Chapter 44: Psychosocial Issues of Infants, Children, and Adolescents

Unit 3: Other Specific Needs

Page 1

SECTION 1 | Other Specific Needs​​​​​​​​​​​​​​

Chapter 44: Psychosocial Issues of Infants, Children, and Adolescents

Nurses care for pediatric clients who have psychosocial issues, as well as physical illness. Psychosocial issues (depression) can occur as a result of a physical illness, be independent from physical illness, or be the cause for somatic manifestations (pain due to maltreatment). It is important that the nurse be familiar with various psychosocial issues to ensure the child receives appropriate screenings, referrals and treatment.

Depression

• Difficult to detect and often overlooked in school-aged children because children have limitations in expressing their feelings.

• Findings must be present for 1 year to diagnose major depressive disorder in children and adolescents.

Assessment

Risk Factors

• Family history

• Traumatic event

Expected Findings

• Sad facial expressions

• Tendency to remain alone

• Withdrawn from family, friends, and activities

• Fatigue

• Tearful/crying

• Ill feeling

• Feelings of worthlessness

• Weight loss or gain

• Alterations in sleep

• Lack of interest in school, drop in performance in school

• Statements regarding low self-esteem

• Hopelessness

• Suicidal ideation

• Constipation

A nurse is caring for a child who has a depressive disorder. List 3 clinical manifestations the nurse should expect.

Submit your response to compare it to an expert response.

Patient-Centered Care

Nursing Care

• Plan care that is individualized.

• Obtain health history and growth and development information.

• Assess for substance use.

• Assess for actual or potential risk to self (including a suicide plan, lethality of the plan, and the means to carry out the plan).

• Assist with coping strategies.

• Encourage peer group discussions, mentoring, and counseling.

• Interview the child.

Medications

Tricyclic antidepressants or selective serotonin reuptake inhibitors (SSRIs)

Trazodone, sertraline, paroxetine, bupropion, venlafaxine

Nursing Actions

• Monitor for adverse effects.

• Monitor for suicidal ideation.

Client Education

• Observe for adverse effects.

• Therapeutic effectiveness can take up to 2 weeks.

• Do not abruptly discontinue the medication.

Complications

Suicide

Expected Findings

• Monitor carefully for verbal and nonverbal clues. It is essential to ask the client if they are thinking of suicide. This will not give the client the idea.

• Suicidal comments usually are made to someone that the client perceives as supportive.

• Comments or signals can be overt (direct) or covert (indirect).

  • Overt comment: “There is just no reason for me to go on living.”

  • Covert comment: “Everything is looking pretty grim for me.”

• Determine the client’s suicide plan.

  • Does the client have a plan?

  • How lethal is the plan?

  • Can the client describe the plan exactly?

  • Does the client have access to the intended method?

  • Has the client’s mood changed? A sudden change in mood from sad and depressed to happy and peaceful can indicate a client’s intention to commit suicide.

Physical Findings: Lacerations, scratches, and scars that could indicate previous attempts at self-harm

Posttraumatic stress disorder

Develops following a traumatic or catastrophic event

Assessment

Risk Factors

• Potential genetic predisposition

• Traumatic incident

• Repeated trauma

•  Mental health disorder

• Natural disaster

• Sexual assault

• Witness to homicide, suicide or another violent act

Expected Findings

Initial Response

• Lasts a few minutes to 2 hr

• Increased stress hormones (fight or flight)

• Psychosis

Second Phase

• Lasts approximately 2 weeks

• Period of calm (feeling of numbness, denial)

• Defense mechanisms decrease

Third Phase (coping)

• Extends 2 to 3 months

• Client gets worse instead of better.

• Depression, phobias, anxiety, conversion reactions, repetitive movements, flashbacks, or obsessions

Patient-Centered Care

Nursing Care

• Refer to psychotherapy services.

• Monitor for behavior changes/problems.

• Assist the client and family with coping strategies.

• Allow the client and family to express their feelings.

• Prevent or reduce long-term effects.

Medications

Selective norepinephrine reuptake inhibitors may be used on an individual basis.

A nurse is discussing with a guardian about posttraumatic stress disorder (PTSD). Which of the following information should the nurse include?

Select all that apply.

Attention-Deficit/Hyperactivity Disorder

• Inattentiveness, hyperactivity, and impulsiveness usually revealed prior to age 7.

• Common in childhood and can persist into adulthood.

• A child must meet diagnostic criteria for diagnosis of attention-deficit hyperactivity disorder (ADHD).

