ALTERATIONS IN PERCEPTION AND COORDINATION AND MENTAL

HEALTH
COGNITIVE CHALLENGE
- Is also known as Intellectual disability
- “significant subaverage” that is at least two or more standard deviations below individual
peers’ average level
- It is based on two criteria: Intellectual functioning significantly below average and
concurrent deficits in adaptive functioning in conceptual, social, and practical domains.
Causes: Genetic abnormalities, metabolic disorders, brain malformations, maternal disease,
and environmental influences
o Some causes that can occur before or at conception include Inherited disorders
and chromosomal abnormalities.
o Some causes that can occur during pregnancy include Severe maternal
undernutrition, Infections, Alcohol (Fetal Alcohol Spectrum Disorder), Drugs,
Abnormal Brain Development, Preeclampsia and multiple births.
o Some causes that occur during birth include hypoxia, and extreme prematurity.
o Some causes that can occur after birth include brain infections, severe head injury,
undernutrition of child, poisons, severe emotional neglect or abuse, and brain
tumors and their treatments.
Classification:
o Mild Intellectual Disability
▪ Children exhibit difficulties in acquisition of academic skills and are
typically more concrete in their problem solving.
▪ Socially: they are observed as less mature, have limited understanding of
risk, and demonstrate poorer affect regulation than similarly aged peers
▪ Adults: they can usually achieve adequate social and vocational skills for
minimum self-support and independent living but need guidance and
assistance with complex daily living tasks.
o Moderate Intellectual Disability
▪ Language and preacademic skills develop slowly during preschool age,
and continue to advance slowly through school, typically peaking with
academic skills at the elementary level.
▪ Socially: communication is much less complex, with poor interpretation of
social cues when compared to peers of a similar age
▪ Through adolescence and into adulthood, simple activities of daily living
can be learned through extended periods of teaching and caregiver
support.
▪ As adults: they may be able to contribute to their own support by
performing unskilled or semiskilled work under close supervision.
o Severe Intellectual Disability
▪ Develop a limited understanding of language and academic skills, with
minimal acquisition of communicative speech, such as with single words
and phrases, or augmented means.
▪ They require parental support in all activities of daily living and constant
supervision is mandatory to ensure safety.
o Profound Intellectual Disability
▪ Demonstrate only minimal capacity for sensorimotor functioning and are
nonverbal and nonsymbolic in communication.
▪ Some are able to respond to training in minimal self-care, such as
toothbrushing, but only very limited self-care is possible.
▪ They need highly structured environment and are dependent on others for
activities of daily living, help, and supervision for safety.

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 Assessment:
o Individualized Intellectual Quotient (IQ) testing, culturally sensitive standardized
measures, and careful clinical evaluation and judgement. IQ testing assesses
intellectual function and clinical evaluation assesses adaptive functioning.
o Intellectual Quotient Tests are tools to measure intellectual abilities and
potential. They’re designed to reflect a wide range of cognitive skills, such as
reasoning, logic, and problem-solving.
o Intelligence is routinely measured with individualized, standardized tests and
must be interpreted with sound clinical judgement by professionals in the mental
health field.
o Adaptive behavioral functioning is judged according to several methods,
including standardized instruments for assessing mental status, social maturity,
and adaptive skills with respect to cultural differences.
Therapeutic Management
o Encourage parents to seek early intervention, education, and support in their
community through involvement in support groups, parent education, and
agencies like The Arc. The Arc is a community mental health center offering in-
person or telehealth psychotherapy, psychiatric care, and in-home social
assistance services.
o Validate parents’ and caregivers’ own needs, such as encouraging respite care
through trusted family members, friends, or their local department of social
services.
o Ensure that caregivers are aware of the full impact of intellectual disabilities so
that they may appropriately help the child to cope and adapt to various situations.

