Psychiatric-Mental Health Nursing | NCM 0117
MODULE 8 a. “Right before bedtime”
Nursing Care Management of
Clients with Childhood and Adolescent
Mental Disorders and Domestic Violence
PRE-TEST ASSESSMENT
1. Which domain below is NOT associated with the diagnosis of an
intellectual disability?
a. Practical
b. Social
c. Spatial
d. Conceptual
2. The nurse is discussing the need for early diagnosis and treatment
of autism spectrum disorder (ASD) with parents of children
suspected of having the condition. Which statement should the
nurse include?
a. "Early diagnosis and treatment provides the only means
for a cure of ASD."
b. "Early diagnosis and treatment gives your child the best
chance of becoming a fully functioning adult."
c. "Early diagnosis and treatment provides the best way to
ensure that your child can be admitted to an assisted
living facility as an adult."
d. "Early diagnosis and treatment prevents your child from
developing any other mental condition."
3. The nurse observes that a client is pacing, agitated, and presenting
aggressive gestures. The client's speech pattern is rapid, and affect
is belligerent. Based on these observations, which is the nurse's
immediate priority of care?
a. Provide safety for the client and other clients on the unit
b. Provide the clients on the unit with a sense of comfort and
safety.
c. Assist the staff in caring for the client in a controlled
environment.
d. Offer the client a less stimulating area in which to calm
down and gain control.
4. Under social domain, the nurse should institute what changes in the
treatment plan if a school-aged patient with attention-
deficit/hyperactivity disorder is displaying disruptive behaviors at
home.
a. Establish eye contact before giving directions.
b. Initiate a point system, to reward the patient for
appropriate behavior.
c. Instruct the patient to work on one homework
assignment at a time.
d. Maintain a predictable environment in the home.
5. The nurse is caring for an 8-year-old with attention deficit
hyperactivity disorder (ADHD) that has just been prescribed
methylphenidate (Ritalin) extended release (ER). When is this
medication best given?
b. “Several times a day”
c. “Early in the day”
d. “Before meal time”
6. Which among the assessment in a child is constant with a diagnosis
of conduct disorder?
a. Arguing with adults.
b. Gross impairment in communication.
c. Physical aggression toward others.
d. Refusal to separate from caretaker.
7. Which of the following findings would lead the nurse to suspect that
a client is a victim of sexual abuse?
a. The child is fearful of the caregiver and other adults.
b. The child has a lack of peer relationships.
c. The child has self-injurious behaviour.
d. The child has an interest in things of a sexual nature.
8. One should recognize that the priority nursing intervention for a
child or elder victim of abuse is:
a. Assess the scope of the abuse problem.
b. Analyze family dynamics.
c. Implement measures to ensure the victim’s safety.
d. Teach appropriate coping skills.
9. A client suspected of being raped is brought to an emergency
department. Which nursing action is appropriate?
a. Probe for further, detailed description of the rape event.
b. Discourage the client from discussing the rape, because
this may lead to further emotional trauma.
c. Meet the client's self-care needs by assisting with
showering and perineal care.
d. Remain non-judgmental while actively listening to the
client's description of the violent rape event.
10. Which statement made by an emergency department nurse
indicates accurate knowledge of domestic violence?
a. "Power and control are central to the dynamic of domestic
violence."
b. "Poor communication and social isolation are central to
the dynamic of domestic violence."
c. "Erratic relationships and vulnerability are central to the
dynamic of domestic violence."
G.M.M.E. | A.J.E.F. | T.A.M.M. – MARILAG
d. "Emotional injury and learned helplessness are central to
the dynamic of domestic violence."
Child and adolescent mental disorders manifest
themselves in many domains and in different ways. It is now understood
that mental disturbances at a young age can lead to continuing
impairment in adult life (WHO, 2005).
risk factors for childhood mental and
The
developmental disorders can be divided into lifelong and age-
specific risk factors (Kieling et. al., 2011).
 Psychiatric-Mental Health Nursing | NCM 0117

The health of children is highly dependent on the GENERAL INTERVENTIONS FOR CHILDREN
health and well-being of their caregivers; the environments in AND ADOLESCENTS WITH MENTAL ILLNESS
which the children live (including home and school); and, the influence 1. Family Therapy
of their peers as they transition into adolescence. • Family counselling is key.
• Specific Goals are defined for each member
RISK FACTORS • Homework assignments
Neurobiological 2. Group Therapy
§ Rapid anatomical and physiological changes • Young children: use play
o Low Emotional Regulation • Grade school: Play, learning skills, Talking
o Frustration Intolerance • Adolescents: Learning social skills, Talking
Psychologic 3. Behavioral Therapy
§ Temperament • Rewards for Acceptable Behavior
o Style of behavior habitually used to cope with the • Follows the principle of Least Restrictive Intervention
demands and expectations of environment • Seclusion and physical restraints used ONLY when very
o Present at Infancy; modified by environment severe or dangerous behavior is exhibited
o Poor FIT between child and caregiver temperament 4. Play Therapy
§ Resilience – The resilient child demonstrates: • A work of childhood: Masters impulses and Adapt to
o Adaptability to changes in the environment the environment
o Ability to form nurturing relationships with other adults • Medium of communication to assess developmental and
when parent is not available emotional status, diagnose and intervene
o Ability to distance the self from emotional chaos • Occur in playrooms with age-appropriate toys
o Good social intelligence • Provide child with opportunities to express conflicts and
o Good Problem-solving skills situations with family
o Ability to perceive long term future • Work through feelings
Environmental • Develop more adaptive ways of coping
§ Severe Marital Discord 5. Bibliotherapy
§ Low socio-economic status • Using literature to help the child and adolescent express
§ Large Families feelings in a supportive environment, gain insight into
§ Overcrowding feelings and behavior, learn new ways to cope
§ Parental Criminality 6. Therapeutic Drawing
§ Maternal psych d/o • Non-verbal means of expressing difficult or confusing
§ Foster Care emotions
§ Witnessing Violence • Illustrate thoughts, feelings and tension children cannot
§ Neglect express verbally, are unaware of, or are denying
§ Bullying: Depression, Suicide 7. Journaling
• Recording feelings and viewing emotions
CHARACTERISTICS OF MENTAL HEALTH IN A CHILD • A way to begin dialogue with others
§ Trusts others; sees the world as safe and supportive • Setting Goals

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§ Correctly interprets reality
§ Makes accurate perception of environment and one’s ability CHILDHOOD AND ADOLESCENT ONSET
to influence it through actions MENTAL DISORDERS
§ Behaves in a way that’s developmentally appropriate and
does not violate social norms
Neurodevelopmental Disorders
§ Positive, realistic self-concept and developing identity
• The neurodevelopmental disorders occur early in a child's
§ Adapts to and copes with anxiety and stress using
development, often before grade school (around 5-6 years
appropriate behavior
old). = frequently co-occur (at least 2 NDD)
§ Can learn and master developmental tasks and new
• These disorders include developmental deficits that range
situations
from limitations of learning to global impairments of social
§ Expresses self in spontaneous and creative ways
skills which can impact a client’s personal, social, academic, or
§ Develops and maintains satisfying relationships
occupational functioning. = encompassing a lot of domains
when a client is impacted with neurodevelopment disorders
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• Under the primary influences of genes and environment, o Three skill types: conceptual skills = academic
neurodevelopment of attention, cognition, language, affect, domain (language, literacy, money, time, number
and social and moral behavior can be affected leading to concepts), social skills = awareness of others
manifestation of these disorders. However, with the difference (interpersonal skills, social responsibility, self-esteem,
in its symptoms, a common feature is a significant delay gullibility, ability to follow rules and to avoid being
in one or more lines of development. victimized, social problem-solving) and, practical
skills = self-management (ADLs, health care, travel
Intellectual Disability and transportation, schedule and routines, safety, use
• Intellectual disability is defined as a disability characterized of money, telephone etc.)
by significant limitations in both intellectual function Higher ability to 3 domains = lower severity level
(mental abilities – reasoning, problem-solving skills, how Severity level increases as the deficit increases also
would a person plan for himself, academic learning, Higher IQ = lower classification (DSM 4)
judgement, learning from instruction) and in adaptive c. Developmental stage onset
behavior (learning from experience – social o Begins before the age of 18 years.
responsibilities, ADLs, social participation, occupational § Conceptual, Practical and Social Domain
functioning, personal independence, how well you treat
yourself and how well you interact with other people) that Conceptual Practical Social
covers many everyday social and practical skills (American competence in learning and self- awareness of others'
Association on Intellectual and Developmental Disabilities memory, language, management across thoughts, feelings,
[AAIDD], 2017). = two functions/domains are affected reading, writing, life settings, and experiences;
• The disability begins before the age of 18 years. math reasoning including personal empathy;
• Aka Intellectual Developmental Disorder acquisition of care, job interpersonal
• Previously known as Mental Retardation practical knowledge responsibilities, communication
• May result from an acquired insult during the developmental problem solving, money skills; friendship
period and judgment in management, abilities; and social
• Approximately 6/1000; M > F novel situations recreation, self- judgment
management of
ETIOLOGY behavior, and school
§ Prevalence of intellectual disabilities to be about 1% in the and work task
United States and worldwide (McKenzie, Milton, Smith, & organization
Ouellette-Kuntz, 2016). § Mild, Moderate, Severe, Profound
§ The cause is unknown in many of the cases (Batshaw, § Prognosis
Roizen, & Lotrecchiano, 2013). Most common etiology
related to genetic syndromes, chromosomal changes or NURSING DIAGNOSIS
defects (e.g., Down syndrome) and exposure to toxins Associated nursing diagnoses may include:
during prenatal development (e.g., fetal alcohol 1) Ineffective Coping = inability to form valid appraisal of the
syndrome).
stressors which may lead to feeling of distress
§ Pregnancy and perinatal complications
2) Delayed Growth and Development = development

