Revised -ppt of child psychiatric problems [Autosaved].pptx

RITIKA SONI, ASS. PROF. -SNC, SHIMLA

1. COMMON PSYCHIATRIC DISORDERS IN CHILDREN Presented By: RITIKA SONI

2. INTRODUCTION

3. DEFINITION These are the disorders of psychological, behavioural and emotional development disorders with onset usually occurring in childhood and adolescence.

4. Historical Developments in Child Psychiatry

5. CLASSIFICATION OF CHILD PSYCHIATRIC DISORDER M ental sub normality / Mental retardation Specific developmental disorders Pervasive developmental disorders Hyperkinetic disorders Behavioral disorders

6. MENTAL SUBNORMALITY Acc. to WHO, incomplete or insufficient general development of the mental capacities. It has two components: Mental deficiency and mental retardation ( now named intellectual disability by American Association on Intellectual and developmental disability, 2015). Intellectual disability has been defined by significant cognitive deficits, with an IQ score of below 70 and deficit in functional and adaptive skills in three domains or areas, :

7. The conceptual domains includes skills in language, reading, writing, math, reasoning , knowledge and memory. The social domains refers to empathy, social judgment, interpersonal communication skills, the ability to make and retain friendships, and similar capacities. The practical domains centers on self management in areas such as personal care, job responsibilities money management, recreation, and organizing school and work.

8. Mental retardation begins in childhood or  adolescence  before the age of 18. In most cases, it persists throughout adulthood. MR is preferred term in both ICD-10 and DSM- I V. Generalized  neurodevelopmental disorder  characterized by significantly impaired  intellectual  and  adaptive functioning . A diagnosis of mental retardation is made if an individual has an intellectual functioning level well below average and significant limitations in two or more adaptive skill areas.

9. MENTAL RETARDATION Mental retardation is defined as significantly sub average general intellectual functioning , associated with significant deficit or impairment in adaptive functioning , which manifests during the developmental period (before 18 yrs of age). APA, 2000

10. MR:  It is defined by an  IQ  score  under 70  in addition to deficits in two or more  adaptive behaviors  that affect everyday, general living.  A historical image of a person with intellectual disability

11. Components Syndromic MR It is intellectual deficits associated with other medical and behavioral signs and symptoms. Nonsyndromic MR Refers to intellectual deficits that appear without any abnormalities.

12. Prevalence and incidence Affects about2-3% of people 75-90% of the affected people have mild MR Non- syndromic or idiopathic MR accounts for 30-50 % of cases. About a quarter of cases are caused by a genetic disorder.

13. Classification of mental retardation by IQ:

14. DEVELOPMENTAL CHARACTERSTICS OF MR Ability to perform self-care activities Mild Cognitive/educational capabilities Moderate Social or communication capabilities Severe Psychomotor capabilities Profound

15. SIGNS AND SYMPTOMS Intellectual disability (ID) begins during childhood and involves deficits in : mental abilities, social skills, and core  activities of daily living  (ADLs) when compared to same-aged peers.  There often are no physical signs of mild forms of ID , although there may be characteristic physical traits when it is associated with a genetic disorder (e.g., Down syndrome). The level of impairment ranges in severity for each person. Some of the early signs can include: Delays in reaching or failure to achieve milestones in motor skills development (sitting, crawling, walking) Slowness in learning to talk or continued difficulties with speech and language skills after starting to talk

16. Difficulty with self-help and self-care skills (e.g., getting dressed, washing, and feeding themselves) Poor planning or problem solving abilities Behavioral and social problems Failure to grow intellectually or continued infant-like behavior Problems keeping up in school Failure to adapt or adjust to new situations Difficulty in understanding and following social rules

17. Oblique Palpebral Fissure Epicanthic Fold Furrowed Tounge

18. FLAT OCCIPUT

19. ETIOLOGY 1. GENETIC: (5%) a) CHROMOSOMAL ABNORMALITIES Disability is caused by abnormal  genes  inherited from parents, errors when genes combine, or other reasons. The most prevalent  genetic conditions  include : Down syndrome , (1 out of 700 births) Klinefelter syndrome , Fragile X syndrome  (common among boys, 1out of 1000 births) & Turners syndrome

20. INBORN ERRORS OF METABOLISM- involving amino acids, lipids, carbohydrates . Phenylketonuria (.5-1% of all cases of MR) Niemann- Pick disease- sphingolipidosis (harmful quantities of fatty substances or lipids , accumulate in spleen, liver, Lungs, bone marrow and brain). Glycogen storage disease SINGLE-GENE DISORDERS Tuberous sclerosis(autosomal dominant disorder)/ Epiloia )- 1: 15,000 VOGT’S TRIAD Dystrophia myotonica CRANIAL ANOMALIES Microcephaly

21. b) PERI-NATAL CAUSES(10%)

22. INFECTIONS : Rubella, syphilis, toxoplasmosis etc. Prematurity Birth trauma Hypoxia IUGR Kernicterus Placental abnormalities Drugs during first trimester c) ACQUIRED PHYSICAL DISORDERS IN CHILDHOOD (2-5%) - Infections, encephalitis - Cretinism( severe iodine deficiency) , cerebral palsy - Trauma, lead poisoning, - Malnutrition

23. d) SOCIOCULTURAL CAUSES: (15%) Deprivation of sociocultural stimulation e) PSYCHIATRIC DISORDERS (1-2%) Pervasive developmental disorders – infantile Autism Childhood onset schizophrenia

