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Mental health in children
What is mental health?
• Sense of personal wellbeing involving
successful engagement in activities and
relationships and the ability to adapt to and
cope with change. cope with change.
Mental Health in children
• 25% of children in US have MH issues that
impair their ability to function in home or at
school
• Many who need services do not receive them. • Many who need services do not receive them.
• Goal of treatment is to assist child & family to
achieve & maintain optimal level of
functioning through interventions that reduce
risk factors and enhance coping.
Statistics close to home
• Massachusetts
• Salem
– Survey of teachers in Salem 19% children with
Behavioral Health DisordersBehavioral Health Disorders
• ADHD
• Anxiety
• Depression
– 2/3 of educators feel insufficiently trained in BH
Mental Health Assessment
• Appearance
• Behavior
�Development
• Life events• Life events
• History
– Prenatal events
Assessment
• Tools exist for many behavioral health
problems
– Use a valid, appropriate, agency approved tool to
validate any subjective ideas about behavioral/ validate any subjective ideas about behavioral/
mental health problems
– Removes bias in assessment
Planning and Implementation
treatment modes
• Group therapy
– Supportive
– Effective with adolescents
• Individual Therapy• Individual Therapy
– Cognitive therapy
• Family therapy
Planning and Implementation
Therapeutic strategies
• Play therapy
• Art therpay
• Behavior and cognitive therapy
• Visualization and guided imagery• Visualization and guided imagery
• Hypnosis
Inpatient care
• Nursing responsibilities
– Medication administration with careful attention
to therapeutic action and side effects
– Ensure safety– Ensure safety
– Collaborate regarding medical concerns
– Involve the family
Discussion of mental health disorders
in children
• Pervasive developmental disorders
• Attention deficit disorders
• Cognitive disorders
• Violence• Violence
• Abuse
Pervasive Developmental Disorders
• Begin in early childhood
• Characterized by impaired social interactions
and communication
• Restricted interests, activities, behaviors• Restricted interests, activities, behaviors
• Unusual ways of learning
• 4x more likely in boys than girls
Pervasive Developmental disorders
• Autistic Disorder
• Asperger’s syndrome
• Rett’s disorder
• Childhood disintegrative disorder• Childhood disintegrative disorder
• Pervasive developmental disorder NOS
Other medical disorders that should be
ruled out before a diagnosis is made
• Hearing loss
• EEG
• Metabolic screening
• MRI• MRI
• C T
• Genetic testing
Autistic disorder
• Impaired social, communication, and
behavioral development usually noted in the
first year of life
Clinical therapy involves early
intervention
•OT
•PT
•Speech
Autistic disorder
• Impaired social interaction
• Impaired communication
• Restricted repetitive and stereotyped patterns
of behavior, interests or activitiesof behavior, interests or activities
• Onset prior to age 3 years
• Not better accounted for by Rett’s disorder or
childhood disintegrative disorder
Spectrum disorder
RememberToddler language development
• Concrete use of single words (labeling)
– Combining words to express ideas
• Expanded phonology (range of sounds)
• Expanded semantics (meanings of words)• Expanded semantics (meanings of words)
• Increased symbolic understanding
• Expanded pragmatics
– Conversation & language as social tools
Behaviors and Autism Spectrum
disorders
• Strong preference for routine
• Perseveration
– Focus on same nonfunctional activity for hours
• Restricted range of interests• Restricted range of interests
– Trains, dinosaurs,
• Stereotypical behaviors
– Spinning, hand flapping, visual regard
Play and Autism
• Lack of or impaired imaginative play
• Purposeless or idiosyncratic play
– Lining up toys– Lining up toys
– Sensory exploration of objects/toys
• Preoccupied with parts/aspects of object
– Repetitive car wheel spinning
– Flashing/beeping interest exclusively
Red Flags for Autism Spectrum
Disorder
• 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• No 2 word phrases at 24 months
• Any loss of any language/social skills at any
age
Autism and genetics
• Some genetic contribution
• Familial incidence
– Monozygotic twins: 60% autism; 92% PDD
– Dizygotic twins: 0% autism; 10-30% PDD– Dizygotic twins: 0% autism; 10-30% PDD
– Sibling risk: 4-7%
• Increased risk with genetic differences
