Child and Adolescent

Disorders





ANGELBERN NARAG GANNABAN


Psychiatric disorders are not diagnosed as easily in
children as they are in adults because:
Children lack abstract cognitive abilities and
verbal skills to describe what is happening
Children are constantly changing and developing
The most common childhood psychiatric disorders
include:
Pervasive developmental disorders
Attention deficit hyperactivity disorder (ADHD)
Disruptive behavior disorders
Disturbances and emotions and thoughts
that cause prolonged, serious distress or
impairment of functioning are referred to as
mental disorders.
Degrees of Retardation
Mild (IQ 50 to 70)
Moderate (IQ 35 to 50)
Severe (IQ 20 to 35)
Profound (IQ below 20)

Mental Retardation
Mild
Can be taught to live independently: can
develop social skils and ability to verbalize:
Good academic skills
Limited ability to abstract
Has gross and fine motor abilities
Can do unskilled manual labor
Moderate
Requires a structure in living arrangement
Can learn words, numbers, sign poor
abstract thinking, follow simple
instructions; can participate in repetitive
task
Severe
Requires a great deal of assistance and
structured living arangements; say a few
words, no abstract ability, rarely can read
write or use math uncoordinated motor
moements
Profound
Requires full time care; unable to relate
verbally, no academic skills, no fine gross
skills
Heredity
Tay-Sachs disease or fragile X chromosome
syndrome
Early alterations in embryonic development
Maternal alcohol intake
Causes
Down Syndrome
5% of mild MR, 30% of severe
Trisomy 21: occurs randomly, not inherited
Related to maternal age, over 40
Reduced brain size, reduced number and density of neurons and
dendrites
Identical brain plaques and tangles found in Alzheimers by age 35-40
75% of Down adults have symptoms of Alzheimers by age 70
physical features noted: upward slant of eyes, folds in corner of eyes,
facial flatness, fissured and thick tongues, broad hands and feet, poor
muscle tone
Retardation ranges from mild to severe
Language skills delays; deficit in short-term memory
Personality: mild-mannered, friendly, socially competent, cooperative,
follow rules; in somehyperactivity, aggression, noncompliance
Emotional development lags; emotions seem muted
Fragile X
Second to Down syndrome as causation of retardation
More males than females
Males have double-jointed thumbs, flat feet, velvet
skin, long faces, big ears, oversized testicles
Comorbid with autism
Mild to moderate MR: language skills to age 4, then
plateau
Slowing of intellectual growth from 8 to 15
Weakness in expressive language, not receptive
language
Williams syndrome
Gene deletion on chromosome 7; rare
Elfinlike face, growth deficiency, cardiac,
kidney problems
Mild to moderate retardation
Causes cont
Pregnancy or perinatal problems
Fetal malnutrition, hypoxia, infections, and
trauma
Medical conditions of infancy
Infection or lead poisoning
Environmental influences
Deprivation of nurturing or stimulation

Learning Disorders
Diagnosed when the childs achievement in reading,
mathematics, or written expression is below that
expected for the childs age, formal education, and level
of intelligence
Interfere with academic achievement, life activities,
development of self-esteem, and social skills
Early identification, intervention, and coexisting
problems are associated with better outcomes
Reading Disorder: dyslexia; the most common
of the learning disorders; decoding problems
suggest difficulty recognizing or pronouncing
words, reading slowly or haltingly; limited
vocabulary; difficulty comprehending or
remembering what was read reading disorder
is fundamentally related to language disorder
Reading problems persist through adulthood
for many


Writing Disorder: Dysgraphia; visual-motor
coordination is blamed for poor handwriting;
spelling errors, awkward placement of words,
poor sentence structure, poor punctuation, lack
of clarity in meaning are common; diagnosis
most likely after the age of 8 when motor skills
are developed; prevalence unknown; prognosis
unknown; some improvement with proper
skills, which justifies continued work to write a
coherent essay: develop a topic sentence,
organize points to be made, link ideas with
transitions, provide detail and elaboration on
major points, summarize succinctly.


