2-14-08 Mrs.

Travis

Disorders of Children and

Adolescents
Attention Deficit Hyperactivity Disorder (ADHD)

• Persistent pattern of inattention, hyperactivity, and impulsiveness

• Difficult to diagnosis before age 4 years

• Dually diagnosed

• Family history

• Very forgetful

• Lose things easily

• Can’t sit still

• Disruptive, can’t function in school/church

Predisposing factors

• Biological

• Environmental/ social

• Cultural/ ethnic

• Genetics

• Temperament

Diagnostic Criteria

• Symptoms of inattention, hyperactivity and impulsivity for at least 6 months

• Signs and symptoms present before age of 7

• causes impairment in 3 or more settings

• symptoms are not better accounted for by another mental disorder

Assessment Guidelines for ADHD

• Relationship between child and caregiver

 • Caregiver’s understanding of growth and development, parenting skills, and
handling of problematic behaviors

• Cognitive, psychosocial, and moral development for lags or deficits

• Observe for level of physical activity, attention span, talkativeness, ability to

follow directions, and impulse control

• Difficulty in making friends and performing in school

• Problems with enuresis (bedwetting) and encopresis (BM)

• Observe behavior in restrictive settings

Nursing Diagnosis

• Risk for injury R/T hyperactivity

• Impaired social interaction

• Self-esteem disturbance

• Noncompliance with task expectations

ADHD Interventions

• Behavior modification

• Pharmacological

• Special Education

• Psychotherapy

Treatment of ADHD:

• CNS Stimulants

o Methlphenidate (MPH)

 Ritalin/ SR/LA

 Metadate ER/CD

 Concerta
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 Focalin

 Daytrana Patch

o Amphetamine

 Adderall/ XR

Side Effects of CNS Stimulants

• Insomnia

• Mood changes

• Anorexia

• Weight loss

• Tachycardia

• Increased anxiety

• Headache

• Stomach ache

• Irritability

• Temporary decrease in growth and development

• Physical tolerance

Nursing Actions : CNS Stimulants

• Assess mental status

• Give after meals

• Weight

• Don’t give at bedtime

• Drug “holiday”

• Avoid OTC medications

• Do not withdraw abruptly

Other Meds for ADHD continue

• Atomoxetine hydrochloride (Strattera)

• Antidepressants

o Bupropion (Wellbutrin)

o Fluoxetine (Prozac)

• Alpha-adrenergic

o Guanfacine (Tenex)

o Clonidine (Catapres

Conduct Disorder
• Repetitive and persistent pattern of behavior in which the rights of others and
major age-appropriate societal norms or rules are violated

• Behaviors occur in a variety of settings

• Social, academic, and/ or occupational function is impaired

• Childhood onset

o Before age of 10, may persist into adolescence

o More physical aggression

o Lack of concern for others

o Poor peer relationships

• Adolescent onset

o Less physical aggressions

o Gangs

o Skipping school

o Prostitution

o Running away from homes

o May outgrow this behavior before adulthood

• Diagnostic Criteria for Conduct Disorder

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o Aggression

o Destruction of property

o Deceitfulness or theft

o Serious violations of rules

• Nursing Assessment:

o Seriousness of disruptive behavior

o Level of anxiety, aggression, or anger

o Self-control over impulses

o Moral development: understanding of impact of behaviors

• Interventions

o Focus on correcting personality development

o Teach development of coping mechanisms

o Inpatient hospitalization often needed for crisis intervention

o Therapeutic foster care

o Long-term residential treatment

• Treatment

o Medications

 Mood Stabilizers: controls anger

• Lithium, depakote, tegretol

 Antidepressants

• Zoloft

• Celexa

• Lexapro

 Antipsychotics :controls aggression

• Risperdal
 • Abilify

• Zyprexa or zyprexa zydis

Oppositional Defiant Disorder

• Recurrent pattern of behavior

• Negativistic

• Defiant

• Disobedient

• Hostile

• Especially toward authority figures

• Without violated the rights of others

• Diagnostic Criteria

o Behavior for at least 6 months

o Must have at least 4 symptoms listed

o Symptoms by age 8

o More common in boys

o Lead to conduct disorder

o Impairment in social, academic, and occupational functioning

• Signs and Symptoms

o Passive aggressive behavior

o Running away

o School avoidance/ under achievement

o Temper tantrums

o Fighting

o Argumentative

o Stubborn
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o Eating/ sleeping problems

o Oppositional

o Behavior may or may not be seen outside home

o Difficulty in forming interpersonal relationships

o Refuse to accept blame for misdeeds

• Nursing assessment

o Identify issues that result in power struggles

o Assess severity of defiance and impact at home, school, with peers

• Nursing diagnosis

o Impaired social interaction

o Defensive coping

o Self esteem disturbance

• Interventions

o Early intervention

 Can lead to conduct disorder if interventions are not performed

early

o Family therapy

o Group therapy

o Behavior therapy

Pervasive Developmental Disorder

(Autistic)
• Behavioral syndrome resulting from abnormal brain function

• Characteristics

o Bizarre

o Inability to maintain eye contact

 o Limited functional play

o Constipation

o Self-abusive

o Mental retardation

o Language is delayed

o Don’t like people touching them

• Diagnostic Criteria

o Impairment in communication and imaginative activity

o Impairment in social interaction

o Markedly restricted, stereotypical patterns of behavior, interest and

activities

• Nursing Considerations

o Behavior modifications

o Family support

o Pharmacological agents

 Risperdal

 Haldol for irritability

• Asperger’s

o Higher functioning autism

o Slow in caring for themselves and thinking

o May get a fixed sensation on something (butterflies) and that is all they
can talk about

