of dys- ply represent the consequences of a lifetime of poor
lexia, including loci on chromosomes 2, 3 . 6. 15 and reading rather than a causal factor in dyslexia. However,
18 (Fishel." & De-Fries. 2002). There is evidence from functional magnetic resonance imaging (fMRI) stud-
molecular genetics to suggest that many of these genes ies of the brains of young children with dyslexia indi-
participate in brain development and cause the abnor- cate that they show significantly less activation in a
malities in brain development associated with dyslexia number of left hemisphere sites when reading than do
(Galaburda, LoTurco. Ramus, Fitch & Rosen, 2.006; non-impaired children. These areas include the inferior
Sc.erri & SchJ.Ute-Koene, 2010). frontal, superior temporal, parietotemporal and middle-
temporal-middle-occipital gyri (Shaywitz, Shaywitz,
Cognitive factors Re.search on the aetiology of dys- Pugh, Mencl et al., 2002). This represents a common
lexia has recently converged on the view that reading finding from functional brain imaging studies suggest-
disabilities in dyslexia are caused primarily by difficulties ing that a failure of proper functioning in left hemi-
in di.ffere.ntiatiIJg the elements of speech (phonemes) sphere posterior brain systems is a cause of impaired
an<l associating these sounds with the letters in a reading in children \\ii.th dyslexia. Studies of lesions of
\Vrimm word (Shaywitz, 2.00-3 ) . This is known as the the temporoparietal a.reas of the brain also indicate that
phonological theory of dysle..'"{ia where, in order to learn this area may be critical for analysing the written word
to read. .t he child must and transforming the symbol into the sounds associated
phonologic-al theory The vtew that Ieam to r~cognize that with the linguistic structure of the word (Damasio &
madlng dl56h11ltres ln tlys\e;t(ii.t are t:aused letters and letter strings Damasio. .1983; M.cCandliss, Cohen & Dehaen.e, 2003 ).
pmnarily b)l d1ffirulhes in diffeientiating
rhe elc?ment~of s~h (phonemesJ and ·
represent the sounds of lnterestingly. brain imaging studies also suggest that
associating theie ~\.Inds with the letters, in spoken language. The individuals with dysle.-tia may attempt to. compensate for
a wntti,1 WOfd. deficits in dysle.tja impair the lack of function in the temporoparie-tal areas. of the
the child\, abilitv to break brain by using other brain areas ro help the.th id~ntify
up a:spoken word into i~s baskphonological el~ments ,,'O:tds an~ -assoc.iate them Vi.11th sound.s. These (:Ompen-
and fink each letter to its corresponding sound, This satory effects involve brain sites required for physically
.11·~tuh\tm~ :1 word, ('1h1bling lh\,, in:d.iv1dt1<\I wh h dys,
lt~I~
·
t n dev1.:lnp an awa1•c.n.ess of rb,-· si ,,.
Llf .i ,vnrd
•
bv• 1-ornung
.
-t
" · '- '" ··(,urn. snucttn·c
the WQl'd wi'·t\, ti'\, · . I
CHAPTER 17 NEURODEVELOPMENTAL DISORDEJlS

sound production rnay nor represent the. whole pkrure •

-
For example. thc:re. is growing evide1:1.1:e of a familia.l and
• . ' . Cit lf)S , tongue gen<.•tic componenr to communication diso.rclers such
.u,J ,·ni..a l ,l.pp,\r,m.ts ~nrunsw 1ck. Ml'Crorv p 1-.1 - 1-t.· h
. I· Qv ) .... .,, He • .lit . <1s srmr.t•ri ng tCanh~tti-OliveiH & Richieri•Cosra, l006;
t(. Fr1t ' · \ . ,i . Cornpc:nsntnry cfft:cts such "s tl . .
. -·b -,. 1. .. - "· . 11s may Andrews, Morris-Ycares. Howie & Martin. 1991 l that
t)..l'h'.n \\• Y ~'(;.il'_lllg perform;\nc:t.• in children wirh dvs- indicates that rhe heritability of sn.mering may be as high
lt>i11,1 1~1pt'L)~cs ~1th age bm still fui\s tn reach tlw srni;d .ts i1 per cent. There is also evidence from brain scan
:11\\ of n0tMt11p,un•d d\ildnm .
studies of abnormalities in certain brain circuits that. are
related io stut'te,ring. One such circuit is the basalg,mglia-•
Dysccdculia thahuno-rnrtical motor cit"C'Uit. which, if impaired. may
Dyscuk\lli.1 nppears to be ,t s1-wdlic but dwonic condl• affect the ability of the basal .g anglia to prQduce tim-
11,1n, in whkh S\~tforers may p~rform better th«n ave 1-.1gc ing cues for the initi,uion of the next n:1otor segm.em
L'l\ 11\:asun·~ ol l<?, v_ oc.~hulary nnd working menwry, ill speech (Alm, 2.004). The fact that stutte1ing may be
but ~t,11 pt'rfonn s1gmfic mtly poorly on tesL'< of n1.ath- .) problem associ.1ted with the Sc'quential production of
c111.nic.il ,1.bilily O.anderl. 'Bevan & But:tetwonh. 2004). sounds and words is supported by evidence that suggests
Tlw disorder appcat·s to h e tl-w result of specific disabi1i- that stuttering rarely occtn-s in one-word utterances and
1ks in basic munhc.r processing an~t can take three b ~\Sic is ;ttlected by the length and grammatical co~1plexity of
forms: ( l ) a ddicit in the m emori,dng and retrieval of utterances (Bloodstcin, 2006 ). Furthermore, sn1ttering is
ll'ithmetic fa~ts. (2.) devclopn1cntnlly immature strate- often a consequence of brain injury in the basal ganglia,
gies frir solving arithmetic prnble rns. and (J) impaired suggesting that it is an important area i.n the production
visuospittfal skills resulting in errors in aligning numbe rs of normal speech (Tani & Sakai, 2.01 l ) .
or plJcing decimal points (Gea ry. l 993, 2004) . Finally, there is some evidence that the production
Dys.l'ak1.11ia appears to h,we a familial component of sounds in communication disorders may be affe.cr·e d
t~lonut~i\UX , Faraone, Herzig. Nuvsaria & Biederman. by emotional factors such as anticipatory anxiety or lack
2005) and .,bnormalitics in brain function assod;ued of control over emotional n~act:ions (Karrass, \Valden,
with dyscakulia may be partially transmitted genetically Conture. Graham ct al. . 2006). However, at least some
(vo11 Astt!t, Kudan, Schweicer & Martin, 2005), and are researchers view this association benveen disorders such
ulsn associated with the genes that mediate m athemati• as stuttering and anticipatory anxiety as secondary. and
ml ability generall.y (Plomin & Kovas . .2005). However, a as ,, conditioned consequence of previous stuttering
number of studies have also implicated prenatal factors CJ..1)eriences (Alm, 2004).
such as fetal alcohol spectrum disorder (FASO ) and low
birth wejght (O' Mallcy & N,mson, 2002; Shalev. 2004) .
Bn1in functions specializing in number processing are 17.2.4 The Treatment of Specific
loc(\tcd in various areas of the brain: fMRI studies have Learning Disabilities
implicated abnormalities in the left parictotemporal
and infc.rior prefrontal cortex areas of the brain. and the The inclusion of specific learning and communic-ation
intraparietal sulcus in mathematics disorder _(Dcl~a~ne, difficulties in DSM over the years has been controversial.
Molko, Cohen & Wilson. 2004; Molko, Caclua, Riviere , Many view these problems as developmental ones that
M:mgin ef aL, 2.003 ). Thus, the current evidence.. suggests require attention in an educational i~ather than a dlnkal
a genetic or develQptnent-al cause that resul~ m abno~- setting and, indeed, many learning disabilities are tackled
malities of function in those areas of i:hc brain res~ons 1• primarily in the context of the child's educational devel-
bit> for prorl•ssing numbers aud artthmctic c.ikulat10ns. opment (Mishna, 1996). However; specific learning dif-
ficulties nre frequently associated with clinical problems
S\lch as anxiety, depression and disruptive behaviour,
Communication disorders d b
M.,ny communi.cation •disorders may be cause Y and they can create significant problems in social. educa•
· . el . .. -l ot·mal deve\c)pment of tion~l ~nd fa:m~al functioning that, may rcqt1ire referral .
organ.ic problems r atmg t<.> a ,n - · · _. . .
the physical apparatus required ro n~ak.e and art~i;ulatc to chmcal services. Many of the treatments required bv
stiunds. For cxJmple, speech sound disorder and :-nttte.r- individuals with specific learning disorders l.'.ao be p~-
ing can be associated with physical causes st1ch as h~a~ng vidcd by educational psyd1ologists or speech therapists
.u11p.iirmeot . deft• pa1ate , ce,ie
. bral palsy ai1d car. nose and rather than dinkal psychologists at1d it ls not inteuded to
.
· ' · d. . e theories of stuttermg cover these forms oftre.att11et1f here .
throat nroblem1>. Tri ad 1t1on, sor.n _ . .: h
r _ 1 . fro m prob1ems w1t1. 1 t e. In m any cases, such as reading impaitme:nc., apprn·
s
argue that thi s di:,or(kl' re u ts ·· h _ d ·1 .
. , . f . ·d. . . the mout an i'lrynx priate reading .instruction for at-risk younger children
physical · aroculatton
· · o soun l:i m· ct•ffi lties re late d to can enable them to becl)me accurate a.nd fluent reade.ts
(Agnello, · 1975 ). However, organic · 1 c:u
- PSYCHOPATHOLOGY

(Alexander & Slinger-Constant, 2004). However, with
older individuals suffering from reading disabilities sUl:h
as dyslexia. a common approach in educational settings is
to provide learning materials in a form that allows them
to be most easily negotiated by the dyslexic student. In
addition, to compensate for the fact that the dyslexic stu-
dent's reading is less automatic and more eftortful. extra
time is given during assessments such as examinations.
Treatment of communication disorders is normally
the domain of speech therapists and related disci-
plines, and there is a range of successful n·eatment pro-
grammes and equipment available for disabilities such
as phonological disorder and stuttering (Saltuklaroglu
& Kalinowski, 2005 ; Law, Garren & Nye, 2004) . For
example, himd-held equip-
altered auditory feedback (AAF)
A form of treatment for stuttering in which ment can provide altered
delayed auditory feedback or a change in auditory feedback (AAF)
frequency of the voice Is given to clients for the stutterer, either
when they are speaking.
in terms of the delay of
,1uditory feedback it gives the s1.tlfrl't'I' wht'.11 s1w:1king
or through a change 111 freque ncy of the voice . Sud1
devices appear to have success in rcdm ing the h~wl&
of stutte ring, hut it is still not dc~ir by whJ I' nwr ha •
nism they have this effect or whether t.hry work equally
well for everyone with a ::.tuttering problem ( Lincoln.
Packman & Onslow. 2006; Lincoln, Packman , Onslow
& Jones. 20 IO). Ano! her successful set of techniques
u sed to address stuttering is known as prolonged speech
This teaches the sutlerer a set of new speet:h pattern~
that result in changes in the phrasing and arriculatton of
speech and of the respiratory patterns produced by !>tut
terers while speaking (Packman, Onslow & van Doorn ,
I 994). The success rates of treatments frn stuttcti ng
are particularly high and estimated to he around 60-- 80
per cent, but this may at least in part be confounded
by the fact that much childhood stuttering will usually
spontaneously remit after a few years (Saltuk.la roglu &
Kalinowski, 2005).

• What are the defining characteristics of specific learning disorder as a diagnostic category?
• What are the individual skills that may be impaired in dyscalculia?
• What are the main characteristics of language disorder, speech sound disorder and childhood-onset fluency disorder?
