PPN 302 Class 10: Partnering with children/youth or older adults experiencing mental health and substance use conditions

Key factors that promote mental health for children & youth 

• Positive Adult Relationships

• Secure Attachment

• Supportive Home/School/Community Environment

• General Health (nutrition, safety, security, social and physical development)

• Supportive Social Networks

• Positive Childhood & Adolescent Experiences

Community (It takes a village to raise a child- Nigerian proverb)

• Connected and positive community environments 

• Social supports and connections 

Families & siblings (It takes a village to raise a child- Nigerian proverb)

• Important roles as protectors, nurturers, mediators, and mentors for surviving & thriving

Secure attachment (It takes a village to raise a child- Nigerian proverb)

• The bond between parent/ guardian begins in infancy 

• When secure, allows a child to explore the world without fear of rejection

Common childhood challenges/stressors 

• Attachment- disrupted

• Grief-Loss/Death

• Family Separation/Divorce

• Sibling relationships

• Physical illness

• Adolescent risk-taking behaviours

Grief & loss in childhood key points 

• Grief and loss are common types of stress for children and adolescents

• Subjective experience that accompanies the perception of loss. (Death of family member, moving schools, transitions in relationships) 

•  Children respond to loss and grief based on their developmental stage 

• Learning to mourn losses can lead to renewed appreciation of value of relationships 

Preschool-aged (Grief and loss developmental considerations)

• Express grief through somatic complaints, regression, behaviour problems, withdrawal, and hostility

• May experience complicated grief

• React more to parents’ distress

• Need reassurance

• Avoid euphemisms (e.g., “he went to sleep”)

School-aged/Adolescents (Grief and loss developmental considerations)

• May have an idealized/romantic idea of death

• If a parent is dead, may assume parental role

Physical illness 

• Perception of an event will influence the family’s ability to cope.

• Chronic physical illness is linked to emotional/behavioural problems.

• Common childhood reactions include: 

  • Regression

  • Sleep and feeding difficulties

  • Behaviour problems

  • Somatic complaints

  • Depression

Protective factors

• Individual attributes, such as problem-solving skills, sense of self-efficacy, accurate processing of interpersonal cues, positive social orientation, and self-regulation

• A supportive family environment, including attachment with adults in the family, Sibling relationships, low family conflict, and supportive relationships

• Environmental supports, including those that reinforce and support coping efforts and recognize and reward competence

Risk factors for poor mental health 

• Poverty and homelessness 

  • 14% of children in Canada live in poverty 

  • Recent immigrant families had a low-income rate of 39.3%

  • A national study found that, in 2009, an estimated 29,964 youth (ages 16 to 24 years) and 9,459 children (under the age of 16 years) stayed in emergency shelters across the country

• Child abuse and neglect 

• Children in care 

• Children with parents who are struggling with substance use disorders or mental illness

Adolescent risk-taking behaviours 

• Many adolescents experiment with risk-taking behaviours, such as smoking, alcohol, unprotected sex, truancy or delinquent behaviours, and running away.

• 2SLGBTQIA+ youth face additional challenges of stigma, exclusion, and anxiety

Interventions (Adolescent risk-taking behaviours)

• Intervene at peer level, educational programmes, peer counselling,alternative recreation activities

Promotion & prevention intervention approaches 

• Mental health promotion

  • Individual level

  • community level

  • System level 

• Psychoeducation

• Social skills training 

• Bibliotherapy 

Mental illness among children and adolescents

• The Mental Health Commission of Canada (MHCC) estimates that 1.2 million children and youth are affected by mental illness in our country.

• Over 800,000 Canadian children and youth experience significant mental health issues.

• For Canadians aged between 15 and 34, suicide is the leading nonaccidental cause of death.

  • Indigenous youth experience higher rates

Psychiatric disorders in children/adolescents 

• Schizophrenia spectrum and other psychotic disorders

  • Most often substance induced or brief psychotic disorder

• Bipolar and related disorders

• Depressive disorders

• Anxiety disorders

• Obsessive-compulsive disorders

• Trauma-and stressor-related disorders

• Neurodevelopment disorders

• Disruptive, impulse control, and conduct disorders

• Motor disorders

• Elimination disorders

Schizophrenia spectrum and other psychotic disorders 

• Schizophrenia

• Brief psychotic disorder

• Treatment

Schizophrenia (Schizophrenia spectrum and other psychotic disorders)

• Onset often in early adolescence as prodrome or first episode onset 

Brief psychotic disorder (Schizophrenia spectrum and other psychotic disorders)

• Related to substance use or other unknown cause or illness 

Treatment (Schizophrenia spectrum and other psychotic disorders)

