Disorders of Infancy, Childhood and Adolescence

Objectives Recognize symptomatology for children, adolescents

and infants with autism, mental retardation, attention deficit hyperactivity disorder, separation anxiety disorder, intermittent explosive disorder, oppositional defiant and conduct disorder. Differentiate between childhood symptoms and adult symptoms in major depressive, bipolar schizophrenia and anxiety disorders.

Objectives Continued Discuss the necessary components for a nursing

assessment and care plan. List nursing interventions for children and adolescents who are diagnosed with behavioral disorders. Identify effect ways to include the family in most interventions.

Historic and Theoretic Perspectives Since the 1980s children have had to incorporate a

great amount of internet technology and new technological changes into their lifestyles from cell phones to internet, virtual class rooms and email. Family activities and interactions have changed. Meeting developmental milestones has become more difficult as the requirements for knowledge increase

Historic and Theoretic Perspectives Mental disorders in children and adolescents are now

more common than ever before. One in 10 children in the United States has a mental disorder that interferes with their ability to participate effectively in the school environment. These impairments may worsen as child matures. Nurses have the opportunity to assess these children and serve as support advocates.

Historic and Theoretic Perspectives Continued In 1899, the first juvenile court was established in

Chicago, Illinois. The Juvenile Psychopathic Institute (JPI) was established in 1909. Dr. Healy, a neurologist became their first director. A team with a psychologist, social worker, and neuropsychiatrist was created. This became the model for juvenile treatment centers.

Historic and Theoretic Perspectives Continued 1946-President Truman signed National Mental

Health act. 1949-National Institute of Mental Health (NIMH) was formed. Childhood mental problems were blamed on the mother. She was the caretaker of the mental and emotional health of the child as the primary caregiver.

President Truman

Historic and Theoretic Perspectives Continued Psychiatrists and pediatricians began to train as child

psychiatrists. 1953-American Academy of Child Psychiatry was formed. 1950-NIMH sponsored programs for the education of people in infant, child, adolescent and psychiatric mental health nursing.

Mental RetardationEtiology and Epidemiology

Evident. Diagnosed by age 18. Below average intellect. Impaired learning. Interpersonal interactions, poor independent function. 1% of the population in the US has mental retardation. No definitive etiology found in 58-78%. 23-43% have severe or profound mental retardation caused by genetic, medical, environmental or a combination of these factors.

Mental RetardationProblems in adaptive functioning Mild (85%) Academic skills to grade 6

Minimum self-support

Moderate (10%) Academic skills to grade 3 Provide self-care hygiene

Severe (3% to 4%) Rudimentary communication Simple skills Profound (1% to 2%) Sensory-motor problems

Mental Retardation Continued Prognosis-Dependent upon the severity of the mental

retardation, Psychologic, environmental, biomedical and family interaction and support Research shows those who have profound and severe mental retardation usually have a shortened life because of medical conditions like epilepsy, feeding disorders coupled with limitations in communication and self-care.

Pervasive Developmental Disorders Pervasive disorders are neuropsychiatric disorders

where the child exhibits a broad range of deficits in social interactions, communication, cognitive abilities and behavior that can be stereotypical. The most prevalent of these is Autism another is Aspergers Disorder which is a form of autism.

Autistic Disorder Etiology-several causation theories, genetic,

environmental, neurologic, metabolic, immunologic and birth complications. Most accepted theory of causation is that an abnormality of structure and function of the brain causes autism Some believe that it is caused by excess sugars, food sensitivities, food additives, vaccines or allergens. Experts have concluded that these factors do not cause autism.

Autistic Disorder Continued Epidemiology Rate is 1 in 500 or 5 in 10,000 as reported in the DSM

IV-TR 3-4 times more in males than females Females more severe Siblings have increased risks Family members have other developmental disorders such as Aspergers and Attention Deficit Disorder (ADD)

Autistic Disorder Clinical DescriptionImpairment in social interactions-Impaired verbal skills, marked nonverbal behaviors, failure to develop peer relationships appropriate to age level, lack of sharing interests. No social/emotional reciprocity. Impairments in Communication speech/language delays, gestures to communicate, unable to sustain conversations stereotypical patterns and repetitive use of idiosyncratic language not at current age appropriate level.

Autistic Disorder Prognosis No cure Intellectual level and language skills are necessary for

improvement. Only a small percentage grow up to live and function independently in adulthood. Partial independence is possible in 1/3. The high functioning still have social and communication deficits. Early intervention is important.

