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Varcarolis’s Canadian Psychiatric Mental Health Nursing Chapter 28: Sexual Assault Instructor’s Manual Thoughts About Teaching the Topic Since the majority of students in Canadian nursing and psychiatric programs are female, and many have not received other information about rape and rape prevention, there will be both social and clinical education for students. Additionally, one or more members of the group may have been victims of sexual assault. As such, the instructor will need to be prepared for expression of strong feelings and may need to refer the student to the available student health services for counselling. Many instructors find it helpful to use audiovisual materials to provide discussion points. Students often respond best when beginning the discussion by being asked to list the concrete measures the emergency department nurse should take to perform an assessment or to preserve evidence during the examination. Mini–role-playing situations can evolve out of the discussion. Key Terms and Concepts aggravated sexual assault blame controlled style of coping expressed style of coping intrusive thoughts rape-trauma syndrome secondary victimization sexual assault sexual assault nurse examiners (SANEs) Objectives Define sexual assault and aggravated sexual assault. Describe the profile of the survivor and the perpetrator of sexual assault. Distinguish between the acute and long-term phases of the rape-trauma syndrome, and identify some common reactions during each phase. Discuss a trauma-informed approach and describe three related practices. Reflect on one’s own thoughts and feelings and consider the myths about sexual assault and its impact on survivors. Identify five areas to assess and six overall guidelines for nursing interventions related to sexual assault. Instructor’s Manual 28-2 Discuss the long-term psychological effects of sexual assault. Identify three outcome criteria that would signify successful interventions for a person who has suffered a sexual assault. Chapter Outline Teaching Strategies Introduction Sexual assault is a legal term that refers to any sexual activity for which consent is not obtained or freely given (also referred to as sexual violence). Sexual harassment and stalking, also criminal behaviours that are sexual in nature, are not, however, classified as assault. Sexual assault violates the sexual integrity of the victim and can result in a range of injury from no injury to serious injury. Using a weapon, threatening, or even endangering the life of the victim during a sexual attack are all defined as sexual assault; however, sexual assault or violence is more often much less extreme yet nonetheless equally traumatic (Brennan & TaylorButts, 2008). Sexual assault is not about sex but, rather, is an exertion of power and control over another individual. Children, older adults, women, and men can all be victims of sexual assault. Sex offenders may commit acts of sexual violence against children, which are considered sexual abuse (see Chapter 27). These offences are termed sexual interference, invitation to sexual touching, incest, and sexual exploitation in the criminal justice system. Aggravated sexual assault is another legal term that is used when, during a sexual assault, the life of the survivor is endangered or the assault results in injury. Regardless of the descriptor or legal framework of a sexual assault, it is an act of violence. The Canadian Nurses Association’s 2008 position statement on violence outlines the serious implications violence has on the physical and mental health of individuals, families, and society. In particular, research has demonstrated the significant mental health impacts of sexual assault. Epidemiology Sexual assault is a topic people are reluctant to discuss because it is attached to much anguish, blame, shame, and desperation. The silence, however, has far-reaching impacts—it is estimated that 90% of sexual assaults in Canada go unreported. Nonetheless, over 22 000 sexual assaults were reported nationwide in 2010, according to Statistics Canada (2013). Everyone is at risk for sexual assault—it crosses all socioeconomic groups; ages, from infant to older adult; genders; sexual orientations; abilities; and cultural groups (Association of Alberta Sexual Assault Services, 2010). Recent research studies, though, have identified particular risk and resiliency factors to mental health post-assault. It has been noted that rates of post-traumatic stress disorder (PTSD) are two to three times higher for survivors of sexual assault than for any other trauma, including other crimes, motor vehicle accidents, and even disasters (Foa & Street, 2001; Kessler, Davis, & Kendler, 1997). Women who have been sexually assaulted have rates of health care utilization as much as four to five times higher than nonassaulted women and higher rates of chronic disease, particularly if they have mental health effects such as PTSD, depression, or substance abuse (Max, Rice, Finkelstein, et al., 2004). Another important pattern of disease resulting from sexual assault is the concern for secondary victimization. Secondary victimization results when survivors experience further stress or trauma when seeking help, through practices such as victim blaming, delays in treatment and having to repeat the story of assault in numerous interviews. Profile of Sexual Perpetrators Perpetrators are almost always men and tend to be young. About 43% of abusers are under the influence of alcohol or drugs at the time of the offense. A large majority of reported sexual assaults were committed by a friend or acquaintance of the victim. Police-reported data have indicated that 68% of aggravated sexual assaults occur at or near a residence (Brennan & Taylor-Butts, 2008), including at the victim’s or perpetrator’s home, at a house party, or in an outdoor party setting. Relationships Between Victims and Perpetrators The psychological and emotional outcomes of sexual assault seem to vary depending on the level of intimacy and the relationship between the victim and the perpetrator. Sexual distress (including post-assault sexual problems such as dysfunction and pain) is more common among women who have been sexually assaulted by intimate