Chapter 25 Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence.

Chapter 25Chapter 25

Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence

Mental Retardation

• Mental retardation is defined as deficits in general intellectual functioning and adaptive functioning.

Mental Retardation (cont.)

Predisposing Factors• Five major predisposing factors– Hereditary factors– Early changes in embryonic development– Pregnancy and perinatal factors– General medical conditions acquired in infancy or

childhood– Environmental influences and other mental disorders

Mental Retardation: Application of the Nursing Process

Assessment• The extent of severity of mental retardation

is identified by the client’s IQ level. • Four levels have been delineated:

* Mild (50 to 70)

* Moderate (* Severe* Profound (lower than 20)

Autistic Disorder

• Autistic disorder is characterized by a withdrawal of the child into the self and into a fantasy world of his or her own creation.

Autistic Disorder (cont.)

• The affected child has markedly abnormal or impaired development in social interaction and communication and a markedly restricted repertoire of activity and interests.

Autistic Disorder (cont.)

Predisposing Factors• Biological factors– Neurological implications– Genetics– Perinatal influences

Autistic Disorder: Application of the Nursing Process (cont.)

Diagnosis/Outcome Identification• Risk for self-mutilation related to neurological

alterations• Impaired social interaction related to inability

to trust and neurological alterations

Autistic Disorder: Application of the Nursing Process (cont.)

Diagnosis/Outcome Identification (cont.)• Impaired verbal communication related to withdrawal into

the self, inadequate sensory stimulation, and neurological alterations

• Disturbed personal identity related to inadequate sensory stimulation; neurological alterations

Autistic Disorder: Application of the Nursing Process (cont.)

Outcomes (cont.)• The client (cont.):– Is able to communicate so that he or she can be

understood by at least one staff member– Demonstrates behaviors that indicate he or she

has begun the separation/individuation process

Attention Deficit/Hyperactivity Disorder (ADHD)

• The essential feature of ADHD is a persistent pattern of inattention and/or hyperactivity-impulsivity

more frequent and severe than typically observed at a comparable level of development.

ADHD (cont.)

Predisposing Factors• Biological influences– Genetics– Biochemical theory– Anatomical influences– Prenatal, perinatal, and postnatal factors

ADHD (cont.)

Predisposing Factors (cont.)• Environmental Influences

– Environmental presence of lead– Dietary factors – Psychosocial influences

ADHD: Application of the Nursing Process

Assessment• A major portion of the hyperactive child’s

problems relate to difficulties in performing age-appropriate tasks

• Highly distractible• Extremely limited attention span• Impulsivity

ADHD: Application of the Nursing Process (cont.)

Assessment• Difficulty forming satisfactory interpersonal relationships• Demonstrates behaviors that inhibit acceptable social

interaction• Disruptive and intrusive in group endeavors• “Perpetual motion machines”• Accident-prone

ADHD: Application of the Nursing Process (cont.)

Diagnosis/Outcome Identification• Risk for injury related to impulsive and

accident-prone behavior and the inability to perceive self-harm

• Impaired social interaction related to intrusive and immature behavior

ADHD: Psychopharmacological Intervention

• CNS stimulants– In children with ADHD, the effects include

increased attention span, control of hyperactive behavior, and improvement in learning ability.

– Examples include Dexedrine, Ritalin, Cylert, Adderall

ADHD: Psychopharmacological Intervention (cont)

• Selective norepinephrine reuptake inhibitor: atomoxetine (Strattera)– Approved by FDA in 2002 for treatment of ADHD– Mechanism of action in ADHD is unknown

ADHD: Psychopharmacological Intervention (cont.)

• Antidepressants– Some antidepressant drugs have been used with

some success in treatment of ADHD.– Examples include • Bupropion (Wellbutrin) • Desipramine (Norpramin) • Nortriptyline (Pamelor) • Imipramine (Tofranil)

ADHD: Psychopharmacological Intervention (cont.)

Nursing Implications (cont.)• To reduce adverse effect of anorexia,

medication may be administered immediately after meals.

• To prevent insomnia, administer last dose at least 6 hours before bedtime.

• Administer sustained-release forms in the morning.

ADHD: Psychopharmacological Intervention (cont.)

Nursing Implications (cont.)• The client should be weighed regularly (at least weekly)

during hospitalization and at home while on therapy with CNS stimulants because of the potential for anorexia and weight loss and for the temporary interruption of growth and development.

ADHD: Psychopharmacological Intervention (cont.)

Nursing Implications (cont.)• In children with behavior disorders, a drug “holiday” should

be attempted periodically under direction of the physician to determine effectiveness of the medication and need for continuation.

ADHD: Psychopharmacological Intervention (cont.)

Nursing Implications (cont.)• Inform parents that over-the-counter (OTC)

medications should be avoided while the child is receiving stimulant medication.

ADHD: Psychopharmacological Intervention (cont.)

Nursing Implications (cont.)• Some OTC medications, particularly common cold and hay

fever preparations, contain sympathomimetic agents that can compound the effects of the stimulant and create a drug interaction that could be toxic to the child.

