6 - Childhood Personality Disorders

Childhood Personality Disorders

ADHD (Attention Deficit Hyperactivity Disorder)
Reported by: FONG, Ingrid Sasha - Group 6 N3C
Arise in early childhood. Onset before age seven. Long lasting and evident for at least six months Affects 3-5% of all school aged children. 3:1 boys than girls 9:1 in clinical settings

Symptoms Primarily Inattentive Type of Symptoms: Fails to give close attention to details or makes careless mistakes. Has difficulty sustaining attention. Does not appear to listen. Struggles to follow through on instructions. Has difficulty with organization. Avoids or dislikes tasks requiring sustained mental effort. Is easily distracted. Is forgetful in daily activities. Symptoms Primarily Hyperactive/Impulsive Type of Symptoms: Fidgets with hands or feet or squirms in chair. Has difficulty remaining seated. Runs around or climbs excessively. Has difficulty engaging in activities quietly. Acts as if driven by a motor. Talks excessively. Blurts out answers before questions have been completed. Has difficulty waiting or taking turns. Interrupts or intrudes upon others. TREATMENT There is no "cure" for ADHD, however, many treatment approaches may alleviate or significantly decrease ADHD symptoms. As a result, improvements are evident in school/work performance, relationships with others improve, and self esteem increases. Psychopharmacology

6 - Childhood Personality Disorders Common Nursing Diagnosis Risk for self directed or other directed violence Defensive coping Impaired social interaction Ineffective coping Low self esteem Noncompliance Anxiety (moderate to severe) Compromised family coping Imbalanced nutrition: Less than body requirements Ineffective family therapeutic regimen management Interrupted family processes Risk for impaired parenting

Nursing interventions for ADHD Set realistic expectations and limits because the patient with attention deficit hyperactivity disorder is easily frustrated Always remain calm and consistent with the child. Keep all your instructions to the child short and simple. Provide praise and rewards whenever possible. Provide the patient with diversional activities suited to his short attention span. Help the parents and other family members develop planning and organizing systems to help them cope more effectively with the child's short attention span.

Nursing Interventions Risk for self directed or other-directed violence Observe clients behavior frequently. Observe for suicidal behaviors: Verbal statements, such as statement going to kill myself Determine suicidal intent and available means. Ask how where and when you plan to kill yourself Obtain contract from client not to harm self and agreeing to seek out staff when ideation occurs. Help client to recognize when anger occurs and to accept those feelings Act as a role model for appropriate expression of angry feelings. Give positive reinforcement.

Ineffective coping Provide safe environment for continuous large muscle movement, If client is hyperactive Provide large motoric activities Does not debate, argue, rationalize, or bargain with the client.

6 - Childhood Personality Disorders Explore with client and discus alternative ways of handling frustration that would be most suited for client

Anxiety Establish a trusting relationship Maintain an atmosphere of calmness Offer support during times of elevated anxiety, Use of touch is comforting for some clients When anxiety diminishes, help client to recognize specific events that preceded onset of anxiety. Provide help to client to recognize signs of escalating anxiety On escalating anxiety provide tranquilizing medication, as ordered

Conduct Disorder
Reported by: GONZALES, Nathaleen Joy M. - Group 6 N3C)
A disruptive behavior that violates the basic rights of others or major ageappropriate norms or rules. (Shives, 2008) Characterized by persistent antisocial behavior in children and adolescents that significantly impairs their ability to function in social, academic, or occupational areas. (Videbeck, 2011)

People with conduct disorders have the ff: (Videbeck, 2011) low empathy for others low self- esteem poor frustration tolerance temper outbursts Risk Factors (Shives, 2008) Parenteral and Family Sociocultural Psychological Attachment Theory Environmental - School- related - Neighborhoods Neurobiologic Theories Psychosocial (7 Risk Factors) Seven Psychosocial Risk Factors (Shives, 2008) 1. Children in Families With Conflict or Divorce 2. Children Who Experience Poverty 3. Children of Minority Ethnic Status 4. Children Who are Abused 5. Children of Substance- Abusing and Mentally Ill Parents 6. Children of Teenaged Parents 7. Children With Chronic Illness or Disability

6 - Childhood Personality Disorders

3 Classifications (Videbeck 2011) Mild Moderate The person has some The number of conduct problems conduct problems that cause relatively increases as does the minor harm to others. amount of harm to others. e.g. lying, truancy, e.g. vandalism and and staying out late theft without permission

Severe The person has many conduct problems that cause considerable harm to others. e.g. forced sex, cruelty to animals, use of a weapon, burglary, and robbery

Signs and Symptoms (Videbeck, 2011) Cluster 1: Cluster 2: Aggression to Destruction of people and Property animals Bullies, Fire setting threatens, or intimidates others Initiates physical Vandalism fights Use of weapons Deliberate property destruction