24. DIAGNOSTIC EVALUATION

25. HISTORY PHYSICAL EXAMINATION DETAILED NEUROLOGICAL EXAMINATION MSE- ASSESSMENT OF ASSOCIATED PSYCHIATRIC DISORDER

26. PSYCHOLOGICAL TESTS: MEASURMENT OF INTELLIGENCE STANFORD – BINET OR BINET KAMATH TEST WECHSLER INTELLIGENCE SCALE FOR CHILDREN FOR 6-16 YEARS OF AGE. BHATI’S BATTERY OF PERFORMANCE TEST FOR ADAPTIVE FUNCTIONING: VINELAND SOCIAL MATURITY SCALE(VSMS) DENVER DEVELOPMENT SCREENING TEST(DDST) INVESTIGATIONS ROUTINE INVESTIGATIONS URINE TEST- PHENYLKETONURIA EEG-PRESENCE OF SEIZURES BLOOD LEVELS: INBORN ERROR OF METABOLISM

27. CHROSOMAL STUDIES: AMNIOCENTESIS OR CHORIONIC VILLUS BIOPSY CT, MRI SCAN OF BRAIN TFT & LFT - THYROID FUNCTION TEST, LIVER FUNCTION TEST.

28. MANAGEMENT

29. PREVENTION

30. Health promotion: Improvement In Socio-economic Condition Good Perinatal Medical Care Education regarding Misconception about M.R. Universal Immunization Facilitating Research Activities Genetic counselling PRIMARY PREVENTION

31. Good antenatal care and encouraging deliveries in hospitals under proper supervision and care. SPECIFIC PROTECTION : Good prenatal, natal, postnatal care to the pregnant mother at risk. Genetic counseling to at risk patients. Avoid childbirths in late stage of the mother. Avoiding consanguine marriages. Avoiding marriages of mentally retarded.

32. SECONDARY PREVENTION Early detection and treatment of preventable disorders. Early detection of handicaps Early treatment of infections (antibiotics) anomalies (surgical correction). Early recognition of mental retardation.

33. Mental retardation should be integrated with normal individuals in society. Amniocentesis and medical termination of pregnancy on medical grounds. Early detection of correctable disorder Prevent against abuse.

34. TERTIARY PREVENTION 1.D isability limitation: Treatment of physical and psychological problems. Institutionalization of severe mentally retarded or those with psychological problems. Education (if educable)and training to avoid handicap. Physiotherapy to treat the associated deficits.

35. Behaviour modification using Positive and negative re- Enforcement, institutionalization care, Rehabilitation, legislation Parental counselling Rehabilitation:

36. What can I do to help my intellectually disabled child? Steps to help your intellectually disabled child include: Learn everything about intellectual disabilities . The more you know, the better advocate you can be for your child. Encourage your child’s independence . Let your child try new things and encourage your child to do things by themselves. Provide guidance when it’s needed and give positive feedback when your child does something well or masters something new. Get your child involved in group activities: Taking an art class or participating in Scouts will help your child build social skills. Stay involved : By keeping in touch with your child’s teachers, you’ll be able to follow their progress and reinforce what your child is learning at school through practice at home. Get to know other parents of intellectually disabled children . They can be a great source of advice and emotional support.

37. NURSING MANAGEMENT Risk for injury related to altered physical mobility or aggressive behavior. Interventions: Create a safe environment for the client Ensure that small items are removed from area where client will be ambulating and that sharp items are out of reach. Store items that client uses frequently with in easy reach. Pad side rails with the h/o seizures. Prevent physical aggression & acting out behavior by learning to recognize signs.

38. 2. Self- care deficit related to altered physical mobility or lack of maturity as evidenced by not capable to complete the activities of daily living, poor physical appearance. Interventions: Identify aspects of self care that may be with in the clients capabilities. Work on one aspect of self care at a time. Provide simple, concrete explanations. Offer positive feedback for efforts. When one aspect of self care has been mastered to the best of the clients ability, move on to another. Encourage independence

39. 3. Impaired verbal communication related to developmental alterations as evidenced by lack of communication with others. Interventions: Maintain consistency of staff assignments over time Anticipate and fulfill client’s needs until satisfactory communication patterns are established. Practice these communication skills repeatedly.

40. 4. Impaired social interaction related to speech deficiencies or difficulty in adhering to conventional social behavior as evidenced by lack of contact with others. Intervention: Remain with client during initial interactions with others on the unit. Explain to other clients the meaning behind some of the client ‘s non-verbal gestures and signals. Use simple language to explain to client which behaviors are acceptable and which are not. Reward for appropriate behavior Aversive reinforcement for inappropriate behavior.

41. BIBLIOGRAPHY

42. SPECIFIC DEVELOPMENTAL DISORDERS

43. SPECIFIC DEVELOPMENTAL DISORDERS DEFINITION: SDD are characterised by an inadequate development in usually one specific area of functioning.

44. TYPES OF SPECIFIC DEVELOPMENTAL DISORDERS SPECIFIC READING DISORDERS

45. SPECIFIC ARITHMETIC DISORDER

46. SPECIFIC DEVELOPMENTAL DISORDER OF SPEECH AND LANGUAGE

47. SPECIFIC DEVELOPMENTAL DISORDER OF MOTOR FUNCTION

48. PERVASIVE DEVELOPMENTAL DISORDER Pervasive developmental disorders (PDD) refers to  a group of disorders characterized by delays in the development of socialization and communication skills . Parents may note symptoms as early as infancy, although the typical age of onset is before 3 years of age.

