Transcript Attention Deficit with Hyperactivity Disorder (ADHD)

Sensory-Cognitive Stressors and
Adaptation
Common Sensory-Cognitive
Disorders in Children
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ADHD
Cerebral Palsy
Mental Retardation
Depression
Autistic Spectrum Disorders
Downs Syndrome
Visual and Hearing impairments
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
Symptoms
Attention Deficit
• unable to complete tasks
effectively due to
inattention or impulsivity
Hyperactivity
• excessive or exaggerated
muscular activity
*symptoms must be
present in at least 2
settings
*must have been present
before age 7
“Engaging” Personality
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
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
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
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
Cerebral Palsy
• A nonspecific term applied to
disorders of early onset of
impaired movement and posture
secondary to abnormal muscle
tone and coordination
• May be accompanied by
intellectual impairment and
language deficits
• The most common physical
disability in children
Factors Associated with Cerebral
Palsy
Prenatal
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Maternal diabetes
Rh or ABO incompatibility
Rubella in the first trimester
Genetics
Intrauterine ischemic event
Toxoplasmosis
Cytomegalovirus
Congenital brain abnormality
Factors Associated with Cerebral
Palsy (cont’d)
Perinatal
• Anoxia
• Asphyxia
• Prolonged labor
• Low birth weight
• Perinatal metabolic
condition (diabetes)
• Prematurity
• Precipitous delivery
• Pregnancy-induced
hypertension
• Birth trauma
• Intracranial
hemorrhage
Factors Associated with Cerebral
Palsy (cont’d)
Postnatal
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Infections
Trauma
Stroke
Poisoning
Types of CP
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Spastic
Dyskinetic
Ataxic
Mixed-type
Rigid
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
Dyskinetic
• abnormal involuntary
movement
• Athetosis: slow wormlike, writhing
movements that
involve extremities,
trunk, neck, facial
muscles and tongue
• Poor oral tone,
drooling, difficulty
with speech
Ataxic
• wide based gait
• rapid repetitive movements
poorly performed
• disintegration of movement
when child reaches for an object
Mixed
• combination of spasticity and
diskinetic
Rigid
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Rare form
Rigid flexor and extensor muscles
Tremors at rest and movement
Very Poor Prognosis due to lack of active
movement
Clinical Manifestations of all
types in infants
• Delayed gross motor
development
• Abnormal motor
performance
• Alterations of muscle tone
Clinical Manifestations of all
types in infants
• Reflex abnormalities
• Associated disabilities
(subnormal learning: MR in
2/3 of pop, seizures,
impaired vision or hearing)
Diagnosis
• Neurologist
• MRI- identifies lesions and spinal cord
pathology
• ECG
• CT head
*early recognition important to maximize child’s
abilities
Management
GOAL:
to promote optimal development
Therapy on individual basis (PT, OT, Speech)
home
school
hospital
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
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
Diagnosis
Major Characteristics
• Should have at least one of these present for 6 months:
• Depressed mood
and/or
• Loss of interest or pleasure
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
Symptoms
• Solitary play
• Withdrawn from previously enjoyed
activities
• Tearful
• Clinging
• Aggressive
• Physiologic symptoms
Etiology
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Biologic basis (neurotransmitter level)
Genetic basis
Interpersonal factors
Greater incidence in adolescents
Treatment
• SSRI’s
• TCA
• Therapy
• Individual
• Group
• Family
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
Definition
IQ of < 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
Causes of Cognitive Impairment
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Hereditary origin
Early embryonic alterations
Early intrauterine or neonatal alterations
Acquired childhood conditions or diseases
Environmental problems and behavioral
syndromes
• Unknown causes
Assessment
• Few physical indicators
• History
• Developmental milestones
• IQ test
Classification
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Borderline
Mild
Moderate
Severe
Profound
Early behavioral signs
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Nonresponsive to contact
Poor eye contact during feeding
Diminished spontaneous activity
Decreased alertness to voice or
movement
• Irritability
• Slow feeding
Classification
Normal IQ: 85-115
Borderline: 71-84
• Early milestones achieved
• Noticed when school
performance is monitored
• Vocational skills adequate for
competitive employment
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
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
Classification
Severe: 20-40
• Marked delay in all motor
skills
• Limited expressive speech
• Constant supervision
required
Classification
Profound: 0-19
• May be able walk
• May have primitive speech
• Constant supervision
required
Problems Related to
Cognitive Impairment
• Mild
• Self-esteem issues related to presence or absence of
physical features
• Social isolation and loneliness
• Depression
• Severe
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Self-injury
Fecal smearing
Tearing of personal clothes and objects
Severe temper tantrums
Disrobing
Goals of Nursing Care
• The child will be educated using
effective teaching strategies.
• The child’s optimal development
will be promoted.
• The child will learn self-care
skills.
• The family will plan for future
care.
Education
• most do well in pre-school
• helps them learn to be comfortable
with other children
• depending on the degree of MR
should be included in regular classes
as much as possible
• offers stimulation
• helps them to reach their best
potential and learn to work and
socialize with people of average
intelligence
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
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
Safety for the Child with a Cognitive
Impairment
• Safety is a persistent concern for children
with cognitive impairments
• The child’s 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
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
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)
Autism Specgtrum Disorders
• Increased awareness of health care professionals and
public
• High estimations of prevalence and incidence (1/250
births)
• Chronic life-long condition
• Potentially severe impact
Individual, family, society
• Ranges from MILD to SEVERE
Autism Spectrum Disorders
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Autistic disorder
High Functioning Autism
PDD NOS
Asperger’s Syndrome
Childhood Disintegrative Disorder
Rett’s disorder
Etiology
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Unclear
Neurological origins
Genetic Factors
Possible Infectious, metabolic and immunologic
causes
• Possible environmental causes
• Probably multifactoral
• NO RESEARCH TO SUPPORT VACCINES AS
A CAUSE!!!!!
