Transcript Child and Adolescent Mental Health

Child and Adolescent
Mental Health
Module Content
 Mood and Anxiety Disorders
 Attention Deficit and Disruptive
Behavior Disorders
 Developmental Disorders: Autism
Spectrum
 Bullying
 Psychopharmacology
 Cognitive and Behavioral Therapies
Cognitive Development
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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 of
School Age Children
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10-13% of children have serious MH
problems
655,000 Texas children
Mental Health Disorders
In Children
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Many conditions overlap-make diagnosis
and treatment a challenge
Examples: ADHD with Bipolar Disorder
Obsessive-compulsive Disorder
with Disruptive Behavior Disorders
Etiology of Childhood
Mental Health Problems
Concept:
Vulnerability vs.
Resilience
Etiology of MH 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
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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 Disorders
 Depression: risk increases when a parent
is depressed.
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Symptoms may differ from adult depression,
e.g.
Poor school performance
 Behavioral problems
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cont’d
Depression Symptoms Specific
to Younger Populations
 In Children: Lack of verbal skills affects
expression
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Irritable or resistant.
May have somatic sx.
 In Adolescents:
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Blues in boys: aggressive behavior or acting out
Blues in girls: eating disorders, and/or self-injury.
Suicide in Younger Populations
 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’d
 Bipolar D/O —Primarily dx. in adolescence
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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 Disorders
Trauma-Related (PTSD)
 Separation Anxiety Disorder
 Social Anxiety Disorder
 Pediatric OCD
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Behaviors may manifest as oppositional or
resistent
Attention Deficit/
Hyperactivity Disorder (ADHD)
 Up to 11% of school age children
 Correlates with psychological adversity
 Dx: >6 months, before age 7
 Types:
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Inattentive
 Disorganized, poor-follow through
Impulsive and Over-active
 Restless, distractible, reckless, disruptive
Co-Morbidity 0f ADHD with
Other Childhood Disorders
Etiology of ADHD:
Neurobiological 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
Neurobiological Factors
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Defective inhibitory mechanisms
Dysfunctional Reticular Activating System
(inability to regulate incoming stimuli and to
attend to stimuli)
ADHD Issues-Etiology
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Exposure to chemicals?
TV and electronic media?
Pharmacotherapy for ADHD
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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
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Affect norepinephrine release or
reuptake:
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clonidine (Catapres)
guanfacine (Tenex, Intuniv)
atomoxetine (Strattera)
Stimulant Medication Issues
 Rebound effects common, esp. with
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multi-
dose forms
Side effects: anorexia, weight loss,
abnormal movements/tics, labile mood,
insomnia, agitation
Potential for drug abuse
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dextroamphetamine with l-lysine (Vyvanse)
psychostimulant that reduces abuse potential
Stimulant Medication Issues, cont’d
 Ethical
issue: Are stimulants overprescribed?
Disruptive Behavior Disorders
Oppositional Defiant Disorder (ODD)
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Argumentative, disobedient, fighting, explosive anger
Conduct Disorder (CD)
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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 Disorders
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 Asperger’s D/O
Viewed as being on the same
spectrum, differentiated by severity of
symptoms and impairment
Autistic Disorder (Autism)
 Early Age of onset
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30 months of age
Constant delayed development
May or may not have low intellectual function
“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
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Cont’d
Autistic Disorder “Triad”
#2 Alteration in Communication
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Delayed
Restricted
Abnormal intonation
Pronoun reversals
Echolalia
May be nonverbal
Autistic Disorder “Triad”
#3 Restricted, Repetitive and/or
Stereotypical Behaviors or Interests
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Rocking, hand flapping, spinning
Insistence on sameness
Preoccupation with peculiar interests
Autism You Tube
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http://www.youtube.com/watch?v=FDMMw
G7RrFQ (Autism Every Day 7 min. docu.)
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http://www.youtube.com/watch?v=mc1H0a
Vqn20 (Toddler boy 5 min.)
Asperger’s Disorder
 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, cont’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
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http://www.youtube.com/watch?v=V0DBHx
S5Zv0&feature=related (2 teens)
Other Characteristics of Autism
Spectrum Disorders
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Hypersensitivity to sensory stimuli
Difficulties with transitions or change
Etiology of Autism Spectrum
D/Os
Multiple causes are proposed:
 Genetic-Highly heritable
 Infection
 Intrauterine
 Childhood
Autism Issues
 The vaccination controversy
Bullying
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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
Bullying
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
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Results of Bullying:
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Emotional problems, school refusal
Substance use
Suicide
Revenge on persons or institutions
Interventions for Bullying
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School nurse is often the first responder
Interventions need to be institution-based
and community-based
Education
General Nursing Interventions
for Children:
A Behavioral Focus
 Simple step-by-step instructions
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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.”
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Short term rewards/re-enforcers
Nurse-Client Communications
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 Management
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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 Behavioral
Therapies
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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
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May be used in inpatient settings as part of
milieu management
Cognitive and Behavioral
Interventions, cont’d
 Social Skills Training- e.g. for Asperger’s
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Prompting and sensory reinforcement:
Autism
More Nursing Interventions
 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 Interventions
 Antidepressants
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SSRIs :
fluoxetine (Prozac) 
sertraline (Zoloft) 
fluvoxamine (Luvox) 
paroxetine (Paxil)
citalopram (Celexa)
escitalopram (Lexapro)
 Also used for OCD
Pharmacotherapy:
Antidepressants
 SSRIs, cont’d
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Activating effects may precipitate hypomania,
mania or suicide
 TCAs –many SE’s; lethal doses have occurred
Pharmacotherapy, cont’d
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Antipsychotic Agents
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For aggressive behavior, self-injury, psychotic
symptoms, mood stabilization
Typicals: Highly correlated with EPSEs
Atypicals: FDA approved = risperidone/Risperdal
and aripiprazole/Abilify
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Weight gain problematic; fatty livers
(risperidone/Risperdal)
Pharmacotherapy, cont’d
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Antianxiety agentsbest choices
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buspirone/Buspar
clonazepam/Klonipin
Mood Stabilizers-dose based on weight
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Lithium-age 12 and older
Atypical antipsychotic agents
Issues in Pharmacotherapy
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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: Psychotherapy
Individual Therapy
 Play therapy for children
Group Therapy
Family Therapy
Community Resources
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Support groups, camps, web resources,
literature (e.g. workbooks), parenting
classes