neurodevelopmental disorders

by Mohammed j
 neurodevelopmental disorders
 The neurodevelopmental disorders are a group of conditions with onset in the
developmental period.
 The disorders typically manifest early in development, often before the child enters grade
school, and are characterized by developmental deficits that produce impairments of
personal, social, academic, or occupational functioning.
 The range of developmental deficits varies from very specific limitations of learning or
control of executive functions to global impairments of social skills or intelligence.
 The neurodevelopmental disorders frequently co-occur; for example, individuals with autism
spectrum disorder often have intellectual disability (intellectual developmental disorder),
and many children with attention-deficit/hyperactivity disorder (ADHD) also have a specific
learning disorder.
 For some disorders, the clinical presentation includes symptoms of excess as well as
deficits and delays in achieving expected milestones.
 For example, autism spectrum disorder is diagnosed only when the characteristic deficits of
social communication are accompanied by excessively repetitive behaviors, restricted
interests, and insistence on sameness.
 1. Intellectual disability (intellectual developmental
disorder)
 IDD is characterized by deficits in general mental abilities, such as reasoning, problem
solving, planning, abstract thinking, judgment, academic learning, and learning from
experience.
 The deficits result in impairments of adaptive functioning, such that the individual fails
to meet standards of personal independence and social responsibility in one or more
aspects of daily life, including communication, social participation, academic or
occupational functioning, and personal independence at home or in community
settings.
 Global developmental delay, as its name implies, is diagnosed when an individual fails
to meet expected developmental milestones in several areas of intellectual functioning.
 The diagnosis is used for individuals who are unable to undergo systematic
assessments of intellectual functioning, including children who are too young to
participate in standardized testing.
 Intellectual disability may result from an acquired insult during the developmental
period from, for example, a severe head injury, in which case a neurocognitive disorder
also may be diagnosed.
 2. Communication disorders
 Communication disorders are language disorder, speech sound
disorder, social (pragmatic) communication disorder, and childhood-
onset fluency disorder (stuttering).
 The first three disorders are characterized by deficits in the
development and use of language, speech, and social communication,
respectively.
 Childhood-onset fluency disorder is characterized by disturbances of
the normal fluency and motor production of speech, including
repetitive sounds or syllables, prolongation of consonants or vowel
sounds, broken words, blocking, or words produced with an excess of
physical tension.
 Like other neurodevelopmental disorders, communication disorders
begin early in life and may produce lifelong functional impairments.
 3. Autism spectrum disorder
 Autism spectrum disorder is characterized by persistent deficits in
social communication and social interaction across multiple contexts,
including deficits in social reciprocity, nonverbal communicative
behaviors used for social interaction, and skills in developing,
maintaining, and understanding relationships.
 In addition to the social communication deficits, the diagnosis of
autism spectrum disorder requires the presence of restricted, repetitive
patterns of behavior, interests, or activities.
 Because symptoms change with development and may be masked by
compensatory mechanisms, the diagnostic criteria maybe met based
on historical information, although the current presentation must cause
significant impairment.
 Autism spectrum disorder
 Within the diagnosis of autism spectrum disorder, individual clinical
characteristics are noted through the use of specifiers (with or without
accompanying intellectual impairment; with or without accompanying
structural language impairment; associated with a known medical/genetic or
environmental/acquired condition; associated with another
neurodevelopmental, mental, or behavioral disorder), as well as specifiers
that describe the autistic symptoms (age at first concern; with or without
loss of established skills; severity).
 These specifiers provide clinicians with an opportunity to individualize the
