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299.10 Childhood Disintegrative Disorder



Diagnostic Features


The essential feature of Childhood Disintegrative Disorder is a marked regression in multiple areas of functioning following a period of at least 2 years of apparently normal development. Apparently normal development is reflected in age-appropriate verbal and nonverbal communication, social relationships, play, and adaptive behavior. After the first 2 years of life (but before age 10 years), the child has a clinically significant loss of previously acquired skills in at least two of the following areas: expressive or receptive language, social skills or adaptive behavior, bowel or bladder control, play, or motor skills. Individuals with this disorder exhibit the social and communicative deficits and behavioral features generally observed in Autistic Disorder. There is qualitative impairment in social interaction and in communication, and restricted, repetitive, and stereotyped patterns of behavior, interests, and activities. The disturbance is not better accounted for by another specific Pervasive Developmental Disorder or by Schizophrenia. This condition has also been termed Heller's syndrome, dementia infantilis, or disintegrative psychosis.



Associated Features and Disorders

Childhood Disintegrative Disorder is usually associated with Severe Mental Retardation, which, if present, should be coded on Axis II. Various nonspecific neurological symptoms or signs may be noted. There seems to be an increased frequency of EEG abnormalities and seizure disorder. Although it appears likely that the condition is the result of some insult to the developing central nervous system, no precise mechanism has been identified. The condition is occasionally observed in association with a general medical condition (e.g., metachromatic leukodystrophy, Schilder's disease) that might account for the developmental regression. In most instances, however, extensive investigation does not reveal such a condition. If a neurological or other general medical condition is associated with the disorder, it should be recorded on Axis III. The laboratory findings will reflect any associated general medical conditions.





Prevalence

Epidemiological data are limited, but Childhood Disintegrative Disorder appears to be, very rare and much less common than Autistic Disorder. Although initial studies suggested an equal sex ratio, the most recent data suggest that the condition is common among males.



Course

By definition, Childhood Disintegrative Disorder can only be diagnosed if the symptoms are preceded by at least 2 years of normal development and the onset is prior to age 10 years. When the period of normal development has been quite prolonged (5 or more years), it is particularly important to conduct a thorough physical and neurological examination to assess for the presence of a general medical condition. In most cases, the onset is between ages 3 and 4 years and may be insidious or abrupt. Premonitory signs can include increased activity levels, irritability, and anxiety followed by a loss of speech and other skills. Usually the loss of skills reaches a plateau, after which some limited improvement may occur, although improvement is rarely marked. In other instances, especially when the disorder is associated with a progressive neurological condition, the loss of skills is progressive. This disorder follows a continuous course and in the majority of cases, the duration is lifelong. The social, communicative, and behavioral difficulties remain relatively constant throughout life.



Differential Diagnosis

Periods of regression may be observed in normal development, but these are neither as severe or as prolonged as in Childhood Disintegrative Disorder. Childhood Disintegrative Disorder must be differentiated from other Pervasive Developmental Disorders. For the differential diagnosis with Autistic Disorder. In contrast to Asperger's Disorder, Childhood Disintegrative Disorder is characterized by a clinically significant loss in previously acquired skills and a greater likelihood of Mental Retardation. In Asperger's Disorder, there is no delay in language development and no marked loss of developmental skills.

Childhood Disintegrative Disorder must be differentiated from a dementia with onset during infancy or childhood. Dementia occurs as a consequence of the direct physiological effects of a general medical condition (e.g., head trauma), whereas Childhood Disintegrative Disorder typically occurs in the absence of an associated general medical condition.









299.80 Pervasive Developmental Disorder

Not Otherwise Specified (including Atypical Autism)




This category should be used when there is a severe and pervasive impairment in the development of reciprocal social interaction, verbal and nonverbal communication skills, or the development of stereotyped behaviour, interests and activities, but the criteria are not met for a specific Pervasive Developmental Disorder, Schizophrenia, Schizotypal Personality Disorder, or Avoidant Personality Disorder. Examples include:



(1) Atypical autism: cases that do not meet the criteria for Autistic Disorder because of late age onset, atypical symptomatology, or subthreshold symptomatology, or all of these.


