Transcript Care of the Child with a Mental or Cognitive Disorder

Care of the Child with a Mental or
Cognitive Disorder
Chapter 32
Cognitive Impairment
• Most common developmental disability affecting
up to 3% of the population
• Significantly sub average general intellectual
functioning existing concurrently with deficits in
adaptive behavior and manifested during the
developmental period
• Formerly referred to as mental retardation
Cognitive Impairment
• Classified into four general categories on
the basis of intelligence quotient (IQ)
• Intelligence Quotient – an index of relative
intelligence determined through the
subject’s answers to arbitrarily chosen
questions
Cognitive Impairment
• IQ
– Mild – educable cognitive impaired
• IQ – 50 or 55 to approximately 70
– Moderate – trainable cognitive impaired
• IQ – 35 or 40 to 50 or 55
– Severe – IQ – 20 or 25 to 35 or 40
– Profound – IQ below 20 to 25
Cognitive Impairment
• Causes are varied
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Biochemical
Infectious
Genetic
Endocrine
Idiopathic
• Specific causes
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Down Syndrome
Perinatal infections
Perinatal anoxia
Maternal drug or
alcohol abuse
– Metabolic disorders
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PKU
Lead poisoning
Hypothyroidism
Prematurity
Cognitive Impairment
• Manifestations
– Vary according to age & degree of impairment
– May fail to achieve developmental milestones
– Delays in motor, social, cognitive, and
language skills
Cognitive Impairment
• Diagnostic Tests
– Assessment should begin as soon as child is
not developing normally
– Diagnostic studies
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Neurologic exam
CT scan
Serum metabolic screening
Developmental screening
Standardized intellectual tests
Chromosomal analysis & genetic screening
Cognitive Impairment
• Nursing Interventions
– Promote optimal development
– Provide the family with support
• Encourage to enroll in early intervention programs
• Encourage to emphasize the normal needs
– Education
– Referrals
Cognitive Impairment
• Patient/Family Teaching
– Provide with information on:
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Normal developmental milestones
Stimulation techniques
Safety
Normal speech development
Sexual development
– Role of positive self-esteem in motivating
children to accomplish goals
Cognitive Impairment
• Prognosis
– Chronic condition
– Remain at home – changes in philosophy of
care
Down Syndrome
• Most common chromosomal abnormality affecting 1 in 800 live births
• 95% attributed to an extra chromosome on
the twenty first pair
• Trisomy 21
• Risk increases with increasing maternal
age – women over 35
Down Syndrome
• Clinical manifestations
– Characteristic facial appearance
– Small rounded skull with a flat occiput
– Upward-slanting eyes
– Broad, flat nose
– Protruding tongue
– Short, thick neck
– Hypotonic extremities
Down Syndrome
• Clinical manifestations
– Mottled skin
– Low set ears
– Simian crease on the palmar side of the hand
– Some degree of intellectual impairment
• Low normal to severe cognitive
Down Syndrome
• Clinical manifestations
– Prone to URI
– Congenital heart defects
– Hypothyroidism
– Increased incidence of leukemia
Down Syndrome
• Diagnostic tests
– Chromosomal analysis
• Medical management
– Routine medical care
– Corrective surgery - ?heart defects
– Auditory & vision screening
– Thyroid function tests
Down Syndrome
• Nursing interventions
– Similar to those previous
– Set realistic, reachable goals
– Mainstream daily routines to promote
normalcy
– Support the family
– Referrals to agencies that provide supportive
services
Down Syndrome
• Patient/Family Teaching
– Education
• Prognosis
– Life expectancy has improved
– Associated with early aging
Autism
• Complex developmental dsorder of brain
function
• Broad range & severity of intellectual
deficits
• Manifested at 24-48 months
• Four times more common in males than
females
Autism
• Etiology
-unknown
-evidence supports multiple biologic
causes
Autism
• Clinical manifestations
– Peculiar, bizarre characteristics
– Hallmark- inability to maintain eye contact
– Limited functional play
– Interact with toys in unusual manner
Autism
• Clinical manifestations
– GI symptoms with constipation common
– Primary feature- deficits in social development
– Some have mental retardation (50-70%)
– Savants – excel in particular areas such as
art, music, memory, math, or perceptual skills
Autism
• Clinical manifestations
– Speech & language delays
• Immediate eval- does not display language skills or
sudden deterioration in expressive speech
• Early recognition, referral, diagnosis & intensive
early intervention
-Unfortunately diagnosis is made late
Autism
• Nursing interventions
– No cure
– Highly structured and intensive behavior
modification programs
• Promote positive reinforcement, increase social
awareness of others, teach verbal communication