PERVASIVE DEVELOPMENTAL DISORDERS

- Is now known as AUTISM SPECTRUM DISORDER. It was changed in 2013 when
the American Psychiatric Association updated the DSM (Diagnostic and Statistical
Manual of Mental Disorders) to its fifth edition.
- Under the DSM-IV, PDD included four separate disorders:
o Autistic disorder - characterized by significant language delays, social and
communication challenges, and unusual behaviors and interests.
o Asperger’s disorder- is the difficulty of relating to others socially and the
person’s behavior and thinking patterns can be rigid and repetitive.
o Childhood disintegrative disorder - causes regression of previously acquired
skills in social, language and motor functioning.
o Rett syndrome - is a rare genetic neurological and developmental disorder that
affects the way the brain develops. This disorder causes a progressive loss of
motor skills and language.
o However, Rett syndrome is no longer considered ASD because it is caused by
genetic mutation.
- ASD is characterized by difficulties in three main areas: social deficits, communication
issues, and restricted behaviors, with onset in the early developmental stages, that
impair everyday functioning.
- Within 36 months of life, children with ASD often lack responsiveness to people around
them, display gross impairment in communication skills, and produce abnormal
responses to various aspects of the environment.
- It occurs more commonly in males.
Assessment:
o Commons symptoms:
▪ Failure to develop social relations
▪ Stereotyped behaviors such as hand gestures
▪ Extreme resistance to change in routine
▪ Abnormal responses to sensory stimuli
▪ Decreases sensitivity to pain
▪ Inappropriate or decreased emotional expressions

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 ▪ Specific, limited intellectual problem-solving abilities
▪ Stereotyped or repetitive use of language
▪ Impaired ability to initiate or sustain a conversation
o ASD is often recognizable in children between 12 and 24 months
o A child must have deficits in three areas of social communication and at least two
of four types of restricted behaviors based on criteria from the DSM-5.
▪ Deficits in social communication and interaction may include deficits in
social-emotional reciprocity, deficits in nonverbal communicative
behaviors, and deficits in understanding relationships.
▪ Restricted, repetitive patterns of behavior include repetitive motor
movements, insistence on sameness, fixated interests, and abnormal
responses to sensory input may be seen.
o Communication impairment includes both verbal and nonverbal skills.
▪ Deficiencies in grammatical structure, nominal aphasia (inability to name
objects), abnormal speech melody, echolalia (repetition of words or
phrases spoken by others) and concrete interpretation.
▪ Nonverbal deficiencies include abnormal eye contact, deficits in use of
body movements and gestures, and lack of facial expressions.
o Abnormal responses to the environment may include intense reaction to minor
changes, attachment to odd objects, and a rigid demand for routine. S
▪ Signs in children prior to school age include repetitive hand movements
and constant body rocking.
▪ Aggressive actions, such as hitting, head banging, and biting, or the
inability to feel pain, may also be present.
o Children are said to have labile mood (crying occurs suddenly and is followed
immediately by giggling or laughing or vice versa).
o They may overrespond to sensory stimuli, such as light or sound, but then be
unaware of a major event in the room, such as the sound of a fire alarm.
o Long-term memory and “savant” skills (exceptional skills such as virtuosos piano
playing) may be excellent.
Therapeutic Management:
o Primary treatment includes educational, compensatory, and behavior modalities,
such as the evidence-based applied behavior analysis (ABA) treatment based on
the associations between behavior and learning.
▪ ABA is a therapy based on the science of learning and behavior. It applies
our understanding of how behavior works to real situations. The goal is to
increase behaviors that are helpful and decrease behaviors that are harmful
or affect learning.
▪ It is intensive and can involve the entire family.
▪ Parental involvement is essential to facilitate development of self-care
skills.
o No specific medications are approved for the treatment of ASD; However,
medications may be used to address coexisting conditions such as ADHD,
depression, or seizures.
o It is important for nurses to ask if parents are finding time for care of their child
and themselves.
▪ Encourage parents of children with ASD to seek support through
organizations in the community to help support their own well-being and
that of their families.
o A day care program can help promote social awareness, because they develop
greater awareness and attachment to parents and other familiar adults, as they
mature.
Nursing Interventions:
o Choose words carefully when speaking to verbal autistic child because they are
likely to interpret words concretely.
o Advise parents to have close, face-to-face contact with their child to promote
communication.

