Chapter 54
Nursing Care of the Child with a Cognitive or Mental Health Disorder
Key Terms
anhedonia
binge eating
catatonia
choreiform movements
complex vocal tics
coprolalia
dyslexia
echolalia
flat affect
graphesthesia
hyperactivity
labile mood
motor tics
palilalia
purging
stereognosis
vocal tics
Objectives
After mastering the contents of this chapter, you should be able to:
Describe common cognitive and mental health disorders in children.
Assess a child for a cognitive or mental health disorder.
Formulate nursing diagnoses related to the cognitive or mental health disorders of childhood.
Establish expected outcomes for a child with a cognitive or mental health disorder.
Plan nursing care for a child with a cognitive or mental health disorder.
Implement nursing care for a child with a cognitive or mental health disorder, such as helping a parent reduce environmental stimuli.
Evaluate expected outcomes for achievement and effectiveness of care.
Identify National Health Goals related to cognitive or mental health disorders nurses can be instrumental in helping the nation achieve.
Identify areas related to cognitive or mental health that could benefit from additional nursing research or application of evidence-based practice.
Analyze ways that care of a child with a cognitive or mental health disorder can be more family centered.
Integrate knowledge of childhood cognitive and mental health disorders and nursing process to achieve quality maternal and child health nursing care.
You are working as a school nurse and meet Todd, a second grader who was diagnosed with attention-deficit hyperactivity disorder (ADHD) approximately 6 months ago. You observe Todd coloring; running to the window; running to the door, opening and closing the door; and then throwing pamphlets out of an information rack. His mother tells you she is “at her wits' end” because Todd's attention span is so short and his behavior so disruptive. His father tells you he's proud that his son is “all boy.”
Previous chapters described the growth and development of well children and the care of children with physiologic disorders. This chapter adds information about the dramatic changes that occur when children demonstrate a cognitive or mental health disorder. This is important information because it builds a base for care and health teaching.
How can you help Todd's family?
What additional education do they need?
After you've studied this chapter, access the accompanying website. Read the patient scenario and answer the questions to further sharpen your skills, grow more familiar with RN-CLEX types of questions, and reward yourself with how much you have learned.
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A child who is mentally healthy successfully masters the tasks of each developmental phase, develops the ability to trust adults, and possesses a positive self-concept and sense of contentment within his or her own limits. In addition, there is a good emotional relationship between the parents and the child and a sense of safety and security in the home environment. Promoting healthy family functioning during health care visits, providing anticipatory guidance for parents about developmental milestones and needs, and listening carefully to both children and parents are important in fostering both the physical and mental health of children.
Mental health implies that a child is able to use adaptive coping mechanisms appropriately to meet the normal stressors of life. Often, these stressors provide growth-producing challenges in life or help a child achieve the tasks of each developmental phase, such as establishing a sense of trust or independence. This is one of the reasons why providing age-appropriate stimulation is an essential nursing responsibility. Some stressors in life, however, go beyond what is considered “the norm.” Acute illness and hospitalization are examples of increased stress. Chronic illness may provide an even greater stress, as the acute phase fades into recognition of long-term disability or an ultimately fatal prognosis. Nurses must be able to recognize the effects of illness and hospitalization on children and their families and to provide interventions to prevent maladaptive coping mechanisms. Being aware of the potential emotional responses a child might have to a particular illness and the implications for family functioning is essential to this ability.
Children can develop the same mental health disorders that affect the adult population, such as depression or schizophrenia. In addition, a number of disorders (e.g., pervasive developmental disorders such as autistic disorder) appear to begin in childhood. Some problems, such as separation anxiety, may consist of behavior that is considered normal at one stage of development (infancy) but pathologic at another (adolescence). Current research attributes some of these disorders to genetic vulnerability and others to disruption in family life, temperament, or inadequate parent–child bonding and attachment difficulties. Children with mental illness, whatever the cause, must be evaluated and treated by specialists in the mental health field as early in their disease process as possible. The child health nurse is often the first to become aware of such problems and can be instrumental, through appropriate referrals, in helping the child and family adjust to the disorder.
Cognitive and mental health disorders addressed by National Health Goals are shown in Box 54.1.
Nursing Process Overview
For Care of a Child with a Cognitive Challenge or Mental Illness
Assessment
Both personality and mental growth potential in a child are influenced by a number of factors, including genetic makeup, cultural background, family environment, and community resources. All of these need to be taken into account when assessing a child's cognitive or mental health. Assess children for emotional as well as physical problems at regular health maintenance visits. If an emotional problem has been identified or is suspected, obtain a detailed history of the presenting problem, the presumed reason for its appearance, relevant past history, the child's school and social history, the child's developmental history, the family history, and the current pattern of family functioning.
Table 54.1 lists some helpful observational and interview data for assessing these areas.
Nursing Diagnosis
Nursing diagnoses established for ill children often address mental health or the response of children and their families to their condition or treatment. Examples of these diagnoses are the following:
Anxiety related to surgical experience
Deficient diversional activity related to lack of appropriate play materials for hospitalized child
Fear related to potential loss of independence secondary to traumatic injury
Situational low self-esteem related to disfiguring scars after accident
Impaired social interactions related to hearing deficit
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Powerlessness related to loss of independence and control in hospital environment
Decisional conflict related to lack of relevant information
Hopelessness related to prolonged caretaking responsibilities for chronically ill child
Compromised family coping related to overwhelming number of stressors placed on family at one time
TABLE 54.1 Guidelines for the Mental Health Interview of a Child
Observational Data
General appearance Height, weight, grooming and hygiene, nutrition, physical health, distinguishing features (deformities, tics), maturity level
Motor behaviors Fine and gross balance, bizarre motor activity
Speech and language Receptive, expressive; content, tone, and articulation
Affect Range of emotion, predominant emotion (depressed, angry, anxious, happy, irritable, labile), emotional reactions to process and/or content of interview (appropriate, inappropriate)
Thought process Estimated intellectual level via language and knowledge base (organization and thought content), orientation (to person, place, time), perceptual distortions (hallucinations, illusions, tangentiality, obsessions, delusions), attention span, learning disabilities
Ability to relate to evaluator Eye contact, attitude toward interviewer (negative, positive, shy, suspicious, withdrawn, friendly, self-centered)
Behaviors displayed during interview Impulsivity, aggression, inhibition, distractibility, low frustration tolerance, ability to have fun, sense of humor, creativity
Interview Data
Interpersonal relationships Attitudes toward and perceptions of family, siblings, peers, transitional objects (inanimate objects used to allay anxiety), pets; social skills with peers, best friend; relationships with family, siblings, and peers; conflicts; behavior problems; adjustment to changes in routine or new situations
Self-concept and image Self-appraisal (does child like self?), comparison of self with others (siblings, peers), what does child like most about self? What would he or she like to change about self? Sense of pride in accomplishments, sex role, and gender identity
Conscience Understands right and wrong, is able to express common judgments or values.
Additional nursing diagnoses are appropriate if a problem of cognitive or mental health is present:
Risk for self-directed violence related to impulsivity
Impaired social interaction related to short attention span and distractibility
Interrupted family processes related to inability of child to follow instructions
Disturbed thought processes related to the effects of schizophrenia
Impaired verbal communication related to depression and withdrawn behavior
Ineffective health maintenance related to inattention to food or hygiene needs
Situational low self-esteem related to lack of successful coping strategies
Disturbed sleep pattern related to hallucinations
Social isolation related to low self-esteem
Compromised family coping related to chronic mental health problems in child
Outcome Identification and Planning
Although the diagnosis of a mental health disorder or referral to a child guidance or psychiatric clinic does not carry the stigma it once did, many parents still believe that such a referral is a mark of inadequacy or a sign of failure for themselves as parents. Help parents to see that this type of referral is no different from one to a cardiologist or orthopedist for a purely physical reason.
Parents can be reminded that everyone recognizes the many pressures and stresses on children today that cannot be controlled or guarded against completely. Many parents find it reassuring to be told that their contact with a child guidance clinic, psychologist, or psychiatrist will be kept confidential. They also feel reassured by knowing that the health care personnel making the referral will continue to offer episodic or health maintenance care—that they are not being “transferred out” but asked to seek additional help only in this one area.
Implementation
Often what parents and children need most when a cognitive or mental health disorder is identified is an empathic but uninvolved person to listen to their story objectively and to provide support for them as they try to resolve and manage the situation to a satisfactory conclusion. Recognizing when you are the person best able to serve this function requires professional
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judgment. Serving in this capacity can be important and can provide a source of personal satisfaction.
Additionally, outside organizations may be a source of support and education for the family. Organizations that might be helpful for referral include the following:
Anorexia Nervosa and Related Eating Disorders, Inc. (http://www.anred.com)
Autism Society of America (http://www.autism-society.org)
Tourette Syndrome Association, Inc. (http://www.tsa-usa.org)
National Association for Down Syndrome (http://www.nads.org)
National Mental Health Association (http://www.nmha.org)
Outcome Evaluation
Children who have a cognitive or mental health disorder need ongoing evaluation by health care personnel at routine visits, because these disorders are long term. In addition, it is important to determine whether any circumstances that might have led to a temporary problem have truly been corrected or only superficially changed, which could lead to the problem's resurfacing. On the whole, if the circumstances surrounding the child remain the same, the child's problem may return or be manifested later in another way.
Examples suggesting achievement of expected outcomes are the following:
Child does not injure himself during the coming month.
Parents state they are able to cope with child's disruptive behavior since prescription of antipsychotic drug.
Child ingests a minimum of 500 calories daily with no binge eating.
Parents state that they accept that their child is cognitively challenged.
Box 54.1 Focus on National Health Goals
Cognitive and mental health disorders in children produce major costs to the nation, as well as to individual families, because these disorders have the potential to reduce the earning power and contributions of future citizens. Two National Health Goals directly address this issue:
Increase the proportion of children with mental health problems who receive treatment.
Reduce the proportion of children and adolescents with disabilities who are reported to be sad, unhappy, or depressed, from a baseline of 31% to a target level of 17% (DHHS, 2000).
Nurses can help the nation achieve these goals by educating parents to seek prenatal care, so that low birth weight and the threat of physical challenges can be reduced; educating about ways to reduce stress in families; and identifying children in school and health care agency settings who demonstrate a high level of stress or other symptoms of mental illness.
Additional nursing research questions for this area could include the following: What are the questions on a health history that would best reveal mental stress? Can nurses successfully identify adolescents who are at high risk for eating disorders? What support measures are most helpful to families of a child with mental illness or cognitive challenge?