Aspergers Disorder

Similar features of autism Sustained social impairment Restricted, repetitive behaviors No delays in development of language, cognitive skills Restricted behavior patterns, interests and activities. Impaired social and occupational functioning. Lifelong course. Prognosis best with early intervention @24-36 months. Differs from autism because, no delays in language, cognitive development, adaptive behavior or curiosity. Selfhelp skills are age appropriate.

Disorders of Infancy or Childhood Reactive Attachment Disorder Etiology/Epidemiology-develops in children

exposed to poverty, parental physical and emotional abuse, neglect and institutionalization. Rare, less than 1%. Prognosis-Symptoms can improve if child is placed in a loving and supportive home or environment where the adults are nurturing and supportive.

Disorders of Infancy or Childhood Reactive Attachment Disorder Clinical Description-Develops in first few years of

life. Inhibited or disinhibited. Child unable to interact socially for developmental level. Lack of early healthy bonding and intimacy if inhibited. Disinhibited -react without boundaries unable to tell strangers from safe relationships. Seek comfort with strangers.

Separation and Anxiety Disorder

Etiology/Epidemiology Common in first degree relatives More common if mother has panic disorder. Develops after child experiences stressful event (death of sibling, parent, pet or twin). More common in females Occurs in 4% of children Presents before late adolescence.

Separation and Anxiety DisorderClinical Description Developmentally inappropriate and excessive anxiety considering separation from home or individuals. Occurs with distress, persistent excessive worry, reluctance, refusal to be separated, excessive fear, nightmares, complaints of physical problems like headaches, nausea, vomiting, stomach aches. Lasts 4 weeks, onset before age 18,causes social, academic and occupational impairment.

Separation and Anxiety DisorderPrognosis Periods of severity Periods of symptom reduction

Anxiety about separation and the avoidance of

stressful situations may continue for several years.

Tic Disorders-Tourettes

Etiology and Epidemiology Neurological genetic disorder, Affects 10-15% of children. Caused by head trauma, carbon monoxide poisoning, pregnancy complications Occurs in 5-30 children per 10,000 Occurs in 1-2per 10,000 adults Twice as common in males than females Associated disorders include ADHD, Obsessivecompulsive disorder and learning disorders.

Tic Disorders-Tourettes

Clinical Components Tic-rapid, sudden involuntary, repetitive movement or vocal event. Exacerbated by stress. blinking, jerking, shrugging, grimacing, coughing, throat clearing, grunting, snorting, barking , sniffing. May involve grooming gestures, touching, stamping, touching, stamping and smelling. Echopraxia-Imitates others movements Coprolalia-repeating socially obscene words. Palilalia-repeats ones own sounds and words Echolalia-Repeats last heard words

Tic Disorders-Tourettes

Prognosis Can begin at 2 years of age Typically starts during childhood or beginning adolescence. Lifelong disorder. Symptoms sometimes diminish during adulthood and adolescence

Attention-Deficit and Disruptive Behavioral DisordersAttention-Deficit/Hyperactivity Disorder(ADHD) Etiology-Cause unknown, possible psychosocialbiological factor interaction. Genetic factors, Concordance is 51% in monozygotic twins and 33% in dizygotic twins. Occurs in first degree children of the afflicted. Epidemiology-School age- 3-7%. 2/3 also meet criteria for another DSM disorder-50% for Oppositional Defiance disorder (conduct disorder), mood, anxiety, Tourettes, substance abuse and learning disorders

Attention-Deficit/Hyperactivity Disorder(ADHD)

Clinical Description Behavioral manifestations occur in many different environments school, home, church. Levels of problematic behavior varies from time to time. Symptoms worsen in environments where sustained attention is required. Symptoms can disappear or minimal when strict controls are exercised. And worsen in unstructured environments.

