Mental Health

What is the difference between Mental Health Diagnoses in adults vs children?

the developing CNS: children differ in scope, presentation, and progression

What shapes risk for Mental Health Disorders?

social determinants: nutrition, relationships, housing

How is trauma defined in children?

by the experience, not the event itself

True or False: Humans are primarily relational rather than rational.

True

What are the subjective aspects of an Mental Health assessment?

• birth history (including prenatal period)

• past medical history (past neurological disorders)

• family history (alcohol and substance use disorders)

• social history and behavioral symptoms

What are the objective aspects of a Mental Health assessment?

• developmental screenings

• physical exam

• diagnostic testing to rule out organic causes

• ASD Screening

What is a common developmental screening to assess for Mental Health disorders?

Child Development Inventory

What are the common ASD Screenings?

• M-CHAT

• Pervasive Developmental Disorders Screening Test

How can you maintain a safe environment for these patients?

• ensure safety from self harm

• environmentally assess: no sharp objects or tubing, standard safety measures, adult superivison

• outpatient: assess the home environment

• inpatient: assess the hospital environment

What are the general nursing interventions when it comes to Mental Health Disorders?

• early identification

• referral to early intervention

• multidisciplinary team: involve the family in counseling

• Individualized Education Plan (IEP) if learning affected

What are the three aspects of an Intellectual & Learning Disability?

difficulty receiving, processing, and responding to information

Define: Dyslexia

disorder of receptive language → difficulty using letters to decode written language

Define: Dysgraphia

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

Define: Dyscalculia

affects quantities, memorizing math facts, and mathematical symbols

When do symptoms of intellectual and learning disabilities begin to reveal themselves?

when the child enters formal school

What are common manifestations of intellectual & learning disabilities?

• slower language and math acquisition

• difficulty recognizing letters and numbers

• problems with reading comprehension

What is often the first sign of intellectual and learning disabilities?

delayed language

If a child is suspected to have delayed language, what ought to be screened? What do you implement?

• screen:

  • hearing

  • language

  • vision

• implement:

  • IEP

What are the risk factors for intellectual and learning disabilities?

• congenital infection (rubella, syphilis)

• fetal alcohol syndrome

• chronic lead ingestion

• brain trauma

• gestational disorders

• pre-existing disease

What pre-existing diseases commonly lead to intellectual and learning disabilities?

• Down Syndrome

• microcephaly

• hydrocephaly

• metabolic disorders

• cerebral palsy

Define: Autism Spectrum Disorder

delays in social interaction and/or social communication

What are the early manifestations associated with Autism Spectrum Disorder?

• abnormal eye contact

• feeding and language difficulties

• fine and gross motor delays

• decreased alertness

• reduced response to name / social cues

• echolalia

Define: Echolalia

the automatic, non-voluntary repetition of words, sounds, or phrases

What are other common manifestations associated with Autism Spectrum Disorder?

• distress when routines change

• unusual attachment to objects

• minimal pretend play

• heightened or lowered senses, including decreased pain sensation

Define: Autism Regression

milestones may be lost between 15-30 months

What is the treatment associated with Autism Spectrum Disorder?

• early identification and referral to early intervention

• limit sensory overstimulation

• collaborate with school personnel

• consult speech therapy

• use a multidisciplinary team

How do medications treat Autism Spectrum Disorder?

treat target symptoms only

What types of medications are commonly used for Autism Spectrum Disorder?

SSRIs → decrease aggression

antipsychotics & melatonin → insomnia

What is the sequence in which the Nervous System try in Traumatic Events?

1. Social Engagement System

2. Sympathetic Nervous System

3. Parasympathetic Nervous System

What does the Social Engagement System (1) look like in response to Trauma?

the child negotiates using face, vocalization, or language

What does the Sympathetic Nervous System (2) look like in response to trauma?

if social engagement doesn’t negate the threat, the protective circuit activates to promote mobilization: fight or flight

What does the Parasympathetic Nervous System (3) look like in response to trauma?

