Transcript Chapter 23

Chapter 23
Children and Adolescents
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
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Disorders in Children and Adolescents:
Prevalence and Comorbidity
• Prevalence
– One in five children and adolescents in U.S.
suffers from major psychiatric disorder
causing impairment in functioning
• About 2/3 of those needing mental health services
are not getting them
• 60% of all children in out-of-home care have
moderate to severe mental health problems
• Comorbidity: often more than one
psychiatric diagnosis present
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Theory Related to Disorders in
Children and Adolescents
• Child’s vulnerability to psychopathology
– Complex interactions between biological,
psychological, genetic, and environmental
factors
• Genetics
– Implicated in autism, bipolar disorder,
schizophrenia, ADHD, and mental retardation
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Theory Related to Disorders in
Children and Adolescents
• Biochemical factors
– Alterations in neurotransmitters
• Environmental factors
– Abuse, severe marital discord, low
socioeconomic status, overcrowding, parental
criminality, maternal psychiatric disorders and
foster care placement
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Concept of Resilient Child
• Vulnerable child who does not develop
psychiatric disorder has resiliency
characteristics of:
– Temperament that adapts to changes
– Ability to form nurturing relationships with
other adults
– Ability to distance self from emotional chaos
in family
– Social intelligence
– Ability to use problem-solving skills
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Mental Health Assessment of Children
• Mental status assessment
– Provides information about problems in
thinking, feeling, and behaving
• Developmental assessment
– Information about child’s current maturational
level compared with chronological age as well
as identifying developmental deficits
• Denver II Developmental Screening Test (used for
infants and children up to age 6)
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Mental Health Assessment of Children
• Methods of data collection
– History collected from parents, caregivers,
child or adolescent, and other family members
– Interviewing (semistructured) in which
child/adolescent is asked about life at home
and at school
– Use of activities such as games, drawings,
puppets, and free play (especially for younger
children)
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Disorders in Children/Adolescents:
Mental Retardation
• Most common developmental disorder,
affecting approximately 1% of population
• Lack of intellectual development that
impairs function, learning, communication,
interpersonal skills, and social adjustment
• Degree of mental retardation assessed by
intelligence quotient (IQ)
– Mild, moderate, severe, profound
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Disorders in Children/Adolescents:
Pervasive Developmental Disorder
(PDD)
• Severe, impaired social interaction and
communication skills, accompanied by
stereotyped behavior
– Autistic disorder
• Impairment in communication and imaginative
play, lack of responsiveness and interest in others,
markedly restricted and stereotyped behaviors
– Asperger’s syndrome
• Similar to autistic disorder, with later onset and
less severe symptoms
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Nursing Process: Assessment
Guidelines for Developmental
Disorders
• Assess for developmental spurts or lags,
loss of previous abilities
• Assess quality of relationship between
child and parent or caregiver
• Be aware that children with
behavioral/developmental problems are at
risk for abuse
– Assess for abuse
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Nursing Process: Diagnosis and
Outcomes Identification
• Common nursing diagnoses
– Defensive coping, Ineffective coping, Delayed
growth and development, Risk for impaired
parent/child attachment
• Outcomes identification
– Long-term outcomes established: help child
with PDD to reach full potential by fostering
developmental competencies and coping
skills
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Nursing Process: Planning and
Implementation for PDD
• Planning
– Intervention takes place in therapeutic nursery
schools, day treatment programs, and special
education classes in public schools
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Nursing Process: Planning and
Implementation for PDD
• Implementation
– Increase child’s interest in reciprocal
interaction
– Foster development of social skills
– Facilitate expression of emotional responses
– Foster development of communication,
cognitive skills
– Foster development of adequate self-concept
and self-control
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Anxiety Disorders in
Children/Adolescents
• Most common mental disorder of children
and adolescents (19% of ages 9 to 17)
• Characteristics similar to those in adults
with exception of:
– Separation anxiety disorder: excessive
anxiety when separated from or anticipating