skills & decrease unacceptable behavior
Autism
• Hospitalization
– Parents should stay
– Decrease stimulation
– Minimum holding and eye contact
Child Maltreatment
• Complicated and prevalent problem
• Broad term – describes physical &
emotional neglect and physical, emotional,
& sexual abuse of children
• Number of cases has increased
dramatically
• 1997 – 1 million confirmed cases of
children suffering from maltreatment
• Many more go undetected
Child Maltreatment
• Child neglect
– 2 categories
• Physical – failure of a parent or caretaker to supply
a child with adequate food, clothing, shelter,
education, or health care although financially able
to do so or offered financial or other means to do
so
• Emotional – failure by a parent or caretaker to
meet a child’s needs for emotional nurturance,
affection, and attention
Child Maltreatment
• Child abuse
– Three broad categories
• Physical – intentional, non accidental infliction of physical
injury upon a child by a parent or guardian
• Emotional – intentional attempt by a parent or caretaker to
impair or destroy the mental or emotional state of a child
• Sexual – commission of a sexual offense by an older person
against a child who is dependent or developmentally
immature for the purpose of the perpetrator’s own sexual
stimulation or gratification
Child Maltreatment
• Etiology
– Many factors contribute
such as parental, child,
situational
– Parental factors – parent’s
own culture
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Socialization history
History of abuse
Age
Developmental level
Attitudes toward the child
Psychological state
– Child
• Temperament
• Age
• Exceptional physical
needs
• Disabilities
• Health or behavior
problems
– Situational
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Stress
Support
Financial difficulties
Drugs & alcohol
Poor social network
Child Maltreatment
• Clinical
manifestations
• Behavioral indicators
– Physical neglect
• Begging or stealing
food
• Extended stays at
school
• Fatigue
• Delinquency
• Alcohol &/or drugs
• Physical indicators
– Physical neglect
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Failure to thrive
Lag in G&D
Consistent hunger
Poor personal hygiene
Inappropriate dress
Unattended medical
needs
• Abandonment
Child Maltreatment
• Failure to thrive
– Abnormal retardation of growth and
development of the infant resulting from
conditions that interfere with normal
metabolism, appetite, and activity
Child Maltreatment
• Behavioral Indicators
– Physical abuse
• Frequent injuries
• Wary of contacts with
parents
• Apprehension when other
children cry
• Fear of parents
• Wears concealing clothing
• Low self esteem
• Suicide attempts
• Physical Indicators
– Physical abuse
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Bruises or welts
Human bites
Lacerations or abrasions
Burns
Fractures:
– Skull, nose, or face
– Multiple or spiral
– Various stages of
healing
• Discovered by exam
Child Maltreatment
• Behavioral Indicators
– Sexual abuse
• Promiscuous behavior
• Unwillingness to
change for gym
• Withdrawal
• Poor peer relationships
• Fear of being touched
• Suicide attempts
• Prostitution
• Age-inappropriate
sexual knowledge
• Forcing sexual acts on
other children
• Low self esteem
• Excessive or public
masturbation
• Declining school
performance
Child Maltreatment
• Physical Indicators
– Sexual abuse
• Difficulty in walking or
sitting
• Torn or stained
underclothing
• Pain or pruritis in
genital area
• Bruises or bleeding in
external genitalia
• STD – preteen
• Bruises to hard or soft
palate
• Adolescent pregnancy
• Enuresis/encopresis
• Vaginal or penile
discharge
• Foreign bodies in
vagina or rectum
• Presence of semen
• Recurrent UTI
Child Maltreatment
• Behavioral Indicators
– Emotional neglect and
abuse
• Stranger anxiety
• Emotional withdrawal
• Inappropriate
fearfulness
• Delinquency
• Language difficulties
• Suicide attempts
• Physical Indicators
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Failure to thrive
Feeding difficulties
Enuresis/encopresis
Sleep disturbances
Child Maltreatment
• Nursing interventions
– Identification of the child
– Thorough history &
physical exam
– Presence of behavioral or
physical indicator
– Question parent & child
separately
– Using drawing or play
– Mandatory reporting
– Nonjudgmental attitude
towards parents
– Explain procedures
– Document interactions
– Prenatal – identify at risk &
refer
– During child’s health care
visits – identify risks
– Encourage parents to
access resources
School Avoidance
• School phobia & school refusal
– Occurs when a physically healthy child repeatedly
stays home from school or is sent home from school
for physical symptoms of an emotional nature
– Vague physical symptoms
– Affects 5% of elementary school children and 2% of
middle school children
– Decreasing with mothers in the workplace
School Avoidance
• Etiology
– Related to anxiety
