I. Introduction: ETIOLOGY Historically, discovering the cause of mental illness in large part determined the approach to treatment.

Etiological theories have proposed both genetic factors (nature) and childhood experiences (nurture) as predisposing and precipitating causes for the development of a psychiatric illness. It is now recognized that both nature and nurture play a role in the development of health and illness. The effect of experience combined with genetic predisposition begins to explain the complexity of the development of child psychiatric illness. Traumatic events, for example, have been recognized to have a profound impact on children. The symptoms that are characteristic of post-traumatic stress disorder (PTSD) in children are those of increased arousal, including hypervigilance, irritability, anxiety, physiological hyperactivity, impulsivity and sleep difficulty. These symptoms are often also diagnosed as attention deficit-hyperactivity disorder (ADHD), conduct disorder, anxiety disorder, and mood disorder. It is also recognized that the particular constellation of symptoms a child experiences are often related to the family history. Specifically, if a family member has a history of anxiety disorder, the child may experience symptoms that are more anxious in appearance. However, if family members have a strong history of alcoholism and sociopathy, symptoms may pertain more to conduct disorder. Thus it is believed that there is a genetic predisposition to certain symptoms and that these symptoms can be stimulated as a response to an event in the environment. After traumatic events, many factors are important in the development of the intensity of symptoms, including the nature of the trauma, the degree to which body integrity is threatened, the threat posed by the event to the childs self-system and security, and the nature of the family support system. The neurophysiology activated during acute stress is usually rapid and reversible. The brain has mechanisms that down-regulate the stress reaction after the threat has passed, returning the brain to its prior level of functioning. However if the stress is prolonged, severe or repetitive, the resulting increase in neurotransmitter activity are often not reversible. This process has a significant impact on the development of the childs brain. A trauma-induced brain response would probably result in abnormal patterns, time, and intensity of catecholamine activity in the developing brain. Young children who are exposed to a high rate of stress-induced trauma are at risk for developing permanent changes in neuronal organization, making it more difficult for them to learn and to control their behavior. Psychiatric disorders are not diagnosed as easily in children as they are in adults. Children usually lack the abstract cognitive abilities & verbal skills to describe what is happening. Because they constantly are changing & developing, children have no sense of a stable, normal self to allow them to discriminate unusual or unwanted symptoms from normal feelings & sensations. Additionally, behaviors that are normal in a child of one age may indicate problems in a child of another age. For example, an infant who cries & wails when separated from her mother is normal. If the same child at 5 years of age cries & shows extreme anxiety when separated from her or his mother, however, this behavior would warrant investigation. Children & adolescents experience some of the same mental health problems as adults, such as mood & anxiety disorders, & are diagnosed with these disorders using the same criteria as for adults. II. Disorders Usually Diagnosed A. Mental Retardation The essential feature of mental retardation is below-average intellectual functioning (IQ less than 70) accompanied by significant limitations in areas of adaptive functioning such as communication skills, self-care, home living, social or interpersonal skills, use of community resources, self-direction, academic skills, work, leisure, & health & safety. The degree of retardation is based on IQ & greatly affects the persons ability to function: Mild Retardation: IQ 50 to 70 Moderate Retardation: IQ 35 to 50 Severe retardation: IQ 20 to 35 Profound Retardation: IQ less than 20 Causes of mental retardation include heredity such as Tay-Sachs disease or fragile X chromosomes syndrome; early alterations in embryonic development such as trisomy 21 or maternal alcohol intake that causes fetal alcohol syndrome; pregnancy or perinatal problems such as fetal nutrition, hypoxia, infections, & trauma; medical conditions of infancy such as infection or lead poisoning; & environmental influences such as deprivation of nurturing or stimulation.

Some people with mental retardation are passive & dependent; others are aggressive & impulsive. Children with mild to moderate mental retardation usually receive treatment in their homes & communities & make periodic visits to physicians. Those with severe or profound mental retardation may require residential placement or day care services.

B. Learning Disorders A learning disorder is diagnosed when a childs achievement in reading, mathematics, or written expression is below that expected for age, formal education & intelligence. Learning problems interfere with academic achievement & life activities requiring reading, math, or writing. Reading & written expression disorders usually are identified in the first grade; math disorder may go undetected until the child reaches fifth grade. About 5% of children in U.S. public schools are diagnosed with a learning disorder. The school dropout rate for students with learning disorder is 1.5 times higher than the average rate for all students. Low self-esteem & poor social skills are common in children with learning disorders. As adults, some have problems with employment or social adjustment; others have minimal difficulties. Early identification of the learning disorder, effective intervention, & no coexisting problems are associated with better outcomes. Children with learning disorders are assisted with academic achievement through special education classes in public schools. C. Motor Skills Disorders The essential feature of developmental coordination disorder is impaired coordination severe enough to interfere with academic achievement or activities of daily living. This diagnosis is not made if the problem with motor coordination is part of a general medical condition such as cerebral palsy or muscular dystrophy. This disorder becomes evident as a child attempts to crawl or walk or as an older child tries to dress independently or manipulate toys such as building blocks. Developmental coordination disorder often coexists with a communication disorder. Its course is variable; sometimes lack of coordination persists to adulthood. Schools provide adaptive physical education & sensory integration programs to treat motor skills disorder. Adaptive physical education programs emphasize inclusion of movement games such as kicking a football or soccer ball. Sensory integration programs are specific physical therapies prescribed to target improvement in areas where the child has difficulties. For example, a child with tactile defensiveness (discomfort at being touched by another person) might be involved in touching & rubbing skin surfaces. D. Communication Disorders A communication disorder is diagnosed when a communication deficit is severe enough to hinder development, academic achievement, or ADLs including socialization. Expressive language disorder involves an impaired ability to communicate through verbal & sign language. The child has difficulty learning new words & speaking in complete & correct sentences; his or her speech is limited. Mixed receptive-expressive language disorder includes the problems of expressive language disorder along with difficulty understanding (receiving) & determining the meaning of words & sentences. Both disorders can be present at birth (developmental) or they may be acquired as a result of neurologic injury or insult to the brain. Phonologic disorder involves problems with articulation (forming sounds that are part of speech.) Stuttering is a disturbance of the normal fluency & time pattering of speech. Phonologic disorders & stuttering run in families & occur more frequently in boys than in girls. Communication disorders may be mild to severe. Difficulties that persist into adulthood are related most closely to the severity of the disorder. Speech & language therapists work with children who have communication disorder to improve their communication skills & to teach parents to continue speech therapy activities at home. E. Pervasive Developmental Disorders Pervasive developmental disorders are characterized by pervasive & usually severe impairment of reciprocal social interaction skills, communication deviance, & restricted stereotyping behavioral patterns. This category of disorders also called autism spectrum disorders & includes autistic disorder (classic autism), Retts disorders, childhood disintegrative disorder, & Aspergers disorder. Approximately 75% of children with pervasive developmental disorders have mental retardation. 1. Autistic Disorder
Autistic disorder, the best known of the pervasive developmental disorders, is more prevalent in boys than girls & is identified no later than 3 years of age. Children of autism display little eye contact with & make few facial expressions toward others; they do not use gestures to communicate. They do not relate to peers or parents. They lack spontaneous enjoyment, have apparently no moods or emotional affect, & cannot engage in play or make-believe with toys. There is little intelligible

speech. These children engage in stereotyped motor behaviors such as hand-flapping, body-twisting, or head-banging. Eighty percent of cases of autism are early-onset with developmental delays starting in infancy. The other 20% of children with autism have seemingly normal growth & development until 2 or 3 years of age when developmental regression or loss of abilities begin. They stop talking & relating to parents & peers & begin to demonstrate the behaviors describe above. Autism was once thought to be rare & was estimated to occur in 4 to 5 children per 1,000 in the 1960s. Current estimates suggest that 1 in 1000 to 1 in 500 U.S. children from 1 to 15 years of age have autism. Autism does have a genetic link; many children with autism have a relative with autism or autistic traits. Controversy continues about whether or not measles, mumps, & rubella (MMR) vaccinations contribute to the development of late-onset autism. The National Institute of Child Health & Human Development states there is no relationship & the MMR vaccine is safe. Autism tends to improve, in some cases substantially, as children start to acquire & to use language to communicate with others. If behavior deteriorates in adolescence, it may reflect the effects of hormonal changes or the difficulty meeting increasingly complex social demands. Autistic traits persist into adulthood, & most people with autism remain dependent to some degree on others. Manifestations vary from little speech & poor daily living skills throughout life to adequate social skills that allow relatively independent functioning. Social skills rarely improve enough to permit marriage & child rearing. Adults with autism may be viewed as merely odd or reclusive or they may be given a diagnosis of obsessive-compulsive disorder, schizoid personality disorder, or mental retardation. Until the mid-1970s, children with autism usually were treated in segregated, specialty outpatient, or school programs. Those with more severe behaviors were referred to residential programs. Since then, more residential programs have been closed; children with autism are being mainstreamed into local school programs whenever possible. Short-term inpatient treatment is used when behaviors such as head-banging or tantrums are out of control. When the crisis is over, community agencies support the child & family. The goals of treatment of children with autism are to reduce behavioral symptoms & to promote learning & development particularly the acquisition of language skills. Comprehensive & individualized treatment including special education & language therapy is associated with more favorable outcomes. Pharmacologic treatment with antipsychotic such as haloperidol (Haldol) or risperidone (Risperdal) may be effective for specific target symptoms such as temper tantrums, aggressiveness, self-injury, hyperactivity, & stereotyped behaviors. Other medications such as naltrexone (ReVia), clomipramine (Anafranil), clonidine (Catapres), & stimulants to diminish selfinjury & hyperactive & obsessive behaviors have varied but unremarkable results.

