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Child and Adolescent Disorders

Psychiatric disorders are not diagnosed as easily in children as they are in adults because: Children lack abstract cognitive abilities and verbal skills to describe what is happening Children are constantly changing and developing The most common childhood psychiatric disorders include: Pervasive developmental disorders Attention deficit hyperactivity disorder (ADHD) Disruptive behavior disorders

Mental Retardation
Degrees of Retardation

Mild (IQ 50 to 70) Moderate (IQ 35 to 50) Severe (IQ 20 to 35) Profound (IQ below 20)

Causes
Heredity Tay-Sachs disease or fragile X chromosome syndrome Early alterations in embryonic development Maternal alcohol intake Pregnancy or perinatal problems Fetal malnutrition, hypoxia, infections, and trauma Medical conditions of infancy Infection or lead poisoning Environmental influences Deprivation of nurturing or stimulation

Learning Disorders
Diagnosed when the childs achievement in reading, mathematics, or written expression is below that expected for the childs age, formal education, and level of intelligence Interfere with academic achievement, life activities, development of self-esteem, and social skills Early identification, intervention, and coexisting problems are associated with better outcomes

Motor Skills Disorder Marked impairment in coordination severe enough to interfere with academic achievement or activities of daily living Often coexists with communication disorders Provide adaptive physical education and sensory integration to foster normal growth and development

Communication Disorders
Diagnosed when communication deficit is severe enough to hinder development, academic achievement, or activities of daily living, including socialization Expressive language disorder Mixed receptive-expressive language disorder Phonologic disorder Stuttering disorder Speech therapy to improve communication skills

Pervasive Developmental Disorders Characterized by pervasive and usually severe impairment of reciprocal social interaction skills, communication deviance, restricted stereotypical behavioral patterns Autistic disorder (classic autism) Retts disorder Childhood disintegrative disorder Aspergers disorder

Pervasive Developmental Disorders (contd)


Present by early childhood Little eye contact, few facial expressions, does not communicate verbally or with gestures, doesnt relate to peers or parents, lacks spontaneous enjoyment; apparent absence of mood and affect; cannot engage in play or make-believe with toys Hand flapping, body twisting, head banging Autism may improve, sometimes substantially, as language and communication skills are learned Traits persist into adulthood; few attain complete independence, marry, or have children

Pervasive Developmental Disorders (contd)


Most autistic children are mainstreamed in school Medications may be used to target specific behaviors: Antipsychotics for temper tantrums, aggressiveness, self-injury, hyperactivity, and stereotyped behaviors Naltrexone (ReVia), clomipramine (Anafranil), clonidine (Catapres), and stimulants to diminish self-injury and hyperactive and obsessive behaviors Goals are to reduce behavioral symptoms and promote learning, development, and language skills

Attention Deficit Hyperactivity Disorder (ADHD)


Inattentiveness, overactivity, and impulsiveness Important to distinguish ADHD from normal, active behavior, behavioral signs of psychosocial stressors, inadequate parenting, or other psychiatric disorders such as bipolar disorder Can persist into adulthood Often diagnosed when child starts school

Attention Deficit Hyperactivity Disorder (ADHD) (contd)


At school age, symptoms of ADHD begin to interfere significantly with behavior and performance: Fidgets constantly Makes excessive noise Normal environmental noises are distracting Cannot listen to directions or complete tasks Blurts out answers before questions are completed Hurried, careless mistakes in schoolwork Loses or forgets homework assignments Fails to follow directions Peers may ostracize

Etiology
Unknown Environmental toxins Prenatal influences Heredity Damage to brain structure and functions

Cultural Considerations More prevalent in Western cultures Increasing numbers of children from culturally diverse groups are being diagnosed with ADHD African-American, Asian/Pacific Islander Americans, and Latino parents are less likely to endorse biopsychosocial causes of mental illness than non-Hispanic white parents

Treatment
Combination of pharmacotherapy with behavioral, psychosocial, and educational interventions Psychopharmacology Stimulants: methylphenidate (Ritalin), an amphetamine compound (Adderall), dextroamphetamine (Dexedrine), and pemoline (Cylert) Common side effects: insomnia, loss of appetite, and weight loss or failure to gain weight

Strategies for Home and School Helping with parenting strategies Providing consistent rewards and consequences for behavior Offering consistent praise Using time-out Giving verbal reprimands Issuing daily report cards for behavior Using point systems for positive and negative behavior Using therapeutic play techniques

