Childhood and Adolescent Disorders

Childhood and Adolescent Disorders

1What is it?Child psychiatric nursing is different from adult psychiatric nursing in these 3 waysUsually parents bring children, who think that some aspect of behavior or development is abnormalThe childs stage of development determines whether behavior is normal or abnormalChildren are generally less able to express themselves in words, therefore evidence of disturbance is based more on observations of behavior made by parents, teachers and othersMain emphasis of treatment is on changing the attitudes of parents, reassuring and retraining children, working with family and coordinating with others 2ICD 10 Classification F70-79 Mental retardationF70 Mild mental retardationF71 Moderate mental retardationF72 Severe mental retardationF73 Profound mental retardationF79 Unspecified mental retardation3F80 F89 Disorders of psychological developmentF80 Specific developmental disorders of speech and languageF81 Specific developmental disorders of scholastic skillsF82 Specific developmental disorder of motor functionF83 Mixed specific developmental disorderF84 Pervasive developmental disordersF88 Other disorders of psychological developmentF89 unspecified disorder of psychological development4F90 98 Behavioral and emotional disorders with onset usually occurring in childhood and adolescenceF90 Hyperkinetic disorderF91 Conduct disordersF92 Mixed disorders of conduct and emotionsF93 Emotional disorders with onset specific to childhoodF94 Disorders of social functioning with onset specific to childhood and adolescenceF95 Tic disordersF98 Other behavioral and emotional disorders with onset usually occurring in childhood and adolescence5Mental Retardation (mental sub-normality)MR is a generalized disorder, characterized by significantly impaired cognitive functioning and deficits in two or more adaptive behaviors with onset before the age of 18It is the state of developmental deficit, beginning in childhood those results in significant limitation of intellect or cognition and poor adaptation to the demands of everyday life6Definition DSM IV- TR defines mental retardation as significantly sub average intellectual functioning An intelligence quotient of approximately 70 or below. Concurrent deficits or impairments in adaptive functioning in at least 2 of the following areas: Communication, self care, home living, social/ interpretational skills, use of community resources, self direction, functional academic skills, work, leisure, health and safety7Mental retardation refers to significantly sub average general intellectual functioning resulting in or associated with concurrent impairments in adaptive behavior and manifested during the developmental period American Association on Mental Deficiency, 1983.8Epidemiology Approximately 3% of population is affectedIn India 5/1000 children are MR40 70% has diagnosable psychiatric diseases It is common in boys than girlsMortality is due to associated physical diseases9Etiology Infections Congenital CMVCongenital rubellaCongenital toxoplasmosisEncephalitisHIV infectionListeriosisMeningitis 102. Chromosomal abnormalitiesChromosome deletionsChromosomal translocationsChromosomal inheritance Errors in chromosome numbers113. Prenatal factorsDisturbances in the embryonic developmentInfections during pregnancyDrug abuse or alcoholism of mothers4. Perinatal factorsPremature birthLBWFetal oxygen deprivationStress on the fetus during birth125. Postnatal causesEnvironmental toxinsExposure to childhood diseaseInfections (whooping cough, measles, rubella, mumps. Meningitis)Any injury to brainLead poisoning 136. Genetic abnormalities and inherited metabolic disordersAdrenoleukodystrophyGalactosemiaHunter syndrome Lesch Nyhan syndromePhenylketonuriaRett syndromeTuberous sclerosis 147. Trauma Intracranial hemorrhage before or after birthFetal hypoxiaSevere head injury8. Other factorsPoor environmental conditionMalnutritionLead poisoning15Types TypeIQMild (Educable)50-70Moderate (Trainable)35-50Severe (Dependent retarded)20-35Profound (life support)110Behavioral manifestationsMild MRCommonest form of MR (85 % among all MR)Poor academic performanceWhen they reach adulthood, many patients learn to live independently and maintain gainful employmentEducable up to primary school levelThey can learn and use social skills in structured settings172. Moderate MRThey account 10% of MRThey require considerable support in school, at home and in communityAs adults, they may live with parents, in supportive group homeEducable up to 2nd classHave certain speech limitationsHave difficulty following expected social norms

183. Severe MRThey account 3-4% of MRDevelopment is greatly slowed in pre school yearsMany of them can be helped to look after themselves under close supervisionAs adults, they can undertake simple tasks and engage in limited social activitiesThey need supervision and clear structure to their livesPoor motor skills, delayed speech and communication skillsHave limited verbal skills

