(ppt)

Motor Skills DisorderMotor Skills DisorderCommunication Communication

DisordersDisordersPsy 610APsy 610A

Gary S. Katz, Ph.D.Gary S. Katz, Ph.D.

Developmental Developmental Coordination Disorder Coordination Disorder

(315.4)(315.4)A.A. Performance in daily activities that require motor Performance in daily activities that require motor

coordination is substantially below that expected given coordination is substantially below that expected given the person’s chronological age and measured intelligence. the person’s chronological age and measured intelligence. This may be manifested by marked delays in achieving This may be manifested by marked delays in achieving motor milestones (e.g., walking, crawling, sitting), motor milestones (e.g., walking, crawling, sitting), dropping things, “clumsiness”, poor performance in dropping things, “clumsiness”, poor performance in sports, or poor handwriting.sports, or poor handwriting.

B.B. The disturbance in (A) significantly interferes with The disturbance in (A) significantly interferes with academic achievement or activities of daily living.academic achievement or activities of daily living.

C.C. The disturbance is not due to a general medical condition The disturbance is not due to a general medical condition (e.g., cerebral palsy) and does not meet criteria for a (e.g., cerebral palsy) and does not meet criteria for a Pervasive Developmental Disorder.Pervasive Developmental Disorder.

D.D. If Mental Retardation is present, the motor difficulties are If Mental Retardation is present, the motor difficulties are in excess of those usually associated with it.in excess of those usually associated with it.

Note: If a general medical (e.g., neurological) condition or Note: If a general medical (e.g., neurological) condition or sensory deficit is present, code the condition on Axis III.sensory deficit is present, code the condition on Axis III.


(315.4)(315.4) Manifestations of this disorder may vary by ageManifestations of this disorder may vary by age

Younger children may have difficulty with crawling, Younger children may have difficulty with crawling, walking, zipping pants.walking, zipping pants.

Older children may have trouble with handwriting, Older children may have trouble with handwriting, assembling puzzles.assembling puzzles.

Commonly seen with delays in other nonmotor Commonly seen with delays in other nonmotor (e.g., language) milestones (e.g., language) milestones Phonological Disorder, Expressive Language Phonological Disorder, Expressive Language

Disorder, Mixed Receptive-Expressive Language Disorder, Mixed Receptive-Expressive Language DisorderDisorder

May be as high as 6% of children aged 5-11yrsMay be as high as 6% of children aged 5-11yrs Usually noticed when the child first attempts Usually noticed when the child first attempts

gross or fine motor tasks.gross or fine motor tasks.


(315.4)(315.4) Problems with motor coordination may be due Problems with motor coordination may be due

to a range of neurological problems. to a range of neurological problems. These are not DCC; they are motor impairment due These are not DCC; they are motor impairment due

to a general medical condition.to a general medical condition. If MR is present, motor impairment must be If MR is present, motor impairment must be

beyond what would be expected for that beyond what would be expected for that individual.individual.

If a PDD Diagnosis is given, cannot diagnose If a PDD Diagnosis is given, cannot diagnose DCC.DCC.

ADHD kids tend to knock things over, fall ADHD kids tend to knock things over, fall down, end up in the ER – but this is due to down, end up in the ER – but this is due to impulsivity and inattention, impulsivity and inattention, notnot motor motor impairment.impairment. If both conditions are present, can diagnose both.If both conditions are present, can diagnose both.

Expressive Language Expressive Language Disorder (315.31)Disorder (315.31)

A.A. The scores obtained from standardized individually administered The scores obtained from standardized individually administered measures of expressive language development are substantially measures of expressive language development are substantially below those obtained from standardized measures of both below those obtained from standardized measures of both nonverbal intellectual capacity and receptive language nonverbal intellectual capacity and receptive language development. The disturbance may be manifest clinically by development. The disturbance may be manifest clinically by symptoms that include having a markedly limited vocabulary, symptoms that include having a markedly limited vocabulary, making errors in tense, or having difficulty recalling words or making errors in tense, or having difficulty recalling words or producing sentences with developmentally appropriate length or producing sentences with developmentally appropriate length or complexity.complexity.

B.B. The difficulties with expressive language interfere with academic The difficulties with expressive language interfere with academic or occupational achievement or social communication.or occupational achievement or social communication.

C.C. Criteria are not met for Mixed Receptive-Expressive Language Criteria are not met for Mixed Receptive-Expressive Language Disorder or a Pervasive Developmental Disorder.Disorder or a Pervasive Developmental Disorder.

