care of the child with a mental or cognitive disorder chapter 32 mosby items and derived items ©...

Care of the Child with a Mental or Cognitive Disorder

Chapter 32Chapter 32

Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.


Disorders of Cognitive FunctionDisorders of Cognitive Function

• Cognitive Impairment Formerly referred to as mental retardation The most common developmental disability, affecting

up to 3% of the population Defined as significantly subaverage general

intellectual functioning existing concurrently with deficits in adaptive behavior and manifested during the developmental period



• Cognitive Impairment (continued) Four Categories

• Mild: IQ of 50 or 55 to 70

• Moderate: IQ of 35 or 40 to 50 or 55

• Severe: IQ of 20 or 25 to 35 or 40

• Profound: IQ below 20 to 25



• Cognitive Impairment (continued) Etiology/pathophysiology

• Down syndrome

• Perinatal infections Cytomegalovirus, rubella, syphilis

• Perinatal anoxia

• Maternal drug or alcohol abuse

• Metabolic disorders Phenylketonuria, lead poisoning, hypothyroidism, and

prematurity



• Cognitive Impairment (continued) Clinical manifestations

• They vary according to the child’s age and degree of impairment.

• Children may fail to achieve developmental milestones at appropriate ages.

• In general, children may manifest delays in motor, social, cognitive, and language skills.



• Cognitive Impairment (continued) Diagnostic tests

• Neurologic examination

• CT scan

• Serum metabolic screening

• Developmental screening tests (Denver II)

• Standardized intellectual tests

• Chromosomal analysis

• Genetic screening



• Cognitive Impairment (continued) Nursing interventions

• Interventions are focused on promoting optimal development and providing the family with support, education, and referrals.

• Parents should be encouraged to enroll the child in an early intervention program.

• Each task that is taught should be broken into small, specific steps.

• Parents should be encouraged to emphasize the normal needs of all children: love, social interaction, and play.



• Cognitive Impairment (continued) Patient/family teaching

• It is essential to provide parents with information on normal developmental milestones, stimulation techniques, safety, normal speech development, sexual development, and the role of positive self-esteem in motivating children to accomplish goals within their limitations.

Prognosis• Cognitive impairment is a chronic condition.



• Down Syndrome Etiology/pathophysiology

• An extra chromosome on the 21st pair, trisomy 21.

• The risk of having a child with Down syndrome increases with aging maternal age, especially for women over 35 years of age.



• Down Syndrome (continued) Clinical manifestations

• Small, rounded skull with a flat occiput

• Upward-slanting eyes

• Broad, flat nose; low-set ears

• Protruding tongue

• Short, thick neck

• Hypotonic extremities

• Mottled skin

• Simian crease on the palmar side of the hand

• Intellectual impairment



• Down Syndrome (continued) Diagnostic tests

• Chromosomal analysis Medical management

• Routine medical care

• Corrective surgery for heart defects

• Auditory and vision screening

• Thyroid function tests



• Down Syndrome (continued) Nursing interventions

• Primary nursing goals include supporting the family at the time of diagnosis and referring the child and family to agencies that provide support and services.

Prognosis• Life expectancy has improved in recent years but

remains lower than that for the general population.

• Over 80% survive to age 30 years and beyond.


Figure 32-1Figure 32-1

Down syndrome in infant.

(From Hockenberry-Eaton, M.J., Wilson, D., Winkelstein, M.L., Kline, M.D. [2003]. Wong’s nursing care of infants and children. [7th ed.]. St. Louis: Mosby.)



• Autism Etiology/pathophysiology

• Complex developmental disorder of brain function accompanied by a broad range and severity of intellectual and behavioral deficits.

• Multiple biologic causes

• Strong evidence for a genetic basis



• Autism (continued) Clinical manifestations and diagnostic tests

• There is inability to maintain eye contact.

• Body contact is avoided at a very early age.

• Child has limited functional play and may interact with toys in an unusual manner.

• Constipation is common.

• There are deficits in social development.

• A majority have some degree of mental retardation, but some may excel in particular areas, such as art, music, memory, or mathematics.



• Autism (continued) Nursing interventions

• Therapeutic intervention is a specialized area involving professionals with advanced training.

• During hospitalization Parents are essential to planning care. Decrease stimulation. Minimize holding and eye contact. Care must be taken when performing procedures. Introduce new situations slowly.



• Autism (continued) Prognosis

• This is usually a severely disabling condition.

• Some children improve with acquisition of language skills and communication.

• Some ultimately achieve independence, but most require lifelong adult supervision.

• Prognosis is most favorable for children with communicative speech development by age 6 years and an IQ above 50 at the time of diagnosis.


