Transcript attention deficit with hyperactivity disorder

Sensory-Cognitive
Common Sensory-Cognitive
Disorders in Children
0 ADHD
0 Cerebral Palsy
0 Cognitive Impairment
0 Depression
0 Autistic Spectrum Disorders
0 Downs Syndrome
0 Visual and Hearing impairments
Attention Deficit with
Hyperactivity Disorder (ADHD)
0 Behavioral disorder
0 Ranges from mild to severe
0 Etiology is unknown
0 Suspect genetic component
0 Possible neurologic abnormality
0 Increased incidence in males
Manifestations
0 Attention Deficit- unable to complete tasks
0 inattention
0 impulsiveness
0 Hyperactivity- excessive/exaggerated muscular activity
0 Other
0 developmentally inappropriate for the age
0 no deficits in intelligence
0 “engaging” personality
0 Symptoms must be present home and school
Assessment
0 Can not be made by diagnostic tests, imaging, etc.
0 Diagnosis is confirmed by comprehensive tests
0 Assessment usually begins in school
0 Need to have exact description “all or none” reaction
to stimuli
0 Difficulty with right & left, today & tomorrow
0 Difficulty with common tasks
0 Awkward motor movements
0 Early identification is critical
0 Maladaptive behavior patterns
0 Exposed to negative feedback
Management
Environmental Manipulation
0 Stable learning environment with special
instruction
0 Encourage parents to be fair but firm
0 Encourage parents to build self-esteem
0 Correct bad behavior immediately
0 Assign age appropriate chores with slow
instructions
Management
0 Medication (Stimulants)
Ritalin, Dexedrine, Adderal
0 Work by increasing dopamine and norepinephrine levels
0 Should be used in adjunct to environmental manipulation
and therapy
0 Side effects
0 insomnia (give first thing in morning)
0 anorexia (monitor height & weight)
Management
0Family support
0 Remind parents to be patient
0 Usually a “childhood condition”
0 May resolve by adolescence
(increased attention span, ability to
filter stimuli improves)
Pervasive Developmental Disorders
0 Autism Spectrum Disorders
0 Autistic disorder
0 High Functioning Autism
0 PDD
0 Asperger’s Syndrome
0 Childhood Disintegrative Disorder
0 Rett’s disorder
Etiology
0 Unclear
0 Neurological origins
0 Genetic Factors
0 Possible Infectious, metabolic and
immunologic causes
0 Possible environmental causes
0 Probably multifactoral
0 NO RESEARCH TO SUPPORT VACCINES AS A
CAUSE!!!!!
Developmental disability
0 Symptoms are present before age three, in the
developmental period
0 It causes delays in many different areas from
infancy into adulthood
0 Symptoms range from mild to severe in
individuals
Clinical Manifestations
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
Restrictive, Repetitive, Stereotyped
Behavior
0 Abnormal intensity or focus
0 Inflexible and/or nonfunctional routine and rituals
0 Repetitive motor mannerisms (hand flap, whole body
movements)
0 Preoccupation with parts of an object
Hyper/Hypo Sensitivity
0 Oral
0 Touch
0 Sounds
0 Photosensitivity
Leads to Seeking/Avoiding Behavior
Impaired Social Interaction
0 Lack of peer relationships
0 Lack of social reciprocity
Lack of Symbolic Play
0 Prefers to line up toys in a row
0 May play with non-toy items
0 May not acknowledge toys with “faces”
0 Interested in parts of a toy
0 Lacks ability to pretend play
Impaired Communication
0 Ranges from minor impairment in either receptive or
expressive language to lack of spoken language without
alternative modes (gestures, mine)
0 In adequate speech, lack ability to initiate or sustain
conversation
0 Repetitive or idiosyncratic language
Treatment Plan
0 No known cure
0 Wide variety of therapeutic options
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Behavior management
ABA (Applied Behavior Analysis)
Speech-language therapy
OT
PT
Social Skills therapy
School and special education services
0 Early therapy - positive effect
0 Characteristics may improve with age
0 Can not generalize successful therapy to others
Recognize ‘Red Flags” and Refer!
