11.2 W1 3.常見兒童發展障礙的診斷準則(E3-2041) Presentation/Day 2-1/Workshop 1-3.pdf ·...

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Dr.LeePui IConsultantPediatrician

PediatricandNeonatologydepartmentCHCSJ,Macau2/11/2014

Diagnosticcriteriaforcommondevelopmentalproblemof

children DSM5

DSM5 TheDiagnosticandStatisticalManualofMentalDisordersDSM

HistoryofDSM DSMI1952,60

DSMII1968, DSMIII1980 DSMIIIR1987 DSMIV1994297

DSMIVDSMIVTR2000

2013518DSMV

DSM5 (DSM5)1999(SteveHyman(StevenM.MirinDavidJ.Kupfer (NIMH)

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RevisionofDiseaseRelativetoChildren 20072

20082

5CharacteristicsofDSM5 5DSM52013518(APA)

:

DSM5(Spectrum)

DSM5Mainchangesofthediagnosiscriteria DSM5ABCDEbereavementgamblingdisorder

DSM5 Neurodevelopmental Disorders IntellectualDisabilities

IntellectualDisability(IntellectualDevelopmentalDisorder)

GlobalDevelopmentalDelay UnspecifiedIntellectualDisability

(IntellectualDevelopmentalDisorder)

CommunicationDisorders LanguageDisorder SpeechSoundDisorder(previously

PhonologicalDisorder) ChildhoodOnsetFluencyDisorder

(Stuttering) Social(Pragmatic)Communication

Disorder UnspecifiedCommunicationDisorder

AutismSpectrumDisorder AutismSpectrumDisorder

AttentionDeficit/HyperactivityDisorder AttentionDeficit/HyperactivityDisorder OtherSpecifiedAttention

Deficit/HyperactivityDisorder UnspecifiedAttention

Deficit/HyperactivityDisorder

SpecificLearningDisorder SpecificLearningDisorder

MotorDisorders DevelopmentalCoordinationDisorder StereotypicMovementDisorder TicDisorders Tourettes Disorder Persistent(Chronic)MotororVocalTic

Disorder ProvisionalTicDisorder OtherSpecifiedTicDisorder UnspecifiedTicDisorder

OtherNeurodevelopmental Disorders OtherSpecifiedNeurodevelopmental

Disorder UnspecifiedNeurodevelopmental

Disorder

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IntellectualDisabilities IntellectualDisability(IntellectualDevelopmentalDisorder) GlobalDevelopmentalDelay UnspecifiedIntellectualDisability(IntellectualDevelopmentalDisorder)

CommunicationDisorders LanguageDisorder SpeechSoundDisorder(previouslyPhonologicalDisorder))

ChildhoodOnsetFluencyDisorder(Stuttering)

Social(Pragmatic)CommunicationDisorder

UnspecifiedCommunicationDisorde

DSM5 AutismSpectrumDisorder

AutismSpectrumDisorder AttentionDeficit/HyperactivityDisorder/ AttentionDeficit/HyperactivityDisorder/

OtherSpecifiedAttentionDeficit/HyperactivityDisorder/

UnspecifiedAttentionDeficit/HyperactivityDisorder/

SpecificLearningDisorder SpecificLearningDisorder

DSM5 MotorDisorders

DevelopmentalCoordinationDisorder StereotypicMovementDisorder TicDisorders Tourettes Disorder Persistent(Chronic)MotororVocalTicDisorder

ProvisionalTicDisorder OtherSpecifiedTicDisorder

OtherNeurodevelopmental Disorders OtherSpecifiedNeurodevelopmental Disorder UnspecifiedNeurodevelopmental Disorder

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DifferentfromDSM5toDSMIV Neurodevelopmental Disorders MentalRetardationintellectualdisabilityintellectualdevelopmentaldisorder

PhonologicaldisordercommunicationdisordersspeechsounddisorderchildhoodonsetfluencydisorderSocialcommunicationdisorder

Neurodevelopmental Disorders Onsetearlyindevelopment,oftenbeforethechildentersgradeschool

characterization: developmentaldeficits:impairmentsofpersonal,social,academic,oroccupationalfunctioning.

