science writing question and need the explanation and answer to help me learn.
Hi! Please follow this assignment per steps:
Step 1) Fill out the scientific planning document. The sources are given in it and one of them is a book (it is a pdf attached), but please provide an explanation for each one describing why it’s needed and how it will be used. THIS WHOLE THING WILL BE COMPLETED IN APA STYLE 7
Step 2) For this assignment, you will design, construct, and present a scientific poster if you were to use it at a mock conference. The poster itself will be a large .pdf document that contains pictures, text, figures, tables, graphs, et cetera. The topic is ADHD, but please create a creative title that is not so vague using the sources. The poster must include at least 5 figures (illustrations, graphs, tables, photographs, et cetera) that are of high quality and help describe your topic.Several good programs can be used to design large-format posters: Microsoft PowerPoint, Canvas, Apple Keynote, Apple Pages, Adobe Illustrator, CorelDRAW, Inkscape, Omnigraffle, Scribus, LaTeX. MAKE SURE THE DESIGN IS CREATIVE AND UNIQUE
poster should contain the following elements. You can combine these with one another or present them as separate parts of the poster.
Title of the poster, name
Introduction to the topic or scientific question.
Overview of the scientific issue or problem.
A minimum of 5 figures, tables, graphs, graphics, photos, maps, et cetera showing results and/or solutions.
Summary or conclusion.
References (minimum of 6) cited in APA STYLE 7 (IT IS GIVEN)
Figures and tables should be designed in such a way that they can stand alone, meaning that they should only require a brief description (e.g., figure caption) or minimal explanation from the presenter. The poster should be designed so that each part (e.g., figures, tables, introduction, body, and conclusion) complements the other parts.
FOLLOW THIS RUBRIK;):
Design: Does the poster tell a story in a manner that is easy to understand? Does the poster draw the audience in or is it dull and boring? Is the font size big enough to read? Are photographs high-resolution or faded and blurry? Are the graphs and tables nice and neat, easy to understand? Is the poster well organized?
Creativity: Is the topic important? Is the poster interesting? Is the poster just a copy and paste job from the articles that the presenter read or did she/he put some of her/his own thoughts, ideas and design into their poster?
Knowledge: Is it evident that the presenter has a thorough understanding of her/his topic?
Content: Does the poster contain all the necessary components needed to describe a particular topic to the audience? For example, does the poster have a title, name, introduction, body, and conclusion? Does the poster have figures, tables, graphs, etc.? Each poster will be unique and may or may not have all of these parts, but the poster should contain enough parts so that it tells a complete story.
Requirements: as specified
ADHD and the Concept of ESSENCE (Early Symptomatic Syndromes Eliciting Neurodevelopmental Clinical Examinations)
ADHD is listed in the DSM-IV as a psychiatric disorder with onset in childhood. In the DSM-5 it is listed among neurodevelopmental disorders. Debate sometimes gets heated about whether or not it should be considered a “psychiatric,” “neuropsychiatric,” or “neurodevelopmental” disorder. Depending on the definitions of these three concepts, ADHD, of course, is well placed within all three categories. Debate also sometimes centers around whether or not ADHD is a “discrete categorical” disorder or a “dimensional” disorder, and also whether or not it can occur together with other conditions or disorders. The most reasonable answer to these three questions is “yes”: ADHD can be separated out as a categorical disorder, it can be construed as one of the end sections on a dimension of attention (or for that matter on a dimension of impulsivity), and it can definitely occur together with other problems. Indeed, almost all the epidemiological evidence relating to ADHD indicates that it is almost never an isolated disorder or collection of symptoms.
While in the past child psychiatry showed little interest in operationalized diagnosis, in recent times categorical diagnosis has become an integral part of everyday clinical and research practice. We are now so insistent on the distinction between “disorder” and “not disorder” (“normalcy”) that clinics and clinicians become more and more specialized and cater to the needs of children with “attention-deficit/hyperactivity disorder/ADHD only,” “autism only,” or “tourette syndrome only.” This has led to a situation in which the typical clinical diffuseness of disorder has come to be underestimated.
At the same time, rather belatedly, there is growing acceptance that coexistence of disorders and sharing of symptoms across disorders (so-called comorbidity, a misnomer if ever there was one, seeing as we are usually not dealing with completely separate coexisting disorders) is the rule rather than the exception (e.g., Kadesjö & Gillberg 2001). This was pointed out more than a quarter of a century ago (Gillberg, 1983), but, in clinical practice, this insight has not led to new approaches when trying to address the needs of children and families with “complex needs.” Instead, diversification has boomed.
There are legislational, scientific, and clinical attempts to separate out children with certain disorders/diagnoses (e.g., IDD and ASD) from those who do not meet the criteria for the disorder/diagnoses, all aiming to provide better societal guidelines, more focused attempts at finding the causes, and more specific services. children with ADHD are targeted in similar ways, even though legislation has yet to catch up with them. The same holds for children with language impairments (often erroneously referred to as “specific” language impairment [SlI]—erroneous because the impairments are only very rarely specific), visual impairments, and hearing deficits (children who may, or may not, have additional impairments as regards general cognition, motor performance, ADHD, or ASD).
