INTELLECTUAL DISABILITY.pptx nursing students

intelectual disorders

1. Disorders of Childhood

2. NORMAL vs. NOT NORMAL

3. Normal child development  What is growth and development ?  Process of growing to maturity.  Refers to process of biological and psychological changes in human being between birth and end of adolescence as the individual progresses from dependency to increasing autonomy.

4. What is the rationale behind the knowledge of normal developmental process ? For the better understanding of childhood psychiatry. To identify whether the observed emotional, social, or intellectual functioning is abnormal as it has to be compared with the corresponding normal range for the age group.

5. Distinct areas of development Physical Cognitive Social Emotional Moral psychosexual

6. Age related developmental periods newborn (ages 0–1 month) infant (ages 1 month – 1 year) toddler (ages 1–3 years) preschooler (ages 4–6 years) school-aged child (ages 6–10 years) adolescent (ages 11–19)

7. Cognitive development Includes capacity to learn, remember, recognise, solve problems and organize the environment. Newborn-learns to suck 8-12 mths-plays peek-a-boo 2yrs - knows animal sounds, names objects 3yrs – knows colors 5-6yrs - understands humor 7-11yrs - think logically, personal sense of right and wrong

8. Social development Learn to develop sense of themselves so that they can think and relate their experiences in other situation. Infant- recognizes care giver, shows stranger anxiety 2yrs- may separate from care giver 3-6 yrs – curiosity about sex 6-12 yrs – rules of the games are key, separation of the sexes, demonstrating competence is key.

9. Emotional development Recognition and use of their emotions appropriately. 2 mths - social smile 1-3yrs - likes attention 3-5yrs - shows sensitivity to criticism 5-7 yrs – can express feelings >7 yrs – can react to feelings of others and are more aware of other’s feeling

10. Moral development Learning concept of right and wrong 4-7 yrs - self control develops, guilt appears 7-11 yrs – feels empathy Early teens - peers considered in principles

11. Psychosexual development Process of learning to view themselves and others in terms of gender. 12-18 months: can differentiate play; girls like dolls 2-3 yrs: child can label self, picture, other children’s sex using clothes, toys, hair etc. 3-6 yr: same sex peers favored 6-11 yrs: heterosexual play >12 yrs: sexual activity begins

12. Developmental milestone

13. motor milestones Key Gross motor milestones: 3 mths – neck holding 5 mths – sitting with support 8 mths – sitting without support 9 mths –standing with support 10 months – cruising 12 mths – standing without support 14 mths – walking without support 18 mths – running 24 mths – walking upstairs

14. UNDERS T ANDING “NOT NORMAL”

15. Understanding when its not normal Anything which is: Delayed more than expected milestones Increased Dependence on others Requiring support for things which can be done independently Interfering day to day life like studies, play, peer relations etc Seems things are going out

16. American Academy of Neurology Warning Signs Any child with any of the following five symptoms should be evaluated: No babbling by 12 months. No gesturing, pointing, or waving goodbye by 12 months. No single words by 16 months. No two words spoken together spontaneously by 24 months 5. Any loss of previously acquired language or social skills at any time.

17. CHILD MENTAL HEALTH – The Major Concerns Worldwide 10-20% of children and adolescents experience mental disorders. One in 5 children (birth to 18) has a diagnosable mental disorder. One in 10 youth have serious mental health problems that are severe enough to impair how they function at home, in school, or in the community.

18. CHILDHOOD PSYCHIATRIC DISORDERS

19. Classification of childhood psychiatric disorders – DSM V Neurodevelopmental disorders Intellectual disability Communication disorders Autism spectrum disorders ADHD Learning disorders Motor disorders Disruptive mood dysregulation disorder Anxiety disorders Separation anxiety disorder Selective mutism Specific phobia OCD – trichotillomania, excoriation Trauma and stressor related disorders – Reactive attachment disorders, Disinhibited Social Engagement Disorder, PTSD for 6 years and below Feeding and eating disorders – pica, rumination disorder, Avoidant food intake disorder, Anorexia nervosa, bulimia nervosa, Elimination disorders Disruptive, impulse control and conduct disorders – ODD, IED, CD

