Autism Spectrum Disorder (ASD) & Attention Deficit Hyperactivity Disorder (ADHD) - PDF

**Autism spectrum disorder (ASD):** - Characterized by a wide range of social difficulties, communication impairments, and restricted/repetitive behaviors. - Persistent impairment in reciprocal social communication or interactions and restricted or repetitive patterns of behavior,...

**Autism spectrum disorder (ASD):** - Characterized by a wide range of social difficulties, communication impairments, and restricted/repetitive behaviors. - Persistent impairment in reciprocal social communication or interactions and restricted or repetitive patterns of behavior, interests and/or activities - Prevalence is about 1 in 54 children - **Dx features:** - **Persistent deficits in social communication & interaction across multiple contexts:** - Social-emotional reciprocity, Nonverbal communication - Developing, maintaining, and understanding relationships - May avoid eye contact with others - **Restricted, repetitive patterns of behaviors, interests, or activities:** - Stereotyped or repetitive motor movements, use of objects, or speech - Insistence on sameness - Highly restricted, fixed interest - Hyper or hypo reactivity to sensory input or unusual interest in sensory aspects of the environment - **ASD: levels of severity (each level requires different nursing interventions and education)** - Level 1: requiring support - Level 2: requiring substantial support - Level 3: requiring very substantial support - Predisposing factors: - Neurological implications - Abnormalities in brain structure or function - Role of neurotransmitters under investigation - Genetics: Familial association, Chromosomal involvement - Prenatal & perinatal influences: Maternal asthma or allergies - Psychopharmacological intervention: - **FDA Approved Medications: Risperidone, Aripiprazole** - Dose based on child's weight and response - Targeted symptoms: Aggression, Deliberate self-injury, Temper tantrums, Hyperactivity - Nonpharmacological interventions: - Behavioral and Communication Therapies, Education Therapies, Family Therapy - **Nursing assessment:** - It is important to understand the symptoms of ASD along a spectrum and with varying levels of functionality. - Some individuals who meet criteria for ASD may be highly functional and highly intelligent in spite of communication impairments and repetitive or restrictive behaviors. - Assessment focus: - Impairment in social interaction - Impairment in communication & imaginative activity - Restricted activities and interests - Nursing dx: - **Risk for self-mutilation related to neurological alterations** - Impaired social interaction related to inability to trust and neurological alterations - Impaired verbal communication related to withdrawal into the self; neurological alterations - Disturbed personal identity related to neurological alterations - Outcomes: - The client: - Exhibits no evidence of self-harm - Interacts appropriately with at least one staff member - Demonstrates trust in at least one staff member - Is able to communicate so that they can be understood by at least one staff member - Demonstrates behaviors that indicate they have begun the separation/individuation process - Planning/implementation: - Interventions should include working with the child on a one-on-one basis, giving positive reinforcement, and assisting the child in recognizing separateness. - Nursing interventions are aimed at: - Protection of the child from self-harm - Improvement in social functioning (initiating social interactions) - Improvement in verbal communication - Enhancement of personal identity (ego-identity) - Evaluation of care for the child with autism spectrum disorder (ASD) reflects whether nursing actions have been effective in achieving the established goals. **Attention deficit hyperactivity disorder (ADHD)** - Categorized by clinical presentation (three types) - 1\. Combined type (meeting the criteria for both inattention and hyperactivity/impulsivity) - 2\. Predominantly inattentive presentation - 3\. Predominantly hyperactive/impulsive presentation - The most frequently cited characteristics (in order of frequency) are hyperactivity, attention deficit, impulsivity, memory and thinking deficits, specific learning disabilities, and speech and hearing deficits - **Dx features:** - **Inattention** - Poor attention to details or careless mistakes - Impaired tasks completion - Seems to listen when spoken to directly - Impaired ability to maintain attention in activities - Poor organizational skills - Avoids/reluctant engage in certain tasks - Loses important/required items - Easily distracted - Forgetful in daily activities - **Hyperactivity--Impulsivity** - Fidgets or "squirms" - Unable to remaining seated (leaves seat) - Runs or climbs in situations where not appropriate - Unable to play quietly - Behavior