Psychosocial_Abuse and Neglect_Chronic Illnesses and Loss

Attention deficit hyperactivity disorder (ADHD, ADD)

Diagnostic criteria for ADD and ADHD include symptoms of inattention, impulsivity, and hyperactivity.

Most prevalent, common neuro-behavioral disorder of childhood
Deficiency in self regulation
5 - 10 %, more common in boys

Unknown theories focus on:
Genetic as 10-35% have a first degree relative with symptoms
Physiological - Deficiency in dopamine
Environmental - head injury, lead poisoning, prenatal cigarette and alcohol exposure

Symptoms generally present before age 7
Clear evidence of social, academic or occupational impairment
Impairment from the symptoms are present in two or more settings
The symptoms do not occur just during a mental disorders presentation
Nursing Care involves tracking growth and development

ADHD’s principal characteristics are inattention, hyperactivity, and impulsivity.

Symptoms of Hyperactivity-Impulsive Type:
• Restlessness, often fidgeting with hands or feet, or squirming while seated
• Running, climbing, or leaving a seat in situations where sitting or quiet behavior is expected
• Blurting out answers before hearing the whole question
• Difficulty waiting in line or taking turns

Symptoms of Inattention Type:
• Ignores details; makes careless mistakes
• Has trouble sustaining attention in work or play
• Does not seem to listen when directly addressed
• Does not follow through on instructions; fails to finish

Symptoms of Combined Type (most children and adolescents with ADHD have this type):
• Demonstrates symptoms of both inattention and hyperactivity-impulsivity (six or more symptoms of both)
• Has symptoms that have persisted for at least six months

Inattention, poor planning, organization, and time management
Trouble with schools, teachers, friends

How It Is Diagnosed
ADHD can be difficult to diagnose.
A diagnosis of ADHD is based on the number, persistence, and history of symptomatic behaviors
Parents or teachers may be the first to notice possible signs of ADHD.
Diagnosis of adult ADHD is based on symptoms, impairments, and history.
Diagnosis should be made by a professional with training in ADHD or mental disorders.

CDC's Checklist/Survey:
Simply fill out the child's name, age and today's date and then check off the signs or symptoms the child has shown. Take the completed checklist to your child's health care provider.

Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is inappropriate for developmental level
* Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.

* Often has trouble keeping attention on tasks or play activities.

* Often does not seem to listen when spoken to directly.

* Often does not follow through on instructions and fails to finish schoolwork, chores, or duties (loses focus, gets sidetracked).

* Often has trouble organizing activities.

* Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort for a long period of time (schoolwork)

* Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools).

* Is often easily distracted.

* Is often forgetful in daily activities.

Hyperactivity / Impulsivity
Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level

* Often fidgets with hands or feet or squirms in seat when sitting still is expected.

* Often gets up from seat when remaining in seat is expected.

* Often excessively runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).

* Often has trouble playing or doing leisure activities quietly.

* Is often "on the go" or often acts as if "driven by a motor".

* Often talks excessively.

* Often blurts out answers before questions have been finished.

* Often has trouble waiting one's turn.

* Often interrupts or intrudes on others (e.g., butts into conversations or games).

What do you see?

Ask a relative, friend, coach, teacher or child care provider to tell you what your child does.

Print a blank checklist and forward them.


Stimulant medication: Ritalin, Dexedrine, Adderall (increase availability of dopamine increasing concentration and attention) Side effects - anorexia, weight loss, abdominal pain, headache, insomnia, tachycardia, hypertension

Antihypertensive medications Clonidine or Tenex (decrease impulsivity)

Antidepressants (Strattera) selective norepinephrine reuptake inhibitor (not controlled substance,not habit forming, not for drug abuse) Observe for liver damage

Behavior management: help to follow rules, complete tasks, positive reinforcement
Educational interventions: developmental disability free public education, least restrictive environment
Family education: Caregivers not at fault, support groups

Possible Nursing diagnoses:
Impaired social interaction
Risk for injury
Chronic low self esteem
Compromised family coping

Acceptable social skills, improved ability to interact with peers
Free of injury, free from unnecessary risk
Increased feelings of self worth
Identify family coping strategies for disruptive behaviors
Appropriate limit setting and environmental structure

