EMOTIONAL

DISORDERS IN
CHILDREN AND
ADOLESCENTS
GROUP 8C
• Defined by sub average intelligence
(IQ below 70 that is accompanied by
impairments in performing age-
expected activities in daily.

• Intelligence is measured by a
standardized test and can be used to
define the degree of mental
retardation.
CLASSIFICATION OF MENTAL
RETARDATION
1. Normal : 90 to 110 IQ
2. Borderline : 71 to 89 IQ
3. Mild : 50/55 to 70 IQ

a. Educable : can achieve a mental age of 8

to 12 years
b. Can learn to read, write, do arithmetic,
achieve a vocational skill, and function
in society
4. Moderate : 35/40 to 50/55 IQ

a. Trainable : can achieve a mental

age of 3 to 7 years
b. Can learn the activities of daily
living, social skills; can be trained
to work in a sheltered workshop
5. Severe : below 20/25 to 35/40 IQ

a. Barely trainable : can achieve a

mental age of 0 to 2 years
b. Totally dependent on others
and in need of custodial care
6. Profound : below 20/25 IQ

a. May attain mental age of young

infant
b. Requires total care
 ETIOLOGIC FACTORS
• Infection and Intoxication –
congenital rubella; syphilis; maternal
alcohol or drug consumption; chronic
lead ingestion; kernicterus ( high
bilirubin level)
• Injury to the brain suffered during
the prenatal, perinatal, or postnatal
period; intracranial hemorrhage;
anoxia; physical injury
• Inadequate nutrition
• Gestational disorders including low
birth weight, prematurity, or post-
maturity
• Chromosomal abnormalities such as
Down Syndrome
• Hereditary – family history of mental
retardation
 CLINICAL FINDINGS
• Delayed milestones • Mental abilities are
concrete; abstract
• Infants fails to suck
ability is limited; may
• Head lag after 4 to 6 repeat words
months of age (echolalia)
• Slow in learning self- • Cannot carry out
help complex instructions
• Slow to respond to • Does not relate to
new stimuli peers; more secure
• Slow or absent with adults;
speech development comforted by physical
touch
• Short attention span,
 THERAPEUTIC
INTERVENTIONS
• Prevent causes that damage brain
cells such as hypoxia, untreated PKU
• Identify condition early
• Minimize long term consequences:
• Treatment of associated problems
• Infant stimulation
• Parental education
 NURSING CARE PLAN
• ASSESSMENT
– Developmental screening
– Associated illnesses/ risk factors

• NURSING DIAGNOSIS
- Interrupted family processes r/t having a child
who is cognitively impaired
- Compromised family coping r/t situational/
developmental crisis
- Delayed growth and development r/t impaired
cognitive function
Planning/Implementation

• Educate the parents regarding developmental age

• Set realistic goals : teach by simple steps for
habit formation rather than for understanding of
transference of learning
• Break down the process of skills into simple
steps that can be easily achieved.
• Recognize that behavior modification is a
very effective method of teaching these
children; praise accomplishments to develop
the child’s self-esteem.
• Keep discipline simple, geared toward
learning acceptable behavior rather than
developing judgment.
Evaluation
– Perform activities of daily living at
optimum level
– Family members make realistic
decisions based on their needs and
capabilities
• Refer to a group of disorders that
affect a broad range of academic and
functional skills including the ability
to speak, listen, read, write, spell,
reason and organize information.

• A learning disability is not indicative

of low intelligence. Indeed, research
indicates that some people with
learning disabilities may have average
or above-average intelligence.
 The 4 stages of information
processing
• Input - This is the information perceived
through the senses, such as visual and
auditory perception.
• Difficulties with visual perception can
cause problems with recognizing the
shape, position and size of items seen.
• Difficulties with auditory perception
can make it difficult to screen out
competing sounds in order to focus on
one of them, such as the sound of the
teacher's voice.
• Integration - This is the stage during
which perceived input is interpreted,
categorized, placed in a sequence, or
related to previous learning.
• Students with problems in these areas may
be unable to tell a story in the correct
sequence, unable to memorize sequences of
information such as the days of the week,
able to understand a new concept but be
unable to generalize it to other areas of
learning, or able to learn facts but be
unable to put the facts together to see
the "big picture."
• Storage - retention of information in
memory over an extended period of
time.
• Problems with memory can occur with
short-term or working memory, or
with long-term memory. Most memory
difficulties occur in the area of
short-term memory, which can make
it difficult to learn new material
without many more repetitions than
is usual. Difficulties with visual
memory can impede learning to spell.
• Output - Information comes out of the
brain either through words, that is,
language output, or through muscle
activity, such as gesturing, writing or
drawing.
• Difficulties with language output can
create problems with spoken language.
• Difficulties with motor abilities can
cause problems with gross and fine motor
skills.
• People with gross motor difficulties
may be clumsy, that is, they may be
prone to stumbling, falling, or
bumping into things.

• People with fine motor difficulties

may have trouble buttoning shirts,
tying shoelaces, or with handwriting.
 SPECIFIC LEARNING
DISABILITIES
• Reading disability
• The most common learning disability.
Of all students with specific learning
disabilities, 70%-80% have deficits in
reading.
• Dyslexia - synonym for reading
disability
• Common indicators of reading
disability include difficulty with
phonemic awareness -- the ability to
break up words into their component
sounds, and difficulty with matching
letter combinations to specific
sounds.
• Writing disability
• Impaired written language ability
may include impairments in
handwriting, spelling,
organization of ideas, and
composition

• Dysgraphia - used as an
overarching term for all
disorders of written expression.
• Math disability
• Sometimes called dyscalculia, a
math disability can cause such
difficulties as learning math
concepts (such as quantity, place
value, and time), difficulty
memorizing math facts,
difficulty organizing numbers,
and understanding how problems
are organized on the page.
 ETIOLOGIC FACTORS
• No single definitive cause has been
established; theories is to the cause
are being studied.
• Frequently found in association w/ a
variety of medical condition
ex. Lead poisoning , fetal alcohol
syndrome
 CLINICAL FINDINGS
• Difficulty understanding and following
instructions

• Trouble remembering what someone just

told them

• Failing to master reading, spelling, writing,

and/or math skills and therefore fails
schoolwork
• Difficulty telling the difference
between "right" and "left," problems
identifying words or a tendency to
reverse letters, numbers or words
(e.g., confusing "b" with "d," 18 with
81, or "on" with "no.")

