Soft Signs Research Articles

P.213 Specific polygenic risk scores discriminate asymptomatic at-risk individuals according to their brain amyloid load

Despite substantial efforts in the last decades, objective measures that can predict clinical outcome in patients with schizophrenia (SZ) after an acute psychotic episode are still lacking. Here, we introduced a comprehensive assessment of sensorimotor function to predict mid-term clinical outcome following an acute psychotic episode. This naturalistic follow-up of 43 patients with DSM-IV-TR diagnosis of SZ examined sensorimotor abnormalities (i.e. Neurological Soft Signs (NSS), parkinsonism, akathisia, catatonia and acute dyskinesia), psychopathology, cognition and psychosocial functioning using well-established instruments. A collection of statistical methods was used to examine the relationship between sensorimotor domain, psychopathology, cognition and psychosocial functioning. We also tested the clinical feasibility of this relationship when predicting clinical outcome after an acute psychotic episode. Longitudinal data were collected on 43 individuals after a follow-up period of >6 months. At follow-up, patients showed significantly reduced general symptom severity, as well as decreased levels of NSS, parkinsonism and catatonia. Further, NSS scores at baseline predicted PANSS negative scores and cognitive functioning at baseline. Finally, NSS scores at baseline predicted symptom change (reduction of PANSS positive and negative scores) at follow-up. In conclusion, our results suggest that NSS are significant predictors of poor clinical outcome in SZ at baseline and >6 months after an acute psychotic episode. These findings propose sensorimotor domain as state biomarker of SZ and support its predictive power with respect to treatment outcome.

The efficacy of the "no zone" approach for the assessment of traumatic neck injury: a case-control study.

PurposeRecently, several studies have demonstrated symptom-based, non-zonal algorithms for approaching penetrating neck injuries. The purpose of this study was to confirm the effectiveness of the “no zone” approach in traumatic neck injuries.MethodsMedical charts of patients with traumatic neck injuries who presented at the Regional Trauma Center in South Korea between January 2014 and December 2018 were retrospectively reviewed. Negative final neck findings (FNFs) were compared with positive FNFs (which include major vascular, aerodigestive, nerve, endocrine gland, cartilage, or hyoid bone injuries) using multivariate logistic regression analysis including values of the “zone” and/or no zone approach.ResultsOut of 168 trauma patients, 70 patients with a minor injury and 7 patients under the age of 18 years were excluded. Of the remaining 91 patients, 74 (81.3%) had penetrating neck injuries and 17 (18.7%) had blunt neck injuries. Initial diagnosis most frequently revealed external wounds in zone II (84.6%). Twenty (22.0%) and 36 (39.5%) patients had hard and soft signs, respectively, using the no zone approach. Further, there was a significant difference between the negative and positive FNFs in patients with hard signs (11.6% vs. 54.5%; P < 0.01, respectively). According to the multivariate logistic regression analysis, the hard signs were associated with an odds ratio (OR) for FNFs (OR, 18.92; 95% confidence interval, 3.55–157.60).ConclusionTraumatic neck injuries classified as having hard signs based on the no zone approach may be correlated with internal organ injuries of the neck.

Associations between neurological soft signs, chronotype and sleep quality in schizophrenia

Associations between neurological soft signs, chronotype and sleep quality in schizophrenia

A study of neurological soft signs and potential psychiatric comorbidities in children with specific learning disorders

Context: Children with specific learning disorders (SLD) are often observed with neurological soft signs (NSS) and adjunctive emotional/behavioral symptoms. Aims: This study attempts to quantify both NSS and subclinical psychiatric comorbidities in known SLD cases. Statistically relevant data, if generated, would provide clinicians with a clearer picture and further a more well-rounded treatment plan. Settings and Design: The study was observational, cross-sectional, and quantitative, conducted in learning disability clinic attached to a child psychiatry outpatient department in a public-sector tertiary-care teaching hospital in urban India. One hundred and sixty children of age 7–18 years fitting inclusion criteria were enrolled after appropriate consent/assent. Subjects and Methods: A sociodemographic data pro forma, and two scales, the child behavior checklist and Physical and Neurological Examination for Subtle Signs – Revised (PANESS-R), were used. A single-setting interview was conducted, data collected and statistically analyzed. Statistical Analysis: It was done by a qualified statistician using SPSS-16 software. Results: 36.25% had “total” psychopathology, 41.875% “internalizing problem,” and 30% “externalizing problem,” which were associated with poor interpersonal relations, more physical discipline, and “overflow” component of NSS. On PANESS-R, repetitive speed of movement was the most common. More NSS were found in younger age groups, boys and in association with perinatal maternal age of below 20 and above 30 years. Countering previous findings, right-handed children had high incidence of mixed handedness. Conclusions: We recommend routine screening for NSS and psychopathology in SLD children as these may complicate treatment outcome with secondary psychological/neurodevelopmental issues. Prompt detection and appropriate management might redress them more holistically.

