Wesleyan University –Philippines

Cabanatuan City
College of Nursing

NCM 109- Care of Mother and Child at

Risk or with Problems
(Acute and Chronic)-LECTURE
MIDTERM PERIOD
WEEK 11
NURSING CARE OF A FAMILY WHEN A CHILD
HAS AN INTELLECTUAL OR MENTAL HEALTH
DISORDER
 HEALTH PROMOTION AND RISK MANAGEMENT
 -nurses play a key role in assessing and promoting the mental health of
children and their families at health maintenance visits.
 Preventive education and actions can be taken to increase the coping
capacity of families.
 A thorough assessment can identify risk factors and suggest strategies to
reduce their impact through counseling or early intervention programs.
 NEURODEVELOPMENTAL DISORDERS

INTELLECTUAL DISABILITY
 Commonly defined as a “significant
subaverage” that is at least two or more
standard deviations below individual peers
average level.
 Based on two criteria: intellectual
functioning significantly below average and
concurrent deficits in adaptive functioning
in conceptual, social, and practical domains.
 IQ Testing assess intellectual functioning and
clinical evaluation assesses adaptive
functioning.
 Diagnosis is specified as mild, moderate,
severe, or profound, defined based on
adaptive functioning.
 ASSESSMENT
 Early assessment is key and should be initiated as soon as health care providers or
parents become aware of a delay in motor , language or social milestone.
 Early assessment and diagnosis allow parents to appreciate and understand the
needs of their children, adopt realistic expectations and identify and implement
appropriate resources and supports.
 To aid in planning, parents need a realistic prognosis for their child.
AUTISM SPECTRUM DISORDER
 Autism spectrum disorders (ASD) are a diverse group of conditions.
 They are characterized by some degree of difficulty with social
interaction and communication. Other characteristics are atypical
patterns of activities and behaviours, such as difficulty with transition
from one activity to another, a focus on details and unusual reactions to
sensations.
 The abilities and needs of autistic people vary and can evolve over time.
 Characteristics of autism may be detected in early childhood, but autism
is often not diagnosed until much later.
 People with autism often have co-occurring conditions, including epilepsy,
depression, anxiety and attention deficit hyperactivity disorder as well as
challenging behaviours such as difficulty sleeping and self-injury.
 The level of intellectual functioning among autistic people varies widely,
extending from profound impairment to superior levels.
 Available scientific evidence suggests that there
are probably many factors that make a child
more likely to have autism, including
environmental and genetic factors.
 It is important that, once autism has been
diagnosed, children, adolescents and adults with
autism and their carers are offered relevant
information, services, referrals, and practical
support, in accordance with their individual and
evolving needs and preferences.
 Signs of autism in children
 not responding to their name.
 avoiding eye contact.
 not smiling when you smile at them.
 getting very upset if they do not like a certain
taste, smell or sound.
 repetitive movements, such as flapping their
hands, flicking their fingers or rocking their
body.
 not talking as much as other children.
 Children and adults with ASD often display unusual, repetitive behaviors or
mannerisms. These behaviors may manifest or increase in intensity when the
individual is upset, frustrated, scared, or anxious.
 Diagnosing autism spectrum disorder (ASD) can be difficult because there is no medical
test, like a blood test, to diagnose the disorder. Doctors look at the child’s
developmental history and behavior to make a diagnosis.
 TREATMENT: ABA-APPLIED BEHAVIOR ANALYSIS
SPECIFIC DEVELOPMENTAL DISOREDERS
 Include learning disorder, communication disorders and
motor skills disorders with diagnoses at varying times
during childhood
 Learning disabilities often affect academic skills in
reading, mathematics or writing.
 Communication disorders involve problems of
speech(expressive production), language(form, function,
and use), phonologic disorders and stuttering, and
communication, both verbal and nonverbal.
 Those conditions can lead to a lack of self-esteem unless a
child receives support and encouragement.
ATTENTION DEFICIT
HYPERACTIVITY DISORDER- ADHD
 ADHD is one of the most common neurodevelopmental disorders of childhood.
It is usually first diagnosed in childhood and often lasts into adulthood.
 Children with ADHD may have trouble paying attention, controlling impulsive
behaviors (may act without thinking about what the result will be), or be
overly active.
 It is normal for children to have trouble focusing and behaving at one time or
another. However, children with ADHD do not just grow out of these
behaviors.
 The symptoms continue, can be severe, and can cause difficulty at school, at
home, or with friends.
 A child with ADHD might:
 daydream a lot
 forget or lose things a lot
 squirm or fidget
 talk too much
 make careless mistakes or take unnecessary risks
 have a hard time resisting temptation
 have trouble taking turns
 have difficulty getting along with others

