1. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 22 Neurodevelopmental Disorders

2. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Neurodevelopmental Disorders Not diagnosed as easily as in adults: lack of abstract cognitive abilities and verbal skills; constant state of change and development Similar problems of adults such as mood, anxiety, eating disorders Other disorders usually first diagnosed in infancy, childhood, and occasionally in adolescence

3. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Intellectual Disability Below-average intellectual functioning IQ less than 70 accompanied by significant limitations in: –Communication skills –Self-care –Home living –Social/interpersonal skills –Work –Leisure –Health and safety

4. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Intellectual Disability (cont.) Causes: heredity, altered embryonic development; maternal alcohol intake; perinatal problems; infant medical conditions; environmental influences

5. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Autism Spectrum Disorders Pervasive, usually severe impairment of reciprocal social interaction skills, communication deviance, restricted stereotypical behavioral patterns Autism spectrum disorders –Autism (classic autism) –Rett’s disorder –Childhood disintegrative disorder –Asperger’s disorder

6. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Autism Spectrum Disorders (cont.) Autism –Present by early childhood; boys more than girls –Little eye contact, few facial expressions, limited gestures to communicate, limited capacity to relate to peers or parents, lack of spontaneous enjoyment, apparent absence of mood and affect, inability to engage in play or make-believe with toys, little intelligible speech, stereotyped motor behaviors (hand flapping, body twisting, head banging)

7. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Autism Spectrum Disorders (cont.) Autism (cont.) –Genetic link; controversy with MMR vaccine –Tendency to improve; traits persist into adulthood –Goals: reduce behavioral symptoms, promote learning and development –Special education, language therapy; medications for target symptoms

8. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Autism Spectrum Disorders (cont.) Rett’s disorder: –Multiple deficits after period of normal functioning; almost exclusively in girls

9. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Autism Spectrum Disorders (cont.) Childhood disintegrative disorder: –Marked regression in multiple areas of functioning after 2 years of normal growth and development. Typically includes symptoms of nonspecific anxiety and agitation.

10. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Autism Spectrum Disorders (cont.) Asperger’s disorder: –Similar to autism disorder; no language or cognitive delays; motor clumsiness is common; occurs more frequently in boys

11. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following would be considered an autism spectrum disorder? –A. Expressive language disorder –B. Learning disorder –C. Rett’s disorder –D. Intellectual disability

12. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer C. Rett’s disorder Rationale: Autism spectrum disorders include autism, Rett’s disorder, childhood disintegrative disorder, and Asperger’s disorder. –Expressive language disorder is a type of communication disorder. Learning disorders and intellectual disability are separate classifications of disorders.

13. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Autism Spectrum–Related Disorders Includes: –Tic disorders –Learning disorders –Motor skill disorders –Communication disorders –Elimination disorders

14. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Tic Disorders Rapid, sudden, recurrent, nonrhythmic stereotyped motor movement or vocalization Treatment with atypical antipsychotics (olanzapine or risperidone) Tourette’s disorder: multiple motor tics; one or more vocal tics Chronic motor or tic disorder: either motor or vocal tics; not both

15. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Learning Disorders Achievement in reading, mathematics, written expression below expected for child’s age, formal education, level of intelligence Interference with academic achievement, life activities, development of self-esteem, social skills Early identification, intervention, coexisting problems associated with better outcomes

16. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Motor Skill Disorders Developmental coordination disorder –Marked impairment in coordination severe enough to interfere with academic achievement or ADLs –Often coexisting with communication disorder Adaptive physical education, sensory integration to foster normal growth, development

17. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Communication Disorders Communication deficit severe enough to hinder development, academic achievement, or ADLs, including socialization

18. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Communication Disorders (cont.) Types –Expressive language disorder –Mixed receptive–expressive language disorder –Phonologic disorder –Stuttering disorder Speech therapy to improve communication skills

19. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Elimination Disorders Encopresis: defecating in or into inappropriate places (child at least age 4) –Involuntary encopresis –Intentional encopresis Enuresis: repeated urination during day or night in clothes or bed after age 5 –Most often involuntary –Intentional enuresis associated with disruptive behavior disorder

20. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Attention Deficit Hyperactivity Disorder (ADHD) Inattentiveness, overactivity, impulsiveness; persistent pattern of inattention and/or hyperactivity and impulsivity Often diagnosed when child starts school Fidgeting, noisy, disruptive, unable to complete tasks, failure to follow directions, blurting out answers, lost or forgotten homework Possible ostracize/ridicule by peers

21. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Attention Deficit Hyperactivity Disorder (ADHD) (cont.) Etiology –Cause unknown: possible cortical-arousal, information-processing, maturational abnormalities in the brain –Other theories: environmental toxins, prenatal influences, heredity/genetic link, damage to brain structure and functions –Risk factors –Occurrence in various cultures

22. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins No one treatment effective Goals: managing symptoms, reducing hyperactivity and impulsivity, increasing child’s attention Combination of medications, behavioral, psychosocial, and educational interventions Attention Deficit Hyperactivity Disorder (ADHD) (cont.)

23. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Home and school strategies –Behavioral strategies –Environmental strategies –Parental education Rewards and consequences, consistent praise, time-out, verbal reprimands Daily report cards, point systems –Therapeutic play; creative play Attention Deficit Hyperactivity Disorder (ADHD) (cont.)

24. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Medications (see Table 22.1): –Stimulants: methylphenidate (Ritalin), amphetamine compound (Adderall), lisdexamfetamine (Vyvance) –Antidepressants as second choice –Nonstimulant (SNRI): atomoxetine –Antihypertensives: clonidine (Kapvay), guanfacine (Intuniv) Attention Deficit Hyperactivity Disorder (ADHD) (cont.)

25. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? Atomoxetine is a stimulant agent used to treat ADHD.

26. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer False Rationale: Atomoxetine is not classified as a stimulant. It is a nonstimulant agent, an antidepressant, and more specifically a selective norepinephrine reuptake inhibitor.

27. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins ADHD and Nursing Process Application Assessment –History: fussy as infant; “out of control”; difficulties in all major life areas –General appearance, motor behavior: inability to sit still; inability to carry on conversation; abrupt jumping from topic to topic –Mood, affect: possibly labile, anxiety, frustration, agitation –Thought process, content

28. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins ADHD and Nursing Process Application (cont.) Assessment (cont.) –Sensorium, intellectual processes: impaired ability to pay attention or concentrate –Judgment, insight: poor; no thinking before action –Self-concept: low self-esteem –Roles, relationships: academic, social problems –Physiologic, self-care

29. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins ADHD and Nursing Process Application (cont.) Data analysis/nursing diagnoses –Risk for injury –Ineffective role performance Outcome identification –Free of injury –No violation of boundaries of others –Demonstrate age-appropriate social skills –Complete tasks

30. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins ADHD and Nursing Process Application (cont.) Interventions –Ensuring safety –Improving role performance –Simplifying instructions –Promoting structured daily routine –Providing patient, family education and support Evaluation

31. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following would the nurse most likely assess in a child with ADHD? –A. High self-esteem –B. Aggression toward animals –C. Impulsiveness –D. Limited gestures to communicate

32. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer C. Impulsiveness Rationale: A child with ADHD will often exhibit impulsiveness. –Self-esteem is not a key indicator of ADHD. Children with conduct disorder exhibit aggression toward animals. Children with autism spectrum disorders exhibit limited gestures.

33. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Mental Health Promotion Parenting classes Child anxiety management Parent–child intervention emphasizing coping skills Early detection of potential problems (SNAP-IV Teacher and Parent Rating Scale; see Box 22.2)

34. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Nurse’s Role in Health Promotion Early detection and intervention are key in helping children with autism spectrum disorders reach their full potential Early intervention may include collaborating with: –School psychologist –Pediatrician –Physiotherapist –Teacher –Neurologist –Family –Speech therapist –OT

35. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? A treatment option for ADHD includes educational interventions.

36. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer True Rationale: Treatment options for ADHD include educational interventions to support the child at school in learning, as well as behavioral and psychosocial interventions. Medications also play a role.

37. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Self-Awareness Issues Recognize own beliefs about parenting, how they differ from others. Focus on child’s and parents’ strengths, not just problems. Try to have positive impact on child even when disability is severe. Support parents.