SEPARATION ANXIETY

DISORDER
PREPARED AND PRESENTED BY :
SHILPA GUPTA
BNS 2 ND YEAR
ROLL NO.28
GENERAL OBJECTIVES
At the end of the session, BSC 2nd year students
will be able to explain separation anxiety
disorder.
SPECIFIC OBJECTIVES
At the end of the session, BSc 2nd year students will
be able to :
introduce separation anxiety disorder.
define separation anxiety disorder.
state the epidemiology of separation anxiety
disorder.
CONTD..
state the causes of separation anxiety disorder.
enumerate the signs and symptoms of separation
anxiety disorder.
describe the treatment measures of separation
anxiety disorder.
explain the nursing management of separation
anxiety disorder.
 INTRODUCTION
Separation anxiety disorder is a disorder characterized
by excessive anxiety lasting at least two weeks during
which separation from an attachment figure : individual
or an object or a place. It is very common in young
children ( those between 8 – 14 months) but it can
occur any time before 18 years of age more common in
boys than in girls.
DEFINITION
Separation Anxiety Disorder is an abnormal
condition characterized by excessive anxiety
concerning separation from the home or from those
to whom the person is attached.
 DEFINITION
Separation anxiety disorder ( SAD) is an anxiety
disorder in which an individual experiences
excessive anxiety regarding separation from
people to whom he or she has a strong emotional
attachment e.g. parent, care giver , significant
other or sibling.
EPIDEMIOLOGY
Separation anxiety disorder has an early age of
onset. The peak onset is between 7 and 11 years of
age. Prevalence is 3 % – 5 % in children and
adolescents and it decreases with increasing age . It is
less common in teenagers and affects both boys and
girls.
CAUSES
1) Biological Influences
Genetics.
Temperaments
2) Environmental influences
Stressful life events
3) Family influences
 CLINICAL FEATURES

Persistent reluctance or refusal to go to sleep

without being near or next to a major attachment
figure.
Persistent inappropriate fear of being alone.
Repeated occurrence of physical symptoms.
CONTD..
Excessive tantrums.
Unwillingness to interact with others.
Diagnosis
The diagnostic measures of separation anxiety
disorder are :
History taking
Physical examination
Mental status examination
TREATMENT
Treatment measures of separation anxiety disorder
includes :
Individual counseling.
Play therapy.
Relaxation techniques.
Cognitive therapy.
 Contd..
Parental counseling.
Family therapy.
Pharmacological management :
Anxiolytic drugs such as diazepam may be needed
occasionally when anxiety is extremely severe but
should be used only for a short period of time.
 Nursing management
1. Assessment (background data assessment)
History taking about :
Age of onset of the disorder (may be as early as
preschool age ; it rarely begins as late as adolescence.
Symptoms like tantrums, crying, complaints of physical
problems and clinging are anticipations of separation.
Contd…
Reluctance or refusal to attend school (especially
common among adolescence)
Younger children may follow the person from whom
they are afraid to be separated.
During middle childhood or adolescence, they may
refuse to sleep away from home.
Contd..
Specific phobias are common e.g. fear of dark,
ghosts, animals .
Onset of the anxiety symptoms which commonly
occurs following a major stressor .
Nursing diagnosis, outcome and
interventions
Diagnosis no . 1 :
Severe anxiety related to family history, temperaments,
over attachment to parent , negative role modeling.
outcome :
Client will maintain anxiety at no higher than moderate
level in the face of events that formerly have
precipated panic.
 Nursing Interventions
Establish an atmosphere of calmness, trust and genuine
positive regard.
Help parents and child initiate realistic goals e.g. child to
stay with the sitter for 2 hours with minimal anxiety or
child to stay at friend’s house without parents until 9 pm
without panic anxiety.
Contd..
Assure client of his or her safety and security.
Explore the child’s or adolescent’s fear of separating
from the parents.
Give and encourage parents to give , positive
reinforcement for desired behaviors
Diagnosis : 2
Ineffective coping related to unresolved separation,
conflicts and inadequate coping skills evidenced by
numerous somatic complaints
Outcome
Client will demonstrate use of more adaptive coping
strategies ( rather than physical symptoms) in
response to stressful situation.
 Nursing Interventions
Encourage child or adolescent to discuss specific
situations in life that produce the most distress and
describe his or response to these situations. Include
parents in the discussion.
Help the child or adolescent who is perfectionist to
recognize that self expectations may be unrealistic.
Connect times of unmet self expectations to the
exacerbation of physical symptoms.
Contd..
Encourage parents and child to identify more
adaptive coping strategies that the child could use in
the face of anxiety that feels over whelming practice
through role play.
 Diagnosis no . 3
Impaired social interaction related to reluctance to
be away from attachment figure.
Outcome :
Client will be able to spend time with staff and peers
without excessive anxiety.
 Nursing Interventions
Develop a trusting relationship with the client.
Attend groups with the child and support others. Give
feed back.
Convey to the child the acceptability of his or her not
participating until client is able to participate more fully.
CONTD..
Help client set small personal goals e.g. today I
will speak to one person I don’t know.
SUMMARY
 ASSIGNMENT
Fill in the blanks
Separation anxiety disorder occurs commonly between
the age group of ………… and before the age of ……………….
The I.Q level of children with mild mental retardation
is………
Life support is required for children with …….mental
retardation
Short question answer
Write short note on separation anxiety disorder.
State the causes of separation anxiety disorder.
Long question answer
Describe the nursing management of mental
retardation.
What are the diagnostic criteria of separation anxiety
disorder.
 REFERENCES
Louise , R S. (2012) . Basic Concept Of Psychiatric
Mental Health Nursing . Lippincott . Willams & Wilkins.
Margaret , J H . ( 2014) . VARCAROLIS’ Foundations OF
Psychiatric Mental Health Nursing . United States Of
America. ELSEVIER.
Shreevani, R.. K , Reddema . ( 2010) . A Guide TO
Mental Health And Psychiatric Nursing. New Delhi.
Jaypee.
 CONTD..
Townsend, C M. (2005). Essentials Of Psychiatric Mental
Health Nursing. Philadelphia. The Taber’s publisher.

