Childhood and neurodevelopmental disorders

CHAPTER 11


Childhood and neurodevelopmental disorders


Cindy Parsons and Elizabeth Hite Erwin



Objectives



1. Identify the significance of psychiatric disorders in children and adolescents.


2. Explore factors and influences contributing to neurodevelopmental disorders.


3. Identify characteristics of mental health and factors that promote resilience in children and adolescents.


4. Describe the specialty area of psychiatric mental health nursing.


5. Discuss the holistic assessment of a child or adolescent.


6. Compare and contrast at least six treatment modalities for children and adolescents with neurodevelopmental disorders.


7. Describe clinical features and behaviors of at least three child and adolescent psychiatric disorders.


8. Formulate one nursing diagnosis, stating patient outcomes and interventions for patients with intellectual development disorder, autism spectrum disorder, and attention deficit hyperactivity disorder.




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We tend to think of mental illness as a phenomenon of adulthood, but in one large study more than 75% of young adults with a psychiatric disorder were first diagnosed between 11 and 18 years of age (Copeland et al., 2009). It is estimated that 20% of children and adolescents in the United States suffer from a major mental illness that causes significant impairment at home, at school, with peers, and in the community (Merekangas et al., 2010).


Because of their timing, these disorders can disrupt the normal pattern of childhood development and may carry devastating consequences in terms of academic, social, and psychological functioning. These disorders not only affect the child but also can cause significant stress for families and disrupt family functioning. Stigma and misconceptions can cause patients and families to attempt to conceal the conditions or even limit help seeking and professional care. Fortunately, this often silent public health epidemic is being addressed by increasingly sophisticated screening and treatment methods that show promise in reducing the impact of mental illness in children and on into adolescence and adulthood.


Younger children are more difficult to diagnose than older children because of limited language skills and cognitive and emotional development. Additionally, children undergo more rapid psychological, neurological, and physiological changes over a briefer period than adults. The rapidity and complexity of this development must be considered during assessment for psychiatric disorders. Clinicians and parents often wait to see whether symptoms are the result of a developmental lag or trauma response that will eventually correct itself; therefore, intervention may be delayed. Considering all the developmental changes, associated vulnerabilities, and resiliencies that occur during adolescence, it is clear that this is an optimal time to target intervention.


Unfortunately, lack of services and premature termination of treatment are two main problems, especially for vulnerable populations (poor children with single mothers, minority children, and those with serious presenting problems at intake) (Children’s Defense Fund, 2011). The suffering experienced by children and adolescents with mental disorders is significant, and the cost to society is high.


The U.S. government’s recognition of childhood and adolescent mental health problems and efforts toward identifying effective treatments were first identified in Mental Health: A Report of the Surgeon General (U.S. Department of Health and Human Services [USDHHS], 1999). More than two decades later, there continue to be barriers to assessment and treatment including: (1) lack of consensus and clarity about conditions for screening children; (2) lack of coordination among multiple systems; (3) lack of community-based resources and long waiting lists for services; (4) lack of mental health providers; and (5) cost and inadequate reimbursement (Children’s Defense Fund, 2011).


The passage of the Mental Health Parity Act of 2011 has created opportunities to improve funding, access to care, and research to understand the reasons for underutilization and early termination of services. The Substance Abuse and Mental Health Services Administration (SAMHSA) has created an ambitious 3-year plan to improve the use of resources in the prevention, early detection, treatment, and recovery services for individuals with mental or substance abuse disorders (SAMHSA, 2011).


In this chapter, we will begin with an overview of overall discussion of the risk factors of psychiatric disorders in children, overall assessments, general interventions, and an overview of the specialty of child-adolescent psychiatric nursing. Several neurodevelopmental disorders – communication disorder, learning disorder, and motor disorder—are described briefly. Other disorders in this group—intellectual developmental disorder, autism spectrum disorders, attention deficit hyperactivity disorder—will be discussed in greater depth.




Etiology


Experts believe that the course of mental illness may be less severe if early detection and effective intervention are implemented. A genetic vulnerability coupled with the parent’s inability to model effective coping strategies can lead to learned helplessness, creating anxiety or apathy and an inability to master the environment.



