CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF BEHAVIOUR ACUTE AND CHRONIC

NCM 117 LECTURE Prelim Notes

EVOLUTION OF MENTAL HEALTH-PSYCHIATRIC The Middle Ages

NURSING PRACTICE − Mentally ill people:
− Often imprisoned or forced to live in streets and beg for
Definition of Key Terms food.
Complimentary Therapies - unconventional therapies that − For more humane treatment, they depend on charity of
encompasses a spectrum of practices and beliefs, religious groups, who dispenses alms or food or other
including herbs, visual imagery, acupunctures, and donations to the needy or poor and ran almshouses and
massage therapy. general hospitals.
Decade of Brain - proclamation by the state Congress that − First mental asylum: St. Mary of Bethlehem
explains mental illness as a disease of the brain. It − Built in London, England during the 14th Century.
underscores the significance of technological − Conceived as a sanctuary or refuge for the destitute and
advances in neurobiology and genetics and their afflicted.
impact on understanding mental illness. − Model for similar institutions elsewhere.
Deinstitutionalization - caring for people outside the
hospital who have been previously hospitalized for
an extended period, caring for people in the
community rather than in a state facility.
Mental Health Movement - a movement that begun more
than 25 years ago that focuses on humane
treatment of the mentally ill, initially advocating
their release from state institutions to community
mental health centers.
Moral treatment - humane treatment of the mentally ill; for
The Fifteenth - Seventeenth Centuries
example, releasing clients from mechanical
− Continued skepticism about the curability of mental
restraints and improving physical care.
illness.
Psychotropics - various pharmacologic agents, such as
− Asylums became the repositories for prolonged
antidepressants and antipsychotic, antimanic and
enclosure of the mentally ill.
antianxiety agents used to affect behavior, mood
and feelings. − Insane people were treated more like animals than
Neurobiology - biology of the nervous system, particularly humans.
the brain. − Inhabitants were poorly clothed and fed; often chained
Neuroscience - the science and study of the central nervous and caged, and deprived of heat and sunlight.
system.

Early History (Ancient times) The Eighteenth Century (Period of Enlightenment)

− Insanity was associated with demonic possession. − The insane was no longer treated as less than human.
− Healers extract unseen spirits through rituals using − The concept of asylum developed from the humane
herbs, ointments and precious stones. efforts of Pinel and Tuke.
− Mental illness was perceived as incurable, and
treatment of the insane was sometimes inhumane and
brutal.

Cut from Hieronymus

Bosch, 1480: "The
Extraction of the Stone of
Madness"

1|P a g e Ma. Regina P. Maprangala BSN 3-D

Benjamin Rush (1745-1813)
− Emphasized the need for
pleasant surroundings and diversional
and moral treatment of the mentally ill.
− Treatment includes
(considered controversial): bloodletting
and the administration of cold and hot
baths, harsh purgatives, and emetics.
− Considers inducement of fright
or shock would cause the mentally ill to
regain their insanity.
− Invented the tranquilizer chair and the Gyrator.
− Tranquilizer chair- the mentally ill's extremities is
strapped down and this reduces motor and pulse rates;
thought to produce calming effect.
− Gyrator- a form of shock therapy consisting of a rotating,
swinging platform onto which the person was strapped
and moved at high speed; Thought to increase cerebral
circulation.
− Author of the first American treatise on Psychiatry:
Medical Inquiries and Observations upon the Disease of
the Mind.
Gyrator
Tranquilizer Chair
Philippe Pinel (1745-1862)
− "Advocated kindness and moral
treatment.
− Greatest impact came after he was
placed in charge of Bicerte Hospital.
− Proved that releasing the insane
from chains and providing moral
treatment improved their prospect.
William Tuke (1732-1822)
− Began a 4-yaer dynasty that
advocated humane treatment of the
mentally ill.
Franz Anton Mesmer (1734- 1815)
− Renewed the art of suggestive
healing that stemmed from the
ancient use of trances, which
became the basis of hypnosis.
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The Nineteenth Century: The Evolution of the
Psychiatric Nurse
− US and other European Countries began a movement
that championed reformation of ideas in establishing
state hospitals.
− 1772- First psychiatric hospital in America in
Williamsburg, Virginia.
− 1817 - Mclean Asylum
in Massachusetts
became the first US
institution to provide
humane treatment for
the mentally ill.
− Humane treatment-
emphasized an
environment of understanding and promoted a sense of
contentment and mental and physical health.
− Increased concerns and sensitivity to the needs of the
mentally ill generated a need for better-educated
attendants to care for severely disturbed clients.
Dorothea Lynde Dix (1802-1887)
− "A retired school teacher from
Massachusetts.
− Led crusade that brought
attention of these conditions to the public
and legislature.
− The result is an improvement in
standards of care for mentally ill which
led to proliferation of state hospitals.
Linda Richards
− The first American Psychiatric Nurse
− Graduate of New England
Hospital for Women
− Developed nursing care in state
hospitals and also directed a
school of psychiatric Nursing in
Mclean Psychiatric Asylum in
1880.
− Her efforts resulted to the
development of school for nurses
in more than 30 asylums
The Twentieth Century: The Era of Psychiatry/ Period of
scientific Study
− Exploration of the reasons for mental disease
accelerated with contributions from numerous theorists
and researchers who laid the foundation for
understanding and demystifying mental illness.
Ma. Regina P. Maprangala BSN 3-D
 Adolph Meyer (1866-1950)
− Initiated psychobiological theory
and dynamic concept of psychiatric care.
− Theory centered on treatment
rather than disease and integrated
biochemical, genetic, psychosocial, and
environmental stresses on mental illness.
Clifford Beers (1876-1943)
− Had been treated for mental illness.
− Contributed to preventive care
though his classic work, A Mind
That Found Itself, published in
1908.
− Played a major role in establishing
Mental Health Movement in New
Haven, Connecticut, in 1908 and
promoting the early detection of mental illness.
Emil Kraepelin (1856-1926)
− Devised a classification of
mental disorders.
− Shifted from an emphasis on
research in the pathobiological
laboratory to the observation and
research in conditions known as
praecox dementia and mania.
Eugen Bleuler (1857-1939)
− Coined the term schizophrenia and
included its characteristics the four as:
apathy, associative looseness, autism,
and ambivalence.
Sigmund Freud (1856-1939)
− Development
psychoanalysis, psychosexual theories,
and neurosis.
− Psychoanalysis - a method that
serves as the basis for treatment and a
theory for personality development.
Carl Gustav Jung (1875-1961)
− Founded analytic psychology.
− Proposed and originated the
concepts extroverted and
introverted personality.
− Integrated spiritual concepts,
reasoning, ancestral emotional
trends, and mysticism, and the
creative notion of human beings.
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Karen Horney (1885-1952)
− Objected to Freud's notions that
neurosis and personality development were
based on biological drives.
− Her theory suggested that neuroses
stem from cultural factors and impaired
interpersonal relationships.
Harry Stack Sullivan (1892-1949)
− Postulated the Hypothesis of
interpersonal theory and the
development of multidisciplinary
approaches to psychiatric and
milieu therapy.
− He surmised that anxiety could be
reduced through a meaningful
interpersonal relationship that
stresses the process of effective
communication.
Deinstitutionalization
− A deliberate shift from institutional care in state
hospitals to community facilities.
− Community mental health centers:
o provides less restrictive treatment located closer to
homes, families and friends.
1990s: Decade of the Brain
− Declared by the US Congress as the Decade of the Brain
− Increase in brain research; increased interest in biologic
explanations for mental disorders.
− Significant changes in public awareness which enabled
clinicians to address relatively complex topics with
patients and families.
− Nursing responded by significant augmentation of
psychobiologic content in academic nursing programs
of
and a torrent of continuing education programs.
First Psychiatric Nursing Textbook
− "Nursing Mental Diseases"
− Written by Harriet Bailey in 1920
− In 1937, psychiatric nursing became a part of the
curriculum of general nursing programs.
First Psychiatric Nursing Theorist
− Hildegard Peplau
− Developed a model for psychiatric
nursing practice
− Wrote the book "Interpersonal
Relationship in Nursing" (1952),
heavily influenced by Harry Stack
Sullivan.
Ma. Regina P. Maprangala BSN 3-D
− Emphasizes the interpersonal dimension of practice. Today:
− Wrote a history of psychiatric nursing o Bed capacity: 4,200
− Single most important figure in psychiatric nursing o Daily average in-patients: 3, 400
o 46.7 hectares
The Diagnostic "Bible" of Psychiatry o 35 pavilions/ cottages
− The Diagnostic and Statistical Manual of Mental o 52 wards
Disorders (DSM): outlines the signs and symptoms o Personnel: 1,993
required in order for clinicians to assign a specific o Doctors: 116
diagnosis to a patient. o Nurses: 375
− Has been published in six editions since its inception in o Administrative staff: 651
1952 o Medical Ancillary Personnel: 196

DSM-I ……… 1952 NCMH

DSM-II ……… 1968
− A special training and research hospital mandated to
DSM-III ……… 1980
DSM-IIIR (REVISED) ……… 1987 render a comprehensive (preventive, promotive,
DSM-IV ……… 1994 curative and rehabilitative) range of quality mental
DSM-IV-TR (text revision) ……… 2000 health services nationwide.
− Gives and creates venues for quality mental health
Five axes for the clinician to use in the assessment of the education, training and research geared towards
patient: hospital and community mental health services
Axis I: Clinical disorders (e.g., schizophrenia, major nationwide.
depression, bipolar disorder)
Axis II: Personality or developmental disorders (e.g.,
paranoid and borderline personality disorders,
mental retardation)
Axis III: General medical conditions that relate to axis I or II
or have bearing on treatment (e.g., neoplasms,
endocrine disorders)
Axis IV: Severity of psychosocial stressors (e.g., divorce,
housing, educational issues)
Axis V: Global assessment of functioning, on a scale of 0 to
100 (e.g., score of 30 means that the patient's
behavior is highly influenced by delusions and
hallucinations)

