Online lp 8 childhood disorders

Unit 8 Mental Health Disorders of Children & Adolescents

Community and Mental Health Concepts

Miscellaneous Facts Barriers to dx & tx Under recognized/under treated

Who & when to assess/screen

child will outgrow stigma of dx

Multiple people involved

Early dx important Risk for abuse

Lack of providers/services Lack of reimbursement

Co-morbidity Bipolar disorder + ADHD and oppositional defiant disorder Conduct disorder + substance use disorder, mood disorders, oppositional defiant disorder, and ADHD. Depression + conduct disorder, ODD, anxiety disorders and ADHD

1

Etiology Genetic Biological Environmental Psychological

Resiliency Temperament that can adapt to change Ability to form nurturing relationships Ability to distance self from emotional chaos Good social intelligence Ability to use problem solving skills

Mental Health Assessment Physical Examination Coordination or motor function

Mental Status Assessment Appearance Activity level Affect Manner of relating Intellectual functions Thought processes and content Characteristic of child’s play

2

Assessment Tools Autism: Checklist of Autism in Toddlers (CHAT) Modified Checklist for Autism in Toddlers (M-CHAT) Screening Tool for Autism in Two-Year-Olds (STAT) Social Communication Questionnaire (SCQ) Communication and Symbolic Behavior Scales (CSBS) Autism Spectrum Screening Questionnaire (ASSQ)

Asperger syndrome: Australian Scale for Asperger’s Syndrome (ASAS) Childhood Asperger Syndrome Test (CAST)

Mental Retardation Dx: IQ testing and assessment of developmental milestones Mild -IQ 50 -70 6th grade Vocational skills ? independent

Moderate -IQ 35-50 2nd grade Supervised setting

Severe -IQ 20-35 Profound- IQ below 20 Causes: Hereditary, embryonic dvlp, perinatal, neonatal

Mental Retardation Cognitive Concrete thinking Limited judgment Social and functional limitations Physical Appearance Genetic – Down’s Syndrome Gait, scoliosis, orofacial abnormalities

3

Autism Spectrum Disorders Social and communication skills Basic skills Self-care Language Learning Mobility

Mental retardation often accompanies

Autism Presenting Symptoms: Dx: approx age = Language delay/absence of language/ immature grammatical structure Failure to imitate Lack of interest in others Rigid adherence to routines and rituals Sensory sensitive Stereotypical behavior Patient goal?

Savants

4

Data 2002 = 1: 150 2004 = 1: 125 2006 = 1: 110 2008 = 1:88 1. Tracking?

2. Genetics 3. Toxins?

Asperger’s Disorder Dx: approx age = No significant delay in development of cognitive/language skills Motor skill problems May want to “fit in” Restricted patterns of behavior and interests may develop Ritual – i.e. getting dressed/ textures (food/linen) Limited interest…obsessive Repetitive behaviors (hand wringing)

►Problems with empathy and social relationships No eye contact

Asperger’s

Autism

Motor Ability

Problems moving, appear clumsy, poor coordination, may also have a rigid gait or problems with their posture

Do not have mobility problems; instead, they move constantly and perform repetitive movements

Cognitive

Lower cognitive functioning Do not have any delays in their cognitive development; the NIH notes many have above-average intelligence.

Delay in language skills and do not reach developmental milestones at the normal ↑ vocabulary but may not use it in a age. For example, an autistic child will not socially accepted manner babble by age 1.

Nonverbal

Severe difficulties with nonverbal communication. They have problems with facial expressions, gestures, body postures and eye contact

Rely on gestures to communicate, choosing to use them over spoken words; have poor eye contact when speaking to people

5

Nursing Diagnoses Risk for violence Defensive coping Ineffective coping Delayed growth and development Personal identity disturbance Impaired verbal communication Impaired social interaction Self care deficit

Intervention/Implementation Implement early intervention programs Collaborate with multi-disciplinary teams Encourage mainstream Arrange intensive home therapy Provide/education: Psychopharmacology SSRI, propranolol, antipsychotics [Aripiprazole (Geodon); risperidone (Risperdal)]

Anxiety Disorders Separation Anxiety Generalized anxiety disorder Panic disorder Specific phobia Social phobia OCD PTSD

6

Assessment Guidelines: Anxiety Disorders Stressors Physical symptoms

Separation Anxiety Disorder Age on onset: Excessive distress when separated parental figures Excessive worries about being lost or kidnapped or that parental figures will be harmed Fear of being home alone or in situations without other significant adults Refusal to sleep unless near a parental figure and refusal to sleep away from home Refusal to attend school or other activities without a parental figure Physical symptoms

Disordered or “Normal�?

