Sensory-Cognitive

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• Sensory-Cognitive

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Common Sensory-Cognitive Disorders in Children

• ADHD
• Cerebral Palsy
• Cognitive Impairment
• Depression
• Autistic Spectrum Disorders
• Downs Syndrome
• Visual and Hearing impairments

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Developmental and Behavioral Disorders
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Attention Deficit with Hyperactivity Disorder
(ADHD)

• Behavioral disorder affects 6 of US school age
  children
• Ranges from mild to severe
• Child has inattention, impulsiveness and
  hyperactivity developmentally inappropriate for
  the age w/o deficits in intelligence
• Etiology is unknown
• Suspect genetic component
• Possible neurologic abnormality
• Increased incidence in males

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Symptoms

• Attention Deficit
• unable to complete tasks effectively due to
  inattention or impulsivity
• Hyperactivity
• excessive or exaggerated muscular activity
• Often have an engaging Personality
• symptoms must be present in at least 2
  settings
• must have been present before age 7

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Assessment

• Can not be made by diagnostic tests, imaging,
  etc.
• Diagnosis is confirmed by comprehensive tests
• Assessment usually begins in school
• Need to have exact description all or none
  reaction to stimuli
• Difficulty with right left, today tomorrow
• Difficulty with common tasks
• Awkward motor movements
• Early identification is critical
• Maladaptive behavior patterns
• Exposed to negative feedback

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Management

• A Multiple approach is needed
• Environmental Manipulation
• Stable learning environment with special
  instruction
• Encourage parents to be fair but firm
• Encourage parents to build self-esteem
• Correct bad behavior immediately
• Assign age appropriate chores with slow
  instructions

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Management

• Medication (Stimulants)
• Ritalin, Cylert, Dexedrine, Adderal
• Work by increasing dopamine and norepinephrine
  levels
• Should be used in adjunct to environmental
  manipulation and therapy
• Side effects
• insomnia (give first thing in morning)
• anorexia (monitor height weight)
• Diet nothing substantiated in research

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Management

• Family support
• Remind parents to be patient
• Usually a childhood condition
• Resolves by adolescence (increased attention
  span, ability to filter stimuli improves)
• Long Term Planning is still necessary

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Pervasive Developmental Disorders

• Autism Spectrum Disorders
• Autistic disorder
• High Functioning Autism
• PDD
• Aspergers Syndrome
• Childhood Disintegrative Disorder
• Retts disorder

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Etiology

• Unclear
• Neurological origins
• Genetic Factors
• Possible Infectious, metabolic and immunologic
  causes
• Possible environmental causes
• Probably multifactoral
• NO RESEARCH TO SUPPORT VACCINES AS A CAUSE!!!!!

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Developmental disability

• Symptoms are present before age three, in the
  developmental period
• It causes delays in many different areas from
  infancy into adulthood
• Symptoms range from mild to severe in individuals

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Symptoms

• Restrictive repetitive and stereotyped pattern of
  behavior, interests and activities
• Hypo/hyper sensitivity
• Qualitative Impairment in
• social interaction
• symbolic or imaginative play
• communication

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Restrictive, Repetitive, Stereotyped Behavior

• Abnormal intensity or focus
• Inflexible and/or nonfunctional routine and
  rituals
• Repetitive motor mannerisms (hand flap, whole
  body movements)
• Preoccupation with parts of an object

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Hyper/Hypo Sensitivity

• Oral
• Touch
• Sounds
• Photosensitivity
• Leads to Seeking/Avoiding Behavior

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Impaired Social Interaction

• Ranges from mild to marked impairment in
  nonverbal communication (eye-to-eye gaze, facial
  expressions, postures and gestures for
  communication)
• Lack of peer relationships
• Lack of social reciprocity

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Lack of Symbolic Play

• Prefers to line up toys in a row
• May play with non-toy items
• May not acknowledge toys with faces
• Interested in parts of a toy
• Lacks ability to pretend play

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Impaired Communication

• Ranges from minor impairment in either receptive
  or expressive language to lack of spoken language
  without alternative modes (gestures, mine)
• In adequate speech, lack ability to initiate or
  sustain conversation
• Repetitive or idiosyncratic language

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Treatment Plan

• No known cure
• Wide variety of therapeutic options
• Behavior management
• ABA (Applied Behavior Analysis)
• Speech-language therapy
• OT
• PT
• Social Skills therapy
• School and special education services
• Early therapy - positive effect
• Characteristics may improve with age
• Can not generalize successful therapy to others

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Recognize Red Flags and Refer!

