Disorders Of Children And Adolescents
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2-14-08
Mrs. Travis
Disorders of Children and Adolescents Attention Deficit Hyperactivity Disorder (ADHD) •
Persistent pattern of inattention, hyperactivity, and impulsiveness
•
Difficult to diagnosis before age 4 years
•
Dually diagnosed
•
Family history
•
Very forgetful
•
Lose things easily
•
Can’t sit still
•
Disruptive, can’t function in school/church
Predisposing factors •
Biological
•
Environmental/ social
•
Cultural/ ethnic
•
Genetics
•
Temperament
Diagnostic Criteria •
Symptoms of inattention, hyperactivity and impulsivity for at least 6 months
•
Signs and symptoms present before age of 7
•
causes impairment in 3 or more settings
•
symptoms are not better accounted for by another mental disorder
Assessment Guidelines for ADHD •
Relationship between child and caregiver
•
Caregiver’s understanding of growth and development, parenting skills, and handling of problematic behaviors
•
Cognitive, psychosocial, and moral development for lags or deficits
•
Observe for level of physical activity, attention span, talkativeness, ability to follow directions, and impulse control
•
Difficulty in making friends and performing in school
•
Problems with enuresis (bedwetting) and encopresis (BM)
•
Observe behavior in restrictive settings
Nursing Diagnosis •
Risk for injury R/T hyperactivity
•
Impaired social interaction
•
Self-esteem disturbance
•
Noncompliance with task expectations
ADHD Interventions •
Behavior modification
•
Pharmacological
•
Special Education
•
Psychotherapy
Treatment of ADHD: •
CNS Stimulants o
Methlphenidate (MPH)
Ritalin/ SR/LA
Metadate ER/CD
Concerta
2-14-08
Mrs. Travis
o
Focalin
Daytrana Patch
Amphetamine
Adderall/ XR
Side Effects of CNS Stimulants •
Insomnia
•
Mood changes
•
Anorexia
•
Weight loss
•
Tachycardia
•
Increased anxiety
•
Headache
•
Stomach ache
•
Irritability
•
Temporary decrease in growth and development
•
Physical tolerance
Nursing Actions : CNS Stimulants •
Assess mental status
•
Give after meals
•
Weight
•
Don’t give at bedtime
•
Drug “holiday”
•
Avoid OTC medications
•
Do not withdraw abruptly
Other Meds for ADHD continue
•
Atomoxetine hydrochloride (Strattera)
•
Antidepressants
•
o
Bupropion (Wellbutrin)
o
Fluoxetine (Prozac)
Alpha-adrenergic o
Guanfacine (Tenex)
o
Clonidine (Catapres
Conduct Disorder •
Repetitive and persistent pattern of behavior in which the rights of others and major age-appropriate societal norms or rules are violated
•
Behaviors occur in a variety of settings
•
Social, academic, and/ or occupational function is impaired
•
Childhood onset
•
•
o
Before age of 10, may persist into adolescence
o
More physical aggression
o
Lack of concern for others
o
Poor peer relationships
Adolescent onset o
Less physical aggressions
o
Gangs
o
Skipping school
o
Prostitution
o
Running away from homes
o
May outgrow this behavior before adulthood
Diagnostic Criteria for Conduct Disorder
2-14-08
•
•
•
Mrs. Travis o
Aggression
o
Destruction of property
o
Deceitfulness or theft
o
Serious violations of rules
Nursing Assessment: o
Seriousness of disruptive behavior
o
Level of anxiety, aggression, or anger
o
Self-control over impulses
o
Moral development: understanding of impact of behaviors
Interventions o
Focus on correcting personality development
o
Teach development of coping mechanisms
o
Inpatient hospitalization often needed for crisis intervention
o
Therapeutic foster care
o
Long-term residential treatment
Treatment o
Medications
