Neurodevelopmental and Disruptive Behavior Disorders Study Guide unit8

Communication Disorders and Early Assessment

  • Communication disorders are classified based on the severity of the deficit, which can range from mild to severe and can hinder a child's development, academic achievement, and Activities of Daily Living (ADLs).
  • Expressive Language Disorder: Characterized by difficulty learning new words and forming complete sentences. Verbal communication is significantly limited.
  • Mixed Receptive-Expressive Language Disorder: Characterized by difficulty both in understanding words (receptive) and in expressing language.
  • Speech Disorders:
    • Phonologic Disorder: Difficulty with the sound system of language.
    • Articulation Problems: Difficulty pronouncing specific sounds correctly.
  • Stuttering: Defined as a disruption in fluency.
  • Treatment: Early intervention yields the best outcomes. The primary therapeutic approach is Speech and Language Therapy.

Elimination Disorders

  • Elimination disorders involve inappropriate voiding of urine or defecation.
  • Clinical and Psychosocial Impact: These disorders often lead to poor self-esteem, embarrassment, social rejection, and feelings of being ridiculed by caregivers.
  • Developmental Considerations:
    • Expectations must be aligned with the child's developmental stage. For example, it is not developmentally appropriate to expect a child at age 2.52.5 to be completely potty trained, though some may exhibit early mastery.
    • Encopresis: The repeated passage of stool into inappropriate places, whether involuntary or intentional. It is diagnosed if the problem persists at or after age 44.
      • If intentional, clinicians should investigate the possibility of Conduct Disorder or Oppositional Defiant Disorder (ODD).
    • Enuresis: The repeated voiding of urine into bed or clothes, whether involuntary or intentional. It is diagnosed at or after age 55.
      • If intentional, it is often linked to disruptive disorders.

Interventions and Parental Teaching for Elimination Disorders

  • Behavioral Interventions:
    • Scheduled Toileting: Generally involves offering the child the opportunity to use the toilet every 1515, 3030, or 45 minutes45\text{ minutes}.
    • Clinical context is vital: if a child is drinking large amounts of fluids (e.g., Pedialyte), they will need more frequent intervals. Conversely, if dehydrated, the frequency will decrease.
    • Bed Alarms: Used as a behavioral trigger for waking during nocturnal enuresis.
  • Pharmacological Treatment: Medications like Tofranil may be utilized.
  • Nursing Education for Caregivers:
    • Do Not Shame: Caregivers must avoid shaming the child.
    • Avoid Attention to Negative Behavior: Giving attention to the inappropriate behavior may inadvertently reinforce it, as children may continue the behavior to receive that attention.
    • Maintain Neutral Tone: Getting upset or yelling typically causes the child to react negatively or become more upset.
    • Avoid Belittling: Caregivers should never belittle the child's struggle.
    • Positive Reinforcement: Attention and praise should be directed toward good behavior and successful toileting.

Questions & Discussion: Enuresis and Trauma

  • Student Question: If a child presents with enuresis, should the nurse suspect child sexual assault immediately?
  • Response: Enuresis can be a symptom of child sexual assault, but the nurse must put all clues into context. Usually, abuse is accompanied by other indicators such as:
    • Behavioral issues in school.
    • Acting out vulgar scenarios or using sexualized language unexpected for their age.
    • Playing out specific scenarios during therapeutic interactions.
    • The nurse must rule out other causes while remaining vigilant for these associated signs.

Attention-Deficit/Hyperactivity Disorder (ADHD)

  • Clinical Presentation:
    • Appears easily distracted, overactive, and impulsive.
    • Behaviors include being fidgety, blunting out answers, and forgetfulness.
    • Crucially, they are distracted by unimportant stimuli (e.g., someone moving a chair or walking by).
    • Described as being "driven by a motor," making it impossible for them to sit still.
    • Likely to make careless mistakes because they do not read full instructions or sentences due to overactivity.
  • Diagnosis and Overdiagnosis:
    • ADHD must be diagnosed by a specialist, such as a pediatric neurologist, pediatric psychologist, or pediatric psychiatrist, rather than a general pediatric provider.
    • Risk of overdiagnosis exists because highly active or difficult-to-handle children are sometimes mislabeled. Testing boundaries and having high energy is a normal part of development.
  • Functional Impact:
    • Academic: Incomplete work and forgetfulness regarding assignments often lead to academic failure.
    • Social: Peers may avoid interaction with the child.
    • Adulthood: Constant negative feedback and disciplinary actions create a negative environment.
    • Adolescence: Increased risk for substance abuse, legal issues, and promiscuity.
  • Etiology: While definitive causes are unknown, theories include genetics, environmental toxins, and prenatal exposures.
    • Some recent studies suggest a link between Tylenol use during pregnancy and ADHD risk.
    • Brain abnormalities often include decreased activity in the frontal lobe.

