Kristine Ruggiero, CPNP, MSN, RN

Child Health Nursing: Partnering with Children and Families; Ch 34 pp1369-1384; 1396-1401

Sense of personal well-being involving successful engagement in activities and relationships and the ability to adapt to and cope with change.

Many children who need services don’t receive them

25% of children in the US suffer from mental illness that impairs functioning at home or school

Only 30% of those children receive MH services Many of these interventions are not

comprehensive, multidisciplinary or evidence-based

MH issues are among the top 2 leading causes of hospitalization in 10-21 year-olds◦ Indicates children are not receiving adequate MH

services

Appearance Behavior Development History

◦ Prenatal, natal and post-natal hx Assessment:

◦ Include a valid, reliable tool to assess behavioral/ mental health problems

Pervasive Developmental Disorders◦ Autistic disorder◦ Asperger’s syndrome◦ Rett’s disorder◦ Childhood disintegrative disorder◦ Pervasive developmental disorder NOS

Attention Deficit Disorders Cognitive Disorders

◦ Trisomy 21◦ Fragile X◦ FAS

Aka “Autistic Spectrum Disorders” 5 types Begin in early childhood Characterized by impaired social

interactions and communication, with restricted interests, activities, and behaviors

about 2 or more/ 1,000 are dx w/ ASD 4X more common in males

It can be difficult to know at first if a child has a pervasive developmental disorder (PDD). PDDs are a wide spectrum of social and communication disorders, including autism, that can be complicated to diagnose.

However, there are acknowledged criteria for determining if a child has a PDD and there are ways to help children with these disorders at an early age. Typically, the symptoms should be recognizable before a child is 3 years old. Although a toddler's behaviors might seem to fit the criteria, they also might just be part of a youngster's developing personality.

Autism and Genetics:◦ Some genetic contribution◦ Familial incidence

Monozygotic twins: 60% autism: 92% PDD Dizygotic twins: 0% autism: 10-30% PDD Sibling risk: 4-7%

◦ Increased risk with genetic differences Fragile X, Williams Syndrome, Angleman’s

Impaired social, communication and behavioral development usually noted in the first year of life

Impaired social interaction◦ Stereotypy (rigid obsessive behavior)

Head banging, twirling, flapping hands Impaired Communication

◦ Speech delay or language difficulty (often 1st symptom)

◦ Echolalia (parroting of what is heard)◦ Use of “you” in place of “I“

Restricted or repetitive patterns of behaviors

Difficulty mixing with other children

Inappropriate laughing Little or no eye

contact Insensitive to pain Prefers to be alone Spins objects Physical over-activity

or extreme under activity

Insistence on sameness No real fear of dangers Sustained odd play Echolalia May not want to cuddle Not responsive to verbal

cues Tantrums Uneven gross or fine

motor skills Difficulty expressing

needs

Onset prior to age 3 Remember this disorder occurs on a

spectrum Clinical Therapy:

◦ Early intervention is key to maximize outcomes…this means early assessment and dx is key to treatment!...Screening tools in primary care!

◦ Interventions focus on improving behaviors and communication skills, PT and OT, structuring play interactions with other children, educating parents of child’s needs

◦ Combination of behavioral and cognitive tx

Strong preference for routine Perseveration

◦ Focus on same nonfunctional activity for hours Restricted range of interests Stereotypical behaviors

◦ Spinning, hand flapping

No Babbling at 12 months No gesturing (pointing, waving) at 12

months No single words at 16 months No 2-word phrases at 24 months Any loss of language/ social skills at any age

Nursing assessment: Early and frequesnt developmental screening is KEY!

Nursing Dx include:◦ Impaired verbal communication◦ Impaired social interaction◦ Disturbed thought processes◦ Risk for injury◦ Risk for caregiver role strain

State program run by DPH Services for children 0-3 Children who are at risk d/t

◦ Biological factors◦ Environmental factors◦ Psychological factors

Clinical manifestations:◦ Impaired social interactions w/ normal language

development for age; pitch, tone and other speech characteristics may be abnormal.

◦ Verbal skills involving spelling and vocabulary are high with concept formation, language flexibility, and comprehension low.

◦ So, the child w/ Asperger’s can have normal language development and normal or above normal cognition, but will have impairments in social interactions and functioning

Treatment:◦ Applied Behavior Analysis◦ Positive Reinforcement ◦ Language and communication therapy◦ Social skills training◦ Medications:

No tx for core sxs of social and relationship problems Meds target some secondary sxs: hyperactivity,

aggression and anxiety Common drug used= Risperidone Decreases abberant behavior (aggression, hyperactivity)

Early development appears normal and sxs appear b/t 6-18 months

Affects only girls (X-linked dominant disorder)

Ataxia, hangwringing, intermittent hyperventilation, dementia, and growth retardation show progressive increase.

Fist 2-5 years of development appear normal followed by deterioration in many areas of functioning. Behaviors finally stabilize at some point w/o further deterioration.

Clinical therapy:◦ Focuses on areas of developmental function that

show abnormality.◦ IEPs for school

PDD NOS: severe social impairment w/o meeting DSM criteria for other types of autistic spectrum disorders.

Clinical Tx:◦ Focuses on building social skills

Background: The term attention deficit is misleading. In general, the current predominating theories suggest that persons with ADHD actually have difficulty regulating their attention; inhibiting their attention to nonrelevant stimuli, and/or focusing too intensely on specific stimuli to the exclusion of what is relevant. In one sense, rather than too little attention, many persons with ADHD pay too much attention to too many things, leading them to have little focus.

