Chapter 11- Childhood and Neurodevelopmental Disorders

Highest risk for a child to develop a psych disorder = having a parent with a substance abuse or other psych disorder

Autism spectrum disorders = display profoundly disturbed social relatedness - Seem aloof and indifferent to other, often preferring inanimate objects to human interaction - Language is often delayed and deviant ---> cx of relationships Tx Effective: IMPROVE RELATIONSHIPS Ex: Hold that parent’s hand while walking - Relate to other children ** Social skill training = teaches pt. to recognize the impact of behavior on others - uses instruction, role-playing and positive reinforcement to enhance social outcome - Distortions in development of social skills and language * Perception * Excessive Motor movement * Attention * Reality testing

ADHD (Neurodevelopment disorder) in Children S/S: Unable to set for expected lengths of time (Excessive movement) Inattentive (Distractible) Screams unexpectedly/ talks excessively Aggressive toward others - Often receive negative feedback from parents, teachers, and peers = self-esteem disturbance - May cause peers to avoid the child, leaving the child with ADHD = vulnerable to loneliness Tx: CNS stimulants = increase BF to the brain; reduce S/S of ADHD * Methyphenidate (Ritalin) * Dexedrine * Pemoline (Cylert) Most common side effects: - GI disturbances - reduced appetite - weight loss - urinary retention - dizziness - fatigue

Mental Health Test 4

- insomnia/sleep disturbances Tx: Antipsychotic meds = manage aggressive or violent behavior Effective Tx: social interaction/cooperative play with others Group therapy for young children = PLAY TIME!!!

** Nurse should alway manage the milieu w/ structure and limit setting & Reassure parents to be their for their children **

** Nurse should ALWAYS listen (Actively) to their pt’s and encourage them to talk about feelings**

Problem w/ Parents: Build TRUST to develop relationship w/ child to build up security --- pt. may question trust w/ their parents --- Familial rx factors correlate w/ child psych disorders ** severe marital discord ** low economic status ** large families and overcrowding ** parental criminality ** maternal psych disorders ** foster-care placement Behaviors: Impulsivity = inability to take turns, blurt out answers to questions before question, etc. Hyperactive = physical in nature (running, pushing, and inability to sit still) Inattention = failure to listen Defiance = willfully doing what you were told NOT to do

Tourette’s = tics (sudden, rapid, involuntary, repetitive movements or vocalizations) Resiliency = able to handle the stresses of a difficult lifestyle Children: Adapt to changes in the environment - Take advantage of nurturing relationships w/ adults other than their parents - Distance themselves from emotional chaos occuring w/in family - Learn, and use problem-solving skills

Modern Intellectual Disorder - progress academically to ~ 2nd grade

- learn to travel in familiar ares - perform unskilled and semiskilled work - w/ supervision = functional appropriately within the community - able to perform self-care activities

Chapter 19 - Sleep-Wake DisordersSleep Deprivation = A discrepancy between hours of sleep obtained and hours required leads to sleep deprivation - Common complaints = poor general health - physical and mental distress - limitations in ADLs - depressive or anxious s/s - pain - Assess for hrs of sleep

Safety = PRIORITY ** Sleep Deprivation causes psychomotor deficits (Driving w/sleeplessness = DANGEROUS)

**Sleep Deprivation can lead to MV ACCIDENTS**

EEG (electroencephalogram) = measures NREM & REM sleep REM = dreaming occurs ** Cycles of rapid eye movement sleep increase in the second half of sleep and occupy longer periods, up to 1 hr. **

Sleep latency = refers to the amount of time it takes a person to fall asleep

* Obesity is the leading factor for obstructive sleep apnea, which causes sleep fragmentation *

Sleep Drugs: Benzodiazepines = reduces slow-wave sleep Antidepressants = suppresses REM sleep Hypnotics/Sedatives = HELP w/ sleep

Increased periods of wakefulness = SUMMER * Days are longest in Summer ==== Light = promotes wake Darkness = promotes sleep

