Neurobehavioral Concerns in Children with Down Syndrome
Behavior is often a presenting concern by parents on behalf of children with Down syndrome. Although maladaptive behaviors are in no way unique to either young children with trisomy21, or intellectual disability both the type and severity of certain behaviors could be considered a marker, heralding the presence of some underlying neurobiological difference associated with atypical development. It's estimated that about 20% of children with Down syndrome have a secondary behavioral diagnosis. However parents and teachers may have concerns about behavior which do not warrant a secondary diagnosis, but nonetheless are present under certain circumstances or situations.
What behaviors are considered typical for preschool children with Down syndrome?
Behaviors considered typical in any preschool child:
- Separation or stranger-anxiety, bedtime problems
- Increased motor activity, very busy
- Mischievous behavior for social attention
- Mild tantruming when limits are set or privileges denied
Behaviors which may be character-traits of some children with Down syndrome:
- Routine-oriented, resistant to change
- Stubborn, persistent
- Overly sociable, affectionate
- Deliberate mischievous behavior for social attention
What other behaviors may be seen in some preschool children with Down syndrome?
Repetitive motor acts which are occasional and easy to interrupt
- Waves objects, dangles strings, stares at hands, hums-moans, grinds teeth, rocks (especially when bored)
- Tenses arms-legs, shakes-waves arms, grimaces, makes happy noises, (especially when excited)
- Hypersensitive to touch (haircuts, tooth-brushing); sounds (loud noises, chaos)
- Food refusal –based on textures
What behaviors are NOT typical for preschool children with Down syndrome?
Behaviors which result in significant interference with learning, socialization or safety concerns, especially when they occur across multiple environments (home-school-community)
- Repetitive motor acts which are frequent, intense and difficult to interrupt
- Body rocking, hand flapping, dangling strings-beads-belts, prolonged staring, throaty noises
- Inability to focus, attend to tasks or organize play activities
- Lack of interest imitating other children at play
- Inability to understand spoken words
- High motor activity resulting in unsafe or risky behavior- climbing, running off
Behaviors resulting in physical harm to self or to others
- Self: Head banging or hitting, slapping, biting, poking eyes-ears-nose, skin-picking or scratching
- Others: Hitting, kicking, hair-pulling or biting
- Property destruction: throwing or breaking objects
- Self injury: head-banging, hitting, bitting, skin picking
What is meant by the term “dual diagnosis”?
What features distinguish a psychiatric or neurobehavioral disorder from willful misbehavior?
An example of complex-severe behavior
Intensity: behaviors are becoming more frequent and longer lasting, across different settings
Complexity: irritability and agitation occurs with episodes of urinary or bowel incontinence, followed by kindness and remorse.
What are some other “clues’ to look for besides the behavior itself?
Physiologic symptoms may be present
Abnormal or highly inconsistent: sleep pattern, fluctuating (irritable or unstable) mood, unusual response to sensory stimuli
Neurocognitive changes may be present
Abnormal or highly inconsistent: attention, gaze-preference, initiative-spontaneity, cognitive planning-organization, play routines or social interactions. Actual loss of established skills “developmental regression”
A medical condition may be present
Conditions causing pain, discomfort or high anxiety
A psychiatric disorder may be present in a 1st degree relative
Bipolar disorder, Schizophrenia, Autism, Obsessive-compulsive or Tic disorder
What is meant by the term co-morbidity or “co-occurring feature”?
A co-morbidity or “co-occurring feature” is when a primary neurobehavioral or psychiatric condition has other distinguishing features which can complicate the diagnosis, management and outcome, for example:
- Autism with irritability and self-injury
- ADHD with oppositional-defiant behavior
- Disruptive behavior with anxiety and compulsive features
- Obsessive-compulsive disorder with vocal tics
- Depression with repetitive self-talk and yelling at imagined others
Who should make the call regarding a dual diagnosis?
Be prepared for what can be a litany of helpful but contradictory suggestions that are difficult to sort out, especially for a family in crisis! You want to work with professionals who can help you understand, evaluate and prioritize your various options, and are not overtly critical or threatened by your attempts to design a program that is best for your child. Professionals who offer you “my way or the highway” are no fun to work with, but occasionally do get it right.
Is it actually beneficial to have a dual diagnosis of ADHD, Autism or Disruptive disorder?
What may need to be done differently for your child if a dual-diagnosis is confirmed?
Develop Your Action Plan