Sheila, L V . (2008) . Psychiatric Mental Health Nursing. 4 th

edition . Lippincott Williams & Wilkins.

Retrieved from www. slideshare.net

CHILDHOOD
PSYCHIATRIC
DISORDERS

PREPARED AND PRESENTED BY

SARALA SHRESTHA
BNS 2 ND YEAR
ROLL NO : 20
REVIEW
GENERAL OBJECTIVES
At the end of this teaching learning session, BSc 2 nd
year students will be able to explain conduct
disorders and encopresis
SPECIFIC OBJECTIVES
At the end of this teaching learning session, BSc 2nd
year students will be able to :
introduce conduct disorders
define conduct disorders
classify conduct disorders
state the causes of conduct disorders
CONTD..
Enumerate the causes of conduct disorder
Identify the diagnostic measures of conduct
disorders
Describe the management of conduct disorders
Explain the management of conduct disorders
CONTD..
introduce encopresis
define encopresis
state the types of encopresis
state the causes of encopresis
enumerate the signs and symptoms of encopresis
describe the management of encopresis
 
INTRODUCTION
Conduct disorder are childhood psychiatric
disorders that are characterized by a repetitive and
persistent pattern of behavior in which basic rights of
others or major age appropriate social norms or rules
are violated, physical aggression is common. The
rules of societies are not followed .
CONTD..

It encompasses a range of dysfunctional behaviors that

emerge over the course of the childhood . Commonly seen
in older children and adolescents. Conduct disorders have
more deleterious consequences for individual, family and
society at large.
CONTD..

 For example, hostile and defiant behaviors

disobedience, temper tantrums, school refusal, rule
violations , argumentativeness , lying , fighting ,
bullying others etc.
CONTD..
The onset occurs much before 18 years of age and
usually even before puberty . This disorder is much
more common in boys ( about 5 to 10 times ) .
 
DEFINITION

Conduct disorders are one of the major childhood

psychiatric disorders that are characterized by a
persistent , repetitive and significant pattern of
conducts in which the basic rights of others are
violated and the rules of society are not followed.
 
CLASSIFICATION
1 . ICD 10 classification
F 91 : Conduct disorders
F 91.0 : Conduct disorders confined to the family
context
F 91.1 : Unsocialized conduct disorders
F 91.2 : Socialized conduct disorder
Contd..
F 91.3 : Oppositional conduct disorder
F 91.8 : Other conduct disorders
F 91.9 : Conduct disorder, unspecified
2. DSM IV CLASSIFICATION

Childhood onset type

 Adolescent onset type
CAUSES
GENETIC FACTORS
Twins
Parental history
Alcoholism and personality disorder in father
BIOCHEMICAL FACTORS
High plasma testosterone levels
CONTD..
ORGANIC FACTORS
Brain damage, Epilepsy
PSYCHOSOCIAL FACTORS
Poor peer relationships.
Family relationships
CLINICAL FEATURES
CONTD..
In addition to the typical symptoms of conduct
disorder, secondary complications often develop like
drug and dependence, unwanted pregnancies ,
syphilis, AIDS, criminal record , suicidal and homicidal
behavior can also be seen.
DIAGNOSIS

Complete team approach ( including medical and

psychiatric evaluations, feed - back from parents, a
school consultant’s recommendations , a case
manager’s plan) is important because anti- social
behaviors tend to be underreported.
CONTD..
Educational assessment to determine if there are
cognitive deficits, learning disabilities or problems in
intellectual functioning .
A neurological examination if there is a history of
head trauma or seizures.
TREATMENT

Parental instruction to teach how to deal with the

child’s demand .
May need to learn to reinforce appropriate
behaviors and to harsh punishment for inappropriate
behaviors .
CONTD..
Parents should be encouraged to find ways to bond
more strongly with the child.
Juvenile justice system, if needed to provide
structured rules and a means for monitoring and
controlling the child’s behavior.
CONTD..
Pharmacotherapy
Aims :
 To alleviate aggression
To reduce reactivity , moderate levels of emotional
arousal .
 CONTD..
 DRUGS :
Psycho stimulants e.g. : mthylphenidate
 Mood stabilizers e.g. lihium
Anti psychotics e.g. chlorpromazine , haloperidol ,
clozapine
Adrenergic agents : clonidine, propranolol , metoprolol
 NURSING MANAGEMENT

