Disorders Of Children And Adolescents

Disorders of Children and Adolescents

Pervasive Developmental Disorders • Characterized by pervasive and usually severe impairment of reciprocal social interaction skills, communication deviance, and restricted stereotypical behavioral patterns • Also called autism spectrum disorders – – – –

Autistic disorder (classic autism) Rett’s disorder Childhood disintegrative behavior Asperger’s disorder

• Approximately 75% of children with these disorders have mental retardation

AUTISTIC DISORDER • A pervasive developmental disorder characterized by inappropriate responses to the environment and pronounced impairments in language, communication, and social interaction • It begins during childhood and lasts throughout life. • Occurs in 10-12 of every 10,000 children and is up to 5 times more common in boys than girls.

AUTISTIC DISORDER • Causes: – No known single cause for autism exists, but some studies suggest it may stem from abnormalities in brain structure or function. Brain scans show differences in brain shape and structure in autistic children – Autism does have a genetic link; many children with autism have a relative with autism or autistic traits – Controversy continues about whether MMR vaccinations contribute to the development of late-onset autism.

AUTISTIC DISORDER • Signs and symptoms – It’s commonly discovered when parents notice their child doesn’t appear to hear. – Sometimes the child appears to develop normally until about age 2, and then regresses rapidly – Young children with autism usually have impaired language development and difficulty expressing their needs. They may laugh or cry for no apparent reason

AUTISTIC DISORDER • Indifference toward others • Delayed and impaired verbal and nonverbal communication • Abnormal speech patterns, such as echolalia • Lack of intonation and expression in speech • Repetitive rocking motions • Hand flapping • Insistence on sameness

AUTISTIC DISORDER • Dislike of changes in daily activities and routines • Self-injurious behaviors, such as headbanging, hitting or biting • Unusual fascination with inanimate objects, such as fans and air conditioners • Dislike of touching or cuddling • Frequent outburst and tantrums • Little or no eye contact with others • Increased or decreased sensitivity to pain • No fear of danger

Diagnostic criteria • At least 6 characteristics from the following 3 categories must be present, including at least 2 from the social interaction category and one each from the communication and pattern categories • Social interaction – Marked impairment in the use of multiple nonverbal behaviors, such as eye-to-eye gaze, facial expression, body postures and gestures to regulate social interaction – Failure to develop peer relationships appropriate to developmental level – No spontaneous sharing of enjoyment, interests, or achievements with others – Lack of social or emotional reciprocity – Gross impairment in the ability to make peer friendships

Diagnostic criteria • Communication – Delay in, or total lack of, spoken language development (not accompanied by an attempt to compensate through alternative modes of communication, such as gestures or mime) – In an individual with adequate speech, marked impairment in initiating or sustaining a conversation with others – Stereotyped and repetitive use of language or idiosyncratic language – Lack of varied, spontaneous make believe play or social imitative play appropriate to developmental level

Diagnostic criteria • Patterns: The person demonstrates restricted, repetitive, and stereotyped patterns of behavior, interests, and activities as manifested by at least one of the ff. criteria: – Encompassing preoccupation with one or more stereotyped and restricted patterns of interest that’s abnormal either in intensity or focus – Apparently inflexible adherence to specific nonfunctional routines or rituals – Persistent preoccupation with parts of objects

Diagnostic criteria • Additional criteria: The person exhibits delays or abnormal functioning in at least one of the following areas before age 3: – Social interaction – Language as used in social communication – Symbolic or imaginative play

Treatment • A combination of early intervention, special education, family support, and in some cases medication may help some autistic children lead more normal lives • Early intervention and special education programs may increase the child’s capacity to learn, communicate, and relate to others. This approach also may reduce the severity and frequency of disruptive behaviors

Nursing interventions • Choose your words carefully when speaking to a verbal autistic child. The child is likely to interpret words concretely and may interpret a harmless request as a threat. • Offer emotional support and information to the parents. Suggest they meet with parents of other autistic children for advice on coping with tantrums, toilet training, and other problems • To promote communication, advise the parents to have close, face-to-face contact with the child. • Teach the parents to maintain regular, predictable daily routine, with consistent times for waking up, dressing, eating, attending school, and going to bed. • Suggest that the parents use a picture board showing the activities that will occur during the day to help the child make transitions more easily

Nursing interventions • Advise the parents to avoid situations known to trigger outbursts. • Teach the parents how to recognize the behaviors that precede temper tantrums, such as increased hand flapping. Instruct them to intervene before a tantrum occurs. • Instruct the parents on ways to make home safer-for example, by installing locks and gates so that the child can’t wander unsupervised. • Inform the parents that punishment may worsen self-injurious behavior

Rett’s Disorder • A pervasive developmental disorder characterized by the development of multiple deficits after a period of normal functioning • It occurs exclusively in girls. • It is rare, and persists throughout life. • It develops between birth and 5 months of age. The child loses motor skills and begins showing stereotyped movements instead. She loses interest in the social environment, and severe impairment of expressive and receptive language becomes evident as she grow older.