Mood Stabilizers: controls anger •
Lithium, depakote, tegretol
Antidepressants •
Zoloft
•
Celexa
•
Lexapro
Antipsychotics :controls aggression •
Risperdal
•
Abilify
•
Zyprexa or zyprexa zydis
Oppositional Defiant Disorder •
Recurrent pattern of behavior
•
Negativistic
•
Defiant
•
Disobedient
•
Hostile
•
Especially toward authority figures
•
Without violated the rights of others
•
Diagnostic Criteria
•
o
Behavior for at least 6 months
o
Must have at least 4 symptoms listed
o
Symptoms by age 8
o
More common in boys
o
Lead to conduct disorder
o
Impairment in social, academic, and occupational functioning
Signs and Symptoms o
Passive aggressive behavior
o
Running away
o
School avoidance/ under achievement
o
Temper tantrums
o
Fighting
o
Argumentative
o
Stubborn
2-14-08
•
•
•
Mrs. Travis o
Eating/ sleeping problems
o
Oppositional
o
Behavior may or may not be seen outside home
o
Difficulty in forming interpersonal relationships
o
Refuse to accept blame for misdeeds
Nursing assessment o
Identify issues that result in power struggles
o
Assess severity of defiance and impact at home, school, with peers
Nursing diagnosis o
Impaired social interaction
o
Defensive coping
o
Self esteem disturbance
Interventions o
Early intervention
Can lead to conduct disorder if interventions are not performed early
o
Family therapy
o
Group therapy
o
Behavior therapy
Pervasive Developmental Disorder (Autistic) •
Behavioral syndrome resulting from abnormal brain function
•
Characteristics o
Bizarre
o
Inability to maintain eye contact
•
•
•
o
Limited functional play
o
Constipation
o
Self-abusive
o
Mental retardation
o
Language is delayed
o
Don’t like people touching them
Diagnostic Criteria o
Impairment in communication and imaginative activity
o
Impairment in social interaction
o
Markedly restricted, stereotypical patterns of behavior, interest and activities
Nursing Considerations o
Behavior modifications
o
Family support
o
Pharmacological agents
Risperdal
Haldol for irritability
Asperger’s o
Higher functioning autism
o
Slow in caring for themselves and thinking
o
May get a fixed sensation on something (butterflies) and that is all they can talk about
o
No significant delay in cognitive and language development
o
Etiology unknown
o
Familial pattern
2-14-08
Mrs. Travis o
•
Restricted and repetitive patterns of behavior and idiosyncratic interests
Rett’s o
Females
o
Before age 4 years
o
Cause unknown, may be associated with brain abnormalities, seizures, and mental retardation
o
Prognosis is much worse than Asperger’s
o
These children are severely to profoundly mentally retarded as well as having seizure disorders
Mental Retardation •
Comprised of three areas o
Intellectual functioning
o
Functional strengths and weaknesses
o •
•
Being able to care for yourself
Communication
Social skills
Leisure activities
Age younger than 18 years
Diagnosis o
Suspicion of family member or professional
o
Confirmed at birth
o
Problems such as speech delays arouse concerns
o
Standardized tests- assess abilities of functional strengths
Classification o
Mild
o
Moderate
o
•
•
20-40 IQ
Profound
o
35-55 IQ
Severe
o
50-75 IQ
Less than 20 IQ
Looks at three different areas (Wong 591)
Etiology o
Genetics
o
Biochemical
o
Infections
o
Trauma
o
Gestational disorders
o
Psychiatric disorders
o
Inadequate nutrition and metabolic
o
Cerebral and cranial malformations
o
Brain disease
o
Environmental
o
Chromosomal
Nursing Care o
Assessment
Newborn and early infancy
Developmental milestones
Parental concerns
2-14-08
Mrs. Travis o
o
Nursing diagnosis
