Transcript Mental Health Lecture - Salem State University

Kristine Ruggiero, CPNP, MSN, RN
Child Health Nursing: Partnering with Children and
Families; Ch 34 pp1369-1384; 1396-1401
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Sense of personal well-being involving
successful engagement in activities and
relationships and the ability to adapt to and
cope with change.
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Many children who need services don’t receive
them
25% of children in the US suffer from mental
illness that impairs functioning at home or
school
Only 30% of those children receive MH services
Many of these interventions are not
comprehensive, multidisciplinary or evidencebased
MH issues are among the top 2 leading causes of
hospitalization in 10-21 year-olds
◦ Indicates children are not receiving adequate MH
services
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Appearance
Behavior
Development
History
◦ Prenatal, natal and post-natal hx
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Assessment:
◦ Include a valid, reliable tool to assess behavioral/
mental health problems
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Pervasive Developmental Disorders
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Autistic disorder
Asperger’s syndrome
Rett’s disorder
Childhood disintegrative disorder
Pervasive developmental disorder NOS
Attention Deficit Disorders
Cognitive Disorders
◦ Trisomy 21
◦ Fragile X
◦ FAS
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Aka “Autistic Spectrum Disorders”
5 types
Begin in early childhood
Characterized by impaired social interactions
and communication, with restricted interests,
activities, and behaviors
about 2 or more/ 1,000 are dx w/ ASD
4X more common in males
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It can be difficult to know at first if a child has a
pervasive developmental disorder (PDD). PDDs are
a wide spectrum of social and communication
disorders, including autism, that can be
complicated to diagnose.
However, there are acknowledged criteria for
determining if a child has a PDD and there are ways
to help children with these disorders at an early
age. Typically, the symptoms should be
recognizable before a child is 3 years old. Although
a toddler's behaviors might seem to fit the criteria,
they also might just be part of a youngster's
developing personality.
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Autism and Genetics:
◦ Some genetic contribution
◦ Familial incidence
 Monozygotic twins: 60% autism: 92% PDD
 Dizygotic twins: 0% autism: 10-30% PDD
 Sibling risk: 4-7%
◦ Increased risk with genetic differences
 Fragile X, Williams Syndrome, Angleman’s
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Impaired social, communication and
behavioral development usually noted in the
first year of life
Impaired social interaction
◦ Stereotypy (rigid obsessive behavior)
 Head banging, twirling, flapping hands
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Impaired Communication
◦ Speech delay or language difficulty (often 1st
symptom)
◦ Echolalia (parroting of what is heard)
◦ Use of “you” in place of “I“
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Restricted or repetitive patterns of behaviors
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Difficulty mixing with
other children
Inappropriate laughing
Little or no eye contact
Insensitive to pain
Prefers to be alone
Spins objects
Physical over-activity
or extreme under
activity
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Insistence on sameness
No real fear of dangers
Sustained odd play
Echolalia
May not want to cuddle
Not responsive to verbal
cues
Tantrums
Uneven gross or fine
motor skills
Difficulty expressing
needs
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Onset prior to age 3
Remember this disorder occurs on a
spectrum
Clinical Therapy:
◦ Early intervention is key to maximize
outcomes…this means early assessment and dx is
key to treatment!...Screening tools in primary care!
◦ Interventions focus on improving behaviors and
communication skills, PT and OT, structuring play
interactions with other children, educating parents
of child’s needs
◦ Combination of behavioral and cognitive tx
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Strong preference for routine
Perseveration
◦ Focus on same nonfunctional activity for hours
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Restricted range of interests
Stereotypical behaviors
◦ Spinning, hand flapping
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No Babbling at 12 months
No gesturing (pointing, waving) at 12 months
No single words at 16 months
No 2-word phrases at 24 months
Any loss of language/ social skills at any age
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Nursing assessment: Early and frequesnt
developmental screening is KEY!