Health Promotion and Risk Management
Nurses play a key role in assessing and promoting the mental and cognitive health of children and their families. A working knowledge of the typical growth and development of a child provides the basis for assessment. This knowledge also helps in developing appropriate educational strategies for parents so that they can better identify problems early on. Like adults, children and adolescents are exposed to stress; however, they cope with these stresses differently. Nurses can help parents better understand how children respond to and cope with stress, which also aids in early identification should a problem arise. Acting as educator, facilitator, and advocate, nurses can assist children and families to identify their needs and implement measures to meet them.
Various factors have been associated with an increased risk for mental health disorders in children, including the following:
Trauma or neglect
Difficult temperament
Attachment problems
Experience of major losses
Negative sibling relationships
Medical problems and illnesses
Exposure to high-risk activities, such as drug abuse
Poverty and homelessness
Parental substance abuse
A thorough assessment of the child and family can provide clues to the existence of such possible risk factors and suggest strategies to reduce their impact.
If a child develops a cognitive or mental health disorder, nurses can act as advocates to obtain referrals to support services and early intervention programs, helping to minimize the overall effects of the disorder on the child and family.
Classification of Mental Health Disorders
For many years, psychopathology in children was not classified according to a standard system; as a result, conditions were not clearly defined or described. Today, after several revisions, the Diagnostic and Statistical Manual of Mental Disorders—Text Revised, fourth edition (DSM-IV-TR; 2000), published by the American Psychiatric Association (APA), provides a standardized classification system that can be used by all members of the mental health care team.
Developmental Disorders
Developmental disorders, although not related by etiology, typically share a common feature in that there is a delay in one or more areas of development. These areas include attention, cognition, language, affect, and social and moral behavior. Because these behaviors are interrelated, a delay in one area may interfere with development in another area. Developmental disorders include cognitive challenge, pervasive developmental disorders, and specific developmental disorders such as learning disorders, motor skills disorders (developmental coordination disorders), and communication disorders.
Cognitive Challenge
The DSM-IV-TR defines cognitive challenge (mental retardation) on the basis of two criteria: significantly subaverage general intellectual functioning—an intelligence quotient (IQ) of 70 or lower with onset before 18 years of age—and concurrent deficits in adaptive functioning (APA, 2000). For infants, because available intelligence tests do not yield numerical values, a clinical judgment of significant subaverage intellectual function must be made.
Approximately 2% of children in the United States are cognitively challenged. This is not the result of a single cause but of conditions such as genetic abnormalities (e.g., fragile X syndrome, Down syndrome [trisomy 21]) and metabolic disorders (e.g., phenylketonuria). In addition, an interplay of several genes with environmental factors (polyfactorial causes) has been identified as a possible cause in some children (Box 54.2).
Children who are cognitively challenged are seen in health care settings for diagnosis, and they come to health settings throughout their lives for the same reasons as other children do—for well-child care at ambulatory health
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maintenance visits; for treatment of lacerations or poisoning in emergency departments; or for treatment of illnesses such as pneumonia or appendicitis in in-service units. For these reasons, child health nurses need to be skilled in meeting the needs of cognitively challenged children.
Box 54.2
Common Causes of Cognitive Challenge
Chromosomal abnormalities such as Down syndrome and fragile X syndrome
Infection in utero, such as rubella or cytomegalic inclusion disease
Anoxia at birth from such causes as umbilical cord compression
Fetal alcohol syndrome
Inherited metabolic disorders such as phenylketonuria
Head trauma
Lead poisoning
Hypothyroidism
Brain malformations such as anencephaly
Very low birth weight
Infections such as measles encephalitis
Classification
Assessing children who are cognitively challenged for physical disorders is difficult because they cannot relate symptoms as well as other children (Roberts et al., 2004). It is unfair to categorize children only according to the results of intelligence tests, because children do not always perform well in testing situations. Commonly, cognitive challenge is classified as mild, moderate, severe, or profound according to IQ. The IQ level of 70 was chosen as the upper limit of cognitive challenge because most children with IQs below this level are so limited in their functioning that they require special services, protection, and schooling. IQ tests are considered to have an error of measurement of about 5 points. Therefore, many children with an IQ of 75 are included in special schooling programs.
Mild Cognitive Challenge
About 85% of children who are cognitively challenged fall into this category (APA, 2000). In this group, a child's IQ is between 50 and 70. The category is equivalent to the educational category “educable.” During early years, these children learn social and communication skills and are often not distinguishable from average children. They are able to learn academic skills up to about the sixth-grade level. As adults, they can usually achieve social and vocational skills adequate for minimum self-support. They can live independently but need guidance and assistance when faced with new situations or unusual stress.
Moderate Cognitive Challenge
Children in this category have an IQ between 35 and 49. About 10% of cognitively challenged children fall into this category (APA, 2000). During preschool years, these children learn to talk and communicate, but they have only poor awareness of social conventions. They can learn some vocational skills during adolescence or young adulthood and can learn to take care of themselves with moderate supervision. They are unlikely to progress beyond the second-grade level in academic subjects. As adults, they may be able to contribute to their own support by performing unskilled or semiskilled work under close supervision in a sheltered workshop setting. They may learn to travel alone to familiar places. They need supervision and guidance when in stressful settings.
Severe Cognitive Challenge
Children in this group have an IQ between 20 and 34. About 4% of cognitively challenged children fall into this category (APA, 2000). During the preschool period, these children develop only minimal speech and little or no communicative speech. They usually have accompanying poor motor development. During school years, they may learn to talk and can be trained in basic hygiene and dressing skills. As adults, they may be able to perform simple work tasks under close supervision, but as a group they do not profit from vocational training. They need constant supervision for safety.
Profound Cognitive Challenge
The IQ of children in this group is less than 20. Fewer than 1% of cognitively challenged children fall into this group (APA, 2000). During the preschool period, these children show only minimal capacity for sensorimotor functioning. They need a highly structured environment and a constant level of help and supervision. Some children respond to training in minimal self-care, such as toothbrushing, but only very limited self-care is possible.
Assessment
Assessment as to whether a child is cognitively challenged is done by history taking and IQ testing. Early assessment is key and should be done as soon as parents become aware that their child is experiencing problems with development. This helps to prevent the parents from developing unrealistic expectations of the child or punishing the child for doing things that he or she doesn't understand not to do. Assessment also allows parents to look at the things the child can do and to see where they can be of most help (King et al., 2005).
Intelligence is routinely measured with standardized tests, such as the Stanford-Binet test. Adaptive behavioral functioning, which may vary in different environments, is judged according to several methods, including standardized instruments for assessing social maturity and adaptive skills. A composite picture of life functioning is drawn from these multiple sources.
Parents may react to the diagnosis of cognitive challenge in the same way as parents who have been told that their child has a chronic or fatal illness—with a grief reaction. This may be manifested as disbelief, anger, or extreme sorrow. The grief may become chronic—always present, always waiting to strike a parent especially hard at times when the child would have reached milestones in his or her life, such as the first day of school or high school graduation. Work with the family to develop plans that are realistic. A child cannot achieve more than his or her individual disability will allow, but you can help parents better accept the child's limited capabilities (Box 54.3).
Box 54.3 Focus on Diversity of Care
Cognitive and mental health disorders have always been perplexing to people, so the history of acceptance for children with such disorders is poor. In ancient civilizations, physicians bored holes in children's heads to let out what they perceived to be evil spirits; modern television programs or movies still show distorted perceptions of behaviors associated with people who are cognitively challenged or have a mental illness. Such misperceptions make it difficult for parents or siblings to accept these diagnoses. Taking time to talk with them about modern management of these disorders and the ways that children who are mentally ill or cognitively challenged can be integrated into a family can be a major intervention in helping families adjust to and grow with these disorders.
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Therapeutic Management
To aid in planning, parents need a realistic prognosis for their child. This may be difficult to offer in early life, because infant intelligence tests are not accurate and more sophisticated tests are difficult to administer until the preschool years. Because prediction based on these early tests involves some subjective input, a child's potential may be overrated or underrated by them. Once parents have a realistic expectation based on the best judgment possible, however, they are ready, with guidance, to help their children achieve their full potential.
Nursing Diagnoses and Related Interventions
Nursing Diagnosis:
Health-seeking behaviors related to increasing knowledge of care needs of a cognitively challenged child
Outcome Evaluation:
Parents identify their particular options; identify child's care needs; demonstrate measures to care for child.
Parents of children who are cognitively challenged have a number of important decisions to make concerning care of their child.
Institutional Care Versus Home Care
At one time, if a child was born with a disorder such as Down syndrome, parents were advised to place the child in an institution immediately. Today, very few institutions of this type are available. Parents are encouraged to keep children at home and to maintain a home and school environment for them that is as near normal as possible. This plan has definite advantages for children who are only mildly or moderately delayed. The give-and-take of a home environment improves their ability to relate to other people. Because a small group of people cares for them, stimulation and desire to achieve are increased.
Parents shoulder a great deal of responsibility to provide constant watchful care, especially for a child with problems affecting judgment. This responsibility increases as both the child and the parents grow older. The parents' freedom to go on vacation or to have an adult life apart from the child is restricted. They may spend so much time with the child that other children in the family feel left out, unloved, or burdensome.
If parents are unable to care for a child at home, a suitable foster home placement may be possible, offering the child the advantage of a family setting. Halfway houses or group homes (6 to 12 children living in a home with assigned counselors) can provide a care setting with a home atmosphere and community experiences.
Before giving advice to any family about where a child should be raised, consider the individual circumstances of the family. Every family has its own coping mechanisms, and individual parents may be at different stages of coping, especially during the first year after the birth of a child with a severe disability. Be certain to consider the feelings of each family member and how adequately they are coping.
Health Maintenance Needs
Children who are cognitively challenged need the same health maintenance supervision as other children do. At health care visits, parents may need reinforcement and review of precautions against accidents. Remind them to treat children according to their intellectual age, not their chronologic age. All 2-year-old children would turn on the burners of the stove to see the flame if they could reach them. Most do not, however, because they cannot reach that high. The mother of a 6-year-old child who thinks like a 2-year-old must be exceedingly careful: her child can reach the same dangerous areas as any 6-year-old child can but may explore and touch them with a 2-year-old child's judgment.