– Fragile X, Williams syndrome, 15 duplication,
Angelman’s
Autism specific characteristics
• Difficulty mixing with other children
• Inappropriate laughing
• Little or no eye contact
• Insensitive to pain
• Insistence on sameness
• No real fear of dangers
• Sustained odd play
• Echolalia
• May not want cuddling• Insensitive to pain
• Prefers to be alone
• Spins objects
• Inappropriate attachment to objects
• Physical over activity or extreme under activity
• May not want cuddling
• Not responsive to verbal cues
• Difficulty expressing needs
• Tantrums
• Uneven gross or fine motor skills
Nursing Assessment and diagnosis
• Impaired verbal communication
• Impaired social interaction
• Disturbed thought processes
• Risk for injury• Risk for injury
• Risk for caregiver role strain
Autism disorder
• Click to start
www.autismspeaks.org/sponsordevents/autis
m_every_day.phpautism speaks
Early intervention services
• State program run by Department of Public
Health
• Services children 0-3
• Children who are at risk due to • Children who are at risk due to
– Biological factors
– Environmental factors
– Psychological factors
Asperger’s Syndrome
• Neurological disorder that, like others on the
spectrum, is marked by difficulties in
communication and social interaction The set
of characteristics easily identified with the of characteristics easily identified with the
conditon was first identified by Austrian
pediatrician Hans Asperger.
Differences between aspergers and
traditional autism
• Impairment in social interactions
• Restricted, repetitive, or stereotyped
behaviors
• Significant impairment in functioning• Significant impairment in functioning
• No significant general delay in language
• Normal cognition, curiosity, adaptation
(normal IQ, meet milestones on time)
• Not schizophrenia or other PDD
Treatment of Aspergers
• Applied Behavior Analysis
• Positive reinforcement
• Language and communication therapy
• Social Skills training• Social Skills training
• Hippotherapy
• Martial arts therapy
• Medications
Pharmacotherapy
• No treatment for core symptoms of social and
relationship problems in autism
• Medications do target some secondary
symptoms: hyperactivity, self-injurious symptoms: hyperactivity, self-injurious
behavior, aggression, anxiety
• Since most require long-term treatment
periodic attempts to discontinue or decrease
medication is prudent
Risperidone for Autism
• Decrease in aberrant behavior
– Aggression
– Streotypic and hyperactive behavior
• Adverse Effects• Adverse Effects
– Weight gain
– Tremor
– Fatigue
Retts syndrome
• Occurs only in girls
• Genetic disorder
• Deceleration of head growth followed by loss of hand skills and the appearance of stereotypic hand wringing between the ages of 5 months and hand wringing between the ages of 5 months and 4 years
• Social skills and expressive/receptive language loss between ages 2-3
• Development of ataxia, apraxia, broad-based/jerky gait, breathing problems
ADHD
• According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), the essential features of ADHD include:
1. persistent and developmentally inappropriate pattern of inattention, impulsivity, and/or hyperactivity;
2. presence of symptoms before 7 years of age;2. presence of symptoms before 7 years of age;
3. impairments apparent in at least two different settings (e.g., home and school);
4. interference with social, academic, or occupational function; and
5. symptoms are not due to some other psychiatric disorder
ADHD
• Occurs more often in boys
• Multifactorial etiology
– Genetics
– Environment– Environment
– Biologic risk
• Three subtypes
– ADD (primarily inattentive)
– ADHD (primarily hyperactive-impulsive)
– Combined
ADHD diagnosis
• Physical exam
• Teacher/parent rating scales
– Vanderbilt
– Conner– Conner
• Psychoeducational testing
What else could it be?
• Depression
• Anxiety
• Learning disabilities
• Oppositional defiant disorder• Oppositional defiant disorder
Are there co-morbidities?
• Learning disabilities
• Tourette syndrome
• Oppositional defiant disorder
• Conduct disorder• Conduct disorder
• Anxiety and depression
• Bipolar disorder
ADHD treatment
• Stimulants
– Work on neurotransmitter dopamine
• Nonstimulants
– Work on neurotransmitter norepinephrine– Work on neurotransmitter norepinephrine
• Behavioral therapy
• Accomodations
– Provide an environment that best fits the needs of the child
– Focus on being proactive rather than reactive
What approach works best?