is \"on the go\" or as if \"driven by a motor\" - Excessive talking - Blurts out or answers questions before completed - Difficulty waiting their turn - Frequently interrupts or intrudes on others - What we see - Behavior pattern includes symptoms of inattention and/or hyperactivity and impulsivity with an onset prior to 12 y/o. - Subsets are predominantly inattentive, predominantly hyperactive/ impulsive, and combined type - Hyperactivity: - Excessive psychomotor activity that may be purposeful or aimless, accompanied by movements or speech that can be more rapid than normal. - Inattention/ distractibility are common with hyperactive behavior. - Impulsivity: - Acting without reflection or thought to the consequences of the behavior; urges to act (and the inability to resist acting) - **Sign of impaired executive function:** - Interrupt others often - Difficulty stopping or changing ongoing behavior - Difficulty returning to an activity after interruption - Impatient - Excessive touching/moving objects - Difficulty with delayed gratification - Disinhibition that decreases with age - Difficulties with motor coordination & sequencing - Impaired working memory and recall - Impaired planning ability - Difficulty following strict or command directions - Impaired emotional regulation ("meltdowns") - ADHD: common comorbidities - Oppositional defiant disorder (50%), Conduct disorder, Anxiety (20%), Depression (30%), Bipolar disorder (20%), Substance use disorders, Frontal lobe epilepsy (89.4%), Disruptive Mood Dysregulation Disorder (DMDD) - The frontal lobe is responsible for executive functioning, so if this is impaired, you will most often times see a correlation with ADHD and frontal lobe epilepsy - Predisposing factors: - Genetic - Biochemical Theories (Still under investigation) - Anatomical: Decreased volume/activity in prefrontal cortex & other areas - Prenatal, perinatal, & postnatal factors - Maternal smoking, exposure to toxic substances, maternal infections - **KNOW Low birth weight**, trauma, early infancy infections, brain injuries - Environmental Influences: Disorganized/chaotic environments, early life trauma - Psychosocial Influences - Single-parent, young maternal age, parental antisocial behavior, maternal depression, & low socioeconomic status - Psychopharmacological interventions: - **Central Nervous System Stimulants** - Examples: **Dextroamphetamine, methamphetamine, lisdexamfetamine**, **methylphenidate**, dexmethylphenidate, dextroamphetamine/amphetamine mixture - **KNOW Side effects:** Insomnia, anorexia, weight loss, tachycardia, decrease in rate of growth and development - **Education**: give with or AFTER meals - Nonpharmacological interventions: - Trigeminal nerve stimulation, Neurofeedback, Cognitive training, Cognitive behavioral therapy, Child or parent training, Dietary omega fatty acid supplementation - **Trigeminal nerve stimulation:** influences brain activity and improve attention and focus - **Dietary omega fatty acid supplementation:** believed to support brain health and function and can relieve ADHD s/s such as impulsivity and hyperactivity - **Nursing assessment:** - Difficulty performing age-appropriate tasks - Highly distractible, Extremely limited attention span, Impulsive behaviors - Difficulty forming satisfactory interpersonal relationships - Demonstrates behaviors that inhibit acceptable social interaction - Disruptive and intrusive in group endeavors - Excessive levels of activity, restlessness, and fidgeting - Accident prone, Low frustration tolerance, and temper outbursts - Nursing dx: - Risk for injury related to impulsive and accident-prone behavior and the inability to perceive self-harm - Impaired social interaction related to intrusive and immature behavior - Low self-esteem related to dysfunctional family system and negative feedback - Noncompliance with task expectations related to low frustration tolerance and short attention span - Outcomes: - The client: - Has experienced no physical harm, Interacts with others appropriately - Verbalizes positive aspects about self, Demonstrates fewer demanding behaviors - Cooperates with staff in an effort to complete assigned tasks - Planning/implementation: - Nursing interventions are aimed at: - Ensuring that the client remains free of injury - Encouraging appropriate interactions with others - Increasing feelings of self-worth - Fostering motivation for compliance with tasks - Interventions include: - Ensuring safe environment - Developing a trusting relationship - Offering recognition of successful endeavors - Establishing goals that allow the client to complete tasks - Evaluation involves examining client behaviors following implementation of the nursing actions to determine whether goals of therapy have been achieved. **Tourette's disorder** - The essential feature of Tourette disorder is the presence of multiple motor tics and one or more vocal tics. - May appear simultaneously or at different periods during the illness. - May cause distress or interfere with social, occupational, or other important areas of functioning. - Peak severity pre-teen & teen years - **Onset may be as early as 2 years but occurs most commonly around age 6 or 7 years.