Mathematics Disorder: Dyscalcula; problems
in reading numbers, performing
addition/subtraction, understanding
terms/symbols, understanding spatial
organization; visual-spatial impairment;
developmental milestones from 3-6: arranging
objects by size, counting to ten, copying
numbers and block designs, sorting objects by
characteristic, understanding concepts like
more than, less than; prevalence rate: 1%; little
research on prognosis

Motor Skills Disorder
Marked impairment in coordination severe
enough to interfere with academic
achievement or activities of daily living
Often coexists with communication
disorders
Provide adaptive physical education and
sensory integration to foster normal growth
and development
Communication Disorders
Diagnosed when communication deficit is
severe enough to hinder development,
academic achievement, or activities of daily
living, including socialization
Expressive language disorder
Mixed receptive-expressive language disorder
Phonologic disorder
Stuttering disorder
Speech therapy to improve communication
skills

CAUSES
Brain abnormalities: Brocas area for
speech production; Wernickes areas for
language comprehension (both in frontal
lobe); L and R hemisphere differences in
symmetry;
Genetics: high heritability for LDs;
single- and multiple-gene effects
suspected; specific chromosomes
suspected
CAUSES
Psychosocial factors: family variables,
such as how much parents speak to
children and the verbal interactions
between child and parents; parental
attitudes toward learning, child
management practices, social class,
cultural values; quality of school
instruction, overcrowded classrooms
Interactional nature-nurture theory
proposed

TREATMENT
Individualized Education Program (IEP);
a plan that guides the services that a
special student must receive; delineates a
specific course of action to address
recognized problems; this plan is created
by the special education teacher, special
education supervisor, school psychologist,
principal, counselor and/or classroom
teacher and the parents.


An array of special education services is
organized as a continuum going from least
to most restrictive, as follows:

Consultation and support for general teachers
Special education up to 1 hour per day
Special education 1-3 hours per day; resource
program
Special education more than 3 hours per day;
self-contained special education
Special day school
Special residential school
Home/hospital
Pervasive Developmental
Disorders
Characterized by pervasive and usually
severe impairment of reciprocal social
interaction skills, communication
deviance, restricted stereotypical
behavioral patterns
Autistic disorder (classic autism)
Retts disorder
Childhood disintegrative disorder
Aspergers disorder
Research to confirm brain anatomical
abnormalities suggests that neurons in the
amygdala (the area responsible for processing
emotions and behavior)
and the hippocampus (involved in learning and
memory) are smaller, more densely packed in
some areas, and have shorter, less-developed
branches than normal.
Low blood circulation in some parts of the
cerebral cortex during certain intellectual
functions and a reduced number of cells relaying
inhibitory messages have been demonstrated.
It has been hypothesized that these severe
developmental disorders of childhood are the
result of a disturbance in the central nervous
system integration and in the biological process
of maturation.
Predisposing organic factors include maternal
rubella, phenylketonuria, encephalitis, meningitis,
hydrocephalus, hypothyroidism, and tuberous
sclerosis.

