Disorders of Children and Adolescents

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Chapter 28

• Disorders of Children and Adolescents

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Epidemiology

• One in five children and adolescents in the
  United States has a major mental illness.
• Two-thirds of all young people with mental health
  problems are not getting treatment.

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Comorbidities

• Attention deficit hyperactivity disorder (ADHD)
• Juvenile-onset bipolar disorder
• Oppositional defiant disorder
• Conduct disorders
• Childhood depression
• Conduct or oppositional disorders
• Anxiety disorders

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Risk Factors

• Parent who has a mental disorder
• History of abuse
• Physical or sexual
• History of neglect
• Witnessed violence
• Injury, toxic exposure, physical complications in
  utero or during prenatal period

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Etiology

• Biological factors
• Genetic
• Brain development and biochemicals
• Temperament
• Resilience
• Environmental factors
• Cultural considerations

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Assessing Development and Functioning

• Assessment data (Box 28-2)
• Data collection
• Mental status examination
• Developmental assessment
• Suicide risk
• Cultural influences

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Assessing Signs of Abuse

• Risk indicators
• History of previous injuries
• Inconsistencies in physical exam and report of
  injury
• Delay in seeking treatment
• Risk factors
• Experiences of significant loss
• Family discord
• Abuse or neglect
• Psychiatric problems such as depression

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Assessing Intellectual Impairment

• Intellectual impairment
• Mild (IQ 50/5570)
• Moderate (35/4050/55)
• Severe (20/2535/40)
• Profound (below 20/25)
• Deficits in adaptive functioning
• Communication
• Social/interpersonal skills
• Safety

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General Interventions

• Family therapy
• Group therapy
• Milieu management
• Behavioral therapy
• Seclusion and restraint
• Quiet room
• Time-out

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General InterventionsContinued

• Cognitive-behavioral therapy
• Play therapy
• Mutual storytelling
• Therapeutic games
• Bibliotherapy
• Therapeutic drawing
• Psychopharmacology

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Specific Developmental Disorders

• Learning disorders
• Major problem is reading
• Motor skills disorders
• Impairment in development of motor coordination
• Communication disorders
• Impairments in language expression, understanding
  of language, phonology, or stuttering

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Pervasive Developmental Disorders

• Autistic disorder
• Impairment in communication and imaginative
  activity
• Impairment in social interactions
• Markedly restricted, stereotypical patterns of
  behavior, interest, and activities
• Aspergers disorder
• Retts disorder

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Pervasive Developmental Disorders Diagnoses and
Outcomes
Nursing Diagnoses Outcome Indicators
Impaired social interaction Follows simple rules of interactive games with peers
Impaired verbal communication Speech understood by strangers
Delayed growth and development Expresses emotions during play activities
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Attention Deficit Hyperactivity Disorder and
Disruptive Behavior Disorders

• Attention deficit hyperactivity disorder
• Inattention
• Hyperactivity
• Impulsivity
• Oppositional defiant disorder
• Conduct disorder
• Childhood onset and adolescent onset

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Attention Deficit Hyperactivity Disorder

• Assessment
• Relationship between child and parents/caregivers
• Developmental competencies
• Level of physical activity, attention span,
  talkativeness
• Nursing Diagnosis
• Risk for self-directed or other-directed violence
• Defensive coping
• Impaired social interaction

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Attention Deficit Hyperactivity Disorder
Continued

• Outcomes Identification
• Remains safe
• Learns effective coping methods
• Develops friendships with peers

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Attention Deficit Hyperactivity Disorder
Continued

• Implementation
• Pharmaceutical agents (Table 28-5)
• Behavior modification
• Family counseling
• Special education programs
• Cognitive-behavioral therapy
• Play therapy

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Anxiety Disorders

• Anxiety is part of normal development
• Anxiety is a problem when
• An individual fails to move beyond the fears
  associated with a particular problem
• It interferes with normal functioning over an
  extended period of time
• Two anxiety disorders of children and
  adolescents
• Separation anxiety disorder
• Posttraumatic stress disorder

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Separation Anxiety Disorder and Posttraumatic
Stress Disorder

