Stage	Disturbance	Assessment: Symptoms or Characteristics	Analysis: Behavior Related To:	Plan/Implementation
Oral (birth–1 yr)	Feeding disturbances	Refusal of food.	Rigid feeding schedule. Psychological stress. Incompatible formula. Physiological: pyloric stenosis.	Pediatric evaluation, especially if infant is not gaining weight or is losing weight. Rule out physiological etiology or incompatible formula. Evaluate feeding style of caregiver. Is infant ondemand feeding? Is caregiver sensitive to infant’s needs or communications about holding, hunger, or satiation?
		Colic. Crying is usually confined to one part of day and starts after a feeding.	Periodic tension in infant’s immature nervous system, causing gas and sharp intestinal pains.	Reassure parents and teach about condition and how to relieve it with hot water bottle, rocking, rubbing back, pacifier, which may soothe infant.
		Commonly lasts from first to third month.
	Sleeping disturbances	Infant resists being put down for sleep or going to sleep.	Need for parental attention. A pattern formed during period of colic or other illness. Emotional disturbance related to anxiety.	If it is attention-getting strategy, suggest parental lack of response for a few nights to break pattern. If emotional disturbance is suspected, evaluate infant-caregiver interaction and refer for psychotherapeutic intervention.
	Failure to thrive	Infant does not grow or develop over a period of time.	Psychological: inadequate caregiving. Physiological: heart, kidneys, central nervous system (CNS) malfunction.	Hospitalization is essential. Assist in evaluation of physiological functioning, especially heart, kidneys, and CNS. Nurturing plan for infant, using specifically assigned personnel and the caregiver parent. If the infant grows and develops with nurturing, thus confirming problems of parenting as causative factor, psychotherapeutic and child protective interventions are necessary.
	Severe disturbances	Pervasive developmental disorders: Very early onset; lack of response to others; bizarre, repetitive behavior; normal to above-normal intelligence; failure to develop language or use communicative speech. Autism is one of the most severe and debilitating psychiatric disturbances.	Uncertain etiology; regression or fixation at earlier developmental stage, before child differentiates “me” from “not me.” A “nature versus nurture” controversy over the causative factors. These are variously thought to be: Environment only: Infant is tabula rasa and all disturbance is directly attributable to the environment (primarily the parenting). Heredity only: For genetic, biochemical, or other predetermined reasons, some infants will be psychotic regardless of the environment. Combination of environment and heredity plus the interaction between them: An infant who is susceptible, less than optimal parenting, and negative interaction between parent and infant will combine to produce disturbance.	The child who is severely disturbed requires intensive psychotherapy and often milieu therapy available in residential or day-care programs. Therapy is usually indicated for parents also. Nurses can work on a primary level of prevention by assessing parenting skills of prospective parents and teaching them these skills. On a secondary level of prevention, nurses can be knowledgeable about and teach others the early signs of childhood psychosis, making appropriate referrals. The earlier the intervention, the better the prognosis. On a tertiary level of prevention, nurses work with children who are severely disturbed and their families in child guidance clinics and residential and day-care settings. Occupational therapy: provide tactile, oral-tactile, visual, auditory, gravitational sensory input to normalize response. Health teaching would include play activities that foster support, acceptance, and a nonthreatening mode of communication and interaction with a significant other. Simplify language by avoiding abstracts and metaphors. Keep gestures clear and simple. Give one instruction at a time, not a sequence. Give time to respond.
		Symbiotic psychosis: Identified later than autistic type, usually between 2 and 5 yr of age. These children seem to be unable to function independently of the caregiving parent. A situational stress, such as hospitalization of parent or child or entry into school, may precipitate a psychotic break in the child.	The same “nature versus nurture” controversy with respect to the origin of symbiotic psychosis. The child progresses beyond the selfabsorbed autistic stage to form an object relationship with another (usually the mother). Having progressed to this stage, the child then fails to differentiate his or her own identity from that of the mother.
Anal (1–3 yr)	Elimination disorders (disturbances related to toilet training)	Constipation.	Diet. Child withholding due to history of one or two painful, hard bowel movements. Psychological causation: child withholds from parents to express anger, opposition, or passage through a very independent developmental stage.	Evaluate diet and consistency of stools. Fecal softener may be prescribed if necessary. In all cases, help parent avoid making an issue of constipation with the child. Enemas are contraindicated. If child is withholding, work with parents around not forcing rigid toilet training on child. Most children are more cooperative about toilet training at 18–24 mo.
		Encopresis (soiling).	Child’s expression of anger or hostility. It is usually directed toward the parent with whom the child is experiencing conflict and is rarely physiological.	Medical evaluation, then assessment and intervention in the child-parent relationship. Therapy for child and parent may be indicated.