History of the National Center for Mental Health

National Center for Mental Health (NCMH)
− Was established thru Public Works Act 3258
− Was first known as Insular Psychopathic Hospital,
situated on a hilly piece of land in Barrio Mauway,
Mandaluyong, Rizal and was formally opened on
December 17, 1928.
− Later known as National Mental Hospital
− November 12, 1986:
was given its present
name National Center
for Mental Health
thru Memorandum
Circular No. 48 of the
Office of the President
− January 30, 1987:
categorized as Special Research Training Center and
Hospital under the DOH

4|P a g e Ma. Regina P. Maprangala BSN 3-D

 PSYCHIATRIC NURSING
Health (WHO)
− It is a state of complete physical, mental, and social well-
being and not merely the absence of disease and
infirmity.
Mental Hygiene
− The branch of psychiatry that deals with the science and
practice of maintaining and restoring mental health, and
of preventing mental disorder through education, early
treatment, and public health measures.
Mental Hygiene
− Science of maintaining mental health and preventing
disorders to help people function at their full mental
potential
6 Techniques to Take Care of Our Mental Hygiene
By: Edward G. Brown
1. Transcend the environment
2. Cultivate constructive acceptance
3. Visualize the ideal self
4. Use positive affirmation
5. Practice psychological counterpunching
6. Change your internal computer chip
Mental Health
− It is a state of emotional, psychological and social
wellness evidence by satisfying interpersonal
relationships, effective behavior and coping, a positive
self-concept and emotional stability.
− It is a psychological state of well-being, characterized by
continuing personal growth, a sense of purpose in life,
self- acceptance, and positive relations with others.
− It is the absence of mental illness.
− It is the ability to solve problems, fulfill one’s capacity
for love and work, cope with crisis without assistance
beyond the support of family and friends, and maintain
a state of well-being by enjoying life’s setting goals and
realistic limits, and becoming independent,
interdependent, or dependent as the need arises
without permanently losing one’s independence.
Factors influencing mental health
1. Inherited characteristics
2. Nurturing childhood
3. Life’s circumstances
Ways to maintain mental health
a) Good interpersonal communication
b) Ego defense mechanisms
c) Significant others or support people.
d) Involvement in physical activities
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Characteristics of Mental Health
• Accepts self and others
• Is able to cope with or tolerate stress
• Can return to normal functioning if temporarily
disturbed
• Is able to form close and lasting relationship
• Uses sound judgment to make decisions.
• Accepts responsibility for actions
• Is optimistic
• Recognizes limitations (abilities and deficiencies)
• Can function effectively and independently
• Is able to distinguish imagined circumstances from
reality
• Is able to develop potential talents to fullest extent
• Is able to solve problems
• Can delay gratification
• It reflects a person’s approach to life by communicating
emotions, giving and receiving, working alone as well as
with others, accepting authority, displaying a sense of
humor, and coping successfully with emotional conflict.
Mental Disorder (APA)
− It is a clinically significant behavioral or psychological
syndrome or pattern that occurs in an individual and
that is associated with present distress or disability or
with a significantly increased risk of suffering death,
pain, disability or an important loss of freedom.
Characteristics of Mental Illness
• Feels inadequate
• Has poor self- concept
• Is unable to cope
• Exhibits maladaptive behavior
• Is unable to establish a meaningful relationship
• Displays poor judgment
• Is irresponsible or unable to accept responsibility for
actions
• Is pessimistic
• Does not recognize limitations, exhibits dependency
needs because of feelings of inadequacy.
• Is unable to perceive reality
• Does not recognize potentials and talents because of
poor self-concept.
• Avoids problems rather than coping with them or
attempting to solve them
• Desires or demands immediate gratification
• It reflects a person’s inability to cope with stress,
resulting in disruption, disorganization, inappropriate
reactions, unacceptable behavior, and the inability to
respond according to the person’s expectations and the
demands of society.
Ma. Regina P. Maprangala BSN 3-D
Psychiatry
− It is the science of curing or healing of the psyche.
− It is the medical specialty that is derived from the study,
diagnosis, treatment and prevention of mental
disorders.
Psychiatric Nursing
− It is the ‘diagnosis and treatment’ of human responses to
actual and potential mental health problems.
− It is a specialized area of nursing practice, employing
theories of human behavior as its science and
purposeful use of self as its art. (ANA)
− It is an interpersonal process that strives to promote
and maintain behavior which contributes to integrated
functioning. (Gail Stuart)
− It is an interpersonal process whereby the professional
nurse practitioner assists an individual, family and
community to promote health, to prevent or cope with
the experience of mental illness and suffering and if
necessary to find meaning in these experiences.
(Travelbee)
Selected Nursing Interventions that are Commonly Used
in Psychiatric Nursing
o Active listening ○ Anger control assistance
o Assertiveness training ○ Behavior management
o Body image enhancement ○ Caregiver support
o Delusion management ○ Grief work facilitation
o Hallucination management ○ Impulse control training
o Milieu therapy ○ Mood management
o Role enhancement ○ Sleep enhancement
o Spiritual support ○ Suicide prevention
o Substance abuse treatment ○ Teaching
o Communication enhancement
o Eating disorders management
Philosophical beliefs related to the effective practice of
Psychiatric Nursing
− The individual had worth and dignity
− The goal of the individual is one of growth, health,
autonomy, and self- actualization.
− Every individual has the potential to change and the
desire to pursue personal goals.
− The person functions as a holistic being that acts on,
interacts with, and reacts to the environment as a whole
person. Each part affects the total response.
− All people have common, basic, and necessary human
needs.
− All behavior is meaningful
− Behavior consists of perceptions, thoughts, feelings and
actions
− Individuals vary in their coping capacities, which
depend on genetic endowment, environmental
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influences, nature & degree of stress and available
resources.
− Illness can be a growth- producing experience.
− All people have a right to equal opportunity for
adequate care regardless of gender, race, religion, ethics,
sexual orientation, or cultural background.
− Mental health is a critical and necessary component of
comprehensive health care services.
− The person has the right to participate in decision- making.
Use of Psychiatric-Mental Health Nursing Skills in Career
Opportunities
A. Obstetric Nursing
− Helping the mother in labor and support person cope
with anxiety or stress during labor and delivery.
− Providing support to the bereaved parents in the event
of fetal demise, inevitable abortion, or the birth of an
infant with congenital anomalies.
− Providing support to a mother considering whether to
keep her child or give the child for adoption.
B. Forensic Nursing
− Providing services to incarcerated clients
− Acting as consultant to medical and legal agencies
− Serving as an expert witness in a court
− Providing support for victims of violent crimes.
C. Oncologic Nursing
− Helping cancer patients or other terminally ill
individuals on oncologic units work through the
grieving process.
− Providing support groups to families of terminally ill
patients.
D. Industrial (Occupational Health) Nursing
− Implementing or participating in industrial substance
abuse programs for employees and their families.
− Providing crisis intervention during an industrial
accident or acute onset of a physical or mental illness
− Teaching stress management
E. Public Health Nursing
− Assessing the person both physically & psychologically
(e.g. the newly diagnosed diabetic client may develop a
low self- concept, or the recovering stroke client may
exhibit symptoms of depression due to slow recovery)
F. Office Nursing
− Assisting the client by explaining somatic or emotional
concerns during the assessment process
− Providing support with problem-solving process when
people call the office and the physician is unavailable.
− Acting as community resource person
Ma. Regina P. Maprangala BSN 3-D
G. Emergency Room Nurse
− Providing crisis intervention as the need arises (e.g.
during natural disasters, accidents, or unexpected
illnesses causing increased anxiety, stress or
immobilization)
Roles And Functions of Mental Health and Psychiatric
Nurse
− The mental health and psychiatric nurse provide direct
care to patients with mental or emotional disorders,
including:
• Promoting self-care and independence.
• Assisting with problem solving to facilitate
activities of daily living.
• Aiding communication and interpersonal
relations
• Helping the client examine behaviors the test
alternatives.
• Teaching about the disorder
• Administering prescribed medications and
treatments
− The nurse is also responsible for constructing and
maintaining a therapeutic environment.
− Patient and family teaching
− She also coordinates in diverse aspects of care
− Acting as an advocate on behalf of the patient and
family, she:
• Teaches about rights and responsibilities
• Shares information about self- help groups
− Responsibilities associated with primary prevention
include:
• Teaching principles of mental health
• Teaching how to recognize and reduce stress
• Promoting effective family functioning
• Participating in community activities related to
mental health promotion.
DSM 5
− Released in 2013 by APA
− It is the listing of officially recognized mental disorders.
− Is intended to assist researchers, health care providers,
insurance providers, regulatory institutions, and other
parties in the medical field in guiding treatment of
mental health issues.
7 Biggest Changes from DSM IV-TR to DSM 5
1. Modification of Artificial Categorization
− The use of multi-axial system to group disorders
into 5 categories is no longer used
− The categorization has been simplified to clarify
relationships between different disorders
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2. The Autism Spectrum
− The previous categories of autism were Asperger’s,
childhood disintegrative disorder, and pervasive
developmental disorder are no longer used.
− It is now unified as autism spectrum disorder
3. Elimination of Childhood Bipolar Disorder
− In response to an observed trend of harmful over-
diagnosis and over-treatment of childhood bipolar
disorder, the DSM 5 removes this disorder and
replaces this with Disruptive Mood Dysregulation
Disorder (DMDD), it does provide a new diagnosis
that more accurately matches a set of symptoms
characterized by extreme temper outbursts
4. Revisions of ADHD Diagnosis
− DSM 5 broadens the ADHD diagnosis, allowing for
adult-onset and relaxing the strictness of the
criteria to more accurately reflect new research on
this bipolar. Given that adults have more developed
brains and generally greater impulse control, adults
can now be diagnosed with ADHD if they have fewer
signs and symptoms than children do.
5. Increasing Detail on PTSD Diagnosis
− Partly due to the wars in Iraq and Afghanistan,
medical researchers have gained a great deal more
insight into PTSD in the last 15 years.
− The DSM-5 reflects this increased understanding,
adds nuance for children with PTSD, and describes
four main types of symptoms:
1. Arousal
2. Avoidance
3. Flashbacks
4. Negative impacts on thought patterns and
mood
6. Reclassification of Dementia
− In DSM-5, both dementia and the category of
memory/ learning difficulties called amnestic
disorders have been subsumed into a new category,
neurocognitive Disorder.
− The DSM-5 splits this disorder into 2 broad
severities (major and mild) to encourage early
detection and treatment of these issues
7. Intellectual Disability
− To reflect common language, the issues previously
referred to as “mental retardation” are now
classified as “intellectual disability”
− It also uses the term Intellectual Development
Disorder.
− The diagnostic criteria for this disorder have also
been updated to more strongly focus on adaptive
functioning, rather than IQ score.
Ma. Regina P. Maprangala BSN 3-D
 BASIC CONCEPTS OF PERSONALITY DEVELOPMENT
Personality
− Early established behavior patterns related to how one
thinks, feels and relates to the environment and to
others.
− The sum total of one’s behaviors (John Watson)
− It is complex, dynamic and unique
General concepts
1. Behaviors have meaning and can be understood
2. All behavior is goal-oriented
3. Emotionally painful experience/anxiety motivates
behavior.
4. The early years of life are extremely important to
personality development.
Factors that influence personality
• Heredity
• Environment
• training
Theories Of Personality Development
Different theories view the life cycle through their
own discipline and individual theories of personality
development.
The contribution of Freud, Erikson, Sullivan an
Piaget form the theoretical foundation in the practice of
nursing and medicine.
Sigmund Freud (1856-1939)
− An Austrian psychiatrist and the founder of
psychoanalysis
− He also stressed that early childhood experiences are
important in the development of personality.
4 Major Components of Personality Development
• Levels of awareness
• Personality structure
• Concept of anxiety and defense mechanism
• Psychosexual stages of development
Levels of awareness
1. Conscious
− Part of the mind which functions when the person is
awake and that makes a person a thinking being.
− Focus on the here and now
− Past experiences are recalled without exerting
effort.
− Corresponds to the ‘ego’ or ‘self’
− It is logical and regulated by the reality principle.
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2. Preconscious/ sub conscious
− Part of the mind in which ideas and reactions are
stored and partially forgotten
− Acts as a watchman, it prevents unacceptable,
disturbing unconscious memories from reaching the
conscious mind
− Thoughts and experiences can be recalled at will.
− This is manifested during “tip of the tongue”
experience.
3. Unconscious
− Largest part of the mind which exerts greatest
influence in one’s personality. It is the storehouse
for all experiences, memories and feelings
experienced by the individual in his entire life.
− the memories cannot be recalled at will only
through hypnotism, psychoanalysis or drugs
(hallucinogens)
− The unconscious part of the mind can be expressed
as: dreams, slips of the tongue (Freudian slip),
unexplained behavior, jokes, lapses of memories
Components/ Structure of Personality
1. ID
− Unconscious part of the person which serve as the
reservoir of primitive and biologic drives and urges
(libido-sexual drives)
− It is primitive, it demands immediate satisfaction
− Functions according to pleasure principle
2. Ego “self”
− Begins to develop during the 4th and 5th month.
− Known as the integrator of personality
− Operates on reality principles
− Controls and regulates instinctual drives.
− Mediates between id drives and demands of reality.
− Evaluates and judges external world.
− Stores up experiences in ‘memory’
− Solves problems
− Uses defense mechanisms to protect self
3. Super-ego “the conscience”
− Internal representative of the values, ideals, and
moral standards of society.
− The ‘moral arm’ of the personality
− Develops at 3 to 5 years (phallic) pre-school age
− It strives for perfection rather than pleasure and
represents the ideal rather than the real
2 Sub-Systems
a. Conscience - parents view as improper- punish the
child- guilt (maladaptive behavior as seen in
depression)
b. Ego-ideal - what parents approve of and what they
reward will be incorporated as the ego-ideal
Ma. Regina P. Maprangala BSN 3-D
− Living up to one’s ego-ideal results in the person’s
feeling proud and increases self-esteem.
− Strict super ego- leads to rigid, compulsive, unhappy
person
− Weak/defective super ego- leads to antisocial behavior,
hostility, anxiety or guilt
THEORY OF PSYCHOSEXUAL DEVELOPMENT
1. Oral 0 - 1 1/2 Years Old
− Erogenous zone/pleasure and gratification- MOUTH
− Narcissistic-self love
− Behaviors: dependency, eating, crying, biting,
sucking
− Primary conflict is weaning
− Tasks: mastery of gratification of oral needs,
beginning of ego development
− Desired outcomes: trust in the environment
develops with the realization that needs can be met.
− Possible personality traits: fixation at the oral stage
is associated with passivity, gullibility and
dependence, the use of sarcasm and the
development of orally focused habits e.g. nail biting
and smoking
2. Anal 11/2 – 3 Years Old
− Anus- site of tension and sensual gratification
− Terrible twos
− Pleasure through elimination or retention of feces
− Behaviors: control of (defiance) or letting go
− Primary conflict: toilet training
− Cues to readiness for toilet training
a. Can stand alone
b. Can walk steadily
c. Can keep themselves dry in an interval of at
least 2 hours
d. Can demonstrate awareness of defecating and
voiding
e. Is able to use words and gestures regarding
toilet training and toilet needs
f. Has desire of pleasing the primary care giver
g. Age at which toilet training is achieved:
o Bowel control- 18 months
o Daytime bladder control- 21/2 years
o Nighttime bladder control- 3 years
− Possible personality traits:
a. Fixation associated with anal retentiveness:
stinginess, rigid thought process/patterns,
frugality
b. Anal expulsive character: messiness,
destructiveness, cruelty, temper tantrums
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3. Phallic- 3 - 6 Years Old
− Genital region: source of pleasure/ erogenous zone
− Behaviors: touching of genitals (masturbation)
erotic attachment to the parent of the opposite sex.
Sexual identity with parent of the same sex
− Beginning of super ego development
− Boys develop castration anxiety
− Major conflict is Oedipus/ Electra complex
− Unresolved outcomes may result to difficulties with
sexual identity and difficulties with authority
figures.
− Fixation: masturbation
4. Latency (6 - 12 Years)
− Stage of development marked by expanding peer
relationship
− Libidinal energy is not focused on any one area in
the body
− Libido is channeled into school, home, organization
activities, hobbies, relationship with peers
− Time to increase intellectual activity
− They are very modest. They refuse to expose their
bodies for physical examination.
− Significant others are the schoolmates and
neighbors.
− Fixation may result to feeling of inadequacy and
inferiority
5. Genital (13 - 20 Years)
− The period of storm and stress
− Sexual pleasure through genitals (sexual
intercourse)
− Behaviors: becomes independent of parents,
responsible for self, develops sexual identity, ability
to love and work.
− Fixation: emotional and financial dependence,
inability to form satisfying and intimate relationship
PSYCHOSOCIAL STAGES OF DEVELOPMENT
− Founded by Erik Erikson - an American psychoanalyst
and a close follower of Freud.
− Born in Frankfurt, Germany
− Each stage is confronted with a major problem that is
really
− Emphasized on psychosocial than psychosexual
1. Trust Vs. Mistrust- 0 To 18 Months
− Needs are met unconditionally
− Mother plays a crucial role
− Learns to trust self and others vs. withdrawal
− Time when a child would most likely develop
separation anxiety
Ma. Regina P. Maprangala BSN 3-D
2. Autonomy Vs. Shame & Doubt (18 Months - 3 Years
Old)
− Fear of being unacceptable to others
− It is characterized by clear assertions of ego which may
result to non-compliance behavior
INTERPERSONAL MODEL
Harry Stack Sullivan (1892-1949)
− American born theorist in Dynamic Psychiatry
− Behavior motivated by need to avoid and satisfy needs.

