THE CHILD WITH A COGNITIVE

IMPAIRMENT OR PSYCHOSOCIAL

DISORDERChapters 53 & 54

DEVELOPMENTAL DISORDERS

• Mental retardation– Rated from mild to severe

– Majority of children fall into “mild” stage

– Parents need a realistic prognosis for their child

– Institutional vs. Home Care• More severely challenged may need institutionalization

• A major burden on parents, esp. when both work outside the home

DEVELOPMENTAL DISORDERS

• Pervasive developmental disorders:– Autism

• marked by severe deficits in language, perceptual, and motor development

• Often not diagnosed until age 2-3 though parents noted unusual behaviors before then

• Unknown etiology, linked to MMR and thermosal though any official link has been denied

• A subgroup, Idiot Savants, may be exceptionally talented in one area

DISRUPTIVE BEHAVIOR DISORDERS

• Attention deficit hyperactivity disorder (ADHD) and Attention deficit disorder (ADD)

• ADHD– Found more often in boys– Characterized by inattention, impulsiveness, and hyperactivity– During evaluation, important to get an accurate history and a

description of the child’s ordinary day– Treatment

• Structured learning situations• Medications

– Ritalin, Concerta, Adderall» All stimulants, work paradoxically, cause anorexia, insomnia» Kids need a drug holiday to catch up on weight gain

– Strattera» New drug, non stimulant, supposedly no anorexia

DISRUPTIVE BEHAVIOR DISORDERS

• Oppositional Defiant Disorders– Conduct Disorders

• Persistent antisocial acts– Stealing– Destruction of Property– Fire starting– Sexual behaviors– Animal abuse

• Seen more in males• Home environment often implicated• Treatment involves modifying home environment and problem-

solving skills

DISRUPTIVE BEHAVIOR DISORDERS

• ADD– Found more in girls

– Less disruptive, these girls do more day–dreaming than anything else

– Evaluation and treatment is the same though these are less likely to be diagnosed

EATING DISORDERS

• Anorexia nervosa– Found mostly in girls

(90%)– Distorted body image,

poor self-esteem– Usually in oldest/only

children who have high expectations to live up to

– May vomit, use laxatives, etc.

EATING DISORDERS• Bulimia nervosa

– Found mostly in girls– These people know their eating habits are

abnormal and try to hide them– Cycle of bingeing and purging– May abuse laxatives, emetrol, etc– Teeth often show erosion– These girls aren’t super thin like anorexics

TIC DISORDERS

• Transient tic disorder– Many children have these and are in

response to periods of high stress

– Management is aimed at reducing stress

• Tourette’s syndrome– Syndrome of motor and phonic vocal tics

– Includes the repeated use of words out of context…specifically obscenities

– More common in boys, age of onset is around 7 years

– Treated with Haldol

Anxiety and Depression• Anxiety

– Some anxiety is normal, i.e., first day of school, oral presentations

– When anxiety prevents child from attending school or school functions, professional help is sought

• Depression– Again, some depression is normal, especially in

adolescence, due to hormone fluctuations– Depression that persists needs to be treated

• Warning…some SSRIs may raise suicide risk, especially initially

Suicide• Females try it more, Males succeed more

• Nurses must– Recognize warning signs– Screen for depression– Ask!– Be available for grief counseling should suicide occur

• CHILD ABUSE

• Theories of child abuse– parents who abuse

• Many were abused themselves

• Don’t know the difference between spanking and beating

• Isolated

• Extremely religiously conservative

• Poor coping skills

• Little self restraint

• Alcohol/drug abuse

– children who are abused• May be seen as different, i.e. different father, birth defect,

less intelligent, etc.

• Born prematurely or had an illness at birth that affected the bonding process

– special circumstance: stress• Cuts across socioeconomic lines

• Affects those without strong support systems more

• Isolated families more likely to be affected

– Reporting• Nurses are mandatory reporters

• Chart objectively, use exact quotes

• Better to err on the side of reporting than not

• Have parents account for all signs of injury• Look for inconsistencies, esp. an injury out of

proportion to the story• Look for bruises in all stages of healing• X-rays will show old fractures• Burning is highly suspicious• Watch for the parents who don’t want the child

questioned alone• Try to remain emotionally uninvolved…anger

won’t help

• Shaken Baby Syndrome

• Average shaken baby is a male, age 3-8 months

• Average “shaker” is a male, age 24-27

• The usual trigger is inconsolable crying

• One out of four shaken babies will die

• People who would never strike a baby might shake them as a “gentler” alternative

• Physical Neglect

• Harder to identify than abuse

• Suspect when children are unwashed and poorly dressed and parents are not

• Suspect when children are not immunized or are brought in late for treatment

• Neglect also encompasses lack of supervision

• Psychological Abuse

• Includes belittling, threatening, rejecting, isolating, or exploiting a child

• May be just as damaging as physical abuse

• Harder to identify

• Suspect when parent uses only negative terms to describe a child

• Munchausen Syndrome by Proxy• Most perps are mothers, fathers are usually distant

or completely out of the picture• Children are repeat customers to the ER and

hospital• Symptoms are vague and only seen by the mother• Mother makes friends with the staff, is seen as the

perfect mother and caretaker…very medically savvy

• Bottom line…mother gets some sort of satisfaction from this role

• Failure to Thrive

• Can originate from organic or non-organic causes

• Non-organic is a form of neglect

• This can be multifactorial– Mother is unable to pick up on infant cues– Immature mother too busy with her issues to

worry about baby– Infant is “fussy” or colicky or neurologically

damaged

• Failure to Thrive

• Assess growth at every visit

• Develop rigid system to monitor growth and development– May be inpatient– May involve diary, role modeling, etc– Must have follow-up

SEXUAL ABUSE

• Molestation, Incest, Pornography & Prostitution– Boys and girls are victims– Perps are overwhelmingly male but may be

older children or adolescents– Involve bribery or threats to keep it quiet– Extremely harmful to the child, destroys

trust and self-esteem– Rehabilitation of the perp is difficult

Sexual Abuse

• Assessment– Be perceptive– Is child sexually savvy beyond their years?– Are there physical signs of sexual activity?– Remember, a child cannot give consent to

sexual activity.– Mandatory reporting