Emotional Disorders In Children And Adolescents

EMOTIONAL DISORDERS IN CHILDREN AND ADOLESCENTS GROUP 8C

• Defined by sub average intelligence (IQ below 70 that is accompanied by impairments in performing ageexpected activities in daily. • Intelligence is measured by a standardized test and can be used to define the degree of mental retardation.

CLASSIFICATION OF MENTAL RETARDATION 1. Normal : 90 to 110 IQ 2. Borderline : 71 to 89 IQ 3. Mild : 50/55 to 70 IQ a. Educable : can achieve a mental age of 8 to 12 years b. Can learn to read, write, do arithmetic, achieve a vocational skill, and function in society

4. Moderate : 35/40 to 50/55 IQ a. Trainable : can achieve a mental age of 3 to 7 years b. Can learn the activities of daily living, social skills; can be trained to work in a sheltered workshop

5. Severe : below 20/25 to 35/40 IQ a. Barely trainable : can achieve a mental age of 0 to 2 years b. Totally dependent on others and in need of custodial care

6. Profound : below 20/25 IQ a. May attain mental age of young infant b. Requires total care

ETIOLOGIC FACTORS • Infection and Intoxication – congenital rubella; syphilis; maternal alcohol or drug consumption; chronic lead ingestion; kernicterus ( high bilirubin level) • Injury to the brain suffered during the prenatal, perinatal, or postnatal period; intracranial hemorrhage; anoxia; physical injury • Inadequate nutrition

• Gestational disorders including low birth weight, prematurity, or postmaturity • Chromosomal abnormalities such as Down Syndrome • Hereditary – family history of mental retardation

CLINICAL FINDINGS • Delayed milestones • Infants fails to suck • Head lag after 4 to 6 months of age • Slow in learning selfhelp • Slow to respond to new stimuli • Slow or absent speech development

• Mental abilities are concrete; abstract ability is limited; may repeat words (echolalia) • Cannot carry out complex instructions • Does not relate to peers; more secure with adults; comforted by physical touch • Short attention span,

THERAPEUTIC INTERVENTIONS • Prevent causes that damage brain cells such as hypoxia, untreated PKU • Identify condition early • Minimize long term consequences: • Treatment of associated problems • Infant stimulation • Parental education

NURSING CARE PLAN

• ASSESSMENT

– Developmental screening – Associated illnesses/ risk factors

• NURSING DIAGNOSIS - Interrupted family processes r/t having a child who is cognitively impaired - Compromised family coping r/t situational/ developmental crisis - Delayed growth and development r/t impaired cognitive function

Planning/Implementation • Educate the parents regarding developmental age • Set realistic goals : teach by simple steps for habit formation rather than for understanding of transference of learning • Break down the process of skills into simple steps that can be easily achieved. • Recognize that behavior modification is a very effective method of teaching these children; praise accomplishments to develop the child’s self-esteem. • Keep discipline simple, geared toward learning acceptable behavior rather than developing judgment.

Evaluation – Perform activities of daily living at optimum level – Family members make realistic decisions based on their needs and capabilities

• Refer to a group of disorders that affect a broad range of academic and functional skills including the ability to speak, listen, read, write, spell, reason and organize information. • A learning disability is not indicative of low intelligence. Indeed, research indicates that some people with learning disabilities may have average or above-average intelligence.

The 4 stages of information processing

• Input - This is the information perceived through the senses, such as visual and auditory perception. • Difficulties with visual perception can cause problems with recognizing the shape, position and size of items seen. • Difficulties with auditory perception can make it difficult to screen out competing sounds in order to focus on one of them, such as the sound of the teacher's voice.

• Integration - This is the stage during which perceived input is interpreted, categorized, placed in a sequence, or related to previous learning. • Students with problems in these areas may be unable to tell a story in the correct sequence, unable to memorize sequences of information such as the days of the week, able to understand a new concept but be unable to generalize it to other areas of learning, or able to learn facts but be unable to put the facts together to see the "big picture."

• Storage - retention of information in memory over an extended period of time. • Problems with memory can occur with short-term or working memory, or with long-term memory. Most memory difficulties occur in the area of short-term memory, which can make it difficult to learn new material without many more repetitions than is usual. Difficulties with visual memory can impede learning to spell.

• Output - Information comes out of the brain either through words, that is, language output, or through muscle activity, such as gesturing, writing or drawing. • Difficulties with language output can create problems with spoken language. • Difficulties with motor abilities can cause problems with gross and fine motor skills.

• People with gross motor difficulties may be clumsy, that is, they may be prone to stumbling, falling, or bumping into things. • People with fine motor difficulties may have trouble buttoning shirts, tying shoelaces, or with handwriting.

SPECIFIC LEARNING DISABILITIES • Reading disability • The most common learning disability. Of all students with specific learning disabilities, 70%-80% have deficits in reading. • Dyslexia - synonym for reading disability

• Common indicators of reading disability include difficulty with phonemic awareness -- the ability to break up words into their component sounds, and difficulty with matching letter combinations to specific sounds.

• Writing disability • Impaired written language ability may include impairments in handwriting, spelling, organization of ideas, and composition • Dysgraphia - used as an overarching term for all disorders of written expression.

• Math disability • Sometimes called dyscalculia, a math disability can cause such difficulties as learning math concepts (such as quantity, place value, and time), difficulty memorizing math facts, difficulty organizing numbers, and understanding how problems are organized on the page.

ETIOLOGIC FACTORS • No single definitive cause has been established; theories is to the cause are being studied. • Frequently found in association w/ a variety of medical condition ex. Lead poisoning , fetal alcohol syndrome

CLINICAL FINDINGS • Difficulty understanding and following instructions • Trouble remembering what someone just told them • Failing to master reading, spelling, writing, and/or math skills and therefore fails schoolwork

• Difficulty telling the difference between "right" and "left," problems identifying words or a tendency to reverse letters, numbers or words (e.g., confusing "b" with "d," 18 with 81, or "on" with "no.") • Lacking motor coordination when walking, playing sports, holding a pencil or trying to tie a shoelace

• Frequently loses or misplaces homework, schoolbooks or other items • Unable to understand the concept of time, confused by the difference between "yesterday," "today," and "tomorrow."

