Chapter 22: Mental Health Issues of Children and Adolescents

Chapter 22: Mental Health Issues of Children and Adolescents

Childhood and adolescent mental health & neurodevelopmental disorders are often difficult to identify and diagnose, leading to delayed treatment and interventions.

Children and adolescents may meet criteria for multiple mental health disorders and may have comorbid conditions.

Behaviors become problematic when they interfere with:

• Home life

• School performance

• Peer interactions

Disorders That Can Appear During Childhood and Adolescence

Depressive Disorders – Major depressive disorder, persistent depressive disorder

Anxiety Disorders – Separation anxiety disorder, panic disorder

Trauma- & Stressor-Related Disorders – PTSD

Substance Use Disorders – Alcohol, tobacco, cannabis use disorder

Feeding & Eating Disorders – Anorexia nervosa, bulimia nervosa, binge eating disorder

Disruptive, Impulse Control, & Conduct Disorders – Oppositional defiant disorder, disruptive mood dysregulation disorder, conduct disorder

Neurodevelopmental Disorders – ADHD, autism spectrum disorder, intellectual developmental disorder, specific learning disorder

Bipolar & Related Disorders

Schizophrenia Spectrum & Other Psychotic Disorders

Nonsuicidal Self-Injury & Suicidal Behavior Disorder – Suicide is a leading cause of death ages 10–24

Impulse Control Disorders – Intermittent explosive disorder

Factors Impeding Diagnosis (3)

Limited language/cognitive/emotional skills to describe symptoms

Wide variation of “normal” behaviors by developmental stage

Difficulty distinguishing emotional problems from typical behavior delays diagnosis

Characteristics of Good Mental Health in Youth (6)

Accurately interpret reality; correct perception of environment

Positive self-concept

Cope with stress/anxiety in age-appropriate ways

Master developmental tasks

Express self spontaneously/creatively

Develop and maintain satisfying relationships

Etiology and General Risk Factors

Genetic Links / Chromosomal Abnormalities

• Associated with: schizophrenia, bipolar disorder, autism spectrum disorder, ADHD, intellectual developmental disorder

Biochemical Factors

• Neurotransmitter alterations (norepinephrine, serotonin, dopamine) contribute to some mental health disorders

Social & Environmental Factors

• Risk factors: severe marital discord, low socioeconomic status, large families, overcrowding, parental criminality, substance use disorders, maternal psychiatric disorders, parental depression, foster care placement

Cultural & Ethnic Factors

• Difficulty with assimilation, lack of cultural role models, lack of support from dominant culture

Resiliency

• Ability to adapt to change, form nurturing relationships, use effective coping/problem-solving skills can protect against developing a mental disorder

Trauma Exposure

• Witnessing or experiencing traumatic events (e.g., physical or sexual abuse) during formative years

Depressive Disorders in Children and Adolescents

Risk Factors

• Family history of depression

• Physical or sexual abuse, neglect

• Homelessness

• Parental disputes, family/peer conflict, rejection

• Bullying (as aggressor or victim; includes cyberbullying)

• High-risk behaviors

• Learning disabilities

• Chronic illness

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Expected Findings

• Sadness

• Temper tantrums (verbal/behavioral outbursts)

• Loss of appetite

• Vague health complaints

• Solitary play or work

• Appetite changes → weight changes

• Sleep pattern changes

• Crying

• Fatigue/low energy

• Irritability

• Aggression

• High-risk behavior

• Poor school performance / school dropout

• Hopelessness about the future

• Suicidal ideation or attempts

Anxiety Disorders & Trauma- and Stressor-Related Disorders

Expected Findings

• Interferes with normal growth and development

• Severe enough to impair normal functioning at home, school, and other areas

Separation Anxiety Disorder

Excessive, developmentally inappropriate anxiety when separated from home/parents

Can lead to school phobia or fear of being alone

Depression is common comorbidity

May occur after a specific stressor (death, illness, move, assault)

Can progress to panic disorder or other phobias

Interventions

• Provide emotional support that accepts regression/defense mechanisms

• Offer protection during panic-level anxiety by meeting needs

• Use strategies to boost self-esteem and achievement

Posttraumatic Stress Disorder (PTSD)

Triggered by experiencing/witnessing/learning of a traumatic event

Signs in children/adolescents: anxiety, depression, phobia, conversion reactions

External signs: irritability, aggression, poor academic performance, somatic complaints, belief in shortened life expectancy, sleep disturbances

