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REIMBURSEMENT ISSUES

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Title: REIMBURSEMENT ISSUES


1

Chapter 32 Care of the Child with a Mental or
Cognitive Disorder
2
Disorders of Cognitive Function
  • Cognitive Impairment
  • Formerly referred to as mental retardation
  • The most common developmental disability,
    affecting up to 3 of the population
  • Defined as significantly subaverage general
    intellectual functioning existing concurrently
    with deficits in adaptive behavior and manifested
    during the developmental period

3
Disorders of Cognitive Function
  • Cognitive Impairment (continued)
  • Four Categories
  • Mild IQ of 50 or 55 to 70
  • Moderate IQ of 35 or 40 to 50 or 55
  • Severe IQ of 20 or 25 to 35 or 40
  • Profound IQ below 20 to 25

4
Disorders of Cognitive Function
  • Cognitive Impairment (continued)
  • Etiology/Pathophysiology
  • Down syndrome
  • Perinatal Infections
  • Cytomegalovirus, rubella, syphilis
  • Perinatal anoxia
  • Maternal drug or alcohol abuse
  • Metabolic disorders
  • Phenylketonuria, lead poisoning, hypothyroidism,
    and prematurity

5
Figure 32-1
(From Hockenberry-Eaton, M.J., Wilson, D.,
Winkelstein, M.L., Kline, M.D. 2003. Wongs
nursing care of infants and children. 7th ed..
St. Louis Mosby.)
Down syndrome in infant.
6
Disorders of Cognitive Function
  • Cognitive Impairment (continued)
  • Clinical Manifestations
  • They vary according to the childs age and degree
    of impairment.
  • Children may fail to achieve developmental
    milestones at appropriate ages.
  • In general, children may manifest delays in
    motor, social, cognitive, and language skills.

7
Disorders of Cognitive Function
  • Cognitive Impairment (continued)
  • Diagnostic Tests
  • Neurologic examination
  • CT scan
  • Serum metabolic screening
  • Developmental screening tests (Denver II)
  • Standardized intellectual tests
  • Chromosomal analysis
  • Genetic screening

8
Disorders of Cognitive Function
  • Cognitive Impairment (continued)
  • Nursing Interventions
  • Interventions focused on promoting optimal
    development and providing the family with
    support, education, and referrals.
  • Parents should be encouraged to enroll the child
    in an early intervention program.
  • Each task that is taught should be broken into
    small, specific steps.
  • Parents should be encouraged to emphasize the
    normal needs of all children love, social
    interaction, and play.

9
Disorders of Cognitive Function
  • Cognitive Impairment (continued)
  • Patient/Family Teaching
  • It is essential to provide parents with
    information on normal developmental milestones,
    stimulation techniques, safety, normal speech
    development, sexual development, and the role of
    positive self-esteem in motivating children to
    accomplish goals within their limitations.
  • Prognosis
  • Cognitive impairment is a chronic condition.

10
Disorders of Cognitive Function
  • Down Syndrome
  • Etiology/Pathophysiology
  • An extra chromosome on the twenty-first pair,
    trisomy 2.
  • The risk of having a child with Down syndrome
    increases with aging maternal age, especially for
    women over 35 years of age.

11
Disorders of Cognitive Function
  • Down Syndrome (continued)
  • Clinical Manifestations
  • Small, rounded skull with a flat occiput
  • Upward-slanting eyes
  • Broad, flat nose low-set ears
  • Protruding tongue
  • Short, thick neck
  • Hypotonic extremities
  • Mottled skin
  • Simian crease on the palmar side of the hand
  • Intellectual impairment

12
Disorders of Cognitive Function
  • Down Syndrome (continued)
  • Diagnostic Tests
  • Chromosomal analysis
  • Medical Management
  • Routine medical care
  • Corrective surgery for heart defects
  • Auditory and vision screening
  • Thyroid function tests

13
Disorders of Cognitive Function
  • Down Syndrome (continued)
  • Nursing Interventions
  • Primary nursing goals include supporting the
    family at the time of diagnosis and referring the
    child and family to agencies that provide support
    and services.
  • Prognosis
  • Life expectancy has improved in recent years but
    remains lower than that for the general
    population.
  • Over 80 survive to age 30 years and beyond.

14
Disorders of Cognitive Function
  • Autism
  • Etiology/Pathophysiology
  • Complex developmental disorder of brain function
    accompanied by a broad range and severity of
    intellectual and behavioral deficits.
  • Multiple biologic causes
  • Strong evidence for a genetic basis

15
Disorders of Cognitive Function
  • Autism (continued)
  • Clinical Manifestations and Diagnostic Tests
  • There is inability to maintain eye contact.
  • Body contact is avoided at a very early age.
  • Child has limited functional play and may
    interact with toys in an unusual manner.
  • Constipation is common.
  • There are deficits in social development.
  • A majority have some degree of mental
    retardation but some may excel in particular
    areas, such as art, music, memory, or mathematics.

