Chapter 20

Child and Adolescent Disorders

MENTAL RETARDATION
• Essential feature is below-average intellectual functioning (IQ less
than 70) accompanied by significant limitations in areas of adaptive
functioning.
• The degree of retardation is based on IQ and greatly affects the
person’s ability to function:
 Mild retardation: IQ 50 to 70
 Moderate retardation: IQ 35 to 50
 Severe retardation: IQ 20 to 35
 Profound retardation: IQ less than 20
• Cause of mental retardation
 hereditary conditions (Tay-scale disease or fragile X
chromosome syndrome)
 early alteration in embryonic development ( Trisomy 21 or
maternal alcohol intake)
• Some people with mental retardation are passive and dependent ;
other are aggressive and impulsive
• Children with mild to moderate mental retardation usually receive
treatment in their homes and communities and make periodic visits
to physicians

LEARNING DISORDERS
• Is diagnosed when a child’s achievement in reading, mathematics,
or written expression is below that expected for age, formal
education, and intelligence
• Reading and written expression disorder – identified in the first
grade
• Math disorder may go undetected until the child reaches fifth
grade.
• Low self-esteem and poor social skills are common in children with
learning disorders.
• Children with learning disorders are assisted with academic
achievement through special education classes in public school.

Communication Disorders
• Is diagnosed when a communication deficit is severe enough to
hinder development, academic achievement, or activities of daily
living including socialization.
• Expressive language disorder- involves an impaired ability to
communicate through verbal and sign language

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 • Mixed receptive language disorder – includes problems of
expressive language disorder along with difficulty understanding
(receiving) and determining the meaning of words ad sentences.
• Both disorders can be present at birth (developmental) or may be
acquired as a result of neurologic injury or insult to the brain
• Phonologic disorder - involves problem with articulation (forming
sounds that are part of speech).
• Stuttering – is a disturbance of the normal influency and time
patterning of speech.
Pervasive Developmental Disorders
Pervasive developmental disorders are characterized by pervasive and
usually severe impairment of reciprocal social interaction skills,
communication deviance, and restricted stereotypical behavioral patterns.
• Autistic Disorder
- The best known of the pervasive developmental disorders, is more
prevalent in boys than in girls, and it is identified usually by 18
month and no later than 3 years of age.

Signs and symptoms:

1. Little eye contract with and
2. make facial expressions towards others;
3. use limited gestures to communicate
4. limited capacity to relate to peers or parents
5. lack of spontaneous enjoyment
6. express moods or emotional affect
7. And cannot engage in play or make believe with toys.

- Cases of Autism are early onset, with developmental delays starting in

infancy. 20% of children with autism have seemingly normal growth and
development until 2 or 3 years of age, when developmental regression or loss
of abilities begins.

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 - Manifestations vary from little speech and poor daily living skills
throughout life to adequate social skills that allows relatively independent
functioning.
-Goals of treatment of children with autism are to reduce behavioral
symptoms (e.g. stereotyped motor behaviors) and to promote learning and
development, particularly the acquisition of language skills. Comprehensive
and individualized treatment, including special education and language
therapy, is associated with more favorable outcomes.
- Pharmacologic treatment with antipsychotics, such as haloperidol (Haldol)
or Risperidone (Risperdal), may be effective for specific target symptoms
such as temper tantrums, aggressiveness, self – injury, hyperactivity, and
stereotyped behaviors.
-Other medications: Naltrexone (ReVia), Clomipramine (Anafranil), Clonidine
(Catapres), and stimulants to diminish self – injury and hyperactive and
obsessive behaviors.