20. Classification and Diagnosis of Childhood Disorders Relationship between child and adult psychopathology Some disorders are unique to children e.g., separation anxiety disorder Some disorders are primarily childhood disorders, but may continue into adulthood e.g., attention-deficit/hyperactivity disorder Some disorders are present in children and adults e.g., depression

21. Classification and Diagnosis of Childhood Disorders DSM-5 splits childhood disorders into two chapters: Neurodevelopmental Disorders Disruptive , Impulse Control, and Conduct Disorder DSM-5 has new names for disorders e.g., mental retardation will now be called intellectual developmental disorder DSM-5 will combine some disorders Autistic disorder, Asperger’s disorder, and pervasive developmental disorder not otherwise specified combined into Autism Spectrum Disorder

22. Organization of Childhood Disorders in DSM-IV-TR and DSM-5

23. Diagnoses of Childhood Disorders: Likely Changes for DSM-5

24. Classification and Diagnosis of Childhood Disorders Externalizing disorders Characterized by outward-directed behaviors Noncompliance, aggressiveness, over activity, impulsiveness Includes attention-deficit/hyperactivity disorder, conduct disorder, and oppositional defiant disorder. More common in boys Internalizing disorders Characterized by inward-focused behaviors Depression, anxiety, social withdrawal Includes childhood anxiety and mood disorders More common in girls

25. Psychological tests for children Psychological test is one of the sources of data used within the process of assessment , usually more than one test is used Purpose: Standardized psychological tests used to assess a child’s cognitive and behavioral functioning. It is used in clinical, education and correctional environments to assess a child’s personality To evaluate an attitudes , coping styles and behavior patterns who use the tests: Psychological testing of patients is ideally conducted by a clinical psychologist who has been trained in the administration , scoring and interpretation of these procedure

26. Psychiatric History taking in children

27. Anthropometric measurement in children Anthropometric measurement used to assess the nutritional status and as indicator of growth and development in children

28. Introduction When child has an intellectual disability (ID), their brain doesn’t develop properly. Their brain may also not function within the normal range of both intellectual and adaptive functioning. In the past, medical professionals called this condition “mental retardation .”

29. Understanding IDD Deficits in intellectual functions/ mental abilities such as reasoning, problem solving, abstract thinking etc Deficits in everyday adaptive functions that result in failure to meet developmental and socio cultural standards for personal independence and social responsibility. Such as communication, social participation, independent livings etc. Onset of deficits in intellectual period

30. Impairment in domains of: Conceptual Domain : memory, langauge, reading, writing, math reasoning, acquisition of practical knowledge, problem solving, judgment Social domain: Awareness of others thoughts, feelings, experiences, empathy, interpersonal communication skills, friendship abilities social judgment Practical domain: personal care, schooling, job responsibilities, money management, self management of behaviour etc.

31. Intellectual Developmental Disorder Formerly known as Mental Retardation in DSM-IV-TR Followed the guidelines of the American Association on Intellectual and Developmental Disabilities ( AAIDD) The AAIDD Definition of Intellectual Disability: Intellectual disability is characterized by significant limitations both in intellectual functioning and in adaptive behavior as expressed in conceptual, social, and practical adaptive skills This disability begins before age 18

32. Intellectual Developmental Disorder Proposed DSM-5 criteria : Intellectual deficit of 2 or more standard deviations in IQ below the average score for a person’s age and cultural group, which is typically an IQ score less than 70 Significant deficits in adaptive functioning relative to the person’s age and cultural group in one or more of the following areas: communication , social participation, work or school, independence at home or in the community, requiring the need for support at school, work, or independent life Onset before age 18 DSM-5 changes: There is clear identification that an IQ score must be considered within the cultural context of a person Adaptive functioning must also be assessed and considered within the person’s age and cultural group

33. Diagnostic Criteria for Intellectual Disability

34. Specific Examples of Adaptive Behavior Skills

35. Classification of ID There are four levels of ID : M ild , Moderate , Severe , and Profound . Sometimes ID may be classified as “other” or “unspecified .” Almost all cases of ID are diagnosed by the time a child reaches 18 years of age.