Nursing Dx include:
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Impaired verbal communication
Impaired social interaction
Disturbed thought processes
Risk for injury
Risk for caregiver role strain
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State program run by DPH
Services for children 0-3
Children who are at risk d/t
◦ Biological factors
◦ Environmental factors
◦ Psychological factors
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Clinical manifestations:
◦ Impaired social interactions w/ normal language
development for age; pitch, tone and other speech
characteristics may be abnormal.
◦ Verbal skills involving spelling and vocabulary are
high with concept formation, language flexibility,
and comprehension low.
◦ So, the child w/ Asperger’s can have normal
language development and normal or above normal
cognition, but will have impairments in social
interactions and functioning
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Treatment:
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Applied Behavior Analysis
Positive Reinforcement
Language and communication therapy
Social skills training
Medications:
 No tx for core sxs of social and relationship problems
 Meds target some secondary sxs: hyperactivity,
aggression and anxiety
 Common drug used= Risperidone
 Decreases abberant behavior (aggression, hyperactivity)
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Early development appears normal and sxs
appear b/t 6-18 months
Affects only girls (X-linked dominant
disorder)
Ataxia, hangwringing, intermittent
hyperventilation, dementia, and growth
retardation show progressive increase.
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Fist 2-5 years of development appear normal
followed by deterioration in many areas of
functioning. Behaviors finally stabilize at
some point w/o further deterioration.
Clinical therapy:
◦ Focuses on areas of developmental function that
show abnormality.
◦ IEPs for school
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PDD NOS: severe social impairment w/o
meeting DSM criteria for other types of
autistic spectrum disorders.
Clinical Tx:
◦ Focuses on building social skills
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Background: The term attention deficit is
misleading. In general, the current
predominating theories suggest that
persons with ADHD actually have difficulty
regulating their attention; inhibiting their
attention to nonrelevant stimuli, and/or
focusing too intensely on specific stimuli to
the exclusion of what is relevant. In one
sense, rather than too little attention, many
persons with ADHD pay too much attention
to too many things, leading them to have
little focus.
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Frequency:
In the US: The prevalence of ADHD in children appears to be
3-7%. ADHD is associated with significant psychiatric
comorbidities.
Approximately 50-60% of individuals with this disorder meet
DSM criteria for at least 1 of the possible coexisting
conditions, which include learning disorders, restless-legs
syndrome, depression, anxiety disorder, antisocial personality
disorder, substance abuse disorder, conduct disorder, and
obsessive-compulsive behavior.
The risk of a person having ADHD if his or her family member
has ADHD or one of the disorders commonly associated with
ADHD is significant.
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According to the DSM IV, the essential features of
ADHD include:
persistent and developmentally inappropriate
pattern of inattention, impulsivity, and/ or
hyperactivity
presence of sxs b/f 7 y.o.a
Impairments apparent in at least two different
settings (ie home and school)
Interference w/ social, academic, or occupational
function
Sxs are not d/t some other psychiatric disorder
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Occurs 4X more often in boys
Multifactorial etiology
◦ Genetics
◦ Environment
◦ Biologic risk
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Three subtypes
◦ ADD (primarily inattentive)
◦ ADHD (primarily hyperactive-impulsive)
◦ Combined
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In obtaining the PMHx, it is important to
thoroughly review the social hx,
◦ including school performance, substance abuse,
and violence in the home, etc.
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School or education interventions
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Psychotherapeutics
◦ The age of the child at initial diagnosis and the
severity of the symptoms of ADHD likely affect
the extent to which the child benefits from
working with education specialists.
◦ For adolescents, ADHD coaching, participating in
a support group, or both can help normalize the
disorder and assist them in obtaining wellfocused peer feedback and general information.
◦ affected children and their families.
◦ Behavioral modification and family therapy are
usually necessary for optimal care.