• RETT’S DISORDER
-Characterized by the development of multiple deficit after a period of
normal functioning
-It occurs exclusively in girls is rare and persists throughout life
-Rett’s develops between birth and 5 months of age
-The child loses motor skills and begins showing stereotyped movements
-She loses interest in the social environment and severe impairment of
expressive and receptive language becomes evident as she grows older
-Treatment is similar to that of autism

• CHILDHOOD DISINTEGRATIVE DISORDER

-Characterized by marked regression in multiple areas of functioning after
at least 2 years of apparently normal growth and development
-Typical age at onset is between 3 and 4 years
-Children with this disorder have same social and communication deficits
and behavioral patterns seen with autistic disorder
-Rare disorder occurs slightly more often in boys than girls

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 • ASPERGER’S DISORDER
-Characterized by the same impairments of social interaction and restricted
stereotyped behavior seen in autistic disorder, but there are no language
or cognitive delays
-Occurs more often in boys than in girls and the effects are generally
lifelong

Attention Deficit and Disruptive Behavior Disorders:

• Attention deficit hyperactivity disorder (ADHD)
- characterized by inattentiveness, overactivity, and impulsiveness. ADHD is
a common disorder, especially in boys, and probably accounts for more child
mental health referrals than any other single disorder.
- ADHD is a persistent pattern of inattention and / or hyperactivity and
impulsivity more common than generally observed in children of the same
age.
- ADHD affects an estimated 3% to 5% of all school aged children.

Onset and Clinical Course:

-ADHD usually is identified and diagnosed when the child begins preschool or
school, although many parents report problems from a much younger age.
- Symptoms of ADHD begins interfere significantly with behavior and
performance. The child fidgets constantly, is in and out or playing with
pencils or other objects. Normal environmental noises, such as someone
coughing, distract the child.
-Adolescents with ADHD have discipline problems serious enough to warrant
suspension or expulsion from high school. The secondary complications of
ADHD, such as low self-esteem and peer rejection, continue to pose serious
problems.
Etiology:
-Combined factors, such as environmental toxins, prenatal influences,
heredity, and damage to brain structure and functions, are likely responsible.

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- Prenatal exposure to alcohol, tobacco and lead and severe malnutrition in
early childhood increase the likelihood of ADHD.
-Although the relation between ADHD and dietary sugar and vitamins has
been studied, results have been inconclusive.

Cultural Considerations:
- ADHD is known to occur in various cultures. It is more prevalent in Western
Cultures, but that may be the result of different diagnostic practices rather
that the actual differences in existence.

Treatment:
-No one treatment has been found to be effective for ADHD this gives rise to
many approaches such as sugar controlled diets and megavitamin therapy.
- Goals of treatment involve managing symptoms reducing hyperactivity and
impulsivity, and increasing the child’s attention so that he or she can grow
and develop normally

Psychopharmacology:
Medications often are effective in decreasing hyperactivity and impulsiveness
and improving attention; this enables the child to participate in school and
family life.
- The most common medications are Methylphenidate (Ritalin) and an
Amphetamine compound (Adderall).
- The most common side effects of these drugs are insomnia, loss of appetite,
and weight loss or failure to gain weight.
-Giving stimulants during the daytime hours usually effectively combats
insomnia. When stimulant medications are not effective or their side effects
are intolerable, antidepressants are the second choice for treatment.

Strategies for home and school:

-Behavioral strategies are necessary to help the child to master appropriate
behaviors.
-Environmental strategies at school and home can help the child to succeed
in those settings.

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- Educating parents and helping them with parenting strategies are crucial
components o effective treatment of ADHD.
-Effective approaches include providing consistent rewards and
consequences for behaviors, offering consistent praise, using time out, and
giving verbal reprimands.
- Therapeutic play – play techniques are used to understand the child’s
thoughts and feelings and to promote communication.
-Dramatic play is acting out an anxiety – producing situation.

APPLICATION OF NURSING PORCESS: ATTENTION DEFICIT

HYPERACTIVITY DISORDER

Assessment:
History
-Fussy and had problems as an infant or they may not have noticed the
hyperactive behavior until the child was a toddler or entered day care or
school.
- The child probably has difficulties in all major life areas such as school or
play, and he or she likely displays overactive or even dangerous behaviors at
home.

General Appearance and Motor behavior

- Child cannot sit still in a chair and squirms and wiggles while trying to do so.
- Speech is unimpaired, but the child cannot carry on a conversation: he or
she interrupts, blurts out answers before the question is finished, and fails
pay attention to what has been said.