Autism
Rare condition: 4 cases in 10,000; boys >
girls: 3:1. Autism in girls is more severe in
retardation. Most recent research suggests
that the number of autistic children is
increasing, reason unknown.
Autism
Negative responses to changes in routine;
insistence on rigid adherence to the usual
way of doing everything; Kanner, who
first described autism in 1943 described
their obsessive desire for the maintenance
of sameness; change brings tantrums;
intense attachment to objects; stereotypies;
self-injurious behaviors such as head
banging
Autism
Apparent social deficits and bizarre responses:
failure to cuddle, lack of eye contact, aversion to
physical affection;
indifferent to social contact, proneness to temper
tantrums;
autistic aloneness in areas of language, behavior,
cognitive development and social relationships;
echopraxia;
physical and emotional distance; inability to
respond to others feelings;
Autism
mindblindness (the inability to interpret the
intentions, beliefs or behaviors of others);
may walk on tiptoe;
great deal of time spinning objects, flicking
their fingers or rocking their bodies.
Abnormal language development, including
echolalia, pronominal reversal;
THEY TALK IN A THIRD PERSON
Autism
perserveration; high-pitched, bird-like squeaking
voice;
verbal skills may be stilted, too perfect, with no
subtleties of emotional tone;
failure to imitate gestures or imaginative play;
nonverbal skills remain poor.
Approximately half of all autistic children do not
develop speech at all. Executive functions of the
cerebral cortexplanning, inhibition of response,
flexibility and working memoryare often poor
or missing

INCIDENCE RATE
25-40% score above 70 on IQ tests, and
range from normal to gifted, but
approximately 70% are mentally retarded;
sometimes accompanied by savant
capacities (areas of surprising talent in other
wise low functioning individuals include
music, drawing, and calendar calculations),
i.e. Dustin Hoffmans character in Rain
Man
Autism
The following disorders are related to Autism, but
show a different developmental course and pattern
of symptoms:

Retts Disorder: rare disorder only occurring in
females, due to a gene mutation; onset in first four
years; normal first year, then a slowing down in
head growth and a decline in motor and
communication skills; then a social withdrawal,
stereotypic and repetitive hand or finger
movements or whole body movements; mental
retardation; persistent and progressive

Autism
Childhood Disintegrative Disorder:
normal development for first two years;
typical onset between three and four years;
loss of skills in at least two of the following:
expressive or receptive language, social
skills or adaptive behaviors, bowel or
bladder control, play, and motor skills;
other symptoms similar to autism noted;
etiology unknown

Autism
Aspergers Disorder: latest onset of the disorders:
preschool or later; associated with less severe
deficits; impairment in social interactions,
repetitive patterns of behavior, limited interests;
failure to make eye contact; inexpressive facial
expressions; mechanical and robotic body posture
and gestures; few friends, no interest in recreation
or humor; may be a milder form of autism; more
common in males; may be gifted in certain areas

Aspergers Disorder
A. Qualitative impairment in social interactions, as
manifested by at least two of the following:
marked impairment in the use of multiple nonverbal behaviors such
as eye-to-eye gaze, facial expression, body postures, and gestures to
regulate social interaction
failure to develop peer relationships appropriate to developmental
level
a lack of spontaneous seeking to share enjoyment, interests, or
achievements with other people (e.g. by a lack of showing, bringing,
or pointing out objects of interest to other people)
lack of social or emotional reciprocity
Aspergers Disorder
B. Restricted repetitive and stereotyped patterns
of behavior, interests, and activities, as
manifested by at least one of the following:
encompassing preoccupation with one or more
stereotyped and restricted patterns of interest that are
abnormal either in intensity or focus
apparently inflexible adherence to specific,
nonfunctional routines or rituals
stereotyped and repetitive motor mannerisms (e.g. hand
or finger flapping or twisting, or complex whole-body
movements)
persistent preoccupation with parts of objects
Neurobiological Abnormalities
Aspergers d/o
Large brain size in toddlers
Smaller corpus collosum connecting the
hemispheres, suggesting disturbances in brain
connectivity
Left frontal macrogyria, bilateral opercular
polymicrogyria and left temporal lobe damage
have been found in AD children
Chromosomes 15, 7 and 2 are implicated in
linkage studies
Neurobiological Abnormalities
Aspergers d/o
Temporal lobe-limbic system, frontal
lobe and cerebellum: the social brain
targeted
decreased number and size of cells, high
cell density, dendritic branching,
abnormal cell migration
Reduced activity in the amygdala during
face perception
Neurobiological Abnormalities
Aspergers d/o
Reduced activity in frontal lobe and other
areas related to social and emotional
functioning
Reduced activity in the cerebellum
related to attention problems
Biochemical systems: serotonin and
dopamine levels are abnormal in
childhood and adolescence

