Sensory-Cognitive Stressors and Adaptation

Common Sensory-Cognitive Common Sensory-Cognitive Disorders in ChildrenDisorders in Children

• ADHD• Cerebral Palsy• Mental Retardation• Depression• Autistic Spectrum Disorders• Downs Syndrome• Visual and Hearing impairments

Attention Deficit with Attention Deficit with Hyperactivity Disorder (ADHD)Hyperactivity Disorder (ADHD)

• Behavioral disorder affects 6% of US school age children

• Ranges from mild to severe• Child has inattention, impulsiveness and

hyperactivity developmentally inappropriate for the age w/o deficits in intelligence

• Etiology is unknown• Suspect genetic component• Possible neurologic abnormality• Increased incidence in males

SymptomsSymptoms

Attention Deficit• unable to complete tasks

effectively due to inattention or impulsivityHyperactivity

• excessive or exaggerated muscular activity

*symptoms must be present in at least 2 settings*must have been present before age 7

“Engaging” Personality

AssessmentAssessment• Can not be made by diagnostic tests, imaging,

etc.• Diagnosis is confirmed by comprehensive tests• Assessment usually begins in school• Need to have exact description “all or none”

reaction to stimuli• Difficulty with right & left, today & tomorrow• Difficulty with common tasks • Awkward motor movements• Early identification is critical

• Maladaptive behavior patterns• Exposed to negative feedback

ManagementManagement**A Multiple approach is needed

Environmental Manipulation• Stable learning environment with special

instruction• Encourage parents to be fair but firm• Encourage parents to build self-esteem• Correct bad behavior immediately • Assign age appropriate chores with slow

instructions

ManagementManagementMedication (Stimulants)

Ritalin, Cylert, Dexedrine, Adderal• Work by increasing dopamine and

norepinephrine levels• Should be used in adjunct to

environmental manipulation and therapy

Side effects:• insomnia (give first thing in morning)• anorexia (monitor height & weight)Diet: nothing substantiated in research

ManagementManagementFamily support• Remind parents to be patient• Usually a “childhood condition”• Resolves by adolescence

(increased attention span, ability to filter stimuli improves)

• Long Term Planning is still necessary

Cerebral PalsyCerebral Palsy• A nonspecific term applied to disorders

of early onset of impaired movement and posture secondary to abnormal muscle tone and coordination

• May be accompanied by intellectual impairment and language deficits

• The most common physical disability in children

•

Factors Associated with Cerebral Factors Associated with Cerebral PalsyPalsy

Prenatal• Maternal diabetes• Rh or ABO incompatibility• Rubella in the first trimester• Genetics• Intrauterine ischemic event• Toxoplasmosis• Cytomegalovirus• Congenital brain abnormality

Factors Associated with Cerebral Factors Associated with Cerebral Palsy (cont’d)Palsy (cont’d)

Perinatal• Asphyxia• Low birth weight• Prematurity• Precipitous delivery• Pregnancy-induced

hypertension• Birth trauma

• Anoxia• Prolonged labor• Perinatal metabolic

condition (diabetes)• Intracranial

hemorrhage

Factors Associated with Cerebral Factors Associated with Cerebral Palsy (cont’d)Palsy (cont’d)

Postnatal• Infections• Trauma• Stroke• Poisoning

Types of CPTypes of CP

• Spastic• Dyskinetic• Ataxic• Mixed-type• Rigid

SpasticSpastic• may involve one or

both sides of body• hypertonicity with poor

control of posture, balance, and coordinated movement

• impaired fine and gross motor skills

• active attempts at movement increase abnormal posture

DyskineticDyskinetic• abnormal involuntary

movement• Athetosis: slow worm-

like, writhing movements that involve extremities, trunk, neck, facial muscles and tongue

• Poor oral tone, drooling, difficulty with speech

AtaxicAtaxic• wide based gait• rapid repetitive movements

poorly performed• disintegration of movement

when child reaches for an object

MixedMixed

• combination of spasticity and diskinetic

RigidRigid• Rare form• Rigid flexor and extensor muscles• Tremors at rest and movement• Very Poor Prognosis due to lack of active

movement

Clinical Manifestations of all Clinical Manifestations of all types in infantstypes in infants