• Lacking motor coordination when

walking, playing sports, holding a
pencil or trying to tie a shoelace
• Frequently loses or misplaces
homework, schoolbooks or other
items

• Unable to understand the concept of

time, confused by the difference
between "yesterday," "today," and
"tomorrow."
 THERAPEUTIC
INTERVENTION
• Accept child and focus on strengths
to raise self esteem
• Identify learning deficits early
• Minimize long term consequences
• Treatment of associated problems
• Infant child stimulation
• Parent Education
 NURSING CARE PLAN
• ASSESSMENT
• Attainment or delay of
developmental milestones
• Parental behavior and attitude
– Expectations
– Acceptance or rejection
– Encouragement or pressure
• Social History
– Social activities
– Peer and sibling relationships
– Personal and social
relationships
– Specific and outstanding
accomplishments
• Medical history
– Vision

– Hearing
– General Health
– Pregnancy, neonatal, and birth
data
– Past illness
– Family History
• NURSING DIAGNOSIS
• Anxiety related to frequent lack
of success the inability to meet
expectations of others, and the
failure to develop meaningful
relationships.
• Impaired verbal communication
r/t cerebral deficits and
psychologic barriers.
• Interrupted family processes r/t
to disturbed family interactions
and the disturbed behavior of
infant, child, or adolescents
• PLANNING/IMPLEMENTATION
• Develop a trusting relationship with the
child and family
• Provide activities consistent with disorder
• Provide guidance and supervision
• Maintain routines based on the child’s
usual schedule
• Set consistent and limits for behavior
• Assist the parents to gain an accurate
understanding of their child’s strength and
weaknesses.
• EVALUATION
• Participates in school and home
activities
• Follows directions
• Carries task to completion
• Motor skills disorder, also called
motor coordination disorder or motor
dyspraxia, is a common disorder of
childhood. It is estimated to be
present in about 6% of school age
children (between ages 5 and 11 yrs).
• Children with this disorder have
associated problems including
difficulty in processing information
needed to guide their motor actions
they may not be able to recall or plan
complex motor activities such as:
– dancing,
– doing gymnastics,
– catching or throwing a ball with
accuracy, or
– producing fluent legible handwriting.
• Motor skills disorder can be
extremely disabling both in academic
settings (school) as well as in
everyday life due to impairment of
functioning. Children and adults with
this disorder are at risk for obesity,
due to the higher rates of physical
inactivity, and often suffer from low
self-esteem as well as academic
underachievement.
 ETIOLOGIC FACTORS
• There is no known exact cause of this
disorder; however, it is often associated
with physiological or developmental
abnormalities such as:
• prematurity,
• developmental disabilities (cognitive
deficit),
• attention deficit hyperactivity disorder
(ADHD), and
• mathematics or reading learning disorders.
• It should be differentiated from
other motor disorders, such as:
• cerebral palsy,
• muscular dystrophy, and
• Inherited metabolic disorders.
 CLINICAL FINDINGS
• Children with this disorder have
variable symptoms, depending on the
age of diagnosis (as with most
childhood disorders).
• Young infants may present with non-
specific findings, such as hypotonia
(floppy baby) or hypertonia (rigid
baby).
• Older infants may be delayed in their
ability to sit, stand or walk.
• Toddlers may have difficulty feeding
themselves.
• Older children may have a hard time
learning to hold a pencil, and tend to
knock over drinking glasses more
often than expected.
• As children with this disorder age,
they often avoid physical activities,
especially those requiring complex
motor behaviors such as:
• dancing,
• gymnastics,
• swimming,
• catching or throwing a ball,
• writing, or
• drawing.
 THERAPEUTIC
INTERVENTION
• Physical therapy
• Occupational therapy
• Early interventional program to help
prepare child physically and socially
for school
• Ongoing assistance to promote social
and academic success
 A. Developmental
Coordination Disorder
• Developmental coordination disorder is
diagnosed when children do not develop
normal motor coordination (coordination
of movements involving the voluntary
muscles).
• It has been called clumsy child
syndrome, clumsiness, developmental
disorder of motor function, and
congenital maladroitness.
• Developmental coordination disorder is
usually first recognized when a child
fails to reach such normal
developmental milestones as walking or
beginning to dress him- or herself.
 ETIOLOGIC FACTORS
• The symptoms of developmental
coordination disorder vary greatly from
child to child. The general characteristic is
that the child has abnormal development
of one or more types of motor skills when
the child's age and intelligence quotient
(IQ) are taken into account. In some
children these coordination deficiencies
manifest as an inability to tie shoes or
catch a ball, while in other children they
appear as an inability to draw objects or
properly form printed letters.
 CLINICAL FINDINGS
• difficulty performing tasks that involve
both large and small muscles, including
forming letters when they write,
throwing or catching balls, and
buttoning buttons.
• can lead to social or academic problems
for children.
• problems forming letters when they
write by hand, or drawing pictures,
• general unsteadiness and slight
shaking
• an at-rest muscle tone that is below
normal
• muscle tone that is consistently
above normal
• inability to move smoothly because of
problems putting together the
subunits of the whole movement
• inability to produce written symbols
• visual perception problems related to
development of the eye muscles
• Children with
developmental
coordination
disorder have
difficulty
performing tasks
that require
motor skills or
eye-hand
coordination, such
as catching a
ball.
 NURSING CARE PLAN
• ASSESSMENT
• Developmental screening for
delayed milestones
• Associated illness/ risk factors
• Visual acuity
• Play activities
• Child’s response to lack of
coordination
• NURSING DIAGNOSIS
• Anxiety r/t a frequent lack of
success, the inability to meet
expectations of others, and the
failure to develop meaningful
relationships
• Risk for injury r/t sensory deficits,
altered judgment and sensorimotor
deficits
• Risk for falls r/t impairment in motor
coordination (gross motor skills) and
sensorimotor deficits
• PLANNING/IMPLEMENTATION
• Teach need for prevention of injury
from falls
• Encourage exercises such as swimming
• Foster independence by emphasizing
abilities and achievements rather
than limitations
• Help parents to cope w/ child’s lack of
coordination
• Reward achievement of motor
milestones ( crawling, sitting, walking,
improved handwriting)
• EVALUATION
• Maintains or increases mobility
• Participates in desired activities
• Verbalizes positive self-image
• Engage in activities suitable to
interest, capabilities, and
developmental level
• A. AUTISM (mindblindedness)

