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Chapter 20Child and Adolescent Disorders

Chapter 20Child and Adolescent Disorders



Psychiatric disorders are not diagnosed aseasily in children as they are in adultsbecause:

± Children lack abstract cognitive abilities and verbalskills 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) AndDisruptive behavior disorders



Degrees of Retardation

Mild (IQ 50 to 70)

Moderate (IQ 35 to 50)

Severe (IQ 20 to 35)

Profound (IQ below 20)

Mental RetardationMental Retardation

dm1



Slide 3

dm1 Changed from 50 to 49 so t hat Moderat e and Mild didn't overlap, and changed from 35 to 34 so t hat Severe and Moderat e didn't

overlap--OK?dmichaely, 7/25/2005



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

CausesCauses



Learning DisordersLearning Disorders Diagnosed when the child¶s achievement in

reading, mathematics, or written expressionis below that expected for the child¶s age,formal education, and level of intelligence

Interfere with academic achievement, lifeactivities, development of self-esteem, and

social skills Early identification, intervention, and

coexisting problems are associated withbetter outcomes



Motor Skills DisorderMotor Skills Disorder Marked impairment in coordination severe

enough to interfere with academicachievement or activities of daily living

Often coexists with communication disorders

Provide adaptive physical education andsensory integration to foster normal growthand development



Communication DisordersCommunication 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-prob in the normal fluency.

Speech therapy to improve communicationskills



Pervasive Developmental DisordersPervasive Developmental Disorders

Characterized by pervasive and usuallysevere impairment of reciprocal social

interaction skills, communicationdeviance, restricted stereotypicalbehavioral patterns

± Autistic disorder (classic autism)

± Rett¶s disorder

± Childhood disintegrative disorder

± Asperger¶s disorder



Pervasive Developmental Disorders(cont¶d)Pervasive Developmental Disorders(cont¶d) Present by early childhood

Little eye contact, few facial expressions, does not

communicate verbally or with gestures, doesn¶trelate to peers or parents, lacks spontaneousenjoyment; 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(cont¶d)Pervasive Developmental Disorders(cont¶d) 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 HyperactivityDisorder (ADHD)Attention Deficit HyperactivityDisorder (ADHD)

Inattentiveness, overactivity, and

impulsiveness Important to distinguish ADHD from normal,

active behavior, behavioral signs of psychosocial stressors, inadequate

parenting, or other psychiatric disorderssuch as bipolar disorder

Can persist into adulthood

Often diagnosed when child starts school



Attention Deficit HyperactivityDisorder (ADHD) (cont¶d)Attention Deficit HyperactivityDisorder (ADHD) (cont¶d) 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



EtiologyEtiology

Unknown

Environmental toxins

Prenatal influences

Heredity

Damage to brain structure andfunctions



Cultural ConsiderationsCultural Considerations

More prevalent in Western cultures

Increasing numbers of children fromculturally diverse groups are beingdiagnosed with ADHD

African-American, Asian/Pacific Islander

Americans, and Latino parents are less likelyto endorse biopsychosocial causes of mentalillness than non-Hispanic white parents



TreatmentTreatmentCombination of pharmacotherapy with

behavioral, psychosocial, and educationalinterventions

P sychopharmacology

Stimulants: methylphenidate (Ritalin), anamphetamine compound (Adderall),

dextroamphetamine (Dexedrine), andpemoline (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 forbehavior

Offering consistent praise

Using time-out

Giving verbal reprimands

Issuing daily report cards for behavior

Using point systems for positive and negativebehavior

Using therapeutic play techniques



Application of the Nursing Process: ADHDApplication 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 feelunable 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, doesn¶t payattention, jumps from one topic to another



Assessment (cont¶d)

Mood and affect: labile; verbal outbursts;temper tantrums; anxiety; frustration;

agitation

Thought processes and content: intact

Sensorium and intellectual processes: alertand oriented; no sensory or perceptualalterations; concentration markedlyimpaired; says, ³I don¶t know´ rather thantaking time to answer; unable to completetasks

Application of the Nursing Process: ADHD(cont¶d)Application of the Nursing Process: ADHD(cont¶d)




Judgment and insight: poor judgment, takesrisks, doesn¶t perceive potential harm

Self-concept: may be unaware that behavioris different from that of others, saying ³no

one likes me´; generally low self-esteem dueto lack of success and difficulty with peerrelationships; may see self as stupid





Roles and relationships: unsuccessful;intrusive and disruptive, incites negativeresponses from others; parents and teacherschronically frustrated and exhausted

Physiologic and self-care considerations:child may be thin if no time taken to eatproperly; trouble settling down for bed;sleeps poorly; may have history of injury if

engaged in risky behaviors




Data Analysis

Nursing diagnoses include:Risk for Injury

Ineffective Role Performance

Impaired Social Interaction

Compromised Family Coping




Outcomes

The client will: Be free of injury

Respect boundaries of others

Demonstrate age-appropriate social skills

Complete tasks

Follow directions




I ntervention

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 andsupport




E val uation

Is the child¶s hyperactivity andimpulsivity decreasing?

Is the child¶s attention improving?

Is the child improving sociability, peerrelationships, and academicachievement?




