Disorders of Childhood and

UNIT 13 CHILDHOOD AND Adolescents-I

NEURODEVELOPMENTAL
DISORDERS-II*

Structure
13.0 Introduction
13.1 Intellectual Disability
13.1.1 Clinical Picture
13.1.2 Causal Factors
13.1.3 Treatment
13.2 Autism Spectrum Disorder
13.2.1 Clinical Picture
13.2.2 Causal Factors and Treatment
13.3 Specific Learning Disorder
13.3.1 Clinical Picture
13.3.2 Causal Factors and Treatment
13.4 Summary
13.5 Keywords
13.6 Review Questions
13.7 References and Further Reading
13.8 References for Images
13.9 Web Resources
Learning Objectives
After reading this Unit, you will be able to:
Explain the nature of neurodevelopmental disorders;
Elaborate on the clinical picture, causal factors, and treatment of Intellectual
Disability, and Autism Spectrum Disorder (ASD); and
Discuss the clinical presentation, causal factors, and treatment of and Specific
Learning Disorder.

13.0 INTRODUCTION
Developmental disorders refer to those conditions that occur early in life and
may affect one or more domains of a child’s development (physical, cognitive,
social-emotional, and moral). In the previous Unit, we covered the clinical features
of childhood depression, elimination disorder, oppositional defiant disorder/
conduct disorder and attention deficit/hyperactivity disorder. There causal factors
and treatment were also be discussed.

Some of the disorders like Autism Spectrum Disorders, Intellectual Disability,

Specific Learning disability are better understood as conditions that emerge in
childhood and continue till adulthood. These are known as neurodevelopmental

* Dr. Itisha Nagar, Assistant Professor of Psychology, Kamala Nehru College, University of
Delhi, New Delhi 339
Disorders of Childhood and disorders or a group of severely disabling conditions considered to be a result of
Adolescence Trauma Related
and Neurocognitive Disorders
structural and/or functional differences in the brain that are usually evident at
birth or become apparent as the child begins to develop. In this Unit, thus we
will focus on such disorders like autism spectrum disorder, intellectual disability,
and specific learning disability. There clinical features, causes and treatment
will be discussed in the following sections.

13.1 INTELLECTUAL DISABILITY

Intellectual disability (ID) also known as intellectual developmental disorder is
defined as sub-average functioning in general mental abilities such as reasoning,
problem solving, planning, abstract-thinking, judgment, academic learning, and
learning from experience beginning before the age of 18 years. The definition
covers deficits in intelligence as well as problems with performance. The age
criterion is important as it distinguishes between individuals who have had
intellectual impairments throughout of his/her development and those who
acquired intellectual functioning impairment after maturity. The latter category
of individuals is diagnosed with dementia rather than intellectual disability. The
causal factors for intellectual disability range from biological, psychosocial, socio-
cultural or a combination of the three.

Compared to any other mental disorder, people with intellectual disability have
received most of the devaluing, stigma, bullying, and shameful treatment from
lay people and medical professions. The medical terms used to classify different
levels of intellectual ability were turned into pejoratives over the ages, namely,
idiot, moron, and imbecile. Similarly, the term used for intellectual disability
used in DSM IV was mental retardation (“retarded”) that also turned into an
abuse.

About, 1-3 percent of general population falls into the category of intellectual
disability (APA, 2013), with largest number of those diagnosed with ID are
assessed to be at mild intellectual disability. People with mild intellectual
impairments can, with proper preparation carry out most of the day-to-day
activities.Many can learn to use mass transportation, purchase groceries, and
hold a variety of jobs. Whereas those with more severe impairments may need
help to eat, bathe, and dress themselves although with proper training and support
they can achieve independence. Difficulties for both mild and severe cases affect
many areas of functioning. For example, communication in mild cases may lead
to difficulties with articulation and expression of though. By contrast, people
with more severe problems may never learn to use speech as a form of
communication and may require sign language.Cognitive processes are adversely
affected in people with intellectual disability, making learning a challenge
however, the level of challenge depends on how extensive the cognitive disability
is. Unlike in DSM IV, the severity levels in DSM-5 (mild, moderate, severe, and
profound) are determined on the basis of adaptive functioning and not on
Intelligence Quotient (IQ) scores. This is because adaptive functioning and not
IQ scores is necessary to determine level of support necessary to maintain an
acceptable condition of life. IQ scores are not overemphasized and considers
functioning levels as important. The three domains of adaptive functioning have
been identified: conceptual, social and perceptual domain. The assessment of
intelligence across three domains (conceptual, social, and practical) ensures that
clinicians base their diagnosis on the impact of the deficit in general mental
340
abilities on functioning needed for everyday life. With early diagnosis, parental Disorders of Childhood and
Adolescents-II
assistance and special educational programs people with intellectual disabilities
are able to achieve significant degrees of functionality.

THE CONCEPTUAL DOMAIN includes skills in language,

reading, writing, math, reasoning, knowledge, and memory

THE SOCIAL DOMAIN refers to empathy, social

judgment, interpersonal communication skills, the ability
to make and retain friendships, and similar capacities

THE PRACTICAL DOMAIN centers on self-management in

areas such as personal care, job responsibilities, money
management, recreation, and organizing school and work tasks.