36. ID IQ (intelligence quotient) is measured by an IQ test . The average IQ is 100, with the majority of people scoring between 85 and 115. A person is considered intellectually disabled if he or she has an IQ of less than 70 to 75.

37. Causes of intellectual disability Anytime something interferes with normal  brain  development, intellectual disability can result . However, a specific cause for intellectual disability can only be pinpointed about a third of the time.

38. Etiology of Intellectual Developmental Disorder : Neurological Factors Down syndrome Chromosomal trisomy 21: an extra copy of chromosome 21 47 instead of 46 chromosomes Fragile-X syndrome Recessive-gene disease Phenylketonuria (PKU) Maternal infectious disease, especially during first trimester Cytomegalovirus, toxoplasmosis, rubella, herpes simplex, HIV, and syphilis

39. The most common causes of intellectual disability are: Genetic conditions.  These include things like  down syndrome  and  fragile X syndrome . Problems during  pregnancy.  Things that can interfere with fetal   brain development include alcohol or drug use, malnutrition, certain infections, or  preeclampsia. Problems during child birth . intellectual disability may result if a baby is poor of oxygen during childbirth or born extremely premature

40. ID Illness or injury .   Infections like   Meningitis,   whooping cough, or the  measles  can lead to intellectual disability . Severe  head injury , extreme malnutrition, infections in the brain, exposure to toxic substances such as lead, and severe neglect or abuse can also cause it . None of the above . In two-thirds of all children who have intellectual disability, the cause is unknown.

41. Causes of ID can include: trauma before birth, such as an infection or exposure to alcohol, drugs, or other toxins trauma during birth, such as oxygen deprivation or premature delivery inherited disorders, such as phenylketonuria (PKU ).

42. Causes Risk Factors

43. For a genetic or  metabolic disorder , a variety of tests may be done to confirm the diagnosis . These include  blood tests , urine tests, imaging tests to look for structural problems in the  brain, or electroencephalogram to look for evidence of seizures .

44. ID In children with developmental delays, tests performed to rule out other problems, including hearing problems and certain neurological disorders. If no other cause can be found for the delays, the child will be referred for formal testing.

45. ID Three things factor into the diagnosis of intellectual disability : a three-part evaluation: 1) Interviews with the parents, 2)Observation of the child, and 3)Testing of intelligence and adaptive behaviours (standard tests) A child is considered intellectually disabled if he or she has deficits in both IQ  and  adaptive behaviours. If only one or the other is present, the child is not considered intellectually disabled .

46. ID I ntelligence tests, such as the Stanford- Binet Intelligence Test. This will help the doctor determine child’s IQ. The doctor may  also administer other tests such as the Vineland Adaptive Behaviour Scales. This test provides an assessment of your child’s daily living skills and social abilities, compared to other children in the same age group

47. IQ Intelligence of a person is referred to in terms of intelligence quotient [IQ]. It is calculated from mental age [MA] and chronological age [CA] MENTAL AGE IQ = ……………………………….. * 100 CHRONOLOGICAL AGE

48. Assessment IQ tests correlate with & predict school achievement; a measure of academic intelligence IQ tests are relatively stable but not unchanging (stability increases with age) Heredity and environment influence IQ scores No test is free from cultural influences IQ is a score on a test – it is descriptive, not explanatory IQ fails to measure many factors – creativity, perseverance & discipline, social ability, etc.

49. Tests of Intelligence Wechsler Scales (most common): Wechsler Preschool & Primary Scale of Intelligence WPPSI-III (2.6 – 7.3 yrs) Wechsler Intelligence Scale for Children WISC-IV (6.0 – 16.11 yrs) Wechsler Adult Intelligence Scale WAIS-III (16 – 89 yrs) Other commonly used scales: Stanford-Binet Intelligence Scale Kaufman Assessment Battery for Children Woodcock-Johnson Tests of Cognitive Ability, etc.