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 o Maintain a regular and predictable daily routine to prevent outbursts. Prepare
child for changes of routine.
o Educate parents on behaviors that signal tantrums such as increased hand
flapping. Emphasize the importance of intervening and anticipating needs before
a tantrum occurs.
o Advise patients on ways to provide a safe environment for the child (e.g.
installing locks and gates).
o Educate family members on the medications (e.g. stimulants, selective serotonin
reuptake inhibitors, lithium, etc.) the child is taking.
o Offer emotional support and information to parents.
o Arrange for family counseling to help parents better understand the disorder. This
also assists them with their coping mechanisms.
o Provide referrals for early intervention, home care assistance, and support groups,
as needed. Early intervention and special education programs increase a child’s
capacity to learn, communicate, and relate to others. This also reduces the severity
and frequency of disruptive behaviors. Special schools for behavior modification
are alright but educational mainstreaming is preferred.

ADHD (Attention Deficit Hyperactivity Disorder)

- Is one of the most common neurobiologic conditions in childhood that can also persist
into adulthood.
Symptoms: inattention, hyperactivity, and impulsivity that can create an impairment in
functioning
- It involves a number of factors with environmental, genetic, and physiologic factors.
o Its cause and risk factors are unknown, but current research shows that genetics
play an important role.
- It affects more males.
- It is characterized by three major behaviors:
o Inattention: difficulty organizing tasks and a reluctance to do tasks that require
mental effort over time.
o Impulsiveness: child acting before thinking, having difficulty with such tasks as
waiting before their turn, blurting answers before a question is completed, and
interrupting or intruding on other’s conversations.
o Hyperactivity: children may shift excessively from one activity to another.

Assessment:
o Thorough initial history taking
→ includes complete birth history and environmental history and consider
developmental milestones,
→ dietary history,
→ social history (including child abuse, neglect, and foster care),
→ past infections (such as encephalitis)
→ family history because it is most common in fist-degree relatives,
→ rule out other causes of behavior problems.
o Physical examination which includes:
→ height, → toxicology screen,
→ weight, → assess for comorbid
→ BMI, conditions that are
→ Vision and hearing, common with ADHD
→ CBC with differential, (specific learning
→ thyroid-stimulating disabilities, oppositional
hormone and free defiant disorder,
thyroxine test, depression/anxiety
→ lead screen, disorders, bipolar
→ genetic screen, disorders, fetal alcohol

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 affect, Tourette psychosocial
syndrome, and morbidities)
→ During PA, children may show the following:
• “soft” neurologic signs such as difficulty with finger-to-nose or
rapid hand movement tests, “mirroring” with movements, inability
to perform a tandem walk or a heel-to-shin test.
• They may also not show the normal responses of graphesthesia
(the ability to recognize symbols when they're traced on the skin)
or stereognosis (is the ability to identify the shape and form of a
three-dimensional object, and therefore its identity, with tactile
manipulation of that object in the absence of visual and auditory
stimuli).
• When asked to stand with arms outstretched, choreiform
movements (sudden, unintended, and uncontrollable jerky
movements of the arms, legs, and facial muscles) are often present.
• Unilateral Babinski reflex may be present.
→ Testing children with games may be necessary so that their attention is
maintained long enough to complete the assessment.
o Completion of evidence-based rating scales by an individual who is familiar with
the child. Wechsler Intelligence Scale for Children (WISC) consists of two
portions:
→ Verbal Scale and Performance Scale
→ A child is given three final scores: Verbal IQ, Performance IQ, and a
combination or full-scale IQ.
→ Children with ADHD show a “scatter” pattern on both performance and
verbal portions, doing well on some parts and poorly on others.
Nursing Diagnosis
o Defensive coping related to feelings of inadequacy and need for acceptance from
others.
o Impaired social interaction related to developmental disabilities (hyperactivity).
o Altered thought processes related to personality disorders.
Nursing Interventions
The role of the nurse in caring for the patient with ADHD involves the following:
o Accept the child or individual as what he is. Consider his condition and
communicate with him as an equal.
o Approach the child at his current level of functioning.
o Use simple and direct instructions.
o Implement scheduled routine every day.
o Avoid stimulating or distracting settings.
o Give positive reinforcements.
o Encourage physical activity.
Therapeutic Management:
o Environmental Modification:
→ A stable learning environment: a child with ADHD may benefit
educational accommodations provided under the federally mandated 504
plan which includes: preferential seating, extended time for test taking,
written lists of assignments and due dates, and note-taking support.
• Rehabilitation Act of 1973 Section 504 is a federal law designed to
protect the rights of individuals with disabilities in programs and
activities that receive Federal financial assistance from the U.S.
Department of Education (ED).
→ Help the parents understand how the child’s condition interferes with the
functioning in school so a special program will offer their child the best
chance to succeed.
→ Teach parents to give instructions slowly and to make certain they have
their child’s attention before beginning instructions.