diagnosis and communicate a richer clinical description of the affected
individuals.
 For example, many individuals previously diagnosed with Asperger’s
disorder would now receive a diagnosis of autism spectrum disorder without
language or intellectual impairment.
 4. ADHD
 ADHD is a neurodevelopmental disorder defined by impairing levels of
inattention, disorganization, and/or hyperactivity-impulsivity.
 Inattention and disorganization entail inability to stay on task, seeming
not to listen, and losing materials, at levels that are inconsistent with age
or developmental level.
 Hyperactivity-impulsivity entails over activity, fidgeting, inability to stay
seated, intruding into other people’s activities, and inability to wait
symptoms that are excessive for age or developmental level.
 In childhood, ADHD frequently overlaps with disorders that are often
considered to be “externalizing disorders,” such as oppositional defiant
disorder and conduct disorder.
 ADHD often persists into adulthood, with resultant impairments of social,
academic and occupational functioning.
 5. Motor disorders
 Motor disorders:- the neurodevelopmental motor disorders include
developmental coordination disorder, stereotypic movement disorder, and
tic disorders.
 Developmental coordination disorder is characterized by deficits in the
acquisition and execution of coordinated motor skills and is manifested by
clumsiness and slowness or inaccuracy of performance of motor skills
that cause interference with activities of daily living.
 Stereotypic movement disorder is diagnosed when an individual has
repetitive, seemingly driven, and apparently purposeless motor behaviors,
such as hand flapping, body rocking, head banging, self biting, or hitting.
 The movements interfere with social, academic, or other activities.
 If the behaviors cause self-injury, this should be specified as part of the
diagnostic description.
 Motor disorders
 Tic disorders are characterized by the presence of motor or vocal
tics, which are sudden, rapid, recurrent, no rhythmic, stereotyped
motor movements or vocalizations.
 The duration, presumed etiology, and clinical presentation define the
specific tic disorder that is diagnosed: Tourette’s disorder, persistent
(chronic) motor or vocal tic disorder, provisional tic disorder, other
specified tic disorder, and unspecified tic disorder.
 Tourette’s disorder is diagnosed when the individual has multiple
motor and vocal tics that have been present for at least 1 year and that
have a waxing-waning symptom course.
 6. Specific learning disorder
 Specific learning disorder, as the name implies, is diagnosed when there are
specific deficits in an individual’s ability to perceive or process information
efficiently and accurately.
 This neurodevelopmental disorder first manifests during the years of formal
schooling and is characterized by persistent and impairing difficulties with learning
foundational academic skills in reading, writing, and/or math.
 The individual’s performance of the affected academic skills is well below average
for age, or acceptable performance levels are achieved only with extraordinary
effort.
 Specific learning disorder may occur in individuals identified as intellectually gifted
and manifest only when the learning demands or assessment procedures (e.g.,
timed tests) pose barriers that cannot be overcome by their innate intelligence and
compensatory strategies.
 For all individuals, specific learning disorder can produce lifelong impairments in
activities dependent on the skills, including occupational performance
 Specific learning disorder
 The use of specifiers for the neurodevelopmental disorder diagnoses
enriches the clinical description of the individual’s clinical course and current
symptomatology.
 In addition to specifiers that describe the clinical presentation, such as age at
onset or severity ratings, the neurodevelopmental disorders may include the
specifier “associated with a known medical or genetic condition or
environmental factor.”
 This specifier gives clinicians an opportunity to document factors that may
have played a role in the etiology of the disorder, as well as those that might
affect the clinical course.
 Examples include genetic disorders, such as fragile X syndrome, tuberous
sclerosis, and Rett syndrome; medical conditions such as epilepsy; and
environmental factors, including very low birth weight and fetal alcohol
exposure (even in the absence of stigmata of fetal alcohol syndrome).
 Chapter-X
PSYCHOPHARMACOLOGY