Illness
It may be more difficult to detect illness in a child who is cognitively challenged because he or she may not be able to describe the problem. For example, children experiencing pain may respond to it by generalized crying, as infants do. Parents must observe their child closely for symptoms such as tugging at an ear, refusing to swallow food, rapid breathing, or limping, because these symptoms will help to localize the discomfort. When they call health care personnel, parents may be apologetic about their lack of ability to judge their child. Help parents to become advocates for their child. They know their child better than anyone else. The parents may not know exactly what is wrong, but they do know that something is wrong. Reassure the parents that they have done the correct thing by calling to check out the problem.
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When children with a cognitive challenge are seen in an emergency department or an ambulatory setting for care, they need simple explanations of what will happen. The average 6-year-old child sees you with a thermometer in your hand and thinks, “She's going to take my temperature.” Your explanation that you are going to do that only confirms what the child has already guessed. A child who is cognitively challenged may be unable to make this association between the thermometer and what you are going to do. Your explanation, therefore, is the first introduction to the event. Make certain that it is adequate.
When children are admitted to the hospital, nursing care must meet the needs of their intellectual age, not their chronologic one. For example, whether safety precautions such as side rails or possibly restraints will be necessary must be judged according to intellectual age. The explanations and preparations for procedures also must be geared to intellectual age.
When cognitively challenged children are discharged from a hospital, parents need careful explanations of signs and symptoms to look for to ensure continued good health in the child. Remember that such signs may be more difficult to elicit, depending on the degree of the child's cognitive delay. Be sure parents have a telephone number they can call to seek further information or advice if they are unsure of their own observations in the period immediately after discharge.
Education
Most children who are cognitively challenged do well in preschool programs, possibly giving them a head start in learning to socialize with peers and to develop fine and gross motor coordination.
The school chosen for the child depends on the degree of intellectual delay and on the school situations available in the community. Children should be included in regular classes as much as possible (Fig. 54.1). These classes offer children a great deal of stimulation and help them reach their best potential. They also help them learn to work and socialize with people, something they will need to do for the rest of their lives. Advocating for school placement of a child in an inclusive program may be necessary. By federal law, children have the right to be educated in the least restrictive environment possible. Children who are cognitively challenged need an individualized education plan (IEP) developed based on the child's individual learning style and projected capabilities. In addition, they need safety instructions such as how to locate the correct bus for the trip home from school. If they walk to school, they need appropriate supervision to ensure safety when crossing streets.
Nursing Diagnosis:
Delayed growth and development related to cognitive impairment
Outcome Evaluation:
Child performs self-care within limits of disorder; exhibits feelings of satisfaction with accomplishments.
Self-Care Activities
Children who are cognitively challenged need to learn the maximum amount of self-care possible. Doing so provides them with a sense of control and accomplishment. Carefully assess whether children need special aids to achieve such skills as brushing teeth, combing hair, taking a bath, and eating. Even after children learn how to perform these skills, they may need continued reminders to do them, because they are unaware of the reason for or importance of the skill. If you perform these skills for children, such as during a period of hospitalization, they can forget how to perform them and need to be retaught after they return home (Box 54.4).
Play
Children with intellectual delays enjoy play like any child. Guide parents to choose toys that are appropriate for their child's developmental, not chronologic, age. Toys that cover a wide age range, such as music boxes or tape players, are good choices. Because children who are cognitively challenged may be older and stronger than the age stated for a toy, toys that are developmentally correct still may not be appropriate because they break too easily to be safe.
Social Relationships
The ability to communicate may be delayed in children who are cognitively challenged, because the ability to develop language is often delayed. Speech therapy may be necessary to help them articulate correct sounds. Talking picture boards (boards with pictures on them, available commercially or made by parents), to which children can point if they want something, can help speed communication.
Teaching early social behavior, such as saying “thank you” and “excuse me,” shaking hands, and taking turns, is important to help children relate to other children and adults. Cognitively challenged children imitate this type of behavior the same as other children do. Providing good role models is an effective way of teaching social behavior.
Encourage parents to enroll children in preschool programs to help them learn to be comfortable with other children at the earliest time possible. Many programs enroll children as early as 1 year of age to begin education. For a school-age child, participating in organized groups such as Girl Scouts or Special Olympics is an important way to learn to interact with others and feel successful.
Preparation for Adulthood
As children who are cognitively challenged reach adolescence, they benefit from orientation to sexual responsibility, the same as all children do. Girls can understand a simple explanation of menstruation and necessary menstrual hygiene. Both boys and girls need explanations of how pregnancy occurs and the measures they need to take to prevent this. Help them understand socially acceptable sexual activities.
If a girl is going to use a contraceptive and lives with a responsible adult, she can be given an oral
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contraceptive daily by that adult. Longer-acting contraceptives, such as Depo-Provera and Norplant, which do not require daily administration, also are available. Sterilization is not recommended, because it is difficult for a cognitively challenged adolescent to understand fully the implications of the procedure, so their consent is not fully informed. If pregnancy should occur, an adolescent who is cognitively challenged can be counseled but not forced to have an abortion. If the adolescent decides to continue the pregnancy, assist her through the pregnancy and planning safe care for her child.
FIGURE 54.1 A teenage boy with Down syndrome participates in a high school art class. (© Richard Hutchings/Science Source/Photo Researchers.)
What if …
a 15-year-old girl who is mildly cognitively challenged, comes to your school office. During your conversation, she asks you if she should have a baby. How would you respond?
View Answer
1. This is an interesting question because it makes you wonder why the girl is asking. Is she worried she is pregnant? Is she seeking sex education information on where babies come from? Does she need contraceptive information? Did she simply watch a television show last night in which there was a cute baby? Once the unvoiced question (why is she asking) is answered, the answer to the actual question will differ depending on the reason it was raised.
Pervasive Developmental Disorders: Autistic Disorder
As a category, pervasive developmental disorders are characterized by impairment in social and communication skills and the display of stereotypical behaviors (APA, 2000). Autistic disorder is marked by severe deficits in language, perceptual, and motor development; defective reality testing; and an inability to function in social settings. There often is a lack of responsiveness to other people, gross impairment in communication skills, and bizarre responses to various aspects of the environment, all developing within the first 30 months of age. It is a rare condition, occurring in only 2 to 10 of every 10,000 children, although its incidence may be increasing. A former concern that immunization may precede or cause the disorder has now been ruled out as a cause (Jack, 2004). Autism occurs more often in boys than in girls. As many as 50% of children with the disorder are also cognitively challenged (APA, 2000).
Box 54.4 Focus on Family Teaching
Teaching Guidelines for the Cognitively Challenged Child
Q. The mother of a child who is cognitively challenged says to you, “How can we make sure our son can learn as much as he is able?”
A. Here are some guidelines for teaching:
Teach one step at a time. Short-term memory is often possible, whereas long-term memory is not. This means a child can learn only one step of a skill at a time (remembering three consecutive steps requires long-term memory).
Introduce motivators for learning, such as generous praise. Learning may not be rewarding all by itself when intelligence is impaired.
Reduce the number of extra stimuli present. Faced with too many stimuli, a child cannot focus attention on the task to learn (or realize that the task is more important than surrounding stimuli).
Demonstrate the skill to be learned. Seeing a skill performed is generally better than just hearing it explained.
Keep things simple. Cognitively challenged children may have difficulty with learning principles or abstractions. They may be able to learn to wash their hands, for example, but not why they should wash them (other than that it pleases you).
Give praise accordingly. Remember that accomplishing even the most simple skill may be very difficult for your child. Learning to tie shoes may take the same effort as another child spends learning mathematics. Learning to cross streets safely may be equivalent to earning a high school diploma.
Assessment
Common symptoms of autistic disorder are summarized in Box 54.5. Because of the lack of responsiveness to people that is part of the syndrome, normal attachment behavior does not develop. Although autism often is not diagnosed until the child is 2 to 3 years of age, parents report that they were worried much earlier because their infant failed to cuddle, make eye contact, or exhibit facial responsiveness. Infants may not reach to be picked up. They are unable to play cooperatively or make friendships. Parents may first bring a child to a health care facility thinking that he or she is deaf because of this inability to establish normal relationships.
The impairment in communication is shown in both verbal and nonverbal skills. Language may be totally absent.
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If a child does speak, grammatical structure may be impaired, such as the use of “you” when “I” is intended. There is inability to name objects (nominal aphasia) and abnormal speech melody, such as question-like rises at the end of statements. Echolalia (repetition of words or phrases spoken by others) and concrete interpretation also may be present.
Box 54.5
Common Symptoms in the Child with Autistic Disorder
Failure to develop social relations
Stereotyped behaviors such as hand gestures
Extreme resistance to change in routine
Abnormal responses to sensory stimuli
Decreased sensitivity to pain
Inappropriate or decreased emotional expressions
Specific, limited intellectual problem solving abilities
Stereotyped or repetitive use of language
Impaired ability to initiate or sustain a conversation
Bizarre responses to the environment may include intense reactions to minor changes in the environment (e.g., screaming if a toy box is moved across the room) and attachment to odd objects (e.g., always carrying a string or a shoe). Repetitive hand movements, rocking, and rhythmic body movements are often observed. Children are intensely preoccupied by objects that move, such as a fan, the swirling water in the toilet bowl, or a spinning top. Music often holds a special interest for them. Hitting, head banging, and biting also may be present.
Children with autistic disorder have a labile mood (e.g., crying occurs suddenly and is followed immediately by giggling or laughing). They may react with overresponsiveness to sensory stimuli, such as light or sound, but then be unaware of a major event in the room, such as the sounding of a fire alarm.
In contrast to these mannerisms, long-term memory and “savant” skills may be excellent (Volkmar et al., 2005). Autistic children may be able to recall dates and spoken words from conversations that took place years before. This excellent memory previously led to the belief that most of these children have normal intelligence. Actually, the majority of children with autistic disorder have an IQ of less than 70 (APA, 2000). Intelligence testing is difficult, however, because children with autistic disorder do not respond well to test situations, and they score poorly on the verbal parts of these tests. Tasks requiring manipulative or visual skills or immediate memory may be performed at above-normal levels.
Therapeutic Management
Autistic disorder is a perplexing condition. Parents need a great deal of support so that they do not reject their child because he or she seems to be rejecting them. Behavior modification therapy may be effective in controlling some of the bizarre mannerisms that accompany autism, but, because the basic cause of the disorder is not known, therapy will not always succeed. Although various medications such as tranquilizers or antidepressants have been tried, no medications specific for autism are available (Volkmar et al., 2005).
