3. Disorders usually first evident in infancy, childhood, or adolescence

There are psychiatric disorders that commonly occur during the period from infancy to adolescence. This chapter addresses autistic disorder, attention-deficit/hyperactivity disorder, conduct disorce' and oppositional defiant disorder.

Autistic Disorder

DSM-IV CATEGORY

299.00 Autistic disorder

Autism is a pervasive developmental disorder of childhood that is manifested by gross impairment in social interaction and language skills and a lack of imaginative activity. There is a limited repetitive repertoire of movements and activities that are often bizarre and inappropriate and sometimes self-destructive. Examples of such activities are rocking, spinning, head banging, and extremity biting. The child also shows a lack of responsiveness and failure to bond with caretakers, which are manifested by treating all people as objects. An autistic child doesn't seek comfort from others when hurt, ill, or tired. The child doesn't engage in social activities or contact with peers but prefers solitary play. There is a complete disinterest in people, fantasy characters, animals, and play that imitates adult roles. In the area of communication, spoken language may not exist, or it may consist of babbling, echolalia (repeating the speech of another person), neologisms (forming new words), symbolic use of words, unconnected comments, and reversal of pronouns. An example of pronoun reversal is when the child says, "You want a drink”, instead of saying "I want a drink." The child may interact through the use of abnormal nonverbal communication methods, such as body posture extremes, fixed stares, and socially inappropriate actions. Frequently, the child becomes markedly distressed if a change in the environment or daily routine occurs. The age of onset is before 30 months, and this disorder affects boys more than girls by a 3:1 ratio. Various biological conditions, such as maternal rubella, anoxia during birth, untreated phenylketonuria, and encephalitis, have been linked to the development of autistic disorder.

Neurobiological research suggests that prenatal complications create defects in the central nervous system. Immunologic problems, such as incompatibilities between maternal and fetal tissue, as well as altered brain functioning due to injury and genetic factors may also contribute to the development of autism. Autistic children demonstrate functional problems with the left cerebral hemisphere manifested by difficulties in language and logical reasoning. Many of the same children excel in musical, mathematical, and other visual spatial skills. There is EEC evidence of failed cerebral lateralization, and many autistic children are ambidextrous.

COMMUNICATION STRATEGIES

• Keep all verbal and nonverbal communication brief and direct.
• Focus on the client's nonverbal behavior and look for its meaning.
• Determine the meaning of neologisms.
• Don't use abstract phrases or humor.
• Try to understand the client's use of pronoun reversal.
• Don't initially communicate through physical touch, but introduce it gradually.
• Communicate nonverbally through eye contact, facial expressions, and simple gestures.

Long-Term Goal
The client will refrain from harming set for others.

Short-Term Goal #1: The client will decrease the frequency of bizarre responses to the environment.

Interventions and Rationales

• Maintain a calm, nonthreatening environment. Decreased stimuli prevent Overreaction and consequent episodes of destructive rages.
• Develop a routine similar to the daily routine at home. Structure ensures consistency and prevents regression.
• Limit and then gradually increase contact with new people. Gradually increasing contact with new people prevents the client from being overwhelmed and engaging in impulsive behavior.
• Monitor temper tantrums, repetitive motor behaviors or mannerisms (rocking, hand flapping), and self-abuse (head banging) by documenting the behavior, precipitating factors, and effective management strategies. Monitoring provides feedback necessary to plan interventions.
• Don't focus on temper tantrums that are not life-threatening. Giving attention to negative behavior reinforces it.

Short-Term Goal #2: The client will demonstrate safe ways to deal with anxiety-provoking situations.

Interventions and Rationales

• Stop the client from engaging in self-mutilating behaviors. Safety is the first priority in all clinical situations.
• Provide a helmet, mittens, and other protective equipment. Protective equipment safeguards the client during destructive rages.
• Label incidents and feelings. Identification ofstressors may help defuse the energy used for acting out.
• Stop violent actions directed at others by separating the client from others or redirecting energy to inanimate objects (for example, a punching toy). Placing the client in a time-out or quiet area removes stimuli; redirecting energy prevents further injury.
• Stay with the client at times of change in routine or when the client is upset and frightened. Offering to be with the client promotes feelings of security and decreases the tendency to become violent.

Long-Term Goal
The client will develop effective methods for communicating.

Short-Term Goal #1:The client will begin to develop a sense of trust in the present surroundings and the reliability of caretakers.