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 PSYCHOPHARMACOLOGY

Learning objectives
After studying this unit, the student should be able to:
 Define psychopharmacologies
 Identify different antipsychotic drugs
 Identify commonly used antipsychotic drugs
 Identify commonly used antidepressants
 Identify commonly used anxiolytic drugs
 Identify commonly used mood stabilizer drugs
 Discuss nursing actions in drug administration
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 Psychopharmacology
• Psychopharmacology is the scientific study of medicines and drugs acting
upon psychic aspects of human being and animals
• Medications used to treat psychiatric disorders are referred to as
psychotropic drugs
• These drugs are commonly described by their major clinical application,
• for example, antidepressants, antipsychotics, mood stabilizers, anxiolytics,
hypnotics, cognitive enhancers, and stimulants.

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• Psychotropic drugs have the following characteristics:
– It should cure the underlying pathology; the drug can be stopped after
sometime.
– It should benefit all the patients suffering from that disorder.
– It should have low side-effects or toxicity in the therapeutic range.
– It should have rapid onset of action.
– There should be no or minimal dependence on the drug and no withdrawal
symptoms on stopping the drug.
– There should be no tolerance to the drug so that same dose is effective for
long duration of time.
– It should not be lethal in overdoses.
– It can be given in both inpatient and out patient settings.

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 1. Antipsychotic (neuroleptics)
• Antipsychotics are the drugs currently used in the prevention & treatment of
psychotic disorders.
• They have also been termed neuroleptics.
• Despite chemical differences, their pharmacologic actions and antipsychotic
effectiveness are relatively similar
• Actions of neuroleptics: The antipsychotic drugs act primarily by occupying
dopamine receptors in brain tissue, by decreasing the effects of dopamine, a
catecholamine neurotransmitter.
• Excessive dopamine activity is believed to be an important factor in the
development of psychotic.
• Antipsychotic activity derives from inhibition of dopaminergic
neurotransmission.
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• Choice of drug: The choice of particular anti-psychotic drug is largely empirical.
• Some general factors to consider include:-
– the client’s age and physical condition;
– severity and duration of illness;
– frequency and severity of adverse effects produced by each drug;
– response to antipsychotic drugs in the past;
– subjective response to the drug (such as the adverse reaction a person is
willing to tolerate);
– supervision available; and the experience of the personnel with a particular
drug.

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 Common specific characteristics of Antipsychotic.
 Antipsychotic drugs are apparently equally effective regardless of the client’s
symptoms.
• Drugs producing greater sedation are often prescribed for agitated, over active
persons and drugs producing less sedation are prescribed for those who are
apathetic and withdrawn.
 Some clients who do not respond well to one type of antipsychotic drug may
respond to another.
• there is no way of predicting which drug is likely to be most effective for
particular client.
 There is no logical basis for giving more than one antipsychotic agent at a time.
 Antipsychotic drugs are usually given for months or years

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 If lack of therapeutic response requires another substituted for the one a client
and must be done gradually.
 Non-phenothiazine antipsychotics are used for clients with chronic
schizophrenia whose controlled symptoms.
 Unless the choice of a drug is depends on previous favorable response to a
particular drug,
• the preferred drug should be available in both parenteral and oral forms for
flexibility of administration.
 Clients who are unwilling to take daily doses of a maintenance antipsychotic
may be given periodic injections of a long- acting form of fluphenazine.
 Any person who has had an allergic or hypersensitivity reaction to antipsychotic
drug should generally not be given that particular drug again or any drug in the
same chemical group.
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 Antipsychotic Medications
1.Conventional/typical 2.Atypical or Novel
– Chloripromazine(thorazine) – Clozapine (Clozaril)
– Triflupenazine(stelazine) – Risperidone (Risperdal)
– Thioridazine(mellaril) – Olanzapine (Zyprexa)
– Fluphenazine(prolixine) – Quetiapine (Seroquel)
– Haloperidol (Haldol) – Ziprasidone (Geodon)
High Potency Antipsychotics Low Potency Antipsychotics
BRAND NAME(GENERIC NAME) BRAND NAME(GENERIC NAME)
• Haldol (Haloperidol) • Mellaril(Thioridazine)
Initial:5-10 mg/day
Maintenance:5-20 mg/day. -Initial dosage:25-100 mg tid; titrate to
• Prolixin (Fluphenazine) 100-400 mg bid max 800
Initial:2.5-10 mg/day, may be titrated to 40 mg/day. -Maintenance: 200-800 mg/day;
Maintenance:10-20 mg/day.
– Thorazine(Chlorpromazine)
• Navane (Thiothixine)
-Initial:10-50 mg PO bid-qid , titrate to 200-800 mg/day in
• Stelazine (Trifluoperazine) divided doses (max 2000 mg/day).
Initial:2-5 mg bid-tid. -Acute agitation: 25-50 mg IM q 4-6h.
Maintenance:5-20 mg/day -Maintenance:200-800 mg/day.

