Child and Child and Adolescent Adolescent
Mental HealthMental Health
Module ContentModule Content
Mood and Anxiety Disorders Attention Deficit and Disruptive
Behavior Disorders Developmental Disorders: Autism
Spectrum Bullying Psychopharmacology Cognitive and Behavioral Therapies
Cognitive DevelopmentCognitive Development
Moves from concrete thinking to “formal operations” –i.e. Abstract thinking
Physical development precedes cognitive development
The last part of the brain to mature is the prefrontal cortex
Adolescence is a time of profound change in brain function.
Mental Health Problems Mental Health Problems of School Age Childrenof School Age Children
10-13% of children have serious MH problems
655,000 Texas children
Mental Health Disorders Mental Health Disorders In ChildrenIn Children Many conditions overlap-make diagnosis
and treatment a challenge Examples: ADHD with Bipolar Disorder
Obsessive-compulsive Disorder with Disruptive Behavior Disorders
Etiology of Childhood Etiology of Childhood Mental Health ProblemsMental Health Problems
Concept:
Vulnerability vs. Resilience
Etiology of MH Etiology of MH Problems:Problems:
Genetics: strong for Depression, Anxiety, OCD, Tic disorders, ADHD, Bipolar disorder
Neurological Anomalies Prenatal Infection or Toxicity
e.g. Fetal Alcohol Syndrome (FAS)
Etiology, cont’d Psychosocial Adversity
Parent(s) with mental illness, drug or alcohol addiction, criminal behavior
Abuse and neglect Family and/or community stress or trauma Poverty
Etiology, cont’d Other Environmental Factors
Lead poisoning, Accidents/Brain injury, etc.
Mood DisordersMood Disorders
Depression: risk increases when a parent is depressed. Symptoms may differ from adult depression,
e.g. Poor school performance Behavioral problems
cont’d
Depression Symptoms Depression Symptoms Specific to Younger Specific to Younger PopulationsPopulations In Children: Lack of verbal skills affects
expression Irritable or resistant. May have somatic sx.
In Adolescents: Blues in boys: aggressive behavior or acting out Blues in girls: eating disorders, and/or self-injury.
Suicide in Younger Suicide in Younger PopulationsPopulations Risk for suicide: each year after
puberty Child abuse: risk for suicide X30 3rd leading cause of death in males
11-14 Population with greatest in rate =
Hispanic females 12-17
Mood Disorders, cont’dMood Disorders, cont’d Bipolar D/O —Primarily dx. in adolescence
Evidence is growing for early bipolar sx. Sx. in children: irritability, impulsivity, temper
tantrums Highly susceptible to mania caused by
prescribed antidepressants and stimulants
Anxiety DisordersAnxiety Disorders Trauma-Related (PTSD) Separation Anxiety Disorder Social Anxiety Disorder Pediatric OCD
Behaviors may manifest as oppositional or resistent
Attention Deficit/ Attention Deficit/ Hyperactivity Disorder Hyperactivity Disorder (ADHD)(ADHD)
Up to 11% of school age children Correlates with psychological adversity Dx: >6 months, before age 7 Types:
Inattentive Disorganized, poor-follow through
Impulsive and Over-active Restless, distractible, reckless, disruptive
Co-Morbidity 0f Co-Morbidity 0f ADHD with Other ADHD with Other
Childhood DisordersChildhood Disorders
Etiology of ADHD: Etiology of ADHD: Neurobiological TheoriesNeurobiological Theories
Frontal Lobe Dysfunction: area of brain responsible for planning, attention, regulation of motor activity
“Underactive Brain” Reduced metabolic activity Not enough Dopamine Hypoperfusion
ADHD: Other Possible ADHD: Other Possible Neurobiological FactorsNeurobiological Factors
Defective inhibitory mechanisms Dysfunctional Reticular Activating System
(inability to regulate incoming stimuli and to attend to stimuli)
ADHD Issues-Etiology ADHD Issues-Etiology Exposure to chemicals? TV and electronic media?
Pharmacotherapy for ADHD
Stimulants: methylphenidate (Ritalin, Concerta), dextroamphetamine (Dexedrine), and mixed amphetamine (Adderall), pemoline (Cyclert) Extended release--Ritalin LA/Concerta/Metadate
CD, Adderall XR--decrease dosing to once daily
Non-Stimulant Medications for ADHD Affect norepinephrine release or
reuptake: clonidine (Catapres) guanfacine (Tenex, Intuniv) atomoxetine (Strattera)
Stimulant Medication Issues
Rebound effects common, esp. with multi-dose forms
Side effects: anorexia, weight loss, abnormal movements/tics, labile mood, insomnia, agitation
Potential for drug abuse dextroamphetamine with l-lysine (Vyvanse)
psychostimulant that reduces abuse potential
Stimulant Medication Issues, cont’d
Ethical issue: Are stimulants over-prescribed?
Disruptive Behavior Disruptive Behavior DisordersDisorders Oppositional Defiant Disorder (ODD)
Argumentative, disobedient, fighting, explosive anger
Conduct Disorder (CD) More serious behavioral violations e.g. aggression,
violence, torture of animals, etc. May be criminal in nature e.g. arson, stealing, etc.