ADHD and ASD, which were long treated as and believed to be completely separate and recognizable “disorders,” are now increasingly often diagnosed “together” within one and the same individual, and there is growing awareness that they sometimes overlap and constitute amalgams of problems, and that in some families they separate together and probably represent different aspects of the same underlying disorder (constantino et al., 2007).
With increased understanding that early-onset childhood problems, such as those reflected in children who are diagnosed in the preschool or early school years as suffering from ADHD or ASD, have long-term, indeed probably often lifetime, consequences (billstedt et al., 2005; cederlund et al., 2010; rasmussen & Gillberg, 2000), the incentives to screen and to diagnose these conditions have become main priorities for clinicians and administrators hoping to alter the often negative outcome typically seen in patients who have had little or no intervention (or indeed an exclusionary attitude on the part of those “responsible”) during the course of growing up. The question to be addressed is this: Would making discrete diagnosis (of, say, ADHD or ASD) before age 5 to 6 years contribute to a better understanding, better intervention, and more positive outcomes in children who present with problems that could be indices of these disorders?
WHAT IS ESSENCE?
The acronym eSSence refers to early Symptomatic Syndromes Sliciting neurodevelopmental clinical examinations. It was coined with a view to highlighting the clinical reality of children (and their parents) presenting in first-, second-, or third-tier clinical settings with usually complex, impairing developmental symptoms before age 5 to 6 years. The children are reported to have problems in the fields of (a) general development, (b) communication and language, (c) social inter-relatedness, (d) motor coordination, (e) attention/“ listening,” (f) activity, (g) behavior, (h) mood, and/or (i) sleep. children with major difficulties in one or more (usually several) of these fields will be referred to and seen by health visitors, nurses, social workers, education (including preschool) specialists, pediatricians, GPs, speech and language therapists, child neurologists, child psychiatrists, psychologists, neurophysiologists, dentists, clinical geneticists, occupational therapists, and physiotherapists, but in the vast majority of cases they will be seen by only one of these specialists when, in fact, they would have needed the input of two or more (occasionally even all) of the “experts” referred to.
The syndromes encompassed under the eSSence umbrella acronym are listed in table 3.1.
Most of these syndromes are conceptualized as more or less discrete disorders in the DSM and IcD. Here they are listed, not because they are conceptualized as existing “in their own right” (even though occasionally they do show up as isolated conditions in individuals), but because
ESSENCE (I.E., NEURODEVELOPMENTAL SYNDROMES/DISORDERS
USUALLY MANIFESTING WITH CLINICAL SYMPTOMS LEADING TO
REFERRAL OR ASSESSMENT BEFORE ABOUT 6 YEARS OF AGE)
overlap of the various syndromes subsumed under the eSSence umbrella. Figure by S. lundström.
they currently drive development in the whole field of child health, and all of them have links to one or more of the other conditions/disorders on the list. Figure 3.1 illustrates—in simplified two-dimensional format—the complex overlap of the various syndromes subsumed under the eSSence label.
AN EXAMPLE FROM THE FIELD OF SLI
In a recent population study, Miniscalco and colleagues (2006) identified 25 children with SlI at age 2.5 years. They had been screened by child health nurses and had screened positive (on one or more of the following items: (i) fewer than 25 communicative words, (ii) comprehension difficulties, (iii) articulation difficulties) and been deemed to have some degree of speech and language impairment after formal testing by a pediatric speech and language therapist (Slt). They were contrasted with 80 children from the general population without SlI and followed as regards speech and language development for 5 years (seen by an Slt at ages 4, 6, and 7.5 years). When they were 7.5 years old they were, in addition, examined by a neuropsychiatric team, who remained blind to the original assessments. At this age, more than 70% of the children with Slt had ADHD, ASD, IDD, or bIF (or combinations of these). none of them had been suspected of having any of these problems at the original diagnosis of SlI. by age 4 and 6 years, only a small fraction had been recognized to suffer from ADHD or ASD, and an even smaller proportion had received appropriate interventions for such problems.
What can we conclude on the basis of these and similar findings from previous studies? children with SlI at 2.5 years are a large group—several percent are affected according to U.K. and Swedish studies (law et al., 2008; Miniscalco et al., 2005). When a child is recognized as having SlI in a child health setting he or she is usually referred for a hearing test and assessment and possibly for speech and language therapy to a pediatric Slt. The results of the study referred to indicate that this might not be appropriate. It would probably be reasonable to characterize the problem signaled by the SlI as belonging to the eSSence group and refer the child for multidisciplinary evaluation by a community pediatrician, a psychologist, and an Slt.
AN EXAMPLE FROM THE FIELD OF ASD
two decades ago, our group demonstrated that autism diagnoses made before age 3 years were relatively stable over time, 75% of patients still meeting the criteria for ASD at follow-up years later (Gillberg et al., 1990). However, in 25% this was not the case, but all the children in this latter group met the criteria for another developmental disorder, such as IDD without ASD, or ADHD. In a new study of more than 300 preschool children with a clinical diagnosis of ASD, the vast majority met the research DSM-IV criteria for autistic disorder, Asperger disorder, or pervasive developmental disorder not otherwise specified at follow-up after 2 years. However, about one in 10 were not diagnosed with ASD but had other developmental disorder diagnoses, such as ADHD, IDD, bIF, SlI, or combinations of these (Fernell et al., 2010). rates of “comorbid” speech and language problems, ADHD, DcD, gastrointestinal problems, epilepsy, IDD, or bIF in the ASD group varied from about 10% to 60%, but this had not been revealed in connection with the original clinical diagnosis of ASD. The findings provide good support for the notion that these were children suffering from eSSence, and, depending on the inclination, interest, and training of the professional first seeing the child because of eSSence problems, the child may first have been diagnosed with ADHD, IDD, SlI, or ASD, and any number of the comorbid problems might have been missed.
