SENSORY DISORDERS
Children with sensory disorders and their families face special challenges. Alterations in the senses greatly affect growth and development, academic performance, development of socialization skills, and communication.
Visual Impairment
The most frequent causes of visual impairment include genetic or congenitally acquired cataracts (caused by rubella), optic nerve atrophy, and retrolental fibroplasia resulting from oxygen toxicity. Other causes are amblyopia, retinitis pigmentosa, refractory errors, strabismus, and trauma.
Severely visually impaired children are dependent on others for learning socialization skills. They lack visual cues, resulting in socialization delays. For older children, special education programs can assist with academics. Audiovisual aids and instruction in the use of Braille reading are other available learning tools.
Teach family caregivers to remove limitations in the surrounding environment and to promote independent functioning for such children. Clocks with large numbers, calendars with large letters.Encourage nonsighted children to participate in activities with their peers, such as music, guided skiing, swimming, and so forth. Family caregivers should encourage nonsighted infants and toddlers to explore their environment, while at the same time ensuring their safety.
Hearing Impairment
Hearing impairment can result from fetal exposure to cytomegalovirus, herpes, rubella, or syphilis. Meningitis, chronic ear infections, Down syndrome, exposure to loud noises, and certain medications also can cause hearing damage. Manifestations of hearing impairment in a child include avoiding social interaction, playing alone, acting timid, not learning to talk, and displaying poor socialization skills.
Children with impaired hearing face the related problem of poor speech development. Communication and safety are major issues for families with hearing-impaired children. Promoting communication is critical. Speech therapy and sign language are important tools for learning and communication. Assistance with socialization in school is essential; classmates must learn to relate to these children and understand that they are not intellectually impaired.
Speech Impairment
Impairment of speech can result from a hearing deficit, muscular disorders, or cleft lip or palate. Environmental and emotional factors can also influence speech. Disorders in articulation are related to the ability to produce the correct sound. An example of a speech impairment is the child who speaks with a lisp (pronounces “th” instead of “s”).
A dysfluency is an interruption in the natural flow of speaking. An example is the child who stutters. Stuttering is normal for preschool children because, at this age, the ability to understand is more developed than vocabulary and command of the language. Stuttering in school-age children requires evaluation.
Some children benefit from speech therapy. Others require surgical intervention or orthodontics. Evaluation by an otolaryngologist or neurologist also may be appropriate, depending on the specific circumstances. Specialists will test hearing. They will also make necessary referrals to psychologists or counselors for children with emotionally related speech disorders. Computers are especially valuable for these children.
Key Concept Hearing disorders are common causes of speech disorders in children. A professional audiologist should test the hearing of a child who is having speech problems. Learning to talk is difficult for one who has never heard anyone speak. If a person loses his or her hearing later; he or she can often maintain speech.
NCLEX Alert When taking an examination, be alert for descriptive terms in the clinical scenario, such as ataxia, autism, Downs syndrome, and so forth. Each of these clues could influence the choice of the correct response.
MENTAL ILLNESS
Childhood Depression
Depression is a serious disorder in children. It can be difficult to identify and differentiate from other disorders. Young children and adolescents often have difficulties expressing themselves and their feelings, and their depression can go unnoticed. Many adolescents are sometimes moody and withdrawn, and family caregivers may be unable to differentiate typical adolescent moods from clinical depression.
Signs and Symptoms. Typical symptoms of depression include isolation and sadness, withdrawal from friends and family, fatigue and decrease in activity level, decrease in appetite, and a change in sleep patterns (e.g., excessive sleep or an inability to sleep). School grades may decline, and the child may miss school for various reasons. The child may make statements that reflect low self-esteem. The primary clue is a marked change in behavior.
Diagnosis. Diagnosis may be difficult. Physicians need to rule out organic causes of diseases. Professional pediatric counselors are generally required to assist in the identification of the proper diagnosis.
Some depression is related to chemical imbalances in the brain. Other cases are situational, occurring in response to a traumatic event, such as the death of a family member or pet or the breakup of a relationship. Children with low selfesteem or those overwhelmed with stressful situations are more susceptible to depression. Depression can also occur in children with a chronic illness or disability.
