Boyd 8e

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UNIT VII • Care of Children and Adolescents

intensity, complexity, and interference of the tics and their effects on functioning; determine the child’s level of adaptive functioning; identify the child’s areas of strength and weakness in general and in school; and identify social supports for the child and family. Another important aspect of the assessment is to determine the effects of the tic symptoms on the child and family. Some children and families adjust well; how ever, others are embarrassed or devastated and tend to withdraw socially. Because of the likelihood of comorbid mental, behavioral, or developmental disorders, in addi tion to inquiring about tics, the nurse should assess the child’s overall development, activity level, and capacity to concentrate and persist with a single task, as well as explore repetitive habits and recurring worries. Analyzing Cues and Developing Hypotheses Children with Tourette syndrome generally have typical intellectual ability, but their tics can interfere with their ability to relate to others and perform well in school. The nurse should determine the degree of anxiety experienced by the child, the impact of the tics on the child’s ability to cope, and whether the tics contribute to interference with social relationships and interactions. Taking Action: Nursing Interventions The approach to planning nursing interventions depends on the primary source of impairment: tics themselves; OCD symptoms; or the triad of hyperactivity, inattention, and poor impulse control. The nurse can provide coun seling and education for the patient, education for the parents, and consultation for the school. Most children and their families need some education about Tourette syndrome. Individual psychotherapy with a mental health specialist (e.g., a psychologist or an advanced practice nurse) may be indicated for some children and adoles cents with Tourette syndrome to deal with maladaptive responses to the chronic condition. There is evidence that comprehensive behavior therapy is effective in reducing the tics (Kohler et al., 2024). Medications Although there is no cure for Tourette syndrome, med ications can be prescribed to help control tics that interfere with daily activities. Two classes of drugs are commonly used in the treatment of tics: antipsychotics and alpha-adrenergic receptor agonists. Aripiprazole is replacing the use of older antipsychotics, such as haloper idol and pimozide (He et al., 2024). These potent dopa mine blockers are often effective at low doses. Attempts to eradicate all tics by increasing the dosages of these antipsychotics almost certainly will result in diminishing

therapeutic returns and additional side effects. The most frequently encountered side effects include drowsiness, dulled thinking, muscle stiffness, akathisia, increased appetite and weight gain, and acute dystonic reactions. Long-term use carries a small risk for tardive dyskinesia. Stimulant medications, such as methylphenidate and dextroamphetamine, can reduce symptoms of ADHD in individuals with Tourette syndrome without increasing tic severity (Farhat et al., 2023; NIH NINDS, 2024). Psychoeducation Teachers, guidance counselors, and school nurses may need current information about Tourette syndrome and its related issues. Discussions with school personnel often include issues such as how to deal with tic behaviors that are disruptive in the classroom, how to manage teasing from other children, and how to handle medication side effects. A careful discussion of the boundaries of Tourette syndrome and tic symptomatology can usually resolve these matters. Teachers who understand the involuntary nature of tics can often generate creative solutions, such as excusing the child to do errands. This strategy allows the child to step out of the classroom briefly to release a bout of tics, thereby reducing stress. In some situations, a brief presentation about Tourette syndrome to the class will reduce teasing and help both teachers and classmates tolerate the tic symptoms (Box 37.11). Before initiating these interventions with the school personnel, it is essential to identify the child’s needs and to pursue these strategies in collaboration with the fam ily and other clinical team members. The Education for the Handicapped Act (Public Law 94–142) ensures that children with conditions such as Tourette syndrome are eligible for special education services even if they do not meet full criteria for having a learning disability. Thus, if evidence shows that Tourette disorder is hindering academic progress, parents can demand special education services for their child. Nurses can help families negotiate with the school to obtain appropriate services. Evaluation of Patient Outcomes Treatment outcomes will vary over the years and will be influenced by growth and development changes, family interaction and understanding of the disorder, and reduc tion or elimination of the frequency of the tics. Outcomes should include improvement of the child’s quality of life and ability to learn to manage the symptoms of the disorder. ❚ OTHER MENTAL DISORDERS SEPARATION ANXIETY DISORDER Separation anxiety is not unusual for very young children but typically declines between the ages of 3 and 5 years.

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