Cluster 3: Deceitfulness

Cluster 4: Theft

Lying

Shoplifting

Cons others to avoid responsibility Serious violation of rules Stays overnight without parental consent Runs away from home overnight Truancy from school

Breaks into house, building, or car

FORCED SEXUAL ACTIVITY

6 - Childhood Personality Disorders Possible Nursing Diagnosis (Videbeck, 2011) Risk for other- directed violence Noncompliance Ineffective coping Impaired social interaction Chronic low self- esteem Nursing Intervention (Videbeck, 2011) Decreasing violence and increasing compliance with treatment - protect others from clients aggression and manipulation - Provide CONSISTENCY with the clients treatment plan - Use behavioral contracts - Institute TIME- OUT - Provide a routine schedule of daily activities Improve coping skills and self- esteem - Show acceptance of the person; NOT NECESSARILY THE BEHAVIOR - Encourage the client to keep a diary - Teach and practice problem- solving skills Promote social interaction - Teach age- appropriate social skills - Role model and practice social skills - Provide positive feedback for acceptable behavior Provide client and family education

Oppositional Defiant Behavior

(Reported by: GONZALES, Nathaleen Joy M. - Group 6 N3C)
Consists of an enduring pattern of uncooperative, defiant, and hostile behavior toward authority figures without major antisocial violations (Shives, 2008). Recurring pattern of negativistic and hostile behavior in a child or adolescent (Videbeck, 2011). More prevalent in boys than in girls; especially BEFORE PUBERTY (Videbeck, 2011). Occurs equally among male and female ADOLESCENTS (Shives, 2008).

Etiology: Most authorities believe that genes, temperament, and adverse social conditions interact to create the behavior (Videbeck, 2011)

Manifestations (Shives, 2008) Loss of temper Anger Resentment Vindictiveness Frequently argues with adult Deliberately annoys others, yet easily annoyed Blames others for their mistakes

6 - Childhood Personality Disorders

Nursing Intervention (Shives, 2008) Challenging: Client has a chronologic age of 10 years, maturational age as that of a teenager, and FRUSTRATION TOLERANCE OF A 2- YEAR- OLD. Primary treatment is family intervention All areas and settings in which the client exhibits behavior problems should be identified and addressed. Individual psychotherapy provides the client with an opportunity to restore selfesteem and practice adaptive responses to adult or authority figures Anger management is recommended; but is not widely available.

Autistic Disorder
(Reported by: FERRO, Prudence Mae - Group 6 N3C)
Definition Autistic disorder (also called autism; more recently described as "mindblindedness") is a neurological and developmental disorder that usually appears during the first three years of life.

Etiology Cause of autism is not known. Research suggests that autism is a genetic condition. It is believed that several genes are involved in the development of autism. Research studies in autism have found a variety of abnormalities in the brain structure and chemicals in the brain, however, there have been no consistent findings.

Manifestations Does not socially interact well with others, including parents. - Shows a lack of interest in, or rejection of, physical contact. Parents describe autistic infants as "unaffectionate." Autistic infants and children are not comforted by physical contact. - avoids making eye contact with others, including parents. - Fails to develop friends or interact with other children. Does not communicate well with others. - is delayed or does not develop language. - Once language is developed, does not use language to communicate with others. - has echolalia (repeats words or phrases repeatedly, like an echo).

6 - Childhood Personality Disorders Demonstrates repetitive behaviors. - has repetitive motor movements (such as rocking and hand or finger flapping). It is preoccupied, usually with lights, moving objects, or parts of objects Does not like noise Has rituals Requires routines

Diagnosis For the first time, standard guidelines have been developed to help identify autism in children before the age of 24 months. In the past, diagnosis of autism was often not made until late preschool-age or later. The new guidelines can help identify children with autism early, which means earlier, more effective treatment for the disorder.

What are the guidelines? Diagnosis of autism actually involve two levels of screening for autism. Level one screening, which should be performed for all children coming to a physician for well-child check-ups during their first two years of life, should check for the following developmental deficits: No babbling, pointing or gesturing by age 12 months. No single words spoken by age 18 months. No two-word spontaneous (non-echolalic, or not merely repeating the sounds of others) expressions by age 24 months. Loss of any language or social skills at any age. The second level of screening should be performed if a child is identified in the first level of screening as developmentally delayed. - it is a more in-depth diagnosis and evaluation that can differentiate autism from other developmental disorders. May include more formal diagnostic procedures by clinicians skilled in diagnosing autism, including: - Medical History, Neurological Evaluation, Genetic Testing, Metabolic Testing, Electrophysiologic Testing (i.e., CT scan, MRI, PET scan), Psychological Testing.

