Post on 09-Apr-2018
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Chapter 20Child and Adolescent Disorders
Chapter 20Child and Adolescent Disorders
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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EtiologyEtiology
Unknown
Environmental toxins
Prenatal influences
Heredity
Damage to brain structure andfunctions
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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
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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
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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
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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
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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)
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Assessment (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
Application of the Nursing Process: ADHD(cont¶d)Application of the Nursing Process: ADHD(cont¶d)
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Assessment (cont¶d)
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
Application of the Nursing Process: ADHD(cont¶d)Application of the Nursing Process: ADHD(cont¶d)
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Data Analysis
Nursing diagnoses include:Risk for Injury
Ineffective Role Performance
Impaired Social Interaction
Compromised Family Coping
Application of the Nursing Process: ADHD(cont¶d)Application of the Nursing Process: ADHD(cont¶d)
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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(cont¶d)Application of the Nursing Process: ADHD(cont¶d)
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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
Application of the Nursing Process: ADHD(cont¶d)Application of the Nursing Process: ADHD(cont¶d)
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E val uation
Is the child¶s hyperactivity andimpulsivity decreasing?
Is the child¶s attention improving?
Is the child improving sociability, peerrelationships, and academicachievement?
Application of the Nursing Process: ADHD(cont¶d)Application of the Nursing Process: ADHD(cont¶d)
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Conduct DisorderConduct Disorder
Persistent antisocialbehavior thatsignificantly impairsability to function insocial, academic, or
occupational areas
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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
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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
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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
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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
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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
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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
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Assessment (cont¶d)
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)
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Assessment (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
Application of the Nursing Process:Conduct Disorder (cont¶d)Application of the Nursing Process:Conduct Disorder (cont¶d)
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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 (cont¶d)Application of the Nursing Process:Conduct Disorder (cont¶d)
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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
Application of the Nursing Process:Conduct Disorder (cont¶d)Application of the Nursing Process:Conduct Disorder (cont¶d)
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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
Application of the Nursing Process:Conduct Disorder (cont¶d)Application of the Nursing Process:Conduct Disorder (cont¶d)
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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?
Application of the Nursing Process:Conduct Disorder (cont¶d)Application of the Nursing Process:Conduct Disorder (cont¶d)
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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
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Mental Health PromotionMental Health Promotion
Parenting classes
Child anxiety management
Parent±child intervention emphasizingcoping skills
Early detection of potential problems
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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
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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
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Tic DisordersTic Disorders
Rapid, sudden, recurrent, nonrhythmicstereotyped motor movement or
vocalizationFamilial tendencies
Treated with atypical antipsychoticssuch as olanzapine or risperidone
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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
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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
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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
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Reactive Attachment DisorderReactive Attachment Disorder
Markedly disturbed and
developmentally inappropriate socialrelatedness in most situations
Associated with grossly pathogenic
careBegins before age 5
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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
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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