Pediatric Clients

Protective Factors Increasing a Childs Resistance

to Stress
Personality traits, such as positive self-image
Family cohesion and absence of discord
Support from significant others
A positive relationship with at least one parent

Shonkoff & Phillips, 2000

Risk Factors for Psychiatric Disorders in Children

and Adolescents
Family history of mental illness
Immature development of the brain
Brain abnormality
Family problems and dysfunction
Poverty
Mentally ill or substance-abusing parents

Risk Factors for Psychiatric Disorders in Children

and Adolescents (contd)
Teen parents
Abuse
Discrimination based on race, creed, or color
Chronic parental conflict or divorced parents
Chronic illness or disability

Nursing Assessments for the Client With

Psychiatric Disorders
Family functioning
Current problem
History
Mental status
Physical examination

Interventions for Children with Psychiatric

Disorders
Prevention and early

identification
Psychosocial

modalities

Parent management

training
Group therapy

Individual therapy

Milieu therapy

Brief psychotherapy

Pharmacologic

Play therapy
Family therapy

therapy

Nursing Interventions for the Client With

Psychiatric Disorders
Providing medication education
Meeting families needs

Promoting the rights of children in treatment sett

Avoiding seclusion and restraint
Providing advocacy

Disruptive Behavior Disorders

Attention-deficit hyperactivity disorder

(ADHD)
Oppositional-defiant disorder
Conduct disorder
Adjustment disorder

Other Psychiatric Disorders

Mood disorders

Depression

Bipolar disorder

Autism spectrum disorders

Autism

Aspergers syndrome

Eating disorders
Substance abuse

DSM Diagnostic Criteria for Mental Retardation

An intelligence quotient (IQ) of approximately

70 or below
Concurrent deficits or impairments in present

adaptive functioning in at least two of the

following areas: communication, self-care,
home living, social/interpersonal skills
Onset before age 18 years

Attention Deficit Disorder (ADD)

Term used to describe syndrome

of behaviorally related problems that
impair learning such as distractibility,
hyperactivity, impulsivity, short attention
span & excitability
other terms: hyperkinetic
reaction of childhood;
hyperactive; minimal brain
dysfunction; neurologically
handicapped
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ADD: Subtypes

Attention deficit disorder: ADD

Attention deficit hyperactivity disorder: ADHD
Incidence: 4-12%of all school age have
ADD/H ( 2 million); 50-70% of juvenile crime
by kids w/ADD/H or CD; M>F by 3:1-->9:1; 1
in every classroom
Onset: typically 3-4 y/o; dx before age 7
M: 2-3X more often
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Etiology

Genetics
Catecholamine dysfunction; Increased levels of
glutaminate; Decreased levels of GABA
Maternal smoking, substance abuse, prematurity, fetal
distress, POL, cerebral palsy, epilepsy, trauma, infections,
lead
Dyes, additives, preservatives, sugar-no clear support-not
primary cause
chaotic environment; disruption in bonding during 1st 3 yrs;
family sociopathic behavior, hyperactivity
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Manifestations
Client must manifest at least 6 total findings

from the three following categories of

inattention, hyperactivity and impulsivity for a
period of at least 6 mos or more

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Inattention:S/S- 6 mos w/@ least 6:

fails to finish
doesnt seem to listen
cant sustain attention
easily distracted
loses things
forgetful in daily activities
doesnt follow through w/tasks

15

Hyperactivity: S/S- 6 mos w/@ least 6:

fidgets/squirms;
wont stay seated
cant play quietly
talks excessively
always on the go
runs or climbs excessively

16

Impulsivity: S/S- 6 mos w/@ least 6:

cannot wait turn

blurts out
interrupts or intrudes on others

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S/S across lifespan

baby: cries or screams w/o reason

child: too many eating/sleeping problems
toddler: in perpetual motion, accident prone,
fussy eater, clumsy, stubborn, temper fits
1st grader: inattentive, talkative, day dreamer,
bothers others
elementary: sloppy writing, letter reversals,
reading or math weakness

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S/S across lifespan

jr high: depressed, delinquent, substance

abuser, low self esteem, out of mainstream,
decreased hyperactivity
adult: rapid mood swings, tempers, frequent
job changes, inability to make decisions,
social misfits