Small children may reduce play or engage in trauma-related play

Interventions

• Assist in processing traumatic events or losses to reach acceptance

• Encourage group therapy participation

Disruptive, Impulse Control, and Conduct Disorders

Expected Findings

• Behavioral problems occur in school, home, and social settings

• Common comorbidities: ADHD, depression, anxiety, substance use disorders

• Symptoms often worsen in:

  • Situations requiring sustained attention (e.g., classroom)

  • Unstructured group situations (e.g., playground)

Interventions

• Use calm, firm, respectful approach

• Model acceptable behavior

• Gain attention before giving instructions; keep directions short/clear

• Set and consistently enforce behavior limits

• Plan physical activities for energy release and success

• Help parents develop reward systems (e.g., wall charts, tokens) with child involvement

• Focus on strengths, not just problems

• Support parental hopefulness

• Maintain safe environment for all

• Give positive feedback for meeting expectations

• Identify causes of power struggles and address them

• Teach effective coping skills

• Promote group, individual, and family therapy participation

• Administer and monitor medications (antipsychotics, mood stabilizers, anticonvulsants, antidepressants)

Oppositional Defiant Disorder (ODD)

Recurrent antisocial behaviors:

• Negativity, disobedience, hostility

• Defiant behavior (esp. toward authority)

• Stubbornness, argumentativeness, limit testing

• Unwillingness to compromise

• Refusal to accept responsibility for misbehavior

Misbehavior directed at person best known; usually at home

Clients don’t see behavior as defiant, but as a response to perceived unreasonable demands

Associated with: low self-esteem, mood lability, low frustration tolerance

May progress to conduct disorder

Disruptive Mood Dysregulation Disorder (DMDD)

Severe, recurrent temper outbursts (verbal/physical) inappropriate for developmental level

Outbursts occur ≥3 times/week in at least two settings (home, school, with peers)

Mood between outbursts: irritable/angry

Onset between ages 6–18

Not due to another mental health disorder (e.g., bipolar disorder)

Intermittent Explosive Disorder (IED)

Recurrent, episodic violent/aggressive behavior (verbal or physical) with potential harm to people, property, or animals

Onset: as early as age 6; most common ages 13–21

More common in males

Triggered by minor events; followed by shame/regret

Can impair relationships/employment; linked to chronic diseases (e.g., hypertension, diabetes)

Conduct Disorder (Childhood or Adolescent Onset)

Persistent pattern violating rights of others or societal rules

Categories:

• Aggression toward people/animals

• Property destruction

• Deceit/theft

• Serious rule violations

Onset:

• Childhood-onset: before age 10; males more prevalent

• Adolescent-onset: after age 10; male-to-female ratio equal

Contributing Factors

• Parental rejection/neglect

• Difficult temperament

• Harsh/inconsistent discipline

• Abuse (physical/sexual)

• Lack of supervision

• Early institutionalization

• Frequent caregiver changes

• Large family size

• Association with delinquent peers

• Parent with psychological illness

• Chaotic home life

• Lack of male role model

Manifestations

• Lack of remorse/empathy

• Bullying/threats/intimidation

• Justifies aggression

• Low self-esteem, irritability, reckless behavior, temper outbursts

• Possible suicidal ideation

• Concurrent learning/cognitive impairments

• Physical cruelty to people/animals

• Weapon use causing serious harm

• Property destruction

• Theft, shoplifting, truancy

• Running away from home

A nurse is performing an admission assessment on an adolescent client who has depression. Which of the following findings are expected for this disorder?

Select all that apply.

a

Fear of being alone

b

Substance use

c

Weight gain

d

Irritability

e

Aggressiveness

b Substance use

d Irritability

e Aggressiveness

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Solitary play or work, rather than the fear of being alone, is an expected finding associated with depression.

Loss of appetite and weight loss, not weight gain, are expected findings associated with depression.

A nurse is teaching a group of guardians about manifestations of conduct disorder. Which of the following findings should the nurse include?

Select all that apply.

a

Bullying of others

b

Threats of suicide

c

Law-breaking activities

d

Narcissistic behavior

e

Flat affect

a Bullying of others

b Threats of suicide

c Law-breaking activities

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Low self-esteem, rather than narcissism, is an expected finding of conduct disorder.

