INTRODUCTION:

Childhood behavioral disorders include Attention Deficit Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder (ODD), and Conduct Disorder (CD). Although these disorders are characterized in to externalizing disorders/ disruptive behavior disorders, they have different psychopathology involved; hence the Nursing management can also be discussed under these headings. Nurses play a vital role in the management of Childhood Behavioral Disorders. The nursing management of Childhood Behavioral Disorders shall be discussed well through the application nursing process approach.

APPLICATION OF THE NURSING PROCESS IN CHILDHOOD BEHAVIORAL DISORDERS: Attention Deficit Hyperactive Disorders (ADHD)

Attention Deficit Hyperactive Disorders (ADHD) is a chronic condition marked by persistent inattention, hyperactivity, and sometimes impulsivity.

ADHD begins in childhood and often lasts into adulthood. About 30% to 50% of children with ADHD continue to have symptoms as adults.

ASSESSMENT:

During assessment, the nurse gathers information from the child’s parents, day care providers (if any), and teachers as well as through direct observation. Assessing the child in a group of peers is likely to yield useful information because the child’s behavior may be subdued or different in a focused one-to-one interaction with the nurse. It is often helpful to use a checklist when talking with parents to help focus their input on the target symptoms or behaviors their child exhibits.

History:

Parents may report that the child was fussy and had problems as an infant or they may not have noticed the hyperactive behavior until the child was a toddler or entered day care or school. The child probably has difficulties in all major life areas, such as school or play, and displays overactive or even dangerous behavior at home. Often parents say the child is “out of control,” and they feel unable to deal with the behavior. Parents may report many largely unsuccessful attempts to discipline the child or to change the behavior.

General Appearance and Motor Behavior:

The child cannot sit still in a chair and squirms and wiggles while trying to do so. He or she may dart around the room with little or no apparent purpose. Speech is unimpaired, but the child cannot carry on a conversation: he or she interrupts, blurts out answers before the question is finished, and fails to pay attention to what has been said. Conversation topics may jump abruptly. The child may appear immature or lag behind in developmental milestones.

Mood and Affect:

Mood may be labile, even to the point of verbal outbursts or temper tantrums. Anxiety, frustration, and agitation are common. The child appears to be driven to keep moving or talking and appears to have little control over movement or speech. Attempts to focus the child’s attention or redirect the child to a topic may evoke resistance and anger.

Thought Process and Content:

There are generally no impairments in this area, although assessment can be difficult depending on the child’s activity level and age or developmental stage.

Sensorium and Intellectual Processes:

The child is alert and oriented with no sensory or perceptual alterations such as hallucinations. Ability to pay attention or to concentrate is markedly impaired. The child’s attention span may be as little as 2 or 3 seconds with severe ADHD or 2 or 3 minutes in milder forms of the disorder. Assessing the child’s memory may be difficult; he or she frequently answers, “I don’t know” because he or she cannot pay attention to the question or stop the mind from racing. The child with ADHD is very distractible and rarely able to complete tasks.

Judgment and Insight:

Children with ADHD usually exhibit poor judgment and often do not think before acting. They may fail to perceive harm or danger and engage in impulsive acts such as running into the street or jumping off high objects. Although assessing judgment and insight in young children is difficult, children with ADHD display more lack of judgment when compared with those of the same age. Most young children with ADHD are totally unaware that their behavior is different from that of others and cannot perceive how it harms others. Older children might report, “No one at school likes me,” but they cannot relate the lack of friends to their own behavior.

Self-Concept:

Again, this may be difficult to assess in a very young child, but generally the self-esteem of children with ADHD is low. Because they are not successful at school, may not develop many friends, and have trouble getting along at home, they generally feel out of place and bad about themselves. The negative reactions their behavior evokes from others often cause them to see themselves as bad or stupid.

Roles and Relationships:

The child is usually unsuccessful academically and socially at school. He or she frequently is disruptive and intrusive at home, which causes friction with siblings and parents. Until the child is diagnosed and treated, parents often believe that the child is willful, stubborn, and purposefully misbehaves. Generally measures to discipline have limited success; in some cases, the child becomes physically out of control, even hitting parents or destroying family possessions. Parents find themselves chronically exhausted mentally and physically. Teachers often feel the same frustration as parents, and day care providers or babysitters may refuse to care for the child with ADHD, which adds to the child’s rejection.