• Incidence: Boys
• Onset: 3y.o. above
• Characteristic: Impairment of
interaction skills
 ETIOLOGIC FACTORS
• Idiopathic
• Genetic factor
• Abnormality in Brain Chemicals
• Abnormality in Brain Structure
 CLINICAL FINDINGS
• Difficulty in Social Interactions
– Unaffectionate
– Loner
– Inapt. Attachment to objects
– Inapt. Laughing
– Lack of interest in the environment
– May avoid eye contact
• Difficulty with Communication
• Echolalia
• Communicate in gestures
• Difficulty in expressing needs

• Stereotype Behavior
• Sustained repetitive motor behavior
(spinning self)
• Insensitive to pain
• No real fear of Danger
How Autism Diagnosed?
• for the first 2years of life, the child
should be checked for the following
developmental deficits;
• 12mos – No gestures and pointing
• 18mos – No single words spoken
• 24mos – No two words spontaneous
expression, Loss of any language or
social skills at any age
 THERAPEUTIC
INTERVENTION
• Reduce behavioral symptoms
– Reduce temper tantrums
– Aggressiveness
– self-injury

• DOC: Haloperidol (Haldol) &

Resperidone (Risperdal)
• Prevent Self-Injury
• Promote Learning and Development
• SpEd (Special Education)
• Family Therapy
B. RETT’S DISORDER

• Incidence: Girls
• Characteristic: multiple
deficits after a
period of normal functioning
• Onset: from birth to 5mos
 CLINICAL FINDINGS
• Behavioral pattern (stereotype)
– Head Banging
– Tantrums
– Body twisting
• Difficulty with Communication
– Loss of Expressive language
– Difficulty in expressing needs
• Social Interaction
– Loss of interest in Social
Environment
 Difference between Rett’s
from Autistism
RETT’S
AUTISM
• Common on girls • Common in boys
• Loss of acquired language • Inapt. language
• Loss of hand function • Preserved hand function
• (+) Ataxia • (-)Ataxia
• Seizure prone • No seizure
• Abnormal Chewing • Normal Chewing ability
• Microcephaly • Normal
• Delayed physical growth • Normal
C. CHILDHOOD DISINTEGRATIVE
DISORDER
also known as Heller's syndrome
and disintegrative psychosis, is a
rare condition characterized by late
onset (>3 years of age) of
developmental delays in language,
social function, and motor skills.
• CDD has some similarity to autism, and is
sometimes considered a low-functioning
form of it, but an apparent period of fairly
normal development is often noted before
a regression in skills or a series of
regressions in skills.

• The syndrome was originally described by

Austrian educator Theodore Heller in
1908, 35 years before Leo Kanner
described autism, but it has not been
officially recognized until recently. Heller
used the name dementia infantilis for the
syndrome.
 CLINICAL FINDINGS
• A child affected with childhood
disintegrative disorder shows normal
development, generally up to an age
of 2 years, and he/she acquires
"normal development of age-
appropriate verbal and nonverbal
communication, social relationships,
motor, play and self-care skills"
comparable to other children of the
same age.
• However, from around the age of 2
through the age of 10, skills acquired
are lost almost completely in at least
two of the following six functional
areas:
• Language skills
• Receptive language skills
• Social skills & self-care skills
• Control over bowel and bladder
• Play skills
• Motor skills
• Lack of normal function or
impairment also occurs in at least two
of the following three areas:
– Social interaction
– Communication
– Repetitive behavior & interest
patterns
 ETIOLOGIC FACTORS
• The exact causes of childhood
disintegrative disorder are still unknown.
Sometimes CDD surfaces abruptly within
days or weeks, while in other cases it
develops over a longer period of time
• Comprehensive medical and neurological
examinations in children diagnosed with
childhood disintegrative disorder seldom
uncover an underlying medical or
neurological cause
• Lipid storage diseases: In this condition, a
toxic buildup of excess fats (lipids) takes place
in the brain and nervous system.
• Subacute sclerosing panencephalitis: Chronic
infection of the brain by a form of the measles
virus causes sub acute sclerosing
panencephalitis. This condition leads to brain
inflammation and the death of nerve cells.
• Tuberous sclerosis (TSC): TSC is a genetic
disorder. In this disorder, tumors may grow in
the brain and other vital organs like kidneys,
heart, eyes, lungs, and skin. In this condition,
non-cancerous (benign) tumors grow in the
brain.
 THERAPEUTIC
INTERVENTION
• Behavior therapy: Its aim is to teach
the child to relearn language, self-care
and social skills. The programs designed
in this respect "use a system of rewards
to reinforce desirable behaviors and
discourage problem behavior.“
•
A consistent approach by all concerned
result into a better treatment.
•
Medications: There are no medications
available to treat directly CDD.