2. Retts Disorder
Retts disorder is a pervasive developmental disorder characterized by the development of multiple deficits after a period of normal functioning. It occurs exclusively in girls, is rare, & persists throughout life. Retts disorder develops between birth to 5 months of age. The child loses motor skills & begins showing stereotyped movement instead. She loses interest in the social environment, & severe impairment of expressive & receptive language becomes evident as she grows older. Treatment is similar to those for autism.

3. Childhood Disintegrative Disorder

Childhood disintegration disorder is characterized by marked regression in multiple areas of functioning after at least 2 years of apparently normal growth & development. Typical age of onset is 3 to 4 years. Children with childhood disintegrative disorder have the same social & communication deficits & behavioral patterns seen with autistic disorder. This rare disorder occurs slightly more often in boys than girls.

4. Aspergers Disorders
Aspergers disorder is a pervasive developmental disorder characterized by the same impairments of social interaction & restricted, stereotyped behaviors seen in autistic disorder but there is no language or cognitive delays. This rare disorder occurs more often in boys than in girls; the effects are generally life-long.

F. Attention Deficit & Disruptive Behavior Disorders 1. Attention Deficit Hyperactivity Disorder

Attention deficit hyperactivity disorder (ADHD) is characterized by inattentiveness, overactivity, and impulsiveness. ADHD is a common disorder, especially in boys, and probably accounts for more child mental health referrals than any other single disorder (McCracken, 2000a). The essential feature of ADHD is a persistent pattern of inattention and or hyperactivity and impulsivity more common than generally observed in children of the same age. ADHD affects an estimated 3% to 5% of all school-age children. The ratio of boys to girls ranges from 3:1 in nonclinical settings to 9:1 in clinical settings (McCracken, 2000a). To avoid overdiagnosis of ADHD, a qualified specialist, such as pediatric neurologist or a child psychiatrist, must conduct the evaluation for ADHD. Children who are very active or hard to handle in the classroom can be diagnosed and treated mistakenly for ADHD. Some of these overly active children may suffer from psychosocial stressors at home, inadequate parenting, or other psychiatric disorders (Blackman, 1999). Onset and Clinical Course ADHD usually is identified and diagnosed when the child begins preschool or school, although many parents report problems from a much younger age. As infants, children with ADHD are often fussy and temperamental and have poor sleeping patterns. Toddlers may be described as always on the go and into everything, at times dismantling toys and cribs. They dart back and forth, jump and climb on furniture, run through the house, and cannot tolerate sedentary activities such as listening to stories. At this point in a childs development, it can be difficult for parents to distinguish normal, active behavior from excessive, hyperactive behavior. By the time the child starts school, symptoms of ADHD begin to interfere significantly with behavior and performance (Pary, Lewis, Matuschka & Lippmann, 2002). The child fidgets constantly, is in and out of assigned seats, and makes excessive noise by tapping or playing with pencils or other objects. Normal environmental noises, such as someone coughing, distract the child. He or she cannot listen to directions or complete tasks. The child interrupts and blurts out answers before questions are completed. Academic performance suffers because the child makes hurried, careless mistakes in schoolwork, often loses or forgets homework assignments, and fails to follow directions. Socially, peers may ostracize or even ridicule the child for his or her behavior. Forming positive peer relationship is difficult because the child cannot play cooperatively or take turns and constantly interrupts others (APA, 2000a). Studies have shown that both teachers and peers perceive children with ADHD as more aggressive, more bossy, and less likable (McCracken, 2000a). This perception results from the childs impulsivity, inability to share or take turns, interruptions, and failure to listen to and follow directions. Thus peers and teachers may exclude the child from activities and play, may refuse to socialize with the child, or may respond to the child in a harsh, punitive, or rejecting manner. About two-thirds diagnosed with ADHD continue to have problems in adolescence. Typical impulse behaviors include cutting class, getting speeding tickets, failing to maintain interpersonal relationships, and adopting risk-taking behaviors such as using drugs or alcohol, engaging in sexual promiscuity, fighting, violating curfew. Many adolescents with ADHD have discipline problems serious enough to warrant suspension or expulsion from high school (McCracken, 2000a). The secondary complications of ADHD, such as low self-esteem and peer rejection, continue to pose serious problems. Previously it was believed that children outgrew ADHD, but it is now known that ADHD can persist into adulthood (Wender, 2000). Estimates are that 30% to 50% of children with ADHD have symptoms that continue into adulthood (Searight, 2000). In one study, adults, who had been treated for hyperactivity 25 years earlier were three to four times more likely than their brothers to experience nervousness, restlessness, depression, lack of friends, and low frustration tolerance (Wender, 2000). Adults in whom ADHD was diagnosed in childhood also have higher rates of impulsivity, alcohol and drugs use, legal troubles, and personality disorders. Etiology A combination of factors, such as environmental toxins, prenatal influences, heredity, and damage to brain structure and functions, is likely responsible (McCracken, 2000a). Prenatal exposure to alcohol, tobacco, and lead and severe malnutrition in early childhood increase the likelihood of ADHD (McCracken, 2000a; Pary et al., 2002). Brain images of people with ADHD have suggested decreased metabolism in the frontal lobes, which are essential for attention, impulse control, organization, and sustained goal-directed activity. Studies have shown decreased blood perfusion of the frontal cortex in children with ADHD and frontal atrophy in young adults with a history of childhood ADHD. Another study showed decreased glucose use in the frontal lobes of parents of children with ADHD who had ADHD themselves (McCracken, 2000a; Pary et al., 2002). There seems to be a genetic link for ADHD that is most likely associated with abnormalities in catecholamine and possibly serotonin metabolism. Despite the strong evidence supporting a genetic

contribution, there are also sporadic cases of ADHD with no family history of ADHD; this furthers the theory of multiple contributing factors. Risk factors for ASDHD include family history of ADHD; male relatives with antisocial personality disorder or alcoholism; female relatives with somatization disorder; lower socioeconomic status; male gender; marital or family discord, including divorce, neglect, abuse, or parental deprivation; low birth weight; and various kinds of brain insult (McCracken, 2000a). Culture Considerations ADHD is known to occur in various cultures, prevalently in Western cultures. Parents from various cultures have a different threshold fro tolerating specific behaviors and that rates of problems differ among cultures. Child Behavior Checklist can be used across cultures to determine problems (indicated by total score), but the focus of the problems (indicated by individual category scores) would vary according to the culture of the child and parents. Treatment No one treatment has been found effective for ADHD; this gives rise to many different approaches such as sugar-controlled diets and megavitamin therapy. ADHD is chronic; goals of treatment involve managing symptoms, reducing hypersensitivity and impulsivity, and increasing the childs attention so that he or she can grow and develop normally. The most effective treatment combines pharmacotherapy with behavioral, psychosocial, and educational interventions (Pary et al., 2002). Psychopharmacology The most common medications are methylphenidate (Ritalin) and an amphetamine compound (Adderall) (Lehne, 2001; McCracken, 2000a). Methylphenidate reduces hyperactivity, impulsivity, and mood lability and helps the child to pay attention more appropriately. Dextroamphetamine (Dexedrine) and pemoline (Cylert) are other stimulants used to treat ADHD. The most common side effects of these drugs are insomnia, loss of appetite, and weight loss or failure to gain weight. Methylphenidate, dextroamphetamine, and amphetamine compound are also available in sustained-release form taken once daily; this eliminates the need for additional doses when the child is at school. Because pemoline can cause liver damage, it is the last of these drugs to be prescribed. Giving stimulants during daytime hours usually effectively combats insomnia. Eating a good breakfast with the morning dose and substantial, nutritious snacks late in the day and at bedtime will help the child to maintain an adequate dietary intake. When stimulant medications are not effective or their side effects are intolerable, antidepressants are the second choice for treatment. Atomoxetine (Strattera) is a nonstimulant drug, an antidepressant, specifically norepinephrine reuptake inhibitor. The most common side effects in children during clinical trials were decreased appetite, nausea, vomiting, tiredness, and upset stomach. In adults, side effects were similar to other antidepressants including insomnia, dry mouth, urinary retention, decreased appetite, nausea, vomiting, dizziness, and sexual side effects (Eli Lily, 2002). Strategies for Home and School Medications do not automatically improve the childs academic performance or ensure that he or she makes friends. Behavioral strategies are necessary to help the child to master appropriate behaviors. Environmental strategies at school and home can help the child to succeed in those settings. Educating parents and helping them with parenting strategies are crucial components of effective treatment of ADHD. Effective approaches include providing consistent rewards and consequences for behavior, offering consistent praise, using time-out, and giving verbal reprimands. Additional strategies are issuing daily report cards for behavior and using point systems for positive and negative behavior (McCracken, 2000a). In the therapeutic play, play techniques are used to understand the childs thoughts and feelings and to promote communication. This should not be confused with play therapy, a psychoanalytic technique used by psychiatrists. Dramatic play is acting out an anxiety-producing situation such as allowing the child to be a doctor or use a stethoscope or other equipment to take care of a patient (a doll). Play techniques to release energy could include pounding pegs, running, or working with modeling clay. Creative play techniques can help children to express themselves, for example, by drawing pictures of themselves, their family, and peers. These techniques are especially useful when children are unable to express themselves verbally. Application of the Nursing Process: ADHD Assessment The nurse gathers information from the childs parents, day care providers (if any), and teachers as well as through direct observation. Assessing the child in a group of peers is likely to yield useful

