Children and Adolescents Chapter 22 Children and Adolescents

Introduction It is often difficult to determine whether a child’s behavior indicates emotional problems

Introduction (cont.) An emotional problem exists if behavioral manifestations Are not age-appropriate Deviate from cultural norms Create deficits or impairments in adaptive functioning

Mental Retardation

Mental Retardation (cont.) Defined as deficits in general intellectual functioning and adaptive functioning

Mental Retardation (cont.) General intellectual functioning is measured by a person’s performance on IQ tests Adaptive functioning refers to the person’s ability to adapt to requirements of activities of daily living and the expectations of his or her age and cultural groups

Etiological Implications Hereditary factors Early alterations in embryonic development Pregnancy and perinatal factors General medical conditions acquired in infancy or childhood Environmental influences and other mental disorders

Application of the Nursing Process Assessment The extent of severity of mental retardation is identified by the client’s IQ level Four levels have been delineated: mild, moderate, severe, profound

Assessment (cont.) Knowledge regarding level of independence in the performance of self-care activities is essential to the development of an adequate plan for the provision of nursing care

Diagnosis/Outcome Identification Risk for Injury related to altered physical mobility or aggressive behavior Self-Care Deficit related to altered physical mobility or lack of maturity Impaired Verbal Communication related to developmental alteration

Diagnosis/Outcome Identification (cont.) Anxiety (moderate to severe) related to hospitalization and absence of familiar surroundings Defensive Coping related to feelings of powerlessness and threat to self-esteem

Outcomes The client Has experienced no physical harm Has had self-care needs fulfilled Interacts with others in a socially appropriate manner

Outcomes (cont.) The client (cont.) Has maintained anxiety at a manageable level Is able to accept direction without becoming defensive Demonstrates adaptive coping skills in response to stressful situations

Planning/Implementation Although this plan of care is directed toward the individual client, it is essential that family members or primary caregivers participate in the ongoing care of the client with mental retardation

Planning/Implementation (cont.) Clients’ families need to receive information regarding The scope of the client’s condition Realistic expectations and client potentials Methods for modifying behavior as required Community resources from which they may seek assistance and support

Evaluation Evaluation of care given to the client with mental retardation should reflect positive behavioral changes

Autistic Disorder

Autistic Disorder (cont.) Autistic disorder is characterized by a withdrawal of the child into the self and into a fantasy world of his or her own creation

Autistic Disorder (cont.) The child with autistic disorder has markedly abnormal or impaired development in social interaction and communication and a markedly restricted repertoire of activity and interests

Etiological Implications Biological factors Neurological implications Genetics Perinatal influences Physiological Implications

Assessment Impairment in social interaction Impairment in communication and imaginative activity Restricted activities and interests

Diagnosis/Outcome Identification Risk for Self-Mutilation related to neurological alterations Impaired Social Interaction related to inability to trust and neurological alterations

Diagnosis/Outcome Identification (cont.) Impaired Verbal Communication related to withdrawal into the self, inadequate sensory stimulation, and neurological alterations Disturbed Personal Identity related to inadequate sensory stimulation; neurological alterations

Outcomes The client Exhibits no evidence of self-harm Interacts appropriately with at least one staff member Demonstrates trust in at least one staff member

Outcomes (cont.) The client (cont.) Is able to communicate so that he or she can be understood by at least one staff member Demonstrates behaviors that indicate he or she has begun the separation/individuation process

Planning/Implementation Nursing interventions for the child with autistic disorder are aimed at Ensuring safety of client Encouraging social interactions with others Establishing a means of communication Assisting child with separation/individuation process

Evaluation Evaluation of care for the autistic child reflects whether nursing actions have been effective in achieving established goals

Attention-Deficit/Hyperactivity Disorder (ADHD)

Attention-Deficit/Hyperactivity Disorder (ADHD) (cont.) The essential feature of ADHD is a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than is typically observed in people at a comparable level of development

Attention-Deficit/Hyperactivity Disorder ( ADHD) (cont.) DSM-IV-TR subtypes Attention-Deficit/Hyperactivity Disorder, combined type Attention-Deficit/Hyperactivity Disorder, predominantly inattentive type Attention-Deficit/Hyperactivity Disorder, predominantly hyperactive-impulsive type

Etiological Implications Biological influences Genetics Biochemical theory Anatomical influences Prenatal, perinatal, and postnatal factors

Etiological Implications (cont.) Environmental influences Environmental presence of lead Dietary factors Psychosocial influences

Assessment A major portion of the child’s problems relates to difficulties in performing age-appropriate tasks Highly distractible Extremely limited attention span Impulsivity

Assessment (cont.) Difficulty forming satisfactory interpersonal relationships Demonstrates behaviors that inhibit acceptable social interaction Disruptive and intrusive in group endeavors “Perpetual motion machines” Accident-prone

