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Research Article                                                                                                                                        Open Access

## Collection of developmental history in the evaluation of schizophrenia spectrum disorders

Angela M. Reiersen

Washington University in St. Louis School of Medicine, MO, USA

Corresponding author: reiersea@psychiatry.wustl.edu

## Abstract

Background : Schizophrenia is a heterogeneous disorder that is characterized by varying levels of hallucinations, delusions, negative symptoms, and disorganized features. The presence and severity of neurodevelopmental precursors and premorbid psychopathology also vary among individuals. To fully understand individual patients and to sort out phenotypic heterogeneity for genetic research studies, instruments designed to collect developmental history relevant to schizophrenia may be helpful.

Objective: The  goal  was  to  describe  a  pair  of  self-report  and  parent-report  instruments  developed  for  the  purpose  of collecting the developmental history of patients with known or suspected schizophrenia spectrum disorders.

Method: Two developmental history instruments were designed for use in studies of brain morphology and cognition in schizophrenia probands and their unaffected siblings. The instruments focus mainly on motor abnormalities and other features that have been described as schizophrenia precursors.

Results : The Motor Skills History Form is a brief self-report form that asks about patients' childhood and adolescent motor abilities as well as their current motor functioning. The Developmental & Motor History Form is a more detailed parent-rated form that covers aspects of patients' early (infant/preschool) development; their childhood and adolescent motor abilities; any  childhood  behaviors  that  may  be  related  to  later  psychosis  risk;  and  their  history  of  any  neurological,  emotional,  or cognitive disorders diagnosed during childhood or adolescence. The instruments can be used either for interviews or as selfadministered questionnaires. The parent-rated form has been used for research and for the clinical assessment of children and adolescents with complex neurodevelopmental presentations with or without strong evidence of schizophrenia risk.

Conclusions: The  collection  of  developmental  history  information  is  important  when  evaluating  individuals  with schizophrenia and related disorders. The Motor Skills History Form and the Developmental & Motor History Form can be used to collect this information for clinical evaluation or research purposes.

Keywords: Schizophrenia; Precursors; Motor; Language; Neurodevelopmental Disorders

## Introduction

The collection of a developmental history during the clinical evaluation of patients with schizophrenia and related  disorders  is  important  for  the  following reasons:

1.  When  evaluating  schizophrenia  risk  states,  a history  of  developmental  delays  (1-5),  abnormal movements  (6-9), motor  coordination  problems (10,11), cognitive dysfunction(2,12,13), and specific psychiatric symptoms or behaviors (14-17) may help to predict the risk of conversion to schizophrenia or another psychotic disorder.
2.  A  history  of  premorbid  neurodevelopmental disorders such as autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder (ADHD), or learning disorders may require specific interventions or predict an individual's potential level of functioning and the degree of support that he or she will continue to need even after any active psychotic symptoms are under good control.
3.  Individuals  with  a  history  of  social  and  nonsocial cognitive problems may benefit from cognitive remediation (18-22).
4.  The  presence of complex neurodevelopmental problems  may  suggest  a  higher  likelihood  that  an

abnormality  would  be  found  with  genetic  testing such  as  chromosomal  microarray  or  whole  exome sequencing  (23-33).  If  a  specific  genetic  cause  is found (e.g., 22q11.2 deletion, which is present in 4% of patients with childhood-onset schizophrenia and 0.3% to 1% of patients with adult-onset schizophrenia [23]), this may warrant specific medical monitoring or treatment.

This  article  describes  a  set  of  self-report  and parent-report instruments that were originally designed in 2005 for the collection of developmental history information from research assessment participants at the Conte Center for the Neuroscience  of  Mental  Disorders  at  Washington University School of Medicine. At the Conte Center, the  instruments  were  used  in  a  study  of  brain morphology and cognition in research subjects with schizophrenia and their unaffected siblings (34-39). Motor abnormalities  such  as  abnormal  involuntary movements and poor motor coordination that were present  before  a  schizophrenia  diagnosis  were  of particular  interest  based  on  a  review  of  existing literature  about  neurodevelopment  in  patients  with schizophrenia.

We  will  now  focus  on  the  description  of  the instruments themselves, and future publications will provide  reports  of  actual  research  findings  as  they become available.