Application of the Nursing Process: ADHD

Assessment History: fussy as an infant; may not have noticed the hyperactive behavior until later; difficulties in all major life areas; parents feel unable to deal with the behavior; unsuccessful attempts to discipline General appearance and motor behavior: cannot sit still, darts around the room, interrupts, blurts out answers, doesnt pay attention, jumps from one topic to another

Application of the Nursing Process: ADHD (contd)

Assessment (contd) Mood and affect: labile; verbal outbursts; temper tantrums; anxiety; frustration; agitation Thought processes and content: intact Sensorium and intellectual processes: alert and oriented; no sensory or perceptual alterations; concentration markedly impaired; says, I dont know rather than taking time to answer; unable to complete tasks

Application of the Nursing Process: ADHD (contd)

Assessment (contd) Judgment and insight: poor judgment, takes risks, doesnt perceive potential harm Self-concept: may be unaware that behavior is different from that of others, saying no one likes me; generally low self-esteem due to lack of success and difficulty with peer relationships; may see self as stupid

Application of the Nursing Process: ADHD (contd) Assessment (contd) Roles and relationships: unsuccessful; intrusive and disruptive, incites negative responses from others; parents and teachers chronically frustrated and exhausted Physiologic and self-care considerations: child may be thin if no time taken to eat properly; trouble settling down for bed; sleeps poorly; may have history of injury if engaged in risky behaviors

Application of the Nursing Process: ADHD (contd)

Data Analysis Nursing diagnoses include: Risk for Injury Ineffective Role Performance Impaired Social Interaction Compromised Family Coping

Application of the Nursing Process: ADHD (contd)

Outcomes The client will: Be free of injury Respect boundaries of others Demonstrate age-appropriate social skills Complete tasks Follow directions

Application of the Nursing Process: ADHD (contd)

Intervention Can be used in variety of settings and taught to parents, teachers, and caregivers: Ensuring safety Improving role performance Simplifying instructions Providing a structured daily routine Providing client and family education and support

Application of the Nursing Process: ADHD (contd)

Evaluation Is the childs hyperactivity and impulsivity decreasing? Is the childs attention improving? Is the child improving sociability, peer relationships, and academic achievement?

Conduct Disorder
Persistent antisocial behavior that significantly impairs ability to function in social, academic, or occupational areas

Conduct Disorder (contd)


Aggression to people and animals Destruction of property Deceitfulness and theft Serious violation of rules Little empathy for others Low self-esteem Poor frustration tolerance Temper outbursts Frequently is associated with early onset of sexual behavior, drinking, smoking, use of illegal substances, and other reckless or risky behaviors

Onset and Clinical Course


Childhood-Onset Type Symptoms before 10 years of age: Physical aggression toward others Disturbed peer relationships More likely to have persistent conduct disorder and to develop antisocial personality disorder as adults Adolescent-Onset Type No behaviors of conduct disorder until after 10 years of age: Less likely to be aggressive Have more normal peer relationships Less likely to have persistent conduct disorder or antisocial personality disorder as adults

Etiology Genetic vulnerability Environmental adversity Poor coping Risk factors include: poor parenting, low academic achievement, poor peer relationships, low self-esteem Protective factors include: resilience, family support, positive peer relationships, good health

Cultural Considerations
In high-crime areas, aggressive behavior may be protective and not necessarily indicative of conduct disorder In immigrants from war-ravaged countries, aggressive behavior may have been necessary for survival

Treatment
Early intervention is more effective; prevention is more effective than treatment: Preschool programs Parenting education Social skills training Family therapy Individual therapy Antipsychotics, lithium, or other mood stabilizers such as Carbamazepine (Tegretol) or Valproic acid (Depakote) for labile moods or aggressive behavior

Application of the Nursing Process: Conduct Disorder


Assessment History: disturbed peer relationships; aggression toward people or animals; destruction of property; deceitfulness; theft; truancy; running away; staying out all night General appearance and motor behavior: typical for age group; may be extreme in terms of piercing, tattoos, use of profanity; disparaging remarks about parents and other authority figures

Application of the Nursing Process: Conduct Disorder (contd)