• Medication alone
• Intense therapy alone
• Combination
• Community care (nothing different)• Community care (nothing different)
COMBINATION
Stimulant side effects
• Decreased appetite
• Headaches
• Difficulty sleeping
• Tics
Things to remember about ADHD
meds
• Medication for ADHD help many children
focus and be more successful at school, home
and play. Avoiding negative experiences now
may actually help addictions and other may actually help addictions and other
emotional problems later
• About 80% of children who need medication
for ADHD still need it as teenagers. Over 50%
need medication as adults
Cognitive deficits
• Mental retardation is not something you have, like blue eyes, or a bad heart. Nor is it something you are, ike short, or thin.
• It is not a medical disorder or a mental • 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.
Cognitive Deficits
• Generally measured by IQ (<70=MR)
• Affects 3% of population. Occurs before age
18.
• Causes• Causes
– Prenatal errors in development
– Pre or postnatal changes in biologic environment
– External forces leading to CNS damage
Mental Retardation
• In 1967 there were 194,650 people living in public institutions
• Massachusetts Consent decree deinstitutionalized individuals living in state deinstitutionalized individuals living in state schools
• Established community services
• PL94-142 all children have right to a free appropriate public education to all children with disabilities.
Cognitive deficits
• Trisomy 21
• Fragile X
• Fetal Alcohol syndrome
Trisomy 21
• One in every 733 live births– More frequent in older mothers
• Wide range of intellectual abilities
• Medical risks– Cardiac– Cardiac
– Immunologic
– ENT
– GI
– Thyroid disorders
– Alzheimers
Trisomy 21 characteristics
• Single transverse palmar crease
• Almond shape to the eyes (epicanthal fold)
• Upslanting papebral fissures
• Shorter limbs• Shorter limbs
• Poor muscle tone,
• Larger than normal space between the big and second toe
• Protruding tongue
• Low set ears
Trisomy 21
prenatal diagnosis
• Maternal alpha feto protein, nonspecific test,
increase indicates risk
• Amniocentesis
• Chorionic villus sampling• Chorionic villus sampling
• In 2002 study found that 91-93% of
pregnancies with a diagnosis of down
syndrome were terminated.
Fragile X
• Most common known cause of inherited
mental retardation worldwide
• DNA analysis of FMR1 gene
– Disease severity related to the number of CGG – Disease severity related to the number of CGG
trinucleotide repeats in FMR1 gene
• Normal is 6-44 repeats
• Full mutation is >200 repeats
Fragile X
clinical manifestations
• Cognitive (IQ)
– Ranges: mental retardation to learning disabilities
– 85-90% males with mental retardation
– 70% girls with borderline/ mental retardation– 70% girls with borderline/ mental retardation
• Behavioral
– Sensory defensiveness
– ADHD-like features
– Autistic-like features
Fetal Alcohol Spectrum Disorder
• Alcohol use during pregnancy is the leading
known preventable cause of mental retardation
and birth defects in the United States
• Affects an estimated 40,000 infants each year • Affects an estimated 40,000 infants each year
(more than spina bifida, down 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.
Fetal Alcohol spectrum disorder
• FAS
• Partial FAS
• Alcohol related neurodevelopmental disorder
• Alcohol-related birth defects• Alcohol-related birth defects
Effects of fetal alcohol spectrum
disorder• Specific facial characteristics
• Growth deficits
• Mental retardation
• Heart, lung, kidney deficits
• Hyperactivity and behavior problems• Hyperactivity and behavior problems
• Attention and memory problems
• Poor coordination r motor skill delays
• Difficulty with judgment and reasoning
• Learning disabilities
FAS nursing care
• Help parents or caregivers acknowledge and understand the reality of their child’s situation
• Be nonjudgmental, building an alliance with caregivers and nurturing both their strengths and the strengths of the affected childthe strengths of the affected child
• Staying abreast of treatment research in related areas
• Refer to specialized medical services
• Follow-up on all referrals and coordinate care as needed