Sleep requirements = most accurately determined by going to bed at the usual time and waking up without an alarm for several nights * Average = estimated requirements

GABA and genolin = promote sleep ACh, NE, & dopamine = promote wakefulness

Rapid Eye Movement (REM) Sleep Behavior Disorder = pt. engages in violent and complex behaviors during REM sleep as through acting out in dreams - Older men have higher incidence

Sleep Paralysis = sudden inability to perform voluntary movement at either sleep onset or awakening from sleep

Bruxism = grinding teeth during stage 2 sleep

Night terror Disorder = occurs as arousal in the first third of the night during NREM sleep accompanied by feelings of panic

Nightmares = long, frightening dreams from which people awaken in a frightened state - Occur during REM sleep late in the night - May lead to sleep deprivation

Short sleepers = require less sleep (< 8hrs) Long sleepers = requires more sleep (> 8hrs)

Restless Leg Syndrome (RLS) = sensory and movement disorder characterized by an unpleasant, uncomfortable sensation in the legs accompanied by an urge to move - S/S begin or worsen during periods of inactivity (rest, sleep) = can affect pt. sleep pattern and

Disturbed sleep can be caused by: - caffeine (CNS stimulants) - exercise before bedtime - loud noises (television, loud music, parties, etc.)

Chapter 21 - Impulse Control Disorders Conduct Disorder Manifested by:- aggressive against people and animals - destructive against property - deceitfulness - rule violations - impairment in social, academic, or occupational functioning - adolescent and parents must agree on a behavioral contract consists of: outlined rules expected behaviors consequences of misbehavior rewards following the rules - adolescent and parents must continue w/ family therapy to work on boundary and communication issues ** Separation is detrimental to the healing process ** - Important for behavior to be managed for a pt. dx w/ a conduct disorder Manifested by: ** persistent pattern of behavior in which rights of others and age-appropriate societal norms are violated. ** Ex: shoplifting kleptomaniac - Important to establish firm limits to ensure physical safety and emotional security * protect other patient from others thoughtlessness and aggressive behavior * Use clear, sharp statements about prohibited behavior and guidance for performing a behavior that is expected Tx: ANTIPSYCHOTICS * Meds are directed by problematic behaviors such as: aggression, impulsivity, hyperactivity, and mood symptoms.

D/t: Reduced gray matter bilaterally in the anterior insulate cortex and the amygdala. - May be related to aggressive behavior and deficits of empathy = less likely to feel remorse for their actions of victims

Intermittent explosive disorder = pattern of behavioral outbursts characterized by an inability to control aggressive impulses in adults 18 yrs or older - May have differences in serotonin regulation in the brain and ^^ levels of testosterone

Oppositional defiant disorder = a repeated and persistent pattern of having an angry and irritable mood in conjunction with demonstrating defiant and vindictive behavior Manifested by: negative, hostile, and spiteful toward parents - blames other for misbehavior Tx: Redirecting the expression of feelings into nondestructive age-appropriate behaviors (NO medication is used)

- Ex: physical activity (swimming, running, jumping, etc) = helps defuse the situation; helps the child learn how to modulate the expression of feelings and exert self-control

Advanced Nurse Role: - Individual, group and family psychotherapist - Educator of nurses, other professions, and the community - Clinical supervisor - Consultant to professional and nonprofessional groups - Researcher

Parent-child interaction therapy (PCIT) = therapist sits behind one-way mirrors and coaches parents through an ear audio device while they interact with their children - therapist can suggest strategies that reinforce positive behavior in the adolescent unit Goal: improve parenting strategies and thereby reduce problematic behavior

Differences: ODD= TESTS LIMITS & DISOBEYS CD = VIOLATES the Rights of others

Chapter 23 - Neurocognitive Disorders Delirium Characterized by abrupt onset of : - fluctuating levels of awareness - clouded consciousness - perceptual disturbances - disturbed memory and orientation Tx: Provide a quiet, shadow-free room = produces the fewest sensory perceptual distortions - Treat the underlying cause (UTI, medication interactions, drug toxicity, etc)