Irritability and temper outbursts, rather than a flat affect, are expected findings of conduct disorder.

Neurodevelopmental Disorders

Etiology & General Risk Factors

• Prevalence increasing in the U.S. (current rate: 1 in 6 children)

• Symptoms may change with maturation but can persist into adulthood

• Often multifactorial: hereditary + environmental influences affect neurological development

Comorbidities

• May occur alongside various medical conditions

• Diagnosis challenging due to overlapping symptoms with other disorders

Attention Deficit Hyperactivity Disorder (ADHD)

Inability to control behaviors requiring sustained attention

Core Behaviors:

1. Inattention – Difficulty paying attention, listening, focusing

2. Hyperactivity – Fidgeting, inability to sit still, inappropriate running/climbing, difficulty playing quietly, excessive talking

3. Impulsivity – Difficulty waiting turns, frequent interruptions, acting without considering consequences

Risks & Requirements

• Inattentive/impulsive behaviors increase risk of injury

• Diagnosis: symptoms before age 12, present in more than one setting, and causing impairment

• Associated behaviors differ from typical attention patterns in adults/peers

Types

• Predominantly Inattentive – Main symptoms are inattention

• Predominantly Hyperactive-Impulsive – Main symptoms are hyperactivity/impulsivity

• Combined Type – Both inattentive and hyperactive-impulsive symptoms present

Interventions

• Use calm, firm, respectful approach

• Model acceptable behavior

• Gain attention before giving instructions; keep directions short/clear

• Set and consistently enforce behavior limits

• Plan physical activities for energy release and success

• Help parents develop reward systems (e.g., wall charts, tokens) with child involvement

• Focus on strengths, not just problems

• Support parental hopefulness

• Maintain safe environment for all

• Give positive feedback for meeting expectations

• Identify causes of power struggles and address them

• Teach effective coping skills

• Promote group, individual, and family therapy participation

• Administer and monitor medications (antipsychotics, mood stabilizers, anticonvulsants, antidepressants)

Autism Spectrum Disorder (ASD)

Genetic origin; affects communication and social interaction

Common signs: poor eye contact, repetitive actions, strict routines

Onset: early childhood; more common in boys

Possible physical issues: sensory integration dysfunction, sleep disorders, GI problems, seizures, allergies

Functioning ranges from severe impairment to near-normal abilities

Interventions

• Refer for early interventions (physical, occupational, speech therapy)

• Provide structured environment

• Collaborate with parents for consistent, individualized care

• Use short, concise, developmentally appropriate communication

• Identify/reward desired behaviors

• Model social skills and role-play conflict resolution

• Encourage verbal communication

• Replace self-stimulatory behaviors with alternative play

• Identify emotional/situational triggers

• Give advance notice of routine changes

Intellectual Developmental Disorder

Onset: infancy/childhood

Deficits in intellectual functions: reasoning, abstract thinking, learning

Impaired independence and social responsibility (daily living, social participation, school)

Severity: mild to severe

Specific Learning Disorder

Persistent difficulty in reading, writing, or math

Performance below expected level for age/intelligence/education

May require individualized education program (IEP)

Communication Disorders

Problems with language and speech skills

Speech issues: stuttering

Difficulty with conversational skills, worsened by age-related social pressures

Match the following manifestations with the appropriate mental health disorder for children or adolescents.

Conduct disorder

Attention deficit hyperactivity disorder

Disruptive mood dysregulation disorder

Depressive disorder

Oppositional defiant disorder

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Recurrent temper outbursts that are severe and do not correlate with situation. 

Feeling of sadness. 

Limit testing. 

Demonstrates lack of remorse. 

Inability of a person to control behaviors requiring sustained attention.

Recurrent temper outbursts that are severe and do not correlate with situation. 

• Disruptive mood dysregulation disorder

Feeling of sadness. 

• Depressive disorder

Limit testing. 

• Oppositional defiant disorder

Demonstrates lack of remorse. 

• Conduct disorder

Inability of a person to control behaviors requiring sustained attention.

• Attention deficit hyperactivity disorder

A nurse is assessing a 4-year-old child for indications of autism spectrum disorder. For which of the following manifestations should the nurse assess?

a

Impulsive behavior

b

Repetitive counting

c

Destructiveness

d

Somatic problems

b Repetitive counting

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Impulsive behavior is an indication of ADHD rather than autism spectrum disorder.