Interventions and Rationales

• Spend time orienting the client to the environment. Spending time with the client promotes safety and comfort with surroundings.
• Maintain consistent staff assignment. Consistency in staffing promotes better understanding of the client's actions and communications, facilitating trust.
• Connect with the client by verbalizing what the client expresses only through behavior or acting out. This response conveys empathy and facilitates trust.

Short-Term Goal #2:The client will develop several new, more effective ways to communicate with others.

Interventions and Rationales

• Repeat and reinforce information about daily routine. Talking with the client often about the daily schedule of events aids development of communication skills.
• Verbally and nonverbally promote self-care activities. Constant contact with the client provides many opportunities to teach seif-care.
• Anticipate and meet the client's needs while talking about them. Talking and doing illustrate the use of both verbal and nonverbal communication.
• Analyze and interpret pronoun reversal, neologisms, and improper use of grammar. Responding to the client's attempts to communicate fosters further interactions and helps to identify the client's needs.

Long-Term Goal
The client will initiate interactions with the nurse and peers.

Short-Term Goal #1:The client will establish daily interpersonal contact with a caregiver during self-care activities.

Interventions and Rationales

• Schedule uninterrupted, routine time to be with the client. The routine presence of the nurse is reassuring: it promotes trust and safety.
• Assist the client with self-care activities, recognize strengths, and make a mental note of which areas require assistance. Self-care activities increase opportunities for the nurse to recognize ana evaluate how to best meet client needs.
• Have the client practice activities of daily living, and verbally and nonverbally reinforce involvement in self-care activities. Repetition and reinforcement facilitate desirable behavior.

Short-Term Goal #2:The client will participate in interactions with peers.

Interventions and Rationales

• Prepare the environment with toys and safe, comforting objects before initiating contact with peers. Items such as pillows, blankets, and toys provide a sense of security if interactions with peers become stressful.
• Sit at the same level as the client and make nonverbal contact by smiling and playing with a toy. These actions convey warmth and build a trust relationship.
• Gradually introduce more nonverbal communication (smiling. facial expressions, touch). Introducing stimuli slowly decreases the probability that the new stimuli will frighten or upset the client.
• Encourage the client's continuing play activities and nonverbal communication with the nurse. Positive reinforcement encourages repetition of behaviors.
• Introduce one or two other children to the client's environment while maintaining the supportive presence of the nurse. An established relationship with the nurse provides a sense of security when a potentially stressful situation is occurring.
• Have the client participate in a small-group play activity with one or two peers. Play allows for awareness of others and crea:es a way to interact with them.

THERAPIES

There is no evidence to support the use of psychotherapy or psychoanalysis with autistic children.

Behavior Modification Therapy

• Focus only on inappropriate behavior, not on possible underlying emotional disturbance.
• Give positive feedback and rewards for appropriate behavior.
• Ignore negative behavior, such as a temper tantrum, if it's not destructive or life threatening.

Milieu Therapy

• Provide repetitive ordinary experiences on a daily basis, such as maintaining a constant schedule of care and play activities. For instance, the client can work toward putting on socks or putting away toys.
• Control environmental stimuli by minimizing change in the client's surroundings as much as possible.
• Decrease or alter disruptive behavior by keeping tasks simple and not requiring the client to use abstract thinking or developed social language.

Play Therapy

• Investigate the client's views of the world and current environment as a way to develop structured interactions and practice social skills through play.
• Provide positive reinforcement for appropriate behavior.

MEDICATIONS

The medications listed below may be given to reduce anxiety, severe psychomotor agitation, and extreme sensitivity to environmental stimuli. They don't actually relieve the symptoms of autism.

• Antipsychotics help control agitated, aggressive, or impulse e behavior. The dopamine level is elevated in autism; giving a dopamine antagonist, such as halopperidol (Haldol), facilitates behavioral management. Sometimes the use of an antipsychotic produces the additional benefit of enhancing an autistic child's limited ability to communicate.
• A central nervous system stimulant, such as dextroamphetamine (Dexedrine), may have a paradoxical calming effect on hyperactive children.
• Antidepressants, such as lithium, have been used for their calming as well as antipsychotic effects, and imipramine (Tofranil) has been used for its ability to decrease a child's impulsiveness. (See Appendix D for medication information.

