TOURETTE DISORDER :

Characterized by multiple , involuntary & uncontrollable motor & vocal tics that appear simultaneously or at different periods
Tics = sudden, swift, repetitive, arrhythmic, &stereotyped movement or vocalization
Motor tics affect the head, trunk & limbs, characterized by facial grimacing , tongue protrusion , snorting, blinking, extremity
jerking
Vocal tics is characterized by loud barking, grunting or shouting words . Involuntary utterance of obscene or vulgar words
( coprolalia )

Causes :
Genetics
Biochemical factors – abnormal levels of dopamine, serotonin, GABA, acetylcholine, & nor-ephineprine
Structural factors – dysfunction in the area of basal ganglia
Autoimmune reaction following infection of group A beta-hemolytic streptococcal infection =PANDAS
(pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection)
DSM IV criteria
12 months minimum duration
3 months longest interval without tics
Tics during active phase can be motor only or vocal only
Motor & vocal tics must occur together at some point
****ability to temporarily suppress tics makes it different from EPS due to antipsychotic drugs, seizure disorders, Huntington
disease, Wilson disease

Treatment
Pharmacologic- atypical / typical antipsychotic drugs ( risperidone, ziprasidone, haloperidol, pimozide, fluphenazine )
- alpha adrenergic agents ( guanfacine, clonidine)
Behavioral treatment – supportive psychotherapy , education may help improve symptoms of depression or social isolation,
minimize negative social consequences of tics, and improve supportive family functioning

Nursing intervention
Develop & foster a trusting relationship and acceptance
Teach them about the disorder and ways to manage symptoms
Help them address behaviors that contribute to irritability and frustrations
Teach family that stress increases tics and quite activities can diminish tics
Help him/ her learn to cope with impulses, negativity & unacceptable behavior
Promote child strengths and self esteem
SEPARATION ANXIETY DISORDER
Distress upon separating the child from his/ her caregiver
Excessive anxiety concerning separation from the home or from those to whom the person is attached (APA)
** fear of harm to self & loved ones is an underlying fear that drives the child to feel distress
***age 1-3 normal behavior, after 3 years –pathologic

Predisposing factors: traumatic separation

Very close family dynamic
Mimicking of exaggerated anxiety about separation modeled by parents

Symptoms
Refusal to go to school or sleep alone
Somatic symptoms- belly ache, head ache
Crying / screaming when being physically separated
Can progress to full blown panic attacks

Treatment
Behavioral psychotherapy – most effective
Systematic desensitization , operant conditioning
Pharmacologic –SSRI, benzodiazepines when panic is associated with separation
SOCIAL PHOBIA IN CHILDHOOD
Excessive shyness and avoidance of interaction with people unfamiliar to the child after 2-5 years of age
Complication= disruption in psychosocial, psychosexual, self-confidence and self esteem development

Treatment – cognitive behavioral psychotherapy with the goal of developing assertiveness

Ineffective therapy = persistence to adulthood resulting in isolation , depression. & lack of normal social bonds

GAD in CHILDHOOD
Excessive worry about past behavior , future events or their own competence
They exhibit nervous habits , somatic complaints seeking of reassurance, approval , difficulty sleeping
Predisposing factors- birth order= oldest is at most risk
- family dynamics of high performance expectations of the child
- upper socioeconomic background
-small family
Treatment = psychotherapy , occasional SSRI or benzodiazipines
VICTIMS OF ABUSE & VIOLENCE
Abuse- maltreatment of one person by another
Child abuse- any physical or mental injury, sexual abuse, exploitation, negligent treatment or maltreatment inflicted to a
child by a parent, caregiver or any other persons.
Abuse should not be confused with discipline .
Types of Child Abuse
1. Physical abuse – intentional physical harm inflicted on the child by a parent or other persons as a result of punching,
beating, kicking, shaking, burning, choking etc.
4B’s –Battered , Bruised, Broken, Burned
Manchausen Syndrome by proxy- a phenomenon in w/c a parent usually the mother , fabricates the illness in her child
and presents the problem to the doctor in the hope of gaining attention.
Shaken Baby Syndrome – sometimes a fatal form of abuse typically occurs when an adult losses control and violently
shakes the child who has been crying incessantly . Physical findings include major head injury, subdural hematoma,
cerebral edema or retinal hemorrhage
2. Emotional abuse – involves a pattern of behavior on the parent or caretaker that results in serious impairment of the
of the child’s social, emotional, or intellectual functioning.
ex. Belittling, rejecting the child, ignoring & blaming the child for things he/she can’t control , harsh & inconsistent
discipline .
3. Sexual abuse –exploitive sexual act imposed on a child who lacks the emotional ,
cognitive/ maturational development to deal with the action.
this includes assault, incest, exploitation, exhibitionism, child molestation.
4. Child neglect & abandonment
Child neglect – harmful malicious or ignorant with holding of physical nutrition, health care
or emotional necessities that provide a foundation for healthy childhood.
Child abandonment – includes when a child is left to die, left with others & caregivers &
does not return , locked out of the house and left to survive on the streets, left without
supervision, does not receive any love or affection or parents refuses custody

