Chapter 22: Mental Health Issues of Children and Adolescents (Week 7)

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 Action / Use

Increase norepinephrine and dopamine levels in the CNS

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ADHD in children and adults

CNS Stimulants Admin / Interactions

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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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

CNS Stimulants Complications: ANOREXIC Bane injects TOXIC PSYCHOTIC drugs to WITHDRAW his SKIN ALLERGIES but it STIMULATES his CNS and BAD HEART (chest pain, HTN, dysrhythmias)

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

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

• Nursing Actions

  • Treat hallucinations: chlorpromazine

  • Treat seizures: diazepam

    • Administer fluids

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

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)

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

CNS Stimulants Complications: ANOREXIC Bane injects TOXIC PSYCHOTIC drugs to WITHDRAW his SKIN ALLERGIES but it STIMULATES his CNS and BAD HEART (chest pain, HTN, dysrhythmias) / Contraindications

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

Teratogenic — avoid during pregnancy

CNS Stimulants Meds: With ADHD, I DATE at the AMPHitheater for less STIMULATION (CNS)

Prototype Medication

• Methylphenidate

Other Medications

• Amphetamine mixture

• Dextroamphetamine

• Dexmethylphenidate

• Lisdexamfetamine dimesylate

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.

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) (-loxetine, -faxine) Contraindications / Complications AN ANOREXIC SEXUAL HANDSy SNaps depression and HYPERTENSION like a DIURETIC

Pregnancy Risk: Category C.

Contraindicated with MAOIs.

Duloxetine contraindicated in hepatic disease or heavy alcohol use.

Client Education

• Avoid abrupt discontinuation.

• Avoid alcohol.

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Anxiety

Anorexia / Weight loss

Sexual dysfunction

Headache, nausea, agitation, dry mouth, sleep disturbances

Hypertension

Hyponatremia (esp. older adults on diuretics)

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) (-loxetine, -faxine) Interactions / Admin

MAOIs & St. John’s Wort → risk of serotonin syndrome.

• Nursing Action: Discontinue MAOIs 14 days before starting SNRI.

• Client Education: Avoid St. John’s Wort.

CNS Depressants (alcohol, opioids, antihistamines, sedatives/hypnotics) → ↑ CNS depression.

• Nursing Action: Avoid concurrent use.

NSAIDs & Anticoagulants → ↑ risk of bleeding.

• Client Education: Monitor for bleeding (bruising, hematuria), notify provider.

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Duloxetine contraindicated in hepatic disease or heavy alcohol use.

Client Education:

• Avoid abrupt cessation.

• May take with food.

• Take daily to maintain therapeutic plasma levels.

• Takes up to 4 weeks for therapeutic effect.

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) Meds: SportsNet (SN)’s DULO smart wear sponsored BJJ champ VENLA luukkonen.

Prototype Medication

• Venlafaxine

Other Medication

• Duloxetine

Tricyclic Antidepressants (TCAs) (Amitriptyline/Nortriptyline) Contraindications / Complications (Trilogy - O DO AS SW)

Children under 12

Recent heart attack

Cardiac dysrhythmias

Seizure disorders

Concurrent MAOI use

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Overdose risk (life-threatening dysrhythmias)

Drowsiness, sedation

Orthostatic hypotension

Anticholinergic effects (dry mouth, constipation, blurred vision)

Seizure disorders contraindication/increase

Suicide risk increase (especially in children, adolescents)

Withdrawal symptoms (anxiety, headache, nausea)

Tricyclic Antidepressants (TCAs) Meds: the IPRA MINES bitcoin and DOXs PINs for AMOXAPINE and TRICYCLES on TRIPLINES

Imipramine

Trimipramine

Doxepin

Amoxapine

Amitriptyline

Nortriptyline

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 2 Adrenergic Agonists Action / Use Indications / Contraindications

Activates presynaptic receptors in the brain

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ADHD, tic disorders, conduct/oppositional defiant disorders

Alpha 2 Adrenergic Agonists Complications / Contraindications

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

---

Not established for use in children < 6 years old

Use cautiously in clients with cardiac disease

Alpha 2 Adrenergic Agonists Interactions / Administration

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

---

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

Alpha 2 Adrenergic Agonists Meds: ALPHA wizards CLONe 2 fireballs with extra bat GUANo