FAMILY CARE

• Provide anticipatory guidance for parent-child interactions sc that parents may learn how to use effective response patterns to the child's behaviors.
• Discuss how to manage the child's disruptive behavior.
• Facilitate discussions about guilt and embarrassment related the child's condition and the family's situation.
• Prevent the family from becoming socially isolated by connecting the family to support groups for parents with autistic children, obtaining appropriate professional child care, and teaching the parents how to handle the child's disruptive behavior if it occurs in a social situation.
• Encourage the parents to also focus on their own needs as well as those of their other children.
• Assist the parents to grieve the loss of normal parental hopes and expectations for the child's future.
• Establish methods to obtain respite care and day care.

Attention Deficit / Hyperactivity Disorder

DSM-IV CATEGORY

314.xx Attention-deficit/hyperactivity disorder

314.01 Attention-deficit/hyperactivity disorder, combined type

314.00 Attention-deficit/hyperactivity disorder, predominantly inattentive type

314.01 Attention deficit/hyperactivity disorder, predominantly hyperactive-impulsive type

314.9 Attention-deficit/hyperactivity disorder NOS

Children with attention-deficit/hyperactivity disorder (ADHD) display three core behavioral symptoms: inattention, impulsiveness, and hyperactivity. These features impact on the child's emotional and social development and are especially problematic in school, home, and work settings. The symptoms are exacerbated when the child's involvement is required in an activity or situation over an extended period. Children with ADHD have difficulty completing tasks, waiting their turns, following directions, and engaging in quiet activities. They interrupt others, continually move around, are easily distracted, and are accident-prone. They also tend to engage in dangerous activities without considering the harmful consequences. Mood swings, low self-esteem, and a low threshold of frustration are present. The onset of ADHD is typically before age 4, but some children may not be identified until they enter school. Boys are affected with this disorder more frequently than girls. No specific biological basis for ADHD has been identified. ADHD is viewed as being inherited because many parents of affected children have several ADHD symptoms themselves. Research suggests that a dopamine marker for the dopamine transporter gene is linked to the transmission of ADHD from the parent to the child.

CHARACTERISTICS OF ADULTS WITH ADD

Limited attention span Poor listening skills, "lungs out" Easily overwhelmed by personal, financial, and career responsibilities Low self-esteem Chronic procrastination and disorganization Spends excessive time doing tasks because of inefficiency Transposes tetters, numbers, and words "Mind goes blank" when asked to problem solve Difficulty sleeping Uncomfortable in social settings Forgetful Frequently tactless and embarrasses self and others Poor reading and writing skids Creative but an underachiever Demonstrates addictive behaviors

Neurotransmitters, specifically dopamine, norepinephrine, and serotonin, are believed to mediate behavioral activation and inhibition. Diagnostic studies of the brain further reveal that children with ADHD have decreased blood flow in the corpus stria-turn, which may account for the motivational deficit and disregard of consequences seen in daily behavior.

In some children concurrent neurologic disorders, such as cerebral palsy and epilepsy, occur with ADHD. Other preexisting conditions that occur with ADHD are a chaotic family environment, child abuse, lead poisoning, drug exposure while in utero. and low birth weight.

Adults diagnosed with ADHD in partial remission are individuals who have some ADHD symptoms that negatively influence their functioning at home or work. Sometimes the diagnosis isn't made in childhood; the collection of school records, data or. childhood behavior, and family history can be of assistance. Many adults are diagnosed with attention deficit disorder (ADD rather than ADHD. Clinically, the client describes a cycle of frustration, blame, and anger. ADD symptoms commonly reported by adults are restlessness, boredom, negative feelings, relationship difficulties, disorganization, and the searching for high-risk stimulation. (See Characteristics of adults with ADD.) Often aduir ADD coexists with depression, anxiety, substance use, and chronic illness. The preferred treatment combination for adult ADD is therapy, medication management, and education.

COMMUNICATION STRATEGIES

• Prevent the client from interrupting when the nurse is speaking by providing immediate feedback and helping the client to set realistic goals for behavior change.
• Have the client stop activities, look at the speaker, and focus on what is being said.
• Use verbal commands to ask the client to perform a task or to stop an inappropriate behavior. If the verbal directive is ineffective, use time-out periods to help the client stop the disruptive behavior.
• Speak quietly but firmly when setting limits; use short, simple sentences.

Long-Term Goal
The client will practice effective coping strategies.

Short-Term Goal #1:The client will develop appropriate ways to handle impulsive behaviors.

Interventions and Rationales

• Assist the client to identify thoughts and feelings about personal behaviors. Issue identification is the first step of problem solving.
• Be supportive of the client's efforts to control undesirable habits and impulses. A supportive relationship provides the framework for future behavioral changes.
• Help the client to identify current disruptive behaviors and their consequences. Knowing the negative consequences of behaviors enables the client to think about other ways of acting.
• Discuss alternative ways of behaving. Providing alternatives empowers the client to make choices.
• Offer positive reinforcement for all the client's attempts to change maladaptive behavior. Positive reinforcement acknowledges the client's efforts to change.