1. Background assessment data ( symptomatology )

 
 2.Nursing diagnosis , outcome and
interventions
  
DIANOSIS NO . 1 : Impaired social interaction related
to negative parental role models, impaired peer
relations evidenced by negativism towards others ,
hostility and cruel behavior with peer groups.
Outcome : Client will be able to interact with staff and
peers using age appropriate, acceptable behavior.
Nursing interventions
Develop a trusting relationship with the client.
Convey acceptance of the person, separate from
unacceptable behaviors.
CONTD..
Discuss with the client which behaviors are and are
not acceptable . Describe the consequences of
unacceptable behaviors .
Provide group situations for the client.
DIAGNOSIS NO . 2
Defensive coping related to low self - esteem and
dysfunctional family system as evidenced by
impulsiveness when spoken to .
 
Outcome : client will accept responsibility for own
behaviors and interact with others without becoming
defensive.
Nursing interventions

Explain to the client the need for acceptance from

others and how these feelings provoke defensive
behaviors such as blaming others for own behaviors.
Provide immediate non-threatening feedback for
unacceptable behaviors.
CONTD..
Help identify situations that provoke defensiveness
and practice through role paly more appropriate
responses.
Provide immediate positive feedback for acceptable
behaviors.
DIAGNOSIS NO . 3

Risk for other- directed violence related to

characteristics of temperaments, peer rejection ,
negative role models and dysfunctional family
dynamics.
 Outcome
Client will not harm others and others’ property
Nursing interventions

Observe behaviors frequently through routine

activities and interactions. Become aware of
behaviors that indicate a rise in agitation .

Encourage client to express anger and act as a role

model for appropriate expression of anger.
CONTD..

Ensure that a sufficient number of staff is

available to indicate a show of strength if
necessary.
CONTD..
Administer tranquilizing medication, if ordered
or use mechanical restrictions or isolation room
only if situation cannot be controlled with less
restrictive means.
3. EVALUATION
Evaluation of nursing interventions is made via
gathering information based on following questions :
Have the nursing actions directed towards managing
the client’s aggressive behavior been effective ?
Have interventions prevented harm to other or
others’ property ?
CONTD..

Is the client able to express anger in an appropriate

way?
Has the client developed more adaptive coping
mechanisms to deal with anger and feelings of
aggressions?
Does the client demonstrate the ability to trust
others ?
CONTD..
Is he or she able to interact with staff and peers in an
appropriate manner ?
Is the client able to accept responsibilities for his or
her own behaviors ? Is there less blaming of others?
SUMMARY
CONTD..

Normally toilet training is achieved between the age

of 2 – 3 years . so, encopresis is defined as occurring
after the age of 4 years.
DEFINITION
Encopresis can be defined as the repeated intended
or unintended passage of feces, usually of normal or
near normal consistency , in places not appropriate
for the purpose in the individual’s socio cultural
setting .
 
TYPES
INTRODUCTION
Encopresis is a childhood psychiatric disorders that can be
characterized by repetitive voluntary or involuntary passage
of feces at inappropriate time and / or places after the
bowel control is physiologically possible . Encopresis is
more common in boys than in girls.
 
CAUSES
The causes of encopresis are :
Underlying hyperkinetic disorder
Emotional disturbances
 Poor parenting
CONTD..
Mental illnesses like Mental retardation, attention
deficit , autism etc.
Sibling rivalry
Improper toilet training
Chronic constipation with resulting overflow
incontinence
CONTD..
Voluntary retention of stool
Involuntary retention due to emotional problems
like faulty mother –child relationships
It may also be a part of anal masturbation.
 CLINICAL MANIFESTATIONS

Voluntary retention is usually temporary with the

history of painful expulsion of stool.
Involuntary retention is associated with a history of
abdominal pain , discomfort , distention , poor appetite
and with periodic passage of voluminous stools.
CONTD
Feels ashamed and may wish to avoid situations.
Rejection by peers and parents cause further
withdrawal and other behavioral manifestations.
It may also be accompanied by smearing of feces
over the body or environment
TREATMENT
Treatment of encopresis includes :
1. Management
Family tensions regarding the symptoms must be reduced
and non- punitive environment must be created .
Parental guidance and family therapy is often needed .
CONTD..
Behavioral technique using reinforcement for e.g.
star charts in which places a star on a chart for dry
days .
Individual psychotherapy to gain co-operation and
trust of the child.
CONTD..
2. PHARMACOTHERY : Anxiolytics and
antidepressants if the causative factor is anxiety or
depression ( severe type )
SUMMARY
ASSIGNMENT
Write the criteria for diagnosing conduct
disorders.