information because the childs behavior may be subdued or different in a focused one-to-one interaction with the nurse. It is often helpful to use a checklist when talking with parents to help focus their input on the target symptoms or behaviors their child exhibits. History Parents may report that the child was fussy and had problems as an infant. The child probably has difficulties in all major life areas, such as school or play, and displays overactive or even dangerous behavior at home. Parents may report many largely unsuccessful to discipline the child or to change the behavior. General Appearance and Motor Behavior The child cannot sit still in a chair and squirms and wiggles while trying to do so. Speech is unimpaired, but the child cannot carry on a conversation. The child may appear immature or lag behind in developmental milestones. Mood and Affect Mood may be labile, even to the point of verbal bursts or temper tantrums. Anxiety, agitation and frustration are common. The child appears to be driven to keep moving or talking and appears to have little control over movement or speech. Attempts to focus the childs attention or redirect the child to a topic may evoke resistance and anger. Thought Process and Content There are generally no impairments in this area, although assessment can be difficult depending on the childs activity level and age or developmental stage. Sensorium and Intellectual Processes The child is alert and oriented with no sensory or perceptual alterations such as hallucinations. Ability to pay attention or to concentrate is markedly impaired. The childs attention span may be as little as 2 or 3 seconds with severe ADHD or 2 or 3 minutes in milder forms of the disorder. Assessing the childs memory may be difficult; he or she frequently answers I dont know because he or she cannot pay attention to the question or stop the mind from racing. The child with ADHD is very distractible and rarely able to complete tasks. Judgment and Insight Children with ADHD usually exhibit poor judgment and often do not think before acting. They may fail to perceive harm or danger and engage in impulsive acts such as running into the street or jumping off high objects. Children with ADHD display more lack of judgment than those of the same age. Most young children with ADHD are totally unaware that their behavior is different from that of others and cannot perceive how it harms others. Self-Concept Self-esteem of children with ADHD is low because they are not successful at school, may not develop many friends, and has trouble getting along at home; they generally feel out of place and bad about themselves. The negative reactions their behavior evokes from others often cause them to see themselves as bad or stupid. Roles and Relationships The child is usually unsuccessful academically and socially at school. He or she is disruptive and intrusive at home, which causes friction with siblings and parents. Generally measures to discipline have limited success; in some cases, the child becomes physically out of control, even hitting parents or destroying family possessions. Parents find themselves chronically exhausted mentally and physically. Teachers often feel the same frustrations as parents, and day care providers or baby-sitters may refuse to care for the child with ADHD, which adds to the childs rejection. Physiologic and Self-care Considerations Children with ADHD may be thin if they do not take time to eat properly or cannot sit through meals. Trouble sitting down and difficulty sleeping are problems as well. If the child engages in reckless or risk-taking behaviors, there also may be a history of physical injuries. Data Analysis and Planning Nursing diagnoses commonly used when working with children with ADHD include the following: Risk for injury

Ineffective role performance Impaired social interaction Compromised family coping

Outcome Identification Treatment outcomes for clients with ADHD may include the following: The client will be free of injury. The client will not violate the boundaries of others. The client will demonstrate age-appropriate social skills. The client will complete tasks. The client will follow directions. Intervention: Ensuring Safety- Safety of the child and others is always a priority. If the child is engaged in a potentially dangerous activity, the first step is to stop the behavior which may require physical intervention. Attempting to talk to or reason with a child engaged in a dangerous activity is unlikely to succeed because his or her ability to pay attention and to listen is limited. When the incident is over, and the child is safe, the adult should talk to the child directly about the expectations for safe behavior. Close supervision may be required for a time to ensure compliance and to avoid injury. Explanations should be short and clear, and the adult should not use a punitive or belittling tone of voice. The adult should not assume that the child knows acceptable behavior but instead should state expectations clearly. To prevent physically intrusive behavior, it also may be necessary to supervise the child closely while he or she is playing. Improving Role Performance - It is extremely important to give the child specific, positive feedback when he or she meets stated expectations. Doing so reinforces desired behaviors and gives the child a sense of accomplishment. Managing the environment helps the child to improve his or her ability to listen, pay attention, and complete tasks. A quite place with minimal noise and distraction is desirable. At school, this may be a seat directly facing the teacher at the front of the room and away from the distraction of a window or door. At home, the child should have a quiet area for home-work away from the television or radio. Simplifying Instructions - Before beginning any tasks, adults must gain the childs full attention. It is helpful to face the child on his or her level and use good eye contact. The adult should tell the child what needs to be done and break the task into smaller steps if necessary. This approach prevents overwhelming the child and provides the opportunity for feedback about each set of problems he or she completes. With sedentary tasks, it is also important to allow the child to have breaks or opportunities to move around. Adults can use the same approach for tasks such as cleaning or picking up toys. Initially the child needs supervision or at least the presence of the adult. The adult can direct the child to do one portion of the task at a time; when the child shows progress, the adult can give only occasional reminders then allow the child to complete the task independently. Promoting a Structured Daily Routine - A structured daily routine is helpful. The child will accomplish getting up, dressing, doing homework, playing, going to bed, and so forth much more readily of there is a routine for these daily activities. Children with ADHD do not adjust to changes readily and are less likely to meet expectations if times for activities are arbitrary or differ from day to day. Providing Client and Family Education and Support Including parents in planning and providing care for a child with ADHD is important. The nurse can teach parents the approaches for use at home. Parents feel empowered and relieved to have specific strategies that can help both them and their child be more successful. The nurse must listen to parents feelings. Parents need to hear that neither they nor their child are at fault, and that techniques and school program are available to help. It often helps parents to attend support groups that can provide information and encouragement from other parents with the same problems. Parents must learn strategies to help their child improve his or her social and academic abilities, but they also must understand how to help rebuild their childs selfesteem. Most of these children have low self-esteem because they have been labeled as having behavior problems and have been corrected continually by parents and teachers for not listening, not paying attention and misbehaving. Parents should give positive comments as much as possible to encourage the child and acknowledge his or her strengths.

The child needs strategies and practice to improve social skills and academic performance. Because these children often are not diagnosed until second or third grade, they may have missed much basic learning for reading and math. Parents should know that it will take time for them to catch up to other children of the same age. Evaluation Parents and teachers are likely to notice positive outcomes of treatment before the child does. Medications are often effective in decreasing hyperactivity and impulsivity and improving attention relatively quickly, if the child responds to them. Improved sociability, peer relationships, and academic achievements happen more slowly and gradually but are possible with effective treatment.

2. Conduct Disorder
Conduct disorder is characterized by persistent antisocial behavior in children and adolescents that significantly impairs their ability to function in social, academic or occupational areas. Symptoms are clustered in four areas: aggression to people and animals, destruction of property, deceitfulness and theft, and serious violation of rules (Steiner, 2000). People with conduct disorder have little empathy for others; they have low self-esteem, poor frustration tolerance, and temper outbursts. Conduct disorder frequently is associated with early onset of sexual behavior, drinking, smoking, use of illegal substances, and other reckless or risky behaviors. It occurs three times more often in boys than in girls. As many as 30% to 50% of these children are diagnosed with antisocial personality disorder as adults. Onset and Clinical Course Two subtypes of conduct disorder are based on age of onset. The childhood-onset type involves symptoms before 10 years of age including physical aggression toward others and disturbed peer relationships. These children are more likely to have persistent conduct disorder and to develop antisocial personality disorder as adults. Adolescent-onset type is defined by no behaviors of conduct disorder until after 10 years of age. These adolescents are less likely to be aggressive, and they have more normal peer relationships. They are less likely to have persistent conduct disorder or antisocial personality disorder as adults (APA, 2000). Conduct disorders can be classifies as mild, moderate, or severe (APA, 2000): Mild: the person has some conduct problems that cause relatively minor harm to others such as lying, truancy, and staying out late without permission. Moderate: the number of conduct problems increases as does the amount of harm to others such as vandalism and threat. Severe: the person has many conduct problems with considerable harm to others such as force sex, cruelty to animals, use of a weapon, burglary, and robbery. The course of conduct disorder is variable. People with the adolescent-onset type or mild problems can achieve adequate social relationships and academic or occupational success as adults. Those with childhood-onset type or more severe problem behaviors are more likely to develop antisocial personality disorder as adults. Even those who do not have antisocial personality disorder may lead troubled lives with difficult interpersonal relationships, unhealthy lifestyles, and an inability to support themselves (Steiner, 2000). Etiology Genetic vulnerability, environmental adversity, and factors such as poor coping interact to cause the disorder. Risk factors include poor parenting, low academic achievement, poor peer relationships, and low self-esteem; protective factors include resilience, family support, positive peer relationship, and good health (Steiner, 2000). There is a genetic risk for conduct disorder, although no specific gene marker has been identified (Steiner, 2000). The disorder is more common in children who have a sibling with conduct disorder or a parent with antisocial personality disorder, substance abuse, mood disorder, schizophrenia, or ADHD (APA, 2000). A lack of reactivity of the autonomic nervous system has been found in children with conduct disorder; this nonresponsiveness is similar to adults with antisocial personality disorder. The abnormality may cause more aggression in social relationships as a result of decreased normal avoidance or social inhibitions (Steiner, 2000). Poor family functioning, marital discord, poor parenting, and a family history of substance abuse and psychiatric problems are all associated with the development of conduct disorder. Child abuse is an especially significant risk factor. The specific parenting patterns considered ineffective are inconsistent parental responses to the childs demands and giving in to demands as the childs behavior escalates. Exposure to violence in the media and community is a contributing factor for the child at risk in other