49. DEFINITION ASD (AUTISM SPECTRUM DISORDER): A group of disorders that are characterized by impairment in several areas of development, including social interaction skills and interpersonal communication . Included in this category are autistic disorder, Rett’s disorder, childhood disintegrative disorder, Asperger’s disorder.

50. 1. Rett syndrome Also called: RTS, cerebroatrophic hyperammonemia  A rare genetic mutation affecting brain development in girls. Despite being caused by a gene mutation, Rett syndrome is rarely inherited . Fewer than 5 thousand cases per year (India ) Infants seem healthy during their first six months , but over time, rapidly lose coordination, speech and use of the hands. Symptoms may then stabilize for years. Requires a medical diagnosis Lab tests or imaging always required There's no cure, but medication, physio- and speech therapy and nutritional support help to manage symptoms, prevent complications and improve quality of life.

51. 2. Asperger syndrome A Neurodevelopmental disorder, affecting the ability to socialize and communicate effectively. Asperger's syndrome is a condition on the autism spectrum, with generally higher functioning. People with this condition may be socially awkward and have an all-absorbing interest in specific topics. Communication training and behavioral therapy can help people with the syndrome learn to socialize more successfully. Restricted interest

52. Lack of eye contact Does not know what to say and how to respond when someone talks to them. Few emotions May not smile when they are happy or laugh at a joke Speak in flat , robotic kind of way. Dislike change (they may eat the same food for breakfast everyday.

53. Rare Fewer than 1 million cases per year (India) Chronic: can last for years or be lifelong Requires a medical diagnosis Lab tests or imaging rarely required Psychologist will diagnose and treat problems with emotions and behavior. Pediatric neurologist treat conditions of brain Developmental pediatrician work for speech and language issues and other developmental problems Psychiatrist have expertise in mental health and can prescribe medicine to treat them.

54. Treatment Every child is different , so there is not one size – fits- all approach. Treatment includes: Social skill training Speech language therapy (SPL) Cognitive behavioural therapy (CBT) Parent education and training Applied behaviour analysis Medicine-no specific drug but- SSRI, Antipsychotic drugs stimulants.

55. 3. Childhood disintegrative disorder Childhood disintegrative disorder  ( CDD ), also known as  Heller's syndrome  and  disintegrative psychosis , dementia infantilis, is a rare condition characterized by late onset of  developmental  delays—or severe and sudden reversals—in  language ,  social function , and  motor skills . Researchers have not been successful in finding a cause for the  disorder . CDD has some similarity to  autism , and is sometimes considered a  low-functioning  form of it. CDD is a rare condition, with only 1.7 cases per 100,000

56. CDD

57. 4.AUTISTIC DISORDER Autistic disorder is characterized by a withdrawal of the child in to the self and in to a fantasy world of his or her own creation. The child has markedly abnormal or impaired development in social interaction and communication . Activities and interests may be considered somewhat bizarre.

58. Epidemiology According to autism and developmental disabilities monitoring ( ADDM) network determined the Prevalence of autism spectrum disorders(ASDs) in the united states to be about 9 per 1,000. Autistic disorder occur about four times more often in boys than in girls . Onset of the disorder occurs before 3 years. Most of the cases it runs a chronic course , with symptoms persisting in to adulthood.

59. FEATURES Absent social smile Lack of eye-to-eye contact Lack of awareness of other’s existence or feelings; treats people as furniture. Lack of attachment to parents and absence of separation anxiety.

60. No or abnormal social play; prefers solitary games Marked impairment in making friends Lack of imitative behaviour Absence of fear in presence of danger

61. 1. BIOLOGICAL FACTORS: * GENETIC- -parents who have more than one child with autistic disorder - both monozygotic and dizygotic twins - several chromosomes-2,7,15,16,17. 2. PHYSIOLOGICAL FACTORS: * MATERNAL RUBELLA(WHEN ASSOCIATED WITH INFANTILE DEAFNESS OR BLINDNESS) ETIOLOGY

62. -women with asthma and allergies - ENCEPHALITIS - MENINGITIS

63. 3. NEUROLOGICAL FACTORS : Abnormalities in brain structure or function Cerebellum, cerebral cortex, limbic system, corpus callosum, basal ganglia, and brain stem. 4.The role of neurotransmitters, such as serotonin, dopamine, and epinephrine.

64. CLINICAL MANIFESTATION : Lack of involvement with others Lack of verbal communication-non-verbal communication like facial expression, or gestures is often absent, socially inappropriate. Preoccupation with inanimate objects- Tape, lamp,desk,building Restricted activities and interests (excessive fascination with objects-fan)

65. Routine may become an obsession ,with minor alterations in routine leading to marked distress. Stereotyped body movements ( hand clapping, rocking) and verbalizations (repetition of words or phrases) are typical. Diet abnormalities includes eating only a few specific foods or consuming an excessive amount of fluids Behaviors that are self-injurious , such as head banging or biting the hands or arms, may be evident.

66. TREATMENT - BEHAVIOR THERAPY - PSYCHOTHERAPY: - PHARMACOTHERAPY: Resperidone Aripiprazole Haloperidol

67. NURSING MANAGEMENT 1.Risk for self -mutilation r/t Neurological alterations. Interventions: Work with the child on one to one basis Try to determine if the self- mutilative behavior occurs in response to increasing anxiety. Try to intervene with diversion or replacement activities. Protect the child when self mutilative behavior occurs. Devices such as- helmet, padded hand mitts, or arm covers.