Oral propranolol for treatment of the subgroups of essential tremor: a systematic review and meta-analysis protocol

IntroductionEssential tremor (ET), a tremor disorder, is one of the most common movement disorders. Only oral drugs (propranolol, primidone, topiramate, etc）are still the first-line treatment recommended by the Food and...

The Influence of IQ Levels on Clinical Features of Developmental Coordination Disorder

Objective: There is no study exploring the correlation between motor coordination dysfunction and high cognitive functioning. We aim to explore the influence of IQ (≥120) on clinical features of DCD. Method: We collected data from 38 children (average age: 9 years old, 2.7 SD) with DCD based on criteria of DSM-5. Two matched groups of DCD were studied according to the IQ: 19 typical children (IQ = 90-110) and 19 HIQ-HIP children. Within this last group, we distinguished superior IQ (120-129) (HIQ), and very superior IQ (≥130) (HIP). All participants completed assessments of neuropsychological, neurovisual, and neuropsychomotor functions. Result: We displayed less Ideomotor (IM), Visio-Spatial/Constructive (VSC)-DCD and more Mixed (MX)-DCD in HIQ-HIP compared to typical children DCD. We showed significant correlations between IM-DCD and executive functions disorders (ρ=+0.519 [95% CI, 0.163 to 0.795], p=0.001), between visuo-constructional task and VSC-DCD subtype (ρ= -0.651 [95% CI, -0.899 to -0.406], p=0.006). A statistical difference between both groups was shown in adiadochokinesia and bimanual coordination disorder in favor of typical children. There is no significant difference between HIP and HIQ. More left-handed in functional laterality was found with IQ≥130, χ2 (1)=4.571, p=0.033, [95% CI, 0.052 to 0.061]. Conclusion: Both groups displayed similar clinical features of DCD. HIQ-HIP groups have better executive functions and visio-spatial functioning than typical children with DCD but worse auditory attention and memory, and more neurological soft signs related to the high rate of MX-DCD. The findings are useful for clinical decision-making processes.

Dysarthria in Patients with Schizophrenia

Speech and language difficulties have been reported in people with schizophrenia since the early 19th century, but they have been relatively poorly characterized. Research has mostly focused on pragmatics and the social aspects of communication, but changes in voice quality are common and can also interfere with intelligibility of speech, thus adding to the patient's disability. These changes in voice quality are not entirely related to effects of neuroleptics. A few common vocal characteristics have been identified; indeed, the most consistent vocal characteristic in people with schizophrenia may be the lack of consistent characteristics between patients. There has been little speculation about the etiology of vocal changes; they have been regarded as “neurological soft signs” indicative of mild central nervous system dysfunction but may be related to longstanding insensitivity to comprehension cues from the listener. Response to speech therapy in people with schizophrenia has been disappointing overall. We present three patients with schizophrenia and representative vocal changes, and we also discuss the sparse available literature available through the PubMed database. This may be a fruitful and relatively unexplored area of investigation with potential to substantially improve social interactions and quality of life for some patients with schizophrenia. [ Psychiatr Ann . 2020;50(1):33–37.]