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 → Consequences regarding inappropriate behavior need to be established and
discussed ahead of time and delivered immediately.
→ Encourage parents to understand that anger should not be directed at the
child’s inability to sequence, filter, or integrate concepts.
→ Help parents build their child’s self-esteem at every developmental stage
possible.
o Family Support
→ The child may need counseling to find career that fits with these behaviors
(impulsivity and inattention, as some children continue to experience it
into adulthood)
o Medication
→ Provide accurate information about the medications, expected response,
and side effects.
→ Medications are aimed at reducing the excessive activity of children with
ADHD as well as lengthening their attention span and decreasing
distractibility.
• Methylphenidate, amphetamine, atomoxetine, and extended-
release guanfacine
→ Stimulants work by stimulating dopamine receptors, so there is more
regular nerve transmission, which results in increased attention span.
→ Side effects include insomnia and anorexia.
• Administer drug early in the day may relieve insomnia, and
decreased appetite can be addressed by administering medication
before breakfast and offering healthy snacks between meals.
• Measure height and weight to assess if long-term appetite
suppression is affecting projected physical growth parameters
based on their individualized growth chart.
→ Atomoxetine, a norepinephrine reuptake inhibitor, may be a first-line
medication for children with ADHD who cannot tolerate stimulants.
→ Guanfacine and clonidine affect norepinephrine discharge rates and
directly affect dopamine.

PTSD (Posttraumatic Stress Disorder)

- It occurs in children who have experienced or witnessed a traumatic event (child abuse,
neglect, domestic violence, a natural disaster, a harrowing accident, or a near-fatal illness)
- Diagnostic criterion: symptoms that occur 1 month following the initial event.
Symptoms: Children continue to have recurring recollections or dreams of the event or
demonstrate intense psychological symptoms, if a reminder of the initiating event occurs;
They may feel guilt they survived the event if a close family member or friend did not.
o Four categories:
→ Intrusive memories: recurrent, unwanted distressing memories of the
traumatic event, flashbacks
→ Avoidance: Avoiding places or things that may remind you of the
traumatic event
→ Alterations in cognition and mood: feeling detached or estranged from
others, Negative thoughts about oneself or other people, inability to
remember important aspects of the traumatic event.
→ Alterations in arousal and reactivity: being irritable and having angry
outbursts, being easily frightened or startled, Self-destructive behavior.
Assessment:
o PTSD Screen - is a very short list of questions about your thoughts, feelings and
behaviors since the trauma. A screen only helps a provider understand if you
should be assessed further.
o 2 types of measures used in PTSD Assessment:

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 → Structured Interviews standard set of questions that an interviewer asks.
Some examples of structured interviews are:
• Clinician-Administered PTSD Scale (CAPS) which is created by
National Center for PTSD staff, the CAPS is one of the most
widely used PTSD interviews. The questions ask how often you
have PTSD symptoms and how intense they are. The CAPS also
asks about other symptoms that commonly occur with PTSD.
• Structured Clinical Interview for DSM (SCID). The SCID can
be used to assess a range of mental health disorders including
PTSD. The information derived by the clinician includes the
following: family history of psychiatric problems, developmental
history, academic performance, past treatment, chief complaint,
past psychiatric history of the client, substance abuse problems,
history of hospitalizations, medications tried and used, medical
history, and diagnoses that have been ruled out, as well as an
assessment of overall functioning.
→ Self-report questionnaires - is a set of questions, usually printed out, that
you are given to answer.
• PTSD Checklist (PCL). This measure asks about how often you
experience each of the PTSD symptoms over a period of time, like
a month. Providers may also use this measure to see how your
symptoms change over time, such as when you are getting
treatment.
Management:
o Administer or assist in the administration of primary PTSD therapies and
treatments.
o Psychological debriefing immediately following a traumatic event can help a
child better understand the event and reduce the feeling of threat.
o Ensure support as absence of effective support can contribute to, and even
exacerbate, symptoms.
Therapy consists of:
o Trauma-focused CBT
→ TF-CBT is an evidence-based treatment that helps children address the
negative effects of trauma, including processing their traumatic memories,
overcoming problematic thoughts and behaviors, and developing effective
coping and interpersonal skills.
→ It also includes a treatment component for parents or other caregivers who
were not abusive. Parents can learn skills related to stress management,
positive parenting, behavior management, and effective communication.
o Integrated play therapy
→ Play therapy is an evidence-based psychotherapeutic intervention that uses
play as the tool of and therapy with children who are experiencing social,
emotional, and behavioral challenges.
→ It is developmentally sensitive and an effective means of responding to
children’s mental health and wellbeing. Play therapy for children is the
equivalent of “talk therapies” for adults.
o Eye movement desensitization and reprocessing (EMDR)
→ A structured therapy that encourages the patient to briefly focus on the
trauma memory while simultaneously experiencing bilateral stimulation
(typically eye movements), which is associated with a reduction in the
vividness and emotion associated with the trauma memories.,
o Family therapy
→ a type of counseling that involves your whole family. A therapist helps you
and your family communicate, maintain good relationships, and cope with
tough emotions. Your family can learn more about PTSD and how it is
treated.

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 o Psychopharmacology.
→ PTSD symptoms can be treated with any of multiple types of medications,
including antidepressants and anti-anxiety drugs. Prazosin has been
identified as a possible aid in reducing or suppressing nightmares in some
people with PTSD, but its efficacy is still being studied.
Nursing Diagnosis
o Fear related to perceived threat or danger
o Anxiety related to anticipation of harm
o Ineffective Coping related to a sudden change in status
o Insomnia related to difficulty maintaining normal sleep
o Hopelessness related to the inability to control the situation

OPPOSITIONAL DEFIANT DISORDERS

- Is a condition in which a child displays an ongoing pattern of uncooperative, defiant,
hostile, and annoying behavior towards people in authority.
- Children with ODD typically have difficulty controlling their temper.
- It is important to distinguish behavior that is symptomatic. The frequency and intensity of
the disruptive outbursts should be considered as well as the distress associated with those
in an individual’s social context (family, peer group, work colleagues).
- The disorder develops most frequently in late preschool or early school age and rarely
later than early adolescence.
Causes and Risk Factors
The causative factors can be divided into categories, namely:
Biological Factor
o Aggressive behavior may be caused by alterations in the neurotransmitter activity
of the brain. Neurotransmitters help nerve cells in the brain communicate with
each other. If these chemicals are out of balance or not working properly,
messages may not make it through the brain correctly, leading to symptoms of
ODD, and other mental illnesses. Also, some studies suggest that defects in or
injuries to certain areas of the brain can lead to serious behavioral problems in
children.

Familial Factor
o Familial influences on child development may be genetically linked, attributed to
conflict in the family home or based on parent-child interactions. Additionally, a
parent’s prior aggressive behavior (in childhood) has been shown to manifest
itself in their child at the same age.

Genetics
o Many children and teens with ODD have close family members with mental
illnesses, including mood disorders, anxiety disorders, and personality disorders.
This suggests that a vulnerability to develop ODD may be inherited.

Environmental Factors
o such as a dysfunctional family life, a family history of mental illnesses and/or
substance abuse and inconsistent discipline by parents may contribute to the
development of behavior disorders.
Assessment:
o Assessing child’s symptoms and behaviors
o Compiling of medical history
o Performing physical examination
o Assessing physical or other mental health issue that may cause problems with
behaviors.

