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    10.children and families 10.children and families Presentation Transcript

    • Mental Health Nursing Children and Families
    • Good Mental Health for an Adolescent  Ability to trust others and to view the world as generally safe and supportive.  Ability to interpret reality correctly and interpret surrounding environment correctly  Positive self concept  Ability to cope with stress and anxiety in age appropriate way.
    • Good Mental Health/Adolescent contd  Mastery of developmental tasks-remember Erickson’s stages of development!  Ability to express self spontaneously and creatively  Ability to develop satisfying relationships
    • Why Children Develop Mental Disorders  Result from interactions between genetics and life experiences  Children more likely to develop mental disorders (but not all)- due to – – Abuse Hardships  Dysfunctional families
    • Manifestations of Dysfunctional Families        Failure to develop sense of trust Excessive fears Misdirected anger manifested as behavioral problems Depression Low self esteem Lack of confidence Feelings of lack of control over themselves and their environment
    • Effect of Mental Disorders on Development  The child’s developmental stage at the onset of a mental disorder determines how the disorder affects him/her  Mental disorders make it more difficult for children to achieve developmental tasks  Example: Industry vs Inferiority- (depression) may be unable to participate in group activities with his/her peers or to accomplish school projects.
    • Question: A child that develops Major Depressive Disorder during the developmental task of Identity vs Role Confusion – What happens if there is no intervention during this time?
    • Developmental Disorders  Autism  Aspergers’s Disorder  Rett’s Disorder  Childhood Disintegrative Disorder
    • Autism  Manifested by motor sensory, cognitive, and behavioral dysfunctions  Involves – – – Impaired social interactions Impaired Communication Preoccupation with odd interests
    • Causes of Autism     May be caused by a defect in neurogenesis in early weeks of fetal life May involve an abnormal neurochemical status with abnormalities in catecholamine pathways and increased serotonin levels. Causes are not confirmed but genetics, viral infections, and chemicals found in environment are suspected causes or contributors Other theories include a reaction to early childhood immunizations, but at this time there is no evidence based research that supports this theory.
    • 5 Signs of Autism Significant signs noticed by 1 year of age; – – – – – Failure to make eye contact, poor attention behavior, poor orientation to one’s name. baby not babbling, baby performing gestures like pointing or grasping at objects
    • Cognitive Delays  No interest in other children and play  Difficulty engaging in pretend play  Solitary play is preference for autistic child
    • Autism  Single most common symptom is impaired social interaction.  Learning disabilities, avoiding eye contact, inability to make friends or respond to others emotions  May rock back and forth, twirl their hair, perform self hurtful and mutilating behaviors such as biting themselves or hitting their head on object
    • Autism Treatment  Usually diagnosed by 4 years of age, although symptoms may appear earlier  Early identification and intervention  Providing well structured home and school environment  Behavior modifications
    • Autism Treatment/Nursing Considerations      Specific drugs to deal with specific behavioral problems. Drug therapy is not a cure all rather the goal is to reduce behavioral symptoms Multidisciplinary approach is essential Nurses need to provide a safe environment Need a highly structured environment with few distractions and a normal homelike routine.
