Behavioral &

Psychological;
Cognitive & Sensory
Issues in Pediatrics
N366-Fall 2019
Melody Goebel, MSN, RN, CPN
Do you ever just feel “Meh”
 Depression
Often overlooked in school aged children because they
have limitations on expressing their feelings

Findings must be present for 1 year to diagnose a major

depressive disorder in children and adolescents

Risk Factors: Family history & Traumatic events

Expected Findings
Sad facial expressions, withdrawn, fatigue, crying/tearful,
alterations in sleep, weight loss/gain, lack of interest in
school or poor performance, hopelessness, suicidal ideation
 Depression
Treatment:
Tricyclic antidepressants or SSRI’s
Trazodone, Sertraline, Paroxetine, Bupropion,
Venlafaxine

Nursing Care:
Individualize care
Assess for substance abuse in older
children/adolescents
Assess for actual or potential risk of harm to self
Assist with coping strategies
Encourage counseling, peer group discussions
 Bullying
Physical, verbal, or emotional abuse that is repetitive
by a person to another person with intent to establish
power and dominance with intimidation.

Happens frequently at school, playground, bus,

texting, or on the internet

Can lead to depression, suicide attempts, or following

through with suicide
 Bullying
Perpetrators of bullying behavior
Male gender, history of depression, decreased
academic performance, decreased social involvement
with peers, Exposure to domestic violence, conduct
problems, Criminal acts, dropping out of school

Recipients of bullying behavior

Low self-esteem, loneliness, anxiety, depression
Attention-Deficit Hyperactivity Disorder
ADHD
Inattentiveness, hyperactivity, and impulsiveness usually revealed before
7-years-old

Common in childhood & can persist into adulthood

Risk factors familial tendency; exposure to toxins/medicines; chronic

otitis media/meningitis/head trauma

Must meet diagnostic criteria

Signs present between ages 4 and 18 years old
Signs present in more than 1 setting
Evidence of social & academic impairment
6 or more findings from a category are present in hyperactivity-
implusivity or inattention (all on next page)
Attention-Deficit Hyperactivity Disorder
ADHD
Inattention
Failing to pay close attention to
detail or making careless mistakes
Blocking incoming stimuli
Difficulty sustaining attention &
organizing activities
Failing to follow through on
instructions
Easily distracted
Losing things
Forgetfulness
Avoiding/disliking activities that
require mental effort for a period
of time….reading a book
Hyperactivity
Fidgeting
Failing to remain seated
Inappropriate running
Difficulty engaging in play
Seeming to be busy all the time
Talking excessively
Impulsivity
Blurting out responses before
questions are asked
Difficulty taking turns
Interrupting often
Striking out, biting, shouting
Attention-Deficit Hyperactivity Disorder
ADHD
Treatment
Methylphenidate or Dextroamphetamine
Psychostimulant, which increases dopamine &
norepinephrine levels
Nursing Considerations  gradually increase dose to
reach therapeutic levels; give 30 min. before meals; give
last dose of the day before 6pm to prevent insomnia;
avoid caffeine; Tricyclic antidepressants are used as
adjunct therapy to treat insomnia
Monitor for adverse effects, including insomnia,
anorexia, nervousness, hyper/hypotension, tachycardia,
& anemia
Autism Spectrum Disorder

Complex neurodevelopmental disorders with a

spectrum of behaviors affecting an individual’s ability
to communicate & interact with others in a social
setting

Risk factors  Possible genetic component; Exact

cause is unknown
 Autism Spectrum Disorder
Expected Findings: (more on ATI chap 44)
Delay in at least 1 of the following: Social interaction; Social
communication; Imaginative play prior to age 3
Distress when routines are changed
Using gestures instead of words
Grunting or Humming
Withdrawn, labile mood
Decreased pain sensation
Typical IQ less than 70
Intense temper tantrums
Showing aggression
Autism Spectrum Disorder
Screening tools
Checklist for Autism in Toddlers (CHAT)
Pervasive Developmental Disorders Screening Test