• Delayed gross motor development

• Abnormal motor performance

• Alterations of muscle tone

Clinical Manifestations of all Clinical Manifestations of all types in infantstypes in infants

• Reflex abnormalities • Associated disabilities

(subnormal learning: MR in 2/3 of pop, seizures, impaired vision or hearing)

DiagnosisDiagnosis

• Neurologist• MRI- identifies lesions and spinal cord

pathology• ECG• CT head

*early recognition important to maximize child’s abilities

ManagementManagement

GOAL:

to promote optimal development

Therapy on individual basis (PT, OT, Speech)

home

school

hospital

ManagementManagement• Establish locomotion,

communication, self-help• Gain optimum development of

motor function (braces, walkers, surgery to release contractures)

• Pain management• Provide educational

opportunities• Promote socialization

DepressionDepression• Childhood depression

hard to detect• Kids can not always

verbalize feelings

• Feelings are usually acted out and overlooked

Depression can be either

Acute

Chronic

DiagnosisDiagnosisMajor Characteristics

• Should have at least one of these present for 6 months:

• Depressed mood

and/or

• Loss of interest or pleasure

Minor CharacteristicsMinor Characteristics

• Must have five of these for 6 months:• Insomnia• Change in appetite or significant weight loss

or gain• Psychomotor agitation• Feelings of worthlessness or inappropriate

guild• Diminished concentration or indecisiveness• Recurrent thoughts of death or suicide

SymptomsSymptoms

• Solitary play• Withdrawn from previously enjoyed

activities• Tearful• Clinging• Aggressive• Physiologic symptoms

EtiologyEtiology

• Biologic basis (neurotransmitter level)• Genetic basis• Interpersonal factors• Greater incidence in adolescents

TreatmentTreatment

• SSRI’s• TCA• Therapy

• Individual• Group• Family

Cognitive ImpairmentCognitive Impairment• Classically defined as sub-average

intellectual functioning, deficits in adaptive behavior and onset before 18 years of age

• AKA Mental Retardation, “cognitive impairment” is preferred term

DefinitionDefinition

IQ of < 85 and adaptive limitations in two or more of the following areas:• communication • self-care• home living• social skills• leisure• health & safety• self-direction• functional academics• community use • work

Causes of Cognitive ImpairmentCauses of Cognitive Impairment

• Hereditary origin• Early embryonic alterations• Early intrauterine or neonatal alterations• Acquired childhood conditions or diseases• Environmental problems and behavioral

syndromes• Unknown causes

AssessmentAssessment

• Few physical indicators• History

• Developmental milestones• IQ test

ClassificationClassification

• Borderline• Mild• Moderate• Severe• Profound

Early behavioral signsEarly behavioral signs• Nonresponsive to contact• Poor eye contact during feeding• Diminished spontaneous activity• Decreased alertness to voice or

movement• Irritability• Slow feeding

ClassificationClassification

Normal IQ: 85-115

Borderline: 71-84• Early milestones achieved• Noticed when school performance

is monitored• Vocational skills adequate for

competitive employment

ClassificationClassificationMild: 50-70

• Slight delay in milestones• Special education services

needed on vocational and self-maintenance skills

• Able to form and maintain adult relationships

ClassificationClassificationModerate: 35-58

• Noticeable delay in motor and speech development

• Early and persistent training in self-care required

• Supervision required for complex activity or problem solving

ClassificationClassification

Severe: 20-40• Marked delay in all motor

skills• Limited expressive speech• Constant supervision

required

ClassificationClassification

Profound: 0-19• May be able walk• May have primitive speech• Constant supervision

required

Problems Related to Problems Related to Cognitive ImpairmentCognitive Impairment

• Mild • Self-esteem issues related to presence or absence of physical

features• Social isolation and loneliness• Depression

• Severe• Self-injury• Fecal smearing• Tearing of personal clothes and objects• Severe temper tantrums• Disrobing

Goals of Nursing CareGoals of Nursing Care

• The child will be educated using effective teaching strategies.

• The child’s optimal development will be promoted.

• The child will learn self-care skills.• The family will plan for future care.

