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Caring for the Child with a Psychosocial or Cognitive Condition

The thing most people want is genuine understanding. If you can understand the feelings and moods of another person you have something to offer.
Paul Brock

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LEA R NING T AR GETS At the completion of this chapter, the student will be able to:

Explain the importance of integrating aspects of developmental psychopathology, and intergenerational transmission of vulnerability and resilience to form a framework to understand how to promote childrens cognitive and psychosocial health. Explore intervention options for children with cognitive and psychosocial problems/disorders. Describe the inuence of ethnicity and culture on the promotion of childrens cognitive and psychosocial health. Examine the incidence of the various cognitive and psychosocial problems/disorders. Relate how developmentally sensitive approaches are used in identication of disorders and strengths used to devise a care plan. Describe criteria for referring children for mental health evaluation or psychological testing.

moving toward evidence-based practice Childhood Depression and Alcohol Use


Wu, P., Bird, H.R., Liu, X., Fan, B., Fuller, C., Shen, S., Durate, C.S., & Canino, G.J. (2006). Childhood depressive symptoms and early onset of alcohol use. Pediatrics, 118(5), 19071915.

The purpose of this study was to examine the relationship between depressive symptoms and the early onset of alcohol use in children and adolescents. The investigation was based on data from a longitudinal study of psychopathology in 2491 children and early adolescents, ages 513 years. A subsample of 1119 children ages 1013 years who reported never having used alcohol at the initiation of the study also completed the baseline and follow-up interviews. All of the children in the study had a Puerto Rican background. Data collection included several types of measurements: A structured interview was conducted with both parents and children. The interview included assessing the children for affective disorders, anxiety disorders, disruptive behavior disorders, and substance abuse and dependence disorders using the Diagnostic Interview Schedule for Children (DISC-IV) and based on the criteria identied in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV).

For study purposes, alcohol use was dened as drinking a full can or bottle of beer, a glass of wine or wine cooler, a shot of liquor, or a mixed drink with liquor in it. Depressive symptoms were considered positive if reported by either the parent or child. The numbers of depressive symptoms were measured in categories: 2 (low level depressive symptoms); 29 (medium-level depressive symptoms); and 10 (high-level depressive symptoms). Parents were asked about the presence of emotional, alcohol, or drug problems in either parent. Parents completed a parental monitoring Likert-type scale that consisted of nine questions. The purpose of the tool was to determine how often the parent monitored the childs television watching, video game playing, and other activities in or outside of the home. A high score indicated a high level of parental monitoring. The parents use of discipline was measured through an interview that consisted of six items regarding the use of physical
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moving toward evidence-based practice (continued) and verbal abuse, various forms of punishments and the withholding of affection. Maternal warmth and support was evaluated using a 13-item Likert-type scale. A high score indicated a close maternalchild relationship. A four-item tool that related to parental behaviors including hitting, beating, or badly hurting the child was used to assess physical abuse. A positive response to any of the four questions was considered to be consistent with physical abuse. Measured socioeconomic factors included the age of the child, gender, highest level of parental education, and family structure/composition (i.e., the number of parent gures). Data analysis revealed the following ndings: One hundred and ten (9.8%) of children who had not used alcohol at the time of the initial interview reported the use of alcohol at the rst follow-up. The rates of alcohol use varied according to the level of depression: at the baseline interview, those with 1 depressive symptoms reported an alcohol use rate of 4.1%; those with 29 depressive symptoms reported an alcohol use rate of 10.2%; and those with 10 symptoms reported an alcohol use rate of 14.1%. Sociodemographic factors revealed that the age of the child was positively associated with the timing of the onset of alcohol use and that parental education made little difference in the childs use of alcohol. No association was found between alcohol use and the childs gender or whether the child lived in a singleparent home. Parent psychopathology and child physical abuse were positively associated with alcohol use in the child. No association was found between alcohol use and a close maternal relationship or the level of parental discipline. Sensation seeking, exposure to violence, and antisocial behaviors were identied as risk factors for child alcohol use. No relationship was found between the childs alcohol use and church attendance or the presence of stressful live events. Children with high-level depressive symptoms and mediumlevel depressive symptoms were more likely to use alcohol than those with low-level symptoms. Children with fewer than two depressive symptoms were less likely to begin drinking than those with two or more depressive symptoms. An early onset of alcohol use may be impacted by early life depressive symptoms. In addition, the presence of parent psychopathology, exposure to violence, and antisocial behaviors were also found to be signicant risk factors for the early onset of alcohol use in children. 1. What might be considered as limitations to this study? 2. How is this information useful to clinical nursing practice? See Suggested Responses for Moving Toward Evidence-Based Practice on the Electronic Study Guide or DavisPlus.

Introduction
Understanding the normal neurological, cognitive, and emotional development of children is important in determining if they are functioning within their appropriate developmental level. For example, developmentally expected anxiety in infants and young children may suddenly arise as a fear of strangers or in response to separation from caregivers. This typically occurs between 7 to 12 months and peaks between 9 to 18 months, but decreases for most children by age 2 1/2 (Zero to Three, 2005a). Also, a child may have an inherent anxious temperament and may be inhibited when encountering new situations, people, or objects and may respond to these with fear and withdrawal. Likewise, nurses should note that normal behaviors for young children (imaginary friends, concrete thinking, etc.) are interpreted differently when displayed in adults (as signs of schizophrenia). Awareness of language development is important in determining learning disabilities, developmental disabilities, or autism. Most children do not develop cognitive or psychosocial disorders. However, it is important for the nurse to have a good history of developmental milestones, including language development, sensory perception, emotion regulation, motor skills, attention, and memory (Denham, 2006; Heffelnger & Mrakotsky, 2006).

Developmental Psychopathology
This chapter uses a framework based on developmental psychopathology, which draws on multiple theoretical models and literature across scientic disciplines, to help explain the interaction between normality and pathology at various stages of child and adolescent development. Developmental psychopathology is an actual discipline that evolved from the contribution of multiple elds of study with the goal to provide understanding between psychopathology and normal adaptation (Cicchetti & Posner, 2005). It combines developmental, biological, and social theories to track deviations from developmental norms as they relate to psychological pathologies. This reects an understanding that adaptive and maladaptive (mental illness) patterns can occur in infancy, childhood, or adolescence. In addition, and most importantly, it is thought that individuals with psychopathologies have the ability to function in an adaptive way. It is expected through the use of this framework that the nurse will gain understanding into individual patterns of cognitive and psychosocial child/adolescent health. Understanding of developmental psychopathology may aid in the prevention and early intervention of mental illness (maladaptive patterns).

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Vulnerability and Resilience


Vulnerability and resilience are important topics in the care of children. The intergenerational transmission model is based on the premise that vulnerability toward maladjustment or resilience in the face of adversity may be passed on from one generation to the next. It is important that the nurse working with children and their families have a good understanding of the key concepts of intergenerational transmission of vulnerability and resilience. Vulnerability is dened as a predispositional factor, or set of factors, that makes a disorder state possible (Ingram & Luxton, 2005, p. 34). Children with resilience show positive adaptation despite signicant life adversity (Cicchetti, 2003). Optimizing Outcomes Understanding resilience
in the face of vulnerability

It is important to keep in mind that not all offspring of parents with mental health issues go on to develop mental health-related problems themselves. In fact, the children of parents or caregivers with mental health issues who do not exhibit any maladjustment or symptoms of mental health problems during childhood are known to be resilient children (Hammen, 2003). Researchers in this area of study found that much can be learned about mental health wellbeing from these children. The best outcome gained from this knowledge can be used to prevent and promote good mental health for all children.

beliefs about health). Race is used to describe categories of people, mostly based on physical characteristics (e.g., skin color, shape of nose). Another issue that deserves a great deal of attention from the nursing community involves health disparities. There is vast information research indicating that health care disparities in racial and ethnic minorities are widespread compared to those in non-minorities, and barriers such as mistrust, fear, and discrimination stand in the way of optimal mental health outcomes in ethnically diverse families (Heffernan, 2004). For instance, the nurse must recognize that new immigrants may be concerned with learning the language and getting and keeping a job, and may focus only on their childrens basic health care needs (e.g., vaccines, treatment for ear infection) and may not at all attend to childrens cognitive and psychosocial health needs. It is important that the nurse do a thorough assessment of health care needs, including cognitive and psychosocial wellbeing. Given the magnitude of mental health disparities in children and adolescents, nurses at all levels of practice along with other health care providers must become better prepared to implement strategies designed to reduce health care disparities. In particular, nurses are well positioned to take a leadership role in the movement toward abating and eliminating health care disparities (Heffernan, 2004).

Nursing Insight Understanding mental health


disparities in children
In contrast to younger children, adolescents have the necessary cognitive and social structures to be able to perceive discrimination. In a study with Latino children and adolescents, researchers found that adolescents who perceived severe discrimination had poorer mental health outcomes compared with their peers (Szalacha et al., 2003). This indicates that childrens perceptions about how they are treated make an important difference in their own mental health outcomes. It is therefore important for the nurse to assess childrens perceptions of how they are viewed by others, including health care professionals.

Culture, Diversity, and Health Disparities


The anthropological model of culture, ethnicity, and race disputes beliefs that culture and race are innate (Smedley & Smedley, 2005). Within an anthropological framework, culture and race are learned behaviors. This dynamic view can be used to illustrate the value of how culture and diversity inuence childrens and families cognitive and psychosocial health. Culture is considered to be an external and acquired phenomenon. It is the complex set of beliefs and attributes passed on within a group. Ethnicity refers to groups of people who share similar cultural characteristics (i.e., common language, religion, food, and

Ethnocultural Considerations Promoting


understanding of culture in diverse families
where research and practice meet:
Is Mental Illness Passed Along to Children? In a study of 166 low-income and racially diverse adolescent children of mentally ill mothers, Mowbray et al. (2004) discovered that the majority of children (30.1%) were actually socially and academically procient, whereas, 15.1% of the children showed anxiety and depression with poor social and academic competence. In addition, 27.1% of the children were delinquent and peer-oriented, and 4.8% were classied as isolated noncomformists. Of the total children, 22.3% were in the middle of these groups (Mowbray et al., 2004). The intergenerational transmission of vulnerability and resilience model is important to consider while the nurse conducts assessment, formulates a nursing diagnosis, devises preventive interventions or plan of care for the child or family, and nally executes evaluation. It is important that nurses gain an in-depth understanding regarding the culture of various people; acquire sensitivity and empathy in working with diverse families (e.g., give up preconceived notions or generalizations about particular ethnic or racial groups); and attain skills in relationship building with children, adolescents, and parents/caregivers of various ethnic and racial backgrounds. It is recommended that nurses working with children and families of diverse socioeconomic backgrounds take an approach of listening, providing as much positive feedback as possible for what families are doing well and keep resilience-promoting strategies in mind. Using anticipatory guidance, nurses working with children and their families may be most effective suggesting alternative ways of handling a specic cognitive or psychosocial-related concern.

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In this way, nurses can provide health and psychoeducation in a nonthreatening way to help families decide what works best for them.

Psychopathology in Children
Children and adolescents are not immune to mental and emotional illnesses. Mental illness in children and adolescents may be confusing and frightening for children and families. The disorders can be quite devastating, particularly if they are not detected and treated.

There is also a awed belief that poverty predisposes children and families to mental illness. Although it needs to be studied more thoroughly, there is evidence suggesting that poverty by itself does not cause mental health problems in children and families (Rutter, 2003). Strategies outlined above for nurses to decrease health care disparities also apply in working with families who may be poor, disenfranchised, affected by substance abuse, family violence, and child maltreatment.

ANXIETY
Anxiety disorders are among the most common psychiatric complaints in children. While children commonly experience transient anxieties at various developmental points, clinically signicant anxiety must be recognized as a problem. It is important to distinguish between developmentally expected anxiety, anxious temperament, and symptoms of a disorder. The following diagnostic categories related to anxiety disorders have been identied in the Diagnostic and Statistical Manual (DSM-IV-TR): separation anxiety disorder (SAD), generalized anxiety disorder (GAD), specic phobia, panic disorder, social phobia, selective mutism, posttraumatic stress disorder, and obsessivecompulsive disorder (OCD) (American Psychiatric Association [APA], 2000). In separation anxiety disorder, children experience overwhelming fear of becoming separated from or losing a caregiver (Fig. 23-1). The nurse understands that some degree of separation anxiety is normal at various stages of development and during transitions, but if the anxiety is severe and excessively disruptive, and if it persists for longer than 4 weeks, the child should be evaluated by a mental health professional. In GAD, children experience excessive worry about everything, including peer relationships, social acceptance, and pleasing others. Specic phobia refers to unrelenting fear of certain objects or situations (i.e., spiders, storms, snakes, water). These may be difcult to evaluate because

Barriers to Child and Adolescent Mental Health


There are a number of barriers to the diagnosis and treatment of childrens cognitive and psychosocial health. A brief overview is provided here to help the nurse gain an understanding of the issues in order to intervene to minimize these barriers. Though there are increasing efforts to educate the public, the stigma of mental illness continues to be a major barrier to accessing mental health services for children and their families (Hinshaw, 2006). The health care community and the lay public have long been skeptical about whether young children, in particular, experience clinically signicant mental health disorders, such as depression. There is a prominent belief that childhood is a sacred happy time free of problems. Health care providers have also had a role in perpetuating barriers by minimizing or dismissing parents or caregivers concerns. Parents may be told that the child is simply going through a stage that will pass, when there are indeed grounds for concern (e.g., early signs of autism spectrum disorder). It is important for the nurse to understand that this type of thinking may lead to several issues for children, adolescents, and their families such as: (1) not getting screened on a timely basis for disordered behaviors and emotional difculties that often can be attenuated or resolved if early intervention is sought in a timely fashion; (2) having a sense of shame for the family if a child or adolescent is eventually diagnosed with a mental health problem that might have been prevented or attenuated earlier; and (3) inability to receive adequate mental health or psychosocial treatment when indicated because of lack of resources (Hinshaw, 2005).

where research and practice meet:


Injury Control Research Centers (ICRC) The Department of Health and Human Services Center for Disease Control and Prevention; Injury Control Research Centers (ICRC) serves to conduct research about injury control in the areas of prevention, acute care, and rehabilitation. In addition, the ICRC serve as training and public information centers. This valuable research can help nurses to understand violent behaviors in youth today (U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2008).

Figure 23-1 This child is displaying signs of separation anxiety.

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at each developmental stage children and adolescents have various expected fears. Panic disorder usually begins in adolescence but may start earlier. Symptoms of a panic attack might include palpitations, sweating, shaking, nausea, dizziness, fear of dying, tingling sensations, chills, or hot ushes. Selective mutism refers to a childs enduring refusal to speak in certain situations. This refusal interferes with the childs functioning and development and is not due to physiological or decit of knowledge. Posttraumatic stress disorder occurs in response to a perceived or actual threat to ones life or safety. There is a clear precipitant and a reaction is generally understandable. The response may persist for weeks, months, or years and is accompanied by panic symptoms. In obsessive compulsive disorder (OCD), the child experiences sometimes debilitating recurrent worries or thoughts (obsessions) and repetitive actions or thoughts that to bind the anxious thoughts (compulsions). It is estimated that 13% of children between the ages of 9 and 17 suffer with some type of anxiety disorder (Substance Abuse and Mental Health Services Administration [SAMHSA], n.d.). Nearly 50% of children with anxiety disorders have at least one other psychiatric disorder (SAMSHA, n.d.).
Signs and Symptoms

It is important for the nurse to understand normal developmental anxiety. This understanding provides a baseline from which to judge the occurrence of clinically signicant distress. Anxiety is an important factor in motivation and alertness. Worries and fears are a part of every developmental stage, even throughout adulthood. An occasional bout of feeling nervous accompanied by sweating, nausea, diarrhea, worry, and/or tearfulness is well within normal limits. But when the anxiety does not abate or it gets worse with time, it may be indicative of an anxiety disorder. The nurse should question a childs or adolescents level of anxiety if it does not respond to reassurance or closeness with a safe person or if it interferes with functioning. Anxiety often presents in the form of somatic complaints like stomachaches and restlessness (Ginzburg, Riddle, & Davies, 2006). The school nurse can recognize anxiety problems when a child persistently presents with symptoms that do not have a recognizable physical cause. Children or adolescents with clinically diagnosable anxiety disorders may suffer from persistent worry, unfounded fears, separation difculties, sleep problems, or obsessions or compulsions (Cleveland Clinic, 2007). Anxious children may also resist going to school or staying there after arriving. They may avoid play time, even with good friends, and not be able to explain why.
Diagnosis

lessen their impact on children. Simply paying attention to any signs of anxiety (SAMSHA, n.d.) is the rst step in recognizing clinically signicant symptoms. The nurse should refer a child to a mental health professional if the childs anxiety interferes with normal functioning or if it persists regardless of attempts to reassure the child. The nurse can provide health teaching related to what makes the child anxious or worried and how to cope with such worries. Teaching may involve teaching relaxation and deep breathing as well as problem-solving techniques (Tomb & Hunter, 2004). Young people are more likely to respond to someone who takes the time to listen and care. Current Western culture is lled with scary images, whether in the form of games, movies, television, or actual events in the news. It is important for the nurse to understand and to help parents think about how and when to protect children from the inux of information that might be overwhelming. There are several evidence-based therapies provided by qualied advanced practice clinicians. The pediatric nurse can be aware of some of these therapies in order to assist parents in nding a referral. The Coping Cat program is designed for children ages 7 to 13 with anxiety disorders and the CAT program is for adolescents (Kendall, Aschenbrand, & Hudson, 2003). Both of these cognitivebehavioral programs are designed to help the child develop skills to cope with anxiety, as well as techniques to decrease fears through systematic exposure to the feared object. These programs are intended to be used with children and adolescents who have SAD, GAD, and social phobia. The FRIENDS program was designed for the parents as well as their children with anxiety disorders (Barrett & Shortt, 2003). It is similar to the Coping Cat in that it uses cognitivebehavioral techniques to help children and their families cope with anxiety. FRIENDS is an acronym for Feeling worried? Relax and feel good. Inner thoughts. Explore plans. Nice work so reward yourself. Dont forget to practice. Stay calm, you know how to cope. This program has proved to be useful in reducing the risk of development of anxiety disorders in children (Barrett, Farrell, Ollendick, & Dadds, 2006), but has proven less useful when used to prevent depression (Spence & Shortt, 2007).