Child MaltreatmentChild Maltreatment

• Child Neglect Physical

• Failure of a parent or caretaker to supply a child with adequate food, clothing, shelter, education, or health care although financially able to do so or offered financial or other means to do so

Emotional• Failure by a parent or caretaker to meet a child’s needs

for emotional nurturance, affection, and attention



• Child Abuse Physical

• The intentional, nonaccidental infliction of physical injury upon a child by a parent or guardian

Emotional • The intentional attempt by a parent or caretaker to

impair or destroy the mental or emotional state of a child



• Child Abuse (continued) Sexual

• Commission of a sexual offense by an older person against a child who is dependent or developmentally immature for the purpose of the perpetrator’s own sexual stimulation or gratification



• Etiology Parental factors

• Parent’s culture

• Socialization history and history of having been an abused child

• Parent’s age and developmental level

• Attitudes toward the child and child rearing

• Knowledge of normal child behavior and development

• Parent’s psychologic state



• Etiology (continued) Child’s factors

• Temperament

• Age

• Exceptional physical needs

• Disabilities

• Health or behavior problems These factors may increase the potential for

maltreatment by a parent or caretaker.



• Etiology (continued) Situational factors

• Marital problems

• Financial difficulties

• Drug and/or alcohol abuse

• Lack of social support or the inability of the parent or caretaker to ask for support

• Poor social network

• Poor relationships with extended families



• Clinical Manifestations Children who have been abused or neglected may

manifest certain physical and/or behavioral indicators that suggest maltreatment (see Table 3-1 in the text).



• Nursing Interventions Identify a child who is being maltreated. The nurse often is the first person to see the child and

parent. The presence of a behavioral or physical indicator of

maltreatment should serve to prompt further investigation.

Special attention should be paid to injuries that are unexplained or inconsistent with the parent’s or caretaker’s explanation of how the injury occurred.



• Nursing Interventions (continued) All states have regulations for the mandatory reporting

of child maltreatment when a health professional has reason to suspect that a child has been abused or neglected.

During the prenatal period, families at risk for abuse can be identified and referred for intervention.

Reinforcement of positive caretaking behaviors is an effective way of affirming positive parenting practices.


School Avoidance (School Phobia, School Refusal)School Avoidance (School Phobia, School Refusal)

• Occurs when a physically healthy child repeatedly stays home from school or is sent home from school for physical symptoms of an emotional origin.

• Etiology/pathophysiology Cause may be related to anxiety or worry about

academic progress, peer conflicts, or marital discord in the home.

Separation anxiety is also common among these children even after the age when this should be mastered (3 to 4 years).

Parents may be too lenient, place little value on education, or be unconcerned about the ramifications of missing school.


• Clinical Manifestations Children who are of the anxious type tend to have

physiologic symptoms of anxiety, including• Headache

• Recurrent abdominal pain

• Vomiting, diarrhea

• Insomnia

• Pallor

• Palpitations

• Hyperventilation



• Clinical Manifestations (continued) May exaggerate or fabricate symptoms

• Sore throat

• Leg pain

• Coughing tics

• Chest pain

• Fatigue No organic cause can be found. The child usually sounds very sick but appears to

be well.



• Medical Management/Nursing Interventions Assist in convincing parents that their child is healthy;

explain the diagnosis. Assist in returning the child to regular school

attendance. Assure parents that this occurs in “normal” children

and is stress-related and not a psychiatric disorder. Encourage parents to be firm if the child refuses to go

to school; reassure child that there is nothing physically wrong with him or her.



Learning DisabilitiesLearning Disabilities

• Etiology/Pathophysiology Cause is multifactorial; often a specific cause cannot

be identified. It may be the result of various physiologic and/or

environmental factors such as intrauterine exposure to drugs or infection, birth trauma, lead poisoning, seizures, malnutrition, and exposure to toxic substances, such as alcohol and lead.

Hearing or vision impairments may lead to learning problems.

Genetic syndromes such as fragile X syndrome or Prader-Willi syndrome may be associated.



• Clinical Manifestations Problems with speech, behavior, and/or motor

coordination Failure to master basic, grade-appropriate academic

skills in one or more subject areas A progressive decline in school performance Delayed acquisition of language milestones, deficient

social skills, avoidance behavior, low frustration tolerance, disorganization, and somnolence



• Diagnostic Tests Thorough history and physical examination may

provide specific indications to obtain• Lead level

• EEG

• Chromosomal studies

• Hearing and vision screenings

• Intelligence and achievement testing

• Neuropsychological testing



• Medial Management/Nursing Interventions Provide educational referrals. Educate parents about the special education process. Therapeutic manipulation of the educational setting:

suggest special arrangements in a regular classroom; alternative classroom placement, tutoring, and remediation assistance.

• Prognosis With early identification, appropriate referrals, and

proper educational interventions, the negative consequences of school failure may be avoided; child can usually function optimally within his or her limitations.