THE EARLY SYMPTOMS OF ESSENCE
The “typical” symptoms of eSSence are listed in table 3.2. These symptoms should not be seen as “specific” for eSSence. rather, they should be taken as markers for the (very likely) presence of a neurodevelopmental disorder that (very likely) will continue to cause symptoms long after their clinical surfacing in the first few years of life.
SYMPTOMS (CAUSING MAJOR IMPAIRMENT AND CONCERN FOR
6 MONTHS OR MORE) SIGNALING ESSENCE IN THE FIRST FIVE YEARS OF LIFE
SCOPE OF THE PROBLEM
The estimated prevalence rates of the syndromes subsumed under the eSSence acronym are listed in table 3.1. Most of the disorders listed have been epidemiologically surveyed during the early or middle school ages, and only a few have been the subject of prevalence studies in the preschool years. even though all of the syndromes are present (and usually symptomatic) from the preschool years, many cases will not have come to the attention of clinicians before school age. Thus, the sum prevalence of about 10% of the general population of children suffering from these syndromes may not reflect how many children come to clinical attention during the preschool period. on the basis of preschool studies of ASD, oDD, and ADHD (Fernell & Gillberg, 2010; Kadesjö et al., 2003), a reasonable estimate would be that about 5% to 7% of children under age 6 years would meet the “criteria” for eSSence (i.e., have clinical symptoms of a syndrome and have presented at a clinic with a view to diagnosis and intervention). boys would be extremely overrepresented in this group, even though they probably wouldn’t outnumber girls by more than 2 to 3:1 had parents, teachers, and clinicians been more aware that girls with ASD, ADHD, oDD, and SlI, while meeting the full criteria for these disorders, might have a slightly/clearly different pattern of comorbidity (Kopp et al., 2010; Mahone and Hoffman 2007; Pinkhardt et al., 2009). Girls, as a group, tend to be less violent, less motorically active, more socially adept, and better at using language skills for communication. All of these factors contribute to masking the early symptomatic presentation of disorders such as ASD and ADHD. With better awareness about the presence of such disorders in preschool girls, more and more female cases are likely to come to attention over the next several years.
ADHD (AND ODD AND CONDUCT DISORDER)
ADHD (with or without oDD) is a very common condition, affecting at least 5% of school-age children (Faraone et al., 2003). It is the most common of all the neurodevelopmental disorders/eSSence.
In about 60% of the cases identified in the preschool years, ADHD is associated with oDD, which is usually symptomatic by around 3 years of age (Kadesjö et al., 2003). About 10% to 20% of all cases of ADHD (usually recruited from the group of ADHD plus oDD) later meet the criteria for conduct disorder, who in turn often meet the full criteria for antisocial personality disorder in adult age. Again, boys are affected much more often than girls, and particularly in the preschool period it is unusual for a girl to be recognized as having the disorder of ADHD (unless it is in the context of having another diagnosis, such as ASD or learning disability).
In about 50% of the cases, ADHD is associated with DcD, and the majority of these patients also have evidence of other learning problems. oDD is quite uncommon in this “ADHD subgroup” (in Scandinavia often referred to as DAMP—i.e., ADHD plus DcD). The outcome for the ADHD plus DcD subgroup is also relatively poor in many cases, but this is usually associated with the consequences of academic failure rather than through a more “primary” antisocial pathway.
Many individuals with ADHD have tics and tic disorders, but these are often not specifically or separately diagnosed unless the differential diagnosis or referral question is “? tourette syndrome.”
ADHD, as we shall see, is also associated with a number of other mental health problems, including depression, and anxiety.
It appears that at least half of individuals diagnosed in childhood with ADHD continue to have impairing ADHD in adult life and that the majority have some remaining problems, even if they do not meet the full criteria for “clinical” ADHD (Dopheide & Pliszka, 2009; rasmussen & Gillberg, 2000). There is evidence that several aspects of the disorder can be positively affected by short- and long-term interventions combining a psychoeducational and pharmacological approach (Ghuman et al., 2008; Vaughan et al., 2009). There are indications that at least when it comes to certain associated conditions (such as ASD), “comorbidity” needs to influence the choice of intervention in important ways to achieve the best possible outcome (ollendick et al., 2008). Preschool oDD, perhaps the most common of all the associated problems in the field of ADHD, indicates a much increased risk that the child may go on to develop conduct disorder, which in turn is a strong predictor of later antisocial personality disorder. recognizing and intervening for oDD in ADHD would probably ameliorate the prognosis in a number of cases. Similarly, recognizing and intervening for DcD in ADHD has the potential of improving outcomes even further. DcD in ADHD is also a strong predictor/marker for associated ASD (Kadesjö & Gillberg, 1999).