• What is the evidence that dyslexia is an inherited disorder?
~ Can you describe the phonological theory of dyslexia?
~ What areas of the brain appear to be most affected in dyslexia?
., What is the evidence that communication disorders might be associated with physical rath th h •
er an psyc o 1og1cal causes?
~ Can you describe treatments for stuttering such as altered auditory feedback (AAF) a d I d
· n pro onge speech?

SECTION SUMMARY
............. .. ..........................................................\
17.2 SPECIFIC LEARNING 01S·ABILITIES
1
In this section we have reviewed the characteristics, aetiology and general treat t f .
ties. These are largely disabilities associated with reading writing and ~e~ o a number of specific learning disabili-

.
. .
.
,
·
rather than cllmcal settings, they may come to the attention of clin·i I
communication generally and th
these disorders 1s the reading disorder known as dyslexia While ma·ny of th
.
d. b. . . . ' e most well-known of
ese is.a 111t1es will require tt t·
h . b
.
a en ion in educational
ca psyc o1og1sts ecause they ma O ft b .
I
ated with mental health problems and cause significant disruption to . 1f T · • Y en ecome assoc1· !
1 nd
To sum up the key points: socia' am, ia a educational functioning.
~
• Specific learning dl5order refers to a range of disabilities that affect p f ·f
mathematics or written expression. er ormance on tests of academic ability such as read_ing, '
• Dyslexia is a learning disability associated with difficulty in recognfzi
expression.
d .
ng wor s, poor spelhng and difficulty with written !
~
t
j
!
 • Dysa:ilculia is a disability that . ff
• Communication disorders inti d . . . art met1c ability.
,a etts mathematical ot I h , ..
CHAPTER 17 NEUROOEVELOPMENTAL DISORDERS

-
~ e 1mpalrments in Ian . . ..
• Language disorder is ad. b'I• guage, speech and communicatIon.
Isa , ity concerned With ,
• Speech and sound d ' d . . problems in vocabulary comprehension and production.
isor er is a disability ass .
• Childhood-ons~tt fl . . . · oc,ated with difficulty in speech sound production.
uency disorder is someti k
p atterning of speech, mes nown as 'stuttering' and involves a problem with the fluency and time-

• Disorders of reading, such as dys/ . k

ex,a, are nown to hav · · d ·
abnormalities in the tempor . . e an important genetic component an are associated with brain
opaneta1areas.
• Dysiexia appears to be associated with d 1'ffi . .
the letters in a written w d ( h ~ult,es differentiating the elements of speech and associating these sounds with
or t e phonolog,cal theory) .
• Treatment for specific learning di b 'lit' ft . .
sa . 1 tes o en occurs in an educational rather than a clinical setting.
• •- . . •h · • • • • • • · • • ~ • • · · • ... • · • • · · •· · .. • • • o • ooOO• O•o o -,,o •o • ~ • OOh o , ooo • · · • • • ~O O OOO O • O oo o ♦ O o o oO O O O O o O o O o ooo Ooo o ooO O OO OOO O hO OO o , o o · • • • ••o . . CO •• • • . . • • •• · • · • • •• • • • •• • • · • • • • ••Ho•o •••• •• ••• •OO o o . OO O oOo o , ooO o o oooo ooo oOO• o O OOo o o o a •o oOO o OooOoo o , •• •• • · • • ...

17.3 INTELLECTUAL DSM-5 SUMMARY TABLE 17.5 Criteria for intellectual disability

• Deficits in intellectual functions as cof')firmed by clinical

DISABILITIES as~essment and standard intelligence tests
• • • r••• ••••••••• • • • ••• ••• •• • • •••• • ••••••• • • •• • •• • • •• ••• • •• •• •••• • •••••• •• • ••• ••• •
• Deficits in adaptive functfoning resulting. in an.ii;iability
to meet development and sociocultural standar~s for
17.3. 1 DSM-5 Diagnostic Criteria personal independence and social responsibility
for Intellectual Disability • Symptoms start in developmental period

Intellectual disability is a disorder with onset during the

individual's developmental period (usually up to the age
of 18 years) that covers impairment in both intellectual
social responsibility, and IQ test scores should be inter-
and adaptive functioning.
ntt!ltttual disability A modern term preted cautiously depending on whether the instrument
DSM-5 defines intellectual
~ing mental retardation to describe is culturally relevant, based on up-to-date norms, and
"t moresevere and general learnihg disability according to three
takes into account any sensory or motor disabilities the
:t$\Htie~. primary criteria: individual may possess.
DSM-5 also allows intellectual disability to be specified
1. significantly below average intellectual f~nctioning
according to its severity into mild, moderate, severe and
in areas such as reasoning, problem solving,
profound, with mild being the least disabling, where suf-
abstract thinking, planning and learning _ge~era!ly;
ferers may only be mildly cognitively impaired, socially
and this below-norrnal intellectual funct1omng is
'immature' rather than impaired, and may be able to deal
defined by scores on IQ teS ts a_p proxi~ately two
with the daily tasks of life given appropriate s,u pport. In
standard deviations below the populat1on mea; the case of profound severity the individual may have
(i.e. an IQ below 70 on IQ tests with a mean o little understanding of symbolic communication and .be
100 and a standard deviation of l5); dependem on others for all aspects of daily care, their
. . . t s in adaptive functioning generally health and their safety. Clinicians assessing individuals
2. 1mpa1rmen • , d cational
. . .. - b·liry to master soCla1 ore u with intellectual disabilities would also gather informa-
~~~/t~:;~~uld be expected for the irtdividual's tion about disabilities from other reliable independent
chronological age); a nd . sources, such as teachers and medical doctors.
. . . h Ould be manifest dunng the
3. these defiats s .· . d (t' e normally up
d 10 .· mental peno · · '
individuaYs feve )P( . SM-S Summary Table 17.5).
to 18 years o age O · 17.3.2 Alternative Approaches
Yood deal of clinicaljudge- to Defining Intellectual Disability
. ,
DS~ -5 m~kes 1t d ear t~at a intell,e ctual disability. ;sin Rather than simply taking a negative approach to
mem 1s reqt.11ted when dt:~heth!r the individual m eets
It sho uld take into accoun ·d . f independence and diagnosis and focusing on an individual's limitations,
, l sta ndat s o
community and cu ltura ·
 imp.air mem.~ and deficn.,., mvrc rco:n r vttwfl .itrempr. w c-h.inw~11 m ~tritucl,-, 'Hippor·t ;md 111~1~1.1111,n; rm,n: _th;m
high!j~ t d,ose fucturs rh~ mJght hf.'." required w fadli h~lr of r.hww peopk wnh lMr-llN w al d111:ih1liw•(j m thi:
t;m: better imdJecwa.J ;md ,1dapttv~ functir,mng in dw CK rlHW l.rvl" w,th tht:l( r,arr.nt~ (fl t ,1rt; l ii-
;ndi•,1dwL Pimp.le wi:t h int(:.lir~ wa! dl$abHit1e11 t.hffi:r •ng,
mlica:ntly m the k-Vt-rity of thcit di,i;.biltw:!i, vmh r.r.tm1:
;d:-k to ftma ioo m t:ver;day trfe alm.,ht whhr.Afl hdn~ 17.3-3 The Prevalence of
nt}t1(..ed while amc~ m..-1; rtq·ufrt W M(;l;tlt supcrll/if(tfl
.m.d ~b..dr~rt:d cnllinmm-e:nt.~ in wh1d1 u, live. Similarly. Intellectual Dlsabllltles
in&r\•idual~ al,w differ :otgmfkamly iu ihct r p<:r~.on.;ihtif~ . F.~tim.m•11 <A th,, pt'<.." nlenn· ltv1·l!i f,f mu·lkd u.il d lt
Somt.: will he p-;1j~l:'1t:, plaad ;ind deptndJ;;nt wtuk orh{.'f<i i1r.lcrfi will ,kprnd V('f'/ mud'I !Jf1 f ,i w, ir,v·ll"d \l!ll
m;ry be ;tggi-e~we and irnpulftve . Tru:\i; kind$ r,f lj,,'i'Ue~ diJablHtk~ ~1r•· dc·foird. D!iiM 'J l·iitrm:m-~ th~ prev;1khn·
rrit:an ~r e.11.c:h inciwW:ual with 2n im,;llenval clliab,hty r,llJ" r,t a dfawu,io, ;,f mt,·ll1u twd di•,11hlhry iif ;;~ouncl I
kS hkdy tc, dilkr in tt..-r.rru of both their k-vd ,A iuncu.vn pu a~nr, 4rn.f prc-,.,·~J,•11, <: f,,r i.1,.'Vtrt· ,r;rdl,:<..tual d,~ahlhly
rng :ind what is r~ ire.d to achJen: any f.Grm of adaptiv,: at amund 11 pt r l{)(JiJ, I k,v11<11c r, a IJK \H idy l,11 ,ktnK ~pt·
funo.i.cmmg,. fn thu ist:11$e, ,he nr,mon nf 'intdlccu.1al dui- n fk aHy at rJ,,. pr~v;,lt:nc.(: rnt.t 1,f I() ~r~,rc~ h•.,),, [h;w 711
abtlit:>/ ~ nro--r.e of a ~. .o ?-f oonnN.fMn r:ha11 a di-agnClitic ')ugg,~~~ lh,il pn:v~len ri:: <>f ~-w h 1'1W I(} 1,Nm- 11 m,1y fw
Cit~gory Ut «:rm tilat ii a produa of partk ul;1r hi.fflnir:il ;.i, high ;J<:- bt-tWt t•n ~ and 111 ptr 1-'.'ent 1r1 ~, hquJ r hildrt•n
;md qdwral c-.mditiora l'.-ther than m,;dicJ i,r p~yd'.l!r ag"d J ~ J 1 y 1; ifl''> hmhct an."lly•i~ 'lu~gc, t.,,:J rh.it r,nJy
lr, ~l f.dent'.e} fWd'Jb & Wn,r.akt:r, V:11 Z;. ;m,und l 5 pe:r amt uf th,n,e wu;h. 1() irc1te~ hefow 711
Th.c Amc'ri~n ,Aj'll.>Cia.tion r,-n lnu:lfe;crual and wr!r,~ alrlZ'a dy m n:cc1p1. uf ;i 111.,i.U:-mc:YJt nf ., pern1J 4!dut..i
~ -ek;-pmgntal Dfoabilititi r AAHJ[)1 ha , prr1mc>ttd .i wm,d ru:t-di (4,,imorwff. Vidd!!~, Chadwick, C:ringai f'! 11 /.
ov;ire irnbv,idu~7.ed ~~,-mc·nt of~ per1u,n'4 1tbll.i, and 2.1Hl6J, 1mplyu1g 1,har du: rm.tJ(Jf-ity ,,1 th4? w •,up with low
nt:~ r~me:-r than AI"I ~wr,~u..h t>a~·d •.oitly (H'S cacc_wm✓--· ro (•1th~r d 1'1 r,ot l'.lt:1-"d cducatiun.al 'tllrJ)<itt' o r w ere 11,
mg i:u.clka.wf and adapts'+'~ 1:mpairm1-nt&, Th1J, appro-ach yc-1 unrem -gni'7,ed a~ tn mx d Qf ~-upport. £1ptckmwlog_,1;al
e.~h#sus th~r 1tid;1,·l.dual, ha-.·e b oth 1m..'11gth.i ,m d 'ltudi.t , mdk ar~ rhat therr ,.rt ar<,tmd ShO,C,IJO P~'JPft
fimir.ai i.om,. art& that in mdi·v1duar11 llmitau,,n, TJ1:.cd 10 in tht tJK wuh mdd 1mdlr,tu<1f d1~<tb,litt~·" ' a prw,a
b~ dw,awr.ctJ ,_n .2 way t hat enabk ~,-uitable i uppon t(J he li-11£'&: r:itt· {If arm.ind r,_c:,5 pn nmo ;md 2 t 7,00{1 Wfth
kvd~ , ~, rathk-"::- than wn.ply fon:mg the iud1vidu.al tA-'1/1:n· 111retlt:ctu.tl dii;1thHltir•,( ta prc-vi,lr-nr,· r;ite 1,f
int,, a diagrt-0'.ltk e:."Vcg.r-1fy, rhi~ 4ppr<.1ach evaluatt:" c~ (>.H pt,-r a ·nt) f Uptu Sti>ciny ln<itirnre, 200,; 1 f 1, iwrvtr.
st-;ectfk w.:edj ,Jf the i111.h~idoaJ i nd then ~ g,ge, r~ ~ rare- the Sim(,nriif, Pi.t;"k}t;ii, Ch,iJw,r k., Oring.u, tL al. ~t udy
~ le!. *..ervic~ and iupp!,rT.'fl tha{ wdl ,,ptim1z,;: individual
impH1:1 then: ar~ Jikdy u, br m;my mr,rc pcl)-pl1· rh:m thi.11
fo.t~noning. 'ii.l'.W,-{lft"\" are dt:ffoi:d ~ •rhc rc~,urc;eg, ,md ~vfforing ,i:,mr form af imd t.~rw,-,J J~.tlnlity <11141 thry
ntdrvidu.i:i &tr.l.tt:~ net-t'i~a,y w pwmou: fhe dtvd ~rr: gomft, wm:t -'>i,;r112c<l.
