child and adolescent[1]

8/21/2019 Child and Adolescent[1]

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Child and Adolescent

Disorders

ANGELBERN NARAG GANNABAN


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Psychiatric disorders are not diagnosed as easily in

children as they are in adults because:

Children lack abstract cognitive abilities andverbal skills 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)

Disruptive behavior disorders


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Disturbances and emotions and thoughts

that cause prolonged, serious distress or

impairment of functioning are referred to as

mental 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 Retardation


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Mild

Can be taught to live independently: can

develop social skils and ability to verbalize:

Good academic skills

Limited ability to abstract

Has gross and fine motor abilities

Can do unskilled manual labor


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Moderate

Requires a structure in living arrangement

Can learn words, numbers, sign poor

abstract thinking, follow simple

instructions; can participate in repetitive

task


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Severe

Requires a great deal of assistance and

structured living arangements; say a few

words, no abstract ability, rarely can readwrite or use math uncoordinated motor

moements


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Profound

Requires full time care; unable to relate

verbally, no academic skills, no fine gross

skills


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Heredity Tay-Sachs disease or fragile X chromosome

syndrome Early alterations in embryonic development

Maternal alcohol intake

Causes


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Down Syndrome

5% of mild MR, 30% of severe

Trisomy 21: occurs randomly, not inherited

Related to maternal age, over 40

Reduced brain size, reduced number and density of neurons and

dendrites Identical brain plaques and tangles found in Alzheimers by age 35-40

75% of Down adults have symptoms of Alzheimers by age 70

physical features noted: upward slant of eyes, folds in corner of eyes,facial flatness, fissured and thick tongues, broad hands and feet, poormuscle tone

Retardation ranges from mild to severe

Language skills delays; deficit in short-term memory

Personality: mild-mannered, friendly, socially competent, cooperative,follow rules; in somehyperactivity, aggression, noncompliance

Emotional development lags; emotions seem muted
http://g/Down%20Syndrome.dochttp://g/Down%20Syndrome.doc


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Fragile X

Second to Down syndrome as causation of retardation

More males than females

Males have double-jointed thumbs, flat feet, velvetskin, long faces, big ears, oversized testicles

Comorbid with autism

Mild to moderate MR: language skills to age 4, thenplateau

Slowing of intellectual growth from 8 to 15 Weakness in expressive language, not receptive

language


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Williams syndrome

Gene deletion on chromosome 7; rare

Elfinlike face, growth deficiency, cardiac,

kidney problems

Mild to moderate retardation


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Causes cont

Pregnancy or perinatal problemsFetal malnutrition, hypoxia, infections, and

trauma

Medical conditions of infancy

Infection or lead poisoning Environmental influences

Deprivation of nurturing or stimulation


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Learning Disorders Diagnosed when the childs achievement in reading,mathematics, or written expression is below that

expected for the childs age, formal education, and level

of intelligence

Interfere with academic achievement, life activities,

development of self-esteem, and social skills

Early identification, intervention, and coexistingproblems are associated with better outcomes


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Reading Disorder: dyslexia; the most common

of the learning disorders; decodingproblems

suggest difficulty recognizing or pronouncingwords, reading slowly or haltingly; limited

vocabulary; difficulty comprehendingor

remembering what was read reading disorder

is fundamentally related to language disorder Reading problems persist through adulthood

for many


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Writing Disorder: Dysgraphia; visual-motor

coordination is blamed for poor handwriting;spelling errors, awkward placement of words,

poor sentence structure, poor punctuation, lack

of clarity in meaning are common; diagnosis

most likely after the age of 8 when motor skills

are developed; prevalence unknown; prognosis

unknown; some improvement with proper

skills, which justifies continued work to write acoherent essay: develop a topic sentence,

organize points to be made, link ideas with

transitions, provide detail and elaboration on

major points, summarize succinctly.