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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
Cerebral Palsy
0 Disorders of early onset
0 Impaired movement and posture
0 Abnormal muscle tone and coordination
0 Hypertonicity
0 Hypotonicity
Cerebral Palsy
0May be accompanied by
intellectual impairment and
language deficits
0The most common physical
disability in children
Associated Factors
Prenatal
0 Maternal diabetes
0 Rh or ABO incompatibility
0 Rubella in the first trimester
0 Genetics
0 Intrauterine ischemic event
0 Toxoplasmosis
0 Cytomegalovirus
0 Congenital brain abnormality
Associated Factors
Perinatal
0 Asphyxia
0 Anoxia
0 Low birth weight
0 Perinatal metabolic
0 Prematurity
0 Precipitous delivery
0 Pregnancy-induced
hypertension
0 Birth trauma
0 Prolonged labor
condition (diabetes)
0 Intracranial hemorrhage
Associated Factors
Postnatal
0 Infections
0 Trauma
0 Stroke
0 Poisoning
Clinical Manifestations
0Delayed gross motor development
0Abnormal motor performance
0Alterations of muscle tone
0Reflex abnormalities
0Associated disabilities
0cognitive impairment
0seizures
0impaired vision or hearing
Types of CP
0Spastic
0Dyskinetic
0Ataxic
0Mixed-type
Spastic
0 may involve one or both sides
of body
0 hypertonicity with poor control
of posture, balance, and
coordinated movement
0 impaired fine and gross motor
skills
0 active attempts at movement
increase abnormal posture
0 because of excessive energy
expended need more calories
Dyskinetic
0 abnormal involuntary
movement
0 slow worm-like, writhing
movements that involve
extremities, trunk, neck,
facial muscles and
tongue
0 poor oral tone, drooling,
difficulty with speech
Ataxic
0 wide based gait
0 rapid repetitive
movements poorly
performed
0 disintegration of
movement when child
reaches for an object
Mixed
0 combination of spasticity and
diskinetic
Diagnosis
0 Neurologist
0 MRI- identifies lesions and spinal cord pathology
0 ECG
0 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
Nursing Management
0 Establish locomotion, communication,
self-help
0 Gain optimum development of motor
function (braces, walkers, surgery to
release contractures)
0 Pain management
0 Provide educational opportunities
0 Promote socialization
Depression
0 Childhood depression
hard to detect
0 Acute Depression
0 Chronic Depression
0 Kids can not always
verbalize feelings
0 Feelings are usually
acted out and
overlooked
Etiology
0 Biologic basis (neurotransmitter level)
0 Genetic basis
0 Interpersonal factors
0 Greater incidence in adolescents
Diagnosis
0 Major Characteristics
0 Should have at least one of these present for 6
months:
0 Depressed mood
and/or
0 Loss of interest or pleasure
Minor Characteristics
0 Must have five of these for 6 months:
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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
0 Solitary play
0 Withdrawn from previously enjoyed activities
0 Tearful
0 Clinging
0 Aggressive
0 Physiologic symptoms
Treatment
0 SSRI’s
0 TCA
0 Therapy
0 Individual
0 Group
0 Family
Cognitive Impairment
0 Sub-average intellectual functioning
0 Deficits in adaptive behavior
0 Onset before 18 years of age
0 AKA Mental Retardation, “cognitive
impairment” is preferred term
Causes of Cognitive
Impairment
0 Hereditary origin
0 Early embryonic alterations
0 Early intrauterine or neonatal alterations
0 Acquired childhood conditions or diseases
0 Environmental problems and behavioral syndromes
0 Unknown causes
Definition
IQ of < 85 and adaptive limitations in two or more of
the following areas:
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communication
self-care
home living
social skills
leisure
health & safety
self-direction
functional academics
community use
work
Assessment
0 Few physical indicators
0 Delay in developmental milestones
0 Nonresponsive to contact
0 Poor eye contact during feeding
0 Diminished spontaneous activity
0 Decreased alertness to voice or movement
0 Irritability
0 Slow feeding
Classification Based
on IQ Testing
0 Borderline
0 Mild
0 Moderate
0 Severe
0 Profound
Problems Related to
Cognitive Impairment
0 Borderline-Mild
0 Self-esteem issues related to presence or absence of
physical features
0 Social isolation and loneliness
0 Depression
0 Moderate-Severe
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Self-injury
Tearing of personal clothes and objects
Severe temper tantrums
Disrobing
Safety for the Child
with a Cognitive Impairment
0 Impaired sense of anticipating danger, problem
solving, and judgment
0 Children with motor disabilities are often unable to
perform skills in ways that
foster safety
Self-care activities
0 need to learn the maximum amount
of self-care possible
0 leads to sense of control and
accomplishment
0 play activities a good teaching tool
Social relationships
0 ability to communicate is often
delayed because speech is delayed
0 teach early social behavior (thank
you, excuse me, taking turns)
Goals of Nursing Care
0The child will be educated using
effective teaching strategies
0The child’s optimal development will
be promoted
0The child will learn self-care skills
0The family will plan for future care
Down Syndrome
0 Most common chromosomal abnormality
0 Caused by extra chromosome due to failure of
chromosomes to separate or fusion of two
chromosomes
