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