peds mental health

general info

1 in 5 children and adolescents (20 percent) may have a diagnosable disorder. Estimates from 7.7 million to 12.8 million.

An estimated two-thirds of all young people with mental health problems are not getting the help they need.

Many disorders occur concurrently making diagnosis difficult

Many learning disabilities can lead to or resemble mental health disorders

etiology physiologic

◦Genetics-runs in families

◦Structural brain abnormalities-chemistry imbalances, hormonal changes

◦Prenatal influences- illness, injury or substance abuse

family dynamics etiology

◦Child abuse- physical / emotional

◦Dysfunctional family system       

◦Poor role modeling

Parental response to child's behavior

environment etiology

◦Poverty-nutritional deprivation

◦Homelessness

Known risk factors for child abuse and violence increased during

the covid pandemic

-Poverty, Stress, Isolation

-Loss of contact with teachers and medical providers

inquire about…

Intimate partner violence

Guns in the home

Parental mental health and well-being

Self-care

Struggles with child and adolescent behavior and discipline

treatment options

Cognitive /Behavioral    Therapy

Group &/or Family Therapy

Play / Art / Music Therapy

Quiet Room

Time Out Seclusion &/or Restraint

Psychopharmacology

early intervention

Program is mandated by the federal government and implemented at the state level through the health departments

** – thorough testing is done – family, psychological, physical, communication.

** – services are provided if delays are noted.  Services are FREE !!!!

Many, many outcomes can be significantly improved if treatment isstarted early. Don’t wait

primary prevention

◦prenatal care, teaching

  about risk factors, parenting skills classes.

2ndary prevention

◦early detection; school & community nurses, NPs, teachers; pediatricians.

tertiary prevention

◦minimizes effect of disorder     via individual, family, group therapy and

   behavior modification.

management

community based treatment

hospital based

specialized units for children and adolescents

assessment H&P

◦Intake questions from parents, teachers.

assessment history

◦PMH:  prenatal/birth Hx, injuries, mood issues, medications, suicide/self-injury .

◦mood/actions at home, with friends...

◦FH: Note strengths and weaknesses of family system…..- who do they live with, willingness to learn/participate in services.

   Abuse issues?.....  Alcohol, physical, emotional 

   Depression/anxiety issues?....

*Take note of child’s: appearance, behavior and developmental stage.

Developmental & Learning Disabilities

1. sensory itnegration

2. auditory processing

3. visual processing difficulties

4. dyslexia

5. speech/language delays

sensory integration

ability to assess environment & react appropriately – (sounds, textures, lights)

auditory processing

(cannot process verbal instructions or remember language-related tasks

visual processing difficulties

(reverses letters, cannot copy correctly)

dyslexia

(Most common)-language/sounds of words/reading/writing/grammar flow

speech/language delays

stuttering, limited vocabulary

pervasive developmental disorders

GROUP of conditions that involve delaysin development of many basic skills.

More prevalent in males than females

are confused in their thinking and generally have problems understanding the world around them.

Delayed socialization

Delayed communication

Peculiar mannerisms

autism spectrum disorders

autism on one end

asperger syndrome on the other end

autism: deficits in:

Communication

Behavior

Social Interaction

autism

A single condition with different levels of severity in two core domains:

1. persistent deficits in social communication & social interaction across multiple contexts.

2. restricted, repetitive patterns of behavior, interest or activities.

-impaired social interaction, unresponsive to people, repetitive movements(rocking, twirling

◦Or self abusive behavior)

stereotypy

Hand Flapping

Head Banging

Self-Biting

Stomping

autistic disporder

impaired social, impaired communication & impaired behavior development

May engage in rigid, repetitive, machine-like movement/obsessive behavior.

Aversion to touch and extreme stimuli.

Unable to respond to social/emotional cues.

At risk for self-injury

when do symptoms of Autistic disorder tend to emerge by?

6 months-3yrs old.

early signs of autism

-No smiling/happy expression by 6 months

- No mimicking sounds/expressions by 9 months

-No babbling by 12 months

-No response to name by 12 months

-No gesturing(pointing/waving…) by 14 months

-No first words by 16 months

-No two-word phrases by 24 months

-Loss or regression of language skills(any age)

asperger

social skills, interactions impaired…

can range from average to high intellectual functioning.

Mild end of the autistic spectrum.

Later onset than autism

Difficulty with social interactions and repetitive behaviors.  Sometimes “loners” or “eccentric”

No language delay

Speech may be monotone, poor ‘give-take’ in a conversation. 

