Download Child and Adolescent Mental Health

Child and Adolescent
Mental Health
Cognitive development
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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
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10-13% of children have serious MH
problems
 655,000 Texas children
Etiology of MH Problems
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Genetics: strong for depression, Anxiety, OCD,
Tic disorders, ADHD, bipolar
 Environment: Abuse and neglect, (actually causes
a change in the structure of the brain)
– Fetal Alcohol Syndrome, Brain damage, poverty of
thought ( mental retardation)
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Neurological Anomalies
– Developmental disorders- MR-IQ below 70 , Axis II
– Pervasive developmental disorders-Autism, Asperger’s,
PDD-NOS, Etc.
Resiliency in Children
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Psychosocial disadvantage: multiple risk factors
– Do not develop a psychiatric disorder
– Well-adjusted adult
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Environmental and constitutional elements
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Not well understood
Relative or community cares for the child
Absence of Neglect
Ability to internalize and define themselves
Foster resiliency
– Predictable family environment
 Structure
 Therapeutic milieu
Content
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Developmental Disorders
Attention Deficit and Disruptive Behavior Disorders
Internalization Disorders
TIC Disorders
Psychotic Disorders
Other Psychiatric Disorders
– Eliminations Disorders
– Psychotic Disorders
– Mood Disorders
 Depression
 Bipolar Disorder
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Psychopharmacology
Cognitive Behavioral Therapy
Developmental Disorders
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Mental Retardation
– IQ< 70
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Pervasive Developmental Disorders
– Autistic Disorder
– Asperger’s Disorder
– Pervasive Developmental Disorder NOS
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Specific Developmental Disorders
– Learning Disorder
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Communication Disorders
– Speech and language disorders are strongly associated with
psychiatric disorders
Attention Deficit and Disruptive
Behavior Disorders
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ADD
– Attention Deficit Disorder (Hyperactive type)
– Attention Deficit Disorder (Withdrawn type)
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Oppositional Defiant Disorder
 Conduct Disorder
Attention Deficit Hyperactive
Disorder (ADHD)
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Inattention
 Impulsivity
 Overactivity
– Restless overactive distractible reckless
disruptive
– Up to 11% of school age children
– Psychological adversity
ADD
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The Frontal Lobe
 Subtle Dysfunction in the Frontal Lobe
– Reduced metabolic activity
– Hypoperfusion
Treatment ADD
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Problem in the Frontal lobe, which is
responsible for planning, attention,
regulation of motor activity-Brain under
active
 Not enough dopamine available
Medication: Stimulants
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Medication: Stimulants
– Ritalin (methylphenidate)
– Dexedrine (dextroamphetamine)
– Adderall (D,L dextroaamphetamine)
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Also used for weight loss
Extended release Ritalin LA; Metadate CD,
Concerta and decrease dosing to once daily
 Adderall XR Vyvanse is also extended release
Medication issues for
Stimulants
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Non-extended release
Side effects
– Anorexia
– Administer regular
– Weight loss
stimulants just prior to
meals to decrease anorexia
– Require noon dosing and a
smaller dose in the evening
to prevent rebound
– Last dose is given at 1600
– Lowers the seizure
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threshold
Abnormal movements
Labile mood
Insomnia,
Hyper-focused
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over focused on details
– Agitation
Non-Stimulant
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Tricyclic Antidepressants
– Imipramine, Desipramine, Clomipramine
– Concern about cardiac conduction
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Clonidine (Catapress)
– Developed as an antihypertensive
– Reduce norepinephrine activity in the brain
Non-Stimulant:
Atomoxetine/Strattera
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Has a different
mode of action, not
a schedule II drug
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Capsule form of
10,18,25,40,60 mg
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Effects reuptake of
Norepinephrine
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Side effects
– 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; ventolin inhalers
can increase
– Drug interactions: Paxil and
Prozac
Disruptive Behavior Disorders
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Oppositional Defiant Disorder
– 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
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Conduct Disorder
– More serious violations of social standards
– Higher than expected rates of ADHD,
depression and learning disorders
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Associated with Antisocial Personality Disorder (if
the child does not make changes in behavior)