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§ Medication conditions
§ Environmental influences are all associated with
intellectual disabilities
CRITERIA
a. Intellectual Deficit of general mental abilities confirmed by
clinical assessment and individualized standardized
intelligence testing
o Usual threshold for intellectual disability is an
intelligence quotient (IQ) of 70 or less
b. Adaptive Functioning Deficit leading to failure in
achieving personal independence and social responsibility
deviating from age group norms
3) Interrupted Family Processes = any presence of
developmental disorder to a family member would greatly
have an impact on the roles and interactions that occur within
the family
Note: For many children with intellectual disability, achieving
independence in adulthood will be delayed but not impossible.
TREATMENT
§ Coordinating the child’s psychological and physiologic needs
§ Behavior management
§ Environmental supervision
§ Monitor child’s developmental needs

§ Programs that maximize speech, language, cognitive,
psychomotor, social, self-care and occupational skills
§ Family therapy
NURSING INTERVENTIONS
ü Assessment of a child with an intellectual disability
focuses on client’s adaptive skills, intellectual status,
and social functioning. *low, medium, severe, profound
ü The nurse should also assess the child's support systems
(family, school, rehabilitative, and psychiatric) to ensure that
the child's special needs have been identified and are being
addressed. Occupational therapy may be recommended to
improve motor coordination.
ü Provide standards of acceptable behavior within the ability of
the child.
ü Determine the child’s strengths and abilities, and develop a
care plan to maintain and enhance abilities.
ü Monitor the child’s developmental levels and initiate
supportive interventions such as speech, language,
occupational skills as needed. *referral to other members of
healthcare team (occupational therapist, speech therapist, etc.)
ü Teach the child adaptive skills: eating, dressing,
grooming, toileting through demonstrations = client’s
adaptation via ADLs (self-care, communication skills,
language, self-direction, how to do simple problem-solving
skills, exercise, how to plan activities)
ü Training in independent living and job skills.
ü Help the parents accept the diagnosis of the child. Should not
be given false hope about their children.
ü Teach him about natural and normal feelings and
emotions: enhanced positive feelings about himself and his
daily accomplishments.
ü Keep communication brief, simple and consistent.
ü Provide for his safety needs: consistent supervised
environment, institute safety precautions.
ü Help parents in everyday living, teaching tasks and training the
child, making use of the 3Rs: ROUTINE (make sure that the
client will be following the same steps in order to aid learning;
tell them what’s about to happen, what comes next),
REPETITION, RELAXATION
ü Teach the child to seek help when in difficulty and to resist
frustrations and achieve emotional control.
ü Aid in shaping other family member’s attitude about the
child’s condition.
Communication Disorder
• Communication disorders involve speech or language
impairments.
• Speech refers to the motor aspects of speaking, language
consists of higher-order aspects of formulating and
comprehending verbal communication. (the way how you
Psychiatric-Mental Health Nursing | NCM 0117
produce sounds, articulate sounds and words; how fluent
are you when you communicate; what is the quality of your
voice)
• Language – form and function of intended message; means
how you convey message to others (spoken, written, etc.)
• Communication – behavior and attitude when you
communicate
• Communication disorders are fairly common and are yet more
common in children with ASDs, ADHD, anxiety, and
conduct disorders (Beitchman, Brownlie, & Bao, 2014).
• A delay in speech or language development can
adversely affect the child's socialization and education.
The resulting isolation could limit opportunities to
negotiate rules, take turns, and learn cooperation.
These same tasks could also be difficult for children with
language delay. Moreover, language appears to play a role in
the regulation of behavior and impulses (Lyons et al., 2016).
1) Language Disorder
• Highly heritable
• May be diagnosed by 4 years of age
• Language being a problem is dependent on two skills:
a. Receptive skills (ability to receive ideas through
communication and comprehending messages)
b. Expressive skills (production of vocals or verbal
inputs)
• Persistent difficulties in the acquisition and use of
language across modalities (i.e., spoken, written, sign
language, or other) due to deficits in comprehension or
production
1. Reduced vocabulary
2. Limited sentence structure
3. Impairments in discourse (exchange of ideas
through communication)
• Abilities are below expected for age: functional
limitations in effective communication, social participation,
academic achievement or occupational performance
• The difficulties are not attributable to hearing or other
G.M.M.E. | A.J.E.F. | T.A.M.M. – MARILAG
sensory impairment, motor dysfunction, or another
medical or neurological condition and are not better
explained by intellectual disability (intellectual
developmental disorder) = to be diagnosed with language
disorder, you must not be classified either deaf or mute
*Normal sensory organs, have the ability to hear,
doesn’t have any mechanical problems with oral
problems ® in order to fit in the criteria of language disorder
2) Childhood Onset Fluency Disorder
• Main feature: “stuttering” (lack of fluency) ® Impairment
of social functioning (aloofness d/t inability to communicate
properly)

• Evident: when you talk to the client, when it becomes
conversational, when the communication becomes social ®
stuttering occurs
• Characterized by disturbances in the normal fluency
and time patterning of speech, inappropriate for an
individual’s age, language skills,
• Persistent over time and occurrence is frequent and
marked
1. Sound and syllable repetitions.
2. Sound prolongations of consonants as well as
vowels.
3. Broken words (e.g., pauses within a word).
4. Audible or silent blocking (filled or unfilled
pauses in speech). *pauses/gaps
5. Circumlocutions (word substitutions to avoid
problematic words).
6. Words produced with an excess of physical
tension.
7. Monosyllabic whole-word repetitions (e.g., “I-
I-I-I see him”).
• The disturbance causes anxiety about speaking or
limitations in effective communication, social participation, or
academic or occupational performance, individually or in any
combination.
• Onset is the developmental period.
• Dysfluency is often absent during oral reading, singing or
talking to inanimate objects or to pets.
• Impairment of social functioning may result from this anxiety.
3) Social (Pragmatic) Communication Disorder
• Social use of language and communication
• Manifested by deficits in understanding and following
social rules of verbal and nonverbal communication
• Rare among children younger than 4 years
• Pragmatic – ability to use terms or words in a practical sense
(semantic – actual definition; opposite)
Autism Spectrum Disorders
• Persistent difficulty in the social use of verbal and
non-verbal communication AEB
1. Deficits in using communication for social
context. (no social interaction, doesn’t share
information, doesn’t greet)
2. Impairment in ability to change
communication to match context or needs of the
listener. (tells whatever they want to share or talk
about without even in a proper environment or
setting)
3. Difficulty following rules for conversation and
storytelling. (they don’t usually listen, doesn’t have
any idea about taking turns, doesn’t ask you back,
doesn’t use any nonverbal signals in regulating
interaction)
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4. Difficulty understanding what is not explicitly
stated. (they would always interpret words according
to their definition (semantics), what the word
actually means)
• The deficits result in functional limitations in effective
communication, social participation, social relationships,
academic achievement or occupational performance,
individually or in combination.
• The symptoms are not attributable to another medical
or neurological condition or to low abilities in the domains
of word structure and grammar, and are not better
explained by autism spectrum disorder, intellectual
disability (intellectual developmental disorder), or another
mental disorder.
• Several nursing diagnoses may include: Impaired
Verbal Communication and Social Isolation (as a result of
limitations in effective communication ® social withdrawal).
• Interventions should focus on fostering social and
communication skills and making referrals for specific
speech or language therapy
• The following is an overview of nursing interventions for
the child with specific developmental difficulties
ü Introduce strategies for increasing communication
skills (e.g., initiating conversation, taking turns in
conversation, facing the listener).
ü Identify and develop specific intervention strategies
for problems secondary to learning communication
disorders, such a low self-esteem.
ü Provide parental support for coping with the
disorder.
ü Maintain interdisciplinary medical, dental, and
speech therapy, and also educational collaboration.
ü Refer to learning or speech specialist for evaluation
and assistance.
• Autism spectrum disorder (ASD) is characterized by
persistent impairment in social communication and
social interaction with others (APA, 2013) and children with
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ASD may or may not have an intellectual disability, but they
commonly show an uneven pattern of intellectual strengths
and weaknesses. *Inability to communicate and interact
• Occurs between 3 to 17 years old
• This condition may be a lifelong pattern of being rigid
in manner, intolerant of change, and prone to
behavioral outbursts in response to environmental
demands or changes in routine.
• May have age-appropriate language and intelligence but also
have severe and sustained impairment in social interaction
and restricted, repetitive patterns of behavior, interests, and
activities. This type of ASD was previously known as Asperger
syndrome and appears to be a milder form of ASD. They may