Complementary Care: Mindful breathing


Mindfulness means paying attention in the present moment. Paying attention to ones breathing may be a way of coping with anxiety. The teaching works best before an anxiety episode. The nurse teaches slow breathing by telling the child to (Fig. 23-2):

As with any emotional or psychiatric difculty, a complete physical, psychosocial and family history helps reveal genetic, biological, and familial contributors to anxiety.
Nursing Care

Consciously direct your attention to your breathing. Breathe in slowly, paying attention as the air enters nose
and mouth and lling your lungs.

Breathe out slowly, paying attention as the air leaves


your body.

There are specic interventions that a nurse may do to help prevent anxiety disorders from occurring or to

Allow your mind to follow the breath in and out. Imagine yourself in a rubber raft riding the gentle waves
of your breath.

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Signs and Symptoms

After a trauma, a child with PTSD exhibits symptoms within each of the following sets of reactions: Re-experiencing the trauma, perhaps in the form of a ashback (intense remembering of the event while feeling as if it were happening at the present moment), nightmares, or sensations. Avoidance of anything that could trigger the memories, through dissociation (a sense of being detached emotionally, mentally, and perhaps even physically) or avoiding places or events reminiscent of the trauma. Physiological symptoms of anxious arousal (insomnia, startle response, sense of panic) (Commission on Adolescent Anxiety Disorders, 2005). The hallmark symptoms of PTSD in children are nightmares, ashbacks, dissociative experiences, psychological and/or physiological distress at reminders of the traumatic event, irritability, anger, hypervigilance, new fears and anxieties and many other symptoms that may interfere with adjustment and daily functioning (Scheeringa, 2006).
Diagnosis

Figure 23-2 The nurse teaches the child how to reduce anxiety with slow breathing.

POSTTRAUMATIC STRESS DISORDER


Posttraumatic stress disorder (PTSD) is an anxiety disorder that occurs in response to a real or perceived trauma or threat to ones life or safety. PTSD in young children has been the subject of great debate at professional meetings because not all children who have endured trauma present with a neat and simple set of symptoms (Scheeringa, 2006). It is known that the types of events that are experienced by young children as traumatic are similar to those of older children, adolescents, adults, and elderly (e.g., automobile crashes, natural disasters, war, witnessing brutal deaths) (Scheeringa, 2006). Other types of trauma, like physical or sexual abuse, or witnessing of domestic violence can be devastating for the child and can cause PTSD that persists even into adulthood if not treated. Children who endure trauma often exhibit additional symptomatology to that of PTSD and frequently may suffer from comorbid disorders such as depression, conduct disorders, and other anxiety disorders as well as physical disorders. While the current DSM-IV-TR (APA, 2000) criteria are not developmentally sensitive for young children, they are used by most clinicians to help develop a diagnosis. Many children do not experience all of the criteria required to meet the DSM diagnosis, but children can still suffer greatly with the anxiety resulting from the original trauma.

A complete history reveals a traumatic event(s) that may help diagnosis PTSD. Diagnosis is based on the symptoms and reaction(s) to the event.
Nursing Care

Nursing Insight Posttraumatic stress disorder


in adolescence
Adolescence is a time of experimentation and of a sense of invincibility. For those reasons, adolescents may be more likely to be in a position to experience traumatic events, thus being exposed to the possibility of PTSD. In a survey of American adolescents, researchers found that 23% had been both a victim and witness a traumatic event (i.e., assault) and more than 20% had symptoms that met criteria for PTSD (Commission on Adolescent Anxiety Disorders, 2005).

Many children who endure posttraumatic distress may not be brought into a health care facility for clinical intervention. A signicant number of seriously traumatized children enter treatment through the court system after having experienced abuse or serious loss within the family of origin (Osofsky, 2004). The nurse may come in contact with these children in primary care or in school or other settings. In the community, the nurse can be instrumental in educating parents about the symptoms and helping the family and child by making referrals for appropriate services. The nurse can reinforce that it is important to provide a secure base for the child, one that includes family or caregivers willingness to be available to and comfort the child without judgment. Be aware of resources available that might provide play therapy for young children and their parents (Van Horn & Lieberman, 2006) or cognitive behavioral therapies (CBTs) for older children. The nurse can also teach the family that pharmacotherapy with selective serotonin reuptake inhibitors (SSRIs) has also been known to be effective in adolescents (Commission on Adolescent Anxiety Disorders, 2005). Implementing nursing care similar to that given with any anxious child may help to allay fears. During an acute panic episode when the child is re-experiencing the triggering event or feels completely out of control, the nurse must remain with him, talk soothingly, and reassure the child that the nurse is providing personal safety.

Mood Disorders
Similar to adult psychiatric disorders, pediatric mood disorders may take the form of major depression (serious, timelimited depression), dysthymic disorder (longer-term, less

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intense depression), or bipolar disorder (consisting of mood swings between depression and mania). These disorders are sometimes more difcult to diagnose in children and adolescents than in adults because of developmental phases and the lack of language and cognitive skills to describe symptoms and experiences. Health care providers may also not have adequate knowledge about prior symptoms.

in solving problems, responding to caregivers or sustaining attention. An example is a drop in grades and/or school performance. Recurrent thoughts of death or suicide with or without a suicide plan, and in younger children consistent engagement in activities or play that involve themes of death and suicide. Depression in infants may include: Listlessness without physical cause Failure to respond to caregiver The nurse understands that symptoms in the infant and very young child mirror the symptoms of attachment disorders and failure to thrive.
Diagnosis

DEPRESSION
Infants born of mothers who have been signicantly depressed or stressed during pregnancy can exhibit depressive symptoms (listlessness, failure to attach, irritability) (Commission on Adolescent Depression & Bipolar Disorder, 2005). Likewise, infants who are unable to attach securely or who are listless or irritable may be difcult for the mother to care for and show attachment. This behavior can perpetuate disengaged attachment and depression in the infant. Some studies have indicated that children as young as 3 years old are capable of experiencing depressive disorders (Luby et al., 2003, 2006). These depressions may be related to environmental factors combined with genetic and biological factors. Depressive symptoms are estimated to occur in 10% to 15% of children and adolescents. Untreated depression in a young person often increases the likelihood of recurrent depression or bipolar illness later in life. For this reason it is important to recognize and treat depression early on (SAMHSA, n.d.).
Signs and Symptoms

Diagnosis is based on the exhibited depressive symptoms.


Nursing Care

Five key features must be present and persistent for most days during a period of 2 weeks for the diagnosis of a major depressive disorder in children and adolescents. The nurse must remember that children can have just a few of these depressive symptoms that will interfere with optimal functioning. This list of symptoms was compiled based on several diagnostic classication publications to reect a developmentally sensitive criterion (APA, 2000; Greenspan, 2005; Zero to Three, 2005b): Persistent sad or irritable moodby subjective report (e.g., sad or empty) or observed by others (e.g., appears tearful). This mood is different from the childs baseline emotional and behavioral state, and is unrelated to events that may cause temporary distress or sadness (e.g., getting a time-out). Loss of interest in activities once enjoyed (anhedonia) reported by child or observed by others. Signicant change in appetite or body weightweight loss or gain reected by more than a 5% change in body weight. Difculty sleeping or oversleepinginsomnia or hypersomnia (excessive sleep). Physical agitation or slowingobserved by others and the childs subjective report of being restless or slowed down. Fatigue or loss of energy. Feelings of worthlessness or excessive/inappropriate guilt. Decreased ability to think or concentrate or to make decisions as self-reported or observed by others, and in younger children this sign may appear as difculty

The most important aspect of helping a depressed child is to ensure safety. It is recommended that any nurse working with a child who is depressed understand how to deal with the potential suicide ideation or intent. Since depression often goes unrecognized in children or adolescents, the nurse can be instrumental in determining its presence. Pediatric and school nurses are in a position to observe changes in a childs behavior and demeanor as well as grades. Developing a trusting relationship with a child and asking about feelings or thoughts may provide evidence of underlying depression and provide the child with a rst step in feeling better. Nurses should talk with the parent(s) or caregiver(s) of a child about suspected depression and suggest referral to a counselor for evaluation and treatment.

BIPOLAR DISORDER
Bipolar disorder (BPD), also known as manicdepression, is a mood disorder that is evidenced by signicant mood swings (from depression to mania). It is thought that childhood or adolescent onset bipolar disorder may have an extended early course and may respond less

medication: Somatic Therapies for Depression


Serotonin Selective Reuptake Inhibitors (SSRIs): Open-label studies suggest that uoxetine (Prozac) is an effective medication in the treatment of pediatric major depression and dysthymia in patients with and without co-occurring mental health disorders (Findling, Feeny, Stansbrey, Delorto-Bedoya, & Demeter, 2001). This type of medication has been used in children as young as 8 years old (National Institute of Mental Health [NIMH], 2001). Other SSRIs are used off-label (meaning use other than specically approved for by the Food & Drug Administration [FDA]) such as sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), escitalopram (Lexipro), or uvoxamine (Luvox) have also been prescribed by some clinicians (NIMH, 2001). NOTE: Recent evidence that SSRIs can contribute to suicide ideation in adolescents and children have left many parents and physicians leery of using this medication to treat depression in young people.

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N u r s i n g C a r e P l a n Depressed Child
Nursing Diagnosis: Self-Esteem: Situational Low related to cognitive and perceptual distortions
Measurable Short-term Goal: Child will use positive talk to interrupt negative thinking about self. Measurable Long-term Goal: Child will demonstrate increased self-esteem by accepting positive feedback

from others
NOC Outcome: NIC Interventions:

Self-Esteem (1205) Personal judgment of self-worth


Nursing Interventions:

Self-Esteem Enhancement (5400) Active Listening (4920)

1. Listen actively to child, displaying interest without judgment or responding too quickly.
RATIONALE: Active listening shows attention to the message and respect for the childs thinking and perceptions. Monitor and help the child to identify statements reecting perceived self-worth. RATIONALE: Provides information about distorted or negative perceptions. Assist the child to examine perceptions of self reected in negative self-talk and turn these into positive statements of self-worth. RATIONALE: Allows replacement of negative self-evaluations with positive statements that enhance self-esteem. Encourage the child to identify personal strengths and accept valid positive responses from others. RATIONALE: Helps the child develop positive self-esteem. Assist child to set realistic goals to enhance self-esteem, providing appropriate praise or rewards for progress. RATIONALE: Positive reinforcement supports progress in meeting realistic personal goals.

2. 3.

4. 5.

favorably to treatment. Children and adolescents with bipolar disorder may have coexisting mental health disorders as well (e.g., attention-decit/hyperactivity disorder, oppositional deant disorder, conduct disorder, anxiety disorder, and substance abuse) (Kowatch et al., 2005). There are three recognized types of bipolar disorder. Bipolar disorder I (BD-I) is dened by the presence of depressive and manic episodes. Bipolar disorder II (BD-II) is characterized by episodes of hypomania (a lesser degree of mania) and depression. Bipolar disorder not otherwise specied (BD-NOS) is commonly the diagnosis given to children when the DSM-IV-TR (APA, 2000) criteria for BD-I and II are not specically met but who show symptoms of bipolar illness. There are little denitive data related to incidence of BD-I since many of the studies done to date have not used standardized criteria to explain the onset of symptoms. The overall lifetime pervasiveness of BD beginning between 15 and 17 is 1.3%. Typically the disorder is diagnosed in early adulthood. While BD was originally thought to be relatively rare in children, more research efforts are aimed at identifying and understanding this disorder.
Signs and Symptoms

Nursing Insight Bipolar disorder


Mania Severe changes in moodeither extremely irritable or overly silly and elated Overly inated self-esteem; grandiosity Increased energy Decreased need for sleepable to go with very little or no sleep for days without tiring Increased talkingtalks too much, too fast; changes topics too quickly; cannot be interrupted Distractibilityattention moves constantly from one thing to the next Hypersexualityincreased sexual thoughts, feelings, or behaviors; use of explicit sexual language Increased goal-directed activity or physical agitation Disregard of riskexcessive involvement in risky behaviors or activities Depression Persistent sad or irritable mood Loss of interest in activities once enjoyed Signicant change in appetite or body weight Difculty sleeping or oversleeping Physical agitation or slowing Loss of energy Feelings of worthlessness or inappropriate guilt Difculty concentrating Recurrent thoughts of death or suicide

Since BPD is a combination of major depression and mania, the nurse must be aware of symptoms associated with BPD. Both manic and depressive symptoms, as described by the National Institute of Mental Health (2000) are listed.

Source: NIMH (2000). Child & adolescent bipolar disorder: An update from the National Institute of Mental Health. (NIH Publication Number: 004778). Retrieved from http://www.nimh.nih.gov/publication/index.cfm

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Although young children do not have distinct episodes of mania, children may have severe mood dysregulation with multiple, intense, prolonged mood swings each day (Kowatch et al., 2005). Also, children are more likely to display irritability or destructiveness than adults who display euphoria.
Diagnosis

nurse can have the family visit the following Web site for more information about bipolar disorder: http://www. bpkids.org, a parent-led organization that provides supportive information for children, caregivers, and families.
Now Can You Differentiate between depression and
bipolar disorder? 1. Describe the signs and symptoms of depression and bipolar disorder? 2. Describe nursing care for the child with depression or bipolar disorder?

Diagnosis is based on a thorough history and physical as well as the identication of the signicant mood swings (from depression to mania). Often family members or signicant others can describe the behavior that may help lead to a diagnosis.
Nursing Care

It is important for the nurse to recognize that if a child is in an acutely manic state, the child is struggling against an internal force and is not being a bad child. The nurse can teach the family and the child, as well as model the following therapeutic parenting techniques presented by the Child and Adolescent Bipolar Foundation (CABF, 2008): Practice and teach relaxation techniques Use rm restraint holds to control rages Prioritize battles and let go of less important matters Reduce stress in the home Use good listening and communication skills Use music and sound, lighting, water, and massage to assist the child with waking, falling asleep, and relaxation Become an advocate for stress reduction and other accommodations at school Help the child anticipate and avoid, or prepare for stressful situations by developing coping strategies beforehand Engage the childs creativity through activities that express and channel gifts and strengths Provide routines, structure and freedom within limits Remove objects from the home (or lock them in a safe place) that could be used to harm self or others during a rage, especially guns Keep medications in a locked cabinet or box

SUICIDE
Suicide represents a devastating consequence resulting from any number of psychiatric difculties. What was relatively rare before the mid-1950s has now become an alarmingly frequent occurrence. Barrio (2007) summarized potential factors that might inuence a child or adolescent to consider or attempt suicide: (1) certain psychiatric disorders that may be related to a sense of helplessness (depression, substance abuse, anxiety disorders, or aggressive disorders); (2) a history of family or friend having attempted or actually committed suicide; (3) personal or familial biological factors (related to depression and/or impulsivity); (4) environmental factors , such as accessibility of a means (guns, poison, etc.), or lack of connection or supervision; previous suicide attempts; and/or (5) disenfranchised status (sexual orientation, minority status). According to the National Center for Health Statistics, suicide is the third leading cause of death in young people 10 to 24 years of age, which in 2004 translated in into the following statistics: 1.3 children (ages 10 to 14) per 100,000, 8.2 adolescents (ages 15 to 19) per 100,000, and 12.5 young adults (ages 20 to 24) per 100,000. Younger children more often resorted to suffocation as a method to kill themselves while older children tended to use rearms or poison. There were gender differences that identied males as four times more likely in their adolescents and six times more likely in early adulthood to succeed at suicide than females (Centers for Disease Control and Prevention [CDC], n.d.). This difference may be due to the choice of method (males tend to chose more lethal means).
Signs and Symptoms

It is also important to note that a person should be present to care for a child experiencing a depressed phase of bipolar disorder. Just in case the diagnosis of bipolar disorder is missed, and an antidepressant is prescribed, the nurse understands that an antidepressant could trigger mania. It is important to fully assess history of symptoms and to teach the family what to watch for in terms of the childs reaction to the medication(s). The

The nurse should suspect suicide potential when faced with any of the following in the child or adolescent: Symptoms of depression or other mental illness Alienation or withdrawal from friendships or relationships Personality changes Decline in schoolwork Giving away personal possessions that were once prized Preoccupation with death in writing or drawings References to dying or no longer being around Access to a method of suicide (e.g., medications, weapons)

medication: Valproate (Depakote)


The nurse needs to be aware that most medications used for the treatment of bipolar disorder have not been studied specically with children. Lithium carbonate (Eskalith, Lithobid) has been the most common treatment. It is a mood stabilizer that calms the manic symptoms.

