Topic 5: Neurodevelopmental Disorders

neurodevelopmental disorders

onset in childhood and are defined as alterations from expected (“normal”) brain development that are persistent and impact the ability of a child to grow, interact, function, and cognitively process

• Biological: genetics (family members with the condition) and neurobiological (substance exposure in utero)

• Environmental: Adverse Childhood Experiences (ACEs) impact reaches into adulthood

What is the RF of a neurodevelopmental disorder

communication disorder, specific learning disorder, autism spectrum disorder, motor disorder, intellectual disabilty, and ADHD

what are the neurodevelopmental disorders

• lack of responsiveness or interest in others, empathy, or sharing

• lack of cooperation or imaginative play with peers

• language delay or absence, stereotyped, or repetitive use of language

• inability to feed, bathe, dress, or toilet self at an age-appropriate level

• head banging, face slapping, hand biting

• frequent disregard for bodily needs

• failure to follow age-appropriate social norms

• depression, inability to concentrate, withdrawal, difficulty in functioning, feeling down, change in vegetative symptoms

• refusal to attend school

• family reports insufficient knowledge about child’s disorder, overprotectiveness interferes with the child’s autonomy, and parental anxiety

what are the S/S of a neurodevelopmental disorder

• impaired socialization

• impaired caregiver-child attachment

• lack of play activity

• situational low self-esteem

• impaired child development

• self-care deficit

• impaired impulse control

• self destructive behavior

• impaired coping

• impaired family coping

• impaired family process

• risk for impaired parenting

• risk for social isolation

• risk for injury

• risk for impaired school performance

what are the nursing diagnoses for neurodevelopmental disorders

language disorder, speech sound disorder, child-onset fluency disorder, social communication disorder

what are the communication disorders

language disorder

communication neurodevelopmental disorder that presents before age 3 and is characterized by difficulty attaining and using language due to deficits in production or comprehension of language; children struggle to either produce language or to comprehend the language they receive; types: expressive or receptive

frequently unknown, hearing loss, neuro disorders, intellectual disabilities, drug misuse, brain injury, physical problems like cleft palate/lip, vocal abuse/misuse

what are the causes of a language disorder

expressive language disorder

type of language disorder in which one has difficulty in finding the right words, forming clear sentences, and using the right gestures and verbal signs

receptive language disorder

language disorder in which one has difficulty in understanding or unable to follow direction and resulting in a poorer prognosis

speech sound disorder

communication neurodevelopmental disorder that is characterized by difficulty forming the sounds required for speech, such as saying Wabbit instead of Rabbit, which can lead to social distress for the child, problems with social participation, academic achievement, and occupational performance, but most children improve their articulation ability with treatment

child-onset fluency disorder

communication neurodevelopmental disorder that is characterized by persistent, distressing hesitation or stuttering beyond what is seen in most children during development and growth, which can lead to social distress for the child and significantly impacts a child’s ability to communicate and participate in social, academic, and occupational activities; treatment is usually effective; aka stuttering

social communication disorder

communication neurodevelopmental disorder that is characterized by difficulty interacting with others using both verbal and nonverbal methods, struggle to relate to others in written communication; a diagnosis of ASD must be ruled out before social communication can be diagnosed

specific learning disorder

neurodevelopmental disorder that is identified during the school years; types: dyslexia, dyscalculia, dysgraphia

dyslexia

specific learning disorder that is characterized by persistent difficulty in reading

dyscalculia

speech learning disorder that is characterized by persistent difficulty in mathematics

dysgraphia

speech learning disorder that is characterized by persistent difficulty in written expression

intellectual disability

neurodevelopmental disorder that is characterized by deficits in 3 areas: intellectual, social, and daily functioning

intellectual functioning deficit

deficit in reasoning, problem solving, planning, judgement, abstract thinking, and academic ability that can be signs of an intellectual disability

social functioning deficit

Deficit characterized by impaired communication and language, interpreting and acting on social cues, and regulating emotions that can be signs of an intellectual disability

daily functioning deficit

deficit in managing age-appropriate ADLs, functioning at school or work, and performing self-care that can be signs of an intellectual disability