EducationEducation• most do well in pre-school• helps them learn to be comfortable with other

children• depending on the degree of MR should be

included in regular classes as much as possible

• offers stimulation• helps them to reach their best potential and

learn to work and socialize with people of average intelligence

Institutional vs.Institutional vs.home carehome care

• severe & profound need constant supervision

• mild & moderate can live at home and keep normal routines or group home setting when older: home atmosphere that allows community experiences

Health maintenance Health maintenance needsneeds

• treat child according to intellectual age not chronological age

Illness:• may be more difficult to detect

illness• cannot describe pain, respond with

generalized crying like an infant

Safety for the Child with a Cognitive Safety for the Child with a Cognitive ImpairmentImpairment

• Safety is a persistent concern for children with cognitive impairments

• The child’s maturation in anticipating danger, in problem solving, and in judgment are generally impaired across the life span

• Children with motor disabilities are often unable to perform skills in ways that foster safety

Self-care activities Self-care activities

• need to learn the maximum amount of self-care possible

• leads to sense of control and accomplishment

• play activities a good teaching tool• choose toys appropriate for

developmental age

Social relationshipsSocial relationships• ability to communicate is often

delayed because speech is delayed• teach early social behavior (thank

you, excuse me, taking turns)

Preparation for adulthood: • Teach socially acceptable sexual

behaviors (abuse, pregnancy)

Autism Specgtrum DisordersAutism Specgtrum Disorders

• Increased awareness of health care professionals and public

• High estimations of prevalence and incidence (1/250 births)

• Chronic life-long condition

• Potentially severe impactIndividual, family, society

• Ranges from MILD to SEVERE

Autism Spectrum DisordersAutism Spectrum Disorders

• Autistic disorder• High Functioning Autism• PDD NOS• Asperger’s Syndrome• Childhood Disintegrative Disorder• Rett’s disorder

EtiologyEtiology

• Unclear• Neurological origins • Genetic Factors• Possible Infectious, metabolic and immunologic

causes• Possible environmental causes• Probably multifactoral• NO RESEARCH TO SUPPORT VACCINES AS

A CAUSE!!!!!

Autism is:Autism is:

Developmental disability

• Symptoms are present before age three, in the developmental period

• It causes delays in many different areas from infancy into adulthood

History of AutismHistory of Autism

• First recognized in 1943 – Dr. Leo Kanner • extreme aloofness & indifference• little eye contact• severe language deficits• lack of desire to communicate• lack of pretend play

• “Infantile Autism”• Since then DSM has changed criteria DSM-I 1952, DSM-

II 1968, DSM-III 1980, DSM IV• Aspergers only entered in 1990

Prevalence/IncidencePrevalence/Incidence

• Gender• Higher incidence in males

• Familial• Higher degree of siblings at risk• Higher incidence in people with other

developmental disorders

AutismAutism1. Restrictive repetitive and stereotyped

pattern of behavior, interests and activities

2. Hypo/hyper sensitivity

3. Qualitative Impairment in:• social interaction• symbolic or imaginative play• communication

Impairment in social Impairment in social interactioninteraction

• Ranges from mild to marked impairment in nonverbal communication (eye-to-eye gaze, facial expressions, postures and gestures for communication)

• Lack of peer relationships• Lack of social reciprocity

Impairment in Impairment in communicationcommunication

• Ranges from minor impairment in either receptive or expressive language to lack of spoken language without alternative modes (gestures, mine)

• In adequate speech, lack ability to initiate or sustain conversation

• Repetitive or idiosyncratic language

Lack of imaginative playLack of imaginative play

• Prefers to line up toys in a row• May play with non-toy items• May not acknowledge toys with “faces”• Interested in parts of a toy• Lacks ability to pretend play

Restricted interests, Stereotyped Restricted interests, Stereotyped behaviorbehavior

• Abnormal intensity or focus• Inflexible and/or nonfunctional routine and

rituals• Repetitive motor mannerisms (hand flap, whole

body movements)• Preoccupation with parts of an object

Autism Red FlagsAutism Red Flags• Language is delayed• Child doesn’t respond to name• Child can not indicate wants• Lack of pointing, waving “bye-bye”• Intense tantrums• Has odd movement patterns• Child doesn’t play with toys in intended way• Child seems independent for age-gets things only for self,

prefers to be alone• Spends time lining things up, putting in certain order• Poor eye contact• Has unusual attachment to objects• Does not seem interested in other children