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Diagnosis

clinical alert
Suicidal behavior related to antidepressant therapy In 2006, the Food and Drug Administration (FDA) requested that pharmaceutical companies manufacturing SSRIs add a black box warning to the packaging. This warning is related to an apparent rise in suicide in children and adolescents recently prescribed an SSRI for depression. Subsequent studies discussed by Goodman, Murphy, & Storch (2007) related that the increased incidence of suicide ideation and attempt was not universal, nor was it related only to those diagnosed with depression, but also in children taking SSRIs for other disorders. The evidence is controversial because other studies have shown antidepressants to be very effective in decreasing the suicide risk by effectively dealing with the underlying causes. Several factors have been proposed to explain the occurrence of suicidal ideation in children treated with these medications. (1) The prescription may be an inadequate dose and therefore the depression is not treated. (2) An energizing phenomenon, which describes a situation in which the depressive symptoms related to energy decrease before the mood symptoms, may occur, thus making it more possible for the depressed individual to have the energy to attempt suicide. (3) The emergence of an activation syndrome may be related to a toxic reaction to the medication. (4) Motor restlessness related to akathisia (motor restlessness that may appear as a side effect of antipsychotic medication) may occur. (5) A shift from depression to mania in a not-yet-diagnosed bipolar child may occur. (6) Idiosyncratic reactions (perhaps related to gene-drug reactions) may occur (Goodman et al., 2007).

Nursing Insight Assessing the child for


suicide risk
If the nurse is concerned that a child or adolescent might be suicidal, the nurse must ask the child about suicidal thoughts or behaviors. This information may help to save the childs life. Have you thought about doing something to hurt yourself or take your life? Do you ever wish you were not alive? What would you do if you were to hurt yourself?

When a child or adolescent gives information that indicates risk for suicidal behavior, the nurse must take steps to keep the child or adolescent safe and make a referral for immediate mental health evaluation.
Nursing Care

The school nurse is in a position to recognize children or adolescents who might be suicidal. This care involves awareness of the signs of suicide ideation and the risk factors that may precede suicide ideation. The nurse must ask about suicide ideation. The nurse can discern: Does the child have a plan? Is that plan possible (i.e., is the means to self-harm accessible)? Has the child attempted suicide before? Foremost, if any of these factors are present, the nurse must refer the child (and family) to a mental health professional that can assess the level of risk. The child or adolescent may need immediate hospitalization to remain safe. If danger is not imminent, the nurse can assist the child or adolescent and the family in identifying and further developing the protective factors available to them. The nurse can identify family strengths and resources available in the community (crisis or suicide hot lines, counseling, inpatient treatment facilities) to help protect the child. The nurse can also talk with the family about other measures that can be implemented to keep their child safe (e.g., remove all guns or other weapons from the home, ridding cupboards of poisons, locking medicines away, monitor the child closely). Specic psychotherapeutic approaches like cognitive behavior therapy (CBT) or dialectical behavior therapy (DBT) focuses on helping the child and adolescent develop skills for coping with emotional intensity and impulsivity (Katz, Cox, Gunasekara, & Miller, 2004). Both types of therapy are performed by specically educated clinicians, but the nurse, particularly in the hospital, can be supportive. Pharmacological treatments include medications to treat the underlying psychiatric difculty (Table 23-1). In the community, the nurse can raise awareness about the programs that seek to prevent suicidal behavior in adolescents. There are some school-based programs that target students who are at-risk for dropping out of school and assist the child or adolescent to remain involved in school. Once a child or adolescent has dropped out of school, economic and social changes also might play a role in suicidal thoughts. In addition, the child or adolescent may be more susceptible to feelings of hopelessness and isolation.

SCHIZOPHRENIA
Schizophrenia is a serious chronic mental health disorder that is thought to be the result of abnormalities in neurodevelopmental processes that occur early (prenatal, infancy, early childhood) as well as later (late childhood and adolescence) in life (Bearden, Meyer, Loewy, Niendam, & Cannon, 2006). The disorder typically begins in late adolescence or early adulthood, but it is possible for children as young as 5 or 6 to exhibit signs. Researchers have found that the age at onset of schizophrenia plays an important role in the course and outcome of illness. The earlier the onset of symptoms occur, the greater the impairment (Bearden et al., 2006). Although schizophrenia is a chronic mental illness, early recognition and treatment can vastly improve the outcome for the child. Untreated, schizophrenia can be devastating for the individual and the family. Schizophrenia is rarer in children younger than preadolescence. About 1% of the worlds population (adult, adolescent, and child) is identied with a diagnosis of schizophrenia (Nicholson & Rapoport, 1999, cited in NIMH, 2001). Further complicating the diagnosis is that early symptoms are similar to those of pervasive developmental disorders such as autism. In some cases, it is thought that a pervasive developmental disorder is a precursor of schizophrenia.
Signs and Symptoms

The nurse knows that discerning the signs and symptoms of schizophrenia begins with a mental health interview that includes a comprehensive developmental and family history. Schizophrenia typically has a gradual onset, is difcult to identify in young children, and may

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Table 23-1 Pharmacological Treatments for Psychological Difculties


Category
Antianxiety

Medications Beta blockers Propanolol (Inderal) Alpha blockers Clonidine (Catapres)

Uses Anxiety

Antidepressants

Selective serotonin uptake inhibitors (SSRIs) Fluoxetine (Prozac) Sertraline (Zoloft) Paroxetine (Paxil) Citalopram (Celexa) Escitalopram (Lexapro) Fluvoxamine (Luvox) Tricyclics Imipramine (Tofranil) Clomipramine (Anafranil) Other Bupropion (Wellbutrin) Venlafaxine

Depression Anxiety OCD Elective mutism

Enuresis Autism

Mood Stabilizer

Lithium carbonate (Lithobid, Lithane, or Eskalith)

Bipolar disorder Mania ODD ADHD

Anticonvulsants

Valproate (Depakote)

Bipolar disorder Mania

Antipsychotics

Traditional Haloperidol (Haldol) Atypical Risperidone (Risperdal) Olanzapine (Zyprexa) Quetiapine (Seroquel) Ziprasidone (Geodon) Aripiprazole (Abilify)

Autism Psychosis Tourettes syndrome Behavioral problems related to other psychiatric disorders (conduct disorder, ADHD, MR)

Stimulants

Methylphenidate (Ritalin and Concerta) Dextroamphetamine (Dexedrine and Adderall)

ADHD

Nonstimulants

Atomoxetine (Strattera)

ADHD

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be indistinguishable from other disorders. The nurse understands that it is important to recognize early signs and symptoms and begin treatment as early as possible (Commission on Adolescent Schizophrenia, 2005). There are two types of symptoms in the presentation of schizophrenia. Positive symptoms are those that are generally seen after observing and listening to the parent or the child. These symptoms include hallucinations (hearing voices, seeing things, experiencing strange sensations), delusions (false beliefs, i.e., beliefs that the radio is sending special messages), and disorganized speech and behavior (APA, 2000). Negative symptoms are less obvious. These symptoms include a decrease or attening of affect (visible expression of mood), speech, and motivation (APA, 2000).
Diagnosis

organization is the National Alliance for the Mentally Ill (NAMI; www.nami.org) that provides parents and families with important information. The nurse is in an ideal position to help identify children and adolescents with early prodromal signs and refer for further evaluation, family psychoeducation, and other interventions such as understanding the importance of medication.

AUTISM SPECTRUM DISORDERS


Autism spectrum disorder (ASD) can be rst diagnosed in infancy or childhood. The DSM-IV-TR denes autism spectrum disorder as a continuum of disorders that involve limitations in social relatedness, verbal and nonverbal communication, and the range of interests and behaviors (APA, 2000). There are ve specic autism spectrum diagnoses. Pervasive developmental disorder (PDD) is the term used by DSM-IV-TR and is synonymous with autism spectrum disorders. The ve pervasive developmental disorders include autistic disorder (serious decits in the development of social and communication skills accompanied by signicant repetitive behaviors), Aspergers disorder (a milder form of autistic disorder), Retts disorder (a rare disorder that predominantly affects girls; development is normal until around 6 to 18 months when autistic symptoms appear), childhood disintegrative disorder (a rare disorder in which the child usually develops normally until age 2 before developing symptoms of autism; predominantly affects boys), and pervasive developmental disorder not otherwise specied (a disorder in which either autism or Aspergers is suspected but the diagnostic criteria are not fully met) (APA, 2000; Ozonoff, Rogers, & Hendren, 2003).
Signs and Symptoms

A diagnosis of schizophrenia is based on a mental health interview that includes a comprehensive developmental and family history. If the child has had has a gradual onset of the signs and symptoms this condition may be suspected. Before the actual evidence of diagnostic symptoms there is often a prodromal (period marked by a shifting in personality) and the emergence of odd behaviors (i.e., withdrawal, obsessions, aloofness), thoughts (distractibility), or emotions (lability, anxiety). Diagnosis may be conrmed by the presence of initial and subsequent psychoses such as hallucinations, delusions, disorganized thinking and speech, lack of motivation and interest in life, and aberrant emotional expressions (Bearden et al., 2006).
Nursing Care

Early treatment for schizophrenia usually involves pharmacological agents (e.g., atypical antipsychotics), adolescent and family psychoeducation, and brief psychotherapy aimed at increasing level of functioning. Treatment is usually divided into the acute and maintenance phase. To obtain the best outcome, the adolescent and family should always stay in treatment (Commission on Adolescent Schizophrenia, 2005). Acute treatment for active psychosis (hallucinations, delusions, fearfulness, acting out) consists of maintaining the safety of the child and others. It is frightening to lose sight of reality. The child may act out against misperceived threats and injure self or others. The majority of treatment at this point is pharmacological adjustment. The nurse uses therapeutic communication to convey a sense of security to the child and family. It is also important to approach the child in a calm and reassuring manner. If the symptoms are severe the child may be hospitalized. The schizophrenic child will always need to take medications to control symptoms. Pharmacological treatment involves the use of antipsychotic medications such as Risperidone (Risperdal), Olanzapine (Zyprexa), and quietapine fumarate (Seroquel). Other forms of care for the child include group training in social skill acquisition (as most schizophrenic children have inadequate social skills) and cognitive behavioral therapy (CBT). Nursing care also includes educating the child and family about the importance of taking the medications and related side effects. Families of children with schizophrenia, like those with any chronic difcult illness, may need ongoing support. There are organizations that offer support and advocacy for families of the mentally ill. One such

Three clusters of symptoms characterize autism spectrum disorder (ASD). The rst symptom cluster involves qualitative impairment in social reciprocity which means the child is unable to engage in socially appropriate communication. This impairment is marked by poor eye contact, lack of interest in other people, and failure to interact appropriately with others. The second symptom cluster is characterized by communication impairment. The child either uses no language at all, or exhibits deviant speech with errors in tone, prosody, pitch, grammar, or pragmatics. Errors in pragmatics, such as difculty taking turns in conversation, are particularly common in higher functioning individuals. Restrictive and repetitive behaviors, interests, or activities characterize the third symptom cluster. Specically, restrictive interests are narrow in focus, overly intense, and/or unusual. An example might include experiencing sensory qualities of objects in unusual ways (e.g., snifng objects or playing with toys in unusual ways). Another example of unusual interests would be a preoccupation with the parts of a toy rather than enjoying the toy. Restrictive behavior is characterized by unreasonable insistence on sameness or following familiar routines in a very rigid or extreme way. Repetitive behavior is a common symptom that is displayed by children with autism spectrum disorder through repetitive motor mannerisms such as hand apping or spinning or rocking, these movements are called stereotypies or tics (sudden uncontrollable movement or vocalization).

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Nursing Insight Autism spectrum disorders


The reported number of children with autism spectrum disorders has increased since the early 1990s. Whether there is a true increase in prevalence or whether past rates were underreported is a matter of debate. The factors involved in understanding the potential increase in prevalence include that the true prevalence rates 10 or 20 years ago are difcult to ascertain retrospectively; changes in diagnostic criteria, e.g., the concept of autism is now viewed as a spectrum of disorders; a heightened public awareness of autism; and increased media coverage of affected children and families. Also relevant is that in 1991, the US Department of Education added autism as a category for special education services. It is speculated that this change led to increases in the number of children classied as autistic, because a diagnosis would allow children to take part in available educational services (Yeargin-Allsopp et al., 2003). The CDC estimates that 1 in 166 children are diagnosed with an autism spectrum disorder (CDC, 2004).

Diagnosis

In 2003, a partnership between the American Pediatric Association and the Center for Disease Control created a program called First Signs. This widely disseminated public awareness campaign was designed to increase pediatric primary care provider and parental awareness about the signs and symptoms of autism. Based on this awareness, a thorough developmental history can be conducted that can lead to an early diagnosis.
Nursing Care

critical nursing action Understanding Autism Spectrum Disorder


The First Signs program uses the acronym Autism A.L.A.R.M. to highlight important clinical guidelines: Autism is prevalent (Wiseman, 2006): 1 out of 6 children are diagnosed with a developmental disorder and/or behavioral problem. 1 in 166 children are diagnosed with an autism spectrum disorder. Developmental disorders have subtle signs and may be easily missed. Listen to patients: Early signs of autism are often present before 18 months. Parents usually do have concerns that something is wrong. Parents generally do give accurate and quality information. When parents do not spontaneously raise concern, ask if they have any concerns.

Act early: Make screening and surveillance an important part of your practice (as endorsed by the AAP). Know the subtle differences between typical and atypical development. Learn to recognize red ags. Improve the quality of life for children and their families through early and appropriate intervention. Refer: To Early Intervention or a local school program (do not wait for a diagnosis). To an autism specialist, or team of specialists, immediately for a denitive diagnosis. To audiology and rule out a hearing impairment. To local community resources for help and family support. Monitor: Schedule a follow-up appointment to discuss concerns more thoroughly. Look for other features known to be associated with autism. Educate parents and provide them with up-to-date information. Advocate for families with local early intervention programs, schools, respite care agencies, and insurance companies. Continue surveillance and watch for additional or late signs of autism and/or other developmental disorders.

Nurses who work in primary care settings can provide care for children with autism. Awareness of the need for early intervention is important because of the substantial cortical plasticity (the ability of tissues to grow during early brain development). There are many successful nonmedical treatments for children with autism. One of the most important interventions involves early language development. Ozonoff et al. noted that language functioning is the strongest predictor of outcome in autism and very limited language at age ve is a powerful indicator of severe handicap in adulthood (2003, p. 134). Poor functional communication skills also contribute signicantly to the problematic behaviors that some autistic children display (e.g., poor frustration tolerance and aggression toward self or others). Equally important are interventions that address social competence. The nurse can teach parents that social skills training and acquisition groups provide the child with an opportunity to learn and practice appropriate social relatedness. Using the actions suggested in the mnemonic A.L.A.R.M., the nurse can assist the child and family in coping with this disorder. Children with autistic spectrum disorders respond best to structure and predictability. Learning and social interactions should be approached systematically and gradually, allowing the child to develop comfort with the concepts (Wiseman, 2006). As with the schizophrenic child, it is important to stay aware of the childs physical boundaries and reluctance to be touched by others.

Psychosocial and Cognitive Disorders


REACTIVE ATTACHMENT DISORDER
Reactive attachment disorder (RAD) mirrors the information on attachment theory. It is important to note that developmental research in attachment is vast and growing but that clinical research regarding attachment disorders is just beginning to emerge and there is much yet to be learned about assessment, prevention, and treatment (Stafford & Zeanah, 2006). There are few if any statistics citing the incidence of RAD. It is reportedly a rare disorder (APA, 2000). Adoptive and foster parents are most frequently faced with attachment difculties in children placed after the rst 11 months of life. There are two types of RAD: emotionally withdrawn/ inhibited and indiscriminately social/disinhibited. The inhibited RAD children usually lack the ability to seek and accept comfort, and to respond to or show affection. These children may have problems with emotion regulation evidenced by withdrawal, avoidance, and frozen watchfulness (APA, 2000).

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The disinhibited RAD children usually show more ability to interact with caregivers but seek comfort and affection from strangers indiscriminately (APA, 2000). This describes the child who arbitrarily wanders off with any stranger, not even thinking to turn back to ensure that the caregiver is near.

Nursing Insight Understanding reactive


attachment disorder
The nurse must rst understand how the attachment system works. Basically, the goal of the attachment system is designed to ensure survival of offspring by promoting mutual proximity of infants and caregivers, thereby providing protection from danger (Stafford & Zeanah, 2006, p. 231). Another role of the attachment system is to help with regulation of developing emotion in the infant and child (Stafford & Zeanah, 2006). The attachment system works in conjunction with other systems that include afliate, exploratory, and wariness (temperament) systems.

in treatment. Developing trust through meeting the childs basic needs or responding to cries or tantrums or listlessness with patience and consistency is exceptionally important. A child with RAD has no true concept about which basic needs will be met. When a caring person is available to the infant or child that person should receive support and education from professionals. Nurses can work with all types of families such as foster care families, families with children adopted from institutions, and children in other situations to help the family with RAD. It is important to let the families know that while the children need loving and nurturing, they may rebuff the care that is offered. Nurses can also identify barriers to intervention that might include parental mental health needs, substance abuse, family violence, and trauma. They can then mobilize the appropriate resources to involve children and families into recovery. Childparent psychotherapy is a respected intervention that should be considered and nurses can connect families with these services (Van Horn & Lieberman, 2006). clinical alert
Dangerous attachment therapies Nurses should know that there is a group of therapies to avoid for children with attachment disorders because of coercive techniques employed, and in fact these therapies have been dangerous as there have been child deaths related to treatment. These therapies are usually known as attachment therapy, holding therapy, rage reduction, and rebirth (Barth, Crea, John, Thoburn, & Quinton, 2005; Stafford & Zeanah, 2006).