ADHD is largely genetic (curatolo et al., 2009), but a very similar phenotype can develop after various types of brain damage/environmentally caused brain dysfunction (Strang-Karlsson et al., 2008). The brain develops differently in children with ADHD than in typically developing children, with loss of the prefrontal component of normal asymmetrical brain development (Shaw et al., 2009). There is also growing evidence that the brain’s dopamine-dependent reward system is dysfunctional in ADHD (Volkow et al., 2009). Interestingly, there is now good evidence that ASD and ADHD are clearly related in some families, and that the central nervous system connectivity genes involved in ASD may also be relevant for the development of ADHD symptoms (Kopp et al., 2010; Mulligan et al., 2009; Sharp et al., 2009).
ADHD is usually not a discrete disorder. Instead, even in the community, not just in clinics dealing with severely impaired individuals, “comorbidity” is the rule (Kadesjö & Gillberg, 2001). oDD, DcD, depression, anxiety, ASD, substance use disorder, and conduct disorder are all relatively or very common coexisting disorders. All these “coexisting disorders” in ADHD, of course, have an important subgroup of patients within their diagnostic category who have marked attention/impulsivity problems and sometimes meet the full criteria for ADHD.
ASD is no longer considered a rare condition (baird et al., 2006); rather, its prevalence during the school years is believed to be slightly higher than 1% of the general population of children. boys are clearly much more often affected than girls, at least if we are referring to the clinically impairing variant of the autism phenotype. Skuse (2009) has argued that the autism phenotype might be equally common in males and females and that other factors are responsible for the large discrepancy in male: female ratios seen in clinical and epidemiological populations. However, others (including baron-cohen et al., 2001) have proposed that the autistic phenotype is an expression of the “extreme male brain,” which would make the male preponderance in ASD a very real thing and not due to gender roles, comorbidity, or other factors making boys more likely to be diagnosed with the condition.
ASD is a group of multifactorially determined conditions, and there are almost as many different causes as there are cases (Gillberg & coleman, 2000). The prefrontal, temporal, brainstem, and cerebellar regions of the central nervous system are usually affected. These areas constitute a functional network, “the default network,” that appears to be critically differently functioning in ASD (buckner & Vincent, 2007; Iacoboni, 2006; Monk et al., 2009). ASD with some degree of cognitive impairment is probably associated with life-long disability in the vast majority of cases (e.g., billstedt et al., 2005), but it is unclear to what extent higher-functioning individuals with ASD (including the group with Asperger syndrome, table 3.4) continue to show pervasive impairments in adult life (e.g., cederlund et al., 2010), even though there are indications that persistence of some problems throughout life is more common than not. There is now increasing evidence that early intensive training programs have some lasting beneficial effects on a number of aspects of the disorder, even though the effectiveness of such programmes in daily clinical practice is still a matter of some debate (Fernell et al., 2011)
ASD is almost never an isolated phenomenon (table 3.3). coexisting problems and disorders are the rule. These include learning disability (including nVlD), epilepsy, motor control problems, ADHD, depression and anxiety, gastrointestinal problems, and sleep disorders. These problems and disorders are sometimes the reason for referral to a specialist for evaluation. For instance, it is not uncommon for an extremely hyperactive child to be referred for evaluation of ADHD, but the full appraisal, once considered, will reveal that the child’s main diagnosis is ASD, and coexisting ADHD may or may not be diagnosed.
AUTISM SPECTRUM DISORDER CRITERIA ACCORDING TO DSM-5
TABLE 3.3. (CONTINUED)
reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth edition, (copyright 2013). American Psychiatric Association.
40 A DH D A n D I t S M A n y AS S o c IAt e D Probl e M S
IDD, NVLD, AND DYSLEXIA
learning problems, including intellectual disability (IDD), borderline intellectual functioning, nVlD, and precursors of dyslexia (including phonological awareness problems) are common in the preschool period and affect several percent of both boys and girls. More often than not, such learning problems coexist with other neurodevelopmental/ neuropsychiatric disorders, such as ADHD, ASD, and oDD. There is currently a clinical diagnostic substitution trend, at least in the United Kingdom, Scandinavia, and the United States(bishop et al., 2008; coo et al., 2008; Fernell & ek, 2010; Howlin, 2008), leading to fewer children being diagnosed with learning disability and more being labeled as suffering from ASD. The problem with this trend is that the very real learning problems suffered by many individuals with ASD and ADHD may go undiagnosed for long periods of time. In the past, the opposite was often true. nVlD is common in Asperger syndrome (cederlund and Gillberg 2004; Klin et al., 1995) but is often not recognized and much less diagnosed. This is unhelpful for patients who are clearly impaired by “both conditions.” Many individuals with Asperger syndrome—and their parents and teachers—benefit greatly from a better understanding of the particular neuropsychological profile (with its characteristic peaks and troughs) associated with nVlD. The reverse is also true, and Asperger syndrome is often missed by neuropsychologists who specialize in nVlD. Phonological awareness problems, a common precursor of dyslexia, are common in ADHD (with or without associated autistic symptoms) but are often missed once the “overshadowing” diagnosis of ADHD/ASD has been established (Åsberg et al., 2010). Many of these clinical problems, stemming from the over focus on one or other of all the preschool neurodevelopmental disorders, could be avoided if clinicians were more aware of the implications of eSSence and had several different diagnoses (and associated/comorbid diagnoses) in mind whenever examining a child presenting with impairing symptoms of eSSence.