3. Initiative Vs. Guilt (3-5 Years) 1. Infancy (0-18 Months)

− Development of super ego − Others will satisfy needs
− Learns to influence the environment − Type of play: solitary play
− Evaluates one’s behavior vs. fear of doing wrong, lack of
self-confidence, over restricting actions 2. Toddlerhood (11/2 -3 Years)
− Headstrong and negativistic
4. Industry Vs. Inferiority (5-13 Years Old) − Favorite word is “NO”
− Creative − Naturally active, mobile and curious which make
− Develop sense of competency vs. sense of inadequacy them vulnerable to accident
− An apprentice in the art of learning the tasks of − Temper tantrums are common
adulthood − Type of play: parallel play

5. Identity Vs. Role Diffusion (13 -21 Years) 3. Pre-Schooler

− The search for identity − Known as later childhood
− Develop a sense of self, planning for adult roles vs. − Love to watch adults and would imitate them
doubts relating to sexual identity, occupation/ career − They are creative and curious
− Emancipation from family, heterosexual relationship, − Favorite word is “WHY”
develops ideology and philosophy in life − They love to tell ‘lies’, to brag and boast in order to
− Highest incidence of schizophrenia impress others
− Very imaginative; imaginary playmates are common
6. Intimacy Vs. Isolation (21-39 Years) − Love offensive language
− Early adulthood − Questions about sex should be answered honestly at
− Develop intimate relationship with others, commitment the level of their understanding
to career vs. avoidance of choices in relationship or life − Type of play: associative or cooperative play
style
− The ability to love and be compassionate 4. Schooler
− 2 period or era
7. Generativity Vs. Stagnation (40-65 Years) a. Juvenile era (6-10 years old)
− Middle age o They turn away from their parents and
− Willingness to assume responsibility for others would look to peers of the same sex to fill
− Productive; use of energies to guide next generation vs. the functions of providing him sense of
lack of interest, concern with own self security and companionship.
o Period of gang loyalties
8. Integrity Vs. Despair (65 Years Old - End of Life) o Child acquires the very important
− Later years interpersonal tools:
− Feelings of self-acceptance 1. Ability to compete
− Sense of dignity, worth and importance 2. Ability to compromise
− Wisdom is achieved b. Pre adolescence (11-12 years old)
− Fear of death o Ability to develop the ability to experience
− Period of reminiscence intimacy
o Chum relationship- an intense love
relationship with a particular person of the
same sex whom the child perceives to be
very similar to himself
o Learns to put other need of his need

10 | P a g e Ma. Regina P. Maprangala BSN 3-D

5. Adolescence (12-18 Years Old) ! No stage is ever skipped
▪ Establish relationship with the opposite sex ! The stages are somewhat related to chronological age
▪ Experience sexual urges termed by Sullivan (lust) ! Each individual reaches each stage according to his or
▪ Development of heterosexual relationship her own time table.