68. 2. Impaired social interaction r/to inability to trust, neurological alterations. Assign a limited number of caregivers to the child Provide child with familiar objects, such as familiar toys or a blanket. Support child’s attempt to interact with child Give positive reinforcement for eye contact with something acceptable to the child(food, familiar objects) Gradually replace with social reinforcement (e.g. touch, smiling, hugging).

69. 3. Impaired verbal communication r/t withdrawal in to self, inadequate sensory stimulation , neurological alterations Maintain consistency in assignment of caregivers. Anticipate and fulfill the child’s needs until communication can be established. Seek clarification and validation Give positive reinforcement when eye contact is used to convey non-verbal expressions.

70. 4. Disturbed personal identity r/t inadequate sensory stimulation ,neurological alterations. Assist child to recognize separateness during self care activities, such as dressing and feeding Assist the child in learning to name own body parts. This can be facilitated by the use of mirrors, drawing, and picture of the child.

71. CHILDHOOD SCHIZOPHRENIA:

72. CHILDHOOD SCHIZOPHRENIA In childhood schizophrenia , children must evidence a deterioration from a previous level of functioning ;a blunt,flat,or inappropriate affect ; a disturbance in perception , a loss of ego boundaries or sense of self ; and a pronounced ambivalence and lack of goal-directed activity , such as posturing or marked decrease in reactivity.

73. Child begin to withdraw from the external world. Disturbance in affect, they display panic reactions, temper tantrum

74. CLINICAL MANIFESTATION

75. - Demonstrates delusional behaviour or false belief with no basis in fact. - They may express fear that someone will eat them. - Child may report auditory illusions such as” voices inside my head”.

76. - Bizarreness in verbalizations. - loose association - Repetitive speech - Inappropriate affect.

77. MANAGEMENT Frequent hospitalization. Counseling to the family members safe environment Anticipate a routine for basic care. Antipsychotics- : chlorpromazine(CPZ) can be used. Place in residential or day schools for individual and group play therapy B ehavior treatment

78. Attention deficit disorder with hyperactivity (Hyperkinetic disorder)

79. CLINICAL REPORT Sunita Mohan's eight-year-old son Girish stood out at school, but not for the right reasons. His teachers complained that he fought with his classmates, that he never paid attention and his marks were going downhill. Initially, his parents thought that he was just a normal child, easily distracted and forever impatient. They knew that other children got into the teachers' bad books occasionally. But their son seemed to be a perpetual troublemaker.

80. Girish's parents gave him pep-talks and tried to make him focus on his studies. But the situation progressively worsened. Girish lost his notebooks often. He would begin a conversation about his day at school . But, suddenly in the midst of his talk he would start discussing his breakfast requirements for the next day, or he would switch on the TV, thus abruptly ending the conversation . A worried Sunita took her son to a clinical psychologist who diagnosed attention-deficit/hyperactivity disorder (ADHD) in Girish.

81. Many children run around wildly. They race cars, yell non-stop, blurt out answers. A few get easily distracted, tend to act impulsively or struggle to concentrate on the tasks at hand. "Such behavior is normal but may be mistaken for ADHD. However, children with ADHD have frequent behavioral problems which severely interfere with their ability to live normal lives.

82. INTRODUCTION This is a syndrome first described by Heinrich Hoff in 1854 . It has been known by a variety of names like Minimal brain dysfunction(MBD), Hyperkinetic syndrome , Strauss syndrome, Organic driveness and Minimal brain damage.

83. This occur in about 3%of school age children Males are more often affected The onset occurs before the age of 7 years and a large variety of patients exhibits symptoms by the 4 th year of age. (Acc to DSM-5 : at least six symptoms of inattention and/or at least six symptoms of hyperactivity and impulsivity . Symptoms must be severe enough to interfere with functioning, must occur in at least two settings (i.e., school and home), and must have an age of onset before 12 years of age.) When the symptoms continue for at least six months and Symptoms must also create a real handicap in at least two areas of the child’s life: in the classroom, the playground, at home, in the community, or in social settings. - Diagnose the child with ADHD.

84. Epidemiology ADHD has a prevalence rate of ~7%–9% of children and 2.5%–4% of adults, ADHD is more common in males than females. and females with ADHD are more likely to have problems primarily with inattention. Associated disorder: Other conditions, such as learning disabilities, anxiety disorder, conduct disorder, depression, and substance abuse, are common in people with ADHD.

85. HYPERACTIVITY Excessive psychomotor activity that may be purposeful or aimless, accompanied by physical movements and verbal utterances that are usually more rapid than normal. Inattention and distractibility are common with hyperactive behavior.

86. INATTENTION   Means a person wanders off task, lacks persistence, has difficulty in sustaining focus, and is disorganized.

87. IMPULSIVITY The trait of acting without reflection and without thought to the consequences of the behavior. An abrupt inclination to act on certain behavioral urges. An impulsive person may be socially intrusive(where one is not welcome) and excessively interrupt others or make important decisions without considering the long-term consequences.