Physiologic and Self-Care Considerations:

Children with ADHD may be thin if they do not take time to eat properly or cannot sit through meals. Trouble settling down and difficulty sleeping are problems as well. If the child engages in reckless or risk-taking behaviors, there also may be a history of physical injuries.

Data Analysis and Planning:

Nursing diagnoses commonly used when working with children with ADHD include the following:

• Risk for Injury

• Ineffective Role Performance

• Impaired Social Interaction

• Compromised Family Coping

OUTCOME IDENTIFICATION:

Treatment outcomes for clients with ADHD may include the following:

• The client will be free of injury.

• The client will not violate the boundaries of others.

• The client will demonstrate age-appropriate social skills.

• The client will complete tasks.

• The client will follow directions.

INTERVENTION

Interventions described in this section can be adapted to various settings and used by nurses and other health professionals, teachers, and parents or caregivers.

Interventions for ADHD:

• Ensuring the child’s safety and that of others Stop unsafe behavior.

• Provide close supervision.

• Give clear directions about acceptable and unacceptable behavior.

• Improved role performance

• Give positive feedback for meeting expectations.

• Manage the environment (e.g., provide a quiet place free of distractions for task completion).

• Simplifying instructions/directions

• Get child’s full attention.

• Break complex tasks into small steps.

• Allow breaks.

• Structured daily routine

• Establish a daily schedule.

• Minimize changes.

• Client/family education and support

• Listen to parent’s feelings and frustrations.

Ø Improving role performance

Ø Simplifying instructions

Ø Promoting a structured daily routine

Ø Providing client and family education and support

CLIENT/FAMILY TEACHING FOR ADHD:

• Include parents in planning and providing care.

• Refer parents to support groups.

• Focus on child’s strengths as well as problems.

• Teach accurate administration of medication and possible side effects.

• Inform parents that child is eligible for special school services. they may have missed much basic learning for reading and math.

• Parents should know that it will take time for them to catch up to other children of the same age.

NURSING CARE PLAN: ATTENTION-DEFICIT HYPERACTIVITY DISORDER

Nursing Diagnosis: Impaired Social Interaction, Insufficient or excessive quantity or ineffective quality of social exchange.

ASSESSMENT DATA

EXPECTED OUTCOMES

•High level of distractibility

• Labile moods

• Low frustration tolerance
• Inability to complete tasks
• Inability to sit still or fidgeting
• Excessive talking
• Inability to follow directions

Immediate The client will:

• Successfully complete tasks or assignments with assistance

• Demonstrate acceptable social skills while interacting with staff or family member Stabilization The client will:

• Participate successfully in the educational setting

• Demonstrate the ability to complete tasks with reminders

• Demonstrate successful interactions with family members Community The client will:

• Verbalize positive statements about himself or herself

• Complete tasks independently

IMPLEMENTATION
Nursing Interventions *denotes collaborative interventions	Rationale
Identify the factors that aggravate and alleviate the client’s performance	The external stimuli that exacerbate the client’s problems can be identified and minimized. Likewise, any that positively influence the client can be effectively used.
Provide an environment as free from distractions as possible. Institute interventions on a One-to-one basis. Gradually increase the amount of environmental stimuli.	The client’s ability to deal with external stimulation is impaired.
Engage the client’s attention before giving instructions (i.e., call the client’s name and establish eye contact).	The client must hear instructions as a first step toward compliance.
Give instructions slowly, using simple language and concrete directions.	The client’s ability to comprehend instructions (especially if they are complex or abstract) is impaired. Repetition demonstrates
Ask the client to repeat instructions before beginning tasks.	Repetition demonstrates that the client has accurately received the information.
Separate complex tasks into small steps.	The likelihood of success is enhanced with less complicated components of a task.
Provide positive feedback for completion of each step.	The client’s opportunity for successful experiences is increased by treating each step as an opportunity for success.
Allow breaks during which the client can move around.	The client’s restless energy can be given an acceptable outlet, so that he or she can attend to future tasks more effectively. outlet, so that he or she can
Clearly state expectations for task completion.	The client must understand the request before he or she can attempt task completion.
Clearly state expectations for task completion.	The client must understand the request before he or she can attempt task completion.
Initially assist the client to complete tasks.	If the client is unable to complete a task independently, having assistance will allow success and will demonstrate how to complete the task.
Progress to prompting or reminding the client to perform tasks or assignments	The amount of intervention gradually is decreased to increase client independence as the client’s abilities increase. to increase client independence as the client’s abilities increase.
Give the client positive feedback for performing behaviors that come close to task achievement	This approach, called shaping, is a behavioral procedure in which successive approximations of a desired behavior are positively reinforced. It allows rewards to occur as the client gradually masters the actual expectation.
Gradually decrease reminders.	Client independence is promoted as staff participation is decreased.
Assist the client to verbalize by asking sequencing questions to keep on the topic (“Then what happens?” and “What happens next?”).	Sequencing questions provide a structure for discussions to increase logical thought and decrease tangentiality.
*Teach the client’s family or caregivers to use the same procedures for the client’s tasks and interactions at home.	Successful interventions can be instituted by the client’s family or caregivers by using this process. This will promote consistency and enhance the client’s chances for success.
*Explain and demonstrate “positive parenting” techniques to family or caregivers such as time-in for good behavior; i.e., being vigilant in identifying the child’s first bid for attention and responding positively to that behavior; special time, i.e., guaranteed time a parent or surrogate spends daily with the child with no interruptions and no discussion of problem-related topics; ignoring minor transgressions by immediate withdrawal of eye contact or physical contact and cessation of discussion with the child to avoid secondary gains	It is important for parents or caregivers to engage in techniques that will maintain their loving relationship with the child while promoting or at least not interfering with therapeutic goals. Children need to have a sense of being lovable to their significant others that is not crucial to the nurse–client therapeutic relationship.

Evaluation:

Parents and teachers are likely to notice positive outcomes of treatment before the child does. Medications are often effective in decreasing hyperactivity and impulsivity and improving attention relatively quickly, if the child responds to them. Improved sociability, peer relationships, and academic achievement happen more slowly and gradually but are possible with effective treatment.

APPLICATION OF THE NURSING PROCESS: OPPOSITIONAL DEFIANT/ CONDUCT DISORDER

Oppositional defiant disorder (ODD) is defined by the DSM-5 as a pattern of angry/irritable behavior, or vindictiveness lasting at least 6 months, and is exhibited during interaction with at least one individual that is not a sibling.

Conduct disorder (CD) is a psychological disorder diagnosed in childhood or adolescence that presents itself through a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate norms are violated.

ASSESSMENT:

History:

Children with oppositional defiant/ conduct disorder have a history of disturbed relationships with peers, aggression toward people or animals, destruction of property, deceitfulness or theft, and serious violation of rules (e.g., truancy, running away from home, staying out all night without permission). The behaviors and problems may be mild to severe.

General Appearance and Motor Behavior:

Appearance, speech, and motor behavior are typically normal for the age group but may be somewhat extreme (e.g., body piercings, tattoos, hairstyle, clothing). These clients often slouch and are sullen and unwilling to be interviewed. They may use profanity, call the nurse or physician names, and make disparaging remarks about parents, teachers, police, and other authority figures.

Mood and affect:

Clients may be quiet and reluctant to talk or openly hostile and angry. Their attitude is likely to be disrespectful toward parents, the nurse, or anyone in a position of authority. Irritability, frustration, and temper outbursts are common. Clients may be unwilling to answer questions or to cooperate with the interview; they believe that they do not need help or treatment. If a client has legal problems, he or she may express superficial guilt or remorse but it is unlikely that these emotions are sincere.

Thought process and content:

Thought processes are usually intact—that is, clients are capable of logical, rational thinking. Nevertheless, they perceive the world to be aggressive and threatening and they respond in the same manner. Clients may be preoccupied with looking out for themselves and behave as though everyone is “out to get me.” Thoughts or fantasies about death or violence are common.

Sensorium and intellectual processes:

Clients are alert and oriented with intact memory and no sensory-perceptual alterations. Intellectual capacity is not impaired, but typically these clients have poor grades because of academic underachievement, behavioral problems in school, or failure to attend class and to complete assignments.

Judgment and insight:

Judgment and insight are limited for developmental stage. Clients consistently break rules with no regard for the consequences. Thrill-seeking or risky behavior is common such as use of drugs or alcohol, reckless driving, sexual activity, and illegal activities such as theft. Clients lack insight and usually blame others or society for their problems; they rarely believe that their behavior is the cause of difficulties.