Altered growth and development
Altered family processes
Intervention
Educate
Teach
Promote optimal development
Play/exercise
Communication
Discipline
Socialization
Sexuality
Delirium •
Disturbance of consciousness
•
Change in cognition
•
Develops over a short period of time
•
Sudden onset
•
Fluctuates
•
Secondary to another cause
•
More pronounced in the evening
•
Recovery when cause corrected
Cause •
Substance abuse
•
Medications
•
Polypharmacy
•
Toxins
•
Infection o
UTI’s
•
Medical illness
•
Fever
•
Post-op
•
Metabolic disorders
•
Psychosocial stress
•
Sleep deprivation
•
Sensory overload
•
Sometimes unknown
Nursing Assessment •
Acuity of onset
•
Orientation
•
Attention span
•
Memory impairment
•
Thought processes
•
Sensory/perceptual changes
•
Mood and affect
•
Sleep pattern
•
LOC
•
Autonomic manifestations
•
Monitor for abrupt changes
Nursing Diagnoses
2-14-08
Mrs. Travis
•
Risk for injury
•
Fluid volume deficit
•
Sleep pattern disturbance
•
Impaired communication
•
Acute confusion
•
Disturbed thought process
•
Fear
•
Self care deficit
•
Impaired social interaction
•
Sensory perception disturbance
Interventions •
Eliminate causative factors
•
Monitor vital and neurological signs
•
Provide support and frequent re-orientation
•
Maintain safety and comfort
•
Provide a quiet environment
•
May need 1:1 supervision
•
Chemical/ Mechanical restraints
Dementia •
A loss of previous levels of cognitive, executive, and memory function in a state of full alertness o
Memory impairement
o
One of more of the following cognitive disturbances
Aphasia
Apraxia
Agnosia •
•
o
Most cases are progressive and irreversible
o
Develops slowly
Classifications o
o
•
•
Spoon a pencil
Primary
Alzheimer’s
Usually not reversible
Progressive
Secondary
May be reversible
Can be caused by infection, meningitis
Etiology o
Pathological
o
Genetic
o
Non-genetic
Increasing age
Down syndrome
Head injury
o
Neurochemical changes
o
True diagnosis is on autopsy (atrophy of brain function) plaque, etc.
Clinical manifestations o
Denial
o
Confabulation
2-14-08
Mrs. Travis o
Making up stories (they think there true)
Preserveration
Repetition of behavior
o
Avoidance of questions
o
Cardinal symptoms
Amnesia or memory
Aphasia •
Apraxia •
•
•
Loss of sensory ability to recognize objeccts
Disturbances in executive functioning •
•
Loss of purposeful movement
Agnosia •
Loss of language ability
Planning, organizing, abstract thinking
Diagnostic tests o
History and physical
o
Labs
o
X-rays
o
Mental status questionnaires
Stages of Alzheimer’s Disease p. 435 o
Stage 1 (Mild) Forgetfulness
o
Stage 2 (Moderate) Confusion
o
Stage 3 (Moderate to Severe) Ambulatory dementia
o
Stage 4 (Late) End stage
Problems in Dementia
•
•
o
Disorientation
o
Memory impairment
o
Risk for injury
o
Needs for physical help
o
Apathy
o
Poor communication
o
Uncontrolled emotion
o
Uncontrolled behavior
o
Incontinence
o
Mistaken beliefs
o
Poor decision making
o
Burden on family
Nursing Interventions o
Unconditional positive regard
o
Caregiver education
o
Communication
o
Planning daily activities
o
Maintaining safety
o
Managing behavior
o
Monitor nutrition and weigh
o
Monitor for increased confusion
Medications o
Cognex, Aricept, Exelon, Reminyl
Improves cognitive function, ADL performance, and behavior
Slow down progression, used in mild to moderate stage
2-14-08
Mrs. Travis
o
o
Increases level of acetycholine
Side effect: GI upset, liver toxicity
Namenda
Moderate to severe dementia
Targets the neurotransmitter glutamate
Vitamin E-suppose to help with brain circulation