** Goal: return pt. to premorbid levels of function ** Amnestic syndrome = memory impairment without cognitive problems

Hallucinations = false perception occuring without a corresponding sensory stimulus **Stay with the patient, acknowledge the patient’s feelings & state the perception of reality ** = increases feelings of security - reduces anxiety - offers the opportunity for reinforcing reality - provides a measure of physical safety

Illusion = misinterpreted sensory perception (ex: misinterpreting shadows) Tx: Help clarify sensory perceptions - Glasses = visual hallucinations - Hearing aides = auditory hallucinations

PRIORITY = RX for injury - Pt. can perceive environment as distorted, threatening, or harmful - Pt. exercises poor judgement - Pt. senses are clouded ** Need: CLOSE SUPERVISION & OBSERVATION ** = Goal: Pt. to remain safe and free from injury

Namenda = antagonist for NMDA = used in moderate-to-late stages of Alzheimer’s disease

Alzheimers Disease Pathophysiology - alolipoprotein E malfunction - neurofibrullary tangles - neuronal degeneration in the hippocampus - brain atrophy Stages of Alzheimers Disease

** Use environmental cues** Nursing Diagnoses - Caregiver Role Strain - Urinary incontinence - Disturbed sleep pattern - Self Care-deficit - Impaired communication

Aphasia = loss of language ability (speaking ) Agnosia = loss of sensory ability to recognize objects Apraxia = lose of purposeful movement Anhedonia = loss of joy in life Hyperorality = placing object into the mouth

Dementia ** Pt. should perform all tasks of which they are capable of” ** - w/ simple directions = pt. is better able to process info and perform simple tasks * Pt. may not be able to recognize family members * Validating, talking with the patient about familiar, meaningful things, and reminiscing give meaning to existence both for the patient and family members Characteristics: Impaired level of consciousness - Disorientation to place, time; however oriented to time - Wandering attention - Flactuating LOC - May experience illusions and hallucinations

Confabulation = making up of stories or answers to questions by a person who does not remember - defensive tactic to protect self-esteem and prevent others from noticing memory loss Preservation = repeating words or phrase over and over

Chapter 24 - Personality Disorders Personality Disorders - Often use rationalization to explain behavior and deny wrongdoing (Ind. who does not believe anything done wrong, will not feel anxiety, remorse, or guilt about the act) - Acknowledge manipulative behavior when appropriate * Maintaining consistent limits is a very difficult intervention - Have problems with social interactions with others

Antisocial personality disorder Characteristics: Manipulative - Clinginess - Aggressive - Callous - Guilt-instilling - Extroverted than reclusive - Rarely show anxiety - Rarely demonstrate clinging or dependent behaviors - Impulsive - Manipulative people frequently make requests of many different staff, hoping one will give in * Have one decision maker provide consistency and avoid the potential for staff splitting (Ex: case manager) - Rarely have feelings of fear or inferiority; rarely seem to learn from experience or feel true remorse (Ex: My dog deserves to be beat) - Often impulsively acts out feelings of anger and feels no guilt * Acts in haste without taking time to consider the consequences of the action - Common problems with anger management and impulse control Tx: Limits must be set in areas in which the patient’s behavior affects the right’s of others = A lack of internal controls leads to manipulative behaviors such as lying, cheating, conning, and flattering ====> external controls must be maintained (protect rights of others) - Occasionally w/: dependent & histrionic behavior

Borderline Personality Disorder - Characteristics: demonstrates manipulative, splitting and self-destructive behaviors - fear of abandonment (exacerbated when under success or growth) - Consistent limit setting is vital for the patient’s safety Tx: Mood stabilizing medications Dialectical behavior therapy = = assist the pt. to choose alternative coping strategies * Use telephone access to the therapist for “coaching” during crises Effective: Seeking a staff member instead of impulsively self-mutilating * Use matter-of-fact approach