Pervasive Developmental
Disorders (contd)
Most autistic children are mainstreamed in
school
Medications may be used to target specific
behaviors:
Antipsychotics for temper tantrums, aggressiveness, self-
injury, hyperactivity, and stereotyped behaviors
Naltrexone (ReVia), clomipramine (Anafranil), clonidine
(Catapres), and stimulants to diminish self-injury and
hyperactive and obsessive behaviors
Goals are to reduce behavioral symptoms and
promote learning, development, and language
skills
Attention Deficit Hyperactivity
Disorder (ADHD)
Inattentiveness,
overactivity, and
impulsiveness
Incidence Rates
Boys are three
times more likely
than girls to
develop ADHD

4. By 5 to 8 years old, 45-70% of children
with ADHD have begun to show significant
problems with defiance, resistance to parental
authority, hostility towards others and quick-
temperedness; symptoms of inattentiveness
often emerge a year or more later than the
symptoms of hyperactivity and impulsiveness
5. As adolescents, these children are labeled
socially disabled and often experience intense
interpersonal problems

6. As adults, children diagnosed with ADHD
are at increased risk for antisocial personality
disorder, substance abuse, marital problems,
traffic accidents, legal infractions and frequent
job changes
7. Comorbid disorders include mood
disorders, anxiety disorders, OCD, personality
disorders, tic disorders, sleep disorders, autism
and Aspergers syndrome
8. The remaining one-third grow out of
their symptoms by early adulthood and go on
to lead normal and healthy lives

CAUSES
2. Recent twin studies find that concordance
for ADHD was .67 in MZ twins and .37 in DZ
twins, based on ratings by teachers
3. Children with ADHD differ from children
with no disorder on measures of neurological
functioning and cerebral blood flow
4. Areas of the brain most likely involved
include the frontal lobes, the caudate nucleus
within the basal ganglia, the corpus collosum,
which connects the two lobes, and the pathways
between these structures
5. Immaturity theory suggests that the brains
of these children are slower to develop than
those of children without the disorder; this
theory helps explain the ADHD decline with
age in many children

7. Prenatal and birth complications have
been related to ADHD, including gestation of
nicotine or barbiturates during pregnancy, low
birth weight, premature delivery, and difficult
delivery leading to oxygen
deprivation. Moderate to severe drinking in
mothers during pregnancy may lead to
problems in inhibiting behaviors seen in
children with ADHD

8. Biological abnormalities translates into behavioral
problems in four realms (Barkley, 1998): (1) nonverbal
working memory, (2) internalization of self-directed
speech, (3) the self-regulation of mood, motivation and
level of arousal, and (4) reconstitutionthe ability to
break down observed behaviors into component parts
that can be recombined into new behaviors directed
toward a goal


9. No dietary factors, such as consumption of
sugar or food dyes, as a correlate to ADHD
have been supported in controlled studies,
although there are vocal supporters of this
theory, i.e. the Feingold diet advocates; about
5% of children are relieved of symptoms with
change of diet, mostly young children with food
allergies
10. Cultural and social influences include
disturbed family environment, academic failure
Attention Deficit Hyperactivity
Disorder (ADHD)
Three subtypes of
ADHD: predominantly hyperactive-
impulsive type, predominantly inattentive
type and combined type
Criteria for ADHD fall into three
clusters: inattention, hyperactivity and
impulsivity:

Inattention
Does not pay attention to details and makes careless
mistakes
Has difficulty sustaining attention unless they are doing
something they really enjoy
Does not seem to be listening when others are talking
Does not follow through on instructions or finish tasks
Has difficulty organizing behaviors
Avoids activities that require sustained effort and
attention
Loses things frequently
I s easily distracted

