Pediatric Mental Health

Definitions are the same for children and adults

DSM-5

developing CNS:

children differ in the scope, presentation, and progression of mental and
cognitive disorders.

Social determinants shape risk

access to good nutrition, positive relationships, and safe housing influence whether mental illness and cognitive disability develop.

Trauma is defined by the child’s experience

not by the event. Two children in the same event may have entirely different outcomes

Humans are primarily relational rather than

rational — the therapeutic relationship is itself an intervention.

SUBJECTIVE assessment

• Birth history, including problems in the prenatal period.

• Past medical history, including past neurologic disorders.

• Family history, including alcohol and substance use disorders in the family.

• Social history and behavioral symptoms

OBJECTIVE assessment

• Developmental screenings such as the Child Development Inventory.
• Physical examination, including general appearance.
• Diagnostic testing to rule out organic causes.
• ASD screening: M-CHAT or the Pervasive Developmental Disorders
Screening Test.

Ensure safety from self-harm

the first priority in every setting

Environmental assessment:

no sharp objects or tubing, standard safety measures, adult supervision

ACROSS DISORDERS- interventions

• Early identification and referral to early intervention.
• Multidisciplinary team; involve the family in counseling.
• Individualized education plan (IEP) where learning is affected

INTELLECTUAL & LEARNING DISABILITY

Difficulty receiving, processing, and responding to information

Dyslexia

is most common — a disorder of receptive language creating difficulty using letters to decode written language.

Dysgraphia

affects the physical act of writing: handwriting, spelling, and grammar.

Dyscalculia

affects quantities, memorizing math facts, and mathematical symbols.

Symptoms of INTELLECTUAL & LEARNING DISABILITY

are often unrecognized until the child enters formal school. Manifestations include slower language and math acquisition, difficulty recognizing letters and numbers, and problems with reading comprehension.

Delayed language

is often the FIRST sign. Screen hearing, language, and vision; identify
through standardized developmental evaluation and treat with an IEP

Risk factors: INTELLECTUAL & LEARNING DISABILITY

congenital infection (rubella, syphilis), fetal alcohol syndrome, chronic lead ingestion, brain trauma, gestational disorders, and pre-existing disease such as Down syndrome, microcephaly, hydrocephaly, metabolic disorders, and cerebral palsy

AUTISM SPECTRUM DISORDER

Delays in social interaction and/or social communication.

ASD Early manifestations

abnormal eye contact, feeding and language difficulties, fine and gross
motor delays, decreased alertness, reduced response to name and to social cues, and echolalia

ASD characteristics

• Distress when routines change; unusual attachments to objects; minimal pretend play.

Heightened or lowered senses, including decreased pain sensation — the child may not report or show pain as expected.

Milestones may be LOST between 15 and 30 months

autism regression

Treatment: ASD

early identification and referral to early intervention are the cornerstones. Limit sensory overstimulation, collaborate with school personnel, consult speech therapy, and use a multidisciplinary team.

ASD Meds

treat target symptoms only: SSRIs may decrease aggression; antipsychotics and melatonin may help insomnia

SOCIAL ENGAGEMENT SYSTEM

the first circuit. The child negotiates using face, vocalization, or language. This is the circuit a calm, regulated nurse can reach

SYMPATHETIC NERVOUS SYSTEM

if social engagement does not negate the threat, the protective circuit activates to promote mobilization: fight or flight.

PARASYMPATHETIC IMMOBILIZATION

if fight or flight does not work and the threat persists, the nervous system resorts to its oldest and most primitive response: shutdown, freeze,
collapse

Why it matters at the bedside:

a child who appears calm and compliant may be immobilized rather than settled, and a child who fights is not being difficult — they are in the second circuit.
Approach through the social engagement system first: face, voice, and tone before procedure or instruction.

Paths to dysregulation:

relationship and safety — abuse, neglect, absent nurturing.

Erikson stages at risk: trust vs mistrust (infancy), autonomy vs shame and doubt (toddler), initiative vs guilt (early childhood), industry vs inferiority (6–12 years)

ADHD Treatment

• behavioral therapy, caregiver education, an IEP, and pharmacotherapy

• Stimulants (methylphenidate, amphetamine products) increase
  dopamine and norepinephrine. They are controlled substances
  — store securely; there is potential for misuse

Side effects: ADHD

anorexia and weight loss, tachycardia, hypertension, insomnia, nervousness

Nursing: ADHD

titrate gradually, give 30 minutes before a meal, give the
last dose before 1800 to prevent insomnia, and avoid caffeine.

Atomoxetine

is a selective norepinephrine reuptake inhibitor — titrate gradually and monitor for suicidal ideation.

ADHD considerations

Monitor growth and height velocity, appetite, sleep, heart rate,
blood pressure, and behavioral response

Anxiety disorders

• Worry and fear beyond adaptive coping, causing stress and
impairment; a combination of genetics and environment.
• Generalized anxiety, separation anxiety, and panic disorder.

