Download Child and Adolescent Mental Health

Child and Adolescent
Mental Health
Cognitive 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
School Age Children
10-13% of children have serious MH
problems
 655,000 Texas children

Etiology 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’d
• Neurological Anomalies
– Developmental disorders- MR-IQ below 70
, Axis II
– Pervasive developmental disordersAutism, Asperger’s, PDD-NOS, Etc.
Main 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 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
Hyperactivity Disorder
(ADHD)
Inattention
Impulsivity
Overactivity
– Restless overactive, distractible, reckless,
disruptive
– Up to 11% of school age children
– Psychological adversity
Etiology of ADHD:
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 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 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 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 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 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’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
Disorders
Impairment across multiple domains
(impairment is global)
– Psychological Impairment
– Social Impairment
– Academic Impairment
– May meet the standard for Mental
retardation
Pervasive Developmental
Disorders

Autistic Disorder

Asperger’s Disorder

Pervasive Developmental Disorder
NOS
PDD’s
Are now viewed as being on the same
spectrum, differentiated by severity of
symptoms and impairment
Autistic 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’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 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
Disorder NOS

Does not meet criteria for more specific
type of PDD

Traits of both Autism and Asperger’s
Tic 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 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,
cont’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
Younger 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
Interventions for Children: A
Behavioral 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 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 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
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’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’d

Antipsychotic Agents
– For aggressive behavior, self-injury, tics,
psychotic symptoms
– Typicals: Highly correlated with EPSEs
– Atypicals: Weight gain problematic; fatty
livers
Interventions: Psychotherapy
Individual Therapy
– Play therapy for children
Group Therapy
Family Therapy
Community Resources

Support groups, camps, web resources,
and literature