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What is it?
 Child psychiatric nursing is different from adult psychiatric
nursing in these 3 ways
1. Usually parents bring children, who think that some
aspect of behavior or development is abnormal
2. The child’s stage of development determines whether
behavior is normal or abnormal
3. Children are generally less able to express themselves in
words, therefore evidence of disturbance is based more
on observations of behavior made by parents, teachers
and others
4. Main emphasis of treatment is on changing the attitudes
of parents, reassuring and retraining children, working
with family and coordinating with others
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ICD 10 Classification
 F70-79 Mental retardation
 F70 Mild mental retardation
 F71 Moderate mental retardation
 F72 Severe mental retardation
 F73 Profound mental retardation
 F79 Unspecified mental retardation
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 F80 – F89 Disorders of psychological development
 F80 Specific developmental disorders of speech and
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language
F81 Specific developmental disorders of scholastic skills
F82 Specific developmental disorder of motor function
F83 Mixed specific developmental disorder
F84 Pervasive developmental disorders
F88 Other disorders of psychological development
F89 unspecified disorder of psychological development
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 F90 – 98 Behavioral and emotional disorders with
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onset usually occurring in childhood and adolescence
F90 Hyperkinetic disorder
F91 Conduct disorders
F92 Mixed disorders of conduct and emotions
F93 Emotional disorders with onset specific to childhood
F94 Disorders of social functioning with onset specific to
childhood and adolescence
F95 Tic disorders
F98 Other behavioral and emotional disorders with onset
usually occurring in childhood and adolescence
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Mental Retardation (mental subnormality)
 MR is a generalized disorder, characterized by
significantly impaired cognitive functioning and
deficits in two or more adaptive behaviors with onset
before the age of 18
 It is the state of developmental deficit, beginning in
childhood those results in significant limitation of
intellect or cognition and poor adaptation to the
demands of everyday life
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Definition
 DSM IV- TR defines mental retardation as
significantly sub average intellectual functioning – An
intelligence quotient of approximately 70 or below.
Concurrent deficits or impairments in adaptive
functioning in at least 2 of the following areas:
Communication, self care, home living, social/
interpretational skills, use of community resources,
self direction, functional academic skills, work, leisure,
health and safety
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 Mental retardation refers to significantly sub average
general intellectual functioning resulting in or
associated with concurrent impairments in adaptive
behavior and manifested during the developmental
period – American Association on Mental Deficiency, 1983.
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Epidemiology
 Approximately 3% of population is affected
 In India 5/1000 children are MR
 40 – 70% has diagnosable psychiatric diseases
 It is common in boys than girls
 Mortality is due to associated physical diseases
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Etiology
1. Infections
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Congenital CMV
Congenital rubella
Congenital toxoplasmosis
Encephalitis
HIV infection
Listeriosis
Meningitis
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2. Chromosomal abnormalities
 Chromosome deletions
 Chromosomal translocations
 Chromosomal inheritance
 Errors in chromosome numbers
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3. Prenatal factors
 Disturbances in the embryonic development
 Infections during pregnancy
 Drug abuse or alcoholism of mothers
4. Perinatal factors
 Premature birth
 LBW
 Fetal oxygen deprivation
 Stress on the fetus during birth
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5. Postnatal causes
 Environmental toxins
 Exposure to childhood disease
 Infections (whooping cough, measles, rubella, mumps.