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Medications:
◦ Stimulants:
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Amphetamines (Adderall)
Methylphenidate (Ritalin, Concerta)
Pemoline (Cylert)
Dextroamphetamine (Dexedrine)
◦ Nonstimulants
 Bupropion (Wellbutrin)
 Atomoxetine (Strattera)
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For children, a major side effect of some of
the stimulant medication for treatment of
ADHD is what?
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Monitor G+D; if child is receiving
methylphenidate growth may be slowed
Give one instruction at a time to a child w/
ADHD
Give meds in morning and at lunch to avoid
interfering w/ sleep
Ensure adequate nutrition
Provide consistency and routine w/
schedule (teach parents)
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Learning disabilities
Trisomy 21
Fragile X
Fetal Alcohol Syndrome
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Prefer to call them Learning Differences
Affects 5% of school children
They involve neurologic conditions in which
the brain cannot receive or process
information in the “normal” manner.
Often the impairment is only in 1 or 2 types
of learning making the dx difficult
Children should have IEPs established w/
realistic goals
Nurses role: ID of children w/ learning
disabilities, help to access services for
child/family w/in the community
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Mental retardation is not something you have,
like blue eyes, or a bad heart. Nor is it
something you are like short or thin.
It is not a medical disorder or a mental
disorder.
Mental retardation is a particular state of
functioning that begins in childhood and is
characterized by limitation in both intellectual
and adaptive skills.
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MR is defined as significant limitation in
intellectual functioning and adaptive
behavior.
◦ IQ below 70-75
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Mild retardation occurs in 3-6 per 1,000
people
MR affects about 3% of the population.
Occurs b/f age 18
Causes:
◦ Prenatal errors in the development of the CNS
◦ Prenatal or postnatal changes in the biologic
environment of the person
◦ External forces leading to CNS damage
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One in every 733 live births
◦ More frequent in mothers over 35 years of age
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Wide range of intellectual abilities
Medical risks
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Cardiac
Immunologic
ENT
GI
Thyroid disorders
Alzheimer’s
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Triple screen: newest test for Down’s
syndrome
Maternal alpha feto protein, nonspecific test,
increase indicates risk
Amniocentesis
Chorionic villus sampling
In 2002, a study found that 91-93% of
pregnancies w/ a dx of Down’s syndrome
were terminated
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Single transverse palmar crease
Almond shape to the eyes (epicanthal fold)
Upslanting paperbral fissures
Shorter limbs
Poor muscle tone
Larger than normal space b/t the big and
second toe
Protruding tongue
Low set ears
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Most common known cause of inherited
mental retardation worldwide
DNA analysis of FMR1 gene
◦ Disease severity r/t the number of CGG
trinucleotide repeats in this gene
 Normal= 6-44 repeats
 Full mutation> 200 repeats
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Clinical Manifestations:
◦ Cognitive (IQ)
 Ranges: mild learning disabilities to mental retardation
 95-90% males w/ MR
◦ Behavioral
 Sensory defensiveness
 ADHD-like features
 Autistic-like features
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Alcohol use during pregnancy is the leading
known preventable cause of mental
retardation and birth defects in the US
Affects an estimated 40,000 infants each year
(more than spina bifida, down’s syndrome,
and muscular dystrophy combined)
FASD is an umbrella term describing the
range of effects that can occur in an
individual whose mother drank alcohol during
pregnancy
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Specific facial characteristics
Growth deficits
Mental retardation
Heart, lung, kidney deficits
Hyperactivity and behavior problems
Attention and memory problems
Poor coordination and motor skills delay
Difficulty w/ judgment and reasoning
Learning disabilities
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Once the dx has been made, a functional
assessment of the child should be performed
Assess the availability of services for the child
and family
Possible Nursing Diagnosis include:
◦ Delayed growth and development r/t neonatal
condition
◦ Imbalanced nutrition: less than body requirements
r/t inability to ingest sufficient food
◦ Self-care deficit: dressing, toileting, bathing r/t
developmental disability