    • Asperger’s Disorder  Also a developmental disorder  Compared to those with autism, children with this are less disabled  Those who suffer from Asperger’s have no significant delays in thinking or language development
    • Asperger’s Disorder  Characterized – – – • by the following; Severe impairment in social interactions Repetitive and stereotyped behaviors Significant impairment in social, school, or occupational functioning This disorder is usually apparent between the ages of 3 and 5 years of age
    • Asperger’s Disorder  May be able to function independently as adults  Continue to have impaired social behavior and have difficulty understanding the feelings of others
    • Nursing Considerations  Decrease environmental stimulations  Decrease anxiety by decreasing and managing stressors
    • Rett’s Disorder         Developmental disorder Observed only in females The essential feature is the development of multiple deficits following a period of normal functioning Rate of head growth decreases Previously acquired hand skills are lost Gait is slow and poorly coordinated This disorder persists throughout life and the lost of skills is progressive Usually associated with mental retardation
    • Childhood Disintegrative Disorder     Developmental disorder More common in males In this disorder there will be a period of regression in multiple areas of function followed by a period of at least 2 years of normal development This child will have significant loss of skills in at least two of the following areas: – – – language and social skills bowel or bladder control play or motor skills
    • Anxiety Disorders  Separation anxiety  Post traumatic stress disorder (PTSD)
    • Separation Anxiety  Characterized by excessive anxiety about separation  More severe than expected for the child’s developmental level  Lasts for more than 4 weeks, begins before age 18 and causes significant distress or impairment in social, school, or other functioning
    • Features of Separation Anxiety        Recurrent excessive stress when separating Persistent and excessive worry about losing or about harm coming to parental figures Excessive worry that something will lead to separation from parental figures- being lost or kidnapped Fear of going to school Fear of being alone without parent Repeated nightmares about separation Repeated complaints about physical symptoms- HA’s, nausea, stomachaches
    • Separation Anxiety  May manifest because of a stressor such as the loss of a loved one, pet, illness, immigration, or a move to a new neighborhood.  Periods of exacerbations and remissions
    • PTSD  Affects children differently than it does adults  Adults tend to relive the event  Children tend to react with behaviors of internalized anxiety
    • PTSD  Behaviors – – – – – – – – of PTSD Irritability Temper tantrums Sleep difficulties Agitation Disorganized behavior Regression Nightmares Withdrawl
    • Nursing considerations with PTSD  Have child draw or talk about their fears  Nurse may have to provide for the child’s most basic physical needs while the child is experiencing sever or panic anxiety  Nurses have to help children make choices and decisions  Improve self esteem and hope
    • Mental Retardation
    • Difference Between Mental Retardation and Down Syndrome  Mental retardation is a side effect of Down Syndrome.  Down syndrome or trisomy 21 is a chromosomal disorder caused by the presence of all or part of an extra twenty-first chromosome.  Down Syndrome also causes mild to moderate mental retardation.
    • Mental Retardation  Characterized by significantly below average intellectual functioning which begins before the child is 18 years of age  Accompanied by impairment in adaptive functioning which is the ability of the individual to cope with the demands of everyday life  Can vary in degree from mild to profound
    • Causes of Mental Retardation  Genetics  Alterations in embryonic development  Problems during pregnancy and the perinatal period  Environmental influences  Mental disorders  General medical conditions acquired in infancy or childhood
    • Learning Disorders         Reading disorder Mathematics disorder Disorder of written expression Developmental Coordination Disorder Expressive language disorder Mixed receptive expressive language disorder Phonological disorder Stuttering
    • Obsessive Compulsive Disorder
    • Obsessive Compulsive Disorder (OCD)  Differences between OCD in children and adults  Symptoms are not usually part of an obsessive personality  May start as early as 4 yrs of age displaying symptoms but can go unnoticed until 10 yrs of age. Children are usually aware of their behaviors and may even voluntarily control them while in school or with peers.
    • OCD Causes  Related to depression and other psychiatric disorders such as Tourette’s syndrome  Suicidal behavior is a high risk for adolescents with OCD  OCD has a genetic origin
    • OCD Behaviors  Behaviors that may be evident in the child with OCD – – Children often become withdrawn and isolate from their peers and family Poor school performance rather than a deficit in intelligence
    • OCD Treatment  Treatment –Behavioral therapy combined with medication is the best approach.  For behavioral therapy to be successful, the child must be motivated and capable of following directions.  Parent and total family involvement are essential
    • Depression (Mood Disorder) and Suicide
    • Depression in Children  How do children usually express depression?  Depression is an emotion common to childhood  They have difficulty expressing their feelings and often “act-out” instead
    • Signs of Depression – – – – – – – – – – – loss of appetite sleep problems lethargy social withdrawal sudden drop in grades or dropping out of school substance abuse and other high risk behaviors suicide irritability aggressiveness feelings of hopelessness nonspecific complaints to health
    • Depression in Children  Factors associated with adolescent depression – – – – – – – – physical or sexual abuse or neglect homelessness disputes among parents conflict with peers or family and rejection by peers or family engaging in high risk behavior learning disabilities having a chronic illness
    • Depression in Children      Like adults, life happenings, death, bad grades, break ups, etc happen. Adolescents depression for a short period of time is normal. If depressed for a prolonged period of time causing interference with school, family life or age-specific activities occur, action should be taken. Treatment -Prozac is only FDA approved SSRI for children under 18. Cognitive behavior therapy is also useful.