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

Why does knowing the order in which the Nervous System responds to Trauma matter at the bedside?

• a child who appears calm and compliant may be immobilized rather than settled

• a child who fights is not being difficult — they are in the second circuit

What should approach look like when it comes to a procedure?

• approach through the Social Engagement System first: face voice, tone

• then — procedure and instruction

What are the paths to dysregulation?

relationship and safety → abuse, neglect, absent nurturing

What are the Erikson stages at risk when it comes to Trauma?

1. Trust vs Mistrust (infancy)

2. Autonomy vs Shame and Doubt (toddler)

3. Initiative vs Guilt (preschooler)

4. Industry vs Inferiority (6-12 years)

What is the Treatment for ADHD?

• behavioral therapy

• caregiver education

• pharmacotherapy

• IEP

What medications are used to treat ADHD?

• Methylphenidate

• Amphetamine products

Why are these medications used to treat ADHD?

they increase dopamine and norepinephrine

What is the piece of education vitally associated with ADHD medications?

they are controlled substances → store securely, there is potential for misuse

What are the side effects associated with ADHD medications?

• anorexia and weight loss

• tachycardia

• hypertension

• insomnia

• nervousness

What are the nursing interventions associated with treating ADHD?

• titrate gradually

• give 30 minutes before a meal

  • last dose before 1800 (to prevent insomnia)

• avoid caffeine

What should nurses monitor for in ADHD patients?

• growth and height velocity

• appetite

• sleep

• heart rate

• blood pressure

• behavioral response

If methylphenidate / amphetamine products are not used, what is a medication alternative?

Atomoxetine

What is Atomoxetine? Describe it and its concerns.

a Selective Norepinephrine Reuptake Inhibitor (SNRI) - keeps Norepi in the blood

• titrate gradually

• monitor for suicidal ideation

Describe: Anxiety Disorders

worry and fear beyond adaptive coping → stress and impairment, a combination of genetics and environment

What are the types of Anxiety Disorders?

• generalized anxiety

• separation anxiety

• panic disorder

What are the manifestations associated with Anxiety Disorders?

• somatic

  • abdominal pain

  • N / V

  • palpitations

  • dyspnea

  • dizziness

• aggression

• defiance

Define: Separation Anxiety

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

How do you diagnose Anxiety Disorders?

standardized anxiety rating scales + structured diagnostic interviewing

How do you treat Separation Anxiety / School Refusal?

exposure-based Cognitive Behavioral Therapy

How do you treat Generalized Anxiety Disorders?

SSRIs (Fluoxetine)

What does Depression look like in kids?

may present as irritability, somatic complaints, declining function, withdrawal, or suicidality

What is the timeline of symptom presentation that → Depression diagnosis?

symptoms persist most of the day, nearly every day, for at least 2 weeks & impair functioning

What are the Risk Factors associated with Depression?

family history, traumatic event

What is the ideal Treatment combination associated with Depression?

counseling + medication

What are the medications often used to treat Depression ?

SSRI / SNRI (tricyclic antidepressant)

• Sertraline

• Paroxetine

• Venlafaxine

• Bupropion

• Trazodone

What are the Nursing Interventions associated with Depression medication?

monitor for adverse effects and suicidal ideation

What are the Teaching Points associated with Depression medications?

therapeutic effect may take up to 2 weeks, never stop it abruptly

Define: Anorexia Nervosa

preoccupied fear of gaining weight with a severely distorted body image

What is the typical onset associated with Anorexia Nervosa?

late adolescence

What are the risks associated with Anorexia Nervosa?

• adolescence

• perfectionist personality / OCD

• family history of eating disorder

• low self-esteem

• female gender

What are the findings associated with Anorexia Nervosa?

• low BMI

• dehydration

• lanugo

• cold intolerance / hypothermia

• orthostatic hypotension

• weak pulse

• compulsive exercising

• depression

• suicidal thoughts

What are the complications associated with Anorexia Nervosa?