Assessment (cont.) Comorbidity Common comorbid disorders with ADHD Oppositional defiant disorder Conduct disorder Anxiety Depression Substance abuse

Assessment (cont.) Comorbidity (cont.) Depression and anxiety may be treated concurrently with ADHD Substance abuse and bipolar disorder must be stabilized before beginning treatment for ADHD

Diagnosis/Outcome Identification Risk for Injury related to impulsive and accident-prone behavior and the inability to perceive self-harm Impaired Social Interaction related to intrusive and immature behavior

Diagnosis/Outcome Identification (cont.) Low self-esteem related to dysfunctional family system and negative feedback Noncompliance with task expectations related to low frustration tolerance and short attention span

Outcomes The client Has experienced no physical harm Interacts with others appropriately Verbalizes positive aspects about self Demonstrates fewer demanding behaviors Is cooperative with staff in an effort to complete assigned tasks

Planning/Implementation Nursing interventions for the child with ADHD are aimed at Ensuring that client remains free of injury Encouraging appropriate interactions with others Increasing feelings of self-worth Fostering motivation for compliance with tasks

Evaluation Involves examining client behaviors following implementation of the nursing actions to determine whether goals of therapy have been achieved

Psychopharmacological Intervention for ADHD CNS stimulants In children with ADHD, the effects include increased attention span, control of hyperactive behavior, and improvement in learning ability Examples: Dexedrine, Ritalin, Concerta, Focalin, Adderall

Psychopharmacological Intervention for ADHD (cont.) Selective norepinephrine reuptake inhibitor: atomoxetine (Strattera) Approved by FDA in 2002 for treatment of ADHD Mechanism of action in ADHD is unknown

Psychopharmacological Intervention for ADHD (cont.) Antidepressants Some antidepressant drugs have been used with some success in treatment of ADHD Examples include Bupropion (Wellbutrin) Desipramine (Norpramin) Nortriptyline (Pamelor) Imipramine (Tofranil)

Psychopharmacological Intervention for ADHD (cont.) Alpha Agonists Clonidine (Catapres) Guanfacine (Tenex)

Agents for ADHD Action CNS stimulants: increase levels of norepinephrine, dopamine, and serotonin in the CNS Atomoxetine: inhibits reuptake of norepinephrine Bupropion: blocks neuronal uptake of norepinephrine, serotonin, and dopamine Alpha agonists: stimulate central alpha- adrenoreceptors in the brain, reducing CNS sympathetic outflow

Agents for ADHD (cont.) Background assessment data (cont.) Contraindications (CNS stimulants) Contraindicated in clients with hyper- sensitivity to sympathomimetic amines; clients with advanced arteriosclerosis, symptomatic cardiovascular disease, hypertension, hyperthyroidism, glaucoma, agitated or hyperexcitability states; clients with a history of drug abuse; during or within 14 days of receiving therapy with MAOIs; in children younger than 3 years of age; and in pregnancy

Agents for ADHD (cont.) Background assessment data (cont.) Contraindications (cont.) Atomoxetine is contraindicated in clients with narrow-angle glaucoma Bupropion is contraindicated in clients with seizure disorder, acute phase of myocardial infarction, and bulimia or anorexia nervosa Both are contraindicated in known hypersensitivity and in concomitant use with, or within 2 weeks of, using MAOIs

Agents for ADHD (cont.) Contraindications (cont.) Alpha agonists: contraindicated in clients with known hypersensitivity to the drugs

Agents for ADHD (cont.) Background assessment data (cont.) Precautions CNS stimulants: caution with lactating clients; psychotic children; clients with Tourette’s disorder, anorexia, or insomnia; elderly, debilitated, or asthenic clients; and clients with history of suicidal or homicidal tendencies. Prolonged use may result in tolerance and physical and psychological dependence.

Agents for ADHD (cont.) Background assessment data (cont.) Precautions (cont.) Atomoxetine and bupropion: Use cautiously in clients with urinary tention; hepatic, renal, or cardiovascular disease; suicidal clients; pregnancy and lactation; and elderly and debilitated clients

Agents for ADHD (cont.) Precautions (cont.) Alpha agonists: use cautiously in clients with coronary insufficiency, recent MI, or cerebrovascular disease; with chronic renal or hepatic failure; in elderly clients; and in pregnancy and lacation

Agents for ADHD (cont.) Interactions With CNS stimulants Hypertensive crisis, headache, hyperpyrexia, intracranial hemorrhage, and bradycardia with MAOIs May alter insulin requirements Enhanced effects of amphetamines with urine alkalinizers; decreased effects with urine acidifiers Decreased effects of both drugs when used with phenothiazine

Agents for ADHD (cont.) Interactions (cont.) With atomoxetine Increased cardiovascular effects with albuterol Increased risk of neuroleptic malignant syndrome when used within 14 days of MAOIs Increased effects of atomoxetine with CYP 2D6 inhibitors (e.g., paroxetine, fluoxetine, quinidine)

