CHILD HEALTH NURSING

2. MANAGEMENT
OF
COMMON PSYCHIATRIC
PROBLEMS
PRESENTED BY:
K. SIVASAKTHI,
M.SC NURSING,
COLLEGE OF NURSING,
PIMS.

3. INTRODUCTION
There are many behaviour and psychological
problems of childhood. It is essential to know the
patterns of child development. The various psychiatric
problems seen in children are disorders of
psychological development.

4. I. SPECIFIC
DEVELOPMENTAL
DISORDERS

5. Some common psychiatric problems seen in children are:
1. Specific Developmental Disorders
2. Pervasive Developmental Disorders (PDD)
3. Disruptive Behavior Disorders
1. Oppositional Defiant Disorder (ODD)
2. Conduct Disorder
3. Attention Deficit Hyperactivity Disorder (ADHD)
4. Anxiety Disorders

6. I. SPECIFIC DEVELOPMENTAL
DISORDERS
Specific developmental disorders
are characterized by inadequate
development, in usually one
specific area of functioning. The
deficit in functioning may be in
any of the following areas:
Dyslexia Dysphasia
Dyscalculia Dyslalia
Dyspraxia

7. 1. Reading (Developmental reading disorder or
Dyslexia: There are two types of learning
disabilities in reading.
i. Basic reading problems occur when there is
difficulty understanding the relationship
between sounds, letters and words.
ii. Reading comprehension problems occur when
there is an inability to grasp the meaning of
words, phrases, and paragraphs.

8. 2. Language (Developmental
language disorder or Dysphasia):
Signs of a language-based learning
disorder involve problems with verbal
language skills, such as the ability to
retell a story and the fluency of
speech, as well as the ability to
understand the meaning of words,
parts of speech, directions, etc

9. 3. Mathematics (Developmental mathematics
disorder or Dyscalculia): Learning disability with
mathematics.
A child’s ability to do maths will be affected
differently by a language learning disability, or a
visual disorder or a difficulty with sequencing,
memory or organization.

10. 4. Articulation (Developmental articulation
disorder or phonological disorder or
Dyslalia)
5. Coordination (Developmental
coordination disorder or dyspraxia):
Learning disability in motor skill
• Motor difficulty refers to problems with
movement and coordination whether it is with
fine motor skills or gross motor skills.

11. MANAGEMENT
• Early identification and intervention
• Phonetic awareness
• Increasing fluency
• Using abstract/concrete teaching sequence
• Setting goals
• Using verbalization while solving problems
• Using computerized instruction
• Consistently using a basic framework of planning, writing and
revision
• Providing consistent feedback regarding the child’s learning

12. II. PERVASIVE
DEVELOPMENTAL
DISORDERS (PDD)

13. II. PERVASIVE DEVELOPMENTAL
DISORDERS (PDD)
Pervasive development disorders are more common (3-4 times) in
males than females. Typically, the onset occurs before the age of 2
years. In some cases, the onset may occur later in childhood. This
syndrome has been described as autistic disorder, childhood
psychosis and pseudo -defective psychosis.

14. Autism spectrum disorder is a complex developmental condition that
involves persistence challenges in social interaction, speech and non
verbal communication and restricted/repetitive behaviour

15. This rare genetic disorder affects the
way the brain develops, causing a
progressive inability to use muscles
for eye and body movements and
language.

16. Childhood disintegrative disorder (CDD),
also known as Heller's syndrome and
disintegrative psychosis, is a rare condition
characterized by late onset (>3 years of age)
of developmental delays in language, social
function, and motor skills.

17. CLINICAL FEATURES
PDD is characterized by:
1. Autism: It is characterized by withdrawal of the child into self and
into a fantasy world of his or her Own. The child has markedly
abnormal or impaired development in social interaction and
Communication. Following features are seen:
 Absent social smile
 Lack of eye-to-eye contact
 Solitary play
 No attachment with parents and absence of separation anxiety
 Inability to make friends
 Absence of fear in presence of danger

18. 2. Impaired language and communication
 Lack of response to voice or sounds.
 Absence of communicative sounds like
babbling during infancy.
 Absent or delayed speech
 Impaired abstract thinking
 Abnormal speech content and pattern like
echolalia, perseveration, poor articulation
etc.

19. 3. Abnormalities in behavior
 Mannerism
 Stereotyped behavior like head-banging, body-
spinning, rocking, clapping, hand-flicking etc.
 Ritualistic and compulsive behavior
 Attachment to non-living objects

20. 4. Mental Retardation
Less than 25% of autistic children have an IQ
of more than 70. Most of them have profound
mental retardation. About 70% of these children
lead dependent lives
5. Other features
Epilepsy is common in these children.
Exceptional calculating ability or musical
ability may be present.

21. ETIOLOGY
The cause of infantile autism seems to be biological. The
evidence for biological causation includes history of
perinatal CNS infection or injury, EEG abnormalities,
epilepsy, increased serotonin levels in brain and
neurophysiological abnormalities in few patients.

