1. Care of Children and Adolescents With Psychiatric Disorders Chapter 26

2. Psychiatric Disorders: Diagnosed in Childhood or Adolescence Mental retardation Learning disorders Motor skills disorders Communication disorders Pervasive developmental disorders Attention-deficit and disruptive disorders Feeding and eating disorders of infancy or early childhood Tic disorders Elimination disorders Others

3. Epidemiology 5%-9% of children between ages of 9-17 have serious emotional disturbance with severed functional impairments 4%-6% -- seriously emotionally disturbed with some functional impairment

4. Developmental Disorders Significant delay in one or more lines of development Mental retardation Below average intelligence (Table 29.2) No one cause Dx through clinical assessment, history, and tests Nursing management determined by the needs of the child

5. Developmental Disorders: Pervasive Developmental Disorders Group of disorders marked by severe developmental disturbance May or may not be mentally retarded Uneven pattern of intellectual strengths and weaknesses Developmental delay -- development outside the norm socialization communication peculiar mannerisms idiosyncratic interests

6. Pervasive Developmental Disorders Autistic Disorder Early onset: before 30 months Disturbance in social relations Clinical symptoms Marked impairment of development in social interaction and communication Delayed and deviant language, or concrete thinking Pronoun reversals and abnormal intonation Stereotypic behavior repetitive rocking hand flapping insistence on sameness self-injurious behavior

7. Autistic Disorder 2-10/ 10,000 More boys than girls Girls more severe with poorer outcomes 1/2 have mental retardation 1/4 have seizure disorder Cause unknown genetic ?first timesaver insult increased platelet serotonin, excessive dopaminergic activity, alteration in opioids

8. Autistic Disorder Pharmacologic Interventions Antipsychotics -- behavior Methylphenidate -- inattention, impulsivity, and overactivity Opioid antagonist -- naltrexone for activity level and attention Clonidine -- reduces hyperactivity, self-stimulation, and irritability SSRIs -- compulsive behavior, withdrawal, irritability Lithium -- mood Beta-blockers -- reduce anxiety Buspirone and trazodone -- reduce agitation

9. Asperger’s Disorder Severe and sustained impairment in social interaction and restricted, repetitive patterns Not associated with MR Normal intelligence, good verbal skills, low performance Profound social deficits inappropriate initiation of social interactions inability to respond to social cue concrete in interpretation of language stereotypic behavior

10. Asperger’s Disorder More common in boys Runs in families, recurrence in fathers Estimated 1-3/1,000 Recently recognized

11. Nursing Management Pervasive Developmental Disorders Biologic Domain Assessment Physical health and neurologic status Eating and sleep patterns Co-morbid disorder Current medication Nursing Diagnosis Self-care deficits Impaired verbal communication Disturbed sensory perceptions Disturbed sleep pattern Altered growth and development Disturbed thought processes

12. Pervasive Developmental Disorders Biologic Interventions Teaching self-care skills adapting to child’s age list of activities posted on bedroom drawings for nonverbal children Physical safety Medications

13. Nursing Management Pervasive Developmental Disorders Psychological Domain Assessment ( direct observation) Intellectual ability Linguistic competence Adaptive functioning Nursing Diagnosis Anxiety Disturbed thought process

14. Pervasive Developmental Disorders Psychological Interventions Need specific behavioral interventions that are based on careful evaluation Management of repetitive behaviors depends on consequences of specific behavior may be ignored (ie, rocking) redirecting, using positive reinforcement (ie, head banging )

15. Nursing Management Pervasive Developmental Disorders Social Domain Assessment Review of child’s capacity for self-care, self-injury, and aggression Impact of developmental delays on family Ability to live within family Functioning in school Nursing Diagnosis Impaired social interaction Social isolation Ineffective role performance Caregiver role strain Interrupted family processes

16. Pervasive Developmental Disorders : Social Interventions Foster nonverbal social interactions getting mail, passing out snacks, taking turns Milieu management consistent, structured environment with predictable routines Integration of medical, psychiatric social agencies Residential care Family interventions support education counseling

17. Specific Developmental Disorders Learning disorders -- discrepancy between actual achievement and expected achievement Verbal (reading and spelling) Nonverbal (mathematics) Communication disorders Speech Language

18. Nursing Management Specific Developmental Disorder Assessment evidence of disorder ability to communicate child’s perception of disability Nursing Diagnosis Impaired verbal communication Low self-esteem Social isolation Interventions Building self-esteem Connect families with educational resources Use strategies for increasing communication -- taking turns, facing the listener

19. Disruptive Behavior Disorders Externalizing disorders Attention Deficit Hyperactivity Disorder Oppositional Defiant Disorder Conduct Disorder Attention Deficit/Hyperactivity Disorder persistent inattention hyperactivity impulsiveness

20. ADHD Common psychiatric disorder 6% of school age children Boys more affects (3-8X more) Many continue to have problems with attention and impulsiveness into adulthood Multiple etiological factors (not food)

21. ADHD Etiology Biologic Genetics Frontal lobe functioning Striatum (caudate and putamen) involvement Psychosocial Influences Family stress marital discord poverty Overcrowded living conditions Overall family dysfunction

22. Nursing Management Attention Deficit Hyperactivity Disorder Biologic Domain Assessment Collection of data through direct observation Restlessness Sleep Daily food intake Caffeinated products Several assessment tools (see Ch. 11) Nursing Diagnosis Self-care deficit Risk for imbalanced nutrition Risk for injury Disturbed sleep

23. Nursing Management Attention Deficit Hyperactivity Disorder Biologic Interventions Planning within the context of the family, treatment setting, and school Medication management Stimulants: methylphenidate Short-acting, peak 2 hours, effective for 4

24. Nursing Management Attention Deficit Hyperactivity Disorder Psychological Domain Assessment Hyperactivity lmpulsivity Inattention Discipline issues Nursing Diagnosis Anxiety Defensive coping Low self-esteem

25. Nursing Management Attention Deficit Hyperactivity Disorder Psychological Interventions Cognitive behavioral techniques Set clear limits with clear consequences Establish-maintain predictable environment with decrease stimuli Establish eye contact before giving directions; ask to repeat what was heard Encourage child to do homework Encourage one assignment at a time

26. Nursing Management Attention Deficit Hyperactivity Disorder Social Domain Assessment Family environment School environment Nursing Diagnosis Impaired social interaction Ineffective role performance Compromised family coping

27. Nursing Management Attention Deficit Hyperactivity Disorder Social Interventions Family treatment School programming Specific remediation for child

28. Other Disruptive Behavior Disorders Oppositional Defiant Disorder Disobedience, argumentative Trouble making friends Conduct Disorder Serious violations of social norms

29. Separation Anxiety Disorder School phobia 4% of school age children Runs in family May emerge after a change May need medication -- antidepressants Treatment psychotherapy behavior therapy flooding vs desensitization

30. Obsessive Compulsive Disorder May have onset in childhood Treatment similar to adults

31. Depression 1%-5% of school age children (adolescents higher) Similar to adult treatment Associated with suicide

32. Childhood Schizophrenia Rare -- 2 per 100,000 Poorer pre-morbid functioning than adult onset Nursing care follow PDD

33. Elimination Disorders Enuresis involuntary excretion of urination after an age of attainment of bladder control most common in boys etiology unknown limit fluid intake in evening behavioral treatment -- pad, buzzer Encopresis soiling clothing with feces or depositing feces in inappropriate places more common in boys usually not a result of physical problems education and behavioral interventions

34. http://intramural.nimh.nih.gov/chp/adhd/ National Institute of Mental Health