also display stereotypic behaviors, such as rocking and
hand flapping, and have highly restricted areas of
interest, such as train schedules, fans, air conditioners,
or dogs. Signs of developmental delay may not be apparent
until preschool or school age, when social deficits become
evident
• Two conditions, autism disorder and Asperger syndrome, were
previously diagnosed as separate disorders. However, because
they have many overlapping symptoms and are difficult to
differentiate from each other, the DSM-5 no longer considers
autism and Asperger syndrome as separate disorders, but
considers both as an ASD differentiated by language or
intellectual impairment (APA, 2013).
• May also engage in self-injurious behavior, such as
hitting, head banging, or biting. ® SAFETY is a priority
• In some children, their unusual interests may evolve into
fascination with specific objects, such as fans or air
conditioners, or a particular topic.
ETIOLOGY
§ ASD is estimated to occur in 1.1% of children 3 to 17 old
(CDC, 2016). It occurs in boys more often than girls (CDC,
2013)
§ Genetic – Multiple etiologic hypotheses are related to this
disorder. Recent studies support a shared genetic etiology
between ASD and schizophrenia (McCarthy et al., 2014).
§ Metabolic disorders – One line of research is determining
defects in the metabolism of cellular antioxidants (low levels)
(Raymond, Deth, & Ralston, 2014).
§ Chemical exposure – Studies show that higher levels of lead
and mercury and lower levels of antioxidants are found in
inpatients with ASD when compared to control groups
(Alabdali, Al-Ayadhi, & El-Ansary, 2014).
§ Autoimmunity – Other researchers suggest a role for
maternal autoantibodies in the fetal brain in some cases
(Elamin & Al-Ayadhi, 2014).
CRITERIA
a. Deficit in social interaction and communication
1. Deficit in social emotional reciprocity
o These children appear aloof and indifferent to
others and often seem to prefer inanimate objects.
(inability of conversing back and forth)
2. Deficit in non-verbal communicative behaviors
used for social interaction
o Impairment in communication is severe and affects
both verbal and nonverbal communication.
(doesn’t understand the use of gestures, doesn’t do
eye contact with others, lack of facial expression, no
reaction)
o Children with ASD may manifest delayed and
deviant language development, as evidenced by
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echolalia (repetition of words or phrases spoken by
others) and a tendency to be extremely literal in
interpretation of language.
o Pronoun reversals and abnormal intonation are
also common.
3. Deficit in developing, maintaining and
understanding relationships (problems in play
activities/behaviors, doesn’t have much friends d/t social
a.
interaction problems, doesn’t care about others/peers)
b. Restricted, repetitive patterns of behavior, interest or
activities (at least 2) *hand/foot flapping, lining up some toys
or other items = idiosyncratic behavior (sometimes weird
and eccentric)
o ASD usually would have restricted repetitive
patterns of behavior such as stereotypic or
repetitive motor movement, use of objects,
inflexible adherence to routine or ritualized
patterns, and fascination with lights or movement.
o Describes children to have profound isolation of
these children and has extreme desire for
sameness.
1. Stereotyped or repetitive motor movements, use
of objects or speech
2. Insistence on sameness, inflexible to routines or
ritualized patterns of verbal or nonverbal behavior
3. Highly restricted or fixated interest abnormal in
intensity or focus
4. Hyper or hypo-reactivity to sensory input or
unusual interest in sensory aspects of the environment
§ Other common features of ASD are stereotypic
behavior, self-stimulating, non-functional repetitive
behaviors, such as repetitive rocking, hand flapping, and an
extraordinary insistence on sameness.
§ Symptoms must be present in the early developmental period.
§ Symptoms must cause clinically significant impairment in
social, occupational, or other important areas of functioning.
NURSING DIAGNOSES
Assessment data generate several potential nursing diagnoses:
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1) Readiness for Enhanced Self-Care
2) Risk for Delayed Development = problems with social
communication and social interaction; problem with
development of social skills
3) Disturbed Sleep Pattern = insomnia (takes 11 minutes
longer to sleep than normal people)
4) Anxiety = co-occur with other disorders
5) Acute Confusion
6) Social Isolation = problems with establishing relationship
® loneliness (poor social abilities)
Treatment outcomes need to be individualized to the child, family, and
social environment and may change with time.

NURSING INTERVENTIONS
ü Offer emotional support to parents.
ü Institute injury precautions. Safety is always a concern.
ü Teach parents to keep the home safer. Physical safety is an
important concern for children who are cognitively delayed
and may have impaired judgment.
ü Advise the parents to avoid situations known to trigger
temper tantrums (anger or frustration outburst). *modify
the environment
ü Teach the parents how to recognize behaviors that
precede temper tantrums such as increased hand flapping,
intervene ASAP. *provision of tangible items
ü Always maintain consistency. A structured physical
environment will most likely be important to a child with a
development disorder. Keeping furniture, dishes, and toys in
the same place helps ease anxiety and fosters secure feelings.
*don’t mess with the structure of their environment
ü Teach parents to maintain a regular, predictable daily routine,
with consistent times for waking up, dressing, eating,
attending school and going to bed.
ü If the child’s routine be changed, instruct the parents to
prepare the child for these changes. By structuring the
environment and using visual cues to signal the end of
one activity and the start of another, it may be possible to
reduce the number and intensity of responses to transitions.
ü To promote communication, encourage parents to have
close, face-to-face contact with the child. *deliberate
instructions
ü Interventions fostering nonverbal social interactions may be
more useful than those based on speech.
ü For higher functioning children, activities such as getting the
mail, passing out snacks, or taking turns in the context of
simple games can engage them in social activities without
requiring the use of their limited language skills.
ü Choose words carefully when conversing with the child.
Building on their strengths and using positive reinforcement
are very important.
ü Give tangible rewards to appropriate behaviors. *intervene
when there is already an impending tantrums ® provide
positive reinforcement
ü No medication has proved effective at changing the core social
and language deficits of autism. However, some atypical
antipsychotics (i.e., risperidone, aripiprazole) are.
Attention Deficit / Hyperactivity Disorder
• Attention-deficit hyperactivity disorder (ADHD) is one of the
most commonly diagnosed disorders in school aged
children (CDC, 2016). It is almost certainly a heterogeneous
disorder with multiple etiologies.
• Affect males more than females
• ADHD is also diagnosed in adults, but it is less common than
in children (Torgersen, Gjervan, Lensing, & Rasmussen, 2016).
Psychiatric-Mental Health Nursing | NCM 0117
• Essential feature: Persistent pattern of inattention
and/or hyperactivity- (seems always to be on the mood)
impulsivity (disability to stop and think about the
consequences before speaking or acting) that interferes
with functioning or development
• Children with ADHD are prone to impulsive, risk taking
behavior and often fail to consider the consequences of
their actions (CDC, 2013).
• They often require a high degree of structure and
supervision (Singh, Yeh, Verma, & Das, 2015). d/t risk for
injury to self and others
• Although hyperactivity is a characteristic often associated with
ADHD, controversy is long standing about whether attention-
deficit disorder can occur without over activity.
• Parents typically report that a child's hyperactivity was
manifested early in life and is evident in most situations (APA,
2013).
• Hyperactivity and impulsivity in childhood are associated with
conduct disorder and intimate partner violence perpetration in
adults (Guendelman, Ahmad, Meza, Owens, & Hinshaw,
2016).
• ADHD is usually diagnosed in childhood and was traditionally
viewed as a problem of children. ADHD begins in childhood
and is most often identified during elementary school
years.
• ADHD persists into adulthood and it is sometimes first
diagnosed later than in childhood. In adults, symptoms of
hyperactivity and impulsivity tend to decline with age and
deficit of attention persist and become more varied (Torgersen
et al., 2016). However, the majority of the adults with ADHD
are undiagnosed and untreated (Ginsberg, Quintero, Anand,
Casillas, & Upadhyaya, 2014).
• Family stress, marital discord, and parental substance
use are also associated with exacerbation of ADHD
behaviors (Sigfusdottir et al., 2017). Other implicated
psychosocial factors are poverty, overcrowded living
conditions, and family dysfunction.
• Associated with reduced school performance and
academic attainment, social rejection.
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• More likely to develop conduct disorder in adolescence and
antisocial personality disorder in adulthood.
ETIOLOGY
§ ADHD in school-aged children is about 6.8%, of children aged
3 to 17 years old (CDC, 2016). Boys are twice as likely as girls
to be diagnosed with ADHD (CDC, 2013).
§ No single explanation for the occurrence of ADHD exists;
instead, this disorder is viewed as having multiple causes.
§ Genetic factors – They clearly play a fundamental role in the
manifestation of the ADHD behavior (Sciberras, Mulraney,
Silva, & Coghill, 2017).
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§ A familial history of ADHD, bipolar disorder, or substance NURSING DIAGNOSIS