Fig. 13.1: Domains of Adaptive Functioning in DSM-5

Box 13.1: Case Study: Intellectual Disability

Jagdish’s mother contacted psychologists because he was being disruptive
at school and at work. Jagdish was 17 years old with Down’s syndrome and
was described as likable and at times, mischievous. Since childhood, Jagdish
had undergone many tests of IQ functioning in the range of 40-50, which
placed him in moderate intellectual disability. In school, Jagdish attended
separate classrooms meant for children with special problems. Jagdish was
placed in regular classes but was unable to proceed beyond class II, after
which his teachers placed him in special classes. Jagdish has been cheerful
and pleasant for his teachers and has made many friends in his class. He is
very social and participates in all school activities that involve music and
dance. However, lately his teachers complained to his parents that he was
being difficult and oppositional. When Jagdish’s mother was interviewed,
she expressed frustration at the classes because he was asked to do boring
and repetitive tasks like folding paper. Jagdish felt frustrated too, because
he was “being treated like a baby”. Whenever Jagdish though that he was
been given work too easy for him, he would respond by being disruptive
and naughty. However, his behaviour was interpreted by the teacher as
communicating that the work was too hard for him and responded by giving
even simpler tasks after which Jagdish protested and resisted more vigorously.

Box 13.2: DSM-5 Criteria for Intellectual Disability (APA, 2013)

A. Deficit of intellectual functions, such as reasoning, problem solving,
planning, abstract thinking, judgment, academic learning or learning
from experience, and confirmed by both individual clinical assessment
and standardized intelligence testing.
341
Disorders of Childhood and
Adolescence Trauma Related B. Deficits in adaptive functioning that failure to meet developmental and
and Neurocognitive Disorders socio-cultural standards for personal independence and social
responsibility.
Without ongoing support, the adaptive deficits limit functioning in one
or more activities of daily life, such as communication, social
participation, and independent living, across multiple environments,
such as home, school, work and community.
C. Onset of intellectual and adaptive deficits during the developmental
period.

13.1.1 Clinical Picture

The DSM-5 criteria classifies severity on the basis of daily skills. The categories
are as follows:

Mild Intellectual Disability: Largest number of people diagnosed with

intellectual disability are those with mild intellectual disability. These individuals
are considered to be educable (third-sixth grade), there intellectual levels as adults
are comparable to average 8-11year olds. Socially they are considered to be that
of adolescents, although they lack the imagination, inventiveness, and judgment
of a typical teenager. Most cases of individuals with intellectual disability do not
show any sign of brain pathology or physical anomalies. These individuals may
require some intermittent and limited supervision, because of their limited ability
to foresee the consequences of their action. Adults can marry, have children, but
may need significant help during episodes of distress. Early diagnosis, parental
assistance, special educational programs can help these individuals achieve simple
academic and occupational skills and become self-supporting citizens.

Moderate Intellectual Disability: Individuals with moderate intellectual ability

usually attain intellectual levels of 4-7-year olds all into ‘educable’ and ‘trainable’
category. They may be able to read and write a little and manage to communicate
verbally but their rate of learning and level of conceptualization is very limited
(first-second grade). They are presumed to be able to achieve partial independent
in in daily self-care, acceptable behaviour, hold a job in a sheltered environment.

Severe Intellectual Disability: Sensory defects, motor disability and speech

development are severely affected in these individuals. There is limited level of
personal hygiene and self-help skills, which somehow lessen their dependency,
but they are always dependent on others for care. Some individuals may gain to
certain extent from training and can perform simple occupational tasks under
supervision.

Profound Intellectual Disability: Such individuals are severely deficient in

adaptive behaviour and unable to master even simple tasks like buttoning, using
spoon to eat, toilet training, bathing etc. In some individuals, speech may not
develop or may be rudimentary. Generally related to organic brain damage
resulting from physical abnormalities, central nervous system pathologies,
seizures etc. and can be diagnosed in infancy. The individuals require constant
support and custodial care all must their lives. They usually have poor health
and low resistance to diseases, thus short life expectancy.

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13.1.2 Causal Factors Disorders of Childhood and
Adolescents-II

People with intellectual disability can be classified in two groups based on their
causes. First, biological basis i.e. intellectual ability caused by some known brain
pathology or organic impairments. In these cases, the level of functioning is
almost always at least moderate. Profound intellectual disability, although rarer
is also related to organic pathology. Second, cultural-familial basis of intellectual
disability, about 25 percent of cases with intellectual disability, usually with mild
intellectual disability are thought to be a result of social and environmental
influences such as neglect, abuse and social deprivation (Barlow & Durand, 2015).
Environmental factors like child abuse, neglect and socio-emotional deprivation
combine with biological influences to cause intellectual disability.

Genetic Factors: Intellectual disability (especially mild intellectual disability)

tends to run in families; about 300 genes have been identified as having the
potential to contribute to intellectual disability. However, it is also important to
note that poverty and socio-cultural deprivation that may contribute to impaired
brain development also tends to run in families. Genetic aberrations may lead to
metabolic alterations that negatively affect the brain’s development. Mild
intellectual disability is usually attributed to multiple genes, whereas severe and
profound intellectual disability is likely to be associated with identifiable single
gene disorders. Dominant gene disorder (only one gene is needed for its
expression) includes conditions such as tuberous sclerosis. About 60 percent of
people in tuberous sclerosis have intellectual disability along with seizures and
characteristic bumps on skin (Curatolo, Bombardieri, & Jozwiak, 2008).
Recessive gene disorder (expresses itself only when paired with another copy of
itself) such as phenylketonuria (PKU) in which the child has an inability to
breakdown the protein phenylalanine found in food. If detected early, intellectual
disability can be prevented through special diet. Finally, X-linked gene (present
on X chromosome) conditions such as fragile X syndrome primarily affects males
and causes moderate-severe intellectual disability and autism like symptoms.