50. WISC-III WISC-III Verbal IQ Performance IQ Full Scale IQ

51. WISC-IV Verbal Comprehension Index Similarities, vocabulary, comprehension, information, *word reasoning Perceptual Reasoning Index Block design, picture concepts, *matrix reasoning, picture completion Working Memory Index Digit span, *letter-number sequencing, arithmetic Processing Speed Index Coding, *symbol search, *cancellation

52. Special Purpose Measures Infant/Early Childhood Gessell Developmental Scales, etc. Mental Retardation Vineland Adaptive Behavior Scale AAMR Adaptive Behavior Scale Physically Handicapped Hiskey Nebraska Test of Learning Aptitude (hearing impaired) Leiter International Perf Scale (limited reading) Cross Cultural Testing

53. Achievement Tests Group Administered Tests Stanford Achievement Tests (Stanford 9) California Achievement Tests (CAT) IOWA Tests of Basic Skills, etc. Individually Administered Tests Wide Range Achievement Tests 3 (WRAT 3) Wechsler Individual Achievement Tests (WIAT) Woodcock-Johnson Psychoeducational Battery, rev (WJ-R), etc.

54. Classification of ID LEVELS IQ RANGE ……………… ……………. 1] mild ID 50-69 2] moderate ID 35-49 3] severe ID 20-34 4] profound ID below 20

55. ID Laboratory and imaging tests may also be performed . These can help your child’s doctor detect metabolic and genetic disorders, as well as structural problems with your child’s brain. Other conditions, such as hearing loss, learning disorders, neurological disorders, and emotional problems can also cause delayed development. Your child’s doctor should rule these conditions out before diagnosing your child with ID.

56. Rolling over, sitting up, crawling, or walking late Talking late or having trouble with talking Slow to master things like potty training , dressing, and feeding himself or herself Difficulty remembering things Inability to connect actions with consequences Behaviour problems such as explosive tantrums Difficulty with problem-solving or logical thinking

57. ID In children with severe or profound intellectual disability, there may be other health problems as well. These problems may include  seizures, mood disorders   (anxiety, autism etc .), motor skills impairment , vision  problems, or hearing problems.

58. Symptoms of intellectual disability Symptoms of ID will vary based on your child’s level of disability and may include: failure to meet intellectual standards sitting, crawling, or walking later than other children problems learning to talk or trouble speaking clearly memory problems

59. ID inability to understand the consequences of actions inability to think logically childish behaviour contradictory with the child’s age lack of curiosity learning difficulties IQ below 70 inability to lead a normal life due to challenges communicating, taking care of themselves, or interacting with others

60. ID Behavioural Symptoms: aggression dependency withdrawal from social activities attention-seeking behaviour depression during adolescent and teen years lack of impulse control passivity

61. ID tendency toward self-injury stubbornness low self-esteem low tolerance for frustration psychotic disorders difficulties paying attention

62. Some people with ID may also have specific physical characteristics. These can include having a short stature or facial abnormalities.

63. Levels of intellectual disability ID is divided into four levels, based on your child’s IQ and degree of social adjustment. Mild intellectual disability Some of the following symptoms of mild intellectual disability include: taking longer to learn to talk, but communicating well once they know how

64. MILD ID being fully independent in self-care when they get older having problems with reading and writing social immaturity inability to deal with the responsibilities of marriage or parenting benefiting from specialized education plans having an IQ range of 50 to 69

65. ID Moderate intellectual disability If your child has moderate ID, they may exhibit some of the following symptoms: are slow in understanding and using language may have some difficulties with communication can learn basic reading, writing, and counting skills are generally unable to live alone can often get around on their own to familiar places can take part in various types of social activities generally have an IQ range of 35 to 49

66. ID Severe intellectual disability Symptoms of severe ID include: noticeable motor impairment severe damage or abnormal development of their central nervous system generally have an IQ range of 20 to 34

67. ID Profound intellectual disability Symptoms of profound ID include: inability to understand or comply with requests or instructions possible immobility incontinence very basic nonverbal communication inability to care for their own needs independently the need of constant help and supervision having an IQ of less than 20

68. ID Other intellectual disability People in this category are often physically impaired, have hearing loss, are nonverbal, or have a physical disability. These factors may prevent from conducting screening tests. Unspecified intellectual disability If child has an unspecified ID, they will show symptoms of ID, but consultant doesn’t have enough information to determine their level of disability.

