Cognitive Disorder S25-combined

Cognitive Disorders

• Cognitive disorders involve disruption or impairment in higher-level brain functions, affecting the brain's ability to process, retain, and use information. Cognitive abilities include reasoning, judgment, perception, attention, comprehension, and memory.

• Neurocognitive disorders (NCDs) include delirium, major NCD, mild NCD, and subtypes. The terms dementia and neurocognitive disorders are often used interchangeably.

Learning Objectives

• Describe the characteristics of and risk factors for cognitive disorders.
• Distinguish between delirium and dementia in terms of symptoms, course, treatment, and prognosis.
• Plan care for clients with cognitive disorders.
• Identify methods for meeting the needs of people who provide care to clients with dementia.
• Provide education to clients, families, caregivers, and community members to increase knowledge and understanding of cognitive disorders.
• Evaluate your feelings, beliefs, and attitudes regarding clients with cognitive disorders.

Delirium

• Delirium is a syndrome involving a disturbance of consciousness with a change in cognition that usually develops over a short period.
• The cause of delirium almost always results from an identifiable physiological, metabolic, or cerebral disturbance or disease or from drug intoxication or withdrawal.

Etiology

• Physiological or Metabolic:
  • Hypoxemia
  • Electrolyte disturbances
  • Renal or hepatic failure
  • Hypoglycemia or hyperglycemia
  • Dehydration
  • Sleep deprivation
  • Thyroid or glucocorticoid disturbances
  • Thiamine or vitamin B12 deficiency
  • Vitamin C, niacin, or protein deficiency
  • Cardiovascular shock
  • Brain tumor
  • Head injury
  • Exposure to gasoline, paint solvents, insecticides, and related substances
• Infection
  • Systemic: Sepsis, urinary tract infection, pneumonia
  • Cerebral: Meningitis, encephalitis, HIV, syphilis
• Drug Related
  • Intoxication: Anticholinergics, lithium, alcohol, sedatives, and hypnotics
  • Withdrawal: Alcohol, sedatives, and hypnotics
  • Reactions to anesthesia, prescription medication, or illicit (street) drugs

Treatment and Prognosis

• Delirium is a transient condition, clearing with the treatment of the underlying cause.
• Psychopharmacology: sedation, antipsychotic medication
• Other medical treatments address the underlying cause.

Delirium and Nursing Process Application

• Assessment
  • History: Medical history, medications
  • General appearance and motor behavior: Disturbed psychomotor behavior, possible speech problems
  • Mood and affect: Rapid, unpredictable shifts
  • Thought process and content: Disorganized, fragmented thoughts
  • Sensorium and intellectual processes: Decreased awareness of environment
  • Judgment and insight: Impaired
  • Self-concept: Fear, feel threatened
  • Roles and relationships: Inability to fulfill roles
  • Physiological and self-care: Sleep problems, ignore or fail to perceive internal body cues
• Data analysis and priorities
  • Risk for injury
  • Acute confusion
  • Hallucinations and other sensory disturbances
  • Disorganized/disrupted thought processes
  • Inadequate sleep and rest
  • Dehydration
  • Inadequate food and fluid intake
• Outcome identification
  • Freedom from injury
  • Increased orientation, reality contact
  • Balance of activity and rest
  • Adequate nutrition and fluid balance
  • Return to optimal level of functioning
• Actions
  • Promoting client safety
  • Managing client’s confusion: orienting cues; speaking in low, clear voice; use of touch; avoiding sensory overload
  • Promoting sleep, proper nutrition
• Evaluation

Delirium and Community-Based Care

• Referrals for continued cognitive problems
• Home health care/visiting nurses
• Rehabilitation program
• Adult day care
• Residential care
• Support groups

Dementia

• Dementia is a progressive cognitive impairment characterized by multiple cognitive deficits.
  • Initially memory, later the following may be seen:
    • Aphasia
    • Apraxia
    • Agnosia
    • Disturbance in executive functioning
• Onset, clinical course:
  • Stages: Mild, Moderate, Severe
• Etiology: variable causes; decreased metabolic activity found postmortem