THERAPEUTIC INTERVENTION • Accept child and focus on strengths to raise self esteem • Identify learning deficits early • Minimize long term consequences • Treatment of associated problems

• Infant child stimulation • Parent Education

NURSING CARE PLAN • ASSESSMENT • Attainment or delay of developmental milestones • Parental behavior and attitude – Expectations – Acceptance or rejection – Encouragement or pressure

• Social History – Social activities – Peer and sibling relationships – Personal and social relationships – Specific and outstanding accomplishments

• Medical history – Vision – Hearing – General Health – Pregnancy, neonatal, and birth data – Past illness – Family History

• NURSING DIAGNOSIS • Anxiety related to frequent lack of success the inability to meet expectations of others, and the failure to develop meaningful relationships. • Impaired verbal communication r/t cerebral deficits and psychologic barriers. • Interrupted family processes r/t to disturbed family interactions and the disturbed behavior of infant, child, or adolescents

• PLANNING/IMPLEMENTATION • Develop a trusting relationship with the child and family • Provide activities consistent with disorder • Provide guidance and supervision • Maintain routines based on the child’s usual schedule • Set consistent and limits for behavior • Assist the parents to gain an accurate understanding of their child’s strength and weaknesses.

• EVALUATION • Participates in school and home activities • Follows directions • Carries task to completion

• Motor skills disorder, also called motor coordination disorder or motor dyspraxia, is a common disorder of childhood. It is estimated to be present in about 6% of school age children (between ages 5 and 11 yrs).

• Children with this disorder have associated problems including difficulty in processing information needed to guide their motor actions they may not be able to recall or plan complex motor activities such as: – dancing, – doing gymnastics, – catching or throwing a ball with accuracy, or – producing fluent legible handwriting.

• Motor skills disorder can be extremely disabling both in academic settings (school) as well as in everyday life due to impairment of functioning. Children and adults with this disorder are at risk for obesity, due to the higher rates of physical inactivity, and often suffer from low self-esteem as well as academic underachievement.

ETIOLOGIC FACTORS • There is no known exact cause of this disorder; however, it is often associated with physiological or developmental abnormalities such as: • prematurity, • developmental disabilities (cognitive deficit), • attention deficit hyperactivity disorder (ADHD), and • mathematics or reading learning disorders.

• It should be differentiated from other motor disorders, such as: • cerebral palsy, • muscular dystrophy, and • Inherited metabolic disorders.

CLINICAL FINDINGS • Children with this disorder have variable symptoms, depending on the age of diagnosis (as with most childhood disorders). • Young infants may present with nonspecific findings, such as hypotonia (floppy baby) or hypertonia (rigid baby). • Older infants may be delayed in their ability to sit, stand or walk.

• Toddlers may have difficulty feeding themselves. • Older children may have a hard time learning to hold a pencil, and tend to knock over drinking glasses more often than expected.

• As children with this disorder age, they often avoid physical activities, especially those requiring complex motor behaviors such as: • dancing, • gymnastics, • swimming, • catching or throwing a ball, • writing, or • drawing.

THERAPEUTIC INTERVENTION • Physical therapy • Occupational therapy • Early interventional program to help prepare child physically and socially for school • Ongoing assistance to promote social and academic success

A. Developmental Coordination Disorder • Developmental coordination disorder is diagnosed when children do not develop normal motor coordination (coordination of movements involving the voluntary muscles). • It has been called clumsy child syndrome, clumsiness, developmental disorder of motor function, and congenital maladroitness.

• Developmental coordination disorder is usually first recognized when a child fails to reach such normal developmental milestones as walking or beginning to dress him- or herself.

ETIOLOGIC FACTORS • The symptoms of developmental coordination disorder vary greatly from child to child. The general characteristic is that the child has abnormal development of one or more types of motor skills when the child's age and intelligence quotient (IQ) are taken into account. In some children these coordination deficiencies manifest as an inability to tie shoes or catch a ball, while in other children they appear as an inability to draw objects or properly form printed letters.

CLINICAL FINDINGS • difficulty performing tasks that involve both large and small muscles, including forming letters when they write, throwing or catching balls, and buttoning buttons. • can lead to social or academic problems for children. • problems forming letters when they write by hand, or drawing pictures,

• general unsteadiness and slight shaking • an at-rest muscle tone that is below normal • muscle tone that is consistently above normal • inability to move smoothly because of problems putting together the subunits of the whole movement • inability to produce written symbols • visual perception problems related to development of the eye muscles

• Children with developmental coordination disorder have difficulty performing tasks that require motor skills or eye-hand coordination, such as catching a ball.

NURSING CARE PLAN • ASSESSMENT • Developmental screening for delayed milestones • Associated illness/ risk factors • Visual acuity • Play activities • Child’s response to lack of coordination

• NURSING DIAGNOSIS • Anxiety r/t a frequent lack of success, the inability to meet expectations of others, and the failure to develop meaningful relationships • Risk for injury r/t sensory deficits, altered judgment and sensorimotor deficits • Risk for falls r/t impairment in motor coordination (gross motor skills) and sensorimotor deficits

• PLANNING/IMPLEMENTATION • Teach need for prevention of injury from falls • Encourage exercises such as swimming • Foster independence by emphasizing abilities and achievements rather than limitations • Help parents to cope w/ child’s lack of coordination • Reward achievement of motor milestones ( crawling, sitting, walking, improved handwriting)