• Worried about academic progress, peer conflicts, or marital
discord
– Separation anxiety
• Should already have this mastered
• Parents tend to be overprotective
– Secondary gains
• Parents are too lenient, place little value on education, or
unconcerned about the ramifications
School Avoidance
• Clinical manifestations
– Anxious type
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Anxiety
Headache
Recurrent abdominal pain
Vomiting
Diarrhea
Insomnia
Pallor
Palpitations
Hyperventilation
– Secondary gains
• Exaggerate or fabricate
symptoms
• Sore throat
• Leg pain
• Coughing tics
• Chest pain
• Fatigue
– No organic cause is found
– Sounds sick, appears well
School Avoidance
• Symptoms appear in the morning and
decrease once they are told they do not
have to go to school
• Diagnostic tests
– Usually not indicated
School Avoidance
• Medical management/Nursing
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Assist in convincing parents child is healthy
Explain diagnosis
Assist in returning child to school
Educate parents – stress related
Parents need to be firm
Somatic complaint – PCP
Reassure child - support
Attendance is non negotiable
Learning Disabilities
• Approximately 10% of all school aged
children are affected
• Impair a child’s ability to understand,
assimilate, recall, or produce information
• Do not become apparent until academic
demands are placed on the child
Learning Disabilities
• Etiology
– Multifactorial and often a specific cause is not
identified
– Positive family history
– Result of various physiologic and/or
environmental factors
Learning Disabilities
• Factors
– Intrauterine exposure
to drugs or infection
– Birth trauma
– Lead poisoning
– Seizures
– ADD
– Head trauma
– Malnutrition
• Coexisting psychiatric
disorder
• Hearing or vision
impairments
• Genetic syndromes –
fragile X or PraderWilli
Learning Disabilities
• Clinical manifestations
– Problems with:
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Speech
Behavior and/or motor coordination
Failure to master basic, grade appropriate academic skills
Progressive decline in school performance
Delayed acquisition of language milestones
Deficient social skills
Avoidance behavior Low frustration tolerance
Learning Disabilities
• Diagnostic tests
– Thorough history & physical exam
– General intelligence & achievement testing
– Neuropsychologic testing
Learning Disabilities
• Medical management/Nursing
– Appropriate educational referrals
– Educate parents
– Comprehensive evaluation from school
– Therapeutic manipulation of the educational
setting
– Reevaluation every 3 years
– Referral source – National Center for
Learning Disabilities
Learning Disabilities
• Prognosis
– Early identification, appropriate referrals, &
proper educational interventions – negative
consequences can be avoided
Attention Deficit Hyperactivity
Disorder
• Group of behaviors – hyperactivity,
inattentiveness, & impulsivity – that appear
early in child’s life, persist throughout
childhood and adolescence, & may extend
into adulthood.
• Most prevalent behavioral disorder
• 3-5% of school aged children
ADHD
• Etiology
– Multifactorial
– 25% incidence in first-degree relatives
– Animal studies – altered neurotransmitter
profiles
– Environmental factors
• Low socioeconomic status
• Parental psychopathology
ADHD
• Clinical manifestations
– Exhibit decreased attention
span
– Impulsivity
– Failure to follow
instructions
– Hyperactivity
– Poor self regulation
– Non compliance
– Aggression
– Fidgeting
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Immaturity during play
Failure to follow rules
Lack of turn taking
Easy distraction
Poor school performance
Learning disabilities
Antisocial behaviors
• Lying
• Cheating
• Stealing
– Anxiety
– Sleep disturbances
ADHD
• Diagnostic tests
– Report of characteristics by multiple
observers
– Rating scales
ADHD
• Medical management
– Behavioral counseling
– Educational intervention
– Pharmaocotherapy
• Interventions are aimed at achieving
optimal academic, emotional, social, and
vocational outcomes
– Preserving good self esteem
ADHD
• Medical management
– Medications
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Ritalin
Dexedrine
80% of children significantly improve
Watch side effects as they may be dose related
Positive results
– Increased attention span
– Normalization of activity level
– Reduced impulsiveness
ADHD
• Nursing interventions
– Parent counseling
– Educate parents
– Counsel parents on controversial therapies
– Assist in development of educational plan
– Educate on follow up for meds – every 6
months
ADHD
• Prognosis
– Symptoms may persist into adulthood
– Early identification, referrals and care have
effective results
Depression
• Mood disturbance with overall feelings of
sadness, despair, worthlessness, or
hopelessness
• Prevalence rates
– 2% in prepubertal children
– 5% in adolescence
Depression
• Etiology
– Causes have not been established
– Risk factors
• Genetic