D.D. If Mental Retardation, a speech-motor or sensory deficit, or If Mental Retardation, a speech-motor or sensory deficit, or environmental deprivation is present, the language difficulties environmental deprivation is present, the language difficulties are in excess of those usually associated with these problems.are in excess of those usually associated with these problems.

Note: If a speech-motor or sensory deficit or a neurological condition Note: If a speech-motor or sensory deficit or a neurological condition is present, code the condition on Axis III.is present, code the condition on Axis III.


Linguistic features vary depending on its Linguistic features vary depending on its severity and the age of the child.severity and the age of the child. Can see limited amount of speech, limited Can see limited amount of speech, limited

vocabulary, a variety of gramamtical errorsvocabulary, a variety of gramamtical errors ELD can be acquired or developmental.ELD can be acquired or developmental.

Acquired – occurs after a period of normal Acquired – occurs after a period of normal development (usually due to insult, accident, or development (usually due to insult, accident, or injury)injury)

Developmental – impairment not associated with Developmental – impairment not associated with postnatal neurological insult of known origin.postnatal neurological insult of known origin.

Children with ELD often begin speaking late Children with ELD often begin speaking late and progress more slowly.and progress more slowly.


ELD is often accompanied by Phonological ELD is often accompanied by Phonological Disorder and dysfluencies (e.g., cluttering, Disorder and dysfluencies (e.g., cluttering, rapid speech)rapid speech)

Often have associated Learning DisordersOften have associated Learning Disorders Can have some receptive language problems Can have some receptive language problems

as well (but if significant, Dd: Mixed Receptive-as well (but if significant, Dd: Mixed Receptive-Expressive Language Disorder)Expressive Language Disorder)

Also see Developmental Coordination Disorder Also see Developmental Coordination Disorder (with motor delays) and Enuresis(with motor delays) and Enuresis

Social withdrawal, ADHD also common in ELD.Social withdrawal, ADHD also common in ELD.


Need to make sure assessment tools are Need to make sure assessment tools are culturally & linguistically appropriate culturally & linguistically appropriate (not always possible).(not always possible).

Advisable to consult with / refer to Advisable to consult with / refer to Speech/Language Pathologist.Speech/Language Pathologist.

PrevalencePrevalence Under age 3, relatively common: 10-15% of Under age 3, relatively common: 10-15% of

all childrenall children By school age, prevalence drops to 3-7% of By school age, prevalence drops to 3-7% of

all childrenall children


Usually recognized by 3yrs of age but milder Usually recognized by 3yrs of age but milder forms may not be identified until later forms may not be identified until later adolescence when language becomes more adolescence when language becomes more complex.complex.

Acquired type is more sudden, and outcome Acquired type is more sudden, and outcome is linked to the severity of the trauma.is linked to the severity of the trauma.

Outcome of developmental type is more Outcome of developmental type is more variable. Most children improve variable. Most children improve substantially with intervention; a smaller substantially with intervention; a smaller proportion have difficulties persisting into proportion have difficulties persisting into adulthood.adulthood.


Some family aggregation seen in the Some family aggregation seen in the developmental type; not so in the acquired developmental type; not so in the acquired type.type.

Differential Diagnoses:Differential Diagnoses: ELD from Mixed Receptive-Expressive Language ELD from Mixed Receptive-Expressive Language

Disorder (impairment in receptive language as well).Disorder (impairment in receptive language as well). PDD or Autism = no diagnosis of ELDPDD or Autism = no diagnosis of ELD MR, sensory deficit: need to have more extreme MR, sensory deficit: need to have more extreme

ELD than expected with deficits.ELD than expected with deficits. Disorder of Written Expression (problem is with Disorder of Written Expression (problem is with

writing; can have both).writing; can have both). Selective Mutism (will see normal language in some Selective Mutism (will see normal language in some

settings)settings)

Mixed Receptive-Expressive Mixed Receptive-Expressive Language Disorder (315.32)Language Disorder (315.32)A.A. The scores obtained from standardized individually The scores obtained from standardized individually

administered measures of both receptive and expressive administered measures of both receptive and expressive language development are substantially below those language development are substantially below those obtained from standardized measures of both nonverbal obtained from standardized measures of both nonverbal intellectual capacity. Symptoms include those for Expressive intellectual capacity. Symptoms include those for Expressive Language Disorder as well as difficulty understanding words, Language Disorder as well as difficulty understanding words, sentences, or specific types of words such as spatial terms.sentences, or specific types of words such as spatial terms.

B.B. The difficulties with receptive and expressive language The difficulties with receptive and expressive language interfere with academic or occupational achievement or interfere with academic or occupational achievement or social communication.social communication.