69. Prevention Certain causes of intellectual disability are preventable. The most common of these is  fetal alcohol syndrome. Pregnant women shouldn’t drink alcohol. Getting proper prenatal care, taking a prenatal vitamin, and getting vaccinated against certain infectious diseases can also lower the risk that your child will be born with intellectual disabilities .

70. ID In families with a history of genetic disorders, genetic testing may be recommended before conceptions Certain tests, such   as ultrasound   and   amniocentesis, can also be performed during pregnancy to look for problems associated with intellectual disability. Although these tests may identify problems before birth, they cannot correct them.

71. Treatment of Intellectual Developmental Disorder Residential treatment Small to medium-sized community residences Behavioral treatments Language, social, and motor skills training Method of successive approximation to teach basic self-care skills in severely retarded e.g., holding a spoon, toileting Applied behavioral analysis Cognitive treatments Problem-solving strategies

72. Role of nurse in ID The management of ID can be discussed under prevention at Primary Secondary Tertiary levels

73. Primary prevention Improvement in socio-economic condition [elimination of malnutrition, prematurity, perinatal factors] Education in public; aiming at removal of misconception about ID. Medical measures for good; to prevent infections. Trauma. Excessive use of medication, malnutrition.

74. ID Universal immunization children with BCG,POLIO, DPT, MMR Genetic counseling in at risk parents eg.. Down syndrome,

75. Secondary prevention Early detection and treatment of preventable disorder; hypothyroidism [thyroxine] Early detection of handicaps Early treatment of correctable disorders eg..infections[antibiotics]

76. Tertiary prevention Behavioral modification using the principles of positive and negative reinforcement Rehabilitation in vocational, physical, social areas. Parental counseling Institutionalization or residential care

77. management Early intervention programs are available. A team of professionals works with parents to write an Individualized Family Service Plan.

78. ID Early intervention may include speech therapy, occupational therapy,  physical therapy, family counselling , training with special assistive devices, or  nutrition   services The point of special education is to make adaptations, accommodations, and modifications that allow a child with an intellectual disability to succeed in the classroom.

79. ID School-age children with intellectual disabilities (including  preschoolers) are eligible for special education for free through the public school system. This is mandated by the Individuals With Disabilities Education Act (IDEA). Parents and educators work together to create an  individualized education program.

80. ID The main goal of treatment is to help child reach their full potential in terms of education, social skills, and life skills. Treatment may include behaviour therapy, occupational therapy, counselling, and in some cases, medication.

81. Learning Disorders

82. Who is a Student with a Learning Disability? A student with a Learning Disability is a student with learning abilities who: falls within the range of intellectual ability from average to superior intelligence; is able to learn ( including tertiary level subjects ); has disabilities in one or more of the academic skills of reading, writing, spelling or mathematics; and is able to progress in their learning by navigating around their learning difficulties.

83. ADHD Introduction ADHD is a common neurobehavioral disorder of childhood that can result in significant functional impairment and if not adequately treated can lead to impaired quality of life. Attention-deficit/hyperactivity disorder (ADHD) is a neuropsychiatric condition affecting preschoolers, children, adolescents, and adults around the world, characterized by a pattern of diminished sustained attention, and increased impulsivity or hyperactivity.

84. Attention Deficit/Hyperactivity Disorder Excessive levels of activity Fidgeting(restless movements), squirming(move from side to side), running around when inappropriate, incessant talking( continuously talkative) Distractibility and difficulty concentrating Makes careless mistakes, cannot follow instructions, forgetful Congress created National ADHD Awareness Day First observed September 7, 2004

85. Proposed DSM-5 Criteria for Attention-Deficit/Hyperactivity Disorder • Either A or B: A. Six or more manifestations of inattention present for at least 6 months to a maladaptive degree and greater than what would be expected given a person’s developmental level, e.g., careless mistakes, not listening well, not following instructions, easily distracted, forgetful in daily activities B. Six or more manifestations of hyperactivity-impulsivity present for at least 6 months to a maladaptive degree and greater than what would be expected given a person’s developmental level, e.g., fidgeting, running about inappropriately (in adults, restlessness), acting as if “driven by a motor,” interrupting or intruding, incessant talking • Some of the above present before age 12 • Present in two or more settings, e.g., at home, school, or work • Significant impairment in social, academic, or occupational functioning • For people age 17 or older, only four signs of inattention and/or four signs of hyperactivity-impulsivity are required to meet the diagnosis.