## Methods

## General Description of the Instruments

Self-report  and  parent-report  questionnaires  were developed on the basis of the existing literature (as referenced previously) and personal experience working  with  child,  adolescent,  and  adult  patients with schizophrenia or schizophrenia risk states (Table 1). The Motor Skills History Form (MSHF) is a brief self-report instrument that focuses on elements of the developmental history (particularly motor  function)  that  individuals  may  remember about  themselves,  even  after  they  have  reached adulthood.  The  Developmental  &  Motor  History Form  (DMHF)  is  a  parent-report  measure  that covers some of the same areas (particularly related to child  and  adolescent  motor  abilities)  and  that  also asks about  additional  childhood  and  adolescent symptoms, behaviors, and diagnoses. It also covers relevant  aspects  of  early  (infant  and  preschool) development.

There are problems inherent to the collection of retrospective developmental history, particularly related to an individual's poor recall of events that occurred  years  ago.  Child,  adolescent,  and  adult patients are unlikely to know the details of their own early  childhood  development  unless  a  parent  has provided  this  information  to  them.  However,  they may remember aspects of their motor development history, particularly if they experienced poor motor coordination that affected their ability to participate in  sports  and  other  activities  during  childhood  or adolescence. They may remember how their abilities compared  with  those  of  other  children  their  age, whether they were teased about their poor abilities, whether they avoided physical education classes due to their lack of ability, their degree of participation in organized sports, and perhaps the age at which they learned to ride a bicycle. Individuals can also comment on their perception of their own current motor abilities and any difficulties that they may have had  learning  complex  motor  behaviors,  such  as driving  a  car.  Therefore,  the  self-report  MSHF focuses on these elements. The MSHF focuses on childhood and adolescence, because it is unlikely that individuals will have an accurate recollection of their infancy and preschool years.

Sections A and B of the MSHF focus exclusively on  the  age  range  of  5  to  18  years.  Section  A  asks about specific childhood  and adolescent  motor abilities, while section B focuses on experiences that may have occurred as a consequence of the level of motor ability. Parent-report versions of some of the MSHF Section A and B items are also included in Section C of the DMHF.

Because they ask about current abilities and events, Sections C and D of the MSHF include coverage of adult  experiences  if  the  individual  completing  the questionnaire is an adult.  Section C of the MSHF asks about current motor functioning, including the degree  of  difficulty  experienced  when  learning  to drive a car (if applicable), an overall rating of current athletic  ability,  and  current  interest  in  team  sports game participation for recreational purposes. Section D of the MSHF asks about any neurological or other medical disorders that may have affected motor skills or athletic ability, the patient's age and sex, and the date of the rating.

The  DMHF  collects  parent-report  information about  patients'  developmental  and  motor  history. Section A addresses infancy and the preschool years, and this is followed by sections B through D, which focus on childhood and adolescence. Parents often have  difficulty  remembering  the  details  of  their children's  early  developmental  history,  particularly the exact ages at which their children reached specific developmental  milestones.  Collecting  information about the timing of early developmental milestones (i.e.,  the  ages  at  which  patient  first  sat,  crawled, walked, spoke words, used phrases, and conversed in full sentences) may still be useful in terms of getting a general idea of whether development was seriously delayed, so the DMHF does include questions about these. In the case of motor milestones, there is also an item that asks about the parent's level of certainty regarding the timing. Even if parents do not remember the exact timing of developmental milestones, they are likely to remember major events such as concerns about development that led to an evaluation  of  motor  or  speech  delays  or  to  the provision of speech, occupational, or physical therapy  to  address  developmental  problems.  Thus, questions  about  the  evaluation  and  treatment  of developmental concerns are also included.

TABLE 1 . Descriptions and Sections of the Motor Skills History Form and the Developmental & Motor History Form

Note. Section C of the DMHF includes some items that are also asked in sections A and B of the MSHF. Both instruments also collect information about age, sex, and date of rating at the end of section D.

| Motor Skills History Form (MSHF)                                                                                                                  | Developmental &Motor History Form (DMHF)                                                                                                                              |
|---------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Self-report                                                                                                                                       | Parent-report                                                                                                                                                         |
| Focuses on the developmental history, particularly motor function during the age range of 5 to 18 years. Also asks about current motor abilities. | Focuses on the developmental history from infancy through age 18 years, and also asks about additional symptoms, behaviors, and diagnoses during the same time period |
| Section A: Motor Abilities                                                                                                                        | Section A: Early Development                                                                                                                                          |
| Section B: Motor Consequences                                                                                                                     | Section B: Childhood& Adolescent Behavior                                                                                                                             |
| Section C: Current Motor Functioning                                                                                                              | Section C: Child & Adolescent Motor Skills                                                                                                                            |
| Section D: Untitled section including questions about past and current medical disorders that may have affected motor skills.                     | Section D: Child& Adolescent Neurological, Emotional, and Cognitive Disorders                                                                                         |