 The cause(s) and risk factors for ADHD are unknown, but current research shows that genetics
plays an important role. Recent studies link genetic factors with ADHD.
 In most cases, ADHD is best treated with a combination of behavior therapy and medication. For
preschool-aged children (4-5 years of age) with ADHD, behavior therapy, particularly training for
parents, is recommended as the first line of treatment before medication is tried. What works
best can depend on the child and family. Good treatment plans will include close monitoring,
follow-ups, and making changes, if needed, along the way.
 There are three different ways ADHD presents itself, depending on which types of
symptoms are strongest in the individual:
 Predominantly Inattentive Presentation: It is hard for the individual to organize or
finish a task, to pay attention to details, or to follow instructions or conversations.
The person is easily distracted or forgets details of daily routines.
 Predominantly Hyperactive-Impulsive Presentation: The person fidgets and talks a
lot. It is hard to sit still for long (e.g., for a meal or while doing homework). Smaller
children may run, jump or climb constantly. The individual feels restless and has
trouble with impulsivity. Someone who is impulsive may interrupt others a lot, grab
things from people, or speak at inappropriate times. It is hard for the person to wait
their turn or listen to directions. A person with impulsiveness may have more
accidents and injuries than others.
 Combined Presentation: Symptoms of the above two types are equally present in the
person.
 THERAPEUTIC MANAGEMENT:
 1. ENVIRONMENTAL MODIFICATION-stable learning environment
 2. FAMILY SUPPORT
 3. MEDICATION-stimulants
OPPOSITIONAL DEFIANT DISORDERS
ODDs

 Consist of a pattern of irritability and defiant behaviors that

results in disturbed functioning in academic and social
domains.
 Children has difficulty in controlling their temper
 Common on late preschooler or early school age
 Causes: combination of temperament, inheritance and
adverse social factors
 Treatment: structured psychosocial interventions (parent
management training, multisystemic therapy, cognitive
behavior)
CONDUCT DISORDERS
 Persistent antisocial acts that involve violations
of personal rights or societal rules.
 Symptoms: aggression toward people and
animals, destruction of property, deceitfulness,
theft, serious violations of family and community
rules.
 Etiologic factor: genetic predisposition,
neurologic deficit correlates, and sociologic
factors related to poverty and cultural
disadvantage.
 The home environment may be characterized by
rejection, frustration, and harsh and inconsistent
discipline.
 Therapy needs to be individualized. Parental
education and problem solving skills are
included.
 ANXIETY DISORDER
 Fear and anxiety can be a normal part of a child development but should
not interfere with functioning or persist beyond developmentally
appropriate times.
 FEAR defined as the emotional response to a real or perceived impending
threat whereas ANXIETY is the anticipation of a future threat.
 Anxiety disorders are characterized by excessive fear and worry and
related behavioral disturbances.
 Anxiety disorder are associated with other major classes of disorders,
including bipolar and related disorders, depressive disorders, disruptive
disorders, eating and substance use disorders.
 Anxiety disorders among children and adolescents include separation
anxiety disorder, specific phobia, social anxiety disorder, agoraphobia,
panic disorder and GAD.
 Symptoms are severe enough to result in significant distress or significant
impairment in functioning includes:
 feeling restless or on edge
 being irritable
 getting tired easily
 having difficulty concentrating or feeling your mind goes blank
 having difficulty getting to sleep or staying asleep
 having tense muscles
 Effective psychological treatment exists, and depending on the age and
severity, medication may also be considered(individual therapy)
 Family intervention are focused on educating parents about anxiety
management and encouraging a child to gain more confidence in the ability to
function independently.
 Medication: selective serotonin reuptake inhibitors, benzodiazepams, and
tricyclic anti depressant
POSTTRAUMATIC STRESS DISORDER
PTSD
 -occurs in children who have experienced or witnessed a traumatic event such
as child abuse, neglect, domestic violence, a natural disaster, a harrowing
accident, or a near-fatal illness.
 Diagnostic criteria for PSTD include symptoms that occur 1 month following
the initial event.
 Signs and symptoms:
 Therapy; trauma focused, CBT-cognitive behavioral therapy, integrated play
therapy, eye movement desensitization and reprocessing(EDMR), FAMILY
THERAPY.
 PSYCHOLOGICAL DEBRIEFING immediately following a traumatic event can
help a child better understand the event and reduce the feeling of threat.
Eating disorder
 The DSM-5( diagnostic and statistical manual of mental disorder 5th edition)
states that feeding and eating disorders are characterized by persistent
disturbance of eating or eating-related behavior that results in altered
consumption or absorption and significantly impairs physical health or
psychosocial functioning.
 These includes pica, rumination, and food aversion in young children and
anorexia nervosa and bulimia nervosa in older children.
 PICA