Teaching about medication regimen and side effects
Height, weight BP monitored
Drug holidays
Home care (time routines for waking, homework, chores; Clear written rules; Simple instructions with demonstration, ask to repeat back; 1 or 2 instructions at a time; special quiet spot, choices within time limits,; Self expression, activities that feed sense of success, sleep schedule)
Evaluate care

School phobia
School avoidance, school refusal
Notable that symptoms subside after misses school and on weekends
Reentry programs combine readying for school with relaxation techniques

Recurrent abdominal pain

Clinical Manifestations:
Three episodes of abdominal pain in 3 months that interferes with functioning and has spastic bowel symptoms
Pain irregular in time, duration, and intensity

Often occurs in sensitive over achievers who are not comfortable with expressions of anger from caregivers

Acid reduction agents and antispasmodics
Rest, comfort, quiet, heating pad

Separation anxiety
School Phobia
Social Phobia
Generalized anxiety disorder (GAD - 10-20%) excessive worry about future events, worriers, perfectionists
Separation anxiety disorder (SAD)
Obsessive-compulsive disorder recurrent, intrusive, thoughts, fears (cleanliness, aggressive thoughts, worry, symmetry); obsessive, compulsive rituals or behaviors (washing, repeating, checking, counting, ordering, touching) Behaviors aimed at reducing stress or preventing a dreaded event

Post traumatic stress disorder
* Social anxiety can lead to depression - deficit social skills lead to ineffective interactions with environment and peers leading to lowered self esteem.

Clinical Manifestations:
Stomachaches, headaches, nausea, vomiting
Vertigo, palpitations, faintness
Restlessness, fatigue, difficulty concentrating
Irritability, sleep disturbances, muscle tension

Assessment developmental, social history, and coping styles
Anxiety that interferes with ability to function, perform

Reduce symptoms, relieve distress
Minimize disability
Enhance developmental potential
Consultation with schools
Cognitive behavioral therapies
Pharmacological therapy adjunct (antidepressants, maybe benzodiazepines short term)

Nursing Diagnosis:
Fear related to separation
Impaired social interaction
Ineffective individual coping

Normal development with minimal anxiety
Child will attend school, social functions with minimal anxiety
Child will initiate social interactions
Child will cope with anxiety
Child will use relaxation, deep breathing, self talk to control anxiety

Include child in care
School nurses to note changes
Child to identify outlets for anxiety
Evaluation can child attend school

Mood disorders/Depression:
2 types: Major depressive disorders (MDD); Dysthymic disorders (DD) less intense but more chaotic

Signs and Symptoms:
• Depressed mood
• Frequent sadness, tearfulness, or crying
• Feelings of hopelessness
• Loss of interest in favorite activities
• Lack of enthusiasm, energy or motivation
• Changes in eating or sleeping habits, or fatigue
• Relationship difficulty and/or social withdrawal
• Increased irritability, anger or hostility
• Frequent physical complaints
• Poor concentration, forgetfulness, indecision
• Feelings of worthlessness or excessive guilt
• Extreme sensitivity to rejection or failure
• Talk of running away or actually running away
• Poor school performance or excessive absences
• Talk or thoughts of suicide, or self-destructive behavior

Distinction between sadness and depression = duration * Depression exists most of the day, almost everyday for at least 2 weeks.

Children's depression inventory
Children's depression rating
Physical assessment to rule out Mono, seizure disorder, hypo/hyperthyroidism, drug abuse/withdrawal

Psychotherapy: individual, family, play and group therapy and cognitive behavioral therapy (CBT - behavior modification to change negative cognitions)

Psychotropic medications (not tricyclic antidepressants (Tofranil, Elavil) but selective serotonin reuptake inhibitors (SSRI - best due to low side effects, low lethality, easy administration once a day -Prozac, Zoloft, Paxil)

Hospitalization for safe controlled environment (firearms used in 67%), inadequate supervision, agitated behavior, mania, intoxication, substance abuse, psychotic, male, prior attempt, familial history for completed suicide)

Teach coping, parenting skills, to identify risk factors,
Care for, debriefing, support groups for care givers/family