Mood and Affect

- Mood may be labile, even to the point of verbal outbursts or temper
tantrums.
- Anxiety, frustration, and agitation are common.

Thought Process and Content

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-there are generally no impairments in this area, although assessment can
be difficult depending on the child’s activity level and age or developmental
stage.

Sensorium and intellectual Processes

-Child is alert and oriented with no sensory or perceptual alterations such
hallucinations.
-ability to pay attention or to concentrate is markedly impaired.

Judgment and insight

- Children with ADHD usually exhibit poor judgment and often do not think
before acting

Roles and Relationships

-The child is usually unsuccessful academically and socially at school. He or
she frequently is disruptive and intrusive at home which causes friction with
siblings and parents.

Physiologic and self –care considerations

-Children with ADHD may be thin if they do not take time to eat properly or
cannot sit through meals.

Data Analysis and Planning

Nursing diagnosed commonly used when working with children with ADHD
include the ff.
• Risk for injury
• Ineffective Role performance
• Impaired social interaction
• Compromised family coping

Outcome identification
Treatment outcomes for clients with ADHD may include the following:
• The client will be free of injury

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 • The client will not violate the boundaries of others.
• The client will demonstrate age – appropriate social skills
• The client will complete tasks
• The client will follow directions

Intervention
Intervention described in this section can be adapted to various settings and
used by nurses and other health professionals, teachers and parents or
caregivers.
• Ensuring safety
• Improving role performance
• Simplifying instructions
• Promoting a structured daily routine
• Providing client and family education and support

Conduct Disorder
-Characterized by persistent antisocial behavior in children and adolescents
that significantly impairs their ability to function in social, academic or
occupational areas.
-Symptoms are clustered in four areas: Aggression to people and animal,
destructions of property, deceitfulness and theft
-Associated with early onset of sexual behaviors, drinking smoking, use of
illegal substances and etc.

Onset and Clinical Course

-Mild: The person has some conduct problems that cause relatively minor
harm to others.
-Moderate: The number of conduct problems increases as does the amount of
harm to others.
-Severe: The person has many conduct problems that cause considerable to
others
Etiology

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-Researchers generally accept that genetic vulnerability, environmental
adversity, and factors like poor coping interact to cause the disorder.
-Risk factor include poor parenting, low academic achievement, poor peer
relationships, and low self esteem; protective factors include resilence, family
support, positive peer relationships, and good health.
- the disorder is more common in children who have siblings with conduct
disorder or a parent with antisocial personality disorder, substance abuse,
mood disorder, schizophrenia.
-Poor family functioning, martial discord, poor parenting, and a family history
of substance abuse and psychiatric problems are all associated with the
development of conduct disorder.

Cultural Considerations
-Concerns have been raised that “difficult” children may be mistakenly
labeled as having conduct disorder in high-crime areas; aggressive behavior
may be protective and not necessarily indicative of conduct disorder.

Treatment
-Many treatments have been used for conduct disorder with only modest
effectiveness. Early intervention is more effective, and prevention more
effective than treatment.
-Dramatic interventions, such as “boot camp” or incarceration, have not
proved effective and may even worsen the situation.
-Treatment must be geared toward the client’s developmental age; no one
treatment is suitable for all ages.
-Medications alone have little effect but may be used in conjunction with
treatment for specific symptoms.

APPLICATION OF THE NURSING PROCESS: CONDUCT DISORDER

Assessment:
History

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-Children with conduct disorder have a history of disturbed relationships with
peers, aggression toward people or animals, destruction of property,
deceitfulness or theft, and serious violation of rules.

General Appearance and Motor Behavior

-Appearance, speech and motor behavior are typically normal for the age
group but may be somewhat extreme body piercings, tattoos, hairstyle, and
clothing. These clients often slouch and are sullen and unwilling to be
interviewed.

Mood and Affect

-Clients may be quiet and reluctant to talk or openly hostile and angry. Their
attitude is likely to be disrespectful toward parents, the nurse, or anyone in a
position of authority. Irritability, frustration, and temper outbursts are
common.

