Centro Escolar University College of Nursing Mendiola, Manila

In Partial Fulfilment of the Requirements
In

NCM 103 Mental Institution
National Center for Mental Health

MILD MENTAL RETARDATION WITH UNDIFFERENTIATED SCHIZOPHRENIA
Submitted by: Gallos, Randell M. BSN 3A /Group 3A

Submitted to: Donie L. Brabante, RN, MAN Clinical Instructor
1

TABLE

OF CONTENTS

CHAPTER I: INTRODUCTION A. Introduction to Psychopathology B. Theoretical Framework C. Biographical Data D. Nursing History 1. Chief Complaint 2. History of present Illness 3. Previous Illness 4. Past Personal History 5. Family History 6. Social History CHAPTER II: Presentation, Interpretation & Analysis of Data A. General Appearance B. Motor Behavior C. Sensorium & Cognition D. Perception E. Attitude F. Defense Mechanisms G. Affective States H. Thought Process CHAPTER III DIAGNOSIS A. Predisposing Factors B. Psychodynamics / Psychopathology C. Related Literature 1. Summary 2. Reaction D. Drug Study CHAPTER IV: NURSING CARE PLAN A. B. C. Process Recording List of Prioritized Psychiatric Nursing Diagnosis  5 prioritized nursing diagnosis with rationale Psychiatric Nursing Care Plans  First 3 highly prioritized nursing diagnosis

CHAPTER V: PSYCHOTHERAPY A. Play Therapy B. Music & Art Therapy C. Bibliotherapy D. Occupational Therapy E. Remotivation Therapy APPENDICES A. MSA Tool used with the patient B. Art Therapy Output C. List of Reference Materials used a. Title of the Book / website

b. c.

Author Date published/searched from the net

2

CHAPTER

1
INTRODUCTION

3

A.

Introduction to Psychopathology

Psychopathology is a term which refers to either the study of mental illness or mental distress, or the manifestation of behaviors and experiences which may be indicative of mental illness or psychological impairment, such as abnormal, maladaptive behavior or mental activity. Psychopathology is that branch of psychiatry which deals with the study of manifestation of behaviours and experiences indicative of mental illness.

Psychopathology as the study of mental illness Many different professions may be involved in studying mental illness or distress. Most notably, psychiatrists and clinical psychologists are particularly interested in this area and may either be involved in clinical treatment of mental illness, or research into the origin, development and manifestations of such states, or often, both. More widely, many different specialties may be involved in the study of psychopathology. For example, a neuroscientist may focus on brain changes related to mental illness. Therefore, someone who is referred to as a psychopathologist, may be one of any number of professions who have specialized in studying this area. Psychiatrists in particular are interested in descriptive psychopathology, which has the aim of describing the symptoms and syndromes of mental illness. This is both for the diagnosis of individual patients (to see whether the patient's experience fits any pre-existing classification), or for the creation of diagnostic systems (such as the Diagnostic and Statistical Manual of Mental Disorders or International Statistical Classification of Diseases and Related Health Problems) which define exactly which signs and symptoms should make up a diagnosis, and how experiences and behaviours should be grouped in particular diagnoses (e.g. clinical depression, paraphrenia, paranoia, schizophrenia). Psychopathology should not be confused with psychopathy, which is a type of personality disorder.

4

Psychopathology as a descriptive term The term psychopathology may also be used to denote behaviours or experiences which are indicative of mental illness, even if they do not constitute a formal diagnosis. For example, the presence of a hallucination may be considered as a psychopathological sign, even if there are not enough symptoms present to fulfill the criteria for one of the disorders listed in the DSM or ICD. In a more general sense, any behaviour or experience which causes impairment, distress or disability, particularly if it is thought to arise from a functional breakdown in either the cognitive and neurocognitive systems in the brain, may be classified as psychopathology. Mental retardation is an idea, a condition, a syndrome, a symptom, and a source of pain and bewilderment to many families. Its history dates back to the beginning of man's time on earth. The idea of mental retardation can be found as far back in history as the therapeutic papyri of Thebes (Luxor), Egypt, around 1500 B.C. Although somewhat vague due to difficulties in translation, these documents clearly refer to disabilities of the mind and body due to brain damage (Sheerenberger, 1983). Mental retardation is also a condition or syndrome defined by a collection of symptoms, traits, and/or characteristics. It has been defined and renamed many times throughout history. For example, feeblemindedness and mental deficiency were used as labels during the later part of the last century and in the early part of this century. Consistent across all definitions are difficulties in learning, social skills, everyday functioning, and age of onset (during childhood). Mental retardation has also been used as a defining characteristic or symptom of other disorders such as Down syndrome and Prader-Willi syndrome. Finally, mental retardation is a challenge and potential source of stress to the family of an individual with this disorder. From identification through treatment or education, families struggle with questions about cause and prognosis, as well as guilt, a sense of loss, and disillusionment about the future. The objective of this chapter is to provide the reader with an overview of mental retardation, a developmental disability with a long and sometimes controversial history. Following a brief historical overview, the current diagnostic criteria, epidemiological information and the status of dual diagnosis will be presented. Comprehensive assessment and common interventions will also be reviewed in some detail.

5

Mental Retardation
Mental retardation is a generalized disorder, characterized by significantly impaired cognitive functioning and deficits in two or more adaptive behaviors with onset before the age of 18. Once focused almost entirely on cognition, the definition now includes both a component relating to mental functioning and one relating to individuals' functional skills in their environment

Alternative terms The term "mental retardation" is a diagnostic term denoting the group of disconnected categories of mental functioning such as "idiot", "imbecile", and "moron" derived from early IQ tests, which acquired pejorative connotations in popular discourse. The term "mental retardation" acquired pejorative and shameful connotations over the last few decades due to the use of "retarded" as an insult. This may have contributed to its replacement with euphemisms such as "mentally challenged" or "intellectual disability". While "developmental disability" may be considered to subsume other disorders (see below), "developmental disability" and "developmental delay" (for people under the age of 18), are generally considered more acceptable terms than "mental retardation". * In North America mental retardation is subsumed into the broader term developmental disability, which also includes epilepsy, autism, cerebral palsy and other disorders that develop during the developmental period (birth to age 18.) Because service provision is tied to the designation developmental disability, it is used by many parents, direct support professionals, and physicians. However, in school-based settings, the more specific term mental retardation is still typically used, and is one of 13 categories of disability under which children may be identified for special education services under Public Law 108-446. * The phrase intellectual disability is increasingly being used as a synonym for people with significantly below-average cognitive ability.[1] These terms are sometimes used as a means of separating general intellectual limitations from specific, limited deficits as well as indicating that it is not an emotional or psychological disability. Intellectual disability may also used to describe the outcome of traumatic brain injury or lead poisoning or dementing conditions such as Alzheimer's disease. It is not specific to congenital disorders such as Down syndrome.

6

The American Association on Mental Retardation continued to use the term mental retardation until 2006.[2] In June 2006 its members voted to change the name of the organization to the "American Association on Intellectual and Developmental Disabilities," rejecting the options to become the AAID or AADD. Part of the rationale for the double name was that many members worked with people with pervasive developmental disorders, most of whom do not have mental retardation.[3] In the UK, "mental handicap" had become the common medical term, replacing "mental subnormality" in Scotland and "mental deficiency" in England and Wales, until Stephen Dorrell, Secretary of State for Health for the United Kingdom from 1995-7, changed the NHS's designation to "learning disability." The new term is not yet widely understood, and is often taken to refer to problems affecting schoolwork (the American usage), which are known in the UK as "learning difficulties." British social workers may use "learning difficulty" to refer to both people with MR and those with conditions such as dyslexia.

In England and Wales between 1983 and 2008 the Mental Health Act 1983 defined "mental impairment" and "severe mental impairment" as "a state of arrested or incomplete development of mind which includes significant/severe impairment of intelligence and social functioning and is associated with abnormally aggressive or seriously irresponsible conduct on the part of the person concerned."[4] As behavior was involved, these were not necessarily permanent conditions: they were defined for the purpose of authorizing detention in hospital or guardianship. The term Mental Impairment was removed from the Act in November 2008, but the grounds for detention remained. However, English statute law uses "mental impairment" elsewhere in a less well-defined manner—e.g. to allow exemption from taxes—implying that mental retardation without any behavioral problems is what is meant.

7

Signs Children with mental retardation may learn to sit up, to crawl, or to walk later than other children, or they may learn to talk later. Both adults and children with mental retardation may also exhibit the following characteristics:

* Delays in oral language development * Deficits in memory skills * Difficulty learning social rules * Difficulty with problem solving skills * Delays in the development of adaptive behaviors such as self-help or self-care skills * Lack of social inhibitors The limitations of cognitive functioning will cause a child with mental retardation to learn and develop more slowly than a typical child. Children may take longer to learn language, develop social skills, and take care of their personal needs such as dressing or eating. Learning will take them longer, require more repetition, and skills may need to be adapted to their learning level. Nevertheless, virtually every child is able to learn, develop and become participating members of the community. In early childhood mild mental retardation (IQ 50–69) may not be obvious, and may not be identified until children begin school. Even when poor academic performance is recognized, it may take expert assessment to distinguish mild mental retardation from learning disability or emotional/behavioral disorders. As individuals with mild mental retardation reach adulthood, many learn to live independently and maintain gainful employment. Moderate mental retardation (IQ 35-49) is nearly always apparent within the first years of life. Children with moderate mental retardation will require considerable supports in school, at home, and in the community in order to participate fully. As adults they may live with their parents, in a supportive group home, or even semi-independently with significant supportive services to help them, for example, manage their finances.

8

A person with a more severe mental retardation will need more intensive support and supervision his or her entire life.

Diagnosis According to the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV),[5] three criteria must be met for a diagnosis of mental retardation: an IQ below 70, significant limitations in two or more areas of adaptive behavior (as measured by an adaptive behavior rating scale, i.e. communication, self-help skills, interpersonal skills, and more), and evidence that the limitations became apparent before the age of 18.

It is formally diagnosed by professional assessment of intelligence and adaptive behavior. IQ below 70 The first English-language IQ test, the Terman-Binet, was adapted from an instrument used to measure potential to achieve developed by Binet in France. Terman translated the test and employed it as a means to measure intellectual capacity based on oral language, vocabulary, numerical reasoning, memory, motor speed and analysis skills. The mean score on the currently available IQ tests is 100, with a standard deviation of 15 (WAIS/WISC-IV) or 16 (StanfordBinet). Sub-average intelligence is generally considered to be present when an individual scores two standard deviatons below the test mean. Factors other than cognitive ability (depression, anxiety, etc.) can contribute to low IQ scores; it is important for the evaluator to rule them out prior to concluding that measured IQ is "significantly below average". The following ranges, based on Standard Scores of intelligence tests, reflect the categories of the American Association of Mental Retardation, the Diagnostic and Statistical Manual of Mental Disorders-IV-TR, and the International Classification of Diseases-10:

9

Class IQ Profound mental retardation Below 20 Severe mental retardation 20–34

Moderate mental retardation 35–49 Mild mental retardation 50–69 70–80

Borderline intellectual functioning

Since the diagnosis is not based only on IQ scores, but must also take into consideration a person's adaptive functioning, the diagnosis is not made rigidly. It encompasses intellectual scores, adaptive functioning scores from an adaptive behavior rating scale based on descriptions of known abilities provided by someone familiar with the person, and also the observations of the assessment examiner who is able to find out directly from the person what he or she can understand, communicate, and the like.

Significant limitations in two or more areas of adaptive behavior Adaptive behavior, or adaptive functioning, refers to the skills needed to live independently (or at the minimally acceptable level for age). To assess adaptive behavior, professionals compare the functional abilities of a child to those of other children of similar age. To measure adaptive behavior, professionals use structured interviews, with which they systematically elicit information about persons' functioning in the community from people who know them well. There are many adaptive behavior scales, and accurate assessment of the quality of someone's adaptive behavior requires clinical judgment as well. Certain skills are important to adaptive behavior, such as: * daily living skills, such as getting dressed, using the bathroom, and feeding oneself; * communication skills, such as understanding what is said and being able to answer; * social skills with peers, family members, spouses, adults, and others.

10

Evidence that the limitations became apparent in childhood This third condition is used to distinguish it from dementing conditions such as Alzheimer's disease or due to traumatic injuries with attendant brain damage.

Causes Down syndrome, fetal alcohol syndrome and Fragile X syndrome are the three most common inborn causes. However, doctors have found many other causes. The most common are: * Genetic conditions. Sometimes disability is caused by abnormal genes inherited from parents, errors when genes combine, or other reasons. The most prevalent genetic conditions include Down syndrome, Klinefelter's syndrome, Fragile X syndrome, Neurofibromatosis, congenital hypothyroidism, Williams syndrome, Phenylketonuria (PKU), and Prader-Willi syndrome. Other genetic conditions include Phelan-McDermid syndrome (22q13del), MowatWilson syndrome, genetic ciliopathy,[6] and Siderius type X-linked mental retardation (OMIM 300263) as caused by mutations in the PHF8 gene ((OMIM 300560).[7][8] In the rarest of cases, abnormalities with the X or Y chromosome may also cause disability. 48, XXXX and 49, XXXXX syndrome affect a small number of girls worldwide, while boys may be affected by 47, XYY, 49, XXXXY, or 49, XYYYY. * Problems during pregnancy. Mental disability can result when the fetus does not develop properly. For example, there may be a problem with the way the fetus' cells divide as it grows. A woman who drinks alcohol (see fetal alcohol syndrome) or gets an infection like rubella during pregnancy may also have a baby with mental disability. * Problems at birth. If a baby has problems during labor and birth, such as not getting enough oxygen, he or she may have developmental disability due to brain damage. * Exposure to certain types of disease or toxins. Diseases like whooping cough, measles, or meningitis can cause mental disability if medical care is delayed or inadequate. Exposure to poisons like lead or mercury may also affect mental ability. * Iodine deficiency, affecting approximately 2 billion people worldwide, is the leading preventable cause of mental disability in areas of the developing world where iodine deficiency is endemic. Iodine deficiency also causes goiter, an enlargement of the thyroid gland. More common than full-fledged cretinism, as retardation caused by severe iodine deficiency is called, is mild impairment of intelligence. Certain areas of the world due to natural deficiency and governmental inaction are severely affected. India is the most outstanding, with 500 million
11

suffering from deficiency, 54 million from goiter, and 2 million from cretinism. Among other nations affected by iodine deficiency, China and Kazakhstan have instituted widespread iodization programs, whereas, as of 2006, Russia had not. * Malnutrition is a common cause of reduced intelligence in parts of the world affected by famine, such as Ethiopia. * Absence of in the brain of the arcuate fasciculus.

Treatment and assistance By most definitions mental retardation is more accurately considered a disability rather than a disease. MR can be distinguished in many ways from mental illness, such as schizophrenia or depression. Currently, there is no "cure" for an established disability, though with appropriate support and teaching, most individuals can learn to do many things. There are thousands of agencies in the United States that provide assistance for people with developmental disabilities. They include state-run, for-profit, and non-profit, privately run agencies. Within one agency there could be departments that include fully staffed residential homes, day rehabilitation programs that approximate schools, workshops wherein people with disabilities can obtain jobs, programs that assist people with developmental disabilities in obtaining jobs in the community, programs that provide support for people with developmental disabilities who have their own apartments, programs that assist them with raising their children, and many more. The Burton Blatt Institute at Syracuse University works to advance the civic, economic, and social participation of people with disabilities. There are also many agencies and programs for parents of children with developmental disabilities. Although there is no specific medication for mental retardation, many people with developmental disabilities have further medical complications and may take several medications. Beyond that there are specific programs that people with developmental disabilities can take part in wherein they learn basic life skills. These "goals" may take a much longer amount of time for them to accomplish, but the ultimate goal is independence. This may be anything from independence in tooth brushing to an independent residence. People with developmental disabilities learn throughout their lives and can obtain many new skills even late in life with the help of their families, caregivers, clinicians and the people who coordinate the efforts of all of these people.

12

Archaic Terms * Idiot indicated the greatest degree of intellectual disability, where the mental age is two years or less, and the person cannot guard himself or herself against common physical dangers. The term was gradually replaced by the term profound mental retardation. * Imbecile indicated an intellectual disability less extreme than idiocy and not necessarily inherited. It is now usually subdivided into two categories, known as severe mental retardation and moderate mental retardation. * Moron was defined by the American Association for the Study of the Feeble-minded in 1910, following work by Henry H. Goddard, as the term for an adult with a mental age between eight and twelve; mild mental retardation is now the term for this condition. Alternative definitions of these terms based on IQ were also used. This group was known in UK law from 1911 to 1959/60 as "feeble-minded". * Mongolism was a medical term used to identify someone with Down syndrome. For obvious reasons, the Mongolian People's Republic requested that the medical community cease use of the term as a description of mental retardation. Their request was granted in the 1960s, when the World Health Organization agreed that the term should cease being used within the medical community. * In the field of special education, educable (or "educable mentally retarded") refers to MR students with IQs of approximately 50-75 who can progress academically to a late elementary level. Trainable (or "trainable mentally retarded") refers to students whose IQs fall below 50 but who are still capable of learning personal hygiene and other living skills in a sheltered setting, such as a group home. In many areas, these terms have fallen out of favor in favor of "severe" and "moderate" mental retardation. While the names change, the meaning stays roughly the same in practice. * Retarded comes from the Latin retardare, "to make slow, delay, keep back, or hinder." The term was recorded in 1426 as a "fact or action of making slower in movement or time." The first record of retarded in relation to being mentally slow was in 1895. The term retarded was used to replace terms like idiot, moron, and imbecile because it was not a derogatory term. By the 1960s, however, the term had taken on a partially derogatory meaning as well. Perhaps the negative connotations associated with these numerous terms for mental retardation reflect society's ambivalent attitude about the condition. There are competing desires among elements of society, some of whom seek neutral medical terms, and others who want to use such terms as weapons with which to abuse people.
13

Today, the term "retarded" is slowly being replaced by new words like "special" or "challenged." The term "developmental delay" is rapidly gaining popularity among caretakers and parents of individuals with mental retardation. Using the word "delay" is preferred over "disability" by many people, because that term (delay) encapsulates the core deficit that creates mental retardation in the first place. Delay suggests that a person has been held back from their potential, rather than someone who has been disabled. Usage has changed over the years, and differed from country to country, which needs to be borne in mind when looking at older books and papers. For example, "mental retardation" in some contexts covers the whole field, but previously applied to what is now the mild MR group. "Feeble-minded" used to mean mild MR in the UK, and once applied in the US to the whole field. "Borderline MR" is not currently defined, but the term may be used to apply to people with IQs in the 70s. People with IQs of 70 to 85 used to be eligible for special consideration in the US public education system on grounds of mental retardation.

Along with the changes in terminology, and the downward drift in acceptability of the old terms, institutions of all kinds have had to repeatedly change their names. This affects the names of schools, hospitals, societies, government departments, and academic journals. For example, the Midlands Institute of Mental Subnormality became the British Institute of Mental Handicap and is now the British Institute of Learning Disability. This phenomenon is shared with mental health and motor disabilities, and seen to a lesser degree in sensory disabilities.

Historical Perspective The plight of individuals with developmental disabilities has been dependent on the customs and beliefs of the era and the culture or locale. In ancient Greece and Rome, infanticide was a common practice. In Sparta, for example, neonates were examined by a state council of inspectors. If they suspected that the child was defective, the infant was thrown from a cliff to its death. By the second century A.D. individuals with disabilities, including children, who lived in the Roman Empire were frequently sold to be used for entertainment or amusement. The dawning of Christianity led to a decline in these barbaric practices and a movement toward care for the less fortunate; in fact, all of the early religious leaders, Jesus, Buddha, Mohammed, and Confucius, advocated human treatment for the mentally retarded, developmentally disabled, or infirmed (Sheerenberger, 1983).

14

During the Middle ages (476 - 1799 A.D.) the status and care of individuals with mental retardation varied greatly. Although more human practices evolved (i.e., decreases in infanticide and the establishment of foundling homes), many children were sold into slavery, abandoned, or left out in the cold. Toward the end of this era, in 1690, John Locke published his famous work entitled An Essay Concerning Human Understanding. Locke believed that an individual was born without innate ideas. The mind is a tabula rasa, a blank slate. This would profoundly influence the care and training provided to individuals with mental retardation. He also was the first to distinguish between mental retardation and mental illness; "Herein seems to lie the difference between idiots and madmen, that madmen put wrong ideas together and reason from them, but idiots make very few or no propositions and reason scarce at all (Doll, 1962 p. 23)." A cornerstone event in the evolution of the care and treatment of the mentally retarded was the work of physician Jean-Marc-Gaspard Itard (Sheerenberger, 1983) who was hired in 1800 by the Director of the National Institutes for Deaf-Mutes in France to work with a boy named Victor. Victor, a young boy, had apparently lived his whole life in the woods of south central France and, after being captured and escaping several times, fled to the mountains of Aveyron. At about age 12, he was captured once again and sent to an orphanage, found to be deaf and mute, and moved to the Institute for Deaf-Mutes. Based on the work of Locke and Condillac who emphasized the importance of learning through the senses, Itard developed a broad educational program for Victor to develop his senses, intellect, and emotions. After 5 years of training, Victor continued to have significant difficulties in language and social interaction though he acquired more skills and knowledge than many of Itard's contemporaries believed possible. Itard's educational approach became widely accepted and used in the education of the deaf. Near the end of his life, Itard had the opportunity to educate a group of children who were mentally retarded. He did not personally direct the education of these children, but supervised the work of Edouard Seguin (Sheerenberger, 1983). Seguin developed a comprehensive approach to the education of children with mental retardation, known as the Physiological Method (Sheerenberger, 1983). Assuming a direct relationship between the senses and cognition, his approach began with sensory training including vision, hearing, taste, smell, and eye-hand coordination. The curriculum extended from developing basic self-care skills to vocational education with an emphasis on perception, coordination, imitation, positive reinforcement, memory, and generalization. In 1850, Seguin moved to the United States and became a driving force in the education of individuals with mental retardation. In 1876, he founded what would become the American Association on Metal Retardation. Many of Seguin's techniques have been modified and are still in use today. Over the next 50 years, two key developments occurred in the United States: residential training schools were established in most states (19 state operated and 9 privately operated) by 1892, and
15

the newly developed test of intelligence developed by Binet was translated in 1908 by Henry Goddard, Director of Research at the training school in Vineland, New Jersey. Goddard published an American version of the test in 1910. In 1935, Edgar Doll developed the Vineland Social Maturity Scale to assess the daily living skills/adaptive behavior of individuals suspected of having mental retardation. Psychologists and educators now believed that it was possible to determine who had mental retardation and provide them with appropriate training in the residential training schools. During the early part of the 20th century, residential training schools proliferated and individuals with mental retardation were enrolled. This was influenced by the availability of tests (primarily IQ) to diagnose mental retardation and the belief that, with proper training, individuals with mental retardation could be "cured". When training schools were unable to "cure" mental retardation, they became overcrowded and many of the students were moved back into society where the focus of education began to change to special education classes in the community. The training schools, which were initially more educational in nature, became custodial living centers. As a result of the disillusionment with residential treatment, advocacy groups, such as the National Association of Retarded Citizens and the President's Commission on Mental Retardation, were established in the 1950's through the 1970's. The Wyatt-Stickney federal court action, in the 1970's, was a landmark class action suit in Alabama establishing the right to treatment of individuals living in residential facilities. Purely custodial care was no longer acceptable. Concurrent with this case, the United States Congress passed the Education for the Handicapped Act in 1975, now titled the Individuals with Disabilities Education Act. This Act guaranteed the appropriate education of all children with mental retardation and developmental disabilities, from school age through 21 years of age. This law was amended in 1986 to guarantee educational services to children with disabilities age 3 through 21 and provided incentives for states to develop infant and toddler service delivery systems. Today, most states guarantee intervention services to children with disabilities between birth and 21 years of age.

16

Definition/Diagnosis/Classification. According to Sheerenberger (1983), the elements of the definition of mental retardation were well accepted in the United States by 1900. These included: onset in childhood, significant intellectual or cognitive limitations, and an inability to adapt to the demands of everyday life. An early classification scheme proposed by the American Association on Mental Deficiency (Retardation), in 1910 referred to individuals with mental retardation as feeble-minded, meaning that their development was halted at an early age or was in some way inadequate making it difficult to keep pace with peers and manage their daily lives independently (Committee on Classification, 1910). Three levels of impairment were identified: idiot, individuals whose development is arrested at the level of a 2 year old; imbecile, individuals whose development is equivalent to that of a 2 to 7 year old at maturity; and moron, individuals whose mental development is equivalent to that of a 7 to 12 year old at maturity. Over the next 30 years, the definitions of mental retardation focused on one of three aspects of development: the inability to learn to perform common acts, deficits or delays in social development/competence, or low IQ (Yepsen, 1941). An example of a definition based on social competence was proposed by Edgar Doll who proposed that mental retardation referred to "social incompetence, due to mental subnormality, which has been developmentally arrested, which obtains at maturity, is of constitutional origin, and which is essentially incurable" (Doll, 1936 p. 38). Fred Kuhlman, who was highly influential in the early development of intelligence tests in the United States, believed mental retardation was "a mental condition resulting from a subnormal rate of development of some or all mental functions" (Kuhlman, 1941 p. 213). As a result of the conflicting views and definitions of mental retardation, a growing number of labels used to refer to individuals with mental retardation, and a change in emphasis from a genetic or constitutional focus to a desire for a function-based definition, the American Association on Mental Deficiency (Retardation) proposed and adopted a three part definition in 1959. "Mental retardation refers to subaverage general intellectual functioning which originates in the developmental period and is associated with impairment in adaptive behavior" (Heber, 1961). Although this definition included the three components of low IQ (<85), impaired adaptive behavior, and origination before age 16, only IQ and age of onset were measurable with the existing psychometric techniques. Deficits in adaptive behavior were generally based on subjective interpretations by individual evaluators even though the Vineland Social Maturity Scale was available (Sheerenberger, 1983). In addition to the revised definition, a five level classification scheme was introduced replacing the previous three level system which had acquired a very negative connotation. The generic

17

terms of borderline (IQ 67-83), mild (IQ 50-66), moderate (IQ 33-49), severe (16-32), and profound (IQ <16) were adopted. Due to concern about the over or misidentification of mental retardation, particularly in minority populations, the definition was revised in 1973 (Grossman, 1973) eliminating the borderline classification from the interpretation of significant, subaverage, general intellectual functioning. The upper IQ boundary changed from <85 to < 70. This change significantly reduced the number of individuals who were previously identified as mentally retarded impacting the eligibility criteria for special school services and governmental supports. Many children who might have benefitted from special assistance were now ineligible for such help. A 1977 revision (Grossman, 1977) modified the upper IQ limit to 70 - 75 to account for measurement error. IQ performance resulting in scores of 71 through 75 were only consistent with mental retardation when significant deficits in adaptive behavior were present. The most recent change in the definition of mental retardation was adopted in 1992 by the American Association on Mental Retardation. "Mental retardation refers to substantial limitations in present functioning. It is characterized by significantly subaverage intellectual functioning, existing concurrently with related limitations in two or more of the following applicable adaptive skill areas: communication, self-care, home living, social skills, community use, self-direction, health and safety, functional academics, leisure, and work. Mental retardation manifests before age 18" (American Association on Mental Retardation, 1992). On the surface, this latest definition does not appear much different than its recent predecessors. However, the focus on the functional status of the individual with mental retardation is much more delineated and critical in this definition. There is also a focus on the impact of environmental influences on adaptive skills development that was absent in previous definitions. Finally, this revision eliminated the severity level classification scheme in favor of one that addresses the type and intensity of support needed: intermittent, limited, extensive, or pervasive. Practically, a child under age 18 must have an IQ < 75 and deficits in at least 2 of the adaptive behavior domains indicated in the definition to obtain a diagnosis of mental retardation.

18

Educational Classifications. While the medical and psychosocial communities were developing an acceptable definition and classification system, the educational community adopted their own system of classification. Their three level system separated school age children with mental retardation into three groups based on predicted ability to learn (Kirk, Karnes, & Kirk, 1955). Children who were educable could learn simple academic skills but not progress above fourth grade level. Children who were believed to be trainable could learn to care for their daily needs but very few academic skills. Children who appeared to be untrainable or totally dependent were considered in need of long term care, possibly in a residential setting. Some form of this scheme is still in use today in many school systems across the country.