Alterations of plasma cytokine biomarkers for identifying age at onset of schizophrenia with neurological soft signs

Several studies have been suggested that immunity plays a part in neurodevelopment and schizophrenia pathogenesis. Early age of onset in schizophrenia is associated with genetic factors which affect neurodevelopment. This study aims to identify immune abnormalities associated with neurodevelopmental impairments in early-onset schizophrenia (EOS) and adult-onset schizophrenia (AOS) patients. We determined the plasma levels of six cytokines (IL-1β, IL-4, IL-6, IL-10, IL-12 and TNF-α) in schizophrenia patients and healthy controls. Measurements included neurological soft signs (NSS) to distinguish and subgroup those with neurodevelopmental impairments. The study included 210 schizophrenia patients, which were divided into 84 EOS and 126 AOS patients, as well as 122 healthy controls. We observed significant differences in levels of IL-4, IL-6 and IL-10 between EOS and AOS patients. The results demonstrated the area under ROC curve (AUC) of the IL-4 in EOS and healthy controls was 0.81. Moreover, these results indicated that AUC of the IL-4 and the combination of IL-4, IL-6 and IL-12 in EOS with NSS and healthy controls were 0.91 and 0.95. These cytokines are altered in EOS and schizophrenia patients with neurodevelopmental impairments and demonstrated good classification abilities. These findings manifested that both pro- and anti-inflammatory cytokines are contributed to the clinical and pathophysiological features of schizophrenia. Future works are expected to explore potential genetic effectors and predictors as well as therapeutic directions in personalized medicine for early-onset schizophrenia.

Análisis de narraciones orales en preescolares con signos neurológicos blandos y dificultades de lenguaje

&lt;p&gt;La narración oral consiste en la expresión de una serie de experiencias o eventos secuenciados que tuvieron lugar en el tiempo dentro de un contexto. El objetivo de la investigación fue analizar las narraciones orales en niños preescolares con signos neurológicos blandos ante la presencia o ausencia de dificultades de lenguaje. Se eligieron 80 niños preescolares (32 niñas y 48 niños) con edad promedio de 5 años 8 meses, DE=5.2, de nivel socioeconómico bajo a medio de escuelas públicas de Xalapa, Veracruz, México. Se evaluó la inteligencia verbal con la escala Wechsler para los niveles preescolar y primario; los signos neurológicos blandos y la narración de una historieta. Se observaron diferencias significativas en el nivel de coherencia narrativa con las dificultades de lenguaje donde, los niños con dificultades moderadas a severas de lenguaje se ubicaron en los niveles iniciales de coherencia. Las narraciones son herramientas relevantes para la evaluación y desarrollo del lenguaje.&lt;/p&gt;

Neurological Soft Signs and Brain Network Abnormalities in Schizophrenia.

Neurological soft signs (NSS) are often found in patients with schizophrenia. A wealth of neuroimaging studies have reported that NSS are related to disturbed cortical-subcortical-cerebellar circuitry in schizophrenia. However, the association between NSS and brain network abnormalities in patients with schizophrenia remains unclear. In this study, the graph theoretical approach was used to analyze brain network characteristics based on structural magnetic resonance imaging (MRI) data. NSS were assessed using the Heidelberg scale. We found that there was no significant difference in global network properties between individuals with high and low levels of NSS. Regional network analysis showed that NSS were associated with betweenness centrality involving the inferior orbital frontal cortex, the middle temporal cortex, the hippocampus, the supramarginal cortex, the amygdala, and the cerebellum. Global network analysis also demonstrated that NSS were associated with the distribution of network hubs involving the superior medial frontal cortex, the superior and middle temporal cortices, the postcentral cortex, the amygdala, and the cerebellum. Our findings suggest that NSS are associated with alterations in topological attributes of brain networks corresponding to the cortical-subcortical-cerebellum circuit in patients with schizophrenia, which may provide a new perspective for elucidating the neural basis of NSS in schizophrenia.

Neurological soft signs in schizophrenia spectrum disorders are not confounded by current antipsychotic dosage

Neurological soft signs (NSS) have garnered increasing attention in psychiatric research on motor abnormalities in schizophrenia spectrum disorders (SSD). However, it remains unclear whether the assessment of NSS severity could have been confounded by current antipsychotic dosage. In this study, we recruited 105 patients with SSD that underwent a comprehensive motor assessment evaluating NSS and extrapyramidal motor symptoms (EPMS) by means of standardized instruments. Current antipsychotic dosage equivalence estimates were determined by the classical mean dose method (doses equivalent to 1 mg/d olanzapine). We used multiple regression analyses to describe the relationship between NSS, EPMS and antipsychotic medication. In line with our expectations, current antipsychotic dosage had no significant effects on NSS total score (p = 0.27), abnormal involuntary movements (p = 0.17), akathisia (p = 0.32) and parkinsonism (p = 0.26). Further, NSS total score had a significant effect on akathisia (p = 0.003) and parkinsonism (p = 0.0001, Bonferroni corr.), but only marginal effect on abnormal involuntary movements (p = 0.08). Our results support the notion that NSS are not significantly modulated by current antipsychotic dosage in SSD. The associations between NSS, akathisia and parkinsonism, as revealed by this study, support the genuine rather than medication-dependent origin of particular motor abnormalities in SSD.