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Adults
4-5% (8 million) of US adults estimated to

have ADHD
Adults outgrow hyperactivity; what you see
instead is impulsivity
Low % graduate from college
Hi % have children by age 20
Hi % have poor driving records & have been
fired
Cant read & assimilate info as quickly
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Comorbid Conditions
Bipolar disorder
Depression
Anxiety
Oppositional defiant disorder
Conduct disorder
Substance abuse

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Diagnostic Tests
Rule out other causes
Blood lead level
EEG
Thyroid function
Hearing & vision
Neuro exam
***Developmental history & screening

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Nsg Dxs

HR for injury r/t impulsive behavior

impaired social interaction
self-esteem disturbance
noncompliance w/therapy
defensive coping
impaired verbal communication

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Treatment
Medication therapy
Home behavior management
School interventions
Psychological services
Behavior modification

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Behavior modification
Reward + behavior
Organizational tips
Stress management
Time-outs
Response-cost: addresses specific

behavioral indictors to be targeted for change

Self-monitoring

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Home Behavior
Structured routine-posting schedule,

consistent & clear rules-tokenism

Acknowledging good behavior
immediately & frequently
Time & place to do homework
Affect child w/ADHD has
on other children

26

Family Rx
Anger & discipline management training
How to set realistic expectations
Availability of resources, support groups
General ed re: meds

27

School Intervention
Regular class for most-preferential seat
May qualify for special ed
Ideal-small class, high structure, organization &

routine
Behavior Modification: daily report cards
May need extra time for testing
Assignment notebook
Note-taking assistance
Tutoring
Quiet work space
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Teacher Guidelines
Clear rules
Short work sessions
Immediate consequences for behavior
+ reinforcement
Coordinated w/family

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Psychological Intervention
Behavior modification-Targeting problem

behavior w/+ reinforcement

Social skills training
Cognitive training
Individual counseling

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Meds: Nonstimulants-Strattera
1st FDA approved for rx of kids>6,

adolescents & adults w/ADHD

Selective norepinephrine reuptake inhibitor
MOA: works by blocking & slowing the
reabsorption of norepinephrine which is
considered to play a key role in regulating
attention, impulsivity, & activity levels
No stimulant/euphoriant properties
Not a controlled substance
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Strattera (atomexetine HCL)

Can be given w/o regard to food
ADRs in kids: AP, N, V, decreased appetite,

H/A, fatigue, mood swings

ADRs in adults: C, N, dry mouth, decreased
appetite, insomnia, urinary difficulties, sexual
dysfunction
Contraindications: narrow angle glaucoma, &
use of MAOIs
Onset: some improvement 1-2 wks, but may
take up to 1 mos
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Meds: Psychostimulants

primary site cerebral cortex & RAS

First line Rx
MOA: promote nerve impulse transmission by
increasing availability of norepinephrine from nerve
terminals in brain & also affect dopamine system as
well, normalizing brain function
increase attention span, control hyperactive
behavior & improve learning ability
children 6 y/o & >; tolerance
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Meds: Psychostimulants

ADRs: insomnia& anorexia-most common

side effects-may improve; most serious
adverse effects are motor or vocal tics; wt
loss, tachycardia & decreased growth &
develop
Methylphenidate (Ritalin, Concerta) &
dextroamphetamine (dexedrine)
Adderall-combination/mixed
may have rebound when meds wears off
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Nursing Considerations

assess response to meds-mood, activity level, behavior

give meds immediately pc to minimize anorexia; weekly
wts
to prevent insomnia give last dose @ least 6 hrs before
hs
periodic drug holiday
do not w/draw abruptly
wks for onset
watch OTCs
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Meds: Antidepressants

Second line
MOA: affect availability of norepinephrine &
dopamine in brain by blocking their reuptake
& allowing to accumulate
side effects: dry mouth, constipation,
hypotension, N, V, cardiac-ekg, risk of OD
examples: imipramine (Tofranil) or
desipramine (Norpramine)
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Meds: Others

Antipsychotics:MOA: blocks post-synaptic

dopamine receptors in brain;side effects: dry
mouth, blurred vision, hypotension, urine
retention, constipation; examples: thorazine,
haldol
Clonidine (Catapres)-early onset, high
activity, oppositional behavior; MOA
unknown; takes several weeks; side effectdrowsiness
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Emotionally Disturbed Children

prevalence: 11.8% (7.3 million)

risk factors: M>F-2:1 ratio; severe marital
distress; low SES; overcrowding; paternal
criminality; maternal psychiatric illness;
admission of child into foster home;
genetic/organic; stress; dysfunctional families