Mrs. Travis
Disorders of Children and Adolescents Attention Deficit Hyperactivity Disorder (ADHD) •
Persistent pattern of inattention, hyperactivity, and impulsiveness
•
Difficult to diagnosis before age 4 years
•
Dually diagnosed
•
Family history
•
Very forgetful
•
Lose things easily
•
Can’t sit still
•
Disruptive, can’t function in school/church
Predisposing factors •
Biological
•
Environmental/ social
•
Cultural/ ethnic
•
Genetics
•
Temperament
Diagnostic Criteria •
Symptoms of inattention, hyperactivity and impulsivity for at least 6 months
•
Signs and symptoms present before age of 7
•
causes impairment in 3 or more settings
•
symptoms are not better accounted for by another mental disorder
Assessment Guidelines for ADHD •
Relationship between child and caregiver
•
Caregiver’s understanding of growth and development, parenting skills, and handling of problematic behaviors
•
Cognitive, psychosocial, and moral development for lags or deficits
•
Observe for level of physical activity, attention span, talkativeness, ability to follow directions, and impulse control
•
Difficulty in making friends and performing in school
•
Problems with enuresis (bedwetting) and encopresis (BM)
•
Observe behavior in restrictive settings
Nursing Diagnosis •
Risk for injury R/T hyperactivity
•
Impaired social interaction
•
Self-esteem disturbance
•
Noncompliance with task expectations
ADHD Interventions •
Behavior modification
•
Pharmacological
•
Special Education
•
Psychotherapy
Treatment of ADHD: •
CNS Stimulants o
Methlphenidate (MPH)
Ritalin/ SR/LA
Metadate ER/CD
Concerta
2-14-08
Mrs. Travis
o
Focalin
Daytrana Patch
Amphetamine
Adderall/ XR
Side Effects of CNS Stimulants •
Insomnia
•
Mood changes
•
Anorexia
•
Weight loss
•
Tachycardia
•
Increased anxiety
•
Headache
•
Stomach ache
•
Irritability
•
Temporary decrease in growth and development
•
Physical tolerance
Nursing Actions : CNS Stimulants •
Assess mental status
•
Give after meals
•
Weight
•
Don’t give at bedtime
•
Drug “holiday”
•
Avoid OTC medications
•
Do not withdraw abruptly
Other Meds for ADHD continue
•
Atomoxetine hydrochloride (Strattera)
•
Antidepressants
•
o
Bupropion (Wellbutrin)
o
Fluoxetine (Prozac)
Alpha-adrenergic o
Guanfacine (Tenex)
o
Clonidine (Catapres
Conduct Disorder •
Repetitive and persistent pattern of behavior in which the rights of others and major age-appropriate societal norms or rules are violated
•
Behaviors occur in a variety of settings
•
Social, academic, and/ or occupational function is impaired
•
Childhood onset
•
•
o
Before age of 10, may persist into adolescence
o
More physical aggression
o
Lack of concern for others
o
Poor peer relationships
Adolescent onset o
Less physical aggressions
o
Gangs
o
Skipping school
o
Prostitution
o
Running away from homes
o
May outgrow this behavior before adulthood
Diagnostic Criteria for Conduct Disorder
2-14-08
•
•
•
Mrs. Travis o
Aggression
o
Destruction of property
o
Deceitfulness or theft
o
Serious violations of rules
Nursing Assessment: o
Seriousness of disruptive behavior
o
Level of anxiety, aggression, or anger
o
Self-control over impulses
o
Moral development: understanding of impact of behaviors
Interventions o
Focus on correcting personality development
o
Teach development of coping mechanisms
o
Inpatient hospitalization often needed for crisis intervention
o
Therapeutic foster care
o
Long-term residential treatment
Treatment o
Medications
Mood Stabilizers: controls anger •
Lithium, depakote, tegretol
Antidepressants •
Zoloft