partners; PTSD symptoms are common among those assaulted by someone they know; and fear and anxiety are more common in those assaulted by strangers. Depression has been found to be common among survivors, whether the perpetrators were known to them or not (Carter-Snell & Jakubec, 2013). Psychological Effects of Sexual Assault Most people who are sexually assaulted suffer severe and longlasting emotional trauma. Long-term psychological effects of sexual assault may include depression, suicide, anxiety, and fear; difficulties with daily functioning; low self-esteem; sexual dysfunction; and somatic complaints. Rape-Trauma Syndrome: Acute Phase This phase occurs immediately following the assault and may last for 2 weeks. Symptoms include shock, numbness, disbelief, disorganization in lifestyle, cognitive impairment with confusion, poor concentration, poor decision making, and somatic symptoms. Hysteria, restlessness, crying, and smiling may be noted. Denial after assault is a protective action to give the person time to prepare for reality. Long-Term Reorganization Phase of Rape-Trauma Syndrome This phase occurs 2 or more weeks after the rape. Nurses can help the patient prepare for reactions that are likely to occur, such as intrusive thoughts of the event; flashbacks; dreams; insomnia; increased motor activity; anxiety; mood swings; development of fears and phobias (e.g., fear of indoors or outdoors, being alone, crowds, sexual activity). Intervention and support for the survivor can help prevent sequelae such as anxiety, depression, suicide, difficulties with daily functioning, interpersonal relationships, sexual dysfunction, and somatic complaints. Application of the Nursing Process Trauma-Informed Approach The impact of trauma may be felt throughout an individual’s life in areas of functioning both related to and far removed from the trauma. Using a trauma-informed approach in the care of patients who have experienced sexual assault appropriately responds to the deep and profound impact of trauma. This approach emphasizes the physical, psychological, and emotional safety of both patients and caregivers and creates opportunities for patients to rebuild a sense of control and empowerment. A trauma-informed approach can include a range of specific practices (Box 28-2). Assessment The nurse talks with the victim, people accompanying the victim and police to gather data. Interventions include treatment and documentation of injuries, treatment for sexually transmitted disease (STD), pregnancy risk evaluation and prevention, crisis intervention and arrangements for follow-up counselling, and collection of medicolegal evidence while maintaining the proper chain of evidence. Assessment should ascertain the level of patient anxiety, coping mechanisms used, availability of support systems, signs and symptoms of emotional trauma, and signs and symptoms of physical trauma. A sexual assault nurse examiner or forensic nurse specialist may perform these activities. General Assessment The nurse should gather data from the survivor, family, friends, and police and then analyze assessment findings to formulate nursing diagnoses. Level of Anxiety Patients in severe to panic-level anxiety will be unable to problem solve or process information. Nursing intervention should focus on lowering patient anxiety to moderate or below, where goals can be set and information assimilated. Coping Mechanisms The same coping skills that have helped the patient before are used in adjusting to the rape. New ways may also be developed. Behavioural responses include crying, withdrawing, smoking, wanting to talk about the event, or acting hysterical, confused, disoriented, or incoherent—even laughing or joking. These behaviours are examples of an expressed style of coping. A controlled style of coping reaction is evidenced by masked faces; calm, subdued appearance or shocked, numb, confused appearance; distractibility; and indecisiveness. An emotional style of coping reaction is evidenced by anxiety, shock, humiliation, embarrassment, self-blame, low self-esteem, shame, guilt, and anger. If the nurse can help the patient verbalize the patient’s thoughts, understanding of his or her cognitive coping mechanisms can be gained. The nurse can facilitate this process with questions such as, “What do you think might help?” “What can I do to help you in this difficult time?” Support Systems Available Availability, size, and utility of a survivor’s social support system need to be assessed. Often partners or family do not understand rape and may not be good supports. Be alert to the victim’s nonverbal communication. Signs and Symptoms of Emotional Trauma The extent of psychological trauma may not be readily apparent from behaviour, especially if the person uses the controlled style of coping during the acute phase of rape trauma. Conduct a nursing history. Allow the patient to talk at a comfortable pace. Pose questions in nonjudgemental descriptive terms. Avoid “why” questions. If suicidal thoughts are expressed, assess what precautions are needed by asking direct questions. Signs and Symptoms of Physical Trauma Characteristic physical signs of rape involve injuries to the face, head, neck, and extremities, which should be documented on a body map. The nurse takes a brief gynecological history, including last menstrual period, likelihood of current pregnancy, and history of sexually transmitted disease (STD). The pelvic examination should be explained, understanding that the patient may see it as another body violation. Medicolegal evidence must be collected and preserved. Explanations should be given along with support and reassurance. Consent forms must be signed for photos, pelvic examination, collection of body fluids for DNA testing, and the like. Be sure to follow agency protocols to preserve evidence. HIV testing may be advised. Pregnancy prophylaxis and STD prevention may be undertaken. Self-Assessment A nurse’s attitude, belief in myths about rape, and preconceived judgements can influence the care given to rape victims. Nurses must examine their feelings about abortion because a patient might choose to abort a fetus produced as a result of rape. Assessment Guidelines: Sexual Assault There is a list of suggested methods to assess the victim of sexual