Charlie, now 11 years old , is entering 6th grade in a middle school. Each September since kindergarten the start of school has always been a struggle for him. This year his distress escalated with the added demand of starting in a new school, and by November he missed twenty-six days of school. His academic work has suffered, and his teachers have sent his assignments home.

Charlie insists that he can't complete them without his mother's presence. He worries that something bad may happen to his mom while he is in school.

7

PTSD Preschool Children Sleep, regression, withdrawal

School Age Children Fighting, play out event

Nursing Diagnosis: Anxiety Disorders Anxiety Fear Ineffective Coping Post trauma syndrome

Nursing Process: Implementation Anxiety Disorders Foster developmental of coping skills/increase self esteem Assist in working through traumatic events or losses Arrange psychotherapy Desensitization

Administer/teach: Pharmacologic therapy

8

Mood Disorders Major Depressive Disorder Dysthymia Bipolar disorder

Major Depressive Disorder Symptoms (5+ for 2+weeks): Depressed or irritable mood most of day, nearly every day Anhedonia (decreased pleasure/interest) Weight changes Sleep disturbance Psychomotor agitation or retardation Fatigue/loss of energy Worthlessness or guilt Poor concentration, indecisiveness Suicidal ideation, thoughts of death

Childhood Depression ďƒ˜ Family history is the single best predictor Irritable mood vs depressed mood Physical complaints Social withdrawal Loss of interest or pleasure Behavioral problems Often minimized/ignored ‌ Why? Suicide is leading cause of death

9

Assessment Guidelines: Bipolar changes in mood or affect Shrieking cry/scream Uncontrollable anger Rapid mood swings Onset gradual or present at birth

physical status major life-changing events, stressors/losses family history of mood disorders and suicide vs. Disruptive Mood Dysregulation Disorder Unipolar vs bipolar

Nursing Diagnoses Risk for injury Risk for violence Grieving Hopelessness Ineffective coping Self esteem disturbance Social isolation

Interventions Mood Disorders Safety/physical needs Psychotherapy (family, individual, CBT, IPT) Rewards/Choices Self-esteem Cognitive skills

Psychoeducation Psychopharmacology

10

Medications for Depression  SSRIs (Prozac, Zoloft, Paxil, Lexapro, Celexa) = 1st line 

Fluoxetine (Prozac) 

only drug approved by the FDA for children/adolescents

 Consider medications if: Moderate to severe depression Incomplete response to psychotherapy  Chronic or recurrent depression  Suicidality, agitation, or psychosis  

 Side effects 

GI, sleep problems, restlessness, HAs, changes in appetite,

 Black box warning- may increase risk of suicide 

Meds help more than they hurt and results in a reduction in suicidality

Medication for Bipolar Disorder Mood stabilizers Lithium (Eskalith or Lithobid).

AEDs: Carbamazepine (Tegretol), Divalproex (Depakote).

Lamotrigine (Lamictal).

Atypical antipsychotics Aripiprazole (Abilify) Quetiapine (Seroquel) Risperidone (Risperdal)

Antidepressants + mood stabilizer  

fluoxetine (Prozac) Antidepressants alone are not used due to risk of inducing mania/hypomania

32

Lithium May take several weeks Tablet/capsule/XR/liquid Start ___ Go ____ Monitor levels:

2 major LT risks Lab =

Hydration/Diet Less salt may cause Li level to rise.

More salt may cause Li level to fall

Adverse effects toxicity = diarrhea, vomiting, tremor, mild ataxia, slurred speech, drowsiness, muscular weakness

33

11

Other Childhood Mental Illnesses ADHD Oppositional Defiant Disorder Conduct Disorder Tourette's Schizophrenia

Attention Deficit Hyperactivity Disorder (ADHD) •Inattentive •the ability to not pay attention or focus

•Hyperactive/Impulsive type – •extremely active and having impulsive movements

Restless Intrusive Risk-taking Impulsive

Low frustration Reduced attention span Can’t delay gratification Excess speech Difficulty completing tasks Makes careless mistakes

Research – acetaminophen, smoking, alcohol, sugar, additives, pharmaceutical

Oppositional Defiant Disorder Uncooperative Defiant/stubborn Hostile Argumentative Test Limits Unwilling to negotiate Blames others Doesn’t involve major antisocial behaviors

12

Conduct Disorder Rights of others and societal rules/norms are violated.