DSM-IV. DSM-IV attempts to blend the 1977 and 1992 definitions put forth by the American Association on Mental Retardation. It adopts the 1992 definition, but retains the severity level classification scheme from the 1977 definition. The upper IQ limit is 70, and an individual must have delays in at least two of the 10 areas outlined in the 1992 definition. In general, the overview of mental retardation in DSM-IV is thorough and easy to follow. However, it should be noted that comprehensive cognitive and adaptive skill assessment is necessary to make the diagnosis; it should not be made on the basis of an office visit or developmental screening.

ICD-10. ICD-10 is the tenth revision of the International Classification of Diseases (World Health Organization, 1993). It is currently in use in some countries around the world but will not be adopted for use in the United States until after the year 2000. ICD-10 differs from ICD-9 in at least two key ways. First, it includes more diagnoses and is, consequently, much larger. The second major change is the coding scheme. The diagnostic codes have been changed from numeric codes to codes that begin with an alphabet letter and are followed by two or more numbers (e.g., mild mental retardation has changed from 317 to F70). ICD-10 characterizes mental retardation as a condition resulting from a failure of the mind to develop completely. Unlike DSM-IV and the Classification Manual of the AAMR, ICD-10 suggests that cognitive, language, motor, social, and other adaptive behavior skills should all be used to determine the level of intellectual impairment. ICD-10 also supports the idea of dual diagnosis, suggesting that mental retardation may be accompanied by physical or other mental disorders. Four levels of mental retardation are specified in ICD-10: F70 mild (IQ 50 - 69), F71 moderate (IQ 35 - 49), F72 severe (IQ 20 - 34), and F73 profound (IQ below 20). IQ should not be used as the only determining factor. Clinical findings and adaptive behavior should also be used to
19

determine level of intellectual functioning. Two additional classifications are possible: F78 other mental retardation and F79 unspecified mental retardation. Other mental retardation (F78) should be used when associated physical or sensory impairments make it difficult to establish the degree of impairment. Unspecified mental retardation (F79) should be used when there is evidence of mental retardation but not enough information to establish a level of functioning (e.g., a toddler with significant delays in development who is too young to be assessed with an IQ measure).

Epidemiology Over the past 50 years the prevalence and incidence of mental retardation have been affected by changes in the definition of mental retardation, improvements in medical care and technology, societal attitudes regarding the acceptance and treatment of an individual with mental retardation, and the expansion of educational services to children with disabilities from birth through age 21. The theoretical approach to determining the prevalence of mental retardation uses the normal bell curve to estimate the number of individuals whose IQ falls below the established criterion score. For example, 2.3% of the population of the United States has an IQ score below 70, and 5.5% has an IQ score below 75. However, this estimate does not account for adaptive behavior skills. Based on empirical sampling, Baroff (1991) suggested that only 0.9% of the population can be assumed to have mental retardation. Following a review of the most recent epidemiological studies, McLaren and Bryson (1987) reported that the prevalence of mental retardation was approximately 1.25% based on total population screening. When school age children are the source of prevalence statistics, individual states report rates from 0.3% to 2.5% depending on the criteria used to determine eligibility for special educational services, the labels assigned during the eligibility process (e.g., developmental delay, learning disability, autism, and/or mental retardation), and the environmental and economic conditions within the state (U.S. Department of Education, 1994). It is estimated that approximately 89% of these children have mild mental retardation, 7% have moderate mental retardation, and 4% have severe to profound mental retardation. In addition, McLaren and Bryson (1987) report that the prevalence of mental retardation appears to increase with age up to about the age of 20, with significantly more males than females identified.

20

Etiology. There are several hundred disorders associated with mental retardation. Many of these disorders play a causal role in mental retardation. However, most of the causal relationships must be inferred (McLaren & Bryson, 1987). The American Association on Mental Retardation subdivides the disorders that may be associated with mental retardation into three general areas: prenatal causes, perinatal causes, and postnatal causes. It should be noted that some causes can be determined much more reliably than others. For example, chromosomal abnormalities such as Down syndrome can be assumed to be causal with more certainty than some postnatal infections. It should also be noted that mental retardation is both a symptom of other disorders as well as a unique syndrome or disorder.

Causes associated with level of mental retardation. The most common factor associated with severe mental retardation (including the moderate, severe, and profound levels of mental retardation) has been chromosomal abnormality, particularly Down syndrome (McLaren & Bryson, 1987). In approximately 20 to 30% of the individuals identified with severe mental retardation the cause has been attributed to prenatal factors, such as chromosomal abnormality. Perinatal factors such as perinatal hypoxia account for about 11%, and postnatal factors such as brain trauma account for 3 to 12% of severe mental retardation. In 30 to 40% of cases, the cause is reported to be unknown. The etiology of mild mental retardation is much less delineated. Between 45 and 63% of the cases are attributed to unknown etiology. Fewer cases of prenatal and perinatal causes are reported, with the largest number attributed to multiple factors (prenatal) and hypoxia (perinatal). Very few postnatal causes have been linked to mild mental retardation (McLaren & Bryson, 1987).

Associated disorders. A variety of disorders are associated with mental retardation. These include: epilepsy, cerebral palsy, vision and hearing impairments, speech/language problems, and behavior problems (McLaren & Bryson, 1987). The number of associated disorders appears to increase with the level of severity of mental retardation (Baird & Sadovnick, 1985).

21

Psychopathology Studies estimating the prevalence of mental health disorders among individuals with mental retardation suggest that between 10 and 40% meet the criteria for a dual diagnosis of mental retardation and a mental health disorder (Reiss, 1990). The range in prevalence rates appears to be due to varying types of population sampling. When case file surveys are conducted, the prevalence rates are consistently around 10%. The use of psychopathology rating scales in institutional or clinic samples produces the much higher 40% prevalence rate (Reiss, 1990). The actual prevalence may lie somewhere in between these two estimates. This may be the case due to the tendency of mental health professionals to consider behavior disorders in individuals with mental retardation as a symptom of their delayed development. Nevertheless, individuals with mental retardation appear to display the full range of psychopathology evidenced in the general population (Jacobson, 1990; Reiss, 1990). Individuals with mild cognitive limitations are more likely to be given a dual diagnosis than children with more significant disabilities (BorthwickDuffy & Eyman, 1990).

Assessment Assessment of a child suspected of having a developmental disability, such as mental retardation, may establish whether a diagnosis of mental retardation or some other developmental disability is warranted, assessing eligibility for special educational services, and/or aid in determining the educational or psychological services needed by the child and family. At a minimum, the assessment process should include an evaluation of the child's cognitive and adaptive or everyday functioning including behavioral concerns, where appropriate, and an evaluation of the family, home, and/or classroom to establish goals, resources, and priorities. Globally defined, child assessment is the systematic use of direct as well as indirect procedures to document the characteristics and resources of an individual child (Simeonsson & Bailey, 1992). The process may be comprised of various procedures and instruments resulting in the confirmation of a diagnosis, documentation of developmental status, and the prescription of intervention/treatment (Simeonsson & Bailey, 1992). A variety of assessment instruments have been criticized for insensitivity to cultural differences resulting in misdiagnosis or mislabeling. However, assessments have many valid uses. They allow for the measurement of change and the evaluation of program effectiveness and provide a standard for evaluating how well all children have learned the basic cognitive and academic skills necessary for survival in our culture. Given that the use of existing standardized instruments to obtain developmental information as part of the assessment process may bring about certain challenges, there does not appear to be a reasonable alternative (Sattler, 1992). Thus, it becomes necessary to understand assessment and
22

its purpose so that the tools which are available can be used correctly, and the results can be interpreted in a valid way. The four components of assessment (Sattler, 1992), norm-referenced tests, interviews, observations, and informal assessment, complement each other and form a firm foundation for making decisions about children. The use of more than one assessment procedure provides a wealth of information about the child permitting the evaluation of the biological, cognitive, social and interpersonal variables that affect the child's current behavior. In the diagnostic assessment of children, it is also important to obtain information from parents and other significant individuals in the child's environment. For school-age children, teachers are an important additional source of information. Certainly, major discrepancies among the findings obtained from the various assessment procedures must be resolved before any diagnostic decisions or recommendations are made. For example, if the intelligence test results indicate that the child is currently functioning in the mentally retarded range, while the interview findings and adaptive behavior results suggest functioning in a average range, it would become necessary to reconcile these disparate findings before making a diagnosis.

Developmental Delay or Mental Retardation In diagnosing infants or preschoolers, it is important to distinguish between mental retardation and developmental delay. A diagnosis of mental retardation is only appropriate when cognitive ability and adaptive behavior are significantly below average functioning. In the absence of clear-cut evidence of mental retardation, it is more appropriate to use a diagnosis of developmental delay. This acknowledges a cognitive or behavioral deficit, but leaves room for it to be transitory or of ambiguous origin (Sattler, 1992). In practice, children under the age of 2 should not be given a diagnosis of mental retardation unless the deficits are relatively severe and/or the child has a condition that is highly correlated with mental retardation (e.g., Down syndrome).

23

Cognitive/Developmental Assessment Tools Bayley Scales of Infant Development - Second Edition (Bayley, 1993): The Bayley Scales is an individually administered instrument for assessing the development of infants and very young children. It is appropriate for children from 2 months to 3½ years. It is comprised of three scales, the Mental Scale, the Motor Scale, and the Behavior Rating Scale. The Mental Scale assesses the following areas: recognition memory, object permanence, shape discrimination, sustained attention, purposeful manipulation of objects, imitation (vocal/verbal and gestural), verbal comprehension, vocalization, early language skills, short-term memory, problem-solving, numbers, counting, and expressive vocabulary. The Motor Scale addresses the areas of gross and fine motor abilities in a relatively traditional manner. The Behavior Rating Scale is used to rate the child's behavioral and emotional status during the assessment. Performance on the Mental and Motor Scales is interpreted through the use of standard scores (mean = 100; standard deviation = 15). The Behavior Rating Scale is interpreted by the use of percentile ranks. The Bayley Scales were standardized using a stratified sample of 1,700 infants and toddlers across 17 age groupings closely approximating the U.S. Census Data from 1988. The manual includes validity studies and case examples. The Bayley Scales is one of the most popular infant assessment tools. It can also be used to obtain the developmental status of children older than 3 ½ who have very significant delays in development and cannot be evaluated using more ageappropriate cognitive measures (e.g., a 6 year old with a developmental level of 2 years). The Differential Ability Scales (DAS) (Elliott, 1990): The DAS consists of a battery of individually administered cognitive and achievement tests subdivided into three age brackets: lower preschool (2 ½ years to 3 years, 5 months), upper preschool (3 ½ years to 5 years, 11 months), and school age (6 years to 17 years, 11 months). The cognitive battery focuses on reasoning and conceptual abilities and provides a composite standard score, the General Conceptual Ability (GCA) score. Verbal and Nonverbal cluster standard scores and individual subtest standard scores are also available. The DAS has several advantages over other similar measures. It has a built-in mechanism for assessing significantly delayed children who are over the age of 3 ½ years. It can also provide information comparable to other similar instruments in about half the time. Finally, it is very well standardized and correlates highly with other cognitive measures (i.e., the Wechsler Scales). Wechsler Preschool and Primary Scale of Intelligence-Revised (WPPSI-R) (Wechsler, 1989): The WPPSI-R can be utilized for children ranging in age from 3 years to 7 years, 3 months. Though separate and distinct from the WISC-III (discussed below), it is similar in form and content. The WPPSI-R is considered a downward extension of the WISC-III. These two tests overlap between the ages of 6 and 7 years, 3 months. The WPPSI-R has a mean of 100 and standard deviation of 15, with scaled scores for each subtest having a mean of 10 and a standard
24

deviation of 3. It contains 12 subtests organized into one of two major areas: the Verbal Scale includes Information, Similarities, Arithmetic, Vocabulary, Comprehension, and Sentences (optional) subtests; the Performance Scale includes Picture Completion, Geometric Design, Block Design, Mazes, Object Assembly, and Animal Pegs (optional) subtests. The WPPSI contains 9 subtests similar to those included in the WISC-III (Information, Vocabulary, Arithmetic, Similarities, Comprehension, Picture Completion, Mazes, Block Design, and Object Assembly) and 3 unique subtests (Sentences, Animal Pegs, and Geometric Design). Three separate IQ scores can be obtained: Verbal Scale IQ, Performance Scale IQ, and Full Scale IQ. The WPPSI-R was standardized on 1,700 children equally divided by gender and stratified to match the 1986 U.S. census data. This instrument cannot be used with severely disabled children (IQ's below 40) and, with younger children, may need to be administered over two sessions due to the length of time required to complete the assessment. Wechsler Intelligence Scale for Children-III (WISC-III) (Wechsler, 1991): The WISC-III can be utilized for children ranging in age from 6 years through 16 years of age. It is the middle childhood to middle adolescence version of the Wechsler Scale series. It contains 13 subtests organized into two major areas: the Verbal Scale includes Information, Similarities, Arithmetic, Vocabulary, Comprehension, and Digit Span (optional) subtests; the Performance Scale includes Picture Completion, Picture Arrangement, Block Design, Object Assembly, Coding, and the optional subtests of Mazes, and Symbol Search. Three separate IQ scores can be obtained: Verbal Scale IQ, Performance Scale IQ, and Full Scale IQ. Each of these separate IQ's are standard scores with a mean of 100 and a standard deviation of 15, with scaled scores for each subtest having a mean of 10 and a standard deviation of 3. The WISC-III was standardized on a sample of 2,200 American children selected as representative of the population on the basis of 1988 U.S. census data. Wechsler Adult Intelligence Scale - Revised (WAIS-R) (Wechsler, 1981): The WAIS-R covers an age range of 16 years, 0 months to 74 years, 11 months. The revised version contains about 80% of the original WAIS and was modified mainly due to cultural considerations. There are 11 subtests: Verbal Scale - Information, Similarities, Arithmetic, Vocabulary, Comprehension, and Digit Span; Performance Scale - Picture Completion, Picture Arrangement, Block Design, Object Assembly, and Digit Symbol. The WAIS-R was standardized in the 1970's on a sample of 1,880 white and non-white Americans equally divided among gender. The WAIS-R has a mean of 100 and a standard deviation of 15 with the scaled scores for each subtest having a mean of 10 and a standard deviation of 3. Stanford-Binet:Fourth Edition (SB: FE) (Thorndike, Hagen, & Sattler, 1986): The SB: FE is appropriate for use on individuals ranging in age from 2 to 23. It is comprised of 15 subtests, though only 6 (Vocabulary, Comprehension, Pattern Analysis, Quantitative, Bead Memory, and
25

Memory for Sentences) are used in all age groups. The other 9 subtests (Picture Absurdities, Paper Folding and Cutting, Copying, Repeating Digits, Similarities, Form-Board Items, Memory for Objects, Number Series, and Equation Building) are administered on the basis of age. Unlike previous editions, the SB: FE uses a point scale similar to that of the Wechsler Scales, is more culturally sensitive, and includes some new items in the areas of memory for objects, number series, and equation building. Once administered, the SB: FE yields three types of scores: age scores (or scaled scores), area scores (general intelligence, crystallized intelligence and short-term memory, specific factors, and specific factors plus short-term memory), and a Composite Score (similar to the Full-Scale IQ of the Wechsler). The SB: FE Composite Score has a mean of 100 and a standard deviation of 16 (unlike the Wechsler's standard deviation of 15). Overlap between the WISC-III and the Stanford-Binet:Fourth Edition: The WISC-III is appropriate between the ages of 6-16, while the Stanford-Binet: Fourth Edition is appropriate between the ages of 2 and 23. While the child is between 6 and 16, either test is appropriate. Correlations range from .66 to .83 between the WISC-R Full Scale IQ and the Fourth Edition composite. Results from Thorndike, Hagen, and Sattler (1986) show that while the two tests yield approximately equal scores, they are not interchangeable. This is partly due to the fact that they operate on different standard deviations (Sattler, 1992). Overlap between the WAIS-R and the Stanford-Binet:Fourth Edition: Results for individuals with and without mental retardation are similar in that the WAIS-R yields higher scores than the Stanford-Binet Fourth Edition. Special Note: Assessment Tools for Individuals with Mental Retardation. The Stanford-Binet: Fourth Edition and the Wechsler Scales are useful instruments in assessing mild mental retardation; however, neither is designed to test individuals with severe/profound mental retardation. In addition, due to the high floor on the Wechsler Scales the publisher recommends that a child obtain raw score credit in at least 3 subtests of the Verbal Scale and the Performance Scale before assuming they provide useful information. Raw score for 6 subtests, 3 Verbal and 3 Performance are recommended for a valid Full Scale IQ. McCarthy Scales of Children's Abilities (McCarthy, 1972): The McCarthy Scales can be used with children between the ages of 2 ½ years and 8 ½ years. It contains six scales: Verbal Scale, Perceptual-Performance Scale, Quantitative Scale, Memory Scale, Motor Scale, and General Cognitive Scale. In addition to yielding a General Cognitive Index (GCI), the McCarthy Scales provide several ability profiles (verbal, non-verbal reasoning, number aptitude, short-term memory, and coordination). The overall GCI has a mean of 100 and a standard deviation of 16 and is an estimate of the child's ability to apply accumulated knowledge to the tasks in the scales.
26

The ability profiles, in particular, make the McCarthy Scales useful for assessing young children with learning problems. The GCI is not interchangeable with the IQ score rendered by the Wechsler Scales; therefore, caution is advised in making placement decisions based on the GCI, especially in the case of children with mental retardation (Sattler, 1992).

Assessing Adaptive Behavior Adaptive behavior is an important and necessary part of the definition and diagnosis of mental retardation. It is the ability to perform daily activities required for personal and social sufficiency (Sattler, 1992). Assessment of adaptive behavior focuses on how well individuals can function and maintain themselves independently and how well they meet the personal and social demands imposed on them by their cultures. There are more than 200 adaptive behavior measures and scales. The most common scale is the Vineland Adaptive Behavior Scales (Sparrow, Balla, & Cicchetti, 1984). Vineland Adaptive Behavior Scales (VABS) (Sparrow, Balla, & Cicchetti, 1984): The VABS is a revision of the Vineland Social Maturity Scale (Doll, 1953) and assesses the social competence of individuals with and without disabilities from birth to age 19. It is an indirect assessment in that the respondent is not the individual in question but someone familiar with the individual's behavior. The VABS measures four domains: Communication, Daily Living Skills, Socialization, and Motor Skills. An Adaptive Behavior Composite is a combination of the scores from the four domains. A Maladaptive Behavior domain is also available with two of the three forms of administration. Each of the domains and the Composite has a mean of 100 and a standard deviation of 15. Three types of administration are available: the Survey Form (297 items), the Expanded Form (577 items, 297 of which are from the Survey Form), and the Classroom Edition (244 items for children age 3-13). The Survey and Expanded Forms were standardized on a representative sample of the 1980 U.S. census data including 3,000 individuals ranging in age from newborn to 18 years, 11 months. There are norms for individuals with mental retardation, children with behavior disorders, and individuals with physical handicaps. The Classroom Edition was standardized on a representative sample of the 1980 U.S. census data including 3,0000 students, ages 3 to 12 years, 11 months. Caution is advised when using this scale with children under the age of two because children with more significant delays frequently attain standard scores that appear to be in the low average range of ability. In this case more weight should be placed on the age equivalents that can be derived. The American Association on Mental Retardation (AMMR) Adaptive Behavior Scale (ABS): The ABS has two forms which address survival skills and maladaptive behaviors in individuals living in residential and community settings (ABS-RC:2; Nihira, Leland, & Lambert, 1993) or school
27

age children (ABS-S:2; Lamber, Nahira, & Leland, 1993). It is limited in scope and should be used with caution. A new scoring method has recently been devised that can generate scores consistent with the 10 adaptive behavior areas suggested in the 1992 definition of mental retardation (Bryant, Taylor, & Pedrotty-Rivera, 1996). The results of this assessment can be readily translated into objectives for intervention.

Achievement Tests Intelligence tests are broader than achievement tests and sample from a wider range of experiences, but both measure aptitude, learning, and achievement, to some degree (Sattler, 1992). Achievement tests (such as reading and mathematics) are heavily dependent on formal learning, are more culturally bound, and tend to sample more specific skills than do intelligence tests. Intelligence tests measure one's ability to apply information in new and different ways, whereas achievement tests measure mastery of factual information (Sattler, 1992). Intelligence tests are better predictors of scholastic achievement contributing to the decision-making processes in schools and clinics, and they are a better predictor of educability and trainability than other achievement tests because they sample the reasoning capacities developed outside school which should also be applied in school. To determine if learning potential is being fully realized, results from an IQ test and standardized tests of academic achievement can be compared. If there is a significant difference between IQ and achievement, the child may benefit from special assistance in the academic area identified. Achievement Assessment Tools That Can Be Used With Children With Mild Learning Disorders. Woodcock-Johnson Psycho-Educational Battery - Revised (Woodcock & Johnson, 1990): The Woodcock-Johnson is comprised of 35 tests assessing cognitive ability (vocabulary, memory, concept formation, spacial relations, and quantitative concepts) and achievement (reading, spelling, math, capitalization, punctuation, and knowledge of science, humanities, and social studies). Though the test batteries can be used with individuals from age 2 through adulthood, not all tests are administered at every age. The Cognitive Ability Battery and the Achievement Battery each have a recommended standard and supplemental batteries. The Achievement Battery can be used with preschool children (4 or 5 year olds) through adults. They each provide scores which can be converted into standard scores with a mean of 100 and a standard deviation of 15. By comparing the Tests of Cognitive Ability and the Tests of Achievement, the Woodcock-Johnson allows for the assessment of an Aptitude/achievment discrepancy. The discrepancy reflects disparity between cognitive and achievement capabilities. The Woodcock28

Johnson was standardized on a representative sample of 6,359 individuals ranging in age from 2 to 95 from communities throughout the United States. The Wide Range Achievement Test - Revised (WRAT-R) (Jastak & Wilkinson, 1984): The WRAT-R is a brief achievement test and contains three subtests: Reading, Spelling, Arithmetic. The WRAT-R is divided into two levels: Level One (ages 5 years, 0 months to 11 years, 11 months), and Level Two (ages 12 years, 0 months to 74 years, 11 months). The WRAT-R has a mean of 100 and a standard deviation of 15. It also provides T scores, scaled scores, gradeequivalent scores, and percentile ranks. It was standardized on a sample of 5,600 individuals in 28 age groups (5-74 years). A variety of other achievement tests are available for assessing academic performance. These include, but are not limited to, the Kaufman Test of Educational Achievement (Kaufman & Kaufman, 1985) and the Wechsler Individual Achievement Test (1992).

Other Assessment Tools Peabody Picture Vocabulary Test - Revised (PPVT-R) (Dunn & Dunn, 1981): The PPVT-R is appropriate for individuals between the ages of 2½ and adulthood and measures receptive knowledge of vocabulary. It is a multiple choice test requiring only a pointing response and no reading ability, thus making it useful for hearing individuals with a wide range of abilities, particularly children with language based disabilities. The revised edition is more sensitive to gender-based stereotypes and cultural issues; in fact only 37% of the original items were retained. The PPVT-R has two forms, L and M, with 175 plates in each form in ascending order of difficulty. Each plate consists of four clearly drawn pictures, one of which is the correct response to the word given by the experimenter. Standard scores have a mean of 100 with a standard deviation of 15. The PPVT-R was standardized on a national sample of 4,200 children (2½ - 18) and 828 adults (19 - 40) equally divided among gender and based on 1970 U.S. census data. The PPVT-R was designed to assess breadth of receptive vocabulary and not as a screening tool for measuring intellectual level of functioning. PPVT-R scores are not interchangeable with IQ scores obtained via the Stanford-Binet: Fourth Edition or the Wechsler Tests. Columbia Mental Maturity Scale: The Columbia Mental Maturity Scale (Burgemeister, Blum, & Lorge, 1972) is a test of general reasoning ability that can be used with children who have significant physical limitations. It is appropriate for children between the ages of 3 ½ years and 9 years, 11 months. The Columbia has a mean of 100, a standard deviation of 16, and can be interpreted using age equivalents. When used in conjunction with the Peabody Picture

29

Vocabulary Test - Revised, it can provide reasonably accurate cognitive status information comparable to the more common intelligence tests. Leiter International Performance Scale: The Leiter International Performance Scale (Leiter, 1948) is a nonverbal assessment of intelligence. Although the norms are dated, it provides useful information about the cognitive status of children with hearing impairments or severe language disabilities. It can be used with children aged 2 through adults. It is currently under revision and will likely be a useful tool in the future (Roid & Miller, 1997). For a description of a wide range of other specialty tests, the reader is referred to the Assessment of Children by Jerome Sattler (1992).

Dual Diagnosis Appropriate assessment of psychopathology in people with dual diagnosis is important because: a) it can suggest the form of treatment; b) it may ensure access to and funding for special services; and c) it can be used to evaluate subsequent interventions (Sturmey, 1995). Brain damage, epilepsy and language disorders are risk factors for psychiatric disorders and are often associated with mental retardation (Rutter, Tizard, Graham, & Whitmore, 1976; Sturmey, 1995). Social isolation, stigmatization, and poor social skills put individuals with mental retardation at further risk for affective disorders (Reiss & Benson, 1985). The relationship between emotional disorders and mental retardation has been noted by many researchers (Bregman, 1991;Menolascino, 1977; Reiss, 1982). Rates of emotional disorders are more prevalent in children with mental retardation than children without mental retardation (Bregman, 1988; Lewis & MacLean, 1982; Matson, 1982, Russell, 1985). As noted previously, epidemiological studies of psychiatric disorders in individuals with mental retardation show that this population experiences higher rates of psychopathology (Corbett, 1985; Gostason, 1985). Though children with mental retardation are diagnosed with psychiatric disorders more often than children without mental retardation, they are usually diagnosed with the same types of disorders. However, uncommon psychiatric disorders may be found in children with severe and profound levels of mental retardation (Batshaw & Perret, 1992). An additional problem is the application of DSM-IV criteria to individuals with mental retardation. Though the DSM has proven useful in diagnosing individuals with mild or moderate mental retardation (especially when the criterion are modified in some way, leading to problems in clearly operationalized definitions), many psychologists and psychiatrists rely more on biological markers, observable signs, and patterns of family psychopathology to diagnose individuals with severe and profound mental retardation thus implying that the DSM may not be
30

as useful with this population (Sturmey, 1995). The mismatch between behaviors scripted in the DSM-IV and psychopathology presented in individuals with mental retardation can lead to under diagnosing of these individuals (Sturmey, 1995). Because the DSM is so widely used by psychiatrists, psychologists, health insurance companies, and because of the way it is coordinated with the International Classification of Diseases (ICD), it will continue to be the main diagnostic source. Practitioners should take care not to modify the DSM criteria for their own use and instead should use the criteria as they are prescribed and document cases where the criteria are inadequate to make a comprehensive diagnosis (Sturmey, 1995). Most psychologists in the mental health field have little exposure to individuals with mental retardation and are sometimes uncomfortable treating these individuals; in fact, many professionals seem unaware that this group can experience mental health problems (Reiss & Szyszko, 1983). Mental health and mental retardation systems have been separated in this country for many years making it difficult to administratively serve people with both mental retardation and mental health disorders (Matson & Sevin, 1994). Recently, there has been a heightened awareness of need to pursue behavioral-psychiatric assessment, diagnosis, and treatment of people with mental retardation and mental health problems (Bregman, 1991; Eaton & Menolascino, 1982; Reiss, 1990). A variety of behavioral assessment tools are available and provide key information for practioners in this area. A few of the commonly used measures or checklists include: the Child Behavior Checklist (Achenbach & Edelbrock, 1986), the Conners Parent (or Teacher) Rating Scale (Conners, 1990), the Revised Behavior Problem Checklist (Quay & Peterson, 1987), and the Social Skills Rating System (Gresham & Elliott, 1990). These measures are only as reliable as the parent, guardian, or teacher completing them. However, they can provide useful information about the nature of the behavioral problems or competencies of the child. All of the scales noted above focus primarily on behavioral difficulties with the exception of the Social Skills Rating System which includes items that address prosocial behaviors.