  • Manifestations are present between the ages of 4 and 18 years.

  • Manifestations are present in more than one setting.

  • Evidence of social or academic impairment.

  • Six or more findings from a category are present (inattention or hyperactivity-impulsivity).

Assessment

Risk Factors

• Can be a familial tendency

• Exposure to toxins or medicines

• Chronic otitis media, meningitis, or head trauma

Expected Findings

Inattention

• Failing to pay close attention to detail or making careless mistakes

• Blocking incoming stimuli

• Difficulty sustaining attention

• Does not seem to listen

• Failing to follow through on instructions

• Difficulty organizing activities

• Avoiding or disliking activities that require mental effort for a period of time (reading)

• Losing things

• Easily distracted

• Forgetfulness

Hyperactivity

• Fidgeting

• Failing to remain seated

• Inappropriate running

• Difficulty engaging in quiet play

• Seeming to be busy all the time

• Talking excessively

Impulsivity

• Blurting out responses before questions are asked

• Difficulty waiting turns

• Interrupting often

• Striking out, biting, shouting

A nurse is discussing with the guardian of a child about risk factors for attention-deficit/hyperactivity disorder (ADHD). Which of the following risk factors should the nurse include?

Patient-Centered Care

Nursing Care

• Obtain medical, developmental, or behavioral history.

• Use behavioral checklists with adaptive scales.

• Use a calm, firm, respectful approach with the child.

• Use modeling to demonstrate acceptable behavior.

• Obtain the child’s attention before giving directions. Provide short and clear explanations.

• Set clear limits on unacceptable behaviors and be consistent.

• Plan physical activities through which the child can use energy and obtain success.

• Focus on the child’s and family’s strengths, not just the problems.

• Support the parents’ efforts to remain hopeful.

• Provide a safe environment for the child and others.

• Provide the child with specific positive feedback when expectations are met.

• Identify issues that result in power struggles.

• Assist the child in developing effective coping mechanisms.

• Encourage the child to participate in a form of group, individual, or family therapy.

• Assist the family with behavioral strategies.

  • Positive reinforcement

  • Rewards for good behavior

  • Age-appropriate consequences 

• Assist the family with modification of the environment to help the child become successful.

  • Structured environment

  • Charts to assist with organization

  • Decreasing stimuli in the environment

  • Consistent study area

  • Modeling positive behaviors

  • Using steps when assigning chores

  • Using pastel colors

• Assist with appropriate classroom placement in the school.

  • Collaborate with the school nurse.

  • Allow more time for testing.

  • Place in classroom that has order and consistent rules.

  • Offer verbal instruction combined with visual cues.

  • Plan academic subjects in the morning.

  • Include regular breaks.

  • Provide for small classroom settings or work groups.

A nurse is discussing with the teacher of a child who has attention-deficit/hyperactivity disorder (ADHD). Which of the following classroom strategies should the nurse include?

Select all that apply.

Medications

Methylphenidate, dextroamphetamine

Psychostimulant, which increases dopamine and norepinephrine levels

Nursing Actions

• Gradually increase dose to reach therapeutic results.

• Give last dose of the day prior to 1800 to prevent insomnia.

• Monitor for adverse effects, including insomnia, anorexia, nervousness, hyper/hypotension, tachycardia, and anemia.

• Avoid caffeine.

• Store properly. The medication has potential for misuse by others.

• Tricyclic antidepressants are used as adjunct therapy to treat insomnia.

Atomoxetine

Selective norepinephrine reuptake inhibitor

Nursing Actions

• Gradual increase in dose to reach therapeutic results.

• Monitor for adverse effects (suicidal ideation).

Autism Spectrum Disorder

Complex neurodevelopmental disorders with spectrum of behaviors affecting an individual’s ability to communicate and interact with others in a social setting.

Assessment

Risk Factors

• Possible genetic component

• Exact cause unknown

Expected Findings

• Delays in at least one of the following

  • Social interaction

  • Social communication

  • Imaginative play prior to age 3 years 

• Distress when routines are changed

• Unusual attachments to objects

• Inability to start or continue conversation

• Using gestures instead of words

• Delayed or absent language development

• Grunting or humming

• Inability to adjust gaze to look at something else

• Not referring to self correctly

• Withdrawn, labile mood

• Lack of empathy

• Decreased pain sensation

• Spending time alone rather than playing with others

• Avoiding eye contact

• Withdrawal from physical contact

• Heightened or lowered senses

• Not imitating actions of others

• Minimal pretend play

• Exhibiting repetitive movements

• Typical IQ less than 70

Patient-Centered Care

Nursing Care

• Assist with screening assessment tools, such as the Checklist for Autism in Toddlers (CHAT) or Pervasive Developmental Disorders Screening Test.