Asperger’s Disorder • Same impairments of social interaction and restricted stereotyped behaviors seen in autistic disorder, but there are no language or cognitive delays. • Occurs more often in boys than in girls, and the effects are generally lifelong.

Childhood Disintegrative Disorder • Characterized by marked regression in multiple areas of functioning after at least 2 years of apparently normal growth and development • Typical age at onset is between 3 an 4 years • Children with CDD have the same social and communication deficits and behavioral patterns seen with autistic disorder

Attention Deficit and Disruptive Disorders

Attention Deficit Hyperactive Disorder • Characterized by inattentiveness, overactivity, and impulsiveness. • Affects roughly 3%-5% of school-age children • Affects at least twice as many boys as girls. The child’s behavior may cause problems at school, in the home, and in the community and may influence his emotional development and social skills.

Diagnostic criteria • The person must have at least 6 symptoms from the inattention group or at least 6 from the hyperactivity-impulsivity group. Symptoms must have persisted for at least 6 months to a degree that’s maladaptive and inconsistent with the person’s developmental level • Symptoms of inattention – Often fails to pay close attention to details or makes careless mistakes in school, work, or other activities – Often has trouble sustaining attention in tasks or play activities

Diagnostic criteria – Often seems not to listen when spoken to directly – Often fails to follow through on instructions or to finish schoolwork, chores or workplace duties ( not because of oppositional behavior or failure to understand instructions) – Often has trouble organizing tasks and activities – Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) – Often loses things necessary for tasks or activities – Often becomes distracted by extraneous stimuli – Often demonstrates forgetfulness in daily

Diagnostic criteria • Symptoms of hyperactivity – Often fidgets with his hands or feet or squirms in his seat – Often leaves his seat in the classroom or in other situations in which remaining seated is expected – Often runs about or climbs excessively in inappropriate situations – Often has trouble playing or engaging in leisure activities quietly – Often is described as “on the go” or “driven by a motor” – Often talks excessively

Diagnostic criteria • Symptoms of impulsivity – Often blurts out answers before questions have been completed – Often has difficulty awaiting his turn – Often interrupts or intrudes on others in conversation or games

• Additional features – Some symptoms causing impairment appear before age 7 – Impairment form the symptoms is present in two or more settings (at school and at home) – Clinically significant impairment in social, academic or occupational functioning is clearly evident

Treatment • Focuses on coordinating the child’s psychological and physiologic needs. • Psychotherapy can reduce ADHD symptoms and teach the child ways to modify behavior. • Pharmacologic agents – Dextroamphhetamine (Dexedrine) – Methylphenidate (Ritalin) – Pemoline (Cylert)

Treatment • The child also may benefit from an individualized educational plan, with special services that support his strengths and minimize problems stemming from his vulnerabilities

Conduct Disorder • Characterized by persistent antisocial behavior in children and adolescents that significantly impairs their ability to function in social, academic, or occupational areas • Symptoms are clustered in 4 areas – Aggression to people and animals – Destruction of property – Deceitfulness and theft – Serious violation of rules

Conduct Disorder • People with conduct disorder have little empathy for others; have low self-esteem; poor frustration tolerance; temper outbursts • Occurs 3x more often in boys than in girls • As many as 30% to 50% of these children are diagnosed with antisocial personality disorder

Diagnostic criteria • At least 3 of the criteria from any of the categories below must have been present in the past year, and at least one criterion must have been present within the past 6 months • Aggression to people and animals – Often initiates physical fights – Has used a weapon that can cause serious physical harm to others – Has been physically cruel to people/animals – Has stolen while confronting a victim (as in mugging, purse snatching, extortion) – Has forced someone into sexual activity

Diagnostic criteria • Destruction of property – Deliberately set fire with the intention of causing serious damage – Deliberately destroyed other’s property (other than by setting a fire)

• Deceitfulness or theft – Has broken into someone else’s house, car, or building – Often lies to obtain goods or favors or to avoid obligations – Has stolen items of nontrivial value without confronting a victim

Diagnostic criteria • Serious violations of rules – Often stays out at night despite parental prohibitions, starting before age 13 – Has run away from home overnight at least twice while living the parent’s or surrogate parent’s home. – Often skips school, beginning before age 13

• Additional criteria – The behavior disturbance must cause clinically significant impairment in social, academic, or occupational functioning – The person is age 18 or older and doesn’t meet the criteria for antisocial personality disorder

• Studies show that roughly 30% to 50% of clinical populations with conduct disorder also has ADHD.

Treatment • Treatment focuses on coordinating the child’s psychological, physiologic, and educational needs. • Psychotherapy can help him learn problem-solving skills, decrease disruptive symptoms, and modify behavior