SIGNS OF PHYSICAL ABUSE;

Indicators :
• Has unexplained burns, bites, bruises & broken bones or black eyes
• Has fading bruises or other marks noticeable after an absence from school
• Seem frightened of the parents & protects or cries when its time to go home
• Shrinks at the approach of adults
• Reports injury by a parent or another adult care giver
• *Offers conflicting , unconvincing or no explanation for the child’s injury
• *Describes the child as evil or in a very negative way
• *Use harsh physical discipline with the child
• *Has a history of abuse as a child
Behavioral indicators of emotional abuse :
 Shows extremes in behavior =overtly compliant or demanding, extreme
passivity or aggression
 Inappropriately adult or infantile
 Delayed in physical or emotional development
 Has attempted suicide
 Reports of lack of attachment to parents
 *Constantly blames , belittles, or berates the child
 *Unconcerned about the child & refuses to consider offers of help for the child’s problem
 Overtly rejects the child

Indicators of sexual
 Has difficulty walking or sitting
 Suddenly refuses to change for gym or to participate in physical activities
 Reports bedwetting or nightmares
 Experiences sudden change in appetite
 Demonstrates bizarre, sophisticated or sexual knowledge or behavior
 Runs away
 Becomes pregnant or contacts a venereal disease under age 14
 Reports sexual abuse by a partner or another adult caregiver
 *is unduly protective of the child or severely limits the child’s contact with other children,
especially of the opposite sex
 *is secretive & isolated
 *is jealous or controlling with family members

Indicators of neglect :
 Frequently absent from school
 Begs or steals food or money
 Lacks medical or dental care, immunization or glasses
 Is consistently dirty & has severe body odor
 Lacks sufficient clothing for the weather
 Abuses alcohol or other drugs
 States that there is no one at home to provide care
 *appears to be indifferent to the child
 *seems apathetic or depressed
 *behaves irrationally or in a bizarre manner
 *Is abusing alcohol or other drugs
Characteristics of abuser:
a. Expressing a stressful life situation ( unemployment , poverty)
b. Having few, if any support systems, commonly isolated from others
c. Lacking understanding of child development or care needs
d. Lacking adaptive coping strategies , angers easily, has difficulty trusting others
e. Expecting the child to be perfect , may exaggerate any mild difference the child manifest
from the usual

Etiological aspect of being an abuser

Biological – neurophysiological influences –temporal lobe , limbic system. And the amygdaloid
nucleus
- biochemical influences-neurotransmitters- norepinephrine, dopamine, serotonin play a
role in aggressive impulses
-genetic influences-
-disorders of the brain-brain tumors in limbic system & temporal lobes, trauma to the brain
Psychological –psychodynamic theory-underdeveloped ego & weak superego due to unmet
needs
-learning theory- learn by imitating their role models
Sociocultural –societal influences –aggressive behavior is a product of ones culture & social
system
Treatment modalities
Crisis intervention
Family therapy

Nursing intervention for sexual abuse

Communicate to the patient that it is not her fault, she is safe ,
Explain every assessment that will be done and the reason
Ensure client has adequate privacy for all immediate post crisis intervention
Encourage the client to give an account to what happened , just listen & not probe
Discuss with patient about support systems

Nursing intervention for abuse –physical

Perform complete physical assessment
Ensure physical wounds receive attention- take photos if the victim allows
Take him/ her in a private area for interview
Conduct an in-depth interview
Use games / play therapy to gain child’s trust
Ensure her safety
Offer support
CRISIS INTERVENTION
It is an attempt to resolve an immediate crisis when a person’s life or goals are obstructed & the
usual problem solving method fails.
It requires problem solving skills that are often diminished by the level of anxiety accompanying
disequilibrium

Goals of the intervention

1. Decrease emotional stress & protect the client from additional stress
2. Assist in organizing & mobilizing resources or support system
3. Return the client to a higher level of functioning

Principles of Crisis Intervention

4. Help individual confront the reality of crisis by helping him verbalize & comprehend the reality of
the situation
5. Help him confront the crisis in doses & amount he can manage
6. Help him find the fact or reality
7. Don’t give false reassurance
8. Do not encourage him to blame others
9. Help him seek & accept help
10. Help him accept assistance & everyday test
Steps in Crisis Intervention
a. Establish a positive relationship by displaying acceptance & concern
b. Identify the degree of disruption experienced by the client
c. Assessing the client’s perception of the event
d. Reduce immobility caused by anxiety & encourage verbalization of feelings
e. Help confront the reality of crisis , do not encourage the client to focus at once on all
implementation of crisis
f. Explain the clients emotions are normal reaction to crisis
g. Avoid giving false reassurance
h. Do not encourage the client to put the blame for the crisis on others.
i. Set limits on destructive behavior
j. Emphasize the clients responsibility for behavior & decisions
k. Assist the client with his /her activity of daily living until resolution occurs
l. Evaluate & modify interventions as necessary