Child and adolescent disorders

Psychiatric disorders are not diagnosed as easily in children as they are in adults.

Children lack the abstract cognitive abilities and verbal skills to describe what is happening.

Mental retardation

Mild retardations: IQ 50-70

Moderate retardation: IQ 35-50

Severe retardation: IQ 20-35

Profound retardation: IQ less than 20.

Adolescent depression

Some issues are due to background and family issues

Transition into adulthood often very difficult

Depression is almost always due to a combination of factors

Boys are more successful in committing suicide; more violent in attempts

o Acetaminophen affects liver

o Ibuprophen affects kidneys

Presents as “classic” symptoms in girls

In boys, depression is more likely to be “acted out” with aggressive behavior such as risk taking, substance abuse, confrontations with authority.

o Drinking in teenage years (ages 15-17) stops emotional growth. Kids that grow into adults are stuck in this stage (Identity vs. Role confusion). They learn that drinking is the way to cope. This is not awesome.

First major episode are during adolescent years; often between the ages of 15-19

Manic depression

o Teens may be sad and gloomy one day and excited and elevated the next

o Mood stabilizers are important in decreasing mood swings

Lithium (check blood levels!)

Depakote

Tegretol

Neurontin

In depression, one of the first cues is a large drop in school performance

Other symptoms disguised:

o Drug/alcohol abuse

o Lack of concentration

o Restlessness or hyperactivity

o Anti-social behavior (conduct disorder)

Extreme fatigue, sleep all the time but are not rested

Suicide warning signs…

o Constant insomnia; may be on computer at all hours of the night

o Changes in behavior

o Dropping grades—again, school is a huge issue

Interventions for suicide

o High risk teens make their decisions after a “disaster” has occurred: break-ups, academic failure, fight with parents, or run-in with authority

o Alcohol is involved in ½ of all suicides; seriously impairs judgement

Suicide is not chosen; it happens when pain exceeds resources for pain

Talk to your kids!

o The best place is in the car when they’re trapped, haha.

Start with the basics; “How are you doing?”

Then, praise

Then get down and dirty to the real subject

Childhood Schizophrenia

Group of disorders of thought processes characterized by gradual disintegration of mental function

Occurs in adolescents or as young adults

Suicide is the #1 cause of death in young people with schizophrenia

Treatment and prognosis

o Lifetime of therapy and family support

o Medications

o Struggle for family to stay involved

Often rejected or just can’t take anymore disruption in their lives.

Obsessive-Compulsion disorder

Symptoms often begin slowly and gradually during their childhood or teenage years and increase in severity as time goes on.

Though a chronic disease, there will be periods of reduced symptoms followed by “flare-ups”, often stressful times in person’s life.

Relief is only temporary; usually both obsessions and compulsions occur together

Recognize thoughts or behaviors are irrational; but are compelled to continue them “against their will”.

Treatment:

o Exposure and response prevention

o SSRIs help reduce symptoms of OCD—monitor for side effects

Compulsions

o Washing, cleaning, constant checking, mental counting rituals

o Touching, ordering, rearranging

o Asking for reassurance or confessing

o Masturbation—especially seen in children who haven’t yet discovered this is socially unacceptable behavior

Autistic disorder

Most prevalent in boys; identified no later than 3-years of age

Child has little eye contact, few facial expression, doesn’t use gestures to communicate

Does not relate to parents or peers, lacks spontaneous enjoyment, apparent absence of mood and emotional affect, can not be engaged in play or make believe

Repetitive motor behaviors such as hand-flapping, body twisting, or head banging

May improve as child acquires language skills

Short term impatient therapy is used when behaviors such as head banging or tantrums are out of control

o Haldol or Risperadol may be effective (prn, of course)