16
Disorders of Cognitive Function
  • Autism (continued)
  • Nursing Interventions
  • Therapeutic intervention is a specialized are
    involving professionals with advanced training.
  • During hospitalization
  • Parents are essential to planning care.
  • Decrease stimulation.
  • Minimize holding and eye contact.
  • Care must be taken when performing procedures.
  • Introduce new situations slowly.

17
Disorders of Cognitive Function
  • Autism (continued)
  • Prognosis
  • This is usually a severely disabling condition.
  • Some children improve with acquisition of
    language skills and communication.
  • Some ultimately achieve independence, but most
    require lifelong adult supervision.
  • Prognosis is most favorable for children with
    communicative speech development by age 6 years
    and an IQ above 50 at the time of diagnosis.

18
Child Maltreatment
  • Child Neglect
  • Physical
  • Failure of a parent or caretaker to supply a
    child with adequate food, clothing, shelter,
    education, or health care although financially
    able to do so or offered financial or other means
    to do so
  • Emotional
  • Failure by a parent or caretaker to meet a
    childs needs for emotional nurturance,
    affection, and attention

19
Child Maltreatment
  • Child Abuse
  • Physical
  • The intentional, nonaccidental infliction of
    physical injury upon a child by a parent or
    guardian
  • Emotional
  • The intentional attempt by a parent or caretaker
    to impair or destroy the mental or emotional
    state of a child

20
Child Maltreatment
  • Child Abuse (continued)
  • Sexual
  • Commission of a sexual offense by an older person
    against a child who is dependent or
    developmentally immature for the purpose of the
    perpetrators own sexual stimulation or
    gratification

21
Child Maltreatment
  • Etiology
  • Parental Factors
  • Parents culture
  • Socialization history and history of having been
    an abused child
  • Parents age and developmental level
  • Attitudes toward the child and child rearing
  • Knowledge of normal child behavior and
    development
  • Parents psychologic state

22
Child Maltreatment
  • Etiology (continued)
  • Childs Factors
  • Temperament
  • Age
  • Exceptional physical needs
  • Disabilities
  • Health or behavior problems
  • These factors may increase the potential for
    maltreatment by a parent or caretaker.

23
Child Maltreatment
  • Etiology (continued)
  • Situational Factors
  • Marital problems
  • Financial difficulties
  • Drug and/or alcohol abuse
  • Lack of social support or the inability of the
    parent or caretaker to ask for support
  • Poor social network
  • Poor relationships with extended families

24
Child Maltreatment
  • Clinical Manifestations
  • Children who have been abused or neglected may
    manifest certain physical and/or behavioral
    indicators that suggest maltreatment (See Table
    3-1 in the text).

25
Child Maltreatment
  • Nursing Interventions
  • Identify a child who is being maltreated.
  • The nurse often is the first person to see the
    child and parent.
  • The presence of a behavioral or physical
    indicator of maltreatment should serve to prompt
    further investigation.
  • Special attention should be paid to injuries that
    are unexplained or inconsistent with the parents
    or caretakers explanation of how the injury
    occurred.

26
Child Maltreatment
  • Nursing Interventions (continued)
  • All states have regulations for the mandatory
    reporting of child maltreatment when a health
    professional has reason to suspect that a child
    has been abused or neglected.
  • During the prenatal period, families at risk for
    abuse can be identified and referred for
    intervention.
  • Reinforcement of positive caretaking behaviors is
    an effective way of affirming positive parenting
    practices.

27
School Avoidance (School Phobia, School Refusal)
  • Occurs when a physically healthy child repeatedly
    stays home from school or is sent home from
    school for physical symptoms of an emotional
    origin.
  • Etiology/Pathophysiology
  • Cause may be related to anxiety or worry about
    academic progress, peer conflicts, or marital
    discord in the home.
  • Separation anxiety is also common among these
    children even after the age when this should be
    mastered (3 to 4 years).
  • Parents may be too lenient, place little value on
    education, or be unconcerned about the
    ramifications of missing school.

