Care of Children and Adolescents With Psychiatric Disorders

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Care of Children and Adolescents With Psychiatric
Disorders

• Chapter 26

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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

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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

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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

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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

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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

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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

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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

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Aspergers 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

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Aspergers Disorder

• More common in boys
• Runs in families, recurrence in fathers
• Estimated 1-3/1,000
• Recently recognized

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Nursing Management Pervasive Developmental
DisordersBiologic 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

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Pervasive Developmental Disorders Biologic
Interventions

• Teaching self-care skills
• adapting to childs age
• list of activities posted on bedroom
• drawings for nonverbal children
• Physical safety
• Medications

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Nursing Management Pervasive Developmental
DisordersPsychological Domain

• Assessment
• (direct observation)
• Intellectual ability
• Linguistic competence
• Adaptive functioning

• Nursing Diagnosis
• Anxiety
• Disturbed thought process

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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)

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Nursing Management Pervasive Developmental
DisordersSocial Domain

• Assessment
• Review of childs 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

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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

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Specific Developmental Disorders

• Learning disorders -- discrepancy between actual
  achievement and expected achievement
• Verbal (reading and spelling)
• Nonverbal (mathematics)
• Communication disorders
• Speech
• Language

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Nursing ManagementSpecific Developmental Disorder

• Assessment
• evidence of disorder
• ability to communicate
• childs 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

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Disruptive Behavior Disorders

• Externalizing disorders
• Attention Deficit Hyperactivity Disorder
• Oppositional Defiant Disorder
• Conduct Disorder
• Attention Deficit/Hyperactivity Disorder
• persistent inattention
• hyperactivity
• impulsiveness

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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)

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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

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Nursing ManagementAttention Deficit
Hyperactivity DisorderBiologic 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

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Nursing ManagementAttention Deficit
Hyperactivity DisorderBiologic Interventions

• Planning within the context of the family,
  treatment setting, and school
• Medication management
• Stimulants methylphenidate
• Short-acting, peak 2 hours, effective for 4

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Nursing ManagementAttention Deficit
Hyperactivity DisorderPsychological Domain

• Assessment
• Hyperactivity
• lmpulsivity
• Inattention
• Discipline issues

• Nursing Diagnosis
• Anxiety
• Defensive coping
• Low self-esteem

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Nursing ManagementAttention Deficit
Hyperactivity DisorderPsychological 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

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Nursing ManagementAttention Deficit
Hyperactivity DisorderSocial Domain

• Assessment
• Family environment
• School environment

• Nursing Diagnosis
• Impaired social interaction
• Ineffective role performance
• Compromised family coping

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Nursing ManagementAttention Deficit
Hyperactivity DisorderSocial Interventions

• Family treatment
• School programming
• Specific remediation for child

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Other Disruptive Behavior Disorders

• Oppositional Defiant Disorder
• Disobedience, argumentative
• Trouble making friends
• Conduct Disorder
• Serious violations of social norms

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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

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Obsessive Compulsive Disorder

• May have onset in childhood
• Treatment similar to adults

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Depression

• 1-5 of school age children (adolescents higher)
• Similar to adult treatment
• Associated with suicide

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Childhood Schizophrenia

• Rare -- 2 per 100,000
• Poorer pre-morbid functioning than adult onset
• Nursing care follow PDD

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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

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