Ch.

22: Neurodevelopmental Disorders 1

Key Terms:
Attention deficit hyperactivity disorder (ADHD): characterized by inattentiveness, overactivity, and
impulsiveness
Autism spectrum disorder (ASD): neurodevelopmental disorder first seen in childhood, conceptualized
across a continuum with symptoms varying from mild to severe; may include communication deficits,
problems building social relationships, overdependence on routines, and high level of sensitivity to the
environment
Encopresis: the repeated passage of feces into inappropriate places, such as clothing or the floor, by a
child who is at least 4 years of age either chronologically or developmentally
Enuresis: the repeated voiding of urine during the day or at night into clothing or bed by a child at least
5 years of age either chronologically or developmentally
Stereotyped motor behavior: repetitive, seemingly purposeless movements; may include waving,
rocking, twirling objects, biting fingernails, banging the head, biting or hitting oneself, or picking at the
skin or body orifices
Therapeutic play: play techniques are used to understand the childs thoughts and feelings and to
promote communication
Tic: a sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization
Tourettes disorder: involves multiple motor tics and one or more vocal tics, which occur many times a
day for more than 1 year


Ch. 22: Neurodevelopmental Disorders 2
Learning Objectives:
1. Discuss the characteristics, risk factors, and family dynamics of attention deficit hyperactivity
disorder (ADHD) and autism spectrum disorder (ASD).
a. ASD:
i. Characteristics
1. Pervasive and usually severe impairment of reciprocal social interaction skills,
communication deviance, and restricted stereotypical behavioral patterns.
2. Children with autism display little eye contact with and make few facial
expressions toward others; they use limited gestures to communicate. They have
limited capacity to relate to peers or parents. They lack spontaneous enjoyment,
express no moods or emotional affect, and cannot engage in play or make-
believe with toys. There is little intelligible speech. These children engage in
stereotyped motor behaviors such as hand flapping, body twisting, or head
banging.
3. Autism has a tendency of improving, as children start to acquire and use
language to communicate with others.
4. Behaviors common with ASD
a. Not responding to own name, by 1 year
b. Doesnt show interest by pointing to objects or people by 14 months of
age
c. Doesnt play pretend games by 18 months of age
d. Avoids eye contact
e. Prefers to be alone
f. Delayed speech and language skills
g. Obsessive interests (gets stuck on an idea)
h. Upset by minor changes in routine
i. Repeats words or phrases over and over
j. Flaps hands or rocks or spins in a circle; answers are unrelated to
questions
k. Unusual reactions to sounds, smells, or other sensory experiences
ii. Risk factors
1. 5 times more prevalent in boys than in girls, identified usually by 18 months and
no later than 3 years of age
Ch. 22: Neurodevelopmental Disorders 3
2. 80% of cases are early onset, with developmental delays starting in infancy. The
other 20% with autism have seemingly normal growth and development until 2
or 3 years of age when developmental regression or loss of abilities begins.
3. Currently, 1 in 68 children in the US are diagnosed with ASD.
4. Genetically linked
5. The National Institute of Child Health and Human Development, Centers for
Disease control (CDC) and the Academy of Pediatrics have all conducted research
studies for several years and have concluded that there is no relationship
between vaccines and autism and that the MMR vaccine is safe.
iii. Family dynamics:
1. 70% of adults with ASD are unable to live independently; 49% live with parents
and 32% live in residential facilities
2. Manifestations vary from little speech and poor daily living skills throughout life
to adequate social skills that allow relatively independent functioning. Social
skills rarely improve enough to permit marriage and child rearing.
b. ADHD
i. Characteristics
1. ADHD is characterized by inattentiveness, overactivity, and impulsiveness.
2. Often diagnosed when a child starts school
3. Fidgeting, noisy, disruptive, unable to complete tasks, failure to follow
directions, blurting out answers, lost or forgotten homework
4. Possible ostracize/ridicule by peers at school
5. Affects 5-8% of school-aged children with 60-85% having symptoms persisting
into adolescence
6. By the time the child starts school, symptoms of ADHD begin to interfere
significantly with behavior and performance. He or she cannot listen to
directions or complete tasks. The child interrupts and blurts out answers before
questions are completed. Academic performance suffers because the child
makes hurried, careless mistakes in schoolwork, often loses or forgets
homework assignments, and fails to follow directions. Socially, peers may
ostracize or even ridicule the child for his or her behavior. The child often loses
necessary things.
ii. Risk factors:
1. Family history of ADHD;
2. Male relatives with antisocial personality disorder or alcoholism;
Ch. 22: Neurodevelopmental Disorders 4
3. Female relatives with somatization disorder;
4. Lower socioeconomic status;
5. Male gender;
6. Marital or family discord, including divorce, neglect, abuse, or parental
deprivation;
7. Low birth weight
8. And various kind of brain insult.
iii. Family dynamics:
1. Approximately 70% to 75% of adults with ADHD have at least one coexisting
psychiatric diagnosis, with social phobia, bipolar disorder, major depression, and
alcohol dependence being the most common.
2. Parents feel empowered and relieved to have specific strategies that can help
them and their child be more successful. Including parents in planning and
providing care for the child with ADHD is important. The nurse must listen to the