areas. Socioeconomic advantages such as inadequate housing, crowded conditions, and poverty also increase the likelihood of conduct disorder in at-risk children (Steiner, 2000). Academic underachievement, learning disabilities, hyperactivity and problems with attention span are all associated with conduct disorder. Children with conduct disorder have difficulty functioning in social situations. They lack the abilities to respond appropriately to others and to negotiate conflict, and they lose the ability to restrain themselves when emotionally stressed. They often are accepted only by peers with similar problems (Steiner, 2000). Cultural Considerations - Concerns have been raised that difficult children may be mistakenly labeled as having conduct disorder. In high-crime areas, aggressive behavior may be protective and not necessarily indicative of conduct disorder. In immigrants from war-ravaged countries, aggressive behavior may have been necessary for survival so they should not be diagnosed with conduct disorder (APA, 2000). Treatment - Prevention is more effective than treatment. Dramatic interventions such as boot camp or incarceration have not proven effective and may even worsen the situation (Steiner, 2000). Treatment must be geared toward the clients developmental age; no one treatment is suitable for all ages. Preschool programs 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. For school-age children with conduct disorder, the child, family, and school environment are the focus of treatment. Techniques include parenting education, social skills training to improve peer relationships, attempts to improve academic performance and increase the childs ability to comply with demands from authority figures. Family therapy is considered essential for children in this age group (Steiner, 2000). Adolescents rely less on their parents and more on peers, so treatment for this age group includes individual therapy. Many adolescent clients have some involvement with the legal system as a result of criminal behavior, and they may have restrictions on their freedom as a result. Use of alcohol and other drugs plays a more significant role for this age group; any treatment plan must address this issue. The most promising treatment approach includes keeping the client in his or her environment with family and individual therapy. The plan usually includes conflict resolution, anger management, and teaching social skills. Medications alone have little effect but may be used in conjunction with treatment for specific symptoms. For example, a client with a labile mood may benefit from lithium or another mood stabilizer such as carbamazepine (Tegretol) or valproic acid (Depakote) (Steiner, 2000). Application of the Nursing Process: Conduct Disorder Assessment History - Children with conduct disorder have a history of disturbed relationships with peers, aggression toward people or animals, destruction of property, deceitfulness or theft, and serious violation of rules (e.g., truancy, running away from home, staying out all night without permission). The behaviors and problems may be mild to severe. General Appearance and Motor Behavior - Appearance, speech, and motor behavior are typically normal for the age group but may be somewhat extreme (e.g., body piercing, tattoos, hairstyle, and clothing). These clients often slouch and are sullen and unwilling to be interviewed. They may use profanity, call the nurse or physician names, and make disparaging remarks about parents, teachers, police, and other authority figures. Mood and Affect - Client may be quiet and reluctant to talk or openly hostile and angry. Their attitude is likely to be disrespectful toward parents, the nurse, or anyone in a position of authority. Irritability, frustration, and temper outburst are common. Clients may be unwilling to answer questions or to cooperate with the treatment. If a client has legal problems, he or she may express superficial guilt or remorse but it is unlikely that these emotions are sincere. Thought Process and Content - Thought processes are usually intactthat is, clients are capable of logical, rational thinking. Nevertheless, they perceive the world to be aggressive and threatening and they respond in the same manner. Clients may be preoccupied with looking out for themselves and behave as though everyone is out to get me. Thoughts or fantasies about death or violence are common.

Sensorium and Intellectual Processes - Clients are alert and oriented with intact memory and no sensory perceptual alterations. Intellectual capacity is not impaired, but typically these clients have poor grades because of academic underachievement, behavioral problems in school, or failure to attend class and to complete assignments. Judgment and Insight - Judgment and insight are limited for developmental stage. Clients consistently break rules with no regard for the consequences. Thrill-seeking or risky behavior is common such as use of drugs or alcohol, reckless driving, sexual activity, and illegal activities such as theft. Clients lack insight and usually blame others or society for their problems; they rarely believe that their behavior is the cause of difficulties. Self-Concept - Although these clients generally try to appear tough, their self-esteem is low. They do not value themselves any more than they value others. Their identity is related to their behaviors such as being cool if they have had many sexual encounters or feeling important if they have stolen expensive merchandise or been expelled from school. Roles and Relationships - Relationships with others, especially those in authority, are disruptive and may be violent. Verbal and physical aggression is common. Siblings may be a target for ridicule or aggression. Relationships with peers may be limited to others who display similar behaviors; these clients see peers who follow rules as dumb or afraid. Clients usually have poor grades, have been expelled, or have dropped out. It is unlikely that they have a job (if old enough) because they would prefer to steal they want or needed. Their idea of fulfilling roles is being tough, breaking rules, and taking advantage of others. Physiologic and Self-Care Considerations - Clients are often at risk for unplanned pregnancy and sexually transmitted diseases because of their early and frequent sexual behavior. Use of drugs and alcohol is an additional risk to health. Clients with conduct disorders are involved in physical aggression and violence including weapons, these results in more injuries and deaths than compared with others of the same age. Data Analysis and Planning Risk for other-directed violence Noncompliance Ineffective coping Impaired social interaction Chronic low self-esteem Outcome Identification The client will not hurt others or damage property. The client will participate in treatment. The client will learn effective problem-solving and coping skills. The client will use age-appropriate and acceptable behaviors when interacting with others. The client will verbalize positive, age-appropriate statements about self. Intervention - Decreasing violence and increasing compliance with treatment The nurse must protect others from the manipulation or aggressive behaviors common with these clients. He or she must set limits on unacceptable behavior at the beginning of treatment. Limit setting involves three steps: Inform clients of the rule or limit. Explain the consequences if clients exceed the limit. State expected behavior. The nurse can negotiate with a client a behavioral contract outlining expected behaviors, limits, and rewards to increase treatment compliance. The client can refer to the written agreement to remember expectations, and staff can refer to the agreement should the client try to change any terms. A contract can help staff to avoid power struggles over requests for special favors or attempts to alter treatment goals or behavioral expectations. Time-out is retreat to a neutral place so clients can regain self-control. It is not a punishment. When a clients behavior begins to escalate, such as threatening someone, a time-out may prevent aggression or acting out. The goal is for clients to recognize signs of increasing agitation and take self-instituted timeout to control emotions and outbursts. After the time-out, the nurse should discuss the events with the

client. Doing so can help clients to recognize situations that trigger emotional responses and to learn more effective ways of dealing with similar situations in the future. Providing positive feedback for successful efforts at avoiding aggression helps to reinforce new behaviors for clients. Improving coping skills and self-esteem - The nurse must show acceptance of clients as worthwhile persons even if their behavior is unacceptable. This means that the nurse must be matter-of-fact about setting limits and must not make judgmental statements about clients. He or she must focus only on the behavior. Clients with a conduct disorder often have a tough exterior and are unable or reluctant to discuss feelings of emotions. Keeping a diary may help them to identify and express their feelings. The nurse can discuss these feelings with clients and explore better, safer expressions than through aggression or acting out. Clients also may nee to learn how to solve problems in a process with the help of the nurse. Problem solving skills are likely to improve with practice. Promoting social interaction - Clients with conduct disorder may not have age-appropriate skills, so teaching social skills is important. The nurse can role-model these skills and help clients to practice appropriate social interaction. The nurse identifies what is not appropriate, such as profanity, and name calling, and also what is appropriate. Clients may have little experience discussing the news, current events and other topics. As they begin to develop social skills, the nurse can include other peers in these discussions. Positive feedback is essential to let clients know they are meeting expectations. Providing client and family education - The nurse can teach parents age-appropriate activities and expectations for clients such as reasonable curfews, household responsibilities, and acceptable behavior at home. The parents may need to learn effective limit setting with appropriate consequences. Parents often need to learn to communicate their feelings and expectations and directly to these clients. Some parents may need to let the client experience the consequences of their behavior rather than rescuing them. Evaluation Treatment is considered effective if the client stops behaving in an aggressive or illegal way, attends school, and follows reasonable rules and expectations at home. The client will not become a model child in a short period; instead, he or she may make modest progress with some setbacks over time. Community-Based Care Clients with conduct disorder are seen in acute care settings only when their behavior is severe and only for short period of stabilization. Much long-term work takes place at school and home or another community setting. Some clients are placed outside their parents home for short or long periods. Group homes, halfway houses, and residential treatment settings are designed to provide a safe, structured environment and adequate supervision if that cannot be provided at home. Clients with legal issues may be placed in detention facilities, jails, or jail-diversion programs.

3. Oppositional Defiant Disorder

Oppositional defiant disorder consists of an enduring pattern of uncooperative, defiant, & hostile behavior towards authority figures without major antisocial violation. A certain level of oppositional behavior is common in children & adolescence; indeed, it is almost expected at some phases such as 2 to 3 years of age & in early adolescence. It is diagnosed only when behaviors are more frequent & intense than in unaffected peers & cause dysfunction in social, academic, or work situations. This disorder is diagnosed in 5% of the population & occurs equally among male & female adolescents. Most authorities believe that genes, temperament, & adverse social conditions interact to create oppositional defiant disorder. 25% of people with this disorder develop conduct disorder; 10% are diagnosed with antisocial personality disorder as adults. Treatment approaches are similar to those used for conduct disorder.