• Anti-psychotic medications (2nd generation atypical ie. olanzapine risperidone) 

• Symptoms management 

• Psychosocial supports and counselling

Bipolar and related disorders 

• First presents during adolescence

• Symptoms include periods of mania (extreme optimism, euphoria, and feelings of grandeur; rapid, racing thoughts and hyperactivity; a decreased need for sleep; increased irritability; impulsiveness and possibly reckless behaviour; and alternate periods of depression)

Treatment intervention (Bipolar and related disorders)

• lithium carbonate, mood stabilizers (carbamazepine)

Depressive disorders 

• Major depressive disorder

• Disruptive mood dysregulation disorder

• Treatment interventions 

  • Cognitive-behavioural therapy (cbt)

  • mindfulness

• Nursing care: ruling out concerns of suicidality

Anxiety disorders 

• Most prevalent mental illness in Canadian children between 4 and 17 years of age 

• Assessment: does the child:

  • Often seem worried?

  • Consistently avoid age-appropriate situations or activities? 

  • Have frequent episodes of stomach aches, headaches, or hyperventilation? 

  • Have daily repetitive rituals? 

Generalized anxiety disorder 

• Characterized by excessive anxiety and worry about many events or activities.

• GAD affects an estimated 1 out of 150 school-aged children in Canada.

• Risk for developing GAD includes a genetic predisposition.

• Psychodynamic theory and cognitive-behavioural theory.

Treatment interventions (Generalized anxiety disorder)

• CBT

• Pharmacotherapy

Treatment interventions (Separation anxiety disorder)

• Individual psychotherapy, behavioural treatment, and pharmacotherapy

Trauma and stressor-related disorders

• It is well documented that early chronic stress or trauma affects how the developing brain grows and evolves

Causes (Trauma and stressor-related disorders)

• Physically or emotionally absent parent

• Erratic or inconsistent caregiving

• Abuse

• Neglect

• Violence in the home or community

• War or disasters

Child abuse 

• Duty to report in cases where there is report of neglect, physical, or sexual abuse of child.

• Are the child's immediate circumstances unsafe? Does the child have to be taken into care or removed to a safe place?

• For current cases, what is the assessed risk of repeat abuse? What are the issues that merit intervention on a priority basis?

• For ongoing cases, to what extent are interventions working? What is the current situation of the child, the family, and any substitute care arrangement?

Reactive attachment disorder 

• Typically identified prior to the age of 5 years

• May experience lifelong struggle with relationships

Four types (Reactive attachment disorder)

• Secure; insecure avoidant; insecure ambivalent/resistant; and disorganized

Disinhibited social engagement disorder

• Blatant disregard of social inhibition when approaching strangers verbally and physically.

• The prevalence of this disorder remains unknown; however, in high-risk populations, the incidence is about 20% of children.

• Causes similar to RAD.

Neurodevelopmental disorders

•  Significant developmental delays or deficits in one or more of following areas:

  • Attention, cognition, language, affect, or social and moral behaviours

    • Developmental delay is the development of a child that is outside the norm, including delayed socialization, communication, peculiar mannerisms, and idiosyncratic interests.

Autism in children  

• Delayed and divergent language development, echolalia, and a tendency to be extremely concrete in the interpretation of language

  • Stereotypic behaviour

  • Self-injurious behaviour

  • May or may not have an intellectual disability but commonly show an uneven pattern of intellectual strengths and weaknesses.

• Nursing care: positive relationship with child and family

• Connection to assessment, early intervention support services

Continuum of care

• Promoting interaction 

• Ensuring predictability and safety 

• Self-care 

• Supporting family 

• Support groups 

Reframing behavioural interventions in autism: Autistic and family perspectives: 

• Autism interventions with children often tend to focus on teaching normative skills and behaviours, sometimes using operant conditioning principles like rewards and aversives

• Though forcing children to suppress who they are can have important mental health consequences.

• Estee Klar and her son Adam Wolfond share their story. Of note, Adam was recently the first non-speaking autistic person to obtain a master’s degree in Canada.

Specific learning disorders

• Are among the most common neurodevelopmental disorders in children and are defined as difficulties in learning and using academic skills 

• Intervention focus on building self-confidence and family support 

Communication disorders

• Involve deficits in speech, language, and communication

• Interventions focus on fostering social and communication skills, identifying and addressing low self-esteem, and making referrals for specific speech or language therapy 

Attention Deficit Hyperactivity Disorder

• Associated with functional impairments such as school challenges, peer problems, and family conflict.