As children mature, they develop greater awareness of and attachment to parents and other familiar adults. A day care program can help to promote social awareness. Some children may eventually reach a point where they can become passively involved in loosely structured play groups. Some children may be able to lead independent lives, although social ineptness and awkwardness may remain, especially if accompanied by cognitive challenges.
Checkpoint Question 1
Suppose Todd had symptoms of autism. Which of these symptoms is common in autism?
a. Lack of short-term memory
b. Hallucinations of voices talking
c. Whirling and whirling around in a circle
d. Severe depression or feelings of sadness
View Answer
1. C. Repetitive movements are a common symptom of autism.
Specific Developmental Disorders
Specific developmental disorders may be characterized by the more narrowed area of development involved with the delay. Typically, these include learning disorders, communication disorders, and motor skills disorders.
Learning disorders occur in approximately 5% of the children in the United States. Although the degree may vary, these disorders involve a discrepancy between actual achievement and what is expected based on the child's age and intelligence. Learning disorders may involve reading (e.g., dyslexia [reading reversal]), mathematics, or writing. Children may develop accompanying low self-esteem and deficits in social skills (APA, 2000). Children need individualized educational plans to help them achieve at the highest level possible.
Communication disorders involve problems of speech (motor aspect) or language (formulation and comprehension of verbal communication). Examples include expressive disorders, phonologic disorders, and stuttering. Like learning disorders, these conditions can lead to a lack of self-esteem unless a child receives support and encouragement from parents, teachers, and health care providers. Speech therapy can effectively improve these disorders and allow children to achieve sufficiently to become successful adults.
Attention-Deficit and Disruptive Behavior Disorders
Attention-deficit disorder and the disruptive behavior disorders may begin with behavior problems that are not so different from what most families experience. For this reason, parents may be unaware of the need for intervention initially. By the time they do seek help, they may already be extremely distressed about the seeming unmanageability of their child.
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These disorders need to be diagnosed as early as possible, before the child's behavior leads to a deteriorating level of self-esteem, compromised social skills, and social and legal complications in family functioning. The home environment may be the most important factor in determining whether a disorder turns into a more complicated psychopathologic process or can be channeled into purposeful, productive activity.
Attention-Deficit Hyperactivity Disorder
Attention-deficit hyperactivity disorder (ADHD) is a persistent pattern of inattention and/or hyperactivity-impulsiveness revealed before the age of 7 years (APA, 2000). It is estimated to occur in about 3% to 7% of school-age children in the United States. Boys are affected more frequently than girls. Although the cause is unknown, it occurs more frequently among some families than in the general population, indicating a possible genetic etiologic component. ADHD has also been associated with child neglect, lead poisoning, and drug exposure in utero (APA, 2000). Both drug and behavior modification treatment methods have been used with success, a fact that may support the theory of varying causes.
The disorder is characterized by three major behaviors: inattention, impulsiveness, and hyperactivity (Hechtman, 2005). Inattention makes children unable to complete tasks effectively. They become easily distracted and often may not seem to listen. Impulsiveness causes them to act before they think and therefore to have difficulty with such tasks as awaiting turns at games. With hyperactivity, children may shift excessively from one activity to another, exhibiting excessive or exaggerated muscular activity, such as excessive climbing onto objects, constant fidgeting, or aimless or haphazard running.
Assessment
The disorder is diagnosable by 36 months of age, although parents may excuse the behavior as “active” or “always on the go” until school age, when it is apparent that the child cannot sit still in school or concentrate on problem solving for longer periods. When the disorder is first suspected, a thorough initial history to reveal the extent of the problem must be obtained. The history is important, because some children have enough control in a one-to-one situation that their extremes of behavior are not apparent in an ambulatory health care setting.
Review the pregnancy and birth history, the child's ability to meet developmental milestones, and a typical day for the child. The term hyperactivity, or excessive movement, is commonly carelessly used by parents to describe any active child. Have the parent give an exact description of what the child is unable to do, such as sitting still long enough to finish a full meal or running to the window 10 times in 15 minutes, to document that hyperactivity truly exists.
Assess for activity that is not only excessive but also disorganized. For example, in school, children with ADHD may run from the back of the room to the front of the room, to the window, to the teacher's desk, to their own desk throughout class. They perform repetitive activities such as pencil tapping, arm swinging, and finger tapping. At home, they may leave a project they are working on or a television program they are watching intently and run to the window or open the refrigerator door, unaware of why they are running. This is driven or compulsive behavior.
Variability is another important symptom. Everyone has days when they perform at their peak and days when their performance is less than optimum. Children with ADHD may have behavior so variable that they have good and bad moments. This type of variability causes them to lose track of systems and methods, not just answers, so school performance may falter. When asked to add, for example, a child might add 4 and 3 correctly, but then lose track of the system and add 2 and 3 as 23 or 32.
A high level of impulsiveness can cause children to make statements without thinking, to touch objects they have just been told not to touch, or to speak or act before they have time to think about what they want to say or do. When angered, they may shout, strike out, or bite before they can be offered an explanation. They may be unable to wait in line for a drink of water—their impulsiveness tells them that they must have their drink immediately.
Usually, average children can filter out stimuli that are not important to them at that moment. Children with ADHD seem to have an “all-or-none” reaction to stimuli. They may block out all incoming stimuli and, as a result, do not hear their parents or a teacher calling them. They may be disciplined at school for something such as not answering a fire drill (unaware that a bell was ringing and that children around them were moving toward the exit). At other times, they may be unable to suppress any incoming stimuli. They mean to concentrate on a desk assignment in school, but, outside the window, they hear a bird singing; next to them, they smell a girl's perfume; they feel their watch on their wrist—so they cannot concentrate on the problem at hand. This may be reported by parents or teachers as an exceedingly short attention span.
Children with ADHD may also have difficulty with concepts such as right and left, before and after, in front of, in back of, and yesterday and tomorrow, because these concepts call for sequencing, the process of relating things to one another in time or space. If children cannot tell the difference between left and right, they can have difficulty forming common letters such as b and d, which vary only in the direction of the bottom loop. They can have difficulty with common tasks such as washing their hands, because they never know which way to turn a faucet. Turning door knobs and keys, tying shoe laces, and screwing on bottle caps are all complex tasks for a child who has difficulty with sequencing. They may show awkward motor movements and cannot work all muscles gracefully in proper sequence. These children may reach beyond an object, possibly spilling a glass of milk at the table at every meal.
Long after the average child is speaking in fluent sentences, children with ADHD may have difficulty using conjunctions or prepositions correctly (sequencing of words). They may have difficulty learning to read. To read words of more than one syllable, they must sound the first syllable, then retain that sound in their mind while they sound the second syllable. If they have difficulty retaining the first syllable long enough to connect it with the second, they cannot
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construct the word. Similarly, they can have difficulty with arithmetic, because they may be unable to retain the sum of two numbers long enough to add a third. Spelling may be equally difficult. Not only are they unable to sequence the letters in a word correctly, but they also cannot retain memory rules such as “i before e” to help them.
As a rule, children with ADHD do not have a deficit in intelligence, although they may seem to because of their impulsive behavior. They may be unaware that their behavior is upsetting to family, friends, and teachers and therefore are not anxious about their inability to conform to society's rules.
On physical assessment, these children often show many “soft” neurologic signs, such as inability to use a pencil or scissors well. A thorough neurologic examination often is difficult because their attention span is so short. On such an examination, they often have difficulty performing tests such as a finger-to-nose test or rapid hand movements (e.g., touching one finger after another with the thumb). They tend to show “mirroring” with this movement (the second hand imitates what the first hand attempts to do). Cerebellar difficulty may be evidenced further by inability to perform a tandem walk or a heel-to-shin test. They may be able to identify one touch but not two simultaneous touches on their body. They may not show the normal responses of graphesthesia (ability to recognize a shape that has been traced on the skin) or stereognosis (ability to recognize an object by touch). When asked to stand with arms outstretched, choreiform movements (aimless movements) and rising of the fingers are often present. More definite neurologic signs, such as a unilateral Babinski reflex or strabismus, may also be present. Testing children through the use of games may be necessary so that their attention is maintained long enough to complete the assessment.
IQ testing is used to document a child's intelligence. The Wechsler Intelligence Scale for Children (WISC), the test most often chosen, consists of two portions: a verbal scale and a performance scale. A child is given three final scores: verbal IQ, performance IQ, and combination or full-scale IQ. The child with perceptual and motor deficits tends to do poorly on the performance scale but average or better on the verbal scale. Children with language difficulty typically do poorly on the verbal scale but average or greater on the performance scale. Children with ADHD show a “scatter” pattern on both performance and verbal portions, doing well on some portions and poorly on others.
Children who have difficulty filtering out stimuli do poorly on group-administered intelligence tests because they are too distracted by those around them. For this reason, such children should take IQ tests individually. Neurologic examinations also should be performed in rooms that are free of distractions such as attractive toys.
Children with ADHD are often referred to a health care facility because they have had difficulty achieving in school. Parents may have been reassured on previous occasions that, although their child had difficulty settling down to tasks, this was because he was “all boy” or “every child is different.” They may need time to accept that their child has a condition that interferes with learning. Active listening is essential. This is a difficult situation that may have persisted for a long time. The parents may be unaware themselves of the strain that has been produced until they start to describe it.
Therapeutic Management
A variety of treatment methods are used, often in combination, in the management of ADHD.
Environment
Construction of a stable learning environment is crucial for children with ADHD. This may include special instruction, free from the distractions of an entire class. Parents may have difficulty accepting the fact that their child needs special schooling (the intelligence test, after all, said that he or she was above average). They may need help in seeing that their child's condition interferes with intellectual functioning and that a special program must be constructed for the child to succeed.
Parents at home need to construct an environment that is as free of stimulating distractions as possible. Exposure to the soothing influence of green may reduce behavior symptoms (Kuo & Taylor, 2004). Parents having difficulty at home with discipline and management often appreciate support and advice. Encourage them to be fair but firm and to set consistent limits. Although every child has the right to an opinion, many decisions that the average child enjoys making for himself or herself must be made for a child with ADHD. “Do you want to wear your red or your blue shirt today?” is less effective than “Here is your blue shirt to wear today.”
Children who are easily distracted have difficulty completing chores or picking up their toys. They can be assigned age-appropriate chores with the understanding that a parent must give many reminders to them to get the job completed. Teach parents to give instructions slowly and to make certain that they have their child's attention before beginning instructions. Breaking down a chore into several steps may help (get the toy box is one step; pick up toys is a second). This helps to avoid confrontation that may arise later if children do not hear or do not process what is said to them.