Signs and Symptoms

Infants and children diagnosed with attachment disorders have usually endured neglect or maltreatment or have experienced severe trauma. Many of these children have been institutionalized during the rst year of life when the ability to connect with another is forming. The main sign/symptom is children who experience difculties attaching or bonding (even to a parent).
Diagnosis

There are currently no established tools to use to make a diagnosis of RAD, but a thorough clinical interview and observation is essential in identifying behaviors that suggest a diagnosis of attachment disorder (Stafford & Zeanah, 2006). Infants typically exhibit attachment patterns around 9 to 12 months of age. The pediatric nurse can aid in the diagnostic process by observing how the child interacts around parents and strangers. The medical diagnosis of RAD as per DSM-IV-TR (APA, 2000) requires that marked disturbances and developmentally inappropriate social relatedness symptoms start before the age of 5 and must be evident in most situations.
Nursing Care

FAILURE TO THRIVE
Failure to thrive (FTT) is not a diagnosis but a description of a condition that usually happens early in life when the infant does not meet age-appropriate weight gain (Locklin, 2005). It is known that FTT infants do not obtain or are unable to take in enough nutrition to adequately meet standard growth and weight expectations. Certain situations from a mental health perspective are related to the development of FTT. Families in vulnerable situations (e.g., poverty, young and/or single parent, mentally ill or substance-abusing parents), or those in which child abuse or neglect exist, are at risk for FTT. Bassali and Benjamin (2007) reported that in the 1980s, 1% to 5% of the admissions to tertiary care for children younger than 1 year were related to FTT and 10% of outpatient visits were related to FTT. This condition is more common in underdeveloped countries where poverty and hunger are more rampant. Poverty is by far the greatest determinant in FTT (Block & Krebs, 2006).
Signs and Symptoms

Since attachment disorders in infants and children result from the lack of opportunity to experience a caring relationship, this opportunity should be offered as a rst step

where research and practice meet:


Patterns of Attachment Through the Strange Situation procedure (Ainsworth, Blehar, Waters, & Wall, 1978) researchers are able to assess the infants or children organizational patterns of attachment during low- and high-stress episodes involving a caregiver. The patterns are divided into three categories of strategies: secure organized, insecure organized (avoidant, resistant, dependent), and insecure not organized (disorganized, controlling, defended/coercive, unclassied) (Stafford & Zeanah, 2006).

Assessment of the signs and symptoms of failure to thrive is accomplished by tracking the growth rate of the infant or child to determine if an actual lack of adequate progression exists. Physical examination and evaluation of the childs developmental status is also important, since lack of sufcient nutrition on an ongoing basis will affect the childs cognitive and emotional development. Beyond that, it is important to develop an understanding of the underlying cause(s).

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Historically, health care providers distinguished FTT according to organic (medical conditions or illnesses that would affect the childs ability to take in or use nutrition) versus nonorganic (related to abuse, neglect, or attachment difculties) classications. In recent years, however, these distinctions have been less useful as many children with FTT exhibit symptoms of both causes (Block & Krebs, 2006). As a result, there is much less emphasis on attributing FTT to a problematic infantcaregiver relationship or maternal deprivation (Locklin, 2005). Still, psychosocial factors cannot be ruled out without assessing the family situation as well as potential physiological causes.
Diagnosis

of the child, it must also encompass the emotional needs. If the nurse suspects neglect or abuse, steps must be taken to the appropriate child protection agency.
nursing diagnoses Failure to Thrive
Imbalanced Nutrition: less than body requirements related to inability to ingest or digest food or absorb nutrients because of biological or psychological factors Delayed Growth and Development related to inadequate caretaking, environmental and stimulation deciencies, or physical/psychosocial conditions Risk for Impaired Parenting related to unmet social and emotional needs of parental caregivers, ineffective role modeling, insufcient knowledge or crisis

Infants that have weights below the 3rd percentile or are two standard deviations below the mean for their gestational age on standardized growth charts are commonly diagnosed with FTT (Locklin, 2005) (Fig. 23-3).

ATTENTION-DEFICIT/HYPERACTIVITY DISORDER
Attention-decit/hyperactivity disorder (ADHD) is familiar to parents, school teachers, and others who know the child. Images of the overactive, talkative child bouncing off the walls, and always in trouble are likely portrayed. ADHD is one of the most publicized and perhaps overdiagnosed psychiatric conditions of childhood. A child can have attention-decit disorder with or without hyperactivity. The category of ADHD without hyperactivity typically has symptoms of distractibility. While ADHD without hyperactivity garners much less attention than ADHD with hyperactivity, it can cause just as much difculty in the life of the child and the family. The CDC indicated that a total of 4 million children between the ages of 3 and 17 have been diagnosed with ADHD. This comprises 6.5% of the children of the number of U.S. children born since the diagnosis of ADHD has been used.
Signs and Symptoms

Nursing Insight Failure to thrive


During a nursing assessment the nurse can discern: How does the caretaker interact with the child? Are there signs of abuse or neglect? Does the caretaker understand appropriate feeding amounts and routines? Does the caretaker mistakenly believe that a healthy adult diet (i.e., lower fat) is also healthy for an infant?

Nursing Care

A comprehensive history and physical examination are vital in identifying the source of the problem and developing a plan of care. There are sometimes challenging cases of FTT that require specialized intervention by developmental pediatric or mental health care providers. Nurses can help identify these cases and provide education regarding feeding practices and the importance of support for caregivers and families. The nurse can also provide support and reassurance to new mothers and caregivers who are struggling with FTT infants and young children. While nursing care must address the physiological needs

Symptoms of ADHD may include hyperactivity, impulsivity, distractibility, and inattention. Although ADHD is most often diagnosed in early school-age children, symptoms can be seen in much younger children. Children with these symptoms often have difculty with school performance as well as social and peer interaction. While poor school performance is usually the driving factor in seeking help for children with these symptoms, difculty with peer groups and family relationships are just as evident. Many children with ADHD also have comorbid conditions such as depression, anxiety, oppositional deant disorder, and learning disabilities.
Diagnosis

Figure 23-3 Failure to thrive.

Evaluations for ADHD are conducted by advanced practice nurses, physicians, and other heath care providers. For appropriate assessment of ADHD, the child must rst meet the diagnostic criteria outlined in the DSM-IV-TR (APA, 2000) (Table 23-2). When the criterion is met, the nal diagnosis requires evidence of the childs behavior in a variety of settings, such as classroom, during homework, or playtime. Evidence is obtained by asking parents, teachers, and other caregivers to complete rating scales about behavior. Additional information needed includes the age at onset of symptoms, duration of symptoms, and degree of impaired functioning.

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Table 23-2 Characteristics of Attention Decit Hyperactivity Disorder


Developmentally inappropriate or maladaptive symptoms consisting of either inattentive symptoms (1st column), hyperactive or impulsive symptoms (2nd column), or a combination (both columns). Inattention Hyperactivity or Impulsivity Distractibility Inability to complete projects Easily bored Disorganized Inattentiveness Avoidance of detailed tasks Forgetfulness Excessive energy and activity Restlessness Overactivity Inability to sit still or stay in one place for long Excessive talking Poor boundariesinterrupts or intrudes Difculty delaying

as positive versus negative reinforcement (used as often as possible when child demonstrates acceptable behavior). School nurses are in a position of supporting teaching and other staff in the use of behavioral charts. Pediatric nurses in the community can offer support to parents and families in ongoing use of behavior modication. Some families may resist medications. Other families may put all of their faith into medications, thus not following through with the entire treatment plan. It is important for the nurse to help the family make use of all of the treatment options available to them and to participate actively with their health provider(s) in developing a plan for their child.

OPPOSITIONAL DEFIANT DISORDER AND CONDUCT DISORDER


Antisocial behavior is at the core of disordered behavior that can often explode into clinical disorders most often known as oppositional deant disorder (ODD) and conduct disorder (CD). ODD and CD have multifactorial and complex etiologies. Studies have identied a number of biological and psychosocial factors that may be associated with the development of CD and ODD in children and adolescents. Among the biological factors is temperament, hormonal changes (especially in adolescence), neurotransmitter dysfunction, and prenatal toxin exposures (e.g., fetal alcohol exposure). Psychosocial factors include less competence in problem-solving skills, less ability to take on anothers viewpoint, family or parental history of depression, antisocial personality, and criminal behavior, disruptions in family functioning (e.g., parental conict, parenting practices), peer group rejection, and lower-socioeconomic background. Specically, there is evidence showing that parental hostile attributions and parental harsh discipline styles may lead to child behavioral problems (Dishion & Patterson, 2006).
Signs and Symptoms

Nursing Care

The nurse understands that ADHD is evaluated by using a variety of rating scales. Specic rating scales are the DuPaul ADHD Rating Scale, the Connors Parent/Teacher Rating Scale and the Child Behavior Checklist (teacher, parent versions) (Achenbach, 2001; Achenbach & Rescorla, 2000) have been validated as useful in diagnosing ADHD. Each of these rating scales asks caregiver or teacher rate the childs behavior (e.g., behavior occurs extremely often, often, sometimes, rarely or never). A school nurse may be trained to perform observations of the child while in class to assist in the information gathering. These scales in combination with a clinical family interview provide the examiner with valuable information to determine a diagnosis. A thorough clinical interview with the child is also important in determining the appropriate diagnosis and treatment. The most effective treatment for ADHD is a combination of pharmacological and psychosocial interventions. Using both modalities allows for the control or abatement of symptomatic behavior by the medication while at the same time working on changing maladaptive behavior patters through therapy with the child and family. When recommending psychosocial intervention, clinicians must keep in mind the developmental level of the child and family. Also, from a developmental psychopathology perspective it is important to inform the family that early intervention works best and that the child and family may have periods of adaptive and maladaptive behavior.
PHARMACOLOGICAL INTERVENTION. Stimulants are the most commonly used medication for this condition. Ritalin and other forms of methylphenidate, Adderall (amphetamine salts), and atomoxetine (Strattera), a nonstimulant medication, are commonly used in this condition. The FDA recently approved a transdermal methylphenidate patch for children 6 years and older. This patch was designed for children who were unable to swallow any tablets or capsules. PSYCHOSOCIAL INTERVENTION. The nurse recognizes that children often respond to therapeutic approaches that include behavioral therapy, rewards (sticker charts), as well

There is evidence indicating that early childhood problem behaviors may include noncompliance, oppositional behavior, and temper tantrums. Sometimes it can be difcult to distinguish between normative and problematic behavior in young children. It is important that the nurse become familiar with normal development stages and not to overpathologize negative behavior during childhood (Wakschlag & Danis, 2004). In middle childhood, children may show overt (e.g., hitting) and covert (e.g., saying mean things about a friend) antisocial behavior (experienced by others as aversive, disruptive and unpleasant), and relational aggression (aggression toward people who have a relationship with the child). It may be less clear about what behavior problems demonstrated in middle childhood may be grouped into either ODD or CD. Later in adolescence, behavior may include delinquency, substance abuse, and high-risk sexual behavior. The set of behavior problems typically exhibited in early childhood are often identied as oppositional deant disorder (ODD). Finally, behaviors observed later in adolescence are often identied as CD (Dishion & Patterson, 2006).

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where research and practice meet:


Oppositional Deant and Conduct Disorder Disruptive, aggressive, and antisocial behaviors in children are often the type of behaviors that lead families to seek help for psychosocialrelated problems. These behaviors are often difcult to tolerate by parents, family members, peers, teachers, and others. The nurse will encounter families with children exhibiting these behaviors. There are a number of preventive intervention studies that show promise for clinical application. One such study is the Family Check-UP (FCU), a randomized trial of parental management strategies used in the context of increasing young childrens autonomy. The FCU also addresses other familial issues including parental depression, housing and daycare needs, and feedback sessions using motivational interviewing approach. These management strategies were administered to the families of young children (enrolled when children were 1727 months old) and showed promising results. The ndings included decreased Child Behavior Check List [CBCL] Destructive Scale scores for 3-year-old boys and improved maternal engagement when children were 2 years of age (Shaw, Dishion, Supplee, Gardner, & Arnds, 2006).

The Incredible Years program (Baydar, Reid, & WebsterStratton, 2003): This program was developed by Carolyn Webster-Stratton, a pediatric nurse practitioner as well as a clinical psychologist. The program is an evidence-based intervention program designed to help parents and young children (ages 310) who have or are at-risk to develop aggressive, disobedient, hyperactive and inattentive behaviors. The Family Check-UP (FCU) (Dishion & Kavanagh, 2003; Shaw, Dishion, Supplee, Gardner, & Arnds, 2006): This intervention program assesses families to identify those with children at risk for substance abuse or antisocial behavior. These families are then offered support and therapeutic and case management services to decrease the risk factors.

Diagnosis

Improvement in self-report measures (Achenbach & Rescorla, 2000), and better criteria in the DSM-IV-TR as well as the help of other tools (Greenspan, 2005), has made it easier for clinicians to diagnose behavior disorders. What is less well known is the difference between ODD and CD. It is important to note that many children who meet the criteria for ODD or CD often have comorbid mental health problems and may also function poorly in interpersonal relationships with peers and caregivers (Dishion & Patterson, 2006).
Nursing Care

Evidence-based programs have been found to be effective across various socio-demographic and ethnic samples in the United States and northern European countries (Webster-Stratton, Reid, & Hammond, 2004). Some of the programs have also been implemented from a preventive perspective with at risk preschool and school-age families (Baydar et al., 2003). Although it takes special training, the programs are comprehensive and intensive. The programs are valuable for nurses to learn about in order to help families nd proper resources. The nurse can also help parents learn some basic behavioral techniques. For example, the nurse can teach the parent about the value of ignoring annoying behaviors exhibited by the child. If the behaviors do not present safety issues, ignoring the behavior can be one of the best ways of extinguishing it because the child does not garner the desired attention. The nurse can tell the parent that it is also important to offer positive verbal feedback when behaviors are within acceptable limits.

Nursing Insight Youth violence: Fact sheet


The Youth Violence: Fact Sheet at http://www.cdc.gov/ ncipc/factsheets/yvfacts.htm offers a comprehensive resource about the problem of violence (compiled and referenced from research and refereed articles). The nurse can access this information to be used as an educational tool when talking to youth and families about violence. Examples of fact sheet topics are the following: Occurrence Consequences Groups at Risk Risk Factors Individual Risk Factors Family Risk Factors Peer/School Risk Factors Community Risk Factors Protective Factors Individual Protective Factors Family Protective Factors Peer/School Protective Factors

Early assessment of these conditions is important, using multimethod and multi-informant approaches that include: self-report scales (e.g., CBCL), child interview, parent interview, physical assessment, observation of childparent interaction, and thorough family assessment (e.g., history of exposure to violence in the family and community). When working with children and adolescents who exhibit ODD or CD, it is important for the nurse to be aware and manage personal feelings that may be aroused by the patient and family. The nurse can educate the family about the family-based prevention and intervention programs.

Nursing Insight Prevention and intervention


programs using a family-based approach for oppositional deant disorder and conduct disorder
The NurseFamily Partnership (Olds, 2002): Incorporates nurse home visits by specially trained nurses to low-income rst-time families and their support systems. The nurse helps the family learn about preventive prenatal and postnatal health and offers support in maintaining optimum health. (Another resource is www.nursefamilypartnership.org).

Nursing care for this condition also includes educating the family about medications. It is important that the child and family understand the action, potential side effects, and additional information about prescribed medications. Children with ODD or CD may be prescribed

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medications from a number of categories such as stimulants for ADHD symptoms; antipsychotics for behavior regulation; mood stabilizers for regulation of high and low mood presentations; as well as antianxiety agents. Nurses who work with families that have children with ODD or CD must be mindful of the stress that these disorders have on the whole family. It may be exhausting for parents to cope with the deant behaviors. Siblings may be put at risk simply spending time with the misbehaved child. Respite care (short-term care) can give the family a rest from the child who has the disorder. Encouraging family members to take care of personal needs as well as the childs may be useful in helping them to nd balance in daily living.
nursing diagnoses Oppositional Deant Disorder and

premonitory urge (warning signal) (Spessot & Peterson, 2006). Tics occur more frequently in children than in adults. The incidence is estimated to be 5 to 30 per 10,000. The tic can begin as early as 2 years of age and can last throughout the lifetime with asymptomatic periods (APA, 2000).
Signs and Symptoms

Conduct Disorder
Ineffective coping related to personal vulnerability Impaired social interaction related to hostile, negative, and deant behavior Chronic low self-esteem related to difculties with positive social interactions Compromised family functioning related to inadequate information and family disorganization

Children with Tourettes syndrome often exhibit symptoms of other disorders, similar to obsessivecompulsive disorder (APA, 2000; Leckman et al., 2006; Snider & Swedo, 2003), autism spectrum disorders (Canitano & Vivanti, 2007), and ADHD (Leckman et al., 2006). Many of the symptoms are similar. Children with co-existing disorders are more likely to suffer depression, low self-esteem, negative peer acceptance, and poor school performance than those with tics alone (Leckman et al., 2006).
Diagnosis
diagnostic tools Tourettes Syndrome
The nurse can help the family recognize certain features of Tourettes syndrome to assist in the diagnosis of the condition: The child may have both multiple motor and one or more vocal tics present at some time but not necessarily concurrently. The tics occur several times a day The tics occur almost every day or intermittently throughout a period of more than 1 year. The onset of tics is before age 18 years. The disturbance is not due to the direct physiological effects of a substance or a general medical condition. (Canitano & Vivanti, 2007).

