Week 4 Professor Cheesmen Childhood and Neurodevelopmental disorders

Factors Impeding Diagnosis

• Factors impeding diagnosis

  • Might not have the language skills and cognitive and emotional development to describe what is happening

  • Wide variation of “normal” behaviors

    • Especially in different developmental states

  • Difficult to determine whether a child’s behavior indicates an emotional problem

    • Can delay diagnosis and interventions

Protective Factors

• Ability to appropriately interpret reality

• Correct perception of the surrounding environment

• Positive self-concept

• Ability to cope with stress and anxiety in an age-appropriate way

• Mastery of developmental tasks

• Ability to express oneself spontaneously and creatively

• Ability to develop and maintain satisfying relationships

Etiology and General Risk Factors

• Genetic links or chromosomal abnormalities

  • Associated with some disorders 

    • Schizophrenia

    • Bipolar disorder

    • Autism Spectrum disorder 

    • Intellectual developmental disorder 

• Social and environmental 

  • Severe marital discord

  • Low socioeconomic stress

  • Large Families

  • Overcrowding

  • Parental Criminality

  • Substance Use disorders 

  • Maternal Psychiatric Disorders 

  • Parental Depression

  • Foster Care Placement

• Biochemical

  • Alterations in Neurotransmitters

    • Norepinephrine 

    • Serotonin

    • Dopamine 

• Cultural and ethnic

  • Difficulty with assimilation

  • Lack of cultural role models

  • Lack of support from the dominant culture 

• Resiliency 

  • Ability to adapt to changes in the environment 

  • Form nurturing relationships

  • Exhibit effective coping strategies

  • Use problem-solving skills

• Witnessing or experiencing traumatic events

  • Physical or sexual abuse in the formative years

Impulse Control Disorders: Expected Findings

• Various disorders

  • Oppositional defiant disorder

  • Intermittent Explosive Disorder

  • Conduct Disorder

  • Disruptive mood dysregulation disorder

• Behavioral problems occur in multiple locations

  • School

  • Home

  • Social Settings

• Comorbid disorders can be present

  • ADHD

  • Depression

  • Anxiety

  • Substance Use Disorders

• Manifestations generally worsen in school locations

  • Situations that require sustained attention

    • Classroom

  • Unstructured group situations

    • Playground

Impulse Control Disorders: Oppositional Defiant Disorder

• Recurrent patterns of antisocial behavior

  • Negativity

  • Disobedience

  • Hostility

  • Defiant behaviors espcially toward authority figures

  • Stubbornness

  • Arguementativeness

  • Limit Testing

  • Unwillingness to compromise

  • Refusal to accept responsibility for misbehavior

• Usually demonstrated at home woard the person best known

• Don’t see themselves as defiant

  • View their behavior as a response to unreasonable demands/circumstances

• Exhibit

  • Low Self-esteem

  • Mood lability

  • Low frustration threshold

• Can develop into conduct disorder

Impulse Control Disorder: Intermittent Explosive Disorder

• Recurrent violent aggressive behavior with the possibility of hurting people, property, or animals 

• Diagnosed as early as 6 years old

  • Typically between 13-21 y/o

• Males more affected

• Includes verbal or physical aggression

• Characterized by aggressive overreaction to normal events followed by feelings of shame and regret

• If present in adulthood, may affect healthy relationships and/or employment

• Can lead to chronic issues like HTN and DM

Impulse Control Disorders: Conduct Disorder

• Persistent pattern of behavior that violates the rights of others or rules/norms of society

• Categories

  • Aggression to people and animals

  • Destruction of property

  • Deceitfulness or theft

  • Serious violtions of rules

• Childhood-onset develops before the age of 10

  • Males being more prevalent

• Adolescent-onset occurs after the age of 10

  • Ratio of males to females is equal

Conduct Disorder: Contributing Factors 

• Parental rejection and neglect

• Difficult infant temperament

• Inconsistent child-rearing practices with harsh discipline

• Physical or sexual abuse

• Lack of supervision

• Early institutionalization

• Frequent changing of caregivers

• Large family size

• Association with delinquent peer groups

• Parent with a history of psychological illness

• Chaotic home life

• Lack of male role model

Conduct Disorder: Manifestations

• Demonstrates a lack of remorse or care for the feelings of others

• Bullies, threatens, and intimidates others

• Believes that aggression is justified

• Exhibits low self-esteem, irritability, temper outbursts, and reckless behavior