Progression of Dementia

• Mild
  • Forgetfulness is the hallmark of beginning, mild dementia.
  • It exceeds the normal, occasional forgetfulness
  • Difficulty finding words
  • Frequently loses objects
  • Experience anxiety about these losses.
  • Occupational and social settings are less enjoyable causing avoidance
  • Most people remain in the community during this stage.
• Moderate
  • Confusion
  • Progressive memory loss
  • No longer perform complex tasks but remains oriented to person and place
  • Can recognize familiar people.
  • Toward the end of this stage, the person loses the ability to live independently and requires assistance because of disorientation to time and loss of information (Address and phone number)
  • The person may remain in the community if adequate caregiver support is available, but some people move to supervised living situations.
• Severe
  • Personality and emotional changes occur
  • Delusional
  • Wander
  • Forget the names of their spouse and children
  • Require assistance with ADLs
  • Most people live in nursing facilities when they reach this stage, unless extraordinary community support is available

Types of Dementia

• Alzheimer’s disease
• Lewy body dementia
• Vascular dementia
• Frontotemporal lobar degeneration (Pick’s disease)
• Prion diseases (Creutzfeldt–Jakob disease)
• Dementia related to human immunodeficiency virus (HIV) infection
• Parkinson’s disease
• Huntington’s disease
• Dementia due to traumatic brain injury

Treatment and Prognosis

• Importance of identifying underlying cause
• Progressive types—progressive deterioration until death
• Medications for degenerative dementias: cholinesterase inhibitors
  • Donepezil (Aricept): 5-10 mg orally per day. Nursing Considerations: Monitor for nausea, diarrhea, and insomnia. Test stools periodically for gastrointestinal bleeding.
  • Rivastigmine (Exelon): 3-12 mg orally per day divided into two doses. Nursing Considerations: Monitor for nausea, vomiting, abdominal pain, and loss of appetite.
  • Galantamine (Reminyl, Razadyne, Nivalin): 16-32 mg orally per day divided into two doses. Nursing Considerations: Monitor for nausea, vomiting, loss of appetite, dizziness, and syncope.
  • Memantine (Namenda): 10-20 mg/day divided into two doses. Nursing Considerations: Monitor for hypertension, pain, headache, vomiting, constipation, and fatigue.
  • Namzaric (Memantine/Donepezil): 28 mg/10 mg orally per day. Nursing Considerations: Monitor for nausea, diarrhea, abdominal pain, loss of appetite, headache, and dizziness.
  • Aducanumab (Aduhelm): Dose based on weight; IV infusion over 1 hour every 4 weeks. Nursing Considerations: Monitor for edema, headache, and microhemorrhage.
• Symptomatic treatment for behaviors
  • Antidepressants
  • Antipsychotics

Dementia and Nursing Process Application

• Assessment
  • Mental status examination
  • History: Client may be unable to provide accurate history.
  • General appearance and motor behavior: Aphasia; apraxia; uninhibited behavior
  • Mood and affect: Increasingly labile mood; emotional outbursts
  • Thought process and content: Impaired abstract thinking; delusions of persecution
  • Sensorium and intellectual processes: Loss of intellectual function; memory deficits; confabulation
  • Judgment and insight: Poor judgment; unrealistically appraise abilities
  • Self-concept: Sadness; loss of self-awareness
  • Roles and relationships: Profoundly affected
  • Physiological and self-care: Disturbed sleep; incontinence; hygiene deficits
• Data analysis and priorities
  • Risk for injury
  • Disturbed sleep
  • Dehydration
  • Inadequate food and fluid intake
  • Chronic confusion
• Outcome identification
  • Freedom from injury
  • Involvement in surroundings
  • Interaction with others in environment
• Actions
  • Promoting the client’s safety
  • Promoting adequate sleep and proper:
    • Nutrition
    • Hygiene
    • Activity
  • Structuring the environment and routine
  • Providing emotional support
  • Promoting interaction and involvement
• Evaluation