Describe the role of nurses in child with a

psychiatric disorder.
REFERENCES
Louise , R S. (2012) . Basic Concept Of Psychiatric Mental
Health Nursing . Lippincott . Willams & Wilkins.
Margaret , J H . ( 2014) . VARCAROLIS’ Foundations
OF Psychiatric Mental Health Nursing . United States
Of America. ELSEVIER.
Shreevani, R.. K , Reddema . ( 2010) . A Guide TO
Mental Health And Psychiatric Nursing. New Delhi.
Jaypee.
CONTD..
Townsend, C M. (2005). Essentials Of Psychiatric
Mental Health Nursing. Philadelphia. The Taber’s
publisher.
Sheila, L V . (2008) . Psychiatric Mental Health
Nursing. 4th edition . Lippincott Williams & Wilkins.
Retrieved from www. slideshare.net
 
CHILDHOOD PSYCHIATRIC
DISORDERS

PREPARED AND PRESENTED BY

SARALA SHRESTHA
BNS 2 ND YEAR
ROLL NO : 20
REVIEW
GENERAL OBJECTIVES
AT the end of this session, B.Sc. students will
be able to explain ADHD
SPECIFIC OBJECTIVES
At the end of the session, BSc 2nd year students will
be able to :
Introduce ADHD
Define mental ADHD
identify classification of ADHD according to ICD 10
State the incidence of ADHD
CONTD..
Describe the causes of ADHD
state the signs and symptoms of ADHD
identify the diagnostic criteria of ADHD.
explain the management of ADHD
INTRODUCTION
 DEFINITION

ADHD is a common childhood psychiatric

disorder that is characterized by features like a
persistent pattern of inattention and/or
hyperactivity – impulsivity that is more
frequent and severe that is typically observed
in individuals at a comparable level of
development
 ICD-10 CLASSIFICATION

F 98.8 : Other unspecified behavioral and

emotional disorders with onset usually occurring in
childhood and adolescence.
Includes :
Attention Deficit Hyperactivity Disorder
( ADHD)
Masturbation
Nail-biting, nose picking and thumb sucking
INCIDENCE
The onset of the disorder is difficult to
diagnose in children younger than 4 years of
age because their characteristic behavior is
much more variable than that of older
children.
CONTD..
Frequently the disorder is not recognized
until the child enters school.

A Prevalence of 1.7 % was found among

primary school level children ( taylor et.al
1991 )
CONTD..
ADHD affects an estimated of 3% - 5% of all
school children . The ratio of boys to girls
ranges from 3 : 1 in non clinical setting and
9:1 in a clinical setting ( Hechtman, 2005)
SUBTYPES : ACCORDING TO
ICD 10
CAUSES
A. BIOLOGICAL INFLUENCES
Genetics
Biological theory
Prenatal, intra-natal and post-natal factors
Contd..
B. ENVIRONMENTAL INFLUENCES
Environmental lead
Diet factors
CONTD..
C.PSYCHOSOCIAL INFLUENCES
CLINICAL FEATURES
A.INATTENTION
Contd..
SIX OR MORE OF FOLLOWING FOR AT LEAST 6
MONTHS :
Often fails to give close attention to details or makes
careless mistakes in school works , work or other
activities.

Often has difficulty sustaining attention in tasks or

play activities.
CONTD..
Often does not seem to listen when spoken
directly.
Often does not follow through instructions
and fails to finish school works, chores or
duties in the work place.
Contd..
Often has difficulty in organizing task
activities.
Often avoids, dislikes or is reluctant to
engage in tasks that require sustained
mental effort ( such as reading books, school
works , home works etc.).
CONTD..
Often loses things necessary for tasks or
activities e.g. toys, pencils, books or
school assignments.
Is often easily distracted by external
stimuli.
Is often forgetful in daily activities.
2.HYPERACTIVITY
CONTD..
Six or more of the following symptoms lasting
for at least 6 months :
Often fidgets with hands and feet or squirms
in seat.
Often leaves seat in classroom or in other
situations where remaining seated is
expected.
CONTD..
Often has difficulty playing or engaging in
leisure activities quietly.
Often runs about or climb excessively in
situations in which it is inappropriate.
CONTD..
Is often “on the go” or often acts as if “
driven by motor.”
Often talks excessively.
IMPULSIVITY
CONTD..
Often blurts out answers before questions
have been completed.
Often has difficulty waiting turns.
Often interrupts or intrudes on others( e.g.
butts into conversations of games)
DIAGNOSTIC CRITERIA
In both ICD 10 and DSM IV the cardinal feature for
the diagnosis of the disorder are impaired attention ,
hyperactivity and impulsiveness starting in
childhood and lasting for at lest six months to a
degree that is maladaptive and inconsistent with the
developmental level of the child.
CONTD..
ICD-10 requires both hyperactivity and
impaired inattention ; DSM IV requires
either inattention or hyperactivity with
impulsiveness.
CONTD..