Studies of infants and children  with a high genetic risk  for  schizophrenia  due  to  parental  psychiatric history indicate that these children  often  show atypical patterns of development and certain types of abnormal movements, even without the presence of clearly  abnormal  delays  in  motor  milestones  (5,6). For this reason,  the  early  childhood  section  of  the DMHF includes an item that asks whether the child walked before learning to crawl. There is also a series of items that ask about any specific motor behaviors, such as atypical activity level, abnormal muscle tone, unusual  ways  of  walking  or  running,  and  various abnormal movements that may have been observed during  infancy  and  the  preschool  years.  To  help screen for possible ASD, there are some questions about  sensory  sensitivities,  the  child's  response  to being held, and any speech or language delays. There are  also  questions  about  any  medications  taken during early childhood and whether these seemed to affect motor skills or behavior.

Section B of the DMHF contains questions about general childhood behaviors that may indicate some level  of  increased  risk  for  schizophrenia.  Some  of these behaviors have been described as characteristics of children with childhood schizophrenia,  or  they  may  have  been  reported  as precursor behaviors that appeared in at-risk children who  later  developed  schizophrenia.  For  example, observations of general unusual behaviors and atypical peer behaviors (e.g., a preference for playing alone, difficulty playing with more than one child at a time) have been made regarding children who have been diagnosed with childhood schizophrenia (40). In  addition,  teacher-reports  of  unusual  emotional reactions,  inappropriate  behaviors,  and  uneasiness about  criticism  during  childhood  are  some  of  the unusual behaviors that have predicted the development of adulthood schizophrenia spectrum disorders among  high-risk  individuals  (15,17).  Other  items within Section B of the DMHF ask about relatively common and non-specific childhood symptoms that may  possibly  be  relevant  on  the  basis  of  general clinical experience.

Section C of the DMHF focuses on childhood and adolescent motor abilities, beginning with the motor ability items from section A of the MSHF. Since the self-report  MSHF  has  this  same  set  of  items,  it  is possible to compare parent-reports with self-reports. There are also some questions about motor function and  sports  participation  that  are  similar  to  items found in Section B of the MSHF.

Section  D  of  the  DMHF  asks  about  specific diagnoses that the child was given during childhood or  adolescence,  any  medications  that  may  have affected  child  or  adolescent  motor  function  or behavior, the child's age and sex, and the date of the rating.

## Use and Scoring

For clinical use, scoring of the MSHF and DMHF is not  essential,  but  information  gathered  from  the forms can enhance the level of developmental and psychiatric history that is obtained during assessment. Without any need to calculate scores, the information obtained can be used to assist decision making with regard to further diagnostic testing (e.g., to assess the need for detailed autism assessment or genetic testing). The methods of scoring discussed in the following paragraphs may be most important for researchers  who  seek  to  compare  the  levels  of developmental  abnormalities  among  their  research participant groups.

Section A of the MSHF is composed of 14 items that ask the individual to rate their own motor skill abilities as compared with peers of the same age on a scale  of  1  to  5,  with  1  =  far  below  average,  2  = somewhat below average, 3 = average, 4 = somewhat above  average,  and  5  =  excellent.  Participants  are asked to rate themselves twice: once for childhood (5 to 12 years old) and once for adolescence (13 to 18 years old). If the scale is used for patients who are less  than  13  years  old,  the  ratings  that  apply  to adolescent  abilities  can  be  skipped.  The  scores  on these  items  can  be  averaged  to  determine  a  Total Motor Abilities Score, which provides direct information about an individual's perception of his or her ability level. For example, a total score of 2.5 would  indicate that, on  average, the individual perceives that his or her various motor abilities were somewhere  between  the  average  and  somewhat below  average  range  during  the  specified  period. Suggested  subscales  for  this  section  include  Gross Motor Abilities (items 1 through 8), Balance (items 9 through  11),  and  Fine  Motor  Abilities  (items  12 through 14). These can be calculated by averaging the scores  of  the  relevant  items.  Separate  scores  for childhood  and  adolescence  can  be  calculated,  or overall child and adolescent scores can be calculated by  averaging  the  childhood  and  adolescence  items together. It may also be useful to develop alternate subscales  on  the  basis  of  factor  analysis  after  an adequate amount of research data has been collected.