Infections, Toxic Agents and Radiation: Intellectual disability is associated

with wide range of infections and toxic agents, such as exposure to HIV, German
measles, carbon monoxide, and overdose of any toxicity. Excessive alcohol intake
during pregnancy leads to a condition like foetal alcohol syndrome. RH
incompatibility between parents has also been associated with intellectual
disability in the child. In a medical study, it was found that the deadly gas leaked
from a Bhopal pesticide plant (Bhopal gas tragedy, 3 December, 1984) is
continuing to effect third generation of victims. About 2500 children were
identified with birth defect and about 164 of them were assessed to have
intellectual disability. Additionally, exposure to radiation may lead to mutations,
which is why pregnant women are not allowed in X ray rooms in hospitals.For
example, studies on 1600 children who were irradiated while they were in their
mother’s womb during the atomic bomb explosions in Hiroshima and Nagasaki
(Japanese cities that were bombed during World War II, 1945) revealed that 30
of them suffered clinically severe intellectual disability.

Trauma/Physical Injury: Physical injury at birth for instance because of forceps

delivery, difficulties in labour due to malposition of the foetus, lack of
sufficient oxygen during birth from delayed breathing, and bleeding within the
brain may be caused due to the physical trauma are associated with intellectual
disability. 343
Disorders of Childhood and
Adolescence Trauma Related
and Neurocognitive Disorders

Epicanthi eye folds Small head circumference

Low nasal bridge Small eye opening

Short nose Flat mid-face

Loss of upper-lip groove Thin upper lip

Fig. 13.2: Foetal Alcohol Syndrome

Source: https://healthand.com/in/topic/general-report/fetal-alcohol-syndrome

Malnutrition: Unhealthy and unbalanced diet (devoid of protein and other

essential nutrients) during early development of foetus does irreversible physical
and mental damage. In many villages in India because of poverty and lack of
education many pregnant women do not get healthy and nutritional diet.
Malnutrition continues to plague many children below the age of five years in
India often leading to their death or poor physical and mental development.

Organic Retardation Syndromes: PKU is an inerited disorder in which

phenylalanine is build up to harmful levels in the blood, thus causing intellectual
disability. Intellectual disability stemming primarily from biological causes can
be classified into several recognizable clinical types such as Phenylketonuria
(PKU), Down’s syndrome, and conditions involving cranial abnormalities.
Down’s syndrome (trisomy 21) is a condition in which an individual has extra
21st pair of chromosomes. These individuals have recognizable facial features.
Nearly all adults with Down’s syndrome past the age of 40 show signs of dementia
of the Alzheimer’s type. It is possible to detect Down’s syndrome in utero and
had led to the ethical question of whether it is advisable to abort foetus detected
with Down’s syndrome or not. A mother writes on the matter,
“If we deny someone the chance to be born because we’ve decided they won’t
meet a predetermined measure of status or achievement, then we fail to grasp
what it is to be human”.
Cranial abnormalities like macrocephaly (large headedness), microcephaly (small
headedness), and hydrocephaly (accumulation of abnormal amount of
cerebrospinal fluid) are conditions associated with intellectual disability amongst
other problems.

13.1.3 Treatment
A number of special education and rehabilitative programs have been developed
to improve the adaptability and functionality of individuals with intellectual
disability. Institutionalization of people with intellectual disability depends on
the quality of care and services provided by the institution. Education and training
facilities for individuals with intellectual disability are extremely inadequate.
Educational and training programs can help in improvement of skills such as
344
such as personal grooming, social behavior, basic academic skills, and simple Disorders of Childhood and
Adolescents-II
occupational skills. Behavioural principles such as breaking a complex task into
smaller sub-components can help individuals learn at their pace and experience
success. Vocational training for those with mild intellectual disability can help
individuals become independent and productive community members. Whereas,
special education classes for those with moderate and severe intellectual disability
emphasize on the development of self-care and other skills — e.g., toilet training.
mainstreaming or inclusion programs, regular schooling of children with mild
intellectual disability — requires careful planning, a high level of teacher skill,
and facilitative teacher attitudes.

In general, institutionalization is sought for two types of people with intellectual

disability, those with profound disability and institutionalization is sought in
childhood itself. And second for those with mild intellectual disability where
institutionalization is sought in adolescence because of delinquency and other
problematic behaviours such as, aggression. In general, long term
institutionalization is related to behavioural and emotional problems. In many
cases in India, institutionalization may be very expensive for many families. It is
not uncommon to find children and individuals with intellectual disability to
receive almost no care/support by family or society.