motor disorders

neurodevelopmental disorder that includes developmental coordination disorders, stereotypic movement disorder, and tic disorders and are manifested by impairments in gross and fine motor skill acquisition that can range from mild to severe

development coordination disorde

motor neurodevelopmental disorder that is based on impairments in motor skill development, coordination below the child’s developmental age, and problems interfering with academic achievement or ADLs; treated with PT and OT

delayed sitting or walking, difficulty jumping or performing tasks like typing shoelaces, avoidance of certain tasks

what are the S/S of development coordination disorders (a motor neurodevelopmental disorder)

stereotypic movement disorder

motor neurodevelopmental disorder that is MC in boys and is manifested by repetitive purposeless movements such as hand waving, rocking, head banging, nail biting, and teeth grinding for a period of 4 weeks or more; RF is intellectual disability and interventions include safety and prevention of injury

behavioral therapy that includes habit reversed techniques

naltrexone

opioid receptor antagonist to block euphoric response from the behaviors which reduces their occurence

What are the treatments for a stereotypic movement disorder

tic disorders

motor neurodevelopmental disorder that involves tics and occurs before age 18, with MC onset between 4-6 years old; types are provisional tic disorder, persistent motor/vocal tic disorder, and Tourette’s disorder

provisional tic disorder

tic disorder that is characterized by single or mulitple motor and or vocal tics for less than a year

persistent motor/vocal tic disorder

tic disorder that is characterized by single or multiple motor or vocal tics but not more more than a year

Tourette’s disorder

tic disorder that is characterized by multiple motor tics and at least one vocal tic for more than 1 year

tics

sudden, nonrhythmic, and rapid motor movements or vocalizations

motor tics

tics that involve the head, torso, or limbs and they change in location, frequency, and severity over time

coprolalia

the involuntary outbursts of obscene words or socially inappropriate and derogatory remarks that only occurs in 10% of cases of tic disorder

comprehensive behavioral intervention for tics (CBIT)

treatment for tic disorders that includes learning to recognize an impending tic behavior and using a technique (usually a competing muscle movement or intentional sound) to essentially distract the tic and/or confuse the muscles involved in tic production, so the actual tic is less likely to present

CBIT, medication to inhibit the sudden motor, vocal, or both interruptions like certain antipsychotics, alpha 2 adrenergic agonists, clonazepam, and botulinum toxin type A, treating comorbid ADHD, deep brain stimulation (DBS) as a last resort if other approaches fail

what are the treatments for tic disorders

autism spectrum disorder (ASD)

a complex neurobiological and developmental disability that typically appears during a child’s first 3 years of life and affects the normal development of social interaction and communication skills

restricted, repetitive behaviors, activities and interests

impaired social interactions and social-emotional relations

communication deficits

repetitive speech, obsessive focus on specific objects, over-adherence to routines or rituals, hyperreactivity or hyporeactivity to sensory input, resistance to change

what are the clinical manifestations of ASD

level 1 ASD

level of ASD that requires support

level 2 ASD

level of ASD that requires substantial support

level 3 ASD

level of ASD that requires very substantial support, often nonverbal, and needs support with ADLs

• assess for developmental delays, uneven development, or loss of acquired abilities

• assess the child’s communication skills, sensory, social, and behavioral skills, including the presence of any aggressive or self-injurious behaviors

• assess the parent-child relationship for evidence of bonding, anxiety, tension, and fit of temperaments

• assess for physical and emotional signs of possible abuse

• ensure that screening for comorbid intellectual disability has been completed

• assess the need for community programs with support services for parents and children

what does assessment for ASD include

• early intervention programs (begin once communication and behavioral symptoms are identified, typically around 2nd or 3rd year of life)

• behavior management with a reward system

• PT/OT/ST

what are the nursing interventions for an ASD patient

• applied behavior analysis (ABA)

• early intensive behavioral intervention (EIBI)