• Orap (Pimozide) 2.0 mg tablets. • Serentil(Mesoridazine)

-Initial:25-50 mg po tid. Titrate to 300-400
-Acute agitation:25-50 mg IM
-Maintenance:100-400 mg/day.
 2. Antidepressants
• Antidepressants are those psychotropic drugs which are used for treatment of
depressive disorders.
• These have also been called as mood-elevator
• action of antidepressants is to increase the catecholamine levels in brain
• It is essential to continue the antidepressant for a period of further 6 months
after reaching remission, in the first episode of depressive disorder
• for longer duration in subsequent episodes to prevent recurrence of symptoms.
Drug Selection
• The choice of an antidepressant depends upon the following major factors:
– the type of depression; its severity; drug’s effectiveness and adverse effects.

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1. Selective Serotonin Reuptake Inhibitors(SSRI)
• The SSRIs comprise a class of drugs with six prominent members.
• Inhibit the reuptake of 5-HT into the presynaptic neuron
• They are generally chosen as first-line antidepressants
• Initial response 2-4 weeks
• If there is a response but not adequate response after 3-4 wks.
1. Citalopram: 20 mg initially; maintenance 40 mg per day; maximum dose 60 mg
2. Escitalopram: 10-20 mg in most cases. Maximum dose 20 mg.
3. Paroxetine: 25-40 mg per day and maximum 50 mg per day.
4. Fluoxetine Long half-life; less withdrawal and 20 mg to a maximum 80 mg.
5. Fluvoxamine: Initial dose is 50-100 mg and not to exceed 300 mg per day.
6. Sertraline : Dosing is 50-200 mg per day and should be titrated upward
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2. Tricyclic antidepressants
• TCA are a group of eight chemically and pharmacologically similar drugs.
• These drugs contain a triple-ring structures from which their name is derived.
• They block the reuptake pumps for both serotonin and norepinephrine, and to
a lesser extent, dopamine.
• They produce relatively high incidence of sedation, orthostatic hypotension,
cardiac arrhythmias, and other adverse effects in addition to dry mouth and ant
cholinergic effects.
• Amitriptyline and Imipramin are commonly used TCAs.

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• Essentially the TCA has five actions:
 blocking muscarinic cholinergic M1 receptors,
 blocking the reuptake of 5-HT,
 blocking the reuptake of NE ,
 blockade of H1 histamine receptors, and
 blockade of alpha 1 adrenergic receptors.
• These three pharmacologic properties are thought to account for their SE
• Blockade of the serotonin (SRI) and norepinephrine (NRI) reuptake pumps
accounts for the therapeutic actions of drugs

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• Except of protriptyline, all TCAs can be started at 25 mg a day and increased as
tolerated.
• Protriptyline use should be started at 15 mg a day and raised to 60 mg a day.
• Amitriptyline (Elavil) (25-300) -Moprotiline (Ludiomil)
• Clomipramine (25-300) - Nortriptyline (Aventyl)(25-150)
• Doxepin (Sinequan) - Protriptyline (Vivactil) (15-60)
• Imipramine (Tofranil) (25-300) -Amoxapine (Asendin) (150-400)
• Trimipramine, Desipramine (Norpramin, Pertofrane)