ASPERGER SYNDROME BY GILLBERG (IN ACCORDANCE WITH HANS
ASPERGER’S OWN CASE DESCRIPTIONS)
criteria by Gillberg and Gillberg (1989) elaborated by Gillberg (1991)
42 A DH D A n D I t S M A n y AS S o c IAt e D Probl e M S
DCD (DEVELOPMENTAL COORDINATION DISORDER)
DcD has recently become the subject of more intense systematic study after having been virtually neglected as an important clinical problem and focus of research. It is quite common, affecting about 5% of all school-age children (Gillberg & Kadesjö, 2003), the majority of whom should be recognizable before age 6 years. However, currently, it is rare for a child to be given this diagnosis before school age. All child psychiatrists should be trained in the field of motor coordination assessment, and pediatricians and other “non-psychiatry” physicians should keep abreast of developments in the field of ADHD and ASD, the two psychiatric disorders that appear to be most commonly associated with DcD. A Swedish population study has suggested that there might be a specific connection between ADHD and ASD, and that it is mediated by DcD (Kadesjö & Gillberg, 1999): children with ADHD who also have DcD (about half the group of all with ADHD) have a very high risk of also having impairing autistic symptomatology, whereas those without DcD have a low risk, and a much higher risk for oDD and conduct problems (table 3.5).
TICS AND TOURETTE SYNDROME
tics are extremely common in middle childhood and probably affect at least 15% of all children at some time. Severe, chronic motor and vocal tics (the combination that is referred to as tourette syndrome) are much less common, probably affecting about 1% of all school-age children (Kadesjö & Gillberg, 2000). tics fluctuate in intensity and over time, which means that even some severely affected individuals may not actually show any tics during consultation. tics are rarely diagnosed in the preschool years, but various forerunners of tourette disorder (such as hyperactivity/impulsivity and a variety of obsessive-compulsive phenomena) are usually present long before the typical, sometimes striking, even dramatic, tics occur or surface at early school age. tourette disorder
DEVELOPMENTAL COORDINATION DISORDER CRITERIA ACCORDING
reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth edition, (copyright 2013). American Psychiatric Association.
is considered to be a strongly genetic disorder (but more heterogeneous than previously believed) (Keen-Kim & Freimer, 2006; State et al., 2001).
one of the clinically most important aspects of tourette syndrome (and other severe motor or vocal tic disorders) is its strong association with ADHD and ocD (Debes et al., 2009). Almost all severely handicapped children with tourette syndrome are affected by either ADHD or ocD or both, and they are usually more impaired by these “comorbid” conditions than by the tic disorder itself (table 3.6). These associated problems, particularly ADHD (and perhaps particularly extremes of impulsive-hyperactive behaviors), are often apparent during the preschool years, and they, rather than the tics, are what will lead to referral for clinical neurodevelopmental/neuropsychiatric examination.
TIC DISORDERS CRITERIA ACCORDING TO DSM-5
reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth edition, (copyright 2013). American Psychiatric Association.
Pediatric bipolar disorder is still a somewhat controversial diagnosis (biederman et al., 1989). However, it is becoming increasingly recognized that bipolar disorder can present with symptoms in the preschool years. children with “ADHD” and/or depression who have a family history of bipolar disorder may actually be presenting with signs and symptoms of a bipolar disorder (chang, 2008). extremes of irritability, mood swings, and even classic manic symptoms may appear in the first several years of life and signal the possibility of an underlying bipolar disorder. ADHD and ASD can both occur in conjunction with bipolar disorder (and can probably overshadow the affective disorder). longitudinal systematic study of large groups of children with eSSence will help clarify the prevalence and importance of pediatric bipolar disorder (table 3.7).
BEHAVIORAL PHENOTYPE SYNDROMES
More than 1.0% of all preschool children may be affected by one (or more) of the “rare disorders,” also referred to as behavioral phenotype syndromes (Gillberg, 2010). examples of such disorders are the fragile X syndrome, 22q11deletion syndrome, 22q13 syndrome, neurofibromatosis, tuberous sclerosis, and Smith-lemli-opitz syndrome. each of these disorders is really “rare” (occurring usually in fewer than 1 in 2,000 children), but given that there are hundreds of them, taken as a group they are actually quite common. The majority of these syndromes have a large subgroup—usually the majority—with some degree of cognitive impairment, although many affected individuals do not have learning disability, and some have a high IQ (e.g., most individuals with Marfan syndrome and about half the group with 22q11deletion syndrome). large subgroups of individuals within each category of the rare disorders in addition have ASD or ADHD or both, and other individuals may have other neuropsychiatric/neurodevelopmental problems that are symptomatic from a very young age (Gillberg, I. c., et al., 1994; Hagerman et al., 2009; niklasson
BIPOLAR I & BIPOLAR II DISORDER CRITERIA ACCORDING TO DSM-5
pervasive unhappiness and misery characteristic of a major depressive episode. The thought content associated with grief generally features a preoccupation with thoughts and memories of the deceased, rather than the self-critical or pessimistic ruminations seen in a MDe. In grief, self-esteem is generally preserved, whereas in a MDe, feelings of worthlessness and self-loathing are common. If self-derogatory ideation is present in grief, it typically involves perceived failings vis-à-vis the deceased (e.g., not visiting frequently enough, not telling the deceased how much he or she was loved). If a bereaved individual thinks about death and dying, such thoughts are generally focused on the deceased and possibly about “joining” the deceased, whereas in a major depressive episode such thoughts are focused on ending one’s own life because of feeling worthless, undeserving of life, or unable to cope with the pain of depression.