Interdisciplinary Approach Because children with mental retardation often have other problems, it is necessary to involve a team of practitioners from different areas (e.g., child psychiatrist, social worker, child psychologist, special education teacher, speech and language specialist, and community agencies), in the comprehensive diagnosis. This type of interdisciplinary team approach is relatively new but is considered to be imperative for comprehensive assessment, treatment, and management of children with mental retardation (Lubetsky, Mueller, Madden, Walker, & Len, 1995). A natural extension of the interdisciplinary approach is the involvement of the family in
31

the decision-making process. In fact, recent government and educational initiatives such as Public Law 99-457 and Public Law 102-119 require the involvement of parents and professionals in early intervention services (Lubetsky et al, 1995). A family-centered interdisciplinary approach begins with an assessment of the child (including school history, obtained from parents and school records), family (family marital and parenting history), and community resources. Medical, developmental and psychiatric histories are obtained. Behavioral analysis, psychoeducational, speech and language testing are completed. Medical and neurological assessments are performed.

Intervention

Psychoeducational Intervention As a result of federal legislation developed with the aid and encouragement of a number of advocacy groups (i.e., the Individuals with Disabilities Education Act; Public Law 94-142, Public Law 99-457, and Public Law 102-119), children and adolescents with mental retardation or related developmental disorders are entitled to free and appropriate intervention. Appropriate intervention should be based on the needs of the child as determined by a team of professionals, address the priorities and concerns of the family, and be provided in the least restrictive most inclusive setting (i.e., where they have every opportunity to benefit from interacting with nondisabled peers and the community resources available to all other children).

Infant/Toddler Services Services to infants and toddlers can be home-based, center-based, or some combination of the two. The nature of the services should be determined based on the results of the child assessment and family priorities for the child. These should be used to develop an Individual Family Service Plan for the child which includes all parties participating in the intervention and is coordinated by a Services Coordinator (case manager) who is available and acceptable to the family. The services may include assistive technology, intervention for sensory impairments, family counseling, parent training, health services, language services, nursing intervention, nutrition counseling, occupational therapy, physical therapy, case management, and transportation to services.

32

Preschool and School Services Services to preschool children, ages 3 through 5, and school-aged children, 6 through 21, can be home-based, but are more frequently center-based. As in the case of infants and toddlers, a team evaluation and parent input is used to develop an intervention plan. This plan, the Individualized Education Plan (IEP), details the objectives for improving the child's skills and may include family or parent focused activities. Services may include special education provided by a certified teacher and focused on the needs of the child, child counseling, occupational therapy, physical therapy, language therapy, recreational activities, school health services, transportation services, and parent training or counseling. These services should be provided in the most inclusive least restrictive setting (e.g., a regular preschool program, Headstart Center, child's home).

Social/Interpersonal Intervention Social and interpersonal interventions can be both preventative and therapeutic. As noted above, children with mental retardation are at an increased risk for behavioral disorders. Therefore, a variety of group social and recreational activities should be included in the child's educational program. These activities should include nondisabled peers and may include participation at birthday parties, attending recreational activities such as ball games and movies, participating in youth sports activities, and visiting community sites such as the zoo. The goal of these activities should be to teach appropriate social skills relevant to group participation and building selfesteem. Parents also may benefit from prevention activities. Respite care provided by trained individuals can afford parents the opportunity to address their own needs (e.g., personal time, medical appointments, socializing with peers, etc.). They can be much more effective in parenting when their own needs have been met. Social or parent support groups can also be an outlet for parents to discuss their feelings with individuals who have similar experiences. These groups may be syndrome specific (e.g., Parent Advocates for Down Syndrome) or more generic in nature. Therapeutic interventions with the children and families may include family therapy, individual child behavior therapy, parent training, and group therapy with mildly mentally disabled children and adolescents focusing on developing appropriate social skills. Child behavioral interventions can be used to teach self-care, vocational, leisure, interpersonal, and survival skills (e.g., finding a public restroom). Disruptive behaviors such as tantrumming, self-injury, noncompliance, and aggression toward others can also be addressed through behavioral techniques. The most

33

frequent form of behavioral intervention for problematic behavior involves differential reinforcement of incompatible and/or other behaviors (Batshaw & Perret, 1992).

Psychopharmacological Intervention Treatment specifying the use of medication should only be considered when a particular psychiatric condition know to benefit from a particular drug coexists with the mental retardation or developmental disability. This may take the form of a severe depression, obsessivecompulsive disorder, attention deficit-hyperactivity disorder, or a variety of other psychiatric disorders. There are few well controlled studies of drug treatments with children who have mental retardation. It should also be noted that the use of medication as a form of chemical restraint should be avoided. In addition, when drug treatment is used, it should only be one component of an overall treatment approach (Batshaw & Perret, 1992).

Final Comments An invaluable resource in evaluating and treating children with mental retardation is the child's family. Consequently, including the families of children with or at-risk for disabilities in every phase of intervention, from identification to planning to implementation through monitoring should be considered. However, including families in decisions about the treatment or management of their children's problems presents new challenges. Nevertheless, trying to understand and include families in the decision-making process can ultimately be rewarding and beneficial for all involved.

Level of Family Involvement How and when should families be included in decision making? There is no standard formula for answering this question. Families, like individuals, vary tremendously. Nevertheless, there are some issues that must be considered when involving families in team decisions about their child with a disability. First, the team must be receptive to including families in the decision-making process. This involves some effort on the part of the non-family team members to encourage family participation. In addition, the team must decide what child and family concerns are related to enhancing the development of the child. These should be the focus of generating familyoriented service delivery alternatives.

34

Second, the team must consider the level of knowledge and understanding of the family related to the disability of the child and/or the service/treatment options. If families are to participate in the decision-making process they must have the knowledge necessary to select appropriate alternatives. It is unfair to assume that families will not understand or cannot make appropriate decisions about the care of their child. They are the consumers and need to be given the chance to make an informed choice. Finally, once the family has an adequate understanding of the condition and service/treatment alternatives, they may need to be nurtured through the team decision-making process. Most families have never been faced with participating as a member of a team of professionals and may initially be reticent or nonparticipatory in discussions unless they are specifically invited to do so. Certainly, as a primary care provider the parent or family member has more at stake than the other team members. Over time, however, the cautious or reticent family member may become an active and vital team member.

Encouraging Parent Participation Health and education professionals who participate as team members must actively pursue parent-professional partnerships in the decision-making process. The logical first step is to acknowledge the value of the parent-professional relationship. Parents should be viewed as equal partners who can make important and necessary contributions in the planning, decision-making, process. If professionals are reluctant to or refuse to acknowledge parents as partners in the process, they run the risk of alienating them resulting in a lack of interest or participation in necessary services. Once the non-family team members accept the parents or other relevant family members as equal partners in the planning process, strategies to encourage continued active participation should be developed and implemented.

35

Mild Intellectual Disability (MID) also referred to as Mild Mental Retardation
Many of the characteristics of MID correspond to those of Learning Disabilities. The intellectual development will be slow, however, MID students have the potential to learn within the regular classroom given appropriate modifications and/or accommodations.Some MID students will require greater support and/or withdrawal than others will. MID students, like all students demonstrate their own strengths and weaknesses. Depending on the educational jurisdiction, criteria for MID will often state that the child is functioning approximately 2-4 years behind or 23 standard deviations below the norm or have an IQ under 70-75. The intellectual disability may vary from mild to profound.

How are MID Students Identified? Depending on the education jurisdiction, testing for MID will vary. Generally, a combination of assessment methods are used to identify mild intellectual disabilities. Methods may or may not include IQ scores or percentiles, adaptive skills cognitive tests in various areas, skills-based assessments, and levels of academic achievement. Some jurisdictions will not use the term MID but will use mild mental retardation.

Academic Implications Students with MID may demonstrate some, all or a combination of the following characteristics: • • 2-4 years behind in cognitive development which could include math, language, short attention spans, memory difficulties and delays in speech development. Social Relationships are often impacted. The MID child may exhibit behavior problems, be immature, display some obsessive/compulsive behaviors and lack the understanding of verbal/non verbal clues and will often have difficulty following rules and routines.

Adaptive Skill Implications. (Everyday skills for functioning) These children may be clumsy, use simple language with short sentences, have minimal organization skills and will need reminders about hygiene - washing hands, brushing teeth (life skills). etc.
36

Weak Confidence is often demonstrated by MID students. These students are easily frustrated and require opportunities to improve self esteem. Lots of support will be needed to ensure they try new things and take risks in learning.

Concrete to Abstract thought is often missing or significantly delayed. This includes the lacking ability to understand the difference between figurative and literal language.

Best Practices • • • • • • •

Use simple, short, uncomplicated sentences to ensure maximum understanding. Repeat instructions or directions frequently and ask the student if further clarification is necessary. Keep distractions and transitions to a minimum. Teach specific skills whenever necessary. Provide an encouraging, supportive learning environment that will capitalize on student success and self esteem. Use appropriate program interventions in all areas where necessary to maximize success. Use alternative instructional strategies and alternative assessment methods. Help the MID student develop appropriate social skills to support friend and peer relationships. Teach organizational skills. Use behavior contracts and reinforce positive behavior if necessary. Ensure that your routines and rules are consistent. Keep conversations as normal as possible to maximize inclusion with peers. Teach the difference between literal/figurative language. Be patient! Assist with coping strategies.


• •

Disabilities
• • •

Learning Disabilities Physical Disabilities Mental Retardation

Teaching Strategies
• • •

Inclusional Strategies Helping with Reading Teach Rules and Routines
37

Behavior
• • •

5-Step Behavior Plan Best Practices Behavior Plans

38

Schizophrenia
Schizophrenia occurs in about 1 percent of the general U.S. population. That means that more than 3 million Americans suffer from the illness. The disorder manifests itself in a broad range of unusual behaviors, which cause profound disruption in the lives of the patients suffering from the condition and in the lives of the people around them. Schizophrenia strikes without regard to gender, race, social class or culture. One of the most important kinds of impairment caused by schizophrenia involves the person’s thought processes. The individual can lose much of the ability to rationally evaluate his surroundings and interactions with others. There can be hallucinations and delusions, which reflect distortions in the perception and interpretation of reality. The resulting behaviors may seem bizarre to the casual observer, even though they may be consistent with the schizophrenic’s abnormal perceptions and beliefs. Nearly one-third of those diagnosed with schizophrenia will attempt suicide. About 10 percent of those with the diagnosis will commit suicide within 20 years of the beginning of the disorder. Patients with schizophrenia are not likely to share their suicidal intentions with others, making life-saving interventions more difficult. The risk of depression needs special mention due to the high rate of suicide in these patients. The most significant risk of suicide in schizophrenia is among males under 30 who have some symptoms of depression and a relatively recent hospital discharge. Other risks include imagined voices directing the patient toward self-harm (auditory command hallucinations) and intense false beliefs (delusions). The relationship of schizophrenia to substance abuse is significant. Due to impairments in insight and judgment, people with schizophrenia may be less able to judge and control the temptations and resulting difficulties associated with drug or alcohol abuse.

39

In addition, it is not uncommon for people suffering from this disorder to try to “self-medicate” their otherwise debilitating symptoms with mind-altering drugs. The abuse of such substances, most commonly nicotine, alcohol, cocaine and marijuana, impedes treatment and recovery. The chronic abuse of cigarettes among schizophrenic patients is well-documented and probably related to the mind-altering effects of nicotine. Some researchers believe that nicotine affects brain chemical systems that are disrupted in schizophrenia; others speculate that nicotine counters some of the unwanted reactions tomedications used to treat the disease. It is not uncommon for people diagnosed with schizophrenia to die prematurely from other medical conditions, such as coronary artery disease and lung disease. It is unclear whether schizophrenic patients are genetically predisposed to these physical illnesses or whether such illnesses result from unhealthy lifestyles associated with schizophrenia. Schizophrenia usually first appears in a person during their late teens or throughout their twenties. It affects more men than women, and is considered a life-long condition which rarely is "cured," but rather treated. The primary treatment for schizophrenia and similar thought disorders is medication. Unfortunately, compliance with a medication regimen is often one of the largest problems associated with the ongoing treatment of schizophrenia. Because people who live with this disorder often go off of their medication during periods throughout their lives, the repercussions of this loss of treatment are acutely felt not only by the individual, but by their family and friends as well. Successful treatment of schizophrenia, therefore, depends upon a life-long regimen of both drug and psychosocial, support therapies. While the medication helps control the psychosis associated with schizophrenia (e.g., the delusions and hallucinations), it cannot help the person find a job, learn to be effective in social relationships, increase the individual's coping skills, and help them learn to communicate and work well with others. Poverty, homelessness, and unemployment are often associated with this disorder, but they don't have to be. If the individual finds appropriate treatment and sticks with it, a person with schizophrenia can lead a happy and successful life. But the initial recovery from the first symptoms of schizophrenia can be an extremely lonely experience. Individuals coping with the onset of schizophrenia for the first time in their lives require all the support that their families, friends, and communities can provide. With such support, determination, and understanding, someone who has schizophrenia can learn to cope and live with it for their entire life. But stability with this disorder means complying with the treatment plan set up between the person and their therapist or doctor, and maintaining the balance provided for by the medication and therapy. A sudden stopping of treatment will most often lead to a relapse of the symptoms associated with schizophrenia and then a gradual recovery as treatment is reinstated
40

SYMPTOMS Schizophrenia is characterized by at least 2 of the following symptoms, for at least one month:
• • • • •

Delusions Hallucinations Disorganized speech (e.g., frequent derailment or incoherence) Grossly disorganized or catatonic behavior Negative symptoms (e.g., a "flattening" of one's emotions, alogia,

avolition; see below) (Only one symptom is required if delusions are bizarre orhallucinations consist of a voice keeping up a running commentary on the person's behavior or thoughts, or two or more voices conversing with each other.) For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational achievement). Schizoaffective Disorder and Mood Disorder With Psychotic Features have been considered as alternative explanations for the symptoms and have been ruled out. The disturbance must also not be due to the direct physiological effects of use or abuse of a substance (e.g., alcohol, drugs, medications) or a general medical condition. If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated).

41

DIAGNOSIS OF SCHIZOPHRENIA DSM-IV diagnostic criteria for schizophrenia In DSM-IV, the diagnosis of schizophrenia depends upon the presence of characteristic symptoms, a minimum duration of those symptoms, a minimum duration of the disorder, the presence of social/occupational dysfunction, and adifferentiation from mood, schizoaffective, other psychotic disorders, general medical conditions, substance-induced disorders and pervasive developmental disorder According to DSM-IV, there are no strictly pathognomonic symptomsof schizophrenia. Characteristic symptoms are conceptualized as falling into two broad categories: positive and negative. There are four groups of positive symptoms—delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behaviour—and one group of negative symptoms, which includes affective flattening, alogia avolition.

A. Characteristic Symptoms Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated); (1) delusions (2) hallucinations (3) disorganized speech (e.g. frequent derailment or incoherence) (4) grossly disorganized or catatonic behavior (5) negative symptoms, that is, affective flattening, alogia, or avolition. Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person’s behavior or thoughts, or two or more voices conversing with each other.

B. Social/occupational dysfunction For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal academic, or occupational achievement).

42

C. Duration Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e. active phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or two or more symptoms listed in Criterion A present in an attenuated form (e.g. odd beliefs, unusual perceptual experiences).

D. Schizoaffective and Mood Disorder exclusion Schizoaffective Disorder and Mood Disorder With Psychotic Features have been ruled out because either (1) no Major Depressive, Manic or Mixed Episodes have occurred concurrently with the active-phase symptoms, or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods.

E. Substance/general medical condition exclusion The disturbance is not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition.

F. Relationship to a Pervasive Developmental Disorder If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated). The DSM-IV diagnostic criteria for schizophrenia require the presence of symptoms from at least two of the groups listed above. Symptoms from only one group are required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person’s behaviour or thoughts, or two or more voices conversing with each other. Each of the symptoms must be present for a significant portion of time during a one-month period (or less if successfully treated).
43

According to DSM-IV, schizophrenia is accompanied by marked social or occupational dysfunction for a significant portion of the time since the onset of the disturbance. The dysfunction must be present in at least one major area such as work, interpersonal relations or self-care. DSM-IV requires that continuous signs of the disturbance persist for at least 6 months. This 6month period may include periods when only negative or less severe symptoms are present. Such periods are referred to as prodromal or residual, depending on whether they precede or follow the one-month period of characteristic symptoms described above. Classification of course can be applied only after at least one year has elapsed since the initial onset of active-phase symptoms. According to DSMIV, the course of schizophrenia is variable. The manual lists the following course specifiers: episodic with inter-episode residual symptoms; episodic with no inter-episode residual symptoms; continuous; single episode in partial remission; single episode in full remission; other or unspecified pattern. Concerning differential diagnosis, DSM-IV emphasizes the distinction between schizophrenia and mood disorders. If psychotic symptoms occur exclusively during periods of mood disturbance, the diagnosis is mood disorder with psychotic features. If mood episodes have occurred during active-phase symptoms, and if their total duration has been brief relative to the duration of active and residual periods, the diagnosis is schizophrenia. If a mood episode is concurrent with the active-phase symptoms of schizophrenia, and if mood symptoms have been present for a substantial portion of the total duration of the disturbance, and if delusions or hallucinations have been present for at least 2 weeks in the absence of prominent mood symptoms, the diagnosis is schizoaffective disorder. The differentiation between schizophrenia, brief psychotic disorder and schizophreniform disorder rests upon a criterion of duration: less than one month for brief psychotic disorder; more than one month but less than 6 months for schizophreniform disorder; at least 6 months for schizophrenia. The differential diagnosis between schizophrenia and delusional disorder rests on the nature of the delusions (in delusional disorder they are nonbizarre) and the absence of other characteristic symptoms of schizophrenia such as hallucinations, disorganized speech and behaviour, or prominent negative symptoms. Schizophrenia and pervasive developmental disorder are distinguished by a number of criteria, including in particular the presence of prominent delusions and hallucinations in the former but not in the latter.

44

Finally, the diagnosis is not made if the disturbance is due to the direct physiological effects of a substance or a general medical condition. DSM-IV describes five subtypes of schizophrenia: paranoid, disorganized, catatonic, undifferentiated and residual. Post-psychotic depressive disorder of schizophrenia and simple deteriorative disorder or simple schizophrenia is described in Appendix B, among conditions requiring further study. In both the ICD-10 and the DSM-IV there is a distinction between positive and negative characteristic symptoms of schizophrenia. According to the definition provided in DSM-IV, ‘‘the positive symptoms appear to reflect an excess or distortion of normal functions, whereas the negative symptoms appear to reflect a diminution or loss in normal functions’’. In both ICD-10 and DSM-IV, positive symptoms include hallucinations and delusions, disorganized thought and speech, as well as disorganized and catatonic behaviour. In both systems, negative symptoms include affective flattening or blunting of emotional responses, alogia or paucity of speech, and apathy or avolition. The reliability and validity of psychiatric diagnoses that are based on explicit diagnostic criteria have been investigated in a number of studies during recent decades. According to Kendell [106], psychiatric diagnoses are now as reliable as the clinical judgements made in other branches of medicine. High reliability does not, however, by itself predict high validity.

45

Different Types of Schizophrenia:
Paranoid schizophrenia a person feels extremely suspicious, persecuted, grandiose, or experiences a combination of these emotions. Disorganized schizophrenia a person is often incoherent but may not have delusions. Catatonic schizophrenia a person is withdrawn, mute, negative and often assumes very unusual postures. Residual schizophrenia a person is no longer delusion or hallucinating, but has no motivation or interest in life. These symptoms can be most devastating. Positive Symptoms
• • •

Negative Symptoms

Delusions Hallucinations Disorganized thinking

Lack of drive or initiative

• • •

Social withdrawal Apathy Emotional unresponsiveness

Agitation

The kinds of symptoms that are utilized to make a diagnosis of schizophrenia differ between affected people and may change from one year to the next within the same person as the disease progresses. Different subtypes of schizophrenia are defined according to the most significant and predominant characteristics present in each person at each point in time. The result is that one person may be diagnosed with different subtypes over the course of his illness.

Paranoid Subtype The defining feature of the paranoid subtype is the presence of auditory hallucinations or prominent delusional thoughts about persecution or conspiracy. However, people with this subtype may be more functional in their ability to work and engage in relationships than people with other subtypes of schizophrenia. The reasons are not entirely clear, but may partly reflect that people suffering from this subtype often do not exhibit symptoms until later in life and have achieved a higher level of functioning before the onset of their illness. People with the paranoid subtype may appear to lead fairly normal lives by successful management of their disorder.
46

People diagnosed with the paranoid subtype may not appear odd or unusual and may not readily discuss the symptoms of their illness. Typically, the hallucinations and delusions revolve around some characteristic theme, and this theme often remains fairly consistent over time. A person’s temperaments and general behaviors often are related to the content of the disturbance of thought. For example, people who believe that they are being persecuted unjustly may be easily angered and become hostile. Often, paranoid schizophrenics will come to the attention of mental health professionals only when there has been some major stress in their life that has caused an increase in their symptoms. At that point, sufferers may recognize the need for outside help or act in a fashion to bring attention to themselves. Since there may be no observable features, the evaluation requires sufferers to be somewhat open to discussing their thoughts. If there is a significant degree of suspiciousness or paranoia present, people may be very reluctant to discuss these issues with a stranger. There is a broad spectrum to the nature and severity of symptoms that may be present at any one time. When symptoms are in a phase of exacerbation or worsening, there may be some disorganization of the thought processes. At this time, people may have more trouble than usual remembering recent events, speaking coherently or generally behaving in an organized, rational manner. While these features are more characteristic of other subtypes, they can be present to differing degrees in people with the paranoid subtype, depending upon the current state of their illness. Supportive friends or family members often may be needed at such times to help the symptomatic person get professional help.

Disorganized Subtype As the name implies, this subtype’s predominant feature is disorganization of the thought processes. As a rule, hallucinations and delusions are less pronounced, although there may be some evidence of these symptoms. These people may have significant impairments in their ability to maintain the activities of daily living. Even the more routine tasks, such as dressing, bathing or brushing teeth, can be significantly impaired or lost. Often, there is impairment in the emotional processes of the individual. For example, these people may appear emotionally unstable, or their emotions may not seem appropriate to the context of the situation. They may fail to show ordinary emotional responses in situations that evoke such responses in healthy people. Mental health professionals refer to this particular symptom as blunted or flat affect. Additionally, these people may have an inappropriately jocular or giddy appearance, as in the case of a patient who chuckles inappropriately through a funeral service or other solemn occasion.
47

People diagnosed with this subtype also may have significant impairment in their ability to communicate effectively. At times, their speech can become virtually incomprehensible, due to disorganized thinking. In such cases, speech is characterized by problems with the utilization and ordering of words in conversational sentences, rather than with difficulties of enunciation or articulation. In the past, the term hebephrenic has been used to describe this subtype.

Catatonic Subtype The predominant clinical features seen in the catatonic subtype involve disturbances in movement. Affected people may exhibit a dramatic reduction in activity, to the point that voluntary movement stops, as in catatonic stupor. Alternatively, activity can dramatically increase, a state known as catatonic excitement. Other disturbances of movement can be present with this subtype. Actions that appear relatively purposeless but are repetitively performed, also known as stereotypic behavior, may occur, often to the exclusion of involvement in any productive activity. Patients may exhibit an immobility or resistance to any attempt to change how they appear. They may maintain a pose in which someone places them, sometimes for extended periods of time. This symptom sometimes is referred to as waxy flexibility. Some patients show considerable physical strength in resistance to repositioning attempts, even though they appear to be uncomfortable to most people. Affected people may voluntarily assume unusual body positions, or manifest unusual facial contortions or limb movements. This set of symptoms sometimes is confused with another disorder called tardive dyskinesia, which mimics some of these same, odd behaviors. Other symptoms associated with the catatonic subtype include an almost parrot-like repeating of what another person is saying (echolalia) or mimicking the movements of another person (echopraxia). Echolalia and echopraxia also are seen in Tourette’s Syndrome.

Undifferentiated Subtype The undifferentiated subtype is diagnosed when people havesymptoms of schizophrenia that are not sufficiently formed or specific enough to permit classification of the illness into one of the other subtypes.

48

The symptoms of any one person can fluctuate at different points in time, resulting in uncertainty as to the correct subtype classification. Other people will exhibit symptoms that are remarkably stable over time but still may not fit one of the typical subtype pictures. In either instance, diagnosis of the undifferentiated subtype may best describe the mixed clinical syndrome.

Residual Subtype This subtype is diagnosed when the patient no longer displays prominent symptoms. In such cases, the schizophrenic symptoms generally have lessened in severity. Hallucinations, delusions or idiosyncratic behaviors may still be present, but their manifestations are significantly diminished in comparison to the acute phase of the illness. Just as the symptoms of schizophrenia are diverse, so are its ramifications. Different kinds of impairment affect each patient’s life to varying degrees. Some people require custodial care in state institutions, while others are gainfully employed and can maintain an active family life. However, the majority of patients are at neither of these extremes. Most will have a waxing and waning course marked with some hospitalizations and some assistance from outside support sources. People having a higher level of functioning before the start of their illness typically have a better outcome. In general, better outcomes are associated with brief episodes of symptoms worsening followed by a return to normal functioning. Women have a better prognosis for higher functioning than men, as do patients with no apparent structural abnormalities of the brain. In contrast, a poorer prognosis is indicated by a gradual or insidious onset, beginning in childhood or adolescence; structural brain abnormalities, as seen on imaging studies; and failure to return to prior levels of functioning after acute episodes. The undifferentiated subtype is diagnosed when people have symptoms of schizophrenia that are not sufficiently formed or specific enough to permit classification of the illness into one of the other subtypes. The symptoms of any one person can fluctuate at different points in time, resulting in uncertainty as to the correct subtype classification. Other people will exhibit symptoms that are remarkably stable over time but still may not fit one of the typical subtype pictures. In either instance, diagnosis of the undifferentiated subtype may best describe the mixed clinical syndrome.

49

How Is It Diagnosed? Undifferentiated schizophrenia is a difficult diagnosis to make with any confidence because it depends on establishing the slowly progressive development of the characteristic “negative” symptoms of schizophrenia without any history of hallucinations, delusions, or other manifestations of an earlier psychotic episode, and with significant changes in personal behaviour, manifest as a marked loss of interest, idleness, and social withdrawal.

Psychotherapy Psychotherapy is not the treatment of choice for someone with schizophrenia. Used as an adjunct to a good medication plan, however, psychotherapy can help maintain the individual on their medication, learn needed social skills, and support the person's weekly goals and activities in their community. This may include advice, reassurance, education, modeling, limit setting, and reality testing with the therapist. Encouragement in setting small goals and reaching them can often be helpful. People with schizophrenia often have a difficult time performing ordinary life skills such as cooking and personal grooming as well as communicating with others in the family and at work. Therapy or rehabilitation therapy can help a person regain the confidence to take care of themselves and live a fuller life. Group therapy, combined with drugs, produces somewhat better results than drug treatment alone, particularly with schizophrenic outpatients. Positive results are more likely to be obtained when group therapy focuses on real-life plans, problems, and relationships; on social and work roles and interaction; on cooperation with drug therapy and discussion of its side effects; or on some practical recreational or work activity. This supportive group therapy can be especially helpful in decreasing social isolation and increasing reality testing (Long, 1996). Family therapy can significantly decrease relapse rates for the schizophrenic family member. In high-stress families, schizophrenic patients given standard aftercare relapse 50-60% of the time in the first year out of hospital. Supportive family therapy can reduce this relapse rate to below 10 percent. This therapy encourages the family to convene a family meeting whenever an issue arises, in order to discuss and specify the exact nature of the problem, to list and consider alternative solutions, and to select and implement the consensual best solution. (Long, 1996).