 PICA is a latin word for magpie ( a bird that is an indiscriminate

eater0
 Pica in children is the persistent eating of nonfood substances
such as dirt, clay, paint chips, crayons, yarn, or paper.
 Dangerous disorder because of the possibility of unintentional
poisoning.
 Other Complications: constipation, gastrointestinal mal
absorption, fecal impaction, and intestinal obstruction.
 Predominantly occur between age 2 to 6 years ols
 Environmental factors, including neglect or lack of supervision, as
well as intellectual disability and iron deficiency anemia.
 Therapeutic management; individualized therapy, parental
education, and a safety plan can help to keep the child from
ingesting inedible substances.
RUMINATION DISORDER OF INFANCY
 The term rumination comes from the latin
word for “chewing the cud”(as catlle do).
 The act of repeated regurgitation and then
reswallowing of previously ingested food.
 It is a form of self-stimulation by the
infant, similar to actions such as head
banging and body rocking.
 The exact causes of rumination syndrome
are not known.
 There aren't any medicines available that
effectively treat rumination syndrome. The
best way to stop it is to relearn how to eat
and digest food properly. This requires
diaphragmatic breathing training. A
behavioral psychologist usually teaches
this, and it's easy to learn.
ANOREXIA NERVOSA
 characterized by refusal to maintain a healthy body weight because of a
disturbance in perception of the size or appearance of the body
 May be genetically based and includes three separate features: self induced
starvation to a significant degree, a relentless drive for thinness, and medical
signs and symptoms resulting from starvation.
 Specific characteristics of a child or teen with anorexia nervosa include:
 Severely distorted body image
 BMI less than 17.5 kg/m2 or less than 85% of expected weight
 Intense fear of gaining weight or becoming fat even though underweight
 Refusal to acknowledge seriousness of weight loss
 Occurs most often in females adolescent
 Children and adolescent think of themselves as overweight and severely limit
their intake, begin excessive exercise, or use emetics, laxative, enemas, or
diuretics to better reduce their weight.
 Multifactorial risk factors exist for anorexia nervosa , including
temperament, environment, genetics and physiology.
 Adolescent who are achievers or strive to be the best academically or
at sports may develop the disorder as a way of helping them improve
a poor self-image or feelings of inadequacy.
 Excessive food restriction can offer them a sense of control they
otherwise do not feel. Lack of nutrition can become so extreme that
it causes delayed pubertal development.
 Physical signs and symptoms of anorexia may include:
 Extreme weight loss or not making expected developmental weight
gains, Thin appearance, Abnormal blood counts, Fatigue, Insomnia,
Dizziness or fainting, Bluish discoloration of the fingers, Hair that
thins, breaks or falls out, Soft, downy hair covering the body, Absence
of menstruation, Constipation and abdominal pain, Dry or yellowish
skin, Intolerance of cold, Irregular heart rhythms, Low blood
pressure, Dehydration, Swelling of arms or legs, Eroded teeth and
calluses on the knuckles from induced vomiting
 Anorexia can have numerous complications. At its most severe, it can be fatal. Death may occur
suddenly — even when someone is not severely underweight.
 This may result from abnormal heart rhythms (arrhythmias) or an imbalance of electrolytes —
minerals such as sodium, potassium and calcium that maintain the balance of fluids in your body.
 There's no guaranteed way to prevent anorexia nervosa. Primary care physicians (pediatricians,
family physicians and internists) may be in a good position to identify early indicators of anorexia
and prevent the development of full-blown illness.
 If your doctor suspects that you have anorexia nervosa, he or she will typically do several tests and
exams to help pinpoint a diagnosis, rule out medical causes for the weight loss, and check for any
related complications.
 These exams and tests generally include:
 Physical exam. This may include measuring your height and weight; checking your vital signs, such
as heart rate, blood pressure and temperature; checking your skin and nails for problems; listening
to your heart and lungs; and examining your abdomen.
 Lab tests. These may include a complete blood count (CBC) and more-specialized blood tests to
check electrolytes and protein as well as functioning of your liver, kidney and thyroid. A urinalysis
also may be done.
 Psychological evaluation. A doctor or mental health professional will likely ask about your thoughts,
feelings and eating habits. You may also be asked to complete psychological self-assessment
questionnaires.
 Other studies. X-rays may be taken to check your bone density, check for stress fractures or broken
bones, or check for pneumonia or heart problems. Electrocardiograms may be done to look for
heart irregularities.
 The goal of therapy is gradual weight gain (1 to 3 lb per week)
 Weighing once a week is better than every day to reduce focus on weight.
 There are no medications specifically prescribed for the treatment of anorexia
nervosa. Medication , such as anti depressant or anti anxiety and obsessive
compulsive disorder.
 Children and adolescent with anorexia disorder need continued follow up to
prevent relapse.
 counseling often focuses on appropriate responses to achieve full recovery
with adulthood.
 BULIMIA NERVOSA
 Bulimia refers to recurrent and episodic binge
eating and purging by vomiting, accompanied
by awareness that the eating pattern is
abnormal.
 Eating is considered binge eating when large
amounts of food are consumed in a relatively
short period of time, followed by inappropriate
compensatory measures to prevent weight
gain, typically within 2 hours.
 These actions can include self-included
vomiting, misuse of laxatives, diuretics, or
other medications ; fasting or excessive
exercise.
 A period of depression or guilt usually follows
the period of bingeing.
 Factors associated with the development of bulimia include
being female and having a first age degree relative with a
history of an eating disorder. Psychological and emotional
problems such as anxiety, depression, and low self-esteem may
increase the risk of bulimia.
 Treatment focused on restoring nutritional balance and keeping
a structural nutritional intake is key.
 CBT, FAMILY COUNSELING.
 MEDICATION: antidepressants or other medications to address
obsessive thinking and compulsive behaviors.
 TIC DISORDERS
 Tics are sudden and repetitive movements and/or sounds that people make
involuntarily. Tics commonly affect school-aged children, often starting around early
primary school age.
 One in eight school-aged children are affected by tics at some point for a short period
of time (provisional tic disorder).
 It's not clear what causes tics. They're thought to be due to changes in the parts of the
brain that control movement. They can run in families, and there's likely to be a genetic
cause in many cases.
 When a child develops a tic it can be scary for parents.
 The good news is that most tics go away on their own. But tics that don't, or that start
having an impact on your child's daily life, may need treatment. If you think your child
has developed a tic, start by visiting your pediatrician
 SIGNS: Frequent eye blinking, facial grimacing, shoulder shrugging, sniffling, repetitive
throat clearing or uncontrolled vocalization – these are all symptoms of a tic. Complex
motor tics include:
 kicking
 skipping
 jumping
 mimicking movements by others
 smelling objects
 Types of Tic Disorders
 There are several kinds of tic disorders:
 provisional tic disorder — this is the most common type of tic disorder. With a
provisional tic disorder, the tics have been happening for less than a year.
 chronic (persistent) tic disorder — this is a less common tic disorder. With chronic
(persistent) tic disorder, tics have been happening for more than a year. The tics
may be motor or vocal, but not both.
 Tourette syndrome — this is a much less common tic disorder. With Tourette
syndrome, a person has multiple motor tics and at least one vocal tic happening
for more than a year.