Prolonged Methamphetamine-Induced Psychosis: Difference With Schizophrenia

The main objective of the present study was to compare the distribution of underlying factors such as neurological soft signs, obstetric complications, and family history of psychiatric disorders between two groups of schizophrenic patients and patients with prolonged methamphetamine-induced psychosis. In a case-control study, 30 patients with prolonged methamphetamine-induced psychosis and 30 patients with schizophrenia were selected. Data were collected through a demographic questionnaire, the Buchanan and Heinrichs’ Neurological Evaluation Scale (NES), the Lewis-Murray’s Obstetric Complications Scale (LMOCS), and the Weissman’s Family History Screen (FHS). Mean scores of the neurological soft signs (±SD) in the two groups of schizophrenic patients and patients with prolonged methamphetamine-induced psychosis were 15.7±8.7 and 11.7±6.2, respectively (P=0.040), and a significant difference was observed in the sensory integration between the two groups (P=0.022). Obstetric complications revealed similar distributions in the two groups. Patients with prolonged methamphetamine-induced psychosis reported higher prevalence of alcohol and other substances use disorders (P=0.003 and P=0.001, respectively) in their close relatives; however, the distributions of other disorders were not statistically different between the two groups’ close relatives. Similarities and differences in certain aspects were observed between the two groups, suggesting susceptibility for psychosis in patients with prolonged methamphetamine-induced psychosis; yet we found diversities that distinguish the two disorders. © 2019 Tehran University of Medical Sciences. All rights reserved. Acta Med Iran 2019;57(4):235-243

Lateral Soft Tissue Neck X-ray a Tool for the Otorhinolaryngology Surgeon

Background: Management of aerodigestive emergencies can prove a challenge especially in this sub-Saharan region where there is a dearth of specialized equipment. In some areas, a plain radiograph may be the only investigative tool readily available to the surgeon. It is routinely done in most of these cases. In our environment health care is often financed by the patients through out of pocket expenses since most do not have health insurance. Affordability of a particular treatment becomes paramount. This study, therefore, is aimed at assessing the use of lateral soft tissue neck X-ray and its reliability as a diagnostic tool in aerodigestive emergencies.&#x0D; Objective: To determine the relevance or effectiveness of plain radiograph of the lateral soft tissue neck in patients with upper aerodigestive emergencies and therefore its use as a tool to the otorhinolaryngology (ORL) surgeon as the first-line investigation in these patients.&#x0D; Patients and Methods: It is a prospective study of all patients that presented to the ENT surgery department of UPTH from April 2018 to April 2019 with upper aerodigestive emergencies. Patients who presented in the ENT clinic, accident and emergency department, children`s emergency wards and the clinics with upper aerodigestive emergencies were recruited in this study. All the patients had X-ray lateral soft tissue of the neck done on presentation and the results were then compared with the final operative findings in the operation theatre. Some patients had also chest radiograph done however; the diagnosis was done based on the lateral soft tissue neck finding. Patients that had radiologic investigation other than radiograph of the lateral soft tissue neck as the main investigative tool were excluded from the study. The radiologist opinion was obtained for all the radiographs as a routine. The results were analyzed using the SPSS 20 and presented in simple statistical tables.&#x0D; Results: Sixteen patients were studied. Males were 14(87.5%) while females were 2(12.5%). Age range was from 1.5 to 77 years with children comprising only 31.25% of the study population. The commonest presenting complaint was voice change 68.75%. Positive findings on the x-ray neck were seen as soft signs in 62.5% and radio-opacity in 18.75%. In n=14(87.5%) the lateral neck x-ray positive findings were corroborated by the operative findings. The tool has a specificity of 100% for both foreign body inhalation/ingestion and laryngeal tumour but the sensitivity of 80% in laryngeal tumours but 100% for the foreign body.&#x0D; Conclusion: Study concludes that lateral soft tissue neck x-ray was found to be a good and useful tool in the diagnosis of a good number of upper aerodigestive emergencies such as foreign body ingestion/inhalation and patients with upper airway obstruction caused by laryngeal tumours and some infective conditions such as a retropharyngeal abscess.