(2) Aspergerís disorder: gross and sustained impairment in social interaction and restricted, repetitive and stereotyped patterns of behaviour, interests and activities, occurring in the context of preserved cognitive and language development.



Rett syndrome




Rett Syndrome (RS) is a neurological disorder seen almost exclusively in females, and found in a variety of racial and ethnic groups worldwide. First described by Dr. Andreas Rett, RS received worldwide recognition following a paper by Dr. Bengt Hagberg and colleagues in 1983.

The child with RS usually shows an early period of apparently normal or near normal development until 6-18 months of life. A period of temporary stagnation or regression follows during which the child loses communication skills and purposeful use of the hands. Soon, stereotyped hand movements, gait disturbances, and slowing of the rate of head growth become apparent. Other problems may include seizures and disorganized breathing patterns which occur when awake. Apraxia (dyspraxia), the inability to program the body to perform motor movements, is the most fundamental and severely handicapping aspect of RS. It can interfere with every body movement, including eye gaze and speech, making it difficult for the girl with RS to do what she wants to do. Due to apraxia and lack of verbal communication skills, an accurate assessment of intelligence is difficult. Most traditional testing methods require use of the hands and/or speech, which may be impossible for the girl with RS.

RS is most often misdiagnosed as autism, cerebral palsy or non-specific developmental delay. While many health professionals may not be familiar with RS, it is a relatively frequent cause of neurological dysfunction in females. The prevalence rate in various countries is from 1:10,000 to 1:23,000 live female births. Most researchers now agree that RS is a developmental disorder rather than a progressive, degenerative disorder as once thought. While there is strong evidence of a genetic basis, the origin and cause of RS remain unknown. Barring illness or complications, survival into adulthood is expected.










DIAGNOSTIC CRITERIA






Required for the recognition of Rett syndrome after the exclusion of other handicapping conditions

* Period of apparently normal development until between 6-18 months

* Normal head circumference at birth followed by slowing of the rate of head growth with age (3 mos-4 yrs)

* Severely impaired expressive language and loss of purposeful hand skills, which combine to make assessment of receptive language and intelligence difficult

* Repetitive hand movements including one or more of the following: hand washing, hand wringing, hand clapping, hand mouthing, which can become almost constant while awake

* Shakiness of the torso, which may also involve the limbs, particularly when upset or agitated

* If able to walk, unsteady, wide-based, stiff-legged gait/toe-walking






SUPPORTIVE CRITERIA



Symptoms not required for the diagnosis, but which also may be seen. These features may not be observed in the young girl but may evolve with age.


* Breathing dysfunctions which include breath holding or apnea, hyperventilation and air swallowing which may result in abdominal bloating and distention

* EEG abnormalities -- slowing of normal electrical patterns, the appearance of epileptiform patterns and loss of normal sleep characteristics

* Seizures

* Muscle rigidity/spasticity/joint contractures which increase with age

* Scoliosis (curvature of the spine)

* Teeth grinding (bruxism)

* Small feet ( in relationship to stature)

* Growth retardation

* Decreased body fat and muscle mass (but tendency toward obesity in some adults)

* Abnormal sleep patterns and irritability or agitation

* Chewing and/or swallowing difficulties

* Poor circulation of the lower extremities, cold and bluish-red feet and legs

* Decreased mobility with age
* Constipation






All girls and women with RS do not display all of these symptoms, and individual symptoms may vary in severity. A pediatric neurologist or developmental pediatrician should be consulted to confirm the clinical diagnosis.
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Last edited by gabriela; 08-13-04 at 10:12 AM..
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what are the disorders that make up the autism spectrum disorders group?

Technically, The Autism Spectrum Disorders include
  • Asperger syndrome
  • Autism
  • Childhood disentegrative Disorder
  • Pervasive Developmental Disorder - Not Otherwise Specified
  • Rett Syndrome
Asperger syndrome


From DSM IV (p77):





Diagnostic Criteria FOR 299.80 Asperger's Disorder



A. Qualitative impairment in social interaction, as manifested by at least two of the following:
  1. marked impairments in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction
  2. failure to develop peer relationships appropriate to developmental level
  3. a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g. by a lack of showing, bringing, or pointing out objects of interest to other people)
  4. lack of social or emotional reciprocity
B. Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following:
  1. encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus
  2. apparently inflexible adherence to specific, nonfunctional routines or rituals
  3. stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements)
  4. persistent preoccupation with parts of objects
C. The disturbance causes clinically significant impairments in social, occupational, or other important areas of functioning