Mentalretardation=intellectualdevelopmentaldisorder =

Neurodevelopmental Disorders IntellectualDisabilities

IntellectualDisability(IntellectualDevelopmentalDisorder) A.Deficitsinintellectualfunctions, B.Deficitsinadaptivefunctioningthatresultinfailuretomeet

developmentalandsociocultural standardsforpersonalindependenceandsocialresponsibility

GlobalDevelopmentalDelay undertheageof5years

UnspecifiedIntellectualDisability(IntellectualDevelopmentalDisorder) overtheageof5yearswhenassessmentofthedegreeofintellectual

disability requiresreassessmentafteraperiodoftime

DiagnosticFeatures A.deficitsingeneralmentalabilities B.impairmentineverydayadaptivefunctioning,incomparisontoanindividualsage,gender,andsocioculturally matchedpeers

C.Onsetisduringthedevelopmentalperiod

Thediagnosisofintellectualdisabilityisbasedonbothclinicalassessmentandstandardizedtestingofintellectualandadaptivefunctions.

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Prevalence Intellectualdisabilityhasanoverallgeneralpopulationprevalenceofapproximately1%,andprevalenceratesvarybyage.

Prevalenceforsevereintellectualdisabilityisapproximately6per1,000

Overall,malesaremorelikelythanfemalestobediagnosedwithbothmild(averagemale:female ratio1.6:1)andsevere(averagemale:female ratio1.2:1)formsofintellectualdisability

Thecommunicationdisorders languagedisorder speechsounddisorder)

childhoodonsetfluencydisorder(stuttering)()

social(pragmatic)communicationdisorder()

Thefirstthreedisordersarecharacterizedbydeficitsinthedevelopmentanduseoflanguage,speech,andsocialcommunication,respectively.

LanguageDisorder Thelanguagedeficitsareevidentinspoken Communication,writtencommunication,orsignlanguage

affectsvocabulary andgrammar

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Diagnosisoflanguagedisorder basedonthesynthesisoftheindividualshistory directclinicalobservationindifferentcontexts(home,school,orwork),

andscoresfromstandardizedtestsoflanguageabilitythatcanbeusedtoguideestimatesofseverity.

CauseofLanguagedisorder Geneticandphysiological Languagedisordersarehighlyheritable,andfamilymembersaremorelikelytohaveahistoryoflanguageimpairment.

Speechsounddisorder DiagnosticCriteria

A.Persistentdifficultywithspeechsoundproductionthatinterfereswithspeechintelligibilityorpreventsverbalcommunicationofmessages.

B.Thedisturbancecauseslimitationsineffectivecommunicationthatinterferewithsocialparticipation,academicachievement,oroccupationalperformance,individuallyorinanycombination.

C.Onsetofsymptomsisintheearlydevelopmentalperiod. D.Thedifficultiesarenotattributabletocongenitaloracquiredconditions,suchascerebralpalsy,cleftpalate,deafnessorhearingloss,traumaticbraininjury,orothermedicalorneurologicalconditions.

Childhoodonsetfluencydisorder A.Disturbancesinthenormalfluencyandtimepatterningofspeech

1.Soundandsyllablerepetitions. 2.Soundprolongationsofconsonantsaswellasvowels. 3.Brokenwords(e.g.,pauseswithinaword). 4.Audibleorsilentblocking(filledorunfilledpausesinspeech). 5.Circumlocutions(wordsubstitutionstoavoidproblematicwords).

6.Wordsproducedwithanexcessofphysicaltension. 7.Monosyllabicwholewordrepetitions(e.g.,IIIIseehim).

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Childhoodonsetfluencydisorder B.Thedisturbancecausesanxietyaboutspeakingorlimitationsineffectivecommunication,socialparticipation,oracademicoroccupationalperformance,individuallyorinanycombination.

C.Theonsetofsymptomsisintheearly D.Thedisturbanceisnotattributabletoaspeechmotororsensorydeficit,dysfluency associatedwithneurologicalinsult

Social(pragmatic)communicationdisorder() Persistentdifficultiesinthesocialuseofverbalandnonverbalcommunication

Social(pragmatic)communicationdisorderischaracterizedbyaprimarydifficultywithpragmatics,orthesocialuseoflanguageandcommunication,asmanifestedbydeficitsinunderstandingandfollowingsocialrulesofverbalandnonverbalcommunicationinnaturalisticcontexts,changinglanguageaccordingtotheneedsofthelistenerorsituation,andfollowingrulesforconversationsandstorytelling.