0~n-r. , ~duotion, 1nteru ti ... na
p1:r~omil we!J•bemg
(,f :J. !le!~ ,n with im:d lrcrnaf dt~inhtit i' Supporu c-an
~ prr~1dr.d where'Y-r.r r11:Cli'.$Y&r'f pt partnt&, frtt>fld5,
w.,ch.e-rJ, ptjcr~<,lngiiu. dbc.t.tJn ~n<l r,p"' or ,my 1JtJu.:r 17.3.-4 The Aetiology of
'PP"'J!mW.: Pf::t,Y ,-n m "gr.rw.:-y. t:'t oplr! wrth intdltnual
lntell«ctual Dlsabllity
,J,~,.t-ht!nJ1.;j tn:q1~r1t}f fare rr~y;r Jtr~.i ~d pieJud!-i e,
;md 1tM:--t .£Je ofa:n ~ Jr<mwd wii-h ~ii;:nifk;rni b.irrier~ l-1m, a.nd fortmo~r. the t,w t t>~ ~;t h11dk-ctmll d1111"thrl
i,-.. .
u., hzir,g, tr.tlr own pt,U ntrat. l--/J,v.1,..,11:,:, .tpproachn iry tr, 1tJ.dMd.uaf cas,-. ,.;J'c 1,ru:r1 <!tnc.mdy dtthr uh; v,
~ h <tJ ifai .id~HcW:ii by the /i.A!OO ~rt d(:'.igntd ,~_,l;,ie ;.m d idntttfy. Ewm whitn tht' c:auM~ of db,ah-11i-ty
r,, m;tbk m,~vtd;.t,tu !1/im um-tler,wif di§..·d1ihtid th ,,i
<:im be ~denriJfod (Jurh .i (:rtrom,n1m.J.1J d1•,vrdt·11 twc,
:u.hit-v1t i~H· potmt~ l. fp dw lJ K, tht ',Pf.nal P.dU( .itif.10 indh-'idrr,;111 i~m.i-tfod wn.h the i ~mt , ;.1i.1"'-c may uhibh
~c~-r.. j<ot,td r~hthty Art of 2f;(j J ~'.Ytr.r1.f.·d th e right!} r:tf qum: dttle-rftu lt:v~h I){ d!.mthihty. fJrffn entl11l d1agno,
1ndMduak wrm mtt:Hr.l t w.d d,,..t"h1faw,: 1<, b;; t dtJ.r.i t.1::d t i:. it !'llt0 ,Jttl.U: probkrn.1.H{.: in many ('.:w,,s if ii undear
m m .tm~re1'(1.1 ~ ,:(~ • a~ 5:<'h o,J!t ;.rt> riquirtd w dta.w wb«hi"1 ar, 11tdiv1duiit h~11 ,1 tpc-rifk k.irnir1-g d1i~ih~y,
ur ·U (di if,,m, r •irate~:, f,) fad lJm.£· dw· tndlJ:!k,n ll! h3, rrm-, c #,YWr,d mr.ellt:r t,.1.;il fmpa1nnkm~, i~ t,ufforirt}-5-
VUfJth- 'I>, lth Inti: lfo;..rn~I frt,m .ittt~~ic ~"ftf i::trum di$<1rik r (~:.t' ~cnilm P.4), or
lH!,{#~tf r.ttM'l,itf P."./jf-kft,rr;t-;
•.r,A~···,dl')',... 1 ·/·~~ _,,, ,17,,1:~
,, 11;
dti.ab,btJ<-a and m :l'.fi~ke ~~ p$y<:h1,k,g1e;r! ,11· (;f)')t;d'}n:4!•1~wh!t:rn, M, t'llt !!ha!J
reason.ah:!" .,i.dju« mtru 1. i (,1 fiet !fl tfo: fr.1Hrn,1mn Sr.'C.!llit} i; tbt rm1jc,i r C.~ !,Wt:~ uf hiteJ,
£ '($,,~:~' rj ,v1,•~• ··'·,:.,,,. tl'; ,t'h f.!ft,..-(-?"k(j .
,1,;~,.Clf!,~ •(i (J'4fl/'(!fjf,;. ~ i(' "❖"7".·•,-iW' th;,. rhi,-· are rtJ)t. di;ad"!lin• fll(1.u,a} di~;tl,;-1'.ry are L111l,,,,,ti~.11 j rt o~t,.m:- arut ,,v,l, .1ri00
tJL~~- A-, a fl;.h tli ,of ® t h fom1H1f h11pam:n@t ha~~4 ,,i1 ~llf:t 1( ., d'.lrmw~om~ Im
rnetabolic abnormalities have been identified (Dykens &
Hodapp, 2001 ). However. many researche1·s l 1· .
· d' , d al' . . · ·
rhat an m 1, 1 u s resultant intellectual d'b•i· .
• )e 1eve
. . d ~· . · 1sa 1 ny 1s
also influence considerably by envi·rc) . . c
. nn~n~1 1 a~
tors . . ~or example , mild or moderate intellectual
disab1li~ ten ds to o~cu: more frequently in lower socio-
econonnc_ gr~ups, md1cating that poverty and associ-
ated de~nvat1on may retard intellectual development .
one topical example of this is the case of teenage moth-
ers who choose to rear their children. They more often
live_ in ~oor environments, are more likely to expose
their children to alcohol and poor nutrition, and are less
likely to provide sensitive parenting (Brooks-Gunn &
Chase-Lansdale, 1995 ; Borkowoski, Whitman, Passino,
Rellinger et al. , 1992) . As a result, mild to moderate
intellectual disability is found significantly more fre-
quently in children of teenage mothers than in the chil-
dren of older mothers (Broman, Nichols, Shaughnessy,
Kennedy et al. , 1987) . In the following section, we will
look first at the known biological causes of intellec-
tual disability, followed by some of the environmental
factors thought to be involved. Table 17 .2 provides a
summary of some of the known causes of intellectual
TABLE 17 .2 Causes of intellectual disability
Developmental
period Cause or risk factor
Before/during Inherited recessive gene disorders (e.g.
conception phenylketonuria, Tay-Sachs disease)
Chromosome abnormalities (e.g.
Down syndrome, fragile X syndrome)
During Severe maternal malnutrition
pregnancy Maternal iodine deficiency ..
Maternal infections (e.g. rubella, syphilis,
HIV, herpes simplex) . rate of 0 .15 per cent) (Simonoff, Bolton & Rutter, 1996)
Maternal drug abuse (e.g. alcoholism,
tobacco abuse, illegal drug abuse)
Maternal medications (e.g. cancer
chemotherapy)
. d hypoxia (oxygen starvation
During birth Anox1aan
or insufficient oxygen supply)
Low birth weight
. (e g encephalitis,
Early childhood Brain infections • · ·
meningitis)
h"ldh O od malnutrition
C·t . • . (e g physical accidents,
Severe head in1ury
physical abuse sue as
h. shaken baby
syndrome) . . s (e g lead, mercury)
Exposure t~ tox,1n . an·d·poverty (e.g.
Social depnva~1on unstimulating infant
poor parenting, . age, with broad hands and short fingers. They may also
environment)
CHAPTER 17 NEURODEVELOPMENTAL DISORDERS
disabilities catt~gorized by the developme ntal period
when they have their effect.
-
Biological causes
Biological factors represent the largest known group of
causes of intellectual disabilities and we will divide these
into three main categories: ( 1) chromosomal disorders,
(2) metabolic causes, and (3) perinatal causes.
Chromosoma l disorders For many years now, it
has been known that forms of intellectual disability are
genetically linked to abnormalities in the X chromo-
some (the chromosome that also determines biologi-
cal sex) and these abnormalities will often manifest as
physical weaknesses in the chromosomes or abnor-
malities resulting from irregular cell division during the
mother's pregnancy. Chromosomal abnormalities occur
in around 5 per cent of all pregnancies and the major-
ity usually end in spontaneous miscarriages. However,
it is estimated that 0.5 per cent of all newborn babies
have a chromosomal disorder, although many of these
die soon after birth (Smith, Bierman & Robinson, 1978).
Chromosomal disorders account for around 25- 30 per
cent of all diagnosed cases of intellectual disability and
the two most prominent forms are Down syndrome
and fragile X syndrome.
Down syndrome was Down syndrome A disorder caused by
first described by British the presence of an extra chromo$ome in
doctor Langdon Down pair 21 and characterized by intellectual
in 1866. However, it was disability and distinguishing physical
features.
not until 1959 that French
geneticist Jerome Lejeune first reported that individuals
with Down syndrome almost always possess an extra
chromosome in pair 21 , which is usually caused by errors
in cell division in the mother's womb. Down syndrome
occurs in around 1.5 of every 1000 births (i.e. a prevalence
and risk is related to the age of the mother. For women
aged 20-24 years the risk is 0.07 per cent. This rises to
1 per cent for women aged 40 years and up to 4 per cent
in women aged over 45 years (Thompson, Mcinnes &
Willard, 1991). Although this link between maternal age
and incidence of Down syndrome has been known for
some time, it is still unclear how maternal age contrib-
utes to the chromosomal abnormalities. The majority
of individuals with Down syndrome have moderate to
severe intellectual impairment with a measurable IQ usu-
ally between 35 and 55 . They also have a distinctive phys-
ical appearance with eyes that slant upward and outward
with an extra fold of skin that appears to exaggerate the
slant. They are usually shorter and stockier than aver-
have a larger than normal furrowed tongue that makes
 ·-:
,!_
- PSYCHOPATHOLOGY
it difficult for them to pronounce words easily. They
also suffer physical disabilit)~ such as heart problems,
and appear to age rapidly, with mortality high after 40
years of age. Ageing is also closely associated with signs
of ckmentia similar to Alzheimer's disease (see Chapter
15) and this may be a result of the causes of both disor-
ders being closely located on chromosome 21 (Zigman,
Schupf, Sersen & Silverman , 1995; Selkoe , 1991). Dmvn
syndrome can be identified prenatally in high-risk par-
ents by using a procedure known as amniocentesis which
involves extracting and ana-
amniocel\tesis A procedur_e which lysing the pregnant moth-
irwolVi!S extracting and analysing the er's amniotic fluid. This is
pregnant mother's amniotic fluid used
now a routine procedure
prenatally in identifying Down syndrome
in high;isk parents. fur pregnant mothers that
is carried out after week 15
of pregnancy and is recommended in the UK and US for
mothers over the age of 35 years. The results of this process
can leave prospective parents with difficult decisions about
vvh.ether to maintain a pregnancy or not but, even so, amni-
ocentesis will only identify between 15 and 30 per cent of
Down syndrome cases in pregnant mothers who are tested.