EVIDENCE-BASED PRACTICE


Substance Abuse as a Family Problem


Caldwell, R., Silver, N.C., & Strada, M. (2010). Substance abuse, familial factors, and mental health: Exploring racial and ethnic differences among African American, Caucasian and Hispanic juvenile offenders. The American Journal of Family Therapy, 38, 310-321.




Method


The study consisted of 438 participants, ranging in age from 11-18, who were incarcerated in juvenile facilities in the western part of the U.S. The racial mix was 34% African American, 28% Caucasian, and 38% Hispanic. The study used a demographic questionnaire to determine a key variable—family composition, which was defined as intact, reconstituted, single-parent household, or other (living with grandparents or siblings etc.). Questionnaires were used as well to determine participant’s family history of substance abuse; individual substance abuse was measured using a 32-question, Likert scale Substance Abuse Index. Mental symptoms were measured with the Major Depression Sub-Scale Psychopathology Scale Short Form (APS-SF) (Reynolds 2000) and the Rosenberg Self Esteem Scale (Rosenberg, 1965).



Key findings


Family composition was correlated with race, depression, self-esteem, and substance use. Those coming from intact families had higher self-esteem than those from single-parent or reconstituted families. The study findings showed negative correlations between depression and self-esteem for African Americans and Hispanics, with Caucasians having a stronger negative correlation between depression and self-esteem.


African Americans reported lower cocaine use than Caucasians and Hispanics while Caucasians had more severe methamphetamine use. Caucasians also indicated greater severity of narcotic/barbiturate use than African Americans and Hispanics. Females indicated greater use of cigarettes than males, and Caucasians used cigarettes most. This study did not find differences in substance abuse as a function of family composition among the three racial and ethnic groups.





Biological factors




Neurobiological

Dramatic changes occur in the brain during childhood and adolescence, including a declining number of synapses (they peak at age 5), myelination of brain fibers, changes in the relative volume and activity level in different brain regions, and interactions of hormones (Blakemore et al., 2010). Myelination increases the speed of information processing, improves the conduction speed of nerve impulses, and enables faster reactions to occur. The teen years are also marked by changes in the frontal and prefrontal cortex regions, leading to improvements in executive functions, organization and planning skills, and inhibiting responses (Evans & Seligman, 2005). These changes, including cerebellum maturation and hormonal changes, reflect the emotional and behavioral fluctuations characteristic of adolescence. Early adolescence is typically characterized by low emotional regulation and intolerance for frustration; emotional and behavioral control usually increases over the course of adolescence.



Psychological factors



Temperament

Temperament is the style of behavior a child habitually uses to cope with the demands and expectations of the environment. This style is present in infancy, modifies with maturation, and develops in the context of the social environment (Gemelli, 2008). All people have temperaments, and the fit between the child and parent’s temperament is critical to the child’s development. The caregiver’s role in shaping that relationship is of primary importance, and the nurse can intervene to teach parents ways to modify their behaviors to improve the interaction. If there is incongruence between parent and child temperament and the caregiver is unable to respond positively to the child, there is a risk of insecure attachment, developmental problems, and future mental disorders.


By the time children enter grade school, temperament and behavioral traits can be powerful predictors of substance use and abuse in later life. These traits include shyness, aggressiveness, and rebelliousness. External risk factors for substance abuse include peer or parental substance use and involvement in legal problems such as truancy or vandalism. Researchers have also identified childhood protective factors that shield some children from drug use, including self-control, parental monitoring, academic achievement, anti–drug-use policies, and strong neighborhood attachment (National Institute on Drug Abuse, 2008).



Resilience

Many children with risk factors for the development of mental illness develop normally. The phenomenon of resilience has been used to describe the relationship between a child’s inborn strengths and that child”s success in handling stressful environmental factors. Studies have shown that resilience is influenced by internal and external factors such as self-concept, future expectations, social competence, problem-solving skills, family, and school and community interactions. The resilient child has the following characteristics (Bellin & Kovacs, 2006):




Environmental factors


To a far greater degree than adults, children are dependent on others. During childhood, the main context is the family. Parents model behavior and provide the child with a view of the world. If parents are abusive, rejecting, or overly controlling, the child may suffer detrimental effects at the developmental point(s) at which the trauma occurs. Familial risk factors correlate with child psychiatric disorders; these risk factors include severe marital discord, low socioeconomic status, large families and overcrowding, parental criminality, maternal psychiatric disorders, and foster-care placement.