Short-Term Goal #2:The client will learn how to incorporate new responses into daily activities.

Interventions and Rationales

• Assess the client for beginning signs of hyperactivity (excessive twisting, squirming, leg swinging), and intervene before the activity takes over. Early intervention can prevent aggressive outbursts.
• Channel excess energy into suitable gross motor activities. Redirecting energy decreases anxiety and promotes acceptable ways to handle stress through physical activity.
• Verbally set limits on behaviors. Setting limits is a logical way tc prevent escalation of inappropriate behaviors.
• Discuss the client's frustration, anger, and confusion. Dealing with intense feelings helps prevent acting out.
• Develop brief working periods with planned breaks to decrease the frequency of hyperactive responses. The client's attention span is limited, so frequent breaks promote opportunities to experience successful behavior.
• Monitor body functions, making certain that the client isn't distracted by internal states. Hunger, thirst, fatigue, and a full bladder can generate a hyperactive response.

Long-Term Goal
The client will effectively engage in social interactions with peers and others.

Short-Term Goal #1:The client will be able to verbalize ways to decrease anxiety.

Interventions and Rationales

• Encourage the client to verbally express feelings. Verbalization of feelings helps prevent acting out behaviors.
• Discuss with the client specific steps that can be taken to handle problem situations (such as sharing toys, following rules. waiting in line, and allowing others a turn to speak). Teaching the client specific ways to problem solve enables the client to pursue acceptable solutions.
• Help the client to identify early signs of anxiety. Prompt identification of moderate anxiety enables the nurse to intervene before c crisis occurs.

Short-Term Goal #2:The client will acknowledge the positive points about self.

Interventions and Rationales

• Construct situations to empower the client, such as a step-by-step plan to complete a task. Successful experiences foster the ae-velopment of self-esteem.
• Point out the client's strengths. Positive reinforcement promotes self-esteem.
• Set realistic goals by providing opportunities to engage in helpful activities and complete specific tasks. The experience of success elevates the client's self-confidence and increases the likelihooc of success in similar future endeavors.
• Teach the client to engage in positive self-talk. Self-reinforcement promotes self-esteem.

Short-Term Goal #3:The client will demonstrate beginning social skills.

Interventions and Rationales

• Suggest ways for the client to learn how to get along with peers (taking turns, listening, following rules). Knowing the correct skill for common social situations helps the client interact successfully with peers.
• Model appropriate ways to interact with others by demonstrating listening behavior and repeating the main idea of what the other person said. Learning can occur through imitation of the nurse s behavior.
• Encourage the client to participate in appropriate activities with peers. Age-appropriate activities promote the achievement of normal developmental tasks.
• Assist the client to control or deal effectively with impulses. Have the client count to 10 before speaking or acting. Developing self-control of impulsive behavior helps prevent the occurrence of harmful situations.
• Give the client feedback about positive behavior, along with suggestions for improvement. Feedback encourages repetition c' appropriate behaviors and provides suggestions for managing troublesome behaviors.

Short-Term Goal #4:The client will interact with a small group of peers in the treatment setting.

Interventions and Rationales

• Establish activities for the client and a peer that provide successful interaction. Successful interactions reinforce the capacity to relate to others.
• Monitor interactions by setting limits when necessary. The presence of a nurse-therapist who sets limits helps the client to remember self-control skills.
• When appropriate, introduce additional peers to form a small-group interaction. This conveys the idea that the client is progressing because the message given is that the client can control behavior sufficiently to successfully interact with others.
• If the client becomes irritable or restless, allow the client to separate from the group. The client needs to practice coping strategies, such as taking time out and using quiet time when beginning to feel anxious.

Long-Term Goal
The family will verbalize acceptance of the child and understand the child's strengths and areas of difficulties.

Short-Term Goal #1:The family will learn strategies to deal with the child's ADHD.

Interventions and Rationales

• Assess the family strengths and areas of concern. A baseline understanding of family structure and functioning is necessary for formulating a plan of care.
• Identify family discipline methods, and assess how these methods set limits on unacceptable behavior. Discussion of appropriate discipline methods helps establish a baseline for teaching farm.y discipline techniques.
• Discuss the parents' feelings about caring for the child. Verba. expression of negative feelings may prevent physical or emotionai abuse.
• Teach ways for parents to decrease over stimulation and deal with disruptive behaviors. Learning strategies to intervene effectively empowers parents to take control of problematic situations.