Tic Disorders
A tic is a sudden seemingly uncontrollable movement or vocalization. Many children in the elementary school age group experience motor tics (facial or bodily twitches or shrugs) that are mild and eventually spontaneously resolve Generally, tics are manageable when the child concentrates on controlling them, but they become worse when the child is under stress. Vocal (phonic) tics are characterized by bursts of yelling out words, grunts, and throatclearing (APA, 2000). Tics are more common in boys than in girls.

Nursing Care

TOURETTES SYNDROME
There are a number of tic disorders, including Tourettes syndrome, which is a motor and vocal tic disorder that may have a chronic motor or sometimes transient tic (APA, 2000). Specically, Tourettes syndrome most often includes chronic motor and phonic tics that vary in frequency, intensity, and complexity (Spessot & Peterson, 2006). Children may not initially know they exhibit tics but over time become aware of the behavior. By adolescence most children have become aware of the

where research and practice meet:


Parenting Patterns In a study, Dishion and Patterson (2006) differentiated the parenting patterns in families with children who exhibit antisocial and disruptive behavior from those of families whose children do not show these behavior problems. It was found that proactive parenting (engaging children in positive and joint activities, use of verbal cues that promote positive behavior in children) distracted children from misbehavior.

The nurse working with a child with Tourettes syndrome must recognize the impact the disorder has on the childs functioning and social relationships. The child becomes self-conscious and worried that he will blurt out words or utterances at inopportune times. The child may also be shunned or laughed at by peers who do not understand the behavior. The nurse can help the parents watch for signs that the child is being bullied by peers or siblings. In addition, the nurse can help teachers understand that the child cannot control the tics. Robertson et al. (1999, cited in Leckman et al., 2006) referenced two interesting features of Tourettes: (1) suggestible, meaning talking about tics can trigger the tic, (2) suppressible, meaning that if the child is told to stop the tic or can focus on the tic, the tic might be stopped momentarily. Tic disorders do not often cause impairment of daily living. In fact, many of the manifestations are actually mild. Nursing interventions are predominantly geared toward helping the child and family cope with the disorder. Tourettes and other tics can create stress for the child as the child may experience a low self-esteem. The nurse can also help the family watch for signs of coexisting disorders such as ADHD or OCD. Behavioral skills training and stress management can be helpful in teaching the child to recognize the warning signs and to better decrease stressful situations that might lead to tic episodes. Pharmacological interventions include the use of haloperidol (Haldol) or clonidine (Catapres).

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Maltreatment of Children
Child maltreatment is considered to be any action or failure to act by a person that endangers a childs physical or emotional health and development. A person is abusive if he or she fails to nurture the child, physically injures the child, or relates sexually to the child (U.S. Department of Health and Human Services [USDHHS], 2007). Child abuse may include physical, sexual, emotional abuse, and neglect. Child physical abuse may result in injury inicted by beating, pushing, kicking, pinching, burning, or chocking. Physical abuse includes shaken baby syndrome, which manifests as symptoms related to head trauma as a result of forceful shaking of the infant or young child. Child sexual abuse involves any sexually related act, usually between a child and an adult (related or not) that can include fondling, forced, or assented oral sex or intercourse, sodomy, exposing children to adult sexual behavior (showing pornography to children), and exploiting through child pornography or prostitution. Child emotional abuse includes any behavior, attitude, or failure to act that disrupts childrens socio-emotional development and mental health. Some examples include shaming or humiliating (ascribing derogatory labels to the child, you are worthless), intimidating (threatening and frightening). Child neglect involves failure to provide emotional and physical care as well as opportunity for education. Neglect is most common but also the most difcult to identify. Other types of abuse include Munchausen-by-proxy syndrome (a person, usually the mother, deliberately makes the child sick) as well as the electronic sexual luring (enticing via computer) of children.

contribute to child maltreatment. Children with disabilities or with difcult temperamental characteristics may be abused by frustrated or unprepared parents. Children of very young parents or young single mothers who live in poverty or in situations that are stressful may be more apt to abuse a child. Parents who suffer from mental or chronic physical illness may not have adequate resources available to deal with parenting. Other parents who have extremely stringent ideas of discipline may use harsh punishment. The signs and symptoms of abuse are multifaceted (Table 23-3).
Diagnosis

Abuse may be difcult to diagnosis. However, the health care provider can pay close attention to circumstances where the child is exposed to situations where there is excessive stress, marital conict, parental substance abuse and psychopathology, intergenerational history of abuse, beliefs that children need to be toughened up, and in families who experience hardships. Diagnosis of physical, sexual, or emotional abuse or neglect may take time, and a thorough family history, physical examination, and developmental assessment are necessary for diagnosis.
Nursing Care

Nursing Insight Incidence of child maltreatment


Statistics gathered routinely by the U.S. Department of Health and Human Services (DHHS) track the incidence of child maltreatment and give a breakdown of the incidence of the various types of maltreatment. In 2005, it was estimated that of the 899,000 U.S. (including Puerto Rico and the District of Columbia) children abused, 62.8% were neglected, 16.6% were physically abused, 9.3% had been sexually abused, and 7.1% were emotionally abused (DHHS, 2007). Of these children, 1460 children died related to their abuse or neglect (1.96 children per 100,000). These statistics reect only the cases that were reported and does not address those children subjected to other forms of domestic violence (parents abusing parents or elders). It also does not address the numbers of children and adolescents who are lured into online abuse experiences. Unfortunately, those responsible for maltreatment of children in the U.S. (perpetrators) are most often parents (79.4%). Other offenders include relatives (6.8%) or unrelated caregivers (10.1%) (DHHS, 2007).

Signs and Symptoms

Children from any family can exhibit any signs and symptoms of abuse, but there are certain children who are in a more vulnerable position. Child rearing can be difcult in normal circumstances, but additional stressors can

The nurse can be instrumental in the care of children who have experienced any type of abuse including family education, support, referral, and initiatives to help abate and ultimately stop child abuse (Lieberman & Van Horn, 2005). Educating parents about what to expect from parenthood and from child rearing may help the parents understand how to cope with some of the difcult times related to raising a child. Helping the parents develop resources for support such as babysitters, family members, community sites, and health care resources may help them nd ways to cope with parenting. In addition, the nurse can provide parents with information regarding normal stages of growth and development which may help the parents to avoid pressuring the child to develop faster than physiologically able. It may also be helpful to discuss with parents ways to discipline the child that does not involve physical or verbal aggression. The nurse can educate children and adolescents about the body and personal boundaries. The community nurse is sometimes the rst person who recognizes abuse or the person with whom a child is comfortable sharing information. The nurse understands that it is important to develop a safe and trusting relationship with children. It is also important that the nurse understands what steps to take in reporting maltreatment in children as well as implementing steps toward prevention and intervention. Efforts to stop abuse against children should include the following measures: decrease unintended pregnancies, stop the use of alcohol or drugs during pregnancy, decrease the use of drugs or alcohol by new parents, improve availability of and access to health care across the spectrum of the familys life, and help parents and caregivers learn about nonviolent parenting and discipline. The nurse can also be involved politically and educationally to promote these efforts. Health care professionals cite several reasons for underreporting suspected child abuse. For instance, despite the availability of education and training regarding how to

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Table 23-3 Physical, Sexual, Emotional Abuse and Neglect


Type of Abuse Physical: Bodily injury caused by intentional or unintentional physical aggression. Tactics of Abuse Beating, hitting, slapping, poisoning, kicking, pinching, biting, shoving, choking, pulling hair, burning Excessive corporal punishment Possible Signs and Symptoms in the Child Suspicious bruises, welts, or burns Unexplained fractures or dislocations New and healing or healed lacerations or abrasions Wariness of adults or caregivers Fearful of going home Acting out with aggression Shaken baby syndrome Retinal hemorrhages CNS injury Munchausen by proxy Sexual: Sexual acts involving an adult and a child. Penetration, incest, rape, oral sex, sodomy, fondling Violations of bodily privacy Exposing children to adult sexuality Commercial exploitation Sexual exploitation (prostitution or pornography) Prolonged or recurrent illnesses or injuries that cannot be explained Inappropriate or precocious interest in or knowledge of sexuality Poor peer relationships Sudden changes in behavior (regressive, acting out, sexual) Running away from home or substance abuse Rapidly declining school performance Suicide attempts Emotional: Attitude, behavior, or failure to act that interferes with a childs mental health or social development. Neglect: Pattern of failing to meet basic needs. Intimidation, belittling, shaming, lack of affection and warmth, habitual blaming, ignoring or rejection, extreme punishment, exposure to violence, child exploitation, child abduction Physical, educational, emotional Apathy, depression Hostility Difculty concentrating Clothing unsuited to the weather Poor hygiene Hunger Lack of supervision

report cases of child abuse and neglect, many professionals feel ill equipped to handle the situation once a case is identied. Contrary to current belief, professionals who report child abuse are not revealed to the family in question unless the caller chooses to disclose this information. Also, while all reports are taken seriously, not all reports result in the removal of the child from the home. Every reports is investigated but any action may or not be taken depending on the assessment (Childhelp National Child Abuse Hotline, n.d.). It is also important to note that the nurse is required to report any suspicion of child abuse or neglect.

rst be investigated before conrmed. After documented conrmation the child will be placed in a safe environment free of abuse. National Hotline in USA: 1-800-4-A-Child For more information consult the link: http://www.helpguide.org/mental/child_abuse_physical_ emotional_sexual_neglect.htm#online See also Vieth, Bottoms, & Perona (2006).

Substance Use and Abuse


Substance abuse refers to the repeated use of illicit substances (drugs or alcohol or inhalants) despite the negative consequences (APA, 2000). Substance dependence/ addiction refers to the physiological and/or emotional reliance on that substance (APA, 2000). The incidence of substance abuse by young people has waxed and waned over the decades, but its signicance cannot be ignored. It is known that 80% of deaths in adolescents involve accidents, homicides and suicides and in many of these cases drugs and alcohol are involved (Mayes & Suchman, 2006).

Be sure to Report cases of child abuse


To report suspected child abuse, the nurse can call the local enforcement agency and/or follow the clinical settings guidelines for reporting abuse. All U.S. states have mandatory reporting guidelines for professionally licensed health care workers/providers. It can be a difcult experience to report child abuse because of possible consequences to the child, family, and professional. It is important to remember that all allegations of child abuse must

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Clearly, the problem of alcohol and drug use and abuse in children and adolescents is a grave concern. Youth in the United States are exposed to drug or alcohol abuse at signicant rates. It is estimated that 8.2% of U.S. children, age 12 and older used an illicit substance (SAMHSA, 2003).

Nursing Insight Substance use and abuse


The literature and research is vast regarding drug and alcohol abuse and risk factors. An interesting body of literature involves studies examining biological and genetic factors, especially related to alcohol abuse (Mayes & Suchman, 2006). In studies of twins and family behaviors, researchers found evidence suggesting that both genetic predisposition and behavior were important in adolescents initial use of marijuana (Mayes & Suchman, 2006). These data seem to suggest that there may be an important link between genetic and environmental circumstances (Mayes & Suchman, 2006).

abuse, especially if there is a strong family and genetic history of abuse. Two tools that can be used in the identication of substance abuse are the CRAFFT (Knight, Sherritt, Shrier, Harris, & Chang, 2002) and the CAGE (Ewing, 1984). Both of these tools use simple acronyms to assist in the evaluation of drinking or drug use. After a thorough assessment is done the nurse can help the child and family nd community resources that may help conquer the substance abuse problem. Research indicates that nearly 80% of adolescents with substance abuse receive treatment (Commission on Adolescent Substance and Alcohol Abuse, 2005). There are many different types of treatment, but the most promising appears to be a family-based approach, as it shows the best outcomes for reduction in substance abuse in adolescents (Commission on Adolescent Substance and Alcohol Abuse, 2005). Family treatment means that the entire family receives psychoeducation regarding substance abuse.

Young people may abuse any of the substances abused by adults. The major factors determining which substances are used are availability and cost. Some of the more common substances of abuse for children and adolescents include alcohol, tobacco, marijuana, cocaine, ecstasy (MDMA), methamphetamine, other forms of stimulants, prescription medications (the childs own prescription, or medications stolen from a family member), and inhalants (e.g., glue, gasoline, white-out). It is essential that nurses not be naive about the possibility of substance abuse.
Signs and Symptoms

Eating Disorders
Eating disorders that are mostly apparent in adolescence are classied into four categories that include anorexia nervosa (purging or withholding), bulimia nervosa (binging and purging), binge eating disorder (binging without purging), and eating disorder not otherwise specied (EDNOC) (APA, 2000; Commission on Adolescent Eating Disorders, 2005). Eating disorders most often affect females but adolescent males are also known to suffer from these illnesses. Eating disorders are mostly a phenomenon of Westernized society and thus it is thought that Western media plays a role in these problems (Commission on Adolescent Eating Disorders, 2005). From a developmental psychopathology perspective, there are a number of risk factors that may cause the adolescent to develop an eating disorder. The physiological factors include hormonal and physical changes associated with puberty in conjunction with temperamental factors. In addition, possible genetic factors might contribute to the development of eating disorders (Steiner et al., 2003). Certain experiences can act protect the adolescent from eating disorders, including participation in high school sports that focus on the sport rather than on pursuit of thinness (Steiner et al., 2003) as well as supportive families and peer groups. The prevalence data found in community samples reports rates of 0.3% to 0.58% in female and 2% in male children and adolescents 11 to 20 years old (Commission on Adolescent Eating Disorders, 2005). These data provide limited information for several reasons. The research has ignored populations that have well documented incidences of eating disorders (e.g., children of ethnic minorities in Westernized countries and generally in children of non-Westernized society). Also, studies have not used uniform tools to measure the disorders.
Signs and Symptoms

Signs and symptoms of a child who is using and abusing may be surprisingly similar to those of depression and/or suicide. In fact, psychiatric disorders and the possibility of suicide ideation go hand in hand with the abuse of or addiction to illicit substances. The American Academy of Child & Adolescent Psychiatry (AACAP, n.d.) published a list online of some of the warning signs that a young person might be abusing alcohol or drugs: Physical: fatigue, repeated health complaints, red and glazed eyes, and a lasting cough Emotional: personality change, sudden mood changes, irritability, irresponsible behavior, low self-esteem, poor judgment, depression, and a general lack of interest Family: starting arguments, breaking rules, or withdrawing from the family School: decreased interest, negative attitude, drop in grades, many absences, truancy, and discipline problems Social problems: new friends who are less interested in standard home and school activities, problems with the law, and changes to less conventional styles of dress and music
Diagnosis

Diagnosis of s substance use and abuse is based on the physical, emotional and social factors exhibited by the child. A thorough family history is essential along with information about the childs physical and emotional health.
Nursing Care

Initial nursing care involves the use of screening tools to assess drug and alcohol use in children. The nurse is in an ideal position to identify adolescents at-risk for substance

In general, adolescents with eating disorders (anorexia or bulimia nervosa) have an inordinate concern with body image and body weight. Adolescents with eating disorders are often hiding behaviors related to food and caloric intake from others. It is also not unusual for these adolescents to have other co-occurring or resultant mental

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health and family psychosocial problems (e.g., depression, anxiety, and family discord) as well. Adolescents with anorexia nervosa usually lose up to 85% of ideal body weight by either restricting food or caloric intake or by consuming caloric intake but then purging by vomiting or vigorous physical activity (Commission on Adolescent Eating Disorders, 2005). These behaviors can result in physical symptoms including amenorrhea, weakness, or fatigue that interfere with general health and well-being. In some cases, symptoms may result in a life-threatening situation and even death.

work best. For guidelines and further information, the nurse should consult the American Academy of Pediatrics: Committee on Adolescence Identifying and Treating Eating Disorders http://aappolicy.aappublications.org/cgi/ reprint/pediatrics;111/1/204.pdf.