ICD-10 requires that the criteria are met

both at home and at school, where as DSM
IV requires only that they be present in one
situation with impairment .
MANAGEMENT
1. PSYCHOSOCIAL TREATMENT
 Parental guidance
 Counseling

2.INTENSIVE SUPPORT : Education to the

family
CONTD..
3.Classroom interventions
4. Contingency management
5. Social skills training
6.Cognitive behavior therapy.
7.Individual psychotherapy.
CONTD..
MEDICATIONS : CNS STIMULANTS
First line drugs :
Dexadrine : 2.5mg/day
Ritalin ( methylphenidate) : 0.3- 1 mg /kg
hourly. { most effective 75- 80%}
CONTD..
Dextromphetamine ( 70 – 75 % effective )
 Atypical antidepressants : magnesium
pemoline : 19 mg stat then ½ tablet per
week.
HOME MANAGEMENT
Parental counseling.
Engage children in outdoor activities with
minimal instructions.
Provide adequate rest and sleep.
Contd..
Structure home schedule for daily activities
like : wake uptime, meal time ,bed time etc.
Non physical punishment for aggressive
behaviors
SUMMARY
MULTIPLE CHOICE QUESTIONS

ADHD falls under which of the following

according to ICD 10 ?
a. F 98.8
b. F 98.6
c. F 98.1
d. F 98.4
CONTD..
The clinical features of ADHD is :
a. Inattention
b. Hyperactivity
c. Impulsivity
d. All of the above
FILL IN THE BLANKS
The subtypes of ADHD are Combined Type ,
Predominantly inattentive type and ……….
The most effective 1st line drug for the
treatment of ADHD is……….
ASSIGNMENTS
Describe the nursing management of
attention deficit hyperactivity disorder.
REFERENCES
Louise , R S. (2012) . Basic Concept Of Psychiatric Mental
Health Nursing . Lippincott . Willams & Wilkins.
Margaret , J H . ( 2014) . VARCAROLIS’ Foundations OF
Psychiatric Mental Health Nursing . United States Of
America. ELSEVIER.
Shreevani, R.. K , Reddema . ( 2010) . A Guide TO Mental
Health And Psychiatric Nursing. New Delhi. Jaypee.
CONTD..
Townsend, C M. (2005). Essentials Of Psychiatric
Mental Health Nursing. Philadelphia. The Taber’s
publisher.
Sheila, L V . (2008) . Psychiatric Mental Health
Nursing. 4th edition . Lippincott Williams & Wilkins.
Retrieved from www. slideshare.net

 
CHILDHOOD PSYCHIATRIC
DISORDERS

PREPARED AND PRESENTED BY

SARALA SHRESTHA
BNS 2 ND YEAR
ROLL NO : 20
NIGHTMARE
NIGHT TERRORS
ENURESI
GENERAL OBJECTIVES

At the end of the session, BSc 2nd year students will
be able to explain Nightmare disorders, Night terrors
and Enuresis.
 SPECIFIC OBJECTIVES
At the end of this session, BSc 2nd year students will be able to :
introduce sleep cycle.
introduce nightmares.
state the incidence of nightmares.
enumerate the signs snd symptoms of nightmares.
identify the diagnostic measures of nightmare.
describe the management of nightmares.
Contd..
introduce night terrors
define night terrors
state the incidence of night terrors
state the causes of night terrors.
enumerate the signs and symptoms of night terrors.
identify the diagnostic measures of night terrors .
describe the management of night terrors.
Contd..
introduce enuresis.
define enuresis.
state the incidence of enuresis .
state the causes of enuresis.
classify enuresis.
identify the diagnostic measures of enuresis
describe the management of enuresis.
NIGHTMARES
SLEEP CYCLE
The sleep cycle is an oscillation between the slow
wave and rapid eye movement phases of sleep . This
takes 1 to 2 hours.
 CONTD..
Sleep cycle :
•Interim between consciousness and sleep .
•Heart rate slows down , brain does less complicated tasks.
•Body makes repairs
•Body temperature and blood pressure decrease.
•Increase in eye movement, heartrate, breathing and
temperature.
INTRODUCTION
DEFINITION
Nightmare is an unpleasant dream that cause a
strong emotional response such as fear or horror
with despair , anxiety and great sadness.
INCIDENCE
Nightmares are not uncommon between the age of
3 and 6 years of age and most children outgrow the
phenomena. Many adults report on occasional
nightmares but the incidence of nightmare disorder
is not known.
CAUSES
The causes of nightmares are :
Stress
Trauma
Sleep deprivation
Scary books and movies
OTHER CAUSES
Separation from parents especially among toddlers
and pre-schoolers.
Excessive napping during day time.
Fear about death or real danger.
CONTD..
Boredom and insufficient interactions with adults
Negative reaction to medications.
Distressing events such as accidents, violence etc.
SIGNS AND SYMPTOMS
DIAGNOSTIC CRITEREIA
Repeatedly waking up with detailed recollection of long
frightening dreams that center around threats to survival,
security or physical integrity and usually occur in the second
half of the sleep or nap period .

Being oriented and alert instantly upon awakening.