    Egocentric- low empathy for others.

nursing interventions for autism spectrum disorder

Create safe and stabilized environment

Gradual & Gentle interaction

Enhance communication (picture boards/sign language)

Coach on socialization –collaborative activities

Help parents decrease feelings of blame, provide education and resources

Use child’s established routine and decrease stimuli while hospitalized

◦ learn from the parents what works.

Communication cues / Self-Injury Habits**

Use diversion if they are acting out and  increased anxiety  (appropriate activities).

Provide child with familiar objects.

Change of routine is often very challenging

Medications may be needed for aggression.

Again, ask caregiver to explain cues.

Autism Prevalence & the Vaccine Debate

There have been studies on all sides:

no evidence of a causal association between vaccines and autism.

Chemical exposures( food dyes or environmental )

Processed foods

Research is still ongoing but prevalence for autism is extremely high

Attention Deficit and Disruptive Behavior Disorders

ATTENTION-DEFICIT / HYPERACTIVITY DISORDER (ADHD)

CONDUCT DISORDER (CD)

OPPOSITIONAL DEFIANT DISORDER (ODD)

Attention Deficit – Hyperactivity Disorder (ADHD)

Disorder that makes it difficult for children to control their behavior.

One of the most common chronic conditions of childhood.

About 3 times more boys than girls are diagnosed with ADHD.

adhd onset before?

age 7;  symptoms last at least 6 months

adhd characterized by

inappropriate degrees of inattention, impulsiveness, and/or hyperactivity:

•Trouble paying attention to details

•Making careless mistakes

•Trouble concentrating on one activity at a time

•Talking constantly, even at inappropriate times

•Running around in disruptive manner

more characteristics of adhd:

◦fidgeting and squirming

◦having trouble waiting turn

◦being easily distracted

◦impulsively blurting out answers

◦misplacing school assignments

◦seeming not to listen, even when directly addressed

ADHD comorbidity

High incidence of comorbidity:

 Ex) oppositional defiant disorder,  anxiety disorders, mood disorders, developmental learning disorders such as dyslexia. 

focus of therapy for adhd

Minimize hyperactivity and impulsivity

Increase attention span

Prevent potential future problems…. (substance abuse, conduct disorder)

Manipulate environment to decrease stimuli

Assist family to establish regular scheduled times for eating, sleeping, homework, etc.

Provide emotional support

Promote self-esteem, rewards for positive behavior

stimulants adhd meds

increase dopamine & norepinephrine levels… which are neurotransmitters associated with motivation, pleasure, attention & movement.

Thus, boosts concentration and focus while reducing hyperactive & impulsive behaviors.

Thus, give meds in the morning.

SE-  difficulty sleeping, loss of appetite, tachycardia, tics, upset stomach.

Ex: Adderall, Concerta, Ritalin

Summer time “med vacations”….?

oppositional defiant disorder

All children are defiant at times.  Especially toddlers and early adolescents

Look for a pattern of uncooperative, defiant, and hostile behavior.

Combination of: internal depression/anxiety along with externalizing aggression/temper tantrums.

Treatments include therapy, social skills training, parenting classes, medications

s/s of oppositional defiant disorder

Frequent temper tantrums

Excessive arguing with adults

Often questioning rules

Active defiance and refusal to comply with adult requests and rules

Deliberate attempts to annoy or upset people

Blaming others for his or her mistakes or misbehavior

Often being touchy or easily annoyed by others

Frequent anger and resentment

Mean and hateful talking when upset

Spiteful attitude and revenge seeking

non stimulants adhd meds

(Strattera)  boosts levels of norepinephrine. ( enhances alertness, focus & attention)

Has some anti-depressant features

No “tic” side effects…

However, sometimes…not as effective as stimulants.

SE- sleepiness, headache, mood swings, nausea, loss of appetite.

conduct disorder

Great difficulty following rules

Often viewed as ‘bad’ as opposed to mentally ill.

Lying, aggression, even criminal acts.

Likely to have ongoing & increasingly serious problems if they go untreated.

Serious aggressive behaviors against people, animals or property; no remorse, no empathy.

2 subtypes:

childhood onset or adolescent onset

conduct disorder s/s

Aggression to people and animals  - bullies, threatens, starts fights, cruel to animals.

Destruction of Property – fire starting, vandalism. Linked to poor parental supervision & family violence, substance abuse.

Deceitfulness, lying, or stealing  - money, shoplifting, breaking into house or car, lying to avoid obligations or get something

Serious violations of rules – running away, truant, staying out past parent’s limits.

odd and conduct disorder

Behavior and psychotherapy are tx of choice.