Obesity
The denition of obesity in children and adolescents has been debated a great deal by professionals in the eld. Recently researchers and care providers have agreed upon certain criteria. Youth are considered overweight if they reach a body mass index (BMI) above the 85th percentile and obese when the BMI is above the 95th percentile. These denitions take into account the childs or adolescents age and gender (Anderson & Butcher, 2006). While obesity is not technically classied as an eating disorder, the psychological factors involved are signicant. Being overweight or obese deserves the collaborative attention of pediatric primary care providers, nurses, nutritionists, educators, mental health specialists, public health researchers and clinicians, policy makers, parents and children, and others (Anderson & Butcher, 2006; Caprio, 2006). Daniels (2006) describes many of the physiological problems that go along with obesity including hypertension, diabetes, sleep disorders related to breathing difculties, and increased risk for cardiovascular disease. In addition to the physiological problems encountered, children who are overweight or obese may be teased or bullied by peers, leading to difculties with self-esteem and social development. Obesity in children and adolescents is widespread and is considered to be an important US and International public health problem. In the United States, 17% of children between the ages of 2 and 19 are obese. The breakdown of these statistics shows that 13.9% of 2- to 5-year-olds, 19% of 6- to 11-year-olds, and 17% of teens between 12 and 19 years old fall rate above the 95th percentile for weight related to their height. These statistics show a dramatic increase since the late 1980s and early 1990s (Ogden et al., 2006). Childhood obesity is of epidemic proportions.
Signs and Symptoms

clinical alert
Anorexia nervosa Anorexia nervosa can become a life-threatening problem or cause death because of severe weight loss that can result in electrolyte imbalance and hemodynamic instability.

Diagnosis

The diagnosis of anorexia nervosa or bulimia can be challenging and based on both physical and emotional signs and symptoms. Adolescents with this disorder are below their ideal body weight and are often preoccupied with food. During an interview, the adolescent may express that he or she refuses to eat or consumes very large amounts of calories and then purges by self-induced vomiting or using laxatives or other means (Commission on Adolescent Eating Disorders, 2005).
Nursing Care

The nurse can communicate to the family that treatment of anorexia nervosa and bulimia involves contacting a physician to address the physical symptoms based on the dangerously low body weight. In some instances, adolescents may require hospitalization to correct electrolyte imbalance and homodynamic stability. Because this condition has both physical and psychological implications, nurses caring for children with anorexia nervosa must have the appropriate education and training. Often, once the childs physical health has been stabilized the child is admitted to a psychological unit or directed to outpatient psychological care. Antidepressant and antipsychotic medications have yielded some promising results. Research shows that antidepressant medication in combination with cognitive behavior therapy has been effective in the treatment of adolescents with bulimia nervosa (Commission on Adolescent Eating Disorders, 2005). The nurse can provide support to the adolescent and family. Along with physical and mental care, adolescents with bulimia nervosa may need dental care for repair of dental erosion and cavities that result from vomiting. The nurse may be in the best position to identify early cases of eating disorders and refer for preventive individual and family treatment. The nurse has to keep in mind that the assessment needs to be conducted within a growth and developmental perspective and that intervention should be considered within a family-based approach. When making referrals for treatment, it is important to consider the skill level of the treatment clinician and often a team approach with expertise in this area of health and mental health

The nurse understands that it is important to identify obesity as early as possible in the child. The nurse can begin with a comprehensive individual and family history (diabetes, dyslipidemia, cardiovascular disease) and physical assessment as well examining a set of laboratory tests (e.g., metabolic prole). The height, weight, and body mass index (BMI) should be assessed and plotted on the charts identied by the CDC (Caprio, 2006). Currently there is research assessing the possible link between the environment (physical space available for children to be physically active) and obesity (Epstein, 2003). The link between environment and obesity is not yet conclusive (Sallis & Glanz, 2006). Golan and Crow (2004) present information about the obesogenic factors present in Western society. Obesogenic refers to the role that environment plays in the development of obesity (Pearce, Blakely, Witten, & Bartie, 2007; Swindburn & Egger, 2004). Certain factors found in modern Western lifestyles contribute to eating disorders in general, including the availability of high-density, highcaloric energy foods, decreased physical activity, inactivity,

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media (constant barrage of food commercials targeting children), and the glorication or thinness and diets (Golan & Crow, 2004). It is also important to assess individual and family attitudes and practices related to food and weight. Parents who are fearful that their child will become fat may inadvertently over restrict food to the point that the child hoards food or uses it for comfort. On the other hand, parents who do not understand or cannot afford a healthy diet may reinforce poor dietary habits.

habits that can last throughout the lifetime is essential. It is important to empathize with the child who expresses dissatisfaction with his or her weight and provide education and guidance related to healthful eating and exercise.

Across Care Settings: Prevention of childhood


obesity in schools
The school environment is a good community site to begin implementing prevention of obesity programs because it is the place where most children spend most of their awaking hours. The nurse can help ensure that the school provides healthy meals; replaces soda machines with water; promotes and improves physical activity, and provides education about nutrition, physical activity, and acceptable weight (Story, Kaphingst, & French, 2006). The nurse can become involved in school-based programs by providing health education that is known to promote healthy eating, physical activity, and well-being. The nurse can also become involved at other levels, including as a parent, researcher, and advocate for change in school policy.

Ethnocultural Considerations Disparities


in childhood obesity
Despite the fact that African American and Latino children and adolescents have higher prevalence rates of obesity compared to white children and adolescents, researchers have found that African American and Latino children receive much less attention related to obesity. It is also known that African American and Latino are also more likely to develop obesityrelated problems, such as type 2 diabetes (Caprio, 2006). Children in low-income families also experience higher levels of obesity. Access to high-quality, low-fat foods is limited, as is often the education of the parents in providing such foods. Lower-income families often have less access to programs than more privileged families have (Kumanyika & Grier, 2006). Nurses and especially nurses of African American and Latino backgrounds are well positioned to close the gap and help eliminate these disparities by becoming involved or taking leadership roles in programs that identify and involve these youngsters and their families in interventions.

Sleep Disorders
Sleep and lack of sleep is a complex issue. Reports of sleep problems in children are often identied by the parents or caregivers because children do not usually complain of sleep issues (Kryger, 2005). The childs sleep problem is an issue that can affect the entire family. Often, the nurse encounters sleep-deprived parents based on the childs sleeping difculties. During the nursing assessment, the nurse discovers that a variety of daytime difculties can contribute to sleeplessness at night. These difculties include the child taking long naps during the day, excessive caffeine consumption, worry and stress, or childhood illness. In addition, parents may communicate that teachers complain about the childs irritability or hyperactivity or about the child falling asleep during class. There are few studies about childhood sleeping patterns that include infants, children, and adolescents but the existing evidence provides some understanding into this important area of study (Owens & Mindell, 2005). It is estimated that about 25% of all children experience sleeping issues during childhood and the degree of problems varies from mild to severe difculties with falling asleep or staying asleep. Studies of childhood sleep disturbances, using mostly caregiver-reported data, suggest that 6% to 50% of preschool- and school-age children have sleeping problems (Owens & Mindell, 2005).
Signs and Symptoms

Diagnosis

Diagnosis of obesity is based on an excess of fat in proportion to lean body mass. Basically, the child is considered obese when his or her weight is greater than what is considered healthy for his or her height (BMI above the 95th percentile).
Nursing Care

An important role of the nurse is assessing the risk factors and early onset of obesity (family history, sedentary lifestyle, availability of healthy nutritional resources) in order to begin preventive teaching efforts. The nurse can communicate to families that the Women Infants and Children (WIC) program educates families and provides food packages to underprivileged families. In addition, clinic nurses have the opportunity to help new parents learn healthful attitudes about food and feeding. The nurse can use the information from Healthy People 2010 obesity prevention to guide family teaching. Improving the activity level of children and adolescents should be included in teaching. The nurse can be instrumental when working with school programs to offer adequate physical education along with academics. Nurses can also encourage parents to monitor their childs nutrition and activity levels, particularly passive entertainment (computer, television, or video games). The nurse should also be aware that dieting is not suggested for young people. In fact, in the long run restrictive eating often contributes to boomerang overweight or to other eating problems. Nevertheless, focusing on healthy eating

It is thought that the problem of sleep disorders stems from an interaction between neurodevelopment and behavior (Sheldon, 2005). Temperamental tendency for being awake at night, developmental issues, the quality of the childs health, and the way parents or caregivers manage the child sleep routines are all thought to play important roles in the outcome of sleep related difculties. Signs and symptoms of a child having a sleep disorder might include sleepwalking, difculties getting to sleep or staying asleep, nightmares, excessive daytime sleepiness, or irregularity of sleep routine (Owens & Mindell, 2005).

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Family Teaching Guidelines...


Sleep Hygiene Shelton (2005), a pediatric sleep medicine specialist, recommends the following sleep hygiene guidelines for children:

The nurse can help the family by providing support while listening without passing judgment and then provide information on sleep hygiene. Bathing before bedtime is not recommended
Did you know that a bath before bedtime is no longer considered to have a calming effect? The literature says that a bath before bedtime can have the opposite effect as it stimulates the child and therefore it is not recommended (Sheldon, 2005). The most important principles that nurses can suggest to parents are that there be a consistent bedtime and standard routines (Sheldon, 2005). The nurse can ask parents to describe the bedtime routines and help parents create good sleep hygiene habits for the child. Medications such as hypnotics may be prescribed for children, but it is thought that over time medications do not improve sleeping patterns in otherwise healthy children (Sheldon, 2005).

Provide a quiet, dark, and comfortable environment or bedroom. Set a strict bedtime and awake routine that remains consistent on a daily basis. Avoid long daytime naps. Allow a long space of time between day time nap and bedtime. Provide a healthy snack before bedtime so the child is not hungry. Avoid substances such as caffeine, chocolate, and medications that contain alcohol or other foods/beverages that are stimulating to children. Cut down on uids before bedtime so that a full bladder or wetness does not interrupt sleep. Avoid a high level of activity and television viewing before bedtime and replace it with quiet activities (e.g., reading books). Encourage children to fall asleep without the parent/ caregiver in the room.

case study Sleeping Issues


Paul is 4 years old, and according to his mother he has had sleeping difculties since he was born. He voices many fears, makes demands, and sometimes has tantrums at bedtime. He says he is afraid of the dark even though he has a night light in his room. Paul complains of being hungry as soon as he lies down in bed. Unless his mother stays in the room with Paul until he falls asleep, he does not stop crying and often becomes upset for no apparent reason. Paul takes an afternoon nap until 5:00 P.M. Now that the family is expecting a new baby they wish to have Pauls sleeping difculties under control. He has a bedtime of 8:00 P.M. but he does not get to sleep until 11:00 P.M. or midnight unless he has not napped during the day.

Diagnosis

Sleep disorders can be diagnosed based on a positive answer by the caregiver to one or more of these questions: Is it hard for your child to fall asleep? Is it hard for your child to stay asleep though the night? Does your child wake up feeling tired? Is your child sleepy during the day?

critical thinking questions


1. Name the priority nursing diagnosis related to this situation. 2. Discuss the importance of parental education and specic sleep hygiene techniques that the nurse can teach.
See Suggested Answers to Case Studies in text on the

Nursing Care

The nurse must listen carefully to the parents concerns about the childs sleeping issues. The nurse knows that it is important to discover this problem early, understand the causes of sleep disturbances, as well as to implement prevention and intervention strategies. Sheldon (2005) found that children who slept longer had higher intelligence test scores and performed better in school. The nurse can perform a thorough physical assessment of the child. Certain health conditions can interfere with sleeping, including cows milk allergies, otitis media, neurological disorders, attention-decit/hyperactivity disorder (ADHD), and some chronic illnesses. It is also important that the nurse conduct a thorough assessment of the childs sleeping patterns and how these patterns inuence the childs well-being and family functioning. A comprehensive assessment also includes development and behavior history. Sometimes diagnostic data conducted in a sleep laboratory can help confer a sleeprelated diagnosis. The electroencephalogram (EEG) is a diagnostic test that provides important data about stages of sleep as well as the integrity and development of the central nervous system (Sheldon, 2005).

Electronic Study Guide or DavisPlus.

Now Can You Discuss sleep disorders?


1. Explain how a nurse would assess a child who complains of sleep disorders. 2. How can sleep disorders be diagnosed? 3. Explain sleep hygiene.

Developmental Conditions
DEVELOPMENTAL DISABILITIES
Children and adolescents who are diagnosed with developmental disabilities are affected by the disparities in health care (Fisher, 2004). Goals related to developmental disabilities have been included in the Healthy People 2010 initiative as a step toward reducing those disparities. Developmental

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disabilities is a term that encompasses a number of disorders, including Down syndrome (DS), fragile X syndrome, and fetal alcohol spectrum disorders (FASD). Developmental disabilities may also co-occur with a variety of physical symptoms (seizures, sensory impairments, speech and language problems, and cerebral palsy). A number of factors that cause genetic conditions, such as Down syndrome or fragile X syndrome, result when abnormal genes are inherited from parents or when there are errors in genetic combinations. Metabolic conditions such as phenylketonuria (PKU) can lead to developmental disabilities if not recognized and treated early. Pregnancyrelated problems include alcohol ingestion or viral infection such as rubella. In addition, trauma or asphyxia during the birth process can lead to inadequate oxygen availability and may cause developmental disabilities. Certain illnesses or events that may occur during childhood or adolescence (e.g., whooping cough, measles or meningitis, extreme malnutrition, lack of medical care or exposure to toxins like lead or mercury, as well as head trauma) can contribute to the development of developmental disabilities (National Information Center for Children and Youth with Disabilities [NICHCY], 2004). As many as 3 out of every 100 people in the United States have developmental disabilities (The Arc, 2001, revised 2004). More than one half million children ages 6 to 21 have developmental disabilities and require special educational services in school.

quotient (IQ) score signicantly below average (i.e., below 70average score is 100); (2) limitations in functions of daily life, such as communication, social situations, and school activities (APA, 2000; CDC, 2005b); and (3) onset before the age of 18. There are four levels of developmental disabilities: Mild: IQ between 55 and 69; person generally able to live independently; by far the largest group of developmentally disabled children Moderate: IQ between 40 and 54; person able to function semi-independently with help Severe: IQ between 25 and 39; person generally requires institutionalization or very close monitoring Profound: IQ below 25; person requires total care The incidence of each type of developmental disability decreases with the severity of the difculty.
Diagnosis

Nursing Insight Fragile X syndrome


Fragile X syndrome (FXS) is the most common cause of developmental disabilities. It is caused by an expansion mutation in the fragile X gene (FMR1) located on the X chromosome (Wattendorf & Muenke, 2005, p. 111). FXS is known to affect 1 in 4000 male and 1 in 60008000 female children. This genetic disorder is typically not tested for unless there is a family history of developmental disabilities or dysmorphic physical features (e.g., elongated face, large ears, and macroorchidism in boys) associated with the disorder. It is estimated that about 25% of children with FXS also meet the criteria for autism spectrum disorder (ASD) as these children show difculties with relatedness, play, and communication and demonstrate repetitive behaviors. It can be difcult to distinguish between infants who have FXS and infants with other disorders as the physical features are not known to be the best marker of diagnosis. There is new research attempting to look at how best to differentiate these infants from others early on. A group of researchers have sought to examine early sensory-motor patterns through videotape analysis of infants with FXS vs. ASD in retrospective type of research (Baranek et al., 2005). It is imperative that early identication of the disorder be made and that early intervention with the child and family begin so there is the best opportunity to maximize positive outcomes for the child and family. The nurse has an important role to help identify the disorder and then provide family education, support, and connecting families with appropriate special education and health services.

Diagnosis of developmental disabilities is based on IQ and on the signs and symptoms seen during infancy based on the babys physical characteristics (facial features, head circumference) or signicant delays in reaching developmental milestones. Ofcial diagnosis of developmental disabilities is performed by a qualied clinician or a collaborative team of clinicians. These clinicians assess developmental progress at various stages of development as well as perform intelligence and achievement testing. With a conrmed diagnosis of developmental disabilities, the nurse can assess the level of functioning of the child and the family and determine their current level of need. The nurse can communicate to parents that using standardized tests can further suggest a diagnosis.
Nursing Care

Signs and Symptoms

Three criteria must be present for the diagnosis of developmental disabilities to be made: (1) an intelligence

Nursing assessment for developmental disabilities should entail prenatal history, birth history, and developmental progress. Each of these assessment categories provides the nurse and family with valuable information. The nurse understands that there is not one portrait of a developmental disabled child. Some mildly disabled children may not appear different. The nurse must remember that each type of disability has unique needs. An important aspect of nursing care is communication. The nurse can communicate to families that the most preventable forms of developmental disabilities are related to prenatal nutrition and abstinence from alcohol (CDC, n.d.). Genetic counseling may also be helpful, particularly in families where the parents are older or where there is history of fragile X. Promoting good prenatal care as well as encouraging parents to have their children immunized (CDC, n.d.), and enforcing safe practices when bike-riding or playing may help prevent developmental disabilities. Another focus of nursing care is educational and directed toward building life skills for the child based on the degree of disability. The goal is for the child or adolescent to develop the greatest level of functioning and skills possible to maintain daily living. The nurse can encourage the family to use physical therapy, speech and language therapy, and special educational opportunities. The nurse can teach the family about community resources such as the Special Olympics or schools for therapeutic horseback

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riding instruction. Group activities can build both motor and learning skills as well as provide socialization. For eligible school-aged children (including preschoolers), special education and related services are available most often through the public school system. The school teacher, nurse, and parents work together to develop an Individualized Education Plan (IEP). This plan addresses the childs unique needs and provides the services to meet the needs of each child.