6. Young Adulthood or Late Adolescence Other theories of Personality

▪ There is an incorporation of lust (which developed 1. Carl Gustav Jung - a Swiss psychiatrist
in early adolescence with a chum in heterosexual o He believed that libido was broadly derived
relationship from life energy not just from sex.

THEORY OF COGNITIVE DEVELOPMENT 2. Otto Rank - Austrian psychologist/ Psychotherapist-

Jean Piaget (1896-1980)
− A Swiss psychologist.
− After earning a doctorate in Zoology in his hometown in
Switzerland, he went to explore the field of psychology
because according to him humans like living organisms
adapt to their environment.
− He used the word SCHEMATA to refer to the child’s
cognitive structure or framework of thought.
− Cognition is the process of thinking, knowing and
perceiving
first student of Freud
o ‘Birth trauma’ causes primal anxiety
3. Adolf Meyer - Swiss born American psychiatrist.
o Originator of the word ‘mental hygiene’
o Emphasizes on considering the total individual
from all points of view ‘HOLISM’
4. Alfred Adler – Austrian Psychologist
o Coined the word ‘inferiority complex’
o Emphasized ego rather than sexuality.

The child’s interaction with the environment comprises:

a. Assimilation - involves taking in the experiences
from the from the environment.
b. Accommodation - occurs when what is taken in
from the environment does not match the existing
structure and thus changes the structure to match
the new information.
c. Organization - is the process of placing one’s ideas
into a coherent state of order.

These processes are constantly working together to produce

changes in the growing child’s understanding of the world.

4 Major Stages in the Cognitive Development

1. Sensorimotor Period (0-2 Years Old)
− self-exploration of objects

2. Pre-Operational Period (2-7 Years Old)

− at the end of this stage, reasoning becomes
intuitive. The child begins to work with
problems of weight, length, size and time

3. Period Of Concrete Operations (7-11 Years Old)

− sort, classify, order and organize facts of the
world. Collects everything and classify

4. Period Of Formal Operations (11 Years Through

Adulthood)
− Able to deal with abstract symbols, solve
problems, develop hypotheses, test them and
reach conclusion.