CONTD..
Experiencing distress or impairment of social or
other important areas functioning.
Having no general medical condition and using
medications or other substances that would cause
these symptoms.
MANAGEMENT
Advice to the parents to talk to the child about the
dream.
Assessment for any underlying medical condition
and its management.
Keep the linen of the bed clean, dry and free of any
irritants.
CONTD..
Encourage the child to void before going to bed.
Provide transitional objects such as favorite toy, or leaving
a drink or water by bed site.
Provide reassuring hugs when the child awakes from a
nightmare and set hi or her back to sleep
CONTD..
Reward the child with praise and positive
reinforcement who sleeps throughout the night
without any disturbance.
Consult clinical psychologist if the nightmare become
worse and persistent.
CONTD..
Discourage the child beyond 13 years of age to see
horror movies at bed time.
Medical intervention is required if nightmares occur
for more than once a week and prevents sound sleep
for prolonged time.
SUMMARY
NIGHT TERRORS
INTRODUCTION
DEFINITION
Night terrors are sleep disorders that involves
abrupt awakening from sleep in a terrified state with
piercing cry characterized by confusion, unable to
communicate and difficulty going back to sleep again.
INCIDENCE
Night terrors will be observed in 2 percent of
children among age group of 1 to 8 years.
Most common between the age group of 5 to 7
years.
Common in boys than in girls.
CAUSES
1) Heredity
2) Triggered by various stressors like :
Lack of sleep .
Change to routine of sleep.
Extreme tiredness.
Family stress.
Period of emotional tension.
SIGNS AND SYMPTOMS
DIAGNOSTIC CRITERIA
Instance fear and signs of autonomic around like
tachycardia, rapid breathing and sweating during
each episode.
Recurrent episodes of abrupt awakening from
sleep . The duration of the episodes is less then 15
minutes.
CONTD.
No detailed dream is recalled and there is amnesia
for the episode.
Unresponsiveness to efforts of others to comfort him
or her during the episode.
Contd..

 The disturbance is not due to the direct

psychological effect of a substance (e.g. a drug, of
abuse etc ) or a general medical or neurological
condition.
 MANAGEMENT
Any specific treatment is not required for night
terrors. Children with night terrors require only
comfort.
 If a child is unresponsive during night terrors, parents
should not try to wake up the child but hold the child
firmly and speak soothingly until the episode subsides.
Usually the child will ease back to sleep afterwards.
CONTD..
Parents should consult a pediatrician if the night
terror are caused by an underlying condition such as
psychiatric illness or as a result of head injury.
Relaxation techniques or talk therapyParents are
advised to teach the child about the coping
mechanisms.
CONTD..
Medications : benzodiazepines ( Diazepam > Dose :
0.8mg /kg/day per oral)
DIFFERNECES BETWEEN
NIGHTMARES AND NIGHT TERROR
CHARACTERISTICS NIGHTMARE NIGHT TERRORS
DEFINITION Nightmares are Night terror are sleep
frightening dreams disorders that involves
that lead to awakening abrupt awakening
from sleep that is from sleep in a
characterized by terrified state with
repeated occurrence piercing cry , confusion
which interferes with and inability to
social and occupational communicate.
functioning
Characteristics Nightmares Night terrors

Time Second half of the First third of the

sleep. sleep.

Sleep stage Rapid eye movement Slow wave sleep

Orientation Well oriented Disoriented and

confused

Displacement from Occasional May be present

bed during the event
Characteristics Nightmares Night terrors
Recall of the event Frequent recall of the Cannot remember or
dreams recall the event in the
morning.
Returning back to sleep Frightened to go back to Falls bac to sleep after
sleep. the event.
Comfort The child can be The child cannot be
comforted by hugs. comforted during the
episode.

Communication Communicates about The child is unable to

the dreams to the communicate during the
parents event.
SUMMARY
ENURESIS
INTRODUCTION
DEFINITION
Enuresis is the medical term for the inability to
control passage of urine ( involuntary) passage of
urine at day and / or night in persons who are already
toilet trained without any underlying medical
condition.
INCIDENCE
It is commonly observed in children over 5 – 6 years
of age.
Boys suffer more than girls
15 % of children between the age of 5 – 10 years.
1 % of children may continue to bed wet up to 15
years of age.
 CAUSES
The exact cause is unknown. The affecting factors are :
1. GENETICS
CONTD..
2.FAULTY TRAINING
CONTD..
3. EMOTIONAL DISTURBANCES
4. PHYSICAL DISEASES .
TYPES
MANAGEMENT
History taking
Investigation of the renal tract
Explanation and counseling to the parents and child.
 CONTD..
Encouragement of the child to
keep diary of the pattern of
dryness or wetness .
Positive reinforcement for dry
nights and days.
Fluid restriction after 6 pm.
CONTD..
BELL AND PAD TECHNIQUES
In this procedure a bell is attached to the napkins or
underpants and when the child passes urine, the alarm goes
off ; the child has to wake up to change his napkins , bed
sheets etc.
BELL AND PAD TECHNIQUES
CONTD..
Alarm therapy
In this therapy. An alarm is set at usual bed wetting
time of the child so that the child can be awaken
before that time . The child then gets up to void in
the toilet .
CONTD..
MEDICATION
Tricyclic antidepressants like amitriptyline 25 to 30
mg at night .The action is unknown but the results
shown its effectiveness
SUMMARY
Write ‘t’ for true statement and ‘F’ for false
statement
•Children with nightmare disorder can recall the
dream vividly….
•Children with night terrors can be comforted and
returned back to sleep easily…….
•Resumption of enuresis after a period of time is
called secondary enuresis…
•For the management of enuresis , fluid restriction
should be down after 6 pm……
Fill in the blanks
•…………………………..occurs during second half of the
sleep.
•Management of enuresis with the use of bel
attached to the under pants is called ……
ASSIGNMENT
Describe the nursing management of enuresis
REFERENCES
Louise , R S. (2012) . Basic Concept Of Psychiatric Mental
Health Nursing . Lippincott . Willams & Wilkins.
Margaret , J H . ( 2014) . VARCAROLIS’ Foundations OF
Psychiatric Mental Health Nursing . United States Of
America. ELSEVIER.
Shreevani, R.. K , Reddema . ( 2010) . A Guide TO Mental
Health And Psychiatric Nursing. New Delhi. Jaypee.
CONTD..
Townsend, C M. (2005). Essentials Of Psychiatric
Mental Health Nursing. Philadelphia. The Taber’s
publisher.
Sheila, L V . (2008) . Psychiatric Mental Health
Nursing. 4th edition . Lippincott Williams & Wilkins.
Retrieved from www. slideshare.net