separation from home/parent; can lead to
refusal to attend school
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Anxiety Disorders in
Children/Adolescents
– Posttraumatic stress disorder (PTSD)
• Children with this disorder tend to react with
behaviors indicative of internalized anxiety
consistent with developmental level
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Nursing Process: Assessing for
Anxiety Disorders
• Assess quality of child-parent-caregiver
relationship
• Assess for recent stressors affecting child
• Determine developmental level and if
regression occurred
• Assess for physical, behavioral, cognitive
symptoms of anxiety
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Nursing Process: Assessing for
Anxiety Disorders
• Determine child’s previous and current
ability to separate from parent/caregiver
• Determine problems of anxiety in
caregiver
• Assess parent response to child’s anxiety
• Assess for potential exposure to traumatic
event
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Nursing Process: Diagnosis and
Outcomes Identification
• Common nursing diagnoses for anxiety
disorders
– Anxiety, Fear, Delayed growth and
development, Impaired parenting, Ineffective
coping, Post-trauma syndrome
• Outcomes identification
– Goals established to focus on underlying
fears and concerns as well as reinforce selfcontrol behaviors
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Nursing Process:
Planning and Implementation
• Planning for child with anxiety disorder
– Directed toward providing services on
outpatient basis, using cognitive-behavioral
methods in individual, group or family therapy
• Implementation
– Help reach full potential by focusing
developmental potential and coping skills
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Nursing Process:
Planning and Implementation
– Protect from panic levels of anxiety (act as
parent surrogate)
– Accept regression; give support for child to
progress
– Increase self-esteem and feelings of
competence
– Help child/adolescent work through traumatic
events
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Disorders of Children/Adolescents:
Mood Disorders
• Symptoms of depression similar to adult
symptoms with exception:
– Children more likely to have somatic
complaints, be self-critical, and feel unloved
– Depression can also be expressed as
irritability and can lead to aggressiveness
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Disorders of Children/Adolescents:
Mood Disorders
• Factors associated with depression in
children
– Physical and sexual abuse, neglect,
homelessness, marital discord between
parents, death, divorce, separation, learning
disabilities, chronic illness, conflicts with
family/peers
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Nursing Process: Assessing for
Mood Disorders
• Assess for:
– Changes in mood or affect, cognition, social
behavior, physical status
– Major life-changing events
– Maturational level/signs of regression
– Quality of parent/caregiver relationship
– Parent/caregiver understanding of child’s
developmental issues
– Family history of mood disorders
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Nursing Process: Diagnosis and
Outcomes Identification
• Common nursing diagnoses for child with
mood disorder
– Grieving, Hopelessness, Ineffective coping,
Risk for injury, Risk for violence, Self-esteem
disturbance, Social isolation
• Outcomes identification
– Maintain safety is overall goal since risk for
self-harm increased with mood disorders
– Long-term outcome: help child or adolescent
with mood disorder reach full potential
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Nursing Process:
Planning and Implementation
• Planning for mood disorders
– Hospitalization for suicidal child/adolescent
– Psychotherapy and antidepressants important
• Implementation
– Provide for physical/psychosocial needs by
acting as parent surrogate
– Protect child from aggressive episodes
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Nursing Process:
Planning and Implementation
– Help child explore feelings, thoughts, life
events
– Help child develop cognitive, coping, and
social skills
– Increase self-esteem
– Help child accept/work through losses
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Disorders of Children/Adolescents:
Attention Deficit Hyperactivity Disorder
• ADHD difficult to diagnose before age 4
• Characteristics
– Inattention: difficulty paying attention to task at
hand, easily distracted
– Hyperactivity: fidgets, runs and climbs
excessively, talks excessively
– Impulsivity: blurts out answers before
question is finished, has difficulty waiting
one’s turn, interrupts and intrudes on others’
conversations/games
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Nursing Process: Assessment
Guidelines for ADHD
• Observe level of physical activity, attention
span, control of impulses
• Assess difficulty in making friends and
performing in school
• Assess for problems of enuresis and
encopresis
• Assess for quality of child-parent-caregiver
relationship