use (Sanchez-Gistau et al., 2015). 1) Impaired Social Interaction = inability to perceive the
§ Early exposure to pesticides and lead (Rauh, 2016). consequences of their actions which are socially unacceptable
§ Prenatal tobacco exposure (Joelsson et al., 2016). 2) Ineffective Coping
§ Hypersensitive to environmental stimuli such as foods. 3) Ineffective Role Performance = intrusive or destructive
This hypersensitivity to foods may be allergies to specific foods behavior
(e.g., wheat, milk, peanuts, eggs, soy) or to other substances 4) Risk for Injury = impulsivity
such as artificial dyes and flavors or salicylates (Stevenson et
al., 2014). MEDICAL MANAGEMENT
§ Methylphenidate (Ritalin) – DOC; stimulant
CRITERIA (norepinephrine, dopamine = helps in focusing and attention)
a. Inattention § Adderall – increase norepinephrine and dopamine
o A persistent pattern of inattention, hyperactivity, and § Dextroamphetamine – increase norepinephrine and
impulsiveness that interferes with functioning dopamine
characterize ADHD (APA, 2013) § Pemoline – increase norepinephrine and dopamine
o Attention involves concentrating on one activity to the § Atomoxetine – acts upon norepinephrine; reuptake
exclusion of others, as well as the ability to sustain focus inhibitor
o The person finds it difficult to attend to one task at a
time and is easily distracted NURSING INTERVENTIONS
o Often fails to give close attention to details or makes ü Safety
careless mistakes in schoolwork, at work, or during o Stop dangerous behavior
other activities = problems in occupational o Talk to child directly about expected behavior after
performances, attainment, attendance incident
o Difficulty sustaining attention in tasks or play activities o Give clear directions about acceptable and
o Does not seem to listen when spoken directly unacceptable behavior
o Often does not follow through on instructions and fails o Explanations should be short and clear
to finish schoolwork, chores or duties in the workplace o Close supervision
*higher probability of unemployment ® affecting ü Nutrition
relationship (interpersonal conflict) with others ü Social Skills Training
o Difficulty organizing tasks and activities = brainwaves ü Positive and Negative Reinforcement
being tangled up d/t hyperactivity ® not being able to ü Posting schedules/reminders
conceptualized what is tasked to them (problems with ü Simplify tasks
focus) ü Get full attention of child
o Often avoids, dislikes, or is reluctant to engage in tasks ü Limit distractions in environment
that require sustained mental effort ü Limit choices
o Loses things necessary for tasks and activities ü Minimize changes
o Easily distracted by extraneous stimuli ü Educate parents and teachers
o Forgetful in daily activities ü Let child sit near the teacher

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b. Hyperactivity-Impulsivity ü Extra time on tests
o Often fidgets with or taps hands or feet, squirms in seat ü Provide an area where child can be active
o Often leaves seat in situations when remaining seated ü Provide a quiet room
is expected ü Limit setting = allowing boundaries through therapeutic
o Often run about or climbs in situations where it is relationship
inappropriate ü Asking help
o Often unable to play or engage in leisure activities ü During Play
quietly ü Interpret social cue
o “on the go”, or “driven by a motor” ü Explain and demonstrate “positive parenting” techniques to
o talks excessively family or caregivers
o blurts out answers o Time in for good behavior
o can’t wait for his turn o Special Time
o interrupts or intrudes on others o Ignoring minor transgressions

INTERVENTIONS FOR DISRUPTIVE BEHAVIOR
1. Therapeutic Holding, Seclusion and Restraint
• Prompt firm, non-retaliatory protective restraint
reducing risk for others
• Safety of all is a concern
• Requires training
• Order by physician, ANP
• VS and ROM q 15 minutes
• Provide for physiologic needs
• Inform family, Family discusses with Child
• Debriefing
2. Time Outs
• Planned together with child and family
• Halt disruptive behaviors, help in self-reflection and
regain SELF control
• Designated room, periphery, REFLECTION,
DEBRIEFING
• *If overused, or used “automatically,” they lose
effectiveness
3. Quiet Room
• An Area of DECREASED STIMULATION for regaining
and maintain SELF CONTROL
• Feelings room: CARPETED and SOFT MATERIALS
• Sensory room: Relaxation
• Child expresses freely and works with feelings in
private with support person
4. Behavioral Contract
• Written or verbal agreement (px, tx team, family)
about behavior, expectation and needs
• Reviewed and evaluated
5. Planned Ignoring
• For attention seeking behavior
6. Use of Signals
• Word, gesture, hand signal to remind child about
SELF CONTROL
7. Counseling
• Verbal Interaction, Role Playing, Modeling
• Teach, coach, and maintain desired behavior
• Provides positive reinforcement
• For children with expressive skills and who are self-
motivated
8. Physical Distance and Touch Control
• Moving closer to child for calming effect
9. Redirection
• Follows an undesirable activity to engage or re-
engage the child in an appropriate activity
10. Additional Affection
• Giving a child planned emotional support for a
specific problem or enjoyable activity
• To redirect child from undesirable activity
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• Acceptance of the child, builds rapport, ignores
behavior
11. Clarification as an Intervention
• Breaking down the problem for understanding, role
of self and others, examine motivation
12. Restructure
• Changing the way the activity to reduce stimulation
or frustration
13. Limit Setting
• Giving direction
• Stating an expectation
• Should be done FIRMLY, CALMLY, without judgment
or anger
• In advance of the behavior occurring
• Consistently used
14. Simple Restitution
• The individual is expected to correct the adverse
environment or relational effects of his or her
misbehavior by restoring the environment to its
prior state, making plan to correct his or her action
TIC Disorders
• a general term encompassing several syndromes that are
chiefly characterized by motor tics, phonic tics, or both.
• Tics are sudden, rapid, recurrent, non-rhythmic motor
movement or vocalization. This group of disorders are a part of
several mental health problems.
• Motor tics are usually quick jerky movements of the eyes,
face, neck, and shoulders, although they may involve other
muscle groups as well.
• Occasionally involve slower, more purposeful, or dystonic
movements.
• Video: Tick Language – involuntary swearing & obscenities
• It is a condition of the nervous system where there are some
sudden twitches, movements or sounds produced during tic
attacks sometimes repeatedly; person cannot stop this
movements from occurring (ex. blinking repeatedly does not
mean a person is winking at you, he is having tic attack)
G.M.M.E. | A.J.E.F. | T.A.M.M. – MARILAG
EPIDEMIOLOGY AND ETIOLOGY
§ The prevalence of Tourette disorder is estimated to be
between one and 3 to 6 per 1,000 in school-aged children.
§ Boys being affected three to six times more often than girls
two to four times
§ Onset typically between 4 to 6 years of age
§ Obsessive-compulsive disorder (OCD) frequently occurs
in association with Tourette disorder (Matthews & Grados,
2011).
§ Familial: The precise nature of the underlying
pathophysiology in this primarily inherited disorder is

