Child and Adolescent Child and Adolescent Mental HealthMental Health

Cognitive DevelopmentCognitive Development

Moves from concrete thinking to “formal operations” -Abstract thinking

Level of thinking allows the person to transfer information from one situation to another, deal efficiently with complex problems, and plan realistically for the future.

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 Mental Health Problems of School Age ChildrenSchool Age Children

10-13% of children have serious MH problems

655,000 Texas children

Etiology of MH ProblemsEtiology of MH Problems

Genetics: strong for Depression, Anxiety, OCD, Tic disorders, ADHD, Bipolar

Environment: – Abuse and neglect, (actually causes a

change in structure of the brain) – Intrauterine: Fetal Alcohol Syndrome– Other: Poverty, Lead poisoning, Brain injury,

etc.

Etiology, cont’dEtiology, cont’d

• Neurological Anomalies– Developmental disorders- MR-IQ below

70 , Axis II– Pervasive developmental disorders-Autism,

Asperger’s, PDD-NOS, Etc.

Main ContentMain Content

• Developmental Disorders• Attention Deficit and Disruptive Behavior

Disorders• Pervasive Developmental Disorders• TIC Disorders• Psychotic and Mood Disorders• Elimination Disorders• Psychopharmacology• Cognitive Behavioral Therapy

Developmental DisordersDevelopmental Disorders

Mental Retardation– IQ< 70

Pervasive Developmental Disorders– Autistic Disorder– Asperger’s Disorder– Pervasive Developmental Disorder NOS

Specific Developmental Disorders– Learning Disorder

Communication Disorders– Speech and language disorders are strongly associated with

psychiatric disorders

Attention Deficit Attention Deficit Hyperactivity Disorder Hyperactivity Disorder

(ADHD)(ADHD)Inattention ImpulsivityOveractivity

– Restless overactive, distractible, reckless, disruptive

– Up to 11% of school age children– Psychological adversity

Etiology of ADHD: Etiology of ADHD: Neurobiology Neurobiology

Frontal Lobe Dysfunction: area of brain responsible for planning, attention, regulation of motor activity– “Underactive brain”

Reduced metabolic activity Not enough Dopamine Hypoperfusion

Pharmacotherapy for ADHDPharmacotherapy for ADHD

Stimulants: methylphenidate (Ritalin), detroamphetamine (Dexedrine), and mixed amphetamine (Adderall)– Extended release--Ritalin LA; Metadate CD

and Concerta--decrease dosing to once daily

– Adderall XR is also extended release

Stimulant Medication IssuesStimulant Medication Issues

Dose regular stimulants just prior to meals to decrease anorexia

Non-extended release require noon dosing and a smaller dose in the evening to prevent rebound

Side effects: anorexia, weight loss, abnormal movements, labile mood, insomnia, over focused on details, agitation

Other Medications for ADHDOther Medications for ADHD

clonidine (Catapres) also used: reduce norepinephrine activity in the brain

atomoxetine (Strattera)– Has a different mode of action from

amphetamines, not a schedule II drug– Capsule form of 10,18,25,40,60 Mgm– Affects reuptake of Norepinephrine

Side Effects of StratteraSide Effects of Strattera

Most common: dyspepsia, nausea, vomiting, fatigue, appetite decreased, dizziness, and mood swings

Less common: insomnia, sedation, depression, tremor, itching, dry eyes, sexual dysfunction

Adverse events: Increased heart rate and blood pressure--albuterol inhalers can increase CV effects

Drug interactions: Paxil and Prozac

Disruptive Behavior DisordersDisruptive Behavior Disorders

Oppositional Defiant Disorder (ODD)– Enduring pattern of disobedience– Argumentative– Explosive (Impulsive)– Frequently in conflict with adults– Tendency to blame others

Comorbid Diagnosis with ADHD, anxiety and mood disorders

Disruptive Behavior Disorders, cont’dDisruptive Behavior Disorders, cont’d

Conduct Disorder– More serious violations of social standards– Higher than expected rates of ADHD,

depression and learning disorders Associated with adult Antisocial

Personality Disorder dx.