Pervasive Developmental
Disorders
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Impairment across multiple domains
(impairment is global)
– Psychological Impairment
– Social Impairment
– Academic Impairment
– May meet the standard for Mental retardation
Pervasive Developmental
Disorders
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Characterized by impairments across all domains
of development
– Delayed social development
– Stereotypical behaviors
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Hand-flapping
Rocking and spinning
– Peculiar preoccupations
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Moving objects
Water
– Rigid and intolerant of change
PDD’s
Are now viewed as being on the same
spectrum, differentiated by severity of
symptoms and impairment
Pervasive Developmental
Disorders
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Autistic Disorder
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Asperger’s Disorder
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Pervasive Developmental Disorder NOS
Autistic Disorder
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Early Age of onset
– 30 months of age
– Constant delayed development
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Social relatedness is profoundly impaired
– Aloof and indifferent to others
– Prefer inanimate objects to human contact
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Stereotypical Behaviors
– Rocking and Hand flapping
Autistic Disorder
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Communications
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Insistence on sameness and preoccupation with peculiar interests
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Delayed and deviant
Abnormal intonation
Pronoun reversals
Echolalia
Fans
Air conditioners
Train schedules
Windows
Water
The vaccination controversy
Asperger’s Disorder
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Less likely to be mentally retarded
Communication handicap is less severe
– Concrete interpretation of language
– Stilted and abnormal intonation
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Higher performing
Social interactions impaired
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Impaired reading of social cues
Clumsy
Difficulty with transition
Preoccupation with matters of private interest
Pervasive Developmental
Disorder NOS
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Does not meet criteria for more specific
type of PDD
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Traits of both Autism and Asperger’s
Tic Disorders
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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
Medications:
– haloperidol (Haldol)
– clonidine (Catapress)
Other Psychiatric Disorders
 Childhood Schizophrenia- 2 cases per
100,000
 Anxiety Disorders: Separation anxiety 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 Disorder and Schizophrenia
– adolescence (rare earlier onset)
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 cognitive maturity effects expression
 irritable or resistant
 aggression
 In Adolescents
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Both: risk-taking behavior
boys; aggressive behavior or acting out
girls; anxiety, eating disorders, and or self-cutting.
2 symptoms to be concerned about:
 difficulty concentrating
 negative statements about themselves and their place in life
(peer group, family, school); like “I’m stupid”
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
Nursing Interventions for
Attention Problems
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Simple instructions for children with attention
problems
– Do not say-”Clean your room” say- “Put the dirty
clothes in the hamper”, Then,” Make your bed”
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Teaching the family about ADHD
 Assess family history and how successful
 Listen, support groups, books
 Communicate with teachers, School
Cognitive Behavioral Therapy
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Milieu
Negative Reinforcement
Positive Reinforcement
Extinction
Consistency
Points
Levels
Cost Response
Social Skills Training
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Recognize the impact of their behavior
– Fail to recognize the impact on others
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Instructions
 Role Playing
 Positive Reinforcement
Problem-Solving Skills
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Misinterpret the intentions of others
– Perceiving hostility when none is intended
– Teaches a different interpretation of the behaviors of
others
– Options for a response
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Each option is evaluated for the consequence
– What to say:
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What happened?
What did you do?
How did that work for you?
What can you do next time?
Parent Teaching
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Importance of clear limits
 Positive reinforcement
– Praise
– Positive attention
– Tangible rewards
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Point Systems
 Mild punishment
– Time out
Psychotherapy
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Individual Therapy
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Group Therapy
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Family Therapy
– Passes to go home prior to being discharged
Community Resources
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Support groups, camps, web resources,
and literature
The End