11 | P a g e Ma. Regina P. Maprangala BSN 3-D

 INTELLECTUAL DEVELOPMENT DISABILITY
Intellectual And Developmental Disabilities (Idds)
− are disorders that are usually present at birth and
that negatively affect the trajectory of the
individual’s physical, intellectual, and/or emotional
development.
− Many of these conditions affect multiple body parts
or systems.
Intellectual disability starts any time before a child
turns 18 and is characterized by problems with both:
• Intellectual functioning or intelligence, which
include the ability to learn, reason, problem
solve, and other skills; and
• Adaptive behavior, which includes everyday
social and life skills.
Mentally or developmentally challenged
The presence of sub average general
intellectual functioning (an IQ of approximately 70 or
below) associated with or resulting in impairments in
adaptive skills.
It occurs twice frequently in male as in female
children.
They experience of exhibit significant
limitations in at least 2 of the following skill areas:
communication, self-care, home living, social/
interpersonal skills, use of community resources, self-
direction, functional academic skills, work, leisure,
health and safety
Associated features include irritability,
aggressiveness, temper tantrums, stereotyped
repetitive movements, nail biting, and stuttering.
It is not a disease
It is not synonymous to mental illness.
There is no cure for mental retardation;
however, most children with these disorders can learn
to do many things
According to American Association of Mental
Deficiency stressed that IDD is the deficit in adaptive
behavior along with intellectual impairment.
Etiology
1. Genetic conditions: sometimes caused by
abnormal genes inherited from parents, errors
when genes combine, or other reasons.
✓ Down syndrome
✓ Fragile X syndrome- genetic abnormality
✓ Phenylketonuria (PKU)
2. Problems during pregnancy: can result when the
baby does not develop inside the mother properly.
✓ There may be problems with the way the
baby’s cell divide as it grows.
12 | P a g e
✓ A woman who drinks alcohol or gets an
infection like rubella during pregnancy.
✓ Preeclampsia, drug abuse
3. Problems at birth: if baby has problems during
labor and birth, such as not getting enough oxygen.
✓ Injury to the brain suffered during pre-peri and
post-natal period
✓ Cranial malformations such as micro-macro
cephalus
4. Health problems: diseases like whooping cough,
measles, and meningitis, malnutrition, not getting
enough medical care.
✓ Severe neglect or abuse
✓ Exposure to poisons like lead and mercury
✓ Environmental factors: poverty
Severity/Degrees
− Individuals with ID typically has intellectual
functioning that is significantly below average, an
IQ score of around 70 to 75 or lower, and deficits in
conceptual, social and practical skills.
− The severity of the intellectual deficit is classified
as mild, moderate, severe and profound.
− These levels of severity are not based upon IQ but
by evaluating the individual’s ability to perform
day-to-day life skills and activities, as this is what
determines how much support the individual
needs.
Mild
− I.Q. 55 to 70
− None in early childhood
− Can achieve a mental age of 8 to 12 years
old
− Sixth grade level by late teens
− Difficulty adapting to school
− May need assistance when experiencing
social or academic stress
− 85% of all persons with IDD
− Can achieve social and vocational skills for
minimum self-support
− “educable”- can acquire academic skills up
to approximately sixth grade level.
− Can read, write or do arithmetic
Moderate
− I.Q. 35 to 55
− Poor awareness of the needs of others
− Usually no progression beyond second
grade level.
− Need moderate supervision due to self-care
deficit.
− Require supervision and guidance under
mild social or economic stress
Ma. Regina P. Maprangala BSN 3-D
 − 10% of all persons with mental retardation.
− May profit from vocational training
− Can function in sheltered workshops as
unskilled or semi-skilled persons.
− Can achieve a mental age of 3 to 7 yrs. Old.
− “trainable”
− Offer simple, repetitive tasks because it
facilitates learning.
Severe
− I.Q. 25 t0 35
− Poor motor development and minimal
speech.
− Unable to learn academic skills but may
learn to talk and be trained in elementary
hygiene skills or activities of daily living.
− Require complete supervision in a
controlled environment.
− Can achieve a mental age of 0 to 2 years old.
− 3% To 4% of all persons with IDD.
− May learn to perform simple work tasks.
Profound
− I.Q. below 20 0r 25
− Minimal capacity for sensorimotor
functioning.
− Require total nursing care and highly
structured environment with supervision
due to self-care deficit.
− 1% to 2% of all persons with IDD
− “custodial”- requires total care.
− May attain a mental age of young infant
− Does not relate with peers; more secure
with adults
− Comforted by physical touch
− May repeat words
− Short attention span but usually attracted
to music
Signs of IDD
1. Sit up, crawl, or walk later than other children.
2. Learn to talk later, or have trouble speaking.
3. Find it hard to remember things.
4. Not understand how to pay for things
5. Have trouble understanding social rules.
6. Have trouble seeing consequences of actions.
7. Have trouble solving problems.
8. Have trouble thinking logically
How to diagnose intellectual disability
Three things factor into the diagnosis of intellectual
disability:
1. interviews with the parents
2. observation of the child
3. testing of intelligence and adaptive behaviors.
13 | P a g e
How to diagnose intellectual disability
A child is considered intellectually disabled if
they have deficits in both IQ and adaptive behaviors.
If only one or the other is present, the child is not
considered intellectually disabled.
After a diagnosis of intellectual disability is
made, a team of professionals will assess the child’s
particular strengths and weaknesses. This helps them
determine how much and what kind of support the
child will need to succeed at home, in school, and in the
community.
Skills that could be taught
1. Communicating with others
2. Taking care of personal needs (dressing, bathing,
going to the bathroom)
3. Health and safety
4. Home living (helping to set the table, cleaning the
house, or cooking dinner
5. Social skills (manners, knowing the rules of
conversation, getting along in a group, playing a
game)
6. Reading, writing and basic math
7. As they get older, skills that will help them in the
workplace
Steps to help intellectually disabled child
1. Learn everything you about intellectual disabilities.
The more we know, the better advocate we can be
for your child.
2. Encourage the child’s independence. Let the child
try new things and encourage to do things by
themselves. Provide guidance when it’s needed and
give positive feedback when the child does
something well or masters something new.
3. Get the child involved in group activities. Taking an
art class or participating in Scouts will help the
child build social skills.
4. Stay involved. By keeping in touch with the child’s
teachers, parents should be able to follow their
progress and reinforce what the child is learning at
school through practice at home.
5. Get to know other parents of intellectually disabled
children. They can be a great source of advice and
emotional support.
AUTISM SPECTRUM DISORDER
− Is a condition related to brain development that
impacts how a person perceives and socializes with
others, causing problems in social interaction and
communication.
− The disorder also includes limited and repetitive
patterns of behavior
− The term "spectrum" in autism spectrum disorder
refers to the wide range of symptoms and severity.
Ma. Regina P. Maprangala BSN 3-D
− Autism spectrum disorder includes conditions that
were previously considered separate — autism,
Asperger's syndrome, childhood disintegrative
disorder and an unspecified form of pervasive
developmental disorder.
− Some people still use the term "Asperger's
syndrome," which is generally thought to be at the
mild end of autism spectrum disorder.
− Begins in early childhood and eventually causes
problems functioning in society — socially, in
school and at work, for example.
− Symptoms of autism within the first year.
− A small number of children appear to develop
normally in the first year, and then go through a
period of regression between 18 and 24 months of
age when they develop autism symptoms.
− While there is no cure for autism spectrum
disorder, intensive, early treatment can make a big
difference in the lives of many children.
− A brain disorder that affects 1 to 2 in 1,000
Americans
− 75% of children with autism have IDD.
− 5 to 10% of patients have an identifiable
chromosomal
− Impairment in development and use of language.
− This often results to lifetime of impaired thinking,
feeling and social functioning- the most unique
human attributes
− Develops before age 3.
− Withdrawal of the child into the self and into a
fantasy world of his own creation.
− Cha. By a combination of impaired social
interaction, impaired verbal and nonverbal
communication and unusual or bizarre activities
− The disorder is rare, occurs 4 times more often in
males than in female.
− Common in the upper socioeconomic classes.
− Course is chronic & often persisting into adulthood
Predisposing factors
1. Psychodynamic theory
− Fixed in the pre symbiotic phase of development.
− Does not achieve a symbiotic relationship with nor
differentiate self from mother
− Ego development is delayed.
− The child does not communicate or form
relationships
2. Biologic theories
− genetics/ chromosomal abnormality
− Neurotransmitter abnormality
− Brain structure abnormality
− Prenatal infections
− Peri natal insults
− Metabolic disorders
14 | P a g e
Risk factors
Sex
− Boys are about four times more likely to develop
autism spectrum disorder than girls are.
Family history
− Families who have one child with autism spectrum
disorder have an increased risk of having another
child with the disorder.
− It's also not uncommon for parents or relatives of a
child with autism spectrum disorder to have minor
problems with social or communication skills
themselves or to engage in certain behaviors
typical of the disorder.
Other disorders
− Children with certain medical conditions have a
higher-than-normal risk of autism spectrum
disorder or autism-like symptoms.
• fragile X syndrome, an inherited disorder that
causes intellectual problems
• tuberous sclerosis, a condition in which benign
tumors develop in the brain
• Rett syndrome, a genetic condition occurring
almost exclusively in girls, which causes
slowing of head growth, intellectual disability
and loss of purposeful hand use.
Extremely Preterm Babies
− Babies born before 26 weeks of gestation may have
a greater risk of autism spectrum disorder.
Parents' ages
− There may be a connection between children born
to older parents and autism spectrum disorder, but
more research is necessary to establish this link.
Complications
Problems with social interactions,
communication and behavior can lead to:
• Problems in school and with successful
learning
• Employment problems
• Inability to live independently
• Social isolation
• Stress within the family
• Victimization and being bullied
Symptoms
− Some children show signs of autism spectrum
disorder in early infancy, such as reduced eye
contact, lack of response to their name or
indifference to caregivers.
− Other children may develop normally for the first
few months or years of life, but then suddenly
Ma. Regina P. Maprangala BSN 3-D
 become withdrawn or aggressive or lose language
skills they've already acquired.
− Signs usually are seen by age 2 years.
− Each child with autism spectrum disorder is likely
to have a unique pattern of behavior and level of
severity — from low to high functioning.
− Some children with autism spectrum disorder have
difficulty learning, and some have signs of lower-
than-normal intelligence.
− Other children with the disorder have normal to
high intelligence — they learn quickly, yet have
trouble communicating and applying what they
know in everyday life and adjusting to social
situations.
− The unique mixture of symptoms can sometimes
be difficult to determine. It's generally based on the
level of impairments & how they impact the ability
to function.
Social communication and interaction
A child or adult with autism spectrum disorder
may have problems with social interaction and
communication skills, including any of these signs:
1. Fails to respond to his or her name or appears
not to hear you at times
2. Resists cuddling and holding, and seems to
prefer playing alone, retreating into his or her
own world.
3. Has poor eye contact and lacks facial
expression.
4. Doesn't speak or has delayed speech, or loses
previous ability to say words or sentences
5. Can't start a conversation or keep one going, or
only starts one to make requests or label items.
6. Speaks with an abnormal tone or rhythm and
may use a singsong voice or robot-like speech
7. Repeats words or phrases verbatim, but
doesn't understand how to use them.
8. Doesn't appear to understand simple questions
or directions
9. Doesn't express emotions or feelings and
appears unaware of others' feelings.
10. Doesn't point at or bring objects to share
interest
11. Inappropriately approaches a social interaction
by being passive, aggressive or disruptive.
12. Has difficulty recognizing nonverbal cues, such
as interpreting other people's facial
expressions, body postures or tone of voice.
Patterns of behavior
A child or adult with autism spectrum disorder
may have limited, repetitive patterns of behavior,
interests or activities, including any of these signs:
1. Performs repetitive movements, such as rocking,
spinning or hand flapping
15 | P a g e
2. Performs activities that could cause self-harm, such
as biting or head-banging
3. Develops specific routines or rituals and becomes
disturbed at the slightest change
4. Has problems with coordination or has odd
movement patterns, such as clumsiness or walking
on toes, and has odd, stiff or exaggerated body
language
5. Is fascinated by details of an object, such as the
spinning wheels of a toy car, but doesn't
understand the overall purpose or function of the
object
6. Is unusually sensitive to light, sound or touch, yet
may be indifferent to pain or temperature
7. Doesn't engage in imitative or make-believe play
8. Fixates on an object or activity with abnormal
intensity or focus
9. Has specific food preferences, such as eating only a
few foods, or refusing foods with a certain texture
As they mature, some children with autism
spectrum disorder become more engaged with others
and show fewer disturbances in behavior.
Some, usually those with the least severe
problems, eventually may lead normal or near-normal
lives.
Others, however, continue to have difficulty
with language or social skills, and the teen years can
bring worse behavioral and emotional problems.
When to see a doctor
1. Doesn't respond with a smile or happy
expression by 6 months
2. Doesn't mimic sounds or facial expressions by
9 months
3. Doesn't babble or coo by 12 months
4. Doesn't gesture — such as point or wave — by
14 months
5. Doesn't say single words by 16 months
6. Doesn't play "make-believe" or pretend by 18
months
7. Doesn't say two-word phrases by 24 months
8. Loses language skills or social skills at any age
Treatment
No cure exists for autism spectrum disorder,
and there is no one-size-fits-all treatment. The goal of
treatment is to maximize the child's ability to function
by reducing autism spectrum disorder symptoms and
supporting development and learning.
Early intervention during the preschool years
can help your child learn critical social,
communication, functional and behavioral skills.
Ma. Regina P. Maprangala BSN 3-D
Treatment options Nursing Interventions
1. Behavior And Communication Therapies 1. provide parents/ family with support and
− Many programs address the range of social, information
language and behavioral difficulties associated 2. Assist child with activities of daily living
with autism spectrum disorder. 3. Promote reality testing
− Some programs focus on reducing problem 4. Encourage child to develop a relationship with
behaviors and teaching new skills. another person
− Other programs focus on teaching children how to 5. Maintain regular schedule for activities
act in social situations or communicate better with 6. Provide constant routine for child
others. 7. Protect child from self-injury
− Applied behavior analysis (ABA) can help children 8. Provide safe environment
learn new skills and generalize these skills to
multiple situations through a reward-based
motivation system.
2. Educational Therapies
− Children with autism spectrum disorder often
respond well to highly structured educational
programs.
− Successful programs typically include a team of
specialists and a variety of activities to improve
social skills, communication and behavior
− Preschool children who receive intensive,
individualized behavioral interventions often show
good progress.
3. Family Therapies
− Parents and other family members can learn how
to play and interact with their children in ways that
promote social interaction skills, manage problem
behaviors, and teach daily living skills and
communication
4. Other Therapies
− Depending on your child's needs, speech therapy to
improve communication skills, occupational
therapy to teach activities of daily living, and
physical therapy to improve movement and
balance may be beneficial.
− A psychologist can recommend ways to address
problem behavior.

5. Medications
− No medication can improve the core signs of
autism spectrum disorder, but specific medications
can help control symptoms.
For example:
• Certain medications may be prescribed if your
child is hyperactive; antipsychotic drugs are
sometimes used to treat severe behavioral
problems
For example:
• Antipsychotics like Haloperidol- but there is a
greater risk of serious side effects among children
• Atypical antipsychotic like Risperidone (Risperdal)
for reducing aggressive self-injurious behavior
• antidepressants may be prescribed for anxiety
• clomipramine (Anafranil) and fluoxetine (Prozac)
for adults with autism.