• Environmental
– Studies have shown 3 to 6 times greater rate
with a parent suffering from a major affective
disorder
– Feelings of hopelessness & helplessness
secondary to an actual or perceived loss
Depression
• Clinical manifestations
– Vary with age and developmental level
– Infancy
• Separation can lead to protest (crying) followed by apathy,
blank staring, and sad facial expressions
– School age
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Sad facial expressions
Irritability
Crying easily
Accident proneness
Social withdrawal
Eating & sleeping disturbances
Depression
• Clinical manifestations
– School age
• Anxiety symptoms
• Physical aggression
• Academic underachievement
– Adolescents
• Impulsiveness
• Somatization disorders – recurrent, multiple
physical complaints & symptoms for which there is
no organic cause
Depression
• Clinical manifestations
– Adolescents
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Eating disorders
Drug/alcohol use
Antisocial behavior
Withdrawal
Fatigue
Suicidal ideation
Depression
• Diagnostic tests
– Structured questionnaires or interviews
– No definitive biologic tests
Depression
• Medical Management
– Antidepressant medications
• Tricyclic antidepressants
• Selective serotonin reuptake inhibitors
– Prozac & Paxil
– Psychologic therapies
• Play therapy
• Art therapy
• Various talk therapies
Depression
• Nursing interventions
– Establish a trusting relationship
– Support the family
– Open & honest communication
• Patient/Family Teaching
– Review treatment plan with family
– Recovery may be slow & lengthy
Depression
• Prognosis
– For the motivated family & child – prognosis is
good
– Depressive episodes may recur
• Nursing diagnoses:
– Social isolation
– Knowledge deficient
Suicide
• 3rd leading cause of death among 15 to 19
year olds in the US
• Females lead males in attempts
• Males more often complete the act
• Females use passive methods
– Medication ingestion or carbon monoxide
poisoning
• Males use more violent methods
– Hanging, firearms, or wrist slashing
Suicide
• Etiology
– Not caused by a single factor
– Culmination of multiple factors
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Depression
Loss of a loved one or relationship
Social isolation
Lack of attaining a sense of identity – leads to self
doubt & low self esteem
Suicide
• Clinical manifestations
– Many completed ones are a result of previous
attempts
– Warning signs include:
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Depression
Preoccupation with death
Perceived or actual social isolation
Withdrawal
Poor school performance
Drug and/or alcohol abuse
Appetite & sleep disorders
Loneliness
– Symptoms are present for at least 1 month
Suicide
• Diagnostic tests
– Tests for depression are useful if recognized
early
• Medical management
– Responsibility should be shared by many –
indicates others care
– Individual, family, & group therapy
Suicide
• Nursing interventions
– Mental health assessments
– Any concerns – be direct about asking about
their thoughts of death & suicide
– Any threat of suicide – take seriously
– Help develop positive coping strategies in
stressful situations
Suicide
• Prognosis
– Vary
– Greatest risk
• Those children who verbalize suicidal thoughts
• Those that attempt suicide
– Appropriate mental health care can help
Psychogenic Abdominal Pain
Recurrent Abdominal Pain
• RAP origin
– Multifactorial, organic, dysfunctional, or
psychogenic
– Most often seen in school aged and
adolescent children
– Episodes of RAP occurring monthly for at
least 3 consecutive months
– Other causes ruled out
RAP
• Etiology
– Emotional factors in the child/family
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Poor self esteem
Anxiety
Depression
School phobia
Maternal depression
Marital problems/divorce
Other health problems
– Organic causes need to be considered until proven
otherwise
RAP
• Clinical manifestations
– Usually afebrile
– Occasional vomiting
– Constipation
– Abdominal pain – non specific
• Episodic, periumbilical or epigastric pain
– Unrelated to eating, defecation, or exercise
RAP
• Diagnostic tests
– Organic causes must be ruled out
– CBC
– Sedimentation rate
– UA & culture
– Other tests
RAP
• Medical management
– Stressors need to be identified & addressed
– Consult with mental health as needed
– May be seen once every 2 weeks to a month
for pain eval and reassurance
RAP
• Nursing interventions
– Encourage parents to maintain a normal
schedule with regard to school, play, &
exercise
– Emotional support for overprotective parents
– Call if symptoms worsen
• Prognosis
– Very good
1. Which one of the five choices makes the
best comparison?
LIVED is to DEVIL as 6323 is to:
2336
6232
3236
3326
6332
2. Which one of these is least like the
four?
Horse
Kangaroo
Goat
Deer
Donkey
3. Which number should come next? 144
121 100 81 64
17
19
36
49
50
4. Even the most ___________ rose has
thorns.
Ugly
Weathered
Elusive
Noxious
Tempting