• EVALUATION • Maintains or increases mobility • Participates in desired activities • Verbalizes positive self-image • Engage in activities suitable to interest, capabilities, and developmental level

• A. AUTISM (mindblindedness) Incidence: Boys • Onset: 3y.o. above • Characteristic: Impairment of interaction skills •

ETIOLOGIC FACTORS • • • •

Idiopathic Genetic factor Abnormality in Brain Chemicals Abnormality in Brain Structure

CLINICAL FINDINGS •

Difficulty in Social Interactions – – – – – –

Unaffectionate Loner Inapt. Attachment to objects Inapt. Laughing Lack of interest in the environment May avoid eye contact

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Difficulty with Communication • Echolalia • Communicate in gestures • Difficulty in expressing needs

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Stereotype Behavior • Sustained repetitive motor behavior (spinning self) • Insensitive to pain • No real fear of Danger

How Autism Diagnosed? • for the first 2years of life, the child should be checked for the following developmental deficits; • 12mos – No gestures and pointing • 18mos – No single words spoken • 24mos – No two words spontaneous expression, Loss of any language or social skills at any age

THERAPEUTIC INTERVENTION •

Reduce behavioral symptoms – Reduce temper tantrums – Aggressiveness – self-injury

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DOC: Haloperidol (Haldol) & Resperidone (Risperdal)

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Prevent Self-Injury Promote Learning and Development SpEd (Special Education) Family Therapy

B. RETT’S DISORDER Incidence: Girls • Characteristic: multiple deficits after a period of normal functioning • Onset: from birth to 5mos •

CLINICAL FINDINGS •

Behavioral pattern (stereotype)

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Difficulty with Communication

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Social Interaction

– Head Banging – Tantrums – Body twisting

– Loss of Expressive language – Difficulty in expressing needs – Loss of interest in Social Environment

Difference between Rett’s from Autistism RETT’S

• • • • • • • •

Common on girls Loss of acquired language Loss of hand function (+) Ataxia Seizure prone Abnormal Chewing Microcephaly Delayed physical growth

• • • • • • • •

AUTISM Common in boys Inapt. language Preserved hand function (-)Ataxia No seizure Normal Chewing ability Normal Normal

C. CHILDHOOD DISINTEGRATIVE DISORDER also known as Heller's syndrome and disintegrative psychosis, is a rare condition characterized by late onset (>3 years of age) of developmental delays in language, social function, and motor skills.

• CDD has some similarity to autism, and is sometimes considered a low-functioning form of it, but an apparent period of fairly normal development is often noted before a regression in skills or a series of regressions in skills. • The syndrome was originally described by Austrian educator Theodore Heller in 1908, 35 years before Leo Kanner described autism, but it has not been officially recognized until recently. Heller used the name dementia infantilis for the syndrome.

CLINICAL FINDINGS • A child affected with childhood disintegrative disorder shows normal development, generally up to an age of 2 years, and he/she acquires "normal development of ageappropriate verbal and nonverbal communication, social relationships, motor, play and self-care skills" comparable to other children of the same age.

• However, from around the age of 2 through the age of 10, skills acquired are lost almost completely in at least two of the following six functional areas: • Language skills • Receptive language skills • Social skills & self-care skills • Control over bowel and bladder • Play skills • Motor skills

• Lack of normal function or impairment also occurs in at least two of the following three areas: – Social interaction – Communication – Repetitive behavior & interest patterns

ETIOLOGIC FACTORS • The exact causes of childhood disintegrative disorder are still unknown. Sometimes CDD surfaces abruptly within days or weeks, while in other cases it develops over a longer period of time • Comprehensive medical and neurological examinations in children diagnosed with childhood disintegrative disorder seldom uncover an underlying medical or neurological cause

• Lipid storage diseases: In this condition, a toxic buildup of excess fats (lipids) takes place in the brain and nervous system. • Subacute sclerosing panencephalitis: Chronic infection of the brain by a form of the measles virus causes sub acute sclerosing panencephalitis. This condition leads to brain inflammation and the death of nerve cells. • Tuberous sclerosis (TSC): TSC is a genetic disorder. In this disorder, tumors may grow in the brain and other vital organs like kidneys, heart, eyes, lungs, and skin. In this condition, non-cancerous (benign) tumors grow in the brain.

THERAPEUTIC INTERVENTION • Behavior therapy: Its aim is to teach the child to relearn language, self-care and social skills. The programs designed in this respect "use a system of rewards to reinforce desirable behaviors and discourage problem behavior.“ A consistent approach by all concerned result into a better treatment. •

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Medications: There are no medications available to treat directly CDD. •

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Antipsychotic medications - are used to treat severe behavior problems like aggressive stance and repetitive behavior patterns. Anticonvulsant medications - are used to control seizures.

D. ASPERGER’S DISORDER a developmental condition that is relatively rare, but frequently misdiagnosed. Children with this disorder usually have an average to above average intelligence, but have difficulty with social interactions, adherence to rules, and emotional sensitivity and reciprocity – more common in males.

ETIOLOGIC FACTORS • Genetic factors • 50% of AS patients have a history of oxygen deprivation during the birth process, which has led to the hypothesis that the disorder is caused by damage to brain tissue before or during childbirth.

CLINICAL/BEHAVIORAL FINDINGS • socially aloof • may have poor eye contact • do not have the skills to sustain positive interaction • Their major social deficit is an inability to understand the perspective of another person • may create their own rituals and insist that others adhere to their rules.