 Tics can sometimes be diagnosed at a regular checkup after the doctor gets a full
family history, a medical history, and a look at the symptoms. No specific test can
diagnose tics, but sometimes doctors will run tests to rule out other conditions
that might have symptoms similar to tics.
 TOURETTE SYNDROME
 TOURETTE SYNDROME-is a inherited syndrome of motor and one or more
phonic vocal tics.
 Occurs three times more frequently in males than females
 Family often have history of movement disorder
 Onset age is between 4 to 6, peaking at 10 to 12 years.
 Complex vocal tics- repeated use of words or phrases out of context-
specifically,
 (coprolalia- use of socially unacceptable words, usually obscenities),
 (palilalia-repeating one’s own words),
 (echolalia-repeating others words)
 Some children with this syndrome have non specific electroencephalographic
abnormalities and soft neurologic signs that aid in diagnosis.
 Treatment: CBIT-comprehensive behavioral intervention therapy
Depression, Psychiatric And Bipolar And
Related Disorders Affecting Children

CHILDHOOD DEPRESSIVE EPISODES

 It's normal for kids to feel sad, act grouchy, or be in a bad mood at times. But when
a sad or bad mood lasts for weeks or longer, and when there are other changes in a
child's behavior, it might be depression.
 Therapy can help children who are going through sadness or depression.
 Depression negatively impacts growth and development, school performance, and
peer or family relationships and may lead to suicide.
 Biomedical and psychosocial risk factors include a family history of depression,
female sex, childhood abuse or neglect, stressful life events, and chronic illness.
 Some children may not talk about their helpless and hopeless thoughts, and may not
appear sad. Depression might also cause a child to make trouble or act unmotivated,
causing others not to notice that the child is depressed, or to incorrectly label the
child as a trouble-maker or lazy.
 ANHEDONIA-refers to the loss of ability to feel pleasure
Bipolar and related Disorders
 Bipolar and related disorders include bipolar I, bipolar II, and cyclothymia.
 BIPOLAR I- requires at least one manic episode, which is an elevated, expansive,
or irritable mood, such as grandiose behavior, little need for sleep, increased
goal-directed activity, distractibility, or a flight of ideas.
 BIPOLAR II- same as bipolar I but there is no presence of mania, but rather
hypomania a less severe, shorter period of increased energy, mood and activity.
 CYVLOTHYMIC DISORDER-is the presence of hypomanic and depressive periods
that do not meet full criteria for bipolar I or II and persist for at least 1 year in
children or adolescent.
 Risk factor; genetic predisposition
 Monitor for suicidal ideation in children with family history or suspected bipolar
disorder due to the increased risk of suicide.
Childhood Schizophrenia
 Childhood schizophrenia is an uncommon but severe mental disorder in which
children and teenagers interpret reality abnormally.
 Schizophrenia involves a range of problems with thinking (cognitive), behavior or
emotions.
 It may result in some combination of hallucinations, delusions, and extremely
disordered thinking and behavior that impairs your child's ability to function.
 Childhood schizophrenia is essentially the same as schizophrenia in adults, but it
starts early in life — generally in the teenage years — and has a profound impact
on a child's behavior and development.
 With childhood schizophrenia, the early age of onset presents special
challenges for diagnosis, treatment, education, and emotional and social
development.
 Schizophrenia is a chronic condition that requires lifelong treatment. Identifying
and starting treatment for childhood schizophrenia as early as possible may
significantly improve your child's long-term outcome.
 Schizophrenia involves a range of problems with thinking, behavior or emotions.
 Signs and symptoms may vary, but usually involve delusions, hallucinations or
disorganized speech, and reflect an impaired ability to function. The effect can be
disabling.
 Schizophrenia signs and symptoms in children and teenagers are similar to those in
adults, but the condition may be more difficult to recognize in this age group.
 Early signs and symptoms may include problems with thinking, behavior and
emotions.
 Thinking:
 Problems with thinking and reasoning
 Bizarre ideas or speech
 Confusing dreams or television for reality
 Behavior:
 Withdrawal from friends and family
 Trouble sleeping
 Lack of motivation — for example, showing up as a drop in performance at school
 Not meeting daily expectations, such as bathing or dressing
 Bizarre behavior
 Violent or aggressive behavior or agitation
 Recreational drug or nicotine use
 Emotions:
 Irritability or depressed mood
 Lack of emotion, or emotions inappropriate for the situation
 Strange anxieties and fears
 Excessive suspicion of others