ADHD Clinical Description Continued Three main problem areas are Inattention,

Hyperactivity and Impulsivity. Inattention-fails to pay attention, careless, mistakes in schoolwork, work, all activities, difficulty sustaining attention on tasks or play, seems not to listen when spoken to. Does not follow through on instructions. Does not finish schoolwork, chores, duties. Has difficulty organizing tasks, activities, avoids dislikes. Does not want to do tasks with sustained mental effort like school or homework. Loses necessary task items. Easily distracted

Hyperactivity and Impulsivity of ADHD Hyperactivity-Fidgets with feet and hands, squirms in

seat. Leaves seat in class and other situations when seating is required. Runs around, climbs excessively, inappropriately. Restless, difficulty playing or enjoying leisure. Going constantly. Impulsivity-Blurts answers, inattentive, cannot wait turn, interrupts, intrudes on conversations, impaired in more than one setting. Hyper kid videohttp://www.youtube.com/watch?v=pMgGVBJEDqU&f eature=related

ADHD Prognosis Features may continue into adolescence in most but

decrease in early adulthood and late adolescence. Family history, psychosocial adversity and comorbidity with mood, anxiety and conduct disorders Comorbid oppositional defiant disorder can occur Behavioral management is key at school and home.

Oppositional Defiant Disorder (ODD) Etiology-Child raised by several caregivers or harsh,

neglectful, inconsistent child rearing practices are used. Occurs in households with marital problems. Epidemiology-Occurs in 2-6% of population. Occurs more frequently in males. Before puberty. Occurs with same frequency after puberty. At least one parent may have a mood, oppositional, conduct, antisocial personality or ADHD disorder. Can occur with communication and learning disorders.

ODD Continued Clinical description-Patterned negative, hostile and

defiant behavior for at least 6 months. Loses temper, argues, defies rules, refuses to follow requests, annoys people, blames others for mistakes or misbehavior, touchy, easily annoyed by others, angry and resentful, spiteful and vindictive

ODD Prognosis Prognosis-Onset is gradual, occurs over years and

months, can develop into conduct disorder.

Conduct Disorder Etiology-Can be put at risk by physical and sexual

abuse. Parental rejection and neglect, difficult temperament as an infant, inconsistent child rearing rules and practices with harsh discipline, poor supervision, institutional living, frequent caregiver changes, large family, delinquent peer group. Previous diagnosis of ADHD Epidemiology- Higher in urban than rural settings. Highest in 13-16 year olds. Followed by sharp decline from 13-20. Girls peak at 16.

Conduct Disorder Continued Clinical Description-Repetitive behaviors that are

persistent and violates rights of others and norms of society. Aggressive behavior, bully, intimidate, threaten, fights, uses weapons, acts cruelly steals, forced sexual activity. Blames others, deceitful, lying, may lead to smoking, drinking, drugs. Poor empathy, confrontational. Prognosis-Occurs prior to age 10. Can develop into antisocial personality disorder. Usually male.

Intermittent Explosive Disorder Etiology and Epidemiology-Limited research.

Serotonin may be a factor. Diagnosed in childhood and onto early adulthood. Rare. More prevalent in males than females. Clinical Description-aggressive impulses lead to aggression, striking, hurt others,rage,racing thoughts, followed by fatigue Prognosis-School and peer relationship problems.

Other Mental Problems Adolescent suicide-Increased 4 fold since 1950.2.5-

11.2 per 100,000. Hanging is most common method in 10-15 year olds. Fewer signs in children Youth violence-More common in younger children. Risk factors include low IQ, ADHD, TV, video games, peer pressure. Protective factors-positive parental guidance and good role models, good education, family involvement.

Adult Disorders in Children and Adolescents Substance abuse Depression Bipolar disorder

Psychosis Anxiety disorders Suicide Youth violence Schizophrenia

Assessment Developmental stage Within context of family dynamics Identified client? Physical assessment Family life Activities of Daily Life (ADLs)

Nursing DiagnosisLook carefully at: Safety issues Communication Relationships Family issues

Outcome IdentificationFoci: Promotion of normal growth and development Improving dysfunction

Planning Involve client Involve family Involve treatment team

Implementation Support client and family through change process Provide role model

Set consistent boundaries and limits Expect testing behaviors Maintain safety Provide therapeutic activity

Implementation, contd. Behavior modification

Goal setting ADLs Impulse control Relationships Rewards for accomplishment Chart for preschool and school age Contracts for older children, teens; use increased privileges

Nursing Interventions Maintain safe environment. Contraband Suicidality Aggressive behavior Communicate respect. Promote boundaries, expectations. Set fair limits Increase self-confidence, self-esteem. Realistic praise Maintain realistic, hopeful outlook.

Additional Treatment Modalities Pharmacologic Interventions Group activities Behavior Modification programs

Therapeutic Play Medications Activity therapies