    • Suicide  Factors that indicate a potentially successful suicide – Same as adult –  Plan of action, a means to carry out the plan, and an absence of obvious resources to turn to for help  Manifestations of suicidal behavior – – – – – – – flat affect deterioration in school performance isolation from friends and family changes in physical appearance giving away cherished possession talk of death
    • Suicide  Suicide ideation vs. suicide attempt:  Suicide ideation involves the thoughts about suicide  Suicide gesture is an attempt to commit suicide that does not result in injury  Suicide attempt is an action that is seriously intended to cause death
    • Suicide  Rates increasing in children and adolescents  Third leading cause of death in adolescents  Sad – sometimes they exhibit rage behavior or emotional outburst that result in an impulsive act that can result in accidental death  EVERY THREAT OF SUICIDE MUST BE TAKEN SERIOUSLY
    • Suicide  When adolescent opens up to a nurse about feelings of hopelessness an talks about feeling useless or worthless, do not contradict what they are saying, LISTEN.  Encourage them to talk and let them know you care and want to help.  Nurses need to educate, prevent and identify children and young adults that are at risk
    • Suicide     Maternal child book – Review table ---characteristics of abused drugs and their reactions in adolescents Other risky factors – sex, guns, not wearing seatbelts or helmets, dieting, etc. EDUCATE as a nurse. Adolescents feel more comfortable talking to people not directly in their lives. Primary prevention- involve social workers, support groups, eventually family members.
    • Attention Deficit and Disruptive Behavior Disorders  ADHD- Attention Deficit Hyperactivity Disorder  Conduct Disorder  Oppositional Defiant Disorder
    • ADHD  Characterized by a developmentally inappropriate degree of gross motor activity, impulsivity and inattention in school or home.  Begins before age of 7, lasts more than 6 months  Not related to existence of any other CNS illness.  More common in boys than girls.
    • ADHD Symptoms    Inattention – easily distracted, needs calm place to work, fails to complete work, does not appear to listen, difficulty concentrating unless instructions are 1 on 1, needs info r repeated Impulsivity-disruptive with other children, talks out in class, extremely excitable, cannot wait turn, overly talkative, requires lot of supervision Hyperactivity-climbs on furniture, fidgets, always on the go, cannot stay seated, does things in a loud and noisy way
    • Health Promotion for ADHD  Health – – – – – – – promotions increase positive interactions provide tutoring computer assistance behavioral management strategies minimize any distractions remind child to focus his or her attention give clear instructions
    • Nursing Considerations with ADHD  Establish a nurse client relationship  Explain expected behavior  Give positive feedback for positive behavior  Help child to consider alternate behavior  Divide complicated tasks into smaller parts  Provide low stimulation environment  Keep goals and instructions simple and realistic
    • ADHD Medication  Usually treated with Ritalin  Acts as a stimulant to enhance the activity of the brain-Dopamine and Norepinephrine  Giving a stimulant will not increase risk of drug abusing- actually the opposite is true  Common side effects are loss of appetite and insomnia – – Give med 6 hours before bedtime Have a regularly scheduled bedtime
    • New Med for ADHD  Strattera- non stimulating medication for ADHD  Inhibits the transport of norepinephrine in the CNS  This med has been shown to improve attention and reduce hyperactivity
    • Conduct Disorder  Repetitive and persistent pattern of behavior in which the basic rights of others or major societal rules are violated
    • 4 Types of Behavior with Conduct Disorder  Aggressive conduct that causes or threatens physical harm to other people or animals  Nonaggressive conduct that causes property loss or damage  Deceitfulness or theft  Serious violations of rules
    • Diagnosis of Conduct Disorder  Three or more of these behaviors must have occurred in the past 12 months and the behavior must cause significant impairment in social, academic, or job functioning  Usually present in a variety of settings – – – School Home Community