• Language is delayed
• Child doesnt respond to name
• Child can not indicate wants
• Lack of pointing, waving bye-bye
• Intense tantrums
• Has odd movement patterns
• Child doesnt play with toys in intended way
• Child seems independent for age-gets things only
  for self, prefers to be alone
• Spends time lining things up, putting in certain
  order
• Poor eye contact
• Has unusual attachment to objects
• Does not seem interested in other children

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Movement Disorders
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Cerebral Palsy

• A nonspecific term applied to disorders of early
  onset of impaired movement and posture secondary
  to abnormal muscle tone and coordination

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Cerebral Palsy

• May be accompanied by intellectual impairment and
  language deficits
• The most common physical disability in children

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Factors Associated with Cerebral Palsy

• Prenatal
• Maternal diabetes
• Rh or ABO incompatibility
• Rubella in the first trimester
• Genetics
• Intrauterine ischemic event
• Toxoplasmosis
• Cytomegalovirus
• Congenital brain abnormality

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Factors Associated with Cerebral Palsy (contd)

• Perinatal
• Asphyxia
• Low birth weight
• Prematurity
• Precipitous delivery
• Pregnancy-induced hypertension
• Birth trauma

• Anoxia
• Prolonged labor
• Perinatal metabolic condition (diabetes)
• Intracranial hemorrhage

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Factors Associated with Cerebral Palsy (contd)

• Postnatal
• Infections
• Trauma
• Stroke
• Poisoning

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Clinical Manifestations

• Delayed gross motor development
• Abnormal motor performance
• Alterations of muscle tone

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Clinical Manifestations

• Reflex abnormalities
• Associated disabilities
• cognitive impairment
• seizures
• impaired vision or hearing

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Types of CP

• Spastic
• Dyskinetic
• Ataxic
• Mixed-type

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Spastic

• may involve one or both sides of body
• hypertonicity with poor control of posture,
  balance, and coordinated movement
• impaired fine and gross motor skills
• active attempts at movement increase abnormal
  posture
• Because of excessive energy expended, these
  children often need more calories.

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Dyskinetic

• abnormal involuntary movement
• Athetosis slow worm-like, writhing movements
  that involve extremities, trunk, neck, facial
  muscles and tongue
• Poor oral tone, drooling, difficulty with speech

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Ataxic

• wide based gait
• rapid repetitive movements poorly performed
• disintegration of movement when child reaches for
  an object

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Mixed

• combination of spasticity and diskinetic

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Diagnosis

• Neurologist
• MRI- identifies lesions and spinal cord pathology
• ECG
• CT head
• early recognition important to maximize childs
  abilities

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Management

• GOAL
• to promote optimal development
• Therapy on individual basis (PT, OT, Speech)
• home
• school
• hospital

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Nursing Management

• Establish locomotion, communication, self-help
• Gain optimum development of motor function
  (braces, walkers, surgery to release
  contractures)
• Pain management
• Provide educational opportunities
• Promote socialization

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Mood Disorders
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Depression

• Childhood depression hard to detect
• Kids can not always verbalize feelings
• Feelings are usually acted out and overlooked
• Depression can be either
• Acute
• Chronic

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Diagnosis

• Major Characteristics
• Should have at least one of these present for 6
  months
• Depressed mood
• and/or
• Loss of interest or pleasure

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Minor Characteristics

• Must have five of these for 6 months
• Insomnia
• Change in appetite or significant weight loss or
  gain
• Psychomotor agitation
• Feelings of worthlessness or inappropriate guild
• Diminished concentration or indecisiveness
• Recurrent thoughts of death or suicide

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Symptoms

• Solitary play
• Withdrawn from previously enjoyed activities
• Tearful
• Clinging
• Aggressive
• Physiologic symptoms

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Etiology

• Biologic basis (neurotransmitter level)
• Genetic basis
• Interpersonal factors
• Greater incidence in adolescents

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Treatment

• SSRIs
• TCA
• Therapy
• Individual
• Group
• Family

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Cognitive Disorders
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Cognitive Impairment

• Classically defined as sub-average intellectual
  functioning, deficits in adaptive behavior and
  onset before 18 years of age
• AKA Mental Retardation, cognitive impairment is
  preferred term

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Definition

• IQ of lt 85 and adaptive limitations in two or
  more of the following areas
• communication
• self-care
• home living
• social skills
• leisure
• health safety
• self-direction
• functional academics
• community use
• work

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Causes of Cognitive Impairment

• Hereditary origin
• Early embryonic alterations
• Early intrauterine or neonatal alterations
• Acquired childhood conditions or diseases
• Environmental problems and behavioral syndromes
• Unknown causes

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Assessment

• Few physical indicators
• Delay in Developmental Milestones
• Nonresponsive to contact
• Poor eye contact during feeding
• Diminished spontaneous activity
• Decreased alertness to voice or movement
• Irritability
• Slow feeding

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Classification Based on IQ Test