All children like to participate in dinner conversation or discussions about their day. Children with ADHD often have difficulty telling a story or repeating a joke told to them (a sequencing problem). Suggest that parents help them by asking questions such as “Why?” “Where?” or “Who?” to reach the point of the story. Also encourage parents to be sure, when they correct behavior, that their anger is about something the child has deliberately done wrong, not about some incident that happened because of the child's inability to sequence, filter, or integrate concepts. Punishment should follow an offense quickly, because a child with ADHD quickly forgets what he or she did. As with all children, parents should make sure the child understands that the parent is angry at the behavior, not the child. Children with ADHD commonly develop poor self-esteem because, although they are intelligent, they cannot succeed. Help parents to build, not hinder, the development of self-esteem at every stage possible.
Medication
A number of medications are helpful in controlling the excessive activity of the child with ADHD and in lengthening the attention span or decreasing the distractibility so that he or she can function in a normal
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classroom. All of these medications have advantages and disadvantages.
Methylphenidate hydrochloride (Ritalin, Concerta [extended-release form]) is frequently prescribed for this disorder (Box 54.6). It works by stimulating dopamine receptors to achieve a more regular nerve transmission. Insomnia and anorexia are side effects. The insomnia may be relieved by administering the drug early in the day. The extended-release form is advantageous in that it needs to be administered only once a day. Children receiving the drug for extended periods of time need careful height and weight assessment to evaluate that long-term anorexia is not causing weight loss. Caution parents that Ritalin gives a “high” to children who do not have ADHD, so their child must be careful that his medication is not stolen to be used by other children for its drug euphoria effect (Williams et al., 2004). Other medications that may be useful are atomoxetine, norepinephrine reuptake inhibitors, and tricyclic antidepressants (Hectman, 2005).
Box 54.6 Focus on Pharmacology
Methylphenidate Hydrochloride (Ritalin, Concerta)
Classification: Methylphenidate is a central nervous system stimulant.
Action: Acts paradoxically in children with ADHD, possibly by stimulating dopamine receptors to calm rather than simulate activity (Karch, 2004).
Pregnancy Risk Category: C
Dosage: Initially, 5 mg orally before breakfast and lunch, gradually increased in 5- to 10-mg increments weekly, not to exceed 60 mg/day. The extended-release form (Concerta) is administered once daily; dosage is determined by weight and symptoms.
Possible Adverse Effects: Nervousness, insomnia, anorexia, pulse rate changes, hypertension or hypotension, tachycardia, leukopenia, anemia, and growth suppression.
Nursing Implications
Administer the drug exactly as prescribed, and instruct parents to do the same. Reinforce proper administration of once-daily extended-release form; instruct parents to have child swallow extended-release tablets whole and to refrain from chewing or crushing them.
Instruct the parents to administer the drug before 6 PM to prevent interference with sleep.
Advise the parents and child to avoid over-the-counter drugs, such as cold remedies and cough syrups that contain alcohol.
Obtain baseline vital signs and monitor on follow-up visits for changes.
Arrange for follow-up laboratory tests, including complete blood count for children on long-term therapy.
Stress the need for adequate nutrition in light of possible anorexia. Monitor child's weight closely for changes.
Assess child's growth on subsequent visits for possible growth suppression.
Keep in mind that the safety of using methylphenidate for children younger than 6 years of age has not been established.
Family Support
Parents of a child with ADHD often need frequent health care visits while their child is growing up. A responsive, listening ear is crucial to their ability to handle the challenge of raising a child with these symptoms. Any parents can grow short-tempered and irritable at times with a child who does not seem to hear them or follow what they say. They may need reminders at intervals that their child does not act this way on purpose. Help them to understand that, because of a very complex and as yet ill-understood syndrome, the behavior is the best their child can achieve. Children with ADHD have an increased number of childhood accidents such as burns, so they need close parental supervision to avoid injury (Mangus et al., 2004). (See Box 54.7.)
Although hyperactivity fades, some children with ADHD continue to experience problems with impulsivity and inattention into adulthood. They achieve best if they can find careers that allow them to cope with these behaviors.
Oppositional Defiant Disorders
Oppositional defiant disorders consist of hostile, negativistic, or defiant behaviors that result in disturbed functioning in academic and social domains and last for longer than 6 months. Children typically have difficulty controlling their temper; their anger is often directed at an authority figure (APA, 2000).
The disorder develops most frequently in late preschool or early school age. The cause may be a combination of temperament, inheritance, and adverse social factors. Therapy must be individually designed to meet the needs of the child and includes such techniques as family therapy and anger management.
Conduct Disorders
Conduct disorders are persistent antisocial acts that involve violations of personal rights or societal rules, such as disobedience, stealing, fighting, destruction of property, fire setting, and early sexual behavior (APA, 2000). Symptoms can be clustered as involving aggression toward people and animals, destruction of property, deceitfulness and theft, and serious violations of rules. Many teenage runaways may fall into this category. The incidence is about 5% of children (Thomas, 2005).
Children seem to develop an increasing loss of self-regulation or an inability to know when to stop an action.
Conduct disorders are seen more frequently in males than in females, particularly if property or violent crimes are involved; however, the prevalence of conduct disorders in girls is increasing, which may reduce the male predominance over time. A number of etiologic factors have been described for this disorder, including genetic predisposition, neurologic deficit correlates, and sociologic factors related to poverty and cultural disadvantage. In addition,
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the home environment is frequently characterized by rejection, frustration, and harsh and inconsistent discipline. Parents may have marital conflicts or substance abuse problems, or children may have had a series of inconsistent caretaking by stepparents or foster parents.
Box 54.7: Focus on Nursing Care Planning
A Multidisciplinary Care Map for A School-age Child with Attention Deficit Hyperactivity Disorder (ADHD)
Todd, a second grader, is admitted to the 1-day surgery unit to have plaque removed from his teeth under conscious sedation. He was diagnosed with attention-deficit hyperactivity disorder (ADHD) approximately 6 months ago; he has had symptoms since he was 6 months old. You observe Todd coloring; running to the window; running to the door, opening and closing the door; and then throwing pamphlets out of an information rack. His mother tells you she is “at her wits' end” because Todd's attention span is so short and his behavior so disruptive. His father tells you he's proud that his son is “all boy.”
Family Assessment
Child lives with two parents in two-bedroom condominium. Father works as a sail maker; mother woks part-time in local fish market. Father rates finances as “Not good. My wife wants to work more, but we can't find anyone to watch Todd, he's such a handful.”
Client Assessment
7-year-old, slightly overweight male. Child observed holding toy dog tightly. Mother states, “He talks to the dog about what he wants to do.” Some difficulty interacting and talking with others. He often repeats himself, asking “What's your name?” and “What do you like to do?” Mother feeds him mainly fast food meals because his attention span is so short. Toilet trained but sometimes has accidents as he “forgets” to go. Needs supervision dressing because he loses track of task at hand. Refuses to let mother brush teeth. Mother says, “He gets upset and cries easily if his routine changes.” Attends special class in public school, as he was too disruptive in regular classroom.
Nursing Diagnosis
Impaired social interaction related to short attention span and distractibility
Outcome Criteria
Child states he understands purpose of dental procedure; cooperates to extent possible with IV therapy and bed rest after conscious sedation.
Assessment Intervention Rationale Expected Outcome
Activities of Daily Living
Nurse Assess what self-care activities child typically does for himself. Allow child to change to hospital gown; supervise bathroom use. Self-care can offer a sense of control unless it becomes frustrating. Child cooperates to help with self-care to the extent a short attention span will allow.
Consultations
Nurse Assess whether child care specialist is available for consultation. Consult with child care specialist about what games, toys would be best for child with short attention span. Games can become frustrating if they can't be completed in a short period. Child care specialist visits with child and mother and suggests at least two activities for period before surgery.
Procedures/Medications
Nurse Assess whether child has past experience with IV therapy. Begin IV line in nondominant hand. Use of non-dominant hand allows child to complete small, frequent tasks. Child states he understands purpose of IV line. Does not try to remove it.
Nurse Assess whether child took his daily methylphenidate hydrochloride pill before admittance. Check with physician and dental surgeon to determine whether child should receive medicine if it was not taken before procedure. Methylphenidate hydrochloride can substantially reduce behavior symptoms of ADHD. Mother reports whether morning medication was taken.
Nutrition
Nurse/Nutritionist Assess what mother means by “fast food” meals. Discuss a diet with child that doesn't involve so many fatty foods, if appropriate. Child is overweight, a finding that can be caused by eating fat-heavy fast food meals. Mother states she understands that even though child eats in a hurry, his meals can still be nutritious.
Patient/Family Education
Nurse Assess what parent understands about good tooth care. Talk to mother about techniques to make toothbrushing a game, not a chore. Plaque will form again on teeth if they are not brushed after this procedure. Mother suggests two different ways, such as Simon Says, that she could interest child in toothbrushing.
Nurse/Physician Assess what parents understand about ADHD. Educate parents that ADHD is a disorder, not normal boyish behavior. As long as one parent continues to think of child's behavior as within normal limits, it will be difficult for them to be consistent in care. Mother and father state they understand that their son's condition is one that needs therapy.
Psychosocial/Spiritual/Emotional Needs
Nurse Assess what mother means by “at wit's end”; whether she feels she has adequate support to care for a child with extreme behaviors. If appropriate, talk with mother about “respite” time to give her relief; perhaps contact a local school of nursing to find a trusted babysitter. A child's activity level with ADHD can easily exhaust a parent if the parent cannot fit in some time for self. Mother states whether she feels she needs additional outside support or whether her husband can provide this.
Nurse Assess whether child can take favorite toy to operating room. Respect that toy dog is favorite toy and important to child. Children can find comfort and security in a favorite toy. Toy is respected by unit and surgery personnel.
Discharge Planning
Nurse Assess whether parents have any questions about care at home after dental procedure. Discuss that child will be sleepy for remainder of day after conscious sedation. Conscious sedation is necessary because of child's resistance to new procedures. Mother repeats care needed for next 24 hrs to safeguard still sleepy child.