22. MANAGEMENT
The treatment consists of three modes that may be used together:
Behavior Therapy: It includes positive reinforcements to teach self-
care skills, speech therapy and/or sign and behavioral techniques to
encourage interpersonal interactions.

23. Psychotherapy: Parental
counseling and supportive
therapy are useful in allaying
parental anxiety.

24. Pharmacotherapy
 Drug treatment is used for the treatment
of autism and associated epilepsy.
 Fenfluramine is helpful in increasing IQ
and decreasing behavior symptoms.
 Haloperidol decreases dopamine levels in
brain and thus decreases hyperactivity
and abnormal behavioral symptoms.
 Anti-epileptic drugs are used for
generalized seizures.

25. III. DISRUPTIVE
BEHAVIOR
DISORDERS

26. III. DISRUPTIVE BEHAVIOR
DISORDERS
The most common disruptive behavior disorders include:
A. Oppositional Defiant
Disorder (O.D.D)
B. Conduct Disorder
C. Attention Deficit
Hyperactivity Disorder

27. A. OPPOSITIONAL DEFIANT DISORDER
(ODD)
Around 1 in 10 children, under the age of 12 years are
thought to have Oppositional Defiant Disorder (ODD). It is
twice more common in boys than girls. Some typical
behaviors of a child with ODD are:
 Easily irritated or annoyed
 Frequent temper tantrums
 Argues frequently with adults
 Refuses to obey rules
 Low self-esteem
 Low frustration threshold
 Trys to annoy others
 Seeks to blame others for any misdeeds

28. B. CONDUCT
DISORDERS
Children with conduct disorder are often
judged as 'bad kids' because of their
delinquent behavior and refusal to accept
rules.
Around 5% of 10 year olds are thought to
have conduct disorder. It is four times
more common in males than females.
Around one-third of children with
conduct disorder also have Attention
Deficit Hyperactivity Disorder.

29. Some typical behaviors of a child with conduct disorder include:
 Frequent refusal to obey parents
 Repeated truancy
 Tendency to use drugs like cigarettes and alcohol, at an early age
 Lack of empathy for others
 Being aggressive to animals and other people or showing sadistic
behavior including bullying
 Physical or sexual abuse.
 Often starts physical fights
 Frequent lying
 Criminal behaviors such as stealing, deliberately lighting fires, breaking
into houses
 vandalism.
 A tendency to run away from home
 Suicidal tendencies -Rare

30. C. ATTENTION DEFICIT HYPERACTIVITY
DISORDER (ADHD)
 It is a neurobehavioral developmental disorder
and is primarily characterized by” the co-existence
of attention problems, hyperactivity with each
behavior occurring infrequently alone.”
Definition:
 ADHD refers to a chronic bio behavioral disorder
that initially manifests in childhood and is
characterized by hyperactivity, impulsivity, and/ or
inattention. These symptom can lead to difficulty in
academic, emotional, and social functioning.

31. Around 2-5% of children are thought to have attention deficit
hyperactivity disorder times more common in boys than girls. The
characteristics o of ADHD include:
 Lack of attention: It includes difficulty in concentrating,
forgetting instructions, moving from one task to another without
completing anything.
 Impulsivity: Talking over the top of others, having a 'short fuse'
and being accident prone.
 Over activity: Constant restlessness and fidgeting is seen.

32. ETIOLOGY AND RISK FACTORS
 The cause of Oppositional defiant disorder, Conduct disorder and Attention
deficit disorders are unknown, but some risk factors associated with disruptive
behavior disorders are
i. Gender: Boys are more likely than girls to suffer from behavior disorder
ii. Gestation and Birth
iii. Temperament
iv. Family life: Behavior problems are more likely to occur in dysfunctional
families
v. Learning difficulties and intellectual disabilities
vi. Brain activity: Studies have shown that areas of brain that control attention
appear to he less active in children with ADHD.

33. DIAGNOSTIC EVALUATION
Diagnosis of Disruptive behavioral disorders is difficult, as these
are complicated disorders and may include many different factors
working in combination.
 Diagnosis by a specialist, which may include pediatrician,
psychologist or child psychiatrist.
 In-depth interviews with parents, child and teachers.
 Behavior checklists or standardized questionnaires.

34. MANAGEMENT
1.Parental
education
Functional
Family
Therapy
Cognitive
Behavior
Therapy
Social training
Anger
management
Encouragement
Medications

35. Medications:
 For ADHD, stimulant medications like dextroamphetamine (10-40
mg/day), methyl phenidate (10-60 mg/day) and magnesium
pemoline (37.5-115 mg/day) are the treatment of choice. They act
on the reticular activating system, causing stimulation of
inhibitory influences on cerebral cortex, thus decreasing
hyperactivity and/or distractibility.
 In case of conduct disorder, drug treatment may be needed in
presence of epilepsy (anticonvulsants), hyperactivity (stimulant
medication), impulse control disorder, episodic aggressive
behavior (lithium, carbamazepine) and psychotic symptoms
(antipsychotics).