• early denver start model (EDSM)

what evidence based psychotherapies are approved to treat ASD

applied behavior analysis (ABA)

evidence-based psychotherapy for ASD that encourages positive behaviors and discourages negative behaviors; the child’s progress is tracked and measured

early intensive behavioral intervention (EIBI)

evidence-based psychotherapy for ASD that has the strongest evidence for improving language and cognitive skills in children with ASD; it is a long-term (several years), intensive (40 hours a week) approach that combines operant conditioning (reinforcement and negative consequences) with ABA (encouraging positive behaviors and discouraging negative behaviors)

early denver start model (EDSM)

Evidence-based psychotherapy for ASD in which developmental considerations focus on one-to-one interactions, joint play, and activity routines with the adult and child are used as teaching opportunities

no specific drugs to treat but can use to support the client’s safety, comorbid conditions, or to reduce aggression and agitation

what medications are used to treat ASD

aripiprazole and risperidone

what 2nd generation antipsychotics are used to decrease agitation and aggression in those with ASD

aripiprazole

2nd gen antipsychotic used to decrease agitation and aggression in ASD client, thats SE include somnolence, weight gain, and extrapyramidal symptoms

risperidone

2nd gen antipsychotic used to decrease agitation and aggression in ASD client, thats SE include somnolence, weight gain, and extrapyramidal symptoms and adverse effects of gynecomastic and galactorhea that is resolved with dose reduction/discontinuation

extrapyramidal side effects

These can occur when taking 2nd gen antipsychotics like aripiprazole and risperidone to treat ASD; acute dystonic reaction of the neck, eyes, or tongue, which is a prolonged muscle spasm and a medical emergency; treatment is injectable diphenhydramine or benztropine

SSRIs and alpha-2 agonists

what meds are used to reduce anxiety and improve mood in client’s with ASD

naltrexone

what meds are used to reduce repetitive and self-injurious behaviors in those with ASD

inappropriate degree of inattention, impulsiveness, hyperactivity, low frustration tolerance, temper outburts, labile moods, poor school performance, peer rejection, low self-esteem, strained peer relationships, difficulty taking turns, poor social boundaries, intrusive behaviors, interrupting others

what are the S/S of ADHD

ADHD

to diagnose this disorder a client must show inattention in 2+ settings, hyperactivity, impulsivity, not better explained by a different condition that is unintentional and persists for 6+ months before the age of 12 years old

• gather data from parents, caregivers, and teachers of the child and ask about the level of physical activity, span, talkativeness, frustration tolerance, impulse control, and the ability to follow through with direction and complete takss

• assess social skills, friendship history, problem-solving skills, and school performance

• assess for comorbidities such as anxiety and depression

• assess for indicators of learning disorders, ASD, or intellectual disabilities

• gather data on eating and sleeping patterns

how do you assess ADHD in a client

behavioral contract, collaborative and proactive solutions, counseling, modeling, role playing, planned ignoring, use of signals or gestures, physical distance and touch control, redirection, additional affection, use of humor, clarification, restructuring, limit setting, simple restitution, physical restraint

what are the nursing interventions for a client with ADHD

CBT

what therapies are used for ADHD to enhance focus, manage frustrations, develop improved coping skills, and impulse control by changing the pattern of misconduct by fostering the development of internal controls and working with the family to improve coping and support

amphetamines and amphetamine-like stimulants

what medications are the 1st line to treat ADHD and improve focus and concentration, decrease distractibility, decrease hyperactivity, suppress aggression (with higher doses) and have SE of insomnia, anorexia, HA, and increased aggression (with lower doses)

atomoxetine, clonidine, guanfacine

Nonstimulants that are the 2nd line treatment to ADHD

atomoxetine

what 2nd line treatment for ADHD is also the 1st line treatment for those with a tic disorder

atomoxetine

NRI that reduces impulsivity, anxiety, distractibility, restlessness, and hyperactivity to treat ADHD and tic disorders; SE: drowsiness

alpha-2 adrenergic agonists (clonidine, guanfacine)

NRIs that reduce impulsivity, anxiety, distractibility, restlessness, and hyperactivity to treat aggressive behaviors associated with ADHD; SE are decreased BP, HA, and drowsiness

mood stabilizer

medication used in ADHD patients with explosive temper, mood lability, and aggression