Therapy for children with conduct disorders focuses on modifying the home environment and training the child in social and problem-solving skills. Social skills training teaches the child to recognize how his or her behavior affects others. Problem-solving skills training teaches the child to generate alternative solutions to situations, sharpen thinking about the consequences of choices, and evaluate his or her responses. Parental education is also important but can be difficult until the parents realize that this is a family problem. Removing the child from the home to a structured day care environment may be necessary. Unfortunately, the child may interpret this as more rejection, further compounding the problem. Any new environment that is created must be consistent and loving, not institutional, to be effective.
Numerous medications such as carbamazepine (Tegretol), propranolol (Inderal), and lithium carbonate may reduce the aggressive behavior. Long-term therapy with an agent such as buspirone (BuSpar) may be effective in helping children control temper or explosive outbursts.
Checkpoint Question 2
Children like Todd, with ADHD, have difficulty with concepts such as before and after. This difficulty reflects which underlying problem?
a. Not being able to sequence.
b. Not hearing equally in both ears.
c. Feeling chronically depressed.
d. Being too hyperactive to care.
View Answer
2. A. Sequencing depends on being able to recognize the way that events are related to one another in time.
Anxiety Disorders of Childhood or Adolescence
Because anxiety is considered a normal part of certain phases of development (e.g., stranger anxiety in the 6- to 8-month-old child, separation anxiety in the toddler, fear of mutilation and fear of the dark in the preschooler, and performance anxiety or school avoidance in the school-age child or adolescent), genuine anxiety disorders in children may often be overlooked. If these disorders are left untreated, children may cope with fear by becoming overdependent on others for support or by turning away from the problem and withdrawing into themselves. This can leave a child socially immature and unable to achieve in school. The DSM-IV-TR identifies separation anxiety disorder and anxiety-based school refusal as anxiety disorders in children (APA, 2000). School refusal is discussed with other concerns of the school-age child (see Chapter 31).
Posttraumatic Stress Disorder
Posttraumatic stress disorder is a condition that occurs in children who have survived an experience that is more traumatic than usual, such as child abuse, domestic violence, a natural disaster such as a flood, a harrowing accident such as a house fire, a home robbery, or a near-fatal illness. Children continue to have recurring recollections or dreams of the event or demonstrate intense psychological symptoms if a reminder of the initiating event occurs. They may feel guilt that they survived the event if a close family member or friend did not.
Absence of effective support people may contribute to symptoms. Therapy consists of counseling with psychological debriefing to help the child rework the event and reduce the feeling of threat. Play therapy may be helpful (Cohen, 2005).
Separation Anxiety
Separation anxiety, a normal phase of development in the infant (see Chapter 28), is considered a disorder when an older child shows excessive anxiety about separation or the possibility of separation from those to whom the child is attached (Bernstein & Layne, 2005). Children may worry when apart from parents that their parents will have an accident or become ill. They may be so worried that they have difficulty falling asleep at night or insist on sleeping with their parents or just outside their parents' bedroom door. They experience acute distress, frequent nightmares about separation, and reluctance and refusal to separate. Repeated reports of physical symptoms during separations or when separation is anticipated are also possible. Such a degree of anxiety can be incapacitating to children; it may prevent them from visiting at friends' houses, enjoying a camp experience, or actively participating in school.
Separation anxiety tends to run in families and occurs slightly more frequently in girls than in boys. Unresolved internal conflicts, uncertainty about one's caregiver, and parent-induced anxious attachment are psychodynamic factors attributed to this disorder. Temperament may also be a contributing factor.
Treatment for separation anxiety includes individual counseling sessions combined with antidepressant medication. In addition, family therapy may be helpful in allowing the family to gain greater insight into the dynamics of the problem and aiding the child to gain more confidence in his or her ability to function independently. Remind parents that when children take antidepressant medication, it may lead to thoughts of suicide (Culpepper et al., 2004).
Eating Disorders
Eating disorders in young children consist of pica, rumination, and feeding disorders. In older children, eating disorders include anorexia nervosa and bulimia (APA, 2000).
Pica
Children who persistently eat nonfood substances such as dirt, clay, paint chips, crayons, yarn, or paper are said to have pica (Chatoor, 2005). Pica is the Latin word for magpie (a bird that is an indiscriminate eater). The primary danger lies in the possibility of accidental poisoning. Other complications include constipation, gastrointestinal malabsorption, fecal impaction, and intestinal obstruction.
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The disorder is seen predominantly between the ages of 2 and 6 years, although it may be present into adolescence. Often, it is not diagnosed until the child presents with a pica-induced complication, such as lead poisoning (see Chapter 52).
The incidence of pica increases in children who are cognitively challenged, possibly because of their inability to distinguish edible from inedible substances as early as other children can. It is highly associated with iron deficiency anemia, and it occurs with a high incidence in pregnant teenage girls (who also may be iron deficient). In these children, correcting the anemia also corrects the pica. An individualized therapy plan needs to be devised to meet the child's needs until the phenomenon fades. Keeping the child safe from ingesting inedible substances is a major responsibility until then.
Rumination Disorder of Infancy
The term rumination comes from the Latin word for “chewing the cud” (as cattle do). It is the act of regurgitating and then reswallowing previously ingested food. It is a rare disorder that usually affects infants between the ages of 3 and 12 months. It is seen most often in children who are cognitively challenged and appears to be pleasurable (Chatoor, 2005). Both organic and environmental theories have been explored to explain the disorder. In some children, an accompanying gastroesophageal reflux disorder has been implicated. It has also been postulated that rumination is a form of self-stimulation by the infant, similar to actions such as head banging and body rocking. It may be related to an understimulating environment, but attempts to implicate the role of the primary caregiver in contributing to the disorder have failed.
A parent may report that a child is constantly “spitting up” or vomiting or that the child's breath smells sour. Children can lose a great deal of fluid and electrolytes through this process if they do not reswallow the regurgitated fluid, and they may show signs of failure to thrive. (Failure to thrive as a distinct problem is discussed in Chapter 55.) Distracting infants by holding, rocking, and talking to them tends to decrease rumination. Thickening formula with cereal occasionally is effective because this is more difficult to regurgitate. Attachment between the child and the parents may be at risk because of the anxiety the parents suffer from their infant's constant regurgitation of food and lack of growth. Parents may need support, reassurance, and education to help them maintain or reestablish this bond.
Food Refusal or Aversion
Food refusal or aversion is a persistent failure to eat adequately that results in significant failure to gain weight or actual weight loss when no medical reason or lack of food is present. The disorder begins in infancy and is usually seen in children younger than 6 years of age. Meal time becomes a battlefield as parents insist on the child's eating and the child persistently refuses food or exhibits extremely faddish or bizarre food preferences. As many as 35% of children may demonstrate some degree of this disorder.
Therapy is a combination of counseling for the parents, to help them appreciate that food refusal used this way can be a potent controlling measure, and therapy for the child, to learn to recognize hunger as a stimulant to eating rather than using food refusal as a controlling or attention-getting mechanism (Chatoor, 2005).
Anorexia Nervosa
Anorexia nervosa is a disorder characterized by refusal to maintain a minimally normal body weight because of a disturbance in perception of the size or appearance of the body (APA, 2000). It includes three separate features: a self-induced starvation to a significant degree; a relentless drive for thinness, a morbid fear of fatness, or both; and medical signs and symptoms resulting from starvation (Anderson & Yager, 2005).
Specific characteristics of anorexia nervosa include the following:
Body mass index (BMI) less than 17.5 or less than 85% of expected weight
Intense fear of gaining weight or becoming fat even though underweight
Severely distorted body image
Refusal to acknowledge seriousness of weight loss
Amenorrhea (in girls)
Anorexia nervosa occurs most often in girls (90%), usually at puberty or during adolescence, between 13 and 20 years of age. It is more common among sisters and daughters of mothers who also had the disorder. It may be preceded by a traumatic event such as a rape (APA, 2000).
The disorder may be manifested as severe weight restriction controlled by limiting food intake, by excessive exercise, or by binge eating or purging—episodes of uncontrollable intake of large amounts of food over a specified period of time (binge eating) followed by self-induced vomiting or the use of laxatives, enemas, or diuretics (purging).
Children who develop this disorder tend to have a poor self-image (they cannot live up to their own expectations). Excessive dieting gives them a sense of control over their own body.
Lack of nutrition becomes so extreme that it causes delayed psychosexual development. With a lean, almost starved appearance, girls do not appear as sexually developed or as old as they are. They may have significant symptoms of dehydration and acidosis due to starvation.
Assessment
Because of an intense fear of becoming obese, children with anorexia come to perceive food as revolting and nauseating, and refuse to eat or else vomit food immediately after eating. Refusal to eat may be accompanied by the use of laxatives or diuretics and extensive exercising to further lose weight. Girls may ingest ipecac to induce vomiting. These measures lead eventually to excessive weight loss, acidosis, dependent edema, hypotension, hypothermia, bradycardia, and the formation of lanugo (fine, neonatal-like hair). Compulsive mannerisms such as handwashing may develop. If the process is allowed to continue without therapy, it can lead to starvation and death. The use of ipecac can be exceptionally damaging and possibly cardiotoxic.
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Therapeutic Management
By the time most children are seen at health care facilities, they are often already extremely underweight, pale, and lethargic. Amenorrhea is commonly present. Often, the child's parents have tried various methods of getting the child to eat, such as threatening, coaxing, and punishing; as a result, parent–child relationships may be strained. Parents may feel guilty for insisting their child lose weight if the girl was once overweight.
Planning and outcome identification need to be realistic. A girl who grows nauseated just looking at food cannot quickly begin to ingest a large amount of it. When caring for children with anorexia nervosa, remember that, although the condition began as a psychosocial problem, by the time a girl is seen for care, physical starvation and its effects are a second important component. For therapy, typically, oral foods are withheld and total parenteral nutrition is initiated to supply needed fat, protein, and calories. Children usually accept total parenteral nutrition well because they view it as medicine, not as food. Enteral feedings may also be accepted and used to restore weight.
In addition, establishing trust and effective communication are crucial to help the child resolve any interpersonal issues that are present (Box 54.8). Other therapeutic interventions include the following:
Medications such as antidepressants
Identification of emotional triggers
Self-monitoring (awareness training)
Education about normal nutritional needs
Box 54.8 Focus on Communication
Brenda is a 15-year-old female who is diagnosed with anorexia nervosa. She is 5 ft 8 in tall and weighs 95 lb.
Less Effective Communication
Nurse: Let's talk about your weight, Brenda.
Brenda: I'm fat. Look at this belly of mine.
Nurse: You need to eat at least three good meals a day.
Brenda: I do. I eat a lot.
