Child And Adolescent
- 1. Unit 11 Child and Adolescent Disorders PDD ADHD Eating Disorders
- 2. Pervasive Developmental Disorders Three areas of functioning are affected: 1. Reciprocal social interaction impaired 2. Increased stereotypical behavior 3. Mental retardation in the majority of cases
- 3. Categories of PDD Childhood Degenerative Disorders: often due to CNS insult, losses in all areas after age 2 Asperger’s: Rec. later than autism, cognition and language OK, but low social function, lots of repetitive behavior, autistic bx. Rett’s: affects females, increasing deficits as grow. Lose hand coordination, language loss, mental retardation Autism: see next slide
- 4. Autism: Example of PDD Aversion to physical contact, even as infant Little eye contact Low verbal skills Mood abnormalities Repetitive motor behaviors—rocking, banging, unusual solitary play
- 5. Nursing Diagnoses (some) Growth and Development, delayed Injury, risk for Risk for self abuse Impaired social interaction Impaired communication Self care deficit Caregiver role strain
- 6. Downs Syndrome: mild to moderate mental retardation Caused by trisomy 21, not inherited. 1/600 births affected. Older moms more likely Shortened life span, often get dementia in 40s/50s. Physical features: Epicanthal slant eyes, flat nose, short stature, low set ears, short hands, and a single palmar crease.
- 7. ADHD: Attention Deficit Hyperactive Disorder: 3 symptoms Inattention: affects listening, finishing tasks, losing things, careless errors, distractible Impulsivity: affects turn taking, blurting out answers, intrusive, interruptive Hyperactivity: squirmy, fidgety, climbs, no quiet play, motor mouth, never ceasing energy
- 8. Framing the Assessment in ADHD Probably somewhat overdiagnosed currently, lack of structure and parental skill. Diagnosis should be by specialist. All assessment findings must be compared to age appropriate behavior. Only real deviations from this mark ADHD. Examples. Must see Significant impairment in social, academic and /or occupational function. Must emerge prior to age 7 (can be dx later though).
- 9. Intervening in ADHD (31-3) Signal/gestures Move closer Redirection Clarify situation Restructure work for success Remove disruptive child Therapeutic holding Teach “counting” Clear limits clear consequences Avoid bargaining Set a routine and stick to it
- 10. Ritalin: Drug of choice in ADHD CNS Stimulant, schedule II, potential for abuse by non ill individuals. Kids sell. Increases catecholamines to different parts of the brain, focusing attention better. SE: (a few) low growth, low appetite, sleeplessness, rebound effect, timing CONTRAINDICATED: glaucoma, HTN, Tourette’s, Seizure d/o. Interacts with MAOIs
- 11. Conduct Disorder: like Antisocial personality disorder, but as seen in children Aggression toward others, property destruction, deceit, theft, serious rule violation Core sense of unlovability Insecure parental attachment, family problems Difficult child pattern RX: like Antisocial Personality DO
- 12. Eating Disorders Anorexia Nervosa Bulimia Nervosa Compulsive Overeating—Binge Eating Disorder
- 13. Physiologic Aspects/Causes Tied to major mood disorders (depression, anxiety, OCD) with low norepinephrine, low serotonin, increased cortisol. Linked to physiologic release of endogenous opiods (eg B endorphins) Starvation, binging, exercise trigger release “ Starvation dependence” Gives an addictive twist to all of these disorders, that often affects treatment
- 14. Anorexia Nervosa Demographics: white, 12022 yo middle and upper income women in industrialized countries
- 15. Physical Assessment Findings in Anorexia Nervosa 80% wt for ht Amenorrhea Lanugo Jaundice, dry skin Dehydration Low bone density Peripheral edema and cold extremities Bradycardia, hypotension Fatigue, weakness Low T3, T4 Low K+, low Na+ Pancytopenia, anemia Abnormal ECG
- 16. Psychosocial Assessment Findings Refusal to eat, purging Intense fear of getting fat Body Image distortion Denial—focus on food and control over it serves as a defense over other issues OCD traits, perfectionism All or nothing thinking As wt decreases, thinking is less rational Often hx of sexual abuse Developmental delay with enmeshed family
- 17. Behaviors used to keep wt down Rules set about eating Manipulation Counting Lies Exercises Self punishment laxatives Diet pills, herbs Self induced vomiting
- 18. Anorexia Nervosa Treatment Reverse starvation (first). Involves possible refeeding under supervision, NG feeding, TPN. Also prevention of physical sequelae by restricting activity and watching to prevent vomiting, etc. Moniter physical status-cardiac, liver, labs, renal, suicide.
- 19. Nursing Therapeutics Begins right away, but continues past initial refeeding issues. Prevent sabotage. Therapeutic alliance critical Contract and/or level system valuable Teach gentle eating Meds: when physically able—antidepressant, occasionally others
- 20. Issues faced by the ED pt Self esteem Family relationships Body Image Sexuality Thinking disorder Main thing will center around meeting the developmental challenge of separation and individuation
- 21. Bulimia Nervosa Demographics: similar to anorexia but with later average age of onset. 2-28% American women.
- 22. Physical Symptoms of Bulimia Wt for ht may be close to WNL Amenorrhea ECG changes Cardiomyopathy Parotid Gland swelling, hoarse voice Dental erosion Peripheral edema Esophageal dilation and ulceration Scars on fingers, hands Low K+
- 23. Psychosocial Bulimia Symptoms Body image issues Repeated episodes of binging and purging More distressed and less denial than with Anorexia Anger suppression Rigid controlling family with low client autonomy Separation individuation issues Sexual abuse, sexuality issues
- 24. Bulimia Nervosa Treatment Not Grossly Different than for Anorexia Nervosa Instead of the starvation issue, deal with the electrolyte imbalances and sequelae of binging and purging All therapeutic issues apply. Benefit is that the denial system is less intense
- 25. Binge Eating Disorder Demographics: 46% of obese participants in wt loss programs have it 30 to 45% of the American population is overweight
- 26. Binge Eating Disorder: symptoms Obesity: BMI kg/m2 of at least 30 or wt that is 120% of ideal. Pattern of binge eating without purging. Review sequelae of obesity Self esteem disturbance, body image distortion, and sexuality issues Addictive nature of these illnesses