Ch 11 Childhood and Neurodevelopmental Disorders

exam 2

Risk factors Biological and Cognitive

Genetic (biological) Hereditary factors are implicated in numerous childhood-onset psychiatric disorders (declining number of synapses,relative volume and activity level, frontal/prefrontal cortex regions during the teen years)

neurobiological (biological) Dramatic changes occur in the brain during childhood and adolescence

Temperament (Cognitive) refers to the overall mood, attitude, and behavior that a child habitually uses to cope with the demands and expectations of the environment.

Resilience (Cognitive) is the capacity to recover quickly from difficulties. The resilient child has the following characteristics

risk factors cont.

Resilience (Cognitive) is the capacity to recover quickly from difficulties. The resilient child has the following characteristics

1. adaptability to changes in the environment

2. ability to form nurturing relationships w/ other adults when the parent is not available

3. ability to distance self from emotional chaos

4. social intelligence

5. good problem-solving skills

6. ability to perceive a long-term future

risk factors cont.

Environmental factors

-adverse childhood experiences (emotional, physical, sexual, neglect) household challenges such as mental illness, spousal abuse, substance use. 

Cultural factors 

-factors such as age, ethnicity, gender, sexual orientation, worldview, religiosity, and socioeconomic status

General assessment for children 

Data collection

• Methods of collecting data include interviewing, screening, testing (neurological, psychological, intelligence), observing, and interacting with the child or adolescent. In addition to the patient, ideally, data will be taken from multiple sources, including parents, teachers, and other caregivers. Parents and teachers can complete structured questionnaires and behavior checklists. A family diagram, called a genogram, can illustrate family composition, history, and relationships

General assessment for children

Mental status examination

purpose: provides information about the mental state at the time of the examination and identifies problems with thinking, feeling, and behaving.

• must be adapted to be appropriate for the child’s developmental stage, cognitive capabilities, and verbal skills. 

• assess include safety, general appearance, socialization, activity level, speech, coordination and motor function, affect, manner of relating, intellectual function, thought processes and content, and characteristics of play.

what does a developmental assessment look at

developmental assessment will look at milestones such as the age a child starts walking, talking, or toilet training.

• covers four areas: social/personal, fine motor function, language, and gross motor function.

General interventions for children

behavioral interventions (reward desired behaviors to reduce maladaptive behaviors.)

Play therapy (allows children to express feelings such as anxiety, self-doubt, and fear through the natural use of play)

bibliotherapy (involves using literature to help the child express feelings in a supportive environment, gain insight into feelings and behavior, and learn new ways to cope.)

general interventions for children

expressive arts therapy (therapeutic use of art provides a nonverbal means of expressing difficult or confusing emotions.)

journaling (Journaling is a tangible way of recording and viewing emotions and may be a way to begin a dialogue with others)

music therapy (Music can be used to improve physical, psychological, cognitive, behavioral, and social functioning)

family interventions (family members develop specific goals, identify ways to improve, and work to achieve the goals for the family or subunits within the family)

general interventions for children

teamwork and safety (promote safety in inpatient units, long-term residential care, or intensive outpatient care)

disruptive behavior management (: Techniques are selected according to the principle of least restrictive intervention.)

Techniques include:

•Time-out

•Quiet room

•Seclusion and restraint

treatment modalities

Biological treatments:

pharmacotherapy

• multimodal approach

• possible inclusion of medication best when combined w/ psychotherapy

Psychological therapies

• Cognitive-behavioral therapy (CBT): Replacing negative, self-defeating thoughts with more realistic and accurate appraisals to improve functioning

treatment modalities cont.

Group therapy

younger children: uses play & ideas 

grade school children: combines play, learning skills, and talk

Adolescents: identifying emotions, modifying responses, learning skills and talking, focusing largely on peer relationships and addressing specific problems

communication disorder

Communication disorders are manifested in deficits in language, speech, and communication

• result in impairments in academic achievement, socialization, or self-care

• language disorder, speech sound disorder, childhood-onset fluency disorder (stuttering), social (pragmatic) communication disorder

language disorder

have difficulties in attaining and using language due to deficits in production or comprehension of language

• may have an expressive problem

• children may have receptive problems (difficulty understanding or are unable to follow directions)

• Causes: hearing loss, neurological disorders, intellectual disabilities, drug misuse, brain injury, physical problems such as cleft palate or lip, vocal abuse or misuse

speech sound disorder

has to do with problems in making sounds.