• Refer to early intervention, physical therapy, occupational therapy, and speech and language therapy.

• Assist with behavior modification program.

  • Promote positive reinforcement.

  • Increase social awareness.

  • Teach verbal communication.

  • Decrease unacceptable behaviors.

  • Set realistic goals.

  • Structure opportunities for small successes.

  • Set clear rules.

• Decrease environmental stimulation.

• Assist with nutritional needs.

• Introduce the child to new situations slowly.

• Monitor for behavior changes.

• Encourage age-appropriate play.

• Communicate at an age-appropriate level (brief and concrete).

• Provide support to the family.

• Encourage support groups.

Medications

Used on an individual basis to control aggression, anxiety, hyperactivity, irritability, mood swings, compulsions, and attention problems.

• SSRIs can decrease aggression.

• Antipsychotics and melatonin can help with insomnia.

 Intellectual Disability

• Also known as cognitive impairment

• Previously called mental retardation

Assessment

Risk Factors

• Familial, social, environmental, organic or other unknown causes

• Infections (congenital rubella, syphilis)

• Fetal alcohol syndrome

• Chronic lead ingestion

• Trauma to the brain

• Gestational disorders

• Pre-existing disease (Down syndrome, mental health disorders, microcephaly, hydrocephaly, metabolic disorders, cerebral palsy)

Expected Findings

• Can range from mild to severe

• Delayed developmental milestones

• Inability to reason or problem solve

Early Manifestations

• Abnormal eye contact

• Feeding difficulties

• Language difficulties 

• Fine and gross motor delays

• Decrease alertness

• Unresponsive to contact

• Reduced response to name

• Decreased response to social cues

• Echolalia

• Clients “lose” milestones between 15 to 30 months (Autism regression)

Patient-Centered Care

Nursing Care

• DSM-5-TR used to diagnose

• Determine the child’s deficiency.

• Care and teaching should be individualized to the client’s needs.

• Make appropriate referrals (early intervention program, social work, speech therapy, physical therapy, and occupational therapy).

• Add visual cues with verbal instruction.

• Give one-step instructions.

• Assist the family in teaching the child self-cares.

• Assist the family in promoting development.

• Encourage play.

• Assist the family with selecting activities and toys.

• Assist with communication skills.

• Encourage social activities.

Failure to Thrive

Inadequate growth resulting from the inability to obtain or use calories required for growth. It is usually described in an infant or child who falls below the fifth percentile for weight (and possibly for height) or who has persistent weight loss. Failure to thrive (FTT) can be classified according to the cause:

• Inadequate caloric intake (incorrect formula prep, breastfeeding difficulties, or excessive juice consumption)

• Inadequate absorption (cystic fibrosis, celiac or Crohn’s disease)

• Increased metabolism (hyperthyroidism)

• Defective utilization (Down syndrome)

Assessment

Risk Factors

• Preterm birth with low birth weight or intrauterine growth restriction

• Parental neglect, lack of parental knowledge, or disturbed maternal-child attachment

• Poverty

• Health or childrearing beliefs

• Family stress

• Feeding resistance

Organic Causes: Cerebral palsy, chronic kidney failure, congenital heart disease, hyperthyroidism, cystic fibrosis, celiac disease, hepatic disease, Down syndrome, prematurity, and gastroesophageal reflux

Expected Findings

• Less than the fifth percentile on the growth chart for weight

• Malnourished appearance

• Poor muscle tone, lack of subcutaneous fat

• No fear of strangers

• Minimal smiling

• Decreased activity level

• Withdrawal behavior

• Developmental delays

• Feeding disorder

• Wide-eyed gaze, absent eye contact

• Stiff or flaccid body

A nurse is teaching with a group of guardians about characteristics of infants who have failure to thrive. Which of the following characteristics should the nurse include? ​​​​​​​

Patient-Centered Care

Nursing Care

• Child may need to be removed from guardians’ care in order to evaluate carefully and receive therapy.

• Obtain a nutritional history.

• Observe parent-child interactions.

• Obtain accurate baseline height and weight. Observe for low weight, malnourished appearance, and manifestations of dehydration.

• Weigh the child daily without clothing or a diaper.