Nurse: You should have a healthy breakfast. After all, it is the most important meal of the day.
Brenda: I eat huge breakfasts. I'm just so active, I don't gain weight.
More Effective Communication
Nurse: Let's talk about your weight, Brenda.
Brenda: I'm fat. Look at this belly of mine.
Nurse: You feel fat?
Brenda: Yes, just look at me.
Nurse: Tell me what you eat for a typical breakfast.
Brenda: A lot. I pig out for breakfast.
Nurse: Pig out? What did you eat this morning?
Brenda: A quarter piece of toast.
Nurse: Anything else? Tell me more about what it is that you eat.
In the first scenario the nurse is intent on getting the client to eat. In the second scenario, the nurse is attempting to obtain more information about the client, her image of herself, and her diet.
Box 54.9
What Family Members and Friends Can Do to Help Those with Eating Disorders
Tell the person that you are concerned, that you care and would like to help. Suggest that the person seek professional help.
If the person refuses to seek help, encourage reaching out to an adult such as a teacher, school nurse, or counselor.
Do not discuss weight, the number of calories being consumed, or particular eating habits. Try to talk about things other than food, weight, counting calories, or exercise.
Avoid making comments about the person's appearance. Concern about weight loss may be interpreted as a compliment; comments about weight gain may be interpreted as criticism.
Offer support but keep in mind that, ultimately, the responsibility for accepting help and deciding to change belongs to the person.
Read and educate yourself about these disorders.
White, J. H., and Marshall, L. (2005). Eating disorders. In Boyd, M. & Nihart, M. Psychiatric nursing: Contemporary practice (3rd ed.). Philadelphia: Lippincott Williams & Wilkins.
Gradual weight gain is recommended, because rapid gain of weight can cause a child to begin dieting to reduce this weight gain. Weighing once a week is better than every day, to reduce the focus on weight. Box 54.9 describes common strategies for assisting family and friends to help a child with anorexia.
Children who have had anorexia nervosa need continued follow-up after weight is regained, to be certain that they do not revert to their former dieting pattern (Fig. 54.2). Counseling may need to be continued for 2 to 3 years to be certain that self-image is maintained. With adequate counseling, most girls achieve full recovery with adulthood.
Bulimia Nervosa
Bulimia refers to recurrent and episodic binge eating and purging, accompanied by an awareness that the eating pattern is abnormal but not being able to stop (APA, 2000). A period of depression or guilt usually follows the period of bingeing. Like anorexia nervosa, bulimia typically is seen in adolescence or early adult life and predominantly in girls. The disorder may last for months or years. Periods of normal eating may be interspersed, or the girl may constantly move from bingeing to fasting. Food consumed during a binge often has a high caloric content and a texture that facilitates rapid eating. It may be eaten secretly, such as late at night or in the privacy of a bedroom. After ingestion of this food, the girl notices abdominal pain; she vomits to decrease the physical pain of abdominal distention and to improve self-concept (she feels more in control).
FIGURE 54.2 This anorexic teen, who is in the later stages of treatment, continues to meet with the counselor to discuss her food choices, exercise program, and overall well-being. (© Barbara Proud.)
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Children with bulimia may abuse purgatives, laxatives, and diuretics to aid in weight control (Le Grange et al., 2004). The combination of frequent vomiting and use of these drugs can result in serious physical complications, notably electrolyte abnormalities, which can ultimately lead to changes as severe as cardiac arrest. People with bulimia may develop severe erosion of their teeth because of the constant exposure to acidic gastrointestinal juices from vomiting. Esophageal tears may also result (Anderson & Yager, 2005).
Like adolescents with anorexia nervosa, these children exhibit great concern about their weight and overall body image and appearance. In contrast to children with anorexia, most of those with bulimia are only slightly underweight or are of average weight and therefore may be discounted as merely slim unless a thorough history is obtained. As with anorexia nervosa, counseling is aimed at increasing the child's self-esteem and sense of control (APA, 2000).
Checkpoint Question 3
Which child is most apt to have anorexia nervosa?
a. Jake, a 7-year-old boy whose parents are divorced.
b. Mary, a 15-year-old girl who has a poor self-image.
c. Odom, a 14-year-old boy who plays varsity sports.
d. Jenny, a 13-year-old girl who is overweight.
View Answer
3. B. Anorexia nervosa usually occurs in girls who have a poor self image.
TIC Disorders
Tic disorders are abnormalities of semi-involuntary movement that are thought to result from dysfunction in the basal ganglia. Tics are rapid, repetitive muscle movements, such as rapid eye blinking or facial twitching. They usually become more pronounced during periods of stress and diminish during sleep. Motor tics include eye blinking, neck jerking, and facial grimacing. Simple vocal tics include coughing, throat clearing, snorting, and barking. Complex motor tics include facial gestures, grooming behaviors, jumping, touching, and smelling objects.
Children are most prone to these disorders between the ages of 9 and 13 years. They occur more frequently in boys than in girls, and more frequently in children who demonstrate obsessive–compulsive behavior. Some instances tend to be familial, possibly due to dopamine receptor inhibition. Tic disorders are subclassified into Tourette's syndrome, chronic motor or vocal tic disorder, and transient tic disorder. They occur so frequently that as many as 15% of children experience some form of transient tic disorder (APA, 2000). Because transient tics are associated with high stress, treatment usually focuses on reducing areas of stress in the child's life. Pointing out the mannerism to the child is not usually helpful and may intensify the manifestation if it increases stress. Behavior modification may be successful in eliminating a particular tic. If the stress is not removed, however, the child may substitute another compulsive mechanism for the original tic.
Tourette's Syndrome
Tourette's syndrome is an inherited syndrome of motor and phonic vocal tics (Scahill & Leckman, 2005). It occurs three times more frequently in boys than in girls. Often, there is some other form of tic in other family members. Complex vocal tics include the repeated use of words or phrases out of context—specifically, coprolalia (use of socially unacceptable words, usually obscenities), palilalia (repeating one's own words), and echolalia (repeating others' words). Some children with this syndrome have nonspecific electroencephalographic abnormalities and soft neurologic signs. Typically, the age of onset is around 7 years, with motor tics usually occurring before vocal tics. Although most children can suppress their tics for short periods, the syndrome lasts a lifetime. Children with Tourette's syndrome can develop low self-esteem because of their uncontrollable actions before the syndrome is fully diagnosed. Fortunately, this syndrome responds to administration of neuroleptic agents such as haloperidol (Haldol) or pimozide (Orap).
Elimination Disorders
Elimination disorders include functional enuresis (involuntary loss of urine) and encopresis (involuntary loss of feces). Developmental enuresis is discussed in Chapter 30 with the development of the preschooler.
Encopresis
Loss of feces is encopresis if there is repeated passage of feces at least once a month in places not culturally appropriate for that purpose. It is considered primary if the child was never fully toilet trained and secondary if the problem began after effective training. Encopresis is considered to exist only after medical causes such as lactase deficiency, thyroid disease, hypercalcemia, Hirschsprung's disease, and infectious diarrhea have been ruled out. It is more common in boys than in girls (Mikkelsen, 2005).
Isolated occurrences of encopresis may happen when a sibling is born (as part of an overall regression reaction)
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or when a child is visiting a strange house or new school and is too shy to ask for the bathroom. It can occur in school because a teacher does not allow children to use a bathroom when they wish or because a school bathroom is occupied by a school gang.
Encopresis is a distressing condition for children, because other children in school can detect the odor of a bowel movement on their clothing. In a few instances, encopresis occurs because of extreme constipation. Hard bowel movements cause anal fissures. Because it hurts to move the bowels, children avoid bowel movements, leading to chronically distended rectums. They are then no longer able to sense when they need to defecate, so involuntary or overflow defecation occurs.
Assessment
To document encopresis, take a careful history of the condition, including usual bowel evacuation habits, the number of bowel accidents, and the times at which they occur. Investigate any recent changes or stress factors in the child's environment. A physical examination that includes a rectal examination should be done to establish whether there is proper anal sphincter control.
Therapeutic Management
Therapy is based on the apparent cause. Arranging to have children attempt to evacuate their bowels about two times daily (in the morning and after dinner) may create “habit” periods for them. Allowing children adequate time to sit on the toilet or encouraging them to take the time to do so may be helpful. If children evacuate their bowels before they leave for school in the morning, they are less likely to experience encopresis and embarrassment in school. The administration of 1 to 6 tablespoons of mineral oil daily for 2 or 3 months often softens stools so that bowel movements are not painful. Children receiving long-term mineral oil therapy usually are given water-soluble forms of vitamins A, D, and K, because these vitamins tend to be removed from the gastrointestinal tract with the mineral oil. Imipramine (Tofranil), a tricyclic antidepressant, may be helpful in reducing encopresis, just as it is effective for enuresis.
Emphasize to parents that children should not be punished for encopresis. Encourage them to pay as little attention as possible to bowel accidents and to give praise for days when encopresis does not occur. Box 54.10 highlights appropriate outcomes and interventions using the terminology identified by the Nursing Outcomes Classification (NOC) and Nursing Interventions Classification (NIC) for encopresis.
Enuresis
Enuresis is defined as repeated involuntary or intentional urination during the day or at night after an age at which the child has attained or should have attained control over bladder function, when no organic cause for the problem can be found (APA, 2000). Although stress may be a factor in occurrences of enuresis, its primary cause is unknown. Most children outgrow the problem by adolescence. As
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with encopresis, the most serious result of enuresis is related to the child's feelings of failure with each occurrence and associated rejection by peers, parents, or other caregivers. All this contributes to a lowered sense of self-esteem. The problem and associated nursing diagnoses are described in more detail in Chapter 46.