• language development may be delayed • have difficulty deriving the full meaning of both written and spoken language. • Lack of common sense ,they have poor impulse control and deficits in planning, self-monitoring, and transitioning from one situation to another. • Motor clumsiness is not an essential part of the syndrome and is usually seen in pre-school children. Motor clumsiness may extend into later development in children with AD

THERAPEUTIC INTERVENTION • If a child is suspected of having AD, he or she should be referred to a neuropsychologist for evaluation. • The neuropsychologist  will make the diagnosis by: • •

Taking a thorough developmental history; Obtaining detailed information from teachers and parents Administering neuropsychological testing,

• After a clear diagnosis is made, specific interventions can be developed to meet the academic, social, and emotional needs of the child. These include:

• Use of medications like Ritalin or Risperdol; • Behavior therapy that teaches social skills, helps the child to understand emotions, improves motor skills, and encourages the understanding and perspectives of others; • Family education and support; and • Classroom interventions. Not all children with AD need special education,

NURSING CARE PLAN • ASSESSMENT • Behavior associated w/autism • Rejection of physical contact with others • Preference for inanimate, spinning, shiny objects • Behavior directing emotional energy inward rather than toward the external environment

• NURSING DIAGNOSIS • Anxiety r/t failure to develop meaningful relationships and separation from parents. • Impaired verbal communication r/t delay or absence, or repetitive use of language • Personality identity disturbance r/t the inability to distinguish between self and nonself

• PLANNING/IMPLEMENTATION • Increase the use of touch gradually; accept the child’s needs to push away; use touch to reinforce difference between client and nurse. • Provide a consistent routine for activities of daily living • Maintain a consistent, familiar environment

• Use picture boards to assist in communication; participate in child’s activities • Set consistent and firm limits for behavior • Support family’s decision for homecare or institutionalization • Encourage verbalization of feelings • Provide parents with a list of available community resources.

• EVALUATION

• Sits in a group • Decrease self-destructive behavior • Increases use of first-person speech • Uses less stereotyped and repetitive motor behaviors • Depending on age, attends a therapeutic nursery program, a day treatment program or SPED CLASSES

A. ATTENTION DEFICIT

HYPERACTIVITY DISORDER

• Is the latest terminology used to refer to a persistent pattern of inattention or hyperactivity with impulsivity. • For most children, the disorder stabilizes in early adolescence, and in most cases symptoms subside between late adolescence and early adulthood

ADHD CLASSIFIED ACCDG. TO 3 SUBTYPES: •

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Combined type – (most common) the individual has six or more symptoms of inattention and six or more symptoms of hyperactivity and impulsivity. Predominantly inattentive type – the individual has six or more symptoms of inattention but fewer than six symptoms of hyperactivity w/ impulsivity

C. Predominantly hyperactive and impulsive type – the individual has six or more symptoms of hyperactivity and impulsivity but fewer than six symptoms of inattention.

ETIOLOGIC FACTORS • The etiology is uncertain and may be related to any illness or trauma affecting the brain at any stage of development. • Predisposing factors such as; • • • • • • •

Exposure to toxins Medications Chronic otitis media Head trauma Perinatal complications Neurologic infections Mental disorders

CLINICAL/BEHAVIORAL FINDINGS • Inappropriately inattentive • Excessive impulsiveness (ex. cannot take turns, interrupts • Short attention span; easy distractibility; does not complete tasks • Squirming and fidgeting; hyperactivity may or may not be present • Difficulty organizing task and activities • Excessive talking • Symptoms persist although adolescents usually become more goal-directed and less impulsive

THERAPEUTIC INTERVENTION • Psychologic counseling • Teaching and modeling more adaptive coping behaviors • Psychotropic medications: • Methylphenidate HCl (Ritalin) is frequently used

NURSING CARE PLAN • ASSESSMENT • Hx of child’s behavior from parents, teachers, and guidance counselor • Behavior reflecting impulsiveness and pattern of inattention • Difficulty in following instructions • Inability to sit without fidgeting or moving about • Easy distractibility by extraneous stimuli

• NURSING DIAGNOSIS • Anxiety r/t an inability to meet expectation of others • Self-esteem disturbance r/t negative evaluation by self and others about capabilities and performance • Impaired verbal communication r/t to excessive talking and intrusiveness • Impaired social interaction r/t excessive talking and intrusiveness

• PLANNIG/IMPLEMENTATION

• Set realistic, attainable goals • Plan activities to provide a balance bet. Energy expenditure and quiet time • Structure situation to provide less stimulation • Provide firm and consistent discipline; ignore temper tantrums • Provide exercises in perceptual- motor coordination and balance • Provide opportunities so the child can experience success and satisfaction • Administer prescribed medication

• EVALUATION • Participates in school and home activities • Carries task to completion • Follows directions

B. CONDUCT DISORDER

• a persistent antisocial behaviors in children and adolescents that significantly impairs their ability to function in social, academic, or occupational areas. • -it is frequently associated with early onset of sexual behavior, drinking, smoking, use of illegal substances, and other reckless or risky behaviors

SUBTYPES: a. Childhood-onset: involves symptoms before 10 years of age. • - more likely to have persistent conduct disorder and to develop antisocial personality disorder as adults •

Symptoms: physical aggression toward others, disturbed peer relationships

b. Adolescent-onset: no behaviors of conduct disorder until after 10 years of age. • •

- less likely to be aggressive and have normal peer relationships - less possibility to have constant or persisting conduct disorder or antisocial personality disorder as adults

CLASSIFICATIONS: •

•

•

Mild: the person’s conduct problems cause relatively minor harm to others Examples: lying, truancy, staying out late without permission Moderate: the number of conduct problems increases as well as the amount of harm to others Examples: vandalism, theft Severe: many conduct problems that cause considerable harm to others. Examples: forced sex, cruelty to animals, use of a weapon, burglary, robbery

C. OPPOSITIONAL DEFIANT DISORDER • consists of an enduring pattern of uncooperative, defiant, and hostile behavior toward authority figures without major antisocial violations. • diagnosed only when behaviors are more frequent and intense than in unaffected peers and cause dysfunction in social, academic, or work situation.