assault in the text. The guidelines help the nurse to assess psychological trauma, level of anxiety, physical trauma, support systems, and how to encourage the patient to share the traumatic experience. Documentation of assessment data is also addressed in the guidelines. Diagnosis Rape-trauma syndrome, Rape-trauma syndrome: compound reaction, and Rape-trauma syndrome: silent reaction are useful diagnoses. All three include an acute phase of disorganization and a long-term phase of reorganization. Rape-trauma syndrome: compound reaction includes reliance on alcohol or other drugs or reactivated symptoms of previous physical or psychiatric illness. Rape-trauma syndrome: silent reaction applies when the individual is unable to describe or discuss the rape but manifests other behaviours such as change in relationships with men, nightmares, phobic reactions, or marked changes in sexual behaviour. Outcomes Identification Examples of short-term survivor goals are: Patient will begin to express feelings about assault before leaving the emergency department; will speak to community-based rape victim advocate before leaving the emergency department; will keep follow-up appointment. Examples of goals for long-term reorganization phase: Patient will discuss need for follow-up crisis counselling and other support; will state that the acuteness of memory of the rape is less vivid and less frightening by 3 to 5 months; will state that physical symptoms have subsided within 3 to 5 months. Planning Since individuals are mainly treated in the ER, treatment must include follow-up support and care. Implementation Rape is considered an acute adventitious crisis. A return to previous level of functioning requires mourning losses, experiencing anger, and working through fears. Counselling The survivor may be too traumatized, ashamed, or afraid to come to the hospital and may use a telephone hotline instead. Nurses’ attitudes have important therapeutic effects but can also be further traumatizing and revictimizing. Provide nonjudgemental care and maximum emotional support. Confidentiality is crucial. Listen and let victim talk. Feeling understood allows patient to feel more in control of the situation. Help patient separate issues of vulnerability from blame. Focusing on one’s behaviour, which is controllable, allows survivor to believe that similar experiences can be avoided in the future. If the survivor consents, involve her support systems, and discuss with her the nature and trauma of sexual assault and the delayed reactions that may occur. Social support moderates somatic symptoms. Promotion of Self-Care Activities Give referral information and follow-up instructions verbally and in writing. Anxiety is likely to affect the amount of verbal information the patient can retain. Follow-up Care Caring for survivors needs to include physical and psychological care. Survivors may seek help from medical professionals rather than from mental health professionals because medical treatment is more socially acceptable. Outpatient nurses can make a more focused assessment and referral if they are aware of the stigma patients may feel. Reassessment should take place in person or by phone within 24 to 48 hours. Follow-up visits for assessment and necessary treatment should occur at 2, 4, and 6 weeks after the initial evaluation. Patients should be assessed for psychological progress as well as the presence of STD and pregnancy. Advanced-Practice Interventions Sexual Assault Nurse Examiners Internationally, forensic nursing is becoming a specialty, and the largest subspecialty of forensic nursing is caring for the sexual assault survivor. This role is filled by the sexual assault nurse examiner (SANE). Training to become a SANE requires knowledge and skill in the areas of testing and treatment for sexually transmitted infections; collection of forensic evidence; assessment of injuries; documentation; typical survivor responses and crisis intervention; collaboration with community agencies, such as police and women’s shelters; and physical assessment and examination to determine the effects of the sexual assault. Advanced-Practice Interventions: Survivors The survivor is likely to benefit from individual therapy, group therapy, or a support group to alleviate emotional trauma such as fears, phobias, nightmares, or flashbacks. Some survivors are susceptible to psychotic episodes or emotional disturbances so severe that hospitalization is necessary. Depression and suicidal ideation are frequent sequelae. Advanced-Practice Interventions: Perpetrators Therapy is essential for behavioural change to occur, but few acknowledge the need, and no single method or program has been found to be totally effective for perpetrators. Evaluation Survivors are evaluated as recovered if they have an absence of signs and symptoms of PTSD (i.e., sleep well, with only a very few instances of nightmares; eat according to pre-rape pattern; are calm, relaxed, or only mildly suspicious, fearful, or restless; show minimal or no strain in relationships with family and friends; are generally positive about selves; and are free from somatic reactions). CONCEPT MAP Some students, especially those who are visually oriented, find use of a concept map is helpful in learning. On the following page is a concept map for rape. Varcarolis’s Canadian Psychiatric Mental Health Nursing Chapter 29: Disorders of Children and Adolescents Instructor’s Manual Thoughts About Teaching the Topic Most instructors will spend only enough time to give students a broad overview of nursing care of patients with psychiatric disorders of childhood and adolescence, since this is considered a specialty area. But nurses often act as community resources and are asked questions by neighbours, friends, and families. At a minimum, it is important for them to develop a broad base of information and to be able to recognize when a child’s behaviour indicates that consultation with a mental health professional is warranted. Key Terms and Concepts assent Chapter Outline Teaching Strategies Many children and adolescents may struggle with a disabling mental illness, but most go unnoticed and unidentified. Until The Mental Health Strategy for Canada was released by the Mental Health attention deficit–hyperactivity