D. There is no clinically significant general delay in language (e.g., single words used by age 2 years, communicative phrases used by age 3 years)

E. There is no clinically significant delay in cognitive development or in the development of age-appropriate self-help skills, adaptive behavior (other than social interaction), and curiosity about the environment in childhood

F. Criteria are not met for another specific Pervasive Developmental Disorder or Schizophrenia







GILLBERG'S CRITERIA FOR ASPERGER'S DISORDER



  1. Severe impairment in reciprocal social interaction
  1. (at least two of the following)
    • (a) inability to interact with peers
    • (b) lack of desire to interact with peers
    • (c) lack of appreciation of social cues
    • (d) socially and emotionally inappropriate behavior

  2. All-absorbing narrow interest


    (at least one of the following)
    • (a) exclusion of other activities
    • (b) repetitive adherence
    • (c) more rote than meaning

  3. Imposition of routines and interests


    (at least one of the following)
    • (a) on self, in aspects of life
    • (b) on others

  4. Speech and language problems


    (at least three of the following)
    • (a) delayed development
    • (b) superficially perfect expressive language
    • (c) formal, pedantic language
    • (d) odd prosody, peculiar voice characteristics
    • (e) impairment of comprehension including misinterpretations of literal/implied meanings

  5. Non-verbal communication problems


    (at least one of the following)
    • (a) limited use of gestures
    • (b) clumsy/gauche body language
    • (c) limited facial expression
    • (d) inappropriate expression
    • (e) peculiar, stiff gaze

  6. Motor clumsiness: poor performance on neurodevelopmental examination



(All six criteria must be met for confirmation of diagnosis.)









A More Down-to-Earth Description by Lois Freisleben-Cook.



NOTE: (This was originally a post to the bit.listserv.autism newsgroup/listserv)

I saw that someone posted the DSM IV criteria for Asperger's but I thought it might be good to provide a more down to earth description. Asperger's Syndrome is a term used when a child or adult has some features of autism but may not have the full blown clinical picture. There is some disagreement about where it fits in the PDD spectrum. A few people with Asperger's syndrome are very successful and until recently were not diagnosed with anything but were seen as brilliant, eccentric, absent minded, socially inept, and a little awkward physically.

Although the criteria state no significant delay in the development of language milestones, what you might see is a "different" way of using language. A child may have a wonderful vocabulary and even demonstrate hyperlexia but not truly understand the nuances of language and have difficulty with language pragmatics. Social pragmatics also tend be weak, leading the person to appear to be walking to the beat of a "different drum". Motor dyspraxia can be reflected in a tendency to be clumsy.

In social interaction, many people with Asperger's syndrome demonstrate gaze avoidance and may actually turn away at the same moment as greeting another. The children I have known do desire interaction with others but have trouble knowing how to make it work. They are, however, able to learn social skills much like you or I would learn to play the piano.

There is a general impression that Asperger's syndrome carries with it superior intelligence and a tendency to become very interested in and preoccupied with a particular subject. Often this preoccupation leads to a specific career at which the adult is very successful. At younger ages, one might see the child being a bit more rigid and apprehensive about changes or about adhering to routines. This can lead to a consideration of OCD but it is not the same phenomenon.

Many of the weaknesses can be remediated with specific types of therapy aimed at teaching social and pragmatic skills. Anxiety leading to significant rigidity can be also treated medically. Although it is harder, adults with Asperger's can have relationships, families, happy and productive lives.

Dr. Lois Freisleben-Cook








*
"Asperger's Syndrome Characteristics"







by Roger Meyer







Below is a list of Aspergerís Syndrome characteristics. Most have been extracted from medical diagnostic criteria, descriptions offered by medical and counseling professionals, articles by educators and from employment biographies of approximately a dozen independent-living, medically or self-diagnosed AS adults over the age of 25. While every adult occasionally manifests these characteristics, what distinguishes adults with AS is their consistency of appearance, their intensity, and the sheer number of them appearing simultaneously. Some characteristics do not apply to everyone, so persons consulting this list should not feel compelled to find them all. Adults with AS who wish to compose employment biographies for their own enlightenment and/or as contributions to research should weigh the significance of the ones they share, and have their compositions accurately reflect that impact.






