CHILDHOOD DISORDERS
CHILDHOOD DISORDERS
This module aligns with key elements of APNA’s “Growth & Development” and “Clinical Decision Making” (American Psychiatric Nurses Association Education Council, Undergraduate Branch, 2022).
Module Outline
- Assessment of Childhood Disorders
- Problems Associated with Childhood Disorders
- Treatment of Childhood Disorders
Module Learning Outcomes
- Describe the signs and symptoms of Childhood Disorders
- Identify the common nursing problems associated with Childhood Disorders
- Summarize the treatment of Childhood Disorders
Concepts
- Development
- Coping
- Safety
Overview
In this module, we will cover matters related to childhood disorders including their clinical presentation, assessment, and treatment options. Our discussion will include Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Disorder (ASD), and Intellectual Disability (ID). Duckworth (2022) reported half of mental health disorders begin by the age of 14 years and three-quarters by the age of 25 years. Children may experience similar mental health diagnoses as adults. However, assessment and diagnosis of a mental health issue in childhood presents with challenges.
Videbeck (2020) lists several reasons psychiatric disorders are not easily diagnosed in children compared to adults; these reasons are:
- May lack abstract cognitive and language skills to describe their symptomology
- Have a limited sense of stable and normal sense of self-related to constant developmental changes; thus, may not be able to discriminate unusual versus typical/expected feelings/sensations
- Abnormal or problematic behaviors may vary depending on developmental stage and/or age
ADHD
ADHD is characterized by cognitive and functional deficits. Clinically, this typically presents as issues with
- inattention
- hyperactivity
- and impulsiveness (Magnus et al., 2022; Videbeck, 2020).
Historically, ADHD has been misdiagnosed. Alternative explanations for abnormal child behavior may be related to another mental health diagnosis (i.e., not ADHD, but another diagnosis) or stressful family situations (e.g., divorce) (Videbeck, 2020). The key is to look for consistency in signs and symptoms in multiple settings with various caregivers (Magnus et al., 2022; Videbeck, 2020). In puberty, ADHD may result in behaviors such as skipping class, interpersonal relationship difficulties, and risk-taking (Videbeck, 2020). Lastly, it is a myth that children will outgrow ADHD. Instead, untreated, ADHD can result in adulthood dysfunction (e.g., work performance) (Magnus et al., 2022).
ASD
ASD presents with repetitive schemes affecting behaviors, interests, or activities which may be present in early childhood, or the child may begin with typical development, but then may have a regression of skills (Mughal et al., 2022). Diagnostically, Rhoads (2021) provides an overview of the DSM-5 signs and symptoms of ASD that affect the three areas of abnormal or impairment in social interactions, communication impairment, and restricted repetitive or stereotyped behavior patterns. Keep in mind, at this time, there is no cure, nor is there any specific medication for ASD; rather, certain psychotropic medications may be used to treat underlying behaviors (e.g., Risperidone and Aripiprazole) (Rebar et al., 2020). Early identification and treatment of ASD may improve outcomes (Mughal et al., 2022).
Videbeck (2020) provides typical behaviors observed in ASD; these are:
- Avoids eye contact
- A preference to be alone
- Delay in speech and language
- Obsessive interests
- Word/phrase repetition
- Lack of interest or pretend play
- Distressed by minor changes in routine
- Hand-flapping, body rocking or spinning
- Uncommon reactions to sensory experiences
Level Up RN. (2022). ADHD and autism-pediatric nursing-nervous system disorders [Video]. YouTube. https://youtube.com/watch?v=PzFpNWZwl3Q&si=EnSIkaIECMiOmarE
ID
An individual diagnosed with an ID has limitations in intellectual function and adaptive behavior beginning at birth (Lee et al., 2022). A deficit in intellectual functioning may impact one’s ability to logically reason or solve problems, learn, verbal skills (Lee et al., 2022). Deficits in adaptive behavior are related to social/interpersonal, conceptual (e.g., time), and practical skills (e.g., activities of daily living) (Lee et al., 2022). An intelligence quotient (IQ) of 70 or below with adaptive function impairment is suggestive of an ID (Lee et al., 2022).
Psych Hub. (2022). What is IDD? [Video]. YouTube. https://youtube.com/watch?v=rymHXQmiugI&si=EnSIkaIECMiOmarE
Below is an overview of a nurse’s consideration for the assessment, problems, and treatment of neurodevelopmental disorders.
See Magnus et al. (2022) [ADHD], Mughal et al. (2022) [ASD], and Lee et al. (2022) for further reading.
Assessment
Mental health assessment in adults is largely dependent on keen behavior observation, the use of therapeutic communication techniques, and a rapport with the patient. These skills are equally, if not slightly more imperative when assessing and caring for children with mental health issues.
Instruments
- Conners Parent and Teacher Rating Scale (ADHD)
- Pervasive Developmental Disorders Screening Test (ASD)
- The Reiss Scales (ID)
Problems
The problems that may be associated with childhood disorders include:
- Risk for Injury
- Impaired Social Interaction
- Impaired Verbal Communication
Treatment
There are four general treatment considerations for childhood disorders.
- First and foremost, always ensure the child’s safety.