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Mathematics Disorder: Dyscalcula; problems

in reading numbers, performing

addition/subtraction, understandingterms/symbols, understanding spatial

organization; visual-spatial impairment;

developmental milestones from 3-6: arranging

objects by size, counting to ten, copyingnumbers and block designs, sorting objects by

characteristic, understanding concepts like

more than, less than; prevalence rate: 1%; little

research on prognosis


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Motor Skills Disorder

Marked impairment in coordination severeenough to interfere with academic

achievement or activities of daily living

Often coexists with communicationdisorders

Provide adaptive physical education and

sensory integration to foster normal growth

and development


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Communication 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

Speech therapy to improve communication

skills


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CAUSES

Brain abnormalities: Brocas area for

speech production; Wernickes areas for

language comprehension (both in frontallobe); L and R hemisphere differences in

symmetry;

Genetics: high heritability for LDs;single- and multiple-gene effects

suspected; specific chromosomes

suspected


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CAUSES

Psychosocial factors: family variables,

such as how much parents speak to

children and the verbal interactions

between child and parents; parental

attitudes toward learning, child

management practices, social class,

cultural values; quality of schoolinstruction, overcrowded classrooms

Interactional nature-nurture theory

proposed


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TREATMENT

Individualized Education Program (IEP);

a plan that guides the services that a

special student must receive; delineates aspecific course of action to address

recognized problems; this plan is created

by the special education teacher, specialeducation supervisor, school psychologist,

principal, counselor and/or classroom

teacher and the parents.


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An array of special education services is

organized as a continuum going from least

to most restrictive, as follows: Consultation and support for general teachers

Special education up to 1 hour per day

Special education 1-3 hours per day; resourceprogram

Special education more than 3 hours per day;

self-contained special education

Special day school

Special residential school

Home/hospital


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Pervasive Developmental

Disorders Characterized by pervasive and usually

severe impairment of reciprocal social

interaction skills, communication

deviance, restricted stereotypical

behavioral patterns

Autistic disorder (classic autism) Retts disorder

Childhood disintegrative disorder

Aspergers disorder


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Research to confirm brain anatomicalabnormalities suggests that neurons in theamygdala (the area responsible for processingemotions and behavior)

and the hippocampus (involved in learning andmemory) are smaller, more densely packed insome areas, and have shorter, less-developed

branches than normal.

Low blood circulation in some parts of thecerebral cortex during certain intellectualfunctions and a reduced number of cells relayinginhibitory messages have been demonstrated.


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It has been hypothesized that these severe

developmental disorders of childhood are the

result of a disturbance in the central nervoussystem integration and in thebiological process

of maturation.

Predisposing organic factors include maternal

rubella, phenylketonuria, encephalitis, meningitis,

hydrocephalus, hypothyroidism, and tuberous

sclerosis.


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Autism

Rare condition: 4 cases in 10,000; boys >

girls: 3:1. Autism in girls is more severe in

retardation. Most recent research suggeststhat the number of autistic children is

increasing, reason unknown.


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Autism

Negative responses to changes in routine;

insistence on rigid adherence to the usual

way of doing everything; Kanner, whofirst described autism in 1943described

their obsessive desire for the maintenance

of sameness;change brings tantrums;intense attachment to objects;stereotypies;

self-injurious behaviors such as head

banging


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Autism

Apparent social deficits and bizarre responses:

failure to cuddle, lack of eye contact, aversion tophysical affection;

indifferent to social contact, proneness to tempertantrums;

autistic aloneness in areas of language, behavior,cognitive development and social relationships;

echopraxia; physical and emotional distance; inability to

respond to others feelings;


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Autism

mindblindness (the inability to interpret theintentions, beliefs or behaviors of others);

maywalk on tiptoe; great deal of time spinning objects, flicking

their fingers or rocking their bodies.

Abnormal language development, includingecholalia, pronominal reversal;

THEY TALK IN A THIRD PERSON


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Autism

perserveration;high-pitched, bird-like squeakingvoice;

verbal skills may be stilted, too perfect, with no

subtleties of emotional tone; failure to imitate gestures or imaginative play;

nonverbal skills remain poor.

Approximately half of all autistic children do not

develop speech at all. Executive functions of thecerebral cortexplanning, inhibition of response,flexibility and working memoryare often pooror missing


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INCIDENCE RATE

25-40% score above 70 on IQ tests, and

range from normal to gifted, but

approximately 70% are mentally retarded;sometimes accompanied bysavant

capacities (areas of surprising talent in other

wise low functioning individuals includemusic, drawing, and calendar calculations),

i.e. Dustin Hoffmans character inRain

Man


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Autism

The following disorders are related to Autism, butshow a different developmental course and patternof symptoms:

Retts Disorder: rare disorder only occurring infemales, due to a gene mutation; onset in first fouryears; normal first year, then a slowing down in

head growth and a decline in motor andcommunication skills; then a social withdrawal,stereotypic and repetitive hand or fingermovements or whole body movements; mentalretardation; persistent and progressive


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Autism

Childhood Disintegrative Disorder:

normal development for first two years;

typical onset between three and four years;loss of skills in at least two of the following:

expressive or receptive language, social

skills or adaptive behaviors, bowel orbladder control, play, and motor skills;

other symptoms similar to autism noted;

etiology unknown


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Autism

Aspergers Disorder: latest onset of the disorders:

preschool or later; associated with less severe

deficits; impairment in social interactions,repetitive patterns of behavior, limited interests;

failure to make eye contact; inexpressive facial

expressions; mechanical and robotic body posture

and gestures; few friends, no interest in recreationor humor; may be a milder form of autism; more

common in males; may be gifted in certain areas


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Aspergers Disorder

A. Qualitative impairment in social interactions, asmanifested by at least two of the following:

marked impairment in the use of mul tiple nonverbal behaviors suchas eye-to-eye gaze, facial expression, body postures, and gestures to

regulate social interaction failure to develop peer relationships appropriate to developmental

level

a lack of spontaneous seeking to share enjoyment, interests, orachievements with other people (e.g. by a lack of showing, bringing,or pointing out objects of interest to other people)

lack of social or emotional reciprocity


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Aspergers Disorder

B. Restricted repetitive and stereotyped patternsof behavior, interests, and activities, asmanifested by at least one of the following:

encompassing preoccupation wi th one or morestereotyped and restr icted patterns of interest that areabnormal either in intensity or focus

apparently inf lexible adherence to specif ic,nonfunctional routines or r ituals

stereotyped and repeti tive motor mannerisms (e.g. handor f inger f lapping or twisting, or complex whole-bodymovements)

persistent preoccupation with parts of objects


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Neurobiological Abnormalities

Aspergers d/o Large brain size in toddlers

Smaller corpus collosum connecting the

hemispheres, suggesting disturbances in brainconnectivity

Left frontal macrogyria, bilateral opercular

polymicrogyria and left temporal lobe damage

have been found in AD children

Chromosomes 15, 7 and 2 are implicated in

linkage studies


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Aspergers d/o Temporal lobe-limbic system, frontal

lobe and cerebellum: the social brain

targeted decreased number and size of cells, high

cell density, dendritic branching,

abnormal cell migration Reduced activity in the amygdala during

face perception


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Aspergers d/o Reduced activity in frontal lobe and other

areas related to social and emotional

functioning Reduced activity in the cerebellum

related to attention problems

Biochemical systems: serotonin anddopamine levels are abnormal in

childhood and adolescence


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Pervasive Developmental

Disorders (contd) 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 andpromote learning, development, and languageskills


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Attention Deficit Hyperactivity

Disorder (ADHD)

Inattentiveness,

overactivity, andimpulsiveness


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Incidence Rates

Boys are three

times more likely

than girls todevelop ADHD


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4. By 5 to 8 years old, 45-70% of children

with ADHD have begun to show significant

problems with defiance, resistance to parentalauthority, hostility towards others and quick-

temperedness; symptoms of inattentiveness

often emerge a year or more later than the

symptoms of hyperactivity and impulsiveness 5. As adolescents, these children are labeled

socially disabled and often experience intense

interpersonal problems


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6. As adults, children diagnosed with ADHD

are at increased risk for antisocial personality

disorder, substance abuse, marital problems,

traffic accidents, legal infractions and frequent

job changes

7. Comorbiddisorders include mood

disorders, anxiety disorders, OCD, personality

disorders, tic disorders, sleep disorders, autismand Aspergers syndrome

8. The remaining one-third grow out of

their symptoms by early adulthood and go on

to lead normal and healthy lives


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CAUSES

2. Recent twin studies find that concordancefor ADHD was .67 in MZ twins and .37 in DZ

twins, based on ratings by teachers

3. Children with ADHD differ from children

with no disorder on measures of neurologicalfunctioning and cerebral blood flow


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4. Areas of the brain most likely involved

include the frontal lobes, the caudate nucleus

within the basal ganglia, the corpus collosum,

which connects the two lobes, and the pathways

between these structures

5. Immaturity theory suggests that the brains

of these children are slower to develop thanthose of children without the disorder; this

theory helps explain the ADHD decline with

age in many children


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7. Prenatal and birth complications have