Dementia and Community-Based Care

• Programs and services for clients with dementia and their families
  • Home care
  • Adult day care
  • Respite care
  • Residential facilities
  • Skilled nursing home placement
  • Referrals for programs and services
  • At least half of all nursing home residents have Alzheimer’s disease or another dementia-causing illness

Mental Health Promotion

• Research to identify risk factors for dementia
  • Elevated levels of plasma homocysteine
• Measures to decrease risk for Alzheimer’s disease
  • Regular participation in brain-stimulating activities
  • Leisure-time physical activity during midlife
  • Large social network

Role of the Caregiver

• Majority: women (adult daughters or wives)
• Needs of caregivers:
  • Education about dementia, required client care
  • Assistance in dealing with own feelings of loss
  • Respite to care for own needs, role strain
  • Support groups
  • Assistance from agencies
  • Support to maintain personal life

Self-Awareness Issues

• Teaching clients with dementia can be frustrating.
• The nurse may feel frustration or hopelessness.
• Discuss frustrations with others.
• It may be difficult to deal with feelings about people who will never “get better and go home.”
• Remember the importance of providing dignity for the client and family.

Neurodevelopmental Disorders

Learning Objectives

• Describe the impact neurodevelopmental disorders have on a client’s overall health.
• Explore epidemiological and etiological risk factors that contribute to clients experiencing neurodevelopmental disorders.
• Differentiate the clinical presentation of clients experiencing neurodevelopmental disorders.
• Explore the role of the nurse caring for clients experiencing neurodevelopmental disorders.
• Apply the nursing process through use of the clinical judgment functions while providing care to clients experiencing neurodevelopmental disorders.

Psychiatric Disorders in Children

• Not diagnosed as easily in children as in adults
• Lack of abstract cognitive abilities and verbal skills
• Constantly changing and developing
• Similar problems as in adults such as mood, anxiety, and eating disorders
• Neurodevelopmental disorders Usually diagnosed in infancy or childhood; sometimes in adolescence

Overview of NDD

• Neuro-developmental disorders includes:
  • Motor and Tic Disorders
  • Intellectual Disability (ID)
  • Attention Deficit Hyperactivity Disorder (ADHD)
  • Language Communication Disorders
  • Autism Spectrum Disorders (ASD)

Autism Spectrum Disorder (ASD)

• Deficiencies in social communication and social interaction across multiple contexts, characterized by:
  • Social-emotional reciprocity, ranging from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions
  • Nonverbal communicative behaviors used for social interaction, ranging from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication
  • Developing, maintaining, and understanding relationships, ranging from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers
  • Engaging in restricted, repetitive patterns of behavior, interests, or activities
  • Inabilities are not better explained by intellectual disability

Characteristics

• Pervasive, usually severe impairment of reciprocal social interaction skills, communication deviance, restricted stereotypical behavioral patterns
• Previous pervasive developmental disorders (PDDs) now viewed on continuum called autism spectrum
• Range from mild to very severe behaviors and limitations
• Present by early childhood (18 months to 3 years)
• More prevalent in boys
• Little eye contact
• Few facial expressions
• Limited gestures to communicate
• Limited capacity to relate to peers or parents
• Lack of spontaneous enjoyment
• Express no moods or emotional affect
• Inability to engage in play or make-believe with toys
• Little intelligible speech
• Stereotyped motor behaviors (see Box 22.1)
• Genetic link; Claims related to immunizations not supported by evidence
• Tendency to improve with acquisition and use of language
• Traits persist into adulthood.