ASDDifferentinDSM5 (Pervasivedevelopmentaldisorder) (Autismspectrumdisorder,ASD)

(subtype) Asperger's disorder PDD,NOS

DSM5ASDdimensional,FragileXsyndromeRett's disordertuberoussclerosisASDsyndromic ASD

Rett's disorder ChildhoodDisintegrativedisorder

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DiagnosticCriteriaofASD Twocoredomain(From3to2symptomdomains)

DSMIV

A. B. C.

restrictedrepetitivebehavior,interestandactivities()

DiagnosticCriteriaofASD

DSMIV

DSMIV

DSMIV

DiagnosticCriteriaofASD

DSMIV

DSM5ASDASDDSMIV

ASD LevelofASDASD

:

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ASDPrevalence

91 (Kogan MD,etal.,2009;BradstreetJJ,et al.,2010) 41 58ASD

(IntellectualImpairment) 70%70 (LanguageImpairment) 5

X (FragileXSyndrome) (TuberousSclerosis)

Problemafterchange Aspergers syndromePDD

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ADHD impairment,clearevidencethatthesymptomsinterferewith,orreducethequalityof

threshold 175 Onset12(DSMIV:7) ASD

ADHD

ADHDDiagnosticCriteriaDSM5 (1) Inattention 1.

2.

3.

4. ()

5. )

6.

7.

8.

9.

If>17yrs,

ADHDDiagnosticCriteriaDSM5 (2) Hyperactivityandimpulsivity

1.fidgets with or taps hands or feet 2. 3.(adolescentsoradultsmaybelimitedtofeelingrestless)

4. 5. 6.

1. 2. 3.

If >17 yrs,

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ADHDDiagnosticCriteriaDSM5

A.ADHD(1) (2)

B.12C.ADHD()

D.

E.()

ADHDMainchangedinDSM5

(maladaptive)changedto(impactdirectlyon...) (clinicallysignificantimpairment)changedto(interferewithorreducethequalityof...)

Age (1)>17years5ormoreof(inattention)or(hyperactivityandimpulsivity)

(2)12 (subtype)(presentation)

ADHDPrevalence 1798 ():510%2.5% 1025

37ADHD

ADHD ADHDprevalence ADHD

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SpecificLearningDisorder ReadingDisorder,dyslexia MathematicsDisorder,dyscalculia DisorderofWrittenExpression

Change:substantiallybelowexpectednotconsistentwith

SpecificLearningDisorder A.Difficultieslearningandusingacademicskills,asindicatedbythepresenceofatleastoneofthefollowingsymptomsthathavepersistedforatleast6months,despitetheprovisionofinterventionsthattargetthosedifficulties: 1.Inaccurateorslowandeffortfulwordreading 2.Difficultyunderstandingthemeaningofwhatisread 3.Difficultieswithspelling 4.Difficultieswithwrittenexpression 5.Difficultiesmasteringnumbersense,numberfacts,orcalculation 6.Difficultieswithmathematicalreasoning

B.Theaffectedacademicskillsaresubstantiallyandquantifiablybelowthoseexpectedfortheindividualschronologicalage

Withimpairmentinreading Wordreadingaccuracy Readingrateorfluency Readingcomprehension

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Impairmentinwrittenexpression Spellingaccuracy Grammarandpunctuationaccuracy

Clarityororganizationofwrittenexpression

Withimpairmentinmathematics Numbersense Memorizationofarithmeticfacts Accurateorfluentcalculation Accuratemathreasoning

DiagnosticFeatures Specificlearningdisorderisaneurodevelopmentaldisorder withabiologicaloriginthatisthebasisforabnormalitiesatacognitivelevelthatareassociatedwiththebehavioralsignsofthedisorder.

ReasonforSLD Environmental

Prematurityorverylowbirthweightincreasestheriskforspecificlearningdisorder

Geneticandphysiological SLDappearstoaggregateinfamilies 48timesand510times

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DDofSLD Intellectualdisability Learningdifficultiesduetoneurologicalorsensorydisorders

Neurocognitive disorders Attentiondeficit/hyperactivitydisorder Psychoticdisorders

MotorDisorders DevelopmentalCoordinationDisorder StereotypicMovementDisorder TicDisorders

Tourettes Disorder Persistent(Chronic)MotororVocalTicDisorder Withmotorticsonly Withvocalticsonly

ProvisionalTicDisorder otherspecifiedandunspecifiedtic

DevelopmentalCoordinationDisorder DiagnosticCriteria

A.Theacquisitionandexecutionofcoordinatedmotorskillsissubstantiallybelowthatexpectedgiventheindividualschronologicalageandopportunityforskilllearninganduse

B.ThemotorskillsdeficitinCriterionAsignificantlyandpersistentlyinterfereswithactivitiesofdailylivingappropriatetochronologicalage

C.Onsetofsymptomsisintheearlydevelopmentalperiod.