194. Profound MRThey account for 1-2% of MRDevelopmental milestones are delayedThey require constant nursing care, support and supervision even in simple ADLAcademic training may be impossibleHave little speech development and lack social skills20Signs and symptomsFailure to achieve developmental milestonesDeficiency in cognitive functioningInability to follow commandsPoor learning skills in academicsExpressive or receptive language problemsPsychomotor skill deficitsNeurologic impairmentsDifficulty in doing ADLIrritability when frustrated or upsetActing out behavior21Assessment and diagnosisComprehensive historyPatient interviewMental statusMedical reviewNeurological examinationAssessment of developmental milestones22Lab investigationsUrinalysis and blood studies for metabolic disordersCulture for cytogenic and biochemical studiesBrain MRI, head CTChorionic villi samplingThyroid function testPsychological tests like ( stanford binet intelligent scale, Wechsler Intelligence Scale for Children WISC, Vineland Adaptive Behavior ScalesIQ test (MA/CA100)23TreatmentBehavioral managementEnvironmental supervisionMonitor childs developmental needs and problemsSpeech therapyOccupational therapyOngoing evaluation for concurrent psychiatric disorders and ADHDFamily therapySpecial schoolsVocational training24Prevention Primary prevention Genetic counselingImmunizationsFamily planningAdequate nutrition for motherAvoidance of teratogenic substancesAmniocentesisFetoscopy . Fetal biopsy, ultrasoundAvoidance of birth injury

252. Secondary preventionEarly detection and treatment of preventable disorders (PKU, myxedema)Early recognition of presence of MRPsychiatric treatment for emotional and behavioral difficulties263. Tertiary preventionVocational rehabilitationPhysical and social rehabilitationReduction of disability

27Care and rehabilitationMain aims and objectives of rehabilitationPrevention and early detection of mental handicapsTo increase awareness of the community and to sensitize it to issue and bring about positive attitudinal changeTo facilitate bringing patients and their families into the main streamTo mobilize community resources and enhance community participation in building the required services 285. To establish accessible, available and affordable services for majority of people within the community itself.6. To ensure these people and their families have a say in how the services are run7. To have psychiatric and psychological services for mentally retarded child8. To have regular assessment for mentally retarded children9. To promote ownership of the programmes by the community itself so that they continue even without external support29Services includeMedical and psychological servicesParental counselingEarly detection and early stimulationTraining in self help, social and practical skillsSpeech therapyEducationVocational trainingResidential careIndividual and family approachesCommunity based approachesHome based approaches30Successful skill training includesDivide training activity into small stepsGive repeated training in each activityGive training regularly and systematicallyStart giving training from what child already knowsReward the child with appreciationReduce reward as he masters the skillUse training materials appropriate, and attractiveTrain with oriented normal children, for better learningAssess child periodicallyUnderstand and make parents understand the MR child learn slowly.31Nursing diagnosisAltered growth and development related to impaired functioningAssess childs G&D at regular intervalInvolve family members in early infant stimulation programmeHelp family to set realistic goals for childEncourage learning of self care activities to the childCounsel the child, parents about maturational processEncourage optimum vocational training322. Altered social interaction related to impaired cognitive functioningAssess childs social interaction patternEncourage family to teach the child socially acceptable behaviorEncourage grooming and age appropriate dress to encourage acceptance by othersEmphasize that the child has same need for socialization as other children333. Self care deficit related to cognitive impairmentAssist patient in accepting necessary amount of dependenceSet short range goals with patientEncourage independence activities with supervisionProvide positive reinforcementProvide privacy during dressing, bathing etc..Plan daily activitiesOffer frequent encouragement

344. Altered family process related to having a child with MRAssess process of family with a child of MRInform the family as soon as possible after birth to both the parentsProvide adequate information to the family about MR and its careDiscuss with family about pros and cons of home care of child with MRDemonstrate acceptance of child through own behaviorEncourage family to express feelings and concerns355. Impaired communication related to cognitive impairment Assess level of communication and social skillsEstablish free and open communication with patient and family membersInvolve the client to interact with other membersProvide calm, quiet and non threatening environmentAllow client to express emotions slowly and freelyProvide safety and security to child3637383940414243444546474849505152535455565758596061626364656667686970717273747576777879808182