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3. Serotonin-norepinephrine reuptake inhibitors (SNRIs)
 Venlafaxine (Effexor): Also used to treat generalized anxiety disorder and
social anxiety disorder.
• Dose 37.5 mg…Maximum dose 375 mg and
• Blood pressure should be monitored as this medication can increase it.
 Desvenlafaxine (Pristiq)Similar to Venlafaxine.
 Duloxetine(Cymbalta) Dosing 40 mg two times daily or 60 mg once daily.
• All serotonin norepinephrine reuptake inhibitors can increase heart rate and
blood pressure...
– which can cause problems for patients with advanced or unstable heart
failure.
• high circulating levels of NE to compensate for poor cardiac output.
• NE helps to make the heart pump faster and more forcefully.
• Sustained
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response increases demand on an already damaged heart... 27
 4. MonoAmine Oxidase Inhibitors (MAOI)
• They are immediate inhibitors of the enzyme monoamine oxidase.
• They are best known as powerful antidepressants.
• The MAO inhibitors are also therapeutic agents and second-line treatment for certain anxiety
disorders, such as panic disorder and social phobia
• They bind to MAO irreversibly and destroy its function forever.
• Enzyme activity returns only after new enzyme is synthesized.
• Avoid use of MAOIs in pregnancy because of teratogenic potential
• MAOI DOSAGE initial maximum dosege
• Selegiline (Eldepryl)……… 5 mg 10-30
• Isocarboxazide (Marplan)…..10 mg 30-60
• Phenelzine (Nardil)………...15 mg 45-90
• Tranylcypromine (Parnate)….10 mg 20-40

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 3. Anticonvulsants/ mood stabilizer
• Anticonvulsant drugs are mainly used to treat seizure and bipolar disorders.
• Other Indications: Bipolar, Cyclothymia, schizoaffective, impulse control and
intermittent explosive disorders.
• Selection of them depends on what you are treating and again the side effect
profile.
• Therapeutic and adverse effects depend primarily on serum drug levels.
• Most anticonvulsant drugs can be taken orally and are absorbed through the
intestinal mucosa.

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• Mechanisms of actions of anticonvulsants
• anticonvulsants drugs act in two ways to control seizure activity.
• 1st , they may act directly on abnormal neurons to decrease their excitability
and responsiveness to stimuli.
– Consequently, the seizure threshold is raised and seizure activity is
decreased.
• 2nd , they prevent the spread of impulses to the normal neurons that surround
the abnormal ones.
– This helps to prevent or minimize seizures by confining excessive electrical
activity to a small portion of the brain.
– ability to reduce the responsiveness of normal neurons to stimuli may be
related to alterations in the activity of sodium, potassium, calcium, and
magnesium ions at the cell membrane.
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1. Lithium: Only medication to reduce suicide rate.
Effective in long-term prophylaxis of both mania and depressive Factors
predicting positive response to lithium
Prior long-term response or family member with good response
Classic pure mania
Mania is followed by depression
Lithium- how to use it
Before starting :Get baseline creatinine, TSH and CBC.
Monitoring: check 12 hours after last dose.
Once stable check once 3 months and
TSH and creatinine once 6 months.
Goal: blood level between 0.6-1.2

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Lithium side effects
Most common are GI distress including reduced appetite, nausea/vomiting,
diarrhea
Thyroid abnormalities
Polyuria/polydypsia secondary to ADH antagonism.
Hair loss, acne
Reduces seizure threshold, cognitive slowing, intention tremor
Lithium toxicity
Mild- levels 1.5-2.0 see vomiting, diarrhea, ataxia, dizziness, slurred speech,
nystagmus.
Moderate-2.0-2.5 nausea, vomiting, anorexia, blurred vision, clonic limb
movements, convulsions, delirium, syncope
Severe- >2.5 generalized convulsions, oliguria and renal failure