1. In distinguishing grief from a major depressive episode (MDe), it is useful to consider that in grief the predominant affect is feelings of emptiness and loss, while in a MDe it is persistent depressed mood and the inability to anticipate happiness or pleasure. The dysphoria in grief is likely to decrease in intensity over days to weeks and occurs in waves, the so-called pangs of grief. These waves tend to be associated with thoughts or reminders of the deceased. The depressed mood of a MDe is more persistent and not tied to specific thoughts or preoccupations. The pain of grief may be accompanied by positive emotions and humor that are uncharacteristic of the pervasive unhappiness and misery characteristic of a MDe. The thought content associated with grief generally features a preoccupation with thoughts and memories of the deceased, rather than the self-critical or pessimistic ruminations seen in a MDe. In grief, self-esteem is generally preserved, whereas in a MDe feelings of worthlessness and self-loathing are common. If self-derogatory ideation is present in grief, it typically involves perceived failings vis-à-vis the deceased (e.g., not visiting frequently enough, not telling the deceased how much he or she was loved). If a bereaved individual thinks about death and dying, such thoughts are generally focused on the deceased and possibly about “joining” the deceased, whereas in a MDe such thoughts are focused on ending one’s own life because of feeling worthless, undeserving of life, or unable to cope with the pain of depression.
reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth edition, (copyright 2013). American Psychiatric Association.
et al., 2009; Sikora et al., 2006). Indeed, it is very common for such problems to be the original reason for referral. In our center we see quite a number of cases each year in which the behavioral phenotype syndrome (and the genetic abnormality usually underlying it) has been missed.
RARE EPILEPSY SYNDROMES AND FEBRILE SEIZURES
landau-Kleffner syndrome or “verbal auditory agnosia with seizures” is a relatively rare syndrome that often presents in the preschool years and that is sometimes “misdiagnosed” as ASD, ADHD, or both. children with landau-Kleffner syndrome very often meet the criteria for one or both of these types of conditions, but the underlying epileptic syndrome must not remain undiagnosed. Pulsed steroids and in certain cases surgical treatments may be indicated (cross & neville, 2009). The overlap with the syndrome referred to as continuous spike wave activity during slow-wave sleep (cSWS) is considerable, and it is probably more a matter of the child’s age than of any intrinsic difference between landau-Kleffner syndrome (preschool children) and cSWS (older children) which of the named conditions gets a label in the individual case. cSWS is probably a much under diagnosed condition that can sometimes underlie a relatively acute onset of a variety of neuropsychiatric symptoms—including ADHD, tic disorders, and ocD—and can probably be both missed and over diagnosed in cases presenting with the PAnDAS phenotype (see below).
Infantile spasms (Saemundsen et al., 2008) and Dravet syndrome with Scn1A mutations (Arzimanoglou, 2009) carry high risks of intellectual disability, ASD, and ADHD. It is important that such additional diagnoses are not overlooked in the follow-up of preschool children with these rare epilepsy syndromes, given that clinical experience suggests beneficial effects of ASD and ADHD interventions even in the presence of the severe underlying seizure disorder. other rare epilepsy syndromes with onset in the preschool period are usually of such devastating character that making additional diagnoses of neuropsychiatric disorders such as ASD and ADHD is often not discussed or indeed relevant. However, just occasionally, epilepsies of the lennox-Gastaut type (and other, even rarer conditions) can be sufficiently well controlled and ASD- or ADHD-type problems so pronounced that the issue of eSSence might be raised. In such instances it would not be appropriate to conclude that given the nature and severity of the epilepsy syndrome, an additional diagnosis of ASD, ADHD, or another eSSence behavior disorder would make little difference. There is sufficient anecdotal support for the notion that even in cases considered “hopeless,” interventions targeting ASD and/or ADHD may drastically improve quality of life for affected families.
PANDAS (PEDIATRIC AUTOIMMUNE NEUROPSYCHIATRIC DISORDERS ASSOCIATED WITH STREPTOCOCCAL INFECTION)
The term PAnDAS was introduced by Swedo to describe a subset of childhood obsessive-compulsive disorders (ocD) and tic disorders (often with associated symptoms from other categories of eSSence) triggered by group-A beta-hemolytic Streptococcus pyogenes infection (Swedo et al., 1998). More recently, the acronym PAnS (pediatric acute-onset neuropsychiatric syndrome) has been introduced to account for cases with similar acute-onset symptomatology but without a proven link specifically to streptococcal infection. case reports and case series have documented that PAnDAS/PAnS can present with a wide variety of eSSence symptoms, not just ocD and tics, but also ADHD, manic and bipolar symptoms, DcD (specifically acute-onset handwriting difficulties), language regression (and other, usually transient, regressive symptoms), and intrusive thoughts reminiscent of schizophrenia/psychosis. Urinary urgency with an ocD-type quality and acute onset usually combined with separation anxiety should alert the clinician to the possibility of PAnDAS/PAnS.