Frequency:

In the US: The prevalence of ADHD in children appears to be 3-7%. ADHD is associated with significant psychiatric comorbidities.

Approximately 50-60% of individuals with this disorder meet DSM criteria for at least 1 of the possible coexisting conditions, which include learning disorders, restless-legs syndrome, depression, anxiety disorder, antisocial personality disorder, substance abuse disorder, conduct disorder, and obsessive-compulsive behavior.

The risk of a person having ADHD if his or her family member has ADHD or one of the disorders commonly associated with ADHD is significant.

According to the DSM IV, the essential features of ADHD include:

persistent and developmentally inappropriate pattern of inattention, impulsivity, and/ or hyperactivity

presence of sxs b/f 7 y.o.a Impairments apparent in at least two different

settings (ie home and school) Interference w/ social, academic, or

occupational function Sxs are not d/t some other psychiatric disorder

Occurs 4X more often in boys Multifactorial etiology

◦ Genetics◦ Environment◦ Biologic risk

Three subtypes◦ ADD (primarily inattentive)◦ ADHD (primarily hyperactive-impulsive)◦ Combined

In obtaining the PMHx, it is important to thoroughly review the social hx, ◦ including school performance, substance abuse,

and violence in the home, etc.

School or education interventions ◦ The age of the child at initial diagnosis and the

severity of the symptoms of ADHD likely affect the extent to which the child benefits from working with education specialists.

Psychotherapeutics ◦ For adolescents, ADHD coaching, participating

in a support group, or both can help normalize the disorder and assist them in obtaining well-focused peer feedback and general information.

◦ affected children and their families. ◦ Behavioral modification and family therapy are

usually necessary for optimal care.

Medications:◦ Stimulants:

Amphetamines (Adderall) Methylphenidate (Ritalin, Concerta) Pemoline (Cylert) Dextroamphetamine (Dexedrine)

◦ Nonstimulants Bupropion (Wellbutrin) Atomoxetine (Strattera)

For children, a major side effect of some of the stimulant medication for treatment of ADHD is what?

Monitor G+D; if child is receiving methylphenidate growth may be slowed

Give one instruction at a time to a child w/ ADHD

Give meds in morning and at lunch to avoid interfering w/ sleep

Ensure adequate nutrition Provide consistency and routine w/

schedule (teach parents)

Learning disabilities Trisomy 21 Fragile X Fetal Alcohol Syndrome

Prefer to call them Learning Differences Affects 5% of school children They involve neurologic conditions in which

the brain cannot receive or process information in the “normal” manner.

Often the impairment is only in 1 or 2 types of learning making the dx difficult

Children should have IEPs established w/ realistic goals

Nurses role: ID of children w/ learning disabilities, help to access services for child/family w/in the community

Mental retardation is not something you have, like blue eyes, or a bad heart. Nor is it something you are like short or thin.

It is not a medical disorder or a mental disorder.

Mental retardation is a particular state of functioning that begins in childhood and is characterized by limitation in both intellectual and adaptive skills.

MR is defined as significant limitation in intellectual functioning and adaptive behavior.◦ IQ below 70-75

Mild retardation occurs in 3-6 per 1,000 people

MR affects about 3% of the population. Occurs b/f age 18

Causes:◦ Prenatal errors in the development of the CNS◦ Prenatal or postnatal changes in the biologic

environment of the person◦ External forces leading to CNS damage

One in every 733 live births◦ More frequent in mothers over 35 years of age

Wide range of intellectual abilities Medical risks

◦ Cardiac◦ Immunologic◦ ENT ◦ GI◦ Thyroid disorders◦ Alzheimer’s

Triple screen: newest test for Down’s syndrome

Maternal alpha feto protein, nonspecific test, increase indicates risk

Amniocentesis Chorionic villus sampling In 2002, a study found that 91-93% of

pregnancies w/ a dx of Down’s syndrome were terminated

Single transverse palmar crease Almond shape to the eyes (epicanthal fold) Upslanting paperbral fissures Shorter limbs Poor muscle tone Larger than normal space b/t the big and

second toe Protruding tongue Low set ears

Most common known cause of inherited mental retardation worldwide

DNA analysis of FMR1 gene◦ Disease severity r/t the number of CGG

trinucleotide repeats in this gene Normal= 6-44 repeats Full mutation> 200 repeats

Clinical Manifestations:◦ Cognitive (IQ)

Ranges: mild learning disabilities to mental retardation

95-90% males w/ MR◦ Behavioral

Sensory defensiveness ADHD-like features Autistic-like features

Alcohol use during pregnancy is the leading known preventable cause of mental retardation and birth defects in the US

Affects an estimated 40,000 infants each year (more than spina bifida, down’s syndrome, and muscular dystrophy combined)

FASD is an umbrella term describing the range of effects that can occur in an individual whose mother drank alcohol during pregnancy

Specific facial characteristics Growth deficits Mental retardation Heart, lung, kidney deficits Hyperactivity and behavior problems Attention and memory problems Poor coordination and motor skills delay Difficulty w/ judgment and reasoning Learning disabilities

Once the dx has been made, a functional assessment of the child should be performed

Assess the availability of services for the child and family

Possible Nursing Diagnosis include:◦ Delayed growth and development r/t neonatal

condition◦ Imbalanced nutrition: less than body requirements

r/t inability to ingest sufficient food◦ Self-care deficit: dressing, toileting, bathing r/t

developmental disability