•
Antipsychotic medications - are used to
treat severe behavior problems like
aggressive stance and repetitive behavior
patterns.
•
Anticonvulsant medications - are used to
control seizures.
D. ASPERGER’S DISORDER
a developmental condition that is
relatively rare, but frequently
misdiagnosed. Children with this
disorder usually have an average to
above average intelligence, but have
difficulty with social interactions,
adherence to rules, and emotional
sensitivity and reciprocity
– more common in males.
 ETIOLOGIC FACTORS
• Genetic factors
• 50% of AS patients have a history of
oxygen deprivation during the birth
process, which has led to the
hypothesis that the disorder is
caused by damage to brain tissue
before or during childbirth.
 CLINICAL/BEHAVIORAL
FINDINGS
• socially aloof
• may have poor eye contact
• do not have the skills to sustain positive
interaction
• Their major social deficit is an inability to
understand the perspective of another
person
• may create their own rituals and insist
that others adhere to their rules.
• language development may be delayed
• have difficulty deriving the full meaning
of both written and spoken language.
• Lack of common sense ,they have poor
impulse control and deficits in planning,
self-monitoring, and transitioning from
one situation to another.
• Motor clumsiness is not an essential part
of the syndrome and is usually seen in
pre-school children. Motor clumsiness
may extend into later development in
children with AD
 THERAPEUTIC
INTERVENTION
• If a child is suspected of having AD, he
or she should be referred to a
neuropsychologist for evaluation.
• The neuropsychologist  will make the
diagnosis by:
• Taking a thorough developmental history;
• Obtaining detailed information from teachers
and parents
Administering neuropsychological testing,
• After a clear diagnosis is made,
specific interventions can be
developed to meet the academic,
social, and emotional needs of the
child. These include:
• Use of medications like Ritalin or Risperdol;
• Behavior therapy that teaches social skills,
helps the child to understand emotions,
improves motor skills, and encourages the
understanding and perspectives of others;
• Family education and support; and
• Classroom interventions. Not all children
with AD need special education,
NURSING CARE PLAN
• ASSESSMENT
• Behavior associated w/autism
• Rejection of physical contact with
others
• Preference for inanimate, spinning,
shiny objects
• Behavior directing emotional energy
inward rather than toward the
external environment
• NURSING DIAGNOSIS
• Anxiety r/t failure to develop
meaningful relationships and
separation from parents.
• Impaired verbal communication
r/t delay or absence, or
repetitive use of language
• Personality identity disturbance
r/t the inability to distinguish
between self and nonself
• PLANNING/IMPLEMENTATION
• Increase the use of touch gradually;
accept the child’s needs to push
away; use touch to reinforce
difference between client and
nurse.
• Provide a consistent routine for
activities of daily living
• Maintain a consistent, familiar
environment
• Use picture boards to assist in
communication; participate in
child’s activities
• Set consistent and firm limits
for behavior
• Support family’s decision for
homecare or institutionalization
• Encourage verbalization of
feelings
• Provide parents with a list of
available community resources.
• EVALUATION
• Sits in a group
• Decrease self-destructive
behavior
• Increases use of first-person
speech
• Uses less stereotyped and
repetitive motor behaviors
• Depending on age, attends a
therapeutic nursery program, a
day treatment program or SPED
CLASSES
A. ATTENTION DEFICIT
HYPERACTIVITY DISORDER
• Is the latest terminology used to
refer to a persistent pattern of
inattention or hyperactivity with
impulsivity.
• For most children, the disorder
stabilizes in early adolescence, and in
most cases symptoms subside
between late adolescence and early
adulthood
 ADHD CLASSIFIED
ACCDG. TO 3 SUBTYPES:
• Combined type – (most common) the
individual has six or more symptoms
of inattention and six or more
symptoms of hyperactivity and
impulsivity.
• Predominantly inattentive type –
the individual has six or more
symptoms of inattention but fewer
than six symptoms of hyperactivity
w/ impulsivity
C. Predominantly hyperactive and
impulsive type – the individual has
six or more symptoms of
hyperactivity and impulsivity but
fewer than six symptoms of
inattention.
 ETIOLOGIC FACTORS
• The etiology is uncertain and may be
related to any illness or trauma
affecting the brain at any stage of
development.
• Predisposing factors such as;
• Exposure to toxins
• Medications
• Chronic otitis media
• Head trauma
• Perinatal complications
• Neurologic infections
• Mental disorders
 CLINICAL/BEHAVIORAL
FINDINGS
• Inappropriately inattentive
• Excessive impulsiveness (ex. cannot take turns,
interrupts
• Short attention span; easy distractibility; does
not complete tasks
• Squirming and fidgeting; hyperactivity may or
may not be present
• Difficulty organizing task and activities
• Excessive talking
• Symptoms persist although adolescents usually
become more goal-directed and less impulsive
 THERAPEUTIC
INTERVENTION
• Psychologic counseling
• Teaching and modeling more adaptive
coping behaviors
• Psychotropic medications:
• Methylphenidate HCl (Ritalin) is
frequently used
 NURSING CARE PLAN
• ASSESSMENT
• Hx of child’s behavior from parents,
teachers, and guidance counselor
• Behavior reflecting impulsiveness
and pattern of inattention
• Difficulty in following instructions
• Inability to sit without fidgeting or
moving about
• Easy distractibility by extraneous
stimuli
• NURSING DIAGNOSIS
• Anxiety r/t an inability to meet
expectation of others
• Self-esteem disturbance r/t negative
evaluation by self and others about
capabilities and performance
• Impaired verbal communication r/t to
excessive talking and intrusiveness
• Impaired social interaction r/t
excessive talking and intrusiveness
• PLANNIG/IMPLEMENTATION
• Set realistic, attainable goals
• Plan activities to provide a balance bet.
Energy expenditure and quiet time
• Structure situation to provide less
stimulation
• Provide firm and consistent discipline;
ignore temper tantrums
• Provide exercises in perceptual- motor
coordination and balance
• Provide opportunities so the child can
experience success and satisfaction
• Administer prescribed medication
• EVALUATION
• Participates in school and home
activities
• Carries task to completion
• Follows directions
B. CONDUCT DISORDER
• a persistent antisocial behaviors in
children and adolescents that
significantly impairs their ability to
function in social, academic, or
occupational areas.
• -it is frequently associated with early
onset of sexual behavior, drinking,
smoking, use of illegal substances,
and other reckless or risky behaviors
 SUBTYPES:
a. Childhood-onset: involves symptoms
before 10 years of age.
• - more likely to have persistent
conduct disorder and to develop
antisocial personality disorder as
adults

• Symptoms: physical aggression toward

others, disturbed peer relationships
b. Adolescent-onset: no behaviors of
conduct disorder until after 10
years of age.