Destructiveness is an indication of conduct disorder rather than autism spectrum disorder.

Somatic problems are an indication of posttraumatic stress disorder rather than autism spectrum disorder.

A nurse is assisting the guardians of a school-age child who has oppositional defiant disorder in identifying strategies to promote positive behavior. Which of the following strategies should the nurse recommend?

Select all that apply.

a

Allow the child to choose which behaviors are unacceptable.

b

Use role-playing to act out unacceptable behavior.

c

Develop a reward system for acceptable behavior.

d

Encourage the child to participate in school sports.

e

Be consistent when addressing unacceptable behavior.

c Develop a reward system for acceptable behavior.

d Encourage the child to participate in school sports.

e Be consistent when addressing unacceptable behavior.

CNS Stimulants Indications / Contraindications

Purpose

• Expected Pharmacological Action: Increase norepinephrine and dopamine levels in the CNS

Therapeutic Uses

• ADHD in children and adults

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History of substance use disorder, cardiovascular disorders, severe anxiety, psychosis

Teratogenic — avoid during pregnancy

CNS Stimulants Admin / Meds

Administration Guidelines

• Swallow sustained-release tablets whole; do not chew/crush

• Stress regular, consistent dosing schedule (regular or extended-release available)

• Give oral tablets 30–45 min before meals, last dose before 4 p.m.

• Administer oral suspension regardless of meals; shake for 10 seconds before measuring

• For transdermal use: apply patch to one hip daily in the morning, max 9 hours; alternate hips; flush patch after removal

• Full therapeutic response may take up to 6 weeks

• Avoid all OTC meds unless approved by provider

• Avoid alcohol during therapy

Parent/Client Education

• ADHD is not cured by medication; best outcomes occur with combined family and cognitive therapy

• Medications have special handling rules; handwritten prescriptions often required for refills

• Store medications safely to prevent misuse

• Warn of high potential for substance use disorder, especially in adolescents

Nursing Evaluation of Effectiveness

• Look for improved ADHD manifestations:

  • Increased ability to focus and complete tasks

  • Improved peer interactions

  • Decreased hyperactivity and impulsivity

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Prototype Medication

• Methylphenidate

Other Medications

• Amphetamine mixture

• Dextroamphetamine

• Dexmethylphenidate

• Lisdexamfetamine dimesylate

CNS Stimulants Complications / Interactions

CNS Stimulation (insomnia, restlessness)

• Nursing Actions

  • Reduce dosage per provider’s order

  • Give last dose before 4 p.m.

• Client Education

  • Avoid caffeine-containing items (coffee, tea, cola, chocolate)

Weight Loss / Appetite Suppression / Growth Suppression

• Nursing Actions

  • Monitor height/weight vs. baseline

  • Consider medication “holidays” per provider

  • Give medication during or after meals

• Client Education

  • Eat regular meals; avoid unhealthy food choices

Cardiovascular Effects (dysrhythmias, chest pain, hypertension)

• May ↑ risk of sudden death in clients with heart abnormalities

• Nursing Actions

  • Monitor vitals and ECG

  • Teach to report symptoms immediately

Psychotic Manifestations (hallucinations, paranoia)

• Client Education

  • Report immediately; discontinue medication

Withdrawal Reaction (headache, nausea, vomiting, muscle weakness, depression)

• Client Education

  • Avoid abrupt cessation

Hypersensitivity Skin Reaction to Transdermal Methylphenidate (hives, papules)

• Client Education

  • Remove patch and notify provider

Toxicity (dizziness, palpitations, hypertension, hallucinations, seizures)

• Nursing Actions

  • Treat hallucinations: chlorpromazine

  • Treat seizures: diazepam

    • Administer fluids

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MAOIs

• Concurrent use → hypertensive crisis

• Nursing Action: Discontinue MAOIs; wait ≥14 days before starting amphetamines

Caffeine

• Concurrent use → ↑ CNS stimulant effects

• Nursing Action: Avoid caffeine-containing foods/beverages

Phenytoin, Warfarin, Phenobarbital

• Methylphenidate inhibits metabolism → ↑ drug levels

• Nursing Action: Monitor for CNS depression/bleeding; use with caution

OTC Cold & Decongestant Medications

• Concurrent use → ↑ CNS stimulation

• Client Education: Avoid these OTC products

A nurse is caring for a school age child who has conduct disorder and a new prescription for methylphenidate transdermal patches. Which of the following information should the nurse provide about the medication?

a

Apply the patch once daily at bedtime.

b

Place the patch carefully in a trash can after removal.

c

Apply the transdermal patch to the anterior waist area.

d

Remove the patch each day after 9 hr.

d Remove the patch each day after 9 hr.