Treatment Goals

• Reduce behavioral symptoms, promote learning and development
• Special education, language therapy; cognitive behavioral therapy; medications for specific target symptoms

Etiology

• Genetics
  • Linked to specific inherited genes
  • De novo mutations (not inherited)
• Environment
  • Advanced parental age

Autism Levels

• Level 1:
  • Needs some support
  • Sometimes appears just awkward or anti-social
  • Change is difficult, thrives with a good routine
  • Fidgets and can be seen as “quirky” or “annoying” to others
  • Sometimes perceived as “lazy” or “insecure”
• Level 2
  • Needs more support
  • Most people can tell there is a disability
  • Doesn’t engage socially
  • Doesn’t handle change very well
  • Has repetitive behaviors that are noticeable
  • Is developmentally delayed
• Level 3
  • Needs the most support
  • Everyone can tell there is a disability
  • Doesn’t communicate, except when necessary
  • Any change to routine is nearly impossible
  • Repetitive behavior helps client stay calm
  • Major developmental delays or missed milestones are present

ASD Across the Lifespan

• Behavioral issues may worsen with age
• Limited social life
• Unemployment/underemployment

Related Disorders

• Tic disorders
• Learning disorders
• Motor skills disorder
• Communication disorders
• Elimination disorders

Communication Disorders

• Deficits in language, speech, communication severe enough to hinder development, academic achievement, or ADLs, including socialization
• Types
  • Language disorder
  • Speech sound disorder
  • Stuttering
  • Social communication disorder

Types of Communication Disorders

• Receptive
  • Individuals who have a receptive language disorder have challenges understanding and processing verbal and nonverbal information from others.
  • The individual has a hard time comprehending what others say and has a difficult time applying information and following instructions.
  • Receptive refers to information that is received.
• Social
  • Individuals who have a social language disorder have difficulty using appropriate verbal and nonverbal gestures, making it challenging to connect and relate to other people when conversing.
  • The individual has a hard time relating to others resulting in isolation and feeling misunderstood.
• Expressive
  • Individuals who have an expressive language disorder have challenges with forming sentences and using appropriate words and body gestures to communicate their ideas.
  • The individual has a hard time communicating thoughts, concepts, and ideas, as well as relating to others

Etiology

• Most of these speech and language disorders have no known etiology, although there is considerable interest in investigating genetic links
• Boys are two to three times more likely than girls to stutter

Comorbidities

• Hearing impairment
• Intellectual disabilities
• Developmental disabilities
• Autism spectrum disorder
• Attention deficit hyperactivity disorder
• Traumatic brain injury
• Psychological/emotional disorders

Intellectual Disabilities (ID)

Etiology

• Genetic disorders
  • Fragile X
  • Down’s Syndrome
  • Genetic mutations
• Environmental factors
  • Pre/postnatal infections
  • Exposure to toxins
  • Nutritional deficiencies

Diagnostic Criteria (DSM-5)

• Disorder with onset during the developmental period that includes both intellectual and adaptive functioning deficits in conceptual, social, and practical domains
• May be mild, moderate, severe, or profound
• Deficits in intellectual functions such as reasoning, problem solving, planning, abstract thinking, judgement, academic learning, and learning from experience confirmed by both clinical assessment and individualized, standardized intelligence testing.
• Deficits in adaptive functioning that result in failure to meet developmental and sociocultural standards for personal independence and social responsibility. Without ongoing support, the adaptive deficits limit functioning in one or more activities of daily life.
• Onset of intellectual and adaptive deficits during the developmental period

Severity

• Mild (85% of identified cases)
  • Can learn to read, write, and perform math skills at a 3rd to 6th-grade level
  • Usually able to work and live independently
• Moderate (10% of identified cases)
  • Usually able to learn to read and write at a basic level, perform basic life skills
  • Often requires assistance working or living independently
• Severe (5% of identified cases)
  • Likely not able to read or write but able to perform some basic living skills
  • Requires supervision in daily activities
• Profound (1% of identified cases)
  • Usually able to communicate verbally or non-verbally to some degree
  • Needs extensive support and usually has coexisting medical conditions

Associated Challenges

• Epilepsy
• Gastroesophageal reflux disease
• Constipation
• Sensory impairments
• Injuries/falls
• Aspiration and choking
• May lead to comorbidities such as worsening with age