Pervasive Developmental Pervasive Developmental DisordersDisorders

Impairment across multiple domains (impairment is global)– Psychological Impairment– Social Impairment– Academic Impairment– May meet the standard for Mental

retardation

Pervasive Developmental Pervasive Developmental DisordersDisorders

Autistic Disorder

Asperger’s Disorder

Pervasive Developmental Disorder NOS

PDD’sPDD’s

Are now viewed as being on the same spectrum, differentiated by severity of symptoms and impairment

Autistic DisorderAutistic Disorder

Early Age of onset– 30 months of age– Constant delayed development

Social relatedness is profoundly impaired– Aloof and indifferent to others– Prefer inanimate objects to human contact

Stereotypical Behaviors– Rocking and Hand flapping

Autistic Disorder, cont’dAutistic Disorder, cont’d

Alteration in Communication– Delayed and deviant– Abnormal intonation– Pronoun reversals– Echolalia

Insistence on sameness and preoccupation with peculiar interests

The vaccination controversy

Asperger’s DisorderAsperger’s Disorder

Less likely to be mentally retarded Communication handicap is less severe

– Concrete interpretation of language– Stilted and abnormal intonation

Higher performing Social interactions impaired

– Impaired reading of social cues– Clumsy– Difficulty with transition– Preoccupation with matters of private interest

Pervasive Developmental Pervasive Developmental Disorder NOSDisorder NOS

Does not meet criteria for more specific type of PDD

Traits of both Autism and Asperger’s

Tic DisordersTic Disorders

Tourette’s Syndrome -Movement disorder defined by the presence of motor and phonic tics: Rare 1 to 2 per thousand– Motor Tics-rapid, jerky movements of eyes, face,

neck, and shoulders– Phonic tics: grunting, throat clearing, and repetitive

noises– Can be words or obscenities

Treatment: haloperidol (Haldol), clonidine (Catapres)

Other Psychiatric DisordersOther Psychiatric Disorders

Childhood Schizophrenia- 2 cases per 100,000– Compare with Autism

Anxiety Disorders: Separation anx. and OCD Elimination Disorders-often accompany other

disorders or as response to stress– Enuresis –bedwetting and/or incontinence during the

day – Encopresis—fecal incontinence, soiling or

inappropriate depositing of feces Fecal impaction may cause or result

Other Psychiatric Disorders, Other Psychiatric Disorders, cont’dcont’d

Bipolar D/O and Schizophrenia—Primarily dx. in adolescence

Depression: risk increases when a parent is depressed.– How are the symptoms of depression in

children and adolescents different from the symptoms seen in adults?

Depression Symptoms Specific to Depression Symptoms Specific to Younger PopulationsYounger Populations

In Children– Lack of verbal skills affects expression: may be

irritable or resistant In Adolescents

– Blues in boys; aggressive behavior or acting out– Blues in girls; anxiety, eating disorders, and or

self-cutting.– 2 symptoms to be concerned about: difficulty

concentrating and negative statements about themselves and their place in it; like “I’m stupid”

General Nursing General Nursing Interventions for Children: A Interventions for Children: A

Behavioral FocusBehavioral Focus

Keep it simple, structured, and re-enforce good behavior– “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”– Simple step-by-step instructions– Daily routine & short term rewards/re-enforcers

Other InterventionsOther Interventions

Cognitive-Behavioral Therapy– 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– “Reinforcement” concepts (negative/positive)

Points and levels– “Extinguishes” negative thinking

Social Skills Training- e.g. for Asperger’s Problem Solving Skills- reinterpretation of environment

More Nursing InterventionsMore 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

PharmocotherapyPharmocotherapy

Antidepressants– SSRIs : fluoxetine (Prozac) sertraline (Zoloft) fluvoxamine (Luvox) paroxetine (Paxil) citalopram (Celexa) escitalopram (Lexapro)– None are yet officially FDA approved!

Also used for OCD

Pharmacotherapy, cont’dPharmacotherapy, cont’d

SSRIs, cont’d– Activating effects may precipitate

hypomania, mania or suicide

TCAs –have been used for many years but effectiveness not proven

Pharmacotherapy, cont’dPharmacotherapy, cont’d

Antipsychotic Agents– For aggressive behavior, self-injury, tics,

psychotic symptoms– Typicals: Highly correlated with EPSEs– Atypicals: Weight gain problematic; fatty

livers

Interventions: PsychotherapyInterventions: Psychotherapy

Individual Therapy– Play therapy for children

Group Therapy

Family Therapy

Community ResourcesCommunity Resources

Support groups, camps, web resources, and literature