Warning signs of suicide:
3rd leading cause of death during the teen years
Plan that includes a method, place, time, clear intent, and no rescue plan
Major life changes
Conflict with care givers
Suicidal clues/hints giving away possessions
Decreased performance in school
Accident proneness
Mood swings
Withdrawal from family and friends
Increase in drug or alcohol use
Change in appetite
Loss of interest in personal appearance

Nursing management:
Mood - using variety of words - sad, depressed, blue, down, unhappy
Somatic complaints
Sleep patterns
Family life
Recent stressful events
Have you ever so sad that you thought about killing yourself or wished you were dead?
If yes, ask about the plan - method, time, place, availability of means, lethality, support system, resources
Have you ever done anything on purpose to hurt or kill yourself?

Nursing Diagnoses:
Low self esteem
Impaired social interaction
Disturbed sleep
Risk for injury, self directed
Risk for use of drugs, self medication

Express positive feelings
Interact appropriately
Demonstrate less withdrawal
Safe from harm, free from self injurious behavior, or high risk activity engagement

Education of child and family
Education on S&S of depression/suicide
Education that SSRI can take a few weeks for full effect
Sleep: BR just for sleep, no naps, routine, physical exercise, limit caffeine

Substance Abuse

Substance abuse maladaptive use of substances leading to impairment and distress, "self-medicating"
Substance dependence withdrawal - adverse physical symptoms, tolerance and loss of control over use
Substances used: alcohol, tobacco, marijuana, opiates, cocaine, amphetamines, barbiturates, hallucinogens, inhalants

Family factors
Peer influence
Individual factors
Neighborhood factors

Vary depending on the substance, the age and weight of the child
CNS Depressants - Alcohol, barbiturates. Calmness, drowsiness. Toxicity decreased coordination, judgment, accidents, respiratory depression, coma, death
Opiates - euphoria, analgesia Toxicity respiratory depression, cerebral edema, death
CNS Stimulants - Amphetamines - well-being, euphoria. Toxicity hypertension, hyperthermia, convulsions, CV shock
Hallucinogens - alter perceptions, feelings Side effects - convulsions, cardiovascular collapse

Physical Signs and Symptoms:
Bloodshot eyes
Weight loss
Nasal irritation
Slurred speech
Abnormal pupil dilatation or constriction
Increase in accidents/injuries
Gather information from a variety of sources

Nursing management:

Irrational behavior
Preoccupation with occult
Absences from school
Decline in school/work performance
Lethargy, hyperactivity, agitation
Changes in personality, friends, activities, appearance
Mental or physiological deterioration
Loss of money, paraphernalia

Varies depending on substance
Inpatient, residential, day treatment depends on other disorders, hx treatment failure, risk for withdrawal
Pharmacotherapy - treatment of withdrawal
Self help, peer support - Alcoholics Anonymous (AA), Narcotics Anonymous (NA)
Changes in lifestyle, coping

Eating Disorders
Anorexia Nervosa (AN)
Primarily females, 10-19

Theoretical Causes:
Disturbance in levels of neurotransmitters
Individual or Familial conflicts, issues with control


Extreme weight loss
Refusal to eat
Irrational fear of being overweight
Pronounced disturbance in body image
Physical manifestations - amenorrhea, hypothermia, muscle wasting, cardiac dysrhythmias, hypotension, brittle nails

< 85% of expected weight
Altered body perceptions

Initially improvement in weight, normalization of eating patterns, restoration of health
Correction of F&E imbalances
Hospitalization brief to restore health, weight cannot be gained too quickly or it can lead to cardiac overload
Target goal weight gain to within 10% of ideal body weight
Individual therapy - to correct distortions, patient may experience significant fear/anxiety as begin to gain weight
Family therapy - to correct disturbed patterns of interaction
Pharmacologic interventions, SSRIs
Nursing management - kind, nurturing but firm, interventions to ^ self esteem beyond thin body

Bulimia Nervosa (BN)
Binge eating followed by guilt and purging with vomiting and laxative use
Usually female ages 15 -30, peak 18-19
Risk includes involvement in sports which require low body weight, abuse, familial history of depression or eating disorders
Binge/purge activities may occur several times a day
Bulimics lose the ability to response to normal hunger and satiety
Complications - dehydration, esophagitis, tooth erosion
Diagnosed by binge eating, sense of lack of control over eating, vomiting, misuse of laxatives to avoid weight gain