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 2. Valproic acid (Depakote)
• Valproic acid is as effective as Lithium in mania prophylaxis but is not as
effective in depression prophylaxis.
• Factors predicting a positive response:
– rapid cycling patients (females>males)
– comorbid substance issues
– mixed patients
– Patients with comorbid anxiety disorders
• Better tolerated than Lithium
• Before med is started: baseline liver function tests (lfts), pregnancy test and
CBC
• Start folic acid supplement in women
• Monitoring: check 12 hours after last dose and repeat CBC and lfts
• Goal: target level is between 50-125
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 3. Carbamazepine (Tegretol)
First line agent for acute mania and mania prophylaxis
Indicated for rapid cyclers and mixed patients
Before med is started: baseline liver function tests, CBC and an EKG
Monitoring: check 12 hours after last dose and repeat CBC and lfts
Goal: Target levels 4-12mcg/ml
Need to check level and adjust dosing after around a month because induces
own metabolism.
Carbamazepine side effects
Rash- most common SE seen
Nausea, vomiting, diarrhea,
Sedation, dizziness, ataxia, confusion
Aplastic anemia and agranulocytosis
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• Individual anticonvulsant drugs
• Barbiturates: Phenobarbital is a long acting barbiturate and is one of the safest,
most effective, and most widely used anticonvulsant drugs.
• It is most effective in GTCE, temporal lobe and other partial seizures, and
febrile convulsions in children.
• Since phenobarbital has a long half-life, it takes about 2 to 3 weeks to reach
therapeutic serum levels and
• about 3 to 4 weeks to reach a steady state concentration.
• Phenytoin is 2nd effective drug for GTCE and partial seizures.
• Phenytoin is drug of choice, especially in adults.
• The drug may also be used in some cardiac arrhyththmias.

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 Anti-anxiety drugs
• Ant-anxiety agents are psychotropic drugs used to treat and prevent anxiety
and related disorders.
• They are commonly prescribed drugs.
• 1. Benzodiazepines: These are by far the most commonly used drugs for
treatment of situational anxiety and other anxiety disorders.
• Chlordiazepoxide is the prototype of the group, although diazepam (valium)
and others are more frequently prescribed.
• This drug may cause physical and psychological dependence, so that it is
recommended to be prescribed more selectively and for short periods of time.

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• These drugs are highly lipid-soluble, widely distributed in body tissues, and
extensively bound to plasma proteins.
• They are well absorbed with oral administration.
• Chlordiazepoxide, diazepam, and lorazepam are available for parenteral use.
• When given IM, chlordiazepoxide, and diazepam are usually painful, erratically
absorbed, and produce lower serum levels.
• lorazepam is well absorbed with intramuscular use.
• Diazepam is often given intravenously.
• Mechanisms of action
• The benzodiazepines are thought to decrease anxiety by binding with
benzodiazepines receptors in the brain and there by increasing the effects of
GABA)
• GABA is an inhibitory neurotransmitter.
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• An increase in GABA activity results in decreased ability of excitatory
neurotransmitters to stimulate nerve impasses.
• Indications for use
• Major clinical uses of the benzodiazepines are as anti-anxiety, hypnotic, and
anticonvulsant agents.
• They are also used for preoperative sedation, sedation before or during invasive
diagnostic tests such as endoscopy, and angiography, and prevention of
agitation and delirium tremens in acute alcohol with drawl.
• Diazepam has been extensively studied and has more approved use than
others.
• Contraindications for use
• Contraindications include severe respiratory disorders, severe liver or kidney
disease, hyper sensitivity reactions, and a history of drug abuse.
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• Non benzodiazepine antianxiety agents
• Busprone is interacts with serotonin and dopamine receptors in the
brain.
• Compared to other anti-anxiety drugs, buspirone causes less
sedation and does not apparently increase the CNS depression of
alcohol and other drugs.
• It is only indicated in short-term treatment of anxiety.
• It is metabolized by the liver to inactive metabolites, which are then
excreted in the urine and feces.
• Meprobamets is used as a muscle relaxant, but its effectiveness for
that purpose is questionable.
• Drug tolerance, abuse, dependence and withdrawal symptoms occur
with long term use.
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 THE END!!!
QUESTIONS?

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