Autism is:
Developmental disability
• Symptoms are present before age three, in
the developmental period
• It causes delays in many different areas
from infancy into adulthood
History of Autism
• First recognized in 1943 – Dr. Leo Kanner
• extreme aloofness & indifference
• little eye contact
• severe language deficits
• lack of desire to communicate
• lack of pretend play
• “Infantile Autism”
• Since then DSM has changed criteria DSM-I 1952, DSMII 1968, DSM-III 1980, DSM IV
• Aspergers only entered in 1990
Prevalence/Incidence
• Gender
• Higher incidence in males
• Familial
• Higher degree of siblings at risk
• Higher incidence in people with other
developmental disorders
Autism
1. Restrictive repetitive and stereotyped
pattern of behavior, interests and
activities
2. Hypo/hyper sensitivity
3. Qualitative Impairment in:
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social interaction
symbolic or imaginative play
communication
Impairment in 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
Impairment in
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
Lack of imaginative play
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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
Restricted interests, 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
Autism Red Flags
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Language is delayed
Child doesn’t respond to name
Child can not indicate wants
Lack of pointing, waving “bye-bye”
Intense tantrums
Has odd movement patterns
Child doesn’t 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
Diagnostic and Treatment Barriers
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Lack of recognition of the early signs
Parental resistance
Uninformed school professionals
Lack of qualified professionals in early
intervention
• Private insurance non-payment for developmental
disabilities
• Costly services
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= Delay in referral for evaluation
Treatment
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No known cure
Wide variety of therapeutic options
Early therapy - positive effect
Characteristics may improve with age
Can not generalize successful therapy
Comprehensive Plan
• Behavior management
• ABA (Applied Behavior
Analysis)
• Speech-language therapy
• OT
• PT
• Social Skills therapy
• School and special
education services
• Habilitative Services
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Home/family
Respite care
Supervised group living
LTC
• Medications
• Dietary
• Community support
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
Clinical manifestations
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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
Down Syndrome
• Other manifestations:
• Congenital heart defects (septal)
• Upper respiratory infections
• Thyroid dysfunction
• Cognitive impairment
Prognosis:
• More than 80% survive to age 30
Nursing goals
• Family support at time of
diagnosis
• Decisions about future care
• Assist family in preventing
physical complications
Hearing Impairment
Disability that may range in severity from
mild to profound and includes subsets
of deaf & hard of hearing.
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Normal hearing 0– 15 dB
Slight hearing impaired 16–25 dB
Mild hearing impaired 26–40 dB
Moderate hearing impaired 41–65 dB
Severe hearing impaired 66-95 dB
Profound hearing impaired 96+dB
Types and Causes of
Hearing Loss
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Conductive
Sensorineural
Mixed
Central
Etiology
• Prenatal and Postnatal
-anatomic malformation
-asphyxia
-prematurity
-otologic toxic rx
-continuous humming
Perinatal infections
Hearing Impairment
Assessment:
• Early dx (6-12mos of age) is
imperative to prevent social,
physical, and psychological damage
to child
• Identify those at risk
• Observe for behavior that may
indicate loss (See below)
• Screen children for auditory function
Behaviors
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
Behaviors
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
Nursing Care for the
Child with Hearing Loss
• Promote communication
• children will imitate what you say, describe
daily activities, repeat child’s words using
correct pronunciation
• Look directly at child’s face when speaking
• Have the child’s complete attention before beginning
to speak
• Speak clearly but not loudly or slowly
• Eliminate background noise
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
Visual Impairment
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Common in childhood
Range from slight impairment to vision loss
Most can be corrected with lenses
Causes
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Genetic
Anatomic
Pre-post natal infections (rubella, chlamydia)
Trauma
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
Vision Screening
• Thoroughly explain the procedure to the child;
if using a picture chart, have the child identify
the pictures
• Take the child to a quiet, nondistracting area
• Have the child cover one eye; use a colorful,
opaque cover; the parent may hold it in place
• Point to a picture (letter, number) on a line that
the child can probably see; then move to
smaller lines; vary the direction
• Give positive feedback
Vision Screening
• Perform the test as quickly as possible
• Test both eyes
• Refer if there is a discrepancy or if the
child tests in the abnormal range
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
Types of Refractive Disorders
(cont’d)
• Astigmatism
• Unequal curvature of the cornea or lens,
causing light rays to bend in different directions
• May coexist with myopia or hyperopia
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
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
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
Working with a Visually
Impaired Child (cont’d)
• 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
When providing anticipatory guidance to the family
of a child with attention deficit hyperactivity
disorder, the nurse should emphasize the need:
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To have the child take medication prescribed for
the disorder just before bedtime
b. To be lenient and understanding of the child’s
behavior
c. To help build up the child’s self-esteem
d. To involve the child in structured play activities
A 10-year old child with mental retardation 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 nurse’s
response will be based on the fact that children
with MR:
a. Do not have a need for socialization
b. Should not be encouraged to participate in clubs
c. Should participate in clubs for children that are
cognitively impaired
d. Have the same need for socialization as children
w/o mental retardation
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:
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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
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:
a.
The paralysis of their muscles decreased caloric
need
b. The spasticity of their muscles increases caloric
need
c. The hypotonic muscles make eating difficult
d. The child’s inactivity increases the risk of
obesity
When planning activities for a school-age child with
Down Syndrome, the nurse should:
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Speak loudly and clearly to help the child
understand what is going to happen
b. Involve the parents but not he child who is
cognitively impaired
c. Gear the activities to the child’s developmental,
not chronological age
d. Anticipate that the child will not willingly
engage in planned activities