86. Attention Deficit/Hyperactivity Disorder ADHD often comorbid with anxiety and depression Prevalence estimates 3 to 7% worldwide More common in boys than girls May be because boys’ behavior more likely to be aggressive

87. Girls with ADHD Combined type had: More disruptive behaviors than inattentive( Laking concentration, day dreaming) type More comorbid diagnoses of conduct disorder or oppositional defiant disorder than girls without ADHD Inattentive type Viewed more negatively by peers than girls without ADHD Girls with ADHD more likely to: Be anxious and depressed Exhibit neurological deficits (e.g., poor planning, problem-solving) Have symptoms of eating disorder and substance abuse by adolescence

88. Etiology of ADHD Genetic factors twin studies Heritability estimates as high as 70 to 80% There is greater concordance in monozycotic than in dizycotic twins. dopamine genes implicated Dopamine receptor gene( a deficit of dopamine and nor epinephrine has been attributed in the over activity seen in ADHD. Neurobiological factors Poor performance on tests of frontal lobe function

89. Etiology of ADHD Pre, Peri and postnatal factors Low birth weight Toxic exposure, fetal distress, precipitated or prolonged labor, perinatal asphyxia. Postnatal infections, CNS abnormalities resulting from trauma Maternal tobacco and alcohol use Environmental toxins Limited evidence that food additives or food coloring can have a small impact on hyperactive behavior No evidence that refined sugar causes ADHD Nicotine from maternal smoking Exposure to tobacco in utero associated with ADHD symptoms May damage dopaminergic system resulting in behavioral disinhibition

90. Etiology of ADHD Parent-child relationship Parents give more commands and have more negative interactions Family factors Interact with genetic and neurobiological factors

91. Pharmacological management Methlphenidate and amphetamines - most commonly used stimulants for the treatment of ADHD. Indications ADHD Narcolepsy Depressive disorder Obesity

92. Mechanism of action These drugs also inhibitors of catecholamine reuptake, especially dopamine reuptake and inhibitors of monoamino oxidase . The net result of these activities is believed to be the stimulation of several brain regions.

93. Dosage &side effects Starting dose is 5-10mg per day orally Maximum daily is 80mg/day Side effects anorexia weight loss slowed growth dizziness insomnia dysphoric mood tics and psychosis

94. Nurses responsibility To decrease anorexia the medications may be administered immediately after meals. The patient should be weighed regularly(at least weekly) during hospitalization and at home while on therapy with CNS stimulants. To prevent insomnia administer last dose at least 6 hours before bed time. Ensure that parents are aware of the delayed effects of ritalin . Therapeutic response may not seen for 2-4 weeks. the drug should not be discontinued for lack of immediate results.

95. Inform the parents that OTC ( over –the-counter) medications should be avoided while the child is on stimulant medications. Some OTC medications, particularly cold and fever preparations contain certain sympathomimetic agents that could compound effects of the stimulant and create drug interactions that may be toxic to the child. Ensure that parents are aware that the drug should not be withdrawn abruptly. With drawl should be gradual and under the direction of physician.

96. Treatment of ADHD Psychological treatment Parental training Change in classroom management Behavior monitoring and reinforcement of appropriate behavior Supportive classroom structure Brief assignments Immediate feedback Task-focused style Breaks for exercise

97. Academic Interventions Giving Directions Many students with ADHD have trouble following directions. The guidelines below help address this problem. Number of Directions: Give a minimal number of directions or steps at a time. If necessary, have students repeat the directions to the teacher or a peer partner. Form of Directions: Provide written directions or steps, or a visual model of a completed project. Teach students how to refer to these items as reminders of process steps to complete tasks. This strategy is particularly helpful for long-term projects.