• Can demonstrate suicidal ideation

• Can have concurrent learning disorders or impairments in cognitive

functioning

• Demonstrates physical cruelty to others and/or animals

• Has used a weapon that could cause serious injuries ¡ Destroys the property of others

• Has run away from home

• Often lies, shoplifts, and is truant from school

Disruptive Mood Dysregulation Disorder

• Clients who have this disorder exhibit recurrent temper outbursts that are severe

  • Do not correlate with the situation 

  • temper outbursts are manifested verbally and/or physically and can include aggression 

  • Temper outbursts are not appropriate for the client’s developmental level 

• Temper outbursts are present 3 or more ties per week and observable by others 

  • Guardians

  • Peers

  • Teachers

• Occurs in at least 2 settings

  • Home

  • School

• Mood between the temper outbursts is angry and irritable 

• Onset is between 6-18 y/o

• Manifestations are not due to another mental health disorder 

Oppositional Defiant Disorder: Medications

• Medications not generally prescribed 

• Alpha 2 adrenergic agonist

  • Guanfacine 

  • Clonidine

Intermittent Explosive Disorder: Medications

• SSRI

  • Fluoxetine 

• Mood Stabilizer 

  • Lithium

• Antipsychotics

  • Clozapine

  • Haloperidol

• Beta Blockers 

Conduct Disorder: Medications

• 2nd/3rd Generation Antipsychotics

  • Risperidone

  • Olanzapine

  • Quetiapine

  • Aripiprazole 

• TCAs

• Benzodiazepines

• Mood Stabilizers

• Alpha 2-Adrenergic Agonist

  • Guanfacine

  • Clonidine

Disruptive Mood Dysregulation Disorder

• Antidepressant Therapy 

Attention Deficit Hyperactivity Disorder (ADHD)

• Types of ADHD

  • ADHD predominantly inattentive

  • ADHD predominantly hyperactive-impulsive

  • Combined Type

• Involves the inability of a person to control behaviors requiring sustained attention

• Inattentive or impulsive behavior can put the child at risk for injury

• Behaviors associated with ADHD must be present prior to age 12

  • Must be present in more than one setting to be diagnosed

• Behaviors associated with ADHD an receive negative attention from adults and peers

• Characteristics 

  • Inattention

    • Difficulty paying attention 

    • Difficulty Listening 

    • Difficulty focusing

  • Hyperactivity

    • Fidgeting

    • Inability to sit still

    • Running and Climbing Inappropriately

    • Difficulty playing quietly

    • Talking Excessively

  • Impulsivity 

    • Difficulty waiting for turns 

    • Constantly interputing others 

    • Acting without consideration of consequences

Autism Spectrum Disorder

• Complex neurodevelopmental disorder thought to be of genetic origin with a wide spectrum of behaviors affecting an individual’s ability to communicate and interact with others 

• Cognitive and language development are typically delayed

• Characteristics behaviors 

  • Inability to maintain eye contact 

  • Repetitive actions 

  • Strict observance of routines

• Present in early childhood

  • More common in boys than girls

• Physical difficulties experienced 

  • Sensory integration

  • Sleep Disorders 

  • Digestive Disorders

  • Feeding Disorders

  • Epilepsy

  • Allergies

• Wide variety of functioning

  • Can be anywhere from an inability to perform self-care and inability to communicate to near normal functioning

Intellectual Developmental Disorder

• Onset of deficits and impairmenrts during the developmental period of infancy or childhood 