Self-concept:

Although these clients generally try to appear tough, their self-esteem is low. They do not value themselves any more than they value others. Their identity is related to their behaviors such as being cool if they have had many sexual encounters or feeling important if they have stolen expensive merchandise or been expelled from school.

Roles and Relationships

Relationships with others, especially those in authority, are disruptive and may be violent. This includes parents, teachers, police, and most other adults. Verbal and physical aggression is common. Siblings may be a target for ridicule or aggression. Relationships with peers are limited to others who display similar behaviors; these clients see peers who follow rules as dumb or afraid. Clients usually have poor grades, have been expelled, or have dropped out. It is unlikely that they have a job (if old enough) because they would prefer to steal they want or needed. Their idea of fulfilling roles is being tough, breaking rules, and taking advantage of others.

Physiologic and Self-Care Considerations:

Clients are often at risk for unplanned pregnancy and sexually transmitted diseases because of their early and frequent sexual behavior. Use of drugs and alcohol is an additional risk to health. Clients with conduct disorders are involved in physical aggression and violence including weapons; this results in more injuries and deaths than compared with others of the same age.

DATA ANALYSIS AND PLANNING:

Nursing diagnoses commonly used for clients with conduct disorders include the following:

• Risk for Other-Directed Violence

• Noncompliance

• Ineffective Coping

• Impaired Social Interaction

• Chronic Low Self-Esteem

OUTCOME IDENTIFICATION:

Treatment outcomes for clients with conduct disorders may include the following:

• The client will not hurt others or damage property.

• The client will participate in treatment.

• The client will learn effective problem-solving and coping skills.

• The client will use age-appropriate and acceptable behaviors when interacting with others.

• The client will verbalize positive, age appropriate statements about self. for special favors or attempts to alter treatment goals or behavioral expectations. Whether there is a written contract or treatment plan, staff must be consistent with these clients. They will attempt to bend or break rules, blame others for noncompliance, or make excuses for behavior. Consistency in following the treatment plan is essential to decrease manipulation.

Time-out

Improving coping skills and self-esteem

INTERVENTION:

Decreasing violence and increasing compliance with treatment:

The nurse must protect others from the manipulation or aggressive behaviors common with these clients.

He or she must set limits on unacceptable behavior at the beginning of treatment.

Limit setting involves three steps:

1. Inform clients of the rule or limit.

2. Explain the consequences if clients exceed the limit.

3. State expected behavior.

INTERVENTIONS FOR CONDUCT DISORDER:

· Decreasing violence and increasing compliance with treatment

ü Protect others from client’s aggression and manipulation.

ü Set limits for unacceptable behaviour.

ü Provide consistency with client’s treatment plan.

ü Use behavioural contracts.

ü Institute time-out.

ü Provide a routine schedule of daily activities.

· Improving coping skills and self-esteem

ü Show acceptance of the person, not necessarily the behaviour.

ü Encourage the client to keep a diary.

ü Teach and practice problem-solving skills.

· Promoting social interaction

ü Teach age-appropriate social skills.

ü Role-model and practice social skills.

ü Provide positive feedback for acceptable behaviour.

· Providing client and family education

· Clients also may need to learn how to solve problems effectively.

· Problem-solving involves identifying the problem, exploring all possible solutions, choosing and implementing one of the alternatives, and evaluating the results.

· The nurse can help clients to work on actual problems using this process. Problem-solving skills are likely to improve with practice.

Evaluation

Treatment is considered effective if the client stops behaving in an aggressive or illegal way, attends school, and follows reasonable rules and expectations at home. The client will not become a model child in a short period; instead, he or she may make modest progress with some setbacks over time.

COMMUNITY-BASED CARE

Clients with conduct disorder are seen in acute care settings only when their behavior is severe and only for short periods of stabilization. Much long-term work takes place at school and home or another community setting. Some clients are placed outside their parents’ home for short or long periods. Group homes, halfway houses, and residential treatment settings are designed to provide a safe, structured environment and adequate supervision if that cannot be provided at home. Clients with legal issues may be placed in detention facilities, jails, or jail-diversion programs. Chapter 4 discusses treatment settings and programs.