Neurological Soft Signs and Clinical Features of Tic-Related Obsessive-Compulsive Disorder Indicate a Unique Subtype.

Tic-related obsessive-compulsive disorder (OCD) may be a unique OCD subtype. This study examined whether neurological soft signs (NSSs) of patients with tic-related and tic-free OCD enable discrimination of these subgroups. We used the Neurological Evaluation Scale to assess 32 patients with tic-related and 94 with tic-free OCD, as well as 84 controls. Most patients with tic-related OCD were male, with earlier illness onset and poorer insight scores than those of patients with tic-free OCD. Patients with tic-related OCD had poorer motor coordination, sensory integration, and motor sequencing than did tic-free patients. Logistic regression using NSS subscale scores predicted tic-related OCD. Patients with tic-related OCD displayed greater neurodevelopmental abnormalities than did tic-free patients. NSSs of the former group suggest the need to separate this subgroup. Our results also support the newly introduced tic-related specifier in the fifth edition of the Diagnostic and statistical manual of mental disorders.

TO STUDY THE PRESENCE OF NEUROLOGICAL SOFT SIGNS IN CONTROL POPULATION AND TO COMPARE FINDINGS WITH PATIENT POPULATIONS.

Background: The study was conducted at the Mental Health &amp; Hospital, Agra. It is a tertiary referral center and a postgraduate teaching hospital. The hospital has a wide catchments area which includes diagnosis of schizophrenia and bipolar affective disorder.&#x0D; Result: The total number of neurological soft signs present in a subject. Schizophrenia group had the highest number of NSS (mean±SD= 10.43±4.13) then were the bipolar group (mean±SD= 5.63±3.46) and least number of NSS were in control group (mean±SD=1.03±1.73) i.e. bipolar group was intermediate between schizophrenia and control group in terms of total number of positive NSS. Results of one way ANOVA revealed significant group differences F (2, 87) =62.05, p&lt;.01. Games-Howell post hoc comparisons revealed significant differences in Schizophrenia vs Bipolar group (p&lt; .01), Schizophrenia Vs Control group (p&lt; .01) as well as in Bipolar Vs Control group (p&lt; .01) i.e. schizophrenia group had significantly higher number of positive NSS than bipolar and control group. Also bipolar group had significantly higher number of positive NSS than control group.&#x0D; Conclusion: On various subscales of Neurological Evaluation Scale, schizophrenia patients differed from bipolar patients on all the subscale but not on the sequencing of complex motor acts subscale. Neurological Soft Signs are present even during the symptom free period and therefore they are not due to the effects of active illness. Hence, these Neurological Soft Signs in our study may represent a trait like abnormality in both schizophrenia and bipolar disorder.&#x0D; Keywords: Neurology, Schizophrenia, Bipolar Disorder &amp; Sign

Associations between brain structural networks and neurological soft signs in healthy adults

Neurological soft signs (NSS), as minor neurological deficits, have been identified in several psychiatric disorders, especially in schizophrenia. However, it's unclear how the neuropathological processes of the disease affect NSS related brain morphological changes and whether it is confounded by the use of medication. As NSS also exist in healthy people, the potential confounding effects of psychopathology or medication will be excluded if NSS are investigated in healthy people. Therefore, we applied a novel multivariate approach, source-based morphometry (SBM), to study structural networks in relation to NSS in healthy adults based on structural magnetic resonance imaging (MRI) data. The Heidelberg Scale was applied to evaluate NSS. Using SBM, we constructed structural networks and investigated their associations with NSS in healthy adults. Six grey matter (GM) structural networks were identified. Sensory integration subscores were associated with the cerebellar component and the cortico-basal ganglia-thalamic component. Motor coordination subscores and total NSS scores were associated with the sensorimotor component. The present findings indicated that structural network abnormalities in cerebellar, subcortical and cortical sensorimotor areas contribute to NSS performance in healthy adults.

Isolated 'soft signs' of fetal choroid plexus cysts or echogenic intracardiac focus - consequences of their continued reporting.

