neurodevelopmental disorders in children

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neurodevelopmental disorders in children
2015-04-29 22:44:18

children with mental disorder
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  1. Epidemiology
    • 1 in 10 in the US have mental illness
    • Fewer than 1 in 5 receive treatment
    • C&A often present with medical problems
    • none of it is truly nurture and nature it is multifactoral
    • DSM- diagnostic statistic manual leads to:
    • - Subjective distress/impairment in functioning roles
    • Hospitalization:
    • - serious/imminent
    • - risk to harm self
    • - risk to harm others
    • - gravely disable
  2. What children need for good Mental health
    • unconditional love and acceptance
    • self confidence and high self esteem
    • opportunity to play with other children
    • encouraging caregivers and teachers reinforcement praise warranted
    • appropriate guidance and discipline-limits, consequences (no is a love word)
    • criticize the behavior not the child
    • to learn self control not be controlled
    • to know it is ok to be afraid sometimes
    • ** also provide nursing interventions
  3. role of nurse
    • Identify risk and protective factors:
    • - risk: psychosocial, abuse, neglect, temperant, poverty, violence in the community, lack of social support
    • - protective: support parents, intelligence, education, flexibility, diet and excerise
    • surrogate caregiver
    • unconditional accpetance (not the behavior)
    • - therapeutic relationship
    • reinforce positive personality trait
    • improve their problem solving
    • know children do not talk about their problem they act it out (somatic compliant)
    • - need to be taught HOW to talk about problems, concerns issue (where developmentally approriate)
    • - what are feelings? specific feeling state: can easily be identify, facial chart
    • treat C&A within the context of the family (always include the family)
  4. Diagnosing Problems
    • It is often difficult to determine whether a child's behavior indicates emotional behaviors
    • Emotional problems exist if the behavioral manifestations:
    • - are NOT age approriate
    • - deviate from culture norms
    • - interfere with adaptive functioning
    • - impact normal/healthy G&D
  5. Working with children
    • be patient
    • be persistent- not giving up
    • be understanding
    • most importantly, remember to differentiate
    • the behavior from the child
    • - bad behavior are not synonymous with bad child
  6. Autism Spectrum Disorder ASD
    • as mild moderate to severe
    • characterized by a withdrawl of the child into the self and into a fantasy, world of his or her own creation
    • - wide spectrum of behaviors
    • - observed before age  dx 1-2
    • - prevalence is about 1 in 88 children
    • - occurs 4x in boys than girl
    • - onset occurs in early childhood
    • - often runs a chronic course
  7. etiology ASD
    • Not parents fault, not from cold aloof parenting
    • - no environmental factors
    • Neurological:
    • - multiple regions of the brain different
    • - ventricles in brain- looks like a butterfly much bigger more fluid- brain in smaller
    • - lower serotonin levels- neurotransmitter msg cannot be passed on. in condition in anxiety
    • 50% increase over past few decades
  8. Predisposing factors to ASD
    • neurological implications:
    • - abnormalities in brain structure or function
    • - role of neurotransmitters under investigate
    • Physiological implication:
    • - certain medical condition (tubercous sclerosis, fragile x syndrome, maternal rubella, pku)
    • - MMR vaccine and thimerosal not suppport
    • Genetics
    • - familial association- identical twins, if 1 child more likely the other child
    • - chromosomal involvement #11
    • Perinatal influences
    • - maternal asthma or allergies-immune system activation PARENTS DO NOT CAUSE (though their parenting)
  9. ASD
    • Deficits in broad range of developmental areas:
    • Essential features in vary degrees from mild to more severe:
    • - impairment in social interaction
    • - impairment in communication and imaginative activity
    • - restricted activities and interests
    • Behaviors are clearly atypical- no emotions, no eye contact, don't turn when calling name
    • behaviors present across multiple context ie home school
    • parents first notice different behaviors:
    • - lack of emotional reciprocity
    • - unresponsive to people deaf??