28
School Avoidance (School Phobia, School Refusal)
  • Clinical Manifestations
  • Children who are of the anxious type tend to have
    physiologic symptoms of anxiety, including
  • Headache
  • Recurrent abdominal pain
  • Vomiting, diarrhea
  • Insomnia
  • Pallor
  • Palpitations
  • Hyperventilation

29
School Avoidance (School Phobia, School Refusal)
  • Clinical Manifestations (continued)
  • May Exaggerate or Fabricate Symptoms
  • Sore throat
  • Leg pain
  • Coughing tics
  • Chest pain
  • Fatigue
  • No organic cause can be found.
  • The child usually sounds very sick but appears to
    be well.

30
School Avoidance (School Phobia, School Refusal)
  • Medical Management/Nursing Interventions
  • Assist in convincing parents that their child is
    healthy explain the diagnosis.
  • Assist in returning the child to regular school
    attendance.
  • Assure parents that this occurs in normal
    children and is stress-related and not a
    psychiatric disorder.
  • Encourage parents to be firm if the child refuses
    to go to school reassure child that there is
    nothing physically wrong with him or her.

31
Learning Disabilities
  • Etiology/Pathophysiology
  • Cause is multifactorial often a specific cause
    cannot be identified.
  • It may be the result of various physiologic
    and/or environmental factors such as intrauterine
    exposure to drugs or infection, birth trauma,
    lead poisoning, seizures, malnutrition, and
    exposure to toxic substances, such as alcohol and
    lead.
  • Hearing or vision impairments may lead to
    learning problems.
  • Genetic syndromes such as fragile X syndrome or
    Prader-Willi syndrome may be associated.

32
Learning Disabilities
  • Clinical Manifestations
  • Problems with speech, behavior, and/or motor
    coordination
  • Failure to master basic, grade-appropriate
    academic skills in one or more subject areas
  • A progressive decline in school performance
  • Delayed acquisition of language milestones,
    deficient social skills, avoidance behavior, low
    frustration tolerance, disorganization, and
    somnolence

33
Learning Disabilities
  • Diagnostic Tests
  • Thorough history and physical examination may
    provide specific indications to obtain
  • Lead level
  • EEG
  • Chromosomal studies
  • Hearing and vision screenings
  • Intelligence and achievement testing
  • Neuropsychological testing

34
Learning Disabilities
  • Medial Management/Nursing Interventions
  • Provide educational referrals.
  • Educate parents about the special education
    process.
  • Therapeutic manipulation of the educational
    setting suggest special arrangements in a
    regular classroom alternative classroom
    placement, tutoring, and remediation assistance.
  • Prognosis
  • With early identification, appropriate referrals,
    and proper educational interventions, the
    negative consequences of school failure may be
    avoided child can usually function optimally
    within his or her limitations.

35
Attention Deficit Hyperactivity Disorder
  • Etiology/Pathophysiology
  • Multifactorial
  • Incidence in first-degree relatives of 25.
  • Theories of altered neurotransmitter profiles
  • Possible environmental factors low socioeconomic
    status and parental psychopathology

36
Attention Deficit Hyperactivity Disorder
  • Clinical Manifestations
  • May exhibit
  • Decreased attention span
  • Impulsivity
  • Failure to follow instructions
  • Hyperactivity fidgeting
  • Poor self-regulation
  • Noncompliance
  • Aggression
  • Immaturity during play
  • Failure to follow rules of play games

37
Attention Deficit Hyperactivity Disorder
  • Clinical Manifestations (continued)
  • May exhibit
  • Lack of turn-taking during play
  • Easy distraction by extraneous stimuli
  • Poor school performance learning disabilities
  • Antisocial behaviors lying, cheating, stealing
  • Excessive anxiety
  • Sleep disturbances
  • Poor peer relationships
  • Limited fine motor skills
  • Additional psychiatric diagnosis

38
Attention Deficit Hyperactivity Disorder
  • Diagnostic Tests
  • Report of characteristic behaviors made by
    multiple observers, over an extended period of
    time, and in various settings
  • Many rating scales available to assess ADHD

39
Attention Deficit Hyperactivity Disorder
  • Medical Management
  • Behavioral counseling
  • Educational intervention
  • Pharmacotherapy
  • Nursing Interventions
  • Provide counseling.
  • Educate parents on discipline and setting limits.
  • Explain need for increased supervision.
  • Assist in the development of the educational plan
    where appropriate.
  • Explain reasons for medications and risks.

40
Other Disorders
  • Anorexia and Bulimia
  • Eating disorders with significant underlying
    psychologic and emotional issues
  • Primarily affect adolescents, but younger
    children may be affected
  • Substance Abuse
  • Substance abuse usually points to significant
    problems in the child, family, or both,
    warranting professional counseling.
  • In the adolescent, the incentives are usually
    experimental and recreational.