been related to ADHD, including gestation of

nicotine or barbiturates during pregnancy, low

birth weight, premature delivery, and difficultdelivery leading to oxygen

deprivation. Moderate to severe drinking in

mothers during pregnancy may lead to

problems in inhibiting behaviors seen in

children with ADHD


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8. Biological abnormalities translates into behavioral

problems in four realms (Barkley, 1998): (1) nonverbal

working memory, (2) internalization of self-directed

speech, (3) the self-regulation of mood, motivation andlevel of arousal, and (4) reconstitutionthe ability to

break down observed behaviors into component parts

that can be recombined into new behaviors directed

toward a goal


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9. No dietary factors, such as consumption of

sugar or food dyes, as a correlate to ADHD

have been supported in controlled studies,

although there are vocal supporters of this

theory, i.e. the Feingold diet advocates; about

5% of children are relieved of symptoms with

change of diet, mostly young children with foodallergies

10. Cultural and social influences include

disturbed family environment, academic failure


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Attention Deficit Hyperactivity

Disorder (ADHD) Three subtypes of

ADHD: predominantly hyperactive-

impulsive type, predominantly inattentivetype and combined type

Criteria for ADHD fall into three

clusters: inattention, hyperactivity andimpulsivity:


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Inattention

Does not pay attention to detai ls and makes careless

mistakes

Has dif f iculty sustaining attention unless they are doing

something they really enjoy Does not seem to be listening when others are talking

Does not follow through on instructions or f inish tasks

Has dif f icul ty organizing behaviors

Avoids activities that requi re sustained effort andattention

Loses things frequently

I s easily distracted


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Is forgetful

Skips from one activity to the next

Appears spacey, easi ly confused, slow

moving and lethargic

Diff icul ty processing information; may not

understand oral or written instructions


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Hyperactivity F idgets with hands or feet and squirms in

seat

I s restless, leaving his/her seat or running

around when inappropr iate

Has dif f icul ty engaging in quiet activi ties

Always on the go Feeling of internal restlessness

Need to stay busy and try to do several

things at once


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Impulsivity

Blurts out responses while others are

talking

Has dif f icul ty waiting his/her turn

Displays emotions without restraint

Acts without regard for later consequences

Immediate gratif ication more important

than delayed rewards


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Among possible causes of ADHD-like

behavior are the following, which must

be ruled out before diagnosis: 1. A sudden change in the childs life

death, divorce, parents job loss or move

2. Undetected seizures 3. A middle ear infection that cause

intermittent hearing problems


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4. Medical disorders that may affect

brain functioning

5. Underachievement caused bylearning disability

6. Anxiety or depression


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ComorbidDisorders accompanying

ADHD include Learning Disabilities (20-

30%); Tourette Syndrome; ODD (30-50%); Conduct Disorder (20-40%);

Anxiety; Depression; Bipolar Disorder


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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 (contd)


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TreatmentCombination of pharmacotherapy with behavioral,psychosocial, and educational interventions

Psychopharmacology

Stimulants: methylphenidate (Ritalin), an amphetaminecompound (Adderall), dextroamphetamine (Dexedrine),

and pemoline (Cylert)

Common side effects: insomnia, loss of appetite, andweight loss or failure to gain weight


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3 About 50% of children with ADHD

improve with an SSRI antidepressant

4.Psychosocial intervention may addressthe parents own psychological problems

and the impairments in parenting skills

that these problems create


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5. Research results support the use of both medication

and behavioral treatment for the effectiveness both

short-term and long-term

6. Treatment that focuses on promoting parentalcompetence and on treating aggression and defiance in

ADHD children very early in childhood appears to lead

to the most positive long-term outcomes


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Psychosocial Treatment

Behavior modification

o Start with goals that can be achieved in

small steps

o Be consistent across time, settings

o Implement interventions over the long

haul

o Reinforce for gradual improvements

toward goals


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Parent Training

o Establish house rules and

structure O Reinforce appropriate behaviors;

ignore mild inappropriate behaviors

o Use whenthen contingencies

o Plan ahead for activities


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O Daily charts and point/token

