Title: REIMBURSEMENT ISSUES
1 Chapter 32 Care of the Child with a Mental or
Cognitive Disorder
2Disorders 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
3Disorders 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
4Disorders 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
5Figure 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.
6Disorders 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.
7Disorders 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
8Disorders 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.
9Disorders 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.
10Disorders 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.
11Disorders 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
12Disorders 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
13Disorders 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.
14Disorders 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
15Disorders 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.
16Disorders 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.
17Disorders 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.
18Child 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
19Child 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
20Child 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
21Child 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
22Child 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.
23Child 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
24Child 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).
25Child 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.
26Child 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.
27School 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.
28School 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
29School 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.
30School 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.
31Learning 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.
32Learning 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
33Learning 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
34Learning 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.
35Attention 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
36Attention 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
37Attention 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
38Attention 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
39Attention 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.
40Other 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.
41Other 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.
42Other 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
43Other Disorders
- Depression (continued)
- Diagnostic Tests
- Structured questionnaires or interviews
- Childrens Depression Scale
- Depression Self-Rating Scale
- Medical Management
- Antidepressant medications
- Psychologic therapies
44Other 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.
45Other 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.
46Other 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
47Other Disorders
- Suicide (continued)
- Diagnostic Tests
- Structured questionnaires or interviews
- Childrens Depression Scale
- Depression Self-Rating Scale
- Medical Management
- Individual, family, and group therapy
48Other 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.
49Other 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.
50Other 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
51Other 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.
52Other Disorders
- Psychogenic Abdominal Pain (Recurrent Abdominal
Pain) (continued) - Clinical Manifestations
- Usually afebrile
- May have occasional vomiting and constipation
- Abdominal pain usually nonspecific
53Other 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.
54Other 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.