Is forgetful
Skips from one activity to the next
Appears spacey, easily confused, slow
moving and lethargic
Difficulty processing information; may not
understand oral or written instructions

Hyperactivity
Fidgets with hands or feet and squirms in
seat
I s restless, leaving his/her seat or running
around when inappropriate
Has difficulty engaging in quiet activities
Always on the go
Feeling of internal restlessness
Need to stay busy and try to do several
things at once

Impulsivity
Blurts out responses while others are
talking
Has difficulty waiting his/her turn
Displays emotions without restraint
Acts without regard for later consequences
I mmediate gratification more important
than delayed rewards

Among possible causes of ADHD-like
behavior are the following, which must
be ruled out before diagnosis:
1. A sudden change in the childs life
death, divorce, parents job loss or move
2. Undetected seizures
3. A middle ear infection that cause
intermittent hearing problems

4. Medical disorders that may affect
brain functioning
5. Underachievement caused by
learning disability
6. Anxiety or depression

Comorbid Disorders accompanying
ADHD include Learning Disabilities (20-
30%); Tourette Syndrome; ODD (30-
50%); Conduct Disorder (20-40%);
Anxiety; Depression; Bipolar Disorder

Data Analysis
Nursing diagnoses include:
Risk for Injury
Ineffective Role Performance
Impaired Social Interaction
Compromised Family Coping
Application of the Nursing Process:
ADHD (contd)
Treatment
Combination of pharmacotherapy with behavioral,
psychosocial, and educational interventions
Psychopharmacology
Stimulants: methylphenidate (Ritalin), an amphetamine
compound (Adderall), dextroamphetamine (Dexedrine),
and pemoline (Cylert)
Common side effects: insomnia, loss of appetite, and
weight loss or failure to gain weight
3 About 50% of children with ADHD
improve with an SSRI antidepressant
4.Psychosocial intervention may address
the parents own psychological problems
and the impairments in parenting skills
that these problems create

5. Research results support the use of both medication
and behavioral treatment for the effectiveness both
short-term and long-term
6. Treatment that focuses on promoting parental
competence and on treating aggression and defiance in
ADHD children very early in childhood appears to lead
to the most positive long-term outcomes
Psychosocial Treatment
Behavior modification
o Start with goals that can be achieved in
small steps
o Be consistent across time, settings
o Implement interventions over the long
haul
o Reinforce for gradual improvements
toward goals

Parent Training
o Establish house rules and
structure
O Reinforce appropriate behaviors;
ignore mild inappropriate behaviors
o Use whenthen contingencies
o Plan ahead for activities
O Daily charts and point/token
systems for rewards
oSchool-home note system for
tracking homework

School Intervention
o Training in classroom management
O Focus on use of weekly planners
o Study skill training

Child Intervention
o Systematic training of social skills
o Social problem solving
o Teaching behavioral skills important
for children, i.e. sports, board games
o Decreasing undesirable and
antisocial behaviors
o Developing a close friendship

Oppositional Defiant
Disorder
Behaviors cause dysfunction in social,
academic, and work situations
25% go on to develop conduct disorder
10% are diagnosed with antisocial personality
disorder as adults
Treatment is similar to conduct disorder,
depending on severity of behaviors
Oppositional Defiant
Disorder

A pattern of negativistic, hostile, and
defiant behavior lasting at least six
months, and causing clinically meaningful
impairment in the childs social or
academic functioning, during which four
or more of the following are present


1. often loses temper
2. often argues with adults
3. often actively defies or refuses to
comply with adults requests or rules
4. often deliberately annoys people
5. often blames others for his or her
mistakes or misbehavior

6. is often touchy or easily annoyed by
others
7. is often angry and resentful
8. is often spiteful or vindictive
Note that the criteria would fall under
the overt/nondestructive dimensions of
behavior

Conduct Disorder
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 three or more of the following criteria
in the past twelve months, with at least one
criterion present in the past six months.