Individual, family and group therapy
Pharmacologic interventions, SSRIs
Behavior modification, CBT

Failure to Thrive (FFT)
Organic FFT caused by a physical problem (< common, usually gastroesophageal reflux, celiac, pyloric stenosis, heart disease, CNS or endocrine disturbances)
Non-organic FFT (more common, poverty, lack of social support, family stress, errors in formula prep, caregiver knowledge deficit, inadequate breast milk, attachment difficulties)

Growth failure
Failure to maintain weight gain
Loss of SQ fat
Reduced muscle mass
Developmental delays

Observation of dietary interventions

Catch up growth - 150% of recommended calorie intake
Multidisciplinary team with dietician, etc
Nursing management - observation of caregiver child, feeding schedule, education, monitors weight gain, intake, output, role model appropriate interactions, non-blame, encourage family members

Self-Injury from a Youth Development Perspective
• Self-injury is most common in youth having trouble coping with anxiety.
Focus on skill building and identifying environmental stressors that trigger self-injury.

• Self-injury is most often a silent, hidden practice aimed at either squelching negative feelings or overcoming emotional numbness.

* Being willing to listen to the self-injurer while reserving shock or judgment encourages them to use their voice rather than their body as a means of self-expression...drawing

• Self-injury serves a function. An important part of treatment is helping youth to find other, more positive ways to accomplish the same psychological and emotional outcome, i.e. explicitly teach coping skills.

• Assessment and treatment should seek to understand why youth self-injure and then build on the strengths youth already possess.

Cutting/Eating disorders:

Abuse and Neglect, Chronic Illness and Loss

Abuse and Neglect

Child maltreatment – intentional injury of a child includes:
Child Neglect – harmful, malicious withholding of physical, nutritional, health care, emotional or educational necessities
Physical abuse
Psychological abuse
Sexual abuse

Child Neglect:
Inadequate care (inadequate food, clothing, hygiene, healthcare, supervision, drugs)
Inadequate physical care (lack of heat, water, plumbing, beds, garbage, structural chemical, hazards.
Inadequate parenting (school absences, inappropriate discipline, locked out, no limits)

Physical abuse most common:
*Primary cause of death with abuse most often neurological damage -Head – hematomas, lacerations, bruises, brain injuries, shaken baby
*Second most common cause of death from abuse is abdominal damage to internal organs – chest, abdomen, liver, pancreas, spleen, kidney, bladder
* Also, skin, bruises, burns, bites, lacerations and skeletal damage

Psychological damage:
Lack of attention
Lack of affection
Lack of supervision
Children birth to 1 highest rate

Risk factors for abuse:
Stress without social supports
Intolerance of normal development, inappropriate expectations
Intensity of involvement criticism
Coercive actions deficient parenting skills
Right to influence authoritarian, punitive, neglectful
Characteristics 20’s, no diploma, little coping, poverty level
Patterns of abuse intergenerational
Privacy of the home secluded
Difficult transitions births, deaths, separation, loss, unemployment, alcohol

Signs of physical abuse:
Old and new bruises
Bruises on skull, face, buttocks, breast, abdomen
Burns, welts, whip marks
Injury inconsistent with history
Spiral fractures
Burns – scald, immersion, stocking, flexion, splash
Behavioral indications
Hyper alert, increased startle,
Over eager to please
Anxiety hearing children cry
Lack of attachment
Extremes - Aggressive, detached, withdrawn
Day dreaming, staring

S&S Shaken Baby
Extreme irritability
Vomiting with no fever or other signs of illness
Seizure, bulging fontanelles
Redness in eye

Shaken Baby Syndrome –
profound neurological impairment, retinal hemorrhages, subarachnoid, subdural hemorrhages, unconsciousness, scarring, paralysis…

Shaken Baby

Munchausen syndrome by proxy:
Caregivers fabricate signs and symptoms of disease or cause illness in their children
Expose their child to harmful, painful medical procedures.
Treatment is ineffective
Previous child death or illness in family
Attention seeking