41
Other Disorders
  • Depression
  • Depression is generally defined as a mood
    disturbance with overall feelings of sadness,
    despair, worthlessness, or hopelessness.
  • Girls are more likely than boys to suffer from
    depression.
  • Etiology/Pathophysiology
  • Causes have not been established.
  • Risk factors can be genetic or environmental.
  • Cognitive theories attribute to depression to
    actual loss or perceived loss.

42
Other Disorders
  • Depression (continued)
  • Clinical Manifestations
  • Infancy crying, panic, followed by apathy, blank
    staring, and sad facial expressions
  • School-aged sad facial expressions,
    irritability, crying easily, accident-prone,
    social withdrawal, and eating and sleeping
    disturbances
  • Adolescents impulsiveness, somatization
    disorders, eating disorders, drug/alcohol use,
    antisocial behavior, withdrawal, fatigue, and
    suicidal ideation

43
Other Disorders
  • Depression (continued)
  • Diagnostic Tests
  • Structured questionnaires or interviews
  • Childrens Depression Scale
  • Depression Self-Rating Scale
  • Medical Management
  • Antidepressant medications
  • Psychologic therapies

44
Other Disorders
  • Depression (continued)
  • Nursing Interventions
  • Establish a trusting relationship with the child.
  • Provide support to the childs family, using open
    and honest communication
  • Patient/Family Teaching
  • Review the treatment plan with the family to help
    them realize recovery may be a lengthy process.

45
Other Disorders
  • Depression (continued)
  • Prognosis
  • For the child and family motivated to develop
    better supports and relationship skills, the
    prognosis is good, but episodes may recur.

46
Other Disorders
  • Suicide
  • Etiology/Pathophysiology
  • Suicide is not caused by a single factor but is
    the culmination of multiple factors.
  • Depression
  • Loss of a loved one or relationship
  • Social isolation
  • Lack of attaining a sense of identity, leading to
    self-doubt and low self-esteem

47
Other Disorders
  • Suicide (continued)
  • Diagnostic Tests
  • Structured questionnaires or interviews
  • Childrens Depression Scale
  • Depression Self-Rating Scale
  • Medical Management
  • Individual, family, and group therapy

48
Other Disorders
  • Suicide (continued)
  • Nursing Interventions
  • Mental health assessments of children and
    adolescents should be part of every health visit.
  • If concerns exist, be direct in asking questions
    about thoughts of death or suicide.
  • Any threat of suicide needs to be taken very
    seriously and immediately evaluated by a mental
    health professional.
  • Help the child develop positive coping strategies
    in stressful situations.

49
Other Disorders
  • Suicide (continued)
  • Prognosis
  • Prognoses vary.
  • The greatest risk lies in children who verbalize
    suicidal thoughts and those who attempt suicide.
  • Appropriate mental health care can help these
    children to alleviate depression and develop a
    more positive self-image.

50
Other Disorders
  • Suicide (continued)
  • Clinical Manifestations
  • Many completed suicides are the final result of
    previous attempts.
  • Warning signs include
  • Depression withdrawal loneliness
  • Preoccupation with death
  • Perceived or actual social isolation
  • Poor school performance
  • Drug and/or alcohol abuse
  • Appetite and sleep disorders

51
Other Disorders
  • Psychogenic Abdominal Pain (Recurrent Abdominal
    Pain)
  • Etiology/Pathophysiology
  • Psychogenic pain is often related to emotional
    factors in the child/or family members poor
    self-esteem, anxiety, depression, school phobia,
    maternal depression, marital problems/divorce, or
    other health problems in family members.
  • Organic causes should be considered until proved
    otherwise infections of the urinary tract, GI
    tract, and reproductive tract.

52
Other Disorders
  • Psychogenic Abdominal Pain (Recurrent Abdominal
    Pain) (continued)
  • Clinical Manifestations
  • Usually afebrile
  • May have occasional vomiting and constipation
  • Abdominal pain usually nonspecific

53
Other Disorders
  • Psychogenic Abdominal Pain (Recurrent Abdominal
    Pain) (continued)
  • Diagnostic Tests
  • Organic causes must be ruled out.
  • CBC, sedimentation rate, urinalysis and culture,
    serum albumin and amylase, stool for occult
    blood, and culture for bacteria and parasites
  • In adolescent females, a pregnancy test may be
    considered.

54
Other Disorders
  • Psychogenic Abdominal Pain (Recurrent Abdominal
    Pain) (continued)
  • Medical Management
  • Once organic causes have been ruled out,
    stressors in the childs life need to be
    identified and addressed.
  • Consult with a mental health professional.
  • Nursing Interventions
  • Encourage parents to maintain a normal schedule
    for their child with regard to school, play, and
    exercise.
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