Positive reinforcement

Arrange organized, supervised activity

Have to set strict boundaries & consistent consequences

Pharmaceutical:  antidepressants, mood stabilizers

tourettes syndrome

Involuntary motor movements and / or vocalizations  (  TICS )

Throat clearing, snorts

Facial twitching, arm jerking, kicking

May show sudden rage…..frustrated

Neurobiological disorder and or ANXIETY

Frequency & intensity can be up & down

Symptoms worsen with anxiety

Co-morbidities….?

But sometimes with kids…it goes away.

anxiety disorders

Generalized Anxiety Disorder

Panic disorder

Phobias

Separation Anxiety Disorder

Obsessive Compulsive Disorder

Post Traumatic Stress Disorder

anxiety development

Tend to begin in childhood and continue into adolescence

Anxiety normal part of development.

Problem if we fail to move beyond fear.

Lasts at least 3 months

Can include regression behaviors

◦Bedwetting, sucking thumb…..

separation anxiety disorder

Fear of being separated from the person to whom the child is most attached. 

Abnormally excessive or age inappropriate fear

May lead to other generalized anxiety disorders, relationship difficulty later

Separation anxiety is common in infants and toddlers.

By 5 years old, children should be able to be dropped off or left by parents without significant distress.

separation anxiety disorder S/s

refusal to attend school, somatic complaints(anxiety over physical issues), severe anxiety regarding separation, and worry about harm coming to significant caretaker.  Clinging, crying, tantrums.

Separation Anxiety Disorder -  
Nursing Interventions

Maintain calm manner.

Teach parents about consistency in expectations

Therapy – family and / or child

- behavior modification methods.

Education and resources for parents

Medications may be needed

Example:  Get the child back in school    ASAP!!!  KEEP A ROUTINE !

Obsessive Compulsive Disorder

Ritualistic behaviors

◦Worry is alleviated by rigid & time consuming rituals.

Repeatedly perform routines or think thoughts

Can’t control the deep need to do again and again(counting, washing, checking)

-the anxiety and rituals get in the way of daily life

Medications to calm and focus are commonly used.

mood disorders

Only recently recognized as occurring in children.

From depression ->bipolar

thoughts and feelings that are intense, difficult to manage, and persistent

Often associated with

◦ behavioral & social skill deficits,

◦family dysfunction, tragic life event,

Chronic stress, poor achievement

depression symptoms

Poor school grades

Withdrawal from activities previously enjoyed

Sleep and appetite disturbances

Somatic complaints

Decreased energy

Difficulty concentrating

Low self-esteem

Feeling of hopelessness

Warning signs of suicide in teens:

sudden withdrawal; violent behaviors; drug & alcohol use; unusual neglect of personal appearance; truancy; running away; excessive fatigue; poor response to praise; talks about suicide; gives away possessions

Children under 12 also commit suicide:

◦May do so impulsively

◦Many child suicides are recorded as accidents

◦Tend not to give warning signs as adolescents and adults do

◦Careful monitoring for and treatment of depression critical

Nursing Interventions – Mood disorders

Medications

Monitor for side effects of meds

Provide community resources, education

Promote self-esteem

Maintain hopefulness

Provide a safe environment

Use suicide precautions

fetal alcohol syndrome

Completely preventable!!!

Causes many forms of cognitive problems discussed today:

◦Developmental Delays

◦Behavioral Disorders

◦Intellectual Disabilities

anorexia nervosa

Most common in females ages 12-18yrs old

Fear of obesity, thus have dramatic weight loss

Characterized: control issues, “perfectionism”

Distorted body image, anemia, amenorrhea, dry brittle hair, nails.

Laxatives/enemas used frequently

Electrolyte imbalance

–-Behavior Modification Model is useful for tx.

bulimia

Binge eating (large amounts and/or high calorie food in short time)

THEN:  induce vomiting

May be normal, slight under/slight overweight

Electrolyte imbalances

Esophagitis, dental caries

Carry guilt and shame for behavior

**Many eating disorders- body slows itself down ( constipation, bradycardia, low BP )

interventions eating disorders

Behavioral modification therapy

◦Rewarded for correct behavior:

◦Ex:  gains weight each week -  add privileges.

Family therapy

Monitor clinical status

◦Weight, intake, vital sign

PICA

Ingestion of non-nutritional substances

◦Ex:  Clay, chalk, plants, paint chips, hair…..

◦For at least one month

◦Possibly used as a soothing behavior

◦Tx: feeding therapist, psychologist……..

So in the end…..

Be kind

Be aware of others & the struggles of the day.

Simple smile or hello can make someone feel seen and heard.

Decreasing stigma is very essential.

Need better insurance coverage & access to treatment for poor and under-insured.

Plans for transition to adulthood significant.

Social & human costs of non-treatment are enormous.