Witnessing violence is traumatizing and a well-documented risk factor for many mental health problems, including depression, anxiety, PTSD, aggressive and delinquent behavior, drug use, academic failure, and low self-esteem (Farrell et al., 2007). Children who have experienced abuse are at risk for identifying with their aggressor and may act out, bully others, become abusers, or develop dysfunctional interpersonal relationships in adulthood.


Neglect is the most prevalent form of child abuse in the United States. According to the National Child Abuse and Neglect Data System, there were 1.7 million reports of child abuse and neglect in 2010. Of the substantiated cases, 15% were physical abuse, 9% sexual abuse, and 75% neglect. Although neglect has a much higher incidence rate than physical or sexual abuse, research into its effect on children’s mental health has been studied less.


Girls are more frequently the victims of sexual abuse. Boys are also sexually abused, but the numbers are likely underreported due to shame and stigma. Sexual abuse varies from fondling to forcing a child to observe lewd acts to sexual intercourse. All instances of sexual abuse are devastating to a child who lacks the mental capacity or emotional maturation to consent to this type of a relationship. Nurses are required to report suspected abuse of a minor child to the local child protective services.


Bullying is also a risk factor for such problems as depression and suicide disorder. Children may bully and act violently toward one another, and gang involvement is a growing problem among adolescents. It is estimated there are 21,500 gangs and 73,100 members across the United States (U.S. Department of Justice, 2010). The targeted age group for gang initiation seems to be 11-13, a time of particular developmental vulnerability. Decision-making capacities are not fully formed at this stage, and they may look up to older peers for status and belonging.



imageHEALTH POLICY


Cyberbullying Legislation: Why Education is Preferable to Regulation


Cyberbullying is a phenomenon of increasing concern for those working with teens. Compared to previous fears about online predation, which have been greatly overblown, concerns about cyberbullying are more well-founded. There is sufficient evidence to support that the incidence is increasing. The effects of this form of bullying are as damaging as that done face to face and can have severe emotional consequences.


In the wake of a handful of high-profile cyberbullying incidents that resulted in teen suicides, some state lawmakers introduced legislation to address the issue. More recently, two very different federal approaches have been proposed. One approach is focused on the creation of a new federal felony to punish cyberbullying, which would include fines and jail time for violators. The other legislative approach is education-based and would create an Internet safety education grant program to address the issue in schools and communities.


Criminalizing what is mostly child-on-child behavior will not likely solve the age-old problem of kids mistreating one another, a problem that has traditionally been dealt with through counseling and rehabilitation at the local level. Moreover, criminalization could raise thorny free speech and due process issues related to legal definitions of harassing or intimidating speech. To the extent criminal sanctions are pursued as a solution, it may be preferable to defer to state experimentation with varying models at this time. In contrast, education and awareness-based approaches have a chance of effectively reducing truly harmful behavior, especially over the long haul. These approaches have the added benefit of avoiding court challenges or other legal entanglements. At this time it is clear that regulation is, at best, premature and that education is the better approach. If federal criminal law has a role to play, it is in punishing clear cases of harassment of minors by adults.


Szoka, B. M., & Thierer, A. D. (2009). Cyberbullying legislation: Why education is preferable to regulation. Progress on Point, 16(12). Retrieved from http://www.pff.org/interstitial/index.php?url=issues-pubs/pops/2009/pop16.12-cyberbullying-education-better-than-regulation.pdf.




Cultural

Differences in cultural expectations, presence of stressors, and lack of support by the dominant culture may have profound effects on children and increase the risk of mental, emotional, and academic problems. Working with children and adolescents from diverse backgrounds requires an increased awareness of one’s own biases as well as the patient’s needs. The social and cultural context of the patient, including factors such as age, ethnicity, gender, sexual orientation, worldview, religiosity, and socioeconomic status should be considered when assessing and planning care.



imageCONSIDERING CULTURE


The Experience of Attention Deficit Hyperactivity Disorder in African-American Youth


It has long been recognized that cultural factors influence an individual’s perception of health or illness, need for health care, and self-efficacy in symptom management, yet this is an area that has not been well researched. This qualitative study sought to explore how African American teenagers describe and narrate their lived experience with attention deficit hyperactivity disorder (ADHD) as well as how their culture influenced their encounters with health care providers. Previous studies have suggested that ADHD in African American youth is undiagnosed and untreated. Youth with ADHD are at higher risk for impulsive risk-taking behavior, dropping out of high school, and involvement with the juvenile justice system; historically, African American youth already are at higher risk for the latter. In regard to their encounters with health care providers, lack of effective communication (including the cultural and societal context) can adversely affect care.