Another important chromosomal abnormality that
causes intellectual disability is known as fragile X syndrome.
This is where the X chromosome appears to show physi-
cal weaknesses and may be
fragile X syndrome A chromosomal bent or broken, and frag-
abriormaUty that causes intellectual dis-
ile X syndrome occurs in
ability where the X chromosome appears
to show physical weaknesses and may be approximately 0.08--0.4 per
bent or broken. cent of all births (Hagerman
& Lampe, 1999). Individuals
with fragile X syndrome possess mild to moderate levels of
intellectual disability and may also exhibit language impair-
ment and behavioural problems such as mood irregulari-
ties (Eliez & Feinstein, 2001 ; Zigler & Hodapp, 1991). Like
individuals with Down syndrome, they also have specific
physical characteristics, such as elongated faces and large,
prominent ears (see Photo 17.2). Studies suggest there may
be a syndrome of fragile X chromosome in which different
individuals manifest rather different symptoms and degrees
of disability (Hagerman, 1995). For example, some may
have normal IQ levels but suffer specific learning disabili-
ties. Others may exhibit emotional !ability and symptoms
characteristic of autis,n, such as hand,biting, limited speech
and poor eye contact (Dykens, Leckman, Paul & Watson,
1988), and around one in three will exhibit symptoms of
autism ~ u m disorder (Hagerman, 2006). Intellectual
impairment will usually be greatest in males suffering frag-
ile X synqrome because they only have one X chromosome.
Be.cause females possess nvo X chromosomes the risk of
intellecrual disability is less (Sherman, 1996).
Metabof h: disorders Metabolic disorders occur
when the body's ability to produce or break down
chemicals is impaired. There are many different type~ _of
metabolic disorders and many can affect inrellecrual ability.
Such disorders are often caused by genetic factors and
may be carried by a recessive gene. When b~th p_a re~ts
possess rhe defective recessive gene, then their oflspnng
are in danger of developing
recessive gene A gene that must be
the metabolic disturbances pre5ent on both chromosomes in - a
linked to that gene. We pairto show outward signs of a certain
will provide examples of characteristic.
two such genetically deter- ..
mined metabolic disorders that affect intellectual ability.
These are phenylketonuria (PKU) and Tay-Sachs_ disease.
Phenylketonuria (PKU) is caused by a deficiency_ of
the liver enzyme phenylalanine 4-hydroxylase, which
is necessary for the effective metabolism of the amino
acid phenylalanine. As a result of this deficit, phenylala-
nine and its derivative phe- phenylketonuria (PKU) A metabolic
nylpyruvic acid build up in disorder caused by a deficiency of the
the body and irreparably liver enzyme phenylalanine 4-hydroxylase,
damage the brain and cen- which is necessary for the effective metab-
olism of the amino acid phenylalanine.
tral nervous system by pre-
venting effective myelination of neurons (myelination is
the development of a protective sheath around the axons
of neurons that enables effective transmission between
nerve cells). This results in severe intellectual disability
and hyperactivity. In the UK, PKU has an incidence of
around I in 10,000 live births (NSPKU, 2004) and it is car-
ried on the phenylalanine hydroxylase gene (PAH) on
chromosome 12 (Doss & Sethumadhavan, 2009). Several
hundred mutations of this gene have been id.entified,
but just five account for approximately 60 per cent of
PKU cases in European populations. It is estimated that
as many as 1 in 70 people may be carriers of the reces-
sive gene responsible for PKU. At-risk parents who may
carry the gene are now routinely given blood tests to
determine the risk of having a child with PKU. Diet
is also an important factor in controlling intellectual
deficits in fetuses and offspring at risk of PKU. A special
diet low in phenylalanine is recommended for at-risk
pregnant mothers and if children with PKU are given
diets low in phenylalanine from birth to at least 6 years
of age, this can minimize neurological damage and
intellectual deficit (Mazzoco, Nord, van Doorninck,
Greene et al., 1994).
Tay-Sachs disease is also a metabolic disorder caused
by a recessive gene (often found in children of Eastern
European Jewish ancestry). The defective gene results in
an absence of the enzyme hexosaminidase A in the brain
and central nervous system and this eventually causes
neurones to die. The dis-
order is degenerative, with T~-5.ttchs disease A metabolic disorder
infants of around 5 months caused by a l'ec;e.ssive gene which results in
. · ·. an absenc~ of the enzyme hexosominidase
showmg an exaggerated A in the brain and central nervous system,
startle response and poor eventually causing neurons to.die.
 Down syndrome
· OISOROl MS
CHAPTER 17 NEUROOEVELOPMENTAL
-
. .

u)( )( I( )I !
,,
2 3 '"J - J

(( ll II Ji Ii .,
6 7 a 9 10 11

IC II ti ii
13 14 15 16 17

19 l
X V

Fragile X syndrome

.:g,
~
\
E I
]
I /
)
---
. If, tu res o c , ren
· f h •id born with Down syndrome or fragile X syndrome. lnd/v/dua/s with Down
syndrome almost always possess
PHOTO 17.2 The typica/faoa ea an extra chromoso me In pair 21' while In fragile Xsyndrome the X chromosome shows physical
Weaknesses and may be bent or broken.

motor development. Only aroun . d 17 per centthose

) but of sufferers
that do
199 1 Perinata~ cause:i From conception t.o the carl.y posr~
live beyond 4 years ~f age (~l?:n ,m otor and verbal skills. natal period is a dangerous tim e for an organism th at h
show rapid decline m cogmttv ' . •ng in around I in developing as rapidly as a human b,;1by. Because of thh,
i he disorder is· relatively r~re, oc~~:s rate is being sig- there are considerable prenatal and immc dia tdy post.,
360;0.QO live births w orldwide,. an .
..
nificantly reduced by.. e ffi,ecuve
· 'scteenmg.
· natal factors that p ut normal developmt nr at risk and
may cause lifelong intcllec-rua] dfsabiliry. One ty pe of rL<Jk
- PSYCHOPATHOLOGY
involves those factors that can adversely affect the fetus ·s
interuterine environment and its food supply. These
include factors such as maternal infections, substance
abuse or malnutrition. Disorders · acquired during pre·
natal development are known as (ongenital disorders
congenital dlsorders Disorders acquired because they are acquired
during prenatal development prior to birth prior to birth bur a re not
but which are not genetically inherited. genetically inherited.
Maternal diet is one example. For instance, if there
is too little iodine in the mother's diet during pregnancy
this can give rise to the condition known as cretinism.
The mother's iodine deficiency may often be caused
by a hormonal imbal-
cretlnlsm A congenital disorder resulting d fi
fn slow development, intellectual disablli- ance called thyroxine e -
t ies and small stature. ciency. Children suffering
from this disorder show
slow development, intellectual disabilities and often
have a small stature. Thankfully the condition is rela-
tively rare nowadays thanks to the availability of iodized
table salt and the fact that most diets now contain suffi-
cient iodine . Similarly, mineral and vitamin deficiencies
caused by maternal malnutrition during pregnancy can
also result in intellectual
maternal rnalnutritiQn Mineral and
disability and significantly
vitamin deficiencies during pregnancy that
can re.suit in intellectual disabilities in the affect the child's physical
c!iild. and behavioural develop·
ment (Barrett & Frank,
1987). However, the adverse effects of maternal mal-
nutrition can often. be partially rectified by providing
new-born infants with intellectually supportive environ-
ments and appropriate food supplements (Zeskind &
Ramsay, 1981; Super, Herrera & Mora, 1990). In most
Westernized societies maternal malnutrition is rela-
tively rare -but when it does occur it probably occurs in
conjunction with other factors likely to harm the child's
intellectual and physical development, such as mater-
nal drug or alcohol addiction, low socio-economic
status and possibly maternal HIV or syphilis infection
(see below).
Maternal infectious diseases during pregnancy are
another: potential cause of intellectual disability in the
offspring. Such diseases are most damaging during
the first trimester of pregnancy when the fetus has lit-
+le or no immunological protection. Common maternal
· diseases that can cause intellectual impairment in the
offspring include rubella (German measles). syphilis and
HIV amongst others. If a mother contracts rubella dur-
ing the first 10 weeks of
congenitaf rubella syndrome (CRS) The pregnancy, there is altnost
constellation of abnormalit ies caused a 90 per cent chan.ce that
by infectfr,)l'l with the rubella (German the baby will develop con-
measles) virus before birth, The syndrome .
genital rubella syndrome
is characteri~ed by mult iple .congenital
mafformatio ns (birth defects) and Int el , .(CRS) resulting in abor-
fectu al disability. tion, miscarriage, stillbirth
or severe bir th defe cts. Up tl> 20 per n: nt of b ,1hics
born live will have CRS causing he.in db ease. d<~~fnt'~S
and intellecnial impairme-nt. T he. incidence of CRS is
bet ween 70 and 170 pe.r l 00,000 live births and inciden:i.;e
is still relatively high in developing com1tries (Cum &
Vynnyck:y, 1999). In contrast, maternal HIV infection
has becom e an important maternal HIV lnfec;tlo,, The inc1dt>1Ke of
cause of intellectual dis· a mother havirig HIV during pregnancy,
ability. If the mother is leading to a Hkel!hood th.it the 1nfect1,i11
wlll be passed on to the fet11s.
not being treated .for HIV
during pregna1icy there is a likelihood that the infection
will be passed on to the fetus . The infection can also b e
passed on through breastfeeding. The re is then alm,o::;r a
50 per cent chance that the n ewborn child will de,,elop
moderate to severe intellectual disabilities. However, i.n
iitero transmission of HI V can be reduced from 2$ per
cent to 8 per cent if rhe mother is given an antiretrovi ·
ral drug such as zidovudine during pregnancy and if the
newborn child then receives the drug for up to 6 weeks
postnatally (Belfer & Mw1ir, 1997).
A further significant cause of intellectual disability
is maternal drug use during pregn ancy. In many cases
the drugs responsible for offspring intellectual disabil-
ity may be ones taken for m edicinal purposes (such as
drugs taken during cancer chemotherapy treatment)
but most other cases occur where tbe mother is a sub-
stance abuser. For instan ce, US studies indicate that
18 per cent of pregnant women smoke tobacco, 9. 8
per cenr drink alcohol and 4 per cent use illegal drugs
(Jones, 2006). Feral alcohol syndrome ( FAS) is one such
example of maternal cl.rug abuse causing childhood
intel1ectua1 disabilities. Whenever a pregnant m o rher
drinks alcohol, it will enter the fetus 's bloodstream,
slow down its metabolism and aftect development. If
this occui:s on a regular basis, then development of
the fetus will be severely impaired . Children suffer-
ing FAS will usually have lower birth weight, low~r lQ
(between 40 and 80) and suffer motor impalrmcnti: and
deficits in attention and working memory (Niccols,
1994; Burden, Jacobson, Sokol & Jacobson, 2005). ihey
will also freq uently exhibit distinctive facial character•
isrics including slit eyes, short noses, drooping eyelids
and thin upper lips. ln the 'UK around one in every
six to seven thousand babies born have PAS (National
Organization on Fetal Alcohol Syndrome, 2012).