98. Organization Many students with ADHD have significant difficulties with organization. They are more likely to respond positively when teachers establish class routines and set procedures and maintain a well-organized learning environment. Clear rules and advanced planning are keys to success for teachers of students with ADHD.

99. The following organizational supports are particularly useful. Assignment Notebook: Provide the student with an assignment notebook to help organize homework and seatwork. Color-Coded Folders: Provide the student with color-coded folders to help organize assignments for different academic subjects.

100. Homework Partners: Assign the student a partner who can help record homework and other seatwork in the proper folders and assignment book. Clean Out Dates: Periodically ask the student to sort through and clean out his or her desk, book bag, and other special places where written assignments are stored.

101. Checklist of Homework Supplies: Give the student a checklist that identifies categories of items needed for homework assignments. The checklist can be taped to the inside of the student’s locker or desk.

102. Extra Books: Provide the student with an extra set of books or electronic versions of books for use at home. This eliminates the student having to remember to bring books back and forth. Use of Calendars: Teach the student to use a calendar for scheduling assignments. Tape a schedule of planned daily activities to the student’s desk to help with time management and transitions.

103. NURSING INTERVENTION Develop a trusting relationship with the child. Convey acceptance of the child, separate from the unacceptable behavior. Ensure that patient has safe environment. Remove objects from immediate area in which patient could injure self due to random hyperactive movements. Identify deliberate behaviors that put the child at risk for injury.

104. Institute consequences for repetition of this behavior. Provide supervision for potentially dangerous situation Ensure the child’s attention by calling his name and establishing eye contact, before giving instructions.

105. Ask the child to repeat instruction before beginning a task. Establish goals that allow patient to complete a part of the task, rewarding each step completion with a break for physical activity. Provide assistance on a one-to-one basis beginning with simple concrete instructions. Gradually decrease the amount of assistance given to task performance.

106. Give immediate positive feedback for acceptable behavior Provide quiet environment, self-contained classrooms and small group activities. Avoid over stimulating places such as cinema halls, bus stops and other crowded places. Help him learn how to take his turn wait in line and follow rules. Assess parenting skill level considering intellectual, emotional and physical strengths and limitation.

107. Provide information and materials related to the child’s disorder and effective parenting techniques. Give instructional materials in written and verbal form with step-by-step explanation. Educate child and family on the use of psycho-stimulants and anticipated behavioral response.

108. Thank you

109. Elimination Disorders

110. Normal Development Toddler Phase (18 months- 3 years) (During toddler phase a child usually becomes interested in mastering elimination) Bowel Continence Bladder Continence

111. Enuresis When a child fails to successfully achieve toilet training by the age of five and has repeated voiding of urine into the bed or clothes at least twice per week for at least three consecutive months he/she meets DSM diagnostic criteria for enuresis.

112. Enuresis Nocturnal Enuresis- voiding while asleep Diurnal Enuresis(voiding while awake) Primary Enuresis(indicates that a child has never accomplished continence through the night. This type is usually due to maturational and /or physiological delays) Secondary Enuresis(when a child achieved continence for at least 6 consecutive months but began wetting again- This type may be caused by psychological factors or an underlying medical condition

113. Prevalence 5-10% of 5 year olds meet criteria for nocturnal enuresis 2-3% of 12 year olds meet criteria for nocturnal enuresis 1% of 18 year olds still have enuretic symptoms

114. Diagnostic Criteria A. Repeated voiding of urine into bed or clothes (whether involuntary or intentional ) B. The behavior is clinically significant as manifested by either a frequency of twice a week for at least 3 consecutive months or the presence of clinically significant distress or impairment in social, academic (occupa­tional), or other important areas of functioning . C. Chronological age is at least 5 years (or equivalent developmental level ). D. The behavior is not due exclusively to the direct physiological effect of a substance (e.g., a diuretic) or a general medical condition ( e.g., diabetes , spina bifida, a seizure disorder). Specify type: Nocturnal Only Diurnal Only Nocturnal and Diurnal

