Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence

SIENNA MARIE J. GONZALEZ, RN, MAN

OBJECTIVES
After reading this chapter, the student will be able to: Identify psychiatric disorders usually first diagnosed in infancy, childhood, or adolescence. Discuss predisposing factors implicated in the etiology of mental retardation, autistic disorder, attention-deficit/ hyperactivity disorder, conduct disorder, oppositional defiant disorder, Tourettes disorder, and separation anxiety disorder. Identify symptomatology and use the information in the assessment of clients with the aforementioned disorders.

 Identify nursing diagnoses common to clients with these disorders and select appropriate nursing interventions for each. Discuss relevant criteria for evaluating nursing care of clients with selected infant, childhood, and adolescent psychiatric disorders. Describe treatment modalities relevant to selected disorders of infancy, childhood, and adolescence.

Mental Retardation

Mental Retardation
Deficits in general intellectual functioning and adaptive functioning General intellectual functioning is measured by an persons performance on intelligence quotient (IQ) tests. Adaptive functioning refers to the persons ability to adapt to the requirements of daily living and the expectations of his or her age and cultural group.

Diagnostic Criteria for Mental Retardation

A. Significantly subaverage general intellectual functioning: an IQ of approximately 70 or below on an individually administered IQ test B. Concurrent deficits or impairments in adaptive functioning in at least two of the following areas: communication, selfcare, home living, social/interpersonal skills, use of community resources, self-direction, functional academic skills, work, leisure, health, and safety. C. The onset is before age 18 years.

Predisposing Factors: Hereditary

Inborn errors of metabolism TaySachs disease, phenylketonuria, and hyperglycinemia Chromosomal disorders Down syndrome and Klinefelter syndrome Single-gene abnormalities Tuberous sclerosis and neurofibromatosis.

Predisposing Factors: Early Alterations in Embryonic Development

Damages may occur in response to: Toxicity associated with maternal ingestion of alcohol or other drugs Maternal illnesses and infections during pregnancy (e.g., rubella, cytomegalovirus) and Complications of pregnancy (e.g., toxemia, uncontrolled diabetes) also can result in congenital mental retardation

Predisposing Factors: Pregnancy and Perinatal Factors

Factors that occur during pregnancy fetal malnutrition, viral and other infections, and prematurity During the birth process trauma to the head incurred during birth, placenta previa or premature separation of the placenta, and prolapse of the umbilical cord

General Medical Conditions Acquired in Infancy or Childhood

General medical conditions acquired during infancy or childhood infections, such as meningitis and encephalitis; poisonings, such as from insecticides, medications, and lead; and physical trauma, such as head injuries, asphyxiation, and hyperpyrexia

Environmental Influences and Other Mental Disorders

Deprivation of nurturance and social, linguistic, and other stimulation, Severe mental disorders autistic disorder

Application of the Nursing Process to Mental Retardation

Background Assessment Data (Symptomatology)

The degree of mental retardation is identified by the clients IQ level. Mild Moderate Severe, and profound

Diagnosis/Outcome Identification
Risk for injury related to altered physical mobility or aggressive behavior. Self-care deficit related to altered physical mobility or lack of maturity. Impaired verbal communication related to developmental alteration. Impaired social interaction related to speech deficiencies or difficulty conforming to conventional social behavior.

 Delayed growth and development related to isolation from significant others; inadequate environmental stimulation; hereditary factors. Anxiety (moderate to severe) related to hospitalization and absence of familiar surroundings. Defensive coping related to feelings of powerlessness and threat to self-esteem. Ineffective coping related to inadequate coping skills secondary to developmental delay.

Outcome Criteria
The following criteria may be used for measurement of outcomes in the care of the client with mental retardation. The client: 1. Has experienced no physical harm. 2. Has had self-care needs fulfilled. 3. Interacts with others in a socially appropriate manner. 4. Has maintained anxiety at a manageable level. 5. Is able to accept direction without becoming defensive. 6. Demonstrates adaptive coping skills in response to stressful situations.

AUTISTIC DISORDER

Autistic disorder
Characterized by a withdrawal of the child into the self and into a fantasy world of his or her own creation. With markedly abnormal or impaired development in social interaction and communication and a markedly restricted repertoire of activity and interests Activities and interests are restricted and may be considered somewhat bizarre.

Epidemiology and Course

Prevalence of ASD to be about 6 per 1000. It occurs about four times more often in boys than in girls. Onset: before age 3 In most cases it runs a chronic course, with symptoms persisting into adulthood.

Predisposing Factors: Biological Factors

Neurological Implications. Abnormalities in brain structures or functions cerebellum, cerebral cortex, limbic system, corpus callosum, basal ganglia, and brain stem Alterations in serotonin synthesis

 Early developmental problems postnatal neurological infections, congenital rubella, phenylketonuria, and fragile X syndrome Structural and functional abnormalities in the brain
Ventricular enlargement, left temporal lobe abnormalities, and increased glucose metabolism.