Short-Term Goal #2:The family will participate in family therapy to promote successful adaptation to the child's disorder.

Interventions and Rationales

• Assess parental behavior for maladaptive coping techniques c-other stressors, such as illness, substance abuse, financial problems, and job loss. Mental illness, substance abuse, or other sressors further compromise the family's ability to function.
• Provide a forum to express feelings and to learn how to problem solve. Parents must examine how their behavior may reinforce the child's misbehavior or contribute to the child's successful adaptation.
• Inform parents about community resources, such as play groups, community mental health clinics, child development clinics, and other support groups. Parents need to know how to obtain assistance when necessary.
• Teach the parents ways to care for their own social and emotional needs (for example, going out without the child). Parents need to have periodic respite from the responsibilities of caring for a child with ADHD.
• Work to promote cohesion within the family by showing acceptance of the feelings of every family member and by voicing the conviction that the family has the capacity to effectively deal with their child's ADHD. Providing a forum for expression of feelings and opportunities to learn about ADHD strengthens the family system

THERAPIES

Therapy for ADHD is usually short term and focuses on reducing symptoms. The most effective therapies are drug, individual, and family therapy.

Individual Therapy

• Help the client to develop trust.
• Foster the client's self-esteem.
• Help the client to develop appropriate verbal and nonverbal communication skills.
• Assist the client to improve impulse control.
• Help the client alleviate depression associated with negative self-image.
• Help the client to reduce social isolation caused by feeling different from other children.

Play Therapy

• Provide a vehicle for the client to communicate ideas and feelings otherwise unable to be expressed.
• Assist in establishing some control over the environment.
• Use play to solve problems or experiment with solutions to stressful situations.

Special Education

• Consult with school officials for the purpose of combining special education methods with behavior modification techniques.
• Arrange for the client to be in a structured class setting in which frequent repetition of material to be learned is provided
• Provide the client with available resources so that complicated tasks are divided into smaller learning units.
• When possible, allow the client to restart a learning module if the client encounters several difficult days. This strategy can diminish the negative mind-set that may be associated with the material and prevent a negative learning environment from developing for the client.

Other Educational Interventions

• Adapt regular classroom activities by providing reading and mathematics tutors, and help with homework.
• Assist the client to understand and prioritize the subject material that is essential knowledge for examinations. Use study guides for directing the client's studying.
• Allow extra time to complete examinations.
• Work with the client to meet a specific goal, and determine the reward for reinforcement, such as stickers, stars, poker chips. and hash marks on a card.
• For a client 6 years old or older, obtain a contract that stipulates desired behaviors and consequences if behaviors are not followed.
• Teach the client to plan for studying, doing projects, and completing assignments through the use of a calendar or organizing list. Encourage the client to check off tasks that are accomplished.

MEDICATIONS

• Stimulant drugs have been effective in more than 70% of children with ADHD.
• Antipsychotic and tricyclic antidepressant drugs provide some symptom relief and stabilization of mood. Antihypertensive drugs, such as clonidine (Catapres) and guanfacine (Tenex) are used to treat ADHD. These antihypertensives are often used with a stimulant drug because they treat the client's hyperaactivity better than the client's inattention. The client should be carefully monitored for adverse effects, such as orthostatic hypertension and sedation. (See Appendix D for medication information.)

FAMILY CARE

• Instruct parents on the cause and treatment of ADHD.
• Develop a plan for consistent intervention when dealing with inappropriate behavior.
• Teach child behavior management techniques, such as immediate consequences for behaviors, and the use of consistent consequences.
• Discuss how to decrease the likelihood of accidents, injuries and destruction of property.
• Explore effects that the child with ADHD has on the family.
• Advise the family about community home-based services, particularly wrap-around services, that teach the child and parents cognitive behavioral interventions.
• Focus on strengthening communication patterns and each family member's assets.
• Work on positive parental involvement in the child's school and social life.
• Encourage participation in a support group for parents of ADHD children.

Conduct Disorder

DSM-IV CATEGORY

312.8 Conduct disorder (specify type: childhood-onset type/ adolescent-onset type)

A child or an adolescent with a conduct disorder demonstrates a pattern of behaviors that consistently violates the rights of other people and disregards common social standards. It is common for the child or adolescent to cheat, steal, initiate rights, destroy property, and be physically cruel to people and animals. Running away from home and truancy are also evident. Often early drug and alcohol use, sexual activity and offenses, and involvement in criminal activity are part of the child's or adolescent's history. There is a high likelihood that continuation of this behavior will lead to the diagnosis of an antisocial personality disorder.