Choroid plexus cysts (CPC) and echogenic intracardiac focus (EIF) are obsolete soft markers found on morphology ultrasound and not a valid reason for adjusting fetal risk of aneuploidy. We conducted a retrospective audit of women referred to genetic counsellor and fetal medicine services at St George Hospital (SGH) and the Royal Hospital for Women (RHW) for CPC and EIF from 1 January 2006 to 31 December 2016 inclusive. In total, 208 CPC and/or EIF referrals were identified, 118 (57%) of which were for isolated CPC and/or EIF and 102 (49%) occurring in women low risk for aneuploidy prior to morphology ultrasound. Significantly, more women had undergone combined first-trimester screening in the 2014 to 2016 epoch vs. previous years at both SGH (P=0.03) and RHW (P=0.004). However, the number of women referred for CPC and EIF remained relatively constant. No fetus was born with a major structural or chromosomal abnormality in the group of low-risk women with isolated signs. However, 18% of these women were referred to both genetic counselling and fetal medicine services, 7% had NIPT after morphology, 14% had amniocentesis, and 33% had additional ultrasound(s). Despite advances in screening technology, low-risk women are still referred to specialist services for these 2 soft signs and undergoing unnecessary follow-up, NIPT and amniocentesis.

Cognitive Impairment in Marginally Housed Youth: Prevalence and Risk Factors.

Objective: Homeless and marginally housed youth are particularly vulnerable members of society, and are known to experience numerous health problems, including psychiatric illness, substance use, and viral infection. Despite the presence of these risk factors for cognitive compromise, there is limited research on the cognitive functioning of homeless and marginally housed youth. The present study examines the degree and pattern of cognitive impairment and associations with key risk factors in a sample of marginally housed young adults.Method: Participants (N = 101) aged 20–29 years old were recruited from single-room occupancy hotels, and underwent cognitive, psychiatric, neurological, and serological assessments.Results: Forty percent of participants were identified as mildly cognitively impaired across multiple domains, and 16% were moderately-severely impaired. Deficits in memory and attention were most prevalent, while impairments in inhibitory control/processing speed and cognitive flexibility were also present but tended to be less severe. Developmental and historical factors (premorbid intellectual functioning, neurological soft signs, earlier exposure to and longer duration of homelessness or marginal housing), as well as current health risks (stimulant dependence and hepatitis C exposure), were associated with cognitive impairment.Conclusions: The strikingly high rate of cognitive impairment in marginally housed young adults represents a major public health concern and is likely to pose a significant barrier to treatment and rehabilitation. These results suggest that the pathway to cognitive impairment involves both developmental vulnerability and modifiable risk factors. This study highlights the need for early interventions that address cognitive impairment and risk factors in marginalized young people.

Choroid Plexus Carcinoma Enmasked with Soft Signs and Symptoms

AbstractChoroid plexus carcinomas (CPCs) are rare brain tumors, with preponderance in infants. They are highly invasive tumors with a dismal prognosis. The 5-year survival rates for CPC vary between 10% and 50%. They commonly arise from the lateral ventricles. CPCs in infants present with the subtle features of raised intracranial tension (ICT). Surgical resection is the mainstay of management with adjuvant chemotherapy and radiotherapy. We report a case of 11-month-old child with CPC, presented with subtle nonspecific signs and symptoms of raised ICT, treated by surgical resection and chemotherapy.

Conceptos espaciales y nociones de lecto-escritura en preescolares con signos neurológicos blandos

La adquisición de los procesos cognoscitivos en los primeros años de vida muestra una relación estrecha con el desarrollo de habilidades motoras. En la etapa preescolar, el desarrollo de conceptos y las nociones de aprendizajes escolares como la lecto-escritura permiten conocer los procesos cognoscitivos de los niños. Se realizó una investigación descriptiva, observacional, transversal, con 30 niños preescolares (15 niñas y 15 niños) de la ciudad de Xalapa, Veracruz. Se evaluaron los conceptos espaciales y las nociones de lecto-escritura. Se documentaron los factores de riesgo y signos neurológicos blandos. Se encontraron asociaciones negativas entre los signos neurológicos blandos y las nociones de lecto-escritura, así como asociación positiva entre inteligencia verbal y la lecto-escritura. La evaluación de los procesos cognoscitivos de los niños preescolares y los signos neurológicos blandos favorecerá la implementación de adaptaciones en los métodos de enseñanza para los casos con indicadores clínicos de alteraciones sensoriales o motoras y desempeños deficientes en el lenguaje, conceptos espaciales y nociones de lecto-escritura.