disorder (ADHD) bibliotherapy conduct disorder consent dissent mutual storytelling neurodevelopmental disorders oppositional defiant disorder pica play therapy principle of least restrictive intervention rumination disorder temperament therapeutic games Objectives Explore factors contributing to child and adolescent mental disorders, and develop intervention strategies for this population. Explain characteristics associated with resiliency. Identify characteristics of positive mental health and development in children and adolescents. Discuss holistic assessment of a child or adolescent. Explore areas in the assessment of suicide for children and adolescents. Compare and contrast at least six treatment modalities for children and adolescents. Describe clinical features and behaviours of at least three child and adolescent mental disorders. Formulate three nursing diagnoses, stating patient outcomes and interventions for each. Commission of Canada in April 2012, the mental health needs of young people in Canada had not received much attention. Mental health disorders in children and adolescents are associated with disturbances in psychological, physiological, academic, and social functioning. The economic, social, and personal costs to society associated with childhood- and adolescent-onset mental disorders are tremendous because the illness occurs during important developmental periods, has frequent recurrences, and persists into adulthood (Belfer, 2008). Stigma and misconceptions can cause patients and families to attempt to conceal the conditions or even limit help seeking and professional care. Epidemiology One in five children and adolescents in Canada suffers from a major mental illness that causes significant impairments at home, at school, with peers, and in the community. Some of these mental health disorders have a likelihood of recurrence and chronicity in young adulthood. For example, 80% of adults with mental illness experienced problems in childhood or early adolescence. It is estimated that two thirds of young people with mental health problems are not receiving needed services. Suicide ranks as the second leading cause of death for youth aged 10 to 19 years, and suffocation was the predominant means of committing suicide among young Canadians. Suicide rates in Canada are increasing among female youth but decreasing among male children and adolescents. Co-Morbidity Children and adolescents with mental health disorders often meet the criteria for more than one diagnostic category. Attention deficit–hyperactivity disorder (ADHD) occurs in 90% of individuals with juvenile-onset bipolar disorder, 90% of children with oppositional defiant disorder, and 50% of those with conduct disorder. Childhood depression has a high incidence of co-morbidity: 20% to 80% of children with depression have conduct or oppositional disorders, 30% to 75% have anxiety disorders, and 5% to 60% display symptoms of ADHD (Reinhardt & Reinhardt, 2013). Multiple services are often needed by those with coexisting diagnoses, such as special education evaluation and services, afterschool services, family counselling, and behaviour management. Risk Factors A child with a parent with depression is at risk for developing an anxiety disorder, mood disorder, conduct disorder, or substance use. The parent’s inability to model effective coping strategies can lead to learned helplessness, the creation of anxiety or apathy, and an inability to master the environment. A child with a conduct disorder may develop an antisocial personality and enter the criminal justice system. In fact, two thirds of youth in the juvenile justice system have one or more diagnosable mental disorders (Teplin, Welty, Abram, et al., 2012). Children who have been abused or neglected are at great risk for developing emotional, intellectual, and social problems as a result of their traumatic experiences. Etiology Etiology of mental illness in children and adolescents encompasses multiple factors; distinguishing among the genetic, psychosocial, and environmental factors makes diagnosis challenging. Genetic Hereditary factors are implicated in autism, bipolar disorder, schizophrenia, attention-deficit problems, and intellectual developmental disorder. Direct genetic links are noted in Tay-Sachs disease, phenylketonuria, and fragile X syndrome. Brain Development and Biochemical Factors Dramatic changes occur in the brain during childhood and adolescence. Alterations in neurotransmitters play a role in causing depression, mania, and ADHD. Elevated testosterone levels have been studied and may have a role in mediating responses to environmental stress. Temperament Temperament is the style of behaviour the child habitually uses to cope with the demands and expectations from the environment. It is thought to be genetically determined and may be modified by the parent–child relationship. Resilience Resilience is formed by the relationship between the child’s constitutional endowment and environmental factors. Characteristics of a resilient child include temperament that adapts to environmental change, ability to form nurturing relationships with other adults when the parent is not available, ability to distance self from emotional chaos of the parent or family, good social intelligence, and ability to use problem-solving skills. Environmental Factors If parents are abusive, rejecting, or overly controlling, the child may suffer detrimental effects at the developmental point at which the trauma occurs. Cultural Considerations Children and youth in ethnic minority groups may be at risk for a variety of mental health problems. Perceived barriers such as economics, service availability, cultural beliefs, values, and attitudes of health care providers toward young people impact help seeking. Child and Adolescent Psychiatric Mental Nursing Child psychiatric mental health nurses utilize evidence-informed psychiatric practices to provide care that is responsive to the patient and family’s specific problems, strengths, personality, sociocultural context, and preferences. Although the number of young people with acute mental illness in our society is increasing, inpatient and residential treatment time has steadily decreased. The inpatient care since the 1980s has been modified