Cognitive Disabilities

• Confirmation by both clinical assessment and individualized, standardized intelligence testing of deficiencies in intellectual functions
• Reasoning
• Problem-solving
• Planning
• Abstract thinking
• Judgment
• Academic learning
• Learning from experience
• Deficiencies of adaptive functioning that do not meet developmental and sociocultural standards of daily function and social responsibility

Learning Disorders

• Achievement in reading, mathematics, written expression below expected for child’s age, formal education, intelligence
• Interference with academic achievement, life activities, development of self-esteem, social skills
• Early identification, intervention, no coexisting problems associated with better outcomes

Cognitive Signs

• Often spelling the same word differently in a single assignment
• Trouble with open-ended questions on tests
• Poor reading and language comprehension
• Weak memory skills
• Difficulty in adapting skills from one setting to another
• Slow work pace
• Difficulty grasping abstract concepts
• Inattention to details
• Excessive focus on details
• Frequent misreading/misinterpretation of information
• Trouble filling out applications or forms
• Easily confused by instructions
• Poor organizational skills
• Mental health problems like depression or anxiety

Behavioral Signs

• Not wanting to go to school
• Complaining about the teacher
• Reluctance to engage in reading/writing activities
• Saying the work is too hard
• Not wanting to show you schoolwork
• Avoiding assignments/homework
• Saying negative things about his or her academic performance, such as: “I’m dumb”
• Disobeying teacher’s directions
• Frequent misreading/misinterpretation of information
• Cutting class and skipping school (in adolescents and teens)
• Bullying

Dyslexia

• Difficulties with processing
  Mixes up words and sounds. "beddy
  tear for "teddy bear".
  Struggles to find rhyming words "the
  cat sat on the ………
  Finds it hard to say the alphabet in the
  right order.

Dyspraxia

• Difficulties with co-ordination
  Difficulty stacking bricks.
  Handwriting and drawings
  appear scribbled.
  Avoids joining in because they may
  mess something up.

Dysgraphia

• Difficulties with writing
  Writes letters the wrong way
  round: "b instead of d".
  Uses upper case letters when not
  needed: "wAtEr".
  Spells words how they sound: "night
  becomes nite".

Dyscalculia

• Difficulties with numbers
  Forgets the names of numbers when
  shown them.
  Mixes up the meaning of symbols:
  (x) " 1+1 they can read as 1-1".
  Struggles to understand that 6 can
  be made from 5+1 or 3 + 3.

Types of Motor Movement Disorders

• Developmental coordination disorder (DCD) Lack of appropriate motor skills
• Stereotypic movement disorder Repetitive nonpurposeful movement
• Tic disorder
  • Movement disorder characterized by fast, unanticipated, nonrhythmic movement or vocalizations
  • Motor: Shaking, copying others’ movements, obscene gestures, blinking
  • Vocal: Throat clearing, echolalia (repeating words or phrases of others), pallia (repeating self constantly), copropraxia (use of curse words)

Developmental Coordination Disorder (DCD)

• Impairment in coordination severe enough to interfere with academic achievement or activities of daily living (ADLs)
• Often coexisting with communication disorder
• Adaptive physical education, sensory integration to foster normal growth, development

Stereotypic Movement Disorder

• Characterized by rhythmic, repetitive behaviors
• Self-inflicted injuries are common; pain is not a deterrent to the behavior.
• Movements that are repetitive, driven, and seemingly without purpose
• Behavior interferes with social, academic, occupation, or other function and possibly results in self-injury
• Onset occurs in the child’s early developmental period
• No evidence of substance abuse, a neurological condition or other disorder that may cause similar symptoms

Tic Disorders

• Sudden, rapid, recurrent, nonrhythmic stereotyped motor movement or vocalization
• Treatment with atypical antipsychotics (risperidone or aripiprazole)
• Types
  • Tourette disorder: multiple motor tics, one or more vocal tics
  • Chronic motor or tic disorder: either motor or vocal tics, not both
  • Provisional: One or more motor and/or vocal tics for less than 1 year prior to 18 years old
  • Persistent: Chronic Single or multiple motor and vocal tics must be present for 1 year and prior to 18 years old
  • Tourette syndrome: Most severe tic disorder Multiple motor tics and a vocal tic, must persist for one year and must be present prior to age 18