Check Your Progress 1

1) What are the different domains of adaptive functioning in the diagnosis
of intellectual disability?
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2) Mention the different levels of intellectual functioning.
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3) What is organic retardation syndrome?
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13.2 AUTISM SPECTRUM DISORDERS

The term Autism is derived from the Greek word autos meaning self, used by
Eugen Bleuler (Swiss psychiatrist) for the first time. Autism is a
neurodevelopmental condition that is usually identified before a child is 30 months
of age and may be suspected in early weeks of life. Autism is a condition that
affects social communication and is associated with repetitive patterns of
behaviour. DSM-5 has combined four independent diagnoses autistic disorder,
Asperger syndrome, pervasive developmental disorder-not otherwise specified
345
Disorders of Childhood and (PDD-NOS) and childhood disintegrative disorder into one diagnosis of Autism
Adolescence Trauma Related
and Neurocognitive Disorders
Spectrum Disorder (ASD). Recent researches have suggested that all these
disorders have the same essential symptoms, varying in degrees of severity. No
two children with ASD are alike, they have wide range of deficits, abilities,
difficulties, and challenges, therefore spectrum was found to be a suitable word
to describe individuals with autism. Moreover, it has also been found that the
number of children diagnosed as having ASD in the recent years is increasing.
The reason for the same is unclear. Some researchers suggest that the increased
awareness about autism has led to the increased incidence rates of autism. It has
been found that more boys show ASD than girls, with a ratio of 4:1.

13.2.1 Clinical Picture

Lack of reciprocal social interaction is amongst the earliest markers of autism,
irrespective of cognitive or language ability. In infancy, the child seems to be
aloof from others. Mother’s remember that babies diagnosed with autism later in
life fail to respond to their name, do not reach out when picked, would never
smile or look at family when they are played with, or may not notice people
family and strangers alike coming and going from the room. This may make
people assume that children with autism do not have the ability express emotions
or may lack emotions, however the fundamental problem in autism comes from
lack of social understanding. As children with autism grow older, deficits in
social understanding can be seen in lack of initiation for social interactions with
others, social interaction is restricted to getting obvious needs met such as food
and water, the children appear to be content with being alone and may ignore
parents bid for attention, and inconsistent eye contact although not reported for
all children, but has been reported for many children on the spectrum. Some
children may approach others in an unusual manner, for example, by licking,
smelling or biting. In teenage, the social deficits are not manifested in seeming
lack of social interest, but in inability to maintain relationships appropriate to
age level. This is because in adolescence, an individual is faced with a more
complex social milieu, a person on the spectrum may lack the ability to understand
social conventions making socialization extremely challenging. For instance,
the person may have difficulty in understanding jokes, irony, sarcasm, and faux
pas and because of this may become a victim of bullying in school.

Individuals with autism find it difficult to understand and use verbal and non-
verbal communication. Deficits in verbal communication include, delay in
language development, mutism (inability to acquire speech), idiosyncratic uses
of speech (unusual ways of using some words), immediate or delayed echolalia
(repetition of words or phrases either immediately or later sometime), or inability
for pragmatic use of speech (inability to use language for everyday social
interactions). Individuals with autism may fail to initiate, maintain, or respond
to conversations; engage in one-sided conversations which makes others who
have no understanding of autism to reject them. Additionally, children with
ASD find it challenging to understand non-verbal gestures, cues, and body
language of others. About 70 percent of human communication is largely non-
verbal in nature; deficits in verbal in and non-verbal communication prove to be
a major impediment for successful socialization even for extremely intelligent
people on the spectrum.

346
 Disorders of Childhood and
Box 13.2: Case Study: Autism Spectrum Disorder Adolescents-II
Abhishek is 5 years old. His mother took him to a doctor to get his hearing
tested at 2 years of age when he would not respond to his name and had not
started speaking even a single word. Even at 5 years of age, Abhishek would
turn his head away whenever someone would speak to him. Sometimes he
would mumble something unintelligible. Although toilet trained and able to
feed himself, schools asked his parents to take him out of school, because
Abhishek would not mingle with other children. He actively avoided being
touched and, on some days, he would start to cry and scream and no amount
of cajoling or loving him would soothe him. Inconsistent eye contact and
repetitive behaviour like lining up of his toy cars can be seen. When seated
he often rocks back and forth in a rhythmic motion for hours. Any change in
routine is highly upsetting to Abhishek.

Box 13.3: DSM-5 Criteria for Autism Spectrum Disorder (APA, 2013)
A. Persistent deficits in social communication and social interaction across
multiple contexts, as manifested by the following, currently or by history
(examples are illustrative, not exhaustive; see text):
1) Deficits in social-emotional reciprocity, ranging, for example, from
abnormal social approach and failure of normal back-and-forth
conversation; to reduced sharing of interests, emotions, or affect;
to failure to initiate or respond to social interactions.
2) Deficits in nonverbal communicative behaviors used for social
interaction, ranging, for example, from poorly integrated verbal
and nonverbal communication; to abnormalities in eye contact and
body language or deficits in understanding and use of gestures; to
a ( total lack of facial expressions and nonverbal communication).
3) Deficits in developing, maintaining, and understanding
relationships, ranging, for example, from difficulties adjusting
behavior to suit various social contexts; to difficulties in sharing
imaginative play or in making friends; to absence of interest in
peers.
B. Restricted, repetitive patterns of behavior, interests, or activities, as
manifested by at least two of the following, currently or by history
(examples are illustrative, not exhaustive; see text):
1) Stereotyped or repetitive motor movements, use of objects, or
speech (e.g., simple motor stereotypies, lining up toys or flipping
objects, echolalia, idiosyncratic phrases).
2) Insistence on sameness, inflexible adherence to routines, or
ritualized patterns of verbal or nonverbal behavior (e.g., extreme
distress at small changes, difficulties with transitions, rigid thinking
patterns, greeting rituals, need to take same route or eat same food
every day).
3) Highly restricted, fixated interests that are abnormal in intensity
or focus (e.g., strong attachment to or preoccupation with unusual
objects, excessively circumscribed or perseverative interests).
4) Hyper or hyporeactivity to sensory input or unusual inter-est in
sensory aspects of the environment (e.g., apparent indifference to
347
Disorders of Childhood and
Adolescence Trauma Related pain/temperature, adverse response to specific sounds or textures,
and Neurocognitive Disorders excessive smelling or touching of objects, visual fascination with
lights or movement).
C. Symptoms must be present in the early developmental period (but may
not become fully manifest until social demands exceed limited
capacities, or may be masked by learned strategies in later life).
D. Symptoms cause clinically significant impairment in social,
occupational, or other important areas of current functioning.
E. These disturbances are not better explained by intellectual disability
(intellectual developmental disorder) or global developmental delay.
Intellectual disability and autism spectrum disorder frequently co-occur;
to make comorbid diagnoses of autism spectrum disorder and intellectual
disability, social communication should be below that expected for
general developmental level.