Agents for ADHD (cont.) Interactions (cont.) With bupropion Increased risk of seizures with drugs that lower seizure threshold Acute toxicity of bupropion with concurrent use of MAOIs; hypertension, seizures, and death can occur when used within 14 days of MAOIs

Agents for ADHD (cont.) Interactions (cont.) With Alpha agonists Severe cardiac effects with concomitant use of calcium channel blockers or beta blockers Additive sedation with CNS depressants Decreased effects of clonidine with TCAs and prozosin Decreased effects of guanfacine with barbiturates or phenytoin

Agents for ADHD (cont.) Planning/implementation Monitor client for side effects With CNS stimulants Overstimulation, restlessness, insomnia Palpitations, tachycardia, anorexia, weight loss Tolerance, physical and psychological dependence With atomoxetine Nausea, vomiting, constipation With bupropion Anorexia, weight loss, nausea, vomiting, constipation Potential for seizures

Agents for ADHD (cont.) Monitor client for side effects With Alpha agonists Palpitations or tachycardia (clonidine) Bradycardia Constipation; dry mouth; sedation Rebound syndrome (do not discontinue abruptly)

Nursing Implications Assess the client’s mental status for changes in mood, level of activity, amount of stimulation, and aggressiveness Ensure that the client is protected from injury Limit stimuli and keep environment as quiet as possible to discourage overstimulation

Nursing Implications (cont.) To reduce adverse effect of anorexia, medication may be administered immediately after meals To prevent insomnia, administer last dose at least 6 hours before bedtime Administer sustained-release forms in the morning

Nursing Implications (cont.) The client should be weighed regularly (at least weekly) while on therapy with CNS stimulants because of the potential for anorexia and weight loss and for the temporary interruption of growth and development

Nursing Implications (cont.) In children with behavior disorders, a drug “holiday” should be attempted periodically under direction of the physician to determine effectiveness of the medication and need for continuation

Nursing Implications (cont.) Inform parents that over-the-counter (OTC) medications should be avoided while the child is receiving stimulant medication

Nursing Implications (cont.) Some OTC medications, particularly common cold and hay fever preparations, contain sympathomimetic agents that can compound the effects of the stimulant and create a drug interaction that could be toxic to the child

Conduct Disorders

Conduct Disorders (cont.) With this disorder, there is a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated

Conduct Disorders (cont.) Two subtypes Childhood-onset type Adolescent-onset type

Etiological Implications Biological influences Genetics Temperament Biochemical factors

Etiological Implications (cont.) Psychosocial influences Peer relationships

Etiological Implications (cont.) Family influences Parental rejection Inconsistent management with harsh discipline Early institutional living Frequent shifting of parental figures

Etiological Implications (cont.) Large family size Absent father Parents with antisocial personality disorder, alcohol dependence, or both Association with a delinquent subgroup

Etiological Implications (cont.) Marital conflict and divorce Inadequate communication patterns Parental permissiveness

Assessment Classic characteristic of conduct disorder is the use of physical aggression in the violation of the rights of others Stealing, lying, and truancy are common problems

Assessment (cont.) The child lacks feelings of guilt or remorse Use of tobacco, alcohol, or nonprescription drugs as well as participation in sexual activities occurs earlier than the peer group’s expected age norm

Diagnosis/Outcome Identification Risk for other-directed violence related to characteristics of temperament, peer rejection, negative parental role models, dysfunctional family dynamics Impaired social interaction related to negative parental role models, impaired peer relations leading to inappropriate social behaviors

Diagnosis/Outcome Identification (cont.) Defensive coping related to low self-esteem and dysfunctional family system Low self-esteem related to lack of positive feedback and unsatisfactory parent/child relationship

Outcomes The client Has not harmed self or others Interacts with others in a socially appropriate manner Accepts direction without becoming defensive

Outcomes (cont.) The client (cont.) Demonstrates evidence of increased self-esteem by discontinuing exploitative and demanding behaviors toward others

Planning/Implementation Nursing care of the client with a conduct disorder is aimed at Ensuring safety of client and others Assisting in the development of socially appropriate behaviors in interactions with others Encouraging client to accept responsibility for own behaviors Promoting increased feelings of self-worth

Evaluation Evaluation is made of the behavioral changes in the child

Oppositional Defiant Disorder

Oppositional Defiant Disorder (cont.) Characterized by a pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures that occurs more frequently than is typically observed in people of comparable age and developmental level

Etiological Implications Biological influences Family influences Parental problems in disciplining, structuring, and limit-setting Identification by the child with an impulse-disordered parent who sets a role model for oppositional and defiant interactions with other people Parental unavailability