• Intellectual deficits with mental abilities 

  • Reasoning

  • Abstract thinking 

  • Academic Learning 

  • Learning from prior experiences

• Impaired ability to maintain personal independence and social responsibility

  • ADLs

  • Social Participation 

  • Need for ongoing support at school

• Deficits range from mild to severe

Specific Learning Disorder

• Demonstrates persistent difficulty in acquiring scholastic skills 

  • Reading (Dyslexia) 

  • Writing (Dysgraphia) 

  • Mathematics (Dyscalculia) 

• Performance in one or more academic areas is significantly lower than the expected range 

  • Age

  • Level of intelligence

  • Educational Level

• Benefit from an individualized education program

Attention Deficit Hyperactivity Disorder: Medications

• Psychostimulants

  • Elevate norepinephrine and dopamine 

    • Methylphenidate 

    • Amphetamine Mixture 

    • Dextroamphetamine

    • Dexmethylphenidate

    • Lisdexamfetamine dimesylate

• Selective Norepinephrine Reuptake Inhibitor

  • Elevate norepinephrine (Non-Narcotic)

    • Atomoxetine

• Atypical Antidepressant

  • Elevated dopamine and norepinephrine, but non-narcotic

    • Bupropion 

  • Alpha 2-Adrenergic Agonists 

    • Guanafacine 

    • Clonidine 

  • TCAs

Autism Spectrum Disorder: Medications

• SSRIs

• Antipsychotics

  • Risperidone

  • Olanzapine

  • Quetiapine

  • Aripiprazole 

• TCAs

Psychostimulants: Complications

• CNS Stimulants

  • Manifestations

    • Insomnia

    • Restlessness

  • Nursing Actions

    • Decrease dosage as prescribed

    • Administer the last dose before 1600

    • Decrease caffeine

• Weight loss related to reduced appetite

  • Manifestations

    • Growth Suppression

  • Nursing Actions

    • Monitor height and weight and compare to baseline

    • Consult with the provider to give "holdiay” from medication

    • Administer during or after medication

• Toxiity 

  • Manfestations 

    • Dizziness 

    • Palpitations 

    • HTN

    • Hallucinations 

    • Seizures 

  • Nursing actions 

    • Treat hallucinations with chlorpromazine 

    • Treat seizures with diazepam 

    • Administer Fluids 

Psychostimulants: Complications (Contd)

• Withdrawal Reaction 

  • Manifestations 

    • Headache 

    • N/V

    • Muscle Weakness

    • Depression

  • Nursing Actions

    • Avoid abrupt cessation

• Hypersensitivity skin reaction to transdermal methylphenidate

  • Manifestations

    • Hives 

    • Papules

  • Nursing Actions

    • Remove Patch

    • Notify Provider

• Cardiovascular Effects 

  • Manifestations 

    • Dysrhythmias

    • Chest Pain

    • HTN

    • Increased risk of sudden death in patients with cardiac abnormalities

  • Nursing Actions

    • Monitor V/S and ECG

• Psychosis/Paranoia

  • D/C Medications

  • Call Provider

Psychostimulant: Precautions

• Contraindicated in clients with a Hx

  • Substance Use disorder

  • Cardiovascular Disorder

  • Severe Anxiety 

  • Psychosis 

• Pregnancy Risk Catagory C

• Discontinue MAOIs

  • Wait at least 14 days prior to administering 

• Avoid Caffeine 

• Caution with concurrent use 

  • Phenytoin 

  • Warfarin

  • Phenobarbital 

    • Watch for CNS depression and bleeding

• Avoid OTC and decongestant medications

Psychostimulants: Nursing Administration

• Advise clients to swallow sustained-releasaed whole and not to chew/crush them 

• Administer on a consistent schedule 

• Administer 30-45 min AC with last dose given bby 1600

  • Oral suspension regardless of meals 

  • Shake container 10 seconds before measuring 

• Apply patch on hip

  • Alternate daily 

  • Leave it in place no longer than 9 hours 

  • Flush down toilet when finished 

• Full response can take up to 6 weeks 

• Avoid ETOH

• Handwritten prescriptions are required for medication refills 

• High potential for substance abuse 

  • Especially in adolescence