Frequently comorbid with ADHD, learning problems, mood and anxiety disorders
Developmental Developmental DisordersDisorders include:include: Mental Retardation
Low IQ with learning dysfunction
Pervasive Developmental Disorders Autistic Disorder Asperger’s Disorder
Specific Developmental Disorders, e.g. Learning Disorder
Communication Disorders
Autism and Autism and Asperger’s D/OAsperger’s D/O
Viewed as being on the same spectrum, differentiated by severity of symptoms and impairment
Autistic Disorder Autistic Disorder (Autism)(Autism)
Early Age of onset 30 months of age Constant delayed development May or may not have low intellectual function
““Triad of Autism”Triad of Autism”
#1 Impaired Social Skills and Relatedness Aloof and indifferent to others Prefer inanimate objects to human
contact Unable to understand social cues
Cont’d
Autistic Disorder “Triad”Autistic Disorder “Triad”
#2 Alteration in Communication Delayed Restricted Abnormal intonation Pronoun reversals Echolalia May be nonverbal
Autistic Disorder “Triad”Autistic Disorder “Triad”
#3 Restricted, Repetitive and/or Stereotypical Behaviors or Interests Rocking, hand flapping, spinning Insistence on sameness Preoccupation with peculiar interests
Autism You Tube
http://www.youtube.com/watch?v=FDMMwG7RrFQ (Autism Every Day 7 min. docu.)
http://www.youtube.com/watch?v=mc1H0aVqn20 (Toddler boy 5 min.)
Asperger’s Asperger’s DisorderDisorder
Less severe form of autism Less likely to be mentally retarded Higher performing: language development
may be ok Communication handicap is less severe
Concrete interpretation of language Stilted and abnormal intonation
Asperger’s Disorder, Asperger’s Disorder, cont’dcont’d Clumsy Social Interactions are impaired
Problems reading social cues Preoccupation with matters of private interest Obsessive, repetitive routines and rituals
Aspergers’s You tube
http://www.youtube.com/watch?v=V0DBHxS5Zv0&feature=related (2 teens)
Other Characteristics of Other Characteristics of Autism Spectrum Autism Spectrum DisordersDisorders Hypersensitivity to sensory stimuli Difficulties with transitions or change
Etiology of Autism Etiology of Autism Spectrum D/OsSpectrum D/OsMultiple causes are proposed: Genetic-Highly heritable Infection
Intrauterine Childhood
Autism IssuesAutism Issues The vaccination controversy
BullyingBullying Pattern of harm/abuse of power over another
person that is repetitive and has not been provoked
Reporting is low Diagnosis is difficult About half of all US children have been victims
BullyingBullying May be carried out by individuals or groups
Types: Verbal-name calling, racial slurs, malicious
false gossip Physical attacks Cyberbullying-use of electronic media to
invade privacy, defame or embarrass
Results of Bullying:Results of Bullying: Emotional problems, school refusal Substance use Suicide Revenge on persons or institutions
Interventions for Bullying School nurse is often the first responder Interventions need to be institution-based
and community-based Education
General Nursing General Nursing Interventions for Interventions for Children: Children: A Behavioral A Behavioral FocusFocus
Simple step-by-step instructions Daily routines “It’s 5:00; play time is over.—Please put away all
the toys.---We’ll wash hands now because it’s dinner time.—You washed your hands, so we’re ready to go to the table.”
Short term rewards/re-enforcers
Nurse-Client Nurse-Client CommunicationsCommunications
Communication Examples for Children:
“It is unsafe to jump down stairs 2 at a time”
“You walked down the stairs in a safe way”
“It is not OK to grab a toy from another child; you must ask”
“Because you didn’t hit today, you may choose the group snack tonight”
Milieu Milieu ManagementManagement Communicate expectations for behavior Set limits on destructive, aggressive and
inappropriate sexual behavior Support independence as appropriate Rights of the group vs. individual rights
Other Cognitive and Other Cognitive and Behavioral TherapiesBehavioral Therapies Problem Solving Skills- reinterpretation of
environment to reduce negative thinking CBT: Useful for long-term tx., e.g. for OCD,
negative thinking in depression, anxiety May be used in inpatient settings as part of
milieu management
Cognitive and Behavioral Cognitive and Behavioral Interventions, cont’dInterventions, cont’d Social Skills Training- e.g. for Asperger’s Prompting and sensory reinforcement:
Autism
More Nursing More Nursing InterventionsInterventions Teach the family about disorders,
symptoms and intervention techniques Assess family HX: Listen; be objective
when hearing what family has to say Identify family strengths and successes Communicate with teachers, school Passes to go home prior to discharge
Pharmocotherapy Pharmocotherapy InterventionsInterventions Antidepressants
SSRIs : fluoxetine (Prozac) sertraline (Zoloft) fluvoxamine (Luvox) paroxetine (Paxil)
citalopram (Celexa)
escitalopram (Lexapro)
Also used for OCD
Pharmacotherapy:Pharmacotherapy: AntidepressantsAntidepressants SSRIs, cont’d
Activating effects may precipitate hypomania, mania or suicide
TCAs –many SE’s; lethal doses have occurred
Pharmacotherapy, cont’dPharmacotherapy, cont’d
Antipsychotic Agents For aggressive behavior, self-injury, psychotic
symptoms, mood stabilization Typicals: Highly correlated with EPSEs Atypicals: FDA approved = risperidone/Risperdal
and aripiprazole/Abilify Weight gain problematic; fatty livers
(risperidone/Risperdal)
Pharmacotherapy, cont’dPharmacotherapy, cont’d Antianxiety agents-
best choices buspirone/Buspar clonazepam/Klonipin
Mood Stabilizers-dose based on weight Lithium-age 12 and older Atypical antipsychotic agents
Issues in Issues in PharmacotherapyPharmacotherapy Few drugs are FDA approved Most not tested on children Children metabolize and excrete differently
from adults Children may have narrower therapeutic
range for some drugs
Interventions: Interventions: PsychotherapyPsychotherapy Individual Therapy
Play therapy for children
Group Therapy
Family Therapy
Community Community ResourcesResources Support groups, camps, web resources,
literature (e.g. workbooks), parenting classes