by managed care and budget cuts to brief treatment. The nurse must work with more acutely ill patients in a shorter time period, making it more difficult to achieve a therapeutic alliance and bring about lasting behavioural changes. The majority of children hospitalized are diagnosed with a conduct disorder; they infrequently come from an intact home. Lack of a family support system limits the nurse’s ability to work on parenting issues and ensure that gains made in treatment are sustained. Much of the care of child and adolescent patients has moved from inpatient to outpatient facilities and into the community. Assessing Development and Functioning A child or adolescent with mental illness is one whose progressive personality development and functioning are hindered or arrested due to biological, psychosocial, or spiritual factors, resulting in functional impairments. In comparison, a child or adolescent who does not have a mental illness matures with only minor regressions, coping with the stressors and developmental tasks of life. Assessment Data The type of data collected depends on the setting, the severity of the presenting problem, and the availability of resources. Agency policy determines which data are collected and how they are documented. In all cases, the physical examination is part of the complete workup. See Box 29-2 for more details. Methods for Assessment Methods of assessment include interviewing, screening, testing, observing, and interacting. Histories are taken, and structured questionnaires and genograms can be used. Interviews with children and adolescents are semi-structured to give freedom to describe current problems. Play activities are used with younger children who cannot respond to a direct approach. Mental Status Examination The mental status examination in children is similar to the adult assessment except that the developmental level is considered. Developmental Assessment Developmental assessment provides information about the child’s current maturational level. When compared with chronological age, it identifies developmental lags and deficits. Abnormal findings are often related to stress, adjustment problems, or more serious disorders. Suicide Risk Suicide is the second leading cause of death in adolescence (Statistics Canada, 2012); therefore, assessment of suicidality is an essential nursing skill. Areas to explore include suicidal fantasies, thoughts, threats, or attempts; circumstances at the time of the suicidal thought or behaviour; concepts about suicide and death and previous experience with these; depression and other moods and feelings; acting-out behaviours; listening to music or reading books with morbid themes. Assessing lethality of plans is complicated by distorted concepts of death, immature ego functions, and lack of understanding of lethality. Cultural Influences Sensitivity to cultural influences is necessary to avoid inappropriate assessments. See Chapter 7. General Interventions Family Therapy To ensure optimal outcomes for children and adolescents, the family must be involved and educated. Both single-family therapy and multiple-family therapy are being used. Group Therapy For younger children, group therapy takes the form of play; for grade-school children, it combines play and talking. For older children and adolescents, group therapy takes the form of talking. Milieu Management Goals are to provide physical and psychological security, promote growth and mastery of developmental tasks, and ameliorate psychiatric disorders. Therapeutic factors include an environment with boundaries and limits, a reduction in stressors, opportunities for expression of feelings without fear of rejection or retaliation, available emotional support and comfort, assistance with reality testing and support for weak ego functions, interventions in impulsive or aggressive behaviour, opportunities for learning and testing new adaptive behaviours, consistent constructive feedback, reinforcement of positive behaviours and development of selfesteem, corrective emotional experiences, role models for making healthy identifications, opportunities to be spontaneous and creative, and experiences leading to identity formation. Behavioural Therapy Desired behaviour is rewarded; undesirable behaviour is ignored or has limits set to prevent it. A point system awards points for ageappropriate desired behaviours, and points are collected and used to obtain a specific reward. A level system has increasing levels of privileges that can be earned. To ensure that the civil and legal rights of individuals are not violated, and effective treatment is provided, techniques are selected according to the principle of least restrictive intervention. This principle requires that more restrictive interventions be used only after less restrictive interventions to manage the behaviour have been attempted. Intrusive techniques (such as physical restraints) are implemented to manage behaviour and maintain safety only when very severe or dangerous behaviours (i.e., those that may result in injury to the patient or others) are exhibited. Modifying Disruptive Behaviour Disruptive behaviour in the therapeutic milieu must be interrupted early to avoid causing chaos on the unit. Techniques include planned ignoring; use of signals or gestures to remind a child to use self-control; using closeness or touch to calm; redirecting the child’s attention toward an activity; giving additional affection; use of humour to help the child “save face”; direct appeals such as, “Please . . . not now”; extra assistance to avoid blow-ups due to frustration; clarifying the situation for the child; restructuring, such as shortening a story if the child becomes restless; and setting limits and giving permission to do what is expected. Interventions useful for modifying disruptive behaviours and preventing contagion include strategic removal, physical restraint, setting limits and giving permission, promises and rewards, threats, and punishment. Seclusion and Restraint Controversy continues over the use of locked seclusion and physical restraint in managing dangerous behaviour, and evidence suggests both are psychologically harmful and can be physically harmful. Deaths have resulted, primarily by asphyxiation due to physical