• Maintain I&O and calorie counts as prescribed.

• Establish a routine for eating that encourages usual times, duration, and setting.

• Reinforce proper positioning, latching on, and timing for children who are breastfed.

• Provide 24 kcal/oz formula as prescribed.

• Provide high-calorie milk supplements for children.

• Administer multivitamin supplements including zinc and iron.

• Limit juice to 4 oz/day.

• Provide developmental stimulation.

• Nurture the child (rocking and talking to the child).

• Encourage caregivers to do the following.

  • Maintain eye contact and face-to-face posture during feedings.

  • Talk to the infant while feeding.

  • Burp the infant frequently.

  • Keep the environment quiet and avoid distractions.

  • Be persistent, remaining calm during 10 to 15 min of food refusal.

  • Introduce new foods slowly.

  • Never force the infant to eat.

Client Education

• Recognize and respond to the infant’s cues of hunger.

• Mix formula properly according to provided step-by-step written instructions.

Complications

Extreme malnourishment

Nursing actions: Prepare the client and parents for tube feedings or IV therapy.

Maltreatment of Infants and Children

Maltreatment of infants and children is attributed to a variety of predisposing factors, which include parental, child, and environmental characteristics. Child maltreatment can occur across all economic and educational backgrounds and racial/ethnic/religious groups.

Maltreatment of children is made of several specific types of behaviors.

• Physical: causing pain or harm to a child (shaken baby syndrome, fractures, factitious disorder imposed on another)

• Sexual: occurring when sexual contact takes place without consent, whether or not the victim is able to give consent (includes any sexual behavior toward a minor and dating violence among adolescents)

• Emotional: humiliating, threatening, or intimidating a child (includes behavior that minimizes an individual’s feelings of self-worth)

• Neglect: includes failure to provide the following.

  • Physical care: feeding, clothing, shelter, medical or dental care, safety, education

  • Emotional care and/or stimulation to foster normal development: nurturing, affection, attention

Assessment

Risk Factors

Caregiver Characteristics

• Young age

• Having a partner unrelated to the child

• Social isolation

• Low-income situation

• Lack of education

• Low self-esteem

• Lack of parenting knowledge

• Substance use disorder 

• History of having been abused

• Lack of support systems

Characteristics of the Child

• Child 1 year old or younger is at greater risk due to the need for constant attention and increased demands of caregiving.

• Infants and children who are unwanted, hyperactive, or who have physical or mental disabilities are at risk due to their increased demands and need for constant attention.

• Premature infants are at risk due to the possible failure of parent-child bonding at birth.

Environmental Characteristics

• Chronic stress

• Divorce, alcohol or substance use disorder, poverty

• Unemployment, inadequate housing, crowded living conditions

• Substitute caregivers

Expected Findings

Warning Indicators of Maltreatment

• Physical evidence of maltreatment

• Vague explanation of injury

• Other injuries discovered that are not related to the original client concern

• Delay in seeking care

• Statement of possible abuse from a caregiver or client

• Inconsistencies between the caregiver’s report and the child’s injuries

• Inconsistency between nature of injury and developmental level of the child

• Repeated injuries requiring emergency treatment

• Inappropriate responses from the parents or child

Physical neglect

• Failure to thrive, malnutrition

• Lack of hygiene

• Frequent injuries

• Delay in seeking health care

• Dull affect

• School absences

• Self-stimulating behaviors

Physical maltreatment

• Bruises, welts in various stages of healing

• Bruising in a non-mobile client

• Multiple fractures at different stages of healing

• Burns

• Fractures

• Lacerations

• Fear of parents

• Lack of emotional response/reaction

• Superficial relationships

• Withdrawal

• Aggression

Emotional neglect and abuse

• Failure to thrive

• Eating disorder

• Enuresis

• Sleep disturbances

• Self-stimulating behaviors

• Withdrawal

• Lack of social smile (infant)

• Extreme behaviors

• Delayed development

• Attempts suicide 

• Caregiver behaviors: rejecting, isolating, terrorizing, ignoring, verbally assaulting, or over pressuring the child

Sexual abuse defined as the employment, use, persuasion, or inducement of a child to engage in any sexually explicit conduct. Examples include pedophilia, prostitution, incest, molestation, and pornography.

• Bruises, lacerations

• Bleeding of genitalia, anus, or mouth

• Sexually transmitted infection

• Difficulty walking or standing

• UTI

• Regressive behavior

• Withdrawal

• Personality changes

• Bloody, torn, or stained underwear

• Unusual body odor

Abusive head trauma (ART) or shaken baby syndrome: Shaking can cause intracranial hemorrhage. Caregiver’s frustrations with persistent crying can lead to this.