1. Aggression to people and animals
2. Bullies, intimidates, uses a weapon,
physically cruel, stolen, sexual coercion
3. Destruction of property
4. Fire-setting, destroyed others
property)
5. Deceitfulness or theft
6. Broken into houses, buildings, cars;
lies to obtain food or favors, shoplifting
7. Serious violations of rules
8. Stays out all night; run away from
home, truant from school
Note: The Antisocial Personality
Disorder (APD) is applied to individuals
who display a persistent pattern of
aggressive and antisocial behavior since
the age of 15.

Etiology
Genetic vulnerability
Environmental adversity
Poor coping
Risk factors include poor parenting, low
academic achievement, poor peer
relationships, low self-esteem
Protective factors include resilience,
family support, positive peer
relationships, good health

Risk for Other-Directed Violence
Noncompliance
Ineffective Coping
Impaired Social Interaction
Chronic Low Self-Esteem
Nursing diagnoses include:
Treatment
Early intervention is more effective;
prevention is more effective than treatment:
Preschool programs
Parenting education
Social skills training
Family therapy
Individual therapy
Antipsychotics, lithium, or other mood
stabilizers such as carbamazepine (Tegretol)
or valproic acid (Depakote) for labile moods
or aggressive behavior
Intervention
Decreasing violence and increasing compliance
with treatment
Limit setting
Behavioral contract
Consistent
Time-out
Daily schedule
Improving coping skills and self-esteem
Promoting social interaction
Providing client and family education
Application of the Nursing Process:
Conduct Disorder (contd)

Feeding and Eating Disorders
Pica: persistent ingestion of
nonnutritive substances
Rumination disorder: repeated
regurgitation and rechewing of food
Feeding disorder: persistent failure to
eat and gain/maintain adequate weight

Tic Disorders
Rapid, sudden, recurrent, nonrhythmic
stereotyped motor movement or
vocalization
Familial tendencies
Treated with atypical antipsychotics
such as olanzapine or risperidone

Tic Disorders (contd)
Tourettes Disorder
Multiple motor tics and one or more vocal
tics; vocal tics can be name-calling or
profanity
Person is embarrassed and self-conscious and
has significant impairment in academic,
social, and occupational areas
Chronic Motor or Tic Disorder
Involves either vocal or motor tics, not both
Elimination Disorders
Encopresis: defecating in inappropriate
places by a child of at least 4 years
Involuntary encopresis associated with constipation that
occurs for psychological, not medical, reasons
Intentional encopresis associated with oppositional defiant
disorder or conduct disorder
Enuresis: repeated urination during day
or night in clothes or bed after age 5
Most often involuntary
Intentional enuresis associated with a disruptive behavior
disorder

Separation Anxiety Disorder
Excessive anxiety about separation
from home or loved ones, exceeding
what would be expected
Results from combination of:
Temperament traits (passivity,
avoidance, fearful or shy of novel
situations)
Parenting behaviors that encourage
avoidance as a way to deal with
unknown situations
Selective Mutism
Persistent failure to speak in social
situations where speaking is
expected
Excessively shy, socially
withdrawn, isolated, clinging,
temper tantrums
Reactive Attachment Disorder
Markedly disturbed and
developmentally inappropriate
social relatedness in most situations
Associated with grossly pathogenic
care
Begins before age 5

Stereotypic Movement Disorder
Repetitive, nonfunctional motor
behavior that interferes with normal
activities or results in self-injury
requiring medical treatment
Waving, rocking, twirling objects, biting fingernails,
banging the head, biting or hitting oneself, or
picking at the skin or body orifices
Associated with many metabolic,
genetic, and neurologic disorders and
mental retardation
Cause unknown
Self-Awareness Issues
Recognize own beliefs about parenting
and how they differ from others
Focus on patients strengths, not just
problems
Try to have positive impact on child
even when disability is severe
Support parents