115. Differential Diagnosis Maturational Anatomical Abnormalities Endocrine Urinary Tract Disease Neurological Medications Psychological

116. Diagnostic Workup Child’s Age Onset of Symptoms (Primary/Secondary) Timing (Nocturnal/Diurnal/Both) Frequency Family History Developmental History

117. Physical Exam Neurological Exam Throat and Neck Exam Skin Exam Abdominal Exam Routine Blood Draw UA

118. Consults Pediatric Urology Ultrasound of Genitourinary system Voiding Cystourethrogram Renal Ultrasound Pediatric Neurology Sleep Study

119. Treatment Education Watchful Waiting Non-pharmacological Management Pharmacological Management Therapeutic Interventions

120. Education Review and correct parental expectation 2. Waiting until the child is ready for potty training 3. Ensuring there is no teasing/shame given for failures 4. Limiting caffeine and dairy products in evening hours 5. Limiting nighttime and not daytime fluids 6. Remind children that it isn’t their fault 7. Teaching parents patience 8. Educating parents to not punish their child 9. Warning parents about potential relapse

121. Watchful Waiting When parents decide to pursue watchful waiting it is important to educate the family about the natural history, available treatments, and prognosis of enuresis

122. Non-Pharmacological Interventions Education Advice Bell and Pad

123. Pharmacological Interventions Desmopressin Imipraminine Oxybutynin TCAs, SSRIs & Psychostimulants NSAIDs

124. Additional Treatments Cognitive Behavioral Therapy Psychodynamic Psychotherapy Biofeedback Acupuncture

125. Encopresis Encopresis is less common than enuresis -When bowel continence is not achieved by age 4 a diagnosis of encopresis can be made -Etiology may be physiological and/or psychological

126. Encopresis Defined as the repeated passage of feces in in appropriate places (usually undergarments). The voiding is typically regarded as involuntary although it may be volitional. The term is derived from the Greek Word Kopros meaning dung or feces

127. Encopresis Primary Encopresis (soiling in a child who has never gained bowel continence for six months or more) Secondary Encopresis (is due to psychological stress it may be referred to as regressive enuresis) Retentive Encopresis ( Encopresis with Constipation and Overflow Incontinence) Nonretentive encopresis ( Encopresis without Constipation and Overflow Incontinence)

128. Prevalence Secondary encopresis is more common Between ages 7-8 prevalence is 1.5% 3:1 male to female ratio Retentive type is 80-95% of cases

129. Diagnostic Criteria Repeated passage of feces into inappropriate places (e.g., clothing or floor) whether voluntary or unintentional At least one such event a month for at least 3 months Chronological age of at least 4 years (or equivalent developmental level) The behavior is not exclusively due to a physiological effect of a substance (e.g., laxatives) or a general medical condition, except through a mechanism involving constipation.

130. Etiology Delay in Maturation Underlying Medical Condition Psychological/Behavioral Constipation

131. Primary Retentive Encopresis Delayed Physical Maturation Inappropriate Toilet Training

132. Retentive Encopresis Represents 80-95% of cases Infrequent Bowel Movements Large Stools Painful Defecation

133. Secondary Encopresis Birth of sibling Parental Divorce Abuse ODD or CD MR/Autism/ Psychosis/RAD

134. Diagnosis Child’s age Onset (primary/secondary) Timing (day/night) Frequency Location of soiling Bowel Habits (frequency, stool size, consistency) Melena / Hematochezia Pain with Defecation/Fluid and Dietary Habits

135. Physical Exam Abdominal pain/distention Height/Weight Neurological Exam Skin Exam Rectal Exam Abdominal XRAY Stool Collection Blood Testing Rectal Biopsy/Barium Enema

136. Treatment Advice/Education Nonpharmacological Pharmacological Intervention

137. Advice/Education Dietary Changes (foods high in fiber) Increase Fluid Intake Make Toilet Training Non-Threatening Make Toilet Accessible Regular Bathroom Times

138. Nonpharmacological CBT Psychodynamic Psychotherapy Biofeedback Acupuncture

139. Pharmacological Laxatives Suppositories Enemas Mineral Oil Stool Softeners