Genetic Testing Involves an evaluation by a medical geneticist (a physician who has specialized training and certification in clinical genetics), particularly as there are several genetic syndromes which may cause autism, including Fragile-X, untreated phenylketonuria (PKU), neurofibromatosis, tuberous sclerosis, Rett syndrome, as well as a variety of chromosome abnormalities.

6 - Childhood Personality Disorders Treatment for Autism Specialized behavioral and educational programs are designed to treat autism. Behavioral therapy is used to teach social skills, motor skills and cognitive (thinking) skills. Behavior modification is also useful in reducing or eliminating maladaptive behaviors. Individualized treatment planning for behavioral therapy is important as autistic children vary greatly in their behavioral needs. Intensive behavior therapy during early childhood and home-based approaches training and involving parents are considered to produce the best results. Special education programs that are highly structured focus on developing social skills, speech, language, self-care and job skills. Medication is also helpful in treating some symptoms of autism in some children. Mental health professionals provide parent counseling, social skills training and individual therapy. They also help families identify and participate in treatment programs based on an individual child's treatment needs.

Specific treatment will be determined by child's physician based on: Your child's age, overall health and medical history. Extent of the disorder. Your child's symptoms. Your child's tolerance for specific medications or therapies. Expectations for the course of the disorder. Your opinion or preference.

Nursing Responsibilities Preventive measures - to reduce the incidence Severity of autistic disorders are not known at this time.

Separation Anxiety Disorder

(Reported by: FERRO, Prudence Mae - Group 6 N3C)
Definition It is a condition in which a child becomes fearful and nervous when away from home or separated from a loved one, usually a parent or other caregiver to whom the child is attached.

6 - Childhood Personality Disorders Etiology often develops after a significant stress or trauma in the child's life, such as a stay in the hospital, the death of a loved one or pet, or a change in environment (such as moving to another house or a change of schools). Children whose parents are over-protective may be more prone to separation anxiety. In fact, it may not necessarily be a disease of the child but can be a manifestation of parental separation anxiety as well parent and child can feed the other's anxiety. Children with separation anxiety often have family members with anxiety or other mental disorders suggests that a vulnerability to the disorder may be inherited.

Manifestations An unrealistic and lasting worry that something bad will happen to the parent or caregiver if the child leaves. An unrealistic and lasting worry that something bad will happen to the child if he or she leaves the caregiver. Refusal to go to school in order to stay with the caregiver. Refusal to go to sleep without the caregiver being nearby or to sleep away from home. Fear of being alone. Nightmares about being separated. Bed wetting Complaints of physical symptoms, such as headaches and stomachaches, on school days. Repeated temper tantrums or pleading.

When your child is separated from you, there's a pattern to his anxiety known as separation distress and there are three stages to this distress.

Stages Protest Despair

Likely Sign Frustration, anger, loud cries. Very quiet, doesn't participate in activities. Plays by himself, withdrawn from others, does not interact with peers.

Detachment

6 - Childhood Personality Disorders Diagnosis Mental illness in children is diagnosed based on signs and symptoms that suggest a particular disorder. If symptoms are present, the doctor will begin an evaluation by performing a complete medical history and physical exam. Although there are no laboratory tests to specifically diagnose separation anxiety disorder, the doctor may use various tests such as: X-rays and Blood Tests - to rule out physical illness or medication side effects as the cause of the symptoms. If no physical illness is found, the child may be referred to a child psychiatrist or psychologist, mental health professionals who are specially trained to diagnose and treat mental illness in children. Psychiatrists and psychologists use specially designed interview and assessment tools to evaluate a child for a mental illness. The doctor bases his or her diagnosis on reports of the child's symptoms and his or her observation of the child's attitude and behavior.

Treatment 1. Talk therapy. - Talk therapy provides a safe place for your child to express his or her feelings. Having someone to listen empathetically and guide your child toward understanding his or her anxiety can be powerful treatment. 2. Play therapy. - The therapeutic use of play is a common and effective way to get kids talking about their feelings. 3. Counseling for the family. - Family counseling can help your child counteract the thoughts that fuel his or her anxiety, while you as the parent can help your child learn coping skills. 4. School-based counseling. - This can help a child with separation anxiety disorder explore the social, behavioral, and academic demands of school. 5. Medication. - Medications may be used to treat severe cases of separation anxiety disorder. It should be used only in conjunction with other therapy.