Splitting = involves loving a person, then hating the person because the pt. is unable to recognize that a person can have both (+) and (-) qualities Tx: Frequent team meetings to prevent further progression Denial = unconsciously motivated refusal to believe something Reaction formation = unconsciously doing the opposite of a forbidden impulse

Narcissistic Personality Disorder Characteristics: grandiosity, self-importance, and entitlement - arrogant (No genetic links)

Historonic Personality Disorder Characteristics: charm & seductiveness - attention seeking - melodramatic - flirtatious

Obsessive-Compulsive Personality Disorder Characteristics: preoccupation with minute details & admiration seeking - perfectionist - inflexible, rigid - preoccupied with rules and procedures - afraid of making mistakes

Dependent Personality Disorder Characteristics: expressive difficulty being alone; indecisive and submissive - socially aggressive behavior - restless - impulsive

Schizotypal Personality Disorder Characteristics: do not want to be involved in relationships

- shy & introverted; poor social skills - problems thinking, perceiving, & communicating - prefer fantasy and daydreaming to being involved w/ real people

- odd, eccentric appearance - often display perceptual and cognitive distortions * suspicious of others & have difficulty trusting people - highly anxious & frightened in social situations Tx: need to respect their desire for social isolation Outcomes: meet and socialize with others ** Aware of misinterpretations and overtly psychotic symptoms are usu. absent **

Schizophrenic * Use simple language * Keep to concrete topics * Clarify and validate as needed

Avoidant Personality Disorder Characteristics: timid - socially uncomfortable - withdrawn - avoid situations in which they might fail - believe to be inferior and unappealing

Chapter 30 - Psychosocial Needs of the Older AdultAgeism = a bias (negative stereotyping) against older people because of their age * Older adults might be as guilty of ageism as younger individuals Consequences: - Stereotype the elderly as having little to offer = staff avoid working w/ older patients - Staff shortage = long-term carm - Elderly pt. are often provided less info about medical care than younger adults because some health care staff members perceive elders as less able to understand - Public policy discriminates against programs for the elderly Myths of aging - Older adults are able to learn new tasks ---> learning continues long into life - Older adults are prone to become crime victims - Decline in restorative sleep occurs as one ages

Topic of Greatest immediacy = assessment of pain in older adults ** Unmanaged pain can precipitate other problems, such as substance abuse and depression - Elderly pts are less likely to be accurately diagnosed and adequately treated for pain

Assessment * Functional ability and emotional status = provides an overview of patient problems and abilities = guides selection of interventions and services to meet identified needs * Assess for sensory loses (hearing, vision, taste, and smell = decline w/ age) * Low moods occurring with regularity should signal the need for further assessment for other symptoms of depression

Dementia Types: - Lewy body disease The Pain Assessment in Advanced Dementia Scale = evaluates breathing, negative vocalizations, body language, and consolability ** Determine the medications the patient is on == may cause confusion ** (C/b drug interactions and adverse reactions) Legal Issues Advanced Directive = invoked when patients are unable to make their own health care decisions Durable Power of Attorney = instrument that appoints a person other than a HCP to act as an individual’s agent in the event that he or she is unable to make medical decisions

Adult Day Care Program = provides recreation and social interaction as well as supervision in a safe environment

Remotivation therapy = helps to resocialize regressed and apethetic pts by focusing on a single topic, creating a bridge to reality as group members talk about the world in which they live and work and hobbies r/t the topic - Group leaders give members acceptance and appreciation

Alcohol Abuse = Often c/b: losses - retirement - widowhood - loneliness - less than high school education - smoking - low income - male gender Tx: Alcohol Anonymous = provide opportunity for peer bonding & stress coping strategies Reminiscence groups = share memories of the past * Elite-old adults = persons 100+ yrs of age * Young-old adults 65-75 yrs. of age

Suicide in the Elderly * Anhendonia * Sleep pattern changes * Somatic symptoms (^^ concerns with bodily functions) * Anorexia * Delusions of persecution * Nihilistic deslusions