o No significant delay in cognitive and language development

o Etiology unknown

o Familial pattern
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o Restricted and repetitive patterns of behavior and idiosyncratic

interests

• Rett’s

o Females

o Before age 4 years

o Cause unknown, may be associated with brain abnormalities, seizures,

and mental retardation

o Prognosis is much worse than Asperger’s

o These children are severely to profoundly mentally retarded as well as

having seizure disorders

Mental Retardation
• Comprised of three areas

o Intellectual functioning

o Functional strengths and weaknesses

 Being able to care for yourself

 Communication

 Social skills

 Leisure activities

o Age younger than 18 years

• Diagnosis

o Suspicion of family member or professional

o Confirmed at birth

o Problems such as speech delays arouse concerns

o Standardized tests- assess abilities of functional strengths

• Classification

o Mild
  50-75 IQ

o Moderate

 35-55 IQ

o Severe

 20-40 IQ

o Profound

 Less than 20 IQ

o Looks at three different areas (Wong 591)

• Etiology

o Genetics

o Biochemical

o Infections

o Trauma

o Gestational disorders

o Psychiatric disorders

o Inadequate nutrition and metabolic

o Cerebral and cranial malformations

o Brain disease

o Environmental

o Chromosomal

• Nursing Care

o Assessment

 Newborn and early infancy

 Developmental milestones

 Parental concerns
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o Nursing diagnosis

 Altered growth and development

 Altered family processes

o Intervention

 Educate

 Teach

 Promote optimal development

 Play/exercise

 Communication

 Discipline

 Socialization

 Sexuality

Delirium
• Disturbance of consciousness

• Change in cognition

• Develops over a short period of time

• Sudden onset

• Fluctuates

• Secondary to another cause

• More pronounced in the evening

• Recovery when cause corrected

Cause

• Substance abuse

• Medications
 • Polypharmacy

• Toxins

• Infection

o UTI’s

• Medical illness

• Fever

• Post-op

• Metabolic disorders

• Psychosocial stress

• Sleep deprivation

• Sensory overload

• Sometimes unknown

Nursing Assessment

• Acuity of onset

• Orientation

• Attention span

• Memory impairment

• Thought processes

• Sensory/perceptual changes

• Mood and affect

• Sleep pattern

• LOC

• Autonomic manifestations

• Monitor for abrupt changes

Nursing Diagnoses
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• Risk for injury

• Fluid volume deficit

• Sleep pattern disturbance

• Impaired communication

• Acute confusion

• Disturbed thought process

• Fear

• Self care deficit

• Impaired social interaction

• Sensory perception disturbance

Interventions

• Eliminate causative factors

• Monitor vital and neurological signs

• Provide support and frequent re-orientation

• Maintain safety and comfort

• Provide a quiet environment

• May need 1:1 supervision

• Chemical/ Mechanical restraints

Dementia
• A loss of previous levels of cognitive, executive, and memory function in a
state of full alertness

o Memory impairement

o One of more of the following cognitive disturbances

 Aphasia
  Apraxia

 Agnosia

• Spoon a pencil

o Most cases are progressive and irreversible

o Develops slowly

• Classifications

o Primary

 Alzheimer’s

 Usually not reversible

 Progressive

o Secondary

 May be reversible

 Can be caused by infection, meningitis

• Etiology

o Pathological

o Genetic

o Non-genetic

 Increasing age

 Down syndrome

 Head injury

o Neurochemical changes

o True diagnosis is on autopsy (atrophy of brain function) plaque, etc.

• Clinical manifestations

o Denial

o Confabulation
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 Making up stories (they think there true)

o Preserveration

 Repetition of behavior

o Avoidance of questions

o Cardinal symptoms

 Amnesia or memory

 Aphasia

• Loss of language ability

 Apraxia

• Loss of purposeful movement

 Agnosia

• Loss of sensory ability to recognize objeccts

 Disturbances in executive functioning

• Planning, organizing, abstract thinking

• Diagnostic tests

o History and physical

o Labs

o X-rays

o Mental status questionnaires

• Stages of Alzheimer’s Disease p. 435

o Stage 1 (Mild) Forgetfulness

o Stage 2 (Moderate) Confusion

o Stage 3 (Moderate to Severe) Ambulatory dementia

o Stage 4 (Late) End stage

• Problems in Dementia
 o Disorientation

o Memory impairment

o Risk for injury

o Needs for physical help

o Apathy

o Poor communication

o Uncontrolled emotion

o Uncontrolled behavior

o Incontinence

o Mistaken beliefs

o Poor decision making

o Burden on family

• Nursing Interventions

o Unconditional positive regard

o Caregiver education

o Communication

o Planning daily activities

o Maintaining safety

o Managing behavior

o Monitor nutrition and weigh

o Monitor for increased confusion

• Medications

o Cognex, Aricept, Exelon, Reminyl

 Improves cognitive function, ADL performance, and behavior

 Slow down progression, used in mild to moderate stage

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 Increases level of acetycholine

 Side effect: GI upset, liver toxicity

o Namenda

 Moderate to severe dementia

 Targets the neurotransmitter glutamate

o Vitamin E-suppose to help with brain circulation