• - less likely to be aggressive and

have normal peer relationships
• - less possibility to have constant or
persisting conduct disorder or
antisocial personality disorder as
adults
 CLASSIFICATIONS:
• Mild: the person’s conduct problems cause
relatively minor harm to others
Examples: lying, truancy, staying out
late without permission
• Moderate: the number of conduct
problems increases as well as the amount
of harm to others
Examples: vandalism, theft
• Severe: many conduct problems that cause
considerable harm to others.
Examples: forced sex, cruelty to
animals, use of a weapon, burglary,
robbery
C. OPPOSITIONAL DEFIANT
DISORDER
• consists of an enduring pattern of
uncooperative, defiant, and hostile
behavior toward authority figures
without major antisocial violations.
• diagnosed only when behaviors are
more frequent and intense than in
unaffected peers and cause
dysfunction in social, academic, or
work situation.
 CLINICAL/BEHAVIORAL
FINDINGS
• aggression to people and animals
• destruction of property
• deceitfulness and theft
• serious violation of rules
• little empathy for others, low self-
esteem, poor frustration tolerance,
temper outbursts
 ETIOLOGIC FACTORS
• Genetic Vulnerability
• Environmental Adversity
• Poor coping interactions
• The child may be socialized or under
socialized
• The child may be aggressive or
nonaggressive
 RISK FACTORS
• Poor parenting
• Low academic achievement
• Poor peer relationships
• Low self-esteem
 THERAPEUTIC
INTERVENTION
1. Early intervention and prevention is more
effective than treatment
2. NO ONE treatment is suitable for all ages
3. For Pre-school aged: Programs such as head-
start result in lower rates of delinquent
behavior and conduct disorder through use of
parental education about normal growth and
development, stimulation for the child, and
parental support during crises
4. For School-aged: child, family, and
school environment are the focus of
treatment. Family Therapy is essential for
children in this age group.
5. For Adolescents: Peer Dependence.
Individual Therapy is used. Treatment
usually includes conflict resolution, anger
management, and teaching social skills.
6. Medications alone have little effect but
may be used in conjunction with treatment
for specific symptoms.
 NURSING CARE PLAN
• ASSESSMENT
• History:
• (+) history of disturbed relationships with
peers, aggression toward people or
animals, destruction of property,
deceitfulness or theft, and serious
violation of rules
• Appearance, speech, and motor behavior
are typically normal but may be somewhat
extreme.
Examples: body piercing, tattoos,
hairstyle, clothing, etc.
• Quiet and reluctant to talk,
aggressive and hostile, thoughts or
fantasies about death and violence
are common, intellectual capacity is
not impaired but has poor grades.
Consistently breaks rules with no
regard for the consequences.
Appears tough but with low self-
esteem.
• NURSING DIAGNOSES
• Impaired social interaction r/t
aggressive behavior
• Risk for violence: self directed or
other-directed r/ t inability to
discharge emotion verbally and the
inability to control aggression
• Impaired verbal communication r/t
aggressive behavior
• Noncompliance r/t disregard of rules
and norms
• PLANNING/IMPLEMENTATION
• Decreasing violence and

increasing compliance with

treatment
• Improving coping skills and self-
esteem
• Promoting social interaction
• Providing client and family
education
• EVALUATION
• Decreases destructive acts
directed at self or others
• Demonstrates appropriate
behavior
• Parents express realistic
expectations of child
• Verbalizes a realistic self-
appraisal of strengths and
weaknesses
 COMMUNICATION
INCLUDES:
• LANGUAGE is made up of socially shared
rules that include the following:
– What words mean (e.g., "star" can refer to a
bright object in the night sky or a celebrity)
– How to make new words (e.g., friend, friendly,
unfriendly)
– How to put words together (e.g., "Peg walked
to the new store" rather than "Peg walk store
new")
– What word combinations are best in what
situations ("Would you mind moving your
foot?" could quickly change to "Get off my
foot, please!" if the first request did not
produce results)
• SPEECH is the verbal means of
communicating. Speech consists of the
following:
– Articulation: How speech sounds are made (e.g.,
children must learn how to produce the "r"
sound in order to say "rabbit" instead of
"wabbit").
– Voice: Use of the vocal folds and breathing to
produce sound (e.g., the voice can be abused
from overuse or misuse and can lead to
hoarseness or loss of voice).
– Fluency: The rhythm of speech (e.g.,
hesitations or stuttering can affect fluency).
– Intonation, rate, and intensity.
LANGUAGE DISORDER
• Receptive Language – When a person
has trouble understanding others.

• Expressive Language – When a

person has trouble sharing thoughts,
ideas, and feelings to others.
 SPEECH DISORDER

• When a person is unable to produce

speech sounds correctly or fluently,
or has problems with his or her voice,
then he or she has a speech disorder.
 ETIOLOGICAL FACTORS
COMMUNICATION DISORDER
Hearing impairment - full or
partial hearing impairment may
cause difficulty in speech and
language development.

• An assessment of hearing is one of

the first steps in the investigation
of speech and language problems.
• Physical disability - cleft lip and
palate, or malformations of the
mouth or nose may cause
communication disorders.

• More involved disabilities, such as

severe cerebral palsy, may preclude
any speech at all and for these non-
verbal children augmentative
communication methods must be used.
• Developmental disability - some
children (not all) with a developmental
disability or Down's syndrome may be
slower to learn to talk and may need
extra assistance.
• Children with learning disabilities may
have communication disorders.
• Many learning disabled children have
difficulty with receptive or expressive
language.
• Without appropriate intervention children
with communication disorders are at high risk
for educational failure.
• Children with Pervasive Development
Disorders (P.D.D.), or Autism
spectrum disorders will also have
communication disorders.
• Many children with PDD or Autism have
difficulty with social skills and their
behavior and conversation skills may be
limited or inappropriate.
• Children with significant behavior or
emotional problems may also have a
communication disorder.
 TYPES OF COMMUNICATION
DISORDER
• Expressive Language Disorder
Characterized by:
– Having a limited vocabulary and grasp of
grammar.
– A general language impairment that puts
the person onto the level of a younger
person
– A person can be as young as 2 or 3 years
old with the disorder.
• Implications:
• Affects work and schooling in many
ways.
• Socialization is affected.
• Treatment:
• Treated by SPECIFIC speech-
language therapy.
• Usually cannot be expected to go
away on its own.
• Language intervention activities
• Articulation therapy
• Oral motor therapy
B. Mixed Receptive and
Expressive Language Disorder

Characterized by:
• Both the receptive and
expressive areas of
communication may be
affected in any degree, from
mild to severe.
• Low assessment scores for:
• Information
• Vocabulary and Comprehension
» Spatial concepts (e.g.
difference between “over” and
“under;” “here” and “there.”)
» Difficulty in understanding
word problems and instructions
» Difficulty in using words
• Treatment:
• Consult a speech-language pathologist or
therapist to receive treatment.
• Most treatments are short-term and rely
on accommodations made in the person’s
environment (Special schools, environment
modification.)
• Language intervention activities
• Articulation therapy
• Oral motor therapy
C. Phonological Disorder

• If there is no known cause, it is

sometimes called "developmental
phonological disorder."