Etiology

• DCD
  • Low birth weight
  • Premature birth
  • Family history
  • Prenatal exposure to alcohol or drugs
• TS
  • Inherited
  • Maternal stress is being investigated

Comorbidities

• DCD
  • Learning disorders/cognitive functioning
  • ADHD
  • Psychological and behavioral issues
  • Deficient social skills
  • Depression
  • Anxiety
• TS
  • ADHD
  • Depression
  • OCD

Elimination Disorders

• Encopresis: repeated passage of feces into inappropriate places (child at least age 4)
  • Often involuntary
  • Can be intentional
• Enuresis: repeated urination during day or night in clothes or bed by a child at least age 5 years of age
  • Most often involuntary
  • Intentional enuresis associated with disruptive behavior disorder
  • More common in boys than girls

Attention Deficit Hyperactivity Disorders (ADHD)

• A persistent pattern (at least 6 months) of inattention and/or hyperactivity-impulsivity that interferes with functioning, development, social activities, or other academic or occupational activities.

Diagnostic Criteria (DSM-5)

• A persistent pattern (at least 6 months) of inattention and/or hyperactivity-impulsivity that interferes with functioning, development, social activities, or other academic or occupational activities.
• Inattention to details
• Difficulty maintaining attention span
• Appears not to listen when spoken to directly
• Shows a lack of follow-through with instructions, organization, or other tasks
• Easily loses necessary items
• Easily distracted, forgetful in daily activities
• Dislikes tasks that require concentration
• Manifestations are present in two or more settings and are apparent before the age of 12, and interfere with, or reduce the quality of, social, academic, or occupational functioning.
• The manifestations are not better explained by another mental disorder, including psychotic disorders, such as schizophrenia.

Attention-Deficit/Hyperactivity Disorder (ADHD)

• Inattentiveness, overactivity, impulsiveness
• Persistent pattern of inattention and/or hyperactivity and impulsivity
• Often diagnosed when child starts school
• Fidgeting, noisy, disruptive, unable to complete tasks, failure to follow directions, blurting out answers, lost or forgotten homework
• Possible ostracization/ridicule by peers

Etiology

• Cause unknown: possible cortical-arousal, information-processing, or maturational abnormalities in the brain
• Other theories: environmental toxins, prenatal influences, heredity, damage to brain structure and functions
• Parental exposure to drugs, lead
• Decreased metabolism in frontal lobes

Comorbidities

• Learning disabilities (most common)
• Epilepsy
• Children
  • Oppositional defiant disorder (ODD)
  • Conduct disorder (CD) are the most common
• Adolescence and adulthood
  • Substance use disorders
  • Sleep disorders
  • Anxiety disorders
  • Somatic conditions

Treatment

• No one treatment effective
• Goals: managing symptoms, reducing hyperactivity and impulsivity, increasing child’s attention
• Combination of medications with behavioral, psychosocial, and educational interventions
• Medications (see Table 22.1)
  • Stimulants: methylphenidate (Ritalin), amphetamine compound (Adderall), dextroamphetamine (Dexedrine), pemoline (Cylert)
  • Antidepressants as second choice
• Non-Pharmacological
  • Consistent rewards and consequences
  • Therapeutic play
    • Dramatic play
    • Creative play

ADHD Across the Lifespan

• Problems with school/learning
• Problems with relationships
• Problems at work
• May manifest as anxiety or depression

Comorbidities with Neurodevelopmental Disorders

• Aggression
• Seizures
• Depression
• Obesity
• Motor and tic disorders
• ID
• Anxiety
• Psychoses
• PTSD
• Drug abuse
• Sleep disorders
• OCD