88. CLINICAL TYPES With hyperactivity, without hyperactivity, residual types, with conduct disorder 1. ATTENTION DEFICIT DISORDER WITH HYPERACTIVITY: The characteristic features are: Poor attention span with distractibility: Fails to finish the things started Shift from one uncompleted activity to another Doesn't seem to listen Easily distracted by external stimuli Overlook or miss details, make careless mistakes in schoolwork, at work, or during other activities Avoid or dislike tasks that require sustained mental effort, such as schoolwork or homework, for teens and older adults, preparing reports, completing forms or reviewing lengthy papers

89. B . HYPERACTIVITY: Difficulty in sitting still at one place for long Leave their seats in situations when staying seated is expected, such as in the classroom or in the office Moving about here and there Talks excessively Interference in others activity Interrupt or intrude on others, for example in conversations, games, or activities C. IMPULSIVITY: Acts before thinking, on the spur of the moment Difficulty in waiting for turn at work or play

90. 2 . ATTENTION DEFICIT DISORDER WITHOUT HYPERACTIVITY: 3 . RESIDUAL TYPE It is usually diagnosed in a patient in adulthood, with a past history of ADD and presence of a few residual features in adult life 4 . HYPERKINETIC DISORDER WITH CONDUCT DISORDER ( HYPERKINETIC CONDUCT DISORDER)

91. ETIOLOGY -MINIMAL BRAIN DAMAGE -MATURATIONAL LAG -GENETICS- CHROMOSOME -16 - NEUROTRANSMITTERS- ADHD patients have variations on the transporter genes for these neurotransmitters.  ( DOPAMINE, NOREPINEPHRINE, SEROTONIN) -ANATOMICAL INFLUENCES- PREFRONTAL LOBES, BASAL GANGLIA , CEREBELLUM ETC. EARLY DEVELOPMENTAL PSYCHODYNAMIC FACTORS

92. PRENATAL, PERINATAL, POSTNATAL FACTORS: MATERNAL SMOKING, INTRAUTERINE EXPOSURE TO TOXIC SUBSTANCES LIKE ALCOHAL PERINATAL FACTORS LIKE PREMATURITY, LBW BABY, SIGNS OF FETAL DISTRESS, PRECIPITATED LABOUR/PROLONGED ETC. POSTNATAL FACTORS LIKE CEREBRAL PALSY, SEIZURES, AND OTHER CNS ABNORMALITIES BY TRAUMA INFECTIONS ETC.

93. ENVIORNMENTAL FACTORS : ENVIORNMENTAL LEAD- ELEVATED BODY LEAD (>10 ug /dl) MAY LEAD TO COGNITIVE AND BEHAVIORAL PROBLEMS DURING DEVELOPMENT IN CHILDREN EXCESSIVE PAMPERING DIET FACTORS : FOOD DYES AND ADDITIVES LIKE ARTIFICIAL FLAVOURING, PRESEVATIVES.

94. DIAGNOSTIC CRITERIA THE DIAGNOSIS CAN BE MADE ON THE BASIS OF: TEACHER’S SCHOOL REPORT (OFTEN MOST RELIABLE) PARENT’S REPORT CLINICAL EXAMINATION Symptoms present before age 7 At least 6 symptoms of inattention , 6 symptoms of hyperactivity and impulsivity required Clinically significant impairment in social or academic/occupational functioning Some symptoms that cause impairment are present in 2 or more settings (e.g., school/work, home, recreational settings) Not due to another disorder (e.g., Autism, Mood Disorder, Anxiety Disorder)

95. Evidence-Based Assessment & Treatment of ADHD

96. Evidence-Based Assessment Teacher- and parent-completed questionnaires Structured clinical interview with parent(s) IQ/Achievement testing to screen for learning disabilities (50% comorbidity) Behavioral observations at home and school No medical screen, cognitive test, or brain imaging technique can detect ADHD Children with ADHD can focus long enough to watch TV, play videogames or sit still at the doctor’s office.

97. Well-Established ADHD Treatments Stimulant Medications Behavioral Interventions Behavioral parent training Behavioral classroom management Intensive summer treatment programs Pelham & Fabiano , 2008

98. PHARMACOTHERAPY a) STIMULANT MEDICATION: - Dextro-amphetamine (10-40 mg/day) and methylphenidate (10-60 mg/day) ATOMOXETINE (PATIENTS NOT RESPONDING TO STIMULANTS)

99. Medication: Stimulants Most well-researched, effective, and commonly used medication treatment for ADHD. Methylphenidate ( Ritalin , Concerta , and Metadate ) Dextroamphetamine ( Adderall ) T hese medications reduce ADHD symptoms by: Blocking the reuptake of norepinephrine (NOR) and dopamine (DOP) and facilitating their release  Enhances NOR and DOP availability in in certain brain regions: PFC and basal ganglia

100. Non-stimulants These medications take longer to start working than stimulants, but can also improve focus, attention, and impulsivity in a person with ADHD. Doctors may prescribe a non-stimulant: when a person has bothersome side effects from stimulants; when a stimulant was not effective;  Acc to FDA : some antidepressants are sometimes used alone or in combination with a stimulant to treat ADHD. OTHERS: Buspiron / Buspur

101. Well-Established Non-Pharmacological Treatments Behavioral modification Behavioral classroom management Organizations for ADHD

102. 1. BEHAVIOUR MODIFICATION - involve practical assistance, such as help organizing tasks or completing schoolwork, or working through emotionally difficult events. Behavioral therapy also teaches a person how to: monitor his or her own behavior give oneself praise or rewards for acting in a desired way, such as controlling anger or thinking before acting Positive or negative feedback for certain behaviors Therapists may also teach children social skills, such as how to wait their turn, share toys, ask for help, or respond to teasing.  Learning to read facial expressions and the tone of voice in others, and how to respond appropriately  Cognitive behavioral therapy can also teach a person mindfulness techniques, or meditation. Conti….