Attention Deficit Hyperactivity DisorderAttention Deficit Hyperactivity Disorder

• Etiology/Pathophysiology Multifactorial Incidence in first-degree relatives of 25%. Theories of altered neurotransmitter profiles Possible environmental factors: low socioeconomic

status and parental psychopathology



• Clinical Manifestations May exhibit

• Decreased attention span

• Impulsivity

• Failure to follow instructions

• Hyperactivity; fidgeting

• Poor self-regulation

• Noncompliance

• Aggression

• Immaturity during play

• Failure to follow rules of play games



• Clinical Manifestations (continued) May exhibit

• Lack of turn-taking during play

• Easy distraction by extraneous stimuli

• Poor school performance; learning disabilities

• Antisocial behaviors: lying, cheating, stealing

• Excessive anxiety

• Sleep disturbances

• Poor peer relationships

• Limited fine motor skills

• Additional psychiatric diagnosis



• Diagnostic Tests Report of characteristic behaviors made by multiple

observers, over an extended period of time, and in various settings

Many rating scales available to assess ADHD



• Medical Management Behavioral counseling Educational intervention Pharmacotherapy

• Nursing Interventions Provide counseling. Educate parents on discipline and setting limits. Explain need for increased supervision. Assist in the development of the educational plan

where appropriate. Explain reasons for medications and risks.


Other DisordersOther Disorders

• Anorexia and Bulimia Eating disorders with significant underlying

psychologic and emotional issues Primarily affect adolescents, but younger children may

be affected

• Substance Abuse Substance abuse usually points to significant

problems in the child, family, or both, warranting professional counseling.

In the adolescent, the incentives are usually experimental and recreational.



• Depression Depression is generally defined as a mood

disturbance with overall feelings of sadness, despair, worthlessness, or hopelessness.

Girls are more likely than boys to suffer from depression.

Etiology/pathophysiology• Causes have not been established.

• Risk factors can be genetic or environmental.

• Cognitive theories attribute depression to actual loss or perceived loss.



• Depression (continued) Clinical manifestations

• Infancy: crying, panic, followed by apathy, blank staring, and sad facial expressions

• School-aged: sad facial expressions, irritability, crying easily, accident-prone, social withdrawal, and eating and sleeping disturbances

• Adolescents: impulsiveness, somatization disorders, eating disorders, drug/alcohol use, antisocial behavior, withdrawal, fatigue, and suicidal ideation



• Depression (continued) Diagnostic tests

• Structured questionnaires or interviews Children’s Depression Scale Depression Self-Rating Scale

Medical management• Antidepressant medications

• Psychologic therapies



• Depression (continued) Nursing interventions

• Establish a trusting relationship with the child.

• Provide support to the child’s family, using open and honest communication

Patient/family teaching• Review the treatment plan with the family to help them

realize recovery may be a lengthy process.



• Depression (continued) Prognosis

• For the child and family motivated to develop better supports and relationship skills, the prognosis is good, but episodes may recur.



• Suicide Etiology/pathophysiology

• Suicide is not caused by a single factor but is the culmination of multiple factors.

Depression Loss of a loved one or relationship Social isolation Lack of attaining a sense of identity, leading to self-doubt

and low self-esteem



• Suicide (continued) Diagnostic tests

• Structured questionnaires or interviews Children’s Depression Scale Depression Self-Rating Scale

Medical management• Individual, family, and group therapy



• Suicide (continued) Nursing interventions

• Mental health assessments of children and adolescents should be part of every health visit.

• If concerns exist, be direct in asking questions about thoughts of death or suicide.

• Any threat of suicide needs to be taken very seriously and immediately evaluated by a mental health professional.

• Help the child develop positive coping strategies in stressful situations.



• Suicide (continued) Prognosis

• Prognoses vary.

• The greatest risk lies in children who verbalize suicidal thoughts and those who attempt suicide.

• Appropriate mental health care can help these children to alleviate depression and develop a more positive self-image.



• Suicide (continued) Clinical manifestations

• Many completed suicides are the final result of previous attempts.

• Warning signs include Depression; withdrawal; loneliness Preoccupation with death Perceived or actual social isolation Poor school performance Drug and/or alcohol abuse Appetite and sleep disorders



• Psychogenic Abdominal Pain (Recurrent Abdominal Pain) Etiology/pathophysiology

• Psychogenic pain is often related to emotional factors in the child/or family members: poor self-esteem, anxiety, depression, school phobia, maternal depression, marital problems/divorce, or other health problems in family members.

• Organic causes should be considered until proved otherwise: infections of the urinary tract, GI tract, and reproductive tract.



• Psychogenic Abdominal Pain (Recurrent Abdominal Pain) (continued) Clinical manifestations

• Usually afebrile

• May have occasional vomiting and constipation

• Abdominal pain usually nonspecific



• Psychogenic Abdominal Pain (Recurrent Abdominal Pain) (continued) Diagnostic tests

• Organic causes must be ruled out.

• CBC, sedimentation rate, urinalysis and culture, serum albumin and amylase, stool for occult blood, and culture for bacteria and parasites

• In adolescent females, a pregnancy test may be considered.



• Psychogenic Abdominal Pain (Recurrent Abdominal Pain) (continued) Medical management

• Once organic causes have been ruled out, stressors in the child’s life need to be identified and addressed.

• Consult with a mental health professional. Nursing interventions

• Encourage parents to maintain a normal schedule for their child with regard to school, play, and exercise.

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