C.C. Criteria are not met for a Pervasive Developmental Disorder.Criteria are not met for a Pervasive Developmental Disorder.D.D. If Mental Retardation, a speech-motor or sensory deficit, or If Mental Retardation, a speech-motor or sensory deficit, or

environmental deprivation is present, the language environmental deprivation is present, the language difficulties are in excess of those usually associated with difficulties are in excess of those usually associated with these problems.these problems.

Note: If a speech-motor or sensory deficit or a neurological Note: If a speech-motor or sensory deficit or a neurological condition is present, code the condition on Axis III.condition is present, code the condition on Axis III.

Mixed Receptive-Expressive Mixed Receptive-Expressive Language Disorder (315.32)Language Disorder (315.32) Why no “Receptive Language Disorder?”Why no “Receptive Language Disorder?”

Because development of expressive language Because development of expressive language relies on the acquisition of receptive skills, relies on the acquisition of receptive skills, difficulties in receptive skills leads to difficulties difficulties in receptive skills leads to difficulties in expressive skills.in expressive skills.

Can have more severe receptive than Can have more severe receptive than expressive; but quite rare.expressive; but quite rare.

Problems seen in both aspects of speechProblems seen in both aspects of speech Exists in acquired and developmental typesExists in acquired and developmental types

Mixed Receptive-Expressive Mixed Receptive-Expressive Language Disorder (315.32)Language Disorder (315.32) Child may be exceptionally quiet or have Child may be exceptionally quiet or have

difficulty following commands, give tangential difficulty following commands, give tangential responses to questions.responses to questions.

Conversational skills are quite poor.Conversational skills are quite poor. Often see deficits in auditory processing as Often see deficits in auditory processing as

well.well. Difficulties with arbitrary sound-symbol Difficulties with arbitrary sound-symbol

associations used in language.associations used in language. Also seen with Phonological Disorder, Also seen with Phonological Disorder,

Laerning Disorders, ADHD, Developmental Laerning Disorders, ADHD, Developmental Coordination Disorder, Enuresis.Coordination Disorder, Enuresis.

Mixed Receptive-Expressive Mixed Receptive-Expressive Language Disorder (315.32)Language Disorder (315.32) Need to have culturally and linguistic Need to have culturally and linguistic

relevant testing tools. relevant testing tools. Hard to find.Hard to find. Best to consult with / refer to a Best to consult with / refer to a

Speech/Language PathologistSpeech/Language Pathologist Prevalence:Prevalence:

5% of preschoolers5% of preschoolers 3% of school-age children3% of school-age children Probably less common than Expressive Probably less common than Expressive

Language DisorderLanguage Disorder

Mixed Receptive-Expressive Mixed Receptive-Expressive Language Disorder (315.32)Language Disorder (315.32) Course:Course:

Usually undetectable before 4yrs of ageUsually undetectable before 4yrs of age Severe forms detectable by 2yrs of ageSevere forms detectable by 2yrs of age Milder forms not noticeable until elementary Milder forms not noticeable until elementary

school.school. Prognosis generally worse than ELD alonePrognosis generally worse than ELD alone Developmental type responds well to intensive Developmental type responds well to intensive

early intervention; acquired type depends early intervention; acquired type depends upon severity of insult.upon severity of insult.

Familial aggregation among 1Familial aggregation among 1stst-degree -degree relatives for developmental type.relatives for developmental type.

Phonological Disorder Phonological Disorder (315.39)(315.39)

A.A. Failure to use developmentally expected speech Failure to use developmentally expected speech sounds that are appropriate for age and dialect (e.g., sounds that are appropriate for age and dialect (e.g., errors in sound production, use, representation, or errors in sound production, use, representation, or organization such as, but not limited to, substitutions organization such as, but not limited to, substitutions of one sound for another [use of /t/ for target /k/ of one sound for another [use of /t/ for target /k/ sound] or omissions of sounds such as final sound] or omissions of sounds such as final consonants.consonants.

B.B. The difficulties in speech sound production interfere The difficulties in speech sound production interfere with academic or occupational achievement or with with academic or occupational achievement or with social communication.social communication.

C.C. If Mental Retardation, a speech-motor or sensory If Mental Retardation, a speech-motor or sensory deficit, or environmental deprivation is present, the deficit, or environmental deprivation is present, the speech difficulties are in excess of those usually speech difficulties are in excess of those usually associated with these problems.associated with these problems.

Note: If a speech-motor or sensory deficit or a neurological Note: If a speech-motor or sensory deficit or a neurological condition is present, code the condition on Axis III.condition is present, code the condition on Axis III.