unclear, but the basal ganglia and functionally related cortical
areas are presumed to play a central role.
§ Several neurochemical systems have been implicated in
the etiology of Tourette disorder, including dopamine
systems, nor adrenaline, endogenous opioids, and
serotonin (Scharf, Yu, Mathews, Neale, Stewart, Fagerness, et
al., 2013).
§ Maternal smoking → Obstetrical complications, Low
birth weight
FOUR TYPES OF TIC ABNORMALITIES
1) Simple Motor Tics – short duration, only entail one group of
muscle; very jerky, very quick in nature
o ex. shrugging of shoulders, eye blinking, extension
of extremities, clearing throat, sniffing (d/t
irritability of diaphragm)
2) Simple Vocal Tics
3) Complex Motor Tics – combination of simple motor tics
o ex. both head turning and shoulder shrugging
4) Complex Vocal Tics – combination of simple vocal tics
o ex. echolalia with repeating of own sounds, altering
some obscenities (Tick Language)
Hierarchy Order – one cannot be diagnosed with Provisional Tic DO if
dx with Persistent or Vocal Tic Do, and so on.
Tourette’s Disorder
• is the most severe tic disorder, is defined by multiple motor
and phonic ties for at least 1 year.
• Because no diagnostic tests are used to confirm this
disorder, the diagnosis is based on the type and duration
of tics present (Jankovic, Gelineau-Kattner, & Davidson,
2010).
• Both multiple motor and one or more vocal tics have
been present at some time during the illness, although not
necessarily concurrently
• The tics may wax and wane in frequency but have persisted for
more than a year since first tic onset.
• Onset is before 18 years.
• The disturbance is not attributable to the physiological
effects of a substance (drugs that induce tic like anti-
epilepsy) or another medical condition.
Persistent (Chronic) Motor or Vocal Tic Disorder
• Either single or multiple motor or vocal tics have been
present during the illness, but not both motor and vocal.
• Onset is before 18 years.
• Phonic tics typically include repetitive throat clearing
(very common), grunting, or other noises but may also
include more complex sounds, such as words: parts of
words, and in a minority of patients, obscenities.
Psychiatric-Mental Health Nursing | NCM 0117
Provisional Tic Disorder
• Both Single or multiple motor and/or vocal tics
• Transient tics by definition do not endure over time and
appear to be fairly common in school-aged children.
• Onset is before 18 years.
• Tics have been present for less than a year since first tic
onset.
• Simple Motor Tics vs Complex Motor Tics
§ Copropraxia
§ Echopraxia
§ Palilalia
§ Echolalia
§ Coprolalia
• Anxiety, stress, excitement and exhaustion
o The typical age of onset for tics is about 7 years; motor tics
generally precede phonic tics.
o Parents often describe the seeming replacement of one tic with
another.
o In addition to this changing repertoire of motor and phonic tics,
Tourette disorder exhibits a waxing and waning course. The child
can suppress the tics for brief periods. Thus, it is not uncommon to
hear from parents that their child has more frequent tics at
home than at school.
o Older children and adults may describe an urge or a physical
sensation before having a tic. The general trend is for tic
symptoms to decline by early adulthood.
NURSING DIAGNOSES
1) Ineffective Coping
2) Impaired Social Interaction
3) Anxiety
4) Compromised Family Coping (Herdman & Kamitsuru,
2014).
o Children with Tourette disorder typically have normal
intelligence, but their tics can interfere with their ability to relate
to others and perform in school. = no problem in intellect, have
good social relationships, but the problem is motor disorders
G.M.M.E. | A.J.E.F. | T.A.M.M. – MARILAG
either vocal or motor tics
MEDICAL MANAGEMENT
Two classes of drugs are commonly used in the treatment of tics:
1) Antipsychotics (Hadol & Timozin) – suppress occurrence of tic
2) A-adrenergic receptor agonists – induce or promote
smooth contraction so there is prevention of sudden twitches
or movement
3) Aripiprazole is replacing the use of older antipsychotics, such
as haloperidol and pimozide (Cavanna & Seri, 2013).
• These potent dopamine blockers are often effective at
low doses. Attempts to eradicate all tics by increasing the
dosages of these antipsychotics almost certainly will

result in diminishing therapeutic returns and additional
side effects.
• The most frequently encountered side effects
include drowsiness, dulled thinking, muscle
stiffness, akathisia, increased appetite and weight
gain, and acute dystonic reactions. Long-term use
carries a small risk for tardive dyskinesia.
NURSING MANAGEMENT
ü Review of the onset, course, and current level of the symptoms.
= determine the category
ü Goals of the assessment are to identify the frequency,
intensity, complexity, and interference of the tics and their
effects on functioning
ü Determine the child's level of adaptive functioning
ü Identify the child's areas of strength and weakness in
general and in school = social isolation – most often
problem due to abnormal motor function but not intellect
ü Identify social supports for the child and family.
ü Determine the effects of the tic symptoms on the child and
family. = provide counselling & psychoeducation
ü Explore repetitive habits and recurring worries.
NURSING INTERVENTIONS
ü The approach to planning nursing interventions depends
source of impairment:
o ticks themselves and the primary OCD symptoms, and
o the triad of hyperactivity, inattention and poor impulse
control.
ü Provide counselling and education for the patient,
education for the parents.
ü Psychoeducation
Disruptive Impulse Control and Conduct Disorders
• this group of conditions involves problems in self-control
of emotions and behaviors.
• group of mental conditions that have essential features of
irresistible impulsivity = just like ADHD but these
disorders are disruptive in nature
• Behaviors usually violate the rights of others and/or bring the
individual in significant conflict with societal norms or
authority figures. = Conduct Disorder (ex. aggression)
• Emotions = Intermitted Explosive Disorder (ex. anger)
• This disorder is usually more common among males with
childhood or adolescent onset.
Oppositional Defiant Disorder (ODD)
• a frequent and persistent pattern of angry/irritable mood,
argumentative/defiant behavior, or vindictiveness to at least
one individual who is not a sibling, lasting at least 6 months
Psychiatric-Mental Health Nursing | NCM 0117
o ex. disobedience, argumentativeness, outburst, low
tolerance to frustrations, blame other people for mistakes
or misfortunes = trouble making friends, conflict
with adults & problems with obedience to simple
instructions
• both problems with emotion and behavior
• The frequency and persistence is beyond the expectation
for developmental level, culture and gender.
• The behavior must contribute to significant impairment
in important areas of functioning, distress in the
individual or others in the immediate social context.
• The severity is determined by pervasiveness in
multiple settings.
RISK FACTORS
§ Hereditary
§ Harsh, inconsistent, or neglectful child rearing
§ Alcoholic Parents
§ Familial cycle = violence
§ Fixation (not able to feel secure/successfully complete the
stage) in Autonomy vs Shame and Doubt = 2nd Stage based on
Erickson’s Stages → establish Autonomy (“I” or “me”)
CRITERIA
a. Angry/ Irritable Mood
• Often loses temper
• Is often touchy and get easily annoyed
• Is often angry and resentful
b. Argumentative/ Defiant Behavior
• Often argues with authority figures or, for children and
adolescents, with adults
• Often actively defies or refuses to comply with requests
from authority figures or with rules
• Often deliberately annoys others
• Often blames others for his or her mistakes or
misbehavior
c. Vindictive
• Has been spiteful or vindictive at least twice within the
G.M.M.E. | A.J.E.F. | T.A.M.M. – MARILAG
past 6 months. = chance for revenge
Note: Should not occur exclusively in the course of a psychotic, substance
use, depressive or bipolar disorder.
ASSOCIATED MANIFESTATIONS
§ Unable to relate behavior and consequences of behaviors
§ Impaired ability to learn appropriate and inappropriate
behavior
§ Impaired problem-solving skills
§ Deficiencies in attention, flexibility of thinking, and decision-
making
§ Often exists with ADHD, Anxiety and Mood Disorders
 Psychiatric-Mental Health Nursing | NCM 0117

MANAGEMENT RISK FACTORS

1) Parent management training § Physical and emotional trauma in the first 2 decades of life
2) Ranking disruptive behavior and addressing accordingly § Neurotransmitter imbalances of serotonin
3) Parents are taught to ignore maladaptive behavior and reward § Tryptophan depletion
appropriate behavior consistently. § Frontal Lobe dysfunction
4) Use Limit Setting and Matter of Fact Approach.
CRITERIA
5) Role Modelling
6) Individual therapy a. Verbal aggression or physical aggression toward
§ Diary Use property, animals or other individuals, occurring twice
§ Problem Solving Skills weekly on an average, for a period of 3 months. The physical
7) Social Skills training aggression does not result in damage or destruction of
property and does not result in physical injury to animals or
NURSING DIAGNOSIS other individuals
1) Risk for other directed violence = disrespect to other’s b. The magnitude of aggressiveness expressed during the
right recurrent outbursts is grossly out of proportion to the
2) Risk for self-directed violence provocation or to any precipitating psychosocial stressors.
3) Impaired verbal communication = very aggressive, = there should be a stimuli to provoke
poorly controlled emotions so there is problem with c. Chronological age is at least 6 years (or equivalent
connecting to other people effectively developmental level)
4) Ineffective coping d. Three behavioral outbursts involving damage or
5) Compromised family coping destruction of property and/or physical assault involving
6) Impaired social interaction = disruptive/abusive physical injury against animals or other individuals occurring
behaviors from family background in a 12 month period.
e. The recurrent aggressive outbursts are not premeditated
Intermittent Explosive Disorder (IED) and are not committed to achieve some tangible
• episodes of aggressiveness that result in assault or destruction objective.
of property characterize people with intermittent explosive f. The recurrent aggressive outburst cause either marked
disorder. The severity of aggressiveness is out of proportion distress in the individual or impairment in
to the provocation. = response is disproportionate to the occupational or interpersonal functioning, or are
stimuli associated with financial or legal consequences.
• The episodes can have serious psychosocial g. The outbursts are not caused by another mental disorder
consequences, including job loss, interpersonal relationship or in the context of an adjustment disorder.
problems, school expulsion, divorce, automobile accidents, or
jail. ASSOCIATED MANIFESTAITONS
• This diagnosis given only after all other disorders with § Comorbid conditions are common:
aggressive components (e.g., delirium, dementia, head injury, o Substance Abuse,
borderline personality disorder, ASPD, substance abuse) have o ADHD,
been excluded. o ODD,
• The onset is most common in childhood or adolescence and o Conduct disorder,