Social Characteristics
  • Difficulty in accepting criticism or correction
  • Difficulty in offering correction or criticism without appearing harsh, pedantic or insensitive
  • Difficulty in perceiving and applying unwritten social rules or protocols
  • "Immature" manners
  • Failure to distinguish between private and public personal care habits: i.e., brushing, public attention to skin problems, nose picking, teeth picking, ear canal cleaning, clothing arrangement
  • NaÔve trust in others
  • Shyness
  • Low or no conversational participation in group meetings or conferences
  • Constant anxiety about performance and acceptance, despite recognition and commendation
  • Scrupulous honesty, often expressed in an apparently disarming or inappropriate manner or setting
  • Bluntness in emotional expression
  • "Flat affect"
  • Discomfort manipulating or "playing games" with others
  • Unmodulated reaction in being manipulated, patronized, or "handled" by others
  • Low to medium level of paranoia
  • Low to no apparent sense of humor; bizarre sense of humor (often stemming from a "private" internal thread of humor being inserted in public conversation without preparation or warming others up to the reason for the "punchline")
  • Difficulty with reciprocal displays of pleasantries and greetings
  • Problems expressing empathy or comfort to/with others: sadness, condolence, congratulations, etc.
  • Pouting,, ruminating, fixating on bad experiences with people or events for an inordinate length of time
  • Difficulty with adopting a social mask to obscure real feelings, moods, reactions
  • Using social masks inappropriately (you are "xv" while everyone else is ????)
  • Abrupt and strong expression of likes and dislikes
  • Rigid adherence to rules and social conventions where flexibility is desirable
  • Apparent absence of relaxation, recreational, or "time out" activities
  • "Serious" all the time
  • Known for single-mindedness
  • Flash temper
  • Tantrums
  • Excessive talk
  • Difficulty in forming friendships and intimate relationships; difficulty in distinguishing between acquaintance and friendship
  • Social isolation and intense concern for privacy
  • Limited clothing preference; discomfort with formal attire or uniforms
  • Preference for bland or bare environments in living arrangements
  • Difficulty judging othersí personal space
  • Limited by intensely pursued interests
  • Often perceived as "being in their own world"
Physical Manifestations
  • Strong sensory sensitivities: touch and tactile sensations, sounds, lighting and colors, odors, taste
  • Clumsiness
  • Balance difficulties
  • Difficulty in judging distances, height, depth
  • Difficulty in recognizing othersí faces (prosopagnosia)
  • Stims (self-stimulatory behavior serving to reduce anxiety, stress, or to express pleasure)
  • Self-injurious or disfiguring behaviors
  • Nail-biting
  • Unusual gait, stance, posture
  • Gross or fine motor coordination problems
  • Low apparent sexual interest
  • Depression
  • Anxiety
  • Sleep difficulties
  • Verbosity
  • Difficulty expressing anger (excessive or "bottled up")
  • Flat or monotone vocal expression; limited range of inflection
  • Difficulty with initiating or maintaining eye contact
  • Elevated voice volume during periods of stress and frustration
  • Strong food preferences and aversions
  • Unusual and rigidly adhered to eating behaviors
  • Bad or unusual personal hygiene
Morbid (shared, dual, multiple) Diagnostic Conditions
  • Learning Disability
  • Attention Deficit Disorder (ADD)
  • Obsessive Compulsive Disorder (OCD)
  • Central Auditory Processing Disorder (CAPD)
  • Hyperlexia
  • Depression
  • Anxiety
  • Non-verbal Learning Disorder (NVLD)
  • Hypertension
  • Semantic Pragmatic Language Disorder
  • Touretteís Syndrome
  • Dysthymia
Cognitive Characteristics
  • Susceptibility to distraction
  • Difficulty in expressing emotions
  • Resistance to or failure to respond to talk therapy
  • Mental shutdown response to conflicting demands and multi-tasking
  • Generalized confusion during periods of stress
  • Low understanding of the reciprocal rules of conversation: interrupting, dominating, minimum participation, difficult in shifting topics, problem with initiating or terminating conversation, subject perseveration
  • Insensitivity to the non-verbal cues of others (stance, posture, facial expressions)
  • Perseveration best characterized by the term "bulldog tenacity"
  • Literal interpretation of instructions (failure to read between the lines)
  • Interpreting words and phrases literally (problem with colloquialisms, cliches, neologism, turns of phrase, common humorous expressions)
  • Preference for visually oriented instruction and training
  • Dependence on step-by-step learning procedures (disorientation occurs when a step is assumed, deleted, or otherwise overlooked in instruction)
  • Difficulty in generalizing
  • Preference for repetitive, often simple routines
  • Difficulty in understanding rules for games of social entertainment
  • Missing or misconstruing othersí agendas, priorities, preferences
  • Impulsiveness
  • Compelling need to finish one task completely before starting another
  • Rigid adherence to rules and routines
  • Difficulty in interpreting meaning to othersí activities; difficulty in drawing relationships between an activity or event and ideas
  • Exquisite attention to detail, principally visual, or details which can be visualized ("Thinking in Pictures") or cognitive details (often those learned by rote)
  • Concrete thinking
  • Distractibility due to focus on external or internal sensations, thoughts, and/or sensory input (appearing to be in a world of oneís own or day-dreaming)
  • Difficulty in assessing relative importance of details (an aspect o the trees/forest problem)
  • Poor judgment of when a task is finished (often attributable to perfectionism or an apparent unwillingness to follow differential standards for quality)
  • Difficulty in imagining othersí thoughts in a similar or identical event or circumstance that are different from oneís own ("Theory of Mind" issues)
  • Difficulty with organizing and sequencing (planning and execution; successful performance of tasks in a logical, functional order)
  • Difficulty in assessing cause and effect relationships (behaviors and consequences)
  • An apparent lack of "common sense"
  • Relaxation techniques and developing recreational "release" interest may require formal instruction
  • Rage, tantrum, shutdown, self-isolating reactions appearing "out of nowhere"
  • Substantial hidden self-anger, anger towards others, and resentment
  • Difficulty in estimating time to complete tasks
  • Difficulty in learning self-monitoring techniques
  • Disinclination to produce expected results in an orthodox manner
  • Psychometric testing shows great deviance between verbal and performance results
  • Extreme reaction to changes in routine, surroundings, people
  • Stilted, pedantic conversational style ("The Professor")
Work Characteristics