 It's not known what causes childhood schizophrenia, but it's thought that it
develops in the same way as adult schizophrenia does.
 Researchers believe that a combination of genetics, brain chemistry and
environment contributes to development of the disorder. It's not clear why
schizophrenia starts so early in life for some and not for others.
 Early identification and treatment may help get symptoms of childhood
schizophrenia under control before serious complications develop. Early
treatment is also crucial in helping limit psychotic episodes, which can be
extremely frightening to a child and his or her parents. Ongoing treatment can
help improve your child's long-term outlook.
Elimination Disorders

Encopresis
 Encopresis sometimes called fecal incontinence or soiling, is the repeated
passing of stool (usually involuntarily) into clothing.
 Typically it happens when impacted stool collects in the colon and rectum:
The colon becomes too full and liquid stool leaks around the retained stool,
staining underwear.
 Children aged 4 years and older, common in males
 Primary if the child was never fully toilet trained and secondary if the
problem began after effective training.
 Children with encopresis often have the following symptoms:
 Not being able to hold their stool until they get to a toilet.
 Passing stool in their clothes.
 Hiding bowel movements (poop) or keeping them a secret.
 Hiding soiled clothes.
 Not having regular bowel movements.
 Feeling bloated or experiencing pain in their abdomen or stomach.
 Loss of appetite.
 Treatment is unique to each child diagnosed
with encopresis and could include:
 Removal of any stool ball.
 Taking stool softeners, laxatives or enemas to
ensure regular, soft stools.
 Scheduled toilet sitting.
 Eating a diet high in fiber (fruits, whole grains,
vegetables).
 Drinking plenty of water.

 Encopresis can be caused by:

 Constipation.
 An underlying medical condition.
 Psychological causes.
 You can prevent encopresis by avoiding constipation and creating positive toileting
experiences for your child. You can do this by:
 Eating a diet high in fiber.
 Staying hydrated and drinking a lot of fluids.
 Making sure your child gets plenty of exercise.
 Scheduling times to use the toilet after meals.
 Making your child’s toilet training experience positive with encouragement and
support.
ENURESIS
 The medical name for not being able to control your pee is enuresis
(pronounced: en-yuh-REE-sis).
 Sometimes enuresis is also called involuntary urination.
 This behavior may or may not be purposeful. The condition is not diagnosed
unless the child is 5 years or older.
 Nocturnal enuresis is involuntary urination that happens at night while
sleeping, after the age when a person should be able to control their
bladder.
 A child may have 1 or more of these types:
 Nighttime (nocturnal) enuresis. This means wetting during the night. ...
 Daytime (diurnal) enuresis. This is wetting during the day.
 Primary enuresis. This happens when a child has not fully mastered toilet
training.
 Secondary enuresis.
 The main symptoms of enuresis include:
 Repeated bed-wetting
 Wetting in the clothes
 Wetting at least twice a week for approximately three months
 Many factors may be involved in the development of enuresis.
Involuntary, or unintentional, release of urine may result from:
 A small bladder
 Persistent urinary tract infections
 Severe stress
 Developmental delays that interfere with toilet training
 Voluntary, or intentional, enuresis may be associated with other
mental disorders, including behavior disorders or emotional
disorders such as anxiety.
 HEREDITY.
 Most children with enuresis outgrow the disorder by the time they reach
their teen years, with a spontaneous cure rate of 12% to 15% per year.
Only a small number, about 1%, continues to have a problem into
adulthood.
 TREATMENT: behavioral therapy and positive reinforcement
 Medication: DESMOPRESSIN- a synthetic analogue of antidiuretic
hormone a first line pharmacologic agent used in children over the age.
 It may not be possible to prevent all cases of enuresis -- particularly
those that are related to problems with the child's anatomy -- but
getting your child evaluated by a pediatrician as soon as symptoms
appear may help reduce the problems associated with the condition.
 Being positive and patient with a child during toilet training may help
prevent the development of negative attitudes about using the toilet.
End!