103. FAMILY AND MARITAL THERAPY-   can help family members and spouses find better ways to handle disruptive behaviors , to encourage behavior changes, and improve interactions with the patient. COUNSELLING AND SUPPORTIVE PSYCHOTHERAPY

104. Education and Training Parenting skills training (behavioral parent management training)- rewards and consequences to change a child’s behavior Stress management techniques- ability to deal with frustration Support groups  - can help parents and families connect with others who have similar problems and concerns. 

105. 2. Behavioral Classroom management

106. Students with ADHD may: Demand attention by talking out of turn or moving around the room. Have trouble in following instructions. Often forget to write down homework assignments, do them, or bring completed work to school . Often lack fine motor control , which makes note-taking difficult and handwriting a trial to read. Have problems with long-term projects where there is no direct supervision. Not pull their weight during group work and may even keep a group from accomplishing its task.

107. So how do you teach a kid who won't settle down and listen? The answer: with a lot of patience, creativity, and consistency. As a teacher, your role is to evaluate each child's individual needs and strengths. Then you can develop strategies that will help students with ADHD focus, stay on task, and learn to their full capabilities . Successful programs for children with ADHD integrate the following three components: Accommodations:  what you can do to make learning easier for students with ADHD. Instruction:  the methods you use in teaching. Intervention:  How you head off behaviors that disrupt concentration or distract other students.

108. STRATEGIES

109. Seating Seat the student with ADHD away from windows and away from the door. Put the student with ADHD right in front of teacher’s desk unless that would be a distraction for the student. Seats in rows, with focus on the teacher, usually work better than having students seated around tables or facing one another in other arrangements. Create a quiet area free of distractions for test-taking and quiet study. Try to limit other distractions in the room, like excessive noise or visual stimuli like clutter, as much as possible.

110. If a child has an especially difficult time dealing with distractions, being seated near the front of the class close to the teacher may be helpful.

111. Information delivery Give instructions one at a time and repeat as necessary. If possible, work on the most difficult material early in the day. Use visuals: charts, pictures, color coding. Create outlines for note-taking that organize the information as you deliver it.

112. Student work Create worksheets and tests with fewer items, give frequent short quizzes rather than long tests, and reduce the number of timed tests. Test students with ADHD in the way they do best , such as orally or filling in blanks. Divide long-term projects into segments and assign a completion goal for each segment. Accept late work and give partial credit for partial work.

113. Organization Have the student keep a master binder with a separate section for each subject , and make sure everything that goes into the notebook is put in the correct section. Color-code materials for each subject . Make sure the student has a system for writing down assignments and important dates and uses it . Allow time for the student to organize materials and assignments for home .

114. Provide Frequent Feedback Another helpful ADHD strategy is to keep giving kids quick feedback about how they are doing. Kids with and without ADHD benefit from frequent, immediate feedback about their behavior .  When necessary, any consequences given for unwanted behaviors should also be swift . Provide immediate praise for good behavior. If a negative behavior is minimal and not disruptive, it's best to ignore it.

115. Reward Good Behavior Rewards and incentives should always be used before punishment to motivate a student. To prevent boredom, change up the rewards frequently . Do not use the loss of  recess  as a consequence for negative behavior. Kids with ADHD benefit from physical activity and may be able to focus better after being outside or in gym class . Prioritizing rewards over punishment will help ensure that school continues to feel like a positive place for kids with ADHD.

116. Give Them a Break Breaks and regular activity can be important strategies for kids with ADHD. Kids with ADHD tend to struggle with sitting still for long periods of time, so giving them frequent opportunities to get up and move around can be a big help . You can provide them with a physical break by having them hand out or collect papers or classroom materials, run an errand to the office or another part of the building, or erase the board. Even something as simple as letting them go get a drink of water at the water fountain can provide a moment of activity.

117. Establish Rules and Routines: e.g : “ When you come into class, sit straight down .” Make routines and stick to them. This can help a student with ADHD to stay on task and reduce distracting changes.  Be Simple, Clear, and Direct Make Tasks Interactive

118. Involve in various activities Get Moving One of the best activities to help a child with ADHD is to get them moving. This doesn't mean that you have to sign them up for every sport under the sun, but it does mean that they need to be active. Go for a walk, play tag, or ride bikes together. Getting your child's body moving will help them to focus their energy on a fun and rewarding activity . One study found that physical exercise helps decrease anxiety, depression, aggression, and social problems among children with ADHD

119. Create Something Another great way to channel your child's energy is to encourage them to be creative. This could mean painting, drawing, building with blocks, or even just making up stories. Let your child's  imagination  run wild and see what they come up with. Creative expression is beneficial for many mental health conditions, including ADHD.  Expressive arts therapy , for example, can be helpful for both children and adults with ADHD. It may help kids practice and strengthen several skills, including focus, communication, and problem-solving skills. It can also be useful for expressing emotions, building  self-awareness , and reducing stress levels.

120. Get Organized Many kids with ADHD struggle with organization, but cleaning up and getting organized can be a fun activity if you make it into a game. Help your child to organize their  toys , clothes, or school supplies. You can even race to see who can clean up the quickest. Some ideas to help make cleaning and organizing fun and exciting:

121. Set a timer : Try setting a timer for a short amount of time (around five to ten minutes), and then see how much each of you can clean up in that time.  Laundry race : Challenge your child to see how much laundry they can help fold and put away. Fill a basket : Grab a couple of laundry baskets (or find one for each member of the family if everyone wants to get involved), and see who can fill each one with toys or other items lying around the house. Once the first phase of the game is over, you can move on to the next challenge—seeing who can put all of the items in their basket away the quickest.