• Can have no external manifestations of injury

• Vomiting, poor feeding, and listlessness

• Respiratory distress

• Bulging fontanels

• Retinal hemorrhages

• Seizures

• Posturing

• Alterations in level of consciousness

• Apnea

• Bradycardia

• Blindness

• Unresponsiveness

• Bruising in an infant before 6 months of age, should be deemed suspicious by the nurse.

Laboratory Tests

CBC, urinalysis, and other tests that assess for sexually transmitted infections or bleeding

Diagnostic Procedures

Depend upon the assessment findings and injuries.

• Radiograph

• Computed tomography or magnetic resonance imaging scan

Patient-Centered Care

Nursing Care

• Identify maltreatment as soon as possible. Conduct detailed history and physical examination.

• The nursing priority is to have the child removed from the abusive situation.

• Mandatory reporting is required of all health care providers, including suspected cases of child maltreatment. There are civil and criminal penalties for not reporting.

• Assess for unusual bruising on the abdomen, back, and buttocks. Document thoroughly with size, shape, and color. Use diagrams to represent location.

• Assess the mechanism of injury, which might not be congruent with the physical appearance of the injury. Many bruises at different stages of healing can indicate ongoing beatings.

• Observe for bruises or welts in the shape of a belt buckle or other objects.

• Observe for burns that appear glove- or stocking-like on hands or feet, which can indicate forced immersion into boiling water. Small, round burns can be caused by lit cigarettes. Document detailed descriptions of all findings.

• Note fractures that have unusual features (forearm spiral fractures) which could be caused by twisting the extremity forcefully. The presence of multiple fractures is suspicious.

• Check the child for head injuries. Assess the child’s level of consciousness, making sure to note equal and reactive pupils. Monitor for nausea/vomiting.

• Clearly and objectively document information obtained in the interview and during the physical assessment.

• Photograph and detail all visible injuries, if possible, including measuring devices to show size of injuries.

• Conduct the interview with the client and guardians individually.

• Be direct, honest, and professional. 

• Use language the child understands.

• Be understanding and attentive.

• Client circumstances are case-sensitive, and referrals are made to always keep the client safe. When applicable, explain the process if a referral is made to child or adult protective services.

• Assess safety and reduce danger for the victim.

• Use open-ended questions that require a descriptive response. These questions are less threatening and elicit more relevant information.

• Provide support for the child and parents.

• Demonstrate behaviors for child-rearing with the parents and child.

• Provide consistent care to the child.

• Avoid asking the child probing questions.

• Promote self-esteem.

• Assist with alleviating feelings of shame and guilt.

• Assist the child with grieving the loss of parents, if indicated.

• Discharge can begin once legal determination of placement has been decided.

Interprofessional Care

Initiate appropriate referrals for social services.

Bullying

Physical, verbal, or emotional abuse that is repetitive by a person to another person with intent to establish power and dominance with intimidation. This could be with or without face-to-face contact.

Settings: school, playground, bus, texting, or online

Assessment

Risk Factors

Perpetrators of Bullying Behavior

• Male sex

• Depression

• Decreased academic performance

• Decreased social involvement with peers

• Exposure to spouse or partner violence

• Conduct problems

• Criminal acts

• Dropping out of school

Recipients of Bullying Behavior

• Low self-esteem

• Loneliness

• Somatic reports

• Anxiety

• Depression

Patient-Centered Care

Client Education

• Observe for manifestations and be inquisitive.

• Obtain support from the family.

• Refer to counseling and bully prevention programs.

• Follow procedures for investigating and reporting.

• Refer for mental health evaluation because bullying can be an early indication of mental health disorders.

Active Learning Scenario

A nurse is teaching a group of caregivers about abusive head trauma (AHT) or shaken baby syndrome. What manifestations should be included in this presentation? Use the ATI Active Learning Template: Basic Concept to complete this item.

Underlying Principles: Include seven manifestations.

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Active Learning Scenario Key

Click to reveal sample responses.

Underlying Principles

• Vomiting, poor feeding, and listlessness

• Respiratory distress 

• Bulging fontanels

• Retinal hemorrhages

• Seizures

• Posturing

• Alterations in level of consciousness

• Apnea

• Bradycardia

NCLEX Connection: Physiological Adaptation, Illness Management