Treatment. The first step in treating children with depression is identifying the symptoms. Although recognizing depression in children may be difficult, it is important to understand that all behavior is meaningful. Investigate characteristics of depression thoroughly to prevent further complications or suicide. Psychotherapy and counseling are necessary and may be provided on an outpatient basis. More serious cases of depression may require hospitalization. Family counseling is always helpful; antidepressant medications may be necessary.
Nursing Considerations. Parents, caregivers, and healthcare professionals often miss the symptoms. It is important for the healthcare provider to accept and recognize changes in behaviors. Parents may not identify behavioral changes as abnormal, thinking that all children have adjustment difficulties with some periods of sadness.
Suicide
Many situations are associated with suicide and suicide attempts. Family problems may be involved, including financial difficulties, divorce, separation, or substance abuse. Adolescents who are experiencing the physical and emotional changes typical of their age group have minimal coping skills to deal with family-related stressors. Depression, personal substance abuse, and low self-esteem are other risk factors. Children with behavioral disorders are also at risk (see Box 74-1).
BOX 74-1.
Risk Factors for Suicide
♦ Previous suicide attempt(s)
♦ History of mental disorders, particularly depression
♦ Family history of suicide
♦ Family history of child maltreatment
♦ Feelings of hopelessness
♦ Impulsive or aggressive tendencies
♦ Barriers to accessing mental health treatment
♦ Loss (relational, social, work, or financial)
♦ History of alcohol and substance abuse
♦ Physical illness, especially chronic illnesses, such as diabetes mellitus
♦ Easy access to lethal methods
♦ Unwillingness to seek help because of the stigma attached to mental health and substance abuse disorders or suicidal thoughts
♦ Cultural and religious beliefs; for instance, the belief that suicide is a noble resolution of a personal dilemma
♦ Local epidemics of suicide
♦ Isolation, a feeling of being cut off from other people
Signs and Symptoms. Suicidal ideation is the term given to thoughts or ideas of suicide. Suicidal ideation usually precedes a suicide attempt. A suicide gesture is an attempt at inflicting personal injury; the injury is not intended to cause death. Suicide ideation and gestures are cries for help. Ignoring these symptoms of despair can result in an adolescent’s death. Both are key warning signs that must not be ignored (see Box 74-2).
Diagnosis. There is no specific test to determine the state of depression or inclination toward suicide. Key warning signals include morbid discussion of, and preoccupation with, death, giving away important personal belongings, and a sudden cheerfulness following a somber, withdrawn, depressed period. This sudden cheerfulness may indicate that the adolescent has decided to commit suicide and is relieved about the decision. This warning sign can be easily missed.
Treatment. Warn the family to take suicide ideation, gestures, and attempts seriously. Have the child see a professional therapist immediately. Intensive and long-term psychological counseling is essential. Adolescents with severe depression and suicidal thoughts may require hospitalization and close monitoring until suicide is no longer an immediate threat.
Nursing Considerations. Be aware of early signs of depression. Listening is more effective than talking to children about sadness, unhappiness, or depression. Consider using a no-suicide contract with the child, wherein the child agrees not to attempt suicide for a specified period and will contact help immediately if he or she feels suicidal. Children are usually very conscientious about wanting to keep their word, and a no-suicide contract can be effective in some situations.