The onset of a conduct disorder is before age 18. This disorder affects both genders but is much more common in boys. Boys with this diagnosis usually demonstrate antisocial acting out behaviors, such as righting, stealing, vandalism, and school discipline problems. Girls usually display lying, truancy, running away, substance use, and sexual acting out behaviors. The disorder has been subdivided into two subtypes based on the age of onset: childhood-onset type and adolescent-onset type. The childhood-onset type occurs before the child is 10 years old. These children are usually boys who are physically aggressive, demonstrate disturbed peer relationships, and may have been previously diagnosed with oppositional defiant disorder. With the adolescent-onset type, there is less of a tendency to exhibit violent behavior, and these youths have more typical peer relationships.

No specific biological basis for conduct disorder has been identified. Studies that evaluate the neurochemical basis for the demonstrated behaviors have been focused on the roles played by norepinephrine and serotonin. In clinical populations, 30% to 50% of clients with conduct disorder are also diagnosed with ADHD.

COMMUNICATION STRATEGIES

• Verbally set limits and behavioral expectations.
• Keep interactions focused on developing strategies for gaining self-control.
• Talk about consequences for negative behaviors.
• Work on developing alternative ways of expressing anger.
• Always focus on the here and now, and reinforce reality.

Long-Term Goal
The client will interact with others without becoming defensive, evasive, or verbally aggressive.

Short-Term Goal #1:The client will develop ways to meet personal needs without using manipulation.

Interventions and Rationales

• Orient the client, and discuss the rules, regulations, and consequences for rule infractions. A predictable environment helps reduce manipulative behavior.
• Implement a behavior modification system and negotiate behavioral contracts. The use of behavioral contracts emphasizes problem solving and reinforces the use of social skills.
• Explore with the client the need to feel some control over the environment by creating opportunities to make choices. The client needs to realize that using decision making to control one s we eliminates the need for manipulative practices.
• Identify the consequences of manipulative behavior. The client needs to understand the social, academic, familial, and legal consequences of disruptive and dishonest behaviors.
• Help the client to identify personal needs and explore acceptable ways to meet them. The emphasis on participation enables the client to develop a sense of control over a situation.
• Encourage the client to examine current defensive, aggressive, or manipulative behaviors, and discuss ways to alter them. It is beneficial for the client to explore and practice alternative ways of behaving.

Short-Term Goal #2:The client will verbalize responsibility for problems in interpersonal relationships.

Interventions and Rationales

• Have the client discuss issues that interfere with sustaining relationships. Accepting the client's perspective is essential to the nurse-client relationship because it places the client at ease to share relationship issues.
• Assist the client to identify destructive communication patterns (for example, threats, derogatory remarks, and sarcasm Problem identification is the first step toward a solution.
• Teach and have the client practice communication techniques that facilitate problem solving, such as role-playing interactions with the therapist, it is important that the client develop alternatives to defensive, nonproductive behaviors.
• Encourage the client to make verbal contact with others, and discuss the positive and negative aspects of the interaction with the therapist. Feedback can enhance self-esteem as well as teach options for successfully handling problematic situations.

Long-Term Goal
The client will not harm self or others.

Short-Term Goal #1:The client will request assistance from staff whenever aggressive urges are felt.

Interventions and Rationales

• Be available to the client, or make sure that the client has a therapist or other interested adult caretaker available day and night. The nurse's presence indicates concern for the client and willingness to be a resource.
• Teach the client to use healthy outlets for stress (for example. exercising, punching bag, going for help, cooling off periods). Using appropriate outlets for stress decreases the incidence of aggressive behavior.
• Assess the client for depression and suicidal ideation; intervene as appropriate. The client may redirect outward aggression toward the self: therefore, constant assessment and prompt intervention are needed.

Short-Term Goal #2:The client will interact with others without using verbal or physical aggression to solve problems.