CLINICAL/BEHAVIORAL FINDINGS • • • • •

aggression to people and animals destruction of property deceitfulness and theft serious violation of rules little empathy for others, low selfesteem, poor frustration tolerance, temper outbursts

ETIOLOGIC FACTORS Genetic Vulnerability Environmental Adversity Poor coping interactions The child may be socialized or under socialized • The child may be aggressive or nonaggressive • • • •

RISK FACTORS • • • •

Poor parenting Low academic achievement Poor peer relationships Low self-esteem

THERAPEUTIC INTERVENTION 1. Early intervention and prevention is more effective than treatment 2. NO ONE treatment is suitable for all ages 3. For Pre-school aged: Programs such as headstart result in lower rates of delinquent behavior and conduct disorder through use of parental education about normal growth and development, stimulation for the child, and parental support during crises

4. For School-aged: child, family, and

school environment are the focus of treatment. Family Therapy is essential for children in this age group. 5. For Adolescents: Peer Dependence. Individual Therapy is used. Treatment usually includes conflict resolution, anger management, and teaching social skills. 6. Medications alone have little effect but may be used in conjunction with treatment for specific symptoms.

NURSING CARE PLAN • ASSESSMENT

• History: • (+) history of disturbed relationships with peers, aggression toward people or animals, destruction of property, deceitfulness or theft, and serious violation of rules • Appearance, speech, and motor behavior are typically normal but may be somewhat extreme. Examples: body piercing, tattoos, hairstyle, clothing, etc.

• Quiet and reluctant to talk, aggressive and hostile, thoughts or fantasies about death and violence are common, intellectual capacity is not impaired but has poor grades. Consistently breaks rules with no regard for the consequences. Appears tough but with low selfesteem.

• NURSING DIAGNOSES • Impaired social interaction r/t aggressive behavior • Risk for violence: self directed or other-directed r/ t inability to discharge emotion verbally and the inability to control aggression • Impaired verbal communication r/t aggressive behavior • Noncompliance r/t disregard of rules and norms

• PLANNING/IMPLEMENTATION • Decreasing violence and increasing compliance with treatment • Improving coping skills and selfesteem • Promoting social interaction • Providing client and family education

• EVALUATION • Decreases destructive acts directed at self or others • Demonstrates appropriate behavior • Parents express realistic expectations of child • Verbalizes a realistic selfappraisal of strengths and weaknesses

COMMUNICATION INCLUDES: • – – – –

LANGUAGE is made up of socially shared rules that include the following:

What words mean (e.g., "star" can refer to a bright object in the night sky or a celebrity) How to make new words (e.g., friend, friendly, unfriendly) How to put words together (e.g., "Peg walked to the new store" rather than "Peg walk store new") What word combinations are best in what situations ("Would you mind moving your foot?" could quickly change to "Get off my foot, please!" if the first request did not produce results)

SPEECH is the verbal means of communicating. Speech consists of the following:

• –

–

– –

Articulation: How speech sounds are made (e.g., children must learn how to produce the "r" sound in order to say "rabbit" instead of "wabbit"). Voice: Use of the vocal folds and breathing to produce sound (e.g., the voice can be abused from overuse or misuse and can lead to hoarseness or loss of voice). Fluency: The rhythm of speech (e.g., hesitations or stuttering can affect fluency). Intonation, rate, and intensity.

LANGUAGE DISORDER • Receptive Language – When a person has trouble understanding others. • Expressive Language – When a person has trouble sharing thoughts, ideas, and feelings to others.

SPEECH DISORDER • When a person is unable to produce speech sounds correctly or fluently, or has problems with his or her voice, then he or she has a speech disorder.

ETIOLOGICAL FACTORS COMMUNICATION DISORDER Hearing impairment - full or partial hearing impairment may cause difficulty in speech and language development. • An assessment of hearing is one of the first steps in the investigation of speech and language problems.

• Physical disability - cleft lip and palate, or malformations of the mouth or nose may cause communication disorders. • More involved disabilities, such as severe cerebral palsy, may preclude any speech at all and for these nonverbal children augmentative communication methods must be used.

• Developmental disability - some children (not all) with a developmental disability or Down's syndrome may be slower to learn to talk and may need extra assistance. • Children with learning disabilities may have communication disorders.

• Many learning disabled children have difficulty with receptive or expressive language. • Without appropriate intervention children with communication disorders are at high risk for educational failure.

• Children with Pervasive Development Disorders (P.D.D.), or Autism spectrum disorders will also have communication disorders. • Many children with PDD or Autism have difficulty with social skills and their behavior and conversation skills may be limited or inappropriate.

• Children with significant behavior or emotional problems may also have a communication disorder.

TYPES OF COMMUNICATION DISORDER •

Expressive Language Disorder Characterized by: – Having a limited vocabulary and grasp of grammar. – A general language impairment that puts the person onto the level of a younger person – A person can be as young as 2 or 3 years old with the disorder.

• Implications: • Affects work and schooling in many ways. • Socialization is affected.

• Treatment: • Treated by SPECIFIC speechlanguage therapy. • Usually cannot be expected to go away on its own. • Language intervention activities • Articulation therapy • Oral motor therapy

B. Mixed Receptive and Expressive Language Disorder Characterized by: • Both the receptive and expressive areas of communication may be affected in any degree, from mild to severe.

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Low assessment scores for: • Information • Vocabulary and Comprehension » Spatial concepts (e.g. difference between “over” and “under;” “here” and “there.”) » Difficulty in understanding word problems and instructions » Difficulty in using words

• Treatment: • Consult a speech-language pathologist or therapist to receive treatment. • Most treatments are short-term and rely on accommodations made in the person’s environment (Special schools, environment modification.) • Language intervention activities • Articulation therapy • Oral motor therapy

C. Phonological Disorder • If there is no known cause, it is sometimes called "developmental phonological disorder." • If the cause is known to be of neurological origin, the names "dysarthria" or "dyspraxia" are often used.