•
Celexa
•
Lexapro
Antipsychotics :controls aggression •
Risperdal
•
Abilify
•
Zyprexa or zyprexa zydis
Oppositional Defiant Disorder •
Recurrent pattern of behavior
•
Negativistic
•
Defiant
•
Disobedient
•
Hostile
•
Especially toward authority figures
•
Without violated the rights of others
•
Diagnostic Criteria
•
o
Behavior for at least 6 months
o
Must have at least 4 symptoms listed
o
Symptoms by age 8
o
More common in boys
o
Lead to conduct disorder
o
Impairment in social, academic, and occupational functioning
Signs and Symptoms o
Passive aggressive behavior
o
Running away
o
School avoidance/ under achievement
o
Temper tantrums
o
Fighting
o
Argumentative
o
Stubborn
2-14-08
•
•
•
Mrs. Travis o
Eating/ sleeping problems
o
Oppositional
o
Behavior may or may not be seen outside home
o
Difficulty in forming interpersonal relationships
o
Refuse to accept blame for misdeeds
Nursing assessment o
Identify issues that result in power struggles
o
Assess severity of defiance and impact at home, school, with peers
Nursing diagnosis o
Impaired social interaction
o
Defensive coping
o
Self esteem disturbance
Interventions o
Early intervention
Can lead to conduct disorder if interventions are not performed early
o
Family therapy
o
Group therapy
o
Behavior therapy
Pervasive Developmental Disorder (Autistic) •
Behavioral syndrome resulting from abnormal brain function
•
Characteristics o
Bizarre
o
Inability to maintain eye contact
•
•
•
o
Limited functional play
o
Constipation
o
Self-abusive
o
Mental retardation
o
Language is delayed
o
Don’t like people touching them
Diagnostic Criteria o
Impairment in communication and imaginative activity
o
Impairment in social interaction
o
Markedly restricted, stereotypical patterns of behavior, interest and activities
Nursing Considerations o
Behavior modifications
o
Family support
o
Pharmacological agents
Risperdal
Haldol for irritability
Asperger’s o
Higher functioning autism
o
Slow in caring for themselves and thinking
o
May get a fixed sensation on something (butterflies) and that is all they can talk about
o
No significant delay in cognitive and language development
o
Etiology unknown
o
Familial pattern
2-14-08
Mrs. Travis o
•
Restricted and repetitive patterns of behavior and idiosyncratic interests
Rett’s o
Females
o
Before age 4 years
o
Cause unknown, may be associated with brain abnormalities, seizures, and mental retardation
o
Prognosis is much worse than Asperger’s
o
These children are severely to profoundly mentally retarded as well as having seizure disorders
Mental Retardation •
Comprised of three areas o
Intellectual functioning
o
Functional strengths and weaknesses
o •
•
Being able to care for yourself
Communication
Social skills
Leisure activities
Age younger than 18 years
Diagnosis o
Suspicion of family member or professional
o
Confirmed at birth
o
Problems such as speech delays arouse concerns
o
Standardized tests- assess abilities of functional strengths
Classification o
Mild
o
Moderate
o
•
•
20-40 IQ
Profound
o
35-55 IQ
Severe
o
50-75 IQ
Less than 20 IQ
Looks at three different areas (Wong 591)
Etiology o
Genetics
o
Biochemical
o
Infections
o
Trauma
o
Gestational disorders
o
Psychiatric disorders
o
Inadequate nutrition and metabolic
o
Cerebral and cranial malformations
o
Brain disease
o
Environmental
o
Chromosomal
Nursing Care o
Assessment
Newborn and early infancy
Developmental milestones
Parental concerns
2-14-08
Mrs. Travis o
o
Nursing diagnosis
Altered growth and development
Altered family processes
Intervention