- Early identification and treatment are key to promoting a child’s mental health.
- Focus on strengths, not just problems.
- Provide parental support and make referrals as needed.
ADHD
Those diagnosed with ADHD need help to manage inattentiveness, hyperactivity, and impulsivity. As mentioned in the previous paragraph, safety is a priority. Children diagnosed with ADHD may act without thinking of their safety. In the acute care setting, stimulant medications are first-line treatment options (e.g., Methylphenidate/Ritalin) and non-stimulants tend to be the 2nd line of treatment (e.g., Atomoxetine/Strattera) (Rhoads, 2020). See MODULE 4: PSYCHOPHARMACOLOGY for a review of these medications.
Consider using behavior modification and reward for desired behavior (Rhoads, 2020). Some interventions specific to chronic care include:
- Limit distractions, when completing homework
- Help the child organize their environment
- Keep tasks simple and use simple instructions (Rhoads, 2020).
ASD
In general, for the best treatment outcomes a highly structured and specialized treatment plan works best (Mughal et al., 2022; Rhoads, 2020). Rhoads (2020) indicates a multi-faceted treatment program might entail:
- Behavioral and communication approaches (e.g., positive reinforcement and social skills training)
- Biomedical and dietary approaches (e.g., medications used to treat problem behaviors or underlying conditions)
- Community support and parent training (e.g., teach the family about ASD and management strategies)
- Specialized therapies (e.g., speech, occupational, and physical therapy)
- Complementary approaches (e.g., music, play, art, and animal therapy)
ID
Individuals diagnosed with an ID benefit from an interprofessional approach (e.g., physician, psychiatrist, neurologist, speech pathologist, special nurse educator, social worker, and pharmacist) and multimodal interventions such as educational support, behavioral intervention (e.g., CBT, vocational training, family education, governmental resources), and psychotropic medications (if there is a co-existing condition such as aggressive behavior) (Lee et al., 2022).
Summary of Key Nursing Interventions for ADHD, ASD, and ID
(Summarized from Magnus et al., 2022; Mughal et al., 2022; Rebar et al., 2020; Rhoads, 2021; Videbeck, 2020).
| Summary of Key Nursing Interventions | ||
| ADHD | ASD | ID |
| Reduce distractions in the environment | Provide a safe environment; learn triggers that may induce outbursts; mitigate anxiety escalation by diversionary activities; consider using a reward system for behavior modification | Provide a safe environment; prevent self-injury |
| Use simple language and concrete directions | Monitor language; the child’s interpretation may be concrete/literal | Use simple language and concrete directions |
| Divide complex tasks into small sequences | Learn child’s verbal/nonverbal communication style; use a picture board | Determine strengths and abilities; create an individualized plan to enhance capabilities; teach adaptive skills (e.g., ADLs) |
| Provide positive feedback | Maintain a regular/predictable daily routine; prepare the child for any changes in routine | Provide positive feedback about self and daily accomplishments; encourage independence as much as possible |
| Allow breaks | If prone to self-injurious behavior, provide a helmet or protective padding | Set supportive limits on activities, if needed; teach and role model social interactions |
Additional Resources
- Check out the resources listed on the Society for Adolescent Health and Medicine website.
Key Takeaways and Learning Activities
You should have learned the following in this section:
- ADHD is characterized by inattention, hyperactivity, and impulsivity
- When considering a diagnosis of ADHD, look for consistency in signs and symptoms in multiple settings with various caregivers
- Psychotropic classes included stimulants and non-stimulants
- ASD is characterized by social interactions, communication, and repetitive or stereotyped behavior impairments
- There is no cure or specific medication for ASD. However, specific medications may be used to treat problematic behaviors
- ID affects intellectual function and adaptive behavior
- There is no cure or specific medication for ID. Medications may be used to control aggressive behavior
- General nursing considerations: safety is a priority, learn how the child best communicates, promote self-confidence and independence as much as possible with consideration for safety.
Concept Map Activity
- Create a concept map that depicts the assessment and treatment of Childhood Disorders.
- If needed, see the INTRODUCTION for a concept map tutorial.
Case Study: Autism Spectrum Disorder versus Attention Deficit Hyperactivity Disorder
Case Scenario
Dario, a 6-year-old boy, struggles with social interactions, repetitive behaviors, and has difficulty maintaining attention in school. His parents are concerned about his developmental milestones. They indicate that Dario spends most of his time alone, often mesmerized by fans, elevators, and the washing machine. His teacher requested a parent meeting. She stated, “Dario does not socialize with any of the other children. He requires several prompts to pay attention.” On a recent multiple-family vacation to a lavish beach home, Dario spent considerable time washing and re-washing clothes. He declined pool time in favor of offering to keep everyone’s clothes washed and dried.
Reflective Case Study Questions:
- Identify and discuss the key characteristics of autism spectrum disorder in Dario’s case.
- Differentiate between autism spectrum disorder and attention deficit hyperactivity disorder.
- Develop a plan for inclusive care to support Dario in school and social settings.
- How can the nurse collaborate with Dario’s teachers and other healthcare professionals?
- What education should be provided to Dario’s parents about managing his condition at home?