Goals of treatment:

o Reduce behavioral symptoms

o Promotes learning and development

o Language skills development

Attention deficit disorder

Characterized by patterns of inattention, hyperactivity, and impulsiveness

Account for most mental health referrals

Needs to be physically seen for a renewal of ADHD drugs monthly

Often diagnosed when a child starts school

Distinguishing bipolar disorder from ADHD can be difficult but is crucial because treatment is so different for each disorder

Signs and symptoms

o Inattentive behaviors

o Hyperactive/impulsive behaviors

Fidgets

Often leaves seat

Can’t play quietly

Interrupts

Cannot wait turn

Treatment

o The most effective treatment combines pharmacotherapy with behavioral, psychosocial, and educational interventions

Psychopharmacology

o Methylphenidate (Ritalin)

o Amphetamine compound (Adderall)

The most common side effects of these drugs are insomnia, loss of appetite, and weight loss or failure to gain weight.

Giving stimulants during daytime hours usually combats insomnia.

Give the child breakfast and snacks to gain weight

o Atomoxetine (Strattera)

Non-stimulant drug; is an antidepressant—selective norepinephrine reuptake inhibitor.

Most common side effects were decreased appetite, N/V, tiredness, and upset stomach.

Can cause liver damage, must have liver function tests periodically.

Strategies for Home and School

o Behavioral strategies are necessary to help the child master appropriate behaviors.

o Effective approaches:

Provide consistent rewards

Consequences for behavior

Offer consistent praise

Use time out

Give verbal reprimands

Use daily report cards for behavior

Point system for positive and negative behavior

Therapeutic play; use play to understand thoughts and feelings and helps with communication.

Educate parents!

Cultural considerations

o Parents from different cultures have a different threshold for tolerating specific types of behavior.

General appearance and Motor behavior

o Speech is unimpaired, but the child cannot carry on a conversation; he interrupts, blurts out answers before the question is finished, and fails to pay attention to what is said.

Mood and affect

o Mood may be labile, even to the point of verbal outbursts or temper tantrums.

o Anxiety, frustration, and agitation are common

Judgment and insight

o May fail to perceive harm or danger and engage in impulsive acts such as running into the street and jumping off of high objects.

Physiologic and Self-care considerations

o Children with ADHD may be thin if they do not take time to eat properly or cannot sit through meals.

o May be a history of physical injuries due to risk-taking behaviors

Nursing diagnoses

o Risk for injury

Child will remain free from injury

If the child is engaged in a potentially dangerous activity, the first step is to stop the behavior.

This may require physical intervention if the child is running into a street or jumping off of a high place.

Attempting to talk or reason to a child engaged in a dangerous activity is unlikely to succeed because of their inability to pay attention and to listen.

When the incidence is over and the child is safe, talk to the child about the behavior.

o Ineffective role performance

Will not violate others boundaries

Give positive feedback for meeting expectations.

State acceptable behavior clearly

o Impaired social interactions

Demonstrate age-appropriate social skills

Supervise the child closely while he is playing.

It is often necessary to act first to stop the harmful behavior by separating the child from the friend

o Improved role performance

Simplify instructions and directions—give one step of a process at a time

Give the child positive feedback and sense of accomplishment

Manage the environment

Minimal noise and distraction

Face the teacher in the front row and away from window or door

o Ineffective family coping

Will complete tasks

Face the child on his level and use good eye contact

Give the child frequent breaks

Routines are important; child with ADHD do not adjust to changes readily

o Parental support

Listen to parent’s feelings

Because these children often are not diagnosed until the 2nd or 3rd grade, they may have missed much basic learning for reading and math. Parents should know that it takes time for them to catch up to other children the same age.

o Evaluation

Medications are often in decreasing hyperactivity and impulsivity relatively quickly.

Improved sociability, peer relations, and academic achievement happen more slowly.