D.Themotorskillsdeficitsarenotbetterexplainedbyintellectualdisability

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DevelopmentalCoordinationDisorder Themanifestationofimpairedskillsrequiringmotorcoordination(CriterionA)varieswithage

Developmentalcoordinationdisorderisdiagnosedonlyiftheimpairmentinmotorskillssignificantlyinterfereswiththeperformanceof,orparticipationin,dailyactivitiesinfamily,social,school,orcommunitylife

DCDprevalence Theprevalenceofdevelopmentalcoordinationdisorderinchildrenages511yearsis5%6%(inchildrenage7years,1.8%arediagnosedwithseveredevelopmentalcoordinationdisorderand3%withprobabledevelopmentalcoordinationdisorder)

M;F2:1and7:1.

Comorbidity Disordersthatcommonlycooccurwithdevelopmentalcoordinationdisorderincludespeechandlanguagedisorder;specific

learningdisorder(especiallyreadingandwriting);problemsofinattention(Kadesj andGillberg 1999),includingADHD(the

mostfrequentcoexistingcondition,withabout50%cooccurrence);autismspectrumdisorder(Lingametal.2010);disruptive

andemotionalbehaviorproblems(Cairney etal.2010);andjointhypermobility syndrome.

DiagnosticCriteria A.Theacquisitionandexecutionofcoordinatedmotorskillsissubstantiallybelowthatexpectedgiventheindividualschronological ageandopportunityforskilllearninganduse.

B.ThemotorskillsdeficitinCriterionAsignificantlyandpersistentlyinterfereswithactivitiesofdailylivingappropriatetochronological age

C.Onsetofsymptomsisintheearlydevelopmentalperiod.

D.Themotorskillsdeficitsarenotbetterexplainedbyintellectualdisability

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StereotypicMovementsPrevalence Simplestereotypicmovements(e.g.,rocking)arecommoninyoungtypicallydevelopingchildren.Complexstereotypic

movementsaremuchlesscommon(occurringinapproximately3%4%).Between4%and16%ofindividualswithintellectual

disability(intellectualdevelopmentaldisorder)engageinstereotypyandselfinjury

StereotypicMovementsPrevalence Simplestereotypicmovementsarecommonininfancyandearlychildhood.Rockingmayoccurinthetransitionfromsleepto

awake,abehaviorthatusuallyresolveswithage.Complexstereotypies arelesscommonintypicallydevelopingchildrenand

canusuallybesuppressedbydistractionorsensorystimulation.Theindividualsdailyroutineisrarelyaffected,andthe

movementsgenerallydonotcausethechilddistress.Thediagnosiswouldnotbeappropriateinthesecircumstances.

TicsDisorders Aticisasudden,rapid,recurrent,nonrhythmic motormovementorvocalization.

TicDisorders Tourettes Disorder Persistent(Chronic)MotororVocalTicDisorder Withmotorticsonly Withvocalticsonly

ProvisionalTicDisorder otherspecifiedandunspecifiedtic

Prevalence Ticsarecommoninchildhoodbuttransientinmostcases.TheestimatedprevalenceofTourettes disorderrangesfrom3to8

per1,000inschoolagechildren.Malesaremorecommonlyaffectedthanfemales,withtheratiovaryingfrom2:1to4:1

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OtherSpecifiedNeurodevelopmentalDisorder Thiscategoryappliestopresentationsinwhichsymptomscharacteristicofaneurodevelopmentaldisorderthatcauseimpairmentinsocial,occupational,orotherimportantareasoffunctioningpredominatebutdonotmeetthefullcriteriaforanyofthedisordersintheneurodevelopmental disordersdiagnosticclass.

Couldbeassociatedwith

UnspecifiedNeurodevelopmentalDisorder Thiscategoryappliestopresentationsinwhichsymptoms

characteristicofaneurodevelopmental disorderthatcauseimpairmentinsocial,occupational,orotherimportantareasoffunctioningpredominatebutdonotmeetthefullcriteriaforanyofthedisordersintheneurodevelopmental disordersdiagnosticclass.

Theunspecifiedneurodevelopmental disordercategoryisusedinsituationsinwhichtheclinicianchoosesnottospecifythereasonthatthecriteriaarenotmetforaspecificneurodevelopmental disorder,andincludespresentationsinwhichthereisinsufficientinformationtomakeamorespecificdiagnosis

QuestionsWhatisthepurposeofchangeinthenewedition?Isthediagnosiscomplete?Afterdiagnosis,howshallwedo?

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