Box 13.4 : An example of Echolalia from the perspective of an

individual with autism.
Excerpt taken from Nobody Nowhere: The Remarkable Autobiography
of an Autistic Girl by Donna William
Words were no problem, but other people’s expectations for me to respond
to them were. This required my understanding of what was said but I was
too happy losing myself to want to be dragged back by something as two-
dimensional as understanding.
“what do you think you’re doing” came the voice.
Knowing I must respond in order to get rid of this annoyance, I would
compromise, repeating, “what do you think you’re doing?’ addressed to no-
one in particular.
‘Don’t repeat everything I say,’ scolded the voice.
Sensing a need to respond, I’d reply, “Don’t repeat everything I say.’
*Slap*
I had no idea what was expected out of me.

Social and communication deficits have a reciprocal relationship in autism. An

innate inability for socialization affects language development in the child,
language and communication deficits in turn lead to challenges with socialization
as the child grows up. Understanding of this reciprocal relationship between
socialization and communication deficits led DSM-5 to assimilate socialization
and communication impairments under a single heading, ‘social-communication’
impairments. Social-communication impairments in autism have been attributed
to the inability of individuals with autism to ‘read people’s minds’ also known as
mindblindness. Mindblindness refers to the difficulty in seeing things the way
other people do and make educated guesses about what other’s may be thinking
or feeling. This skill helps typical people navigate a number of social situations.
For instance, if a typical child finds her/his friend sitting and sulking, she/he is
likely to enquire about the reason for her/him sulking, whereas a child with autism
may be unable to ‘read’ the non-verbal gestures of sulking and start talking about
a topic that greatly interests him/her.
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 Disorders of Childhood and
Ways of Talking Adolescents-II
Sounds (e.g. Pauses, Posture
(e.g. Laughing) stress on words)
(e.g. Slouching)

Closeness
(e.g. 'Invading Appearance
someone's space') Non-verbal (e.g. untidiness)
communication/
Body contact body language
Head Movements
(e.g. Shaking
(e.g. Nodding)
hands)

Facial
Expression Hand movements
Eye Movements
(e.g. Frown) (e.g. waving)
(e.g. Winking)

Fig. 13.4: Non-Verbal Communication

Along with social-communication difficulties, autism is characterised by a number

of behavioural difficulties in autism. Children with autism may engage in
stereotyped or repetitive speech, motor movements, or use of objects. For instance,
they may engage in self-stimulation i.e. repetitive movements as head banging,
spinning, and rocking, which may continue by the hour. Lining up of objects is
also commonly seen in children. Excessive adherence to routines or rituals and
resistance to changes in routines can also be seen with children on the spectrum.
The child may insist of taking the same route every day, or make the bus stop at
a particular point only then would the child get down. Children may form strong
attachments to unusual objects like rocks, keys, and light switches so much so
that the attachment may interfere with other activities. Highly restricted interest
of unusual magnitude is not just limited to objects such as pens, keys, action,
figures, and particular toys but may also extend to topics like dinosaurs or trains.
Changes in the environment, stereotypical routine, and/or an object with strong
attachment leads to resistance from the child ranging from discomfort to crying
spell that continue until the situation is restored. Finally, an addition to DSM-5
diagnostic criteria for autism is sensory difficulties. Sensory difficulties, i.e.,
hyper or hypo reactivity sensory input from the environment such as indifference
to pain/heat/cold, over-under reaction to certain sounds, distaste for certain food
to the point of being nauseous when made to eat it, fascination with lights etc.
are pervasive and independent of age and ability. Although individuals with autism
have always experienced sensory hyper/hypo reactivity, practitioners have only
recently acknowledged it, because of the social-communication difficulties
inherent in autism. For instance, a child with autism would cry when getting hair
or nails cut, she/he may refuse to wear socks, or t-shirts with labels because of
hyper sensitivity to tactile stimuli. But many adults would interpret this as
disruptive behaviour instead of sensory difficulties in autism.

Autism has a high comorbidity with intellectual disability. Earlier estimates

indicated that approximately 70 percent of individuals with autism also had
intellectual disability (Fombonne, 2005). However, recent estimates have
estimated that 50 percent of individuals with autism are also intellectually impaired
(Polynak, Kubina & Girirajan, 2005). This shift in the distribution has been
primarily attributed to an increase in identification of high functioning children
with autism, who were earlier missed out because their cognitive abilities would
often mask other deficits. 349
Disorders of Childhood and Unlike children with intellectual disability, children with autism are quite adept
Adolescence Trauma Related
and Neurocognitive Disorders
at puzzles and fitting objects together often performing better than even typical
children. However, difficulties meaning is apparent, for instance, if a child with
autism is asked to arrange pictures in an order so that they communicate a story,
she/he is likely to perform poorer than typical children.