• Phonological disorder is characterized by a child's inability to create speech at a level expected of his or her age group because of an inability to form the necessary sounds.

• Treatment: • Consult a speech-language pathologist or therapist to receive treatment. • Most treatments are short-term and rely on accommodations made in the person’s environment (Special schools, environment modification.) • Articulation therapy • Oral motor therapy

D. Stuttering • Flow of speech is disrupted by involuntary repetitions and prolongations of sounds, syllables, words or phrases, and involuntary silent pauses or blocks in which the stutterer is unable to produce sounds. • It has no bearing on intelligence.

• Stuttering is generally not a problem with the physical production of speech sounds or putting thoughts into words. • Anxiety, low self-esteem, nervousness, and stress therefore do not cause stuttering per se, although they are very often the result of living with a highly stigmatized disability and, in turn, exacerbate the problem.

• Treatment: • Consult a speech-language pathologist or therapist to receive treatment. • Articulation therapy • Oral motor therapy.

NURSING CARE PLAN • ASSESSMENT • Characteristics, pattern, and onset of speech disorder • Factors or situations that precipitate disturbed speech patterns • Level of self-esteem • Level of anxiety and frustrations • Family Hx of speech disorder

• NURSING DIAGNOSIS

• Anxiety r/t a frequent lack of success, an inability to meet expectations of others, and a failure to develop meaningful relationships • Risk for situational low self-esteem r/t difficulty with receptive or expressive language skills or the articulation of speech • Ineffective coping r/t an inability to meet role expectations and a poorly developed or inappropriate use of defense mechanism

• PLANNING/IMPLEMENTATION • Encourage client to adhere to speech therapy routine • Allow individual time to verbalize; do not complete word or sentence • Avoid nonverbal behavior that implies impatience to the client

• EVALUATION • Demonstrates a decrease in speechpattern disturbances. • Demonstrates increased participation in social and public situations. • Exhibits an increase in self-esteem • Continues with prescribe therapy

• Tic disorders are characterized by the persistent presence of tics, which are abrupt, repetitive involuntary movements and sounds that have been described as caricatures of normal physical acts. • Tics are sudden, painless, nonrhythmic behaviors that are either motor (related to movement) or vocal and that appear out of context

CLASSIFICATION: B. SIMPLE - using only a few muscles or simple sounds • Simple motor tics are brief, meaningless movements like eye blinking, facial grimacing, head jerks or shoulder shrugs. • They usually last less than one second.

B. COMPLEX - using many muscle groups or full words and sentences • Complex motor tics involve slower, longer, and more purposeful movements like sustained looks, facial gestures, biting, banging, whirling or twisting around, or copropraxia (obscene or disgusting gestures).

ETIOLOGIC FACTORS • Imbalance in neurotransmitters is believed to be the underlying cause • Familial or autosomal-dominant patterns exist in high percentage of tic disorders • Classified as a rapid, recurrent, nonrhythmic , stereotyped motor movement or vocalization involving a few or many muscle movements and vocal tics

• Researchers have also found changes within the brain itself, specifically in the basal ganglia (an area of the brain concerned with movement) and the anterior cingulate cortex. • Functional imaging using Positron Emission Tomography(PET) and Single Photon Emission Computerized Tomography(SPECT) has highlighted abnormal patterns of blood flow and metabolism in the basal ganglia, thalamus, and frontal and temporal cortical areas of the brain.

TYPES OF TIC DISORDER 1. TOURETTE DISORDER • ONSET – before age 18 • DURATION – 12 months • Evidence of multiple motor and at least one vocal tic

TOURETTE’S DISORDER-

The tics occur many times a day, usually in bouts, nearly every day or intermittently for a period of more than one year. The patient is never symptomfree for more than three months at a time.

2. CHRONIC MOTOR OR VOCAL DISORDER • ONSET – before age 18 • DURATION – more than 12 months • Evidence of single or multiple motor or vocal tics, but not both.

CHRONIC MOTOR OR VOCAL DISORDER The tics occur many times a day nearly every day, or intermittently for a period of more than one year. During that time, the patient is never without symptoms for more than three consecutive months. The severity of the symptoms and functional impairment is usually much less than for patients with Tourette's disorder.

3. TRANSIENT DISORDER • ONSET – before age 18 • DURATION – no more than 12 consecutive months • Evidence of motor and or vocal tics lasting for at least 1 month • It is the mildest form of tic disorder, and may be underreported because of its temporary nature

TRANSIENT DISORDER There may be single or multiple motor and/or vocal tics that occur many times a day nearly every day for at least four weeks, but not for longer than one year.

CLINICAL FINDINGS • Involuntary, uncontrolled, multiple rapid movements of muscles Ex. Eye blinking, twitching, and head shaking that occur episodes throughout the day

• Involuntary production of sound Ex. Throat clearing, grunting, barking, or the utterance of socially unacceptable words usually associated with Tourette’s disorder

• Can be controlled for short duration; not usually present during sleep

THERAPEUTIC INTERVENTIONS • Treatment for any precipitating factor such as head injury, psychoactive substance, intoxication, or infection • Supportive individual or group counseling • Medications such as sedatives or anticonvulsants may be prescribed, but usually have minimal effect; CNS stimulant should be avoided because they increase symptoms in most individual

NURSING CARE PLAN

• ASSESSMENT

• Hx, onset, and presence of behavior associated with tic disorders • Exacerbation of tics by stress • Decreased tic activity during sleep • Hx of psychoactive substance use to determine if tic disorder is r/t intoxication • Hx of CNS trauma, infection or degeneration • Family Hx of tic disorder • Hx of neuroleptic agents to determine whether tics are direct physiologic consequence of medication

• NURSING DIAGNOSIS

• Anxiety r/t the inability to meet expectations of others • Disturbed body image r/t uncontrollable body movements and production of sounds • Self-esteem disturbance r/t uncontrollable body movements and production of sounds • Risk for injury r/t sensorimotor deficits