Educate
Teach
Promote optimal development
Play/exercise
Communication
Discipline
Socialization
Sexuality
Delirium •
Disturbance of consciousness
•
Change in cognition
•
Develops over a short period of time
•
Sudden onset
•
Fluctuates
•
Secondary to another cause
•
More pronounced in the evening
•
Recovery when cause corrected
Cause •
Substance abuse
•
Medications
•
Polypharmacy
•
Toxins
•
Infection o
UTI’s
•
Medical illness
•
Fever
•
Post-op
•
Metabolic disorders
•
Psychosocial stress
•
Sleep deprivation
•
Sensory overload
•
Sometimes unknown
Nursing Assessment •
Acuity of onset
•
Orientation
•
Attention span
•
Memory impairment
•
Thought processes
•
Sensory/perceptual changes
•
Mood and affect
•
Sleep pattern
•
LOC
•
Autonomic manifestations
•
Monitor for abrupt changes
Nursing Diagnoses
2-14-08
Mrs. Travis
•
Risk for injury
•
Fluid volume deficit
•
Sleep pattern disturbance
•
Impaired communication
•
Acute confusion
•
Disturbed thought process
•
Fear
•
Self care deficit
•
Impaired social interaction
•
Sensory perception disturbance
Interventions •
Eliminate causative factors
•
Monitor vital and neurological signs
•
Provide support and frequent re-orientation
•
Maintain safety and comfort
•
Provide a quiet environment
•
May need 1:1 supervision
•
Chemical/ Mechanical restraints
Dementia •
A loss of previous levels of cognitive, executive, and memory function in a state of full alertness o
Memory impairement
o
One of more of the following cognitive disturbances
Aphasia
Apraxia
Agnosia •
•
o
Most cases are progressive and irreversible
o
Develops slowly
Classifications o
o
•
•
Spoon a pencil
Primary
Alzheimer’s
Usually not reversible
Progressive
Secondary
May be reversible
Can be caused by infection, meningitis
Etiology o
Pathological
o
Genetic
o
Non-genetic
Increasing age
Down syndrome
Head injury
o
Neurochemical changes
o
True diagnosis is on autopsy (atrophy of brain function) plaque, etc.
Clinical manifestations o
Denial
o
Confabulation
2-14-08
Mrs. Travis o
Making up stories (they think there true)
Preserveration
Repetition of behavior
o
Avoidance of questions
o
Cardinal symptoms
Amnesia or memory
Aphasia •
Apraxia •
•
•
Loss of sensory ability to recognize objeccts
Disturbances in executive functioning •
•
Loss of purposeful movement
Agnosia •
Loss of language ability
Planning, organizing, abstract thinking
Diagnostic tests o
History and physical
o
Labs
o
X-rays
o
Mental status questionnaires
Stages of Alzheimer’s Disease p. 435 o
Stage 1 (Mild) Forgetfulness
o
Stage 2 (Moderate) Confusion
o
Stage 3 (Moderate to Severe) Ambulatory dementia
o
Stage 4 (Late) End stage
Problems in Dementia
•
•
o
Disorientation
o
Memory impairment
o
Risk for injury
o
Needs for physical help
o
Apathy
o
Poor communication
o
Uncontrolled emotion
o
Uncontrolled behavior
o
Incontinence
o
Mistaken beliefs
o
Poor decision making
o
Burden on family
Nursing Interventions o
Unconditional positive regard
o
Caregiver education
o
Communication
o
Planning daily activities
o
Maintaining safety
o
Managing behavior
o
Monitor nutrition and weigh
o
Monitor for increased confusion
Medications o
Cognex, Aricept, Exelon, Reminyl
Improves cognitive function, ADL performance, and behavior
Slow down progression, used in mild to moderate stage
2-14-08
Mrs. Travis
o
o
Increases level of acetycholine
Side effect: GI upset, liver toxicity
Namenda
Moderate to severe dementia
Targets the neurotransmitter glutamate
Vitamin E-suppose to help with brain circulation
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