parents' feelings. The education of a child with ADHD is important, but the child
is only in school for part of their day. The parents must deal with the child and
the other aspects of the child's life at all times.
2. Apply the nursing process to the care of children and adolescents with ADHD and ASD and their
families.
a. ADHD:
i. Assessment Data
1. Short attention span
2. High level of distractibility
3. Labile moods
4. Low frustration tolerance
5. Inability to complete tasks
6. Inability to sit still or fidgeting
7. Excessive talking
8. Inability to follow directions
ii. Diagnoses
1. Risk for injury
2. Ineffective role performance
3. Impaired social interaction
Ch. 22: Neurodevelopmental Disorders 5
4. Compromised family coping
iii. Interventions
1. There is no one treatment found to be effective for ADHD. Goals of treatment
involve managing symptoms, reducing hyperactivity and impulsivity, and
increasing the childs attention so that he or she can grow and develop normally.
The most effective treatment combines pharmacotherapy with behavioral,
psychosocial, and educational interventions.
2. Nursing Care Plan: ADHD
a. Identify factors that aggravate and alleviate the clients performance
b. Provide an environment as free of distractions as possible
c. Engage clients attention before giving directions
d. Give instructions slowly, use simple language and concrete directions
e. Separate complex tasks into smaller steps
f. Give positive feedback for completion of each step
g. Allow breaks so the client can move around
h. State expectations for task completion clearly
i. Initially, assist with completion of tasks
j. Progress to prompting or reminding the client to perform tasks
k. Give positive feedback for performing behaviors that come close to task
achievement
l. Gradually decrease reminders
m. Assist the client to verbalize by asking sequencing questions to keep on
topic.
n. Teach family or caregivers to use the same procedures
o. Explain and demonstrate positive parenting techniques to family or
caregivers
3. Ensuring the childs safety and that of others
a. Stop unsafe behavior
b. Provide close supervision
c. Give clear directions about acceptable and unacceptable behavior
4. Improved role performance
a. Give positive feedback for meeting expectations
b. Manage the environment
Ch. 22: Neurodevelopmental Disorders 6
5. Simplifying instructions/directions
a. Get childs full attention
b. Break complex tasks into small steps
c. Allow breaks
6. Structured daily routine
a. Establish a daily schedule
b. Minimize changes
7. Client/family education and support
a. Listen to parents feelings and frustrations
iv. Evaluation
1. Medications are often effective in decreasing hyperactivity and impulsivity and
improving attention relatively quickly, if the child responds to them. Improved
sociability, peer relationships, and academic achievement happen more slowly
and gradually but are possible with effective treatment.
b. ASD:
i. Assessment
1. Retts Disorder: Multiple deficits after period of normal functioning; almost
exclusively in girls
2. Childhood disintegrative disorder: Marked regression in multiple areas of
functioning after 2 years of normal growth and development. Typically includes
symptoms of nonspecific anxiety and agitation
3. Aspergers disorder: similar to autistic disorder; no language or cognitive delays
4. See objective 1.a.1.
ii. Interventions
1. Pharmacologic treatment with antipsychotics, such as haloperidol (Haldol) or
risperidone (Risperdal), may be effective for specific target symptoms such as
temper tantrums, aggressiveness, self-injury, hyperactivity, and stereotyped
behaviors.
3. Provide education to clients, families, teachers, caregivers, and community members for young
clients with ADHD and ASD.
a. ADHD
Ch. 22: Neurodevelopmental Disorders 7
i. Educating parents and helping them with parenting strategies are crucial components
of effective treatment of ADHD. Effective approaches include providing consistent
rewards and consequences for behavior, offering consistent praise, using time-out,
and giving verbal reprimands. Additional strategies are issuing daily report cards for
behavior and using point systems for positive and negative behavior.
b. ASD
i. Include parents in planning and providing care
ii. Refer parents to support groups
iii. Focus on childs strengths as well as problems
iv. Teach accurate administration of medication and possible side effects
v. Inform parents that child is eligible for special school services
vi. Assist parents to identify behavioral approaches to be used at home
vii. Help parents achieve a balance of praising child and correcting childs behaviors
viii. Emphasize the need for structure and consistency in childs routine and behavioral
expectations
4. Discuss the nurses role as an advocate for children and adolescents.
a. Parents feel empowered and relieved to have specific strategies that can help them and their
child be more successful. Including parents in planning and providing care for the child with
ADHD is important. The nurse must listen to the parents' feelings.
b. Inform parents and children they are not at fault and that techniques and school programs are
available to help. Children with ADHD quality for special school services under the Individuals
with Disabilities Education Act.
5. Evaluate your feelings, beliefs, and attitudes about clients with ADHD and ASD and their parents and
caregivers.
a. Working with parents is a crucial aspect of dealing with children with these disorders. The
nurse's beliefs and values about raising children affect how he or she deals with children and
parents. The nurse must not be overly critical about how parents handle their children's
problems until the situation is fully understood: Caring for a child as a nurse is very different
from being responsible around the clock. Given the opportunity, resources, support, and
education, many parents can improve their parenting.