Conduct Disorders

• With conduct disorder, there is a repetitive and persistent pattern of behavior in which the basic rights of others or

major age-appropriate societal norms or rules are violated.

Conduct Disorders (cont.)

• Two subtypes– Childhood-onset type– Adolescent-onset type

Conduct Disorders (cont.)

Predisposing Factors• Biological influences– Genetics– Temperament– Biochemical factors

Conduct Disorders (cont.)

Predisposing Factors (cont.)• Psychosocial Influences– Peer relationships

Conduct Disorders (cont.)

Predisposing Factors (cont.) • Family Influences

– Parental rejection– Inconsistent management with harsh discipline– Early institutional living– Frequent shifting of parental figures

Conduct Disorders (cont.)

Predisposing Factors (cont.) • Large family size• Absent father• Parents with antisocial personality disorder, alcohol dependence, or both• Association with a delinquent subgroup

Conduct Disorders (cont.)

Predisposing Factors (cont.)• Marital conflict and divorce• Inadequate communication patterns• Parental permissiveness

Conduct Disorders: Application of the Nursing Process

Assessment• Classic characteristic of conduct disorder is the

use of physical aggression in the violation of the rights of others.

• Stealing, lying, and truancy are common problems.

Conduct Disorders: Application of the Nursing Process (cont.)

Assessment (cont.)• The child lacks feelings of guilt or remorse.• Use of tobacco, alcohol, or nonprescription

drugs as well as participation in sexual activities occurs earlier than the peer group’s expected age norm.

Oppositional Defiant Disorder• Oppositional defiant disorder is characterized by a pattern of

negativistic, defiant, disobedient, and hostile behavior toward authority figures that occurs more frequently than is typically observed in people of comparable age and developmental level.

Oppositional Defiant Disorder (cont.)Predisposing Factors • Biological influences• Family influences

– Parental problems in disciplining, structuring, and limit-setting

– Identification by the child with an impulse-disordered parent who sets a role model for oppositional

and defiant interactions with other people– Parental unavailability

Oppositional Defiant Disorder: Application of the Nursing Process (cont.)

Assessment (cont.)• Usually these children do not see themselves as being

oppositional but view the problem as arising from other people they believe are making unreasonable demands on them.

Tourette’s Disorder

• The essential feature of Tourette’s disorder is the presence of multiple motor tics and one or more vocal tics.

• Tics may appear simultaneously or at different periods during the illness.

• Presence of tics causes marked distress.

Tourette’s Disorder (cont.)

Predisposing Factors • Biological factors– Genetics– Biochemical factors– Structural factors

• Environmental factors

Tourette’s Disorder: Application of the Nursing Process

Assessment• Tics may involve the head, torso, and upper and lower limbs.• Signs may begin with a single motor tic, most commonly eye

blinking, or with multiple symptoms• Palilalia-involuntary repetition of words or phrases• Echolalia-repetition of words spoken by others

Tourette’s Disorder: Application of the Nursing Process (cont.)

Diagnosis/Outcome Identification• Risk for self-directed or other-directed violence

related to low tolerance for frustration• Impaired social interaction related

to impulsiveness and to oppositional and aggressive behavior

Tourette’s Disorder: Application of the Nursing Process (cont.)

Diagnosis/Outcome Identification (cont.)• Low self-esteem related to shame associated

with tic behaviors

Tourette’s Disorder: Psychopharmacological Intervention (cont.)

• Medications used to treat Tourette’s disorder include:– Haloperidol (Haldol)– Pimozide (Orap) antipsychotic– Clonidine (Catapres)– Atypical antipsychotics

Separation Anxiety Disorder • The essential feature of separation anxiety

disorder is excessive anxiety concerning separation from the home or from those to whom the person is attached.

Separation Anxiety Disorder (cont.)

• The anxiety exceeds that expected for the person’s developmental level and it interferes with social, academic, occupational, or other areas of functioning.

Separation Anxiety Disorder (cont.)

Predisposing Factors• Biological Influences– Genetics– Temperament

• Environmental Influences– Stressful life events

• Family Influences

Separation Anxiety Disorder: Application of the Nursing Process

Assessment• In most cases, the child has difficulty separating

from the mother.• Anticipation of separation may result in tantrums, crying, screaming,

complaints of physical problems, and clinging behaviors.

Separation Anxiety Disorder: Application of the Nursing Process (cont.)

Assessment (cont.)• Reluctance or refusal to attend school is

especially common in adolescence.• Younger children may “shadow.” • Worrying is common.• Specific phobias are not uncommon.

Separation Anxiety Disorder: Application of the Nursing Process (cont.)

Outcomes• The client:– Is able to maintain anxiety at manageable level– Demonstrates adaptive coping strategies for

dealing with anxiety when separation from attachment figure is anticipated

Separation Anxiety Disorder: Application of the Nursing Process (cont.)

Outcomes (cont.)• The client (cont.):– Interacts appropriately with others and

spends time away from attachment figure to do so