Thought Process and Content

Thought processes are usually intact—that is, clients are capable of logical
rational thinking. Nevertheless, they perceive the world to be aggressive and
threatening, and they respond in the same manner.

Judgment and Insight

-Judgment and insight are limited for development stage. Clients consistently
break rules with no regard for the consequences.

Roles and Relationships

Relationships with others, especially those in authority, are disruptive and
may be violent. This includes parents, teacher, police and most other adults.
Verbal and physical aggression is common.

Physiologic and Self-Care Considerations

Clients are often at risk for unplanned pregnancy and sexually transmitted
diseases because of their early and frequent sexual behavior. Use of drugs

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and alcohol is and additional risk to health. Clients with conduct disorders
are involved in physical aggression and violence including weapons

Data Analysis and Planning

Nursing diagnoses commonly used for clients with conduct disorders include
the following:
• Risk for Other-Directed Violence
• Noncompliance
• Ineffective Coping
• Impaired Social Interaction
• Chronic Low Self-Esteem

Outcome Identification
Treatment outcomes for clients with conduct disorders may include the
following:
• The client will not hurt others or damage property.
• The client will participate in treatment.
• The client will learn effective problem-solving and coping skills.
• The client will use age-appropriate and acceptable behaviors when
interacting with others.
• The client will verbalize positive, age-appropriate statements about
self.
Intervention
• Decreasing violence and increasing compliance with treatment.
• Improving Coping skills and self- esteem
• Promoting Social Interaction
• Providing Client and family Education

COMMUNITY-BASED CARE
-Clients with conduct disorder are seen in acute care settings only when their
behavior is severe and only for short periods of stabilization. Much long-term
work takes place at school and home or another community setting. Group

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Homes, halfway houses, and residential treatment settings are designed to
provide safe, structured environments and adequate supervision if that
cannot be provided at home.

MENTAL HEALTH PROMOTION

Parental behavior profoundly influences children’s behavior. Parents who
engage in risky behaviors such as smoking, drinking, and ignoring their
health are more likely to have children who also engage in risky behaviors,
including early unprotected sex. Group-based parenting classes are effective
to deal with problem behaviors in children and to prevent later development
of conduct disorders.

Oppositional Defiant Disorder

-ODD consists of an enduring pattern of uncooperative, defiant, and hostile
behavior toward authority figures without major antisocial violations. A
certain level of oppositional behavior is common in children and adolescents;
indeed, its is almost expected at some phases such as 2 to 3 years of age
and in early adolescence. Table 20.2 contrasts acceptable characteristics
with abnormal behavior and adolescents. ODD is diagnosed only when
behaviors are more frequent and intense than in unaffected peers and cause
dysfunction in social, academic, or work situations.
ODD is often comorbid with other psychiatric disorders such as ADHD,
anxiety, and affective disorders that need to be treated as well.

FEEDING AND EATING DISORDERS OF INFACNY AND EARLY

CHILDHOOD
• Pica
-Pica is persistent ingestion of nonnutritive substances such as paint, hair,
cloth, leaves, sand, clay, or soil, Pica is commonly seen in children with
mental retardation; it occasionally occurs in pregnant women.
• Rumination Disorder
-Rumination disorder is the repeated regurgitation and rechewing of food.
The child brings partially digested food up into the mouth and usually