50

Medications Schizophrenia appears to be a combination of a thought disorder, mood disorder, and anxiety disorder. The medical management of schizophrenia often requires a combination of antipsychotic, antidepressant, and antianxiety medication. One of the biggest challenges of treatment is that many people don't keep taking the medications prescribed for the disorder. After the first year of treatment, most people will discontinue their use of medications, especially ones where the side effects are difficult to tolerate. As a recent National Institute of Mental Health Study indicated, regardless of the drug, threequarters of all patients stop taking their medications. They stopped the schizophrenia medications either because they did not make them better or they had intolerable side effects. The discontinuation rates remained high when they were switched to a new drug, but patients stayed on clozapine about 11 months, compared with only three months for Seroquel, Risperdal or Zyprexa, which are far more heavily marketed -- and dominate sales. Because of findings such as this, it's generally recommended that someone with schizophrenia begin their treatment with a drug such asclozapine (clozapine is often significantly cheaper than other antipsychotic medications). Clozapine (also known as clozaril) has been shown to be more effective than many newer antipsychotics as well. Antipsychotic medications help to normalize the biochemical imbalances that cause schizophrenia. They are also important in reducing the likelihood of relapse. There are two major types of antipsychotics, traditional and new antipsychotics. Traditional antipsychotics effectively control the hallucinations, delusions, and confusion of schizophrenia. This type of antipsychotic drug, such as haloperidol, chlorpromazine, and fluphenazine, has been available since the mid-1950s. These drugs primarily block dopamine receptors and are effective in treating the "positive" symptoms of schizophrenia. Side effects for antipsychotics may cause a patient to stop taking them. However, it is important to talk with your doctor before making any changes in medication since many side effects can be controlled. Be sure to weigh the risks against the potential benefits that antipsychotic drugs can provide. Mild side effects: dry mouth, blurred vision, constipation, drowsiness and dizziness. These side affects usually disappear a few weeks after the person starts treatment.

51

More serious side effects: trouble with muscle control, muscle spasms or cramps in the head and neck, fidgeting or pacing, tremors and shuffling of the feet (much like those affecting people with Parkinson's disease). Side effects due to prolonged use of traditional antipsychotic medications: facial ticks, thrusting and rolling of the tongue, lip licking, panting and grimacing. There are many newer antipsychotic medications available since the 1990's, including Seroquel, Risperdal, Zyprexa and Clozaril. Some of these medications may work on both the serotonin and dopamine receptors, thereby treating both the "positive" and "negative" symptoms of schizophrenia. Other newer antipsychotics are referred to as atypical antipsychotics, because of how they affect the dopamine receptors in the brain. These newer medications may be more effective in treating a broader range of symptoms of schizophrenia, and some have fewer side effects than traditional antipsychotics. Learn more about the atypical antipsychotics used to help treat schizophrenia.

Coping Guidelines For The Family 1. Establish a daily routine for the patient to follow. 2. Help the patient stay on the medication. 3. Keep the lines of communication open about problems or fears the patient may have. 4. Understand that caring for the patient can be emotionally and physically exhausting. Take time for yourself. 5. Keep your communications simple and brief when speaking with the patient. 6. Be patient and calm. 7. Ask for help if you need it; join a support group.

Self-Help Self-help methods for the treatment of this disorder are often overlooked by the medical profession because very few professionals are involved in them. Adjunctive community support groups in concurrence with psychotherapy is usually beneficial to most people who suffer from schizophrenia. Caution should be utilized, however, if the person's symptoms aren't under control of a medication. People with this disorder often have a difficult time in social situations, therefore a support group should not be considered as an initial treatment option. As the person

52

progresses in treatment, a support group may be a useful option to help the person make the transition back into daily social life. Another use of self-help is for the family members of someone who lives with schizophrenia. The stress and hardships causes of having a loved one with this disorder are often overwhelming and difficult to cope with for a family. Family members should use a support group within their community to share common experiences and learn about ways to best deal with their frustrations, feelings of helplessness, and anger.

Cause of Schizophrenia There is no known single cause of schizophrenia. Many diseases, such as heart disease, result from an interplay of genetic, behavioral and other factors, and this may be the case for schizophrenia as well. Scientists do not yet understand all of the factors necessary to produce schizophrenia, but all the tools of modern biomedical research are being used to search for genes, critical moments in brain development, and other factors that may lead to the illness.

Can It Be Inherited?

It has long been known that schizophrenia runs in families. People who have a close relative with schizophrenia are more likely to develop the disorder than are people who have no relatives with the illness. For example, a monozygotic (identical) twin of a person with schizophrenia has the highest risk -- 40 to 50 percent -- of developing the illness. A child whose parent has schizophrenia has about a 10 percent chance. By comparison, the risk of schizophrenia in the general population is about 1 percent. Scientists are studying genetic factors in schizophrenia. It appears likely that multiple genes are involved in creating a predisposition to develop the disorder. In addition, factors such as prenatal difficulties like intrauterine starvation or viral infections, perinatal complications, and various nonspecific stressors, seem to influence the development of schizophrenia. However, it is not yet understood how the genetic predisposition is transmitted, and it cannot yet be accurately predicted whether a given person will or will not develop the disorder. Several regions of the human genome are being investigated to identify genes that may confer susceptibility for schizophrenia. The strongest evidence to date leads to chromosomes 13 and 6 but remains unconfirmed. Identification of specific genes involved in the development of
53

schizophrenia will provide important clues into what goes wrong in the brain to produce and sustain the illness and will guide the development of new and better treatments. To learn more about the genetic basis for schizophrenia, the NIMH has established a Schizophrenia Genetics Initiative that is gathering data from a large number of families of people with the illness. Is It Caused by a Chemical Defect in the Brain?

Basic knowledge about brain chemistry and its link to schizophrenia is expanding rapidly. Neurotransmitters, substances that allow communication between nerve cells, have long been thought to be involved in the development of schizophrenia. It is likely, although not yet certain, that the disorder is associated with some imbalance of the complex, interrelated chemical systems of the brain, perhaps involving the neurotransmitters dopamine and glutamate. This area of research is promising.

Is It Caused by a Physical Abnormality in the Brain?

There have been dramatic advances in neuroimaging technology that permit scientists to study brain structure and function in living individuals. Many studies of people with schizophrenia have found abnormalities in brain structure (for example, enlargement of the fluid-filled cavities, called the ventricles, in the interior of the brain, and decreased size of certain brain regions) or function (for example, decreased metabolic activity in certain brain regions). It should be emphasized that these abnormalities are quite subtle and are not characteristic of all people with schizophrenia, nor do they occur only in individuals with this illness. Microscopic studies of brain tissue after death have also shown small changes in distribution or number of brain cells in people with schizophrenia. It appears that many (but probably not all) of these changes are present before an individual becomes ill, and schizophrenia may be, in part, a disorder in development of the brain. Developmental neurobiologists funded by the National Institute of Mental Health (NIMH) have found that schizophrenia may be a developmental disorder resulting when neurons form inappropriate connections during fetal development. These errors may lie dormant until puberty, when changes in the brain that occur normally during this critical stage of maturation interact adversely with the faulty connections. This research has spurred efforts to identify prenatal factors that may have some bearing on the apparent developmental abnormality.

54

In other studies, investigators using brain-imaging techniques have found evidence of early biochemical changes that may precede the onset of disease symptoms, prompting examination of the neural circuits that are most likely to be involved in producing those symptoms. Meanwhile, scientists working at the molecular level are exploring the genetic basis for abnormalities in brain development and in the neurotransmitter systems regulating brain function.

55

B.

Theoretical Framework

56

1. Freud’s Theories

a.

Psychosexual Development

Sigmund Freud (1856-1939) is probably the most well known theorist when it comes to the development of personality. Freud’s Stages of Psychosexual Development are, like other stage theories, completed in a predetermined sequence and can result in either successful completion or a healthy personality or can result in failure, leading to an unhealthy personality. This theory is probably the most well known as well as the most controversial, as Freud believed that we develop through stages based upon a particular erogenous zone. During each stage, an unsuccessful completion means that a child becomes fixated on that particular erogenous zone and either over– or under-indulges once he or she becomes an adult.

Oral Stage (Birth to 18 months). During the oral stage, the child if focused on oral pleasures (sucking). Too much or too little gratification can result in an Oral Fixation or Oral Personality which is evidenced by a preoccupation with oral activities. This type of personality may have a stronger tendency to smoke, drink alcohol, over eat, or bite his or her nails. Personality wise, these individuals may become overly dependent upon others, gullible, and perpetual followers. On the other hand, they may also fight these urges and develop pessimism and aggression toward others.

Anal Stage (18 months to three years). The child’s focus of pleasure in this stage is on eliminating and retaining feces. Through society’s pressure, mainly via parents, the child has to learn to control anal stimulation. In terms of personality, after effects of an anal fixation during this stage can result in an obsession with cleanliness, perfection, and control (anal retentive). On the opposite end of the spectrum, they may become messy and disorganized (anal expulsive).

Phallic Stage (ages three to six). The pleasure zone switches to the genitals. Freud believed that during this stage boy develop unconscious sexual desires for their mother. Because of this, he becomes rivals with his father and sees him as competition for the mother’s affection. During this time, boys also develop a fear that their father will punish them for these feelings, such as by
57

castrating them. This group of feelings is known as Oedipus Complex ( after the Greek Mythology figure who accidentally killed his father and married his mother). Later it was added that girls go through a similar situation, developing unconscious sexual attraction to their father. Although Freud Strongly disagreed with this, it has been termed the Electra Complex by more recent psychoanalysts. According to Freud, out of fear of castration and due to the strong competition of his father, boys eventually decide to identify with him rather than fight him. By identifying with his father, the boy develops masculine characteristics and identifies himself as a male, and represses his sexual feelings toward his mother. A fixation at this stage could result in sexual deviancies (both overindulging and avoidance) and weak or confused sexual identity according to psychoanalysts.

Latency Stage (age six to puberty). It’s during this stage that sexual urges remain repressed and children interact and play mostly with same sex peers.

Genital Stage (puberty on). The final stage of psychosexual development begins at the start of puberty when sexual urges are once again awakened. Through the lessons learned during the previous stages, adolescents direct their sexual urges onto opposite sex peers, with the primary focus of pleasure is the genitals.

b. Freud's Structural and Topographical Models of Personality Sigmund Freud's Theory is quite complex and although his writings on psychosexual development set the groundwork for how our personalities developed, it was only one of five parts to his overall theory of personality. He also believed that different driving forces develop during these stages which play an important role in how we interact with the world.

58

Structural Model (id, ego, superego) According to Freud, we are born with our Id. The id is an important part of our personality because as newborns, it allows us to get our basic needs met. Freud believed that the id is based on our pleasure principle. In other words, the id wants whatever feels good at the time, with no consideration for the reality of the situation. When a child is hungry, the id wants food, and therefore the child cries. When the child needs to be changed, the id cries. When the child is uncomfortable, in pain, too hot, too cold, or just wants attention, the id speaks up until his or her needs are met. The id doesn't care about reality, about the needs of anyone else, only its own satisfaction. If you think about it, babies are not real considerate of their parents' wishes. They have no care for time, whether their parents are sleeping, relaxing, eating dinner, or bathing. When the id wants something, nothing else is important. Within the next three years, as the child interacts more and more with the world, the second part of the personality begins to develop. Freud called this part the Ego. The ego is based on the reality principle. The ego understands that other people have needs and desires and that sometimes being impulsive or selfish can hurt us in the long run. Its the ego's job to meet the needs of the id, while taking into consideration the reality of the situation. By the age of five, or the end of the phallic stage of development, the Superego develops. The Superego is the moral part of us and develops due to the moral and ethical restraints placed on us by our caregivers. Many equate the superego with the conscience as it dictates our belief of right and wrong. In a healthy person, according to Freud, the ego is the strongest so that it can satisfy the needs of the id, not upset the superego, and still take into consideration the reality of every situation. Not an easy job by any means, but if the id gets too strong, impulses and self gratification take over the person's life. If the superego becomes to strong, the person would be driven by rigid morals, would be judgmental and unbending in his or her interactions with the world. You'll learn how the ego maintains control as you continue to read.

59

c. Topographical Model Freud believed that the majority of what we experience in our lives, the underlying emotions, beliefs, feelings, and impulses are not available to us at a conscious level. He believed that most of what drives us is buried in our unconscious. If you remember the Oedipus and Electra Complex, they were both pushed down into the unconscious, out of our awareness due to the extreme anxiety they caused. While buried there, however, they continue to impact us dramatically according to Freud. The role of the unconscious is only one part of the model. Freud also believed that everything we are aware of is stored in our conscious. Our conscious makes up a very small part of who we are. In other words, at any given time, we are only aware of a very small part of what makes up our personality; most of what we are is buried and inaccessible. The final part is the preconscious or subconscious. This is the part of us that we can access if prompted, but is not in our active conscious. Its right below the surface, but still buried somewhat unless we search for it. Information such as our telephone number, some childhood memories, or the name of your best childhood friend is stored in the preconscious. Because the unconscious is so large, and because we are only aware of the very small conscious at any given time, this theory has been likened to an iceberg, where the vast majority is buried beneath the water's surface. The water, by the way, would represent everything that we are not aware of, have not experienced, and that has not been integrated into our personalities, referred to as the nonconscious.

60

d. Ego Defense Mechanisms

We stated earlier that the ego's job was to satisfy the id's impulses, not offend the moralistic character of the superego, while still taking into consideration the reality of the situation. We also stated that this was not an easy job. Think of the id as the 'devil on your shoulder' and the superego as the 'angel of your shoulder.' We don't want either one to get too strong so we talk to both of them, hear their perspective and then make a decision. This decision is the ego talking, the one looking for that healthy balance. Before we can talk more about this, we need to understand what drives the id, ego, and superego. According to Freud, we only have two drives; sex and aggression. In other words, everything we do is motivated by one of these two drives. Sex, also called Eros or the Life force, represents our drive to live, prosper, and produce offspring. Aggression, also called Thanatos or our Death force, represents our need to stay alive and stave off threats to our existence, our power, and our prosperity. Now the ego has a difficult time satisfying both the id and the superego, but it doesn't have to do so without help. The ego has some tools it can use in its job as the mediator, tools that help defend the ego. These are called Ego Defense Mechanisms or Defenses. When the ego has a difficult time making both the id and the superego happy, it will employ one or more of these defenses:

DEFENSE

DESCRIPTION
61

EXAMPLE

denial

arguing anxiety

against

an denying

that

your

physician's

provoking diagnosis of cancer is correct and seeking a second opinion

stimuli by stating it doesn't exist displacement

taking out impulses on slamming a door instead of hitting as a less threatening person, yelling at your spouse after an argument with your boss focusing on the details of a funeral as opposed to the sadness and grief target

intellectualization

avoiding unacceptable emotions by focusing on the intellectual aspects

projection

placing

unacceptable

when losing an argument, you state "You're just Stupid;" homophobia

impulses in yourself onto someone else rationalization

supplying a logical or stating that you were fired because rational reason reason as you didn't kiss up the the boss, when real reason was your poor performance the opposite having a bias against a particular race race or culture to the extreme sitting in a corner and crying after hearing bad news; throwing a temper tantrum when you don't get your way opposed to the real the

reaction formation

taking

belief because the true or culture and then embracing that belief causes anxiety

regression

returning to a previous stage of development

repression

pulling

into

the forgetting sexual abuse from your childhood due to the trauma and anxiety

unconscious

sublimation

acting out unacceptable impulses in a socially acceptable way

sublimating your aggressive impulses toward a career as a boxer; becoming a surgeon because of your desire to cut; lifting weights to release 'pent up' energy

suppression

pushing

into

the trying to forget something that causes you anxiety

unconscious

62

Ego defenses are not necessarily unhealthy as you can see by the examples above. In face, the lack of these defenses, or the inability to use them effectively can often lead to problems in life. However, we sometimes employ the defenses at the wrong time or overuse them, which can be equally destructive.

2. Kohlberg’s Stages of Moral Development
Although it has been questioned as to whether it applied equally to different genders and different cultures, Kohlberg’s (1973) stages of moral development is the most widely cited. It breaks our development of morality into three levels, each of which is divided further into two stages:
63

Preconventional Level (up to age nine): ~Self Focused Morality~ 1. Morality is defined as obeying rules and avoiding negative consequences. Children in this stage see rules set, typically by parents, as defining moral law. 2. That which satisfies the child’s needs is seen as good and moral. Conventional Level (age nine to adolescence): ~Other Focused Morality~ 3. Children begin to understand what is expected of them by their parents, teacher, etc. Morality is seen as achieving these expectations. 4. Fulfilling obligations as well as following expectations are seen as moral law for children in this stage. Postconventional Level (adulthood): ~Higher Focused Morality~ 5. As adults, we begin to understand that people have different opinions about morality and that rules and laws vary from group to group and culture to culture. Morality is seen as upholding the values of your group or culture. 6. Understanding your own personal beliefs allow adults to judge themselves and others based upon higher levels of morality. In this stage what is right and wrong is based upon the circumstances surrounding an action. Basics of morality are the foundation with independent thought playing an important role.

Piaget’s Theory of Cognitive Development
Piaget's four stages

64

Sensorimotor period The Sensorimotor Stage is the first of the four stages of cognitive development. "In this stage, infants construct an understanding of the world by coordinating sensory experiences (such as seeing and hearing) with physical, motoric actions." "Infants gain knowledge of the world from the physical actions they perform on it." "An infant progresses from reflexive, instinctual action at birth to the beginning of symbolic thought toward the end of the stage." "Piaget divided the sensorimotor stage into six sub-stages" Sub-Stage Age Description "Coordination of sensation and action through reflexive

behaviors"[. Three primary reflexes are described by Piaget: 1 Simple Reflexes Birth-6 weeks sucking of objects in the mouth, following moving or interesting objects with the eyes, and closing of the hand when an object makes contact with the palm (palmar grasp). Over the first six weeks of life, these reflexes begin to become voluntary actions; for example, the palmar reflex becomes intentional grasping. "Coordination of sensation and two types of schemes: habits (reflex) and primary circular reactions (reproduction of an event 2 First habits and primary circular reactions phase 6 weeks4 months that initially occurred by chance). Main focus is still on the infant's body." As an example of this type of reaction, an infant might repeat the motion of passing their hand before their face. Also at this phase, passive reactions, caused by classical or operant conditioning, can begin 3 Secondary circular 4-8 reactions phase months Development of habits. "Infants become more object-oriented, moving beyond self-preoccupation; repeat actions that bring interesting or pleasurable results." This stage is associated primarily with the development of coordination between vision and prehension. Three new abilities occur at this stage: intentional grasping for a desired object, secondary circular reactions, and differentiations between ends and means. At this stage, infants will intentionally grasp the air in the direction of a desired object, often to the amusement of friends and family. Secondary circular reactions, or the repetition of an action involving an external object begin; for example, moving a switch to turn on a light repeatedly. The differentiation between means and ends also occurs. This is perhaps one of the most important stages of a

65

child's growth as it signifies the dawn of logic "Coordination of vision and touch--hand-eye coordination; coordination of schemes and intentionality." This stage is 4 Coordination of secondary circular reactions stage associated primarily with the development of logic and the 8-12 months coordination between means and ends. This is an extremely important stage of development, holding what Piaget calls the "first proper intelligence." Also, this stage marks the beginning of goal orientation, the deliberate planning of steps to meet an objective "Infants become intrigued by the many properties of objects and by the many things they can make happen to objects; they 5 Tertiary circular reactions, and curiosity novelty, 12-18 months experiment with new behavior." This stage is associated primarily with the discovery of new means to meet goals. Piaget describes the child at this juncture as the "young scientist," conducting pseudo-experiments to discover new methods of meeting challenges "Infants develop the ability to use primitive symbols and form 6 Internalization of 18-24 Schemes months enduring mental representations." This stage is associated primarily with the beginnings of insight, or true creativity. This marks the passage into the preoperational stage. "By the end of the sensorimotor period, objects are both separate from the self and permanent." "Object permanence is the understanding that objects continue to exist even when they cannot be seen, heard, or touched." "Acquiring the sense of object permanence is one of the infant's most important accomplishments, according to Piaget." Preoperational Period The Preoperational stage is the second of four stages of cognitive development. By observing sequences of play, Piaget was able to demonstrate that towards the end of the second year, a qualitatively new kind of psychological functioning occurs.

(Pre)Operatory Thought is any procedure for mentally acting on objects. The hallmark of the preoperational stage is sparse and logically inadequate mental operations. During this stage, the child learns to use and to represent objects by images, words, and drawings. The child is able to form stable concepts as well as mental reasoning and magical beliefs. The child however is still
66

not able to perform operations; tasks that the child can do mentally rather than physically. Thinking is still egocentric: The child has difficulty taking the viewpoint of others. Two substages can be formed from preoperational thought.

The Symbolic Function Substage Occurs between about the ages of 2 and 4. The child is able to formulate designs of objects that are not present. Other examples of mental abilities are language and pretend play. Although there is an advancement in progress, there are still limitations such as egocentrism and animism. Egocentrism occurs when a child is unable to distinguish between their own perspective and that of another person's. Children tend to pick their own view of what they see rather than the actual view shown to others. An example is an experiment performed by Piaget and Barbel Inhelder. Three views of a mountain are shown and the child is asked what a traveling doll would see at the various angles; the child picks their own view compared to the actual view of the doll. Animism is the belief that inanimate objects are capable of actions and have lifelike qualities. An example is a child believing that the sidewalk was mad and made them fall down.

The Intuitive Thought Substage Occurs between about the ages of 4 and 7. Children tend to become very curious and ask many questions; begin the use of primitive reasoning. There is an emergence in the interest of reasoning and wanting to know why things are the way they are. Piaget called it the intuitive substage because children realize they have a vast amount of knowledge but they are unaware of how they know it. Centration and conservation are both involved in preoperational thought. Centration is the act of focusing all attention on one characteristic compared to the others. Centration is noticed in conservation; the awareness that altering a substance's appearance does not change its basic properties. Children at this stage are unaware of conservation. They are unable to grasp the concept that a certain liquid can stay the same regardless of the container shape. In Piaget's most famous task, a child is represented with two identical beakers containing the same amount of liquid.] The child usually notes that the beakers have the same amount of liquid. When one of the beakers is poured into a taller and thinner container, children who are typically younger than 7 or 8 years old say that the two beakers now contain a different amount of liquid. The child simply focuses on the height and width of the container compared to the general concept. Piaget believes that if a child fails the conservation-of-liquid task, it is a sign that they are at the preoperational stage of cognitive development. The child also fails to show conservation of number, matter, length, volume, and area as well. Another example is when a child is shown 7 dogs and 3 cats and asked if there are more dogs than
67

cats. The child would respond positively. However when asked if there are more dogs than animals, the child would once again respond positively. Such fundamental errors in logic show the transition between intuitiveness in solving problems and true logical reasoning acquired in later years when the child grows up. Piaget considered that children primarily learn through imitation and play throughout these first two stages, as they build up symbolic images through internalized activity. Studies have been conducted among other countries to find out if Piaget's theory is universal. Psychologist Patricia Greenfield conducted a task similar to Piaget's beaker experiment in the West African nation of Senegal. Her results stated that only 50 percent of the 10-13 year olds understood the concept of conservation. Other cultures such as central Australia and New Guinea had similar results. If adults had not gained this concept, they would be unable to understand the point of view of another person. There may have been discrepencies in the communication between the experimenter and the children which may have altered the results. It has also been found that if conservation is not widely practiced in a particular country, the concept can be taught to the child and training can improve the child's understanding. Therefore, it is noted that there are different age differences in reaching the understanding of conservation based on the degree to which the culture teaches these tasks.

Concrete operational stage The Concrete operational stage is the third of four stages of cognitive development in Piaget's theory. This stage, which follows the Preoperational stage, occurs between the ages of 7 and 12 years and is characterized by the appropriate use of logic. Important processes during this stage are: Seriation—the ability to sort objects in an order according to size, shape, or any other characteristic. For example, if given different-shaded objects they may make a color gradient. Transitivity- The ability to recognize logical relationships among elements in a serial order, and perform 'transitive inferences' (for example, If A is taller than B, and B is taller than C, then A must be taller than C). Classification—the ability to name and identify sets of objects according to appearance, size or other characteristic, including the idea that one set of objects can include another.

68

Decentering—where the child takes into account multiple aspects of a problem to solve it. For example, the child will no longer perceive an exceptionally wide but short cup to contain less than a normally-wide, taller cup. Reversibility—the child understands that numbers or objects can be changed, then returned to their original state. For this reason, a child will be able to rapidly determine that if 4+4 equals t, t−4 will equal 4, the original quantity. Conservation—understanding that quantity, length or number of items is unrelated to the arrangement or appearance of the object or items. Elimination of Egocentrism—the ability to view things from another's perspective (even if they think incorrectly). For instance, show a child a comic in which Jane puts a doll under a box, leaves the room, and then Melissa moves the doll to a drawer, and Jane comes back. A child in the concrete operations stage will say that Jane will still think it's under the box even though the child knows it is in the drawer. Children in this stage can, however, only solve problems that apply to actual (concrete) objects or events, and not abstract concepts or hypothetical tasks.

Formal operational stage The formal operational period is the fourth and final of the periods of cognitive development in Piaget's theory. This stage, which follows the Concrete Operational stage, commences at around 11 years of age (puberty) and continues into adulthood. In this stage, individuals move beyond concrete experiences and begin to think abstractly, reason logically and draw conclusions from the information available, as well as apply all these processes to hypothetical situations. The abstract quality of the adolescent's thought at the formal operational level is evident in the adolescent's verbal problem solving ability. The logical quality of the adolescent's thought is when children are more likely to solve problems in a trial-and-error fashion. Adolescents begin to think more as a scientist thinks, devising plans to solve problems and systematically testing solutions. They use hypothetical-deductive reasoning, which means that they develop hypotheses or best gueses, and systematically deduce, or conclude, which is the best path to follow in solving the problem.[ During this stage the young adult is able to understand such things as love, "shades of gray", logical proofs and values. During this stage the young adult begins to entertain possibilities for the future and is fascinated with what they can be. Adolescents are changing cognitively also by the way that they think about social matters. Adolescent Egocentrism governs the way that adolescents think about social matters and is the
69

heightened self-consciousness in them as they are which is reflected in their sense of personal uniqueness and invincibility. Adolescent egocentrism can be dissected into two types of social thinking, imaginary audience that involves attention getting behavior, and personal fable which involves an adolescent's sense of personal uniqueness and invincibility.

Jung's Theory of Psychological Types and the MBTI® Instrument
"The purpose of the Myers-Briggs Type Indicator® is to make the theory of psychological types described by C. G. Jung (1921/1971) understandable and useful in people's lives. The essence of the theory is that much seemingly random variation in behavior is actually quite orderly and consistent, being due to basic differences in the way individuals prefer to use their perception and judgment."
70

Perception involves all the ways of becoming aware of things, people, happenings, or ideas. Judgment involves all the ways of coming to conclusions about what has been perceived. If people differ systematically in what they perceive and in how they reach conclusions, then it is only reasonable for them to differ correspondingly in their interests, reactions, values, motivations, and skills. The MBTI instrument is based on Jung's ideas about perception and judgment, and the attitudes in which these are used in different types of people. The aim of the MBTI instrument is to identify, from self self-report of easily recognized reactions, the basic preferences of people in regard to perception and judgment, so that the effects of each preference, singly and in combination, can be established by research and put into practical use. The MBTI instrument differs from many other personality instruments in these ways:

It is designed to implement a theory; therefore the theory must be understood to understand the MBTI instrument. The theory postulates dichotomies; therefore some of the psychometric properties are unusual. Based on the theory, there are specific dynamic relationships between the scales, which lead to the descriptions and characteristics of sixteen "types."