holds during restraints (De Hert, Dirix, Demunter, et al., 2011). At times, a child’s behaviour is so destructive or dangerous that physical restraint or seclusion is needed. All nurses who might be involved in therapeutic holding or physical restraint of children and adolescents must receive education and training to decrease the risk for injury to themselves and the child. This intervention requires prompt, firm, nonretaliatory protective restraint that is gentle and safe. Children are released as soon as they are no longer dangerous, usually a few minutes, and most facilities strive to avoid all intensive interventions that restrict movement, such as holds and restraints. All patients in seclusion or restraints must be monitored constantly. Vital signs, including pulse and blood pressure, and range of motion in extremities must be monitored every 15 minutes. Hydration, elimination, comfort, and other psychological and physical needs should also be monitored. The patient’s family should be informed of any incident of seclusion or restraint, and they should be encouraged to discuss the event with their child and reinforce the treatment plan to reduce the likelihood of future incidents. Debriefing of the restraint process with all involved is part of the treatment plan. Quiet Room An unlocked room used for removing a child from the situation to regain self-control with staff support is called the quiet room. The feelings room, which is carpeted and supplied with soft objects that can be punched or thrown, and the freedom room, which contains a large ball for throwing or kicking, are alternative approaches. Time-Out Time-out may require going to a designated room or sitting on the periphery of an activity until self-control is gained and the incident is reviewed with a staff member. Mind–Body Therapies These approaches focus on interactions between the mind and the body, using the mind to affect physical reactions and promote health. Hypnotherapy, guided imagery, meditation, music therapy, and yoga have been shown to be effective for children and youth with mental health problems such as phobias, self-harming behaviour, anxiety, and eating disorders (Spinazzola, Rhodes, Emerson, et al., 2013). Cognitive- Behavioural Therapy The goal of cognitive-behavioural therapy is to change cognitive and behavioural processes, thus reducing the frequency of maladaptive responses and replacing them with new competencies. Play Therapy 1. Play is the child’s way of learning to master impulses and adapt to the environment. Play therapy usually is a one-on-one session the therapist has with a child in a playroom. The guiding principles of play therapy include the following: Accept the child as he or she is, and follow the child’s lead. Establish a warm, friendly relationship that allows the child free expression of feelings. Recognize the child’s feelings, and reflect them back to promote insight development. Accept the child’s ability to solve personal problems. Set limits only to provide reality and security. Mutual Storytelling Mutual storytelling is a technique for helping young children express themselves verbally. The child is asked to make up a story. At the end of the story, the child is asked to give a lesson or the moral of the story. The nurse retells the story, selecting one or two of its important themes, and provides a healthy resolution. Therapeutic Games Playing a game with the child facilitates the development of a therapeutic alliance and provides an opportunity for conversation. Several therapeutic games exist that require the child to say something or tell a story about various objects in order to collect a chip. A more advanced game for older children requires talking, feeling, and doing activities. Bibliotherapy Bibliotherapy involves using children’s literature to help the child express feelings in a supportive environment, gain insight, and learn new ways to cope with difficult situations. Books are chosen by the nurse to reflect the situations or feelings the child is experiencing. Therapeutic Drawing Drawing captures thoughts, feelings, and tensions a child may not be able to express verbally. Characteristics of human figures are general indicators of a child’s emotions rather than indicators of psychopathology. A number of characteristics and their meanings are given in the text. The nurse may ask the child questions about the pictures and discuss emotions. Psychopharmacology Medicating children typically works best when combined with another treatment such as cognitive-behavioural therapy (Sadock and Sadock, 2008). Neurodevelopmental Disorders These disorders are characterized by severe and pervasive impairment of reciprocal social interaction and communication skills, usually accompanied by stereotyped behaviour, interests, and activities. Intellectual developmental disorder is often present. Intellectual Disabilities Intellectual developmental disorder (intellectual disability), previously called mental retardation, is characterized by developmental deficits in intellectual and adaptive functioning that ranges on a continuum from mild to moderate, severe, and profound. Impairment in children includes deficits in problem solving, reasoning, judgement, communication, self-care activities, and social participation. Communication Disorders Communication disorders occur during the child’s early developmental period and are manifested by difficultly in languageskills acquisition, which impacts academic achievement, social achievement, and self-activities. The main indicators of this condition are speech and language disorders, which affect a child’s ability to communicate. The child has speech-related deficits in both expressive and receptive ability, which may be evident by the inability to make vocal sounds or disturbance in fluency, characterized by stuttering. The child has little or no vocabulary growth, limiting the ability to initiate or maintain engagement with others. Autism Spectrum Disorder It is reported that one in every 165 children born today has autism spectrum disorder (ASD). This is usually first observed before age 3 years. It is a behavioural syndrome resulting from abnormal left brain function (language, logic, reasoning). Presenting symptoms of autism include: 1. Impairment in