Recently attention has also been focused on the tntel-
Iectual and developmental eflects on d1Hdr~n of illegal
drugs use by pregnant moth ers.: Use of both cocaine.
and crack cocaine (see Chapter 9 ) by a pregnant
mother can lead to babies being physically addicted ro
· the. drug .before pirth (knm\in a.s 'crack babies'). 11,ere
is. some. evidence that .this can adver~tc~ly affect physi-
cal development and brajn development in pnt•tkular
(Hade.ed & Siegel. 1989) and re~ult in slow la11gi.tage
 CHAPTER 17 NEURODEVELOPM£HTAL l)ISORDERS -

development {van Haar 1990) p . .

. . ' . · ,owever, 1t 15 cl h
in:1terna Id· rug-taking while pre t:ar t at shaken baby syodromc, 1bis refers ro traumatic brain
tn contexts that may al~o ,. 0.ngntn.a:bnt may often occur injury rhat occurs when a baby is violently shak.en. Jn
'" ute to p· 00 · 1
kcnJaJ development in the off' . . r intc - comparison to babies who
• · spnng, and rhes.e s-haken baby syndrome A form of child
i;.clude the abuse of other drug _ may receive accidental trau- abuse th;1t·is Jcnown to cause intellectual
, ·• · s, pregnancy de · _
nons \such as dietary imbai-ances) and , _pnva matic brain injury, shaken di~bifity, It refers to traumatlc brain
social deprivation (Vidaeff & Mast b ~conomic and baby injuries have a much injury that occurs when a baby Is .violc-nt!y
_ -L·. _ _ ._ • . . · ro attista, 2003 ). As !.haken.
worse prognosis-, in.dud-
. es_tt difficult to assess the sp
suLh, uu.s n _.l.dA! 'fi fli
.. re 1 . ec1 c a ect ing retinal haemorrhaging that is likely to cause blindness
or ma rna , cocaine use o.n offspring intellectual devel-
op-ment (Jones, 2006). and an increased risk of mental disability such as cerebral
palsy or intellectual impairment (Lind, Laurent-Vannier,
O ne final example of a perinatal cause of intellectual
Toure, Brugel & Chevign.ard, 2013 ). Nevertheless, we
disability is anoxia, which must remain cautious about the degree to which sh.a.ken
_.ia ;..: fi!'-=frnatal cause oH ntelfectua!
:·s,!:' :cy, bang a significant period is a significant period baby syndrome may contribute to intellectual disability
.i$lt.,.it':J'.£Y9€" th:rt occurs duri ng o, without oxygen occurring because of current controversies over how the syndrome
n,--.:Qia!Eiy after defivery. during or immediately should be diagnosed (e.g. Kumat, 2005 ).
_ _ after delivery. Lack of oxy- During early development · children may also be
gen ro Ihe brat~ dunng the birth process can damage exposed to toxins that can cause neurological damage
parts of the bram that are yet to develop and as a result resulting in intellectual impairment. One such toxin is
cm cause both physical and intellectual impairment lead, which is still frequently found in the pollution from
_Erickso n , 1992). The main neurological birth s-yndrome vehicles that bum leaded petrol. Lead-based paint is also
caused by anoxia is cerebral palsy which is character- found in older properties and so may well be a risk factor
. ~-palsy The main. nauologk.al ized by motor symptoms in children living in deprived, low socio-economic areas.
::s& ~~ cau~byanmciawhich that affect the strength Lead causes neurological damage by accumulating in
1& - ~ by motor symptoms that and coordination of move- body tissue and interfering with brain and central nerv-
it'o/-t tne ~ngth and COO<di'nation of menr. While the primary ous system metabolism. Children exposed to high levels
"1!:'/Errtent d isabiIi·ties are mai nl y of lead have been found to exhibit deficits in IQ scores of
phys1-cal, around one-third of those suffering from cer- up to 10 points (Dietrich, Berger, Succop, Hammond &
e-bral palsy •Nill also suffer some form of intellectual, cog- Bornschein, 1993). Even in Westernized societies aware
nitive or emotional disability as well. of the risks associated with exposure to lead the preva-
lence of lead poisoning in children aged 1-2 years is still
Childhood causes as high as 1 per cent (Ossiander, Mueller & van Enwyk,
Although a chlld may be born healthy, there are poten- 2005). Prevalence rates are significantly higher than this
ti.ally nu merous early child.hood factors that might put is developing countries (Sun, Zhao, Li & Cheng, 2004).
the child at risk of intellectual disability. Very often these Finally, there is evidence to suggest that social depri-
factors may operate in conjunction _w ith ~ther causes vation and poverty can themselves contribute to intel-
such as perinatal problems. We will look bnefly at fo~r lecrual disability. AJ.though such factors may not directly
cause impairment to the biolog,ical substrates under-
groups _ o f potential childhood causes of intellectual ~tS-
lying intellectual ability, they may contribute a form
ability, namely accidents and injury, e-xpo~re _to toxins,
of intellectual impoverishment that can be measured
ch.ildhc_;od infections, and poverty and depnvauo~d
in terms of lowered IQ scores (Garber & Mcinerney.
During their early developmental years, young ren
1982). Social deprivation and poverty are also inextrica-
->tl ... b . l d in acci.dents and these can often be
v;.u OLt.en . e UlVO ve .- . . skal damage and bly linked to ocher risk factors for intellectual disability,
severe enough to cause irreversible phy including poor infant diet, exposure to toxins (such as
. E . Cobbs Prasa<l Kramer,
.iruellecmal im .unnent ( ~wmg- • ' lead _paint in old or run-down housing), mate rnal drug-
. -· ·P childhood acddenrs that may
Cox et aL. 2006;. Common -· · · · ·. ra11~ taking and alcoholism, and childhood physical abuse. A
cause permanent 1n "'~
. rell,.,..tual disability include . i.>, .car
. · · ·- · suffocation and po-isonmg. cycle of deprivation, poverty and intellectual disability is
a~ m$.. neat drowrunrthe :injuries that cause intellec- ~aplished when young adolescents in deprived environ-
1--towever; at least some O be ine accidents but ments themselves give birth teenag~mothers In relation to intl"liectual
t . . . ·t:....., , t......:t_dren may not genu to children- while still teen- di~billties, young mother$ who become
r.uatdi5a~l=f m cuu •... I abuse by others. A rcu-ospec-
may be m e result of ~h~s•~ hild . aged 1,etween. l and agers (Wddsmith, Manlove, pregnant before J 8 year$ of age, and who
l k. ders "- ,r & are likely tQ have lived in deprived area~
trre suµJy of bead roJunes m c · ren cent of cases could Jekie e An . on ,v100.re prfortogivfng birth, areoftenunmarrk:d,
• red that 81 per Mindell, .2012). Such tun- live In poverty asa result of their premature
6- yea': of _age e~rna _ er cent as definite cases
19 age rnotben ate frequent! y mmherhoQd, and are likely to have a slgnifi-
be dc--finea as acd&e~rs a~ ,, ~Jtte form (if -chil.f abuse
of abuse ;. Reece t,l. Sege, _OOo, al disability is known as foutid to . live jn deprived amtly tow,;:r than average IQ.
mat is .lu-iQV1,""J1 .to· ca.us:t" ,irlrellectu
 PSYCKOPATHOlOGY
~ cas. ~re o fte n unmarried, live in poverty as a resulr
o t their premature motherhood, and have a signifi-
cantly lower than average IQ themselves (Carnegie
Corporation, 1994; Borkowski, Whitmqn, Passino,
Relhnger et al., 1992.). Studies-have shown that teenage
mothers are significantly more likely to punish their chil-
dren than praise them and are significantly less sensitive
tO their children's needs than older mothers (Borkowski,
Whitman, Passino, Rellinger et al. , 1992; Brooks-Gunn &
Chase-Lansdale. 1995). As a result. children born to teen-
age mothers are at increased riskof problematic parent-
child interactions, (Leadbeater, Bishop & Raver, 1996),
behavioural difficulties (Fergusson & Lynskey, 1993), and
cognitive disadvantage and educational underachieve-
ment (Fergusson & Woodward, 1999; Brooks-Gunn,
Guo & Fustenberg, 1993). Consequently, mild intellec-
tual disability is reckoned to occur three times more fre-
quently in the children of teenage mothers (Borkowski,
TEENAGE MOTHERS AND THE CYCLE OF UNDERACHIEVEMENT
The UK has the highest teenage birth rate in Western
Europe (Avery & Lazdane, 2008). In 2006, in England
39,000 girls under 18 years of age became pregnant
(Department for Education and Skills, 2006). Although
around half lead to an abortion, the remainder become
teenage methers. They are mothers who are likely to
have lived in deprived areas prior to giving birth, they are
often unmarr-ied, live in poverty as a result of their pre-
mature motherhood, and are likeJy to have a significantly
lower than average JQ· (Borkowski, Whitman, Passino,
Rellinger et al, 1992). When teenage girls become moth-
ers in deprived areas, this sets up a cycle of deprivation,
poverty anti intellectual underachievement (Wildsmith,
Manlove, J,ekielek,- Anderson Moore & Mincieli, 2012).
a
As result of their relatively poor parenting skills and
the stress that accrues from living in deprived areas, the
chrldren of teenage mothers are significantly more likely
than the children of older mothers to have behavioural
difficulties (Fergusson & Lynskey, 1993), and suffer cog-
nitive impairments and educational underachievement
(Fergusson & Woodward, 1999; Brooks-Gunn, Guo &
Fustenberg, 1993). The UK Department for Education
and Skills (2006) provided the following stark facts:
Teenage mothers are less likely to finish their
education and are more llkely to bring up
their children alone rn poverty.
• The infant mortaftty rate for babies born to teen-
ag.e mothers is 60 per ct>nt higher than for babies
born fo older mothers..
.
··. .
._...... .-.__:. -,---~·--•--- -.....---•·--- ....~ ~----- ·----'----,---- _,.
Whitman, Passino. Rellinger et al.. 1992 ; Broman ,
Nichols. Shaughnessy, Kennedy et al. , 1987). As we said
earlier, it is difficult to estimate solely how much this is
due to the teenage mother's age and her parenting prac-
tices, because the child of a teenage mother is signifi-
cantly more likely to be raised in the kinds of deprived
environments that contain many other risk factors for
intellectualdisabilitv.
Finally, one imp,ortant feature of deprived environ-
ments is that they will usually provide significantly
decreased levels of stimulation for young children,
including lower rates of sensory and educational stimu-
lation, lack. of one-to-one child-parent experiences and
poverty of verbal communication - all factors that are
thought to be associated with poor intellectual develop-
ment. There are some claims that Jack of stimulation can
have a direct effect on the early physical development of
the brain and so result in permanent impairments to
7
I
• Teenage mothers are more likely to smoke dur-
ing pregnancy and are less likely to breastfeed,
both of which have negative consequences for
the child.
• Teenage mothers have three times the rate of '
postnatal depression of older mothers and a
higher risk of poor mental health for 3 years after
the birth.
• Children of teenage mothers are generally at
increased risk of poverty, low educational attain-
ment, poor housing and poor health, and have
lower rates of economic activity in adult life.
• Rates of teenage pregnancy are highest among
deprived communities, so the negative conse-
quences of teenage pregnancy are dispropor-
tionately concentrated among those who are
already disadvantaged.
As we can see from reading section 17.3.4 many 1
of these conditions represent risk factors for intellec-
tual disability and underachievement for the teen-
age mother's offspring. These include poor parenting
skills, maternal mental health problems,, being r?ised
in unstimulating environments abundant in potentia'I
stressors, a high likelihood of maternal drug or alcohol
abuse during pregnancy, and increased risk of physical
abuse or accidents (Moffitt & the E-Risk Te.am, 2002). At
age 5, the children of teenage mothers already have a
significantly lower IQ than the children of older moth-
ers (Lubinski, 2000).