13.2.3 Causal Factors and Treatment

Although most scientists believe that autism is an innate condition that affects
the development of the nervous system of a child, the precise cause/causes of
autism are unknown. Evidence from role of genetics in the etiology of autism
comes from studies examining the incidence rates of autism in families. To have
a parent or sibling with autism raises the chance of an individual to have autism.
According to WHO, 1 in 160 children has ASD. A family with one child with
autism have greater risk of having another with autism. Twin studies have shown
higher concordance for monozygotic (60%) than dizygotic twins. Relatives of
people with autism may show sub-threshold social-communication deficits.
Genetic researches in autism has been found autism to be related to the faulty
working of the brain’s glutamate neurotransmitter system. However, it is unclear
how the genetic vulnerability transmits to leads to faulty wiring in early stages
of development.
Expression of the autism genes may be influenced by environmental factors.
Prenatal environmental factors (exposure to radiation, toxins, alcohol, drugs,
infections etc.) and pregnancy related factors (uterine bleeding, Rh
incompatibility, induced or prolonged labour, oxygen requirements at birth) have
been implicated in children with autism.
Based on the recent researches it is important to note that there is no cure for
autism. In spite of that, many children continue to be subjected to the many fads
in the market, promising them a ‘cure’ for the condition. Many researchers and
350 parents conceive autism to be unlike other mental illnesses like depression and
anxiety. Autism is seen as a condition, that leads to differences in brain wiring Disorders of Childhood and
Adolescents-II
relative to the typical population, Treatment of autism includes management of
problematic behaviours as well training of teachers, schools, and workplaces to
understand and make space for the challenges of autism.
In the past medications for autism have proven to be effective. Currently medicines
are only prescribed for aggression and hyperactivity that may be excessive and
leading to self-harm. Behavioural therapy has been found to be successful in
development of some social and communication skills and elimination of
problematic behaviour. A successful intervention involves one-to-one teaching
of skills every day for several years in diverse settings of the child i.e. clinic,
school, and home. Adults including parents and teachers are taught principles of
behavioural therapy, such as use of rewards and breaking down of complex tasks
into smaller tasks. Use of punishment or aversive techniques must be avoided.
Check Your Progress 2
1) Explain the social-communication deficits in autism
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2) What is mindblindness?
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3) Define echolalia.
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13.3 SPECIFIC LEARNING DISORDERS

Children first learn oral language and then learn to read and write that language.
Written language is a code that stands for oral language whereas reading is the
ability to construct meaning (comprehension) from the printed language.
Academic success of a child depends great deal on reading, writing, spelling and
comprehension. While most children are able to recognize or decode in print the
language and use printed language for the language they use orally, people with
specific learning disability have significant deficits in reading, written expression
and/or Mathematics. Specific learning disorder (SLD) refers to clear impairment
in school performance or (if the person is not a student) in daily living activities—
which is not due to intellectual disability or to another developmental disorder
such as autism or attention deficit and hyperactivity. Further, DSM-5 distinguishes
learning disorder from learning problems that are primarily a result of visual,
hearing and motor disabilities, emotional disturbances, environmental, cultural
or socioeconomic disadvantage. DSM-5 combines the previous DSM IV
diagnoses of poor achievement in reading (dyslexia), writing (dysgraphia), 351
Disorders of Childhood and arithmetic (dyscalculia) and learning disorder not otherwise specified into a single
Adolescence Trauma Related
and Neurocognitive Disorders
diagnosis of Specific Learning Disorder. Learning disorders in reading, writing,
and/or mathematics are designated as specifiers.

Prevalence rate for specific learning disorder varies from one study to another.
In one study conducted on children in Kerala, school-going children from the
fourth standard to the seventh standard were included in the study, the prevalence
of specific learning disorders was 16.75 percent (Chacko & Vidhukumar, 2010)
to the sev. Out of the three, dyslexia is the most common whereas, dyscalculia is
least common. Significantly there are more boys than girls diagnosed with specific
learning disorder, although more recent researches suggest that boys and girls
may be equally affected by this condition.

13.3.1 Clinical Picture

Children with dyslexia have poor phoneme awareness, i.e. they have difficulty
in knowing how to sound out alphabets. A child may achieve phoneme awareness
but may lack word decoding ability, she/he may not be able to read words on a
page. Child lacks fluency and may get stuck when trying to read, reading speed
is slow, she/he may make guesses at words based on the first letter and may find
the entire exercise to be extremely exhausting and may begin to avoid reading
altogether. In dysgraphia, child may have very poor and almost illegible writing,
wrong spellings for even simple words, and lack organization of ideas and
thoughts. Dyscalculia can cause difficulties in learning math concepts such as
quantity, place value, and time, difficulty memorizing mathematical facts,
difficulty organizing numbers etc.