communication and imaginative activity: language delay or absence, immature grammatical structure, 2. pronoun reversal, inability to name objects, stereotyped or repetitive use of language, high-pitched squealing or giggling, repetitive phrases, babbling, singsong speech, lack of spontaneous make-believe play, failure to imitate. Impairment in social interactions: lack of responsiveness to and interest in others, lack of eye contact and facial response, indifference or aversion to affection and physical contact, lack of sharing interest or achievement with others, failure to develop cooperative play with peers, lack of friendships. Markedly restricted, stereotyped patterns of behaviour, interest, and activities: rigid adherence to routine and rituals, with catastrophic reactions to minor changes; stereotyped and repetitive motor mannerisms; preoccupation with certain repetitive activities that is abnormal in intensity or focus. Attention Deficit– Hyperactivity Disorder 1. Affected children show inappropriate inattention, impulsiveness, and hyperactivity. ADHD may be associated with oppositional defiant or conduct disorder or Tourette’s disorder. Presenting symptoms of ADHD include: Inattention Hyperactivity Impulsivity Specific Learning Disorder (SLD) This disorder in children is identified during the school-age years and varies in severity from mild to moderate to severe. One prominent feature is impairment in academic skills such as reading (dyslexia), mathematics (dyscalculia), and written expression (dysgraphia) acquisition. The prevalence of this disorder is 5% to 15% among school-age children and is more common in males than females (Peterson & Pennington, 2012). This disorder is lifelong, so early assessment, intervention and support are important for the child and the family. Nurses are instrumental in teaching parents and children how to manage and live with the disorder. Also, ongoing assessment will involve other professionals with expertise in the areas of specific learning disorder and psychological and cognitive assessment. Motor Disorders These disorders present in the early developmental period, interfering with gross motor and fine motor skills. Developmental coordination disorder is diagnosed before 5 years of age, when acquisition of motor skills or coordination is below what is expected for young children achieving motor milestones such as sitting, crawling, or walking (Zwicker, Missiuna, Harris, et al., 2012). These disorders are chronic and cause impairment in activities of daily living. Prevalence estimates in school-age children range from 3 to 8 per 1000, with males more commonly affected than females Two particular motor disorders are stereotypic movement disorder and Tourette’s disorder. Self-awareness and positive adaptations can be supportive, with behavioural therapy preferred to medication. Application of the Nursing Process Assessment Assessment Guidelines: Neurodevelopmental Disorders 1. Assess for developmental spurts or lags, uneven development, and loss of previously acquired abilities. Assess quality of relationship between child and caregiver for evidence of bonding, anxiety, tension, and fit between temperaments. Be aware that children with behavioural and development problems are at risk for abuse. For attention deficit–hyperactivity disorder: Observe for level of physical activity, attention span, talkativeness, ability to follow directions, and impulse control. Assess difficulty in making friends and performing in school. Assess for problems with enuresis and encopresis. Diagnosis Delayed growth and development, Impaired social interactions, and Impaired verbal communication are often useful. Outcomes Identification The Nursing Outcomes Classification (NOC) identifies a number of outcomes that are appropriate for a child with neurodevelopmental disorder. See Table 29-3. Implementation Interventions centre around helping the child reach his or her full potential by fostering developmental competence and coping skills (e.g., increasing interest in reciprocal interactions, fostering social skill development, facilitating expression of appropriate emotional responses, fostering development of reciprocal communication, fostering cognitive skills, fostering development of self-control, etc.). Disruptive, Impulse- Control, and Conduct Disorders Oppositional Defiant Disorder Oppositional defiant disorder is a recurrent pattern of negativistic, disobedient, hostile, defiant behaviour toward authority figures, without serious violations of the basic rights of others. Such a child may exhibit the following characteristics: loses temper, argues with adults, actively defies, refuses to comply, deliberately annoys people, blames others for mistakes, is easily annoyed by others, is angry or resentful, spiteful, or vindictive. Conduct Disorder Conduct disorder is characterized by a persistent pattern of behaviour in which the rights of others and age-appropriate societal norms are violated. Rates for males range from 6% to 16% and for females 2% to 9%. Predisposing factors are ADHD, parental rejection, inconsistent parenting with harsh discipline, early institutional living, absence of father, alcoholic father, and similar causes. Childhood-onset conduct disorder occurs prior to age 10 and is marked by physical aggression. The youth with adolescent-onset conduct disorder demonstrates less aggressive behaviours and more normal peer relationships, tending to act out misconduct with the peer group. Conduct disorders frequently progress to adult antisocial personality disorder. Types of behaviour noted include the following: (1) aggressive conduct that causes harm to other people or animals, (2) destruction of property, (3) deceitfulness or theft, and (4) serious violation of rules. Bullying Children and youth with disruptive, impulse-control, and conduct disorder may display aggressive behaviour toward others. Bullying is identified as an abuse of power that involves three components: harm, repetition, and unequal power. It is manifested in several ways, often called physical (e.g., hitting, kicking), verbal (e.g., threats, derogatory remarks or names), relational (e.g., social exclusion, spreading of rumours), and cyberbullying (i.e., bullying carried out through electronic means). Nurses