The MBTI instrument contains four separate indices. Each index reflects one of four basic preferences which, under Jung's theory, direct the use of perception and judgment. The preferences affect not only what people attend to in any given situation, but also how they draw conclusions about what they perceive. Extraversion–Introversion (E–I) The E–I index is designed to reflect whether a person is an extravert or an introvert in the sense intended by Jung. Jung regarded extraversion and introversion as "mutually complementary" attitudes whose differences "generate the tension that both the individual and society need for the maintenance of life." Extraverts are oriented primarily toward the outer world; thus they tend to focus their perception and judgment on people and objects. Introverts are oriented primarily toward the inner world; thus they tend to focus their perception and judgment upon concepts and ideas. Sensing–Intuition (S–N) The S–N index is designed to reflect a person's preference between two opposite ways of perceiving; one may rely primarily upon the process of sensing (S), which reports observable facts or happenings through one or more of the five senses; or one may rely upon the less
71

obvious process of intuition (N), which reports meanings, relationships and/or possibilities that have been worked out beyond the reach of the conscious mind. Thinking–Feeling (T–F) The T–F index is designed to reflect a person's preference between two contrasting ways of judgment. A person may rely primarily through thinking (T) to decide impersonally on the basis of logical consequences, or a person may rely primarily on feelings (F) to decide primarily on the basis of personal or social values. Judgment–Perception (J–P) The J–P index is designed to describe the process a person uses primarily in dealing with the outer world, that is, with the extraverted part of life. A person who prefers judgment (J) has reported a preference for using a judgment process (either thinking or feeling) for dealing with the outer world. A person who prefers perception (P) has reported a preference for using a perceptive process (either S or N) for dealing with the outer world. The Four Preferences of the MBTI instrument Index Preferences Between E–I E Extraversion or I Introversion Affects Choices as to Whether to direct perception judgment mainly on the outer world (E) or mainly on the inner world of ideas. Between S–N S Sensing perception or N Intuitive perception Affects Choices as to Which kind of perception is preferred when one needs or wishes to perceive Between T–F

72

T Thinking judgment or F Feeling judgment Affects Choices as to Which kind of judgment to trust when one needs or wishes to make a decision Between J–P J Judgment or P Perception Affects Choices as to Whether to deal with the outer world in judging (J) attitude (using T or F) or in the perceptive (P) attitude (using S or N) The Sixteen Types According to theory, by definition, one pole of each of the four preferences is preferred over the other pole for each of the sixteen MBTI types. The preferences on each index are independent of preferences for the other three indices, so that the four indices yield sixteen possible combinations called "types," denoted by the four letters of the preferences (e.g., ESTJ, INFP). The theory postulates specific dynamic relationships between the preferences. For each type, one process is the leading or dominant process and a second process serves as an auxiliary. Each type has its own pattern of dominant and auxiliary processes and the attitudes (E or I) in which these are habitually used. The characteristics of each type follow from the dynamic interplay of these processes and attitudes. Processes and attitudes Attitudes refer to extraversion (E) or introversion (I). Processes of perception are sensing (S) and intuition (N). Processes of judgment are thinking (T) and feeling (F). The style of dealing with the outside world is shown by judgment (J) or perception (P). In terms of the theory, people may reasonably be expected to develop greater skill with the processes they prefer to use and with the attitudes in which they prefer to use these processes. For example, if they prefer the extraverted attitude (E), they are likely to be more mature and effective in dealing with the world around them than with the inner world of concepts and ideas.
73

If they prefer the perceptive process of sensing (S), they are likely to be more effective in perceiving facts and realities than theories and possibilities, which are in the sphere of intuition. If they prefer the judgment process of thinking (T), they are likely to have better developed thinking judgments than feeling judgments. And if they prefer to use judgment (J) rather than perception (P) in their attitude to the world around them, they are likely to be better organizing the events of their lives than they are to experiencing and adapting to them. On the other hand, if a person prefers introversion, intuition, feeling, and the perceptive attitude (INFP), then the converse of the description above is likely to be true.

Peplau’s Theory of Theory of Interpersonal Relations

Identified four sequential phases in the interpersonal relationship: 1. 2. 3. Orientation Identification Exploitation
74

4. Orientation phase
• • • •

Resolution

Problem defining phase Starts when client meets nurse as stranger Defining problem and deciding type of service needed Client seeks assistance ,conveys needs ,asks questions, shares preconceptions and expectations of past experiences

Nurse responds, explains roles to client, helps to identify problems and to use available resources and services

Factors influencing orientation phase

Identification phase
• •

Selection of appropriate professional assistance Patient begins to have a feeling of belonging and a capability of dealing with the problem which decreases the feeling of helplessness and hopelessness

Exploitation phase
• • • • •

Use of professional assistance for problem solving alternatives Advantages of services are used is based on the needs and interests of the patients Individual feels as an integral part of the helping environment They may make minor requests or attention getting techniques The principles of interview techniques must be used in order to explore ,understand and adequately deal with the underlying problem

75

• • •

Patient may fluctuates on independence Nurse must be aware about the various phases of communication Nurse aids the patient in exploiting all avenues of help and progress is made towards the final step

Resolution phase
• • •

Termination of professional relationship The patients needs have already been met by the collaborative effect of patient and nurse Now they need to terminate their therapeutic relationship and dissolve the links between them. Sometimes may be difficult for both as psychological dependence persists Patient drifts away and breaks bond with nurse and healthier emotional balance is demonstrated and both becomes mature individuals

• •

Interpersonal theory and nursing process
• •

Both are sequential and focus on therapeutic relationship Both use problem solving techniques for the nurse and patient to collaborate on, with the end purpose of meeting the patients needs Both use observation communication and recording as basic tools utilized by nursing Assessment Data collection and analysis [continuous] May not be a felt need Nursing diagnosis Planning Mutually set goals Implementation Plans goals May be accomplished by patient , nurse or family Evaluation
76

Orientation Non continuous data collection Felt need Define needs Identification Interdependent goal setting

Exploitation initiated towards Patient actively seeking and drawing help Patient initiated

achievement of mutually set

Resolution

Based on mutually expected behaviors May led to termination and initiation of new plans Occurs after other phases are completed successfully Leads to termination

3. Carl Roger’s Humanistic Theory
The Person-Centered Approach While Maslow was more of a theorist, Carl Rogers was more of a therapist. His professional goal was more on helping people change and improve their lives. He was a true follower of humanistic ideation and is often considered the person who gave psychotherapy it's basic humanistic undertones.

77

Rogers believed in several key concepts that he believed must be present in order for healthy change to take place. His approach to treatment is called Client or Person-Centered-Therapy because it sees the individual, rather than the therapist or the treatment process as the center of effective change. These basic concepts include: 1. Unconditional Positive Regard: The therapist must believe that people are basically good and must demonstrate this belief to the client. Without unconditional positive regard, the client will not disclose certain information, could feel unworthy, and may hold onto negative aspects of the self. Accepting the client as innately worthwhile does not mean accepting all actions the client may exhibit. 2. Non-Judgmental Attitude: Along with seeing the person as worthy, the therapist should never pass judgment on the individual. Roger's believed that people are competent in seeing their mistakes and knowing what needs to change even if they may not initially admit it. He also believed that by judging a person, you are more likely to prevent disclosure. 3. Disclosure: Disclosure refers to the sharing of personal information. Unlike

Psychoanalysis and many other approaches to therapy, Roger's believed that in order for the client to disclose, the therapist must do the same. Research has shown that we share information at about the same level as the other person. Therefore, remaining secretive as a therapist, encourages the client to hold back important information. 4. Reflection: Rogers believed that the key to understanding the self was not interpretation, but rather reflection. By reflecting a person's words in a different manner, you can accomplish two things. First, it shows the client that you are paying attention, thinking about what he or she is saying, and also understanding the underlying thoughts and feelings. Second, it allows the client to hear their own thoughts in a different way. Many people have said that their beliefs become more real once they are presented back to them by someone else.

By following these concepts, therapy becomes a self-exploration where the therapist is the guide rather than the director. The client, according to Rogers, has the answers and the direction. It is the therapist's job to help them find it.

78

4. Alfred’s Adler’s Theory Of Personality
Inferiority According to Adler's theory, each of us is born into the world with a sense of inferiority. We start as a weak and helpless child and strive to overcome these deficiencies by become superior to those around us. He called this struggle a striving for superiority, and like Freud's Eros and Thanatos, he saw this as the driving force behind all human thoughts, emotions, and behaviors. For those of us who strive to be accomplished writers, powerful business people, or influential politicians, it is because of our feelings of inferiority and a strong need to over come this
79

negative part of us according to Adler. This excessive feeling of inferiority can also have the opposite effect. As it becomes overwhelming and without the needed successes, we can develop an inferiority complex. This belief leaves us with feeling incredibly less important and deserving than others, helpless, hopeless, and unmotivated to strive for the superiority that would make us complete.

Parenting and Birth Order Parenting Styles. Adler did agree with Freud on some major issues relating to the parenting of children and the long term effects of improper or inefficient child rearing. He identified two parental styles that he argued will cause almost certain problems in adulthood. The first was pampering, referring to a parent overprotecting a child, giving him too much attention, and sheltering him from the negative realities of life. As this child grows older, he will be ill equipped to deal with these realities, may doubt his own abilities or decision making skills, and may seek out others to replace the safety he once enjoyed as a child. On the other extreme is what Adler called neglect. A neglected child is one who is not protected at all from the world and is forced to face life's struggles alone. This child may grow up to fear the world, have a strong sense of mistrust for others and she may have a difficult time forming intimate relationships. The best approach, according to this theory, is to protect children form the evils of the world but not shelter them from it. In more practical terms, it means allowing them to hear or see the negative aspects of the world while still feeling the safety of parental influence. In other words, don't immediately go to the school principal if your child is getting bullied, but rather teach your child how to respond or take care of herself at school. Birth Order. Simply put, Adler believed that the order in which you are born to a family inherently effects your personality. First born children who later have younger siblings may have it the worst. These children are given excessive attention and pampering by their parents until that fateful day when the little brother or sister arrives. Suddenly they are no longer the center of attention and fall into the shadows wondering why everything changed. According to Adler, they are left feeling inferior, questioning their importance in the family, and trying desperately to gain back the attention they suddenly lost. The birth order theory holds that first born children often have the greatest number of problems as they get older.

80

Middle born children may have it the easiest, and interestingly, Adler was a middle born child. These children are not pampered as their older sibling was, but are still afforded the attention. As a middle child, they have the luxury of trying to dethrone the oldest child and become more superior while at the same time knowing that they hold this same power over their younger siblings. Adler believed that middle children have a high need for superiority and are often able to seek it out such as through healthy competition. The youngest children, like the first born, may be more likely to experience personality problems later in life. This is the child who grows up knowing that he has the least amount of power in the whole family. He sees his older siblings having more freedom and more superiority. He also gets pampered and protected more than any other child did. This could leave him with a sense that he can not take on the world alone and will always be inferior to others. Adler stressed a positive view of human nature. He believed that individuals can control their fate. They can do this in part by trying to help others (social interest). How they do this can be understood through analyzing their lifestyle. Early interactions with family members, peers, and teachers help to determine the role of inferiority and superiority in their lives. View of Human Nature A Person’s Perceptions are based on His or Her View of Reality (Phenomenology) – – Adler believed that we “construct” our reality according to our own way of looking at the world. “I am convinced that a person’s behavior springs from this idea…because our senses do not see the world, we apprehend it.” (Adler, 1933/1964) Each person must be viewed as an individual from a holistic perspective. – Adler suggested that dividing the person up into parts or forces (i.e., id, ego, and superego) was counterproductive because it was mechanistic and missed the individual essence of each person. – In his view, understanding the whole person is different than understanding different aspects of his life or personality. Human Behavior is Goal Oriented (Teleological) – People move toward self-selected goals. “The life of the human soul is not a ‘being’ but a ‘becoming.’” (Adler, 1963a)

81

This idea requires a very different way of viewing humans than the idea that behavior is “caused” by some internal or external forces or rewards and punishments.

Understanding the causes of behavior is not as important as understanding the goal to which a person is directed. Since we have evolved as social creatures, the most common goal is to belong.

Determinism – – Moving through life, the individual is confronted with alternatives. Human beings are creative, choosing, self-determined decision-makers free to chose the goals they want to pursue. View of Human Nature Conscious and unconscious are both in the service of the individual, who uses them to further personal goals (Adler, 1963a) Striving for superiority to overcome basic inferiority is a normal part of life. – Mosak(2000) reports that Adler and others have referred to this central human striving in a number of ways: completion, perfection, superiority, self-realization, self-actualization, competence, and mastery. Social Interest and a Positive involvement in the community are hallmarks of a healthy personality. – – All behavior occurs in a social context. Humans are born into an environment with which they must engage in reciprocal relations. Adler believed that social interest was innate but that it needed to be nurtured in a family where cooperation and trust were important values. Adlerian Core Concepts and Explanation of Behavior Style of life or Lifestyle – A way of seeking to fulfill particular goals that individuals set in their lives. Individuals use their own patterns of beliefs, cognitive styles, and behaviors as a way of expressing their style of life. Often style of life or lifestyle is a means for overcoming feeling of inferiority.

82

Four areas of lifestyle: 1. The self-concept the convictions about who I am. 2. The self-ideal convictions about what I should be. 3. The Weltbild, or “picture of the world” convictions about the not-self and what the world demands of me. 4. The ethical convictions The personal “right-wrong” code. Adlerian (Theory of Personality) Family Constellation and Atmosphere: – – The number and birth order, as well as the personality characteristics of members of a family. Important in determining lifestyle. The family and reciprocal relationships with siblings and parents determine how a person finds a place in the family and what he learns about finding a place in the world. – Adlerian Theory of Personality explanation of Behavior

Social Interest: – The caring and concern for the welfare of others that can serve to guide people's behavior throughout their lives. It is a sense of being a part of society and taking responsibility to improve it. Superiority – The drive to become superior allows individuals to become skilled, competent, and creative.
83

Superiority Complex: – a means of masking feelings of inferiority by displaying boastful, self-centered, or arrogant superiority in order to overcome feelings of inferiority. Inferiority: – Feelings of inadequacy and incompetence that develop during infancy and serve as the basis to strive for superiority in order to overcome feelings of inferiority. Inferiority complex: – A strong and pervasive belief that one is not as good as other people. It is usually an exaggerated sense of feelings of inadequacy and insecurity that may result in being defensive or anxious. Adlerian explanation of Behavior Birth order: – The idea that place in the family constellation (such as being the youngest child) can have an impact on one's later personality and functioning. Early recollections: – Memories of actual incidents that clients recall from their childhood. Adlerians use this information to make inferences about current behavior of children or adults. Basic mistakes: – Self-defeating aspects of individuals' lifestyle that may affect their later behavior are called basic mistakes. Such mistakes often include avoidance of others, seeking power, a desperate need for security, or faulty values. Assets: – Assessing the strengths of individuals' lifestyle is an important part of lifestyle assessment, as is assessment or early recollections and basic mistakes.

TECHNIQUES FOR CHANGE
84

A lifestyle analysis helps the Adlerian therapist to gain insights into client problems by determining the clients' basic mistakes and assets. These insights are based on assessing family constellation, dreams, and social interest. To help the client change, Adlerians may use a number of active techniques that focus to a great extent on changing beliefs and reorienting the client's view of situations and relationships.

Life tasks: – There are five basic obligations and opportunities: occupation, society, love, self development, and spiritual development. These are used to help determine therapeutic goals. Interpretation: – Adlerians express insights to their clients that relate to clients' goals. Interpretations often focus on the family constellation and social interest. Immediacy: – Communicating the experience of the therapist to the client about what is happening in the moment. Encouragement: – An important therapeutic technique that is used to build a relationship and to foster client change. Supporting clients in changing beliefs and behaviors is a part of encouragement. Acting as if: – In this technique, clients are asked to "act as if" a behavior will be effective. Clients are encouraged to try a new role, the way they might try on new clothing. Catching oneself: – In this technique, patients learn to notice that they are performing behaviors which they wish to change,. When they catch themselves, they may have an "Aha" response. Aha response:

85

Developing a sudden insight into a solution to a problem, as one becomes aware to one's beliefs and behaviors.

Avoiding the tar baby: – By not falling into a trap that the client sets by using faulty assumptions, the therapist encourages new behavior and "avoids the tar baby" (getting stuck in the client's perception of the problem). The Question: – – Asking "what would be different if you were well?" was a means Adler used to determine if a person's problem was physiological or psychological TECHNIQUES FOR CHANGE

Paradoxical intention: – A therapeutic strategy in which clients are instructed to engage and exaggerate behaviors that they seek to change. By prescribing the symptom, therapists make clients more aware of their situation and help them seek to change. By prescribing the symptom, therapists make clients more aware of their situation and help them achieve distance from the symptoms. For example, a client who is afraid of mice may be asked to exaggerate his fear of mice, or a client who hoards paper may be asked to exaggerate that behavior so that living becomes difficult. In this way individuals can become more aware of and more resistant from their symptoms.

Spitting in the client's soup: – Making comments to the client to make behaviors less attractive or desirable.

Homework: – Specific behaviors or activities that clients are asked to do after a therapy session

Push-button technique: – Designed to show patients how they can create whatever feelings they what by thinking about them, the push-button technique asks clients to remember a pleasant incident that they have experienced, become aware of feelings connected
86

to it, and then switch to an unpleasant image and those feelings. Thus clients learn that they have the power to change their own feelings.

5. Karen Horney's Feminine Theory and Theory of Neurosis

Feminine Psychology Perhaps the most important contribution Karen Horney made to psychodynamic thought was her disagreements with Freud's view of women. Horney was never a student of Freud, but did study his work and eventually taught psychoanalysis at both the Berlin and New York Psychoanalytic Institute. After her insistence that Freud's view of the inherent difference between males and females, she agreed to leave the institute and form her own school known as the American Institute for Psychoanalysis.
87

In many ways, Horney was well ahead of her time and although she died before the feminist movement took hold, she was perhaps the theorist who changed the way psychology looked at gender differences. She countered Freud's concept of penis envy with what she called womb envy, or man's envy of woman's ability to bear children. She argued that men compensate for this inability by striving for achievement and success in other realms. She also disagreed with Freud's belief that males and females were born with inherent differences in their personality. Rather than citing biological differences, she argued for a societal and cultural explanation. In her view, men and women were equal outside of the cultural restrictions often placed on being female. These views, while not well accepted at the time, were used years after her death to help promote gender equality.

Neurosis and Relationships Horney was also known for her study of neurotic personality. She defined neurosis as a maladaptive and counterproductive way of dealing with relationships. These people are unhappy and desperately seek out relationships in order to feel good abut themselves. Their way of securing these relationships include projections of their own insecurity and neediness which eventually drives others away. Most of us have come in contact with people who seem to successfully irritate or frighten people away with their clinginess, significant lack of self esteem, and even anger and threatening behavior. According to Horney, these individuals adapted this personality style through a childhood filled with anxiety. And while this way of dealing with others may have been beneficial in their youth, as adults it serves to almost guarantee their needs will not be met. She identified three ways of dealing with the world that are formed by an upbringing in a neurotic family: Moving Toward People, Moving Against People, and Moving Away From People.

Moving Toward People. Some children who feel a great deal of anxiety and helplessness move toward people in order to seek help and acceptance. They are striving to feel worthy and can believe the only way to gain this is through the acceptance of others. These people have an intense need to be liked, involved, important, and appreciated. So much so, that they will often fall in love quickly or feel an artificial but very strong attachment to people they may not know
88

well. Their attempts to make that person love them creates a clinginess and neediness that much more often than not results in the other person leaving the relationship.

Moving Against People. Another way to deal with insecurities and anxiety is to try to force your power onto others in hopes of feeling good about yourself. Those with this personality style come across as bossy, demanding, selfish, and even cruel. Horney argued that these people project their own hostilities (which she called externalization) onto others and therefore use this as a justification to 'get them before they get me.' Once again, relationships appear doomed from the beginning. Moving Away From People. The final possible consequence of a neurotic household is a personality style filled with asocial behavior and an almost indifference to others. If they don't get involved with others, they can't be hurt by them. While it protects them from emotional pain of relationships, it also keeps away all positive aspects of relationships. It leaves them feeling alone and empty.

6. Sullivan’s Interpersonal theory
Sam I am, good or bad Harry Stack-Sullivan was trained in psychoanalysis in the United States, but soon drifted from the specific psychoanalytic beliefs while retaining much of the core concepts of Freud. Interestingly, Sullivan placed a lot of focus on both the social aspects of personality and cognitive representations. This moved him away from Freud's psychosexual development and toward a more eclectic approach. Freud believed that anxiety was an important aspect in his theory because it represented internal conflict between the id and the superego. Sullivan, however, saw anxiety as existing only as a result of social interactions. He described techniques, much like defense mechanisms, that provide tools for people to use in order to reduce social anxiety. Selective Inattention is one such mechanism.
89

According to Sullivan, mothers show their anxiety about child rearing to their children through various means. The child, having no way to deal with this, feels the anxiety himself. Selective inattention is soon learned, and the child begins to ignore or reject the anxiety or any interaction that could produce these uncomfortable feelings. As adults, we use this technique to focus our minds away from stressful situations.

Personifications Through social interactions and our selective attention or inattention, we develop what Sullivan called Personifications of ourselves and others. While defenses can often help reduce anxiety, they can also lead to a misperception of reality. Again, he shifts his focus away from Freud and more toward a cognitive approach to understanding personality. These personifications are mental images that allow us to better understand ourselves and the world. There are three basic ways we see ourselves that Sullivan called the bad-me, the goodme and the not-me. The bad me represents those aspects of the self that are considered negative and are therefore hidden from others and possibly even the self. The anxiety that we feel is often a result of recognition of the bad part of ourselves, such as when we recall an embarrassing moment or experience guilt from a past action. The good me is everything we like about ourselves. It represents the part of us we share with others and that we often choose to focus on because it produces no anxiety. The final part of us, called the not-me, represents all those things that are so anxiety provoking that we can not even consider them a part of us. Doing so would definitely create anxiety which we spend our lives trying to avoid. The not-me is kept out of awareness by pushing it deep into the unconscious.

Developmental Epochs Another similarity between Sullivan's theory and that of Freud's is the belief that childhood experiences determine, to a large degree, the adult personality. And, throughout our childhood, the mother plays the most significant role. Unlike Freud, however, he also believed that personality can develop past adolescence and even well into adulthood. He called the stages in his developmental theory Epochs. He believed that we pass through these stages in a particular order but the timing of such is dictated by our social environment. Much of the focus in Sullivan's theory revolved around the conflicts of adolescence. As you can see from the chart
90

below, three stages were devoted to this period of development and much of the problems of adulthood, according to Sullivan, arise from the turmoil of our adolescence.

Sullivan's Developmental Epochs Infancy From birth to about age one, the child begins the process of near the importance as Freud. Childhood Ages 1 to 5 Juvenile Ages 6 to 8 Preadolescence Ages 9 to 12 The development of speech and improved communication is key in this stage of development. The main focus as a juvenile is the need for playmates and the beginning of healthy socialization During this stage, the child's ability to form a close relationship with a peer is the major focus. This relationship will later assist the child in feeling worthy and likable. Without this ability, forming the intimate relationships in late adolescence and adulthood will be difficult.
91

Age birth to 1 year developing, but Sullivan did not emphasize the younger years to

Early Adolescence Ages 13 to 17

The onset of puberty changes this need for friendship to a need for sexual expression. Self worth will often become synonymous with sexual attractiveness and acceptance by opposite sex peers.

Late Adolescence The need for friendship and need for sexual expression get Ages 18 to 22 or combined during late adolescence. In this stage a long term 23 relationship becomes the primary focus. Conflicts between parental control and self-expression are commonplace and the overuse of selective inattention in previous stages can result in a skewed perception of the self and the world. Adulthood Ages 23 on The struggles of adulthood include financial security, career, and family. With success during previous stages, especially those in the adolescent years, adult relationships and much needed socialization become more easy to attain. commonplace. Without a solid background, interpersonal conflicts that result in anxiety become more

7. Maslow’s Humanistic Theory
King of the Mountain Perhaps the most well known contribution to humanistic psychology was introduced by Abraham Maslow. Maslow originally studied psychology because of his intrigue with behavioral theory and the writings of John B. Watson. Maslow grew up Jewish in a non-Jewish neighborhood. He spent much of his childhood alone and reported that books were often his best friends. Despite this somewhat lonely childhood, he maintained his belief in the goodness of mankind. After the birth of his first child, his devotion to Watson's beliefs began a drastic decline. He was struck with the sense that he was not nearly in control as much as Watson and other behaviorists believed. He saw more to human life than just external reinforcement and argued that human's could not possibly be born without any direction or worth. At the time when he was studying psychology, behaviorism and psychoanalysis were considered the big two. Most courses studies these theories and much time was spent determining which theory one would follow. Maslow was on a different path.
92

He criticized behaviorism and later took the same approach with Freud and his writings. While he acknowledged the presence of the unconscious, he disagreed with Freud's belief that the vast majority of who we are is buried deep beyond our awareness. Maslow believed that we are aware of our motives and drives for the most part and that without the obstacles of life, we would all become psychologically healthy individuals with a deep understanding of ourselves and an acceptance of the world around us. Where Freud saw much negativity, Maslow focused his efforts on understanding the positives of mankind. It could be said that psychoanalytic thought is based on determinism, or aspects beyond our control, and humanistic thought is based on free will. Maslow's most well known contribution is the Hierarchy of Needs and this is often used to summarize the belief system of humanistic psychology. The basic premise behind this hierarchy is that we are born with certain needs. Without meeting these initial needs, we will not be able to continue our life and move upward on hierarchy. This first level consists of our physiological needs, or our basic needs for survival. Without food, water, sleep, and oxygen, nothing else in life matters.

Once these needs are met, we can move to the next level, which consists of our need for safety
93

and security. At this level we look seek out safety through other people and strive to find a world that will protect us and keep us free from harm. Without these goals being met, it is extremely difficult to think about higher level needs and therefore we can not continue to grow. When we feel safe and secure in our world then we begin to seek out friendships in order to feel a sense of belonging. Maslow's third level, the need for belonging and love, focuses on our desire to be accepted, to fit in, and to feel like we have a place in the world. Getting these needs met propels us closer to the top of this pyramid and into the fourth level, called esteem needs. At this level we focus our energy on self-respect, respect from others, and feeling that we have made accomplishments on our life. We strive to move upward in careers, to gain knowledge about the world, and to work toward a sense of high self-worth. The final level in the hierarchy is called the need for self-actualization. According to Maslow, may people may be in this level but very few if anybody ever masters it. Self-actualization refers to a complete understanding of the self. To be self-actualized means to truly know who you are, where you belong in the greater society, and to feel like you have accomplished all that you have set out to accomplish. It means to no longer feel shame or guilt, or even hate, but to accept the world and see human nature as inherently good. Application to Real Life As you read through the section above, many likely tried to place themselves on one of the five levels of the pyramid. This may be an easy task for some, but many struggle with the ups and downs of life. For many of us, life is not that straight forward. We often have one foot in one level, the other foot in the next level, and are reaching at times trying to pull ourselves up while making sure we don't fall backward at other times. As we climb the pyramid, we often make headway but also notice that two steps forward can mean one step back. Sometimes it even feels like two steps forward means three steps back. The goal of mankind, however, is to keep an eye on the top of the pyramid and to climb as steadily as possible. We may stumble at times and we may leap forward at times. No matter how far we fall backward, however, the road back up is easier since we already know the way.

94

8. Glasser’s Control or Choice Theory
William Glasser, in his 'Control Theory' (later renamed to 'Choice Theory') detailed five needs that are quite close to Maslow's Hierarchy, but with some interesting twists. 1. Survival This is similar to Maslow's Physiological and Safety level. They are basic needs which are of little interest unless they are threatened. 2. Love and belonging This is the same as Maslow's Belonging need and recognises how important it is for us as a tribal species to be accepted by our peers. 3. Power or recognition This maps to some extent to Maslow's Esteem need, although the Power element focuses on our ability to achieve our goals (which is perhaps a lower-level control need). 4. Freedom

95

This is the ability to do what we want, to have free choice. It is connected with procedural justice where we seek fair play. 5. Fun An interesting ultimate goal. When all else is satisfied, we just (as Cyndi Lauper sang) 'want to have fun'. Relationships and our Habits:

Seven Caring Habits 1. Supporting 2. Encouraging 3. Listening 4. Accepting 5. Trusting 6. Respecting 7. Negotiating differences

Seven Deadly Habits 1. Criticizing 2. Blaming 3. Complaining 4. Nagging 5. Threatening 6. Punishing 7. Bribing, rewarding to control

The Ten Axioms of Choice Theory
A. B. C. D. E.

The only person whose behavior we can control is our own. All we can give another person is information All long-lasting psychological problems are relationship problems. The problem relationship is always part of our present life. What happened in the past has everything to do with what we are today,

but we can only satisfy our basic needs right now and plan to continue satisfying them in the future.
F.

We can only satisfy our needs by satisfying the pictures in our Quality All we do is behave. All behaviors are Total Behaviors and are made up of four components:

World.
G. H.

acting, thinking, feeling and physiology. All Total Behaviors are chosen, but we only have direct control over the acting and thinking components.
I.

We can only control our feeling and physiology indirectly through how we All Total Behavior is designated by verbs and named by the part that is the

choose to act and think.
J.

most recognizable.Whoops that's ELEVEN?? - Glasser couldn't count!