Manifestations: anxiety disorders

are often somatic: abdominal pain, nausea, vomiting, palpitations, dyspnea, and dizziness — plus aggression and defiance

Separation anxiety

becomes a disorder when an older child shows excessive distress about separation, frequent nightmares, and somatic symptoms severe enough to prevent normal activity

Diagnosing Anxiety

using standardized anxiety rating scales and structured diagnostic interviewing

Treating anxiety disorders

exposure-based CBT for separation anxiety and school refusal; SSRIs for generalized anxiety, with fluoxetine most common in children

Depression

• May present as irritability, somatic complaints, declining function, withdrawal, or suicidality — not necessarily visible sadness.
• Symptoms persist most of the day, nearly every day, for at least 2 weeks and impair functioning

Depression risk factors

family history and a traumatic event

Depression treatment

counseling plus medication — an SSRI or SNRI, occasionally a tricyclic. Examples include sertraline, paroxetine, venlafaxine, bupropion, and trazodone

Depression Nursing

monitor for adverse effects and for suicidal ideation

Teaching for depression

therapeutic effect can take up to 2 weeks, and the medication is never stopped abruptly

ANOREXIA NERVOSA

Preoccupied fear of gaining weight with a severely distorted body image; onset typically late adolescence

ANOREXIA NERVOSA Risk

adolescence, perfectionist personality or OCD, family history of eating disorder, low self-esteem, and female gender

ANOREXIA NERVOSA findings

low BMI, dehydration, lanugo, cold intolerance and hypothermia, orthostatic hypotension, weak pulse, compulsive exercising, anxiety, depression, and suicidal thoughts.

ANOREXIA NERVOSA complications

starvation, fluid and electrolyte imbalance, cardiac complications, renal failure, and potential for suicide.

ANOREXIA NERVOSA treatment

nutritional support, cardiovascular monitoring, a multidisciplinary team, and family involvement. Aim for gradual gain of 2 to 3 pounds per week; nasogastric feeding if required

BULIMIA NERVOSA

• Binge eating followed by purging through self-induced vomiting, diuretics, and/or laxatives. The adolescent knows the pattern is abnormal but cannot stop it.
• Weight is often normal or only slightly low — which is why it is missed.

BULIMIA NERVOSA findings

food rituals, labile mood, repeated fad dieting, thinning hair, brittle nails, hypokalemia, anemia, bradycardia, calluses on the backs of the hands, esophageal irritation and poor dentition.

BULIMIA NERVOSA complications

loss of dental enamel and caries, esophagitis and ulceration, gastric rupture, and cardiac dysrhythmias.

BULIMIA NERVOSA treatment

cognitive behavioral therapy and SSRIs (fluoxetine), journaling, and serum potassium monitoring. Establish a routine for meals and snacks rather than encouraging the child to eat when hungry.

Types of abuse

physical, emotional, spiritual, and sexual abuse; exposure to
domestic violence; and neglect

Caregiver risk for abuse

mental illness, poor self-esteem, substance use, poor coping, and a history of being a victim of abuse

Environmental risk: abuse

low income, unemployment, domestic violence, and lack of a support system

Manifestations of abuse

multiple fractures in various stages of healing, suspicious bruising, sexually transmitted infection, enuresis, and vague somatic complaints

Evidence of abuse

forensic medical team, a SANE for sexual abuse, and a skeletal survey.

Nurses are mandatory reporters.

Document all findings first, then follow agency reporting policy

Munchausen syndrome by proxy

is medical child abuse. The priority is the child’s safety

PTSD

Develops following chronic, traumatic, or catastrophic events. Risk factors include genetic predisposition, a traumatic incident, repeated or chronic trauma, psychiatric disorder, natural disaster, sexual abuse, and witnessing homicide, suicide, or other violence

PTSD Phase 1

minutes to 2 hours: increased stress hormones (fight or flight); psychosis may occur.

PTSD Phase 2

about 2 weeks: a period of calm with numbness and denial as defense mechanisms decrease.

PTSD phase 3

(coping), 2 to 3 months: the client gets worse instead of better — depression, phobias, anxiety, conversion reactions, repetitive movements, flashbacks, or obsessions

PTSD nursing

refer to psychotherapy, monitor for behavior changes, assist the client and family with coping strategies, allow expression of feelings, and prevent or reduce long-term effects.

SSRIs may increase the risk of

suicidality in the pediatric population. This black box warning applies wherever an SSRI appears in this unit — anxiety, depression, bulimia, and target symptoms in autism spectrum disorder

Atomoxetine

(for ADHD) carries the same monitoring requirement. SUICIDE RISK

Monitor for suicidal ideation at

initiation and with every dose change

Therapeutic effect can take up to

2 weeks, and the window in which energy returns before mood lifts is the highest-risk period. Teach families exactly what to watch for and when to call.

Do not abruptly discontinue SSRI

Teach the client and caregiver to observe for adverse effects and to report new agitation, worsening mood, or any talk of self-harm immediately