• If the cause is known to be of

neurological origin, the names
"dysarthria" or "dyspraxia" are
often used.
• Phonological disorder is
characterized by a child's
inability to create speech at a
level expected of his or her age
group because of an inability to
form the necessary sounds.
• Treatment:
• Consult a speech-language pathologist
or therapist to receive treatment.
• Most treatments are short-term and
rely on accommodations made in the
person’s environment (Special schools,
environment modification.)
• Articulation therapy
• Oral motor therapy
D. Stuttering

• Flow of speech is disrupted by

involuntary repetitions and
prolongations of sounds,
syllables, words or phrases, and
involuntary silent pauses or
blocks in which the stutterer is
unable to produce sounds.
• It has no bearing on intelligence.
• Stuttering is generally not a problem
with the physical production of
speech sounds or putting thoughts
into words.
• Anxiety, low self-esteem,
nervousness, and stress therefore do
not cause stuttering per se, although
they are very often the result of
living with a highly stigmatized
disability and, in turn, exacerbate
the problem.
• Treatment:
• Consult a speech-language
pathologist or therapist to
receive treatment.
• Articulation therapy
• Oral motor therapy.
 NURSING CARE PLAN
• ASSESSMENT
• Characteristics, pattern, and onset of
speech disorder
• Factors or situations that precipitate
disturbed speech patterns
• Level of self-esteem
• Level of anxiety and frustrations
• Family Hx of speech disorder
• NURSING DIAGNOSIS
• Anxiety r/t a frequent lack of success, an
inability to meet expectations of others,
and a failure to develop meaningful
relationships

• Risk for situational low self-esteem r/t

difficulty with receptive or expressive
language skills or the articulation of
speech

• Ineffective coping r/t an inability to meet

role expectations and a poorly developed
or inappropriate use of defense mechanism
• PLANNING/IMPLEMENTATION

• Encourage client to adhere to speech

therapy routine

• Allow individual time to verbalize; do not

complete word or sentence

• Avoid nonverbal behavior that implies

impatience to the client
• EVALUATION
• Demonstrates a decrease in speech-
pattern disturbances.

• Demonstrates increased participation in

social and public situations.

• Exhibits an increase in self-esteem

• Continues with prescribe therapy

• Tic disorders are characterized by
the persistent presence of tics,
which are abrupt, repetitive
involuntary movements and sounds
that have been described as
caricatures of normal physical acts.
• Tics are sudden, painless,
nonrhythmic behaviors that are
either motor (related to movement)
or vocal and that appear out of
context
CLASSIFICATION:
B. SIMPLE - using only a few muscles
or simple sounds

• Simple motor tics are brief,

meaningless movements like eye
blinking, facial grimacing, head
jerks or shoulder shrugs.

• They usually last less than one

second.
B. COMPLEX - using many muscle groups
or full words and sentences

• Complex motor tics involve slower,

longer, and more purposeful
movements like sustained looks,
facial gestures, biting, banging,
whirling or twisting around, or
copropraxia (obscene or disgusting
gestures).
 ETIOLOGIC FACTORS
• Imbalance in neurotransmitters is believed
to be the underlying cause

• Familial or autosomal-dominant patterns

exist in high percentage of tic disorders

• Classified as a rapid, recurrent, non-

rhythmic , stereotyped motor movement or
vocalization involving a few or many muscle
movements and vocal tics
• Researchers have also found changes within
the brain itself, specifically in the basal
ganglia (an area of the brain concerned with
movement) and the anterior cingulate cortex.

• Functional imaging using Positron Emission

Tomography(PET) and Single Photon Emission
Computerized Tomography(SPECT) has
highlighted abnormal patterns of blood flow
and metabolism in the basal ganglia, thalamus,
and frontal and temporal cortical areas of the
brain.
TYPES OF TIC DISORDER

1. TOURETTE DISORDER

• ONSET – before age 18

• DURATION – 12 months
• Evidence of multiple motor and at
least one vocal tic
TOURETTE’S DISORDER-
The tics occur many times a
day, usually in bouts, nearly every
day or intermittently for a
period of more than one year.
The patient is never symptom-
free for more than three months
at a time.
2. CHRONIC MOTOR OR VOCAL
DISORDER

• ONSET – before age 18

• DURATION – more than 12
months
• Evidence of single or multiple
motor or vocal tics, but not both.
CHRONIC MOTOR OR VOCAL
DISORDER

The tics occur many times a day nearly

every day, or intermittently for a period of
more than one year. During that time, the
patient is never without symptoms for more
than three consecutive months. The
severity of the symptoms and functional
impairment is usually much less than for
patients with Tourette's disorder.
3. TRANSIENT DISORDER

• ONSET – before age 18

• DURATION – no more than 12
consecutive months
• Evidence of motor and or vocal tics
lasting for at least 1 month
• It is the mildest form of tic
disorder, and may be underreported
because of its temporary nature
TRANSIENT DISORDER

There may be single or multiple

motor and/or vocal tics that occur
many times a day nearly every day
for at least four weeks, but not for
longer than one year.
 CLINICAL FINDINGS
• Involuntary, uncontrolled, multiple rapid
movements of muscles
Ex. Eye blinking, twitching, and head shaking that
occur episodes throughout the day
• Involuntary production of sound
Ex. Throat clearing, grunting, barking, or the
utterance of socially unacceptable words usually
associated with Tourette’s disorder
• Can be controlled for short duration; not
usually present during sleep
 THERAPEUTIC
INTERVENTIONS
• Treatment for any precipitating factor
such as head injury, psychoactive
substance, intoxication, or infection
• Supportive individual or group counseling
• Medications such as sedatives or
anticonvulsants may be prescribed, but
usually have minimal effect; CNS stimulant
should be avoided because they increase
symptoms in most individual
 NURSING CARE PLAN
• ASSESSMENT
• Hx, onset, and presence of behavior
associated with tic disorders
• Exacerbation of tics by stress
• Decreased tic activity during sleep
• Hx of psychoactive substance use to
determine if tic disorder is r/t intoxication
• Hx of CNS trauma, infection or
degeneration
• Family Hx of tic disorder
• Hx of neuroleptic agents to determine
whether tics are direct physiologic
consequence of medication
• NURSING DIAGNOSIS
• Anxiety r/t the inability to meet
expectations of others