G.M.M.E. | A.J.E.F. | T.A.M.M. – MARILAG

rarely begins for the first time after the age 40 years with the o Anxiety Disorders and
mean age at onset is 14 years. o Depression
• It is more prevalent in individuals with a high school
MANAGEMENT
education or less (APA, 2013).
• The anger experience and expression of anger contribute to Multifaceted Treatment – medical, codependent interventions,
suicidality (Hawkins & Cougle, 2013). lifestyle modifications, nonpharmacological interventions (relaxation
o Recurrent behavioral outbursts representing a failure to techniques)
control aggressive impulses in response to subjectively 1) Psychopharmacology
experienced provocation. § Fluoxetine (Prozac) – Antipsychotic so it reduces
o The outbursts are response to a minor provocation by close aggression towards other people and may also answer
intimate or an associate. to depression or impulsivity
o Outbursts are not premeditated. They are impulsive and § Lithium – reduces anger
anger based. § Mood stabilizers
o Not diagnosed among clients younger than 6 years. § Phenytoin
 Psychiatric-Mental Health Nursing | NCM 0117

o The treatment of this disorder is multifaceted. Psycho • stolen while confronting victim
pharmacologic agents are sometimes used as an • forced someone to sexual activity = performed rape
adjunct to psychotherapeutic, behavioral, and social b. Destruction of Property
interventions. • Has deliberately engaged in fire setting with the
o Serotonergic antidepressants and gamma- intention of causing serious damage
aminobutyric acid (GABA)-ergic mood stabilizers • Has deliberately destroyed others' property other than
have been used. fire setting
o Anxiolytics are used to treat obsessive patients who c. Deceitfulness and Theft
experience tension states and explosive outbursts. • Has broken into someone else's house, building, or car
o Medication alone is insufficient, and anger • Often lies to obtain goods or favors or to avoid obligations
management should be included in the treatment plan. • Has stolen items of nontrivial value without confronting
2) Milieu Management the victim
§ Cognitive Behavioral Therapy (CBT) d. Serious Violation of Rules
§ Anger Management Strategies • Often stays out at night despite parental prohibitions,
§ Avoidance of alcohol beginning before age 13 years
§ Relaxation techniques • Has run away from home overnight at least twice while
living in the parental or parental surrogate home, or once
Conduct Disorder without return for a lengthy period.
• behavior problem → inability to control behavior • Is often truant from school, beginning before age 13
• repetitive and persistent pattern of behavior in which the basic years = students who shy away from school but they are
rights of others or major age-appropriate societal norms or enrolled, cut classes without explanations
rules are violated
• The disturbance in behavior causes clinically significant ASSOCIATED MANIFESTAITONS
impairment in social, academic, or occupational functioning § Callous and unemotional behavior
• The behavioral pattern is present in a variety of setting § Misperceive intentions of others and then act aggressively
• Significant symptoms first appear in middle childhood § Temper outbursts
through middle adolescence § Suspiciousness = their behavior requires some punitive action
• ODD is a common precursor § Insensitivity to punishment
§ Increased observation of suicidal ideation, suicide attempts
RISK FACTORS and completed suicide
§ Difficult under controlled infant temperament
§ Parental rejection and neglect = inconsistencies of child MANAGEMENT
rearing practices 1) Pre-schoolers
§ Inconsistent child-rearing practices § Head Start Program for Parents
§ Physical and sexual abuse 2) School Age
§ Lack of supervision § Family Therapy
§ Parental Criminality = parenting environment § Parenting Education
§ Exposure to violence → Harsh discipline § Social Skills Training

G.M.M.E. | A.J.E.F. | T.A.M.M. – MARILAG

§ Familial § Attempts to improve academic performance
o Parents with history of ADHD, Conduct Disorder or § Increase the child's ability to comply with demands
Schizophrenia from authority figures
o Functional differences in affect regulation and affect 3) Adolescents
processing § Individual Therapy
§ Conflict resolution, anger management and
CRITERIA teaching social skills
a. Aggression to People and Animals 4) Psychopharmacology
• bullies, intimidates, threatens initiates fights without any § Risperidone (Risperdol) – Mood stabilizers; used
emotional problems to decrease dopamine & serotonin that has
• had used weapons cause serious physical harm to others something to do with mood
• physically cruel to people physically cruel to animals § Carbamazepine (Tegretol) or Valproic Acid
(Depakote) – most common

EXPECTED OUTCOMES
§ The client will not hurt others or damage property
§ The client will participate in treatment
§ The client will learn effective problem-solving and coping skills
§ The client will use age appropriate and acceptable behaviors
when interacting with others
§ The client will verbalize positive, age-appropriate statement
about self
NURSING INTERVENTIONS
ü Encourage the client to discuss his or her thoughts and feelings
ü Give positive feedback for appropriate discussions
ü Give the client positive attention when behavior is not
problematic
ü Tell the client that he or she is accepted as a person, although
a particular behavior may not be acceptable = focus on the
behavior not the person
ü Teach the client about limit setting (boundaries of behavior)
and the need for limits. Include time for discussion. The three
steps of limit setting:
o Inform the clients of the rule or limit.
o Explain the consequences if clients exceed limit
o State expected behavior.
ü Ensure consistency in limit setting.
ü Negotiate a behavioral contract outlining expected
behaviors, limits and rewards to increase treatment
compliance.
ü Institute time outs. Debrief after.
ü Teach the client the problem-solving process as an
alternative to acting out:
o Identify the problem
o Consider alternatives
o Select and implement an alternative
o Evaluate the effectiveness of the solution
o Help the client practice the problem-solving process
with situations on the unit, then situations the client
may face at home, school and so forth.
ü Role model appropriate conversation and social skills for the
client.
ü Specify and describe the skills you are demonstrating.
ü Practice social skills with the client on a one-to-one basis.
= present come scenarios on how a client can respond to a
certain scenario
ü Gradually introduce other clients into the interactions and
discussions
ü Assist the client to focus on age and situation appropriate
topics
ü Encourage the client to give and receive feedback with
others in his or her age group
ü Facilitate expression of feelings among clients in
supervised group situations
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ü Assess the client's use of alcohol or other substances, and
provide referrals as indicated. = alcohol can cause physical and
mental strain → predispose client to conduct disorder itself
ü Address the client in a matter-of-fact approach. = do not
tolerate whatever the client wants to talk about
ü Keeping a diary may be beneficial for the client.
ü Provide client family education
o Teach parents social and problem-solving skills when
needed.
o Encourage parents to seek treatment for their own
problems.
o Help parents to identify age-appropriate activities and
expectations.
o Assist parents with direct and clear communication.
o Help parents to avoid "rescuing" the client.
o Teach parents effective limit setting techniques
o Help parents identify appropriate discipline strategies
VIOLENCE AND DOMESTIC ABUSE
• Violence in the form of physical and psychological abuse
of intimate partners, children, and elders. Sexual violence is
an underreported phenomenon that is most often perpetrated
by individuals known to the victim, and may or may not occur
in the context of other types of abuse.
• Exposure to violence permanently changes the survivor's
reality and meaning of life. It wounds deeply,
endangering core beliefs about the self, others, and the world.
It can damage or destroy the survivor's self-esteem.
• Nurses encounter survivors of violence and abuse in all health
care settings. For this reason, being knowledgeable about
abuse risk factors, indicators, causes, assessment techniques,
and effective nursing interventions is essential.
• Are non-accidental acts of physical force that result, or
have reasonable potential to result, in physical harm to an
intimate partner, child or elder. e.g. slapping, hair-pulling,
pinching, restraining, biting, throwing, kicking, hitting
someone with an object, burning, poisoning, applying force to
G.M.M.E. | A.J.E.F. | T.A.M.M. – MARILAG
a body part, cutting of air supply, or holding head underwater
• The most common type of abuse is associated with
domestic (family) violence;
o that is, the victim or the narrator is or formerly
was a loved and trusted partner or family member.
o When this kind of violence occurs, the world and
home are no longer safe in the eyes of the
survivor.
• According to DSM-5, may be classified into 4 types:
o Intimate Partner Violence (IPV)
o Child Abuse
o Elder Abuse
o Rape and Sexual Assault
 Psychiatric-Mental Health Nursing | NCM 0117