122. Go On an Adventure Kids with ADHD often love adventure, and new experiences are more likely to hold their interest. Plan a treasure hunt around the house or go on a nature hike and see who can find the most interesting things. Be sure to bring along a camera so that you can document your child's findings. Because kids with ADHD often struggle with  feelings of boredom , introducing novel activities can be a great way to help them stay interested. 

123. Play Games Games are a great way to help kids with ADHD focus their energy in a way that can help entertain them while building valuable skills.  Memory  games or word puzzles can be a good option for some kids or even an active game like musical chairs.

124. Simon –memorize sequence of visual and auditory stimuli

125. For older children & adolescents Cognitive exercises –Lumosity(to improve memory, attention etc.) Others-coin match , match colors

126. Match colors

127. Command games make great ADHD games. For example, “Simon said”. Scavenger hunts are exciting for children, and they’re effective for teaching kids how to follow a sequence of instructions. Outdoor/ indoor: To play, hide an object or prize somewhere in a room. Then, determine places children will go explore to receive further instructions for finding the item. Leave note cards directing the players to the next location at each spot.

128. Indoor Scavenger Hunt

129. Road Trip Scavenger Hunt Keep fresh copies of this one in the car for those long car rides — it's full of things that kids can see out the window, which will keep them occupied during your next road trips.

130. Word Scavenger Hunt Forget about the flash cards and work sheets — this scavenger hunt is a fun way to get them to practice their phonics. For this activity, kids hunt the letters and use them at the end to create words.

131. Art Scavenger Hunt Usually , a scavenger hunt list comes with a set of pictures printed on it already. Little artists will love this one because  they  have to fill in the pictures themselves, inspired by what they see around them.

132. Color Scavenger Hunt This fun color-themed scavenger hunt can help toddlers learn their colors, while older kids discover all the different hues that can be found all around them.

133. Other fun activities to try include: Multiple scavenger hunt Building towers out of cards or blocks Balloon volleyball Playing music and dancing Indoor obstacle course Jumping rope Hula hooping Jumping on a trampoline

134. Do a Project Together Working on a project together can be a fun way to bond with your child while also helping them to focus their energy. Examples of projects you might work on together include: Creating a storybook Learning a musical instrument Craft projects Dress up games

135. Get Out of the House Sometimes , the best way to entertain a child with ADHD is to leave the house. Plan a day trip to somewhere that your child will be interested in. This could be a museum, the zoo, an amusement park, or even just a new playground. Have a picnic : Picnics are fun for everyone and can be a great way to spend some time together outdoors. Pack up some snacks and head to your backyard or a nearby park for a fun-filled afternoon. You can make your picnic as simple or as fancy as you want—just make sure to include plenty of good food and fun games. Go camping : If you really want to get away from it all, go camping! This is a great activity for kids with ADHD because it gets them out in nature where they can run and explore. And if heading for the wilderness isn’t an option, try just camping out in your backyard (or even your living room). Visit a museum:  Museums can be fun for kids of all ages, but they can be especially fun for kids with ADHD. They offer a chance to explore and learn in a stimulating but not overwhelming environment.

136. Cook Together Cooking is a great activity for kids with ADHD because it involves many different senses. Plus, it's a fun way to bond with your child and teach them valuable life skills. Start with simple recipes that are great for beginners before working your way up to more complex ones. For example , one night might be "pizza night," where each member of the family gets to choose their own toppings and prepare their own mini-pizza. 

137. Go Stargazing Stargazing is a calming activity that can be fun for kids of all ages. It's a great way to spend time together while also teaching your child about science and the world around them . you might consider something like a hike, nature walk, or trip to the beach during the day instead. All of these activities offer a chance to explore and learn while also getting some fresh air and exercise . Studies have shown that having more contact with nature and green spaces can positively impact children's mental health, including children who have ADHD.

138. 3. Organizations for ADD & ADHD ADDA NATIONAL RESOURCE CENTER ON AD/HD ADDitude Understood American Academy for child and adolescent psychiatry

139. DISRUPTIVE BEHAVIOR DISORDER (DBD) A disturbance of conduct severe enough to produce significant impairment in social, occupational, or academic functioning because of symptoms that range from oppositional defiant to moderate and severe conduct disturbances

140. CONDUCT DISORDER With conduct disorder, there is a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated/not followed by individuals.

141. Characteristic features: Frequent lying Stealing or robbery Running away from home and school Physical violence like rape, fire setting, assault or breaking-in, use of weapons. Cruelty towards other people and animals. Physical aggression is common. Low self esteem Poor frustration tolerance, irritability, frequent temper out bursts Poor academic performance Symptoms of ADHD

142. According to DSM-IV DIVIDES THIS DISORDER IN TO TWO SUBTYPES : 1. Childhood onset type : this subtype is defined by the onset of at least one criterion characteristic of conduct disorder prior to age 10. Usually boys Physical aggression, disturbed peer relationships In childhood they have ODD and in adulthood develops antisocial personality disorder.

143. 2. Adolescent- onset type: Less likely to display aggressive behavior, may show behavioral changes, antisocial personality disorder.

144. Secondary complications are: Drug abuse and dependence Syphilis AIDS Criminal record Suicidal behavior

145. Predisposing factors Biological influences: Genetics –chromosome-2 Temperament Biochemical factor : Nor- epinephrine, serotonin One study revealed that elevated testosterone in pubertal boys with deviant peers Psychosocial factors : poor peer relation, aggression may cause peer rejection Family influences : parental rejection, harsh discipline, large family size, frequent shifting of parents, parents with antisocial personality disorder, marital conflict, inadequate communication pattern.