Predisposing Factors: Genetics

Parents who have one child with autism are at increased risk for having more than one child with autism

Predisposing Factors: Perinatal Influences

women who suffered from asthma and/or allergies around the time of pregnancy 2nd trimester has twofold elevated risk

Application of the Nursing Process to Autistic Disorder

Background Assessment Data (Symptomatology)

Impairment in Social Interaction Infant: Aversion to affection Toddler: attachment to a significant other may be absent or exxagerated Failure to develop cooperative play, imginative play and friendships

Background Assessment Data (Symptomatology)

Impairment in Communication and Imaginative Activity Language may be totally absent or idiosyncratic Facial expression or gestures often absent or socially inappropriate Imaginative play is stereotypical

Background Assessment Data (Symptomatology)

Restricted Activities and Interests Minor changes in environment is met with resistance, hysterical responses Extreme fascination with objects that move or spin Routine is an obsession Stereotyped body movements Eating a specific food, drinking excessive amounts of fluid Self-injurious behavior

Diagnosis/Outcome Identification
Risk for self-mutilation related to neurological alterations. Impaired social interaction related to inability to trust; neurological alterations. Impaired verbal communication related to withdrawal into the self; inadequate sensory stimulation; neurological alterations. Disturbed personal identity related to inadequate sensory stimulation; neurological alterations.

Outcome Criteria
The following criteria may be used for measurement of outcomes in the care of the client with autistic disorder. The client: 1. Exhibits no evidence of self-harm. 2. Interacts appropriately with at least one staff member. 3. Demonstrates trust in at least one staff member. 4. Is able to communicate so that he or she can be understood by at least one staff member. 5. Demonstrates behaviors that indicate he or she has begun the separation/individuation process.

ATTENTIONDEFICIT/HYPERACTIVITY DISORDER

ATTENTIONDEFICIT/HYPERACTIVITY DISORDER
A persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than is typically observed in individuals at a comparable level

Predisposing Factors: Biological Influences

Genetics a large number of parents of hyperactive children showed signs of hyperactivity during their own childhood hyperactive children are more likely than normal children to have siblings who are also hyperactive when one twin of an identical twin pair has the disorder, the other is likely to have it too

Biochemical Theory
Dopamine, norepinephrine, and possibly serotonin
Abnormal levels of these neurotransmitters may be associated with the symptoms of inattention, hyperactivity, impulsivity, mood, and aggression often observed in individuals with the disorder

Neurotransmitter Functions
Norepinephrine ability to perform executive functions, such as analysis and reasoning, and in the cognitive alertness essential for processing stimuli and sustaining attention and thought Dopamine sensory filtering, memory, concentration, controlling emotions, locomotor activity, and reasoning. Serotonin less significant than norepinephrine and dopamine. It has been suggested that alterations in serotonin may be related to the disinhibition and impulsivity observed in children with ADHD. It may play a role in mood disorders, particularly depression, which is a common comorbid disorder associated with ADHD.

Anatomical Influences
Alterations in specific areas of the brain
frontal lobes, basal ganglia, caudate nucleus, and cerebellum

Functional Areas of the Brain Affected

Prefrontal cortex: Associated with maintaining attention, organization, and executive function. Also serves to modulate behavior inhibition, with serotonin as the predominant central inhibiting neurotransmitter for this function. Basal ganglia (particularly the caudate nucleus and globus pallidus). Involved in the regulation of high-level movements. In association with its connecting circuits to the prefrontal cortex, may also be important in cognition.
Interruptions in these circuits may result in inattention or impulsivity.

Hippocampus: Plays an important role in learning and memory.

Functional Areas of the Brain Affected

Limbic System (composed of the amygdala, hippocampus, mammillary body, hypothalamus, thalamus, fornix, cingulate gyrus and septum pellucidum): Regulation of emotions. A neurotransmitter deficiency in this area may result in restlessness, inattention, or emotional volatility. Reticular activating system (composed of the reticular formation [located in the brain stem] and its connections): It is the major relay system among the many pathways that enter and leave the brain. It is thought to be the center of arousal and motivation and is crucial for maintaining a state of consciousness.

Prenatal, Perinatal, and Postnatal Factors

Prenatal
Maternal smoking Intrauterine exposure to toxic substances, including alcohol

Postnatal
Cerebral palsy Seizures other central nervous system (CNS) abnormalities resulting from:
trauma, infections, or other neurological disorders

Perinatal
Prematurity or low birth weight Signs of fetal distress Precipitated or prolonged labor Asphyxia Low Apgar scores

Environmental Influences
Environmental Lead Studies continue to provide evidence of the adverse effects on cognitive and behavioral development in children with elevated body levels of lead. Diet Factors The possible link between food dyes and additives, such as artificial flavorings and preservatives Sugar

Psychosocial Influences
Disorganized or chaotic environments or a disruption in family equilibrium may predispose some individuals to ADHD. A high degree of psychosocial stress, maternal mental disorder, paternal criminality, low socioeconomic status, poverty, growing up in an institution, and unstable foster care are factors that have been implicated