Treatment interventions (Attention Deficit Hyperactivity Disorder)

• Psychoeducation for the child and family

• Behavioural and/or occupational interventions for the child

• Individual and family support, counselling, and therapy

• School accommodations

• Medication management

Motor disorders: Tourette’s 

• Motor disorders include developmental coordination disorder, stereotypic movement disorder, and tic disorders.

Epidemiology (Motor disorders: Tourette’s)

• The prevalence of Tourette's disorder is estimated to be from 3 to 8 per 1,000 in school-aged children, with boys being affected more than girls at a 2:1 to 4:1 ratio.

Treatment interventions (Motor disorders: Tourette’s)

• Behaviour therapy and the alpha-2-adrenergic antagonists are the first line of therapy for children with tic disorders.

Elimination disorders (enuresis)

• Involuntary or intentional voiding of urine in inappropriate places.

• At night (nocturnal) or during the day (diurnal) or both.

The DSM-5 specifies that bedwetting occurs (Elimination disorders (enuresis)

• At least twice per week for a duration of 3 months.

• Child is at least 5 years of age.

• Behaviour cannot be attributed to a medication side effect or to another medical condition.

Treatment (Elimination disorders (enuresis)

• Behavioural interventions

• Pharmacotherapy

Assessment: psychological domain (Mental health assessment of children and youth)

• Mental status 

• Development assessment 

• Psychosocial development

• Language 

• Attachment 

• Temperament and behaviour 

• Self-concept 

• Maturation 

Interviewing techniques (Mental health assessment of children and youth)

• Interview the child and parent separately.

• Approach should be developmentally and age appropriate

• Children provide better information about internalizing symptoms (mood, sleep, suicide ideation).

• Parents provide better information about externalizing symptoms (behaviour, relationships)

Pre-school children (Approach to interview informed by developmental stage  (Mental health assessment of children and youth)

• Have difficulty putting feelings into words, thinking concrete

  • Use play; conduct assessment in playroom 

School-aged children (Approach to interview informed by developmental stage  (Mental health assessment of children and youth)

• Able to use constructs, provide longer explanations 

  • Establish rapport through competitive games 

Adolescents (Approach to interview informed by developmental stage  (Mental health assessment of children and youth)

• Ego-centric orientation, increased self–conscious, fear of being shamed 

  • Let them know what information will be shared with parents. direct, candid approach 

Pharmacological interventions in children with mental illness 

• SSRIs (fluoxetine, sertraline, escitalopram)

• SARIs (trazodone)

• Antipsychotics (risperidone, olanzapine (prn), quetiapine (prn)

• Lithium

• Benzodiazepines (lorazepam prn)

Stimulant medications in ADHD

• Lots of debates about use of these medications in ADHD; however, if they support functioning, this should be the focus.

• Amphetamines and Methylphenidate stimulants cause release of norepinephrine and dopamine into the synapse and block their reuptake

  • These neurotransmitters play an important role in attention, thought, and motivation

Side effects (stimulants)

• Appetite suppression, insomnia, irritability, weight loss, nausea, headache, palpitations, blurred vision, dry mouth, constipation, and dizziness

• Specific to Amphetamines: blood pressure changes (both hypertension and hypotension), tachycardia, tremors, and irregular heart rates.

Older adult mental health promotion & assessment 

• Late adulthood

  • Young-old: 65 to 74 years

  • Middle-old: 75 to 84 years

  • Old-old: 85 years and older

  • Nurses need  to understand and respond well to the unique needs of this population 

Changes with aging (Older adult mental health promotion & assessment)

• Aging is a gradual bio/psycho/social/spiritual process that may be viewed as both positive and negative.

• Can lead to a loss of independence.

• Friendships change, and losses occur.

• Many are faced with establishing new meaning in life.

• To have a sense of meaning and purpose is a critical factor in older adults’ mental health.

  • A protection against suicide and despair

Social domain (Older adult mental health promotion & assessment)

• Functional status may decrease

• Retirement:

  • Can lead to alterations in self-concept

• Cultural impact

• Social activities change

• Added strains

• Residential care

• Assisted living

Social support transitions (Older adult mental health promotion & assessment)

• Lifestyle support 

• Developing regular exercise habits can help maintain physical and psychological well-being 

  • exercise promotion and nutrition counselling 

• Community & social connection

Spiritual domain  (Older adult mental health promotion & assessment)

• Spiritual needs are basic for all age groups and are requirements for establishing meaning and purpose, love and relatedness, and forgiveness.

• There is growing evidence of the significance that spirituality plays in successful aging.

• The process of spiritual assessment involves active listening, thoughtful observing, and sensitive questioning.