Section  C  of  the  DMHF  includes  14  questions about  motor  abilities  that  are  identical  to  those  of Section  A  of  the  MSHF.  This  allows  for  easy comparison  between  parent-report  and  self-report perceptions.

Section B of the MSHF focuses on behaviors or experiences  that  may  have  occurred  as  a  result  of poor motor coordination, such as a dislike of physical education classes, teasing about poor physical abilities, being clumsy or accident-prone, learning to ride a bicycle at a later age (item C15 of the DMHF asks the same bicycle information), and the order in which  the  participant  was  asked  to  participate  in sports teams. Items B1 through B5 can be averaged to get a score, or they may be examined individually. This  section  also  contains  items  that  ask  about participation  in  organized  sports  (MSHF  items  B6 through B8) and any history of receiving physical or occupational therapy (B9 and B9a). The number of sports listed may be useful as a variable for analysis. DMHF items C16 through C20a also cover sports participation and therapy history.

The items in sections C and D of the MSHF (see earlier description) may  be best considered as individual items rather than being combined into any subscales.

Section A of the DMHF requires parents to recall information about their children's infant and preschool years. As in some other sections of these instruments, respondents are asked to give their best guesses  if  they  are  unsure  about  the  answers.  This instruction  may  minimize  the  tendency  for  some respondents to skip items due to minor uncertainties and  thus  allow  a  greater  amount  of  data  to  be collected. However, when interpreting this particular section,  evaluators  should  keep  in  mind  that  there may be a higher potential for inaccurate responses when  parents  are  trying  to  recall  their  children's earliest  years.  Because  it  is  expected  that  many parents will not accurately recall the exact dates of developmental milestones, caution is warranted when using and interpreting any scores that are based on  the  ages  at  which  milestones  were  met.  The comparison  of  these  values  among  subject  groups may still be useful, especially for cases in which baby books or medical records have been used to confirm the exact timing of developmental milestones. The endorsement of dichotomous yes/no answers regarding specific behaviors and problems, early life evaluation  for  developmental  concerns,  or  specific treatment  interventions  can  be  compared  among research subject groups as appropriate. The questions that ask about the presence or absence of specific early childhood motor behaviors (items A4 through  A24)  can  be  used  to  create  a  score  by counting the number of positive responses. Because such behaviors may or may not be noticed even if they are present, a 'yes' response can be considered to indicate that the behavior was frequent or obvious enough for the parent to recall seeing it, and a 'no' or blank response may indicate that the behavior was either not present or not obvious or frequent enough for the parent to clearly remember it. As long as most items in the section are answered, it may  be appropriate to recode any missing responses as 'no' responses.

Items on Section B of the DMHF, which address childhood  and  adolescent  behavior,  can  either  be considered separately or coded such that each 'yes' answer contributes a point to a total symptom count score. Section D items about childhood and adolescent  disorders  can  be  scored  in  a  similar manner, and subscales can be created to separately indicate the number of neurodevelopmental disorders  (items  D1  through  D4  and  D6  through D13)  and  other  psychiatric  disorders  (items  D14 through D16) that were diagnosed.

The MSHF and the DMHF were first used in the previously mentioned Conte Center research study, which focused on individuals with schizophrenia and their unaffected siblings. Subjects in that study were mainly adolescents and young adults who were in the range of 14 to 30 years old. The measures were later used  in  a  separate  study  of  child,  adolescent,  and adult sibling pairs that were discordant for ADHD. Research  use  of  the  instruments  for  both  projects was approved by the Washington University Human Research Protection Office.

## Results

The original full versions of the MSHF and DMHF are provided along with this report; see the associated Supplemental  Materials.  The  analysis  of  collected MSHF and DMHF research data is ongoing and will be reported in the future. In addition to being used in  the  previously  discussed  research  studies,  the DMHF  has  been  used  in  non-research  clinical diagnostic  evaluations  of  children  and  adolescents with complex neurodevelopmental problems or with features that suggest high risk for the development of a schizophrenia spectrum disorder. These instruments have mainly been used as selfadministered  questionnaires,  but  they  can  also  be used  as  interview-based  measures.  Any  questions regarding instructions for the use of these instruments,  future  updated  versions,  or  progress toward normative data collection can be directed to the author.