Narrative expression serves an important function in the context of African American cultural traditions. Oral narratives traditionally served as a means to preserve and transmit historical events, guide and shape individual behavior to conform to societal expectations, and nurture spirituality. Common characteristics of the oral tradition can be seen to affirm the dignity of the African people, bring good to the community, and reflect on the constant resistance to a system of oppression and past enslavement. Linguistics and music have been intertwined to serve as a means of social entertainment and expression; thus, contemporary hip-hop and rap have served the role of oral narrative.


This study was conducted as part of an ongoing mixed-method longitudinal project studying youth identified as high risk for ADHD during school screenings performed between the school years of kindergarten and fifth grade. Children with developmental disabilities or autism were excluded, and only one child per household was included in the sample. Study subjects were interviewed over the course of three months, and after the initial interview the subjects initiated contact and provided their narrative stories.


Study findings reveal that the teen’s narratives, while acknowledging that they behaved in problematic ways, rarely identified this as specific ADHD symptoms. Both males and females discussed particular behaviors such as “forgetfulness” (inattention); emotional reactivity, such as bad attitude and short temper (impulsiveness); and fidgeting or talking and disrupting peers during class (hyperactivity), which are consistent with ADHD diagnostic criteria. The narratives do provide insight into the teen’s awareness of problematic behavior, yet their experience perceived the difficulty to exist with unrealistic adult expectations or lack of flexibility. Further exploration identified that family or caregivers did not identify the symptoms that interfere with social or academic functioning as sufficiently problematic to warrant medical care. The authors propose that African American teenagers can be useful informants of their symptoms; however, providers must become educated about their linguistics and culture so as to accurately translate this and provide congruent care. Providers need to take the time to discover culturally relevant meanings and experiences through studying narratives, which will lead to improved communication. Providers must modify communication and care to be culturally relevant, leading to recognition of behavioral symptoms and the meaning to the individual.


Koro-Ljunberg, M., Bussing, R., Williamson, P., Wilder J., & Mills, T. (2008). Journal of Child and Family Studies, 17, 467-485.




Child and adolescent psychiatric mental health nursing


In 2007, the American Nurses Association (ANA), together with the American Psychiatric Nurses Association (APNA) and International Society of Psychiatric-Mental Health Nurses (ISPN), defined the basic-level functions in the combined child and adult Psychiatric-Mental Health Nursing: Scope and Standards of Practice. Child psychiatric mental health nurses utilize evidence-based psychiatric practices to provide care that is responsive to the patient and family’s specific problems, strengths, personality, sociocultural context, and preferences. Another important publication for this specialty area is the New Practice Parameters for Child/Adolescent Psychiatric Inpatient Treatment (ISPN, 2007).



Assessing development and functioning


A child or adolescent with mental illness is one whose progressive personality development and functioning are hindered or arrested due to biological, psychosocial, and spiritual factors, resulting in functional impairments. In comparison, a child or adolescent who does not have a mental illness matures with only minor regressions, coping with the stressors and developmental tasks of life. Learning and adapting to the environment and bonding with others in a mutually satisfying way are signs of mental health (Box 11-1). The degree of mental health and illness can be viewed on a continuum, with one’s level on the continuum changing over time.



BOX 11-1      CHARACTERISTICS OF A MENTALLY HEALTHY CHILD OR ADOLESCENT





Assessment data

The type of data collected to assess mental health depends on the setting, the severity of the presenting problem, and the availability of resources. Box 11-2 identifies essential assessment data, including history of the present illness; medical, developmental, and family history; mental status; and neurological developmental characteristics. Agency policies determine which data are collected, but a nurse should be prepared to make an independent judgment about what to assess and how to assess it. In all cases, a physical examination is part of a complete assessment for serious mental problems.