Similar to adult ocD, PAnDAS is suggested to be associated with basal ganglia dysfunction (Moretti et al., 2008). The symptoms overlap with those of Sydenham chorea. other putative pathogenetic mechanisms of PAnDAS include molecular mimicry and autoimmune-mediated altered neuronal signaling, involving calcium-calmodulin dependent protein (caM) kinase II activity. nonetheless, the contrasting results from numerous studies provide no consensus on whether PAnDAS should be considered as a specific nosological entity or simply a useful clinical research framework.
It is still unclear to what extent PAnS responds to a variety of treatments, including antibiotics, steroids, or immunoglobulin therapies. A number of case studies suggest that such (early) interventions could be of considerable positive effect. The relative dearth of research into the fascinating area of autoimmunity and early-onset neurodevelopmental disorders is surprising, given the strong upsurge in interest demonstrated already more than a decade ago (Dale & Heyman, 2002).
RAD (REACTIVE ATTACHMENT DISORDER)
There is emerging evidence that rAD as defined under the DSM-IV-tr/ DSM-5 exists as a relatively distinct problem (Minnis et al., 2009). It can be recognized in the preschool years (Zeanah et al., 2003) and separated from—although symptomatically overlapping with—ADHD during the early school years (Minnis et al., 2009). It also is associated with severe pragmatic language problems that are not explained by the occasional co-occurrence with ASD (Sadiq et al., 2012). It is of considerable interest that a large subgroup of children meeting symptomatic criteria for rAD have not been severely abused or deprived in early childhood (Minnis et al., 2009). A brief screen for the disorder is available for school-age children (Minnis et al., 2002), but there is a need for development of more refined screening and diagnostic tools for preschoolers. The disorder should be considered in all children who have suffered severe maltreatment or deprivation in the early years, and perhaps also in all children with any kind of impairing eSSence symptom who show the possibly discriminating feature of overfriendliness, indeed sometimes even cuddliness, with strangers (Minnis et al., 2009).
OVERLAP, COEXISTENCE, AND “COMORBIDITY”
The word “comorbidity” is inadequate when it comes to describing and delineating the reality and meaning of the co-occurrence of phenomena, problems, symptoms, syndromes and disorders, and diseases in the clinical and research fields of eSSence. Most clinicians and researchers attach different meanings to the word “comorbidity”(caron & rutter, 1991). Using the word in a literal sense, one would assume that a person diagnosed with “comorbid” ASD and ADHD would have two different morbid (“disease”) conditions. These morbid conditions could have different etiologies, the same etiology, or no known etiology (“idiopathic”). In actual fact, when we talk about comorbidity, what we are usually referring to is “coexistence,” “association,” “overlap,” “additional problems” or suchlike. When the word “comorbidity” has been used here (usually within quotes), it has been “in that sense.”
The syndromes subsumed under the eSSence label constitute collections of symptoms—sometimes, but certainly not always, operationalized under rigidly structured algorithms—that, at the current state of our knowledge, appear to delineate clinically meaningful conditions. However, as our knowledge base increases, so the algorithm barriers for making the specific diagnoses will need to be reviewed and, quite often, changed. This has happened over the past 30 years in ASD and ADHD. The DSM-5 introduces another, probably major, change in how these categories are conceptualized, operationalized, algorithmized, and diagnosed. There is growing realization that (a) most so-called syndromes, including ADHD, DcD, IDD, and ASD, are, at least to some extent, partly arbitrary endpoints or cutoff points on normal distribution curves, and depending on where you draw the line, you may be referring to autistic disorder or Asperger syndrome; (b) most syndromes comprise a mixture of symptom collections from endpoints or cutoff points of different normal distribution curves, so that, at intersections, some individuals affected will meet the criteria for ASD, others for ASD with ADHD, and others still for ADHD “only”; (c) most syndromes can be “mimicked by” (or may have actually be modeled around) more circumscribed brain disorders (genetic or environmental) or diffuse or unspecific/specific brain injury/ dysfunction (temporary or chronic) caused by a variety of factors, including the effects of myelin disorder after extreme prematurity, periventricular bleeding after perinatal asphyxia, thalidomide—or extremes of alcohol—exposure in fetal life, and exposure to products included in diets currently considered to be “normal,” or at least not harmful. Against this background, it should come as no surprise that the introduction of the term eSSence, as suggested by the definition of the acronym, is nothing but an attempt to acknowledge this state of affairs, and the fact that we need to implement this approach to thinking about the problems in the whole wide field of child health and development services.
THE IMPLICATIONS OF ESSENCE
In summary, the reasons why a term such as eSSence is needed at this point in time in child psychiatry, developmental medicine, and child neurology, are as follows:
eSSence is a new “label” but not a new way of thinking about early-onset problems that continue to affect children’s development long after the preschool period.
eSSence is intended to query the current trend toward
compartmentalizing syndromes in child and adolescent psychiatry and developmental medicine to the extent that “things” such as ADHD, DcD, and ASD are considered “boxes” that are exclusive and always separable from each other. eSSence draws attention to the fact that there is no simple solution
to diagnosis in young children who present with symptoms indicating eSSence. All children presenting with an eSSence problem need a holistic approach and need to be considered from the point of view of “multiproblems” and the possible need for multidisciplinary assessment and intervention.