Aggression to people and animals Destruction of Property Deceitfulness and theft Serious violation of rules Little empathy Poor frustration tolerance Unknown etiology Adult personality disorder?

Assessment Guidelines ADHD, ODD, CD Assessment tools Family relationships Triggers?

Parent/caregiver knowledge Cognitive, psychosocial, moral development

Nursing Diagnoses ADHD, ODD, CD Risk for other directed violence Risk for caregiver role strain Risk for injury Impaired social interaction Chronic low self esteem Ineffective coping

13

Nursing Process: Interventions Safety Parent training Assess knowledge Explore effects on family Provide support/refer to support group Provide information about medications Role modeling Improve self-esteem

School Behavior contract Increase ability to control impulses

Pharmacology CNS Stimulants Medication

Short acting

Intermediate

Long acting

Methylphenidate

Ritalin Methylin

Ritalin SR Methylin ER

Attenta

-Ritalin LA -Concerta -Daytrana (on – AM) (off – PM) (9º daily) -Quillivant XR

Dexmethylphenidate

Focalin

-Focalin XR

Dextroamphetamine

Dexadrine

-Dexadrine spansules

Amphetamine mixture

Adderall

-Adderall XR

Lisdexamfetamine Dimesylate

Vyvanse

(BID, TID) Last dose early

CNS Stimulants Increase activity in parts of brain that are underdeveloped = ↑attention, ↓impulsiveness

CNS stimulation Insomnia, restlessness Last dose before 4 pm No caffeine, no cough med with ephedrine

Cardiovascular =

Appetite suppression Monitor weight Take with or after meals (not on empty stomach)

↑ glucose Withdrawal reaction Depression/fatigue No drug holiday (life problem not just academic)

14

Non-Stimulant Medications Non-stimulant for ADHD – NRI (norepinephrine selective reuptake inhibitor)

Atomoxetine (Strattera) Don’t cause agitation or sleeplessness Are not controlled substances = ↓risk of abuse or addiction ? efficacy S/E: appetite suppression, wt. loss, growth suppression, n/v, suicidal ideations, hepatotoxicity (liver damage: flu-like sx, jaundice, abd pain), fatigue, dizziness, changes in menstrual cycle

Additional Pharmacologic Treatment Antihypertensives: Guanfacine (Intuniv), Kapvay/Clonidine (Catapres)

Antidepressants: TCA SSRI SNRI – venlafaxine (Effexor)

reduce distractibility and improve attention, working

Tourette’s Disorder Motor/verbal tics occurring many times a day, nearly every day, for more than one year Coprolalia Echolalia

Tics cause marked distress or impairment in functioning (can change in severity & frequency) Co-morbid with other mental disorders diagnosed ADHD Mood disorders OCD

15

Diagnosis Anxiety Impaired social interacting Chronic low self esteem Social Isolation

Nursing Process: Implementation Psychotherapy Relaxation techniques Psychopharmacology Antidepressants Stimulants Antipsychotics Antihypertensives Clonidine (Catapress), Inversine (mecamylamine), Tenex (guanfacine)

Childhood Schizophrenia Extremely rare in pre-pubertal children

Etiology unclear

Same symptoms as adult disorders (hallucinations, delusions, extreme mood swings, fearful, withdrawn) Review types

48

16

Treatment Schizophrenia Team approach Family education Pediatrician Psychotherapist Social worker School - if mainstreamed

Pharmacologic Antipsychotics for control of self-injury & aggression Risperidone (Risperdal) Aripiprazole (Abilify) 5/23/2014

49

Child & Adolescent Treatment Modalities Family Therapy Group Therapy Behavior Therapy Removal & Restraint Quiet room Time Out Therapeutic holding

CBT

Talking, feeling, doing game

Play Therapy Therapeutic Games Bibliotherapy Art Therapy Music Therapy Movement & dance therapy Recreational Therapy

New DMS 5 Diagnoses Attenuated Psychosis Syndrome (a precursor to schizophrenia),

Internet Use Gaming Disorder Non-Suicidal Self-Injury Suicidal Behavioral Disorder treatment = ? not be covered by health insurance; still need more research

17

The End

18