• Disturbed body image r/t uncontrollable

body movements and production of
sounds

• Self-esteem disturbance r/t

uncontrollable body movements and
production of sounds

• Risk for injury r/t sensorimotor deficits

• PLANNING/IMPLEMENTATION
• Accept behavior, recognizing it is often
uncontrollable

• Help client to identify precipitating

factors

• Support client’s attempts to control tic

• Educating the patient and family about

the course of the disorder in a reassuring
manner
• EVALUATION
• Demonstrates a decrease in tic behavior

• Accepts presence of tic

• Functions socially despite presence of tic

• Family members with Tourette’s disorder

respond positively to advice regarding
genetic counseling
 A. PICA
• Persistent ingestion of non nutritive
substance such as:
• Paint
• Hair
• Cloth
• Leaves
• Sand
• Clay or soil
• Commonly seen in children w/ mental
retardation
• Occasionally occurs in pregnant women
• In most instances behavior last for
several months and then remits
• Pica may be benign, or it may have life-
threatening consequences.
• In children aged 18 months to 2 years, the
ingestion and mouthing of nonnutritive
substances is common and is not
considered to be pathologic
 ETIOLOGY
• It is more frequently seen among children with
developmental speech and social devt’l delays
• A substantial number of adolescents w/ pica
exhibited depressive Sx and use of substances
• Nutritional deficiencies - ex. Cravings for dirt
and ice are sometimes associated with iron and
zinc deficiencies which are corrected by their
administration
• Compensatory mechanism to satisfy oral needs
• Malnutrition, especially in underdeveloped
countries, where people with pica most
commonly eat soil or clay
 RISK FACTORS
• parental/child psychopathology
• family disorganization
• environmental deprivation
• pregnancy
• epilepsy
• brain damage
• mental retardation
• pervasive developmental disorders
 CLINICAL FINDINGS
• Sand or soil is associated with gastric pain
and occasional bleeding.
• Chewing ice may cause abnormal wear on
teeth.
• Eating clay may cause constipation.
• Swallowing metal objects may lead to
bowel perforation.
• Eating fecal material often leads to such
infectious diseases as toxocariasis,
toxoplasmosis, and trichuriasis.
• Consuming lead can lead to kidney damage
and mental retardation.
DIAGNOSTIC PROCEDURES:
• Abdominal x rays
• Barium examinations of the upper and
lower gastrointestinal (GI) tracts
• Upper GI Endoscopy to diagnose the
formation of bezoars (solid masses
formed in the stomach) or to identify
associated injuries to the digestive
tract
• Treatment emphasizes psychosocial,
environmental, and family guidance
approaches
• Lead poisoning resulting from pica may be
treated by chelating medications, which
are drugs that remove lead or other heavy
metals from the bloodstream
• Dimercaprol, which is also known as BAL or
British Anti-Lewisite;
• Edetate Calcium Disodium (EDTA).
 THERAPEUTIC
INTERVENTION
• The most effective strategies are based on
behavior modification, One of the first steps is
to encourage children to eat a healthy, balanced
diet. Replacing non-food items that children
ingest with more suitable, nutritious food items
is an important goal.
• Speaking with a dietitian who is familiar with
Pica can be very helpful in coming up with
appropriate and tempting menus.
 B. RUMINATION DISORDER
• repeated regurgitation and rechewing of
food
• the child brings partially digested food up
into the mouth and usually rechews and
reswallows the food
• relatively uncommon
• more often occurs in boys than in girls
• results in malnutrition, weight loss, and
even death in about 25% of affected
infants
 ETIOLOGY
• Physical illness or severe stress may
trigger the behavior
• Neglect of or an abnormal
relationship between the child and
the mother or other primary
caregiver may cause the child to
engage in self-comfort. For some
children, the act of chewing is
comforting.
• It may be a way for the child to gain
attention.
 CLINICAL FINDINGS
• Repeated regurgitation of food
• Repeated re-chewing of food
• Weight loss
• Bad breath and tooth decay
• Repeated stomach aches and indigestion
• Raw and chapped lips
 COMPLICATIONS
• Malnutrition
• Lowered resistance to infections and
diseases
• Failure to grow and thrive
• Weight loss
• Stomach diseases such as ulcers
• Dehydration
• Bad breath and tooth decay
• Aspiration pneumonia and other
respiratory problems (from vomit that is
breathed into the lungs)
• Choking
• Death
THERAPEUTIC INTERVENTIONS
• Encouraging more interaction between mother
and child during feeding; giving the child more
attention
• Reducing distractions during feeding
• Making feeding a more relaxing and
pleasurable experience
• Distracting the child when he or she begins
the rumination behavior
• Aversive conditioning, which involves placing
something sour or bad-tasting on the child's
tongue when he or she begins to vomit
• Psychotherapy (a type of counseling)
for the mother and/or family may be
helpful to improve communication and
address any negative feelings toward
the child due to the behavior.
• There are no medications used to
treat rumination disorder.
 C. FEEDING DISORDERS IN
INFANCY OR EARLY CHILDHOOD
• is characterized by persistent failure to eat
adequately, which results in significant
weight loss or failure to gain weight
• equally common in boys and in girls
• occurs most often during the first year of
life
• Feeding disorders are diagnosed when the
infant or young child appears malnourished
and the problem is not caused by a medical
condition
 ETIOLOGY
• poverty
• dysfunctional child-caregiver
interactions
• parental misinformation about
appropriate diet to meet the child's
needs
• a disorder that causes mental
retardation.
 CLINICAL FINDINGS
• Constipation
• Excessive crying
• Excessive sleepiness (lethargy)
• Irritability
• Poor weight gain
• Weight loss
 COMPLICATIONS
• malnourished or starving children
• irritable
• difficult to console
• apathetic
• withdrawn
• Unresponsive
• Delays in development, as well as
growth, can occur
• Laboratory abnormalities
• Blood tests may reveal a low level
of protein or hemoglobin in the
blood.
• Hemoglobin is an iron-containing
substance in blood that carries
oxygen to body cells.
 THERAPEUTIC
INTERVENTIONS
• Increase the number of calories and
amount of fluid the infant takes in
• Correct any vitamin or mineral
deficiencies
• Identify and correct any underlying
physical illnesses or psychosocial
problems
• A short period of hospitalization may be
required to accomplish these goals.
•
• Collaborative interventions
– Refer to dietitian who can consult
on nutrition and diet issues
– behavioral psychologist who can
design and implement a behavior
modification program
 A. ENCOPRESIS
• repeated passage of feces into inappropriate
places such as clothing or the floor by the child
who is at least 4 years of age either
chronologically or developmentally
• often involuntary, but it can be intentional
• Involuntary encopresis – associated w/
constipation that occurs for psychological not
medical reasons
• Intentional encopresis – often associated w/
oppositional defiant disorder or conduct disorder
 B. ENURESIS
• 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 involuntary
• When intentional it is associated w/
disruptive behavior disorder
• 75% of children w/ enuresis have a first
degree relative who had the disorder
 CLINICAL FINDINGS
• More common in males than females
• No identifiable physical problems are
present
• Chronologic age is at least 4 yrs or
equivalent developmental level
• Primary – occur before bladder training
has been accomplished
• Secondary – after a period of controlled
continence
• Nocturnal bedwetting is most frequent;
child may or may not be aware of voiding
or recall a dream about the act of
urinating
• Loss of self esteem; anxiety, rejection
by peers may cause child to avoid
situations ( camp, school)
 THERAPEUTIC
INTERVENTION
• Psychotherapy
• Medications such as TCA for children
over the age of 5 to treat enuresis
• Bowel retraining program
 NURSING CARE PLAN
• ASSESSMENT
• Hx of toileting behaviors
• Hx of school or family difficulties
• Level of self-esteem
• Secondary gains achieved by behavior
• NURSING DIAGNOSIS
• Anxiety r/t a frequent lack of
success and inability to meet others
expectations
• Risk for impaired parenting r/t child’s
pattern of disturbed behavior
(encopresis or enuresis) not
responding to discipline or other
control measures
• Disturbed sleep pattern r/t emotional
dysfunction
• PLANNING/IMPLEMENTATION