 
GENERAL OBJECTIVES
At the end of the session, BSc 2nd year
students will be able to explain PICA and
School Phobia
SPECIFIC OBJECTIVES
At the end of this session, BSc 2nd year students will be able
to :
introduce Pica
define Pica
state the epidemiology of Pica
describe the causes of Pica
enumerate the signs sand symptoms of Pica
describe the management of Pica
 Contd..
introduce school phobia
define school phobia
state the epidemiology of school phobia
describe the causes of school phobia
enumerate the signs and symptoms of school phobia
identify the diagnostic measures of school phobia
describe the preventive measures of school phobia
describe the management of school phobia
INTRODUCTION
 Formulating the
habit of eating non-
nutritive or non edible
substances such as
mud, dirt, hair , clay,
chalk , wall plaster etc.
is called pica.
CONTD..

Tasking or mouthing of strange objects is normal in infancy

and children up to the age of 2 years. The persistence of this
habit beyond 2 years of age may be a manifestation of
behavioral disorder.
CONTD..
There is strong craving or urgency to consume these
substances among the children with pica.

Pica is commonly observed in low socio economic

group and in malnourished and mentally subnormal
children. It is also seen among pregnant women
DEFINITION
Pica is an eating disorder found primarily in
young children and pregnant women and
marked by persistent craving for unnatural,
non nutritive substances such as plaster,
paint , hair , dirt, starch, clay , mud etc.
 INCIDENCE
 Greater than 50 % is considered normal in children
aged 18 – 36 months
 10% of children older than 12 months has pica.
 Abnormal in children older than 36 months.

 Pica is thought to be decrease with increasing age.

CAUSES
SIGNS AND SYMPTOMPS
Engage in oral activities e.g. thumb sucking
or nail biting.

Ingestion of uncooked substances like corn

starch, flour , rice etc and non food
substances like ash , chalk , soil ,hair etc.
CONTD..
Complains of abdominal pain time and
again.
Slow in motor and mental development.
Exhibit neurological defects
Deviant behaviors.
Hysteric clients eat salt and vinegar.
CONTD..
Schizophrenic client will have peculiar taste at
certain times.
Anemia , diarrhoea or constipation , worm
infestation , lead poisoning and malnutrition
secondary to PICA.
Intestinal obstruction due to hair balls
Diagnostic criteria
1. History taking for signs and symptoms
Persistent eating of non nutritive substances
for a period of at least 1 month.
Although mouthing of objects is normal in
infants and toddlers , pica after 2nd year of
age needs intervention.
CONTD..
Any pre existing mental disorder like mental
retardation, schizophrenia.
Familial relationship and stressful situation
at present .
CONTD..
2. Physical Examination
 Weight , Height and Body mass index examination
to assess any signs of malnutrition.
3. Investigations
 Blood test for hemoglobin, iron and zinc levels.
X-ray : chest and abdomen
 MANAGEMENT
1.Nutritional and emotional needs of the children have to be
met.

2.Discrimination training between edible and inedible items

with negative reinforcement if pica is attempted.

3.Avoid clothing with buttons or bows that can be pulled off

and swallowed.
CONTD..
3. Avoid gifts with small pieces that can be
chewed or broken off and swallowed

4.Behavioral modification techniques can be

applied if the child is facing any stressful
situation or has an extreme fear of something :
systemic desensitization.
Contd..

5.Assess the neurological defects, if needed consult the

neurophysician.

6.Drug therapy
If the child has severe anxiety then benzodiazepines :
diazepam may be required. { dose 1-2 mg TID / QID.
CONTD..
8.Regularize the meal pattern, serve the food in an
attractive manner.

9. Counseling of the child and parents

COMPLICATIONS
Bezoars.
Infection
Lead poisoning
Malnutrition
Intestinal obstruction
Prognosis
Treatment success varies according to types and
the amount of substance ingested. It lasts several
months then disappears on its own.