• result in problems with social participation, academic achievement, and occupational performance

Childhood-onset fluency disorder 

“stuttering” 

• social communication disorder

problems using verbal and nonverbal means for interacting socially w/ others

developmental coordination disorder

-impairments in motor skills development 

-coordination below the child’s developmental age

-problems interfere w/ academic achievement or activities of daily living  

symptoms: delayed sitting/walking or difficulty jumping or performing tasks eg: tying shoelaces. 

treatments: Physical therapy and occupational therapy

may be identified by their avoidance of certain tasks or activities

stereotypic movement disorder

repetitive, purposeless movements for 4 weeks or more eg: hand waving, rocking, head banging, nail biting, and teeth grinding. 

Intervention: focus on safety & prevention

treatment: behavioral therapy (habit-reversal techniques such as folding the arms when the urge to hand-wave begins) medication: Naltrexone, an opioid receptor antagonist, may block euphoric responses from these behaviors

Tic disorders

sudden nonrhythmic and rapid motor movements or vocalizations.

Provisional tic disorder: single or multiple motor and/or vocal tics less than 1 year 

Persistent motor OR vocal tic disorder: single or multiple motor/ vocal tics but not both for more than 1 year 

Tourette’s disorder: multiple motor tics and at least one vocal tic for more than 1 year 

treating tic disorders 

-Behavioral techniques 

comprehensive behavior intervention for tics (CBITS)

habit reversal technique works by helping the patient become aware of the building up of a tic urge then using a muscular response in competition to or incompatible with the tic.

treating tic disorders medications:

Antipsychotics 

1st gen haloperidol (Haldol), 1st gen pimozide (Orap), 2nd gen antipsychotic aripiprazole (Abilify), 2nd gen risperidone (Risperdal)

treating tic disorders medications:

alpha 2- adrenergic agonists: Guanfacine (Tenex/Intuniv)

side effects: somnolence, lethargy, fatigue, insomnia, nausea, dizziness, hypotension, and abdominal pain.

deep brain stimulation (DBS) Users of DBS can turn the device on to control tics or shut it off when they go to sleep. fine wire is threaded into affected areas of the brain and connected to a small device implanted under the collarbone that delivers electrical impulses.

specific learning disorder 

˜Dyslexia (reading)

˜Dyscalculia (math)

˜Dysgraphia (written expression)

outcome of specific learning disorders

Without educational, social, and psychiatric interventions, low self-esteem, poor social skills, higher rates of school dropout, difficulties with attaining and maintaining employment, and poorer social adjustment may result

intellectual development disorder

deficits in:

Intellectual functioning (reasoning, problem solving, planning, judgment, abstract thinking, academic ability)

Social functioning (Impaired communication and language, interpreting and acting on social cues, and regulating emotions)

Daily functioning (deficit in managing age-appropriate activities of daily living, functioning at school or work, and performing self-care)

Etiology:

Heredity, problems with pregnancy or perinatal development, environmental influences, or a direct result of a medical condition

application of the nursing process 

• Nursing Diagnoses and resultant Outcomes vary widely and are dependent on assessment findings and differ widely from one disorder to the next and from patient to patient. Table 11.1 ties specific symptoms/findings to specific nursing diagnoses.

• Treatment plans should be individualized and realistic. family members/caregivers and school personnel should be included in the process. Supportive education should be ongoing regarding the scope and nature of the illness; conceptual, social, and practical deficits; and realistic assessment of the child’s potential. Long-term planning should include consideration of continuing care needs as the child ages and matures into adulthood.

autism spectrum disorder

persistent deficits in social communication and social interaction across multiple contexts. appears first 3yrs of life.

-nonverbal communicative behaviors 

-developing, maintaining, and understanding relationships.

1. Stereotyped or repetitive motor movements, use of objects, or speech

2. Insistence on sameness, excessive adherence to routines, or ritualized patterns of verbal or nonverbal behavior (NO TRANSITIONS) 

3. Highly restricted, fixated interests that are abnormal in intensity or focus

4. Hyperreactivity / hyporeactivity to sensory input or unusual interest in sensory aspects of the environment

autism spectrum disorder symptoms 

symptoms must be present in the early developmental period

symptoms together limit and impair everyday functioning 

not better explained by intellectual disability

DSM-5 (APA, 2013) classifies autism spectrum disorder in three levels depending on the degree of assistance and support the individual requires:

• Level 1 requires support

• Level 2 requires substantial support

• Level 3 requires very substantial support

potential nursing diagnoses outcomes. table 11.1

for social interaction skills include cooperating with others, exhibiting consideration, and exhibiting sensitivity to others. Communication skills outcomes include accurately interpreting messages and accurately exchanging messages. Family normalization is associated with adapting to the challenges of a child with autism spectrum disorder and using community support.

treatment for ASD (pharmacotherapy)

•Second-generation antipsychotics risperidone (Risperdal) and aripiprazole (Abilify) have FDA approval for treating children with autism associated agitation.