Medications  used on individual basis to control

aggression, anxiety, hyperactivity, moos swings,
compulsions, and attention problems
SSRI’S  Decrease aggression
Antipsychotics & Melatonin  help with insomnia
Autism Spectrum Disorder
Nursing Care:
Assist with behavior modification
Promote positive reinforcement
Increase social awareness
Teach verbal communication
Set realistic goals
Structure opportunities for small successes
Set clear rules
Decrease environmental stimulation
Introduce them to new situations slowly
Provide support to family
 Cognitive Impairment
Also known as intellectual disability

Previously called mental retardation

Risk Factors
Infections (congenital, rubella, syphilis)
Fetal alcohol syndrome
Chronic lead ingestion
Trauma to the brain
Pre-existing disease (Down Syndrome, Microcephaly,
Hydrocephaly, Metabolic disorders, Cerebral palsy)
 Cognitive Impairment
Expected findings: (can range from mild to severe)
Delayed developmental milestones
Abnormal eye contact
Feeding difficulties
Language difficulties
Fine & Gross motor delays
Decreased alertness
Inability to reason or problem solve
 Cognitive Impairment
Nursing Care:
DSM-5 used to diagnose
Individualize care to child’s needs
Early consults to Speech therapy, PT/OT, Social work
Assist family with learning the care their child needs
Encourage play
Encourage social activities
 Visual Impairments
Both partial sight & legal blindness

Should screen children for visual impairments yearly

Risk factors
Perinatal infections: herpes, rubella, syphilis,
chlamydia, gonorrhea, toxoplasmosis
Retinopathy of prematurity
Trauma
Chronic illnesses  sickle cell disease, rheumatoid
arthritis, retinoblastoma, albinism, Tay-Sachs disease
 Visual Impairments
Myopia (near-sightedness)

Hyperopia(far-sightedness)

Astigmatism uneven vision where only parts of

letters on a page can be seen; headache and vertigo;
excessive eye rubbing; poor school performance

Amblyopia “lazy eye”; reduced visual acuity in one

eye
 Visual Impairments
Strabismus
Esotrophia inward deviation of the eye
Exotrophia outward deviation of the eye

Cataracts decreased ability to see clearly; possible

loss of peripheral vision; Nystagmus; Strabismus;
Absent red reflex; gray opacity of the lens

Glaucoma Loss of peripheral vision; halos around

objects; red eye; excessive tearing; photophobia;
corneal haziness; possible pain
 Visual Impairments
Partial Visual Impairment
Visual acuity of 20/70 to 20/200

Legal Blindness
Visual acuity of 20/200 or worse or visual field of 20
degrees or less in the better eye

Color Test
Use the Ishihara or Hardy-Rand-Rittler test
 Hearing Impairments
Affects speech and the ability to clearly process
linguistic sounds

Infants will have lack of startle reflex; failure to

respond to noise; absence of vocalization by 7 months
old; lack of response when spoken to

Older children will use gestures rather than talking after

15 months old; fail to develop understood speech by 24
months old; yelling to express emotions; irritability;
withdrawn or shy; loud speaking for the situation
 Hearing Impairments
Can also affect motor development

Hearing screen with trained audiologist

May need hearing aides

May need ear tubes

May need cochlear implant

 Down Syndrome
Cause is unclear; could be maternal age greater than 35;
paternal age greater than 55

Expected findings:
Separated sagittal suture; enlarged anterior fontanel
Small round head; Flattened forehead
Upward, outward slant to eyes
Small nose with depressed nasal bridge
Small ears with short pinna
Protruding tongue; high-arched narrow palate
Short, broad neck
Protruding abdomen
 Down Syndrome
Diagnosis chromosome analysis & ECHO

Surgical interventions depend on the associated

congenital anomalies…most often heart defects

Family may need a lot of support

Child will need many consults for speech, OT/PT,

social work help when ready for school
 Down Syndrome
Complications
Mild to moderate cognitive impairment

Social development can be 2-3 years beyond mental development

Tend to have visual & hearing impairments

Increased incidence of leukemia & thyroid dysfunctions

Frequent respiratory tract infections

Weight gain more rapid than growth in height

Genitalia/sexual development can be underdeveloped and delayed