Diagnostic and Treatment BarriersDiagnostic and Treatment Barriers

• Lack of recognition of the early signs• Parental resistance• Uninformed school professionals• Lack of qualified professionals in early

intervention• Private insurance non-payment for developmental

disabilities• Costly services_______________________________________

= Delay in referral for evaluation

TreatmentTreatment• No known cure• Wide variety of therapeutic options• Early therapy - positive effect• Characteristics may improve with age• Can not generalize successful therapy

Comprehensive PlanComprehensive Plan

• Behavior management• ABA (Applied Behavior

Analysis)• Speech-language therapy• OT• PT• Social Skills therapy• School and special

education services

• Habilitative Services• Home/family

• Respite care

• Supervised group living

• LTC

• Medications• Dietary• Community support

Down SyndromeDown Syndrome• Most common chromosomal abnormality• Etiology unknown

• Late maternal age identified

• Caused by extra chromosome (nondisjunstion) failure of chromosomes to separate during meiosis or (translocation) fusion of two chromosomes

• Usually chromosome 21 and 15• Can be diagnosed in utero

Clinical manifestationsClinical manifestations

• Small, square head• Upward slant of eyes• Flat nasal bridge• Protruding tongue• Mottled skin• Transverse palmar

crease• Hypotonia• Should do

chromosomal analysis to confirm diagnosis

Down SyndromeDown Syndrome• Other manifestations:• Congenital heart defects (septal)• Upper respiratory infections• Thyroid dysfunction• Cognitive impairment

Prognosis:• More than 80% survive to age 30

Nursing goalsNursing goals

• Family support at time of diagnosis

• Decisions about future care• Assist family in preventing

physical complications

Hearing ImpairmentHearing Impairment

Disability that may range in severity from mild to profound and includes subsets of deaf & hard of hearing.

Normal hearing 0– 15 dB Slight hearing impaired 16–25 dB Mild hearing impaired 26–40 dB Moderate hearing impaired 41–65 dB Severe hearing impaired 66-95 dB Profound hearing impaired 96+dB

Types and Causes of Types and Causes of Hearing LossHearing Loss

• Conductive• Sensorineural• Mixed • Central

Etiology• Prenatal and Postnatal

-anatomic malformation

-asphyxia

-prematurity

-otologic toxic rx

-continuous humming

Perinatal infections

Hearing ImpairmentHearing Impairment

Assessment:• Early dx (6-12mos of age) is imperative

to prevent social, physical, and psychological damage to child

• Identify those at risk • Observe for behavior that may indicate

loss (See below)• Screen children for auditory function

BehaviorsBehaviorsIn infancy: poor response to auditory stimuli• No startle reflex• No head turning to voice• Indifference to sound• Absence of babble or inflections in voice

by 7 mos.• Absence of well-formed syllables by 11

mos

BehaviorsBehaviorsIn children:• Failure to develop 3 word vocabulary by 18

months • Use of gestures rather than verbalization to

express needs • Failure to develop intelligible speech by 24

mos. • Responds more to facial expressions and

gestures than to verbal explanation

Nursing Care for the Nursing Care for the Child with Hearing LossChild with Hearing Loss

• Promote communication • children will imitate what you say, describe

daily activities, repeat child’s words using correct pronunciation

• Look directly at child’s face when speaking • Have the child’s complete attention before

beginning to speak

• Speak clearly but not loudly or slowly

• Eliminate background noise

Nursing Care for the Nursing Care for the Child with Hearing LossChild with Hearing Loss

• Encourage the child who has a hearing aid to use it

• Make sure the hearing aid is in place before speaking to the child

• Use visual aids

• Use basic sign language or an interpreter when necessary

Visual ImpairmentVisual Impairment

• Common in childhood• Range from slight impairment to vision loss• Most can be corrected with lenses• Causes