ADHD Treatment and Nursing Care

  • Pharmacological Treatment (Stimulants):
    • Examples: Adderall and Ritalin.
    • Nursing Teaching:
      • Administer in the morning to prevent insomnia.
      • Appetite Management: These meds decrease appetite. Patients should eat a large breakfast before the medication takes effect. High-calorie night snacks can also help prevent malnutrition.
    • Monitoring: Weight must be monitored weekly initially. If weight loss becomes significant, a "drug holiday" (stopping the medication for a period) may be recommended.
  • Non-Stimulant Medication: Strattera is approved and works similarly to an antidepressant.
  • Dietary and Natural Approaches:
    • Avoid sugar and high carbohydrates.
    • Avoid dyes, specifically Red Dye Number 40, which is frequently linked to behavioral issues.
    • High-protein diet and avoidance of common allergens.
    • Exercise: Essential for providing an outlet for excess energy and improving behavior.
  • Non-Pharmacologic / Behavioral Treatment:
    • Consistency and Limit Setting: This involves three steps: 1. State the unacceptable behavior. 2. State the consequences. 3. State the expected behavior.
    • Point Systems: Controversial because they can bring public attention to bad behavior. Many schools are phasing out public "color-changing" charts in favor of private folders to avoid humiliation.
  • Therapeutic Play:
    • Helps caregivers understand the child's thoughts/feelings and promotes communication.
    • Dramatic Play: Acting out anxiety-provoking situations.
    • Energy-Releasing Play: Pounding wooden pegs with a hammer (similar to Whack-a-mole).
    • Creative Play: Drawing or painting as a means of expression.
  • Nursing Management Strategy:
    • Safety First: Stop risky behaviors before the child is injured. Nurses may need to be very stern to capture the child's attention (e.g., using a loud, urgent tone like calling "fire").
    • Instructions: Must be clear, concise, and broken down into small, manageable steps rather than a complex list.
    • Routine: A highly structured routine is vital. Changes in routine often lead to meltdowns or behavioral regression.
    • Positive Reinforcement: Focus on the child's strengths, not just the problems.

Disruptive Behavior Disorders

  • General Characteristics: These behaviors involve anger, hostility, and aggression toward people or property.
  • The Continuum of Aggression: Behavior can progress through levels: ODD →\rightarrow Conduct Disorder →\rightarrow Antisocial Personality Disorder (APD).
    • Note: Antisocial Personality Disorder cannot be diagnosed until age 1818 because personality is not considered fully developed until adulthood.
  • Related Disorders:
    • Kleptomania: Impulsive stealing.
    • Pyromania: Impulsive fire setting.

Oppositional Defiant Disorder (ODD)

  • Clinical Features: A pattern of uncooperative, defiant, disobedient, and hostile behavior toward authority figures, without major violations of laws or the rights of others.
  • Developmental Context: Defiance is normal in toddlers (ages 22 to 33) as they learn autonomy, and in adolescents. ODD is diagnosed only when behavior is more frequent and intense than expected for the age.
  • Progression: Usually begins at home (the comfort zone) before progressing to school and social settings.
  • Prognosis: Earlier onset and the presence of comorbid mental health disorders correlate with a poorer prognosis.
  • Interventions:
    • Parent Management Training: Based on the theory that behavior is learned and can therefore be unlearned/changed.
    • Prioritize addressing the most disruptive behaviors first.
    • Consistency is essential; inconsistency between divorced parents can worsen the disorder.
    • Ignore minor behaviors to avoid reinforcing them with attention.

Intermittent Explosive Disorder (IED)

  • Clinical Features: Characterized by repeated episodes of impulsive, violent outbursts or angry verbal attacks triggered by something minor/minute.
  • Key Characteristics:
    • The reaction is irrational and disproportionate to the trigger.
    • Episodes are short-lived, typically lasting less than 30 minutes30\text{ minutes}.
    • Appear suddenly and unpredictably.
    • Episodes are followed by feelings of embarrassment, remorse, or guilt.
  • Risks: During an episode, the individual may hurt themselves, others, or damage property due to a total loss of control.
  • Demographics: More common in males, adolescents, and young adults, especially those with a history of trauma or abuse.
  • Associated Medical Conditions: Hypertension, Coronary Artery Disease (CAD), stroke, diabetes, and chronic pain.
  • Treatment: SSRIs, mood stabilizers, anticonvulsants, Cognitive Behavioral Therapy (CBT), and anger management. Avoidance of alcohol and drugs is critical.

Conduct Disorder

  • Clinical Features: Persistent behavior that violates the rules, laws, and basic rights of others or animals.
    • Includes destruction of property, deceit, theft, and serious rule violations.
    • Characteristic traits: Callousness, lack of empathy, lack of remorse, and being unemotional.
    • Adolescents may exhibit risk-seeking behaviors, promiscuity, and substance use.
  • Prognosis: Earlier onset leads to worse outcomes and puts the individual at high risk for adult Antisocial Personality Disorder.
  • Contributing Factors: Poor home environment, learned aggression for self-protection, and learning disabilities.
  • Nursing Interventions:
    • Safety: Ensure the safety of the patient and others.
    • Limit Setting: Clearly state unacceptable behaviors, consequences, and expected behaviors.
    • Behavioral Contracts: Use contracts that outline clear expectations and rewards to reduce manipulation.
    • Timeouts: In a mental health context, this means moving the child to a less stimulating place to regain control, not just sitting in a corner.
    • Non-Judgmental Approach: It is possible to like the child while disliking the behavior. Avoid being judgmental.
    • Parental Teaching: Teach consistent discipline. Caregivers should not "rescue" the child from the legal or social consequences of their actions (e.g., let them sit in jail or deal with a speeding ticket).

Behavioral Concepts

  • Externalizing Behaviors: Acting out through aggression and disruption.
  • Internalizing Behaviors: Directing feelings inward, resulting in social withdrawal and somatic complaints (physical symptoms resulting from unexpressed emotions).