Assessment Characterized by passive-aggressive behaviors Stubbornness Procrastination Disobedience Carelessness Negativism

Assessment (cont.) Characterized by passive-aggressive behaviors (cont.) Testing of limits Resistance to directions Ignoring others’ communication Unwilling to compromise

Assessment (cont.) Usually these children do not see themselves as being oppositional but view the problem as arising from other people they believe are making unreasonable demands on them

Diagnosis/Outcome Identification Noncompliance with therapy related to negative temperament, denial of problems, underlying hostility Defensive coping related to retarded ego development, low self-esteem unsatisfactory parent/child relationship

Diagnosis/Outcome Identification (cont.) Low self-esteem related to lack of positive feedback, retarded ego development Impaired social interaction related to negative temperament, underlying hostility, manipulation of others

Outcomes The client Complies with treatment by participating in therapies without negativism Accepts responsibility for his or her part in the problem Takes direction from staff without becoming defensive

Outcomes (cont.) The client (cont.) Does not manipulate other people Verbalizes positive aspects about self Interacts with others in an appropriate manner

Planning/Implementation Nursing care of the client is aimed at Encouraging cooperation with therapy Helping client accept responsibility for own behaviors Promoting increased feelings of self-worth Assisting in the development of socially appropriate behaviors in interactions with others

Evaluation Evaluation calls for reassessment of the plan of care to determine whether nursing actions have been effective in achieving goals of therapy

Tourette’s Disorder

Tourette’s Disorder (cont.) The essential feature is the presence of multiple motor tics and one or more vocal tics Tics may appear simultaneously or at different periods during the illness Presence of tics causes marked distress

Etiological Implications Biological factors Genetics Biochemical factors Structural factors Environmental factors

Assessment Tics may involve the head, torso, and upper and lower limbs Signs may begin with a single motor tic, most commonly eye blinking, or with multiple symptoms Palilalia Echolalia

Diagnosis/Outcome Identification Risk for self-directed or other-directed violence related to low tolerance for frustration Impaired social interaction related to impulsiveness and to oppositional and aggressive behavior

Diagnosis/Outcome Identification (cont.) Low self-esteem related to shame associated with tic behaviors

Outcomes The client Has not harmed self or others Interacts with staff and peers in an appropriate manner Demonstrates self-control by managing tic behavior Follows rules of unit without becoming defensive Verbalizes positive aspects about self

Planning/Implementation Nursing care is aimed at Safety of client and others Encouraging interpersonal interaction using appropriate behaviors Promoting increased feelings of self-worth

Evaluation Evaluation of care reflects whether the nursing actions have been effective in achieving the established goals

Psychopharmacological Intervention for Tourette’s Disorder Medications are used to reduce the severity of the tics in clients with Tourette’s syndrome

Psychopharmacological Intervention for Tourette’s Disorder (cont.) Medications used to treat Tourette’s disorder include Haloperidol (Haldol) Pimozide (Orap) Clonidine (Catapres) Guanfacine (Tenex) Atypical antipsychotics

Psychopharmacological Intervention for Tourette’s Disorder (cont.) Medications are most effective when combined with other forms of therapy, such as Behavioral therapy Individual counseling Psychotherapy Family therapy

Separation Anxiety Disorder

Separation Anxiety Disorder (cont.) The essential feature is excessive anxiety concerning separation from the home or from those to whom the person is attached

Separation Anxiety Disorder (cont.) The anxiety exceeds that expected for the person’s developmental level and it interferes with social, academic, occupational, or other areas of functioning

Etiological Implications Biological influences Genetics Temperament Environmental influences Stressful life events Family influences

Assessment In most cases, the child has difficulty separating from the mother Anticipation of separation may result in tantrums, crying, screaming, complaints of physical problems, and clinging behaviors

Assessment (cont.) Reluctance or refusal to attend school is especially common in adolescence Younger children may “shadow” Worrying is common Specific phobias are not uncommon

Diagnosis/Outcome Identification Anxiety (severe) related to family history, temperament, overattachment to parent, negative role modeling Ineffective coping related to unresolved separation conflicts and inadequate coping skills Impaired social interaction related to reluctance to be away from attachment figure

Outcomes The client Is able to maintain anxiety at manageable level Demonstrates adaptive coping strategies for dealing with anxiety when separation from attachment figure is anticipated

Outcomes (cont.) The client (cont.) Interacts appropriately with others and spends time away from attachment figure to do so

Planning/Implementation Nursing care of the child with separation anxiety disorder is aimed at Helping the client maintain anxiety at manageable level in the face of separation from significant other Assisting with development of more adaptive coping strategies Developing trust and demonstrating the ability to interact appropriately with others

Evaluation Evaluation requires reassessment of the behaviors for which the family sought treatment Both the client and the family members will have to change their behavior

General Therapeutic Approaches Behavior therapy Family therapy Group therapy Psychopharmacology