should be aware that children who are being bullied may not report problems unless asked directly (Vernberg, Nelson, Fonagy, et al., 2011). It is imperative that nurses and parents or other caregivers be knowledgeable of specific signs that may indicate bullying. Some reported behaviours are sleep disturbances, unexplained cuts or bruises, tearfulness, requesting to change schools, fear of walking to and from school, and self-harm behaviours (Weston, 2009). Nurses play an important role in detecting early symptoms and signs through assessment and screening and need to work with the patient, family, and members of the school system to offset difficulties for these children and adolescents. Application of the Nursing Process Assessment Assessment Guidelines: Disruptive, Impulse- Control, and Conduct Disorders 1. For disruptive behaviour disorders: Assess quality of relationship between child and caregiver. Assess caregiver’s understanding of growth and development, parenting skills, and handling of problematic behaviours. Assess cognitive, psychosocial, and moral development for lags or deficits. For oppositional defiant disorder: Identify issues that result in power struggles, when they begin, and how they are handled. Assess severity of defiant behaviour and its impact on the child’s life at home, at school, and with peers. For conduct disorder: Assess seriousness of disruptive behaviour, when it started, and attempts to manage it. Assess levels of anxiety, aggression, anger, and hostility toward others and ability to control destructive impulses. Assess moral development for ability to understand impact of hurtful behaviours on others, for empathy, and for feeling remorse. Diagnosis Risk for self-directed violence, Risk for other-directed violence, Risk for injury, Impaired social interaction, and Ineffective coping are useful diagnoses. Table 29-2 lists other potential diagnoses. Outcomes Identification NOC identifies a number of outcomes that are appropriate for a child with oppositional defiant disorder or conduct disorder. See Table 29-5. Implementation Interventions include behaviour modification (Box 29-5), pharmacological agents such as methylphenidate (See Drug Treatment box), special education programs, play, and psychotherapy. Nursing interventions for working with parents and caregivers: Assess caregiver knowledge of disorder, and give needed information. Explore impact of behaviours on family life. Assess caregiver’s support system. Discuss how to make home a safe environment. Discuss realistic behavioural goals and how to set them. Teach behaviour modification techniques. Give caregivers support. Provide educational information about medications. Refer caregiver to local chapter of self-help group. • Be a child and parent advocate with the educational system. Anxiety Disorders Some anxiety is part of normal development. Anxiety becomes a problem when the individual cannot move beyond fears associated with the developmental stage or when anxiety interferes with normal functioning. Anxiety disorders affect as many as 10% of young people. Separation Anxiety Disorder In this disorder, the child becomes excessively anxious when separated or anticipating separation from home or parental figure. Other characteristics include excessive worry about being lost or kidnapped or that parental figures will be harmed, fear of being home alone or in situations without significant adults present, refusal to sleep unless near a parental figure, refusal to attend school without a parental figure, and physical symptoms as a response to anxiety. Post-traumatic Stress Disorder Children of any age can develop PTSD. Younger children appear to react more with behaviours indicative of internalized anxiety, whereas for older children and adolescents, the anxiety is more often externalized. Application of the Nursing Process Assessment Assessment Guidelines: Anxiety Disorders The nurse assesses the quality of relationships, recent stressors, the parent and caregiver’s understanding of developmental norms; the nurse also assesses developmental level and regression and assesses for physical, behavioural, and cognitive symptoms of anxiety. Diagnosis Table 29-2 lists potential nursing diagnoses in addition to Anxiety, Ineffective coping, and Delayed growth and development. Outcomes Identification NOC identifies a number of outcomes appropriate for the child with an anxiety disorder. See Table 29-6. Implementation • Protect from panic level anxiety and provide for biological and psychosocial needs. Accept regression, but give emotional support. Increase child’s self-esteem and feelings of competence. Help child to accept and work through traumatic events or losses. Other Disorders of Children and Adolescents Mood Disorders Symptoms of mood disorders in children and adolescents may be similar to adult symptoms. Symptoms of depression in children often include somatic complaints, irritability, and social withdrawal. Psychomotor retardation and hypersomnia are more evident in adolescent depression. Associated factors include, among others, physical and sexual abuse, neglect, death, divorce, learning disabilities, conflicts with or rejection by family or peers. Complications include school failure, drug or alcohol abuse, promiscuity, running away, suicide, and similar responses. Adjustment Disorder Adjustment disorder is a residual category used for emotional responses to an identifiable stressor that do not meet other DSM-5 criteria for another disorder. The disorder is characterized by decreased performance at school and temporary changes in social relationships occurring within 3 months of the stress and lasting no longer than 6 months after the stress has ceased. Feeding and Eating Disorders These disorders include pica (persistent eating of nonnutritive substances), rumination disorder (the repeated regurgitation and rechewing of food), and feeding and eating disorders of infancy or early childhood (failure to eat adequate amounts of food though available). Instructor Manual for Varcaroliss Canadian Psychiatric Mental Health Nursing Margaret J. Halter, Cheryl L. Pollard, Susan L. Ray, Mary Haase, Sonya Jakubec, Elizabeth M. Varcarolis 9781926648330, 9781771721400

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