BOX 74-2. Possible Danger Signals Indicating the Need for Intervention
♦ Actual suicide threats, a suicide note, overuse of drugs, constant talk of: death, willingness to die or being ready for death, being worthless or no good, death as a release from pressure and pain
♦ Any suicidal gesture
♦ Extreme anxiety, tenseness, abrupt changes in behavior: withdrawal, and sadness
♦ Deep, lingering depression, with loss of energy and desire
♦ Withdrawal from friends and family
♦ Lack of involvement in school activities
♦ Depression, feelings of hopelessness or helplessness, low self-esteem, loneliness and isolation, impulsiveness
♦ Very dangerous and life-threatening activities, such as playing “Russian roulette” with a gun or “chicken” with a car
♦ Self-injurious behaviors, such as use of drugs, cutting or scratching oneself, self-inflicted cigarette burns
♦ Inability to communicate with family caregivers
♦ Change in eating patterns
♦ No close friends
♦ Sudden giving away of prized or valuable possessions
♦ Change in sleeping patterns
♦ Radical personality change
♦ Unusual neglect of personal appearance
♦ Ambivalence
Childhood Schizophrenia
The schizophrenic person loses contact with reality. Schizophrenia sometimes results from a sudden, severe emotional experience, or sometimes from the person’s inability to adjust to the environment. Familial tendencies have been noted. Play therapy, behavior modification, and drug therapy may help; however, schizophrenia is often chronic. The person must learn how to manage his or her life with the disorder.
Signs and Symptoms. Following are characteristics of childhood schizophrenia:
• The onset of schizophrenia can occur as early as 5 or 6 years of age.
• These children share many characteristics with autistic children, such as lack of speech, ritualistic behavior, and intolerance of change.
• Personality and cognitive development are affected.
• Children with schizophrenia often hear voices (auditory hallucinations).
• These children have impaired relationships.
• These children are often out of touch with reality, have a distorted sense of what is real, and do not know where they are or what day it is.
• These children have an inappropriate affect (e.g., laugh at a sad event).
• Other symptoms include delusions (beliefs not based on fact), paranoia (unreasonable fear), and aggression toward others.
Diagnosis. Diagnosis is basically made by the observation of symptoms over a period of time. Other organic and psychological disorders need to be eliminated. Many theories exist as to the cause of childhood schizophrenia. They include biochemical and organic causes, inadequate caregiver relationships, childhood sexual abuse, and ritualistic abuse. Children whose family caregivers suffered from mental health problems may have an increased tendency to develop psychoses.
Treatment. Treatment emphasizes modifying behavior so schizophrenic children can cope with reality and organize their thoughts. Medications are often helpful in controlling symptoms; however, they sometimes compound symptoms in children. Children require monitoring to ensure medication compliance.
Nursing Considerations. Because behavior is so difficult for all involved, intensive and long-term therapy is often required. Family and caregivers may need supportive counseling. A program of home care with respite care, medical assistance, and social service assistance is preferred to hospitalization.
The child and the caregivers need to maintain the regimen of medications. When symptoms diminish or disappear, it means that the medications are effective. It is important to differentiate this concept of medical management from the hope that the disease has gone away and the drugs are no longer required.
SUBSTANCE ABUSE IN CHILDREN AND ADOLESCENTS
The transition from childhood to adolescence can be one of confusion and turmoil. Any change in family structure adds additional stress to developmental tasks. Some children view the use of chemicals to alter consciousness as a way of dealing with stress, raising self-esteem, and being accepted by peers. All chemicals have the potential for abuse. In Practice: Data Gathering In Nursing 74-1 lists signals of substance abuse. Table 74-2 identifies the effects of chronic drug use on body systems.
The most commonly used drugs are alcohol and tobacco. Other common drugs include marijuana, heroin, amphetamines, barbiturates, narcotic analgesics, and lysergic acid diethylamide (LSD). Cocaine offers users a euphoric high and can be inhaled as a powder, smoked in free-base form, or smoked in a water pipe (“crack cocaine”). Methamphetamine (“crank,” “meth,” “crystal”) is an inexpensively made drug that produces a longer, more intense high than cocaine.
Huffing is a term given to inhaling chemicals that produce a feeling of delirium or a high. Huffing is often the first form of substance abuse; young children, after experimenting with inhalants, may proceed to other drugs. Children may inhale inexpensive household cleaners, hair spray, or paint in aerosol cans. Other common inhalants are fumes from glue, markers, and correction fluid (Box 74-3). Huffing is extremely dangerous because these inhalants are toxic to the CNS.