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The transdermal patch should be applied to a clean, dry area on the hip, and the waist area should be avoided.

For safety when discarding the transdermal preparation, the client should fold the patch and flush it down the toilet to prevent others from using it.

The transdermal patch is applied once daily in the morning.

Selective Norepinephrine Reuptake Inhibitor (SNRI) Indications / Contraindications

Purpose

• Action: Blocks norepinephrine reuptake at CNS synapses (non-stimulant)

• Use: ADHD in children and adults

• Generally well tolerated with minimal side effects

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Contraindications / Precautions — Atomoxetine

• Use cautiously in cardiovascular disorders

• Contraindicated in suicidal ideation

• Contraindicated in angle-closure glaucoma or pheochromocytoma (adrenal tumor → epinephrine/norepinephrine overproduction)

Selective Norepinephrine Reuptake Inhibitor (SNRI) Complications / Interactions

Appetite/Growth Suppression, Weight Loss

• Nursing Actions: Monitor height/weight; give with or after meals

• Education: Encourage regular meals and healthy food choices

GI Effects (nausea, vomiting, abdominal pain)

• Education: Take with food if GI upset occurs

Suicidal Ideation (children/adolescents)

• Nursing Actions: Monitor for depression signs

• Education: Report mood changes, excessive sleeping, agitation, irritability

Hepatotoxicity

• Education: Report flu-like symptoms, jaundice, abdominal pain

CNS Effects (headache, insomnia, irritability)

• Nursing Actions: Lower dose if prescribed; last dose before 4 p.m.

• Education: Monitor for symptoms; avoid caffeine-containing products

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MAOIs

• Risk: hypertensive crisis

• Education: Stop MAOIs ≥14 days before starting atomoxetine

Paroxetine (SSRI), Fluoxetine (SSRI), Quinidine Gluconate (Antiarythmatic)

• Inhibit metabolism → ↑ atomoxetine levels

• Nursing Action: May need to reduce atomoxetine dose

• Education: Monitor/report increased adverse effects

Selective Norepinephrine Reuptake Inhibitor (SNRI) Admin / meds

Nursing Administration

• Monitor for changes related to dose/timing

• Administer once daily (morning) or split into two doses (morning + afternoon), with or without food

Client Education

• Initial effects in days; full therapeutic effect in up to 6 weeks

• Avoid alcohol

• Avoid OTC meds unless approved

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Prototype Medication

• Atomoxetine

Other Medication

• Bupropion

Tricyclic Antidepressants (TCAs) Indications / Contraindications

Purpose

• Expected Pharmacological Action: Block reuptake of norepinephrine and serotonin in the synaptic space, increasing their effects

Therapeutic Uses in Children

• Depression

• Autism spectrum disorder

• ADHD

• Panic disorder, separation anxiety disorder

• Social phobia

• Obsessive-compulsive disorder (OCD)

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Teratogenic

Contraindicated: recent MI, heart failure, prolonged QT

Use cautiously in seizure disorders, CAD, diabetes, liver/kidney/respiratory disease, urinary retention, angle-closure glaucoma, BPH, hyperthyroidism

↑ suicide risk; lethal in overdose

Tricyclic Antidepressants (TCAs) Complications / Interactions

Orthostatic Hypotension

Anticholinergic Effects (dry mouth, blurred vision, photophobia, urinary retention, constipation, tachycardia)

• Client Education:

  • Chew sugarless gum

  • Sip water regularly

  • Wear sunglasses outdoors

  • Eat high-fiber foods

  • Increase fluid intake to 2–3 L/day

  • Void before taking medication

  • Report intolerable effects

Weight Gain (↑ appetite)

• Nursing Action: Monitor weight

Sedation

• Client Education:

  • Effects usually decrease over time

  • Avoid hazardous activities if excessive sedation occurs

  • Take at bedtime to reduce daytime drowsiness and improve sleep

Toxicity

• Manifestations: Cholinergic blockade + cardiac toxicity (dysrhythmias, confusion, agitation → seizures, coma, death)