Aging and sexual health (Older adult mental health promotion & assessment)

• Healthy aging is an ongoing process of adaptation across the four primary bio/psycho/social/spiritual domains.

• Sexual health serves as a good illustration.

• Desire for intimacy does not go away.

• Practicing safe sex is as important for older persons as for younger persons.

• Some physical illnesses, disabilities, and medications can cause sexual problems.

Risk factors for geriatric psychopathology 

• Chronic illness

• Polypharmacy

  • Beers criteria

    • There is an increased risk of drug interactions because of polypharmacy in the elderly.

• Bereavement and loss

• Poverty

• Suicide and the lack of social support

  • Linked to the rate of suicide in older adults

Bereavement and loss 

• Older adults experience many losses.

• Survivors are at higher risk for depression.

• Facilitating meaningful engagement and connectedness can help older persons feel supported and understand that they are not alone.

Poverty 

• Older adults (particularly women) can be at higher risk for poverty than other age groups.

• Poverty may result from:

  • Inadequate retirement income

  • Illness, discrimination against women in pension plans

  • Financial exploitation of older individuals

Suicide and the lack of social support 

• Suicide is a leading cause of preventable death in Canada and worldwide.

• More than 10 older adults over the age of 60 die by suicide every week in Canada, and “approximately 1,000 are admitted to Canadian hospitals each year as a consequence of intentional self-harm.”

• Hanging and firearms are the most common method of suicide for men, while women tend to use self-poisoning or suffocation.

• A lack of social support has been linked to the rate of suicide in older adults

Mental illness prevention and promotion 

• Preventing depression and suicide

  • Recognition and early intervention are the keys.

• Reducing the stigma of mental health treatment

  • Work of the MHCC has recognized the critical importance of combating stigma and discrimination.

• Use of medications

  • New medications helpful

• Avoiding premature institutionalization

Mental health assessment of the older adult 

• Intellectual function, capacity for change, and productive engagement with life remain stable in the older adult.

• As the population ages, there will be an increased numbers of seniors with mental health illnesses and problems.

• Mental health problems in older adults can be especially complex because of coexisting medical problems and treatments.

• A mental health assessment is necessary when psychiatric or mental health issues are identified or when clients with mental illnesses reach their later years.

Mental status exam 

• Appearance

• Behaviour

• Mood & Affect

• Speech

• Thought Process

• Perceptions

• Cognition

• Insight

• Judgement

Appearance (Mental status exam)

• Dress appropriate to weather and season

Behaviour (Mental status exam)

• Calm, vs agitated, etc.

Mood & Affect (Mental status exam)

• Mood-as described by person

• Affect-Facial expression of emotion

Speech (Mental status exam)

• Clear, coherent

Thought Process (Mental status exam)

• Logical, organized vs disorganized, tangential

Thought Content (Mental status exam)

• Logical and organized, goal directed vs. paranoid

Perceptions (Mental status exam)

• No perceptual disturbances vs auditory hallucinations, visual hallucinations

Cognition (Mental status exam)

• Memory,attention, Cognitive abilities, Orientation to Person, place, date, Time

Insight (Mental status exam)

• Awareness of self and current health status

Judgement (Mental status exam)

• Good judgment vs poor judgement

Neuro-cognitive disorders

• Cognition 

  • The ability to think and know; a relatively high level of intellectual processing in which perceptions and information are acquired, used, or manipulated

• Memory 

  • Facet of cognition; ability to recall or reproduce what has been learned or experienced 

• Delirium 

  • Acute cognitive impairment caused by medical condition 

• Dementia 

  • Chronic, cognitive impairment

  • Differentiated by cause, not symptoms 

Delirium: clinical course 

• Fluctuating consciousness and attention with reduced ability to focus, sustain, or shift attention

• Marked by a decline in cognitive function

• Develops over a short period of time

• Usually reversible if the underlying cause identified

• Serious, should be treated as an emergency

Delirium: poor outcomes

• Increased mortality 

• Functional decline 

• Falls 

• LTC admission 

• Worsening dementia 

Delirium: diagnostic criteria 

• Impairment in consciousness-key diagnostic criteria

• Children- can be related to medications, endocrine-metabolic issues, or fever

• Older adults-most common in this group, often mistaken as dementia

  • Postoperative delirium

Delirium: epidemiology and risk factors

• Prevalence rates from 10% to 30% of patients

• In nursing homes, prevalence reaching 60% of those older than age 75

• Occurs in 30% of hospitalized cancer patients

• 30% to 40% of those hospitalized with AIDS

• Higher for women than for men

• Common in elderly, postsurgical patients

Delirium: Atiology #1 

• Complex and usually multifaceted

• Most commonly identified causes: 