## Discussion

Assessment of the developmental history is appropriate as part of clinical or research evaluations of children, adolescents, and adults with schizophrenia or with risk factors for the development of a schizophrenia spectrum disorder. A developmental history is often a key component of the standard clinical evaluations performed by child and adolescent psychiatrists, whether or not schizophrenia  is  part  of  the  differential  diagnosis. However, because schizophrenia is often diagnosed during late adolescence or early adulthood, individuals with schizophrenia may first be evaluated and treated by general psychiatrists, who may or may not routinely ask many questions about developmental history as part of their assessments. Even  if  an  evaluating  psychiatrist  or  psychologist does ask about the patient's developmental history, the questions asked may not be tailored toward the collection of information that is particularly relevant to the developmental course of schizophrenia.

The MSHF and the DMHF are presented here as one  method  for  the  collection  of  developmental history information, with an emphasis on aspects that are relevant to the natural developmental course of schizophrenia spectrum disorders. These questionnaires are particularly appropriate for use in individuals with known or suspected schizophrenia spectrum disorders, but they can also be useful for the  evaluation  of  children,  adolescents,  and  adults with complex forms of psychopathology that do not necessarily  indicate  schizophrenia  risk,  such  as  the co-occurrence of multiple neurodevelopmental problems or behavioral disturbances in young patients who do not have any known family genetic or other risk factors for psychosis.

In clinical practice, when evaluating children with symptoms  that  are  suggestive  of  psychosis,  the developmental history may contribute to the making of decisions about whether to order genetic testing. One study found disease-related copy-number variants (CNVs) in 11.9% of patients with childhood-onset schizophrenia,  and  a  few  of  these individuals  (4  out  of  the  15  with  CNV  findings) actually  had  a  second  neuropsychiatric-disorderassociated CNV  (23). These CNV  rates were significantly  higher  than  those  of  the  two  adult schizophrenia samples that were used for comparison, which were 1.4% and 4.9%. One wellestablished genetic cause of schizophrenia is 22q11.2 deletion syndrome, which is estimated to be present in 0.3% to 1% of patients with adult-onset schizophrenia and in 4% of patients with childhoodonset  schizophrenia  (23).  Individuals  with  22q11.2 deletion  have  about  a  30%  chance  of  developing schizophrenia or another psychotic disorder during their lifetimes (41). These individuals also frequently show  signs  of  ADHD,  ASD,  and  cognitive  or learning problems during childhood (28;42-44). Therefore, the co-occurrence of psychotic symptoms with ADHD,  ASD, or other childhood-onset neurodevelopmental symptoms may prompt chromosomal  microarray  testing  to  evaluate  for 22q11.2 deletion and any other CNVs that may be present. Recent studies of CNVs have suggested that various  specific  genetic  duplications  and  deletions can increase an individual's risk for a broad array of neurodevelopmental disorders, including ASD, ADHD,  various  movement  disorders,  intellectual disability, and schizophrenia (24-26;29-33). Thus, the presence of a higher number of these problems may indicate an increased need for genetic testing.

The  collection  of  detailed  developmental  history information  is  also  important  for  research  studies, particularly those that focus on diagnostic nosology, genetics, and individualized treatment. Recent research suggests that there are several subtypes of schizophrenia, which can be classified according to genotypic  networks  of  interacting  single-nucleotide polymorphisms or specific patterns of schizophrenia symptoms  (45).  Phenotypic  subgroups  of  patients with schizophrenia also were found to have distinct patterns of fractional anisotropy in a diffusion tensor imaging study of brain white matter (46). Defining more genetically homogeneous phenotypic subtypes of schizophrenia may  need  to go beyond  the examination of schizophrenia symptom patterns to include the presence or absence of motor abnormalities,  specific  cognitive  deficits,  learning problems, atypical development patterns, and other co-occurring problems. Future research may reveal that individuals with distinct patterns of developmental history tend to have specific genetic abnormalities that lead to the dysfunction of specific brain systems. If this is the case, then the evaluation of a patient's developmental history in addition to his or  her  current  symptoms  may  ultimately  provide information about that patient's likely responses to specific treatments.

