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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 2

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 3

F80 – F89 Disorders of psychological development F80 Specific developmental disorders of speech and 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 4

F90 – 98 Behavioral and emotional disorders with 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 5

Mental Retardation (mental sub- normality) 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 6

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 7

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,

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 9

Etiology 1. Infections Congenital CMV Congenital rubella Congenital toxoplasmosis Encephalitis HIV infection Listeriosis Meningitis 10

2. Chromosomal abnormalities Chromosome deletions Chromosomal translocations Chromosomal inheritance Errors in chromosome numbers 11

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 12

5. Postnatal causes Environmental toxins Exposure to childhood disease Infections (whooping cough, measles, rubella, mumps. Meningitis) Any injury to brain Lead poisoning 13

6. Genetic abnormalities and inherited metabolic disorders Adrenoleukodystrophy Galactosemia Hunter syndrome Lesch – Nyhan syndrome Phenylketonuria Rett syndrome Tuberous sclerosis 14

7. Trauma Intracranial hemorrhage before or after birth Fetal hypoxia Severe head injury 8. Other factors Poor environmental condition Malnutrition Lead poisoning 15

TypeIQ Mild (Educable)50-70 Moderate (Trainable)35-50 Severe (Dependent retarded)20-35 Profound (life support)<20 16 Normal IQ Genius - >110

Behavioral manifestations 1. Mild MR 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 17

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 2 nd class Have certain speech limitations Have difficulty following expected social norms 18

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 19

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 20

Signs and symptoms 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 21

Assessment and diagnosis 1. Comprehensive history 2. Patient interview 3. Mental status 4. Medical review 5. Neurological examination 6. Assessment of developmental milestones 22

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) 23

Treatment 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 24

Prevention 1. Primary prevention Genetic counseling Immunizations Family planning Adequate nutrition for mother Avoidance of teratogenic substances Amniocentesis Fetoscopy. Fetal biopsy, ultrasound Avoidance of birth injury 25

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 26

3. Tertiary prevention Vocational rehabilitation Physical and social rehabilitation Reduction of disability 27

Care and rehabilitation Main aims and objectives of rehabilitation 1. 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 28

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 29

Services include 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 30

Successful skill training includes 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. 31

Nursing diagnosis 1. Altered growth and development related to 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 32

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 33

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 34

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 35

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 36

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