    • Conduct Disorder         Children may use bullying and intimidating behavior May start frequent fights Might use a weapon to cause serious harm Might by physically cruel to humans and animals Physical violence might take the form of assault or rape Might start fires or cause vandalism Might stay out all night and spend all day away from home More likely to have ADHD, or Antisocial Personality Disorder
    • Oppositional Defiant Disorder  This might be common and normal in some children  This behavior cannot be diagnosed unless there is repeated behavior lasting more than 6 months
    • Behaviors in Oppositional Defiant Behavior         Loses his/her temper Argues with adults Actively defies or refuses to comply with adults Deliberately annoys people Blames others for his/her mistakes Is easily annoyed by others Is angry or resentful Is spiteful or vindictive
    • Oppositional Defiant Disorder  More common in males  More common in males before puberty and equally common in both males and females after puberty  Disorder becomes apparent at the age of 8 and has a gradual onset
    • HEADSSS Psychosocial behavior interview technique        H – home environment relations/ parents and siblings E-education/employment, school performance A-activities, sports, after school activities, peer relations D-Drug, alcohol or tobacco use S-Sexuality S-Suicide Risk/symptoms of depression/ other mental disorders S- “savagery” violence/abuse in home environment or in neighborhood
    • Family and Community Violence  1 2 3 4 5 Child abuse – Many types Emotional abuse –intentional verbal attacks Emotional neglect – omission of actions for development Sexual abuse Physical neglect-Failure to provide basic needs Physical abuse-Deliberate infliction of injury
    • Child Abuse
    • Child Maltreatment Child maltreatment is the general term used to describe all forms of child abuse and neglect.
    • Abuse Statistics CDC 2010  More than 740,000 children and youth are treated in hospital emergency departments as a result of violence each year—that’s more than 84 every hour.  The total lifetime cost of child maltreatment is $124 billion each year.  More than 3 million reports of child maltreatment are received by state and local agencies each year—that’s nearly 6 reports every minute.
    • Abuse Statistics CDC 2010   In 2010 est 1560 children died from maltreatment – 40.8% experienced multiple maltreatment types – 32.6 experienced neglect only – 22.9% experienced physical abuse only Of the fatalities in 2010 – 79.4% were younger than 4 – 11.1% 4-7 years of age – 3.6% 8-11 years of age – 1.8% 16-17 years of age
    • Victims and Perpetrators of Childhood Abuse  Most victims were maltreated by a parent (84%)  Relatives (6.1%)  Unmarried partners of parents (4.4%)  Other (3.8%)  45.2% perps were men  53.6% perps were women
    • Child Abuse  Temperaments of child/parent can be casual factor in child abuse.  Children that are “different” in any way are at particular risk (child sick or disabled, unattractive child, unwanted, illegitimate infant or stepchild)  Child under the age of 3 years of age is also at risk
    • Physical Assessment of a Suspected Abuse Victim Would Include:  Shaken – – – – – – baby syndrome- intracranial hemorrhage respiratory distress bulging fontanel’s and increased head circumference retinal hemorrhage may be present as well. any bruising on an infant before age 6 months is suspicious as well high pitch cry
    • Assessment For Abuse Preschoolers/Adolescents      Assess unusual bruising (abd, back, buttocks). Assess mechanism of injury. Numerous bruises at various stages, shape of bruises or welts should be investigated. Assess for burns, Burns with specific patterns, like “glove” with no splash burns are signs of immersion. Small round burns, think cigarettes. Assess for fractures with unusual features, forearm spiral fractures or multiple fractures. Assess for human bite marks/head injury
    • Other Assessments  Bruising or bleeding  Absence from school  Depression  Withdrawal from friends/social activities  Frequent bladder infections (Sexual abuse)  Frequent visits to ED