36. V. ANXIETY DISORDERs

37. V. ANXIETY DISORDERS
Anxiety is defined as a state of apprehension or unease arising out
of anticipation of danger. It is a normal phenomenon, but it
becomes pathological when causes significant subjective distress or
impairment in functioning of the individual.
Anxiety is of two types:
State
anxiety
Trait
anxiety

38. CLINICAL FEATURES
a. Physical symptoms
i. Motor Symptoms like tremors,
restlessness, muscle twitches and
fearful facial expressions.
ii. Autonomic and visceral symptoms
like dyspnea, palpitation, tachycardia,
Sweating hyperventilation, dry mouth,
frequency of micturition, diarrhea etc.
b. Psychic symptoms
i. Cognitive symptoms: Poor
concentration, distractibility
ii. Perceptual symptoms: Derealization,
depersonalization
iii.Affective symptoms: Diffuse,
unpleasant and vague apprehension,
fearfulness, inability to relax,
irritability and feeling of impending
doom.
iv. Other symptoms: Insomnia and
exaggerated startle response

39. TYPE OF ANXIETY DISORDERS
1. Generalized Anxiety
Disorder
2. Panic Disorder
3. Obsessive-Compulsive
Disorder (OCD)
4. Post-Traumatic Stress
Disorder
5.Phobias

40. A. Generalized Anxiety Disorder:
Chronic, excessive worry about every day,
routine life events and activities that lasts for
atleast 6 months indicates generalized anxiety
disorder.
 Children and adolescents with this disorder
anticipate the worst and often complain of
fatigue, tension, headache and nausea

41. B. Panic Disorder:
It is characterized by episodes of acute anxiety,
which occur repeatedly and without warning.
Physical symptoms include chest pain, heart
palpitations, shortness of breath. dizziness, abdominal
discomfort, feeling of unreality and fear of dying.
Children and adolescents with this disorder may
experience, unrealistic worry, self-consciousness and
tension may restrict ones life.

42. C. Obsessive-Compulsive Disorder (OCD)
OCD is characterized by repeated unwanted
thoughts (obsessions) and /or rituals that seem
impossible to control (compulsions).
Adolescents may be aware that their
symptoms do not make sense and are
excessive, but younger children may be
distressed only when they are prevented from
carrying out their compulsive habits.

43. D. Post-Traumatic Stress Disorder
The symptoms of this disorder occur after
any trauma such as abuse or violence.
Symptoms include nightmares, flashbacks,
depression, anger, irritability and
distractibility.

44. E. Phobias
Phobia is defined as a disabling and irrational fear of
some object, situation or activity. It leads to avoidance
of the feared object or situation and can cause extreme
feeling of terror, dread and panic that may restrict
ones life.

45.  The common types of phobia are:
i. Agoraphobia-fear of being outside
ii. Social phobia-fear of public speaking, meeting new people or other
social situations.
iii.Specific phobias-fear of particular items or situations for e.g.:
 Claustrophobia-fear of closed spaces
 Aerophobia-fear of flying
 Zoophobia-fear of animals
 Arachnophobia-fear of spiders
 Ophidiophobia-fear of snakes
 Acrophobia-fear of height
 Mysophobia-fear of germs
 Thanotophobia -fear of death

46. CAUSES OF ANXIETY
DISORDERS
Although studies suggest that children and adolescent are more
likely to have anxiety, it has not been shown whether biology or
environment plays greater role in the development of these disorders.
High levels of anxiety or excessive shyness in children aged 6-8
may be indicators of a developing anxiety disorders.

47. MANAGEMENT
 Effective treatment for anxiety disorders include:
 Medications like anti-anxiety drugs.
 Specific forms of psychotherapy like behavior therapy and
cognitive behavior therapy.
 Family therapy
 Combination of above stated therapies.

48.  Impaired social interaction related to inability to trust, neurological alterations
 Impaired verbal communication related to withdrawal into the self, inadequate
sensory stimulation, neurological alterations.
 Disturbed personal identity related to inadequate sensory stimulation, neurological
alterations
 Low self esteem related to dysfunctional family system and negative feed back
 Risk for injury related to impulsive and accident prone behavior and inability to
perceive self harm.

49. Although no two children are alike, there are general similarities in
the physical and mental development of all normal children, the
childs existence and emotional development depends on the family
or care givers. The developmental stages are very important in
assessment of the diagnosis. Children are less able to express
themselves in words. It is very important to find the child’s problem
in early age and prompt treatment should be given.

51. BIBLIOGRAPHY
 Book reference:
1. Rimple sharma, “Essentials of pediatric nursing” Jaypee Brothers Medical Publishers, third
edition (2021) page no.771-777
2. Pushpendra magon, “child health nursing”, 1st edition 2022, lotus publication page no.541-
563
3. Wong’s “Essentials of pediatric nursing” Elseiver publication, first south Asian
edition(2015), page no. 419-425 .
 Net reference:
1. https://www.slideshare.net/Revathipriya5/childhood-disorders-55964966
2. https://www.slideserve.com/rebecaa/management-of-common-psychiatric-problems-
powerpoint-ppt-presentation
3. https://www.slideshare.net/ritika555/child-psychiatric-problems-ppt