• starvation

• fluid and electrolyte imbalance

• cardiac complications

• renal failure

• suicide potentiality

How do you treat Anorexia Nervosa?

• nutritional support

• cardiac monitoring

• multidisciplinary team

• family involvement

What are the goals associated with treating Anorexia Nervosa?

• gradual gain of 2-3 lbs / week

• NG feeds if required

Define: Bulimia Nervosa

binge eating followed by purging through self-induced vomiting, diuretics, and/or laxatives

True or False: An adolescent experiencing Bulimia Nervosa knows the pattern is abnormal and cannot stop it.

True

What does the weight of a patient with Bulimia Nervosa look like?

often normal or slightly low, which is why it is oftentimes missed

What are the findings associated with Bulimia Nervosa?

• food rituals

• labile mood

• repeated fad dieting

• thinning hair

• brittle nails

• hypokalemia

• anemia

• bradycardia

• back-of-hand callouses

• esophageal irritation

• poor dentition

What are the Complications associated with Bulimia Nervosa?

• loss of dental enamel

• dental caries

• esophagitis / ulcerations

• gastric rupture

• cardiac dysrhythmias

How is Bulimia Nervosa treated?

• Cognitive Behavioral Therapy

• SSRIs (Fluoxetine)

• journaling

• Serum Potassium monitoring

• routine for meals and snacks

What are types of abuse?

• physical

• emotional

• spiritual

• sexual

• domestic

• neglect

What caregivers are at risk to abuse?

• mental illness

• poor self-esteem

• substance use

• poor coping

• history of being a victim of abuse

What are the environmental risks to abuse?

• low income

• unemployment

• domestic violence

• lack of a support system

What are the manifestations associated with experiencing abuse?

• multiple fractures in various stages of healing

• suspicious bruising

• STI

• enuresis

• vague somatic complaints

What teams are associated with collecting evidence regarding abuse?

• forensic medical team

• a Sexual Assault Nurse Examiner (SANE)

• skeletal survey

True or False: Nurses are not mandatory reporters.

False - they are. Document all findings first.

What type of abuse is Munchausen by Proxy?

medical child abuse

What is priority when it comes to Munchausen by Proxy?

the child’s safety

What types of events lead to the development of PTSD?

• chronic

• traumatic

• catastrophic

What are the Risk Factors associated with PTSD?

• genetic predisposition

• traumatic incident

• repeated / chronic trauma

• psychiatric disorder

• natural disaster

• sexual abuse

• witnessing homicide, suicide, or other violence

What is the length of Phase 1 of PTSD?

minutes → 2 hours

What is experienced during Phase 1 of PTSD?

increased stress hormones (fight or flight), psychosis may occur

What is the length of Phase 2 of PTSD?

2 weeks

What is experienced during Phase 2 of PTSD?

a period of calm, with numbness and denial as defense mechanisms decrease

What is the length of Phase 3 of PTSD?

2-3 months

What is experienced during Phase 3 of PTSD?

the client gets worse instead of better

• depression

• phobias

• anxiety

• conversion reactions

• repetitive movements

• flashbacks

• obsessions

What are the Nursing Interventions associated with PTSD?

• refer to psychotherapy

• monitor for behavior changes

• assist the client and family with coping

• allow expression of feelings

• prevent / reduce long-term effects

What type of medication has a Black Box Warning associated with it?

Selective Serotonin Reuptake Inhibitor (SSRI)

True or False: SSRIs may increase the risk of suicidality in the pediatric population.

True

In addition to SSRIs, what is the drug that also carries a BBW?

Atomoxetine for ADHD

True or False: You do not need to monitor for suicidal ideation with dosage changes.

False - you do!

What is the highest-risk period associated with SSRIs and their BBW?

2 weeks - that’s how long the therapeutic effect takes. Energy and motivation tend to improve quickly, mood lift lags behind.

Is it okay to abruptly discontinue a SSRI?

No - teach the client and caregiver to observe for adverse effects and to report new agitation, worsening mood, or any talk of self-harm