Meningitis)
 Any injury to brain
 Lead poisoning
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6. Genetic abnormalities and inherited metabolic
disorders
 Adrenoleukodystrophy
 Galactosemia
 Hunter syndrome
 Lesch – Nyhan syndrome
 Phenylketonuria
 Rett syndrome
 Tuberous sclerosis
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7. Trauma
 Intracranial hemorrhage before or after birth
 Fetal hypoxia
 Severe head injury
8. Other factors
 Poor environmental condition
 Malnutrition
 Lead poisoning
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Type
IQ
Mild (Educable)
50-70
Moderate (Trainable)
35-50
Severe (Dependent retarded)
20-35
Profound (life support)
<20
Normal IQ - 70-90
Genius - >110
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Behavioral manifestations
1. Mild MR
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Commonest form of MR (85 % among all MR)
Poor academic performance
When they reach adulthood, many patients learn to
live independently and maintain gainful
employment
Educable up to primary school level
They can learn and use social skills in structured
settings
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2. Moderate MR
 They account 10% of MR
 They require considerable support in school, at home
and in community
 As adults, they may live with parents, in supportive
group home
 Educable up to 2nd class
 Have certain speech limitations
 Have difficulty following expected social norms
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3. Severe MR
 They account 3-4% of MR
 Development is greatly slowed in pre school years
 Many of them can be helped to look after themselves under
close supervision
 As adults, they can undertake simple tasks and engage in
limited social activities
 They need supervision and clear structure to their lives
 Poor motor skills, delayed speech and communication
skills
 Have limited verbal skills
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4. Profound MR
 They account for 1-2% of MR
 Developmental milestones are delayed
 They require constant nursing care, support and
supervision even in simple ADL
 Academic training may be impossible
 Have little speech development and lack social skills
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Signs and symptoms
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Failure to achieve developmental milestones
Deficiency in cognitive functioning
Inability to follow commands
Poor learning skills in academics
Expressive or receptive language problems
Psychomotor skill deficits
Neurologic impairments
Difficulty in doing ADL
Irritability when frustrated or upset
Acting out behavior
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Assessment and diagnosis
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Comprehensive history
Patient interview
Mental status
Medical review
Neurological examination
Assessment of developmental milestones
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Lab investigations
 Urinalysis and blood studies for metabolic disorders
 Culture for cytogenic and biochemical studies
 Brain MRI, head CT
 Chorionic villi sampling
 Thyroid function test
 Psychological tests like ( stanford binet intelligent
scale, Wechsler Intelligence Scale for Children –WISC,
Vineland Adaptive Behavior Scales
 IQ test (MA/CA×100)
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Treatment
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Behavioral management
Environmental supervision
Monitor child’s developmental needs and problems
Speech therapy
Occupational therapy
Ongoing evaluation for concurrent psychiatric
disorders and ADHD
 Family therapy
 Special schools
 Vocational training
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Prevention
1. Primary prevention
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Genetic counseling
Immunizations
Family planning
Adequate nutrition for mother
Avoidance of teratogenic substances
Amniocentesis
Fetoscopy . Fetal biopsy, ultrasound
Avoidance of birth injury
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2. Secondary prevention
 Early detection and treatment of preventable disorders
(PKU, myxedema)
 Early recognition of presence of MR
 Psychiatric treatment for emotional and behavioral
difficulties
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3. Tertiary prevention
 Vocational rehabilitation
 Physical and social rehabilitation
 Reduction of disability
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Care and rehabilitation
 Main aims and objectives of rehabilitation
Prevention and early detection of mental handicaps
2. To increase awareness of the community and to
sensitize it to issue and bring about positive
attitudinal change
3. To facilitate bringing patients and their families into
the main stream
4. To mobilize community resources and enhance
community participation in building the required
services
1.
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5. To establish accessible, available and affordable services for
majority of people within the community itself.
6. To ensure these people and their families have a say in how
the services are run
7. To have psychiatric and psychological services for mentally
retarded child
8. To have regular assessment for mentally retarded children
9. To promote ownership of the programmes by the
community itself so that they continue even without
external support
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Services include
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Medical and psychological services
Parental counseling
Early detection and early stimulation
Training in self help, social and practical skills
Speech therapy
Education
Vocational training
Residential care
Individual and family approaches
Community based approaches
Home based approaches
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Successful skill training includes
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Divide training activity into small steps
Give repeated training in each activity
Give training regularly and systematically
Start giving training from what child already knows
Reward the child with appreciation
Reduce reward as he masters the skill
Use training materials appropriate, and attractive
Train with oriented normal children, for better learning
Assess child periodically
Understand and make parents understand the MR child
learn slowly.
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Nursing diagnosis
1. Altered growth and development related to
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impaired functioning
Assess child’s G&D at regular interval
Involve family members in early infant stimulation
programme
Help family to set realistic goals for child
Encourage learning of self care activities to the child
Counsel the child, parents about maturational
process
Encourage optimum vocational training
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2. Altered social interaction related to impaired
cognitive functioning
 Assess child’s social interaction pattern
 Encourage family to teach the child socially acceptable
behavior
 Encourage grooming and age appropriate dress to
encourage acceptance by others
 Emphasize that the child has same need for
socialization as other children
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3. Self care deficit related to cognitive impairment
 Assist patient in accepting necessary amount of
dependence
 Set short range goals with patient
 Encourage independence activities with supervision
 Provide positive reinforcement
 Provide privacy during dressing, bathing etc..
 Plan daily activities
 Offer frequent encouragement
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4. Altered family process related to having a child with
MR
 Assess process of family with a child of MR
 Inform the family as soon as possible after birth to both
the parents
 Provide adequate information to the family about MR and
its care
 Discuss with family about pros and cons of home care of
child with MR
 Demonstrate acceptance of child through own behavior
 Encourage family to express feelings and concerns
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5. Impaired communication related to cognitive
impairment
 Assess level of communication and social skills
 Establish free and open communication with patient
and family members
 Involve the client to interact with other members
 Provide calm, quiet and non threatening environment
 Allow client to express emotions slowly and freely
 Provide safety and security to child
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