    • - focus on 1 objects long periods of time like instead of playing with the car paying attention to wheel
  10. Autism Symptomatology
    • Impairment in social interaction: includes asperger syndrome
    • - impairment in multiple nonverbal behaviors (eye to eye gaze, facial expression, gestures to regulate social interaction)
    • - failure to develop peer relationships approriate to developmental level
    • - lack of spontaneous seeking to share enjoyment, interests, achievements with other people - not interacting with others
    • - lack of emotional reciprocity: distant, unemotional, passive, withdrawn. unresponsive to emotional interaction, cold aloof
  11. Impairment in Communication
    • delay in total lack of development of spoken language
    • impairment in ability to initiate convo and sustain
    • stereotype & repetitive use of language or idiosyncratic language (own personal language)
    • lack of make believe (wrong G&D)
    • - no clinically significant delay in language for asperger syndrome
    • - no clinically significant delay in cognitive development, age approriate seld hel skills adaptive behavior expect social interation
  12. Restrictive repetitive and stereotypic Behavior (RRB)
    • takes alot of interest in one thing ie computers, show tune
    • no flexibility in routine. dont like changes
    • does the same motor mannerism all the time like snapping fingers, flapping
    • limited repertoire of interests and activites
    • will watch parts of things for long periods of time
    • doing the same thing over and over..annoying others
    • can be annoyed with change, gives anxiety
    • may attempt to stimulate self
  13. Additional Specifers for asperbers
    • with intellectual impairment- approx 80% MR
    • with language impairment-
    • associated with known genetic or medical condition
    • associated with other neurodevelopmental, mental behavior disorder
    • with catania (purposeless, rigidity daze, stupor)
  14. Prognosis
    • level of language skill and over intellect strong predictors
    • most adults continue to have difficulties
    • approx 1/3 attain some degree of indepence
  15. Nx Dx- risk for self Mutilation
    • r/t neurological alterations
    • AEB: hx of mutliation, hysterical reaction to changes in environment (head banging)
    • Outcome:
    • ST: some replacement from that behavior
    • LT: not harm self
    • Interventions:
    • - facilitate trust- consistent staff, calm voice
    • - let them know of change ahead of time
    • - diversion replacement activities (is this behavior bc of anxiety or self sooth)
    • - protect w/devices (helmet, hand mitts, arm covers)
    • - decre stimulation
  16. Nx Dx: Impaired social interaction consistency
    • r/t inability to trust, neurological alterations
    • AEB: lack of responsiveness to or interest in people
    • Outcome:
    • ST: demo trust in one caregiver (facial expression, eye contact)
    • LT: initiate social interaction, physical, verbal, nonverbal
    • Intervention:
    • - limit the number of assigned staff, convey warm, acceptance availability
    • - provide with familar objects (toy blanket)
    • - support attempts to interact with other
    • - positive reinforcement for eye contact (food, familar objects) gradually replace with social reinforcement, touch, smile, hug
  17. Nx Dx Impaired verbal communication
    • consistency cause change is so hard
    • r/t withdrawn into self, neurological alterations
    • AEB: inability or unwilling to speak, lack of non verbal expression

    • Outcomes:
    • ST: esta trust with one caregiver (___ time)
    • LT: esta means of communicating needs and desires w/other

    • Interventions:
    • - consistency in assignment of caregivers
    • - anticipate and fulfill needs until communication is established (flash card pics laptop)
    • - seek clarification and validation
    • - positive reinforcement with eye contact is used for non verbal communication
  18. Pharm intervention ASD
    • 2 medications approved by the FDA (atypical antipsychotic)
    • - not medicated the disorder but conditions that come with it like anxiety
    • - risperidone: risperdal
    • - aripiprazole: abilify
    • Targeted for following symptoms
    • - aggresion
    • - delibrate self injury
    • - temper tantrum
    • - quickly changing moods)
    • dosage based on weight of child and clinical response
  19. ADHD
    • Essential features include developmentally inapproriate degrees of:
    • - inattention (attention deficient)
    • - impulsiveness
    • - hyperactive
    • Subtypes:
    • - combo presentation: meet criteria for both inattention and hyperactive
    • - predominately inattentive
    • - predominately hyperactive
  20. ADHD symptoms
    • inattention: distractablity
    • impulsivity
    • hyperactive to a degree where it is inapporiate for age 4yrs old cant sit ok but 12 not ok
    • symptoms usually pervasive (happens everywhere)
    • - shows up in many situation
    • - over span of a few months
    • - may not occur in all settings
  21. ADHD inattention symptoms