Application of the Nursing Process to ADHD

Background Assessment Data (Symptomatology)

Difficulties in performing age-appropriate tasks Highly distractible and have extremely limited attention spans Impulsivity, or deficit in inhibitory control, Difficulty forming satisfactory interpersonal relationships. Disruptive and intrusive in group endeavors

 They have difficulty complying with social norms. Some children with ADHD Some are very aggressive or oppositional Others exhibit more regressive and immature behaviors Low frustration tolerance Outbursts of temper are common. boundless energy, exhibiting excessive levels of activity, restlessness, and fidgeting perpetual motion machines, continuously running, jumping, wiggling, or squirming.

Diagnosis/Outcome Identification
Risk for injury related to impulsive and accidentprone behavior and the inability to perceive selfharm. Impaired social interaction related to intrusive and immature behavior. Low self-esteem related to dysfunctional family system and negative feedback. Noncompliance with task expectations related to low frustration tolerance and short attention span.

Outcome Criteria
The client: Has experienced no physical harm. Interacts with others appropriately. Verbalizes positive aspects about self. Demonstrates fewer demanding behaviors. Cooperatives with staff in an effort to complete assigned tasks.

Psychopharmacological Intervention for ADHD Central nervous stimulants

Dextroamphetamine Methamphethamine, Dextroamphetamine/amphetamine Methylphenidate Dexmethylphenidate
Increased attention Control of hyperactive behavior Improvement in learning ability

 Side effects:
Insomnia- administer last dose 6hours before bedtime Anorexia- administer immediately after meals, weigh regularly Weight loss Tachycardia- personal and family history of heart disease Temporary decrease in rate of growth and development Physical tolerance

 Any of the following side effects should be reported to the physician immediately: shortness of breath, chest pain, jaw/left arm pain, fainting, seizures, sudden vision changes, weakness on one side of the body, slurred speech, confusion, itching, dark urine, right upper quadrant pain, yellow skin or eyes, sore throat, fever, malaise, increased hyperactivity, believing things that are not true, or hearing voices.

CONDUCT DISORDER

CONDUCT DISORDER
Repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated

CONDUCT DISORDER Childhood-Onset Type

The onset of at least one criterion characteristic of conduct disorder before age 10. Are usually boys, Frequently display physical aggression, and have disturbed peer relationships. They may have had oppositional defiant disorder during early childhood, usually meet the full criteria for conduct disorder by puberty, and are likely to develop antisocial personality disorder in adulthood.

CONDUCT DISORDER Adolescent-Onset Type

Absence of any criteria characteristic of conduct disorder before age 10. Less likely to display aggressive behaviors and tend to have more normal peer relationships than those with childhood-onset type. They are also less likely to have persistent conduct disorder or develop antisocial personality disorder than those with childhood-onset type. The ratio of boys to girls is lower in adolescent-onset type than in childhood-onset type.

Predisposing Factors Biological Influences

Genetics. Higher number of conduct disorders among those who have family members with the disorder some of the genes contributing to alcohol dependence in adulthood may also contribute to conduct disorder in childhood

Predisposing Factors Biological Influences

Temperament Difficult temperament at age 3 has significant links to conduct disorder and movement into care or institutional life at age 17 Biochemical Factors Alterations in the neurotransmitters norepinephrine and serotonin

Psychosocial Influences Peer Relationships

Poor Peer Relations
during childhood were consistently implicated in the etiology of later deviance

Family Influences.
Parental rejection Inconsistent management with harsh discipline Early institutional living Frequent shifting of parental figures Large family size Absent father Parents with antisocial personality disorder and/or alcohol dependence Association with a delinquent subgroup Marital conflict and divorce Inadequate communication patterns Parental permissiveness

Application of the Nursing Process to Conduct Disorder

Background Assessment Data (Symptomatology)

Classic characteristic of conduct disorder is the use of 0physical aggression in the violation of the rights of others. The behavior pattern manifests itself in virtually all areas of the childs life (home, school, with peers, and in the community). Stealing, lying, and truancy are common problems. The child lacks feelings of guilt or remorse. Characteristics include poor frustration tolerance, irritability, and frequent temper outbursts.

Diagnosis/Outcome Identification
Risk for other-directed violence related to characteristics of temperament, peer rejection, negative parental role models, dysfunctional family dynamics. Impaired social interaction related to negative parental role models, impaired peer relationships leading to inappropriate social behaviors. Defensive coping related to low self-esteem and dysfunctional family system. Low self-esteem related to lack of positive feedback and unsatisfactory parentchild relationship.

Outcome Criteria
The client: 1. Has not harmed self or others. 2. Interacts with others in a socially appropriate manner. 3. Accepts direction without becoming defensive. 4. Demonstrates evidence of increased selfesteem by discontinuing exploitative and demanding behaviors toward others.

THE END