MENTAL HEALTH PROMOTION:

Parental behavior profoundly influences children’s behavior. Parents, who engage in risky behaviors, such as smoking, drinking, and ignoring their health, are more likely to have children who also engage in risky behaviors including early unprotected sex (Davis, 2002). Gross and Grady (2002) found that group based parenting classes are effective to deal with problem behaviors in children and to prevent later development of conduct disorders. Moyer (2002) reports that an early intervention program for children at risk for anxiety disorders improved behavior. The program consisted of parent sessions, child anxiety management, parent-child sessions emphasizing coping skills, and graduated exposure to anxiety-provoking situations. The ADHD RS/ SNAP-IV Teacher /Parent Rating Scale is an assessment tool that can be used for initial evaluation in many areas of concern such as ADHD, oppositional defiant disorder, conduct disorder, and Such tools can identify problems or potential problems that signal a need for further evaluation and follow-up. Early detection and successful interventions are often the key to mental health promotion.

NURSING CARE PLAN: OPPOSITIONAL DEFIANT /CONDUCT DISORDER

Nursing diagnosis: Ineffective Coping, Inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources.

ASSESSMENT DATA

EXPECTED OUTCOMES

• Few or no meaningful peer relationships
• Inability to empathize with others
• Inability to give and receive affection
• Low self-esteem masked by “tough” act

Immediate
The client will:
• Engage in social interaction
• Verbalize feelings
• Learn problem-solving skills

Stabilization: The client will:

• Demonstrate effective problem solving and coping skills

• Assess own strengths and weaknesses realistically

Community: The client will:

• Demonstrate development of relationships with peers
• Verbalize real feelings of self-worth that are age appropriate
• Perform at a satisfactory academic level

IMPLEMENTATION
Nursing Interventions *denotes collaborative interventions Rationale	Rationale
Encourage the client to openly discuss his or her thoughts and feelings. Give positive feedback for appropriate discussions.	Verbalizing feelings is an initial step toward dealing with them in an appropriate manner. Positive feedback increases the likelihood of continued performance.
Tell the client that he or she is accepted as a person, although a particular behavior may not be acceptable.	Clients with conduct disorders frequently experience rejection. The client needs support to increase self-esteem, while understanding that behavioral changes are necessary.
Give the client positive attention when behavior is not problematic.	The client may have been receiving the majority of attention from others when he or she was engaged in problematic behavior, a pattern that needs to change.
Teach the client about limit-setting and the need for these limits. Include time for discussion.	The client may have no knowledge of the concept of limits and how limits can be beneficial. The client has an opportunity to ask questions when manipulation is not needed. This allows the client to hear about the relationship between aberrant behavior and consequences.
Teach the client a simple problem-solving process as an alternative to acting out (identify the problem, consider alternatives, select and implement an alternative, evaluate the effectiveness of the solution).	The client may not know how to solve problems constructively or may not have seen this behavior modeled in the home.
Help the client to practice the problem-solving process with situations on the unit, then with situations the client may face at home, school, and so forth.	The client’s abilities and skills will increase with practice. He or she will experience success with practice.
Role-model appropriate conversation and social skills for the client.	This allows the client to see what is expected in a nonthreatening situation.
Specify and describe the skills you are demonstrating.	Clarification of expectations decreases the chance that the client will misinterpret expectations.
Practice social skills with the client on a one-to-one basis.	As the client gains comfort with the skills through practice, he or she will increase their use.
Gradually introduce other clients into the interactions and discussions.	Success with others is more likely to occur once the client has been successful with the staff.
Assist the client to focus on age- and situation appropriate topics.	Peer relationships are enhanced when the client is able to interact as other adolescents do.
Encourage the client to give and receive feedback with others in his or her age group.	Peer feedback can be influential in shaping the behavior of an adolescent.
Facilitate expression of feelings among clients in supervised group situations.	Adolescents are reluctant to be vulnerable to peers, and they may need encouragement to be open and honest with their feelings.
Teach the client about transmission of human immunodeficiency virus (HIV) infection and other sexually transmitted diseases (STDs).	All clients need to know how to prevent transmission of HIV and STDs. Because these clients may act out sexually or use intravenous drugs, it is especially important that they be educated about HIV infections.
*Assess the client’s use of alcohol or other substances, and provide referrals as indicated.	Often adolescents with conduct disorders also have substance abuse issues.