The overlap of problems encountered in the field of eSSence indicates that ADHD, DcD, ASD, and so forth are not discrete disorders or syndromes. They share underlying genetic and epigenetically driven brain dysfunctions/neurodevelopmental problems that reflect circuitry breakdown, network dysfunctions, and decreased/aberrant/increased connectivity or, indeed, in some cases, “normal” brain function variants. Therefore, it would be inappropriate to diagnose one problem and not consider the implications of the other(s). The trend toward delivering services and clinics specifically for ADHD, tourette syndrome, or ASD does not appear to be helpful. In the future, as we learn more about the extent of normality, and about the fact that we are all different, there may not be a need for lumping together diagnoses (such as eSSence) but for specific diagnosis of genetic and environmental contributors to the problems encountered in each individual case.
All of the above would appear to combine to suggest the obvious solution. there is a need for child eSSence centers (rather than separate behavioral pediatrics, child psychiatry, child neurology, Slt services, special education units, ADHD, tourette, ASD, or affective disorder centers) to be organized for all preschool and school-age children, catering to the diagnostic medical assessment, intervention planning, and follow-up requirements that are clearly warranted for the vast majority of children presenting with a major eSSence symptom. There is abundant evidence that major problems in at least one eSSence domain before age 5 years signal major problems in the same or overlapping domains several years later. There is no time to “sit down and wait”; something needs to be done, and that something is unlikely to be “just” in the area of hyperactivity and inattention, speech and language, “just” in the area of social communication, or “just” in special education.
The development of problems in eSSence from pregnancy through the early years and adolescence into adult life is depicted in Figure 3.2.
Progress in medical research often leads to refinement of diagnostic criteria and more precise methods of subgrouping according to etiology, with consequences for intervention. Superficially, this much-accepted view of evidence-based medicine could be seen as support for a “splitter”
Figure 3.2. eSSence through the lifespan. Graphics prepared by S. Graham.
approach to medical progress. The introduction of the eSSence label could, therefore, be taken by some to signal a step back in development in child psychiatry, child neurology, and pediatrics, given its implicit support for a “lumper” view. However, lumping of eSSence will be meaningful only if clinicians and researchers start by approaching the area of early child developmental problems by accepting that splitting in a state-ofthe-art way (making detailed and individualized diagnosis and intervention plans) will be possible only if there is anything to start splitting from (i.e., from a “lumped” group of cases). Also, if splitting occurs already in the mind of the original clinician/referring person (i.e., hyperactivity and behavior problems are seen as the domain of the ADHD specialist, delayed language is seen as the “property” of the Slt, social interaction problems are seen as the “remit” of the “autism center,” and delayed overall development with behavior problems is seen as the “business of the learning disability psychiatrist”), this would lead to inadvertent delay in recognizing that the child with eSSence very likely will have more than one problem (i.e., ADHD with DcD, ASD with ADHD and epilepsy, ADHD with tourette syndrome, ocD, and rAD, etc.).
In summary, the introduction of the eSSence mode of thinking about problems to do with deviations from normal child development should not be taken as support for lumping rather than splitting, but for the order in which these two aspects of diagnosis are approached.
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Scientific Research Poster Planning Worksheet
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Source #1 (A BOOK): Gillberg, C. (2014). Adhd and its many associated problems. Oxford University Press.
Source #2: Straughen, J. K., Sitarik, A. R., Wegienka, G., Cole Johnson, C., Johnson-Hooper, T. M., & Cassidy-Bushrow, A. E. (2023). Association between prenatal antimicrobial use and offspring attention deficit hyperactivity disorder. PLoS ONE, 18(5), e0285163.
Calvo, N., Marin, J. L., Vidal, R., Sharp, C., Duque, J. D., Ramos-Quiroga, J.-A., & Ferrer, M. (2023). Discrimination of Borderline Personality Disorder (BPD) and Attention-Deficit/Hyperactivity Disorder (ADHD) in adolescents: Spanish version of the Borderline Personality Features Scale for Children-11 Self-Report (BPFSC-11) Preliminary results. Borderline Personality Disorder and Emotion Dysregulation, 10(1), NA.
Astenvald, R., Frick, M. A., Neufeld, J., Bölte, S., & Isaksson, J. (2022). Emotion dysregulation in ADHD and other neurodevelopmental conditions: a co-twin control study. Child and Adolescent Psychiatry and Mental Health, 16(1), NA.
Soler-Gutiérrez, A.-M., Pérez-González, J.-C., & Mayas, J. (2023). Evidence of emotion dysregulation as a core symptom of adult ADHD: A systematic review. PLoS ONE, 18(1), e0280131.
Wu, Y., Xu, L., Wu, Z., Cao, X., Xue, G., Wang, Y., & Yang, B. (2023). Computer-based multiple component cognitive training in children with ADHD: a pilot study. Child and Adolescent Psychiatry and Mental Health, 17(1), NA.
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