___ __ ----~--------~ .. ..__..,_. __ _..,
.., ,
1
 CHAP'fl!.R 11 NtiUftOtliVELOPM£NTAL OlSOROERS -
br;1ln f\J1,n11_ ,nn1~. llrir .h rnt:.ln,•., , ..
..... . ,,t:' lll a 1 t.lt~\.·r l 1
'
rlw bn 1m t 1H' lll'fi. mnr-t
.
ti.x t~i·,,~i. ,. 1 ..
· '-" n l' Y Hill1l"l!1l lJ , j · h •,,
° 1111 (.•n1 o. 1· n 1!9tti,lil'll l' Ht'<' :He tHJW gom:.• uo(l ptuvu:inn for $UCh pt.o·
vc.i r· Jtti~t· h1n.h (Kl->lh. Wt;tv) .1.. 1 .
, · . . . .
l ' · ' Y u i; c hl'.$ t pit nut 011ly "' tt rn pts tO 1icl.dress. theit· tl(;:.t ds btit ,dso tee•
· •, ,t. i). t 1t , 11t tn t J i
t(.1rnY1cnt 1~ tlftt"m,m·y For furl j ,. . • . • .. ·1 : ,ihtlMe1wl, ognizcs cht>i1' fn11Llanlem.i.l 1'ights 1\s hW'l'l:m beings imd
. • tit:'. Vt! 1npnwnt· of t] · l ,
\ l1'll <-'l ,m· rN<'\l~m1 & lki~(J1w t, 2000). ./\It •, . 'le i 1·n1n s d tlztns to a11 iJ.1du:liVc liC<-styk . Thus. interventions for
1-1.m,tln_·u,it_alinN, stt't'S~ful cuvil'onn••· i ,, u l,,_~tlvdy. ,m i1.1tcllet•t.u.1I disnhillt:ies have a nurnher o f diverse alms. At
. , . • . . . ,,;. ,.: C~ll'\ urtu,uly ri . · , .
\IW )il 'f'J'r tlw1 t.,t hrm11t,,1.. ~ tl· 'lt 1· ' •.
.• .,, . H
r~ I 1--1ggt
,1 ~Vl' !1t l' ·rt ('tt ·•o
I 1-hl' pt·lt11,try level the re· a re tho~c interven.rton.s .ii111ecl at
,trvdf1r,mcnt (Ch,lnliiW 1,JqK) . : • 111 • vc 1,lin 11revl.' nllng irHclk c1ual disability in the first pfoc-e by edu-
~ · · .1 ~rucly ct11·1t•, · l't , ·1 11 rc1tlng pntc11tictl p.u·cnts about the risk factots fm i ntel·
d!'t'll hrnug.hl up In ct_ t'f1riwd lttnt r ··It·\/ ..• . l ,1 ,1g t- l
.. .,,1 d . 1 I . , c 1 ,n c.u1wM1a 1,rotm lel.·tttal di!iahHtt y (r .g. educating parents about the effects
pwvfo l.' w,11 guod nut 1·1\ i<Jt1 an -I . ts .1 . " ~
. ·•, . l 11 , ". I:\ s i111t 1 I.I ting env lton nf mat<:t·n~l alnihnl i:md drng ahllst dur'ing pregnancy).
ruc-nl, c ,mp H~ & lt"m~cy ( 1Ol)-4) fie,• •d h· . .
, ' j 1 . • , . · ' · , It 1 · I. t\ t 1 ) Y I l Yeut1, /\ tiCt'nnd bro.id ail'l! (if interventions is to make training
of aw· r ).~ l,.l tl f'l'lV,.HlOl'l l'XJ'crit·n tt? I by t·h. f' . .·.· . "
· 'f' ~ C Urt\1(:: J' g t'(llll1 prognmnws ~wnilnble th,H will provide th<' suffeter wirh
hacl ~ ~JJ~nl }c-.un IW~;HiVt' dlert. 'ltl ""
l')I"rl i·n. J"I Ut'J.(ti<.ming,
. . ·t
etmugh hnsk skills to ropt' wi.th tnany nf the challenges
ur evet'yday life (t. g. :-;elf-help skills. communication
Summary of the a~tlology of skills) Thirdly. appru.irh~s to hclpb'.1g thost with intel-
Intellectual dlsobllltles lectual dis,1bilities Me based on the principle of inclusion
From tlw lll,tf:1.•rhll
, cuv(•1·rd
· in •'·),1"~ ,~i·•c.: ti on,
. you can in an altPti.1pr ro help strch lntluslon Str,Hegle s intf.'!nded to te.ich
5t l."
rhal the l' i.lU fltS \ii l11tdknt1al disablHLy :u e divt:rsC'. A~ we individuals achieve their high functioning Individuals self-help
1T1cnt
•
ltmcd rJ d tt't,
, . , • ., , ,
v_ttry .~,ft~11
. ., , :
ii ·is ,in\tto~"'t
•. , , • " ·
potcnrial. Por cxam1,k. in strategl~s. social ond living skills, ond ~elf-
'lJlc· 1.,. [ 1· •
.v 111potnt
tlw UK, sthools are now n1t1nogemcnt that are dE:signed to help the
t.ht ~pt ~iJH,_ t •~wa: _ot m~indw1dui1l s 1nt.elkrtu::.1I dl:.nbllity, lndlvldUill fun c.tlon more effectively
but 1ntcllect1.ml d1sabH1ty t.n1:wd by dm..n1iosoitrnl diso r rt•quired tu draw up acces In 5odety.
dt!t'S ymch .is Dc)Wll ~yudrciml~ ut1d fragile x syitdl'onie) slbllity sl'. rategies to allow
M1cl mhcr1tei.J ntt'.tabolic <.Usordcri, tll't somt of 1hl: rnort· pup.ii:- with iritcllet tuul disabilirks to engage in the edu-
easil y ,~fontifi~cl.' Individuals ar~ most at rlsk c_if develop, catiom1l process without being disadvantaged. Similarly.
ing pcnnan cm 11\tt lk c' t tt.,l disabilitks during early dr vcl sodul inclusion is also ~11eolu·aged to providt' chose with
opmc~l of their ttntn tl 1i C.l'Vli \.1:. systc111, whlrh is why i11tcllC'Ctual disabilities the opportunity for pcrso11.al,
rnndlt1ons in tht ut ~rns and in the lt111ne<llatt po:muual ~m•ial. cmurkmnl and sex1.:1al dcvd()pmcnt. We will now
pc1fod arc ,·ri1 ka·1 for t1(H'n1(1 l drwlopm rnt . RJsk fac tors discLtss each of these three types of approach to i.ntet'-
rlrnr can di:wupt'. nornut l prc11,1tal dewlopme1\l cJf the vcnrfon it, more detail.
brain Mld rt•ntr.tl nl'.'rvous sy:.tr m include rnatt•rnal infcc•
tfonii. t1kohollsm, ~lrug .lhUs<' and rrrnh1utritlon . tfa rly Prevention strategies
diildliood f'acwrs th~1t nm affect normal neurologkal 'l';thlc 17 .2 lists rmmy of the nn.1ses a nd risk factors for
dcvcfopmem in.dude ucdc.knts, physical abuse, ex.po· ir1tellcnual disability and you c.::an probably glean from
sure tn 1·oxil1s, in foc tlo11s illnesses -1nd an early rhlklhoud this list that mnny of these en uses are pott:-ntially prevent-
spent In. deprivation und povt:i:-ty, As we hnve mentioned able. This is particularly the c:as~ with many perinatal
many tiines in th.ls sec:tion, 1nany of th(•St risk factc1:>rs causes, and espedally those itw<>lving m:.1tcmal factors
may operate wncurrcntJy to dcn:rmine lewi s of intcl during prebll"lancy, For e,.-xample, furn} alcohol syndrome
l~ctu.:i l c..li:wbllhy. (RA~) ls a signific1mt cause of intellectual disubility and
pre\: ntln? program.mes nim at identityl.ng those won:1cn
'.lt .,.risk _of ak:ohol abuse during pregnancy n.nd provid-
1t1g inter~c~mons such ,\s akohol•reduction counselling
17.3.S Interventions for (Pluy_d, 0 ~ otmo1~ Bert1~.tt'Ld & Sokol. .2006), Recognizing
thos~ at t'ISk e:.m. b~· achieved by u sing established din.g-
Intellectual Disabilities no:mc ~nd scrcc11mg qnestionnrurcs (lsrnail, Budcll..-y,
Most: forms of l11tclle.(~rtrnl db1ahlliry impose HtnirntfotlS Uuuadu. Jnbbar &. Gallicnno, 2010) t1nd interv1;:ntfons
on tht' i.uflh·cr'R ability w ftirtetion foUy and act'iv~ly it~ ~nclude ~rnvidlng fet.>dbark on l'ates of drinking beh:w-
aoctct.y. Thi~ means that' - depc11.cli.ng on the seve:11cy of lOllt durmg pt'cgnarn.:y, discussing strategi~s for ~wo.i ding
the di.sabiliry ,. the irtdi\lic!~al will m:r:d.suppcw~ to ,~opf akohi:>1 cravings a11.d bJnge drinking se~lons and, rnor't~
wlih nw 1y of lht> rigour.!I r,f c·veryday living. A~ a ~t:sL~lt recently, . we~~bas.ed. illte1·ve,n tigns .(Tel'lkku. Mengel.
uf dw c.!isah!Uty. i-uffcret'!'l .1re at rl~k of u.n~t..,·ach1evmg m ~icholsm;1, H1le etaL1 2011) . Comrolled-<:.~mpari.son i ttld-
rno1r1y iu·ra:- of thdr lifo, indtidi.ng rducauor.rn.11~, 01::1.1pa 1es suggest tha,t i.uch screening a-rtd itttervention met.hods
t!c.mally, ~C()Momi('aUy and ~udally. rn rn~s.r soe1ftcl~~\ ~~e. -s.~gt~ifkant.ly •·~,t~ce the ~k for al~ohol-ex:posed pregnat'i~
day~ wht;-t\ pc.opk with inrt 11e~t.,lal .<l~sab1!t-ti~s ~.ve~e smi- des conip.lr~d ~th non•m.tctvcm,on control p,n-ricipam~
(Lngersr)ll, Cepern:h. Nt!ttlen:1an, K.a.r:,ndn ct a1., ZOOS) .
p1y ln~t.Udonalizcd. and provided wLth little 1note th:m
- - PSYCHOPAllfOl.OOY

Pien~nnon. cm al:ro be ~~ in a number of ocher Behavioural techniques that adopt basic principles of
'""'~~ for aample, gen-erx ar.a.lyS'is and counselling ena- operant and classical conditioning are used extensively
bt5 ~ parems at risk of abnormal births to be :idemi-- in these contexts, and the application of learning theory
ficd. ifefonned of the r<Sk and counselled. about how to to training in these areas
,pplied .b ehJviour .inalysis Applying
proceed. Blood rests and tests of amniotic fluid such as is also known as applied
the principles of learning. theory (par-
~ r e s i s enabte. parents tO be informed of risks for behaviour analysis (Davey, ticularry operant conditioning) to the
a range of diwr-d.ers I:ru-luding Down syndrome. Tay- 1998). Basic techniques that aS5essment and treatment of individuals
~~•. phenJlk.etonuria and intellectual disability are used include operant suffering psychopathology.
~ b_r rongenir.tl rtilietla syndrome 1CRS). in -addi- reinforcement ( rewarding
tion, dlo:se_ dtsabilitks related to dietary irregularities cancorrect responses - for example. 'INith attention or praise).