Includes phonological production (articulation) Includes phonological production (articulation) errors, errors in sorting appropriate sounds for errors, errors in sorting appropriate sounds for language from non-language sounds, omissions, language from non-language sounds, omissions, substitutions, and distortions.substitutions, and distortions. Omissions: “Cah” for “Cat”Omissions: “Cah” for “Cat” Substitutions: “Fwend” for “Friend”Substitutions: “Fwend” for “Friend” Distortions: Bostonian “Cah” for “Car”Distortions: Bostonian “Cah” for “Car”

Associated with history of chronic ear infections Associated with history of chronic ear infections (shapes the way sounds are “stored” (shapes the way sounds are “stored” developmentally)developmentally)

Also seen in structural abnormalities of the oral Also seen in structural abnormalities of the oral cavity (e.g., cleft palate)cavity (e.g., cleft palate)

Need to consider culture in assessing – consult!Need to consider culture in assessing – consult! More prevalent in males.More prevalent in males.


2% of 6-7 year old children present with 2% of 6-7 year old children present with moderate to severe Phonological Disorder, moderate to severe Phonological Disorder, milder forms have higher prevalence.milder forms have higher prevalence.

Prevalence = 0.5% by 17yrs of agePrevalence = 0.5% by 17yrs of age Identifiable usually when child enters Identifiable usually when child enters

preschool and teachers identify the speech preschool and teachers identify the speech struggles. More severe problems seen struggles. More severe problems seen when family cannot understand child.when family cannot understand child.

Responds well to early intervention.Responds well to early intervention. Evidences a familial pattern.Evidences a familial pattern.

Stuttering (307.0)Stuttering (307.0)A.A. Disturbance in the normal fluency and time patterning of Disturbance in the normal fluency and time patterning of

speech (inappropriate for the individual’s age), characterized speech (inappropriate for the individual’s age), characterized by frequent occurrences of one or more of the following:by frequent occurrences of one or more of the following:

1.1. Sound and syllable repetitionsSound and syllable repetitions2.2. Sound prolongationsSound prolongations3.3. InterjectionsInterjections4.4. Broken words (e.g., pauses within a word)Broken words (e.g., pauses within a word)5.5. Audible or silent blocking (filled or unfilled pauses in speech)Audible or silent blocking (filled or unfilled pauses in speech)6.6. Circumlocutions (word substitutions to avoid problematic words)Circumlocutions (word substitutions to avoid problematic words)7.7. Words produced with an excess of physical tensionWords produced with an excess of physical tension8.8. Monosyllabic whole-word repetitions (e.g., “I-I-I-I see him”)Monosyllabic whole-word repetitions (e.g., “I-I-I-I see him”)

B.B. The disturbance in fluency interferes with academic or The disturbance in fluency interferes with academic or occupational achievement or with social communication.occupational achievement or with social communication.

C.C. If a sensory-motor or sensory deficit is present, the difficulties If a sensory-motor or sensory deficit is present, the difficulties are in excess of those usually associated with these problems.are in excess of those usually associated with these problems.

Note: If a speech-motor or sensory deficit or a neurological Note: If a speech-motor or sensory deficit or a neurological condition is present, code the condition on Axis IIIcondition is present, code the condition on Axis III

Stuttering (307.0)Stuttering (307.0) Extent of the disturbance varies, often more Extent of the disturbance varies, often more

severe when there is pressure to communicate.severe when there is pressure to communicate. Often absent during oral reading, singing, or Often absent during oral reading, singing, or

talking to inanimate objects or pets.talking to inanimate objects or pets. At onset, speaker may not notice stuttering; At onset, speaker may not notice stuttering;

however fearful anticipation may develop later.however fearful anticipation may develop later. Stuttering may be accompanied by motor Stuttering may be accompanied by motor

movements (jerking of head, eyeblinks)movements (jerking of head, eyeblinks) Impairment in social functioning may Impairment in social functioning may

contribute to anxiety, frustration, low self-contribute to anxiety, frustration, low self-esteem.esteem.