G. Feeding & Eating disorders

The disorders of feeding & eating included in this category are persistent in nature & are not explained by underlying medical conditions. They include pica, rumination disorder, & feeding disorder.

1. Pica
Pica is persistent ingestion of non-nutritive substances such as paint, hair, cloth, leaves, sand, clay, or soil. Pica is commonly seen in children with mental retardation; it occasionally occurs in pregnant women. It comes to the clinicians attention only if a medical complication develops, such as

bowel obstruction or infection, or if a toxic condition develops, such as lead poisoning. In most instances, the behavior lasts for several months & then remits.

2. Rumination Disorder
Rumination disorder is the repeated regurgitation & rechewing food. The child brings partially digested food up into the mouth & usually rechews & reswallows the food. The regurgitation does not involve nausea, vomiting, or any medical condition. This disorder is relatively uncommon & occurs most often in boys than in girls; it results in malnutrition, weight loss, & even death in about 25% of affected infants. In infants, the disorder frequently remits spontaneously but it may continue in severe cases.

3. Feeding Disorder
Feeding disorder of infancy or early childhood is characterized by persistent failure to eat adequately, which results in significant weight loss or failure to gain weight. Feeding disorder is equally common in boys & in girls & occurs most often during the first year of life. Estimates are that 5% of all pediatric hospital admissions are for failure to gain weight & up to 50% of those admissions reflects a feeding disorder with no predisposing medical condition. In severe cases malnutrition & death can result, but most children have improved growth after some time.

H. Tic Disorders
A tic is a sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization. Tics can be suppressed but not indefinitely. Stress exacerbates tics, which diminish during sleep & when the person is engaged in an absorbing activity. Common simple motor tics include blinking, jerking the neck, shrugging the shoulders, grimacing, & coughing. Common simple vocal tics include clearing the throat, grunting, sniffing, snorting, & barking. Complex vocal tics include repeating words or phrases out of context, corolla (use of socially unacceptable words, frequently obscene), palilalia (repeating ones own sounds or words), & echolalia (repeating the last-heard sound or phrase). Complex motor tics include facial gestures, jumping, or touching or smelling an object. Tic disorders tend to run in families. Abnormal transmission of the neurotransmitter dopamine is thought to play a part in tic disorders. Tic disorders usually are treated with risperidone (Risperdal) or olanzapine (Zyprexa), which are atypical antipsychotics. It is important for clients with tic disorders to get plenty of rest & to manage stress, because fatigue & stress increase symptoms.

1. Tourettes Disorder
Tourettes disorder involves multiple motor tics & one or more vocal tics, which occur many times a day for more than 1 year. The complexity & severity of the tics change over time, & the person experiences almost all the possible tics described above during his or her lifetime. The person has significant impairment in academic, social, or occupational areas, & feels ashamed & selfconscious. This rare disorder (4 or 5 in 10,000) is more common in boys & usually identified by 7 years of age. Some people have lifelong problems; others have no symptoms after early adulthood.

2. Chronic Motor or Tic Disorder

Chronic motor or vocal tic differs from Tourettes disorder in that either the motor or the vocal tic is seen, but not both types.

3. Transient Tic Disorder

Transient tic disorder may involve single or multiple vocal or motor tics, but for no longer than 12 months.

I. Elimination Disorders Encopresis is the repeated passage of feces into inappropriate places, such as clothing or the floor, by a child who is at least 4 years of age either chronologically or developmentally. It is often involuntary, but it can be intentional. Involuntary Encopresis usually is associated with constipation that occurs for psychological, not medical reasons. Intentional Encopresis often is associated with oppositional defiant disorder or conduct disorder. Enuresis is the 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 enuresis is involuntary; when intentional, it is associated with a disruptive behavior disorder. Seventy-five percent of children with enuresis have a first-degree relative who had the disorder. Most children with enuresis do not have a coexisting mental disorder.

Both Encopresis & enuresis are more common in boys than in girls; 1% of all 5 years olds have Encopresis can persist with intermittent exacerbations for years; it is rarely chronic. Most children with enuresis are continent by adolescence; only 1% of all cases persist into adulthood. Impairment associated with elimination disorders depends on the limitations on the childs social activities, effects on self-esteem, degree of social ostracism by peers, & anger, punishment, & rejection on the part of parents or caregivers. Enuresis can be treated effectively with imipramine (Tofranil), an antidepressant with a side effect of urinary retention. Both elimination disorders respond to behavioral approaches, such as pad with a warning bell, & to positive reinforcement for continence. For children with a disruptive behavior disorder, psychological treatment of that disorder may improve the elimination disorder.

J. Other Disorders of Infancy, Childhood, or Adolescence 1. Separation Anxiety Disorder

Separation anxiety disorder is characterized by anxiety exceeding that expected for developmental level related to separation from the home or those to whom the child is attached. When apart from attachment figures, the child insists on knowing their whereabouts & may need frequent contact with them such as phone calls. These children are miserable away from home & may fear never seeing their homes or loved ones again. They often follow parents like a shadow, will not be in a room alone, & have trouble going to bed at night unless someone stays with them. Fear of separation may lead to avoidance behaviors such as refusal to attend school or go on errands. Separation anxiety disorder often is accompanied by nightmares & multiple physical complaints such as headaches, nausea, vomiting, & dizziness. Separation anxiety disorders are thought to result from an interaction between temperament & parenting behaviors. Inherited temperament traits, such as passivity, avoidance, fearfulness, or shyness in novel situations, coupled with parenting behaviors that encourage avoidance as a way to deal with strange or unknown situations are thought to cause anxiety in the child. Depending on the severity of the disorder, children may have academic difficulties & social withdrawal if their avoidance behavior keeps them from school or relationships with others. Children may be described as demanding, intrusive, & in need of constant attention, or they may be compliant & eager to please. As adults, they may be slow to leave the family home or overly concerned about & protective of their own spouses or children. They may continue to have marked discomfort when separated from home or family. Parent education & family therapy are essential components of treatment; 80% of children experience remission at 4-year follow-up.

2. Selective Mutism
Selective mutism is characterized by persistent failure to speak in social situation where speaking is expected, such as school. Children may communicate by gestures, nodding or shaking the head, or occasionally one-syllable vocalization in the voice different from their natural voice. These children are often excessively shy, socially withdrawn or isolated, & clinging; they may have temper tantrums. Selective mutism is rare & slightly more common in girls than in boys. It usually lasts only a few months but may persist for years.

3. Reactive Attachment Disorder

Reactive attachment disorder involves a markedly disturbed & developmentally inappropriate social relatedness in most situations. This disorder usually begins before 5 years of age & is associated with grossly pathogenic care such as parental neglect, abuse, or failure to meet the childs basic physical or emotional needs. Repeated changes in primary caregivers, such as multiple foster care placements, also can prevent the formation of stable attachments. The disturbed social relatedness may be evidenced by the childs failure to initiate or respond to social interaction (inhibited type) or indiscriminate sociability or lack of selectivity in choice of attachment figures (disinhibited type). In the first type, the child will not cuddle or desire to be close to anyone. In the second type, the childs response is the same to a stranger or to a parent. Initially, treatment focuses on the childs safety, including removal of the child from the home if neglect or abuse is found. Individual & family therapy (either with parents or foster caregivers) is most effective. With early identification & effective intervention, remission or considerable improvements can be attained. Otherwise the disorder follows a continuous course with relationship problems persisting into adulthood.

4. Stereotyping Movement Disorder

Stereotyping movement disorder is associated with many genetic, metabolic, & neurologic disorders & often accompanies mental retardation. The precise cause is unknown. It involves repetitive motor behavior that is nonfunctional & either interferes with normal activities or results in

self-injury requiring medical treatment. Stereotypic movements may include waving, rocking, twirling objects, biting fingernails, banging the head, biting or hitting oneself, or picking the skin or body orifices. Generally speaking, the more severe the retardation, the higher the risk for self-injury behaviors. Stereotypic movement behaviors are relatively stable over time but may diminish with age. No specific treatment has been shown effective. Clomipramine (Anafranil) & desipramine (Norpramin) are effective in treating severe nail-biting; haloperidol (Haldol) & chlorpromazine (Thorazine) have been effective for stereotypic movement disorder associated with mental retardation & autistic disorder. III. Application of the Nursing Process to Mentally & Emotionally Disturbed Children ASSESING THE CHILD Assessment of the child requires a biopsychoscial approach with attention given to the contribution of biological development, medical illness, cognitive and personality characteristics, cultural context, and the childs family, school, and social environment. The nursing assessment focuses on the specific skills that all children need to become competent adults. Regardless of medical diagnosis, a child should be assessed for mastery of the nine ego competency skills. EGO COMPETENCY SKILLS ESTABLISHING CLOSENESS AND TRUSTING RELATIONSHIPS A basic skill for positive growth and development is the childs ability to establish close and trusting relationships with others. Children with medical diagnosis of generalized anxiety disorder may have difficulty establishing trusting relationships because they are very concerned about their perceived competency. These are the questions that used to evaluate this skill: Does the child enjoy making friends? Does the child often feel picked on by other people? Does the child not know what to say when getting to know someone? To reinforce this skill, nursing staff should encourage interaction and be attentive to the child without being intrusive. Talking with the child in a face-to-face position and offering nurturance are beginning nursing actions. Trust can then be demonstrated by the staff in their interactions with the child. If a child violates a trust, a discussion of the issue should take place, allowing trust to be reestablished. In this way children learn about acknowledging mistakes and the importance of forgiveness in developing trusting relationships. HANDLING SEPARATION AND INDEPENDENT DECISION MAKING Children who have separation anxiety have great difficulty tolerating separation from their mother or home. Yet individuation is an important mental health process. Being able to identify and express feelings and make independent decisions is critical to becoming a competent individual. The following questions are used to evaluate this skill: Does the child get upset or worry when away from his or her mother? Does the child get upset or worry if he or she thinks someone does not like him or her? When upset, is there something the child can do to feel better? Nursing interventions that focus on helping the child identify and clarify aspects of the self are critical exercises for promoting individuation. This may be done in many ways, such as by encouraging children to draw self-portraits, interviewing staff members regarding their opinions on an issue, or identifying personality differences between themselves and others. Any experience that clarifies differences between individuals helps the child to identify himself or herself as a unique individual in a social context. In the therapeutic milieu, opportunities can be provided for the child to make choices and decisions, further supporting the childs growing sense of individuality and ego competency. HANDLING JOINT DECISION MAKING AND INTERPERSONAL CONFLICT Children who have not been allowed to participate in joint decision making or who have not been rewarded for cooperating may be deficient in this skill. A child with oppositional defiant disorder may use aggression instead of negotiation to respond to interpersonal conflict. However, learning the skill of joint decision making is critical for success in interpersonal relationships. The following questions are used to evaluate this skill: When the child has a problem, can he or she usually think of several solutions? Does the child get angry if he or she does not get his or her way? Do other people make the child agitated or easily upset? The therapeutic milieu can provide an opportunity for the child to learn and practice these skills. For example, the nurse can set up opportunities for problem solving. Exercises may be developed for