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 o Assessment tools, rating scales and questionnaire, to measure the severity of the
behaviors.
Complications:
The long-term consequences of untreated or misdiagnosed oppositional defiant disorder
can lead to problems in every area of a child’s life. Effects will vary based upon
individual genetic makeup, symptom severity, presence of co-occurring disorders, and
usage of drugs or alcohol. The most common complications and effects of untreated
ODD may include:
o Poor academic functioning o Antisocial personality disorder
o Inability to hold down a job o Substance abuse
o Poor interpersonal relationships o Self-harm
o Delinquency o Suicidal ideations
o Conduct disorder
Treatment:
o Structured psychosocial intervention that may include:
▪ parent management training focuses on effective disciplining and age-
appropriate supervision to increase support for positive social behavior.
▪ multisystemic therapy, and
▪ cognitive behavioral therapy (CBT).
o Medication may be an additional component to psychosocial treatment of the
symptoms of aggressive behavior and to treat comorbid conditions.
▪ However, it should NOT be the only treatment intervention.
▪ The nurse should explain the importance of compliance of with the
medication regimen, provide education on side effects and laboratory
evaluation as needed.
Nursing Diagnosis:
o Risk for other-directed violence related to aggression to other people or animals.
o Noncompliance related to resentment of those in authority.
o Ineffective coping related to low self-esteem.
o Impaired social interaction related to hostility towards those in authority.
o Chronic low self esteem related to lack of value to self.
Nursing Intervention
o Decreasing violence and increasing compliance with treatment
▪ The nurse must set limits on unacceptable behavior at the beginning of
treatment; for limit setting to be effective, the consequences must have
meaning for the clients- that is, they must value or desire recreation time.
o Improving coping skills and self-esteem
▪ The nurse must show acceptance of clients as worthwhile persons even if
their behavior is unacceptable; this means that the nurse must be matter of
fact about setting limits and must not make judgmental statements about
clients.
o Promoting social interaction
▪ The nurse identifies what is not appropriate, such as profanity and name-
calling, and also what is appropriate; positive feedback is essential to let
clients know they are meeting expectations.
o Providing client and family interaction.
▪ The nurse can teach parents age-appropriate activities and expectations for
clients such as reasonable curfews, household responsibilities, and
acceptable behavior at home.

CONDUCT DISORDER
- Are persistent antisocial acts that may involve violations of personal rights or societal
rules.

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- Children with CD have a lower threshold for disruptive (and perhaps violent) behavior
and lack the capacity to feel guilt or remorse for their actions.
o Also, seem to develop an increasing loss of self-regulation or an inability to know
when to stop a disruptive action.

Causes
o A number of etiologic factors are suggested as the cause of the disorder, including
genetic predisposition, neurologic deficit correlates, and sociologic factors related
to poverty and cultural disadvantage.
o The home environment may be characterized by rejections, frustrations, and harsh
and inconsistent discipline.
Symptoms
A repetitive and persistent pattern of behavior in which the basic rights of others or major
age-appropriate societal norms or rules are violated, as manifested by the presence of at
least three of the following 15 criteria in the past 12 months from any of the categories
below, with at least one criterion present in the past 6 months.
o Aggression to people and animals
▪ Often bullies, threatens, or intimidates others.
▪ Often initiates physical fights.
▪ has been physically cruel to people.
▪ has been physically cruel to animals.
▪ Has stolen while confronting a victim (e.g., mugging, purse snatching,
extortion, armed robbery).
o Destruction of property
▪ Has deliberately destroyed others’ property.
o Deceitfulness or theft
▪ Has broken into someone else’s house, building, or car.
▪ Often lies to obtain goods or favors or to avoid obligations.
▪ has stolen items of nontrivial value without confronting a victim.
Assessment
o Children's medical, developmental, psychological, and social history will be
reviewed.
o Children's behavioral and emotional functioning skills are also assessed across a
variety of settings with checklists.
o Direct observation in classroom and home settings.
o Diagnostic Interview for Children and Adolescents (DICA)
▪ DICA is a semi-structured interview designed to determine whether
children or adolescents currently have (or have ever had) symptoms
consistent with DSM diagnoses such as Conduct Disorder.
o Child Behavior Checklist (CBCL)
▪ CBCL is a widely used paper and pencil test that comes in different
versions appropriate to varying age groups and rather perspectives. This
scale yields scores measuring Aggressive Behavior, Anxiety/Depression,
Attention Problems, Delinquent Behavior, Social Problems, Somatic
Complaints, Thought Problems, and Social Withdrawal.
o Connors Continuous Performance Test (CPT)
▪ CCPT is used to assess children's ability to sustain attention (i.e., to
continuously focus on a single task) and also provides measurements of
children's tendency towards impulsiveness. During the test, children watch
a computer screen upon which various symbols (e.g., numbers and letters)
and sounds are presented. They respond to the presence of particular
symbols and sounds by pressing buttons and by clicking with the
computer's mouse.

