Upload
tamsyn-kelley
View
214
Download
0
Tags:
Embed Size (px)
Citation preview
Introduction
Pervasive Developmental Disorder (PDD) Key Features:
Delay or loss of appropriate social skills, language, and behavior
Affects many developmental areas, starting early and persisting throughout life
Examples: Rett’s Disorder, Autistic Disorder, Childhood
Disintegrative Disorder, Asperger’s Disorder, Pervasive Developmental Disorder Not Otherwise Specified
History 1966 - Dr. Andreas Rett of Austria observed
two females with unusual hand-wringing motions
1983 - Dr. Bengt Hagberg of Sweden published comprehensive review of Rett’s Disorder in an English neurology journal
1984 - First International Rett Syndrome Conference in Vienna
1985 - Dr. Hugo Moser organized first North American International Rett Syndrome Conference in Baltimore, MD; International Rett Syndrome Association established
DSM-IV: Diagnosis of Rett’s Disorder
A. All of the following: (1) apparently normal prenatal and perinatal development (2) apparently normal psychomotor development through the first
5 months after birth (3) normal head circumference at birth
B. Onset of all of the following after the period of normal development:
(1) deceleration of head growth between ages 5 and 48 months (2) loss of previously acquired purposeful hand skills between ages
5 and 30 months with the subsequent development of stereotyped hand movements (e.g., hand-wringing or hand washing)
(3) loss of social engagement early in the course (although often social interaction develops later)
(4) appearance of poorly coordinated gait or trunk movements (5) severely impaired expressive and receptive language
development with severe psychomotor retardation
Differential Diagnosis Rett’s Disorder
Mostly females Deterioration in
developmental milestones, head circumference, overall growth
Loss of purposeful hand movements
Stereotypic hand movements (hand-wringing, hand washing, hand-to-mouth)
Poor coordination, ataxia, apraxia
Loss of verbalization Respiratory irregularity Early seizures Low CSF nerve growth factor
Autistic Disorder Mostly males Abnormalities present from
birth
Stereotypic hand movements not always present
Little to no loss in gross motor function
Aberrant language, but not complete loss
No respiratory irregularity Seizures rare; if occur,
develop in adolescence Normal CSF nerve growth
factor
Differential Diagnosis Continued...
Childhood Disintegrative Disorder Lacks the characteristic deficits of Rett’s Disorder Regression occurs later than Rett’s Disorder
Asperger’s Disorder Marked restriction of interests, activities, and behaviors No significant impairment of language, cognition, or
adaptive behaviors
Pervasive Developmental Disorder Not Otherwise Specified
Lacks the characteristic deficits of Rett’s Disorder or other PDD
Four Stages of Rett’s Disorder
Stage I: Early-onset stagnation Onset: Six months - 1.5 years old Delayed development, but not significantly
abnormal Deceleration of head growth Disinterest in surroundings Hypotonia Normal EEG (or minimal slowing) Duration: Weeks to months
Four Stages of Rett’s Disorder Continued...
Stage II: Rapid developmental regression Onset: One to 3 or 4 years old Loss of acquired skills and communication Mental deficiency appears Irritability Loss of purposeful hand movements Stereotypic hand movements develop (hand-wringing, hand washing,
hand-to-mouth) Loss of expressive language Insomnia Self-abusive behavior Occasional seizures EEG: background slowing with loss of normal sleep patterns;
screaming and sleep disturbances Duration: Weeks up to one year
Four Stages of Rett’s Disorder Continued...
Stage III: Pseudostationary period Onset: After passing Stage II Some restitution of communication Preserved ambulation Increasing ataxia, hyperreflexia, and rigidity Hyperventilation when awake, followed by sleep apnea Bruxism Weight loss Scoliosis EEG: some epileptiform activity Happy disposition; enjoy close physical contact Truncal ataxia Duration: Years to decades
Four Stages of Rett’s Disorder Continued...
Stage IV: Late motor deterioration Onset: Ceasing of ambulation Complete wheelchair dependence Severely disabled and distorted Progressive muscle wasting, spasticity, and scoliosis Growth retardation Cool extremities due to venous stasis Constipation Fewer Seizures Duration: Decades
Variant Forms of Rett’s Disorder
Atypical, or “Forme fruste” Characteristics first appear in late childhood
Late childhood regression Early psychomotor delay; regression later in
childhood Congenital
Lacks initial period of normal development Familial Preserved speech Rett’s Disorder in males
Genetics of Rett’s Disorder
X-linked dominant disorder, lethal in 46,XY males Proof of genetic basis of Rett’s Disorder
Confirmed only in females and males with an extra X chromosome
Complete concordance in monozygotic twins 1989: First vertical transmission identified 1990: Drs. Zoghbi, Percy, and Schultz discovered nonrandom X
inactivation in the mother of two half-sisters with Rett’s Disorder 1998: Drs. Sirianni, Naidu, and Pereira confirmed X-linked
dominant inheritance, localizing gene to Xq28 1999: Drs. Amir, Van den Veyver, and Wan linked Rett’s
Disorder to mutations in X-linked MECP2 gene, which encodes methyl-CpG-binding protein 2 and usually undergoes inactivation
2000: Missense mutations = milder phenotype
Rett’s Disorder in 47,XXY Male
Case described by Dr. Schwartzman, et al.
47,XXY male born in January 1995 Normal prenatal and perinatal periods Eight months - could sit without support and speak Eleven months - lost hand function, head growth
deceleration One year - stereotypical hand movements, bruxism,
constipation Twenty eight months - global retardation, hypotonia Thirty seven months - increasingly severe apnea Conclusion: Two X chromosomes are needed for
the manifestations of Rett’s Disorder
Neurologic Abnormalities and Treatment
Seizures in 75%, most severe earlier in life
Abnormal EEG in 100% Truncal ataxia Treatment: Carbamazepine for
seizures, ketogenic diet for seizures and motor function
Gastroenterologic Abnormalities and Treatment
Weight loss Constipation Bruxism GI reflux Swallowing, chewing difficulties Calcium deficiency Treatment: Nutritionist, therapist to aid
in feeding, multivitamins, gastrostomy tube
Respiratory Abnormalities and Treatment
Cyanotic spells while awake due to central apnea and hyperventilation
Treatment: Acetazolamide for hyperventilation
Sleep Disturbances and Treatment
Night waking, screaming, laughing Increased daytime sleep with age;
delayed onset of sleep at night Treatment: Behavioral modalities
Orthopedic Abnormalities, Motor Disturbances, and Treatment
Early truncal ataxia Agitation Legs abducted Hypotonic early; hyperreflexive and rigid
later Scoliosis (64% prevalence) Treatment: Brace/surgery for scoliosis,
orthopedic and intensive physical therapy, special computers and toys
Gynecologic Concerns
Usually normal onset of puberty, but delayed menarche possible due to decreased body fat
Monitor for UTIs and Candida infections
Communicative and Cognitive Concerns and Treatment
Babbling, single words by 10-12 months; lose verbalization by 18 months
Impaired cerebral cortex due to language loss
More quiet, improved eye contact with time Happy disposition Treatment: Speech/language therapy,
music therapy
Summary Rett’s Disorder is a type of Pervasive Developmental
Disorder with severely impaired social skills, language, behavior, and motor function
Affects females and males with 47,XXY karyotype Normal initial development, regression after 6 months Consists of four stages of progressive deterioration X-linked dominant inheritance; caused by mutations in
MECP2 gene Various therapeutic modalities for individual
dysfunctions of Rett’s Disorder, but no cure at present Future studies: Gene therapy?