** - Predisposing factors: - Biological: Genetics, Biochemical, Structural - Environmental: Complications of pregnancy, Low birth weight, Head trauma, Infection - Pharmacological and nonpharmacological intervention: - Most effective when combined with other therapy, such as: - Behavioral therapy - Individual counseling or psychotherapy - Family therapy - Common medications used for Tourette disorder - **Antipsychotics: Haloperidol & Risperidone** - Alpha agonists: midodrine or brimonidine - **Nursing assessment:** - Tics are compulsive and irresistible but can be suppressed for varying lengths of time. - Many report a buildup of tension as they attempt to suppress tics to the point where they feel the tic must be expressed against their will. - Tics are often worse during periods of stress or excitement and better during periods of calm. - **Types of Tics: Simple and Complex** - **Simple motor tics:** include movements such as eye blinking, neck jerking, shoulder shrugging, and facial grimacing. - **Complex motor tics:** include squatting, hopping, skipping, tapping, touching behaviors, grooming rituals, echopraxia, and retracing steps - **Vocal tics:** include words or sounds such as squeaks, grunts, barks, sniffs, snorts, coughs, and, in rare instances, a complex vocal tic involving the uttering of obscenities. - **Palilalia:** repeating one's own words - **Echolalia:** repeating what others say - Nursing dx: - Risk for self-directed or other-directed violence related to low tolerance for frustration - Impaired social interaction related to impulsiveness, oppositional, and aggressive behavior - Low self-esteem related to embarrassment associated with tic behaviors - Outcomes: - The client - Has not harmed self or others - Interacts with staff and peers in an appropriate manner - Demonstrates self-control by managing tic behavior - Follows rules without becoming defensive - Verbalizes positive aspects about self - Planning/implementation: - Goals for treatment focus on: - Keeping the client from harming themselves or others - Helping the client interact with staff and peers - Helping increase self-worth. - Nursing care is aimed at: - Safety of client and others - Encouraging interpersonal interaction using appropriate behaviors - Promoting increased feelings of self-worth - Evaluation of care for a child with Tourette disorder reflects whether the nursing actions have been effective in achieving the established goals. **Oppositional defiant disorder (ODD):** - **Characterized by a persistent pattern of angry/irritable mood, argumentative/defiant behavior, vindictiveness** - Occurs more frequently than is usually observed in individuals of comparable age and developmental level - Interferes with social, educational, or vocational activities - What we see: - **Leading cause of referral for mental health & SpecEd services** - **Average age of onset 6 years old but symptoms may start much earlier & rarely begin later than early adolescence** - **Primarily due to parenting or other immediate environmental features of early childhood (hostile or overly controlling parenting styles)** - Recurrent pattern of defiance, hostility antagonizing & blaming others for their mistakes - More often times demonstrate reactive aggression and less proactive aggression (not in book for this chapter) - Low frustration tolerance and general emotional reactivity - These behaviors are very common between siblings (lecture) - Predisposing factors: - Biological influences: Role has not been fully established. - Family influences - **If power and control are issues for parents,** or if they exercise authority for their own needs, a power struggle can be established between the parents and the child, which sets the stage for the development of ODD - **Family dynamics:** - There is the combination of a strong-willed child with a reactive and high-energy temperament and parents who are authoritarian rather than authoritative. - The parents become frustrated with the strong-willed child who does not obey and increase their attempts to enforce authority. - The child reacts to the excessive parental control with anger and increased self-assertion. - Tx strategies: - **Family-Based Interventions** - **Ex: parent management training, social skills training** - Social Training Interventions, Pharmacological Interventions - **Nursing assessment:** - Stubbornness & procrastination; Disobedience & negativism - Carelessness & testing of limits; Resistance to directions & unwillingness to cooperate - Running away; School avoidance & underachievement - Temper tantrums, fighting, & general argumentativeness; Impaired interpersonal relationships - Nursing dx: - Noncompliance with therapy related to negative temperament, denial of problems, underlying hostility - Defensive coping related to retarded ego development, low self-esteem, unsatisfactory parent/child relationship - Low self-esteem related to lack of positive feedback, retarded ego development - Impaired social interaction related to negative temperament, underlying hostility, manipulation of others - Outcomes: - The client - Complies with treatment by participating in therapies without negativism - Accepts responsibility for their part in the problem - Takes direction from staff without becoming defensive - Does not manipulate other people - Verbalizes positive aspects about self - Interacts with others in an appropriate manner - Planning/implementation: - Focus of interventions: - Noncompliance with therapy, Defensive coping, Low self-esteem, Impaired social interaction - Nursing care is aimed at: - Encouraging cooperation with therapy, Helping client accept responsibility for own behaviors, Promoting increased feelings of self-worth - Assisting in the development of socially appropriate behaviors in interactions with others - Evaluation calls for reassessment of the plan of care to determine whether nursing actions have been effective in achieving goals of therapy **Conduct disorder:** - Persistent pattern of behavior in which the basic rights of others and major age-appropriate societal norms or rules are violated. - **Physical aggression is common & peer relationships are disturbed.** - Prevalence estimates range 2%-10%; rises from childhood to adolescence - **More common in males than females**; especially with child-onset - Common comorbidities: - ADHD, mood disorders, learning disorders, and substance use disorders. - Dx features (DON\'T MEMORIZE): - 4 Symptom/Behavior Categories (total of 15 criteria) - Aggression to People or Animals - Destruction of Property - Deceitfulness or Theft - Serious Violations of Rules - What we see: - Typically lacking in guilt or remorse for actions - Frequently minimize their behavior severity - **Behaviors often include proactive aggression and confrontational aggression** - **Proactive aggression example:** a child might bully another to get their lunch money or assert dominance (using aggression to achieve a specific goal) - **Confrontational aggression example**: a child might lash out physically or verbally when they feel threatened or challenged by someone else - Interpret the actions of others more hostile and threatening than reality and response with what they feel is justified aggression - Adolescent females are more likely to have issues with substance misuse - Rates of suicide attempts and suicidal ideation are higher than expected - Often have significant abuse/neglect history - Predisposing factors: - Biological: Genetics, Temperament, Neurobiological factors - Psychosocial: Peer relationships, Family Influences - Tx strategies: Family-Based Interventions, Social Training Interventions, Pharmacological Interventions - **Nursing assessment:** - Classic characteristic of conduct disorder is the use of physical aggression in the violation of the rights of others - Use of drugs and alcohol - Sexual permissiveness - Low self-esteem manifested by a "tough guy" image - Problems with inattentiveness, impulsiveness, and hyperactivity - Lack of feelings of guilt or remorse - Use of projection as a defense mechanism - Inability to control anger - Low academic achievement - Nursing dx: - Risk for other-directed violence related to characteristics of temperament, peer rejection, negative parental role models, dysfunctional family dynamics - Impaired social interaction related to negative parental role models, impaired peer relations leading to inappropriate social behaviors - Defensive coping related to low self-esteem and dysfunctional family system - Low self-esteem related to lack of positive feedback and unsatisfactory parent--child relationship - Outcomes: - The client: - Has not harmed self or others - Interacts with others in a socially appropriate manner - Accepts direction without becoming defensive - Demonstrates evidence of increased self-esteem by discontinuing exploitative and demanding behaviors toward others - Planning/implementation: - Focus of nursing care: - Risk for violence - Impaired social interactions - Defensive coping - Low self-esteem - Nursing care is aimed at: - Ensuring safety of client and others - Assisting in the development of socially appropriate behaviors in interactions with others - Encouraging client to accept responsibility for own behaviors - Promoting increased feelings of self-worth - Evaluation is made of the behavioral changes in the child based on achievement of the previously established goals. -