DOWN SYNDROME
Down syndrome (DS) is the most common and readily identiable chromosomal abnormality associated with developmental disabilities. During cell development, the fetus receives 47 chromosomes instead of the normal 46. The extra chromosome changes the development of the body and the brain. Down syndrome affects approximately 1 in every 800 live births in the United States each year. Although a women of any age can have a child with Down syndrome, the chances increase for women older than 35 years of age.
Signs and Symptoms

serves to provide the best possible individualized care to children with DS so these individuals can make the most of personal capabilities. Nursing care should be geared to the special physical, developmental, and emotional needs of each child. The nurse can coordinate programs designed to help children with DS. These programs offer speech therapy, cognitive and social skills, self-help skills, as well as occupational and physical therapies that may improve gross and ne motor development. The nurse is also in a good position to help families cope emotionally with living with a child with disability.

Collaboration in Caring Raising public


awareness
The nurse has a responsibility to raise public awareness and acceptance about children with Down syndrome. Children with DS can be included in mainstream educational curriculum and society. The parent, nurse, school personnel, and other individuals in the community can develop an Individualized Education Plan (IEP). The nurse can also communicate to the family and public sector that the National Information Center for Children and Youth with Disabilities at www.nichcy.org is a good resource. The nurse can help the child with DS throughout the lifespan as the child grows into adulthood. Through improved public acceptance and increased community resources more opportunities for persons with disabilities to live and work independently in the community is possible.

The most common physical characteristics of DS are poor muscle tone, slanting eyes with folds of skin at inner corners (epicanthal folds), hyperexibility, short, broad hands with a single crease across the palm of one or both hands, broad feet with increased space between the rst and second toes, at bridge of the nose, short, low-set ears, short neck with extra folds of skin, small head, small oral cavity and airway, and short, high-pitched cries in infancy. In addition to distinct physical appearance, children with DS frequently have health-related issues. Approximately one third of babies with DS have heart defects, which can be surgically corrected, while some have gastrointestinal anomalies that require surgery. Visual and hearing problems are also common, along with speech difculty, as are sleeprelated issues often due to sleep apnea. Assessment of sleep issues should be conducted usually beginning with asking the caregiver if the child snores and has pauses in breathing during sleep. If that is the case, then further evaluation is needed and it begins with sleep studies that include electroencephalography (EEG). Children with DS are also prone to hypothyroidism and should be evaluated yearly. While this condition is potentially serious, proper diagnosis through an x-ray exam at age 3 can prevent serious injury.
Diagnosis

FETAL ALCOHOL SPECTRUM DISORDER


The teratogenic effects (causing abnormal development of the embryo) of alcohol have long been recognized. Warnings against drinking while pregnant are carried on all alcoholic beverages. Still, fetal alcohol spectrum disorder (FASD) is a common disorder with a range of physical and neurodevelopmental problems that are known to be completely preventable. The term FASD is more commonly used now than fetal alcohol syndrome (FAS) to describe the effects on infants and children caused by maternal alcohol intake during pregnancy (Caley, Kramer, & Robinson, 2005). FASD describes a spectrum of alcoholrelated disorders that includes FAS, alcohol-related neurodevelopmental disorder (ARND), alcohol-related birth defects (ARBD), and fetal alcohol effects (FAE). Epidemiological studies report that the prevalence of FASD is 1 to 1.5 per 1000 live births, but alcohol-related neurodevelopmental disorders (ARND) (i.e., associated problems that do not fully meet the criteria for FASD), are six to eight times more common than FASD (Klug & Burd, 2003). FASD results from maternal consumption of alcohol during pregnancy. Data show that alcohol intake at any time of pregnancy can be harmful.
Signs and Symptoms

The diagnosis of DS is usually made from a chromosomal blood test shortly after birth. In addition, just as intelligence varies in the normal population, there is a wide variation in the DS population as well regarding cognitive abilities, behavior, and developmental progress.
Nursing Care

Nursing care of a child with DS is similar to that of any developmental disorder. The nurse must be sensitive to the needs of parents who have learned the newborn has the disorder. Helping parents cope and providing them with resources is an important nursing intervention. Early intervention with children who have DS has become much more sophisticated. Early intervention

Nurses working in the nursery or in the neonatal intensive care may be able to identify traits of FASD. Characteristics of FASD include facial dysmorhic features (e.g., epicanthal folds, at mid-face, short nose, short eye openings, thin upper lip, under developed jaw, groove in upper lip), low birth weight, failure to thrive and microcephaly. Later on

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developmental delays, hyperactive behavior, learning and attention difculties, poor motor skills, and developmental disabilities are noted (Caley, Kramer, & Robinson, 2005).
Diagnosis

It is estimated that nearly 5% of the children currently in the U.S. school system have a learning disorder. Overall population statistics point to prevalence between 2% and 10% (APA, 2000).
Signs and Symptoms

Early diagnosis is important, but often very difcult without denitive evidence of maternal alcohol ingestion. A diagnosis of FASD requires a good history, including information on maternal consumption of alcohol during pregnancy.
Nursing Care

The nurse can communicate to families that FASD and ARND are 100% preventable, and as such, it is important to develop prevention programs to reduce the rates of these disorders. It is known that prevention programs designed to prevent these disorders would save money that is currently being used to treat children with FASD (Klug & Burd, 2003). Nurses can provide information to families about the effects of alcohol on the fetus. School nurses especially can facilitate early education regarding alcohol consumption during pregnancy (Caley, Kramer, & Robinson, 2005). Since there are no guidelines about safe consumption rates for pregnant women, the public should know that the safe amount is no alcohol intake during pregnancy. Material can be obtained from National Institute on Alcohol Abuse and Alcoholism (NIAAA) Web site (www.science.education. nih.gov). In addition, nurses can help to identify cases of FASD and help families seek appropriate services.

The nurse understands that a multi-dimensional approach is used to assess early learning patterns. The recommended areas for assessment include functional emotional developmental capacities, auditory processing and language, visuospatial capacities, and regulatory-sensory processing patterns (Greenspan, 2005). The Diagnostic Manual for Infancy and Early Childhood has a comprehensive section with details regarding each area of assessment and the interested reader is encouraged to consult this original source (Greenspan, 2005).
Diagnosis

Diagnosis is made through comprehensive assessments involving interviews and observation. Denitive testing is recommended before a learning disorder or challenge is diagnosed. The DSM-IV-TR identies reading disorder, mathematics disorder, disorder of written expression, and learning disorder not otherwise specied. It also species that each disorder must be diagnosed as a result of standardized test administered on an individual basis (APA, 2000).
Nursing Care

Learning Disorders and Cognitive Impairment


The Interdisciplinary Council on Developmental and Learning DisordersDiagnostic Manual for Infancy and Early Childhood (ICDL-DMIC) (Greenspan, 2005) prefers to label learning disorders as learning challenges. The nurse understands that a child may manifest challenges in more than one specic learning area, including math, reading, and organizing skills (Greenspan, 2005). It is known that early learning challenges are inuenced by emotional and social competencies, auditory processing and language skills (memory, ability to retrieve), perceptual motor skills, motor planning (sequencing, visual memory), visual/spatial processing skills, and ability to modulate sensory information (Greenspan, 2005). The ability to learn involves many of these skills working together. Increased information about learning issues may help identify this condition early and initiate preventive interventions. There are several disorders in this area including Reading Disorder (Dyslexiasignicantly impaired ability to read; words or letters may be mixed up or distorted, making it impossible to recognize what others see) Arithmetic Disorder (Dyscalculiasignicant inability to understand or recognize numbers or functions of numbers, or copy them correctly, or follow sequences) Writing Disorder (dysgraphia) Graphomotor Disorder related to poor ne motor skills) Disorder of Written Expression (related to signicantly poor spelling, grammar, handwriting) Language Disorder (delays in or lack of ability to understand or express verbal communication)

Early identication of learning challenges should be conducted before a child is fully immersed in an academic environment so that early intervention can begin. Early identication and treatment gives the child the greatest potential for a good outcome (Greenspan, 2005). The nurse can communicate to the family that the childs strengths should be incorporated as part of assessment, early prevention, and intervention. The nurse can fully inform the parents about their childs rights and entitlements in the public school sector. Often, children who enter public education with a learning challenge or disability will have an IEP (Individualized Education Plan) that is revised every few months. School nurses can provide education and support to children and their families.

Elimination Disorders
ENURESIS
Most children have experienced toileting accidents based on waiting too long to use the bathroom or drinking too much liquid before going to bed. For the most part, these experiences, while embarrassing, are not overly concerning. Parental worries about toilet learning can often be allayed when the nurse instructs parents on the normal growth and development that makes toilet learning possible. Enuresis refers to the occurrence of wetting clothing or the bed at least two times per week for at least 3 months, or that causes signicant embarrassment or restriction of activities for the child, like not attending sleepovers or camp (APA, 2000). Children and adolescents can exhibit either diurnal (daytime), nocturnal (nighttime), or both types of enuresis. Primary enuresis is diagnosed in children who are at least 5 years of age and have not yet achieved toileting control. Secondary enuresis occurs in

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children who have been successful in using the toilet for a signicant period of time (6 to 12 months) and then become regularly incontinent. Causes of enuresis range from physiological problems (urinary tract infections or diabetes) to anatomical problems (genitourinary malformations) to psychological problems (stress or trauma) or disturbances in the sleep cycle (American Academy of Child and Adolescent Psychiatry [AACAP], 2004). Enuresis tends to run in families. Seventy-ve percent of all children with enuresis have a rst-degree relative who has also suffered from the disorder (APA, 2000).
Signs and Symptoms

rings. Other behavioral methods parents can easily employ are to make sure the child stops drinking liquids early in the evening and the child urinates before going to bed. The parent may also choose to awaken the child during the night to use the bathroom. In time, the problem generally resolves. Early pharmacological treatments include the use of the tricyclic antidepressant, Imipramine (Tofranil). It is important to note that other tricyclics do not stop bedwetting. More recently, DDAVP (desmopressin), a vasopressin analog has been shown to work to decrease nighttime enuresis. This medication is administered either nasally or orally.

ENCOPRESIS
The DSM-IV-TR describes encopresis as the repeated passage of feces into inappropriate places (e.g., clothing or oor) (APA, 2000, p. 116). Encopresis can be primary (in children who have not become consistently continent by age 5) or secondary (children who have been continent and then become incontinent for a period of time). The child may present with either constipation with fecal incontinence due to overow of feces, or without constipation.
Signs and Symptoms

The nurse performs a complete history when assessing the child with enuresis. This history will be helpful in the development of a differential diagnosis. First the diagnosing clinician (nurse practitioner or physician) rules out medical conditions, like urinary tract infections, structural problems, diabetes, or kidney disease. Since there is a familial pattern, understanding its presence in biological relatives is an important clue.
Diagnosis

In considering the childs toilet learning history, age of learning, and difculties experienced, the nurse can help the family document the onset of the disorder and situations when accidents happen. The nurse can also assess recent and chronic stressors that may be affecting the child such as the birth of a sibling, divorce, or other family disruption that might contribute to regression and lead to a diagnosis.
Nursing Care

Signs and symptoms of encopresis in the child can be observed or noted as the child may withhold the feces involuntarily due to constipation which may set into motion a cycle of fearfulness of the pain of defecation. The child may also suffer from encopresis related to psychological stressors. If the potty training period is difcult, or if the child uses a toilet that is too tall to get good enough leverage to force the feces out properly, defecation may become associated with pain.
Diagnosis

Initially, the nurse can recognize that it is important to understand parental attitudes about toilet training. Parents who expect their child to be potty trained before the child is physically or emotionally able may stymie their efforts by their insistence. Toilet training
The nurse can communicate to parents that toilet training can begin when both the parents and child are ready. Parents are ready when they can devote about 3 months of time offering lessons and encouragement. The child is ready to be toilet trained when he or she can indicate that his or her diaper is soiled or wet or can communicate that he or she would like to use the toilet. The child can communicate this information at about 1824 months of age. Other indicators that the child is ready include the child showing interest in other people using the bathroom or in underwear, noticing a small toilet in the bathroom, or even playing with the toilet paper. The nurse can remind parents that sometimes the child is not ready to be toilet trained until 2 or 3 years of age (American Academy of Family Physicians [AAFP], 2006).

As with enuresis, children may be diagnosed when they exhibit regression in bowel habits when confronted with stressful situation.
Nursing Care

It is important for the nurse talk to the parents about the childs defecation patterns during a medical appointment. The nurse also understands that it is important to take a thorough history of bowel habits and toilet training. Monitoring the occurrence of constipation will give an indicator of the cause(s). It is also important to evaluate the childs dietary habits, focusing on the amount of ber and liquids the child consumes. The nurse can also talk to the parents to determine any transitions that may be happening in the childs life such as moving, a new baby in the household, or loss of a caregiver.

where research and practice meet:


Encopresis There are few statistics available for encopresis. A study of 13,111 parents and children of various cultures in Amsterdam found that encopresis occurred in 4.1% of 5- to 6-year-olds, and 1.6% of 11- to 12-year-olds. Twenty-ve percent of the children seen by pediatric gastroenterologists present with symptoms of encopresis or constipation. It is estimated that encopresis occurs six times more prominent in boys than in girls (kidshealth.org).

The nurse can also communicate to parents that treatment falls into two categories: behavioral and pharmacological. Behavioral treatments are common and effective. An example of a behavioral treatment is using the bell and pad method, in which a pad that is attached to an alarm is placed under the child at bedtime. If the child urinates, the alarm

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As with enuresis, it is important for the nurse to help the family understand healthy toilet training. Making defecation nonstressful and rewarding may help the child change the behavior. A childs potty is recommended to help the child position him- or herself to push stool out adequately. Nurses can also encourage families to provide a high-ber diet for their child both for prevention and for intervention with constipation. Since family stress and change can contribute to encopresis, referral of the family for counseling may be in order.

(PKU); or pregnancy-related problems, including alcohol ingestion or viral infections such as rubella.

The nurse recognizes that it is important to take a complete nursing history when assessing the child with elimination disorders.

r evi ew quest i ons


Multiple Choice

s umma ry p o in ts

Developmental psychopathology is a discipline that evolved from the contribution from multiple elds of study with the goal of providing an understanding of psychopathology and normal adaptation. Vulnerability is dened as a predispositional factor, or set of factors, that makes a disordered state possible. Resilience is a dynamic developmental process reecting evidence of positive adaptation despite signicant life adversity. There is vast research indicating that health care disparities in racial and ethnic minorities are widespread compared to those in non-minorities, and barriers such as mistrust, fear, and discrimination stand in the way of optimal mental health outcomes in ethnically diverse families. Though there are increasing efforts to educate the public, the stigma of mental illness continues to be a major barrier to accessing mental health services for children and their families. Psychopathology in children includes conditions such as anxiety, depression, posttraumatic stress disorder, suicide, bipolar disorder, schizophrenia, and autism spectrum disorder. The most effective treatment for attention-decit/ hyperactivity disorder (ADHD) is a combination of pharmacological and nonpharmacological interventions. Using both modalities allows for the control or abatement of symptomatic behavior. Child maltreatment is considered to be any action or failure to act by a person that endangers a childs physical or emotional health and development. A person is abusive if the person fails to nurture the child, physically injures the child, or relates sexually to the child. The nurse is in an ideal position to identify adolescents at-risk for substance abuse, especially if there is a strong family and genetic history of abuse; referring for treatment as early as possible. Treatment might involve family psychoeducation regarding substance abuse. Anorexia nervosa can become a life-threatening problem or cause death because of severe weight loss that can result in electrolyte imbalance and hemodynamic instability. A number of factors can cause developmental disabilities: genetic conditions, such as Down syndrome or fragile X syndrome; metabolic conditions such as phenylketonuria

1. In the emergency room, a 10-year-child complains of dizziness, palpitations, sweating, and tingling sensations. The childs mother tells the nurse that recently her child has been talking about death. The pediatric nurse analyzes these behaviors as signs and/ or symptoms related to what condition? A. Selective mutism B. Panic disorder C. Posttraumatic stress disorder D. Suicidal tendencies 2. A nurse working in the newborn nursery admits a newborn with facial dysmorphic features. What other clinical manifestations leads the nurse to believe that this neonate was born to a mother who consumed a large amount of alcohol during her pregnancy? (Select all that apply.) A. Low birth weight B. Hypoactive behavior C. A high pitched cry D. Microcephaly 3. When developing a nursing care plan for a 26-monthold toddler with inorganic failure to thrive, the pediatric nurse determines which diagnosis as the priority? A. Imbalanced Nutrition Less than Body Requirements related to the inability to absorb nutrients B. Delayed Growth and Development related to inadequate ingestion of nutrients C. Risk for Impaired Parenting related to insufcient knowledge D. Imbalanced Nutrition Less than Body Requirements related to vomiting and diarrhea. 4. An infant comes to the genetic clinic to be evaluated for Down syndrome. While performing a nursing assessment, the pediatric nurse documents several clinical manifestations that are suspicious of Down syndrome. Which of the following clinical manifestations are indicative of this genetic disorder? (Select all that apply.) A. Epicanthal folds B. Flattened nose C. Short, low set ears D. Short neck with extra skin folds
Fill-in-the-Blank

5. An infant born to a mother who consumes alcohol during her pregnancy is at risk for developing ______________ _____________ _______________ ______________. 6. Researchers have found that the age at onset of schizophrenia plays an important role in the outcome of this condition. It is believed that the __________ the onset, the ____________ the impairment.