systems for rewards

oSchool-home note system fortracking homework


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School Intervention

o Training in classroom management

O Focus on use of weekly planners

o Study skill training


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Child Intervention

o Systematic training of social skills

o Social problem solving

o Teaching behavioral skills important

for children, i.e. sports, board games

o Decreasing undesirable and

antisocial behaviors

o Developing a close friendship

Oppositional Defiant


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Disorder

Behaviors cause dysfunction in social,

academic, and work situations

25% go on to develop conduct disorder 10% are diagnosed with antisocial personality

disorder as adults

Treatment is similar to conduct disorder,

depending on severity of behaviors



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Disorder A pattern of negativistic, hosti le, anddefiant behavior lasting at least six

months, and causing cl inical ly meaningfulimpairment in the childs social or

academic functioning, dur ing which four

or more of the following are present


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1. often loses temper

2. often argues with adults

3. often actively defies or refuses tocomply with adults requests or rules

4. often deliberately annoys people

5. often blames others for his or her

mistakes or misbehavior


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6. is often touchy or easily annoyed by

others

7. is often angry and resentful 8. is often spiteful or vindictive

Note that the criteria would fall under

the overt/nondestructive dimensions ofbehavior


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Conduct Disorder

A repeti tive and persistent pattern of

behavior in which the basic rights of

others or major age-appropr iate societalnorms or rules are violated, as manifested

by three or more of the following cr iter ia

in the past twelve months, with at least one

criter ion present in the past six months.


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1. Aggression to people and animals

2. Bullies, intimidates, uses a weapon,

physically cruel, stolen, sexual coercion 3. Destruction of property


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4. Fire-setting, destroyed others

property)

5. Deceitfulness or theft 6. Broken into houses, buildings, cars;

lies to obtain food or favors, shoplifting


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7. Serious violations of rules

8. Stays out all night; run away from

home, truant from school Note: The Antisocial Personali ty

Disorder (APD) is applied to individuals

who display a persistent pattern ofaggressive and antisocial behavior since

the age of 15.


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Etiology Genetic vulnerability Environmental adversity

Poor copingRisk factors include poor parenting, low

academic achievement, poor peer

relationships, low self-esteemProtective factors include resilience,

family support, positive peer

relationships good health


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Risk for Other-Directed Violence

Noncompliance

Ineffective Coping

Impaired Social Interaction

Chronic Low Self-Esteem

Nursing diagnoses include:


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Treatment 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

stabilizers such as carbamazepine (Tegretol)


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Intervention 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 (contd)


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Feeding and Eating Disorders Pica: persistent ingestion of

nonnutritive substances

Rumination disorder: repeated

regurgitation and rechewing of food

Feeding disorder: persistent failure toeat and gain/maintain adequate weight


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Tic Disorders Rapid, sudden, recurrent, nonrhythmic

stereotyped motor movement or

vocalization

Familial tendencies

Treated with atypical antipsychoticssuch as olanzapine or risperidone

Tic Disorders (contd)


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Tic Disorders (cont d)

Tourettes 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

Chronic Motor or Tic Disorder

Involves either vocal or motor tics, not both

Elimination Disorders


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Elimination Disorders

Encopresis: defecating in inappropriate

places by a child of at least 4 years Involuntary encopresis associated with constipation that

occurs for psychological, not medical, reasons

Intentional encopresis associated with oppositional defiantdisorder or conduct disorder

Enuresis: repeated urination during day

or night in clothes or bed after age 5 Most often involuntary

Intentional enuresis associated with a disruptive behavior

disorder


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Separation Anxiety Disorder Excessive 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 encourage

avoidance as a way to deal with

unknown situations


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Selective Mutism Persistent failure to speak in social

situations where speaking is

expected

Excessively shy, socially

withdrawn, isolated, clinging,temper tantrums


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Reactive Attachment Disorder Markedly disturbed and

developmentally inappropriate

social relatedness in most situations

Associated with grossly pathogenic

care Begins before age 5

Stereotypic Movement Disorder


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Stereotypic Movement Disorder Repetitive, nonfunctional motor

behavior that interferes with normalactivities or results in self-injuryrequiring medical treatment

Waving, rocking, twirling objects, biting fingernails,banging the head, biting or hitting oneself, orpicking at the skin or body orifices

Associated with many metabolic,

genetic, and neurologic disorders andmental retardation

Cause unknown


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Self-Awareness Issues

Recognize own beliefs about parenting

and how they differ from others

Focus on patients strengths, not just

problems

Try to have positive impact on child

even when disability is severe

child and adolescent[1]

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