96

Fowler's Faith Stage Theory
James Fowler investigated and developed a stage theory for the development of religious faith. In practice, it is also applicable to other areas of general beliefs. Kirst-Ashman and Zastrow (2004) add a 'Primal or Undifferentiated' stage prior to stage 1. This includes Lacan's early stages and entry into the Symbolic Register. Level Stage 1 ~Ages 3-7 Name Intuitive-predictive Characteristics Egocentric, becoming aware of time. Forming images that will affect their later life. Aware of the stories and beliefs of the Stage 2 6-12 Mythical-literal local community. Using these to give sense to their experiences.

Extending faith beyond the family and Stage 3 12Synthetic-conventional using this as a vehicle for creating a sense of identity and values.

97

The sense of identity and outlook on Stage 4 early adult Individuative-reflective the world are differentiated and the person develops explicit systems of meaning. The person faces up to the paradoxes Stage 5 adult Conjunctive of experience and begins to develop universal ideas and becomes more oriented towards other people. The person becomes totally altruistic Stage 6 adult Universalizing and they feel an integral part of an allinclusive sense of being. This stage is rarely achieved.

C.

Biographical Data

Patient is J. He is 22 years old, single. He is a Filipino and a Roman Catholic. He is the eldest among 9 siblings. He lives at Sorsogon, Sorsogon. He was born on August 11, 1987 in Northern Samar. J is currently hospitalized at National Center for Mental Health (NCMH) since November 6, 2009.

98

D.

Nursing History

1. Chief Complaint
“Hindi ko po alam,”, as verbalized by the patient. “Mabuti naman.” , as verbalized by the patient.

As verbalized by the informant (patient’s mother): “nambabato ng bahay” “nananakit” “nagwawala” “tinadyakan ang lola”

2. History of present Illness

99

While working as a plastic bag vendor in a market 12 days prior to admission, the patient suddenly went home crying and anxious. He was restless, assaultive to his siblings when apprehended. He sleeps poorly. He hides under the table. J became non-functional at home.

3. Previous Illness
J suffered from common illnesses like colds, cough, fever and flu.

4. Past Personal History
J was previously admitted at a Hospital in Sorsogon because of his mental illness. He took up Grade 1 twice and repeated Grade 2 twice also. He is a former plastic bag vendor in a market in their province. He is disoriented with time, place and person. He has no special someone since birth. J is not sexually active. Eating gives him pleasure.

5. Family History
His mother is the most important person while he grows up. There is no concrete evidence of sexual abuse or physical abuse but then, the patient verbalized that he was put into “jail” by his mother, tied his hand, chained and was hit by a wood.

6. Social History
The patient belongs to a nuclear structured and patriarchal type of family. He is the eldest among 9 siblings. J reached Grade 2. He has worked as a plastic bag vendor in a market at their place.

100

CHAPTER II
Presentation, Interpretation
101

&
Analysis of Data
(Daily Account of Observed Behavior)
Psychiatric Nursing History and Mental Status Assessment

GENERAL

ADMISSION INFORMATION

102

Name: “J” Age/Gender: 22 y/o, Male Marital Status: Single

Racial and Ethnic Data: Filipino, Bisaya Number and Ages of Children/Siblings: 9 siblings Living Arrangements: Educational Attainment: unfinished Grade 2 Occupation: none Religious Affiliations: Roman Catholic

CONDITIONS OF ADMISSION

Voluntary: __________

Involuntary:

Accompanied to Facility by (Family Friend Police Other): mother Route of Admission (ambulatory, wheelchair, stretcher): ambulatory Admitted from: (home, other facility, street, place of destination): home

I.

PRESENTING PROBLEM A. Statement in the client’s own words of why he or she is hospitalized or seeking help According to the Patient: “mabuti naman” According to the Informant: “nambabato ng bahay” “nananakit” “nagwawala” “tinadyakan ang lola” B. Recent difficulties/alterations in 1. Relationships 2. Usual level of functioning 3. Behavior 4. Perceptions or cognitive abilities C. Increased feelings of 1. Depression 2. Anxiety 3. Hopelessness 4. Being overwhelmed 5. Suspicious 103

6. Confusion D. Somatic changes, such as 1. Constipation 2. Insomnia 3. Lethargy 4. Weight loss or gain 5. Palpitations II. RELEVANT HISTORY – PERSONAL: A. Previous hospitalizations and illness: Provincial Hospital in Sorsogon/mental illness B. Educational background : Grade 1 (2x), Grade 2 (2x) C. Occupational background : former plastic bag vendor 1. if employed, where? : in a market at Sorsogon 2. How long at the job? ___________________________________________ 3. Previous positions and reasons for leaving __________________________ 4. Special skills _________________________________________________ D. Social patterns 1. Describe friends : disoriented with fellow patients 2. Describe a usual day __________________________________________ E. Sexual patterns 1. Sexually active? : not 2. Sexual orientation ___________________________________ 3. Sexual difficulties ___________________________________ 4. Practice safe sex or birth control ________________________ F. Interest and abilities 1. What does the client do in his or her spare time: sleep, rest 2. What is the client good at? ______________________________________ 3. What gives the client pleasure? : eating G. Substance use and abuse 1. What medication does the client take? : haloperidol How often: once a day, at night How much? : 10mg 2. Any herbal or-the-counter medicati ons?__________________________ How often? ________________ How much? __________________ 3. What psychotropic drugs does the client take? ____________________ How often? _______________ How much? ___________________ 4. How many drinks of a alcohol does the client take? _______________ per day? ___________ Per week? _________________ 5. Does the client identify use of drugs as a problem? _______________ H. How does the client cope with stress? ___________________________ 1. What does the client do when he or she gets upset? ________________ _________________________________________________________ 2. Whom can the client talk to? __________________________________ 3. What usually helps to relieve stress? ____________________________ 4. What did the client try this time? _______________________________ III. RELEVANT HISTORY – FAMILY A. Childhood 1. Who was important to the client growing up? mother 2. Was there physical or sexual abuse? ________________________________ 3. Did the parents drink or use drugs? _________________________________ 4. Who was in the home when the client was growing up? Mother, father B. Adolescence 1. How would be client describe his or her feelings in adolescence? ___________ _______________________________________________________________ 104

2. Describe the client’s peer group at the time. ___________________________ C. Use of drugs 1. Was there use or abuse of drugs by any family member? _________________ Prescription _________________ Street __________ By whom? _________ 2. What was effect on the family? ______________________________________ D. Family physical or mental problems 1. Is there any family history of violence or physical/sexual abuse? ______________ 2. Who in the family had physical or mental problems? _______________________ 3. Describe the problem ________________________________________________ 4. How did it affect the family? __________________________________________ E. Was there an unusual or outstanding event the client would like to mention ________ ____________________________________________________________________

IV.

SPIRITUAL ASSESSMENT A. What importance does religion or spirituality have in your life? _______________ __________________________________________________________________ B. Do your religious or spiritual beliefs influence the way you take care of yourself or your illness? How? __________________________________________________ C. Who or what supplies you with hope? ___________________________________

V.

CULTURAL INFLUENCES a. With what cultural group do you identify? Bisaya a. Have you tried any cultural remedies or practices for your condition? If so, what? ________________________________________________________________ a. Do you use any alternative or complimentary medicines/herbs/practices? _______________________________________________________________

/- observed X- not observed

MENTAL STATUS EXAMINATION General Appearance 1 Facial Expression Animated Fixed or Immobile Sad or Depressed
105

Day 2 3 4 5

x / x

x / x

x / x

x / x

/ x x

Angry Pale Reddened Posture Slouched Stooped Upright (erect) Stiff Gait Smooth Rhythmic Shuffling Staggering Dress Appropriately Dressed Inappropriately Dressed Pressed Wrinkled Grooming Well Groomed Unkempt Hygiene Clean Untidy Odor (Body / Breath) None Alcohol Acetone Pungent Cigarette Smoke Foul Smelling

x / x

x / x

x / x

x / x

x / x

/ / x /

/ / x /

/ / x x

/ / x /

/ / x x

/ x x

/ x x

/ x x

/ x x

/ x x

/ x / x

/ x / x

/ x / x

/ x / x

/ x / x

/ x

/ x

/ x

/ x

/ x

/ x

/ x

/ x

/ x

/ x

/ x x x x x

/ x x x x x

/ x x x x x

/ x x x x x

/ x x x x x

106

Physical Deformity: (specify)_____________________ Eye Contact Maintains Good Eye Contact Poor Eye Contact (Lacks Eye Contact) Eye Cast (Client squints his eyes, pupils dilated) x / x / x x / x x / x x / x x

The patient has a fixed facial expression. He is 5’4” and weighs 56 kg. He has a stooped posture. J has smooth rhythmic gait. He is appropriately dressed and well groomed. He is clean. He has no body or breath odor. There is a scar on both patella and on both wrists. Eye contact was established.

MOTOR BEHAVIOR Gestures, stereotyped behavior, pacing, any purposeless activity should be described. 1 2 3

Day 4 5

Purposeful and Coordinated Movement Catatonia Echopraxia Tics Spasm Compulsive Waxy Flexibility Parkinson-like symptoms Akathisia Dyskinesia Apraxia Catatonic Stupor Catatonic Excitement Hyperkinesia

x x x x x x / x x x x x x x

x x x x x x / x x x x x x x

x x x x x x / x x x x x x x

x x x x x x / x x x x x x x

x x x x x x / x x x x x x x

107

Catalepsy Cataplexy

x x

x x

x x

x x

x x

The patient at times has a waxy flexibility.

Speech How the client is communicating, rather than what the client is telling you. Rate, volume, modulation and flow Rate Rapid Slow Volume Loud Soft/mumbled Quantity Paucity Muteness Voluminous Quality Articulate Congruent Spontaneous Monotonous Talkative Repetitious Pressured Speech x x x / x / x x x x / x / x x x x / x / x / x x / x x / x x x / x / x / / x / x / x 1 2 3

Day 4 5

/ x

/ x

x /

x /

/ x x

/ x x

x x x / x / x

x x x / x / x

J has somnolence. There is clouding and stupor. He is disoriented to time, place and person. He is unrespondent to some querries. He has a difficulty to recall personal information and is often confused.

108

Perceptions Process by which physical stimuli are brought to mental awareness 1 2

Day 3 4 5

Hallucinations Auditory Visual Tactile Gustatory Olfactory Illusions Depersonalization Derealization x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

Patient has an auditory hallucination.

Thinking The waythe person functttions intellectually; the process or way of thinking or analysis of the world: the way of connecting or associating thoughts; the overall organization of thoughts. (1) Thought Content-What a client is thinking 1.1 Delusions a. Delusions of Grandeur b. Delusions of Reference c. Delusions of Persecution d. Religious Delusion e. Somatic Delusion f. Paranoid Delusion Phobia: Specify _________________________ 1 2

Day 3 4 5

x x x x

x x x x

x x x x

x x x x

x x x x

1.2

(2) Thought Process - How a person thinks a. Flight of Ideas .b Looseness of Association
109

/ /

/ /

/ /

/ /

/ /

.c Blocking .d Confabulation .e Tangetiality .f Neologism .g Circumstantiality .h Perserveration .i Confabulation .j Word Salad

/ / x x x / / /

/ / x x x / / /

/ / x x x / / /

/ / x x x / / /

/ / x x x / / /

Patient is mumbling to self. He has flight of ideas, looseness of association, blocking, and perseveration. He has faulty judgment and has a poor insight to his illness. Echolalia can be observed as well as mutism at times. Emotional State (Mood/Affect) Expression of emotion as seen by others;what examiner infers from patient’s facial expression/behavior 1 2 Day 3 4 5

Appropriate Inappropriate Flat

x / /

x / /

x / /

x / /

/ x x

Pleasurable Affect Euphoria Exaltation Ecstacy Unpleasurable Depression Anxiety Fear Agitation Ambivalence Aggression Mood Swings x / x x x x x x / x x x x x x / x x x x x x / x x x x x x / x x x x x x x x x x x x x x x x x x x x

110

Lability Panic Anger

x x x

x x x

x x x

x x x

x x x

Mood is ethylic and has an inappropriate affect which in most of the times is flat. He is anxious.

CHAPTER
111

3
DIAGNOSIS

E.
• • • •

Predisposing Factors

Prenatal Alcohol Syndrome Traumatic injury to the brain Intrauterine malnutrition Central Nervous System Malignancy

112

• •

fragile X syndrome Phenylketonuria (PKU)

F. Psychodynamics / Psychopathology
The mental retardation generally results from either of the two causes. The one is chromosomal abnormality and the second is deficiency of certain bio chemicals or neurotransmitters due to the lack of minerals required for that specific function and a third cause can be brain injuries. The DSM (Diagnostic and Statistical Manual) divides the retardation into four categories as mild MR, Moderate MR, severe MR, and profound MR. The level of mental retardation is usually determined with reference to the IQ (Intelligence Quotient) About 30% of cases of mental retardation are caused by hereditary factors. Mental retardation may be caused by an inherited genetic abnormality such as fragile X syndrome, Phenylketonuria (PKU), Down syndrome. etc. Fetal alcohol syndrome (FAS), drug exposure, hyperthyroidism are some of the other causes. Every mental activity involves a series of active involvement of the neurotransmitters, mental waves, and other complex processes in the nervous system. Insufficient physiological process in the nervous system results in the retarded mental functioning.

PKU (enzyme phenylalanine hydroxylase normally converts the amino acid phenylalanine into the amino acid tyrosine)

phenylalanine accumulates

113

tyrosine is deficient excessive phenylalanine metabolism of phenylketones transaminase pathway with glutamate Metabolites formed (phenylacetate, phenylpyruvate and phenethylamine) Saturation of blood-brain barrier (BBB) decreased levels of other large neutral amino acid (LNAAs) transporter in the brain decreased synthesis of proteins and neurotransmitters disrupts brain development mental retardation * Delays in oral language development * Deficits in memory skills * Difficulty learning social rules * Difficulty with problem solving skills * Delays in the development of adaptive behaviors such as self-help or self-care skills * Lack of social inhibitors

G.

Related Literature

DRUG REVERSES MENTAL RETARDATION CAUSED BY GENETIC DISORDER Published: Sunday, June 22, 2008 - 12:35 in Health & Medicine Source: University of California - Los Angeles
114

UCLA researchers discovered that an FDA-approved drug reverses the brain dysfunction inflicted by a genetic disease called tuberous sclerosis complex (TSC). Because half of TSC patients also suffer from autism, the findings offer new hope for addressing learning disorders due to autism. Nature Medicine publishes the findings in its online June 22 edition. Using a mouse model for TSC, the scientists tested rapamycin, a drug approved by the FDA to fight tissue rejection following organ transplants. Rapamycin is well-known for targeting an enzyme involved in making proteins needed for memory. The UCLA team chose it because the same enzyme is also regulated by TSC proteins. "This is the first study to demonstrate that the drug rapamycin can repair learning deficits related to a genetic mutation that causes autism in humans. The same mutation in animals produces learning disorders, which we were able to eliminate in adult mice," explained principal investigator Dr. Alcino Silva, professor of neurobiology and psychiatry at the David Geffen School of Medicine at UCLA. "Our work and other recent studies suggest that some forms of mental retardation can be reversed, even in the adult brain." "These findings challenge the theory that abnormal brain development is to blame for mental impairment in tuberous sclerosis," added first author Dan Ehninger, postgraduate researcher in neurobiology. "Our research shows that the disease's learning problems are caused by reversible changes in brain function -- not by permanent damage to the developing brain." TSC is a devastating genetic disorder that disrupts how the brain works, often causing severe mental retardation. Even in mild cases, learning disabilities and short-term memory problems are common. Half of all TSC patients also suffer from autism and epilepsy. The disorder strikes one in 6,000 people, making it twice as common as Huntington's or Lou Gehrig's disease. Silva and Ehninger studied mice bred with TSC and verified that the animals suffered from the same severe learning difficulties as human patients. Next, the UCLA team traced the source of the learning problems to biochemical changes sparking abnormal function of the hippocampus, a brain structure that plays a key role in memory. "Memory is as much about discarding trivial details as it is about storing useful information," said Silva, a member of the UCLA Department of Psychology and UCLA Brain Research Institute. "Our findings suggest that mice with the mutation cannot distinguish between important and unimportant data. We suspect that their brains are filled with meaningless noise that interferes with learning."
115

"After only three days of treatment, the TSC mice learned as quickly as the healthy mice," said Ehninger. "The rapamycin corrected the biochemistry, reversed the learning deficits and restored normal hippocampal function, allowing the mice's brains to store memories properly." In January, Silva presented his study at the National Institute of Neurological Disorders and Stroke meeting, where he was approached by Dr. Petrus de Vries, who studies TSC patients and leads rapamycin clinical trials at the University of Cambridge. After discussing their respective findings, the two researchers began collaborating on a clinical trial currently taking place at Cambridge to examine whether rapamycin can restore short-term memory in TSC patients. "The United States spends roughly $90 billion a year on remedial programs to address learning disorders," noted Silva. "Our research offers hope to patients affected by tuberous sclerosis and to their families. The new findings suggest that rapamycin could provide therapeutic value in treating similar symptoms in people affected by the disorder."

Title: Mental Retardation Source: nih.com
Thirty Years Ago • Haemophilus Influenzae Type B (Hib) was the leading cause of acquired mental retardation. In the mid-1970s, no means existed to prevent infection from Hib, the cause of meningitis — a
116

serious infection of the membrane surrounding the brain and spinal cord. The disease strikes children under 7 years of age, with most cases occurring in children from six months to two years old. By the late 1980s, roughly 15-20,000 cases of Hib meningitis occurred each year. Antibiotics could treat Hib infection, but couldn’t prevent its devastating consequences. On average, 1 in 10 infected children died from Hib meningitis, 1 in 3 became deaf, and 1 in 3 was left with mental retardation. • More than 10 million children had blood lead levels high enough to affect their cognitive functioning. It was not known in the early 1970s that exposure to even small amounts of lead in the environment — from paint and from automobile exhaust — could have an adverse effect on the developing brain. • Many children of women with the metabolic disorder phenylketonuria (PKU) were born with severe mental retardation — even though they did not have PKU themselves. PKU is a genetic inability to process the nutrient phenylalanine. The disorder occurs once in every 10,000 to 20,000 births, affecting 250 children each year in the United States. Without treatment, a child will suffer irreparable brain damage and require a lifetime of care in a nursing home facility. In the 1960s, a blood test for PKU was developed and children with the disorder were identified at birth. A low phenylanine diet spared them from brain damage. Because the diet is difficult to adhere to, many children, including those that would go on to be mothers, discontinued the low phenylalanine diet at approximately age 7 when the dangers of retardation are past. Unfortunately, by the late 1970s, it was apparent that children carried by moms with PKU were born with mental retardation. • Infants lacking thyroid hormone were destined to a life of mental retardation. In the mid 1970s, more than 1000 U.S. children each year became mentally retarded shortly after birth, because of hypothyroidism — failure to produce sufficient amounts of thyroid hormone. Thyroid hormone is essential for growth, especially of the brain. Although the hormone could be supplied artificially, diagnosis of the condition was usually not made until after an infant’s brain was permanently damaged.

Today • Meningitis from Hib has virtually been eliminated. In the 1970s, the search began for a vaccine to prevent Hib meningitis. The Hib bacterium could hide from a young child’s immature immune system by means of a protective sheath, or capsule, which shields its outer surface. In their first attempt at a vaccine to prevent the infection, researchers at NIH isolated a complex polysaccharide — a sugar molecule — from the bacterium’s covering. By itself, the
117

polysaccharide was not enough to prime the immune system to eliminate the Hib bacterium. The researchers then chemically combined, or conjugated, the sugar molecule to a protein that was easily recognized by the immune system. The protein and sugar “conjugate” became the basis for a new vaccine, which virtually eliminated Hib meningitis from the developed world. In the United States, there are now fewer than 10 cases of Hib meningitis each year. • Lead is no longer an ingredient in paint and gasoline. In 1979, researchers funded by NIH showed that children whose baby teeth contained relatively high amounts of lead fared poorly on a standard intelligence test when compared to children whose teeth contained much lower amounts of lead. The finding eventually led to Federal laws that banned lead as an ingredient in paint in 1974 and as an additive in gasoline in 1978. As a result, the number of children National Institutes of Health Mental Retardation – 1 with elevated blood lead levels fell from 10 million in the 1970s to 434,000 in 2001. Although the two most common sources of environmental lead exposure have been eliminated, many children are still exposed to such sources of lead as paint in older homes, and contaminated soils. • Children of women with PKU can be protected from brain damage. In the 1960s, children with PKU typically discontinued the low phenylalanine diet by the time they reached 7 years of age. The diet’s special protein formulations are expensive, and many find the diet difficult to stick with. To test whether a low phenylalanine diet would prevent mental retardation in the children of women with PKU, the NIH began a large study. The study, which took 18 years to complete, enrolled women from more than 120 clinics in the United States, Canada, and three foreign countries. The study was completed in 2003 and found that limiting phenylalanine in the diets of women with PKU beginning before pregnancy and continuing through pregnancy nearly eliminated mental retardation in their children. Subsequent studies have shown that people with PKU score higher on intelligence tests if they remain on the low-phenylalanine diets throughout their lifetimes, rather than discontinuing it in childhood. • Infants who lack thyroid hormone can be identified in time to help them. Researchers funded by the NIH developed a test to identify newborns that have insufficient thyroid hormones. A large study funded by NIH in the early 1970s showed that hypothyroidism could be easily detected, and treated within two weeks, before any brain damage resulted. Soon, every State required thyroid hormone screening along with PKU screening. Each year in the United States, roughly 1000 cases of mental retardation due to insufficient thyroid hormone are prevented.

Tomorrow

118

• The NIH is supporting the development of new DNA microarray chips and other technologies for newborn screening. The goal is to develop a fast, reliable, cost effective means to screen newborns for a multitude of genetic conditions, including not only causes of mental retardation, but of immune deficiency, blood disorders, nervous system disorders and muscle disorders. Such a screening test would make it possible to begin treatment early, when chances for success are greatest. Large numbers of infants who have disorders lacking effective treatments could also be identified easily. Although treatment might not yet be available for their conditions, they could be offered a chance to participate in studies of new treatments, so that eventually new therapies could be developed for their disorders as well. • NIH-funded researchers hope to develop a drug that may one day treat the symptoms of Fragile X Syndrome. The condition affects one in 6000 births, resulting in mental retardation, sleep problems, attention deficit disorder, aggression, and compulsive behavior. NIH-funded scientists working with mice having the same genetic mutation found in Fragile X Syndrome learned that the mice have increased activity in the metabotropic glutamate receptor (mGluR), which sits atop brain cells. Studies in mice and fruit flies show that chemically blocking the mGluR receptor results in the animals displaying more normal behaviors. Researchers hope that drugs that block the mGluR receptor might one day be used to lessen the disorder’s effects in humans. • Researchers have prevented brain damage in newborn infants deprived of oxygen at birth by lowering body temperature. Accidents of birth — compression of the umbilical cord, or rupture of the uterus, for example — can deprive an infant’s brain of blood and oxygen. Survivors of such accidents may suffer lifelong brain damage and disability. Known scientifically as hypoxic ischemic encephalopathy, or HIE, oxygen deprivation during birth is estimated to occur from 0.5 to 1 times per every thousand births. Researchers in an NIH network were able to reduce the amount of death and disability of a group of infants with HIE, by lowering the infants’ body temperature. The cooling treatment, known as hypothermia therapy, consisted of placing the infants on a soft plastic blanket through which cool water circulates. When the infants were examined at 18 to 22 months of age, 44 percent of those given hypothermia treatment had developed a moderate to severe disability or had died, as compared to 62 percent of infants receiving standard treatment for HIE. Because minor fluctuations in an infant’s body temperature could result in serious harm, the hypothermia treatment requires personnel trained in life support and the use of the cooling blanket. Researchers in the network are working to refine the therapy so that it may one day be used routinely in newborn intensive care units.

3. Summary
119

The literature discussed the causes of mental retardation from early years until these were eradicated, prevented and resolved. The following factors that were considered are Haemophilus Influenza Type B, products with lead content, PKU, fetal injury from oxygen deprivation and deficient thyroid hormone.

4. Reaction
I just want to commend the works and studies of the National Institutes of Health (NIH), an agency of the United States Department of Health and Human Services and the primary agency of the United States government responsible for biomedical and health-related research. NIH research of acquiring new knowledge to help prevent, detect, diagnose, and treat mental retardation is of really huge help and contribution to the world’s wellness especially for the mentally incapacitated patients

120

D. Drug Study – HALOPERIDOL

121

DRUG Generic Name: haloperidol Brand Name: Haldol

CLASSIFICATION

DOSE/ RATE/
ROUTE

ACTION Haloperidol blocks postsynaptic dopamine D1 and D2 receptors in the mesolimbic system and decreases the release of hypothalamic and hypophyseal hormones. It produces calmness and reduces aggressiveness with disappearance of hallucinations and delusions. Absorption: Readily absorbed from the GI tract (oral). Distribution: Crosses the bloodbrain barrier; enters breast milk. Proteinbinding: 92%. Metabolism: Hepatic via oxidative Ndealkylation and reduction of the ketone group; undergoes enterohepatic recycling. Excretion: Urine and faeces; 12-38 hr (elimination halflife).

CONTRAINDICATION

SIDE EFFECTS Cardiovascular Effects: Tachycardia, hypotension, and hypertension CNS: Insomnia, restlessness, anxiety, euphoria, agitation, drowsiness, depression, lethargy, headache, confusion, vertigo, grand mal seizures, exacerbation of psychotic symptoms including hallucinations, and catatonic-like behavioral states Hematologic Effects: mild and usually transient leukopenia and leukocytosis, minimal decreases in red blood cell counts, anemia, or a tendency toward lymphomonocytosis. Liver Effects: Impaired liver function and/or jaundice Dermatologic Reactions Maculopapular and acneiform skin reactions and isolated cases of photosensitivity and loss of hair. Endocrine Disorders Lactation, breast engorgement, mastalgia, menstrual irregularities, gynecomastia, impotence, increased libido, hyperglycemia, hypoglycemia and hyponatremia. Gastrointestinal Effects Anorexia, constipation, diarrhea, hypersalivation, dyspepsia, nausea and vomiting. Autonomic Reactions Dry mouth, blurred vision, urinary retention, diaphoresis and priapism. Respiratory Effects Laryngospasm, bronchospasm and increased depth of respiration. Special Senses

NURSING CONSIDERATIONS • Assess mental status prior to and periodically during therapy. • Monitor BP and pulse prior to and frequently during the period of dosage adjustment. May cause QT interval changes on ECG. • Observe patient carefully when administering medication, to ensure that medication is actually taken and not hoarded. •Monitor I&O ratios and daily eight. Assess patient for signs and symptoms of dehydration. • Monitor for development of neuroleptic malignant syndrome (fever, respiratory distress, tachycardia, seizures, diaphoresis, hypertension or hypotension, pallor, tiredness, severe muscle stiffness, loss of bladder control. Report symptoms immediately. May also cause leukocytosis, elevated liver function tests, elevated CPK. •Do not increase dose or discontinue medication without consulting health care professional. Abrupt withdrawal may cause dizziness, nausea, and vomiting, GI upset, trembling, or uncontrolled movements of mouth, tongue or jaw.