• Change linen and clothing in a

nonjudgmental manner to avoid further
embarrassment for the client
• Recognize and accept the fact that the
act usually is not motivated by hostility
• Help parents cope with feelings such as
guilt, failure or anger
• EVALUATION
• Demonstrates a decrease in encopresis
or enuresis
• Exhibits an increase in self-esteem
• Verbalizes understanding that behavior
is neither good nor bad but solution
requires outside assistance
• Parents verbalize understanding that
behavior is related to an emotional
problem, not hostility
 A. SEPARATION AXIETY
DISORDER
• characterized by anxiety exceeding that
expected for developmental level related to
separation from the home or those to whom the
child is attached.
• may result to avoidance behaviors
• often accompanied by nightmares and multiple
physical complaints
• equally common in males and in females
• begins in infancy (oral phase development)
 CLINICAL/BEHAVIORAL
FINDINGS
• Problems w/ sleeping unless near the person to
whom child has attachment
• Refusal to attend school in order to remain
near the person to whom child has attachment
• Physical complaints of headaches and stomach
aches when separation is anticipated
B. SELECTIVE MUTISM
• persistent failure to speak in social
situations where speaking is expected such
as school
• children may communicate by gestures,
nodding or shaking the head, or
occasionally one-syllable vocalizations in a
voice different from their natural voice
• they are often excessively shy, socially
withdrawn or isolated, and clinging, and
may have temper tantrums
• Interferes with educational , social, and
occupational achievement
• Onset usually before age 5
 CLINICAL/BEHAVIORAL
FINDINGS

• Avoidance of speaking in social

environment outside the home
• Social involvement limited to family
members or people who are familiar to
the child
• Excessive shyness and timidity when
confronted with strangers
 C. REACTIVE
ATTACHMENT DISORDER
• involves a markedly disturbed and
developmentally inappropriate social
relatedness in most situation
• begins before 5 years of age
• associated with grossly pathogenic care such as
parental neglect, abuse, or failure to meet the
child’s basic physical or emotional needs
• repeated changes in primary caregivers prevent
the establishment of stable attachment
• onset before age 5
Types:
• Inhibited Type: disturbed social
relatedness maybe evidenced by the
child’s failure to initiate or respond
to social interaction
2. Disinhibited Type: lack of selectivity
in choice of attachment figures or
indiscriminate stability
– Treatment:
» SAFETY!
» Individual and family therapy
 CLINICAL/BEHAVIORAL
FINDINGS
• Psychosocial deprivation resulting in
child’s failure to initiate or respond
to most special interactions
• Difficulty in choice of attachment
figures
• Onset in the first several years of
life; begins before age 5
 D. STEREOTYPE
MOVEMENT DISORDER
• involves repetitive motor behaviors
that is non-functional and either
interferes with normal activities or
results in self-injury requiring medical
treatment such as waving, rocking,
twirling objects, biting fingernails,
banging the head, biting or hitting
oneself, or picking at the skin or body
orifices.
• the more severe the retardation, the
higher the risk for self-injury
• -associated with many genetic,
metabolic, and neurologic disorders,
and often accompanies mental
retardation
 THERAPEUTICS
INTERVENTIONS

• Psychotherapy: in children usually in

the form of play therapy
• Psychopharmacology
• Stimulants
• Anti-anxiety agents
 NURSING CARE PLAN
• ASSESSMENT
• Hx of child’s behavior from parents
and teachers
• Presence of sleep disturbances
• Interpersonal functioning w/ others
• Physical complaints
• Hx of attendance at school
• Child’s appearance and behavior
• NURSING DIAGNOSIS
• Anxiety r/t the inability to meet
expectations of others and a failure
to develop meaningful relationships
• Ineffective coping r/t inadequately
developed or inappropriate use of
defense mechanism
• Disturbed sleep pattern r/t emotional
dysfunction
• Impaired social interaction r/t
withdrawn behavior and speech
disturbances
• PLANNING/IMPLEMENTATION
• Provide consistent caregivers
• Introduce child to new situations
gradually; permit the child to bring a
familiar, comforting toy
• Allow parents to stay w/ child as long
as possible
• Involve family in multifamily therapy to
work through problems of daily life an
to gain new information and more
adaptive coping skills
• EVALUATION
• Demonstrates a decrease in sleep
disturbances
• Attend school on a consistent basis
• Verbalizes fewer physical complaints
• Develops relationships outside of family
members and the home environment
• States a decrease in episodes of anxiety
and worry
• Behaviors of family members demonstrate
a reduction in overprotection of child