Conduct disorder

Characterized by persistent antisocial behavior in children and adolescents that significantly impair their ability to function in social, academic, or occupational area.

o Symptoms are clustered into 4 areas

Aggression to people and animals

Destruction to property

Deceitfulness and theft

Serious violation of rules and the law

o More symptoms

Decreased self-esteem

Poor frustration tolerance

Tempter often out of control

Early onset of sexual behavior, alcohol and substance abuse, smoking, risky behavior

Anti-social

See more in the red box on page 457

Types of conduct disorder

o Classified by age of onset

Adolescent-onset type is defined by no behaviors of conduct disorder until after 10 years of age.

Least likely to be aggressive

Have more normal peer relationships

Less likely to have persistent conduct disorder or antisocial personality disorder as adults

Childhood-onset type involves symptoms before 10 years of age

Physically aggressive

Disturbed peer relationships

More likely to have persistent conduct disorder and to develop antisocial personality disorder as adults

o Can be classified as:

Mild : few conduct problems causing minor harm to others

Lying, truancy, staying out late without permission

Moderate : Number of conduct problems increase as does the amount of harm to others.

Vandalism and theft

Severe : Many conduct problems that cause considerable harm to others.

Forced sex, cruelty to animals, weapons, burglary, robbery.

Treatment of conduct disorder

o MUST BE GEARED TOWARD DEVELOPMENTAL AGE

o School aged:

Child, family, and school environment are the focus of treatment

Family therapy is essential

o Adolescents

Rely less on their parents, so treatment is based on individual therapy.

Conflict resolution, anger management, social skills

Try to keep the adolescent in his environment (home)

o Medications have little effect

Antipsychotics for clients who present a clear danger to others

Mood stabilizers for clients with labile moods

Cultural considerations

o Be careful of diagnosis of Conduct disorder, must know history and circumstances of each child.

High areas of crime rates

Could be a matter of survival

Nursing process

o Risk for Other-directed violence

The client will not hurt others or damage property

SET LIMITS

Inform the client of the rule or limit

Explain the consequences if broken

State expected behavior

Behavioral contract

Time out; not a punishment—a place to regain self control

Give client a schedule of daily activities

o Noncompliance

The client will participate in treatment

More likely to participate in treatment and daily routines if they have input concerning the schedule

o Ineffective coping

The client will learn effective problem-solving and coping skills

Help identify the problem and to solve problems effectively.

o Impaired social interaction

The client will use age-appropriate and acceptable behaviors when interacting with others.

Teach social skills

Discuss the news, sports, or other topics as the client may not know how to have a normal conversation.

o Chronic low self-esteem

The client will verbalize positive, age-appropriate statements about self

Oppositional Defiant disorder

Consists of an enduring pattern of uncooperative, defiant, and hostile behavior toward authority figures without major antisocial violations.

A certain level of oppositional behavior is common in children in adolescence.

Oppositional defiant disorder is diagnosed only when behaviors are more frequent and intense than unaffected peers and cause dysfunction in social, academic, or work situations.

TIC disorders

Sudden, rapid, recurrent, non-rhythmic motor movement or vocalization

Stress and fatigue exacerbates tics

Treatment: Risperadol and Zyprexia

Complex vocal tics

o Coprolalia : Use of socially unacceptable words, often obscene

o Palilalia : Repeating own sounds or words

o Echolalia : Repeating the last heard sound, word, or phrase

Tourette’s syndrome

Multiple motor tics and one or more vocal tics

May occur many times a day for over a year

Usually identified by 7 years of age

Elimination disorders

Encopresis : repeated passage of feces into inappropriate places such as clothing or floor by a child who is at least 4 years of age either chronically or developmentally. Often involuntary, but can be intentional (oppositional defiant disorder or conduct disorder). Associated with constipation that occurs for psychological, not medical reasons.

Enuresis : Repeated voiding of urine during the day or night into clothing or bed by a child at least 5 years of age.

Treated with imipramine (Tofranil), an antidepressant with a side effect of urinary retention.

o Was once treated with vasopressin which decreases circulatory volume.