0 Can be diagnosed in utero
Clinical manifestations
0 Small, square head
0 Upward slant of eyes
0 Flat nasal bridge
0 Protruding tongue
0 Mottled skin
0 Transverse palmar
crease
0 Hypotonia
0 Chromosomal analysis
will confirm diagnosis
Associated Problems
0Congenital heart defects
0Upper respiratory infections
0Thyroid dysfunction
0Cognitive impairment
Nursing Considerations
0 Follow recommended guidelines suggest times for
evaluation
0 Hearing
0 Growth
0 Cardiac function
0 For early identification and treatment of associated
disorders
Nursing goals
0Family support at time of
diagnosis
0Decisions about future care
0Assist family in preventing
physical complications
Hearing Impairment
0 Range in severity from mild to profound
0 Types
0 Conductive
0 Sensorineural
0 Mixed
0 Central
Causes of Hearing Loss
Prenatal
Postnatal
0 anatomic malformation
0 Otologic toxic
0 Perinatal infections
medication
0 Continuous humming
0 Prematurity
Hearing Impairment
Assessment
0 Early diagnosis (6-12mos of age) is
imperative to prevent social, physical,
and psychological damage to child
0 Nurse should assess to identify those
at risk
0 Screen children for auditory function
Newborn Screening
Behaviors of Hearing Loss
In infancy
0 Poor response to auditory stimuli
0 No startle reflex
0 No head turning to voice
0 Indifference to sound
0 Absence of babble or inflections in voice
by 7 months
0 Absence of well-formed syllables by 11
months
Behaviors of Hearing Loss
In children:
0 Failure to develop 3 word vocabulary by
18 months
0 Use of gestures rather than verbalization
to express needs
0 Failure to develop intelligible speech by
24 mos.
0 Responds more to facial expressions and
gestures than to verbal explanation
Nursing Care for the
Child with Hearing Loss
0Promote communication
0 children will imitate what you say, describe daily
activities, repeat child’s words using correct
pronunciation
0 Look directly at child’s face when speaking
0 Have the child’s complete attention before
beginning to speak
0 Speak clearly but not loudly or slowly
0 Eliminate background noise
Nursing Care for the
Child with Hearing Loss
0 Encourage the child who has a hearing aid to use it
0 Make sure the hearing aid is in place before speaking
to the child
0 Use visual aids
0 Use basic sign language or an interpreter when
necessary
Visual Impairment
0 Common in childhood
0 Range from slight impairment to vision loss
0 Most can be corrected with lenses
0 Causes
0 Genetic
0 Anatomic
0 Pre-post natal infections (rubella, chlamydia)
0 Trauma
Visual Impairment
In infancy
0suspect blindness if an infant does
not react to light
0lack of eye contact
0if parents of any age child express
concern
Types of Refractive Disorders
0 Myopia
0 Nearsightedness
0 Ability to see close objects more clearly than those at a
distance
0 Caused by the image focusing in front of the retina
0 Hyperopia
0 Farsightedness
0 Ability to see distant objects more clearly than those
close up
0 Caused by the image focusing beyond the retina
Types of Refractive Disorders
(cont’d)
0 Astigmatism
0 Unequal curvature of the cornea or lens, causing light
rays to bend in different directions
0 May coexist with myopia or hyperopia
Types of disorders that interfere
with vision
0 Nystagmus
0 rapid irregular eye movement
0 Strabismus
0 malalignment of one eye (may be cross-eyed),
unequal muscle strength
0 Amblyopia
0 reduced visual acuity in one eye (“lazy eye”)
Blind Children
0 blind children do not learn to play
automatically
0 cannot imitate others or actively explore
their environment
0 depend on others to teach them how to play
and to stimulate them
0 select activities that encourage fine & gross
motor development, and that stimulate
senses of hearing, touch, and smell
Working with a Visually
Impaired Child
0 Orient the child to the hospital environment by emphasizing
spatial relations
0 Never touch the child without identifying yourself and
explaining what you plan to do
0 When describing the environment, use familiar terms; avoid
mention of color
0 Remember that parents are often the best source for
communication
0 Identify noises for the child
Working with a Visually
Impaired Child (cont’d)
0 Frequently orient the child to time and place
0 Keep all things in the same location and order
0 Provide detailed explanations and allow child
to progress through care in steps to learn the
order
0 Allow as much control as possible
0 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:
To have the child take medication prescribed
for the disorder just before bedtime
b. To be lenient of the child’s behavior
c. To help build up the child’s self-esteem
d. To involve the child in timed, structured,
preset activities
a.
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 nurse’s
response will be based on the fact that
children with cognitive impairment:
Do not have a need for socialization
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 impairment
a.
b.
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:
a.
b.
c.
d.
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:
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
a.
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
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
a.
0 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