BOX 11-2      TYPES OF ASSESSMENT DATA










Data collection

Methods of collecting data include interviewing, screening, testing (neurological, psychological, intelligence), observing, and interacting with the child or adolescent. Histories are taken from multiple sources, including parents, teachers, other caregivers, and the child or adolescent when possible. Parents and teachers can complete structured questionnaires and behavior checklists. A genogram can document family composition, history, and relationships (refer to Chapter 34). Numerous assessment tools and rating scales are available, and with training, nurses can use them to effectively monitor symptoms and behavioral change.


The observation-interaction part of a mental health assessment begins with a semistructured interview in which the nurse asks the young person about the home environment, parents, and siblings and the school environment, teachers, and peers. In this format, the child is free to describe current problems and give information about his or her developmental history. Play activities, such as therapeutic games, drawings, and puppets are used for younger children who cannot respond to a direct approach. The initial interview is key to observing interactions among the child, caregiver, and siblings (if available) and building trust and rapport.




Developmental assessment

The developmental assessment provides information about the child or adolescent’s maturational level. These data are then reviewed in relation to the child’s chronological age to identify developmental strengths or deficits. The Denver II Developmental Screening Test is a popular assessment tool. For adolescents, tools may be tailored to specific areas of assessment, such as neuropsychological, physical, hormonal, and biochemical. The Youth Risk Behavior Survey for children and adolescents is conducted annually by the Centers for Disease Control and provides data as to the prevalence of risky behaviors in the population, helping the nurse to be aware of trends or increased risk.


Abnormal findings in the developmental and mental status assessments may be related to stress and adjustment problems or to more serious disorders. Nurses need to evaluate behaviors indicative of stress, as well as those of more serious psychopathology, and identify the need for further evaluation or referral. Stress-related behaviors or minor regressions may be handled by working with parents; however, the development and consistent use of maladaptive coping behaviors increases the risk of developing mental disorders. Serious psychopathology requires evaluation by an advanced practice nurse, in collaboration with clinicians from other specialty disciplines.



General interventions for children and adolescents


The interventions described in this section can be used in a variety of settings: inpatient, residential, outpatient, day treatment, outreach programs in schools, and home visits. Many of the modalities can encompass activities of daily living, learning activities, multiple forms of play and recreational activities, and interactions with adults and peers.



Family therapy

The family is critical to improving the function of a young person with a psychiatric illness; family counseling is often a key component of treatment. In family therapy, specific goals are defined for each member, identifying ways to improve and work to achieve the goals for the family or subunits within the family (e.g., parental, sibling). Homework assignments are often used for family members to practice newly learned skills outside the therapeutic environment. In addition, multiple-family therapy may prove useful for (1) learning how other families solve problems and build on strengths, (2) developing insight and improved judgment about their own family, (3) learning and sharing new information, and (4) developing lasting and satisfying relationships with other families.




Behavioral therapy

Behavior modification involves rewarding desired behavior to reduce maladaptive behaviors. Behavioral therapy and milieu management follow principles based on respecting individual rights and are classified according to the level of restrictiveness and intrusiveness. To ensure that the civil and legal rights of individuals are maintained, techniques are selected according to the principle of least restrictive intervention. This principle requires that more-restrictive interventions should be used only after less restrictive interventions have been attempted to manage the behavior and have been unsuccessful. Nurses use clinical knowledge, skills, and judgment to develop a plan for managing behaviors that present imminent danger to self or others. Restrictive techniques (such as the use of seclusion or physical restraints) are implemented to manage behavior and maintain safety only when very severe or dangerous behaviors are exhibited.


Most child and adolescent treatment settings use a behavior modification program to motivate and reward age-appropriate behaviors. One popular method is the point and level system, in which points are awarded for desired behaviors and increasing levels of privileges can be earned. The value for specific behaviors and privileges for each level are spelled out, and daily points earned are recorded. Children who work on individual behavioral goals (e.g., seeking help in problem solving) can earn additional points. Points are used to obtain a specific reward, which can be part of the system or be negotiated on an individual or group basis. These point systems can easily be applied to the home setting and used by parents and teachers to continue to assist the child in learning new skills.