Some may contribute into the teen years or

adulthood especially when it occurs with
developmental disorders.
SUMMARY
INTRODUCTION
DEFINITION
School phobia is a complex syndrome that can be
influenced by the child’s temperaments , the
situation at school and the family situations
characterized by an imprecise, irrational and
persistent fear and reluctance to go to school
INCIDENCE
These behaviors occur in approximately 2-5
% of school children.
It is most common at 3 periods of life :
Between 5 and 7 years ( highest)
At 11 years ( with the change of school )
At 14 years and older .
CAUSES
Genetic predisposition
Non –school related causes
School related causes
 Signs and symptoms
Children persistently refuses to attend school.
Children may have crying spells or throw temper
tantrums.
Frequent complains about not feeling well : vague or
non specific complains.
 CONTD..
Absence of the symptoms on Saturdays and other
holidays.
The child may tell he or she is anxious or afraid of a
certain situation that happens at school to a trusted
family member.
CONTD..
They do not answer questions in the classroom ,
often they will be mute.

Avoid participating in social gatherings or school

programs.
Eating may become aversive when he or she has to
eat in front of others.
 CONTD..
Avoid developing friendship or attachment with peer
groups.
Unreasonable fear or distress experiencing in group
situations.
 CONTD..
Over clingy, shadowing of mother and father around
house.
Constant thoughts and fear about safety of self and
parents
CONTD..
ANXIETY SYMPTOMS
Crying
Headaches
Diarrhea
Feeling faint
Hyperventilation
Vomiting
Rapid heart beat
Shaking
Sweating
Stomach aches
Dizziness
DIAGNOSIS
School phobia can be diagnosed via history taking of
school refusal .
Diagnosis usually requires team approach that
includes physician , parents , the child , teachers and
counselors.
 PREVENTIVE MEASURES
Parents can give their children appropriate opportunities to
separate from them during toddlerhood and preschool years
by exposing them to activities such as preschool play groups,
baby sitters and daycare.
 CONTD..
With older children, parents can step in to stop
bullying behaviors or humiliating situations as soon as
it starts.

The environment of the school should be safe

without humiliating situation.
CONTD..
Parents should help in solving difficulties and in
coping with difficult situations.

Have a physician examine the child to determine

if he or she has a legitimate illness.
CONTD..
Listen to the child talk about school to detect
any clues as to why he or she dose not want to.
MANAGEMENT
AT HOME
Assist the child in overcoming his or her fear by
gradually including exposure to it.
Eliminate any fun activities at home when the school is
in session.
Home Management Contd..

Have the parent who is better at encouraging

attendance take the child to school.
Reassure the child that family will be safe through
hugs , kind words and positive notes.
HOME MANAGEMENT CONTD..
The child should be taught about relaxation and
coping techniques by the parents.
Management Contd..
AT SCHOOL
Have the teacher or other school professionals such
as school counselor, establish a caring relationship
with the child.
Arrange for a school staff member greet the parent
and child at door and take the child to the class.
School Management Contd
Identify particular activities the child enjoys doing
and those that produce anxiety.
Monitor bullying activities that may be taking place
at school.
Include the student in a friendship group facilitated
by the school counselor.
 School Management Contd..
Adjust work assignment to match the student’s
academics.

Discuss the situation with the school nurse who can

attend to the child’s complaints and then return to
him or her to class.
School Management Contd..
Help the child build self confidence by discovering
his or her strengths and by providing opportunities
for the child to excel

Help the child with poor academic skills tested for

special education services.
OTHER TREATMENT MEASURES
Behavior therapy- The individual learns to cope 
with difficult situations often through 
controlled exposure to them.
Cognitive Therapy- The individual examines 
feelings and learns to separate realistic from 
unrealistic thoughts.
Cognitive-Behavior Therapy- The individual learns recovery
skills that are useful for a lifetime.
SUMMARY
ASSIGNMENTS
Write ‘T’ for true statement and ‘F’ for false statement
Pica is an eating disorder found primarily in young
children and pregnant women ………
Eating non food substances is common beyond the
age of 2 years ……….
Contd..
School phobia is a common psychiatric disorders of
adolescents ……..
School phobia can be effectively treated via
combination of behavior and cognitive therapy ……..
CONTD..
2.Short Answer Question
 Write short notes on Pica

3.Long question answer

Describe the nursing management of school phobia.
REFERENCES
Louise , R S. (2012) . Basic Concept Of Psychiatric Mental
Health Nursing . Lippincott . Willams & Wilkins.
Margaret , J H . ( 2014) . VARCAROLIS’ Foundations OF
Psychiatric Mental Health Nursing . United States Of
America. ELSEVIER.
Shreevani, R.. K , Reddema . ( 2010) . A Guide TO Mental
Health And Psychiatric Nursing. New Delhi. Jaypee.
CONTD..
Townsend, C M. (2005). Essentials Of Psychiatric
Mental Health Nursing. Philadelphia. The Taber’s
publisher.
Sheila, L V . (2008) . Psychiatric Mental Health
Nursing. 4th edition . Lippincott Williams & Wilkins.
Retrieved from www. slideshare.net