Box 54.10
Nursing Outcomes Classification (NOC) and Nursing Interventions Classification (NIC)
Encopresis
NOC: Bowel Elimination
Bowel elimination is defined as the ability of the gastrointestinal tract to form and evacuate stool effectively (Johnson, Maas, & Moorhead, 2000). Some specific indicators suggesting that this outcome has been achieved include the following:
Elimination patterns within expected range
Stool color, odor, and fat within normal range with amount appropriate for diet
Stool soft and firm
Absence of bloating, painful cramping, discomfort with stool passage, constipation, diarrhea, and blood or mucus in stool
Uncompromised sphincter control and muscle tone
Ingestion of adequate fluids and fiber
Uncompromised control of bowel movements
NIC: Bowel Incontinence Care, Encopresis
Bowel incontinence care, encopresis is defined as the promotion of bowel continence in children (McCloskey & Bulechek, 2000). Some important activities involved when implementing this intervention include the following:
Obtaining information about child's toilet training history, duration of encopresis, and measures tried to control the problem
Attempting to determine the cause of incontinence as appropriate
Recommending dietary changes or behavioral therapy as indicated
Conducting family psychosocial assessment
Using play therapy to assist child in working through feelings
Investigating family communication patterns, strengths, and coping abilities
Encouraging parents to foster security and demonstrate love and acceptance at home
Discussing the psychosocial dynamics of encopresis with the family
Referring for family therapy as appropriate
Other Psychiatric Disorders Affecting Children
Childhood Depressive Episodes
Children and adolescents both have depressive episodes similar to those experienced by adults. The incidence ranges from 1% to 3% before puberty and 3% to 6% among adolescents (Shaffer, 2005). Depression is becoming an increasing concern in our society, because the escalating suicide rate among children and adolescents that arises from depression has become a major societal problem. A child is considered to be depressed when symptoms such as loss of interest or pleasure, significant weight loss or gain, depressed mood, insomnia, psychomotor agitation, feelings of worthlessness or excessive or inappropriate guilt, diminished concentration, recurrent thoughts of death, and suicidal ideation exist for 2 weeks or longer (APA, 2000). Because these symptoms are easily missed, a history should be taken from the child as well as from the parents (Box 54.11). Depression can be differentiated from “normal” sadness when children report they cannot remember the last time they felt happy or had a good time (anhedonia) (Fig. 54.3).
Box 54.11 Focus on Evidence-Based Practice
Are Children with Type 1 Diabetes More Apt to Feel Depressed than Others?
To investigate this problem, researchers asked 32 children diagnosed with type 1 diabetes and 32 children without a medical diagnosis, matched for age and gender, to fill out several questionnaires designed to detect depression, social anxiety, and loneliness. Results of the study revealed that children with diabetes reported they were more often the victim of bullies than other children. They were also less apt to receive emotional and social support from their peers than those without diabetes. The bullying and poor support were positively linked with increased feelings of depression, social anxiety, and loneliness.
This is an important study for nurses, because it accentuates how medical conditions can be compounded when emotional support is lacking. It is an alert that frank talking may be needed with children about how much emotional support they are receiving and whether their illness is affecting their mental health.
Source: Storch, E. A., et al. (2004). Peer victimization and psychosocial adjustment in children with type 1 diabetes. Clinical Pediatrics, 43 (5), 467–471.
FIGURE 54.3 Symptoms of depression are easily missed in school-aged children unless history taking is thorough. (© Caroline Brown, RNC, MS, DEd.)
Children who are depressed need treatment to prevent their depression from worsening. Counseling to discuss problems is necessary. Many children require antidepressant therapy, such as a selective serotonin reuptake inhibitor, to relieve the symptoms. In addition to the pharmacologic approach, family or individual counseling may be necessary to help the child regain self-esteem and the family to understand the level of depression that has occurred. Few antidepressants are approved for children, and when adolescents have been prescribed these drugs, attempts at suicide have been noticed to rise dramatically (Culpepper et al., 2004)—possibly because, at the point at which the child feels less depressed, increased ability to act makes a suicide attempt possible. Observe any child who is prescribed an antidepressant carefully to detect presuicidal behavior. Adolescent suicide as a result of depression is discussed in Chapter 32 with concerns of the adolescent.
What if …
during a routine health maintenance visit, you notice that an adolescent boy has lost 20 lb in the last 6 months? His mother states, “He's the perfect son, always getting straight As in school.” How would you respond?
View Answer
1. Weight loss in children always should be investigated, as normally children never lose weight. Exploring whether this boy has been dieting or has any additional symptoms would be important. Whether he could be depressed and his stress level—from trying to maintain all those As and be a perfect son—also needs to be explored.
Childhood Schizophrenia
Schizophrenia is actually a group of disorders of thought processes characterized by the gradual disintegration of mental functioning; it occurs in about 2 out of every 10,000 children (APA, 2000). It is a devastating mental illness that usually strikes in adolescence or young adulthood. Symptoms during childhood may be undifferentiated or ill defined.
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Over the years, there has been a great deal of debate about the cause of schizophrenia. For a long time, it was hypothesized that schizophrenia resulted solely from an impaired parent–child relationship. Current research, however, indicates that there is as much a genetic as an environmental basis for this disorder (Sawa & Kamiya, 2003). Magnetic resonance imaging has shown that cerebral involvement, such as enlarged ventricles or decreased blood to the frontal lobe, may be present (APA, 2000). Neurochemical mediators may influence or prolong the disorder.
Children with schizophrenia experience hallucinations (hear or see people or objects that other people cannot). They display rambling or illogical speech patterns. They may not be responsive (have a flat affect), or they may withdraw so completely that they are stuporous (catatonia). They may be extremely suspicious that others want to harm them (paranoia). Although schizophrenic manifestations may occur suddenly after a major stress in a child's life (such as rejection by a boyfriend or girlfriend), subtle signs of mental illness have usually been present for some time (McClellan, 2005).
The diagnosis of a psychotic disorder of this extent is a shock to parents. Fortunately, therapy with modern antipsychotic drugs such as haloperidol (Haldol), a neuroleptic, is effective in reducing children's hallucinations and bizarre thinking. Parents need help to support a child during a long period of therapy. Many children who are diagnosed as having schizophrenia in childhood continue to have mental illness as adults. Continuing support and long-term follow-up are essential (McClellan, 2005).
Key Points
Both cognitive and mental health disorders pose long-term care concerns for children and their families.
For children who are cognitively challenged, a stigma still may be present in many communities, although less so than previously. Parents may have a more difficult time accepting this diagnosis in their child than they would a physical illness. Help parents to gain the insight that cognitive challenges occur in a proportion of infants in every population and that having a child with this problem merely reflects a chance occurrence.
Mental health disorders often begin subtly in children and are often first manifested as behavior problems in school. Assess thoroughly any child who is referred for disruptive behavior in class for the possibility that he or she has a serious mental health problem.
Autistic disorder is a pervasive developmental disorder that has a syndrome of behaviors, including fascination with movement, impairment of communication skills, and insensitivity to pain.
Attention-deficit and disruptive behavior disorders, such as oppositional defiant and conduct disorders, may occur in childhood. Children with ADHD may be treated with methylphenidate hydrochloride (Ritalin, Concerta) to reduce the hyperactivity and allow them to achieve better in school and interact better at home.
Eating disorders seen in childhood include pica, rumination, anorexia nervosa, and bulimia. All of these disorders can lead to loss of weight and electrolyte imbalances if left unrecognized and untreated.
Tic disorders (e.g., Tourette's syndrome) are abnormalities of semi-involuntary movement that are thought to result from dysfunction of the basal ganglia or distorted dopamine reception.
Encopresis is the repeated passage of feces in places not culturally appropriate for that purpose. Therapy is both physiologic and psychological.
Children who are depressed are at high risk for committing suicide. They need thorough assessment and close observation to be certain that this does not happen. Schizophrenia may occur in childhood. This usually presents as disorganized behavior. Long-term therapy is necessary.
Critical Thinking Exercises
Todd is the second grader diagnosed with ADHD whom you met at the beginning of the chapter. His mother feels “at her wits' end” because his attention span is so short and his behavior so disruptive. His father is proud of his behavior. What suggestions could you make to his parents to help them adjust better to a child with ADHD?
A 3-year-old child in your school's preschool program who is cognitively challenged is critically ill with pneumonia. It is difficult to believe that her mother did not recognize how ill the child was becoming and bring her in sooner for care. What reasons might explain a parent's reacting this way?
The parents of an adolescent tell you that he seems increasingly depressed, so much so that he sleeps almost all day on weekends. Does this adolescent need a referral, or is he simply demonstrating usual adolescent behavior? What questions would you want to ask to be able to tell?
Examine the National Health Goals related to mental health disorders in children. Most government-sponsored money for nursing research is allotted based on these goals. What would be a possible research topic to explore pertinent to these goals that would be applicable to Todd's family and also advance evidence-based practice?
References
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Bernstein, G. A., & Layne, A. E. (2005). Separation anxiety disorder and other anxiety disorders. In Sadock, B. J., & Sadock, V. A. (Eds.), Kaplan and Sadock's comprehensive textbook of psychiatry. Philadelphia: Lippincott Williams & Wilkins.
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Shaffer, D. (2005). Depressive disorders and suicide in children and adolescents. In Sadock, B. J., & Sadock, V. A. (Eds.), Kaplan and Sadock's comprehensive textbook of psychiatry. Philadelphia: Lippincott Williams & Wilkins.
Storch, E. A., et al. (2004). Peer victimization and psychosocial adjustment in children with type 1 diabetes. Clinical Pediatrics, 43 (5), 467–471.
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Suggested Reading
Arcia, E., et al. (2004). Modes of entry into services for young children with disruptive behaviors. Qualitative Health Research, 14 (9), 1211–1226.
Armstrong, M. B., & Nettleton, S. K. (2004). Attention deficit hyperactivity disorder and preschool children. Seminars in Speech and Language, 25 (3), 225–232.
Dalle Grave, R. (2003). School-based prevention programs for eating disorders: Achievements and opportunities. Disease Management and Health Outcomes, 11 (9), 579–593.
Demonet, J., Taylor, M. J., & Chaix, Y. (2004). Developmental dyslexia. Lancet, 363 (9419), 1451–1460.
Luther, E. H., Canham, D. L., & Cureton, V. Y. (2005). Coping and social support for parents of children with autism. Journal of School Nursing, 21 (1), 40–47.
Ransby, M. J., & Swanson, H. L. (2003). Reading comprehension skills of young adults with childhood diagnoses of dyslexia. Journal of Learning Disabilities, 36 (6), 538–555.
Rau, J. D. (2004). Is it autism? Contemporary Pediatrics, 20 (4), 54–56.
Schowalter, J. E. (2003). Special report. Child and adolescent psychiatry: A history of child and adolescent psychiatry in the United States. Psychiatric Times, 20 (9), 43–47.
Waslick, B., Schoenholz, D., & Pizzaro, R. (2003). Diagnosis and treatment of chronic depression in children and adolescents. Journal of Psychiatric Practice, 9 (5), 354–366.
Zinner, S. H. (2004). Tourette syndrome. Much more than tics: Management tailored to the entire patient. Contemporary Pediatrics, 21 (8), 38–41.