Stuttering (307.0)Stuttering (307.0) PrevalencePrevalence

1% in prepubertal children1% in prepubertal children 0.8% in adolescence0.8% in adolescence Male:Female ratio 3:1Male:Female ratio 3:1

Onset Onset typically between 2 and 7yrs; peak at 5yrstypically between 2 and 7yrs; peak at 5yrs Before 10yrs in 98% of casesBefore 10yrs in 98% of cases

Familial patternFamilial pattern First-degree biological relatives = 3x risk of gen First-degree biological relatives = 3x risk of gen

population.population. For men with a history of stuttering, 10% of their For men with a history of stuttering, 10% of their

daughters and 20% of their sons will stutter.daughters and 20% of their sons will stutter. Differential DxDifferential Dx

Hearing impairment, speech-motor deficit, normal Hearing impairment, speech-motor deficit, normal dysfluencies that occur in young childrendysfluencies that occur in young children

Communication Disorder Communication Disorder NOS (307.9)NOS (307.9)

Disorders of communication that do Disorders of communication that do not meet criteria for any specific not meet criteria for any specific Communication DisorderCommunication Disorder e.g., Voice Disorder - Abnormality of e.g., Voice Disorder - Abnormality of

pitch, loudness, quality, tone, or pitch, loudness, quality, tone, or resonance.resonance.

Case MaterialCase Material

Ed – 8yr old maleEd – 8yr old male Previous DX of ADHDPrevious DX of ADHD

Taking Concerta (methylphenidate) Taking Concerta (methylphenidate) 45mgs45mgs

Struggles with engaging in Struggles with engaging in appropriate peer play (often plays appropriate peer play (often plays the class clown)the class clown) Will crawl under tables to make other Will crawl under tables to make other

students laughstudents laugh


Unremarkable pregnancy & birth historyUnremarkable pregnancy & birth history Some lack of weight gain early in infancySome lack of weight gain early in infancy Developmental milestones somewhat lateDevelopmental milestones somewhat late

Walking at 12mos Walking at 12mos 11stst words at 18mos words at 18mos Clustering words at 24mosClustering words at 24mos Rec’d SP/L services at 3yrs of ageRec’d SP/L services at 3yrs of age Some infrequent enuresis when hyperfocusedSome infrequent enuresis when hyperfocused


Some continuing difficulty expressing Some continuing difficulty expressing himself verbally & in written expressionhimself verbally & in written expression Speaks very rapidly, appears to stutterSpeaks very rapidly, appears to stutter Reverses written lettersReverses written letters Observations:Observations:

Repeats final sounds of a word: (“The cat is on Repeats final sounds of a word: (“The cat is on the wall …all …all …all.”)the wall …all …all …all.”)

Repeats initial words of a sentence: (“The Repeats initial words of a sentence: (“The thing… the thing… the thing that….”)thing… the thing… the thing that….”)

Phoneme substitutions (“Brudder” for Phoneme substitutions (“Brudder” for “Brother”, “Afross” for “Across”)“Brother”, “Afross” for “Across”)

Case MaterialCase MaterialWechsler Intelligence Scale for Children – 4th Edition

Verbal Comprehension Subtests Perceptual Reasoning Subtests

Similarities 9 Block Design 14 Vocabulary 10 Picture Concepts 10 Comprehension 10 Matrix Reasoning 14 (Information) (9) (Picture Completion) (9) (Word Reasoning) (NA)

Working Memory Subtests Processing Speed Subtests Digit Span 5 Coding 4 Letter-Numbr Seq. 9 Symbol Search 8 (Arithmetic) (8) (Cancellation) (9)

Verbal Comprehension Index 98 Perceptual Reasoning Index 117 Working Memory Index 83 Processing Speed Index 78 Full Scale IQ 94

Case MaterialCase MaterialWoodcock-Johnson Tests of Achievement, Form A - Continued

(norms based on age 8yrs, 1mos) Grade Equivalent Standard Score Oral Language (Ext) 2.1 95 Oral Expression 3.0 104 Listening Comprehension 1.6 91 Total Achievement 2.5 96 Broad Reading 2.3 92 Broad Math 3.1 108 Broad Written Language 2.4 95 Basic Reading Skills 2.3 94 Reading Comprehension 2.1 94 Math Calculation Skills 2.6 99 Basic Writing Skills 2.1 92 Written Expression 2.9 103 Academic Skills 2.4 95 Academic Fluency 2.6 98 Academic Applications 2.6 99 Phon/Graph Knowledge 1.3 80

Diagnoses?Diagnoses?

DiagnosesDiagnosesAxis I: Phonological Disorder Disorder of Written Expression Mathematics Disorder Reading Disorder

Academic Problem Attention-Deficit Hyperactivity Disorder, Combined Type (by history) Stuttering (by history) Adjustment Disorder with Mixed Disturbance of Emotions and Conduct (by history)

Axis II: Deferred

Axis III: Deferred

Axis IV: Problems with the school environment. Problems with the peer group. Axis V: Current estimated GAF: 75

Highest GAF in past year: 75