1. Children and Adolescents
Chapter 22
Children and Adolescents

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

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

4. Mental Retardation

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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

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

13. 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

14. 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

15. 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

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

17. Autistic Disorder

18. 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

19. 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

20. Etiological Implications
Biological factors
Neurological implications
Genetics
Perinatal influences
Physiological Implications

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

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

23. 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

24. 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

25. 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

26. 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

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

28. Attention-Deficit/Hyperactivity Disorder (ADHD)

29. 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

30. 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

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

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

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

34. 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

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

36. 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

37. 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

38. 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

39. 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

40. 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

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

42. 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

43. 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

44. 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)

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

46. 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

47. 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

48. 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

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

50. 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.

51. 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

52. 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

53. 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

54. 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)

55. 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

56. 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

57. 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

58. 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)

59. 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

60. 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

61. 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

62. 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

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

64. 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

65. Conduct Disorders

66. 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

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

68. Etiological Implications
Biological influences
Genetics
Temperament
Biochemical factors

69. Etiological Implications (cont.)
Psychosocial influences
Peer relationships

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

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

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

73. 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

74. 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

75. 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

76. 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

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

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

79. 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

80. Evaluation
Evaluation is made of the behavioral changes in the child

81. Oppositional Defiant Disorder

82. 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

83. 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

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

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

86. 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

87. 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

88. 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

89. 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

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

91. 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

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

93. Tourette’s Disorder

94. 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

95. Etiological Implications
Biological factors
Genetics
Biochemical factors
Structural factors
Environmental factors

96. 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

97. 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

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

99. 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

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

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

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

103. 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

104. 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

105. Separation Anxiety Disorder

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

107. 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

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

109. 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

110. 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

111. 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

112. 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

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

114. 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

115. 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

116. General Therapeutic Approaches
Behavior therapy
Family therapy
Group therapy
Psychopharmacology