Antipsychotics / Anti-vertigo Drugs INDICATION: • Restlessness • Confusion • Schizophreni a • Psychosis • Organic Psychoses • acute psychotic symptoms • Relieve hallucination s, delusions, disorganized thinking • severe anxiety • seizures

10 mg , PO, HS

• • • • • • • •

Severe toxic CNS depression; pre-existing coma; Parkinson's disease; Lactation Glaucoma Seizures Elderly

122

123

CHAPTER IV NURSING CARE PLAN
124

A. Process Recording

125

ORIENTATION PHASE

Description of Phase:


• • •

Problem defining phase Starts when client meets nurse as stranger Defining problem and deciding type of service needed Client seeks assistance ,conveys needs ,asks questions, shares preconceptions and expectations of past experiences

Nurse responds, explains roles to client, helps to identify problems and to use available resources and services

Objectives: After the orientation phase, the nurse will be able to:

 Determine why the patient sought help  Establish trust, acceptance, and open communication  Mutually formulate a contract with the patient  Explore patient’s thoughts, feelings, and actions  Identify patient’s problems  Define goals with the patient

Date/ Time/ Venue: November 25, 2009 at National Center for Mental Health, Pavilion 1 Ward 9

RATIONALE OF THE NURSE-PATIENT INTERACTION NURSE’S COMMUNICATION

ANALYSIS OF THE PATIENT’S RESPONSE

126

TECHNIQUE Nurse: Magandang umaga J. Ako si Ran. Estudyante ako mula sa Centro Escolar University, Manila. Student nurse mo ako ngayon. Magkikita at mag-uusap tayo simula Miyerkules hanggang Biyernes sa susunod na linggo, mula alas-siyete hanggang alas-tres ng hapon. Mag-uusap ulit tayo bukas ha. Therapeutic: Giving Information  Making available the facts that the client needs Use names  Using a person's name makes her feel more valued, and introducing yourself is a basic step in establishing a therapeutic interaction. Patient: Opo…Opo…Opo (with nodding)

Nurse: Puwede ko bang malaman ang buong pangalan mo? Therapeutic: Exploring  Encourages the speaker to expand upon their Patient: (stated the name) remarks/ question  Patient is conscious and comprehending

Nurse: Ano ulit ang pangalan ko J?  Patient is responsive Patient: Ran po. (somnolence)

Nurse: Sige. Ako ang student nurse mo tapos ikaw ang

127

pasyente.

Therapeutic: Help to orient  Illness and hospitalization

 Patient is drowsy and comprehending  According to Jung, perception involves all the ways of becoming aware of things, people, happenings, or ideas. Judgment involves all the ways of coming to conclusions about what has been perceived. If people differ systematically in what they perceive and in how they reach conclusions, then it is only reasonable for them

Patient: Opo.

can be very disorienting for patients, especially the elderly.

Nurse: Mag-uusap tayo J ha. Magkukwentuhan lang tayo.

Patient: Opo. Opo.

Nurse: Alam mo ba kung anong petsa at araw ngayon? Therapeutic: Help to orient  Illness and hospitalization Patient: Sabado can be very disorienting for patients. Nurse: J Huwebes ngayon. November 26, 2009. Therapeutic: Presenting Reality

to differ correspondingly in their interests, reactions, values, motivations, and skills.  Patient is responsive

 He is analyzing the  When it is obvious that the patient is misinterpreting Patient: (stares only) reality, the nurse can indicate that which is real. He does this not by way of Nurse: Ano ulit ang petsa ngayon J? Patient: Sabado Nurse: Huwebes ngayon, November 26, 2009 J. arguing with the patient or belittling his own experiences, but rather by calmly and quietly expressing her own perceptions or the facts  Patient is responsive  Patient had established/formed fixated idea with regards information

128

 He has a difficulty to recall Patient: Opo Therapeutic: Asking Direct Questions: Nurse: Ilang taon ka na pala J?  This allows the patient to try answering a direct question directly, briefly Patient: Napulo and correctly Therapeutic: Reframing the question:  This allows the patient to try answering a direct Nurse: Anong taon nuong ipinanganak ka? question directly, briefly and correctly Therapeutic: Patient: Marso Asking Direct Questions:  This allows the patient to try answering a direct question directly, briefly Nurse: Ano ang birthday mo? Kelan ka ipinanganak? and correctly Therapeutic: Help to orient Patient: Hulyo, Agosto  Illness and hospitalization can be very disorienting for patients.  Disoriented to place  Patient has difficulty in memory skills  He has a difficulty to recall personal information and is often confused. personal information and is often confused.

Nurse: alam mo ba J kung ano ang ginagawa mo dito?

Therapeutic: Asking Direct Questions:  This allows the patient to  Misleading answer

Patient: (looses eye contact, tumingin sa malayo)

try answering a direct question directly, briefly and correctly

129

Nurse: Anong lugar to J?

Therapeutic: Asking Direct Questions:  Trying to recall personal information

Patient: (silence. Spits saliva)..  This allows the patient to Ambot try answering a direct question directly, briefly and correctly Therapeutic: Nurse: Saan ka pala nakatira J? Asking Direct Questions:  This allows the patient to try answering a direct Patient: sa bahay question directly, briefly and correctly Therapeutic: Asking Direct Questions: Nurse: Saan ka galing na probinsiya?  This allows the patient to try answering a direct question directly, briefly and correctly Patient: doon Therapeutic: Asking Direct Questions: Nurse: Saan yung doon na sinasabi mo J? Yung lugar kung saan ka dati nakatira bago ka napunta dito?  This allows the patient to try answering a direct question directly, briefly and correctly Therapeutic: Patient: Bitano Asking Direct Questions:  This allows the patient to Nurse: Saan yung Bitano J? try answering a direct question directly, briefly and correctly

 Patient is responsive

 Patient is responsive

 Patient is responsive

130

Patient: Sorsogon

Therapeutic: Using Broad Opening Statements The use of a broad opening statement allows the patient to set the direction of the conversation. Therapeutic: Asking Direct Questions:

Nurse: alam mo ba kung nasaan ang Sorsogon?

Patient: sa Mindanao

 This allows the patient to try answering a direct question directly, briefly and correctly  Somnolence

Nurse: Naaalala mo pa ba ang mga nangyari bago ka napunta dito?  The patient can’t justify Piaget’s cognitive theory. Therapeutic: Patient: (looses focus, drowsy) Observation:  To help with awareness of Nurse: Sino ang kasama mo pagpunta mo dito? feelings, encourage verbalization of feelings, conveys concern and interest. Patient: (focus returned) Verbalizing Implied Thoughts and Feelings  The nurse voices what the patient seems to have Nurse: J mag-usap pa tayo ha? fairly obviously implied, rather than what he has actually said. Patient: Opo. Therapeutic: Asking Direct Questions:  According to Piaget, the formal operational period is the fourth and final of the periods of cognitive development in Piaget's theory. This stage, which follows the Concrete Operational stage, commences at around 11 years of age (puberty) and continues into adulthood. In this stage, individuals move beyond concrete experiences and begin to think abstractly, reason logically and draw conclusions from the

131

Nurse: Okay ka pa?

 This allows the patient to try answering a direct question directly, briefly

information available, as well as apply all these processes to hypothetical situations.

Patient: Opo.

and correctly

Nurse: Inaantok ka ba J?

Therapeutic: Exploring or delving further into a subject or idea:

 It is observable that the patient has an inappropriate affect

Patient: hindi po  The nurse should recognize when to delve Nurse: Napapagod ka na ba? further. If the patient chooses not to elaborate, the nurse should respect Patient: Hindi po. the patient’s wishes.  Some questions with regards to personal information can be Nurse: Nag-enjoy ka ba knina J? Therapeutic: Focusing: Patient: Opo (flat affect)  It will help the client expand on a topic Therapeutic: Nurse: Nag-exercise ka rin ba? Sequencing:  Helps to identify cause and Patient: Opo effect, recurring pattern of interpersonal difficulties. Therapeutic: Nurse: Kamusta naman ang pag-ehersisyo mo kanina J? Exploring or delving further into a subject or idea:  Flight of ideas  The nurse should Patient: Okay lang po recognize when to delve further – she should refrain from probing or prying. If  a nearly continuous flow of rapid speech that jumps from topic to topic, usually based on discernible answered correctly by the patient.

132

Nurse: Sino pala ang kasama no J pagpunta mo dito?

the patient chooses not to elaborate, the nurse should respect the patient’s wishes. Probing usually

associations, distractions, or plays on words, but in severe cases so rapid as to be disorganized and incoherent.

Patient: Suseng

occurs when the nurse introduces a topic because she is anxious.

Nurse: Kaano-ano mo si Suseng J?

Therapeutic: Sequencing:  Helps to identify cause and

 Patient is fixated with certain numbers like 5 and 10.

Patient: nanay

effect, recurring pattern of interpersonal difficulties.

 When we feel safe and secure in our world then we begin to seek out friendships in order to feel a sense of belonging. Maslow's third level, the

Nurse: Nanay mo siya?

Patient: Opo

need for belonging and love, focuses on our desire Therapeutic: to be accepted, to fit in, and to feel like we have a place in the world.

Nurse: Tapos ano ang nangyari? Exploring or delving further into a subject or idea:  The nurse should Patient: may red na bag, blue recognize when to delve further – she should refrain from probing or prying. If Nurse: Tapos? the patient chooses not to elaborate, the nurse should respect the patient’s Patient: isang bag lang dala ko, namin wishes. Probing usually occurs when the nurse introduces a topic because she is anxious. Nurse: Ilang taon ka na dito? Therapeutic: Asking Direct Questions: Patient: lima  This allows the patient to

 Persons may be called both mentally retarded and learning disabled, meaning that their overall IQ is lower than average, but that they have strengths and weaknesses on various skills.

 Cognitive development is defined as thinking,

133

try answering a direct Nurse: Si Suseng nasaan? question directly, briefly and correctly Therapeutic: Patient: Doon Asking Direct Questions:  This allows the patient to Nurse: Saan yung nanay mo J? try answering a direct question directly, briefly and correctly Patient: sa bahay, dun

problem solving, concept understanding, and information processing and overall intelligence. Many mentally retarded clients have cognitive weaknesses. Their overall potential may be lower than that of their peers and siblings. They still have patterns of strengths and weaknesses in their development and may do very well with certain types of learning.

Nurse: Sa Bitano?

Patient: Opo (nods)

Therapeutic: Sequencing:

Nurse: may mga gamot ka ba na iniinom?

 Helps to identify cause and effect, recurring pattern of interpersonal difficulties.

 Adaptive skills are the skills needed for daily life and include the ability to produce and understand language (communication); home-

Patient: oo, kanina Therapeutic: Nurse: Ano daw yun J? Sequencing: Helps to identify cause and Patient: aspilit, isa lang effect, recurring pattern of interpersonal difficulties

living skills; use of community resources; health, safety, leisure, selfcare, and social skills; selfdirection; functional academic skills (reading, writing, and arithmetic); and work skills.

Patient: gamot, gamot, (showed both arms) Therapeutic: Nurse: may asawa ka naba J? Acknowledging the patient’s Feeling:

134

 The nurse helps the patient Patient: wala to know that his feelings are understood and accepted and encouraged him to continue expressing them. If communication is to be successful, it is Nurse: Nakatapos ka na ba ng elementary o high school J? essential that the nurse accept the thoughts and feelings her patient is expressing. Patient: oo, elementary

Nurse: Hanggang anong grade natapos mo? Include the patient Patient: Grade 1  You must remember that patient care should be collaborative and include Nurse: ano pala palagi mo ginagawa dito J? the patient in decision making whenever possible. The patient often feels at the mercy of the Patient: Toothbrush (acting), ligo, kain system, but you can help him find ways to feel in control. Nurse: Tuwing umaga?

Patient: kain

Nurse: kapag hapon?

135

Patient: tulog

Nurse: ano ang gusto mong pagkain J?

Patient: monggo’

Nurse: ano ang kinain mo kanina?

Patient: monggo

Nurse: Masarap ba J?

Patient: Opo

Nurse: ano ang mga ayaw mo kainin?

Patient: monggo, kanin, apple

Nurse: Di ba sabi mo gusto mo ng monggo knina?

Nurse: Usap ulit tayo bukas ha!

136

Patient: Opo.

WORKING PHASE

Description of Phase:

At this point, the client’s problems are identified and solutions are explored, applied and evaluated. The focus of the assessment and of the relationship is the client’s behavior and the focus of the interaction is the client’s feelings.

Objective: After the working phase, the nurse will be able to:  Explore relevant stressors for the patient  Promote patient’s development of insight and use of constructive coping mechanisms  Overcome resistance behavior

Date/ Time/ Venue: November 26, 2009 at National Center for Mental Health, Pavilion 1 Ward 9

RATIONALE OF THE NURSE’S NURSE-PATIENT INTERACTION Nurse: Magandang umaga sa yo J! COMMUNICATION TECHNIQUE Therapeutic: Use names:  Using a person's name Patient: Magandang umaga din po. makes her feel more valued, and introducing
137

ANALYSIS OF THE PATIENT’S RESPONSE

 Patient is disoriented to time, place and person

 MEMORY AND

yourself is a basic step in Nurse: Ano ulit ang pangalan ko J? establishing a therapeutic interaction.

ATTENTION. Memory deficiencies interfere with learning rote material such as days of the week, months of the year, and times tables. Basic facts are hard to remember and there is a lack in knowledge of general information. There are deficits in attention that interfere with ability to focus and concentrate on tasks.

Therapeutic: Patient: (Kran) Help to orient  Illness and hospitalization Nurse: Ran ako can be very disorienting for patients. Therapeutic: Patient: Ran Using Broad Opening Statements: Nurse: Kamusta naman ang tulog mo J?  The use of a broad opening statement allows the patient to set the direction of the Patient: Maayos conversation. Give the patient an opportunity to begin expressing himself. Nurse: eh ang gising? In using a broad opening statement, the nurse focuses the conversation Patient: ayos directly on the patient and communicates to him that she is interested in him Nurse: Anong araw pala ngayon J? and his problems. Upon sensing that the patient may have a need, the nurse can use a broad opening Patient: Martes statement to initiate discussion, while at the Nurse: J, Biyernes ngayon. Ang petsa ay November 27, 2009. same time allowing the patient to determine what will be discussed. Therapeutic:

138

Giving Information Nurse: Anong araw ang sumunod sa Biyernes?  Studies have shown that a major cause of anxiety or discomfort in hospitalized patients is lack of Patient: Martes information or misconceptions about their condition, treatment, or Nurse: Kung Biyernes ngayon, ano ang araw bukas? Bukas ay? hospital routines. When the patient is in need of information to relieve anxiety, form realistic conclusions, or make Patient: Martes decisions, this need will often be revealed during the interaction by Nurse: Sabado bukas J. Sundan mo ko ha. statements he makes. By providing such information as she prudently can, admitting Nurse: Lunes and finding out what she doesn’t know, or referring the patient to someone Patient: Lunes who can assist him, the nurse can do much to establish an atmosphere of Nurse: Martes helpfulness and trust in her relationship with the patient. Patient: Martes

 The patient can’t justify Piaget’s cognitive theory

 According to Piaget, the formal operational period is the fourth and final of the periods of cognitive development in Piaget's theory. This stage, which follows the Concrete Operational stage, commences at around 11 years of age (puberty) and continues into adulthood. In this stage, individuals move beyond concrete experiences and begin to think abstractly, reason logically and draw conclusions from the information available, as well as apply all these processes to hypothetical situations.

Nurse: Miyerkules

Patient: Miyerkules Therapeutic:

139

Nurse: Huwebes

Using Broad Opening Statements:

Patient: Huwebes

 The use of a broad opening statement allows the patient to set the direction of the conversation. Give the patient an opportunity to begin expressing himself. Therapeutic: Sequencing:

Nurse: Biyernes

Patient: Biyernes

 Patient is responsive.

Nurse: Sabado  Helps to identify cause and effect, recurring pattern of Patient: Sabado interpersonal difficulties.  According to Piaget, the formal operational period is the fourth and final of Nurse: Linggo the periods of cognitive development in Piaget's theory. This stage, which Patient: Linggo Therapeutic: Sharing Observations Nurse: Anu-ano pala mga ginawa mo ngayong umaga?  The nurse shares with the patient observations regarding behavior. The patient who has a need is Patient: Kain, toothbrush, ligo often unaware of the source of this distress, or reluctant to communicate Nurse: Ano yung mga kinain mo? it verbally. However, the tension or anxiety created by his need creates energy which is transformed into Patient: Spanish some kind of behavior, Therapeutic: follows the Concrete Operational stage, commences at around 11 years of age (puberty) and continues into adulthood. In this stage, individuals move beyond concrete experiences and begin to think abstractly, reason logically and draw conclusions from the information available, as well as apply all these processes to hypothetical situations.

140

Nurse: Spanish bread?

Sequencing:  Helps to identify cause and

Patient: Opo

effect, recurring pattern of interpersonal difficulties

Nurse: masarap ba? Reflecting: Patient: Opo In reflecting, all or part of the patient’s statement is repeated to encourage him to go on. Reflecting can be overused, and the patient is likely to become annoyed if his own words or statements are continually repeated to him  Patient is responsive and answers questions with comprehension.

Nurse: pag-usapan natin ang drawing mo kanina.

Patient: iskindi (ice candy)

Nurse: ice candy yung drawing mo?  MEMORY AND Patient: Opo. ATTENTION. Memory deficiencies interfere with learning rote material such Nurse: Anong meron sa ice candy at yun ang dinrawing mo? Ang ice candy ay? Therapeutic: Exploring or delving further into a subject or idea:  The nurse should recognize when to delve further – she should refrain from probing or prying. If the patient chooses not to elaborate, the nurse should respect the patient’s wishes. Probing usually occurs when the nurse introduces a topic because
141

as days of the week, months of the year, and times tables. Basic facts are hard to remember and there is a lack in knowledge of general information. There are deficits in attention that interfere with ability to focus and concentrate on tasks.

Patient: matamis, lamig

Nurse: ano pa?

Patient: tigas, tamis

she is anxious

Nurse: may naalala ka ba sa ice candy? Therapeutic: Asking Direct Questions: Patient: (silence)  This allows the patient to try answering a direct Nurse: paborito mo ba ang ice candy? question directly, briefly and correctly  MEMORY AND ATTENTION. Memory deficiencies interfere with learning rote material such as days of the week, months of the year, and times tables. Basic facts are hard to remember and there is a lack in Patient: Opo. knowledge of general information. There are deficits in attention that Nurse: ano ang paborito mo na lasa ng ice candy? interfere with ability to focus and concentrate on tasks. Patient: monggo

Nurse: Anu-ano pala ang mga kulay ng ice candy? Diyan sa drawing mo J?

Patient: (Points on the lines while identifying its colors, with some mistakes)

Nurse: (corrects the mistakes)

Nurse: okay J, very well.

142

Magaling!

Nurse: Nagtitinda ka ba dati ng ice candy J?

Patient: Hu..

Nurse: Pagod ka na ba J?

Patient: Opo.

Nurse: Okay sige. Pahinga ka na J. Hintayin lana muna natin ang iba na matapos ha.

Patient: Opo.

143

TERMINATION PHASE

Description of Phase:

The nurse terminates the relationship when the mutually agreed goals are met, the patient is discharged or transferred or the rotation is finished. The focus of this stage is the growth that has occurred in the client and the nurse helps the patient to become independent and responsible in making his own decisions. The relationship and the growth or change that has occurred in both the nurse and the patient is summarized.

Objective: During the termination phase, the nurse will be able to:  Establish reality of separation  Review progress of therapy and attainment of goal  Mutually explore feelings of rejection, loss, sadness, and anger and related behaviors

Date/ Time/ Venue: December 3, 2009 at National Center for Mental Health, Pavilion 1 Ward 9

Nurse-Patient Interaction

Rationale of the Nurse’s Communication Technique

Analysis of the Patient’s Response

Nurse: Magandang umaga sa yo J. Patient: Gandang umaga din po.

Therapeutic: Use names  Using a person's name makes her feel more

 The patient is conscious.  The patient talks rapidly.  Adaptive skills are the skills needed for daily life and include the ability to produce and understand language

Nurse: Kumusta ang tulog mo? Patient: Ok lang.

valued, and introducing yourself is a basic step in establishing a therapeutic interaction.
144

Therapeutic: Nurse: Maayos ba naman ang gising? Patient: Opo. The use of a broad opening statement allows the patient to set the direction of the conversation. Give the patient an opportunity to begin expressing himself. Using Broad Opening Statements:

(communication); homeliving skills; use of community resources; health, safety, leisure, selfcare, and social skills; selfdirection; functional academic skills (reading, writing, and arithmetic); and work skills.

Nurse: Anu-ano ang mga ginawa mo kanina? Patient: toothbrush, ligo, kain

Nurse: Ano ang kinain mo J? Patient: tinapay

Therapeutic: Focusing:  It will help the client

 Cognitive development is defined as thinking, problem solving, concept understanding, and information processing and overall intelligence. Many mentally retarded clients have cognitive weaknesses. Their overall potential may be lower than that of their peers and siblings. They still have patterns of strengths and weaknesses in their development and may do very well with certain types of learning.

Nurse: masarap ba J? Patient: Opo.

expand on a topic Therapeutic: Exploring or delving further

Nurse: nabusog ka ba? Patient: (nods)

into a subject or idea:  The nurse should recognize when to delve further – she should refrain from probing or prying. If the patient chooses not to elaborate, the nurse should respect the patient’s wishes. Probing usually occurs when the nurse introduces a topic because she is anxious.

Nurse: Pag-usapan natin J yung tungkol sa niyog. Ano nga ang mga parte ng niyog? Patient: dahon

Nurse: Ahh. Magbigay ka nga ng isang gamit ng dahon. Patient: bubong

 MEMORY AND Nurse: Ano pa J? Magsabi ka pa nga ng isang parte pa ng puno ng niyog? Patient: puno Sequencing: Nurse: Anong gamit ng kahoy ng niyog J?  Helps to identify cause and effect, recurring pattern of
145

ATTENTION. Memory deficiencies interfere with Therapeutic: learning rote material such as days of the week, months of the year, and times tables. Basic facts

Patient: bahay.

interpersonal difficulties.

are hard to remember and there is a lack in knowledge of general information. There are deficits in attention that interfere with ability to focus and concentrate on tasks.

Nurse: Oo. Ginagamit nga to sa paggawa ng bahay.

Therapeutic: Focusing:  It will help the client expand on a topic Therapeutic: Asking Direct Questions:  This allows the patient to

Nurse: Puwede ka bang magkuwento ng tungkol sa mga magulang at mga kapatid mo J? Patient: …

 According to Piaget, the formal operational period is the fourth and final of the periods of cognitive development in Piaget's theory. This stage, which follows the Concrete Operational stage, commences at around 11 years of age (puberty) and

Nurse: Namimiss mo ba sila J? Patient: …

try answering a direct question directly, briefly and correctly

Nurse: Ano ulit pangalan nung nanay mo? Patient: Suseng

Nurse: Ano naman ang pangalan ng tatay mo J? Patient: Mario Therapeutic: Acknowledging the patient’s Feeling:  The nurse helps the patient to know that his feelings Nurse: Nasaan na sila ngayon J? Patient: Ambot. are understood and accepted and encouraged him to continue expressing them. If communication is Nurse: Napaano pala yang mga sugat mo sa kamay J? to be successful, it is essential that the nurse accept the thoughts and

continues into adulthood. In this stage, individuals move beyond concrete experiences and begin to think abstractly, reason logically and draw conclusions from the information available, as well as apply all these processes to hypothetical situations.

Nurse: Ang mga kapatid mo? Naaalala mo ba mga pangalan nila? Patient: Ricoy, Marichu

146

Patient: kadena

feelings her patient is expressing.

Nurse: Sino ang nagkadena sa yo J? Patient: nanay  MEMORY AND ATTENTION. Memory Nurse: Ano daw ang dahilan ni Suseng dahil kinadena ka nya? May nagawa ka ba na kasalanan? Patient: Ambot lang. deficiencies interfere with learning rote material such as days of the week, months of the year, and times tables. Basic facts are hard to remember and Nurse: Ano pa ang mga nangyari J. Sige magkuwento ka pa. Makikinig ako. Patient: Kinulong ako. there is a lack in knowledge of general information. There are deficits in attention that interfere with ability to focus and concentrate on Nurse: Kinulong ka J? Patient: … tasks.

Nurse: Ano ang naramdaman mo? Patient: Nagalit.  According to Piaget, the formal operational period Nurse: Kanino ka nagalit? Patient: Suseng is the fourth and final of the periods of cognitive development in Piaget's theory. This stage, which Nurse: Tapos ano na ang nangyari? Patient: Ambot. follows the Concrete Operational stage, commences at around 11 years of age (puberty) and continues into adulthood. Nurse: J huling beses na pala kita makakausap ng ganito. Patient: … In this stage, individuals move beyond concrete experiences and begin to

147

think abstractly, reason Nurse: Socialization na bukas at huling araw na rin na pupunta ako dito bukas. Patient: …. logically and draw conclusions from the information available, as well as apply all these processes to hypothetical Nurse: May gusto ka pa ba na sabihin o ikuwento sa akin? Patient: Wala na. situations.

Nurse: Sige J. Hintayin na lang natin ang iba na matapos.

148

B. List of Prioritized Psychiatric Nursing Diagnosis

149

NURSING DIAGNOSIS

RANK

RATIONALE

Based on Carl Jung's Theory of Psychological Types, perception involves all the ways of becoming Disturbed cognition Thought as Processes by 1 related to developmental delay of evidenced cognitive dissonance aware of things, people, happenings, or ideas. Judgment involves all the ways of coming to conclusions about what has been perceived. If people differ systematically in what they perceive and in how they reach conclusions, then it is only reasonable for them to differ correspondingly in their interests, reactions, values, motivations, and skills.

According to Karen Horney’s Theory on Personality, moving away from people: The Impaired Verbal Communication related to impaired cognitive abilities as evidenced by loose association of ideas 2 final possible consequence of a neurotic is a personality style filled with a social behavior and an almost indifference to others. If they don't get involved with others, they can't be hurt by them. While it protects them from emotional pain of relationships, it also keeps away all positive aspects of relationships. It leaves them feeling alone and empty.

According to Sullivan’s Interpersonal Theory, the need for friendship and need for sexual Impaired related processes others to Social as Interaction thought by with 3 expression adolescence. get combined during late impaired In this stage a long term

evidenced interaction

relationship becomes the primary focus. Conflicts between parental control and selfexpression are commonplace and the overuse of selective inattention in previous stages can result in a skewed perception of the self and the world.

dysfunctional

Self-Care Deficit, Bathing and Hygiene related to mental delay as evidenced by inability to bathe himself
150

Dorothea E. Orem's Self-Care Deficit Nursing 4 Theory states that nursing is required because of the inability to perform self-care as the result of limitations.

151

PSYCHIATRIC NURSING CARE PLAN Cues / Clues Subjective Cue: When asked about the day, the patient verbalized “Sabado”, mistaken it for Thursday, even if initially oriented. Disturbed Thought Processes related to developmental delay of cognition as evidenced by cognitive dissonance Risk factors are socioeconomic & biochemical Short term outcome: A. INDEPENDENT: 1. Assess degree of disorientation to time, place, person, and situation regularly and frequently. Psychiatric Nursing Diagnosis Psychodynamics PLANNING (RATIONALE) Therapeutic Approach (with Theories) RATIONALE EVALUATION

Outcome Achieved: 1. This will determine the amount of reorientation and intervention the patient will need to evaluate reality accurately. Based on Carl Jung's Theory of Psychological Types, perception involves all the ways of becoming aware of things, people, happenings, or ideas. Judgment involves all the ways of coming to conclusions about what has been perceived. If people differ systematically in what they perceive and in how they reach conclusions, then it is only reasonable for them to differ correspondingly in their interests, reactions, values, motivations, and skills. 2. A calm approach helps to avoid distorting the client’s sensory perceptual field which helps could promote disturbed thoughts and perceptions. The client with disturbed thought process may have difficulty in interpreting correct meanings if the nurse misrepresents

Objective: GA:  Loosing eye contact  Inappropriate affectflat Motor Behavior:  Waxy flexibility Sensory & Cognition:  Conscious but disoriented to time, person & place  Impaired memory on personal information  Poor focus regarding specific topic Attitude:

Neurologic developmental failure

After 8 hours of nursing intervention, the pt will be able to :  Reduce disorientation to time, place, person, and situation.  Interact with others appropriately.  Assist in assuming selfcare responsibilities to the limits of his ability.  Participate in social activities and group therapies

Alteration of function in cognitive and perceptive fields

 The patient reduced disorientation to time, place, person, and situation.  The patient interacted with others appropriately.  The patient assisted in assuming selfcare responsibilities to the limits of his ability.  The patient participated in social activities and group therapies

Inaccurate interpretation of incoming

Providing general leads a. Approach the client in slow, calm, matter-offact manner b. Maintain facial 152

2.