16 | P a g e Ma. Regina P. Maprangala BSN 3-D

 ATTENTION DEFICIT HYPERACTIVITY DISORDER
− It is a disorder that is characterized by a persistent
pattern of inattention and/or
hyperactivity/impulsivity that interferes with
functioning or development which often persists
into adolescence and adulthood.
− The diagnosis of ADHD demands thorough history
taking, application of standardized rating scales,
and close attention to the patient’s behavior and
subjects’ reports.
− It is a developmental condition of inattention and
distractibility, with or without accompanying
hyperactivity.
− ADHD is characterized by inattentiveness,
overactivity, and impulsiveness.
− ADHD is a common disorder, especially in boys,
and probably accounts for more child mental
health referrals than any other single disorder.
− The essential feature of ADHD is a persistent
pattern of inattention and/or hyperactivity and
impulsivity more common than generally observed
in children of the same age.
Statistics and Incidences
In 2016, an estimated 6.1 million US children
aged 2-17 years (9.4%) were diagnosed with ADHD.
− Of these children, 5.4 million currently had ADHD,
which was 89.4 % of children ever diagnosed with
ADHD and 8.4% of all US children 2-17 years of
age.
− According to a study by CDC researchers, more
than 1 in 10 (11%) US school-aged children (4–17
years) had received an ADHD diagnosis by a health
care provider by 2011, as reported by parents.
− ADHD prevalence varies by race and ethnicity, with
Mexican children having consistently lower
prevalence compared with other racial or ethnic
groups.
− In children, ADHD is 3–5 times more common in
boys than in girls.
− The percentages in each group are not well
established, but at least an estimated 15–20% of
children with ADHD maintain the full diagnosis
into adulthood.
− According to the Attention Deficit/Hyperactivity
Disorder (AD/HD) Society of the Philippines, an
estimated 3 to 5 percent of the population aged 0
to 14 years in the Philippines have ADHD.
Causes:
1. Psychodynamic theory
− The child is fixed in the symbiotic phase of
development and has not differentiated self
from mother.
− Ego development is retarded
17 | P a g e
− The impulsive behavior is dictated by the ID
2. Biologic theories
− Genetics - Parents and siblings of children with
ADHD are 2-8 times more likely to develop
ADHD than the general population, suggesting
that ADHD is a highly familial disease.
− CNS abnormalities, such as presence of
neurotoxins, cerebral palsy, epilepsy and other
neurological disorders
− Neuro maturational delays, catecholamine
deficits, altered glucose metabolism in the
brain and frontal lobe dysfunction.
− Perinatal insults such as substance abuse
during pregnancy, poor maternal nutrition,
premature labor, and anoxia; brain injuries
during or after birth.
3. Theories of family dynamics
− There is a dysfunctional spousal relationship,
the focus of the disturbance is displaced into
the child, whose behavior in time begins to
reflect the patterns of the dysfunctional system.
− Disorganized or chaotic environment and child
abuse or neglect may also be a factor.
4. Environment
− According to one study, exposure to second-hand
smoke in the home is associated with a higher
frequency of mental disorder among children.
5. Personality factors
− Although there remains much evidence for the
genetic etiology of ADHD, one study indicated that
the contribution of personality aspects in
combination with genetics may be significant.
Criteria
In DSM-5, people with ADHD exhibit a persistent
pattern of inattention and/or hyperactivity-impulsivity
that interferes with functioning or development
1. Inattention
Six or more symptoms of inattention for
children up to age 16 years, or five or more for
adolescents age 17 years and older and adults;
symptoms of inattention have been present for at least
6 months, and they are inappropriate for
developmental level:
− Often fails to give close attention to details or
makes careless mistakes in schoolwork, at work, or
with other activities.
− Often has trouble holding attention on tasks or play
activities.
Ma. Regina P. Maprangala BSN 3-D
− Often does not seem to listen when spoken to
directly.
− Often does not follow through on instructions and
fails to finish schoolwork, chores, or duties in the
workplace (e.g., loses focus, side-tracked).
− Often has trouble organizing tasks and activities.
− Often avoids, dislikes, or is reluctant to do tasks
that require mental effort over a long period of
time (such as schoolwork or homework).
− Often loses things necessary for tasks and activities
(e.g. school materials, pencils, books, tools, wallets,
keys, paperwork, eyeglasses, mobile telephones).
− Is often easily distracted.
− Is often forgetful in daily activities.
2. Hyperactivity and Impulsivity
Six or more symptoms of hyperactivity-
impulsivity for children up to age 16 years, or five or
more for adolescents age 17 years and older and
adults; symptoms of hyperactivity-impulsivity have
been present for at least 6 months to an extent that is
disruptive and inappropriate for the person’s
developmental level:
− Often fidgets with or taps hands or feet, or squirms
in seat.
− Often leaves seat in situations when remaining
seated is expected.
− Often runs about or climbs in situations where it is
not appropriate (adolescents or adults may be
limited to feeling restless).
− Often unable to play or take part in leisure
activities quietly.
− Is often “on the go” acting as if “driven by a motor”.
− Often talks excessively
− Often blurts out an answer before a question has
been completed.
− Often has trouble waiting their turn.
− Often interrupts or intrudes on others (e.g., butts
into conversations or games)
In addition, the following conditions must be met:
− Several inattentive or hyperactive-impulsive
symptoms were present before age 12 years.
− Several symptoms are present in two or more
settings, (such as at home, school or work; with
friends or relatives; in other activities).
− There is clear evidence that the symptoms
interfere with, or reduce the quality of, social,
school, or work functioning.
− The symptoms are not better explained by another
mental disorder (such as a mood disorder, anxiety
disorder, dissociative disorder, or a personality
disorder).
− The symptoms do not happen only during the
course of schizophrenia or another psychotic
disorder.
18 | P a g e
Based on the types of symptoms, three kinds
(presentations) of ADHD can occur:
• Combined Presentation: if enough symptoms of
both criteria inattention and hyperactivity-
impulsivity were present for the past 6 months
• Predominantly Inattentive Presentation: if
enough symptoms of inattention, but not
hyperactivity-impulsivity, were present for the
past six months
• Predominantly Hyperactive-Impulsive
Presentation: if enough symptoms of
hyperactivity-impulsivity, but not inattention,
were present for the past six months.
• Because symptoms can change over time, the
presentation may change over time as well.
All criteria must be met for a diagnosis of ADHD in
adults:
• Five or more symptoms of inattention and/or
≥5 symptoms of hyperactivity/impulsivity
must have persisted for ≥6 months to a degree
that is inconsistent with the developmental
level and negatively impacts social and
academic/occupational activities.
• Several symptoms (inattentive or
hyperactive/impulsive) were present before
the age of 12 years.
• Several symptoms (inattentive or
hyperactive/impulsive) must be present in ≥2
settings (e.g., at home, school, or work; with
friends or relatives; in other activities).
• There is clear evidence that the symptoms
interfere with or reduce the quality of social,
academic, or occupational functioning.
• Symptoms do not occur exclusively during the
course of schizophrenia or another psychotic
disorder, and are not better explained by
another mental disorder (e.g., mood disorder,
anxiety disorder, dissociative disorder,
personality disorder, substance intoxication, or
withdrawal).
Assessment and Diagnostic Findings
The diagnosis requires the symptoms of ADHD
to be present both in school and at home; furthermore,
all patients must have a full psychiatric evaluation and
physical examination.
Laboratory studies
• The diagnosis of attention deficit hyperactivity
disorder (ADHD) is based on clinical
evaluation; no laboratory-based medical tests
are available to confirm the diagnosis.
• Basic laboratory studies that may help confirm
diagnosis and aid in treatment are serum CBC
count with differential, electrolyte levels, liver
function tests, and thyroid function tests.
Ma. Regina P. Maprangala BSN 3-D
Imaging studies
− Brain imaging, such as functional MRI or single
photon emission computed tomography
(SPECT) scans have been useful for research,
but no clinical indication exists for these
procedures because the diagnosis is clinical.
Treatment
1. Psychosocial interventions like behavioral
interventions
✓ Social skills training: modeling appropriate
behavior
2. Medical Management
No one treatment has been found to be
effective for ADHD; ADHD is chronic, goals of
treatment involve managing symptoms, reducing
hyperactivity and impulsivity, and increasing the
child’s attention so that he or she can grow and
develop normally.
▪ Diet - For decades, speculation and folklore
have suggested that foods containing
preservatives or food coloring or foods high in
simple sugars may exacerbate ADHD.
▪ Activity - In one study of the effect of physical
activity on children’s attention, researchers
found that intense exercise has a beneficial
effect on children with ADHD.
3. Pharmacologic Management
Although health care providers, parents, and
teachers have hoped for effective therapies and
methods that do not involve medications for children
with attention deficit hyperactivity disorder (ADHD),
evidence to date supports that the specific symptoms
of ADHD are poorly treated without medication.
4. Psycho stimulants are commonly used in
treating ADHD in young children but not in
adolescents.
✓ e.g., methylphenidate (Ritalin, Methylene),
Dextro amphetamine (Dexedrine, dextrostat,
adderall)
✓ It has a calming effect on children with ADHD.
✓ It stimulates inhibitory efferent neurons in the
cerebral cortex at low dosage levels, causing a
decrease in motor activity.
✓ It stimulates afferent neurons on the reticular
activating system, increasing input constancy,
thus enabling the brain to concentrate longer
on a particular task.
▪ These agents are known to treat ADHD
effectively.
19 | P a g e
Other psychiatry agents
▪ Selective norepinephrine reuptake inhibitors
have been shown to be effective in the
treatment of ADHD.
Atypical antidepressants
▪ Recent studies support efficacy of venlafaxine
and bupropion in ADHD; they may have a
slower onset of action than stimulants but
potentially fewer adverse effects.
Tricyclic antidepressants
▪ Imipramine inhibits the reuptake of
norepinephrine or serotonin (5-
hydroxytryptamine, 5-HT) at presynaptic
neurons; it may be useful in pediatric ADHD.
Central-acting alpha 2 agonists
▪ Centrally acting antihypertensives clonidine
and guanfacine have been used to treat
children with ADHD; inhibition of
norepinephrine release in the brain may be the
mechanism of action.
Nursing Management
Nursing Assessment
During assessment, the nurse gathers information
through direct observation and from the child’s
parents, daycare providers (if any), and teachers.
▪ History. Parents may report that child is fussy and
had problems as an infant; or they may have not
noticed the hyperactive behavior until the child
was a toddler or entered daycare or school.
▪ General appearance and motor behavior. The
child cannot sit still in a chair and squirms and
wiggles while trying to do so; he or she may dart
around the room with little or no apparent
purpose; the child may appear immature or lag
behind in developmental milestones.
▪ Mood and affect. Mood may be labile, even to the
point of verbal outbursts or temper tantrums;
anxiety, frustration, and agitation may be common.
▪ Sensorium and intellectual processes. Ability to
pay attention or to concentrate is markedly
impaired; the child’s attention span may be as little
as 2 or 3 seconds with severe ADHD or 2 or 3
minutes in milder forms of the disorder.
Nursing Diagnosis
▪ Risk for injury related to inability to remain still
or seated for a short period of time.
▪ Ineffective role performance related to being
intrusive or disruptive with siblings or playmates.
▪ Impaired social interaction related to inability to
perceive the consequences of their actions.
Ma. Regina P. Maprangala BSN 3-D
▪ Compromised family coping related to disruptive
or intrusive behavior with siblings, which causes
friction.