• Nursing Actions:

  • Dispense only 1-week supply for acutely ill clients

  • Obtain baseline ECG

  • Monitor vitals and signs of toxicity; notify provider

Decreased Seizure Threshold

Excessive Sweating

• Client Education: Monitor and perform frequent linen changes

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MAOIs → severe hypertension; wait ≥14 days after stopping MAOIs before starting TCAs

Antihistamines / Other Anticholinergic Agents → additive effects; avoid concurrent use

Epinephrine / Dopamine → hypertensive crisis risk; avoid concurrent use

Alcohol, Benzodiazepines, Opioids, Antihistamines → additive CNS depression; avoid while on TCAs

Tricyclic Antidepressants (TCAs) Admin / Meds

Instruct parents to administer daily as prescribed to maintain therapeutic plasma levels

Emphasize adherence; initial effects in 1–3 weeks, full effects in ~6 weeks

Stress importance of continuing therapy after improvement to prevent relapse

Give at bedtime to reduce daytime drowsiness

Due to suicide risk: give only 1-week supply to acutely ill clients, then 1-month supply thereafter

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Prototype Medication

• Desipramine

Other Medications

• Imipramine

• Clomipramine

Nursing Evaluation of Effectiveness (TCAs)

For Depression

• Reports improved mood

• Better sleep and eating patterns

• Increased peer interaction

For Autism Spectrum Disorder

• Reduced anger

• Less compulsive behavior

For ADHD

• Reduced hyperactivity

• Improved attention span

For OCD, Panic, Anxiety Disorders

• Lower anxiety levels

• Better recognition of symptoms/triggers

• Improved management of episodes

• Enhanced self-care ability

• Increased peer interaction

• Able to resume normal roles

Nursing Evaluation of Effectiveness (SSRIs)

For intermittent explosive disorder:

• ↓ Hyperactivity

• Improved mood

For conduct disorder:

• ↓ Aggressiveness

Nursing Evaluation of Effectiveness (Atypical Antipsychotics)

Autism Spectrum Disorder

• ↓ Hyperactivity

• Improved mood

Conduct Disorder

• ↓ Aggressiveness

OCD

• ↓ Anxiety

• Better control of compulsive actions

• Improved self-care

• ↑ Social interaction

• Able to assume usual role

ADHD

• ↓ Hyperactivity & impulsivity

Alpha-Adrenergic Agonists Indications / Contraindications

Pharmacological Action: Activates presynaptic alpha₂-adrenergic receptors in the brain (exact mechanism not fully understood)

Therapeutic Uses: ADHD, tic disorders, conduct/oppositional defiant disorders

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Not established for use in children < 6 years old

Use cautiously in clients with cardiac disease

Alpha-Adrenergic Agonists Complications / Interactions

CNS Effects (Sedation, Drowsiness, Fatigue)

• Nursing: Monitor and report

• Education: Avoid hazardous activities

Cardiovascular Effects (Hypotension, Bradycardia)

• Nursing: Monitor BP and pulse, especially early in treatment

• Education: Do not abruptly stop — may cause rebound hypertension

Weight Gain

• Nursing: Monitor weight, encourage exercise and healthy diet

GI Effects (Nausea, Vomiting, Constipation, Dry Mouth)

• Nursing: Monitor and report

• Prevention Strategies:

  • Chew sugarless gum

  • Sip water

  • Eat high-fiber foods

  • Engage in regular exercise

  • Increase fluid intake to 2–3 L/day

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CNS Depressants (Including Alcohol)

• ↑ CNS effects

• Nursing: Avoid concurrent use

Antihypertensives

• ↑ Hypotension risk

• Nursing: Avoid concurrent use

High-Fat Meals

• ↑ Guanfacine absorption

• Nursing: Avoid taking with high-fat meals

Alpha-Adrenergic Agonists Administration / Meds

Assess alcohol and CNS depressant use (especially adolescents)

Monitor BP and pulse at baseline, initial treatment, and dosage changes

Avoid abrupt discontinuation → risk of rebound hypertension; taper per prescribed schedule

Do not chew, crush, or split extended-release tablets

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Guanfacine, Clonidine

Atypical Antipsychotics Complications / Interactions

1. Diabetes Mellitus

• Risk: New onset or loss of glucose control in clients with diabetes

• Nursing actions:

  • Obtain baseline fasting blood glucose, monitor periodically

  • Instruct client to report signs (increased thirst, urination, appetite)

2. Weight Gain

• Client education:

  • Follow healthy, low-calorie diet

  • Engage in regular exercise

  • Monitor weight

3. Hypercholesterolemia

• Risk: Higher chance of hypertension & cardiovascular disease

• Nursing actions: Monitor cholesterol, triglycerides, and blood glucose if weight gain > 14 kg (30 lb)

4. Orthostatic Hypotension

• Nursing actions: Monitor BP with first dose; instruct slow position changes

5. Anticholinergic Effects (urinary retention/hesitancy, dry mouth)

• Nursing actions: Monitor and report occurrence

• Client education: Relieve dry mouth (sip fluids throughout the day)

6. Agitation, Dizziness, Sedation, Sleep Disruption

• Nursing actions: Monitor; change medication if prescribed

7. Mild Extrapyramidal Symptoms (EPS) — tremor

• Nursing actions: Monitor and teach clients to recognize EPS; usually dose-related

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1. CNS Depressants (alcohol, opioids, antihistamines)

• Effect: Additive CNS depression

• Client education:

  • Avoid alcohol and other CNS depressants

  • Avoid hazardous activities (e.g., driving)

2. Levodopa

• Effect: Activates dopamine receptors, counteracting antipsychotic effects

• Nursing actions: Avoid concurrent use with levodopa or other dopamine receptor agonists

3. TCAs, Amiodarone, Clarithromycin

• Effect: Prolong QT interval → ↑ risk of cardiac dysrhythmias

• Nursing actions: Avoid concurrent use

4. Barbiturates & Phenytoin

• Effect: Promote hepatic drug metabolism → ↓ drug levels of quetiapine

• Nursing actions: Monitor for effectiveness

5. Fluconazole & other CYP3A4 inhibitors

• Effect: Inhibit metabolism → ↑ drug levels of aripiprazole and quetiapine

• Nursing actions: Monitor for adverse effects

Atypical Antipsychotics Administration / Meds

Administer orally or via IM route.

• Risperidone: Oral solution & quick-dissolving tablets for easier administration.

• Olanzapine: Orally disintegrating tablets.

• Quetiapine: Immediate-release tablets for adolescents.

• Aripiprazole: Tablets, orally disintegrating tablets, or oral solution for adolescents.

May be taken with or without food.

Client education:

• Begin with low doses, gradually increasing.

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Prototype Medication: Risperidone
Other Medications: Olanzapine, Aripiprazole, Quetiapine

Atypical Antipsychotics Indications/Contraindications

Expected Pharmacological Action

• Primarily block serotonin receptors

• To a lesser extent, block dopamine receptors

• Also block receptors for norepinephrine, histamine, and acetylcholine

Therapeutic Uses

• Autism spectrum disorder

• Conduct disorder

• Obsessive-compulsive disorder (OCD)

• Relief of psychotic manifestations

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Avoid alcohol use in adolescents

Use cautiously with cardiovascular disease, seizures, or diabetes

Clients with diabetes require baseline fasting glucose & ongoing monitoring

Selective Serotonin Reuptake Inhibitors (SSRIs) Indications/Contraindications

Expected Pharmacological Action

• Blocks the synaptic reuptake of serotonin, increasing serotonin levels at the neuron junction.

Therapeutic Uses

• Intermittent explosive disorder

• Autism spectrum disorder

• Obsessive-compulsive disorder (OCD)

• Major depressive disorder

• Bulimia nervosa

• Generalized anxiety disorder (GAD)

---

May increase suicidal ideation in children/adolescents.

Abrupt withdrawal can cause discontinuation syndrome (dizziness, insomnia, nervousness, irritability, agitation). Must taper dose.

Selective Serotonin Reuptake Inhibitors (SSRIs) Complications / Interactions

Agitation, anxiety, sleep disturbance, tremors, tension headache

• Nursing actions: Monitor for these adverse effects; agitation & hallucinations may indicate serotonin syndrome.

Weight changes

• Client education:

  • Weigh weekly & report significant changes to provider.

  • Maintain a healthy diet.

GI effects (nausea, constipation, diarrhea, dry mouth)

• Nursing actions: Monitor & report adverse effects.

• Client education:

  • Relieve dry mouth with frequent sips of fluids or sugarless gum.