Despite being recognized as a distinct neurodevelopmental disorder, learning

disorders are poorly understood by teachers, parents, and school administration.
Blaming of victim and attributing the problems to the child’s character (“you’re
lazy, you’re useless, you are stupid”) and lack of motivation is common.
Conventional schooling and parenting can be detrimental for the self-esteem of
a child with learning disorders. It is not uncommon for parents to receive a
diagnosis late, by the time the child’s self-esteem and psychological well-being
has already been compromised though internalization of negative comments,
brickbats and criticisms received. Many well-known and famous people like
Abhishek Bachchan, Winston Churchill, Tom Cruise, Leonardo da Vinci, Walt
Disney, and Jim Carrey are said to have dyslexia. Early intervention, high
intelligence, talent and motivation can help children overcome their disability
through achievements in many fields.

Box 13.5: Some Common Indicators of Specific Learning Disorder

Dyslexia
Poor Phonemic Awareness: i.e. lack of awareness of sound of alphabets.
Poor phoneme-grapheme connection: sound-symbol correspondence.
Making of errors while reading.
Omit words: cat for can’t, wet for went, sig for sing.
Reversals: read 17 for 71, won for now, saw for was.
Sequencing: reading name as amen, reserve as reverse.
Misreads simple words: a for and, from for for, then for there.
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 Disorders of Childhood and
Problems with fluency/slow reading: their reading is painfully slow Adolescents-II
and halting. Reading lacks fluency.
Dysgraphia
Generally illegible writing: writing may resemble scribbles/noodles.
Spelling Mistakes: Poor phoneme-grapheme connection
Mix of upper/lower case letters or cursive/print letters.
Irregular letter shape and sizes.
Dyscalculia
Problems with adding, subtracting, multiplication.
Confused by similar looking Arithmetic signs such as + and x; < and >
; - and ÷
Understand what adding means yet may become confused when asked
to add.
Reverse numbers like 18 and 81, or transpose numbers like 752 becomes
572
Problems with telling time.

Box 13.6: DSM-5 Criteria for Specific Learning Disorder (APA, 2013)
A. Difficulties learning and using academic skills, as indicated by the
presence of at least one of the following symptoms that have persisted
for at least 6 months, despite the provision of interventions that target
those difficulties:
1) Inaccurate or slow and effortful word reading (e.g., reads single
words aloud incorrectly or slowly and hesitantly, frequently guesses
words, has difficulty sounding out words).
2) Difficulty understanding the meaning of what is read (e.g., may
read text accurately but not understand the sequence, relationships,
inferences, or deeper meanings of what is read).
3) Difficulties with spelling (e.g., may add, omit, or substitute vowels
or consonants).
4) Difficulties with written expression (e.g., makes multiple
grammatical or punctuation errors within sentences; employs poor
paragraph organization; written expression of ideas lacks clarity).
5) Difficulties mastering number sense, number facts, or calculation
(e.g., has poor understanding of numbers, their magnitude, and
relationships; counts on fingers to add single-digit numbers instead
of recalling the math fact as peers do; gets lost in the midst of
arithmetic computation and may switch procedures).
6) Difficulties with mathematical reasoning (e.g., has severe difficulty
applying mathematical concepts, facts, or procedures to solve
quantitative problems).
B. The affected academic skills are substantially and quantifiably below
those expected for the individual’s chronological age, and cause
significant interference with academic or occupational performance, or
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Disorders of Childhood and
Adolescence Trauma Related with activities of daily living, as confirmed by individually administered
and Neurocognitive Disorders standardized achievement measures and comprehensive clinical
assessment. For individuals age 17 years and older, a documented history
of impairing learning difficulties may be substituted for the standardized
assessment.
C. The learning difficulties begin during school-age years but may not
become fully manifest until the demands for those affected academic
skills exceed the individual’s limited capacities (e.g., as in timed tests,
reading or writing lengthy complex reports for a tight deadline,
excessively heavy academic loads).

D. The learning difficulties are not better accounted for by intellectual

disabilities, uncorrected visual or auditory acuity, other mental or
neurological disorders, psychosocial adversity, lack of proficiency in
the language of academic instruction, or inadequateeducational
instruction.

13.3.2 Causal Factors and Treatment

Most commonly held view of the cause of Specific Learning Disorder is that it is
caused by subtle central nervous system impairments. Like other
neurodevelopmental disorder, learning disorders also have a heritable component.
Studies have found that people in dyslexia have reduced activation of left
hemisphere. In particular, three areas of left hemisphere: Broca’s area (word
recognition), left parietotemporal area (affects word analysis), and left
occipitotemporal area (recognizing word form) have been found to have reduced
activation in children with dyslexia when given a phonological awareness task.
Further, intervention for reading disability, led to greater activation of these areas
in children than those who received less intensive treatment.

Many treatment programs have been developed for people with learning disorders,
including one-one-one tutoring and school group programs. Early intervention
programs involve imparting of skills such as reading out loud under close
supervision, teaching phonemic awareness through creative methods, readiness
skills, such as letter discrimination, phonetic analysis, and learning letter–sound
correspondences, have been incorporated. Programs have also been designed to
ensure that children experience success that helps boost the self-confidence of
children and makes learning interesting. However, while many single case studies
have claimed success in treatment of learning disorders, interventions based on
direct instruction strategies for learning have had limited success. Some successful
strategies include use of computer assisted tools like podcast/webcast lectures,
tutors, untimed/oral tests and allowing another individual to write answers that
they can dictate out in examinations. Central Board of Senior Secondary Education
(CBSE) in India for instance mandates schools to give special provisions for
children with specific learning disorders as well as autism spectrum disorders

Check Your Progress 3

1) List some common indicators of SLD.