Aspergers Disorder
(Reported by: HUMIILDE, Melissa - Group 6 N3C)
A pervasive developmental disorder (PDD) characterized by the same impairments of social interactions and stereotyped behaviors seen in autistic disorder but there are no language or cognitive delays Children with AD can feed/dress and take care of their other daily needs

6 - Childhood Personality Disorders The most distinctive features of AD are problems with social interaction, particularly making friends with others: difficulties with nonverbal communication (facial expression) Speech habits that include repeating words or phrases or talking on a flat tone of voice This rare disorder occurs more often in boys than in girls

Causes
The exact cause of Aspergers Disorder is not known. However, the fact that it tends to run in families suggests that a tendency to develop the disorder may be inherited ( passed from parent to child)

Signs and Symptoms

Problems with social skills: difficulty interacting with others and often awkward in social interactions. They generally do not make friends easily Eccentric or repetitive behaviors: repetitive movements such as hand wringing or finger twisting Communication difficulties: People with AD may not make eye contact when speaking with someone. They may have travel using facial expressions and gestures and understanding body language Limited range of interests: A child with AD may develop an intense, almost obsessive, interest in a few areas, such as sports schedule, weather, or maps Coordination problems: movements may be clumsy or awkward

Interventions
Some children who are very clumsy benefit from physical therapy that improves their coordination Children may need to work with a speech therapist in order to learn to speak in normal tone of voice Teachers and parents can often help a child with AS work on his/her social skills

Tourettes Syndrome
(Reported by: FONG, Ingrid Sasha - Group 6 N3C)
Gilles de la Tourette Syndrome (TS) is one of a number of tic disorders No biological test Evolve in childhood Standard diagnostic criteria used Impairment defines the condition Diagnosis and Treatment take time

6 - Childhood Personality Disorders

Etiology The cause of Tourette Syndrome is unknown. The basic defect is thought to be a biochemical abnormality in the basal ganglia of the brain.

Transmission Genetically transmitted by autosomal dominant gene Patient has 50% chance of passing the gene to children. However, that genetic predisposition may express itself as TS, as a milder tic disorder or as obsessive compulsive symptom with no tics at all In some cases TS may not be inherited and are identified as Sporadic TS. The cause in these instances is unknown

Diagnostic Criteria Onset before age 18 Multiple motor tics One or more vocal tics Tics evolve in a progressive pattern Symptoms wax and wane* Duration longer than one year Absence of precipitating illness Observation of tics by knowledgeable person *Relapsing Remitting MS. RRMS is identified by distinct periods of disease activity (relapses) followed by longer periods of disease inactivity (remission)

Other terms Chronic Motor or Vocal Tic Disorder Transient Tic Disorder Terms that may be used by doctors because the duration of the tics is less than one year TouretteS Syndrome Affects BOYS 3 - 4:1 more than GIRLS Involuntary with limited capacity to suppress Mean age of onset for tics 6 7 years Affects 2% of the general population- a conservative estimate since it is an under diagnosed condition

6 - Childhood Personality Disorders SYMPTOMS Motor Tics Simple Vocal Tics Simple Throat clearing Sniffing Grunting Humming Whistling Spitting Squealing Clenching teeth Eye blinking Facial Grimacing Shoulder shrugging Head jerking Arm thrusting Nose twitching Mouth opening Eye rolling

Learning Disabilities Writing Disorders ReadingComprehension Disorders Math Disorders Visual-Motor Integration is almost always a problem Processing Speed and Efficiency Difficulties

Common NANDA nursing care plans Diagnosis: Risk for self-directed or other-directed violence Impaired social interaction Low self-esteem Goal: Minimize impairment Maximize adaptive skills

6 - Childhood Personality Disorders Most important in planning: Encourage self-esteem Prevent depression Treatment for TS Medications Drugs such as pimozide (Orap) and clonidine (Catapres) are used to control tics. Nursing interventions Stress increases tics - Teach coping skills to handle stress; may need to avoid competition. Intensive involvement in enjoyable activities (sports, music) decreases tics and stress and calms. Waxing and waning of symptoms of comorbidities and tics - Explain to parents, peers, teachers that student has very limited control and that expression of tics and other symptoms are involuntary as well as ever-changing and coming and going Cognitive dulling, lethargy, seeming lack of interest, decrease in coordination Could be due to medication and/or depression. If worsening or severe, Inform the Physician for reevaluation; Infrom Parents to allow extra time and attention for tutoring, studying, and testing. Short temper and argumentative - Provide opportunity for physical movement; encourage relaxation and body control techniques as well as movement education to increase body control. Provide explanations to parents and peers Psychological Counseling Behavioral Therapy Medications Alternative Therapies Understanding and support from peers and adults

Childhood Personality Disorders (Group 6 N3C)

1) 2) 3) 4) 5) 6) 7) Attention Deficit Hyperactivity Syndrome - FONG, Ingrid Sasha Conduct Disorder- GONZALES, Nathaleen Joy Oppositional Defiant Behavior GONZALES, Nathaleen Joy Autistic Disorder FERRO, Prudence Mae Separation Anxiety Syndrome FERRO, Prudence Mae Aspergers Syndrome HUMILDE, Melissa Tourettes Syndrome - FONG, Ingrid Sasha

6 - Childhood Personality Disorders