Chapter 22
Neurodevelopmental
Disorders
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Neurodevelopmental Disorders
• Not diagnosed as easily as in adults: lack of abstract
cognitive abilities and verbal skills; constant state of
change and development
• Similar problems of adults such as mood, anxiety, eating
disorders
• Other disorders usually first diagnosed in infancy,
childhood, and occasionally in adolescence
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Intellectual Disability
• Below-average intellectual functioning
• IQ less than 70 accompanied by significant limitations in:
– Communication skills
– Self-care
– Home living
– Social/interpersonal skills
– Work
– Leisure
– Health and safety
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Intellectual Disability (cont.)
• Causes: heredity, altered embryonic development;
maternal alcohol intake; perinatal problems; infant
medical conditions; environmental influences
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Autism Spectrum Disorders
• Pervasive, usually severe impairment of reciprocal social
interaction skills, communication deviance, restricted
stereotypical behavioral patterns
• Autism spectrum disorders
– Autism (classic autism)
– Rett’s disorder
– Childhood disintegrative disorder
– Asperger’s disorder
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Autism Spectrum Disorders (cont.)
• Autism
– Present by early childhood; boys more than girls
– Little eye contact, few facial expressions, limited
gestures to communicate, limited capacity to relate
to peers or parents, lack of spontaneous enjoyment,
apparent absence of mood and affect, inability to
engage in play or make-believe with toys, little
intelligible speech, stereotyped motor behaviors
(hand flapping, body twisting, head banging)
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Autism Spectrum Disorders (cont.)
• Autism (cont.)
– Genetic link; controversy with MMR vaccine
– Tendency to improve; traits persist into adulthood
– Goals: reduce behavioral symptoms, promote learning
and development
– Special education, language therapy; medications for
target symptoms
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Autism Spectrum Disorders (cont.)
• Rett’s disorder:
– Multiple deficits after period of normal functioning;
almost exclusively in girls
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Autism Spectrum Disorders (cont.)
• 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.
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Autism Spectrum Disorders (cont.)
• Asperger’s disorder:
– Similar to autism disorder; no language or cognitive
delays; motor clumsiness is common; occurs more
frequently in boys
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Question
• Which of the following would be considered an autism
spectrum disorder?
– A. Expressive language disorder
–
B. Learning disorder
–
C. Rett’s disorder
–
D. Intellectual disability
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Answer
•
C. Rett’s disorder
• Rationale: Autism spectrum disorders include autism,
Rett’s disorder, childhood disintegrative disorder, and
Asperger’s disorder.
– Expressive language disorder is a type of
communication disorder. Learning disorders and
intellectual disability are separate classifications of
disorders.
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Autism Spectrum–Related Disorders
• Includes:
– Tic disorders
– Learning disorders
– Motor skill disorders
– Communication disorders
– Elimination disorders
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Tic Disorders
• Rapid, sudden, recurrent, nonrhythmic stereotyped
motor movement or vocalization
• Treatment with atypical antipsychotics (olanzapine or
risperidone)
• Tourette’s disorder: multiple motor tics; one or more
vocal tics
• Chronic motor or tic disorder: either motor or vocal tics;
not both
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Learning Disorders
• Achievement in reading, mathematics, written expression
below expected for child’s age, formal education, level of
intelligence
• Interference with academic achievement, life activities,
development of self-esteem, social skills
• Early identification, intervention, coexisting problems
associated with better outcomes
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Motor Skill Disorders
• Developmental coordination disorder
– Marked impairment in coordination severe enough to
interfere with academic achievement or ADLs
– Often coexisting with communication disorder
• Adaptive physical education, sensory integration to foster
normal growth, development
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Communication Disorders
• Communication deficit severe enough to hinder
development, academic achievement, or ADLs, including
socialization
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Communication Disorders (cont.)
• Types
– Expressive language disorder
– Mixed receptive–expressive language disorder
– Phonologic disorder
– Stuttering disorder
• Speech therapy to improve communication skills
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Elimination Disorders
• Encopresis: defecating in or into inappropriate places
(child at least age 4)
– Involuntary encopresis
– Intentional encopresis
• Enuresis: repeated urination during day or night in
clothes or bed after age 5
– Most often involuntary
– Intentional enuresis associated with disruptive
behavior disorder
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Attention Deficit Hyperactivity Disorder
(ADHD)
• Inattentiveness, overactivity, impulsiveness; persistent
pattern of inattention and/or hyperactivity and
impulsivity
• Often diagnosed when child starts school
• Fidgeting, noisy, disruptive, unable to complete tasks,
failure to follow directions, blurting out answers, lost or
forgotten homework
• Possible ostracize/ridicule by peers
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Attention Deficit Hyperactivity Disorder
(ADHD) (cont.)