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rechews and reswallows the food. The regurgitation does not involve nausea,
vomiting, or any medical condition. This disorder is relatively uncommon and
occurs more often in boys than in girls; it results in malnutrition, weight loss,
and even death in about 25% of affected infants.
• Feeding Disorder
-Feeding disorder of infancy or early childhood is characterized by persistent
failure to eat adequately, which results in significant weight loss or failure to
gain weight. Feeding disorder is equally common in boys and girls and occurs
most often during the first year of life. In severe cases, malnutrition and
death can result, but most children have improved growth after some time.
• Tic Disorders
-A tic is a sudden, rapid, recurrent, nonrhythmic, stereo-typed motor
movement or vocalization. Tics can be suppressed but not indefinitely. Stress
exacerbates tics, which diminish during sleep and when the person is
engaged in an absorbing activity. Common simple motor tics include blinking,
jerking the neck, shrugging the shoulders, grimacing and coughing. Common
simple vocal tics include clearing the throat, grunting, sniffing, snorting, and
barking.
-Tic disorders tend to run in families. Abnormal transmission of the
neurotransmitter dopamine is thought to play a part in tic disorders. Tic
disorders usually are treated with risperidone or olanzpine, which are atypical
antipsychotics. It is important for clients with tic disorders to get plenty of
rest and to manage stress because fatigue and stress increase symptoms.
• Tourette’s Disorder
-Tourette’s disorder involves multiple motor tics and one or more vocal tics,
which occur many times a day for more than 1 year. The complexity and
severity of the tics change over time, and the person experiences almost all
the possible tics described previously during his or her lifetime.
• Chronic Motor
-Chronic motor or vocal tic differs from tourette’s disorder in that either the
motor or the vocal tic is seen, but not both.
-Transient tic disorder may involve single or multiple vocal or motor tics, but
the occurrences last no longer than 12 months.

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Elimination Disorders
-Encopresis is the repeated passage of feces into inappropriate places such
as clothing or the floor by a child who is at least 4 years of age either
chronologically or developmentally.
-Enuresis is the repeated voiding of urine during the day or at night into
clothing or bed by a child at least 5 years of age either chronologically or
developmentally. Most often enuresis is involuntary; when intentional, it is
associated with a disruptive behavior disorder.
-Impairment associated with elimination disorders depends on the limitations
on a child’s social activities, effects on self-esteem, degree of social
ostracism by peers, and anger, punishment, and rejection on the part of
parents or caregivers.
-enuresis can be treated effectively with Imipramine (Tofranil) an
antidepressant with a side effect of urinary retention. Both elimination
disorders respond to behavioral approaches.

OTHER DISORDERS OF INFANCY, CHILDHOOD OR ADOLESCENCE

• Separation Anxiety disorder
- characterized by anxiety exceeding that expected for developmental level
related to separation from the home or those whom the child is attached.
When apart from attachments figures, the child insists on knowing their
whereabouts and may need frequent contact with them.
-separation anxiety disorders are thought to result form an interaction
between temperament and parenting behaviors. Inherited temperament
traits such as passivity, avoidance, fearfulness, or shyness in novel situations
coupled with parenting behaviors that encourages avoidance as a way to deal
with strange or unknown situations are thought to cause anxiety in the child

• Selective Mutism
- characterized by persistent failure to speak in social situations where
speaking is expected such as school

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-Children may communicate by gestures, nodding or shaking the head, or
occasionally one- syllable vocalizations in a voice different from their natural
voice.

• Reactive Attachment Disorder

- Involves a markedly disturbed and developmentally inappropriate social
relatedness in most situations. This disorder usually begins before 5 years of
age and is associated with grossly pathogenic care such as parental neglect,
abuse, or failure to meet the child’s basic physical and emotional needs.
-Treatment focuses on the child’s safety, including removal of the child from
the home if neglect or abuse is found. Individual and family therapy (either
with parents or foster caregivers) is most effective.

• Stereotypic Movement Disorder

- Associated with many genetic, metabolic, and neurologic disorders and
often accompanies mental retardation.
-Stereotypic movements may include waving, rocking, twirling objects, biting
fingernails, banging the head, orifices.
-No specific treatment has been shown effective. Clomipramine (Anafranil)
and Desipramine (Norpramin) are effective in treating severe nail biting;
Haloperidol (Haldol) and Chlorpromazine (Thorazine) have been effective
stereotypic movement disorder associated with mental retardation and
autistic disorder.

SELF- AWARNESS ISSUES

- The Nurse’s beliefs and values about raising children affect how he or she
deals with children and parents.
-Caring for a child as a nurse is very different from being responsible around
the clock.
-Given their own skills and problems, parents often give their best efforts.

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Del Rosario, Mikhail P.
Napala, Jennylen E.

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