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 Disorders of Childhood and
2) Mention any two treatment options for SLD. Adolescents-II

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13.4 SUMMARY
Now that we have come to the end of this unit, let us list all the major points that
we have already learnt.
Neurodevelopmental disorders have a heritable component.
Intellectual disability also known as intellectual developmental disorder is
defined as sub-average functioning in general mental abilities such as
reasoning, problem solving, planning, abstract-thinking, judgment, academic
learning, and learning from experience beginning before the age of 18 years.
Special education and rehabilitation programmes as well as
institutionalization are being used for intellectually disability depending
upon the functionality of the individual.
Autism is a condition that affects social communication and is associated
with repetitive patterns of behaviour. Although there is no cure for autism,
behavioural interventions and parent/teacher training program can help with
problematic behaviours of children with ASD.
Behavioural therapy has been found to be successful in development of
some social and communication skills and elimination of problematic
behaviour in autism spectrum disorder.
While most children are able to recognize or decode in print the language
and use printed language for the language they use orally, people with
specific learning disability have significant deficits in reading, written
expression and/or mathematics.
Early intervention programs that includes one-to-one tutoring and school-
based programmes have been found to be successful for learning disability.

13.5 KEYWORDS
Intellectual Disability: Also known as intellectual developmental disorder and
is defined as sub-average functioning in general mental abilities such as reasoning,
problem solving, planning, abstract-thinking, judgment, academic learning, and
learning from experience beginning before the age of 18 years.

Mindblindness: Difficulty in seeing things the way other people do and make
educated guesses about what other’s may be thinking or feeling.

Dyslexia: Significantly poor achievement in reading relative to one’s

developmental level which is not due to intellectual disability, another
developmental disorder such as autism or attention deficit and hyperactivity,
primarily a result of visual, hearing and motor disabilities, emotional disturbances,
environmental, cultural or socioeconomic disadvantage.

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Disorders of Childhood and Dysgraphia: Significantly poor achievement in writing relative to one’s
Adolescence Trauma Related
and Neurocognitive Disorders
developmental level which is not due to intellectual disability, another
developmental disorder such as autism or attention deficit and hyperactivity,
primarily a result of visual, hearing and motor disabilities, emotional disturbances,
environmental, cultural or socioeconomic disadvantage.

Dyscalculia: Significantly poor achievement in Mathematics relative to one’s

developmental level which is not due to intellectual disability, another
developmental disorder such as autism or attention deficit and hyperactivity,
primarily a result of visual, hearing and motor disabilities, emotional disturbances,
environmental, cultural or socioeconomic disadvantage.

13.6 REVIEW QUESTIONS

1) Which of the following is a sign of Autism?
a) 2-year-old child does not react or respond when his name is called.
b) Child consistently does not seem interested in the reactions of others,
especially the reactions parents.
c) Person does not seem aware of the feelings of others.
d) All of the above.
2) Which of the following causes Autism?
a) Cold parenting
b) Poor prenatal nutrition
c) A single gene or chromosome
d) There is no known single cause
3) Areas in the ______hemisphere have been implicated in specific learning
disorders.
4) The DSM-5 criteria classifies the severity of _____________ on the basis
of daily skills.
5) The categories of intellectual disability are, ________,_____________,
_________, and ______.
6) Explain the causes and treatment of intellectual disability.
7) Discuss the clinical features of autism spectrum disorder.
8) Elucidate the diagnostic criteria of specific learning disability. Discuss its
treatment.

13.7 REFERENCES AND FURTHER READING

Barlow, D.H. & Durand, M.V. (2015). Abnormal Psychology (7th Edition). New
Delhi: Cengage Learning India Edition.
Mineka, S., Hooley, J.M., & Butcher, J.N., (2017). Abnormal Psychology (16th
Edition). New York: Pearson Publications.
Kring, A. M., Davison, G. C., & Neale, J. M. (2014). Abnormal psychology (13th
Edition). New York: John Wiley & Sons.
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 Disorders of Childhood and
13.8 REFERENCES FOR IMAGES. Adolescents-II

Foetal Alcohol Syndrome. Retrieved 10th September 2019, from https://

healthand.com/in/topic/general-report/fetal-alcohol-syndrome

Non-Verbal Communication. Retrieved 14th September 2019, from https://

g l o b a l c o m m u n i c a t i o n c o r p o r a t i o n . w e e b l y. c o m / n o n - v e r b a l -
communications.html

13.9 WEB RESOURCES

Bhopal Gas Tragedy and Intellectual Disability. https://pulitzercenter.org/
projects/disabled-children-bhopal-gas-tragedy.

Parent’s Opinion on Abortion of Down’s Syndrome Children,

radiotimes.com/news/2016-10-05/sally-phillips-society-wants-to-stop-
down-syndrome-babies-being-born-and-its-wrong/.

Radiation and Intellectual Disability. https://www.hindustantimes.com/static/

groundglass/jadugoda-the-nuclear-graveyard.html.

Identification of Early Signs of Autism. https://www.youtube.com/

watch?v=z7NeBs5wNOA.

Helping children with learning disorders. https://www.helpguide.org/articles/

autism-learning-disabilities/helping-children-with-learning-disabilities.htm.
Answers for Fill in the Blanks (1-5)
(1) All of the above, (2)There is no known single cause, (3) Left (4) intellectual
disability (5) mild intellectual disability, moderate intellectual disability, severe
intellectual disability, and profound intellectual disability.

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