    Affect:

handily cooperative Withdrawn Perplexed apathetic

information

expression and behaviors that are consistent with verbal statements

 Flat affect  Anxious Thought Process:  looseness of association  blocking  perseveration Altered perceptions of surrounding stimuli caused by impairment in the following cognitive processes:  Memory  Judgment  Comprehension  Concentration Inability to reason, problem solve, calculate, and conceptualize

Disturbed thought process

intent with a conflicting or double message. Peplau defined Psychodynamic Nursing as being able to understand one’s own behavior to help others identify felt difficulties and to apply principles of human relations to the problems that arise at all levels of experience.

3. Giving information a. Offer the client clear, simple explanations of environmental events, activities and the behaviors of other clients as necessary

3. Clear direct explanations of environment events help to lessen the client’s suspiciousness and fear or mistrust of the surroundings and other. This can prevent aggressive behavior. According to Sullivan, the strand of interpersonal theory is the principle of complementarities which contends that people in dyadic interactions negotiate the definition of their relationship through verbal and non-verbal cues.

B. COLLABORATIVE

1.

Continue to administer and monitor the effects of the prescribed medication  haloperidol

Haloperidol may cause dehydration. Assessing I/O is important.

153

PSYCHIATRIC NURSING CARE PLAN Cues / Clues Subjective Cue: (conversation between the nurse and the patient) Nurse: Ilang taon ka na pala J? Psychiatric Nursing Diagnosis Psychodynamics PLANNING (RATIONALE) Therapeutic Approach (with Theories) RATIONALE EVALUATION

Impaired Verbal Communication related to impaired cognitive abilities as evidenced by loose association of ideas

Risk factors are socioeconomic & biochemical

Short term outcome:

Patient: Napulo

Nurse: Anong taon nuong ipinanganak ka?

Neurologic developmental failure

After 8 hours of nursing intervention, the pt will be able to :  Use a form of communication to get needs met and to relate effectively with persons and his or her environment.  Demonstrate congruent verbal and nonverbal communication  Participate in social activities and group therapies

C. INDEPENDENT: 4. Assess degree of disorientation to time, place, person, and situation regularly and frequently.

Patient: Marso

Nurse: Ano ang birthday mo? Kelan ka ipinanganak?

Alteration of function in cognitive and perceptive fields

4. This will determine the amount of reorientation and intervention the patient will need to evaluate reality accurately. Based on Carl Jung's Theory of Psychological Types, perception involves all the ways of becoming aware of things, people, happenings, or ideas. Judgment involves all the ways of coming to conclusions about what has been perceived. If people differ systematically in what they perceive and in how they reach conclusions, then it is only reasonable for them to differ correspondingly in their interests, reactions, values, motivations, and skills. 5. Clear direct explanations of environment events help to lessen the client’s suspiciousness and fear or mistrust of the surroundings and other. This can prevent aggressive behavior. According to Sullivan, the strand of interpersonal theory is the principle of complementarities which contends that people in dyadic interactions negotiate the definition of their relationship

Outcome Achieved:

 The patient used a form of communication to get needs met and to relate effectively with persons and his or her environment.  The patient demonstrated congruent verbal and non-verbal communication  The patient participated in social activities and group therapies

Patient: Hulyo, Agosto

Objective:

Inaccurate interpretation of incoming information

5. Giving information b. Offer the client clear, 154

Sensory & Cognition:  Conscious but disoriented to time, person & place  Impaired memory on personal information  Poor focus regarding specific topic Attitude:  Withdrawn Thought Process:  looseness of association  blocking  perseveration  inability to recall familiar words, phrases, or names of known persons, objects, and places impaired cognitive abilities

simple explanations of environmental events, activities and the behaviors of other clients as necessary

through verbal and non-verbal cues. 6. The nurse should set aside enough time to attend to all of the details of patient care. Care measures may take longer to complete in the presence of a communication deficit. Peplau defined Psychodynamic Nursing as being able to understand one’s own behavior to help others identify felt difficulties and to apply principles of human relations to the problems that arise at all levels of experience.

inability to recall familiar words, phrases, or names of known persons, objects, and places

6. Anticipate patient needs and pay attention to nonverbal cues.

7. Give the patient ample time to respond.

8. Face the patient when communicating 155

7. It may be difficult for patients to respond under pressure; they may need extra time to organize responses, find the correct word, or make necessary language translations. 8. 5to9. Humanistic Nursing Communication Theory (Theorist: Bonnie W. Duldt, Ph.D., R.N.) In an interpersonal relationship of trust, selfdisclosure, and feedback, to the degree that dehumanizing communication attitudes are expressed by another, to that degree one tends to use assertiveness as a pattern of interaction. To the degree that assertiveness tends not to re-establish trust, self-disclosure, and feedback, and to the degree that dehumanizing attitudes are expressed by another, to that degree one tends to use

9.

10. 11.

12.

with them, listen and watch them closely Pay attention to their voice inflection and body cues Always speak to the patient in a calm even voice Allow the patient time to complete what they are saying Provide encouragement and reassurance to the patient at all times when they are attempting to communicate with you

assertiveness as a pattern of

COLLABORATIVE

 Refer to speech therapy for assistance in understanding patient's speech patterns  To promote wellness and assistance. PSYCHIATRIC NURSING CARE PLAN 156

Cues / Clues Subjective Cue: “Hindi ko sila kilala” (referring to his fellow patients), as verbalized by the patient.

Psychiatric Nursing Diagnosis

Psychodynamics PLANNING (RATIONALE) Therapeutic Approach

RATIONALE EVALUATION (with Theories)

Objective:

Impaired Social Interaction related to impaired thought processes as evidenced by dysfunctional interaction with others

Risk factors are socioeconomic & biochemical

Short term outcome:

Neurologic developmental failure

After 8 hours of nursing intervention, the pt will be able to : 1. Establish a therapeutic relationship with the nurse. 2. Identify barriers in interpersonal relationships that interfere with socialization. 3. Participate in social activities and group therapies

D. INDEPENDENT 1. Encourage client to verbalize feelings of discomfort about social situations. Identify causative factors, recurring precipitation patterns, and barriers to using support systems

Sensory & Cognition:  Conscious but disoriented to time, person & place  Impaired memory on personal information  Poor focus regarding specific topic Attitude:  Withdrawn Affect:  Anxious

Alteration of function in cognitive and perceptive fields

Disturbed thought process 2. Establish therapeutic relationship using positive regard for the client, active 157

 According to Hildegard Peplau, psychodynamic nursing involves the use of one's (the nurse) knowledge and understanding of one's own behavior to help others (patients) identify felt difficulties, and the application of human relations to problems that arise at all levels of experience (Carey, Noll, Rasmussen, Searcy, and Stark, 1989, p. 205). This interpersonal process is defined by Peplau in the context of four phases of the nurse-patient relationship-orientation, identification, exploitation, and resolution. Although each phase of this relationship is defined separately, Peplau recognized that considerable overlap existed between the phases.  Peplau: During the orientation phase of the nurse-patient relationship, the patient experiences a felt need and seeks professional assistance from the nurse. During this phase, the nurse tries to help the patient in both recognizing and understanding the problem that he or she is experiencing. During the orientation phase, also, the nurse attempts to determine exactly what help is needed by the patient.

Outcome Achieved:

1. The patient established a therapeutic relationship with the nurse. 2. The patient identified barriers in interpersonal relationships that interfere with socialization. 3. The patient participated in social activities and group therapies

Thought Process:  looseness of association  blocking  perseveration

Dysfunctional interaction with others

listening and providing safe environment for selfdisclosure

3. Review/list behaviors observed previously by caregivers, care workers, and so forth 4. Provide positive reinforcement for improvement in social behaviors 5. Encourage classes, reading materials, and lectures for selfhelp in alleviating negative self-concepts that lead to impaired social interaction

 Ida Jean Orlando, The Dynamic NursePatient Relationship: The role of the nurse is to find out and meet the patient's immediate need for help. The patient's presenting behavior may be a plea for help; however, the help needed may not be what it appears to be. Therefore, nurses need to use their perception, thoughts about the perception, or the feeling engendered from their thoughts to explore with patients the meaning of their behavior. This process helps the nurse find out the nature of the distress and what help the patient needs.

 There is a direct correlation between the musical portion of the brain and the language area, and the use of this programs may result in better communication skills

E. COLLABORATIVE 6. Involve client in a music-based program, if available

158

CHAPTER

V
PSYCHOTHERAPY
159

A.

Play Therapy Definition Kahulugan

Play therapy refers to a method of

Ang play therapy ay isang uri ng

psychotherapy in which a therapist uses the psychotherapy kung saan ang partisipasyon ng symbolic meanings of his or her play as a pasyente ay maaring gawing isang obserbasyon medium for understanding and communication ng nars at maaari din itong magsilbing tulay with the client. upang makausap ng nars ang pasyente.

Purposes

Mga Layunin

• • • • •

To improve social and emotional adjustment of the patient To reduce stress and anxiety To improve the self-concept To learn to trust To learn to complete, cooperate and collaborate

Mapaunlad ang pakikipagsalamuha ng pasyente sa ibang tao.

Mabawasan ang stress at takot ng mga pasyente.

Matulungan ang pasyente sa pagpapabuti ng tingin sa sarili

Matuto ang pasyente na magtiwala sa sarili at sa ibang tao

Matuto ang pasyente na makipagtulungan sa iba

HOT POTATO

160

Standard Rules

Mga Patakaran

1. It involves players gathering in a circle and
tossing a small object such as a beanbag or tennis ball to each other while music plays 1. Uupo ng paikot ang mga kasali ng laro. Habang tumutugtog ang musika, pagpapasapasahan ng mga kasali ang bola ng paikot. 2. Kung sino ang makakahawak ng bola sa pagtigil ng musika ay matatanggal sa bilog.
3. Magpapatuloy ang laro hanggang sa isa

2. The player who is holding the "hot potato"
when the music stops is out.

3. Play continues until only one player is left.

nalang ang matira. Ang natira ang pangangalanang panalo.

Techniques 1. The nurse must first explain to the patient what particular activity they are going to perform. Trust should be developed during this stage. 2. The patient must be given an opportunity to perform the activity. 3. During the activity, never forget to talk to your patient using therapeutic ways of communication. ANALYSIS • Patient is interacting with other patients/playmates. • He has a flat affect during the games’ implementation INTERPRETATION • Flat and inappropriate affect is really observable to patients with mental retardation. • It is not obviously observed that the • • •

Pamamaraan 1. Dapat ipaliwanag muna ng nars kung anu-anong mga gawain ang kanilang gagawin. Ang pagtitiwala ay dapat mabuo sa panahong ito. 2. Ang pasyente ay dapat mabigyan ng pagkakataong gawin ang gawain. 3. Huwag gumamit kalimutang ng mga kausapin therapeutic ang na pasyente habang may gawain. Palaging pamamaraan ng pakikipag-usap. ANALISA • Ang kliyente ay nakikipag-ugnayan sa ibang kalahok sa laro. Ang kliyente ay nagpakita ng hindi ukmang emosyon. INTERPRETASIYON Ang hindi ukmang emosyon ng mukha ay normal na makikita sa mga kliyenteng may kakulangan sa pag-iisip. Hindi masasabing masaya ang

161

kliyente kahit na sinabi pa niya na patient enjoys what he is playing even if he told it so. natututwa siya.

B. Music & Art Therapy

162

Definition

Kahulugan

Music Therapy is a research-based health Ang music therapy ay isang propesyong profession in which music activities are pangkalusugan na base sa pananaliksik designed and to accomplish in a non-musical kung saan ang mga pangmusikang gawain therapeutic goals with clients of all ages ay idinisenyo upang magawa ang mga diabilities non-threatening musika panterapeutikang hangarin sa mga kliyenteng may iba’t ibang kapaligiran edad at kakayahan sa isang hindi mapanganib na environment.

Purposes
• • • • • • • • • •

Layunin • • • • • • • • • • • pagbibigay-buhay sa pag-unawa kasanayan na makaya pinaghusay na pag-unlad mapataas ang timpla ng damdamin upang mabawasan ang sakit at pagkabalisa dagdagan ang pagsunod mapalakas ang pag-unlad normalisasyon ng kapaligiran orientasyon sa realidad pagbabagong-tatag ng mga pisikal na pag-unawa at mga kakayahan pagsasapanlipunan Mga Patakaran schedule of 1. Magbigay ng mga pinlanong gawain na makatutulong upang ang pasyente ay makaya ang kanyang mga personal na problema. 2. Magbigay makakuha ng ng ng pagkakataong atensyon sa

cognitive stimulation coping skills enhanced development mood elevation to reduce pain and anxiety increase compliance reinforce progress normalization of environment reality orientation rehabilitation of physical and cognitive abilities socialization

Standard Rules 1. Provide planned

activities which aids patients in dwelling personal problems.

2. Provide opportunity for gaining attention in acceptable ways.

katanggap-tanggap na paraan. 3. Magbigay interes. pagkakataong makabuo ng malusog at maunlad na

3. Provide an opportunity for the
163

development

of

healthy

and

4. Magbigay ng katanggap-tanggap na gawain ng loob. kung saan kanilang mailalabas ang kanilang mga sama

productive interest.

4. Provide planned acceptable outlet for pension and hostility.

Technique 1. The nurse must first explain to the patient what particular activity they are going to perform. Trust should be developed during this stage. 2. The patient must be given an opportunity to perform the activity. 3. During the activity, never forget to talk to your patient ways using of therapeutic communication.

Pamamaraan 4. Dapat ipaliwanag muna ng nars kung anu-anong mga gawain ang kanilang gagawin. Ang pagtitiwala ay dapat mabuo sa panahong ito. 5. Ang pasyente ay dapat mabigyan ng pagkakataong gawin ang gawain. 6. Huwag kalimutang kausapin ang pasyente Palaging therapeutic habang gumamit may ng gawain. mga

na pamamaraan ng

pakikipag-usap.

ART THERAPY Definition Kahulugan

Art therapy is a form of expressive Ang art therapy ay isang anyo ng therapy therapy that uses art materials, such as nagpapahayag na gumagamit ng mga paints, chalk and markers. Art therapy materyal sa sining, tulad ng mga pintura, combines traditional psychotherapeutic tisa at pang-marka. Ito ay nagsasanib ng

164

theories

and

techniques

with

an tradisyonal na teoryang psychotherapeutic

understanding of the psychological aspects at pamamaraan ng pag-unawa sa sikolohikal of the creative process, especially the na aspeto ng malikhaing proseso, lalo na sa affective properties of the different art emosyonal na pag-aari ng iba’t ibang mga materials. materyales na art.

Purposes
• • • • • •

Layunin • • • • • • • Madiskubre ang sarili Nagsasanhi ng isang emosyonal na katarsis Pangsariling Katuparan Empowerment Nagdadala ng ginhawa at nagtatangal ng stress Kaluwagan sa sintomas at pisikal na rehabilitasyon Maaari matulungan nito ang mga tao sa pamamagitan ng biswal na pagpapahayag ng damdamin at takot na hindi nila maaaring ipahayag sa pamamagitan ng pakikipagtalastasan at maaaring magbigay sa kanila ng ilang pag-unawa at kontrol sa kanilang mga damdamin Mga Patakaran

Self-discovery Triggers an emotional catharsis Personal fulfillment Empowerment Relaxation and stress relief Symptom relief and physical rehabilitation Can help people visually express emotions and fears that they cannot express through conventional means, and can give them some sense of control over these feelings

Standard Rules

1. Art materials and techniques should match the age and ability of the client.

Ang materyales at pamamaraan ay dapat na tumugma sa edad at kakayahan ng mga kliyente.

Technique 1. The therapist may have an 1. Ang

Pamamaraan therapist sa ay kliyente maaaring upang

introductory session with the clientartist to discuss art therapy techniques

magkaroon ng isang pambungad na introduksyon

165

and give the client the opportunity to ask questions about the process.

talakayin ang mga pamamaraan sa art therapy at bigyan ang client ng pagkakataon upang magtanong tungkol sa proseso.

2. The therapist ensures that appropriate materials and space are available for the client-artist, as well as an adequate amount of time for the session. 3. An appropriate workspace should 2. Ang therapist ay tinitiyak na angkop ang materyales at espasyo na gagamitin ng kliyente. Sapat din dapat ang dami ng oras para sa sesyon

be available for the creation of art. 4. The artist should have adequate

time to become comfortable with and explore the creative process.

3.

Isang sapat na espasyo ang dapat

gamitin para sa paglikha ng sining.

4. Ang pintor ay dapat magkaroon ng sapat na panahon upang maging komportable at siyasatin ang mga malikhaing proseso.

ANALYSIS • The patient draws straight lines with the colors of green, black, red, orange and yellow • He said that those are ice candies. INTERPRETATION • The patient may have a very memorable experience with regards to ice candies. • Red line indicates hostility, black for anxiety, red and yellow for spontaneous form of expression and behaviour, black represents repression,

ANALISA • Gumuhit siya ng mga tuwid na linyang may mga kulay na berde, itim, pula, dalandan, at dilaw. • Sabi niya na ito raw ay mga ice candies. INTERPRETASIYON • Maaaring mahalagang mayroong isang sa

pangyayari

buhay niya na kasama sa memorya ang ice candies. • Base sa iginuhit ng pasyente, malalaman na siya ay balisa.

166

depression and regression • The patient’s dominant interpreted behaviour is being anxious and depressed at that moment

C. Bibliotherapy

ENGLISH a. Definition a.Kahulugan

TAGALOG

Bibliotherapy is a therapy employed in which literature is used as a stimulus to initiate expression of emotions.

Ang bibliotherapy ay ang paggamit ng babasahin para makatulong sa pagpapalabas ng mga emosyon.

167

b. Purpose

The printed word may be a means of modifying or stimulating the emotions. Reading may help lift the spirit of a depressed patient, improve the attention span of the individual with limited power of concentration, relieve insomnia, stimulate the imagination, and foster desirable attitudes and in patients. Ang babasahin ay pwedeng gamitin upang mabago o makapagpahayag ng emosyon. Ang pagbabasa ay makakatulong sa pagpapataas ng mababang emosyon ng tao, makatulong sa pagkakaroon ng pokus, makakatulong kapag hindi makatulog ang isang tao, mapalawak ang imahinasyon at makatulong sa pagkakaroon ng c. Standard Rules kanainis-nais na katangian ng isang pasyente.

Principles in Selecting Reading Materials for Psychiatric Patients: a. Select literature in accordance with the patient's educational preparation, intellectual capacity and interest. b. Size up the personality of the patient and attempt to select materials which you think may be interesting. c. Avoid literature of controversial nature or the type whose attempt to stir up feeling of distress within the patient. Literature concerning medicine, psychology, psychiatric, politics, and tense murder mysteries may do patients more harm than good. d. For educational reading, choose books recommended by reliable authorities. e. History, travel, art, science, biography, and literature concerning hobbies d. sa mapagkakatiwalaan lamang kumuha ng
168

-sa pagpili ng babasahin: a. dapat pumili ng babasahin na angkop sa kakayahang mental ng pasyente. Dapat ito ibatay sa kakayahan ng pasyenteng maintindihan ang nilalaman ng babasahin. b. mamili ng babasahin na makakakuha ng atensyon ng isang tao.

c. huwag pilliin ang babasahin na magdudulot ng stress sa pasyente. Dapat ang nilalaman ay hidi tungkol sa pulitika, mga kalamidad, mga karahasan at iba pa dahil ito’y magdudulot ng hindi maganda.

are usually interesting subjects his most patients.

babasahing gagamitin sa therapy

e. kasaysayan, paglalakbay, art, siyensya, mga istorya ng buhay ng mga tao at literatura ay mga kanais-nais na babasahin na gusto karaniwan ng mga pasyente.

Ang mga babasahin ay ibinibigay sa pasyente. d. Techniques/Mechanics Tatanungin sa pasyente kung ano ang kanyang pananaw at kung ano ang kanyang masasabi Literature, such as magazines, books and other reading materials, is offered to the patient. Let his view it and asks her what part catches his attention most then the therapist to explore more about the patient's emotions and feelings. tungkol doon. Ang therapist ay maaaring maunawan at makilala ang pasyente sa pamamagitan nito dahil nakapaglalabas ang pasyente ng kanyang emosyon.

ANALYSIS • Not done INTERPRETATION • Not done

ANALISA • Hindi naisagawa INTERPRETASIYON • Hindi naisagawa

169

D. Occupational Therapy

Definition:

Kahulugan:

It is any productive, creative activity. These activities are individualized

Ito ay ang mga gawaing maunlad at malikhain. Ang mga gawaing ito ay ibabase sa pangangailangan ng pasyente at maaaring gawin ng mag-isa o ng grupo. Ang layunin nito ay magamit na ng antas sa indibidwal ng ibang ang pinakamataas kultura, kanyang tao at

depending on the client’s need and may range from individual or group tasks. The major concern is the maximization of an individual’s performance in relation to cultural, social and work environment.

makakaya na may relasyon sa kanyang pakikisama

170

kapaligiran. Purposes: Layunin:

1. To provide work training to the patient. 2. To learn money management and daily living skills. 3. To develop more positive group training skills.

1. Upang makapagbigay ng

mapag-

aaralang trabaho para sa pasyente. 2. Upang matutunan ang paghawak ng pera at ng mga pang-araw-araw na gawain. 3. Upang magkaroon ng panggrupong pag-eensayo positibo. 4. Upang matulungan ang pasyenteng umunlad 5. Upang sa kanyang napiling aktibo at ng kakayahan na

4. To help the patient succeed in the chosen occupational role.

mapagkakakitaan. mapanatiling malikhain ang pag-iisip. 6. Upang makabuo ng magandang

5. To keep mind active and creative at any rate. 6. To 7. To develop increase interpersonal sense of relationships with other patients. accomplishments, satisfaction and control over one’s life. 8. To develop interdependence. Standard Rules:

relasyon sa ibang pasyente. 7. Upang madagdagan ang pagiging bilib sa sarili, pagiging kontento at ang pagpapalakad ng sariling buhay. 8. Upang magkaroon ng malusog na pagdepende sa iba.

Mga Patakaran:

5. Provide

planned

schedule

of

5. Magbigay ng mga pinlanong gawain na makatutulong upang ang pasyente ay makaya ang kanyang mga personal na problema. 6. Magbigay makakuha ng ng pagkakataong atensyon sa

activities which aids patients in dwelling personal problems.

6. Provide opportunity for gaining

katanggap-tanggap na paraan.

171

attention in acceptable ways.

7. Magbigay interes.

ng

pagkakataong

makabuo ng malusog at maunlad na 7. Provide an opportunity for the development of healthy and productive interest. 8. Provide planned acceptable outlet for pension and hostility. 8. Magbigay ng katanggap-tanggap na gawain ng loob. kung saan kanilang mailalabas ang kanilang mga sama

Technique:

Pamamaraan:

4. The nurse must first explain to the patient what particular activity they are going to perform. Trust should be developed during this stage. 5. The patient must be given an opportunity to perform the activity. 6. During the activity, never forget to talk to your patient ways using of therapeutic communication.

7. Dapat ipaliwanag muna ng nars kung anu-anong mga gawain ang kanilang gagawin. Ang pagtitiwala ay dapat mabuo sa panahong ito. 8. Ang pasyente ay dapat mabigyan ng pagkakataong gawin ang gawain. 9. Huwag kalimutang kausapin ang pasyente Palaging therapeutic habang gumamit may ng gawain. mga

na pamamaraan ng

pakikipag-usap.

ANALYSIS • The patient cooperates with the task given to him with moderate assistance. • He tried to process how the parts of the lantern will be made.

ANALISA • Siya ay nakikipag-tulungan sa studyante sa paggawa ng parol at nakakagawa ng may sapat na gabay ng studyante. • Sinubukan iproseso ng kung pasyente paano na ang

paggawa ng parol na gamit ay papel. INTERPRETASIYON • Makikita na mayroong

INTERPRETATION • It is clear, then, that there are deficits in some aspects of information individuals processing with in mental

kakulangangan sa ibang aspeto ng pagproseso ng impormasyon ang naobserbahan sa pasyente.
172

retardation.

E. Remotivation Therapy

Definition:

Kahulugan:

It is a simple group therapy which aims to bridge the fantasy world of the psychotics to the real world. It is a technique of simple group therapy, objective in nature, used with group of patients in an effort to reach the unwounded areas of each patient’s personality and get them moving back into reality

Isang simpleng gawaing panggrupo na kung saan nilalayon nito na ipakita ang realidad. Isa itong pamamaraan na kadalasang napapatungkol sa kalikasan na kung saan hindi nito naabala ang mga sugat sa buhay ng isang tao bagkus ay pinapakita nito ang realidad ng buhay.

Purposes:

Layunin:

173

1. To stimulate patients to be fellow explore the real world. 2. *To develop their ability t pagkilalao communicated and share ideas and experiences with the other people. 3. *To develop feelings of acceptance. 4. *To promote group harmony and identification. Standard Rules:

9. upang mahikayat ang mga pasyente na lakbayin ang tunay na mundo 10. upang madebelop ang abilidad na makisalamuha sa mga tao at maibahagi ang kanilang mga ideya sa mga ito. 11. Upang madama ang pagtanggap 12. Para magkaroon ng maayos na pakikisama sa sriling grupo at magkaroon ng pagkilala sa sarili. Mga Patakaran:

1. .climate acceptance 2. bridge to reality- questions must be short and easy to understand 3. sharing the world we live in-explore the topic 4. appreciation of the works of the world-application of the topic 5. Summarize the topic, subjects to be covered: Geography, history, Literature, Science, Industry, Sports, Hobbies, Nature 6. Subjects not to be touched:Religion, Politics, Family, Problem, Sex, love

9. Pagtanggap sa klima 10. Tulay sa relidad-. Ang mga tanong ay nararapat na maikli at madaling intindihan. 11. Pagbabahagi sa kanila ng mundong ating tinitirhan – palawakin ang paksa. 12. Pagkagalak sa mnga gawa ng mundo- paggamuit ng paksa 13. Ibuod ang paksa , ang mga paksa na maaring gamitin ay ang mga sumusunod: Heyograpiya, kasaysayan, panitikan , siyensiyna , kapaligiran, laro, hilig. 14. Mga paksang hindi nararapat na talakayin: Relihiyon, politika, pamilya, problema, pakikipagtalik at pag-ibig

Technique: 7. The nurse must encourage clients feeling about the topic 8. The nurse must present the reality to the client. 9. Be natural•

Pamamaraan 1. Nararapat na iengganyo ang pasyente sa paksang tatalakayin 2. Kailangang ipakita ang realidad sa pasyente 3. Maging natural

174

10. Approach in non-urging relationship• 11. Don’t side-track into individual conversation ANALYSIS • The patient is not paying

4. Huwag silang pilitin 5. Huwag makielam sa isang usapan.

ANALISA • • Hindi siya nakikinig minsan Inuulit ng pasyente ang anumang kakarinig niya lang kapag siya ay tinanong • Inaantok ang pasyente

attention to the speakers while they are speaking sometimes • Echolalia was observed

• Somnolence was observed INTERPRETATION  Memory deficiencies interfere with learning rote material such as days of the week, months of the year, and times tables. Basic facts are hard to remember and there is a lack in knowledge of general information. There are deficits in attention and focus that interfere with ability to focus and concentrate on tasks.

INTERPRETASIYON • Mahina ang memorya ng

pasyente. May kakulangan din sa pagtuon ng atensiyon at pokus ang pasyente.

175

APPENDICES

176

National Center for Mental Health Mandaluyong City Pavilion 1

GRAND SOCIALIZATION DAY Theme: “Building Bridges towards Holistic Nursing Care”

_________________

177

PROGRAMME...

Acknowledgement:
Food – Far Eastern University (Jay Nantin Ablao R.N) Invitation- Centro Escolar University (Dovie Brabante R.N) Sounds –Metropolitan Medical Center (Precy Samson R.N) Decorations and Aftercare – LORMA Colleges (Ever C. Garcia Jr. R.N, MSN) Games – Capitol University (Honeylou Opanda R.N) Perpetual Help University of Pangasinan (Ignacia Mogro R.N)

Doxology …………Metropolitan
Medical Center

Philippine National

……...Perpetual Help
Anthem
University Capitol of Pangasinan

Calisthenics ……………
University Ever C. Garcia, MSN

Opening Remarks ……………
R.N. All

Yell and Dance ………………
Schools

Presentation Games ……………………Capitol
University

Dance for all………………. Closing Remarks ……………Evelyn
Godines,
177

Supervisor Pavilion 1

Nurse

Sign up to vote on this title
UsefulNot useful