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 Therapy
o It needs to be individualized.
o Educate the child and parent in social skills, anger management, and problem-
solving skills so that children can understand how their behavior affects others.
o Problem solving skills can help children learn to generate alternative solutions to
situations, clarify thinking about the consequences of choices, and evaluate
responses.
o If the home environment cannot be changed, removing the child from the home to
a structured, consistent, and caring day care environment may be an alternative.
o Healthcare providers have an obligation to report potential acts of violence
against the child’s self and others.
o Make sure to put a safety plan in place.
Nursing Diagnosis:
Nursing diagnosis commonly used for clients with conduct disorders include the
following:
• Risk for other-directed violence related to aggression to other people or animals.
• Noncompliance related to resentment of those in authority.
• Ineffective coping related to low self-esteem.
• Impaired social interaction related to hostility towards those in authority.
• Chronic low self esteem related to lack of value to self.
Nursing Intervention
o Decreasing violence and increasing compliance with treatment
▪ The nurse must set limits on unacceptable behavior at the beginning of
treatment; for limit setting to be effective, the consequences must have
meaning for the clients- that is, they must value or desire recreation time.
o Improving coping skills and self-esteem
▪ The nurse must show acceptance of clients as worthwhile persons even if
their behavior is unacceptable; this means that the nurse must be matter of
fact about setting limits and must not make judgmental statements about
clients.
o Promoting social interaction
▪ The nurse identifies what is not appropriate, such as profanity and name-
calling, and also what is appropriate; positive feedback is essential to let
clients know they are meeting expectations.
▪ Healthcare providers have an obligation to report potential acts of violence
against the child’s self and others. If the patient with CD shares a desire to
hurt or harm another person, that patient’s right to confidentiality is not as
great as the protection of a potential target.
o Providing client and family interaction.
▪ The nurse can teach parents age-appropriate activities and expectations for
clients such as reasonable curfews, household responsibilities, and
acceptable behavior at home. When working with the families make sure
to put a safety plan in place. Homicidal behavior requires psychiatric
interventions.

CHILDHOOD SCHIZOPHRENIA
- Is characterized by illogical thoughts, abnormal behavior and hallucinations. It is a
devastating mental illness that most commonly strikes in adolescence or young
adulthood; onset prior to adolescence is rare.
- is an uncommon but severe mental disorder in which children and teenagers interpret
reality abnormally.
- Childhood schizophrenia involves a range of problems with thinking, behavior or
emotions.