Nursing Goals
1. The client will be free of injury.
2. The client will not violate the boundaries of
others.
3. The client will demonstrate age-appropriate
social skills.
4. The client will complete tasks.
5. The client will follow directions.

Nursing Interventions
▪ Ensuring safety. Ensuring the child’s safety and
that of others; stop unsafe behavior; provide close
supervision; and give clear directions about
acceptable and unacceptable behavior.
▪ Improving role performance. Give positive
feedback for meeting expectations; manage the
environment (e.g. provide a quiet place free of
distractions for task completion).
▪ Simplifying instructions. Simplifying
instructions/directions; get child’s full attention;
break complex tasks into small steps; and allow
breaks.
▪ Promoting a structured daily routine.
Structured daily routine; establish a daily schedule;
and minimize changes.
▪ Providing client and family education and
support. The nurse must listen to parents’ feelings;
including parents in providing and planning care
for the child with ADHD is important.
▪ Take time to work with the child and help the
child with school assignments. Focus on the
child’s positive accomplishments
✓ They will need extra time and patience
▪ Reinforce acceptable behaviors immediately.
✓ They will change behavior only when rewards
are immediate and won’t change if delayed.
▪ Manipulate the environment for safety.
✓ The child will not be able to discriminate
between safe and unsafe environment.
▪ Reinforce the child for not talking too much in
groups and for waiting his turn in games.
✓ This feedback helps the child to know when to
focus energies on self-control
▪ Develop activities that will not strain limited
attention span. Keep explanation short and
simple.
✓ It will help the child to stay on task and
experience success
▪ Provide an environment relatively free of
extraneous stimuli.
✓ Cutting down distractions conserves the child’
energy.

20 | P a g e Ma. Regina P. Maprangala BSN 3-D

 Quiz 1 14. The nurse is leading a group session with 10 clients. When
1. I can smell a rotten fish under the table (nothing is under the observing behaviors, the nurse remembers behavioral
table). What kind of hallucination does the patient manifest? symptoms of these clients:
a) Auditory c) Visual a) Are purposeful
b) Gustatory d) Olfactory b) Have meaning
c) Are easily understood
2. Schizophrenic patients frequently experience what type of d) D. Are intentional
hallucination?
a) Auditory c) Olfactory 15. The nursing assessment indicates the patient is creating new
b) Visual d) Tactile words. This is documented as:
a) Magical thinking
3. The concepts of mental health and psychiatric nursing are: b) Cryptic language
a) Preventive c) Rehabilitative c) Neologism
b) Curative d) All of the above d) Word salad

4. A therapeutic community is also termed: Quiz 2

a) Bibliotherapy d) Occupational therapy 1. The proponent of the psychosocial theory of personality
b) Milieu therapy c) Any of the above development.
a) Freud c) Sullivan
5. A nurse who uses nurturing activities such as bathing or b) Erikson d) Piaget
feeding the patient is using the role of a:
a) Ward manager c) Teacher 2. According to Erikson's theory of personality development, an
b) Counsellor d) Parent surrogate infant need for love and attention are not met, the infant is
more likely to develop feeling of;
6. It is the state of complete physical, mental and social well- a) Mistrust c) Shame
being and not merely the absence of disease and infirmity. b) Inferiority d) Guilt
a) Hygiene c) Psychiatry
b) Mental health d) Health 3. A specific period in the life of individuals when the incidence
of psychosis rises is:
7. It is a psychological state of well-being, characterized by a) Senility c) Pre-school
continuing personal growth, a sense of purpose in life, self- b) Adolescence d) Toddlerhood
acceptance, and positive relations with others.
a) Psychiatric nursing c) Mental health 4. According to Erikson, in which of the following stages of
b) Psychiatry d) Mental hygiene personality development does the individual first begin to
assert independence?
8. Which is not a factor that influences mental health? a) Identity vs. role confusion c) Initiative vs. guilt
a) Inherited characteristics c) Nurturing childhood b) Autonomy vs. shame & doubt d) Trust vs. mistrust
b) Life's circumstances d) None of the above
5. He emphasized the need for pleasant surrounding and
9. It is the medical specialty that is derived from the study, diversional and moral treatment of the mentally ill.
diagnosis, treatment and prevention of mental disorders. a) Phillipe Pinel c) Franz Anton Mesmer
a) Psychiatric nursing c) Mental Health b) Benjamin Rush d) William Tuke
b) Psychiatry d) Health
6. She was the first American Psychiatric Nurse.
10. According to this author, psychiatric nursing is an a) Linda Richards c) Karen Horney
interpersonal process that strives to promote and maintain b) Dorothea Lynde Dix d) Hildegard Peplau
behavior which contributes to integrated function.
a) Travelbee c) APA 7. It is at this period that insanity was associated with demonic
b) ANA d) Gail Stuart possession.
a) The Middle Ages c) 18th -19th centuries
11. A young client is admitted to the hospital with a diagnosis of b) 15th – 17th centuries d) Ancient Times
acute schizophrenia. The family relates that one day the client
looked at a linen sheet on a clothesline and thought it was a 8. He postulated the hypothesis of interpersonal theory and the
ghost. The nurse recognizes that this was: development of multidisciplinary approaches to psychiatric
a) A delusion c) A confabulation and milieu therapy.
b) An illusion d) Hallucination a) Benjamin Rush c) Franz Anton Mesmer
b) Harry Stack Sullivan d) William Tuke
12. The following are characteristics of mental health, EXCEPT:
a) Is unable to cope with or tolerate stress 9. He advocated kindness and moral treatment of mentally ill
b) Is able to form close and lasting relationship. patients.
c) Is optimistic a) Franz Anton Mesmer c) Philippe Pinel
d) Is able to distinguish imagined circumstances from reality b) William Tuke d) Benjamin Rush

13. Which is NOT a characteristic of mental illness? 10. It is a taxonomy published by the American Psychiatric
a) Displays poor judgment Association that describes all the mental disorder with specific
b) Exhibits maladaptive behavior diagnosis criteria.
c) Can delay gratification a) DSM V c) SMB IV
d) Does not recognize potentials/talents because of poor b) DSM V-TR d) Any of the above
self-concept.

21 | P a g e Ma. Regina P. Maprangala BSN 3-D

11. A very strict super ego may lead to the development of:
a) a happy, mature and law-abiding citizen
b) aggressive and hostile strivings without guilt
c) anti-social strivings without anxiety
d) an unhappy, rigid individual
12. Mr. Coco, a 36-year-old Tailor was often invited to social
drinking. Lately, he became an alcoholic. Mr. Coco's alcoholism
maybe traced to his fixation during what stage of personality
development?
a) Latency c) Oral
b) Phallic d) Anal
13. Proofs that a person has the unconscious:
a) Nocturnal dreams and sleepwalking
b) Phenomena of hypnosis
c) Slips of the tongue and forgetfulness
d) All of the above
14. Accident rate is high during the toddler period because:
a) Parents tend to neglect their children at this age
b) Their natural curiosity and activity lead them to danger
c) They are negativistic
d) They do not comprehend their parents warning
15. The behavior of the adolescents is influenced more by:
a) Priests and nuns c) Parents
b) Peer group d) School
a) Cognitive c) Psychosexual
b) Interpersonal d) Psychosocial
24. It is a fear expressed by a little boy concerning loss of penis.
a) Social fear c) Castration fear
b) Vivid fear d) Real life fear
25. Personality is unique for it is the result of the person's:
a) Childhood experiences, intelligence and economic status
b) Heredity, placement in the family and education
c) Intelligence, race and social status
d) Biologic constitution, psychological development,
environmental and cultural setting
26. During the oedipal stage of growth and development, the child:
a) Loves the parent of the opposite sex and hates the parent
of the same sex
b) Loves the parent of the same sex and hates the parent of
the opposite sex c.
c) Loves and hates both parents
d) Loves the parent of the same sex and the parent of the
opposite sex.
27. Resolution of the oedipal complex takes place when the child
overcomes the castration complex and:
a) Identifies with the parent of the opposite sex
b) Introjects behavior of both parents
c) Rejects the parent of the same sex
d) identifies with the parent of the same sex

16. Based on the knowledge of Erikson's stages of growth and 28. A person has a mature personality if the:
development, the nurse determines that the task of old age is a) Ego responds to the demands of the super ego.
primarily concerned with: b) Society sets demands to which the ego responds
a) Autonomy vs. shame and doubt c) Ego acts as a balance between the pressures of the id and
b) Ego integrity vs. despair the super ego
c) Trust vs. mistrust d) Super ego is replaced and increased all the controls of the
d) Industry vs. inferiority parents

17. Temper tantrums can be dealt therapeutically by: 29. It is the integrator of the personality.
a) Ignoring behavior c) C. Threatening the child a) Conscience c) Ego
b) Cuddling the child d) Giving candy to the child b) Super ego d) Id