~ be ide:rumed and treated, and me.Se include provid- response shaping (breaking down complex behaviours
ing aNWc pregnant mothers Ywith iodine supplements into small achievable steps and ·then rewarding each step
to pr~! cretinism and providing diets low in phen~·- successively), errorless learning /breaking down a behav-
f ~ ror pregnant mothers and offspring at ris:k of iour to be learnt into simple components that can be learnt
p,.,.1ienrkewnum, without making errors - errorless learning is stronger and
Finally, ai dis:cussed earlier_. conditions associated more durable than learning with errors), imitation learn-
,1,-nh ~-e~- and social depri,ari-on also put children ing (where the trainer demonstrates a response for the
:.n. mk of educatimr.J underachievement, tower than client to unitate), chaining (training the individual on
a.-a:age IQ and mild intellecrual disabiliC:4 and support the final components of a task first and then working
~ogv.mnru:'S in the USA and Europe have been devel- backwards co learn the earlier steps) and self.instruc-
oped ro try to counrerai...--r this risk factor. For example, tional training (teaching the client to guide themsel ves
funn_ty ruppa:-t programmes in the USA have indicated through a task by verbally instructing themselves what
mar mothers of fow .socio-economic status participat- to do at each step). Very often, inappropriate, life-threat-
mg in s-..:ch schemes are tnore affectionate and positive ening or challenging behaviours may inadvertently be
wid1 th-eu children and provide more stimulating env1 • maintained by reinforcement from others in the environ•
r<-W..ments ilian mot:heTs \!;'IJO are not in .such schemes menr f e.g. self-muu1ating behaviour may be maintained
•Jona-~ Wafker. & Rodiiguez. 1996). Being a teenage by the attention it anracts from family or care staff). In
motl:-..er ~ also a risk facror for drildren of lower IQ than these cases, a functional analysis can be carried out to help
:n'erage i ,ree fi::;.cus, Poim 17,I ; and this can be tackled identify the factors maintaming the behaviour, and this is
ma rnunher of wa;,s, in.dud.mg pr0viding teenage girls done by keeping a record of the frequency of the behav-
,;;;iili a:hrkr on md access to contracepoon, improving iours and noting the antecedents and consequences
ieen.-ge mothers' access ro educanon (Department for of rhe behaviour (see Treatment m Practice Box 17. l ).
Chlkiren. Schoo-is & Families. 2010), impr~ing housing Once 1t is known what consequences might be maintain-
quality ,1nd ~ me preserr.e of a co-residenrial mg the behaviour, these can be addressed to prevent the
p.a~ radtu Ehao rasng a child alone (Berrington, behaviour being reinforced (Mazaleski, Iwata, Vollmer,
Diair..ond, Jngbam, Stevenson et aL, 1004J Zarcone & Smith, I 993 ; Wacker, Steege , Northrup,
Sasso etaL, 1990).
Tn,lnlng procfllures
The quahty of life of people ""irh inrcl1ecrual disabili- Inclusion strat~les
ties cm be impr-m-ed s.1gnificandy ~ith the hdp of basic Policy on the development and educ.arion of individu-
~ g p rocedures mar will equip them with a range als with imellccrual disabilities has changed significantly
of skilli dtpendmg on their·!~'el of dis.ability, Types of over the past 3.J years. Prior to inclusion policies being
skills mw!d- .sdf-hefp and adaptive skills (such as- toilet- introduced. even individuals with mild intellectual dis-
ing. feed>.ng and ttrc"fflllg,. languagc, and cornrouruation abilities were ofi:en deprived of any effective participa-
s&;iB.s •incl!.~ .g ~ . comprehension, sign lang..1age\ tion in the society in which they liv.ed~ and more often
ici~ and reaeational skills (such as play,i.'lg g~mes,. than not they would be institutionalized or educated
~ s b T u;,. basiic:da-iiy lit.ing skills ~tb-fug.a telephone. separately. However. many countri~s have intro4uced
handling m<mey1 ati-d ftonttoffing: anger outbursts and. accessibility strateg:ies that extend the rights of individu-
~gress.ivie and cbafknging behaviour ~reducing the: ter-1- als with intellectual dis.abilities. to be educated ac-co-rd-
df;n,cy ro communicate through aggressive or cha.Heng- ing to their needs in w.;ainstream schools. This approach
mg beh2~~ sfil"h .as pri,...shmg or shouting_,. Trnnmg evahl;,tes the inditidual's specific. needs and then s:ug-
merbock can :Jw be used in more ~1::re cases to rnn- ge~ straregies, senices and supports that will optimize
troi hf.e-dJreatening behaviours such a! .self-mutilation err the tunctioning of these individuals v.i.thin society: In the
t't'~ .1-N~, UK. the government's straregy for individuals with
 CHAPTER 17 NEURODEVELOPMEMTAL DISORDERS 581

CLINICAL PERSPECTIVE: TREATMENT IN PRACTICE 17.1

A FUNCTIONAL ANALYSIS OF CHALLENGING BEHAVIOUR

Some .Individuals with intelle . . .

di5play behaviour that ma ctual d1sab1llt1es typi<;ally is undertaken by ~eeprng a record of the frequency of
risk or which mav · · y put th emselves or others at the behaviours and noting the antecedents and co,nse-
' 7 prevent the use 0 f ..
ties or prevent the individu I h . community faC11l- quenc.es of the behaviour. This will take the form of:
Challengiog· behavlours m: ~vking a n9rmal home life,
• If . . Y e the form of aggres A. What happens before the challenging behaviour
s,on, se -lnJury, stereotyped beh . . . ~
destructive behaviour generallyatour or disruptive and (the trigger};
.: I I . . n many cases a func• B. What the individual does (the behaviour);
.,ona ana ys,s may help to ldent·ty1 t h e f actors maintain-
'
· h h . . C. What the person gets as a result of the behaviour
ing t e ' allenging
. behaviour, and th ese . f actors may
(the consequence).
range from social attention• tang·1ble reward s such as a
hug, e~pe from stressful situations or they may sim- A typical 'ABC' chart on whkh family and carers will
ply pmvrde sensory 5timulatlon. A functional analysis keep a record of these behaviours will Qften look like this:

Antecedent (what Behaviour (describe Consequem,:e (what

happened before the exactly what the happened immediately
behaviour occurred ?) person did) aft.er the behaviour?) Signature

A fUNCTIONAL ANALYstS CASE HISTORY in the lounge when there were a number of people in
the room and t he tetevislon was on. The consequence
Andy i& a middle- aged man with severe intellectual of Andy starting to rock c1nd slap himself was that staff
disability. He has re.cently moved Into a group home would remove him from the room and ta~ him into the
which he share$ with seven other people. Since he kitchen where it was empty and qui.e t.
moved in, stQff ha:ve observed several Incidents o f It was hypothesized that the function ofthe behaviour
self-injury. They report that Andy starts to rock back• for Andy was to escape from a noisy and crowded situa-
wards and forw.a:rds in hls chair, and this then escalates tion. Staff decided to respond by watching Andy for early
into him slapping his face repeatedly. Staff have asked s1gns he may be feeling overstimulated and to ask hhn if
he wanted to leave the roor:n.
for hefp. This led to a reductJon of self·lnj1,1ry and later·It was
The staff team· work,nQ with Andy were asked to com-
noted that Andy would ·now·try to attract staf:f atteotfon
plete ABC charts for 4 weeks. These were then analysed
and it was found that the behaviour tended to ow.1r when ht wanted to leave.

with SEN, including the development of suitable educa-

r s dal ed'u cational needs (SEN) involves improving
e support sy ·
stem for these children and young people
'ding an integrated educa-
tional materials, and the training of specialist teachers
and support staff (Department for Education, 2013).
Social and edu cational indusion also has indirect benefits
and their families, and provitiort, health and care ,plan
for the individu al.. Kim, Larson & Lakin.(2001) reviewed
. ~ I -1uatlQnal nffds{SEN} A · for them (from bjrth to age
~ Uted lnt,he UK to \dentifythose who those studies cani.ed out between 1980 and 199~ that
25 years), unprovingeduca
, ·. _-
1 investigated the effects of the shift from institutionalized ·
~1~
1!1'1.,. '~tt.1,1<:.tron'
. or edua.tfon tailored u·on.al pr011ision c.1or pup1ls
~,,,.r ~ fie oee4s, · ·
- PSYCHOPATHOl.OGV

living t <) living in the community. Most studies reported
r10 improvement in three areas: (I) overall improvements
in coping with day-to-day living and increases in self-
csteem. (2) a decrease in the frequency of maladaptive
hl:'haviours, such as aggression o~ anger outbursts, and
(3) aJ1 improvement in self.care behaviours and social
skills. Case History I 7.1 recounts the story of Thomas, a
0(>Wn syndrome sufferer, who lives with his family and
has benefited in a variety of ways from participating in a
range of community activities.
fnclusinn policies have resulted in significant improve-
me11ts to the quality of life experienced by individuals
with intellectual disabilities, and such individuals now
have opportunities ro pursue social, educational and
occupational goals and pursue their own personal dev~l-
opment. Por example, individuals with intellecrual dis-
abilities now have the right to pursue their own sexual
and emotional development - usually with the support
of their family. Whereas in the past involuntary sre_rili-
zation was common for such individuals, appropnate
training and counselling now means that most of them
can be taught about sexual behaviour to a level appropri-
ate for theit functioning. This often means that they can
learn to use contraceptives, employ responsible family
planning, get married and - in many cases - successfully
rear a family, either on their own or with the help of

THOMAS'S STORY
Thomas is 23 and lives with his mum and dad. His brother now lives away but sees him quite regularly.
Thomas has Down's syndrqme and needs a great deal of support. He goes to college four days a week and, on
Fridays, attends a project where he is learning living skills and enjoying cooking. Thomas has a supported work
placement for two hours a week in a riding stable. He has a hectic social lrfe with weekly activities including rid-
ing, sports, going to the gym, trampolining and football. He goes to monthly discos with a group of young people
with learning disabilities and is regularly to be found in the local pub playing pool with his friends.
We were transporting him to and from these activities and were concerned that he should be. able to mix
more with his own age group. We arranged for 15½ hours' worth of direct payments for Thomas to choose some-
one in his peer group to help him access these activities.There was a great deal of interest in the advert we placed
at the local university for a student to help with this and we have had several different students helping over the
past year, who have become firm friends. Thomas's current helper, Laura, accompanies him on his outings and
Thomas has oow become a part of a wider social circle, going to the pub, out for meals and watching videos at
Laura's 'hollse with her friends, which he greatly enjoys.
Thomas's moods, self-esteem and well-being are greatly improved by the stimulation and social nature of all .
that he does, as well as the routine and structure it brings to his life.
Thomas and his friends have gained enormous confidence from attending several drama ·courses and
the group has enjoyed the feeling of empowerment and also the opportunity to show their feelings. La5t year,
a group of 11 young adolescents, including Thomas, attended a week-long outward bound course, run by the
Calvert Trust, without their families. Afterwards, the group made a presentation to about 80 people who had
been involved in organiZing or fundraising their trip, with a very professional PowerPoint presentation and
question-and-answer session. They were all keen to contribute, wanted to find other groups to make t heir
presentation to and gained lots of confidence from this. It makes a change from the usual painting eggs and
bingo offered by local services, which are just not appropriate for a 22-year-old.

Source: From evidence from a family carer given to the Foundat1on for People with Learning Disabillties' tnquiry into Meeting
theMenMI Health Needs ofYoung People with Learning Disabilities - Count Us In.

Clinical CQmm~ntary
Thomas rs an example of how individuals with intellectual disabilities can bene.fit significantly from acces-
sibility and inclusion strategies. He has work in a supported employment setting and has a full social life
in which he can mix with people of his own age. This approach has the bf n,_efit of building confidence and
self-esteem, as well as pmviding the individual with a real sense of empowerment.
 CHAPTER 17 NEURODEVELOPMENTAL DISORDERS

local services_ (L~mley & Scotti, 2001 ; Levesque. ).