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making group decisions in which cooperation and collaboration are rewarded. The child shouldnt be helped to identify fears related to cooperating with others, and assertiveness can be modeled and taught. It is important that the nurses not resolve conflicts for the child. Rather, these situations should be used to teach negotiating skills and shape appropriate through the use of reinforcement. 4. DEALING WITH FRUSTRATION AND UNFAVORABLE EVENTS Tolerating frustration, although difficult, is critical to becoming a competent child. Children with conduct disorders often have difficulty understanding a situation from anothers perspective. The following questions are used to evaluate this skill: Does the child feel bad if he or she has hurt someones feelings? If someone disagrees with the child, does it make him or her angry? Does the child not like playing a game if he or she losses? Children who have little frustration tolerance become angry easily and are often unable to complete tasks. Children typically learn this skill through cooperation and competition in playing childhood games. However, if a child has not had the opportunity to play games in this way and if tolerance has not been modeled for the child, he or she probably has not developed this skill. The child will experience numerous frustrations during the course of treatment. The nurse should use these opportunities to think through the process with the child and help increase the childs frustration tolerance and anger control. CELEBRATING GOOD FEELINGS AND FEELING PLEASURE Healthy children raised in nurturing environment naturally experience good feelings and pleasure. However, who are depressed or anxious are not able to celebrate good feelings or experience spontaneous pleasure. Also, in a maladaptive environment shame is often used to control childrens behavior, with the result that they feel guilty for having angry or unacceptable thoughts. Consequently, they may lose the ability to celebrate life and feel pleasure. The following questions are used to evaluate this skill: Does the child worry about the future a lot? Does the child not like it when people say good things about him or her? Does the child feel good about the things he or she does well? A healthy environment is one in which celebrating good feelings and feeling pleasure are natural, spontaneous occurrences. Celebrating and having fun are important nursing interventions. These activities should not be confined to holidays but should be part of the childs weekly activities. Childrens families can be invited to participate in these celebrations, where nursing staff model having fun with the children and their families learn the skill of celebrating good feelings and feeling pleasure. WORKING FOR DELAYED GRATIFICATION As children grow they are expected to delay needed gratification by following rules and waiting their turn. This skill is often difficult for impulsive children with ADHD or conduct disorder to achieve. The following questions are used to evaluate this skill: Does the child believe that most rules are reasonable and does he or she not mind following them? Does the child find it difficult to be honest and think that lying is the only thing to do? Does the child get angry if his or her mother doesnt give what he or she wants? Delayed gratification can be taught by the nurse through the earning of points for daily expectations, such a tidying ones room or completing homework assignments. Childrens games, such as Red Light, in which they respond to stop and wait commands, are also useful in teaching this skill to younger children. As a childs behavior improves, the reward for the points earned can require the accumulation of many points or tokens. Thus the child is given the opportunity to delay the reinforcer for a reward of higher value to be received at a later time. As the child learns greater self-control, he or she will be better able to delay gratification for longer periods of time. RELAXING AND PLAYING Given the stressful environment of current family life, many children may have little opportunity to learn the skill of relaxing and playing. For children with mood, anxiety or behavior disorders, learning to relax and play is an important skill. The following questions are used to evaluate this skill: Are there some things the child really enjoys doing? Can the child have lots of fun? Does the child enjoy sitting around and thinking about things? Time should be devoted to learning this skill. Children should be given unstructured play time in which the staff participate with them in playing games. Having spontaneous talent shows or other forms of fun can contribute to a childs well-being. In this way, relaxing and playing become part of the therapeutic experience and children learn to value and master this skill.

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COGNITIVE PROCESSING THROUGH WORDS, SYMBOLS AND IMAGES Children with psychiatric illnesses may not have developed the important skill of cognitive processing. The following questions are used to evaluate this skill: Is it difficult for the child to describe how he or she feels? Does the child feel as if he or she never knows how something is going to turn out? Can the child identify his or her strengths? A responsive environment should be created to stimulate childrens cognitive development. Furnishings and toys, communications and interactions, and group experiences should all be designed to support the childs cognitive processing. The nurse can help learn this skill by encouraging abstract thinking whenever possible, such as by asking, What is the moral of the story? or what point do you think the movie was trying to communicate? children who are encouraged to express themselves in a responsive environment will gain greater competency in this important area of development. ADAPTIVE SENSE OF DIRECTION AND PURPOSE Children who experience symptoms of mental illness may feel hopeless about their purpose in life. As they view adult life from watching those around them, they begin to draw conclusions about themselves in the world. The following questions are used to evaluate this skill. Does the child feel that his or her life is going to get better? Is the child confused about growing up and doesnt know what to do about it? Does the child believe that school is important and see it as his or her job in life at present? Having role models for healthy, meaningful adult experience is essential to healthy growth and development. Feeling valued as an individual provides the child with an opportunity to learn to value others. Nurses should actively listen to children in their interactions, and even young children should be encouraged to express their needs and feelings. The childs importance as a person can be shown through the approach the nurse uses in providing basic care. Older children can benefit from more in-depth discussions and the use of journals to gain perspective on the direction of their lives. Above all, the nurse should actively help all children realistically assess their abilities and potential to contribute to a better world. NURSING DIAGNOSES Regardless of the childs medical diagnosis, nursing care must be focused on the childs response to illness and the nursing interventions designed to teach and model to the child and family more adaptive coping responses and improve methods of functioning. Thus nursing diagnosis and intervention proceed independently of and concurrently with medical diagnosis and treatment. Although nursing and medicine have collaborative roles, nursing has a critical and distinct contribution to make in the care of the child with psychiatric illness. Once the nurse has completed the ego competency skill assessment, the appropriate nursing diagnosis should be formulated. Nursing interventions can then be identified for each competency skill deficit, developmental stage for each competency skill and related nursing diagnosis. ALTERED FAMILY PROCESS The family should be included in the childs treatment process as soon as possible. Psychiatric illness affects all other family members. In addition, the most common problem that precipitates hospitalization in children is the inability of the family to control the child at home. When the need for hospitalization is identified, the parents have usually exhausted all immediately available resources. A combination of reflective thinking with the parents about their child, clarifying problems and behavioral parent training provides the best results in reducing family stress. The nurse should focus on the needs of each family and either promote family competence through education and support or engage the family in specific clinical interventions, such as family therapy. In addition, some children with psychiatric problems may not have had consistent nurturing or may come from families that display maladaptive responses. Therefore activities that are less threatening should be used initially to teach the child about family relationships. Pictures of families cut out from magazines can provide opportunities for a child to interpret emotional content in the picture. The nurse can then describe a healthy family scenario for the child to learn about adaptive family functioning. ALTERED GROWTH AND DEVELOPMENT Normal growth and development in childhood require a supportive, nurturing environment. A child with a psychiatric illness often has delayed physical and emotional development. However, through a carefully planned nursing interventions, a child can be taught the skills that have not yet been developed.