Interventions and Rationales

• Provide structured interactional activities with staff and peers. The client can improve social skills while having the security of supervision and intervention if assistance with self-control is necessary.
• Discuss and evaluate behavior in order to help the client learn communication skills and eliminate dysfunctional behavior. The client benefits from analyzing behavior and learning effective ways to maintain healthy functioning.
• Initiate the use of a contract as a means of reinforcing acceptable behavior. The contract specifies expected behaviors, what to do when problems occur, and the consequences for aggressive behavior. The contract helps clarify the client's thinking about the consequences of aggressive behavior and empowers the client to make clear choices about how to control aggressive behavior.
• Monitor circumstances before and after displays of aggressive behavior and discuss them with the client. This information is helpful in fostering client understanding of conditions that cause predisposition to explosive acts.

Short-Term Goal #3:The client will demonstrate appropriate coping skills when dealing with stressful situations.

Interventions and Rationales

• Help the client to identify and decide how to handle situations that put the client at increased risk for acting out. ld.entificaf.cr. of stressful situations enables the client to learn how to avoid them cope with them, and ask staff to set limits on them.
• Help the client to develop a set of reasonable behaviors, such as time out and exercise, and encourage the client to use ther-when feeling stressed. The use of an individualized set of behavioral responses to stress gives the client control over situations.
• Encourage and reinforce the client's practice of coping skills. Reinforcement and reward of attempts to cope with stressors empower the client.

THERAPIES

Therapy for children and adolescents with a conduct disorder focuses on methods of behavior change.

Individual Therapy

• Teach the client how to use self-statements to aid behavior self-control. For example, the client says to self "Stay seated or "Do not touch." This is also known as thinking out loud.
• Instruct the client how to problem solve and work through the steps of completing a selected social task.
• Assist the client to develop a plan for what to do and how to do it when feeling aggressive.

Milieu Therapy

• Maintain a structured environment that teaches and reinforces social skills and assists in eliminating disruptive behavior, aggressive actions, and hostile communication.
• Have the client cultivate living skills.
• Have the client practice ways to modify behaviors.
• Develop methods for decreasing aggressive behaviors.

Family Therapy

• Instruct the family on the course and treatment of conduct disorder.
• Assist the parents to role model and to teach social skills.
• Help the parents establish consistent discipline methods to be used by all caregivers.
• Teach the parents to praise and reinforce appropriate nonaggressive actions.
• Teach the parents to assess the child's understanding of parental expectations by requesting that the child repeat instructions or information.
• Teach behavior management techniques, such as immediate and consistent consequences for behaviors.
• Discuss how to decrease the likelihood of accidents, injuries, and destruction of property.
• Assess for parental problems, such as mental health and drug and alcohol difficulties, that interfere with the parent-child relationship. Make referrals for the parents as appropriate.
• Teach the parents how to determine if the child has an association with a delinquent peer group or cult group.
• Help the parents be positive by demonstrating praise and affection and by having parents spend enjoyable times together with the child.

Group Therapy

• Depending on the age of the child, the focus can be play, social skills, or interpersonal learning.
• Assist the client to understand and appropriately express feelings.
• Promote opportunities to build self-esteem.
• Establish a mechanism for working through conflicts.
• Promote satisfactory peer relationships.
• Give the client feedback and social skills reinforcement.

MEDICATIONS

• Medications can be used to treat symptoms of anxiety and depression. Some clients respond well to lithium. (See Appendix D for medication information.)

FAMILY CARE

• Evaluate the level of family functioning and family conflict.
• Help the parents evaluate the effectiveness of their parenting skills, communications skills, and methods of discipline.
• Assist the parents to evaluate family rules and the family's personal expectations about acceptable behaviors.
• Teach the family to set limits on unacceptable behavior.
• Explore the use of behavior modification techniques and behavior contracts to reinforce desired behavior.
• Help the parents not to focus continually on negative behavior but to also recognize positive behavior.
• Work with the parents to role model healthy expression of emotions and ways to identify and meet social needs.
• Initiate referral for family therapy if deemed appropriate.

Oppositional Defiant Disorder

DSM-IV CATEGORY

313.81 Oppositional defiant disorder

The main characteristics of Oppositional defiant disorder (ODD) are negative, defiant, and hostile behavior. The onset of Oppositional behavior occurs between ages 3 and 19. The child is argumentative, disobedient, uncooperative, stubborn, and often vindictive. There is active defiance of requests and a refusal to abide by the rules. Low self-esteem, a low threshold of frustration, and outbursts of temper may accompany this disorder. These children persist in Oppositional behavior even when it is detrimental to their personal well-being. Although they don't violate the rights of others, they behave in ways that are extremely distressing to parents, teachers, and other authority figures. ADHD may occur concurrently with ODD.

There is no specific biological basis for ODD. Many children who manifest ODD come from families in which there is parental rejection, severe family conflict, and inconsistent or punitive discipline.

