1. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

2. Chapter 18Disorders and Issues of Children and Adolescents

3. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Etiologic Factors Genetic –Family history of mental issues Environmental –Neighborhood, family income, family educational level Parental divorce Combined factors

4. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Developmental Disorders Child demonstrates symptoms of deficit before the age 18 years Characterized by performance testing of mentality, skills, coordination, or activity that is substantially below that anticipated for the child’s chronological age and education level

5. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Types of Developmental Disorders Mental retardation Autistic disorder (pervasive) Asperger’s syndrome (pervasive) Psychosis (pervasive)

6. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Mental Retardation Intellectual functioning significantly below average IQ 70 or below Mild to profound Many behavior problems result from frustration with communication limitations Signs and Symptoms Box 18.1 Page 279

7. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Autistic Disorder Severe impaired ability to socially interact and communicate with the outside world Symptoms usually appear before 3 years of age Withdrawn, fantasy world – little interaction with environment Deficient nonverbal behaviors (eye contact, facial exp) May demonstrate unusual or exaggerated responses to sensory stimuli Inflexible and consistent routine of rituals Signs and Symptoms Box 18.2 Page 280

8. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Asperger’s Syndrome Difficulty with social interaction and communication Preoccupation with a particular subject (high level of expertise) and avoid other activities Average or above average intelligence Develop normally in the areas of thinking and learning language skills Speech is often centered around random factual information Poor social skills and limited interests –Risk for isolation More common in boys; 2:10,000 children http://www.youtube.com/watch?v=WAfWfsop1e0

9. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Developmental Coordination Disorder Significant impairment in development of motor coordination Clumsiness in motor activities Delays in developmental milestones  crawling, walking, dressing May exhibit delays in other developmental areas, such as language skills 6% of children 5-11; more common in boys Can lead to suicidal tendencies, substance use, etc. Signs and Symptoms of DCD Box 18.3 Page 281

10. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Case Application 18.1 “From Martina’s World” Page 280

11. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Psychosis Not specifically a childhood disorder but sometimes confused with autistic disorders Hallucinations, delusions, flat affect, disorganized speech, stereotypical behaviors Poor development of intellectual, motor, emotional, and social skills Unable to differentiate real and unreal Disturbed interpersonal relationships Signs and Symptoms of Psychosis in Children Box 18.4 Page 281

12. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Types of Learning and Communication Disorders Dyslexia Expressive language disorder Phonologic disorder

13. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Dyslexia Deficit in reading/written expression Normal to above average intelligence –May be behind in the level of reading expected for their grade level Inability to process incoming sensory stimuli with correct interpretation Often letter confusion, letter reversal Signs & Symptoms of Dyslexia Box 18.5 Page 282 Often undiagnosed until 4 th grade or later More common in boys

14. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Expressive Language Disorder Impairment in both verbal and sign language as evidenced by standardized testing Limited speech and vocabulary Difficulty learning new words or grammar Decreased ability to process incoming information Signs and Smptoms of Expressive Language Disorder Box 18.2 Page 283 Often younger than 3 when diagnosed 10-15% of children; more common in boys

15. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Phonologic Disorder Failure to utilize sounds or articulate syllables intelligibly during speech Often a hearing impairment contributes to the speech problem Stuttering Increased anxiety often initiates the problem –Leads to frustration and low self-esteem Signs and Symptoms of Phonologic Disorder Box 18.7 Page 283 Typically seen between 2-7 years; less than 2% of children; more common in boys

16. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Types of Behavior Disorders Attention deficit/hyperactivity disorder Conduct disorder Oppositional-defiant disorder

17. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Attention-Deficit/Hyperactivity Disorder (ADHD) Pattern of inattention, hyperactivity, or impulsive behavior Disruptive, inability to maintain focus Easily distracted 3 types –Predominantly inattentive type Attention Deficit Disorder –Predominantly hyperactive-impulsive type Restless, fidgety, talks incessantly, inappropriate –Combination S/S of ADHD Box 18.8 Page 284

18. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Conduct Disorder Pattern of repetitive and continuous behavior that either infringes on the basic rights of others or defies the rules of society that would be appropriate for the child’s age Disruptive, destructive behavior Willful defiance, aggression, truancy, cruelty to animals Behaviors differ in several settings Signs and Symptoms of Conduct Disorder Box 18.9 Page 285 Higher incidence in cities than rural areas Onset can occur before 10 or during adolescence

19. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Oppositional-Defiant Disorder Repetitive behavior of negative, defiant, disobedient, hostility toward authority figures Argue incessantly without compromise Blame others for own behavior Defiant refusal to obey rules or laws Vindictive, spiteful, and resentful Suspension and expulsion from school Predisposing Factors: rejection, neglect, abuse Signs and Symptoms of Oppositional-Defiant Disorder Box 18.11 Page 286

20. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Anxiety Disorders Separation anxiety disorder Tic disorders (Tourette’s disorder)

21. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Separation Anxiety Disorder Severe anxiety when separated from love attachment figure Worry about harm to self/parent Fear of sleep without attachment person present Attention-demanding behavior Must occur before the age 18 and cause significant distress or impairment in functioning for a period of at least 1 month C/O Somatic symptoms (Abd pain, N/V, H/As) Signs and Symptoms of Seperation Anxiety Disorder Box 18.12 Page 288 Tx: reduce anxiety and reinforce a sense of security 4% of children – symptoms decrease during adolescence

22. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Tic Disorders (Tourette’s Disorder) Sudden, repetitive, arrhythmic, stereotyped motor movement or speech that occurs before the age 18 Never a symptom free period of more than 3 months Copropraxia/echopraxia (tic/repetitive movement) A person with tic has irresistible urge to perform tic and feels relief once the behavior has occurred Incidence may increase during periods of stress of demanding and competitive activities Signs and Symptoms of Tic Disorders Box 18.13 Page 288

23. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Elimination Disorders Encopresis –Repeated episodes of fecal passage in inappropriate places –Must be 4 or have attained defection control –Must occur at least 1/month for 3 months to be dx Enuresis –Repeated episodes of urine incontinence during day or night –Must be 5 or have urinary control –Must occur 2/week for3 months during day or night to be dx

24. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Treatment of Mental Disorders in Children and Adolescents Pervasive developmental disorderscombined approach of therapies and behavior management interventions Learning and communication disordersmainstream education Behavior disorderscombination of medication and behavior therapy Anxiety disordersmedication, cognitive-behavioral therapy, group therapy Elimination disordersmost children outgrow problem, some behavior approaches can be used

25. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Process Applied AssessmentPg. 290 –Time when problematic behaviors began –Significant occurrences –Thorough medical and emotional assessment –The child’s ability to communicate and interact

26. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Process Applied (cont.) Selected nursing diagnosesPage 291 –Risk for injury, related to physical mobility or aggressive behavior –Impaired verbal communication, related to verbal expression –Impaired social interaction, related to inappropriate behaviors and decreased self-esteem

27. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Process Applied (cont.) Expected outcomes may includePage 291 –Initiates appropriate interactions with peers –Remains free of self-harm and does not harm others –Demonstrates increased autonomy

28. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Process Applied (cont.) Interventions may includePage 291-292 –Maintain a safe physical environment –Provide encouragement toward independent self-care –Establish a trusting relationship

29. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Process Applied (cont.) EvaluationPage 292 –Increased ability to interact and communicate with others –Progress in ability to trust others and initiate social contact with another person –Ability to control negative and self-harming behaviors

30. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Question An preoccupation with and expertise about a particular topic is associated with which of the following disorders? A. Dyslexia B. Developmental coordination disorder C. Attention deficit/hyperactivity disorder D. Asperger’s syndrome

31. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer D. Asperger’s syndrome Rationale: Children with Asperger’s syndrome tend to have a preoccupation with a particular subject and avoid other activities. Children with this condition have average to above average intelligence.

32. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following developmental disorders is characterized by an IQ of 70 or below? A. Mental retardation B. Autistic disorder C. Asperger’s syndrome D. Psychosis

33. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer A. Mental retardation Rationale: According to the DSM-IV-TR, mental retardation is characterized by an intellectual functioning that is significantly below average (IQ of 70 or lower).

34. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Stuttering is a characteristic of A. Attention deficit/hyperactivity disorder B. Developmental coordination disorder C. Phonologic disorder D. Separation anxiety disorder

35. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer C. Phonologic disorder Rationale: Phonologic disorder is a failure to utilize sounds or articulate syllables intelligibly during speech. Stutteringprolonged or repetitive sounds or syllables that include pauses and broken wordsis a common characteristic of the disorder.