• Borderline
• Mild
• Moderate
• Severe
• Profound

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Classification

• Borderline 71-84
• Early milestones achieved
• Noticed when school performance is monitored
• Vocational skills adequate for competitive
  employment

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Classification

• Mild 50-70
• Slight delay in milestones
• Special education services needed on vocational
  and self-maintenance skills
• Able to form and maintain adult relationships

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Classification

• Moderate 35-58
• Noticeable delay in motor and speech development
• Early and persistent training in self-care
  required
• Supervision required for complex activity or
  problem solving

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Classification

• Severe 20-40
• Marked delay in all motor skills
• Limited expressive speech
• Constant supervision required

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Classification

• Profound 0-19
• May be unable to ambulate
• May have primitive speech
• Constant supervision required

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Problems Related to Cognitive Impairment

• Mild
• Self-esteem issues related to presence or absence
  of physical features
• Social isolation and loneliness
• Depression
• Severe
• Self-injury
• Fecal smearing
• Tearing of personal clothes and objects
• Severe temper tantrums
• Disrobing

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Goals of Nursing Care

• The child will be educated using effective
  teaching strategies.
• The childs optimal development will be promoted.
• The child will learn self-care skills.
• The family will plan for future care.

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Institutional vs.home care

• severe profound need constant supervision
• mild moderate can live at home and keep normal
  routines or group home setting when older home
  atmosphere that allows community experiences

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Health maintenance needs

• treat child according to intellectual age not
  chronological age
• Illness
• may be more difficult to detect illness
• cannot describe pain, respond with generalized
  crying like an infant

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Safety for the Child with a Cognitive Impairment

• Safety is a persistent concern for children with
  cognitive impairments
• The childs maturation in anticipating danger, in
  problem solving, and in judgment are generally
  impaired across the life span
• Children with motor disabilities are often unable
  to perform skills in ways that foster safety

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Self-care activities

• need to learn the maximum amount of self-care
  possible
• leads to sense of control and accomplishment
• play activities a good teaching tool
• choose toys appropriate for developmental age

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Social relationships

• ability to communicate is often delayed because
  speech is delayed
• teach early social behavior (thank you, excuse
  me, taking turns)
• Preparation for adulthood
• Teach socially acceptable sexual behaviors
  (abuse, pregnancy)

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Down Syndrome

• Most common chromosomal abnormality
• Etiology unknown
• Late maternal age identified
• Caused by extra chromosome (nondisjunstion)
  failure of chromosomes to separate during meiosis
  or (translocation) fusion of two chromosomes
• Usually chromosome 21 and 15
• Can be diagnosed in utero

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Clinical manifestations

• Small, square head
• Upward slant of eyes
• Flat nasal bridge
• Protruding tongue
• Mottled skin
• Transverse palmar crease
• Hypotonia
• Should do chromosomal analysis to confirm
  diagnosis

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Down Syndrome

• Other manifestations
• Congenital heart defects (septal)
• Upper respiratory infections
• Thyroid dysfunction
• Cognitive impairment
• Prognosis
• More than 80 survive to age 30

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Nursing goals

• Family support at time of diagnosis
• Decisions about future care
• Assist family in preventing physical complications

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Nursing Considerations

• Follow recommended guidelines suggest times for
  evaluation
• Hearing
• Growth
• Cardiac function
• For early identification and treatment of
  associated disorders

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Sensory Disorders
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Hearing Impairment

• Disability that may range in severity from mild
  to profound and includes subsets of deaf hard
  of hearing.
• Normal hearing 0 15 dB
• Slight hearing impaired 1625 dB
• Mild hearing impaired 2640 dB
• Moderate hearing impaired 4165 dB
• Severe hearing impaired 66-95 dB
• Profound hearing impaired 96dB

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Types and Causes of Hearing Loss

• Conductive
• Sensorineural
• Mixed
• Central

• Etiology
• Prenatal and Postnatal
• -anatomic malformation
• -asphyxia
• -prematurity
• -otologic toxic rx
• -continuous humming
• Perinatal infections

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Hearing Impairment

• Assessment
• Early dx (6-12mos of age) is imperative to
  prevent social, physical, and psychological
  damage to child
• Identify those at risk
• Screen children for auditory function

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Behaviors of Hearing Loss

• In infancy poor response to auditory stimuli
• No startle reflex
• No head turning to voice
• Indifference to sound
• Absence of babble or inflections in voice by 7
  mos.
• Absence of well-formed syllables by 11 mos

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Behaviors of Hearing Loss

• In children
• Failure to develop 3 word vocabulary by 18 months
  
• Use of gestures rather than verbalization to
  express needs
• Failure to develop intelligible speech by 24 mos.
  