COMMUNICATION STRATEGIES

• Respond to interactions, keeping in mind the client's developmental stage.
• Acknowledge and discuss the client's feelings of shame, guilt and anxiety.
• Don't allow the client to control the situation. Develop a behavioral contract that allows the client to negotiate for privileges.
• Communicate patiently with the client, and let the client know that when limits are exceeded, consequences will occur.
• Don't argue with the client.

Long-Term Goal
The client will utilize strategies to reduce episodes of oppositional behavior.

Short-Term Goal #1:The client will identify and explore negative thoughts and feelings.

Interventions and Rationales

• Help the client to recognize and discuss anger and resentment. Awareness of anger helps the client identify the causes behind the negative behavior.
• Have the client identify events and situations that precipitate negative thoughts and feelings. The client gains self-knowieage and beginning self-control by recognizing which events and suctions frequently cause negative thoughts and feelings to arise.
• Discuss the client's perceptions of reality because there is a tendency to blame others rather than accept responsibility for one's own behavior. Correcting self-perceptions of situations and accepting responsibility for one's behavior reinforce reality and promote the client's well-being.
• Help the client to analyze past experiences and identify the consequences resulting from negative thoughts and feelings. Assisting the client to review past experiences allows for evaluation of past unhealthy behaviors.

Short-Term Goal #2:The client will learn and practice positive, alternative behaviors.

Interventions and Rationales

• Assist the client to maintain control of temper and frustrations. The client often needs assistance to retain or regain control of behavior.
• Provide sufficient time, and encourage the client to use drawing as a vehicle for self-expression. Clients, especially young children, can draw what they are experiencing and feeling even wher. they are unable to verbally express themselves.
• Teach the client to talk about troublesome situations, decide o-options, and recognize consequences as a way to problem solve. Learning healthy substitutes for inappropriate behavior gives the client various ways to handle problematic situations.
• Talk about the consequences related to situations in which the client pushes the limits or does the opposite of what is expected. Discussing behavior gives the client new ways to view how oppositional behavior promotes rejection.
• Establish a contract for making behavior changes. Knowing what behavior is expected and what rewards and consequences result from certain behaviors empowers the client to make conscious decisions about behavior.
• Have the client undertake a new activity or play situation that provides the client with an opportunity to experience positive feelings. New experiences promote opportunities to practice skills and positive behaviors.

THERAPIES

Play therapy and group therapy provide the client with mechanisms for self-expression, ways to learn coping skills, and feedback about current behavior.

Family Therapy

• Teach the family about factors that predispose children to op-positional defiant behavior.
• Encourage discussion of problems and resolution of family conflicts.
• Recognize family struggles and low self-esteem in parents,
• Assess for defiant behavior in parents.
• Work to establish effective communication between parents and child.
• Assist the family to demonstrate consistent behaviors and expectations and to develop effective discipline strategies.
• Assist the parents to develop parenting skills, appropriate family rules, adaptive coping skills, and clear boundaries between the parent and child generations.

Play Therapy

• Allow the client to play out needs.
• Enable conflicts to be expressed and resolved.
• Allow the client to present view of reality.
• The client can relate personal stories to the nurse.
• Help client learn ways to follow rules.

Group Therapy

• Fosters learning and refinement of communication skills.
• Promotes development of problem-solving and social skills.
• Provides an environment to safely discuss feelings.
• Focuses on behaviors that need change.
• Encourages the client to learn alternate behaviors through observation and imitation of the therapist and others.

MEDICATIONS

• Antianxiety drugs help alleviate anxiety states and produce mild sedation.
• Lithium and tricyclic antidepressant drugs reduce symptoms of depression. (See Appendix D for medication information.)

FAMILY CARE

• Educate the parents about child and adolescent growth and development.
• Teach and reinforce parenting skills and healthy discipline methods.
• Advise the parents that they can prevent defiant behavior by teaching the child self-management skills.
• Encourage the parents to determine if their stress level is high. thus rendering them unable to be emotionally available to the child.
• Determine if the parents believe that the child does not love them or is out to get them because this belief may make them more resentful and controlling.
• Explain to the parents that patience is more easily developed if they can separate the child from the oppositional behavior.
• Teach the parents about strategies for building the child's self-esteem.
• Teach the parents how to identify and intervene when the child or adolescent is at risk for self-destructive behaviors.
• Assist the parents to monitor the child's academic performance because lack of interest in school compounds the child's problems.