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Nursing Process: Assessment
Guidelines for ADHD
• Asses parent/caregiver’s understanding of
growth and development, handling of
problem behaviors
• Assess developmental level for lags or
deficits
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Disorders of Children/Adolescents:
Disruptive Behavior Disorders
• Oppositional defiant disorder
– Recurrent pattern of negativistic, disobedient,
hostile, and defiant behavior toward authority
figures without seriously violating rights of
others (APA, 2000)
• Conduct disorder
– Persistent pattern of behavior in which rights
of others and age-appropriate societal norms
or rules are violated
• Childhood onset: before age 10
• Adolescent onset
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Nursing Process: Assessing for
Disruptive Behavior Disorders
• Assess for:
– Quality of child-parent-caregiver relationship
– Parent/caregiver’s understanding of growth
and development, handling of problem
behaviors
– Developmental lags/deficits
– Identify issues resulting in power struggles
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Nursing Process: Assessing for
Disruptive Behavior Disorders
• Assess for:
– Severity of defiant behavior
– Seriousness of disruptive behavior
– Levels of anxiety, aggression, anger, and
hostility toward others
– Moral development and ability to feel remorse
and guilt
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Nursing Process: Diagnosis and
Outcomes Identification
• Common nursing diagnoses for children
with ADHD and disruptive behavior
disorders
– Risk for other-directed violence, Risk for
caregiver role strain, Defensive coping, Risk
for injury, Impaired social interaction,
Ineffective coping
• Outcomes identification
– Changing or modifying behaviors that cause
problems with families, peers, and authorities
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Nursing Process:
Planning and Implementation
• Planning
– Children with ADHD and disruptive behavior
disorders are treated with behavior
modification and medication for
hyperactive/impulsive behaviors
• Implementation
– Protect child from harm; provide for needs
– Increase interpersonal relationship skills
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Nursing Process:
Planning and Implementation
– Increase ability to control impulses
– Foster identification with positive role models
– Foster self-esteem, self-identity
– Provide support, education, and guidance for
parents/caregivers
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Medications Used for ADHD and
Disruptive Behavior Disorders
• ADHD
– Psychostimulants: methylphenidate (Ritalin,
Daytrana, Concerta)
– Research ongoing because 30% of children
do not respond to psychostimulants
• Disruptive behavior disorders
– Antipsychotics, lithium carbonate,
anticonvulsants, antidepressants, and ßblockers have been used
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Disorders of Children/Adolescents:
Tourette’s Syndrome
• Motor and verbal tics that cause marked
distress and significant impairment in
social and occupational functions (APA,
2000)
• Nursing process
– Assessment: assess obsessions,
compulsions, hyperactivity, distractibility, and
impulsivity
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Disorders of Children/Adolescents:
Tourette’s Syndrome
– Nursing diagnoses: Anxiety, Impaired social
interaction, Chronic low self-esteem, Social
isolation
– Implementation: help child, family, and school
understand and cope with tic behaviors
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Treatment for Disorders of
Children/Adolescents
• Parental involvement: important in
supportive and educative system
– Single and multiple family therapy used
• Group therapy
– Play therapy for young child, combination of
play and talking therapy for older children
• Milieu therapy
– Physical milieu provides for safe, comfortable
place to live, play, and learn
– Daily schedule exists to structure activities
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Treatment for Disorders of
Children/Adolescents
• Behavior modification
– Rewarded behavior is likely to continue
– Use of point/token systems to reward
desirable behaviors
• Removal and restraint
– Controversial modalities for use in children,
usually perceived as punishment
– Quiet rooms are acceptable alternatives
– Time-out method useful for disruptive
behaviors
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Treatment for Disorders of
Children/Adolescents
• Therapeutic holding
– Prompt, firm, nonretaliatory protective
restraint gently applied and leads to reduction
in youth’s distress
• Cognitive-behavioral therapy
– To change cognitive processes and behaviors
• Play therapy
– Based on notion that play is work of a child
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Treatment for Disorders of
Children/Adolescents
• Forms of play therapy
– Dramatic, therapeutic games, bibliotherapy,
therapeutic drawing
• Other modalities
– Music therapy
– Movement and dance therapy
– Recreational therapy
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