• Etiology
– Cause unknown: possible cortical-arousal,
information-processing, maturational abnormalities in
the brain
– Other theories: environmental toxins, prenatal
influences, heredity/genetic link, damage to brain
structure and functions
– Risk factors
– Occurrence in various cultures
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Attention Deficit Hyperactivity Disorder
(ADHD) (cont.)
• No one treatment effective
• Goals: managing symptoms, reducing hyperactivity and
impulsivity, increasing child’s attention
• Combination of medications, behavioral, psychosocial,
and educational interventions
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Attention Deficit Hyperactivity Disorder
(ADHD) (cont.)
• Home and school strategies
– Behavioral strategies
– Environmental strategies
– Parental education
• Rewards and consequences, consistent praise,
time-out, verbal reprimands
• Daily report cards, point systems
– Therapeutic play; creative play
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Attention Deficit Hyperactivity Disorder
(ADHD) (cont.)
• Medications (see Table 22.1):
– Stimulants: methylphenidate (Ritalin), amphetamine
compound (Adderall), lisdexamfetamine (Vyvance)
– Antidepressants as second choice
– Nonstimulant (SNRI): atomoxetine
– Antihypertensives: clonidine (Kapvay), guanfacine
(Intuniv)
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Question
• Is the following statement true or false?
• Atomoxetine is a stimulant agent used to treat ADHD.
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Answer
• False
• Rationale: Atomoxetine is not classified as a stimulant. It
is a nonstimulant agent, an antidepressant, and more
specifically a selective norepinephrine reuptake inhibitor.
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ADHD and Nursing Process Application
• Assessment
– History: fussy as infant; “out of control”; difficulties
in all major life areas
– General appearance, motor behavior: inability to sit
still; inability to carry on conversation; abrupt
jumping from topic to topic
– Mood, affect: possibly labile, anxiety, frustration,
agitation
– Thought process, content
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ADHD and Nursing Process Application
(cont.)
• Assessment (cont.)
– Sensorium, intellectual processes: impaired ability to
pay attention or concentrate
– Judgment, insight: poor; no thinking before action
– Self-concept: low self-esteem
– Roles, relationships: academic, social problems
– Physiologic, self-care
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ADHD and Nursing Process Application
(cont.)
• Data analysis/nursing diagnoses
– Risk for injury
– Ineffective role performance
• Outcome identification
– Free of injury
– No violation of boundaries of others
– Demonstrate age-appropriate social skills
– Complete tasks
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ADHD and Nursing Process Application
(cont.)
• Interventions
– Ensuring safety
– Improving role performance
– Simplifying instructions
– Promoting structured daily routine
– Providing patient, family education and support
• Evaluation
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Question
• Which of the following would the nurse most likely assess
in a child with ADHD?
–
A. High self-esteem
–
B. Aggression toward animals
–
C. Impulsiveness
–
D. Limited gestures to communicate
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Answer
•
C. Impulsiveness
• Rationale: A child with ADHD will often exhibit
impulsiveness.
– Self-esteem is not a key indicator of ADHD. Children
with conduct disorder exhibit aggression toward
animals. Children with autism spectrum disorders
exhibit limited gestures.
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Mental Health Promotion
• Parenting classes
• Child anxiety management
• Parent–child intervention emphasizing coping skills
• Early detection of potential problems (SNAP-IV Teacher
and Parent Rating Scale; see Box 22.2)
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Nurse’s Role in Health Promotion
• Early detection and intervention are key in helping
children with autism spectrum disorders reach their full
potential
• Early intervention may include collaborating with:
– School psychologist
– Pediatrician
– Physiotherapist
– Teacher
– Neurologist
– Family
– Speech therapist
– OT
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Question
• Is the following statement true or false?
• A treatment option for ADHD includes educational
interventions.
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Answer
• True
• Rationale: Treatment options for ADHD include
educational interventions to support the child at school in
learning, as well as behavioral and psychosocial
interventions. Medications also play a role.
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Self-Awareness Issues
• Recognize own beliefs about parenting, how they differ
from others.
• Focus on child’s and parents’ strengths, not just
problems.
• Try to have positive impact on child even when disability
is severe.
• Support parents.
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