Assessment for abuse:
Location, color, size, shape, of any injuries
Characteristics of bruises
Pain, tenderness associated with injury
Level of hygiene
Date, time, place of event
Chronological account of injury
Exact quotations
Does the account make sense, is it consistent with injury

Caregiver’s willingness to share
Cooperative nature
Empathy toward child
Nonverbal (eye contact)
Child-caregiver relationship

When interviewing the child:
Private, assure confidentiality
Reassure, not in trouble
Use child’s own words in documentation
Allow time to express self and talk
Encourage child to show injuries
Use therapeutic play
Reassure child it is ok to share with caregiver (nurse)

Psychological Abuse:
Ignoring, degrading child
Rejecting child
Isolating child
Terrorizing, threatening child
Verbally assaulting child
Exploiting child
Pressuring child into older responsibilities
Exposing child to violence


Sexual abuse can include:
Assault, statutory, date, rape, incest
Child molestation

Signs and symptoms may include:
Difficulty walking or sitting
Unusual or precocious sexual knowledge or activity
Reports of regression - bed wetting, nightmares
Suddenly refuses to change for gym
Sudden change in appetite
Jealous, controlling family members who isolates child from others

Chronic Illness/Loss and Bereavement
Children who are at risk to develop a chronic physical, developmental, emotional or behavioral problem, which necessitates intervention beyond what is generally required.

Affects the child – lost school days, delays, emotional stresses, scheduling, time consuming treatments
Affects the parents or guardian – lost work days, stress, and fear, finances, time management
Affects the siblings – embarrassed, guilt, anger, fear

Focus is on the developmental level not chronological age or illness

Disability versus handicap?

*A child’s future depends on how well the family functions

Engaged, open, honest, private conversations and teaching
Time for understanding, questions and clarification
Anticipatory guidance…what’s around the corner
Therapeutic relationship
Acknowledge and respect parents expertise
Medical team

Cultural impact
Affects values on life, perceptions, productivity, time, spirituality
Communication, decision making with head of household

Integration into society at large
School, work, hobbies
Assist with support groups
Community resources, early intervention, Baby Net
Maximize potential
Laws - Mainstreaming, individualized educational programs (IEP)

Family adjustment and anticipated stress points:
Initial shock and denial – diagnosis, helplessness, isolation, fear, depression
Resurfaces at times of exacerbation or developmental milestones ~ Chronic Sorrow
Start of school
Reaching ultimate attainment
Future placement

Adaptation includes:
Meeting developmental needs of the child
Meeting developmental needs of the family
Educate others
Establishment of a support system

Peaks and valleys, isolation,
Cope - primary care giver

Feel ineffective as protector
Escape to work to dull pain
Knowledge seeking
Option exploration
Weighing choices

Chronic Sorrow:

Special assistance necessary for single parent families

Changes in recent years as public image of disabled has changed
May feel stigma
Increased responsibility
Decreased family finances, resources, time
Knowledge deficit and increased fear
Support groups can help verbalize feelings

Nurses Assessment of:
Parental Coping
Child adjustment
Family support
Anticipatory guidance
Knowledge level

Approach behaviors move toward acceptance:
Information seeking
Shares burden
Freely expresses sorrow
Acceptance, realistic expectations
Seeks help and resources
Attributes meaning to the disability
Acknowledges personal individual growth

Avoidance behaviors move away from acceptance and adjustment
Fails to acknowledge seriousness of situation
Withdrawal, anger
Resorts to props, alcohol, drugs, self medication
Punishes self, guilt
Magical thinking, defers responsibility of situation
Refuses treatment or conversely looks for cures
Not accepting of disease or reality for future

Expressions of shock and denial:
Physician shopping
Denial of illness, symptoms
Refusal to believe tests
Delaying consent
Withdrawal, asking no questions

Examples of adjustment:
Guilt and self-accusation
Bitterness and anger
Overprotection - sacrifice; restricts growth, play; goals too high or low, no discipline
Rejection - detachment
Denial – deny disorder or overcompensate
Gradual acceptance – promote physical, social, self care activities