Assessment (contd) Mood and affect: may be quiet, sullen, and reluctant to talk, or openly hostile or angry Thought processes and content: has capacity for rational thought but believes everyone is out to get me Sensorium and intellectual processes: alert and oriented, memory is intact, no sensory misperceptions, intact intellectual functions but usually poor academic achievement Judgment and insight: limited insight (blames others), poor judgment (taking risks)

Application of the Nursing Process: Conduct Disorder (contd)

Assessment (contd) Self-concept: may appear tough but has low self-esteem and doesnt value self Roles and relationships: relationships disrupted, even violent; verbal and physical aggression common; unsuccessful in school; unlikely to work Physiologic and self-care considerations: risk for unplanned pregnancy and STDs; use of alcohol and drugs common; may have injuries from fighting

Application of the Nursing Process: Conduct Disorder (contd)

Data Analysis Nursing diagnoses include: Risk for Other-Directed Violence Noncompliance Ineffective Coping Impaired Social Interaction Chronic Low Self-Esteem

Application of the Nursing Process: Conduct Disorder (contd)

Outcomes The client will: Not hurt others or damage property Participate in treatment Learn effective problem-solving and coping skills Interact with others using ageappropriate and acceptable behavior Verbalize positive, age-appropriate statements about self

Application of the Nursing Process: Conduct Disorder (contd)

Intervention
Decreasing violence and increasing compliance with treatment Limit setting Behavioral contract Consistent Time-out Daily schedule Improving coping skills and self-esteem Promoting social interaction Providing client and family education

Application of the Nursing Process: Conduct Disorder (contd)

Evaluation Has the child stopped behaving in an aggressive or illegal way? Is the child attending school? Is the child following reasonable rules and expectations at home?

Community-Based Care
Short-term stabilization in acute care settings only when behavior is severe Long-term care involves:
School Home Group homes, halfway houses, and residential treatment settings Detention facilities, jails, or jail-diversion programs

Mental Health Promotion Parenting classes Child anxiety management Parentchild intervention emphasizing coping skills Early detection of potential problems

Oppositional Defiant Disorder


Enduring pattern of uncooperative, defiant, and hostile behavior toward authority figures that does not involve major antisocial violations Behaviors cause dysfunction in social, academic, and work situations 25% go on to develop conduct disorder 10% are diagnosed with antisocial personality disorder as adults Treatment is similar to conduct disorder, depending on severity of behaviors

Feeding and Eating Disorders Pica: persistent ingestion of nonnutritive substances Rumination disorder: repeated regurgitation and rechewing of food Feeding disorder: persistent failure to eat and gain/maintain adequate weight

Tic Disorders
Rapid, sudden, recurrent, nonrhythmic stereotyped motor movement or vocalization Familial tendencies Treated with atypical antipsychotics such as olanzapine or risperidone

Tic Disorders (contd)


Tourettes Disorder Multiple motor tics and one or more vocal tics; vocal tics can be name-calling or profanity Person is embarrassed and self-conscious and has significant impairment in academic, social, and occupational areas Chronic Motor or Tic Disorder Involves either vocal or motor tics, not both

Elimination Disorders
Encopresis: defecating in inappropriate places by a child of at least 4 years Involuntary encopresis associated with constipation that occurs for psychological, not medical, reasons Intentional encopresis associated with oppositional defiant disorder or conduct disorder Enuresis: repeated urination during day or night in clothes or bed after age 5 Most often involuntary Intentional enuresis associated with a disruptive behavior disorder

Separation Anxiety Disorder Excessive anxiety about separation from home or loved ones, exceeding what would be expected Results from combination of:
Temperament traits (passivity, avoidance, fearful or shy of novel situations) Parenting behaviors that encourage avoidance as a way to deal with unknown situations

Selective Mutism
Persistent failure to speak in social situations where speaking is expected Excessively shy, socially withdrawn, isolated, clinging, temper tantrums

Reactive Attachment Disorder Markedly disturbed and developmentally inappropriate social relatedness in most situations Associated with grossly pathogenic care Begins before age 5

Stereotypic Movement Disorder Repetitive, nonfunctional motor behavior that interferes with normal activities or results in self-injury requiring medical treatment
Waving, rocking, twirling objects, biting fingernails, banging the head, biting or hitting oneself, or picking at the skin or body orifices

Associated with many metabolic, genetic, and neurologic disorders and mental retardation Cause unknown

Self-Awareness Issues
Recognize own beliefs about parenting and how they differ from others Focus on patients strengths, not just problems Try to have positive impact on child even when disability is severe Support parents

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