18. The nurse knows that Erikson identified that the 30. It is the sum total of the individual's pattern of adjustment to
developmental task of the pre-school child from 3 to 5 as: life.
a) Sexual impulsive vs. psychosexual development a) Dynamism c) Adjustment mechanism
b) Breaking away versus staying home b) Personality d) Character
c) Initiative vs. guilt
d) Industry vs. inferiority 31. A slip of the tongue is a manifestation of what part of the
personality?
19. Normal behaviors during infancy are the following, EXCEPT: a) Unconscious c) C. Sub conscious
a) Explores new objects with the mouth b) B. Pre-conscious d) Conscious
b) Completely dependent
c) Self- centered 32. The critical, censoring, inhibiting portion of personality is:
d) Expresses negativism via feces retention a) Id c) Super ego
b) Ego d) Sub-conscious,
20. Brad 5 years old wishes to marry his mother and is jealous
toward his father. This is an example of: 33. The reservoir of memories, experiences and emotions that are
a) Oedipal complex c) C. Electra complex out of the person's awareness is the:
b) Castration anxiety d) Sibling rivalry, a) Conscious c) Subconscious
b) Preconscious d) Unconscious
21. They discovered that pleasure sensation can be aroused from
manipulation of the penis and clitoris. 34. To prevent interpersonal and intrapersonal conflicts, a person
a) Oral c) Anal should develop a strong:
b) Phallic d) Toddler a) Ego c) Super ego
b) Id d) Conscience
22. Libidinal energy of an infant is focused on:
a) Mouth c) Breast 35. One day old Baby Nate is all:
b) Anus d) Penis a) Ego c) Super ego
b) Id d) Conscience
23. Sigmund Freud's theory is all about:

22 | P a g e Ma. Regina P. Maprangala BSN 3-D

Quiz 3 13. The American Association of Mental Deficiency's definition of
1. It is the repetition of words or phrases spoken by others. mental retardation stresses:
a) Word salad c) Echolalia a) Cognitive impairment occurring after age 22 years
b) Echopraxia d) Neologism b) No responsiveness to contact
c) Deficits in adaptive behavior along with intellectual
2. An IQ of 35 to 55 is classified as what degree of mental impairment
retardation? d) IQ level must be below 50
a) Profound c) Severe
b) Moderate d) Mild 14. Nursing consideration in the care of a child with Down
syndrome is NOT advisable.
3. In assessing the behavior of an autistic child, the nurse notes a) Emotional support of parents
that a symptom that characteristically differentiates an autistic b) Placing the child in an institution
child from down syndrome is: c) Assisting parents to set realistic expectations
a) Short attention span d) Genetic counseling appropriate for the type of defect
b) Poor academic performance
c) Difficulty responding to a nurturing relationship 15. Given a choice, the child with autism would usually enjoy
d) Retardation of activity playing with a:
a) Small, yellow block
4. The nurse should observe the autistic child for signs of: b) Cuddly toys
a) Enjoying being with people c) Crying for attention c) Large red blocks
b) Bizarre motor behaviors d) Destroying play things d) Playground merry-go-round

5. The causes of mental retardation are: 16. The primary prevention of mental disorders in children
a) Poor economic and social conditions, rape, philandering includes:
husband a) Day care programs
b) Rape, grief during pregnancy, adolescent pregnancy b) Nutrition program and prenatal care
c) Lack of love, poverty, use of drugs during pregnancy c) Child guidance clinic
d) Poverty, inadequate nutrition, German measles during d) Partial hospitalization
pregnancy, brain injury
17. Which of the following is a behavior of an autistic child?
6. Autism can usually be diagnosed when the child is about: a) Preoccupation with moving objects
a) 1 to 3 years old c) 6 months of age b) Close relationship with mother
b) 2 years old d) 6 years of age c) Mindful of people around
d) Excellence in speech and reading
7. When planning activities for a child with autism, the nurse
must remember that autistic children respond best to: 18. In milieu management for autistic children would include
a) Large group activity c) Individuals in small group which of the following?
b) Loud, cheerful music d) Own self-stimulating acts a) Providing recreational activities
b) Developing an environment that provides physical and
8. When assessing a child with autism, the nurse would expect emotional safety
the child to demonstrate: c) Assisting the child in activities of daily living
a) Flapping hands and rocking d) Providing child with stimulating activities
b) Lack of response to any stimulus
c) Sad, blank facial expression 19. The onset of IDD is before the child reaches what particular
d) Inappropriate smiling with flat emotions age?
a) 15 years c) 17 years
9. Autistic disorder is found more frequently in: b) 16 years d) 18 years
a) Boys c) No data available
b) Girls d) None of the above 20. It is an atypical antipsychotic medicine given to children with
autistic disorder to reduce aggressive self-injurious behavior.
10. A nurse is aware that scores between 50 to 70 on a a) Prozac c) Risperdal
standardized intelligent quotient assessment test is indicative b) Ritalin d) Haldol
of which degree of intellectual impairment?
a) Profound c) Severe 21. Which of the following statements is TRUE of Intellectual
b) Mild d) Moderate Development Disability (IDD)?
a) IDD is a mental illness.
11. Which nursing diagnosis is most applicable for a child with b) Hereditary and prenatal factors do not result to IDD
ADHD? c) Hereditary and prenatal factors are known to result in
a) Altered thought processes related to Impaired reality impaired intellectual functioning
b) Impaired verbal communication related to mutism d) IDD is always accompanied by physical features
c) Potential for injury related to impulsivity
d) Ineffective family coping related to ineffective parenting 22. The nurse would expect to see all of the following symptoms in
a child with ADHD, except:
12. Intellectual Development Disorder may be prevented by a) Interrupts others and cannot take turns
adequate medical care: b) Moody, sullen and pouting behaviors
a) From childhood to adulthood c) Easily distracted and forgetful
b) During prenatal period d) Excessive running, climbing and fidgeting
c) From birth to adolescence
d) During prenatal period, birth and childhood

23 | P a g e Ma. Regina P. Maprangala BSN 3-D

23. ADHD in children is usually treated with:
a) Chlorpromazine hydrochloride (Thorazine)
b) Haloperidol Haldol)
c) Diazepam
d) Methylphenidate hydrochloride (Ritalin)
24. A child suffering from ADHD would most likely exhibit which
of the following symptoms?
a) Good peer relationship
b) Restlessness
c) Hostility
d) Suicidal ideation
25. Which of the following behaviors would indicate the greatest
improvement in a child who has a diagnosis of hyperactivity?
a) The child takes a nap during the day.
b) The child frequently apologizes for his behavior
c) The child completes an assigned task
d) The child stops quarrelling his classmates
26. The medication side effects of giving psycho stimulants to
children with ADHD that is of major concern of parent is:
a) Increased appetite c) Headache
b) Delayed physical growth d) Dizziness
27. The treatment of choice for an autistic child probably will
include:
a) Play therapy c) Group therapy
b) Behavior modification d) Institutionalization
28. When a child is diagnosed as being moderately retarded, it
would be most helpful for the nurse to suggest that the
parents:
a) Concentrate on teaching complicated situations
b) Offer challenging, competitive situations
c) Provide complete and detailed directions at the beginning
of the task to be carried out .
d) Offer, simple, repetitive tasks
29. The school nurse is giving an educational forum on ADHD to
the local school board. Which of the following behaviors is
most common in children with ADHAD?
a) Long attention span c) Lethargy
b) Short attention span d) Preoccupation with body parts
30. Josh, age 6 was diagnosed as having ADHD. In a nursing care
plan for Josh, the nurse identified his nursing diagnosis of
Ineffective coping based on one of the following behaviors.
a) Inability to express feelings
b) Constantly tells lies
c) Easily distracted by extraneous stimuli
d) Initiates fights with his classmates
31. Which of the following types of behaviors demonstrated by a
6-year-old would help the school nurse differentiates between
ADHD and other childhood disorders?
a) The child reverses letters and words while reading
b) The child has difficult time reading a chapter in a book
c) The child is always getting into fights
d) The child easily gets distracted and reacts impulsively.
32. The school nurse administers the psycho stimulating
medication Methylphenidate (Ritalin) to an 8-vear-old male
with diagnosis of ADHD. The purpose of this medication is to:
a) Increase educational achievement
b) Decrease aggressive behavior
c) Decrease abusive thoughts
d) Increase behavioral self-regulation
24 | P a g e
33. alteration relatetrie diagnosis is ADHD. A possible nursing
diagnosis would be 4gensory perception alteration related to
neurological disturbance." With the ald of the medication, a
short-term goal for this child would be:
a) To sit and play with his toys for 10 minutes
b) To seek out the nurse to talk
c) Not to destroy things in his environment
d) To be able to express his anger in an acceptable manner
34. Behavior modification Is Used for several an acceptable mient.
Which of the following techniques is often used in behavior
modification?
a) A purposeful exploration of why the patient behaves as he
does
b) A type of hydrotherapy that promotes relaxation
c) A token economy that rewards desired behaviors
d) A listing of behaviors that need modifying
35. In providing care to school-age child with ADHD, the most
effective intervention would be:
a) Administer drug therapy such as Ritalin and use
behavior modification techniques
b) Provide parental education and diet therapy
c) Encourage delayed achievement of normal
developmental tasks
d) Increase environmental stimulation and peer
interaction
SITUATION: a public health nurse during one of her home visits to a
post-partum mother observed Kiko, 5 years old sitting by
himself in the corner of the room, rocking back and forth and
spinning his toy occasionally. Questions 36 to 40 refer to the
situation.
36. A child suffering from autism manifests one of the following
behaviors?
a) Has difficulty playing quietly
b) May indulge in repetitive play with fingers and hands
c) Talks excessively
d) Often shifts from an incomplete activity to another
37. The nursing diagnosis of autism is impaired social interaction
related to absence of available significant others. This is
manifested by one of the following behaviors.
a) Easily distracted
b) Low self-esteem
c) Withdrawal from other persons
d) Lack of responsiveness to people
38. Autism can usually be diagnosed when the child is about:
a) 6 years old
b) 2 years old
c) 6 months of age
d) 1 to 3 months of age
39. When planning activities for a child with autism, the nurse
must remember that autistic children resp best to:
a) Large group activities
b) Individuals in small group
c) Loud, cheerful music
d) Their own self-stimulating acts
40. When assessing a child with autism, the nurse would expect
the child to demonstrate:
a) Inappropriate smiling with flat emotions
b) Sad, blank facial expression
c) Lack of response to any stimulus
d) Flapping hands and rocking
Ma. Regina P. Maprangala BSN 3-D