• PLANNING/IMPLEMENTATION • Accept behavior, recognizing it is often uncontrollable • Help client to identify precipitating factors • Support client’s attempts to control tic • Educating the patient and family about the course of the disorder in a reassuring manner

• EVALUATION • Demonstrates a decrease in tic behavior • Accepts presence of tic • Functions socially despite presence of tic • Family members with Tourette’s disorder respond positively to advice regarding genetic counseling

A. PICA • Persistent ingestion of non nutritive substance such as: • Paint • Hair • Cloth • Leaves • Sand • Clay or soil

• Commonly seen in children w/ mental retardation • Occasionally occurs in pregnant women • In most instances behavior last for several months and then remits • Pica may be benign, or it may have lifethreatening consequences. • In children aged 18 months to 2 years, the ingestion and mouthing of nonnutritive substances is common and is not considered to be pathologic

ETIOLOGY • It is more frequently seen among children with developmental speech and social devt’l delays • A substantial number of adolescents w/ pica exhibited depressive Sx and use of substances • Nutritional deficiencies - ex. Cravings for dirt and ice are sometimes associated with iron and zinc deficiencies which are corrected by their administration • Compensatory mechanism to satisfy oral needs • Malnutrition, especially in underdeveloped countries, where people with pica most commonly eat soil or clay

RISK FACTORS • • • • • • • •

parental/child psychopathology family disorganization environmental deprivation pregnancy epilepsy brain damage mental retardation pervasive developmental disorders

CLINICAL FINDINGS • Sand or soil is associated with gastric pain and occasional bleeding. • Chewing ice may cause abnormal wear on teeth. • Eating clay may cause constipation. • Swallowing metal objects may lead to bowel perforation. • Eating fecal material often leads to such infectious diseases as toxocariasis, toxoplasmosis, and trichuriasis. • Consuming lead can lead to kidney damage and mental retardation.

DIAGNOSTIC PROCEDURES: • Abdominal x rays • Barium examinations of the upper and lower gastrointestinal (GI) tracts • Upper GI Endoscopy to diagnose the formation of bezoars (solid masses formed in the stomach) or to identify associated injuries to the digestive tract

• Treatment emphasizes psychosocial, environmental, and family guidance approaches • Lead poisoning resulting from pica may be treated by chelating medications, which are drugs that remove lead or other heavy metals from the bloodstream • Dimercaprol, which is also known as BAL or British Anti-Lewisite; • Edetate Calcium Disodium (EDTA).

THERAPEUTIC INTERVENTION • The most effective strategies are based on behavior modification, One of the first steps is to encourage children to eat a healthy, balanced diet. Replacing non-food items that children ingest with more suitable, nutritious food items is an important goal. • Speaking with a dietitian who is familiar with Pica can be very helpful in coming up with appropriate and tempting menus.

B. RUMINATION DISORDER • repeated regurgitation and rechewing of food • the child brings partially digested food up into the mouth and usually rechews and reswallows the food • relatively uncommon • more often occurs in boys than in girls • results in malnutrition, weight loss, and even death in about 25% of affected infants

ETIOLOGY • Physical illness or severe stress may trigger the behavior • Neglect of or an abnormal relationship between the child and the mother or other primary caregiver may cause the child to engage in self-comfort. For some children, the act of chewing is comforting. • It may be a way for the child to gain attention.

CLINICAL FINDINGS • • • • • •

Repeated regurgitation of food Repeated re-chewing of food Weight loss Bad breath and tooth decay Repeated stomach aches and indigestion Raw and chapped lips

COMPLICATIONS

• Malnutrition • Lowered resistance to infections and diseases • Failure to grow and thrive • Weight loss • Stomach diseases such as ulcers • Dehydration • Bad breath and tooth decay • Aspiration pneumonia and other respiratory problems (from vomit that is breathed into the lungs) • Choking • Death

THERAPEUTIC INTERVENTIONS • Encouraging more interaction between mother and child during feeding; giving the child more attention • Reducing distractions during feeding • Making feeding a more relaxing and pleasurable experience • Distracting the child when he or she begins the rumination behavior • Aversive conditioning, which involves placing something sour or bad-tasting on the child's tongue when he or she begins to vomit

• Psychotherapy (a type of counseling) for the mother and/or family may be helpful to improve communication and address any negative feelings toward the child due to the behavior. • There are no medications used to treat rumination disorder.

C. FEEDING DISORDERS IN INFANCY OR EARLY CHILDHOOD • is characterized by persistent failure to eat adequately, which results in significant weight loss or failure to gain weight • equally common in boys and in girls • occurs most often during the first year of life • Feeding disorders are diagnosed when the infant or young child appears malnourished and the problem is not caused by a medical condition

ETIOLOGY • poverty • dysfunctional child-caregiver interactions • parental misinformation about appropriate diet to meet the child's needs • a disorder that causes mental retardation.

CLINICAL FINDINGS • • • • • •

Constipation Excessive crying Excessive sleepiness (lethargy) Irritability Poor weight gain Weight loss

COMPLICATIONS • • • • • • •

malnourished or starving children irritable difficult to console apathetic withdrawn Unresponsive Delays in development, as well as growth, can occur

• Laboratory abnormalities • Blood tests may reveal a low level of protein or hemoglobin in the blood. • Hemoglobin is an iron-containing substance in blood that carries oxygen to body cells.

