Common Neurological Problems of Childhood By Lisa Glickstein, Ph.D, Triplet Mom Originally printed in August, 2005 Premature infants have a higher than average risk of developing a number of disorders of the brain, including pervasive developmental delay (PDD) spectrum disorders, sensory integrative dysfunction, attention-deficit hyperactivity disorder (ADHD), and nonverbal learning disability. Each of these diseases has a genetic component, and likely an environmental component as well. Although they are very different disorders, there is a considerable overlap in symptoms. For example, sensory integrative dysfunction is a common feature of PDD disorders and nonverbal learning disability. In fact, there seems to be some crossover in symptoms between nonverbal learning disability and Asperger's syndrome, one of the PDD disorders. In addition, it can sometimes be difficult, particularly in less severe cases, to determine if a child has ADHD, inattention due to discomfort from sensory integrative dysfunction, or nonverbal learning disability. This overlap suggests that all of these disorders may be related in some way or ways. Ultimately, this may lead researchers to better understanding of the underlying causes, as well as treatment options. In the meantime, there is no laboratory test for any of these disorders, and all are therefore diagnosed by clinical observation and exclusion. Pervasive Developmental Disorders (PDD) Most people have an idea of what autism is. They may have met a severely autistic child, or seen the movie, Rain Man, for example. What they think of therefore when they hear about autism is only the most severe manifestation of a related group of illnesses, termed pervasive developmental disorders (PDD). The other most common manifestation is called Asperger's syndrome. The dominant clinical feature of these disorders is lack of normal social interaction, which may be mild or quite severe. Other symptoms often include repetitive behaviors and speech patterns, some of which may be self-destructive (head-banging), obsessive focus on an object or objects, and behavioral problems including tantrums and hyperactivity. Autism and Asperger's syndrome differ primarily in that only the former is usually characterized by speech or language delay (or absence). Possibly because of this, individuals with autism may test as having a low IQ, while individuals with Asperger's syndrome often have normal or even very high IQ. Although not delayed, individuals with Asperger's may have some of the speech patterning (repetitive or echoed speech) seen in autism. Importantly, both of these are spectrum disorders, and individuals may be severely or only mildly affected in only one or in all of these areas. Therefore, autistic children may, for example, show affection, make eye contact, or be social, to varying degrees. Particularly among children with mild or high-functioning autism, a differential diagnosis with ADHD (if behavior and activity are the affected areas) or sensory integrative dysfunction can be difficult to make. Even with a correct diagnosis of autism, there is now some evidence that treating the frequent underlying sensory issues can alleviate some of the previously thought to be typical autistic behaviors, like head-banging or withdrawal. The remaining several disorders in the PDD group are much more rare, and interestingly, more clearly due to brain injury or catastrophic collapse of an area of brain function. This suggests that some type of brain injury may lead to autism and Asperger's syndrome, as well, and perhaps explains the increased incidence among prematurely born children who frequently suffer from brain injury at or near birth. Brain inflammation or illness may lead to the onset of symptoms, but importantly, there is no evidence that vaccination in general, or the MMR vaccine in particular, causes autism. In other words, while it may be that the onset of autism is triggered in some children following vaccination (even though this has never been proven to occur), it is likely that if the child was not vaccinated, the onset would have been triggered at another time by an infection. There is also a genetic component, well documented in identical-twin studies. Asperger's syndrome is often accompanied by excellence in math and science ability, and is therefore more common among children of scientists, mathematicians, and engineers. Attention-Deficit Hyperactivity Disorder ADHD was the first of the high-functioning learning disabilities to be identified and treated. It is now clear that some children previously diagnosed with ADHD probably have another, less recognized, learning disability. Children may have a variant of ADHD that primarily affects activity, or primarily affects attention. Children are usually socially and verbally within normal limits. However, social interactions may be affected in cases where behavior is severely disordered. In order to receive the diagnosis, children should exhibit the symptoms both at home and away from home (at school, sports, church). Most children with a correct diagnosis will respond to treatment, which is behavioral as well as medical. Children who do not respond, particularly those with a strong sensory, verbal, or social component, should be considered for another diagnosis. There are some children who are misdiagnosed with ADHD who rather have bipolar disorder, a much more serious illness in which the manic phases can lead to ADHD type symptoms. As children get older, testing can