• Genetic• Anatomic• Pre-post natal infections (rubella, chlamydia)• Trauma

Visual ImpairmentVisual ImpairmentBehaviors:• In infancy:• suspect blindness if an infant

does not react to light• lack of eye contact• if parents of any age child express

concern

Vision ScreeningVision Screening

• Thoroughly explain the procedure to the child; if using a picture chart, have the child identify the pictures

• Take the child to a quiet, nondistracting area• Have the child cover one eye; use a colorful,

opaque cover; the parent may hold it in place• Point to a picture (letter, number) on a line that

the child can probably see; then move to smaller lines; vary the direction

• Give positive feedback

Vision ScreeningVision Screening

• Perform the test as quickly as possible• Test both eyes • Refer if there is a discrepancy or if the

child tests in the abnormal range

Types of Refractive DisordersTypes of Refractive Disorders

• Myopia• Nearsightedness• Ability to see close objects more clearly than those at a

distance• Caused by the image focusing in front of the retina

• Hyperopia• Farsightedness• Ability to see distant objects more clearly than those close

up• Caused by the image focusing beyond the retina

Types of Refractive Disorders Types of Refractive Disorders (cont’d)(cont’d)

• Astigmatism• Unequal curvature of the cornea or lens,

causing light rays to bend in different directions• May coexist with myopia or hyperopia

Types of disorders that interfere with Types of disorders that interfere with visionvision

• Nystagmus: rapid irregular eye movement

• Strabismus: malalignment of one eye (may be cross-eyed), unequal muscle strength

• Amblyopia: reduced visual acuity in one eye (“lazy eye”), is correctable if child is treated before 6 years of age

Blind ChildrenBlind Children

• blind children do not learn to play automatically

• cannot imitate others or actively explore their environment

• depend on others to teach them how to play and to stimulate them

• select activities that encourage fine & gross motor development, and that stimulate senses of hearing, touch, and smell

Working with a Visually Working with a Visually Impaired ChildImpaired Child

• Orient the child to the hospital environment by emphasizing spatial relations

• Never touch the child without identifying yourself and explaining what you plan to do

• When describing the environment, use familiar terms; avoid mention of color

• Remember that parents are often the best source for communication

• Identify noises for the child

Working with a Visually Working with a Visually Impaired Child (cont’d)Impaired Child (cont’d)

• Frequently orient the child to time and place• Keep all things in the same location and order• Provide detailed explanations and allow child

to progress through care in steps to learn the order

• Allow as much control as possible• Supervise the child and counsel parents to

supervise the child as needed

When providing anticipatory guidance to the family of a child with attention deficit hyperactivity disorder, the nurse should emphasize the need:

a. To have the child take medication prescribed for the disorder just before bedtime

b. To be lenient and understanding of the child’s behavior

c. To help build up the child’s self-esteem

d. To involve the child in structured play activities

A 10-year old child with mental retardation wants to join his younger brothers Cub scout group. His parents are apprehensive about allowing him to join, and asks the nurse for advice. The nurse’s response will be based on the fact that children with MR:

a. Do not have a need for socializationb. Should not be encouraged to participate in clubsc. Should participate in clubs for children that are

cognitively impairedd. Have the same need for socialization as children

w/o mental retardation

An 11-year-old child with ADHD is being treated with Ritalin twice a day reports that he is having difficulty falling asleep at night. The nurse questions him, and discovers that he is taking the medication in the morning before school and in the late evening after super. Based on this information, the nurse should instruct him to:

a. Continue taking the AM dose, but take the PM dose earlier

b. Stop taking the medication until he can be evaluated by an MD

c. Take both doses in the AMd. Reduce the evening dose to ½ the prescribed dose

A young child has just been diagnosed with spastic cerebral palsy. The nurse is teaching the parents how to meet the dietary needs of their child, and explains the feeding challenges are:

a. The paralysis of their muscles decreased caloric need

b. The spasticity of their muscles increases caloric need

c. The hypotonic muscles make eating difficultd. The child’s inactivity increases the risk of

obesity

When planning activities for a school-age child with Down Syndrome, the nurse should:

a. Speak loudly and clearly to help the child understand what is going to happen

b. Involve the parents but not he child who is cognitively impaired

c. Gear the activities to the child’s developmental, not chronological age

d. Anticipate that the child will not willingly engage in planned activities