Conduct DisorderConduct Disorder

Persistent antisocialbehavior thatsignificantly impairsability to function insocial, academic, or

occupational areas



Conduct Disorder (cont¶d)Conduct Disorder (cont¶d) 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 sexualbehavior, drinking, smoking, use of illegal substances,and other reckless or risky behaviors



Onset and Clinical CourseOnset and Clinical Course C hildhood-Onset TypeSymptoms before 10 years of age:

± Physical aggression toward others

± Disturbed peer relationships

± More likely to have persistent conduct disorder and to developantisocial personality disorder as adults

Adolescent-Onset Type

No behaviors of conduct disorder until after 10years of age:

± Less likely to be aggressive

± Have more normal peer relationships

±L

ess likely to have persistent conduct disorder or antisocialpersonality disorder as adults



EtiologyEtiologyGenetic vulnerability

Environmental adversity

Poor coping

Risk factors include poor parenting, lowacademic achievement, poor peer

relationships, low self-esteem

Protective factors include resilience,family support, positive peerrelationships, good health



Cultural ConsiderationsCultural Considerations In high-crime areas, aggressivebehavior may be protective and not

necessarily indicative of conductdisorder

In immigrants from war-ravagedcountries, aggressive behavior mayhave been necessary for survival



TreatmentTreatment 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 stabilizerssuch as carbamazepine (Tegretol) or valproic acid(Depakote) for labile moods or aggressive

behavior



Application of the Nursing Process:Conduct DisorderApplication 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 otherauthority figures




Mood and affect: may be quiet, sullen, andreluctant to talk, or openly hostile or angry

Thought processes and content: has capacity forrational thought but believes ³everyone is out toget me´

Sensorium and intellectual processes: alert andoriented, memory is intact, no sensorymisperceptions, intact intellectual functions butusually poor academic achievement

Judgment and insight: limited insight (blamesothers), poor judgment (taking risks)

Application of the Nursing Process:Conduct Disorder (cont¶d)Application of the Nursing Process:Conduct Disorder (cont¶d)




Self-concept: may appear ³tough´ but has lowself-esteem and doesn¶t value self

Roles and relationships: relationships disrupted,even violent; verbal and physical aggressioncommon; unsuccessful in school; unlikely to

work Physiologic and self-care considerations: risk for

unplanned pregnancy and STDs; use of alcoholand drugs common; may have injuries fromfighting




Data Analysis

Nursing diagnoses include: Risk for Other-Directed Violence

Noncompliance

Ineffective Coping Impaired Social Interaction

Chronic Low Self-Esteem




Outcomes

The client will:

Not hurt others or damage property

Participate in treatment

Learn effective problem-solving and coping

skills Interact with others using age-appropriate

and acceptable behavior

Verbalize positive, age-appropriate

statements about self




I ntervention

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




E val uation

Has the child stopped behaving in anaggressive or illegal way?

Is the child attending school?

Is the child following reasonable rulesand expectations at home?




Community-Based CareCommunity-Based Care Short-term stabilization in acute care

settings only when behavior is severe

Long-term care involves:± School

± Home

± Group homes, halfway houses, andresidential treatment settings

± Detention facilities, jails, or jail-diversion

programs



Mental Health PromotionMental Health Promotion

Parenting classes

Child anxiety management

Parent±child intervention emphasizingcoping skills

Early detection of potential problems



Oppositional Defiant DisorderOppositional Defiant Disorder Enduring pattern of uncooperative, defiant, and

hostile behavior toward authority figures that doesnot 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 personalitydisorder as adults

Treatment is similar to conduct disorder,depending on severity of behaviors



Feeding and Eating DisordersFeeding and Eating Disorders

Pica: persistent ingestion of nonnutritive substances-commonly

seen in MR

Rumination disorder: repeatedregurgitation and rechewing of food-

boys than girlsFeeding disorder: persistent failure toeat and gain/maintain adequate weight



Tic DisordersTic Disorders

Rapid, sudden, recurrent, nonrhythmicstereotyped motor movement or

vocalizationFamilial tendencies

Treated with atypical antipsychoticssuch as olanzapine or risperidone



Tic Disorders (cont¶d)Tic Disorders (cont¶d)Tourette¶s 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

C hronic Motor or Tic Disorder

Involves either vocal or motor tics, not both



Elimination DisordersElimination Disorders E ncopresis: defecating in inappropriate

places by a child of at least 4 years

± Involuntary encopresis associated with constipation thatoccurs for psychological, not medical, reasons

± Intentional encopresis associated with oppositional defiantdisorder or conduct disorder

E nuresis: repeated urination during day ornight in clothes or bed after age 5± Most often involuntary

± Intentional enuresis associated with a disruptive behaviordisorder



Separation Anxiety DisorderSeparation Anxiety DisorderExcessive anxiety about separationfrom home or loved ones, exceedingwhat would be expected

Results from combination of:

± Temperament traits (passivity,avoidance, fearful or shy of novel

situations)

± Parenting behaviors that encourageavoidance as a way to deal with

unknown situations





Reactive Attachment DisorderReactive Attachment Disorder

Markedly disturbed and

developmentally inappropriate socialrelatedness in most situations

Associated with grossly pathogenic

careBegins before age 5



Stereotypic Movement DisorderStereotypic Movement DisorderRepetitive, nonfunctional motorbehavior that interferes with normalactivities or results in self-injury

requiring medical treatment± Waving, rocking, twirling objects, biting fingernails,

banging the head, biting or hitting oneself, or pickingat the skin or body orifices

Associated with many metabolic,genetic, and neurologic disorders andmental retardation

Cause unknown



Self-Awareness IssuesSelf-Awareness Issues

Recognize own beliefs about parentingand how they differ from others¶

Focus on patient¶s strengths, not justproblems

Try to have positive impact on childeven when disability is severe

Support parents

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