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For example, for the child to achieve independence in dressing, grooming and room cleaning, a checklist can be made using pictures instead of words. When considering altered growth and development, delays are often the presenting problem. However, many children who are unprotected b their parents and have early exposure to abuse or violence can develop a pseudomaturity. At times they may experience a role reversal with their parents; the child may have become more responsible person while the parent assumed the dependent role. The se children appear to be over compliant with adults. Although this behavior may seem well-adapted, it is appropriate developmentally and should not be reinforced. Rather the child should be encouraged to choose developmentally appropriate play activities and the parent encouraged to resume appropriate adult role responsibilities. ALTERED SEXUALITY PATTERNS Children who are exposed to sexual behavior prematurely may exhibit precocious sexuality. Those children who have been sexually abused may reenact the abuse experience by sexually acting out with other children. The nurse can provide the child with needed insight about his or her behavior, information about prevention, and protection from future abuse. Reporting sexual abuse is a legal and ethical issue for nurses. Although they are required by law to report suspected abuse, nurses are not required to prove that the abuse actually occurred. Nurses are permitted to enter evidence and testify on behalf of the victim, especially if the abuse is harmful o r traumatic to the child. However, frequent interviewing can retraumatize a child and distort a childs perception of what occurred and must be carefully considered. Because it is unclear during this process whether a child will be returned to a parents custody, the nurse must be able to maintain a relationship with both the child and the parent. This process may be difficult for a nurse, who may experience a kind of vicarious trauma. Therefore, when working with sexually abused children, it is critically important for the treatment staff to meet regularly to express their feelings and support each other in this difficult work. ALTERED THOUGHT PROCESS Anxious and depressed children often have difficulty thinking, identifying options, and making decisions. Behaviorally disturbed children become easily frustrated and may respond to their frustration with aggressive behavior. The most effective intervention for school-aged children with these problems is to help them think through options in a nonthreatening way. This thinking process can be practiced by inventing a hypothetical situation that is potentially threatening and helping them think through possible options. Through practicing identifying options and making decisions in nonstressful situations, the child can learn to respond more adaptively to stressful situations. Although rare, children may have psychotic episodes. It is important that the psychiatric nurse be able to discriminate between normal and abnormal thought process in children. Healthy preschool and school-aged children typically have vivid imaginations, and their normal fears can become quite intensive; however, these responses should not be confused with psychotic delusions or hallucinations. Psychotic episodes are distinguished by their level of intensity, distress and duration. They are terrifying and should be treated as psychiatric emergencies. ANTICIPATORY GRIEVING Children in chaotic families often experience many losses, including the loss of stability, the loss of security, and in many ways the loss of childhood. Children who have experienced repetitive losses begin to anticipate the future grief. They may lose interest in playing and become withdrawn. Children who are withdrawn can easily be overlooked. However, they need to be encouraged to actively express their grief. Rumination is discouraged, and participation is encouraged. Most importantly, the significance of their grief should not be minimized. ANXIETY Children who are anxious may become very active and appear to be uncooperative, or they may withdraw from their environment. Gentle touch and redirection are often effective in restoring a childs self-control. If this is insufficient, a child may need to be moved to a less stimulating environment to reduce anxiety and regain self-control. Also, children may have separation anxiety related to particular people, often their parents. The child may have difficulty separating from a parent, and the parent may similarly be ambivalent about leaving the child. Each may require a great deal of reassurance to tolerate separation when needed. The nurse in the inpatient setting can help the child reduce anxiety by providing some attachment object, such as a small cuddly toy or other object the parent brings from home. Often, drawing pictures of home, a family gathering, or the familys reaction to the hospitalization can be reassuring to a young child. The nurse can also help the patient by having a frequent telephone contact to report the childs

progress. Nursing interventions are then planted to help the child and parents anticipate the future, reduce anxiety related to the childs sense of self. BODY IMAGE DISTURBANCE Some children may have distorted ideas about their body and experience gender identity confusion. This is usually identified in drawings in which a child consistently deletes important body parts or covers them up by making through them with dark colors. They may also draw gender-specific details that are incorrect, such as breasts on a boy or male genitalia on a girl. An effective nursing intervention is to have a child recline on a large piece of paper and draw a body outline. The child then draws in features, clothes and other accessories. The child can separate himself or herself from the drawing and be more explicit about the details and differences between boys and girls. At this time, open discussion can clarify any distortions or misperceptions. Also, children who have been sexually abused are often confused about body invasions for themselves and others. These children may be intrusive and need to be taught about appropriate and inappropriate touching and respect for body boundaries. CHRONIC LOW SELF-ESTEEM Children with psychiatric illness often have low self-esteem. It may be expressed by infrequent eye contact, lack of motivation, withdrawal or the use of negative behavior to seek attention. Specific therapeutic activities can be planned to improve a childs self-esteem. Accomplishment of a goal, no matter how small is very rewarding and incremental goal setting can be an effective way to provide opportunities for success. For example, a child who is a chronic complainer could be rewarded for refraining from complaining for 15 minutes. The time can then be gradually increased. At the same time, new methods of communication such as initiating a conversation can be taught and rewarded. A bedtime review of accomplishments of the day in which the child lists personal strengths can also be positively reinforcing. Finally, the nurse can provide information and guidance to parents to help them enhance their childs selfesteem. DECISIONAL CONFLICT Children who have been abused or otherwise traumatized often respond to their experience by appearing defiant and oppositional. In evaluating a childs ability to handle interpersonal conflict, the childs developmental level should be considered. There are many tasks that are difficult for children to complete, particular if they are developmentally delayed or anxious. Therefore, expectations must be carefully evaluated to determine whether they exceed a childs capability. An intervention should be planned to reward or positively reinforce a childs appropriate decision-making ability. For example, a point system in which a child earns points and exchanges them for privileges and may be very helpful. FAMILY COPING: POTENTIAL FOR GROWTH Each family has an extensive history that has shaped the development of each family member. This collective family history and its adaptability for a change have a powerful influence on a childs prognosis for learning, practicing and applying new skills. Therefore the familys willingness to participate in the therapeutic process and interest in making change should guide the nursing intervention for the child. During parent education, a nurse models the effective use of reinforcement, communication and behavior management techniques. HOPELESSNESS Many children live in chaotic and dangerous environments. Communities are often unsafe and schools may be plagued with violence. Children in these situations may feel very hopeless. Setting small goals that a child can accomplish may help to reduce feelings of hopelessness. Nurses also have an opportunity to teach these children and families about community helping agencies, to find advocates for the child and to teach the child about self-protection. Trips to the police station, fire station or community centers may help reduce the childs sense of hopelessness. Often, a relative, teacher, guidance counselor or church member can provide the child with a concerned adult in the community. Contact with some agency or individual that can provide safety for the child is an essential nursing intervention. Children who are frequently hospitalized or who live in foster care or residential facilities often experience hopelessness. It can be helpful to make a scrapbook about the childs life. By drawing pictures or using pictures from magazines, the child can create a book. The current hospitalization should be included with a picture of the nursing staff members to the child. The child then can take this record to the next treatment facility or foster home. In this way the child begins to record life events so that hope for the future can be created. IMPAIRED SOCIAL INTERACTION

Children with emotional problems often have not learned basic social skills that help them relate to others. The therapeutic nurse-patient relationship can be used to learn these skills. Group therapy and cognitive-behavioral strategies such as social skills training and modeling socially appropriate responses that demonstrate respect for other people are effective nursing interventions. Through guidance, demonstration, practice and feedback, social interaction can be improved. IMPAIRED VERBAL COMMUNICATION Being able to describe personal experience and express feelings is important to a childs mental health. The nurse can model clear communication by starting a conversation wit ha child about a recent life experience, such. A child as something that happened on the way to work. The nurse can then prompt the child to tell about some personal life experiences. As the child begins, the nurse reinforces communication with a smile, nod, and touch. After the child has mastered the skill of taking about external experiences, the nurse can change the intervention to talking about an internal experience or feeling. Once again the nurse may begin by describing a feeling that has become associated with an event and then prompt the children, wait, and reinforce. A child who has never been encouraged to talk about feelings may require the use of therapeutic play involving dolls to express feelings or may be better able to talk about feelings by drawing. PERSONAL IDENTITY DISTURBANCE As children approach adolescence they begin to struggle with an individual identity. Without role models for finding meaning in life, a childs personal identity formation becomes a crisis. If a child does not have successful adult models in life, people in the news or fictional characters can be used. The nurse may begin by discussing the skills and courage that the person showed in overcoming problems or adversity. This discussion can then flow into finding direction and purpose in life. Within the context of important discussions such as this, a child with personal identity disturbance can develop a competent identity of self and meet the challenges of the adult world. POSTTRAUMA RESPONSE Children who have been traumatized may have sudden and dramatic mood changes. Often some unexpected traumatized event reminds them of previous abuse episode, and they experience the anxiety associated with the earlier abuse. At that time their behavior may change without any identifiable cause. Nursing interventions such as art therapy and play therapy can be very useful I helping a child to cope with a previous abuse incident and reduce a posttrauma response. Through a guided process using a play or drawings, a child may be able to identify the things that are associated with the trauma, such as certain types of weather, body features such as mustaches, or experiences such as hearing loud voices. With this awareness, a child can learn to anticipate responses and may be able to gain some control over them. POTENTIAL VIOLENCE Being able to handle conflict without becoming aggressive toward oneself or others is very important for children to learn. In contemporary American culture, violence is wide-spread and children may perceive it to be an acceptable way of dealing with conflict. Also, with extensive media and television coverage of violent events, children may become numb to feelings related to violence. Therefore alternatives such as anger management must be taught so that child will have repertoire of solutions to use in conflict situations. A brief time-out may be effective in interrupting behavior that is escalating or becoming out of control. During these periods alone it may be helpful for a child to read a story about a similar conflict or for an older child to write thoughts and feelings in a journal. Another useful strategy is to establish a contract wit ha child who is capable of understanding, writing and adhering to it. Such a contract would identify the consequences that the child would face, based on the specific behavior. Contracts allow the child to play an active role in the treatment process and provide immediate and constructive feedback about the childs actions. SLEEP PATTERN DISTURBANCE Children who are experiencing anxiety may have sleep disturbances and nightmares. If a child is receiving psychostimulants, such as methylphenidate (Ritalin), and has disturbed sleeps, the medication should not be given in the evening if the child has insomia. Sleep disturbance can also be treated with various nursing interventions. Back massage can be helpful in encouraging relaxation. Many childrens stories that deal with nightmares and fears related to bedtime can be read and discussed. In general, however, the most effective way to make a successful transition to bedtime and subsequently to sleep is to develop a consistent, predictable bedtime ritual, such as taking a bath followed by quiet time and a

bedtime story. The consistent application of these activities usually reduces this maladaptive response in children. THERAPEUTIC TREATMENT MODALITIES THERAPEUTIC PLAY Because play is normal and fun for children, it is a very effective tool for nurse to use. Interventions that are enjoyable, arouse curiosity, and stimulate the imagination will capture the childs attention and interest. Many children with psychiatric problems may have lost interest in play or may have never experienced the joy of spontaneous play. Learning to play is critical not only to a childs development but also to the mental health. Therapeutic Factor Overcoming resistance Communication Competence Creative thinking Catharsis Abreaction Role playing Fantasy Teaching through metaphors Relationship enhancement Mastering developmental fears Game play Therapeutic aspects of play Beneficial Outcome Working alliance Understanding Self-esteem Problem solving Emotional Release Perspective on traumatic event Learning new behaviors Comprehension and Sublimation Insight Trust in Others Growth and development Socialization