    • Mandatory reporting  Mandatory to report suspected cases.  Most states have penalties for failure to report suspected abuse.  It is Imperative that documentation be complete and objective.  Including measuring sizes of bruises or wounds, staging bruises, describe how the child acts and reacts, remember not to be judgmental and not in include your opinion
    • Elder Abuse/Violence
    • Definition  Abuse: – – To use (something) to bad effect or for a bad purpose; misuse The improper use of something  Violence: – – Behavior involving physical force intended to hurt, damage, or kill someone or something Strength of emotion or an unpleasant or destructive natural force
    • Elder Abuse/Violence  Can include the same types of abuse as with child abuse.  Physical abuse commonly includes slapping, hitting and striking with objects, resulting in bruised, sprains, abrasions, skeletal fractures, burns and other injuries.  Elder abuse takes place in private homes and in established health care facilities
    • Elder Abuse/Violence    Physical – Physical restraints – Chemical- giving them medications they don’t need to sedate them etc. – Denying them food, medicine, and water – Sexual Emotional – Threats – Intimidation – Harassment Financial – Taking control over finances/hiding money – Making them sign documents pertaining to their finances
    • Elder Abuse/Violence  Nurses need to assess for bruises, lacerations, abrasions, or fractures in which the physical appearance does not match the history or mechanism of injury.  Again accurate and concise documentation is imperative.
    • Violence  Violence from one person toward another is a social act involving serious abuse of power  Violence is common with family groups, and most violence is aimed at family and friends rather than strangers  Family violence occurs across all economic and educational backgrounds and racial and ethnic groups
    • Violence  Specific – – – types of behaviors may include: Physical violence which causes pain or harm Sexual violence Emotional violence which includes minimizing an individual’s feelings of self worth or humiliating, threatening, or intimidating a family member.
    • Violence  Neglect which includes failure to provide physical care, emotional care, or education for a child  Economic violence includes depriving family members of resources or support
    • Cycle of Violence  Tension – building phase- abuser has minor episodes of anger and may be verbally abusive or physically violent.  Victim is tense and tends to accept blame for what is happening  Serious battering phase– tension becomes too much to bear and a serious incident takes place
    • Cycle of Violence  Honeymoon – phase- situation is defused for awhile after episode.  Abuser becomes loving, promises to change, and is sorry for the behavior.  Know that victims are at greatest risk for violence when they try to leave the relationship.  Pregnancy tends to increase the likelihood of violence toward domestic partner.
    • Violence  Victim – characteristics – demonstrates low self esteem and feelings of helplessness, hopelessness, powerlessness, guilt and shame  May attempt to protect the perpetrator and accept responsibility for the abuse  May deny severity of situation and feelings of anger and terror
    • Violence (Perpetrator characteristics)  May use threats and intimidation to control victim  Usually an extreme disciplinarian who believes in physical punishment  May have history of substance abuse problems  Likely to have experienced family violence as a child
    • Nursing History and Interventions  Conduct interviews in private  Be direct, honest and professional  Use language client understands  Be understanding and attentive  Tell them a referral must be made  Assess safety and help reduce danger for victim
    • Nursing History and Interventions  Open ended questions/require descriptive responses  Make a safety plan for fast escape  Teach victim to recognize behaviors and situations that may trigger violence  Teach empowerment skills  Stabilize home situation
    • Nursing History and Interventions  Teach strategies to manage stress  Refer to support groups and community resources  Individual psychotherapy, family therapy and group therapy should be considered