ADHD and Nursing Process Application

• Assessment
  • History: fussy as infant; “out of control”; difficulties in all major life areas
  • General appearance and motor behavior: inability to sit still; inability to carry on conversation; abrupt jumping from topic to topic
  • Mood and affect: possible lability; anxiety, frustration, agitation
  • Thought process and content
  • Sensorium and intellectual processes: impaired ability to pay attention or concentrate
  • Judgment and insight: poor; impulsive
  • Self-concept: low self-esteem; feel bad or stupid due to negative reactions to their behavior
  • Roles and relationships: academic, social problems
  • Physiological and self-care: may be thin; trouble settling down; sleeping problems

ADHD and Nursing Process Application

• Data analysis and priorities: problems include—
  • Risk for injury
  • Inability to fulfill roles
  • Inadequate or disruptive social interaction
  • Ineffective family coping
• Outcome identification
  • Freedom from injury
  • No violation of others’ boundaries
  • Demonstration of age-appropriate social skills
  • Completion of tasks
  • Following of directions

Actions

• Ensuring safety
• Improving role performance
• Simplifying instructions
• Promoting structured daily routine
• Providing client and family education and support

Mental Health Promotion

• Early detection and successful intervention as key
• SNAP-IV Teacher and Parent Rating Scale: assessment tool for initial evaluation of various disorders:
  • ADHD
  • Oppositional defiant disorder (ODD)
  • Conduct disorders
  • Depression
• Connor Scale for ADHD Assessment
  • Parent, teacher versions

Nurse’s Role for Specific Conditions

• Intellectual/learning
  • Cognitive-based communication
  • Focus on strengths
• Communication
  • Assess for barriers
  • Create alternative communication strategies
• Autism spectrum disorder
  • Appropriate screening
  • Liaison to community resources
• ADHD
  • Advocacy
• Tic disorders
  • Maintain client dignity
  • Educate client, family, public

Analyze Cues/Prioritize Hypotheses

• Neurodevelopmental disorders often coexist.
• Multiple cues may need to be considered together.
• Consider etiology, abilities, function, severity of impairment.
• Consider which needs/solutions are most urgent, accessible, attainable.

Generate Solutions

• Individualized
• Developmentally appropriate
• Involve parents
• Behavioral interventions vs. medical interventions

Sample Care Plan –Tourette Syndrome

• Teach child and parents behavioral techniques to reduce tics
• Family therapy to improve stress management
• Pharmacological intervention with a second-generation antipsychotic medication, such as risperidone, to treat unresolved tics

Sample Care Plan – ASD

• Refer to an early intervention program at school
• Educate parents to provide structure and consistent expectations
• Use behavior management with a reward system
• Physical, occupational, and speech therapy as needed
• Pharmacological intervention with a stimulant medication, such as methylphenidate, to treat unresolved signs of hyperactivity, impulsivity

D/C Planning

• Early intervention programs
• School services
• Community resources
• Referrals
  • Short-term: Should address a limited range of skills, such as increasing social communication or learning a specific skill or task to improve quality of life
  • Long-term: Should revolve around less focused intervention and include broader behavioral, developmental, and educational improvement, such as acquiring basic skills to be able to have a job as an adult
• Goal-setting

Take Actions

• Managing disruptive behaviors
  • Verbal warning :Allows the child an opportunity to express their emotions and diffuse aggression
  • Time out: Allows an opportunity for self-reflection and time to regain self-control
  • Quiet room: Provides an environment of decreased stimulation and a safe area of privacy to express frustration
  • Medication: Health care provider may prescribe pharmacotherapy as regular regimen or on an as needed basis to provide symptom relief
    Seclusion and restraint Prevents harm to self or others in the event of severe crisis when extremely dangerous or destructive behavior presents but should be last resort and done in harmony with facility and state regulations
    *Modified education
    *Behavioral therapies
    *Closely monitored medications
    *Manage behavioral crises
    *Use least restrictive strategy first

Evaluate Outcomes – Examples

• Autism spectrum disorder
  • Cooperates with others
  • Exhibits