Many of the manifestations found in the categories above can immediately translate into work behaviors or preferences. Here are some additional ones:
  • Difficulty with "teamwork"
  • Deliberate withholding of peak performance due to belief that oneís best efforts may remain unrecognized, unrewarded, or appropriated by others
  • Intense pride in expertise or performance, often perceived by others as "flouting behavior"
  • Sarcasm, negativism, criticism
  • Difficulty in accepting compliments, often responding with quizzical or self-deprecatory language
  • Tendency to "lose it" during sensory overload, multitask demands, or when contradictory and confusing priorities have been set
  • Difficult in starting project
  • Discomfort with competition, out of scale reactions to losing
  • Low motivation to perform tasks of no immediate personal interest
  • Oversight or forgetting of tasks without formal reminders such as lists or schedules
  • Great concern about order and appearance of personal work area
  • Slow performance
  • Perfectionism
  • Difficult with unstructured time
  • Reluctance to ask for help or seek comfort
  • Excessive questions
  • Low sensitivity to risks in the environment to self and/or others
  • Difficulty with writing and reports
  • Reliance on internal speech process to "talk" oneself through a task or procedure
  • Stress, frustration and anger reaction to interruptions
  • Difficulty in negotiating either in conflict situations or as a self-advocate
  • Ver low level of assertiveness
  • Reluctance to accept positions of authority or supervision
  • Strong desire to coach or mentor newcomers
  • Difficulty in handling relationships with authority figures
  • Often viewed as vulnerable or less able to resist harassment and badgering by others
  • Punctual and conscientious
  • Avoids socializing, "hanging out," or small talk on and off the job

DSM-4 Criteria for Autistic Disorder and Pervasive Developmental Disorder, Not Otherwise Specified (PDD NOS)

To be diagnosed with autistic disorder at least one sign (each) from parts A, B, and C must be present plus at least six overall. Those meeting fewer criteria are diagnosable as PDD NOS.