Adjustment can be affected by:
Support system – marriage, extended, alternative, communication
Perception – perception cause, knowledge, effects on family
Coping – rx crisis, rx child, childrearing, religion, culture, attitudes
Concurrent stressors

The child’s coping:
Competence and optimism
Irritable, moody, acts out
Seeks support

Communication and encouraging expression:
Describe the behavior – “You seem angry today…”
Give evidence of understanding – “Being angry is natural…”
Give evidence of caring – “ It must be difficult to endure all this…”
Help focus on feelings – “Maybe you wonder why this has happened…”
Clarification – repeat words of pt./family for clarity, “So you are saying you feel sad”
Silence – is OK, listen, you do not always have to respond
Caring touch
It is alright not to know the answer, “I don’t know but I will find out for you”
Community resources
Parent to parent – locally Family Connections
Respite care

To assist the child:
Prepare them for the reality of the disorder or disability
Allow for participation and self-care, ownership

Chronic Illness:

Loss and Bereavement:

While we typically think of loss as related to death, it can be related to many different situations.
Loss of possession
Pet loss

Child’s concept of death is dependent on age, development and cognitive ability:
Young children:
Death is temporary, reversible, fear separation
Physically may experience decreased activity, appetite, regression
Emotionally may experience fear, anxiety, irritability

School age:
Understand death is not reversible, not inevitable, fear mutilation
May experience depression, fear of rejection, fantasies of reuniting with loved one
Older children (9/10) death irreversible, inevitable, universal but deny own death, experience guilt
*Surviving siblings - physically may exhibit concern over own health, abdominal pain, headache, body aches, nausea, joint and muscle pain

Understand death is permanent
May experience betrayal, anger, withdrawal
Physically may note a decreased or increased activity, appetite
Increase in risky behavior

Expected stages of grief:
Kubler-Ross stages (1969)
Denial – It’s not true
Anger – I hate you
Bargaining – I’ll behave if you stay…let her stay
Depression – Sorrow, don’t leave me…
Acceptance – My friend is in Heaven

Worden suggests that children need to be assisted with acceptance

Task 1: Accept the loss, not believe that the person will return to life
Task 2: Experience the pain or emotional aspects of the loss
Task 3: Adjust to an environment in which the deceased is missing
*Task 4: Relocate the dead person’s memory within one’s life and find ways to memorialize the person

Nursing Measures to help care for the grieving child/family
Physical presence
Repetition may be needed
Utilize books
Acknowledge feelings
Assist with sorting through emotions, acceptance…anger, etc.
Avoid rationalizations
Focus on feelings, good memories

Physical signs of approaching death:
Loss of sensation and movement in lower body moving upward
Sensation of heat although body feels cool
Tactile senses decrease
Sensitivity to light
*Hearing is the last sense to fail
Loss of consciousness, slurred speech
Muscle weakness
Loss of bowel and bladder control
Decreased appetite and thirst
Difficulty swallowing
Change in respiratory pattern
“Death rattle”

Physician health care team
Parental decision making
Treatment options
Hospice or home
Organ donation, autopsy
Fears of pain and suffering, dying alone, death

At death:
Provide for child’s comfort
Do what the parents desire as far as life saving
Allow child and families to relive memories
Express feelings of loss and sorrow too
Provide family with needed information
Allow for respite
Allow time to rock, hold child
Arrange for or offer spiritual support

Attend funeral or visitation
Initiate or maintain contact
Compassionate friends, memorials, and involvement in organizations
Refer to the dead child by name, share memories
Encourage communication and discourage self-medicating to dull pain
Emphasize grief is a process
Different for everyone


Hockenberry, M. J., & Wilson, D. (2009). Wong's essentials of pediatric nursing (8th ed.). St. Louis, MO: Mosby Elsevier.

Potts, N. L., & Mandleco, B. L. (2012). Pediatric nursing: Caring for children and their families (3rd ed.). New York, NY: Delmar Cengage Learning.




Cutting/Eating Disorders

Abuse and Neglect:


Chronic Sorrow:

chronic illness in children

Chronic illness:

Children and grief hospice


Helping children cope with loss

Loss video

Infant mortality

Sibling loss