    • daydreaming- appears not to listen
    • inattention to details, careless mistakes
    • disorganized
    • always losing their things
    • forgetful
    • highly distractive: unable to contain stimuli
    • needs constant supervision
    • child doesn't finish anything they start- most important outcome so they can actually finish something (helps with self esteem)
    • child may have:
    • - low frustration tolerance
    • - difficults in school, completely homework
    • - difficulties with peers and families, home
    • hard to dx bc people will see them as lazy
  22. ADHD impulsivity symptoms
    • impatient difficulties waiting for things
    • always interrupting others- intrusive
    • blurts out answers- before question completed
    • difficulty waiting turn
    • tries to take short cuts on many task (chores, homework etc)
  23. ADHD hyperactivity symptoms
    • two speeds: awake and sleep
    • always on the go as if driven by a motor- running climbing too much
    • figidity can't sit still (leaves sit in class, easily bored)
    • talks excessively hums/makes weird noises
    • have difficulty playing and engaging in leisure activity
  24. ADHD impairments
    • academic performance
    • social/interpersonal relationships
    • overall behavior:
    • - symptoms vary among children in different environment
    • - child not able to perform at age level
    • disorder not easy to dx:
    • - especially inattention predominant
    • - crucial not to overlook
  25. ADHD co morbidities
    • ODD 40%
    • anxiety disorders 35%
    • conduct disorders 10-20
    • substance abuse
    • mood disorders 10-10- unipolar and bipolar
    • treatment reduces/delays
    • learning disorder; 1/3 ADHD will have learning disability
    • - should be suspected
  26. ADHD etiology
    • multifactoral lots of factors
    • brain disorder: neuro-behavoral, developmental, psychotic disorder
    • Biologic factors
    • environmental: inc levels lead
    • psychosocial
    • - family dynamic, foster home, parental mental disorder
    • first line of defense with this disorder is meds
  27. epidemiology ADHD
    • 3:1 males
    • difficult to dx before 4y
    • symptoms present before 7
    • 60-70% in still in adulthood
  28. DX testing for ADHD
    • brain imaging not helpful
    • neuropsychological testing not helpful
    • Assessment most helpful
    • - hx and physical
    • - mental status exam
    • - behavioral - talk about behaviors at home, people at the school
    • - home, school, office
  29. ADHD:
    nx dx: Risk for injury
    • r/t impulsive, accident prone, inability to perceive harm
    • AEB: impulsivity, running, climbing on the go, random touching things, accident prone
    • Outcome: free of injury (ST&LT)
    • Interventions:
    • - med admin- first line treatment
    • - ensure safe environment- free of objects bc of hyperactive movements
    • - identify deliberate behaviors that put child at risk for injury; institute consequences for repitition of behavior
    • - provide adequate supervision & assistance during behaviors that are associated w/risk; limit patients participation if supv. not possible
  30. ADHD:
    Impaired social interaction
    • r/t intrusive and immature behavior
    • AEB: disruptive and intrusive behaviors, aggression, oppositional, regressive behaviors, low frustration tolerance, outburst of temper
    • Outcomes:
    • - ST: will interact in age approriate manner on 1:1 with assigned person
    • - LT: will observe limits set on behavior, demo intrusive behavior, demo ability to interact approriately with other
    • Interventions:
    • - develop trusting relationships, convey acceptance of person, not behavior
    • - discuss behaviors that are acceptable or not acceptable, in a matter of fact manner, describe consequences, unacceptable and follow thru with consequences
    • - provide group situation for practices new social skills
  31. ADHD:
    Noncompliance w/task expectations
    • r/t low frustration tolerance, short attention span
    • AEB: difficulty performing age approriate task, incomplete work, careless mistake, completes a game etc
    • Outcomes:
    • - participate in and cooperate during activites
    • - complete activity success
    • Intervention:
    • - provide environment for task free distractions
    • - assist on 1:1 basis, begin w/simple concrete instructions
    • - ask pt to repeat instructions
    • - break goal into smaller steps, reward for each steps completed
    • - decrease assist gradually, let patient know still available as needed
  32. ADHD: Pharm
    • CNS stimulants
    •  meds effective- 70% work on NE (paradoxical effect)
    • first line (short and long acting):
    • - stimulants: dexedrine (dextroamphetamine), adderall (dextraemphetamine & levoamphetamine), ritalin & concerta (methylphenidate)
    • - cylert (3-4w for effects)
    • - non stimulants: strattera (atomoxatine)
    • - side effect: insomonia, restless, aggression anorexia, weight loss, tachycardia, decr in rate of G&D
    • if med doesn't work another one will. keep trying