Download THE CHILD

THE CHILD
Risk Factors for Childhood Emotional Disorders
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Poverty
Minority status
Homelessness
Severe caregiver conflicts
Caregiver psychopathology or substance abuse
Physical or sexual abuse
Chronic illness or disability of caregivers
ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER (ADHD)
• Diagnosed when signs of inattention, hyperactivity, or both are displayed
Symptoms include:
• Ignoring instructions and tasks
• Disorganization
• Fidgeting and squirming
• Being easily provoked to anger
DIAGNOSIS
• Must be present before age 7
• Must be present in two or more settings
• Must be clear evidence of clinically significant impairment in social, academic, or occupational functioning
• Can only be diagnosed by matching behavior against DSM criteria
ETIOLOGY
• Dopamine hypothesis
• Genetic role
• Diet and food additives
• Maternal use of stimulants and tobacco
PHARMACOLOGICAL TREATMENT
Psychostimulants—Ritalin (methylphenidate) most common
• Side effects—insomnia, decreased appetite, abdominal pain, headaches, jitteriness, tics
Newer drug Strattera (atomoxetine)
• Not a controlled substance, easier dosing
PROGNOSIS
• Many symptoms decrease with time
• May follow into adulthood
• Many adults being diagnosed with ADHD
• Relatively common in childhood
• 10–15% at any time
DEPRESSION
• Early onset may lead to higher risk of mental disorder in adulthood
REACTIVE DEPRESSION
• Adjustment disorder with depressed mood
• Short lived
• Occurs in response to specific experience
MAJOR DEPRESSIVE DISORDER
• One or more major depressive episodes lasting from seven to nine months without treatment
MDD SYMPTOMS
Patient may:
• Appear sad
• Lose interest in previously enjoyed activities
• Criticize self
• Sleep poorly
• Experience appetite changes
• Feel hopeless
• Display irritability/aggressive behavior
• Appear indecisive
• Lack energy
• Neglect appearance
• Experience psychotic symptoms (auditory hallucinations)
• Experience anxiety and somatization
NURSING ALERT !!!
• Depressed children are often irritable, which leads to aggressive behavior
SUICIDE
• Completed suicide is rare in children
• Incidence of attempts peaks during mid-adolescent years
• Mortality from suicide is third leading cause of death in adolescents
NURSING ALERT!!!
• The incidence of suicide in children peaks in mid-adolescence
ASSESS FOR:
• Serious family pathology as underlying cause
• Child abuse
• Domestic violence
• Sexual abuse
• Eating disorders
• Substance abuse
DYSTHYMIA
• Depression that occurs on most days for most of the day
• Interferes with normal psychosocial development
• Affects self-image
• Eventually, depressed mood becomes the norm
CAUSES OF DEPRESSION
• Children of depressed parents are three times more likely to experience an episode
• Research into hypothalamus and pituitary gland growth continues
• Development of a pessimistic attribution bias
PSYCHOLOGICAL TREATMENT OF DEPRESSION
• Self-control therapy may be useful
• Research into other cognitive-behavioral therapies continues
PHARMACOLOGICAL TREATMENT OF DEPRESSION
• Tricyclic antidepressants have not been proven to work in children
• SSRIs do seem to work, currently very controversial
• SSRIs may increase suicidal ideation
BIPOLAR DISORDER
• Episodes of mania alternating with depression
• Manifests as intensive purposive behavior that leads to self-harm
Overeating,
Sexual indiscretion,
Buying sprees
• Begins in adolescence, may also be seen in children
• In older children & adolescence may be associated with:
High levels of energy & activity
Multiple projects started but not finished
Markedly increased talkativeness
Decreased need for sleep
Expansive mood
NURSING ALERT!!!
• Mania in children may be misdiagnosed as hyperactivity
• Mania presents differently in the very young because children do not have the independence or the
developmental level of adults or adolescents
ANXIETY DISORDERS
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Separation anxiety disorder
Generalized anxiety disorder
Social phobia
Obsessive-compulsive disorder
TREATMENT OF ANXIETY
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Contingency management
Desensitization
Cognitive-behavioral therapy
SSRIs
No Benzodiazepines
AUTISM
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10–12 children per 10,000
Profound lack of interest in social interactions
Resist interpersonal contact
Engage in repetitive behaviors—rocking, spinning
TREATMENT
• Early, intensive education
• Special education in highly structured environments
• Haldol (haloperidol)
• Newer neuroleptics
• SSRIs
ASPERGER’S SYNDROME
• Combination of severe impairments in social interaction with highly repetitive patterns of interests and
behaviors
• Consistent inability to regulate social interactions
• No specific neurological abnormalities
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OPPOSITIONAL DEFIANT DISORDER
Consistent pattern of rejecting adult authority
Loses temper
Argues with adults
Deliberately refuses to comply with requests or rules of adults
Blames others for own mistakes
Stubborn and tests limits
CONDUCT DISORDER
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One of most serious disorders of childhood
Patient shows pattern of cruelty and disrespect
Capable of severe violence and murder
Incidence 1–4%
May become antisocial adult
Treatment includes psychosocial methods and psychoactive drugs
Childhood Therapies
• Play therapy
• Younger children have difficulty expressing feelings & concerns due to limited vocabulary
• Provides opportunity to develop therapeutic nurse-child relationship
• Provides opportunity for hidden & threatening content to be presented
• Child can learn basic & social skills, explore the environment, release excess energy, & imitate & acquire
adult roles
• Individual therapy
• Children often feel they are forced into therapy against his or her will
• Nurses are seen as allies to caregivers that forced them into therapy
• Nurse must avoid taking sides in order to develop trusting relationship
• Communicate acceptance of child separate from unacceptable behavior
• Nurse should not guide or direct play or make interpretations
• Family therapy
• Essential for children with psychiatric disorders
• Cannot understand childhood disorders without exploring family context
• Cannot change 1 person without bringing about change in the entire family
• Treating family system brings more rapid & enduring changes
ASSESSMENT
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Presenting problem
Health history
School and social history
Developmental history
Psychiatric history
Physical assessment
Mental status exam
NURSING DIAGNOSIS
• Anxiety
• Impaired social interaction
• Ineffective coping
• Risk for violence
• Self-esteem disturbance
OUTCOME IDENTIFICATION
• Establish realistic and achievable goals
• Take into account child’s developmental level and family situation
PLANNING/INTERVENTIONS
• Support and understanding are essential
• Two levels of intervention—family and child
• Teach coping skills
• Improve self-esteem
• Play therapy
• Individual and family therapy
• Psychopharmacology
EVALUATION
• Child’s progress
• Family unit’s progress
• Progress may be slow
• Help family view successes in increments, realistically
• Family and child should mutually agree on successes and failures
SCHOOLS AND SPECIAL-NEEDS CHILDREN
• More than 5,000,000 children have a disability
• Individuals with Disabilities Education Act (IDEA) mandates “appropriate” education for these children
• Each child has individual educational plan (IEP) that is reviewed and updated yearly