IN PRACTICE:DATA GATHERING IN NURSING 74-1
SIGNALS OF CHILDHOOD OR ADOLESCENT SUBSTANCE ABUSE
Signs that a child or adolescent may be abusing substances include:
• Extreme changes in dress
• Sudden loss of interest in personal appearance
• Sudden change in friends
• Extreme changes in eating or sleeping patterns
• Radical changes in normal behavior patterns or interests
• Extreme changes in relationships with family members
• Tardiness or absenteeism
• Unexpected or unusual failure in school
• Seclusion and withdrawal in room for extended periods
• Slurred speech, glazed look, other physical symptoms
• Defense of the right to use alcohol or drugs
• Prominent mood changes
• Sudden refusal to work; not showing up for work or school
• Feelings of being sad or “bummed out”
• Dishonesty, stealing, hiding things
• Wearing dark glasses during the day to hide the eyes
• Wearing long sleeves to hide needle marks
• Sudden need for large amounts of money
• Sudden, unexplained disappearance of items in the home, such as money or jewelry
• Trouble with the law, speeding tickets, driving while intoxicated (DWI) tickets
• Leaving home for several days at a time, unexplained absences
BOX 74-3.
Commonly Used Toxic Inhalants
• Aerosol paint cans
• Butane lighter fluid
• Cleaning fluids
• Gasoline vapors
• Kerosene vapors
• Liquid typing-correction fluid
• Model glue
• Nail-polish remover
• Paint sprays
• Paint thinners
• Propellant in whipped-cream spray cans
• Rubber cement
• Shellac
• Solvent
• Upholstery-fabric protection spray
• Varnish
Permanent damage to the lungs, CNS, or liver may occur. Users may lose consciousness and have seizures, or quick death can occur with no warning.
Prevention. One way to prevent substance abuse is through public education. In addition, young people must feel that they are worthwhile; try to build the self-esteem of all children. Treatment depends on the extent of the abuse, the age at which abuse began, and whether physical dependence exists. Support groups, individual counseling, and family counseling can be beneficial.
Children of Alcoholics. Children of alcoholics (COAs) are at high risk for developing problems with alcohol and other drugs. Children whose family caregivers are alcoholics are more likely to become alcoholics themselves because alcoholism runs in families. These children often experience problems in school and in coping with stress. They can suffer from school failure, depression, and increased anxiety.
TABLE 74-2. Effects of Marijuana and Cocaine on the Body Systems
|
SYSTEM |
MARIJUANA |
COCAINE |
|
Nervous |
Perceptual difficulties Uncoordinated psychomotor skills Paresthesias Personality/behavioral changes Short-term memory loss |
Anxiety, irritability Tactile hallucinations Paranoia, insomnia, aggression |
|
Sensory |
Tinnitus Disturbed equilibrium |
Visual disturbances |
|
Cardiovascular |
Elevated pulse rate Elevated blood pressure |
Arrhythmias Acute myocardial infarction Ruptured ascending aorta Cerebrovascular accident |
|
Respiratory |
Oropharyngeal irritation Pulmonary damage Precancerous cellular changes |
Pulmonary edema Pneumomediastinum Rhinorrhea, rhinitis Ulceration/perforation of nasal septum |
|
Gastrointestinal |
Enhanced appetite Xerostomia Vomiting |
Weight loss Nausea Intestinal ischemia (gangrene) |
|
Reproductive |
Suppressed sexual functioning Possible teratogenicity |
Problems maintaining an erection Orgasmic delay Miscarriage/preterm infants |
Children of alcoholics need help to understand that they did not cause a family member’s alcoholism and they are not responsible for solving the problem. Encourage COAs to share their thoughts and feelings and help them learn to trust others. Slowly build relationships by doing a regular activity with them and provide some consistent, dependable companionship.
If a child asks for help, follow through by putting him or her in contact with professional counselors. Group therapy sessions help the child realize that others are in the same situation. Asking for help takes an enormous amount of courage; let the child know that you are aware of this courage and that you respect the child’s decision. The younger the child is when help becomes available, the greater the chances for success in breaking unhealthy patterns.
Key Concept Probably the most important factor in breaking the cycle of chemical abuse is building a child’s positive self-esteem.