Disruptive behavior management

Controversy continues over the use of a locked seclusion room and physical restraint in managing dangerous behavior, and evidence suggests both are psychologically harmful and can be physically harmful. Deaths have resulted, primarily by asphyxiation due to physical holds during restraints; however, a child’s behavior may be so destructive or dangerous that physical restraint or seclusion is required for the safety of all. All members of the treatment team who use therapeutic holding, locked seclusion, or physical restraint of children and adolescents must receive training to decrease the risk of injury to the young person and themselves. In general, seclusion is viewed as less restrictive than restraint, where all movement is constrained.


Guidelines and standards of practice for the use of seclusion or restraint have been created by the Centers for Medicare and Medicaid Services (CMS), State Mental Health Acts, and professional nursing organizations such as the International Society for Psychiatric Mental Health Nursing (ISPN) and the American Psychiatric Nursing Association (APNA). These interventions require prompt, firm, nonretaliatory protective restraint that is gentle and safe and reduces the risk of injury to self or others. Children are released as soon as they are no longer dangerous, usually after a few minutes, and adhering to best practices most facilities strive to avoid the use of all intensive interventions that restrict movement.


The decision to restrain or seclude a child is often made by the registered nurse who is working with the patient. A physician, nurse practitioner, or other advanced level practitioner must authorize this action, according to facility policy and state regulation. All patients in seclusion or restraints must be monitored constantly. Vital signs and range of motion in extremities must be monitored every 15 minutes. Hydration, elimination, comfort, and other psychological and physical needs should be monitored. The patient’s family should be informed of any incident of seclusion or restraint, and family members should be encouraged to discuss the event with their child and reinforce the treatment plan to reduce the likelihood of future incidents (Masters, 2009).


Once the child is calm, the staff should discuss what happened with the patient. This helps to strengthen the nurse-patient relationship, which may have been disrupted. Debriefings provide an opportunity for staff members to discuss the event and if it could have been prevented, evaluate their emotional responses, review the plan of care, and enhance their clinical skills.



Time-out.

Asking or directing a child or adolescent to take a time-out from an activity is another method for intervening to halt disruptive behaviors, allow for self-reflection, or encourage self-control. It has been found to be a less restrictive alternative to seclusion and restraint (Bowers et al., 2012). Taking a time-out may require going to a designated room or sitting on the periphery of an activity until self-control is regained and the episode is reviewed with a staff member. Time-out is used as an integral part of the treatment plan, and the child and family’s input are considered in including this modality. The child’s individual behavioral goals are considered in setting limits on behavior and using time-out periods. If they are overused or used as an automatic response to a behavioral infraction, time-outs lose their effectiveness.



Quiet room.

A unit may have an unlocked quiet room for a child who needs an area with decreased stimulation for regaining and maintaining self-control. The types of quiet rooms have evolved and incorporate principles of trauma-informed care. These can include the feelings room, which is carpeted and supplied with soft objects that can be punched and thrown, and the sensory room, which contains items for relaxation and meditation, such as music and yoga mats. The child is encouraged to express freely and work through feelings of anger or sadness in privacy and with staff support. The vignette on the next page shows how, through the use of time-out and a sensory room, a child begins to develop improved coping skills and decrease self-injurious behavior.



VIGNETTE


Levi, a school-aged child, was admitted to the hospital from his foster home placement. He has been in foster care since his mother died from a drug overdose; his father is currently incarcerated for armed robbery and drug-related offenses. Levi has a history of self-injurious behavior that includes biting and pinching himself and hitting his head against the wall when he is frustrated. The nurse and activity therapist have worked to teach Levi to request time in the sensory room when he begins to feel upset or anxious. He has been able to identify certain triggers and to request time in the sensory room, decreasing his episodes of self-injury over the last week.

Related posts:

  1. The nursing process and standards of care for psychiatric mental health nursing
  2. Somatic symptom disorders
  3. Sexual dysfunctions, gender dysphoria, and paraphilias
  4. Biological basis for understanding psychiatric disorders and treatments

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Feb 3, 2017 | Posted by in NURSING | Comments Off on Childhood and neurodevelopmental disorders

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