		Enuresis Ordinarily refers to wetting while asleep (nocturnal enuresis), though some children who are enuretic wet themselves during the day also. Enuresis is a symptom, not a diagnosis or disease entity.	Faulty toilet training (especially if child wets during the day also) or Psychological stress. Physiological etiology, such as genitourinary (GU) tract infections or CNS disease, is rare. The child under 4 yr old is usually not considered enuretic but is included in this section because bladder training is part of toilet training. Etiology is uncertain.	Many approaches have been tried with varying degrees of success. These include fluid restriction, behavioral intervention (in which a buzzer wakes the child when the child starts to wet), and psychotherapy. Educating parents in bladder training techniques and attitudes can help solve the problem on a primary level. It is important when working with children who are enuretic or their parents to suggest ways to help the child overcome feelings of shame and guilt. These feelings are often exacerbated by parents who are well-meaning but misguided.
	Excessive rebelliousness	Frequent temper tantrums, fighting, destruction of toys and other objects, consistent oppositional behavior.	Fear caused by inconsistency in handling the child, the setting of rigid limits, or the parents’ refusal or inability to set limits, which can all create insecurity and fear in the child. Excessive rebelliousness, usually indicating a child who is frightened; should not be confused with expression of negativism normal at around age 2, which is a necessary (though trying) developmental stage.	The nurse should offer parent counseling if necessary. When working with the child, the nurse needs to be receptive and sympathetic while establishing and maintaining firm limits.
	Excessive conformity	Lack of spontaneity, anxious desire always to please all adult authority figures, timidity, refusal to assert own needs, passivity.	Very rigid control established in an attempt to handle fears. Harsh toilet training, resulting in a child who is overcompliant. These children need help as much as children who are overrebellious, but they get it less frequently because their behavior is not a “problem”—that is, it is not difficult for parents to tolerate.	Excessive conformity can lead to compulsive, ritualistic, or obsessive behavior later. The nurse needs to be able to identify such a child, then work with the child and parents to encourage self-expression in the child. Referral for psychotherapy may be necessary to help the child deal with repressed anger.
Oedipal (3–6 yr)	Excessive fears	Child will be frightened even in nonthreatening situations. Nightmares and other sleep disturbances occur. Usually, child will be very “clingy” with parents in an attempt to gain reassurance.	Anxiety as the causative factor. Anxiety can be induced by many things, such as: Parental failure to set appropriate limits. Physical or psychological abuse. Illness. Fear of mutilation. Imaginary worries that are common at this age (e.g., a 4-yr-old who is suddenly afraid of the dark, or dogs, or fire engines is not necessarily suffering from excessive fears).	If possible, identify and deal with the factors that are producing the anxiety. Offer child calm reassurance. Night-light and open doors can help allay night fears, but counsel parents that it is unwise to allow the child to sleep with the parents, because it may make the child feel that the oedipal retaliation has succeeded. With the child who is hospitalized, the nurse needs to be aware of and work with the mutilation fears common at this age. Fears around certain procedures (e.g., injections) can often be resolved by helping the child play out fears.
	Excessive masturbation	Touching and fondling of genitals excessively, sometimes in a preoccupied or absent-minded manner.	Insecurity. Exploration and stimulation of the genital area, which is normal and common in this age group. However, if it is compulsive, the behavior is a signal that the child is insecure. Occasionally, a specific fear. For example, a boy viewing an infant sister’s genitals may have castration fears. These can be dealt with directly.	Assess the child’s masturbating activity. When does it occur and why? Then help the child develop other strategies for defense with anxiety. Answer questions about sexuality in an open manner. Counsel parents that threats and shaming are contraindicated, and help parents deal with their feelings about masturbation.
	Regression	Resumption of activities (such as thumb sucking, soiling and wetting, baby talk) characteristic of earlier developmental levels.	Child’s attempt to regain a more comfortable, previous level of development in response to a threatening situation (such as a new infant), or A response to difficulty resolving oedipal conflicts.	Counsel parents not to make an issue of behavior. Offer child emotional support and acceptance, though not approval of regressive behavior.
	Stuttering	Articulation difficulty characterized by many stops and repetitions in speech pattern.	Anxiety Frustration. Insecurity. Excitement. Stuttering usually occurs when the affected child feels anxious, frustrated, insecure, or excited. Parental concerns and attention to stuttering focuses attention on it and increases anxiety. The origins of stuttering are not understood. It is common around 2–3 yr of age and is not a cause for concern at that time.	Speech therapy is usually indicated. Psychotherapy may also be indicated, if stuttering is an expression of anxiety and conflict, persisting beyond age 6.