• Responds more to facial expressions and gestures
  than to verbal explanation

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Nursing Care for the Child with Hearing Loss

• Promote communication
• children will imitate what you say, describe
  daily activities, repeat childs words using
  correct pronunciation
• Look directly at childs face when speaking
• Have the childs complete attention before
  beginning to speak
• Speak clearly but not loudly or slowly
• Eliminate background noise

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Nursing Care for the Child with Hearing Loss

• Encourage the child who has a hearing aid to use
  it
• Make sure the hearing aid is in place before
  speaking to the child
• Use visual aids
• Use basic sign language or an interpreter when
  necessary

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Visual Impairment

• Common in childhood
• Range from slight impairment to vision loss
• Most can be corrected with lenses
• Causes
• Genetic
• Anatomic
• Pre-post natal infections (rubella, chlamydia)
• Trauma

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Visual Impairment

• Behaviors
• In infancy
• suspect blindness if an infant does not react to
  light
• lack of eye contact
• if parents of any age child express concern

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Types of Refractive Disorders

• Myopia
• Nearsightedness
• Ability to see close objects more clearly than
  those at a distance
• Caused by the image focusing in front of the
  retina
• Hyperopia
• Farsightedness
• Ability to see distant objects more clearly than
  those close up
• Caused by the image focusing beyond the retina

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Types of Refractive Disorders (contd)

• Astigmatism
• Unequal curvature of the cornea or lens, causing
  light rays to bend in different directions
• May coexist with myopia or hyperopia

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Types of disorders that interfere with vision

• Nystagmus rapid irregular eye movement
• Strabismus malalignment of one eye (may be
  cross-eyed), unequal muscle strength
• Amblyopia reduced visual acuity in one eye
  (lazy eye), is correctable if child is treated
  before 6 years of age

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Blind Children

• blind children do not learn to play automatically
• cannot imitate others or actively explore their
  environment
• depend on others to teach them how to play and to
  stimulate them
• select activities that encourage fine gross
  motor development, and that stimulate senses of
  hearing, touch, and smell

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Working with a Visually Impaired Child

• Orient the child to the hospital environment by
  emphasizing spatial relations
• Never touch the child without identifying
  yourself and explaining what you plan to do
• When describing the environment, use familiar
  terms avoid mention of color
• Remember that parents are often the best source
  for communication
• Identify noises for the child

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Working with a Visually Impaired Child (contd)

• Frequently orient the child to time and place
• Keep all things in the same location and order
• Provide detailed explanations and allow child to
  progress through care in steps to learn the order
• Allow as much control as possible
• Supervise the child and counsel parents to
  supervise the child as needed

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Practice Questions!
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• When providing anticipatory guidance to the
  family of a child with attention deficit
  hyperactivity disorder, the nurse should
  emphasize the need
• To have the child take medication prescribed for
  the disorder just before bedtime
• To be lenient and understanding of the childs
  behavior
• To help build up the childs self-esteem
• To involve the child in structured, preset
  activities

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• A 10-year old child with mild cognitive
  impairment wants to join his younger brothers Cub
  scout group. His parents are apprehensive about
  allowing him to join, and asks the nurse for
  advice. The nurses response will be based on the
  fact that children with CI
• Do not have a need for socialization
• Should not be encouraged to participate in clubs
• Should participate in clubs for children that are
  cognitively impaired
• Have the same need for socialization as children
  w/o impairment

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• An 11-year-old child with ADHD is being treated
  with Ritalin twice a day reports that he is
  having difficulty falling asleep at night. The
  nurse questions him, and discovers that he is
  taking the medication in the morning before
  school and in the late evening after super. Based
  on this information, the nurse should instruct
  him to
• Continue taking the AM dose, but take the PM dose
  earlier
• Stop taking the medication until he can be
  evaluated by an MD
• Take both doses in the AM
• Reduce the evening dose to ½ the prescribed dose

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• A young child has just been diagnosed with
  spastic cerebral palsy. The nurse is teaching
  the parents how to meet the dietary needs of
  their child, and explains the feeding challenges
  are
• The paralysis of their muscles decreased caloric
  need
• The spasticity of their muscles increases caloric
  need
• The hypotonic muscles make eating difficult
• The childs inactivity increases the risk of
  obesity

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• When planning activities for a school-age child
  with Down Syndrome, the nurse should
• Speak loudly and clearly to help the child
  understand what is going to happen
• Involve the parents but not he child who is
  cognitively impaired
• Gear the activities to the childs developmental,
  not chronological age
• Anticipate that the child will not willingly
  engage in planned activities

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• Which of the following is a manifestation of
  dyskinetic cerebral palsy (select all that apply)
• 1. Tremulous movements at rest and with
  activity
• 2. Writhing, uncontrolled, involuntary movements
• 3. Hypertonicity with poor control of posture and
  balance
• 4. Clumsy, uncoordinated movements, wide based
  gait
• 5. Poor oral tone, drooling, difficulty with
  speech
•