• Assessment
• Anxiety and conflict between child and parents
• Recent stressors
• Parents understanding of developmental norms
• Parenting skills
• Childs developmental level
• Symptoms of anxiety and coping style

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Separation Anxiety Disorder and Posttraumatic
Stress Disorder Continued

• Nursing Diagnosis
• Anxiety
• Ineffective coping
• Outcomes Identification (Table 28-6)

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Separation Anxiety Disorder and Posttraumatic
Stress Disorder Continued

• Implementation
• Protect child from panic levels of anxiety.
• Provide emotional support to help child progress
  developmentally.
• Increase child's self-esteem and feelings of
  competence.
• Help child accept and work through traumatic
  event.
• Teach coping skills.
• Cognitive therapy
• Focused on underlying fears and concerns

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Mood Disorders

• Most frequently diagnosed mood
• disorders
• Major depressive disorder
• Dysthymic disorder
• Bipolar disorder

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Tourettes Disorder

• Motor and verbal tics
• Causes marked distress
• Causes significant impairment in
• Social functioning
• Occupational functioning
• Average age of onset of motor tics is 7 years of
  age can appear as early as 2 years of age

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Adjustment Disorder

• Psychological response to an identifiable
  stressor
• Symptoms develop within 3 months of stressors
• Cause impairment in school and social
  relationships
• Subtypes classified according to presenting
  symptoms

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Feeding and Eating Disorders

• Pica
• Rumination disorder
• Feeding and eating disorder of infancy or early
  childhood

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Elimination Disorders

• Encopresis
• repeated passing of feces by the child into
  inappropriate places
• Enuresis
• repeated voiding of urine into the bed or clothes

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Selective Mutism

• Persistent failure to speak in specific social
  situations
• Rare disorder slightly more common in girls
• Child may be excessively shy, fearful of
  embarrassment, withdrawn, clinging, and negative
  or have temper tantrums or oppositional behavior,
  especially at home

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Stereotypic Movement Disorder

• Pattern of repetitive and nonfunctional motor
  behavior
• May be self-injurious or life-threatening
• Frequently associated with mental retardation but
  may also occur in children with severe sensory
  deficits

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Psychopharmacology

• Actions and side effects differ for children and
  adults
• Developmental considerations
• Rates of absorption
• Excretion
• Sites of action
• Toxicity
• Benefits must outweigh risks

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Stimulants

• Most frequently prescribed to treat ADHD
• May affect growth
• Include
• Methylphenidate (Ritalin)
• Permoline (Cylert)
• Dextroamphetamine sulfate (Dexedrine)

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Antidepressants

• Used to treat depressive disorders, anxiety
  disorders, enuresis, bulimia, and ADHD
• SSRIs now the medication of choice for
  depression, anxiety, and OCD
• Fewer side effects
• Include fluoxetine (Prozac), paroxetine (Paxil),
  citalopram (Celexa), sertraline (Zoloft),
  fluvoxamine (Luvox)

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Antipsychotics

• Used to treat psychosis, bipolar disorder,
  aggression, Tourettes disorder, schizophrenia
• Atypical antipsychotics have fewer side effects
  and are more effective than typical
  antipsychotics
• Include risperidone (Risperdal), olanzapine
  (Zyprexa), quetiapine (Seroquel)

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Mood Stabilizers and Anxiolytics

• Mood stabilizers
• Lithium carbonate (Lithobid) used for severe
  aggression and agitation but must be used with
  caution
• Anticonvulsants carbamazepine (Tegretol) and
  valproic acid (Depakote)
• Anxiolytics used infrequently

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Nurse Generalist

• Applies knowledge of mental and physical health
  needs
• Assesses psychological and physical needs
• Understands significance of laboratory tests and
  results
• Administers and monitors medications
• Provides case management

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Advanced Practice Nurse

• Is a specialist
• May be primary caregiver
• Provides counseling
• Manages medications
• Works with children and families

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Self-Awareness

• Working with children with emotional problems may
  activate personal feelings about ones own
  unresolved family problems or issues.
• Assessing ones own attitudes and behavior will
  contribute to self-awareness and enhance personal
  growth and development.

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