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Bearden, C.E., Meyer, S.E., Loewy, R.L., Niendam, T.A., & Cannon, T.D. (2006). The neurodevelopmental model of schizophrenia: Updated. In D. Cicchetti & D.J. Cohen (Eds.), Developmental psychopathology: Risk, disorder, and adaptation (Vol. 3, pp. 542569). Hoboken, NJ: John Wiley & Sons. Block, R., & Krebs, N. (2006). Failure to thrive as a manifestation of child neglect. Journal of the American Academy of Child & Adolescent Psychiatry, 45(5), 595. Bulechek, G., Butcher, H.M., & Dochterman, J. (2008). Nursing interventions classication (NIC) (5th ed.). St. Louis, MO: C.V. Mosby. Caley, L.M., Kramer, C., & Robinson, L.K. (2005). Fetal alcohol spectrum disorder. The Journal of School Nursing, 21(3), 139146. Canitano, R., & Vivanti, G. (2007). Tics and Tourette syndrome in autism spectrum disorders. Autism, 11(1), 1928. Caprio, S. (2006). Treating child obesity and associated medical conditions. The Future of Children, 16(1), 209224. Retrieved from www. futureofchildren.org (Accessed August 2, 2007). Centers for Disease Control and Prevention (CDC) Center for Health Statistics (n.d.). Retrieved from http://www.cdc.gov/nchs/Default. htm (Accessed July 15, 2007). Centers for Disease Control and Prevention (CDC). (2004). Autism A.L.A.R.M. Brochure from the American Academy of Pediatrics and the National Center on Birth Defects and Developmental Disabilities at the Centers for Disease Control and Prevention (CDC). Retrieved from http://www.medicalhomeinfo.org (Accessed June 12, 2008). Centers for Disease Control and Prevention (CDC). (2005a). Summary Health Statistics for U.S. Children: National Health Interview Survey, 2005, Appendix III, Table VI. Retrieved from http://www.cdc.gov/ nchs/Default.htm (Accessed July 15, 2007). Centers for Disease Control and Prevention (CDC). (2005b). Developmental disabilities: mental retardation. Retrieved from http://www. cc.gov/ncbddd/dd/mr3/htm (Accessed June 22, 2007). Child and Adolescent Bipolar Foundation. Retrieved from http://www. bpkids.org/site/PageServer (Accessed June 12, 2008). Childhelp National Child Abuse Hotline. (n.d.). Misconceptions of reporting child abuse. Retrieved from http://www.childhelp.org/get_ help (Accessed August 1, 2007). Child Welfare Information Gateway. (2007). Surviving toilet training. Retrieved from http://www.childwelfare.gov/preventing/supporting/ resources/toilettrining.cfm (Accessed July 8, 2007). Cicchetti, D. (2003). Foreword. In S.S. Luthar (Ed.), Resilience and vulnerability: Adaptation in the context of childhood adversities (pp. xixxxvii). Cambridge, UK: Cambridge Press. Cicchetti, D., & Posner, M.I. (2005). Cognitive and affective neuroscience and developmental psychopathology. Development & Psychopathology, 17(3), 569575. Cleveland Clinic. (2007). Treating anxiety disorders in children and adolescents. Retrieved from http://www.clevelandclinic.org/health/ health-info/docs/0700/0772.asp (Accessed July 7, 2007). Commission on Adolescent Anxiety Disorders. (2005). Anxiety disorders. In D.L. Evans, E.B. Foa, R.E. Gur, H. Hendin, C.P. OBrien, M.E.P. Seligman, & B.T. Walsh (Eds.), Treating and preventing adolescent mental health disorders: What we know and dont know: A research agenda for improving the mental health of our youth (pp. 162253). New York: Oxford University Press. Commission on Adolescent Depression & Bipolar Disorder. (2005). Depression and Bipolar Disorder. In D.L. Evans, E.B. Foa, R.E. Gur, H. Hendin, C.P. OBrien, M.E.P. Seligman, & B.T. Walsh, Treating and preventing adolescent mental health disorders: What we know and dont know: A research agenda for improving the mental health of our youth (pp. 474). New York: Oxford University Press. Commission on Adolescent Eating Disorders. (2005). Eating disorders. In D.L. Evans, E.B. Foa, R.E. Gur, H. Hendin, C.P. OBrien, M.E.P. Seligman, & B.T. Walsh. Treating and preventing adolescent mental health disorders: What we know and dont know: A research agenda for improving the mental health of our youth (pp. 257332). New York: Oxford University Press. Commission on Adolescent Schizophrenia. (2005). Schizophrenia. In D.L. Evans, E.B. Foa, R.E. Gur, H. Hendin, C.P. OBrien, M.E.P. Seligman, & B.T. Walsh (Eds.), Treating and preventing adolescent mental health disorders: What we know and dont know: A research agenda for improving the mental health of our youth (pp. 75156). New York: Oxford University Press. Commission on Adolescent Substance and Alcohol Abuse. (2005). Substance use disorders. In D.L. Evans, E.B. Foa, R.E. Gur, H. Hendin, C.P. OBrien, M.E.P. Seligman, & B.T. Walsh (Eds.), Treating and preventing adolescent mental health disorders: What we know and dont

True or False

7. The pediatric nurse is aware that while performing an adolescent assessment, he or she should not be fearful of asking the adolescent questions related to suicidal thoughts. 8. The pediatric nurse must keep in mind when working with children whose parents have mental health problems that these children will likely go on to develop mental health problems. 9. Attention-decit/hyperactivity disorder is one of the most commonly recognized psychiatric childhood conditions. 10. The pediatric nurse working in a clinic must be able to identify appropriate developmental milestones in order to facilitate expected outcomes for the child. See Answers to End of Chapter Review Questions on the Electronic Study Guide or DavisPlus.
REFERENCES
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chapter 23 Caring for the Child with a Psychosocial or Cognitive Condition


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Knight, J.R., Sherritt, L., Shrier, L.A., Harris, S.K., & Chang, G. (2002). Validity of the CRAFFT Substance Abuse Screening Test Among Adolescent Clinic Patients. Archives of Pediatrics and Adolescent Medicine, 156, 607614. Kowatch, R.A., Fristad, M., Birmaher, B., Wagner, K.D., Findling, R.L., Hellander, M., et al. (2005). Treatment guidelines for children and adolescents with bipolar disorder.[see comment]. Journal of the American Academy of Child & Adolescent Psychiatry, 44(3), 213235. Kryger, M.H. (2005). Differential diagnosis of pediatric sleep disorders. In S.H. Sheldon, R. Ferber, & M.H. Kryger (Eds.). Principles and practice of pediatric sleep medicine (pp. 1726). Philadelphia: Elsevier Saunders. Kumanyika, S., & Grier, S. (2006). Targeting interventions for ethnic minority and low-income populations. The Future of Children, 16(1), 187207. Leckman, J.F., Bloch, M.H., Scahill, L., & King, R.A. (2006). Tourette syndrome: The self under siege. Journal of Child Neurology, 21(8), 642649. Lieberman, A.F., & Van Horn, P. (2005). Dont hit my mommy: A manual for child-parent psychotherapy with young witnesses of family violence. Washington, DC: Zero to Three. Locklin, M. (2005). The redenition of failure to thrive from a case study perspective. Pediatric Nursing, 31(6), 474495. Luby, J.L., Heffelnger, A.K., Mrakotsky, C., Brown, K.M., Hessler, M.J., Wallis, J.M., et al. (2003). The clinical picture of depression in preschool children.[see comment]. Journal of the American Academy of Child & Adolescent Psychiatry, 42(3), 340348. Luby, J.L., Sullivan, J., Belden, A., Stalets, M., Blankenship, S., & Spitznagel, E. (2006). An observational analysis of behavior in depressed preschoolers: Further validation of early-onset depression. Journal of the American Academy of Child & Adolescent Psychiatry, 45(2), 203212. Mayes, L.C., & Suchman, N.E. (2006). Developmental pathways to substance abuse. In D. Cicchetti & D.J. Cohen (Eds.), Developmental psychopathology: Risk, disorder, and adaptation (Vol. 3, pp. 599619). Hoboken, NJ: John Wiley & Sons. Moorehead, S., Johnson, M., Maas, M., & Swanson, E. (2008). Nursing outcomes classication (NOC) (4th ed.). St. Louis, MO: C.V. Mosby. NANDA International (2007). NANDA-I nursing diagnoses: Denitions and classications 20072008. Philadelphia: NANDA-I. National Advisory Mental Health Council Workgroup on Child and Adolescent Mental Health Intervention Development and Deployment. (2001). Blueprint for change: Research on child and adolescent mental health. Washington, DC: NIMH. National Institute on Alcohol Abuse and Alcoholism (NIAAA). (n.d.). CAGE Questionnaire. Retrieved from http://pubs.niaaa.nih.gov/publications/Assesing%20Alcohol/InstrumentPDFs/16_CAGE.pd (Accessed August 1, 2007). National Information Center for Children and Youth with Disabilities. Retrieved from www.nichcy.org (Accessed June 12, 2008). National Institute of Mental Health (NIMH). (2000). Child & adolescent bipolar disorder: An update from the National Institute of Mental Health. (NIH Publication Number: 00-4778). Retrieved from http://www. nimh.nih.gov/publicat/index.cfm. National Institute of Mental Health (NIMH). (2001). Blueprint for change: Research on child and adolescent mental health: Report of the National Advisory Mental Health Councils Workgroup on Child and Adolescent Mental Health Development and Deployment (pp. 23-29). Washington, DC: Ofce of Communications and Public Liaison (ERIC Document Reproduction Service No. ED462650). Ogden, C.L., Carroll, M.D., Curtin, L.R., McDowell, M.A., Tabak, C.J., & Flegal, K.M. (2006). Prevalence of overweight and obesity in the United States, 19992004. Journal of the American Medical Association, 295, 15491555. Olds, D. (2002). Prenatal and infancy home visiting by nurses: From randomized trials to community replication. Prevention Science, 3, 153172. Osofsky, J.D. (2004). Young children and trauma: Intervention and treatment. New York: The Guilford Press. Owens, J. (2005). Epidemiology of sleep disorders during childhood. In S.H. Sheldon, R. Ferber, & M.H. Kryger (Eds.), Principles and practice of pediatric sleep medicine (pp. 2734). Philadelphia: Elsevier Saunders. Owens, J., & Mindell, J. (2005). Take charge of your childs sleep: The allin-one resource for solving sleep problems in kids and teens. New York: Marlowe & Company. Ozonoff, S., Rogers, S., & Hendren, R. (2003). Autism spectrum disorders: A research review for practitioners. Washington, DC: American Psychiatric Publishing.

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Pearce, J., Blakely, T., Witten, K., & Bartie, P. (2007). Neighborhood deprivation and access to fast-food retailing. American Journal of Preventive Medicine, 32(5), 375382. Pinto-Martin, J.A., Souders, M.C., Giarelli, E., & Levy, S.E. (2005). The role of nurses in screening for autistic spectrum disorder in pediatric primary care. Journal of Pediatric Nursing, 20(3), 163169. Reynolds, C.R., & Kamphaus, R.W. (2002). The clinicians guide to the Behavior Assessment System for Children (BASC). New York: Guilford Press. Rutter, M. (2003). Poverty and child mental health. Journal of the American Medical Association, 290(15), 20632064. Sallis, J.F., & Glanz, K. (2006). The role of built environments in physical activity, eating, and obesity in childhood. The Future of Children (Special issue), 16(1), 89108. Scheeringa, M.S. (2006). Posttraumatic stress disorder: Clinical guidelines and research ndings. In J.L. Luby (Ed.), Handbook of preschool mental health: Development, disorders, and treatment (pp. 165185). New York: Guilford Press. Shaw, D.S., Dishion, T.J., Supplee, L., Gardner, F., & Arnds, K. (2006). Randomized trial of a family-centered approach to the prevention of early conduct problems: 2-year effects of the family check-up in early childhood. Journal of Consulting and Clinical Psychology, 74(1), 19. Shaw, D.S., Gilliom, M., Ingoldsby, E., & Nagin, D. (2003). Trajectories leading to school-age conduct problems. Developmental Psychology, 39, 189200. Sheldon, S.H. (2005). Introduction to pediatric sleep medicine. In S.H. Sheldon, R. Ferber, & M.H. Kryger (Eds.), Principles and practice of pediatric sleep medicine (pp. 116). Philadelphia: Elsevier Saunders. Shelton, D., & Pearson, G. (2005). ADHD in juvenile offenders: Treatment issues nurses need to know. Journal of Psychosocial Nursing and Mental Health Services, 43(9), 3846. Shortt, A.L., & Spence, S.H. (2006). Risk and protective factors for depression in youth. Behaviour Change, 23(1), 130. Smedley, A., & Smedley, B.D. (2005). Race as biology is ction, racism as a social problem is real: Anthropological and historical perspectives on the social construction of race. American Psychologist, 60(1), 1626. Snider, L.A., & Swedo, S.E. (2003). Childhood-onset obsessivecompulsive disorder and tic disorders: Case report and literature review. Journal of Child and Adolescent Psychopharmacology, 13(S1), S18S88. Spence, S.H., & Shortt, A.L. (2007). Can we justify the widespread dissemination of universal, school-based interventions for the prevention of depression among children and adolescents? Journal of Psychology and Psychiatry, 48(6), 526542. Spessot, A.L., & Peterson, B.S. (2006). Tourettes syndrome; developmental psychopathology. In D. Cicchetti, & D.J. Cohen (Eds.), Developmental psychopathology, Vol 3: Risk, disorder and adaptation (2nd ed., pp. 436469). Hoboken, NJ: John Wiley & Sons. Stafford, B.S., & Zeanah, C.H. (2006). Attachment disorders. In J.L. Luby (Ed.), Handbook of preschool mental health: Development, disorders, and treatment, (pp. 231251). New York: Guilford Press. Steiner, H., Kwan, W., Shaffer, T.G., Walker, S., Miller, S., Sagar, A., & Lock, J. (2003). Risk and protective factors for juvenile eating disorders. European Child & Adolescent Psychiatry (Supplement 1), 12, 3846. Story, M., Kaphingst, K., & French, S. (2006). The role of child care settings in obesity prevention. The Future of Children, 16(1), 143168. Substance Abuse and Mental Health Services Administration [SAMHSA], (n.d.). How families can help children cope with fear and anxiety.

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CONCEPT MAP
Developmental Psychopathology
Factors affecting Vulnerability Resilience Intergenerational transmission Culture/race/ethnicity Health care disparities mistrust/fear/discrimination Barriers Stigma of mental illness Beliefs about childhood Dismissal/minimizing parental concerns Lack of resources

Caring for the Child with a Psychosocial or Cognitive Condition

Miscellaneous Disorders Tic disorders Tourettes syndrome Maltreatment of children Child abuse: physical/emotional Child neglect Shaken baby syndrome Substance use/abuse Eating disorders anorexia; bulimia; obesity Sleep disorder Elimination disorders enuresis; encopresis

Developmental Conditions Developmental disabilities Mild; severe; profound Fragile X syndrome Down syndrome Fetal alcohol spectrum disorder Learning disorders and cognitive impairment, e.g., dyslexia; dyscalculia

Psychosocial/Cognitive Reactive attachment disorder Failure to thrive organic/nonorganic ADHD ODD/conduct disorder

Psychopathology Anxiety e.g., SAD, GAD, phobias, OCD, PTSD Mood disorders e.g., depression, bipolar disorder Suicide Schizophrenia Autism spectrum disorders autistic disorder; Aspergers; Retts; childhood disintegrative disorder

Optimizing Outcomes: Understand resilience in the face of vulnerability

General Potential Nursing Care Assess: Observe for behavioral abnormalities; use active listening; develop trust; be aware of/manage personal feelings Implement: ID positive characteristics; encourage coping behaviors; use age specific therapies e.g., FRIENDS; cognitive behavioral therapy; behavior modification; pharmacotherapy; refer to mental health care providers; report neglect/abuse Teach Parents/Child: Prevention e.g., normal stages of growth and development; therapeutic parenting; support organizations/ community resources; disease versus bad child; medication compliance/side effects; how to provide a secure base

Across Care Settings: Obesity prevention can be promoted in schools

Where Research And Practice Meet: Encopresis is six times more prominent in boys than girls Is mental illness passed along to children? Research can help nurses understand violent behaviors in youth Researchers are able to assess childrens patterns of attachment Family Check-Up Strategy to promote autonomy in ODD/CD Proactive parenting and use of verbal cues can distract children from misbehavior

Ethnocultural Considerations: Understand cultural diversity r/t treatment Disparity in treating obesity

Clinical Alert: Suicide may occur in children on SSRIs Avoid dangerous attachment therapies Anorexia can be fatal

Collaboration In Caring: Raising awareness/acceptance of Down Syndrome

Critical Nursing Action: A.L.A.R.M. as Guideline for ASD

What To Say: Bathing at bedtime not recommended Toilet train when ready

Nursing Insight: Understanding mental health disparities Posttraumatic disorder in adolescents Bipolar disorder Assessing suicide risk Autism spectrum disorders Reactive attachment disorder Failure to thrive Family-based prevention/intervention in ODD/CD Youth violence: fact sheet Incidence of maltreatment Fragile X most common cause of inherited MR

Complementary Care: Mindful breathing for Anxiety

Be Sure To: Report cases of child abuse

Now Can You: Discuss nursing care of the child with depression Assess a child with a sleeping disorder Plan care for a child with a mental health disorder

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