Latency (6–12 yr)	Attention deficithyperactivity disorder (age of onset can occur in preschool children)	Both hyperactivity and hyperkinesis are occasionally observed in school-age children; characterized by a short attention span, restlessness, distractibility, and impulsivity.	An organic disturbance of the CNS, of uncertain origin, as the basis of hyperkinesis. Because the primary symptom—difficulty with attention span—is the same as that presented by the child who is hyperactive, the child who is hyperactive is frequently and incorrectly labeled hyperkinetic. Attempts by child who is hyperactive to control anxiety through reducement (and can attend when interested or relaxed). Does not fit smoothly into environment, but problem may be with the environment rather than the child. In other words, the school situation requires a high degree of conformity. The child who does not fit the mold is not necessarily emotionally disturbed.	For the child who is hyperkinetic, psychopharmaceutical intervention—Ritalin, Concerta (long-acting), Dexedrine, or Adderall (long-acting). Psychotherapy and special education classes may also be indicated. Ritalin is also frequently prescribed for the child who is hyperactive—which raises the issue of whether an individual should be medicated to fit more smoothly into the environment. Drastic improvement in school performance can be seen with behavioral therapy and medication. Therapy can help the child who is hyperactive decrease anxiety and increase self-esteem, thus reducing the symptoms.
	Attention deficit disorder(age of onset can occur throughout adolescence)	Characterized by: a short attention span, distractibility, and subjective feelings of restlessness without hyperactivity.	Difficulty with schoolwork. Child frequently considered unmotivated or not intelligent.	Psychopharmaceutical intervention—Ritalin, Concerta (long-acting), Dexedrine, or Adderall (long-acting)—can drastically increase the attention span. Therapy and behavior modification: work on task for short periods; increase physical energy outlets; tutoring; structure; homework; organizational skills.
	Withdrawal	Reduced body movement and verbalization, lack of close relationships, detachment, timidity, and seclusiveness.	Need to withdraw as a defensive behavior, through which the child controls anxiety by reducing contact with the outer world. Like the child who is overcompliant, the child who is withdrawn frequently is not identified as needing help because this behavior is not a “problem.”	Offer positive reinforcement when child is more active. Help child assert self and experience success at certain tasks. The nurse needs to work with parents who are overprotective. Therapy may be useful to work through anxiety and provide child with a chance to form a trusting relationship with another.
	Psychophysiological symptoms	The child experiences physical symptoms (such as vomiting, headaches, eczema, asthma, colitis) with no apparent physiological cause.	Conversion of anxiety into physical symptoms.	After medical evaluation has established lack of physiological etiology, psychotherapy is usually indicated. Family therapy may be treatment of choice because dysfunctional interpersonal family dynamics are common in these cases. The nurse can also provide the child with a healthy interpersonal relationship. Nurses are frequently in a position to talk to parents and teachers about the importance of mental health counseling for children with physical symptoms.
	Separation anxiety disorders (school “phobia”)	Sudden and seemingly inexplicable fear of going to school. These children often do not know what it is they fear at school. Frequently occurs after an illness and absence from school or birth of sibling.	An acute anxiety reaction related to separation from home (not actually a phobia).	If the child is allowed to stay home, the dread of returning to school usually increases. The child and parent should have psychiatric intervention quickly (before the problem becomes worse) to help the child separate from the parent.
	Learning disabilities	Failure or difficulty in learning at school	Emotional disorders, which cause school failure. Feelings of inferiority, discouragement, and loss of confidence from school failure. Learning disabilities may be caused by many factors or combinations of factors, including anxiety, poor sensory or sensorimotor integration, dyslexia, receptive aphasia.	A comprehensive evaluation is essential. Ideally, this would include assessments by a pediatric neurologist, a mental health worker such as a psychiatric nurse or psychiatrist, a learning disabilities teacher specialist, and possibly an occupational therapist trained to work with sensory integration. Treatment is then based on the specific problem or problems.
	Conduct disorders	Behavior that is nonproductive; that is repeated in spite of threats, punishments, or rational argument; and that usually leads to punishment. Persistent stealing and truancy are examples.	Conflicts that are expressed and communicated through behavior rather than verbally. Child knows what he or she is doing but is unaware of the underlying motivations for the problem behavior.	Counseling or therapy for the child by a child psychiatric nurse or other mental health worker can allow the child to resolve the basic conflict, thus making the problem behavior unnecessary.

Adapted from Wilson, HS, & Kneisl, CR: Psychiatric Nursing, ed 3. Addison-Wesley, Redwood City, CA. (out of print)