THE CHILD WITH A COGNITIVE IMPAIRMENT OR PSYCHOSOCIAL DISORDER Chapters 53 & 54

1. THE CHILD WITH A COGNITIVE IMPAIRMENT OR PSYCHOSOCIAL DISORDER Chapters 53 & 54

2. DEVELOPMENTAL DISORDERS • Mental retardation • Rated from mild to severe • Majority of children fall into “mild” stage • Parents need a realistic prognosis for their child • Institutional vs. Home Care • More severely challenged may need institutionalization • A major burden on parents, esp. when both work outside the home

3. DEVELOPMENTAL DISORDERS • Pervasive developmental disorders: • Autism • marked by severe deficits in language, perceptual, and motor development • Often not diagnosed until age 2-3 though parents noted unusual behaviors before then • Unknown etiology, linked to MMR and thermosal though any official link has been denied • A subgroup, Idiot Savants, may be exceptionally talented in one area

4. DISRUPTIVE BEHAVIOR DISORDERS • Attention deficit hyperactivity disorder (ADHD) and Attention deficit disorder (ADD) • ADHD • Found more often in boys • Characterized by inattention, impulsiveness, and hyperactivity • During evaluation, important to get an accurate history and a description of the child’s ordinary day • Treatment • Structured learning situations • Medications • Ritalin, Concerta, Adderall • All stimulants, work paradoxically, cause anorexia, insomnia • Kids need a drug holiday to catch up on weight gain • Strattera • New drug, non stimulant, supposedly no anorexia

5. DISRUPTIVE BEHAVIOR DISORDERS • Oppositional Defiant Disorders • Conduct Disorders • Persistent antisocial acts • Stealing • Destruction of Property • Fire starting • Sexual behaviors • Animal abuse • Seen more in males • Home environment often implicated • Treatment involves modifying home environment and problem-solving skills

6. DISRUPTIVE BEHAVIOR DISORDERS • ADD • Found more in girls • Less disruptive, these girls do more day–dreaming than anything else • Evaluation and treatment is the same though these are less likely to be diagnosed

7. EATING DISORDERS • Anorexia nervosa • Found mostly in girls (90%) • Distorted body image, poor self-esteem • Usually in oldest/only children who have high expectations to live up to • May vomit, use laxatives, etc.

8. EATING DISORDERS • Bulimia nervosa • Found mostly in girls • These people know their eating habits are abnormal and try to hide them • Cycle of bingeing and purging • May abuse laxatives, emetrol, etc • Teeth often show erosion • These girls aren’t super thin like anorexics

9. TIC DISORDERS • Transient tic disorder • Many children have these and are in response to periods of high stress • Management is aimed at reducing stress • Tourette’s syndrome • Syndrome of motor and phonic vocal tics • Includes the repeated use of words out of context…specifically obscenities • More common in boys, age of onset is around 7 years • Treated with Haldol

10. Anxiety and Depression • Anxiety • Some anxiety is normal, i.e., first day of school, oral presentations • When anxiety prevents child from attending school or school functions, professional help is sought • Depression • Again, some depression is normal, especially in adolescence, due to hormone fluctuations • Depression that persists needs to be treated • Warning…some SSRIs may raise suicide risk, especially initially

11. Suicide • Females try it more, Males succeed more • Nurses must • Recognize warning signs • Screen for depression • Ask! • Be available for grief counseling should suicide occur

12. CHILD ABUSE • Theories of child abuse • parents who abuse • Many were abused themselves • Don’t know the difference between spanking and beating • Isolated • Extremely religiously conservative • Poor coping skills • Little self restraint • Alcohol/drug abuse

13. children who are abused • May be seen as different, i.e. different father, birth defect, less intelligent, etc. • Born prematurely or had an illness at birth that affected the bonding process • special circumstance: stress • Cuts across socioeconomic lines • Affects those without strong support systems more • Isolated families more likely to be affected • Reporting • Nurses are mandatory reporters • Chart objectively, use exact quotes • Better to err on the side of reporting than not

14. Have parents account for all signs of injury • Look for inconsistencies, esp. an injury out of proportion to the story • Look for bruises in all stages of healing • X-rays will show old fractures • Burning is highly suspicious • Watch for the parents who don’t want the child questioned alone • Try to remain emotionally uninvolved…anger won’t help

15. Shaken Baby Syndrome • Average shaken baby is a male, age 3-8 months • Average “shaker” is a male, age 24-27 • The usual trigger is inconsolable crying • One out of four shaken babies will die • People who would never strike a baby might shake them as a “gentler” alternative

16. Physical Neglect • Harder to identify than abuse • Suspect when children are unwashed and poorly dressed and parents are not • Suspect when children are not immunized or are brought in late for treatment • Neglect also encompasses lack of supervision

17. Psychological Abuse • Includes belittling, threatening, rejecting, isolating, or exploiting a child • May be just as damaging as physical abuse • Harder to identify • Suspect when parent uses only negative terms to describe a child

18. Munchausen Syndrome by Proxy • Most perps are mothers, fathers are usually distant or completely out of the picture • Children are repeat customers to the ER and hospital • Symptoms are vague and only seen by the mother • Mother makes friends with the staff, is seen as the perfect mother and caretaker…very medically savvy • Bottom line…mother gets some sort of satisfaction from this role

19. Failure to Thrive • Can originate from organic or non-organic causes • Non-organic is a form of neglect • This can be multifactorial • Mother is unable to pick up on infant cues • Immature mother too busy with her issues to worry about baby • Infant is “fussy” or colicky or neurologically damaged

20. Failure to Thrive • Assess growth at every visit • Develop rigid system to monitor growth and development • May be inpatient • May involve diary, role modeling, etc • Must have follow-up

21. SEXUAL ABUSE • Molestation, Incest, Pornography & Prostitution • Boys and girls are victims • Perps are overwhelmingly male but may be older children or adolescents • Involve bribery or threats to keep it quiet • Extremely harmful to the child, destroys trust and self-esteem • Rehabilitation of the perp is difficult

22. Sexual Abuse • Assessment • Be perceptive • Is child sexually savvy beyond their years? • Are there physical signs of sexual activity? • Remember, a child cannot give consent to sexual activity. • Mandatory reporting