146. MANAGEMENT Treatment is usually difficult. Most frequent mode of management is placement in a corrective institution. Behavioral, educational, and psychotherapeutic measures are usually employed for behavior modification. Hyperactivity/ Inattention - stimulants Impulse control disorder, episodic aggressive behavior- lithium, carbamazepines and psychotic symptoms-antipsychotics .

147. NSG CARE PLAN Risk for other directed violence related to characteristic of temprament,peer rejection, -ve parental role models, dysfxnal family dynamics Impaired social interaction related to -ve parental role models, impaired peer relations as evidenced by inappropriate social behavior Low self-esteem related to lack of positive feedback and unsatisfactory parent/child relationship.

148. Nursing diagnosis & Interventions

149. OPPOSITIONAL DEFIANT DISORDER(ODD) It is characterized by a pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures that occurs more frequently and interferes with social, academic or occupational functioning . More prevalent in boys than in girls before puberty.

150. Clinical features Anger & irritability Loose temper easily Frequent outburst of anger Easily annoyed by others 2. Argumentative and defiant behavior Excessively argue with adults Actively refuses others Blame others for own mistakes Deliberately annoy others 3.Vindictiveness –seeking revenge Saying mean or hateful things when angry or upset

151. Predisposing factors Biological influences Genetics Temperament biochemical alterations :–dopamine, serotonin, nor epinephrine. Family influences: P arental problems in discipline, structuring and limit setting, lack of supervision, financial problems in family Identification by the child with an impulse disordered parent who sets a role model for oppositional defiant interactions Parental unavailability (e.g. : separation, evening work hours, divorce) H/O child abuse or neglect Parents with substance abuse Frequent change of houses or schools

152. Management: - Assessment: Passive aggressive behavior such as stubborn, procrastination(action of delaying or postpone something), disobedience, carelessness, negativism, deliberately ignoring the communication of others and unwillingness to compromise. Other symptoms that may be evident are running away, school avoidance, school underachievement, temper tantrums, fighting, argumentativeness.

153. TREATMENT PARENTING SKILL TRAINING- GIVE CLEAR INSTRUCTIONS & APPROPRIATE CONSEQUENCES IF NEEDED. RECOGNIZING AND PRAISING CHILD’S GOOD BEHAVIOUR AND +VE TRAITS TO ENCOURAGE DESIRED BEHAVIOUR. SET LIMITS SET UP A ROUTINE PARENT –CHILD INTERACTION THERAPY (PCIT) INDIVIDUAL AND FAMILY THERAPY -LEARN TO MANAGE ANGER AND EXPRESS THE FEELINGS IN A HEALTHIER WAY, HELPS TO IMPROVE CHILD’S COMMUNICATION AND RELATIONSHIPS WITH THE FAMILY. PROBLEM SOLVING TRAINING – HELPS TO CHANGE THOUGHT PATTERNS THAT LEAD TO BEHAVIORAL PROBLEMS. SOCIAL SKILL TRAINING

154. NURSING MANAGEMENT

155. SEPARATION ANXIETY DISORDER The essential feature of separation anxiety disorder is excessive anxiety concerning separation from the home those to whom the person is attached. Interferes with social, academic, occupational or other areas of functioning. Onset may occur anytime before age 18 years, most commonly diagnosed around age 5 or 6, when the child goes to school.

156. Predisposing factors: Biological influences: - Genetics Temperament: - irritable as infant, unusually shy, and fearful as a toddler, quite, & withdrawal in the preschool and early school age years with marked behavioral restraint and physiological arousal in unfamiliar situations. Environmental influences: Stressful life events Family influences : over attachment to mother, overprotection , transfer of anxiety through role modeling.

157. General management Behavior therapy Family therapy Group therapy Play therapy Psychopharmacology- Antianxiety drugs.

158. NSG CARE PLAN Anxiety related to family history, temperament, over attachment to parents, negative role modeling. Ineffective coping related to unresolved separation conflicts & inadequate coping skills. Impaired social interaction related to reluctance to be away from attachment figures.

159. Nursing diagnosis & interventions

160. BEHAVIORAL DISORDERS

161. PICA ( Geophagia)

162. ENURESIS

163. Treatment Psychotherapy and training Bladder-strengthening exercises Using an electric alarm (buzzer) device Drugs Imipramine hydrochloride, 0.9-1.5mg/kg/ day Anticholinergic agent, oxybutinin,10-20 mg/ day

164. ENCOPRESIS

165. TREATMENT

166. SLEEP WALKING (somnambulism)

167. BREATH-HOLDING SPELLS

168. THUMB SUCKING AND NAILBITING

169. TEETH GRINDING (Bruxism)

170. STUTTERING

171. It is a chronic type of tics disorder typically characterized by : Multiple motor tics Multiple vocal tics Duration more than 1 year Onset usually before 11 year of age and almost always before 21 years

172. MULTIPLE MOTOR TICS Simple It may include eye-blinking, grimacing, shrugging of shoulders, tongue protrusion Complex: These are facial gestures jumping ,hitting self, squatting etc

173. MULTIPLE VOCAL TICS Simple: It includes barking, throat clearing, sniffing etc Complex: Obsessions and compulsions are often the associated symtoms.

174. SCHOOL PHOBIA

175. SCHOOL PHOBIA

176. SCHOOL PHOBIA

177. ASSIGNMENT