  • Medications, infections

  • Fluid and electrolyte imbalances 

  • Advanced age, brain damage dementia 

  • Sensory overload or underload, immobilization, sleep deprivation and psychosocial stress 

Assessment (delirium)

• Assess for risk factors

  • Baseline cognitive impairment

  • Medications

  • Pain

  • Metabolic disturbance

  • Hypoperfusion/hypoxemia

  • Dehydration

  • Infection

  • Environment

  • Impaired mobility

• Assess for features of delirium (using validated tools)

Prevention (Delirium) 

• Reduces incidence of delirium by 30% (Inouye, 2014)

• Strategies include:

  • Hydration and nutrition

  • Adequate pain management

  • Sensory aids

  • Maximize mobility and avoid restraints

  • Reorientation

  • Therapeutic activities

  • Promotion of sleep (non-pharmacological)

  • Reduced use and doses of psychoactive medications

Management (Delirium)

• Treat the underlying cause(s)

• Continue preventative interventions

• Appropriate sensory stimulation

• Foster familiarity

• Communicate clearly

• Minimize invasive interventions

• Reassure and educate family

• Psychotropics as a last resort

Dementia - features 

• Memory loss

• Language loss

• Difficulties with abstract thinking/ problem-solving

• Disorientation of time and place, and impaired judgement

• Decreased ability to perform everyday activities

• Changes in mood, behaviour and personality

• Loss of initiative

Dementia types 

• Alzheimer's disease 

• Frontal temporal dementia

• Lewy body disease 

• Vascular dementia 

• Creutzfeldt Jakob disease and others

Other major dementias 

• Vascular neurocognitive disorder

• NCD (dementia) with Lewy’s bodies

• NCD (dementia) due to Parkinson’s disease

• Dementia caused by other general medical conditions:

  • NCD (dementia) caused by HIV infection

  • NCD (dementia) due to traumatic brain injury

  • NCD (Dementia) due to Huntington’s disease

  • NCD (Dementia) due to prion disease

  • Substance/medication-induced NCD (dementia)

Dementia: Akzehimer’s type

• Degenerative, progressive neuropsychiatric disorder that results in cognitive impairment, emotional and behavioural changes, physical and functional decline, and ultimately death

• Types

  • Early onset (65 years and younger)

    • Rapid progression

    • Late onset (over 65)

• Stages: early, middle, late

Early stage (Stages of dementia)

• forgetfulness

• problems with orientation (e.g cannot follow directions)

• communication difficulties

• limited attention span

• difficulty learning new things

• changes in mood and behaviours

• may understand how they are changing and may wish to help plan and direct future care

Middle Stage (Stages of dementia)

• memory problems are obvious (e.g does not know address, own history)

• restlessness (e.g wandering, pacing)

• special problems that may affect mobility

• confused, difficulty following a topic of conversation

• problems understanding verbal and written language

• changes in wake-sleep patterns; lack of appetite

• apprehensive and/or withdrawn

• uninhibited behaviour

• delusions and hallucinations

Late stage (Stages of dementia)

• Severe cognitive impairment (memory, information processing, orientation)

• loses the capacity for recognizable speech

• needs help with eating, toileting; may be incontinent

• loses ability to walk without assistance, to sit without support, to smile, hold up head

• may have impaired swallowing and loss of weight

End of life (Stages of dementia)

• changes in blood circulation, skin breakdown

• no longer accepting food and drink

• increased sleepiness; changes in breathing 

• agitation 

• may have buildup of secretions; fever

• still experiences and senses emotion 

• spiritual experience may be important 

Diagnosis of Alzheimer dementia 

• Essential feature- multiple cognitive deficits and cognitive impairment

• Criteria include cognitive and /or behavioral symptoms that: 

  • Interfere with the ability to function at work or at usual activities

  • Represent a decline from previous levels of functioning and performing

  • Are not related to delirium or a major psychiatric disorder

Epidemiology

• Age is the most acknowledged risk factor for developing AD.

• It is estimated that dementia affects 1 in 14 people over the age of 65 and 1 in 6 over the age of 80.

• Females are at higher risk, even discounting the fact that they tend to live longer.

Aetiology

• Neuritic plaques (extracellular lesions)

  • β-Amyloid plaques

  • Alpha-synuclein

• Neurofibrillary tangles

• Oxidative stress and the role of antioxidants

• Inflammation

• Genetic factors

Risks 

• Advanced age

• Cardiovascular risk factors

• Family history

• History of delirium

• New onset of depression in late life

• History of head trauma