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Pervasive Personality Disorder (PPD)

Category of disorders characterized by severe &

pervasive impairment in several areas of

development
500,000-1.5 million in US have some form of M
4x>F
Autistic Disorder
Aspergers Syndrome
Retts Syndrome
Childhood Disintegrative Disorder
PPD-not otherwise specified
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Autism
M>F; M: 80%
Sex hormones may sculpt brain
Dx more common in 3rd yr when language

should explode
Have trouble communicating,
predicting feelings, interpreting
facial expressions
Excel at systemizing; love
order & accuracy
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Red Flags
Does not babble at 1 yr
Begins developing language, then

stops abruptly
Doesnt respond to his name, but has
normal hearing
Doesnt point to things to direct his
mothers attention
Avoids eye contact & cuddling
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Autism

lack of responsiveness to others & w/drawal from

social contact into fantasy world of own creation
Appear during 1st 3 yrs of life
s/s: gross impairment in communication-may not
speak/echolalic/mechanical; stiffens when held;
lack of awareness of feelings of others; does not
seek comfort; no social play; no imitation play;
fascinated w/objects; decreased peer relationships

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Autism
Classic: shows autistic symptoms since birth-

genetic
Regressive: seem to develop normally til
certain point when sy appear-environmental,
biochemical & immunological could trigger
genetic predisposition

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Autism: Etiology

social environment: parental rejection; family

break-up; family stress; insufficient
stimulation; faulty communication patterns
biologic factors: rubella, PKU, encephalitis,
meningitis, anoxia during birth, congenital
syphilis, epilepsy, mental retardation; genetic,
vaccines, meds

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Autism: Dx
Childhood Autism Rating Scale
Impaired non-verbal & verbal communication

is hallmark
Difficulties interacting w/others
Strange play patterns
Repetitive behaviors-spinning, rocking
Difficulty w/change

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Autism: Rx
Speech/language-therapist

& pathologists
Behavior therapy
Educational placement
Occupational therapy-fine motor skills-feeding,
writing, balance, proprioception
Physical therapy-gross motor skills, exercise
Medications-prevent seizures, treat anxiety,
improve attention; ritalin-most commonly rx; B6
w/ Mg-shown to improve well-being
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Conduct Disorder (CD)

M>F-3:1; incidence: 4%
comprises 47-67% of all psychiatric problems in
children
etiology:genetic; elevated testosterone
assoc/ w/aggressive behavior; impaired
social cognition; peer rejection
HR for antisocial behavior later
in life

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Conduct Disorder

repetitive & persistent pattern of conduct in which the

child violates basic rights of others or major ageappropriate social norms
onset: 8-10 yrs
s/s: initial-noncompliance/disobedience
younger: yelling, teasing, fighting, temper tantrums,
hyperactive
older:manipulation, no guilt, violence, theft, unable to form
close peer relations, chronic violations, cant accept
responsibility
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CD: Contributing Family

Influences

parental rejection; early institutional living

large family; absent father
marital conflict/divorce
frequent shifting of parents
ass. w/delinquent groups
inadequate communication patterns
inconsistent mgmt w/harsh discipline
parents w/antisocial, PD or ETOH problems
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CD: Dx criteria-3 or> past 12 mos

destruction of property
deliberate fire setting
deliberate destruction by other then fire
deceitfulness or theft
broken into someones property
lies to obtain goods or favors; cons
stolen nontrivial items-shoplifting
serious violation of rules
stays out all night
run away from home
truant before 13 y/o
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CD Dx Criteria: Aggressionpeople/animals

bullies, threatens, or intimidates

initiates physical fights
has used a weapon to harm
physically cruel to people
physically cruel to animals
stolen while confronting a victim
forced someone into sexual act
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Aggression

intentional behavior designed to harm; may

be +/etiology: genetic, hormonal, acquired
environmental
M>F-5:1

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Aggression: NOs

assess first; provide activities that allow for

controlled aggression
substitute more acceptable response-verbal
diffuse anger-humor
explain consequences of aggression on others-pain, hurt, punishment
decrease exposure to aggression
time outs; advance warnings; immediate
discussion
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Oppositional Defiant Disorder

(for 6 mos)

Frequently loses temper

Argues w/adult
Defient or refuses to follow rules
Deliberately annoys others
Blames others for mistakes
Easily annoyed
Angry & resentful
Vindictive & spiteful
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