1996 workshop have been shown to exhibit higher levels o f
However, while mclusion in its broadest sense continues
job satisfaction than those who \Vork outside such a
ro benefit individuals with intellectual disabilities, there is
scheme, and those living in a semi-independem home
still much confusion over the way in which inclusion is
and also working in a sheltered work.shop shmved th_e
defined and operationalized (Bigby, 2012) and this makes
highest levels of self-esteem (Griffin. Ro senberg iX
objectively measuring the success of such policies diffi-
Cheyney, 1996).
cult (Martin & Cobigo, 2011 ).
People with intellectual disabilities are three to
Summary of Interventions for
four times less likely to be employed than non-disa-
bled counterparts (Verdonschot, de Witte, Reichrath ,
Intellectual Disabilities
This brief insight into some of the interventions
Buntinx & Curfs, 2009), but employment opportuni-
deployed in helping people with intellectual disab~li-
ties are being made increasingly available to individu-
ties has included: ( 1) the use of prevention strategies
als with intellectual disabilities. Many are conscientious
designed to identify those at risk of having offspring
and valued workers employed in normal work envi-
with intellectual disabilities (e.g. those with recessive
ronments. Others with more specific needs may need
gene disorders or mothers at risk during pregnancy).
to pursue employment within sheltered workshops
providing them with skills to minimize risk and coun-
or supported employment settings, which provide
sellina them about the possible outcomes: (2) a range
shelm'ed workshops Settings that pro- employment tailored to
of training programmes and techniques to provide indi-
,-0emdividuals with intellectuaJ disabili- the individuals' own needs.
,riduals with learning difficulties with a variety of eve -
~ withemployment tailored to their own The UK government seeks
ryday skills; and (3) the adoption of inclusion strategies
oeedsand abilities.. to promote employment
that provide the individual with educational and occu-
as another form of social inclusion for individuals with pational environments tailored to meeting their needs
intellectual disabilities. Those working in a sheltered within mainstream society.

Jsf.iF. r&sT-Ques.noNs· -; :
'\..:., . ~ ., '

• Canyou descn·be•bo th the trad. itional and more recent alternative approaches to defining intellectual disability?
• What are the different levels of intellectual disability defined in DSM-5?
· ch romosomal disorders that cause intellectual disability?
• What are t he mam
• Can you descn""e -,1.. at Ieas t t wo metabolic disorders that give rise to intellectual disability?

• What is meant by the term ,co ngenital disorder' . .when

. used in relation to intellectual disability? Can you give some
examples of congenital causes of intellectual d1sab11ity?
. . ch'ldhood
.. What are t h e main 1 causes of intellectual disability?
,.. Can intellectual disability be prevented? If so, how?
• Can you describe the kinds , • •n9 ,procedures that are used to help individuals with intellectual disabilities acquire
O f t~a•~

self,help and communication skills. . . . . . ..

f · dusion strategies that have been used in relation to Intellectual d1sab1ltty?
,. Can you describe some examp 1es o in .. . . .. . . . .

SECTION SUMMARY
17 .3 INTELlECl'UAL DIS"81~;.~~-- - · - ··- - - - -·- ' . " . ' .• - " - .. - ·1
· ,. · · ''. · . . . he DSM-5 diagnostic criteria for intellectual disability and di~cu.ssinQ some alternative \
We began this section by desc:nbmg th t focus on identifying. needs and facilitating adaptive functioning. The aetiology Qf . i::',

types -of defipition and terminology t_ a ith no identifiable ca~ being found for a large proportion of those with-intel~
· · · tw:i.·<;. w. i .arJly-responsible
. intellectual di_sorder:s ··JS .a ·dive{se · ·for those aet10=11ll:?
· t,..,.,• t'-.. at~an-~ ·,.., ·fieu,
'-- 1uentj ,4
and· th.ese m,
· Iud e
· t 1.i;_._.. "'"'logical
.ec-rua. Idisab"f't'=
1 0 "' causes are pr m .. . '
- PSYCHOPATHOLOGY

chromqsomal disorders, recessive gene disorders and perinatal factors. Childhood problems can also contribute to intellec-
tual disability and we discussed the role of accidents, abuse, infectious diseases and the nonspecific detrimental effect that
social deprivation and poverty can have on intellectual development. In the final section we covered interventions for the
prevention of intellectual disability and programmes for the care, development and support of individuals with intellectual
disabilities.
To summarize the key points:
• Intellectual disability is a term that covers impairments in both intellectual and adaptive functioning.
• Intellectual disability involves significantly below average intellectual functioning, usually defined by a score on a standard-
ized IQ test of below 70.
• Modern approaches to defining intellectual disabilities attempt to highlight those factors that might be required to facili-
tate more adaptive functioning, and to draw up accessibility strategies to ensure that such individuals are not excluded or
disadvanta~ed in their education.
• Chromosomal disorders such as Down syndrome and fragile X syndrome account for around 25-30 per cent of all diagnosed
cases of intellectual disability.
• Metabolic disorders that cause intellectual disability are usually carried by a recessive gene and include phenylketonuria
(PKU) and Tay-Sachs disease.
• Congenital disorders are those that are acquired prior to birth but are not genetically inherited. Congenital causes of intel-
lectual disability include maternal malnutrition, congenital rubella syndrome (CRS), maternal HIV infection and fetal alcohol
syndrome (FAS) .
• Childhood environmental causes of intellectual disability include childhood accidents (including intentional physical abuse
by others), exposure to toxins (such as lead), childhood infections and poverty and deprivation.
• Prevention strategies for intellectual disability include prevention campaigns and screening for such factors as maternal
alcohol abuse and genetic risk factors.
• Behavioural training procedures can equip sufferers with a range of self-help and adaptive skills, and the application of
learning theory in these areas is known as applied behaviour analysis.
• Inclusion strategies provide those with intellectual disabilities with access to mainstream educational and occupational l
· ·· ···~: ~~~.~.'.~:.~~.·................. -.........................................................................................................................................................................................•)

skills), and the development of stereotyped or self-injurious

17.4 AUTISTIC SPECTRUM behaviour patterns (e.g. hand biting and hair pulling). Prior
to DSM-5 there were several different ASD diagnostic cat-
DISORDER (ASD) egories and these included autistic disorder (autism), Rett's
disorder, childhood disintegrative disorder and Asperger's
Some disorders are characterized by serious abnormalities syndrome. However, DSM-5 has combined these into
in the developmental process and those that fall under the one single dimensional diagnostic category called autis-
heading of autistic spectrum disorder (ASD) are usually tic spectrum disorder. The reason for this change was that
associated with impair- there was little research evidence to support the independ-
autistic sp ectrum disorder (ASO) An ment in several areas of ence of all these different diagnostic categories and most
umbrella term that refers t-0 all disorders development. From early shared several common features. DSM-5 field studies also
that display autistic-style symptoms across
a wide range ofseverity and disability, infancy, some children will supported the validity of the new DSM-5 diagnostic cri-
exhibit a spectrum of devel- teria, although these new criteria are likely to 1~duce:; the
opmental impairments and number of individuals who would ·receive a diagnosis of
For a video on autistic spectrum
disorder go to
delays that include social autistic spectrum disorder (Frazier, Youngstrom, Speer,
www.wlley-psychopathology.com/ and emotional disturbances Embacher et al., 2012; Wilson, Gillan, Spain, Robertson et
vldeo/ch17 (e.g. poor social interaction al., 2013). We will discuss the DSM·5 diagnostk criteria in
with others), intellectual section 17.4.2 but first we will look more closely at some
disabilities (e.g. low IQ), language and commtmkation of the defining characteristics of individuals with autistic
deficits (e.g. failure .to learn to speak or develop language · spectrum disorder.
 CHAPTER 17 NEUROOEVELOPMENTAL DISORDERS D I..£.
11.4. 1 The Characteristics of ht: appears un able to express b is needs or has his very
Autistic Spectrum Disorder deta iled play i•omines disrupted . The two central feature~
of auti stic spectrum disorder are severe impairm en t in
T:1~e early clevck!_pmcnt. of some chiJdren is so profou nd) social interactiC>n and in communication bu t the sever
d1srurbed that fi om as youhg as less th-an 1
. · ·· ,
. .Y ity of these symptoms w ill depen d o n the dewlopme ntal
yea r o1· ag('
it will, become apparent to fa mily and friends that th~ level and age of the individual.
in~an t s developm~nt is no t proceeding normally. 'l'hc
child may seem w1thdrawt1 have fail ed to d· l Impairments of reciprocal
• .. f . . . ' ·· eve op nor-
mal means ~ . commumcation, appear u11interested in social interaction
it..~ surr~undmgs and have diffi culty learning new skills. The impairment in reciprocal social imeraction is one of
Case H1st0ry 17 .2 rel ates some of the b ehav·1oura I traits
· the most m arked and sustained fe atures of the disorder.
o~ Adar~, .a 1-year-oJd ~hild who was later diagnosed Sufferers will exhibit impairment in the use of nonverbal
with a~t1sttc spectrum disorder. Typical of autistic spec- behaviours (e.g . eye contact, appropriate facial expres-
trum disorders, Adam shows no interest in his surround-- sion) and are qnable to regulate social in teraction and
ings other than an obsessive interest in a small number communication. They will rarely approach o thers
of roys, he lacks normal communication skills for his and almost never offer a spontaneous gree ting o r make
age, and appears withdrawn and unable to learn new eye contact when meeting o r leaving another individu al
responses or skills. He al so has temper tantrums when (Hobson &. Lee, 1998). In yo ung children, this is o ft en

AUTISTIC SPECTRUM DISORDER

After Adam's first birthday party his mother began to pay attention to some characteristics of her son's personal~
ity that didn't seem to match those of the other children. Unlike other toddlers, Adam was not babbling or form-
ing any word sounds, while others his age were saying 'mama' and 'cake'. Adam made no attempt to label people
or objects but would just pronounce a few noises, which he wou ld utter random ly through the day.
At the birthday party and In other situations, Adam seemed uninterested In playing with other children or
even being around them socially. He seemed to enjoy everyone singing 'Happy Birthday' to him but made no
attempt to blow the candles out on the cake - even after others modelled the behaviour for him.
His parents also noted that Adam had very few interests. He wou ld seek out two or three Disney toys and their
corresponding videotapes and that was it. All other games, activities and toy characters were rejected . If pushed
to play with something new, he wou ld sometimes throw intense, inconsolable tantrum s. Even the toys he did
enjoy were typically not played with In an appropriate manner, .o ften he wou ld line them up In a row, in the same
order and would not allow them to be removed until he decided he was fini shed with them. If someone else
tried ; 0 rearrange the toys- he would have a tantrum.
As the months went by and he remained unable to express his wants and needs, Adam's tantrums
became more frequent. ff his mother did not understand his noises and gestures, he would become angry .
at not getting what he wanted. He would begin to hit his ears ·with his hands and cry for longer and tonger
periods of time.' 1

Sou;ce:Adapted from Gore~steln & Cromer, 2004.

Clinical Commentary
. ly age Adam exhibited symptoms of the triad of impairments typical of autistic spectrum dis•
From a very ear , . nJ . . • • • • ( k f·
h .. (1 ) no sign of engaging m ore oying rec1,proca1socw1interactions e.g. the 1ac o interest
0rdflJ, _He -~ ows_th thers at his birthday party), (2) a significant delay in the development of spoken speech
In soc1allzmg w1
.
° I
ed b his (allure to form word sour,ds, lobe objects or _
h. . ·
ex_press . 1s wants and _n~eds), ~nd_(3) a lack of
st
(,Hu : t0
Y d fl 'b/lity of thought (as demonstrated by his mablltty to use toys m 1magmat1ve play and
imagination an . ex1 .
bis inflexibly stereotyped behaviour towards these toys). . :