Intimate Partner Violence (IPV) never happen again. He professes his love for his
• Is the mistreatment or misuse of one person by another in wife and may even engage in romantic behavior
the context of an emotionally intimate relationship. (e.g., buying gifts and flowers) = undoing. This
• Occurs when forced or coerced sexual acts (no his/her will) period of contrition or remorse is sometimes called
with an intimate partner have occurred during the past year. the honeymoon period. The woman naturally
• involves physical violence, sexual violence, stalking, wants to believe her husband and hopes the
and psychological aggression (including coercive acts) by violence was an isolated incident.
a current or former intimate partner ICDC, 2016a). 3. Tension building – occurs where there may be
• The abuse can be emotional or psychological, physical, arguments, stony silence, or complaints from the
sexual, or a combination (which is common). husband. The tension ends in another violent
• The relationship may be spousal, between partners, episode after which the abuser once again feels
boyfriend, girlfriend, or an estranged relationship. regret and remorse and promises to change.
• Occurs on a continuum from psychological abuse to lethal
violence (physical).
• Psychological abuse (emotional abuse) includes name-
calling, belittling, screaming, yelling, destroying property, and
making threats as well as subtler forms, such as refusing to
speak to or ignoring the victim.
• Physical abuse ranges from shoving and pushing to severe
battering and choking and may involve broken limbs and ribs,
internal bleeding, brain damage, and even homicide.
• Sexual abuse includes assaults during sexual relations such
as biting nipples, pulling hair, slapping and hitting, and rape.
• Approximately one in 6 women and one in 14 men are
victims of severe physical violence by an intimate partner at
some point in their lives (CDC, 2014).
• While male are usually the perpetrators of IPV in
heterosexual relationships, men can also be the targets of
partner abuse. • This cycle continually repeats itself. Each time, the victim
• IPV in same-sex couples occurs with at least the same keeps hoping the violence will stop.
frequency as in heterosexual relationships • Even after a victim of battering has “ended” the relationship,
• Youths, people of color, gay men, and transgender problems may continue by stalking.
women are those at highest risk. These individuals are more
likely to be injured, require medical treatment, and experience ASSESSMENT
harassment or bias as a result of IPV.
§ Victim has low self-esteem
RISK FACTORS § Abuser comes from abusive families (behavior
became/becomes a norm inside the family dynamics)
§ Younger, single, divorced, and separated women more
§ Immature

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than married women.
§ Dependent to the abuser (Cannot confront partner because
§ Native American and Alaska Native women more than
he/she is dependent on him/her)
Asian and Pacific Islander women
§ Non-assertive (Victim is being hit but still thinks it is okay)
§ Low income
§ Feelings of inadequacy
§ Similar across rural and urban areas.

Cycle of Abuse and Violence SIGNS & SYMPTOMS

• The cycle of violence or abuse is another reason often cited
for why women have difficulty leaving abusive relationships.
• Typical pattern usually includes:
1. Violent behavior – initial episode of battering or
violence.
2. Period of remorse or contrition – abuser
expressing regret, apologizing, and promising it will
§ Frequent ER visits/hospitalizations for “accidental” injuries
§ Explanation given for injuries that do not match or support,
or actually conflict with the type or intensity of injury
§ Blackened eyes bruising, fractures, burns, “twisting” type
injuries, multiple bruises or injuries at various stages of
healing = trauma that has been inflicted to the client is
recurrent

§ Little or no control over their financial status = overly
dependent to the abuser
§ Socially isolated with no other social support except for
the abuser = withdrawn, intimidated by the abuser,
threatening the victim not to tell anyone
§ Displaying fear, anxiety withdrawal, extreme passivity
or shame when the abuser is present
§ The abuser being unwilling to allow, or being suspicious
of, any healthcare providers spending time alone with the
victim = abuser is always there
§ The abuser answering all questions, even those directed to
the victim, or being evasive or refusing to answer certain
questions = doesn’t want the victim to provide too much
information that can signal signs of abuse
§ The abuser being overly helpful (e.g., insisting on helping
the victim change into a hospital gown, go to the bathroom
rather than allow staff to be alone with the victim); doesn’t
want the victim to be interviewed on a one-on-one basis.
Stalking
• Stalking is a pattern of repeated unwanted contact,
attention, and harassment that often increases in
frequency (CDC, 2016a)
• Behaviour that causes fear or substantial emotional
distress to victims
• May include such behaviours as following someone, showing
up at the person's home or workplace, vandalizing property, or
sending unwanted gifts. Cyber stalking is the use of the
Internet, e-mail, or other telecommunications technology to
harass or stalk another person.
• Intimate partner stalkers are especially dangerous
because they often have a history of violence against their
victim, may feel justified in their behaviours, and may
disregard restraining orders.
MEDICAL MANAGEMENT
§ Antianxiety agents (benzodiazepines), prescribed
occasionally for short-term use to decrease anxiety
§ Trazodone (Desyrel) to facilitate sleep (also to calm the
client); under major depressive disorder ® insomnia
NURSING INTERVENTIONS
ü Trust, empathy, emotional support, and a willingness
to listen are important in all stages of recovery of the client
(giving a feeling of importance)
ü Physical safety and emotional security (safety inside the
health facility). Reassurance, protection from further harm,
and sometimes medical care are needed.
ü Clear, simple directions on what to do, where to go, and
what to avoid.
Psychiatric-Mental Health Nursing | NCM 0117
ü Avoid accusations (blaming), intimidation, unnecessary
intrusions, and invasion of privacy (unless it is for the basis
of interventions)
ü Validation of their self-worth and rights.
ü Support groups with other survivors can be useful.
ü Long-term counselling is sometimes needed to overcome
anxiety, phobias, depression, suicidal ideation, or other
posttraumatic symptoms.
Child Abuse
• Is non-accidental physical injury to a child
• Child maltreatment includes all types of abuse or neglect
of a child under the age of 18 by a parent or anyone else in
a caretaking role (CDC, 2016d).
• Child abuse is defined as words or overt actions that cause
harm, potential harm, or threat of harm and includes physical
(punching, kicking, beating, throwing, choking), sexual, and
psychological abuse.
• It can include physical abuse or injuries, neglect or failure to
prevent harm, failure to provide adequate physical or
emotional care or supervision, abandonment, sexual assault or
intrusion, and overt torture or maiming.
• Child neglect is the most common type of
maltreatment and involves a failure to meet a child's
basic needs such as shelter, food, clothing, education,
medical/dental care, and appropriate supervision.
RISK FACTORS
§ The actual prevalence of child abuse and neglect is unknown.
§ Younger than age 5
§ Those with mental, physical, or emotional disabilities
§ Family situations that are chaotic or stressful increase the
likelihood that abuse or neglect will occur
§ Parental poverty, lack of education, mental health or
substance abuse problems, and difficulty coping are
other significant factors
TYPES
G.M.M.E. | A.J.E.F. | T.A.M.M. – MARILAG
1. Physical abuse
• Purposely injured or put at risk of harm
• Results from unreasonably severe corporal
punishment or unjustifiable punishment such as
hitting an infant for crying or soiling his or her diapers.
• Intentional, deliberate assaults on children
include burning, biting, cutting, poking, twisting limbs,
or scalding with hot water.
• The victim often has evidence of old injuries (e.g.,
scars, untreated fractures, or multiple bruises of various
ages) that the history given by parents or caregivers does
not explain adequately.