THERAPEUTIC INTERVENTIONS • Increase the number of calories and amount of fluid the infant takes in • Correct any vitamin or mineral deficiencies • Identify and correct any underlying physical illnesses or psychosocial problems • A short period of hospitalization may be required to accomplish these goals. •

• Collaborative interventions – Refer to dietitian who can consult on nutrition and diet issues – behavioral psychologist who can design and implement a behavior modification program

A. ENCOPRESIS • repeated passage of feces into inappropriate places such as clothing or the floor by the child who is at least 4 years of age either chronologically or developmentally • often involuntary, but it can be intentional • Involuntary encopresis – associated w/ constipation that occurs for psychological not medical reasons • Intentional encopresis – often associated w/ oppositional defiant disorder or conduct disorder

B. ENURESIS • Repeated voiding of urine during the day or at night into clothing or bed by a child at least 5 years of age either chronologically or developmentally • Most often involuntary • When intentional it is associated w/ disruptive behavior disorder • 75% of children w/ enuresis have a first degree relative who had the disorder

CLINICAL FINDINGS • More common in males than females • No identifiable physical problems are present • Chronologic age is at least 4 yrs or equivalent developmental level • Primary – occur before bladder training has been accomplished • Secondary – after a period of controlled continence

• Nocturnal bedwetting is most frequent; child may or may not be aware of voiding or recall a dream about the act of urinating • Loss of self esteem; anxiety, rejection by peers may cause child to avoid situations ( camp, school)

THERAPEUTIC INTERVENTION • Psychotherapy • Medications such as TCA for children over the age of 5 to treat enuresis • Bowel retraining program

NURSING CARE PLAN • ASSESSMENT • Hx of toileting behaviors • Hx of school or family difficulties • Level of self-esteem • Secondary gains achieved by behavior

• NURSING DIAGNOSIS • Anxiety r/t a frequent lack of success and inability to meet others expectations • Risk for impaired parenting r/t child’s pattern of disturbed behavior (encopresis or enuresis) not responding to discipline or other control measures • Disturbed sleep pattern r/t emotional dysfunction

• PLANNING/IMPLEMENTATION • Change linen and clothing in a nonjudgmental manner to avoid further embarrassment for the client • Recognize and accept the fact that the act usually is not motivated by hostility • Help parents cope with feelings such as guilt, failure or anger

• EVALUATION • Demonstrates a decrease in encopresis or enuresis • Exhibits an increase in self-esteem • Verbalizes understanding that behavior is neither good nor bad but solution requires outside assistance • Parents verbalize understanding that behavior is related to an emotional problem, not hostility

A. SEPARATION AXIETY DISORDER • characterized by anxiety exceeding that expected for developmental level related to separation from the home or those to whom the child is attached. • may result to avoidance behaviors • often accompanied by nightmares and multiple physical complaints • equally common in males and in females • begins in infancy (oral phase development)

CLINICAL/BEHAVIORAL FINDINGS • Problems w/ sleeping unless near the person to whom child has attachment • Refusal to attend school in order to remain near the person to whom child has attachment • Physical complaints of headaches and stomach aches when separation is anticipated

B. SELECTIVE MUTISM

• persistent failure to speak in social situations where speaking is expected such as school • children may communicate by gestures, nodding or shaking the head, or occasionally one-syllable vocalizations in a voice different from their natural voice • they are often excessively shy, socially withdrawn or isolated, and clinging, and may have temper tantrums • Interferes with educational , social, and occupational achievement • Onset usually before age 5

CLINICAL/BEHAVIORAL FINDINGS • Avoidance of speaking in social environment outside the home • Social involvement limited to family members or people who are familiar to the child • Excessive shyness and timidity when confronted with strangers

C. REACTIVE ATTACHMENT DISORDER • involves a markedly disturbed and developmentally inappropriate social relatedness in most situation • begins before 5 years of age • associated with grossly pathogenic care such as parental neglect, abuse, or failure to meet the child’s basic physical or emotional needs • repeated changes in primary caregivers prevent the establishment of stable attachment • onset before age 5

Types: • Inhibited Type: disturbed social relatedness maybe evidenced by the child’s failure to initiate or respond to social interaction 2. Disinhibited Type: lack of selectivity in choice of attachment figures or indiscriminate stability – Treatment: » SAFETY! » Individual and family therapy

CLINICAL/BEHAVIORAL FINDINGS • Psychosocial deprivation resulting in child’s failure to initiate or respond to most special interactions • Difficulty in choice of attachment figures • Onset in the first several years of life; begins before age 5

D. STEREOTYPE MOVEMENT DISORDER •

involves repetitive motor behaviors that is non-functional and either interferes with normal activities or results in self-injury requiring medical treatment such as waving, rocking, twirling objects, biting fingernails, banging the head, biting or hitting oneself, or picking at the skin or body orifices.

• the more severe the retardation, the higher the risk for self-injury • -associated with many genetic, metabolic, and neurologic disorders, and often accompanies mental retardation

THERAPEUTICS INTERVENTIONS • Psychotherapy: in children usually in the form of play therapy • Psychopharmacology • Stimulants • Anti-anxiety agents

NURSING CARE PLAN • ASSESSMENT • Hx of child’s behavior from parents and teachers • Presence of sleep disturbances • Interpersonal functioning w/ others • Physical complaints • Hx of attendance at school • Child’s appearance and behavior

• NURSING DIAGNOSIS • Anxiety r/t the inability to meet expectations of others and a failure to develop meaningful relationships • Ineffective coping r/t inadequately developed or inappropriate use of defense mechanism • Disturbed sleep pattern r/t emotional dysfunction • Impaired social interaction r/t withdrawn behavior and speech disturbances

• PLANNING/IMPLEMENTATION • Provide consistent caregivers • Introduce child to new situations gradually; permit the child to bring a familiar, comforting toy • Allow parents to stay w/ child as long as possible • Involve family in multifamily therapy to work through problems of daily life an to gain new information and more adaptive coping skills

• EVALUATION • Demonstrates a decrease in sleep disturbances • Attend school on a consistent basis • Verbalizes fewer physical complaints • Develops relationships outside of family members and the home environment • States a decrease in episodes of anxiety and worry • Behaviors of family members demonstrate a reduction in overprotection of child