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Symptoms and Causes
o The cause of schizophrenia is unknown but current evidence suggests there may
be both genetic and environmental foundations for the disorder.
o Children with schizophrenia experience;
▪ Hallucinations (hear or see people or objects that other people cannot)
and may display rambling or illogical speech patterns.
▪ They may not be responsive (have flat affect), may withdraw into
themselves so completely they are stuporous (catatonia), or be so
extremely suspicious that others want to harm them (paranoia) that is
difficult for them to function.
o Positive symptoms, specifically, include those that can be represented by
behaviors that are added to the normal presentation of an individual. Positive
symptoms include, but are not limited to, delusions and hallucinations, as well as
symptoms of a formal thought disorder, including rapid or pressured speech.
o Negative symptoms comprise those behaviors that are deficits with regard to
normal behavior. Negative symptoms include flat affect, or diminished emotional
expression, poor hygiene, a lack of motivation and poverty of speech.
o Symptoms can vary in type and severity over time, with periods of worsening and
remission of symptoms. Some symptoms may always be present. Children with
schizophrenia can be difficult to recognize in the early phases.
Assessment
o use of assessment tools in an effort to satisfactorily address the characteristics
residing in the schizophrenic presentation.
▪ Structured Clinical Interview (SCID), allows the clinician to delineate a
diagnosis through interview of the client and her parents.
▪ Brief Psychiatric Rating Scale (BPRS), this instrument determines the
manifestation of symptoms of schizophrenia or other psychotic disorders.
▪ Positive and Negative Symptom Scale (PANSS) also targets the severity
of positive symptoms and negative symptoms.
▪ Scale for Assessment of Positive Symptoms (SAPS) assesses for the
presence of positive symptoms, such as hallucinations, delusions and
bizarre behavior.
▪ Scale for Assessment of Negative Symptoms (SANS) assesses negative
symptoms, such as flat affect, poverty of speech, poor grooming and
hygiene, loss of interest in formerly pleasurable activities, poor
relationships with peers and friends and deficits in attention.
Complications
If left untreated, childhood schizophrenia can result in severe emotional, behavioral and
health problems. Complications associated children with schizophrenia may occur in
childhood or later, such as:
o Suicide, suicide attempts and thoughts of suicide
o Self-injury
o Anxiety disorders, panic disorders and obsessive-compulsive disorder (OCD)
o Depression
o Family conflicts
o Social isolation
o Health and medical problems
o Being victimized

Although schizophrenic manifestations may occur suddenly after a major stress in a

child’s life., subtle signs of mental illness have usually been present for some time.
Medical Management
Therapy with antipsychotic drugs is effective in reducing the children’s hallucinations
and abnormal thought process.

BAULO, CALI, MACARONSING

 o Drug Therapy. Schizophrenia is mainly treated by antipsychotics (neuroleptic)
drugs.
▪ These prevent relapse of acute symptoms.
▪ Psychotic symptoms must be present 12 to 24 months before patients
receive their first medical treatment.
▪ Examples of these drugs include the typical or conventional typical
antipsychotic chlorpromazine (Thorazine) and the atypical
Nursing Diagnosis
• Impaired verbal communication – flight of ideas related to accelerated thinking
• Risk for injury related to accelerated motor activity
• Disturbed thought process related to delusion of grandeur
Nursing Interventions:
- Establish trust and rapport.
o Don’t touch client without telling him first what you are going to do. Use an
accepting, consistent approach; short, repeated contacts are best until trust has
been established. Language should be clear and unambiguous. Maintain a sense of
hope for possible improvement, and convey this to the patient.
- Maximize level of functioning.
o Avoid promoting dependence by doing only what the patient can’t do for himself.
Reward positive behavior and work with him to increase his personal sense of
responsibility in improving functioning.
- Promote social skills.
o Provide support in assisting him to learn social skills.
- Ensure safety
o Maintain a safe environment with minimal stimulation.
- Ensure adequate nutrition
o Monitor patient’s nutritional status and if the patient thinks his food is poisoned,
let him fix his own food if possible or offer him foods in closed containers that he
can open. Institute suicide and/or homicide precautions as appropriate.
- Keep it real
o Engage patient in reality-oriented activities that involve human contact (e.g.,
workshops, inpatient social skills training). Clarify private language, autistic
inventions, or neologisms.
- Deal with hallucinations by presenting reality.
o Explore the content of hallucinations. Avoid arguing about the hallucinations. Tell
them you do not see, hear, smell, or feel it but explain that you know that these
hallucinations are real to him.
- Promote compliance and monitor drug therapy.
o Administer prescribed drugs and encourage the patient to comply. Ensure that
patient is really taking the drug. Observe for manifestations that warrant
hypersensitivity reactions and toxicity.
- Encourage family involvement.
o Involve family in patient treatment and teach members to recognize impending
relapse (e.g. nervousness, insomnia, decreased ability to concentrate). Suggest
ways how families can manage symptoms.

BAULO, CALI, MACARONSING

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