  • Take with food to reduce GI upset.

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Concurrent use with MAOIs, SNRIs, buspirone, or St. John’s wort → Risk of serotonin syndrome.

• Client education:

  • Avoid concurrent use.

  • Allow 2 weeks between fluoxetine and MAOI use.

Selective Serotonin Reuptake Inhibitors (SSRIs) Administration / Meds

Take sustained-release tablets whole, not chewed/crushed.

Explain that initial response occurs 1–3 weeks, maximum effect by 12 weeks.

Can be taken with or without food.

Morning administration minimizes sleep disturbances.

Take daily to maintain therapeutic plasma levels.

Do not abruptly discontinue.

Report suicidal thoughts immediately.

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Select Prototype Medication

• Fluoxetine

• Sertraline

• Fluvoxamine

Major Neurotransmitters: Similarities & Differences (Table)

Key Similarities

• Mood regulation: Serotonin, norepinephrine, dopamine all play roles in depression/anxiety.

• Overlap in drug targets:

  • SSRIs → serotonin

  • SNRIs → serotonin + norepinephrine

  • Stimulants → dopamine + norepinephrine

• Interconnected systems: Dopamine–serotonin balance influences mood/psychosis; dopamine–norepinephrine overlap affects attention/reward.

Key Differences

• Serotonin → more about mood, sleep, appetite.

• Norepinephrine → alertness, stress, “fight-or-flight.”

• Dopamine → reward/pleasure, movement, psychosis.

• Acetylcholine → memory, learning, parasympathetic.

• GABA → inhibitory “brake” on the brain.

Child & Adolescent Psych Medications (Table)

CNS Stimulants (Methylphenidate, Amphetamines)

• Gold standard for ADHD treatment (especially in children).

• Hallmark adverse effect: appetite suppression → weight loss & growth suppression.

• Buzzwords: “Give before meals, last dose before 4 PM, monitor height/weight.”

SNRIs (Atomoxetine, Bupropion)

• Gold standard non-stimulant for ADHD (preferred if substance use disorder or stimulant intolerance).

  • No dopamine “rush” like in CNS stimulants

• Hallmark risk: suicidal ideation in adolescents; hepatotoxicity.

• Buzzwords: “Takes weeks for full effect, not a controlled substance.”

Tricyclic Antidepressants (Desipramine, Imipramine, Clomipramine)

• Second-line/older agents used when SSRIs aren’t effective.

• Hallmark toxicity: cardiac dysrhythmias & seizures in overdose → limit supply to 1 week.

• Buzzwords: “Anticholinergic side effects + lethal overdose risk.”

Alpha₂-Adrenergic Agonists (Guanfacine, Clonidine)

• Alternative for ADHD (esp. if insomnia, tics, or aggression are present).

• Hallmark adverse effect: sedation & hypotension, rebound hypertension if abruptly stopped.

• Buzzwords: “Taper slowly, monitor BP/HR, watch for drowsiness.”

Atypical Antipsychotics (Risperidone, Aripiprazole, Quetiapine, Olanzapine)

• Gold standard for severe irritability & aggression in autism spectrum disorder.

• Hallmark risk: metabolic syndrome (weight gain, diabetes, hyperlipidemia).

• Buzzwords: “Monitor weight, glucose, cholesterol; risk of mild EPS (tremor).”

SSRIs (Fluoxetine, Sertraline, Fluvoxamine)

• Gold standard for pediatric depression & anxiety disorders.

• Hallmark adverse effect: serotonin syndrome (if combined with MAOI/SNRI/St. John’s wort) + suicidal ideation in youth.

• Buzzwords: “Takes 1–3 weeks to start working, full effect at 12 weeks; taper slowly to avoid withdrawal.”

A nurse is providing teaching to an adolescent client who is to begin taking atomoxetine for ADHD. The nurse should instruct the client to monitor for which of the following adverse effects?

Select all that apply.

a

Somnolence

b

Yellowing skin

c

Increased appetite

d

Fever

e

Malaise

b Yellowing skin

d Fever

e Malaise

All are a potential indication of hepatotoxicity that the client should report to the provide

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Insomnia, rather than somnolence, is an adverse effect that the client should report to the provider.

Insomnia vs Somnolence

Difficulty falling asleep, staying asleep, or experiencing non-restorative sleep

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Excessive sleepiness during the day, even after adequate nighttime sleep.