The nurses should keep these elements in mind when incorporating play therapy into the plan of care. The first step is for the nurse to develop a therapeutic alliance and trust with the child so that life can be perceived from the childs perspective and the childs concern can be anticipated. When a child feels understood and safe, participation in therapeutic play with the nurse is common. If the child is anxious, his or her developmental level may fluctuate rapidly, and this should be continuously assessed by the nurse. However, care must be taken to ensure that the child does not fail at the activity, either because the developmental level is too advanced or because of the severity of the childs symptoms. Children will become easily frustrated with play that is too difficult and thus feel a sense of failure when their self-esteem is already compromised. Toys that are age appropriate and imaginative should be offered to a child. These may include blocks, a play house, family characters, soldiers, trucks and rescue vehicles. The child is then encouraged to begin play without specific direction from the nurse. ART THERAPY Drawing is a valuable tool for children to use in describing an event or expressing a feeling. Children often do not have the vocabulary to express themselves, and they feel pressured to answer questions they do not understand. Through drawings, a child can provide information about behavior and developmental maturity that the nurse can then use to help the child in preparing for future change. Art is particularly useful in assessing a childs therapeutic needs. Children may find drawing stressful if they have been criticized about it in the past. However, with some encouragement they will usually produce an interesting and often revealing picture. The nurse might ask what is happening in the picture or to name the people. The nurse should make notes about what-ever the child reports the people are saying or thinking. CHIDLRENS GAMES Children with behavioral disorders often have difficulty with motor control. Games that teach motor controls can be helpful to these children. Such games include Simon says, red light, musical chairs, etc. Games can also be used to increase a childs concentration and frustration tolerance. When initiating these activities, the nurse should consider the childs motor development and level of anxiety and choose among games that engage large or small muscle groups. Thought should also be given to the childs tolerance for frustration and competition. Games may then be modified to meet the specific therapeutic needs of the child. Games can also be played with increasing demands placed on concentration and

cognitive processing; however, it is important to stop playing a game that is too difficult or stressful for a child. BIBLIOTHERAPY Bibliotherapy is the use of literature to help children identify and express feelings within the structure and safety of the nurse-patient relationship. Because children actively engage in imaginary thinking, they can easily identify with the fictional characters in a story and gain insight into their own lives. In implementing this activity the nurse should carefully consider the childs age and attention span. To be effective, the story should have illustrations that capture the childs interest. The nurse should also think about the childs situation or issue relevant to the childs life situation. While reading the story, the nurse should be sensitive to the childs response. It is also important to give the child an opportunity to reflect on the story and discuss any thoughts or feelings about the characters because it is often easier to tell about the feelings of the characters than ones own. STORYTELLING The therapeutic use of story telling for relieving distress and teaching new coping skills is a valuable intervention. Because children do not separate imaginary experiences from real experiences, stories that teach appropriate problem-solving skills can serve as models for real situations. Initially, the nurse must identify a social skill that the child needs to learn, such as assertiveness. The nurse may make up a story about a character who needs that particular skill, giving the hero or heroine characteristics similar to those of the child. It is important to select an ending to the story that will guide the child in learning the skill. The story should be told using animated facial expressions and expressive voice inflections, and the child should be actively involved in the story as much as possible. At the end of the story the nurse should ask the child about the story and how it made the child feel AUTOGENIC STORYTELLING A similar version of storytelling is autogenic storytelling, a therapeutic activity in which the child participates in creating the story. Nurse may find this activity particularly valuable in helping children explore fears related to traumatic events. This intervention is particularly useful for a school-age child who has been traumatized or is having nightmares. A child will often reenact anxiety-related experiences in a story portrayed by animals or other fictional characters. Unlike real life, the child can have control over the experiences if it is relieved in play or storytelling. Children often like audio taping the story and then listening to their voice telling the story. The nurse should discuss the general structure of the story with the child and together they can decide on the main characters and the beginning plot. The nurses should begin the story with the introduction and then stop, allowing the child to add the nest event. PHARMACOTHERAPY Many children with a psychiatric illness receive psychotropic medication as part of their treatment. Psychiatric nurses must be knowledgeable about these medications and develop interventions to monitor, educate and evaluate medication effects with children and their families. Nurses should also be aware that promoting a childs knowledge of medications can have a positive effect on self-esteem feelings of control and self-worth. This area allows many creative nursing interventions. A variety of puppet play, art, graphics and audiovisual materials can be used to successfully teach and prepare children for managing their medications and their illness. Peer group participation is particularly effective in helping children describe common experiences, decrease their sense of isolation, and enhance their responses to the teaching materials. Through imaginative but goal-directed nursing interventions, children can learn important information and experience greater control over the treatment of their illness and their future mental health. Finally, it is important for nurses to realize that children metabolize and eliminate medications more rapidly than adults. Disorders Drug Class Affective disorders: Antidepressants (dopamine, depression, bipolar disorder imipramine, fluoxetine) Mood stabilizers (carbamazepine, lithium) Anxiety, transient insomnia, Antihistamines (Benadryl), acute extrapyramidal benzodiazepines symptoms (EPS) Attention deficit-hyperactivity Stimulates disorder ADHD (dextroamphetamine,

methylphenidate, pemoline) Conduct disorders (aggressive Antipsychotics, stimulants, and nonagressive) antidepressants, mood stabilizers Functional enuresis Antidepressants (imipramine) Impulsivity Antipsychotics, mood stabilizers Mental retardation with Antipsychotics, psychiatric symptoms and antidepressants, stimulants, behavioral problems Lithium, carbamazepine Obsessive-compulsive Antidepressants disorder OCD (clomipramine, SSRIs) Panic and School Phobia TCA, MAOI, SSRIs Pervasive developmental Antipsychotics, disorders (including autism) antidepressants (clomipramin, SSRIs) Psychosis Antipsychotics Rage Haloperidol, mood stabilizers Schizoprenia Antipsychotics Separation anxiety disorder Antidepressants (imipramine, SSRIs) Tic disorders: Tourettes Antipsychotics (haloperidol, disorder SSRI) Alpha-adrenergic agonist (clonidine) MILIEU MANAGEMENT An important role of the child psychiatric nurse is the organization, management and integration of multiple treatment interventions with the child throughout the continuum of care, such as in the inpatient setting, day treatment program or intensive in-home intervention. The developmental needs of children in a psychiatric milieu are complex and dynamic. The design of the unit and treatment philosophy should provide the context of treatment within safe, caring environment. A planned program of activities is essential for safe milieu management. Family participation and support from the staff are also essential for successful treatment outcomes. With escalating aggression among children, the management of a therapeutic milieu in any of these settings is very challenging. The childs day must be organized into manageable time units that are age appropriate with specific but varied activities assigned to each time. Whenever possible, children should be assigned to a small group with specific staff members. A schedule should be set up in advance that is predictable from one day to the next. Consistency and predictability are very important. Transitioning from one activity to the next is often difficult for children; therefore a transitional object such as a reward sheet of stickers that is carried from one activity to the next can be helpful. Before leaving one activity, the child should be prepared for the next activity. Helping children to anticipate what is expected of them in the next time period will help them better manage their anxiety. Anxiety and aggression in any setting can be contagious, and they can escalate abruptly. Nurses should be prepared to act quickly and decisively if a child becomes aggressive. If this occurs, the child who is aggressive or anxious must be separated from children who are in control of their behavior. When the child is isolated, the aggressive behavior will begin to de-escalate, the child can be brought under control and the process of learning about why this occurred can begin. These problems can be minimized by having a well planned schedule and implementing it consistently. Whenever tension in the milieu begins to rise, the staff must be very visible for potential problems. A carefully planned milieu schedule anticipates problems, creates solutions, and capitalizes on the strengths and energy of the children. Keeping the milieu safe and therapeutic is a high priority for child psychiatric nursing intervention. Ongoing clinical supervision and peer review improve communication and collaboration among staff members. These activities allow staff to evaluate and refine their therapeutic skills and facilitate goal-directed interactions in the children. PSYCHOTHERAPY Structured child and adolescent psychotherapy, tested through controlled clinical trials, have produced beneficial effects in hundreds of studies. These include cognitive, behavioral and interpersonal

therapies, as well as contingency management. In contrast, the limited pool of research on traditional child psychotherapy raises doubts about its effectiveness.