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Chapter 18Disorders andIssues ofChildren and Adolescents

Etiologic Factors

•Genetic

–Family history of mental issues

•Environmental

–Neighborhood, family income, family educationallevel

•Parental divorce

•Combined factors

Developmental Disorders

•Child demonstrates symptoms of deficit before the age18 years

•Characterized by performance testing of mentality, skills,coordination, or activity that is substantially below thatanticipated for the child’s chronological age andeducation level

Types of Developmental Disorders

•Mental retardation

•Autistic disorder (pervasive)

•Asperger’s syndrome (pervasive)

•Psychosis (pervasive)

Mental Retardation

•Intellectual functioning significantly below average

•IQ 70 or below

•Mild to profound

•Many behavior problems result from frustration withcommunication limitations

•Signs and Symptoms Box 18.1 Page 279

Autistic Disorder

•Severe impaired ability to socially interact andcommunicate with the outside world

•Symptoms usually appear before 3 years of age

•Withdrawn, fantasy world – little interaction withenvironment

•Deficient nonverbal behaviors (eye contact, facial exp)

•May demonstrate unusual or exaggerated responses tosensory stimuli

•Inflexible and consistent routine of rituals

•Signs and Symptoms Box 18.2 Page 280

Asperger’s Syndrome

•Difficulty with social interaction and communication

•Preoccupation with a particular subject (high level of expertise)and avoid other activities

•Average or above average intelligence

•Develop normally in the areas of thinking and learninglanguage skills

•Speech is often centered around random factual information

•Poor social skills and limited interests

–Risk for isolation

•More common in boys; 2:10,000 children

•http://www.youtube.com/watch?v=WAfWfsop1e0

Developmental Coordination Disorder

•Significant impairment in development of motorcoordination

•Clumsiness in motor activities

•Delays in developmental milestones  crawling, walking,dressing

•May exhibit delays in other developmental areas, such aslanguage skills

•6% of children 5-11; more common in boys

•Can lead to suicidal tendencies, substance use, etc.

•Signs and Symptoms of DCD Box 18.3 Page 281

Case Application 18.1

•“From Martina’s World”

•Page 280

Psychosis

•Not specifically a childhood disorder but sometimesconfused with autistic disorders

•Hallucinations, delusions, flat affect, disorganized speech,stereotypical behaviors

•Poor development of intellectual, motor, emotional, andsocial skills

•Unable to differentiate real and unreal

•Disturbed interpersonal relationships

•Signs and Symptoms of Psychosis in ChildrenBox 18.4 Page 281

Types of Learning and CommunicationDisorders

•Dyslexia

•Expressive language disorder

•Phonologic disorder

Dyslexia

•Deficit in reading/written expression

•Normal to above average intelligence

–May be behind in the level of reading expected for theirgrade level

•Inability to process incoming sensory stimuli with correctinterpretation

•Often letter confusion, letter reversal

•Signs & Symptoms of Dyslexia Box 18.5 Page 282

•Often undiagnosed until 4th grade or later

•More common in boys

Expressive Language Disorder

•Impairment in both verbal and sign language asevidenced by standardized testing

•Limited speech and vocabulary

•Difficulty learning new words or grammar

•Decreased ability to process incoming information

•Signs and Smptoms of Expressive LanguageDisorder Box 18.2 Page 283

•Often younger than 3 when diagnosed

•10-15% of children; more common in boys

Phonologic Disorder

•Failure to utilize sounds or articulate syllables intelligibly duringspeech

•Often a hearing impairment contributes to the speech problem

•Stuttering

•Increased anxiety often initiates the problem

–Leads to frustration and low self-esteem

•Signs and Symptoms of Phonologic Disorder Box 18.7Page 283

•Typically seen between 2-7 years; less than 2% of children;more common in boys

Types of Behavior Disorders

•Attention deficit/hyperactivity disorder

•Conduct disorder

•Oppositional-defiant disorder

Attention-Deficit/Hyperactivity Disorder(ADHD)

•Pattern of inattention, hyperactivity, or impulsivebehavior

•Disruptive, inability to maintain focus

•Easily distracted

•3 types

–Predominantly inattentive type

•Attention Deficit Disorder

–Predominantly hyperactive-impulsive type

•Restless, fidgety, talks incessantly, inappropriate

–Combination

S/S of ADHD

Box 18.8

Page 284

Conduct Disorder

•Pattern of repetitive and continuous behavior that eitherinfringes on the basic rights of others or defies the rulesof society that would be appropriate for the child’s age