2. Sexual abuse
• Involves sexual acts performed by an adult on a child
younger than 18 years.
• Examples include incest, rape, and sodomy
performed directly by the person or with an object, oral–
genital contact, and acts of molestation such as
rubbing, fondling, or exposing the adult’s genitals.
• Sexual abuse may consist of a single incident or
multiple episodes over a protracted period.
• A second type of sexual abuse involves exploitation,
such as making, promoting, or selling pornography
involving minors, and coercion of minors to
participate in obscene acts.
3. Neglect
• Is the malicious or ignorant withholding of physical,
emotional, or educational necessities for the child’s well-
being.
• Child abuse by neglect is the most prevalent type of
maltreatment and includes refusal to seek health care or
delay doing so; abandonment; inadequate supervision;
reckless disregard for the child’s safety; punitive,
exploitive, or abusive emotional treatment; spousal
abuse in the child’s presence; giving the child permission
to be truant; or failing to enroll the child in school.
4. Psychological abuse (emotional abuse)
• Includes verbal assaults, such as blaming, screaming,
name calling, and using sarcasm; constant family
discord characterized by fighting, yelling, and chaos;
and emotional deprivation or withholding of
affection, nurturing, and normal experiences that
engender acceptance, love, security, and self-worth.
• Emotional abuse often accompanies other types of
abuse (e.g., physical or sexual abuse).
• Exposure to parental alcoholism, drug use, or
prostitution—and the neglect that results— also falls
within this category.
ASSESSMENT
§ Serious injuries such as fractures, burns, or lacerations with no
reported history of trauma
§ Delay in seeking treatment for a significant injury (because
there is a possibility that the child will be taken by the social
welfare)
§ Child or parent giving a history inconsistent with severity
of injury
§ Inconsistencies or changes in the child’s history during the
evaluation by either the child or the adult
§ Unusual injuries for the child’s age and level of
development, such as a fractured femur in a 2-month-old or a
dislocated shoulder in a 2-year-old (bones are not fully developed
and not too brittle; only occurs when there is excessive trauma;
their tendons/ligaments is as strong as their bones)
Psychiatric-Mental Health Nursing | NCM 0117
§ High incidence of urinary tract infections; bruised, red, or
swollen genitalia; tears or bruising of rectum or vagina
§ Evidence of old injuries not reported, such as scars, fractures
not treated, and multiple bruises that parent/caregiver cannot
explain adequately
SIGNS & SYMPTOMS
§ Socially withdrawn
§ Little or no attachment to parent/caregiver = due to trauma
§ Malnourished or dehydrated = neglect
§ Has poor hygiene = neglect; unkept
§ Injuries does not “match” the explanation given (e.g.
fracture, intracranial/intraocular bleeding, multiple injuries
but at various stages of healing)
§ Excessive absences from school = socially detached d/t
physical and psychological trauma
§ Is developmentally delayed physically and emotionally =
ineffective coping
§ Has frequent urinary, genital or throat infections;
evidence of injuries to urethra, vagina, or rectum = signs of
sexual abuse
§ Reports being molested, inappropriately touched, or
having sex with an adult
§ Has difficulty walking or sitting = sign of sexual assault;
blood in the child’s underwear if reported immediately
§ Has problems with nightmares and bed wetting –
nocturnal enuresis (a sign of parental conflict/trauma; child
regresses as a response to the stress they have undergone)
NURSING INTERVENTIONS
The goals of all nursing interventions in cases of violence are to prevent
injury, stop the violence (cutting ties with abuser), ensure the
survivor's safety, and restore health.
ü Physical health interventions require treatment of trauma
symptoms may include cleaning and dressing burns or other
wounds and assisting with setting and casting broken bones.
ü Malnourished and dehydrated children and older adults may
require nursing interventions such as intravenous therapy
or nutritional supplements that alleviate the alteration in
G.M.M.E. | A.J.E.F. | T.A.M.M. – MARILAG
nutrition and fluid and electrolyte imbalances.
ü Ensure the child’s safety and well-being.
ü Play therapy
Elder Abuse
• Is the abuse or neglect of adults older than 60 years of age.
• Is the maltreatment of older adults by family members or
others in a caregiver role
• It may include physical and sexual abuse, psychological
abuse, neglect, self-neglect, financial exploitation, and
denial of adequate medical treatment.
• The violence usually occurs at the hands of a caregiver or a
person the older adult trusts.

RISK FACTORS
Victim:
§ Individuals who are isolated
§ Have poor support systems
§ Have mental (neurological) or physical
impairments/deficits (bedridden) that foster dependency
on others
Caregiver:
§ Use of drugs or alcohol
§ High emotional or financial dependence on the older
adult
§ Lack of training in taking care of older adults
§ Depression
ASSESSMENT
§ Suspect abuse if injuries have been hidden or untreated or
are incompatible with the explanation provided.
§ Evaluate an elder who is hesitant to talk openly to the
nurse or who is fearful, withdrawn, depressed, and
helpless.
§ Possible indicators of self-neglect include inability to
manage money (hoarding or squandering while failing to
pay bills), inability to perform activities of daily living
(personal care, shopping, food preparation, and cleaning) =
overly dependent to their caregiver, and changes in
intellectual function (confusion, disorientation,
inappropriate responses, and memory loss and isolation).
§ Assess if the caregiver has a history of family violence or
alcohol or drug problems especially if he/she is not related
to the elder.
§ Symptoms of elder abuse may include depression,
confusion, fearfulness, changes in behavior, and loss of sleep.
SIGNS & SYMPTOMS
§ Shows obvious signs/symptoms of malnutrition or
dehydration
§ Has poor hygiene = neglect
§ Has skin breakdown (abuse or neglect; client is immobile –
prone to pressure sores/ulcers; assess the etiological factor)
§ Is socially withdrawn or apathetic = would not respond to
any emotional stimuli
§ Injuries does not “match” the explanation given (e.g.
fracture, intracranial/intraocular bleeding, burns, abdominal
trauma, multiple injuries but at various stages of healing)
§ Has contractures of extremities = heightened portion of
the body having extreme spasms; do proper positioning
techniques which will not allow the client to manifest
contractures
§ Allows family members to answer any questions even
when questions are directed toward the elder client.
Psychiatric-Mental Health Nursing | NCM 0117
§ Physically withdraws when approached as if expecting
to be hurt = sign of being traumatized
§ Is fearful of contradicting family members = possibility
of violence once the client reaches home
§ Is unable to answer questions related to financial
matters when intellectually able to do so
NURSING INTERVENTIONS
ü Interviewing and obtaining a history from the patient
and caregivers (separately)
ü Identifying the dynamics of an older adult's relationship
with caregivers may provide clues to elder abuse. (Ask about
the boundaries or contract between the client and the
caregiver; what is the caregiver’s specific job; with every need
of the client, what is the caregiver’s response = determine
dynamics)
ü Question the patient alone if the care provider perceives
that a patient is hesitant about speaking about abuse in the
presence of a caregiver
ü Assure privacy and confidentiality for both the patient
and caregivers (always take premium when talking about any
kind of abuse)
Rape and Sexual Assault
• Is the perpetration of an act of sexual intercourse with a
person against his or her will and without her consent,
whether that will is overcome by force, fear of force, drugs,
or intoxicants.
• Rape is defined as "the penetration, no matter how slight, of
the vagina or anus with any body part or object, or oral
penetration by a sex organ of another person, without the
consent of the victim" (unwilling act by the victim)
• Sexual assault includes any form of non-consenting sexual
activity, ranging from fondling to penetration.
RISK FACTORS
§ Women: 93% of reported cases
§ Adolescents, young adults
G.M.M.E. | A.J.E.F. | T.A.M.M. – MARILAG
ASSESSMENT
§ Physical examination should occur before the victim has
showered, brushed teeth, douched, changed clothes,
or had anything to drink.
o If there is no report of oral sex, then rinsing the
mouth or drinking fluids can be permitted
immediately.
§ The nurse may ask needed questions gently and with
care. (Avoid questions that are very intrusive and not
necessary with the planning of care)
 Psychiatric-Mental Health Nursing | NCM 0117

SIGNS & SYMPTOMS

§ Nightmares = sign of conflict; symptom of regression
§ Inability to trust others = trust issues
§ Anxiety and fear
§ Distrust/suspicion of everyone = thinking that every
individual will take advantage of them
§ Guilt, blaming self for this happening = tell them that they
did not do anything wrong and their power was taken away by
someone else
§ Worthlessness, decreased self-esteem
§ Isolation, decreased socialization
§ Emotional distancing = mistrust
§ Decreased motivation
§ Problem with establishing meaningful relationships

INTERVENTIONS
ü Immediate support and can express fear and rage
ü Giving as much control as possible back to the victim is
important = having the ability to decide for themselves
ü Prophylactic treatment for sexually transmitted diseases is
offered = Doxycycline for 3 days/72 hours after the
unprotected sex
ü HIV testing is strongly encouraged
ü Advocacy groups for emotional support = verbalization of
the same experiences
ü Group therapy such as music and arts therapy,
remotivation therapy

G.M.M.E. | A.J.E.F. | T.A.M.M. – MARILAG