When using the MSHF, the DMHF, or any method of collecting a patient's developmental and psychiatric history, several limitations should be kept in  mind.  Memory  is  not  perfect,  so  retrospective reports are not always accurate. There may also be a tendency for recall bias to arise from parents or from the affected individuals themselves as they think back to try to come up with any early risk or causal factors that may help to explain the development of a severe mental  illness.  This  recall  bias  can  be  a  particular problem  in  research  studies  that  compare  patients with  severe  mental  illnesses  to  healthy  individuals. Reviewing physical records (e.g., baby books, school reports,  medical records) rather  than  relying  on  an individual's retrospective recall of events may help to reduce error, but some behaviors and symptoms of interest  may  not  be  captured  in  such  records,  and these additional types of data are not always available.

Since the creation of the DMHF and the MSHF, there  have  been  some  advances  in  the  diagnostic nomenclature of childhood-onset psychiatric disorders. Although the 2005 versions of the forms are still appropriate for picking up the problems and diagnoses  of  interest,  some  modifications  may  be helpful to clarify the types of past diagnoses that were present. For example, the term mental retardation has now fallen out of favor in the United States, and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)  instead  uses  the  terms intellectual disability or intellectual  developmental  disorder. Clinicians and researchers in other countries may use different terminology, so other appropriate adjustments may need  to  be  considered  for  studies  outside  of  the United  States.  Although  a  revised  version  of  the DMHF will include updated terminology, the older term mental  retardation may  be  worth  mentioning parenthetically for the benefit of parents who were told in the past (before the DSM-5) that their child had this condition and who may not be aware of the updated terminology.

On the  basis  of  experience  with  the  use  of  this instrument, it has also become evident that parents sometimes have difficulty distinguishing between the terms speech disorder and learning disorder in communication or language. Additional questioning by the examiner or the  inclusion  of  updated  items  to  help  distinguish among the various DSM-5 communication disorders may be helpful. This could include questions to try to determine  the  presence  or  absence  of  a  childhood language disorder, a speech sound disorder, a childhood-onset fluency disorder (e.g., stuttering), or a  social  (pragmatic)  communication  disorder.  In some  cases,  the  parent  still  may  not  be  able  to provide  full  information  to  confirm  the  specific communication disorder diagnosis (e.g., if the parent only knows that the child was given a diagnosis of 'speech/language  impairment'  by  the school),  but further questions about the specific types of speech/language issues observed may provide some clarification.

Since the creation of these instruments, an association  between  obsessive-compulsive  disorder (OCD) and a future risk of schizophrenia has been reported (47). Although the DMHF includes items about preoccupation with one's own thoughts and certain repetitive behaviors, these symptoms are not specific for OCD, and there is no specific question about past OCD  diagnosis. Therefore, asking additional questions about OCD symptoms may be helpful during the course of clinical evaluation.

Despite the limitations and current lack of normative data, the MSHF and DMHF instruments can be used to collect valuable developmental history information that, according to the existing literature, has  known  relevance  to  schizophrenia  spectrum disorders. Future reports of normative and psychometric  data  as  well  as  studies  that  compare scores among various high-risk and diagnostic groups may greatly increase the usefulness of these instruments for both clinical and research purposes.

## Clinical Significance

When evaluating a patient with a known or suspected schizophrenia spectrum disorder, obtaining an appropriate developmental history may provide information relevant to the patient's prognosis and to decisions about the further diagnostic testing and treatment intervention needs of the patient. The selfreport MSHF and parent-report DMHF can be used as interviews or self-administered questionnaires to collect this developmental history information.

## Funding

This  work  was  supported  by  grant  nos.  P50-MH071616  and  K08-MH-080287  from  the  National Institute of Mental Health. The content is solely the responsibility of the author and does not necessarily reflect the views of the National Institute of Mental Health or the National Institutes of Health.

## Disclosures

The author has received research grant funding from the  National  Institutes  of  Health,  the  McDonnell Center for Systems Neuroscience, and the McDonnell Center for Cellular and Molecular Neurobiology. She has received travel support from the  Child  and  Adolescent  Psychiatric  Department, Region Zealand (a hospital in Denmark), to attend and speak at scientific meetings. The author does not have  any  financial  relationships  with  commercial industry.

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## Supplementary files

- 1) Motor Skills History Form
- 2) Developmental & Motor History Form