•Stimulants are used to treat comorbid ADHD symptoms and may be used to target hyperactivity, impulsivity, or inattention.

•Selective serotonin reuptake inhibitors (SSRIs) are the most often used category in patients with autism. They improve mood and reduce anxiety, which provides the patient with a higher degree of tolerance for new situations.

treatment ASD

Applied Behavior Analysis (ABA)

•Encourages positive behaviors and discourages negative behaviors

Early Intensive Behavioral Intervention (EIBI)

•Improves language and cognitive skills

Early Start Denver Model (ESDM)  

•One-to-one interactions, joint play, and activity routines with the adult and child

what is ADHD

inappropriate degree of inattention, impulsiveness, hyperactivity 

• absence of hyperactivity

further classified as primarily inattentive type (previously know as ADD)

nursing process adhd 

asess: level of physical activity, attention span, talkaitivness, social skills, comorbidity, symptoms present in at least 2 settings. 

outcome: appropriate for the child with ADHD target hyperactivity, impulse self-control, freedom from injury, improved social relationships, the development of self-identity and self-esteem, positive coping skills, and family functioning.

adhd implementation

individual, group, family therapy. managing disruptive behaviors.

•Collaborative and proactive solutions: A therapeutic intervention used with parents and children designed to help both identify and define problematic behaviors, specific triggers, and develop a collaborative method for creating mutually agreeable solutions to the specific situation or trigger.

•Planned ignoring: When behaviors are determined by staff to be attention seeking and not dangerous, they may be ignored. Additional interventions may be used in conjunction (e.g., positive reinforcement for on-task actions).

Use of signals or gestures: Use a word, a gesture, or eye contact to remind the child to use self-control

application of nursing process adhd

Evaluation

ADHD

•Focus: symptom patterns and severity

ADHD, inattentive type

•Focus: academic performance, activities of daily living, social relationships, and personal perception

ADHD, hyperactive-impulsive type, or combined type

•Focus: academic performance, social skills and relationships, impulse control, and behavioral responses

treatment adhd (pharmacotherapy)

medications for aggressive behaviors: stimulants(dose-dependent effect) mood stabilizers(lithium, anticonvulsants, for impulsivity, explosive temper, mood lability.) alpha-adrenergic agonists, and antipsychotics

risk of tardive dyskinesia and metabolic problems

 What are the two most common stimulant medications used to treat ADHD?

A: Methylphenidate (Ritalin) and mixed amphetamine salts (Adderall).

What are common side effects of stimulant medications?

A: Insomnia, appetite suppression, headache, abdominal pain, and lethargy.

What are the main effects of stimulant medications in ADHD?

A: Increase attention and task-directed behavior; decrease impulsivity, restlessness, and distractibility.

How can insomnia from stimulants be minimized?

A: Use the minimum effective dose, avoid dosing after 4 PM, and consider extended-release formulations.

What is a nonstimulant medication approved for ADHD

A: Atomoxetine (Strattera).

When is atomoxetine preferred over stimulants?

A: In patients with comorbid anxiety, tics, or substance use disorders.

How long does atomoxetine take to show full effects?

A: Up to 6 weeks.

What are common side effects of atomoxetine?

A: GI issues, urinary retention, dizziness, fatigue, insomnia, ↑ BP/HR.

What serious risks are associated with atomoxetine?

A: Rare liver injury and increased suicidal ideation (especially in patients with depression).

What monitoring is required with atomoxetine?

A: Regular liver function tests and monitoring of vital signs.

What two alpha-2 adrenergic agonists are used for ADHD?

A: Clonidine (Kapvay/Catapres) and guanfacine (Intuniv/Tenex).

Can clonidine and guanfacine be used with stimulants?

A: Yes, they can be used alone or as adjuncts.

What are common side effects of clonidine?

A: Somnolence, fatigue, insomnia, nightmares, irritability, constipation, dry mouth, respiratory symptoms.

What are common side effects of guanfacine?

A: Somnolence, lethargy, fatigue, insomnia, nausea, dizziness, hypotension, abdominal pain.