be more sophisticated, and follow-up is important to obtain the best diagnosis and the most up-to-date treatment recommendations. Sensory Integrative Dysfunction We integrate, or put together, input from our various senses to make sense of the world. We see the sun and feel its warmth, for example. For some children, the mechanisms for putting together this information are not working. They find the stimuli from the senses overwhelming. As with all of these disorders, the problem may be mild and the child labeled picky, or the problem may be severe and the child plagued with tantrums, withdrawal, hyperactivity, or other manifestations. Therefore, the primary problem with children with social integrative dysfunction is not social or verbal as in autism, but severely affected children may exhibit secondary problems or delays in these areas. Recognition that many disorders, including ADHD and autism, involve sensory integrative dysfunction symptoms may help tremendously in developing behavioral therapies to alleviate some of their symptoms. Treatment usually involves some sensory withdrawal, to a level of input that the child can tolerate, and then gradually increasing the sensory input in a controlled and ordered way as the child learns to integrate it. If you feel your child has issues with sensory integration, be aware of the amount of television or video games (for older children). Both of these are highly visually and aurally stimulating. Adjusting clothes for comfort, particularly school clothes or uniforms, can help children deal with school. Seating children near the board at school, or sending the child out of the classroom for part of the day for small-group reading, are similarly helpful adjustments that can help learning. Giving a child his or her own bedroom if possible, or quiet space (a small tent in the corner of a little-used room) to spend time quietly may be helpful in a home with lots of children and stimulation. Acknowledging that new experiences will take some getting used to, and possibly accommodation, can be an important first step. Food is another common issue in children with sensory integrative dysfunction. Textures and tastes may be a problem. Once children pass infancy, and adjust to solid food, a healthy diet can usually be achieved even without a tremendous amount of variety. Work with your pediatrician and a nutritionist if necessary. Nonverbal Learning Disability In this learning disability, children have normal or even above average verbal ability. Therefore, their disability is nonverbal. (As an aside, it is easy to confuse this terminology with autism, in which children may not speak and be nonverbal). In other respects, nonverbal learning disability can resemble high-functioning autism or Asperger's syndrome, in that affected children can have similar motor, social or sensory issues. In fact, nonverbal learning disability could almost be seen as a variant of autism much like Asperger's syndrome, in which the verbal ability is present. In the case of this disorder, the spatial ability that children with Asperger's syndrome possess is absent or lacking, as are the autistic speech patterns. Children with nonverbal learning disability may have poor executive functioning, a term that refers to ability to make decisions, control impulses, and plan and problem-solve, among other related behaviors and abilities. Thus there may be considerable overlap with some of the impulsive behaviors seen in some children with ADHD. And as in autism, it is possible that some of the manifested symptoms are actually caused by sensory integration dysfunction. The nonverbal learning disability manifests both in problem behavior and difficulty learning at school. Writing and drawing ability may be particularly affected. Children with this disability usually can learn well by listening, but may have trouble learning to read. Intelligence is generally within normal limits (as in Asperger's syndrome, it may even be above average), and children can often do well with some accommodations at school. Similar behavioral modifications and therapies used for impulsive behaviors in children with ADHD, and learning to interact socially as in autism or Asperger's syndrome, have been applied to children with nonverbal learning disability. As one of the newer diagnoses, fewer medical therapies and conclusive research studies are currently available. As with all of these disorders, working with the underlying sensory issues, if present, can mitigate some of the symptoms. Final thoughts Children who are severely affected by autism may afford the most straightforward diagnosis. For the rest, diagnosis is by prevailing symptoms, response to therapy, and doctor and parent preference. The last is important, as doctors may prefer a diagnosis that they are familiar with or biased towards, while parents may strongly advocate for a therapy that they perceive is less socially stigmatizing. For the child, diagnosis is important but a correct diagnosis is less important than early or prompt initiation of therapy according to symptoms and open-mindedness about changing diagnosis and optimizing therapy. Sensory issues are a common denominator among many of these disorders and while probably not causal, can lead to many of the behavioral symptoms especially if left untreated. Finally and most importantly, most children with these disorders generally have normal or even above average IQ and can lead largely normal lives, especially with early diagnosis and intervention.