A. Qualitative impairments in reciprocal social interaction:
  1. Marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body posture, and gestures to regulate social interaction.
  2. Failure to develop peer relationships appropriate to developmental level
  3. Lack of spontaneous seeking to share enjoyment, interests, or achievements with others.
  4. Lack of socioemotional reciprocity.
B. Qualitative impairments in communication:
  1. A delay in, or total lack of the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime).
  2. Marked impairment in the ability to initiate or sustain a conversation with others despite adequate speech.
  3. Stereotyped and repetitive use of language or idiosyncratic language.
  4. Lack of varied spontaneous make- believe play or social imitative play appropriate to developmental level.
C. Restricted, repetitive, and stereotyped patterns of behavior, interest, or activity:
  1. Encompassing preoccupation with one or more stereotyped and restricted patterns of interest, abnormal either in intensity or focus.
  2. An apparently compulsive adherence to specific nonfunctional routines or rituals.
  3. Stereotyped and repetitive motor mannerisms (e.g. hand or finger flapping, or twisting, or complex whole body movements).
  4. Persistent preoccupation with parts of objects.
Abnormal or impaired development prior to age three manifested by delay or abnormal functioning in at least one of the following areas: (1) social interaction, (2) language as used in social communication, or (3) symbolic or imaginative play.






Autism is the common term for a range of disabilities medically classified as Pervasive Developmental Disorders (PDD). Autism/PDD is characterized by qualitative differences in the development of cognitive, language, social or motor skills, and these are usually apparent before age three. Research evidence suggests that autism may result from an underlying difficulty with expressive movement and its regulation, severely challenging the individual to keep body movements, including sensory responses, in control. These sensorimotor problems can make it difficult to respond consistently and productively to other individuals and to the environment.

Autism/PDD occurs in approximately fifteen out of every 10,000 births and is four times more common among males than females. It is found throughout the world in families of all racial, ethnic and social backgrounds. While autism was once erroneously believed to arise from stresses in a child's psychological environment, modern medical evidence suggests that irregularities in the development of the brain and central nervous system give rise to the syndrome of autism. Causes of this development are diverse and may include chemical exposure, viral and genetic factors.

Autism/PDD is not an illness or a "thing" a person "has." It is a collection of responses which must be viewed in context, and observation is always more productive than labeling. Across the wide spectrum of the autism/PDD syndrome, individual variations on several key features can be recognized. Reciprocal social interactions, both verbal and nonverbal, are unusual in quality and generally difficult to synchronize and to carry out. Impairments of the central nervous system typically result in over-reactions, under-reactions, or inconsistent responses to various sensory stimuli. Because sensory input is difficult to organize and control, the individual's activities and interests may appear restricted in their nature and repertoire, frequently involving significant repetition and a need for predictability rather than change. It is important to view the behavior of people with autism/PDD as meaningful adaptations and to take a positive, respectful approach to them, forgoing the common tendency to judge their competence and capacity on the basis of their sensorimotor challenges.











Diagnostic Criteria for 299.10 Childhood Disintegrative Disorder

A. Apparently normal development for at least the first 2 years after birth as manifested by the presence of age-appropriate verbal and nonverbal communication, social relationships, play, and adaptive behavior.

B. Clinically significant loss of previously acquired skills (before age 10 years) in at least two of the following areas:
      1. expressive or receptive language
      2. social skills or adaptive behavior
      3. bowel or bladder control
      4. play
      5. motor skills
C. Abnormalities of functioning in at least two of the following areas:
      1. qualitative impairment in social interaction (e.g., impairment in nonverbal behaviors, failure to develop peer relationships, lack of social or emotional reciprocity)
      2. qualitative impairments in communication (e.g., delay or lack of spoken language, inability to initiate or sustain a conversation, stereotyped and repetitive use of language, lack of varied make believe play)
      3. restricted, repetitive, and stereotyped patterns of behavior, interests, and activities, including motor stereotypies and mannerisms
D. The disturbance is not better accounted for by another specific Pervasive Developmental Disorder or by Schizophrenia.




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