•Disruptive, destructive behavior

•Willful defiance, aggression, truancy, cruelty to animals

•Behaviors differ in several settings

•Signs and Symptoms of Conduct Disorder Box 18.9Page 285

•Higher incidence in cities than rural areas

•Onset can occur before 10 or during adolescence

Oppositional-Defiant Disorder

•Repetitive behavior of negative, defiant, disobedient, hostilitytoward authority figures

•Argue incessantly without compromise

•Blame others for own behavior

•Defiant refusal to obey rules or laws

•Vindictive, spiteful, and resentful

•Suspension and expulsion from school

•Predisposing Factors: rejection, neglect, abuse

•Signs and Symptoms of Oppositional-Defiant DisorderBox 18.11 Page 286

Anxiety Disorders

•Separation anxiety disorder

•Tic disorders (Tourette’s disorder)

Separation Anxiety Disorder

•Severe anxiety when separated from love attachment figure

•Worry about harm to self/parent

•Fear of sleep without attachment person present

•Attention-demanding behavior

•Must occur before the age 18 and cause significant distress orimpairment in functioning for a period of at least 1 month

•C/O Somatic symptoms (Abd pain, N/V, H/As)

•Signs and Symptoms of Seperation Anxiety Disorder Box18.12 Page 288

•Tx: reduce anxiety and reinforce a sense of security

•4% of children – symptoms decrease during adolescence

Tic Disorders (Tourette’s Disorder)

•Sudden, repetitive, arrhythmic, stereotyped motormovement or speech that occurs before the age 18

•Never a symptom free period of more than 3 months

•Copropraxia/echopraxia (tic/repetitive movement)

•A person with tic has irresistible urge to perform tic andfeels relief once the behavior has occurred

•Incidence may increase during periods of stress ofdemanding and competitive activities

•Signs and Symptoms of Tic Disorders Box 18.13Page 288

Elimination Disorders

•Encopresis

–Repeated episodes of fecal passage in inappropriate places

–Must be 4 or have attained defection control

–Must occur at least 1/month for 3 months to be dx

•Enuresis

–Repeated episodes of urine incontinence during day ornight

–Must be 5 or have urinary control

–Must occur 2/week for3 months during day or night to bedx

Treatment of Mental Disorders in Childrenand Adolescents

•Pervasive developmental disorderscombined approachof therapies and behavior management interventions

•Learning and communication disordersmainstreameducation

•Behavior disorderscombination of medication andbehavior therapy

•Anxiety disordersmedication, cognitive-behavioraltherapy, group therapy

•Elimination disordersmost children outgrow problem,some behavior approaches can be used

Nursing Process Applied

•AssessmentPg. 290

–Time when problematic behaviors began

–Significant occurrences

–Thorough medical and emotional assessment

–The child’s ability to communicate and interact

Nursing Process Applied (cont.)

•Selected nursing diagnosesPage 291

–Risk for injury, related to physical mobility oraggressive behavior

–Impaired verbal communication, related to verbalexpression

–Impaired social interaction, related to inappropriatebehaviors and decreased self-esteem

Nursing Process Applied (cont.)

•Expected outcomes may includePage 291

–Initiates appropriate interactions with peers

–Remains free of self-harm and does not harm others

–Demonstrates increased autonomy

Nursing Process Applied (cont.)

•Interventions may includePage 291-292

–Maintain a safe physical environment

–Provide encouragement toward independent self-care

–Establish a trusting relationship

Nursing Process Applied (cont.)

•EvaluationPage 292

–Increased ability to interact and communicate withothers

–Progress in ability to trust others and initiate socialcontact with another person

–Ability to control negative and self-harming behaviors

Question

•An preoccupation with and expertise about a particulartopic is associated with which of the following disorders?

A. Dyslexia

B. Developmental coordination disorder

C. Attention deficit/hyperactivity disorder

D. Asperger’s syndrome

Answer

•D. Asperger’s syndrome

•Rationale: Children with Asperger’s syndrome tend tohave a preoccupation with a particular subject and avoidother activities. Children with this condition have averageto above average intelligence.

Question

•Which of the following developmental disorders ischaracterized by an IQ of 70 or below?

A. Mental retardation

B. Autistic disorder

C. Asperger’s syndrome

D. Psychosis

Answer

•A. Mental retardation

•Rationale: According to the DSM-IV-TR, mentalretardation is characterized by an intellectualfunctioning that is significantly below average (IQ of 70or lower).

Question

•Stuttering is a characteristic of

A. Attention deficit/hyperactivity disorder

B. Developmental coordination disorder

C. Phonologic disorder

D. Separation anxiety disorder

Answer

•C. Phonologic disorder

•Rationale: Phonologic disorder is a failure to utilizesounds or articulate syllables intelligibly during speech.Stutteringprolonged or repetitive sounds or syllablesthat include pauses and broken wordsis a commoncharacteristic of the disorder.