Guanfacine

Clonidine

Antipsychotics: Second- and Third-Generation (Atypical) (-apine, idone, -ipra-) Action / Use

Second-gen: Block serotonin (main) and dopamine (lesser degree) receptors

Third-gen: Stabilize dopamine system as agonist + antagonist (partial agonist)

Both block norepinephrine, histamine, acetylcholine receptors

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Treat positive & negative symptoms of schizophrenia spectrum disorders

Psychosis induced by levodopa therapy

Relief of psychotic manifestations in other disorders (e.g., bipolar disorder)

Impulse control disorders

Antipsychotics: Second- and Third-Generation (Atypical) (-apine, idone, -ipra-) Complications (AMASS DOPES) / Contradindications

Agranulocytosis

• Nursing actions: Monitor for infection (CBC, discontinue if WBC < 3,000/mm³)

Anticholinergic Effects

• Dry mouth, blurred vision, photophobia, urinary hesitancy/retention, constipation, tachycardia

Orthostatic Hypotension

Metabolic Syndrome

• New onset diabetes or loss of glucose control

• Dyslipidemia → ↑ risk for cardiovascular disease

• Weight gain

Agitation, Dizziness, Sedation, Sleep Disruption

Mild EPS (e.g., Tremor) - Use AIMS test

Elevated Prolactin Levels

• Client education: Report galactorrhea, gynecomastia, amenorrhea

Sexual Dysfunction

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Risperidone

• Dementia (↑ risk of cerebrovascular accident, infection, death)

• Avoid alcohol

• Use cautiously with cardiovascular/cerebrovascular disease, seizures, or diabetes (monitor glucose carefully)

Antipsychotics: Second- and Third-Generation (Atypical) (-apine, idone, -ipra-) Interactions / Admin

Immunosuppressants (anticancer meds) – further suppress immune function

• Nursing actions: Avoid with clozapine

Alcohol, opioids, antihistamines, CNS depressants – additive CNS depression

• Client education: Avoid alcohol, CNS depressants, driving/hazardous activity

Levodopa & dopamine agonists – counteract antipsychotics

• Nursing actions: Avoid concurrent use

Tricyclic antidepressants, amiodarone, clarithromycin – prolong QT interval → ↑ dysrhythmia risk

• Nursing actions: Avoid combining with other QT-prolonging agents

Barbiturates & phenytoin – ↓ levels of aripiprazole, quetiapine, ziprasidone

• Nursing actions: Monitor effectiveness

Fluconazole – ↑ levels of aripiprazole, quetiapine, ziprasidone

• Nursing actions: Monitor effectiveness

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Depot/long-acting injections:

• Risperidone: IM every 2 weeks

• Paliperidone ER injection: every 28 days

• Invega Trinza (paliperidone palmitate, generic): every 3 months

• Aripiprazole LAI: monthly

• Therapeutic effect: 2–6 weeks after first depot dose

Use orally disintegrating tablets if client might “cheek” or has difficulty swallowing

Administer lurasidone and ziprasidone with food for absorption

Monitor cost barriers → may require case management support

Client Education

• Start with low dose, titrate gradually (“Start low and go slow”)

• Take consistently as prescribed

• If taking asenapine → avoid eating/drinking ×10 min after dose

Antipsychotics: Second- and Third-Generation (Atypical) Meds: I’m DONE tying 3 IPRA bulls to A PINE tree like a PSYCHO.

Prototype

• Risperidone

Other Medications

• Second-generation: Asenapine, Clozapine, Iloperidone, Lurasidone, Olanzapine, Paliperidone, Quetiapine, Ziprasidone

• Third-generation: Aripiprazole, Cariprazine, Brexpiprazole

Selective Serotonin Reuptake Inhibitors (SSRIs) Complications: EA TeNDS to LATEly GIB SW (HA)ters BRUtal depreSSion WITHout SALTINESS

Early Adverse

• Tremors, Nausea, Diaphoresis, Sleepiness

Late Adverse

• GI Bleeding, Sexual Dysfunction, Weight Gain, Headache

Serotonin Syndrome

Withdrawals

Hyponatremia (Without Saltiness)

Selective Serotonin Reuptake Inhibitors (SSRIs) (-xetine, -pram) Interactions / Admin

TCAs, MAOIs, St. John’s Wort → ↑ risk of serotonin syndrome.

• Discontinue MAOIs 14 days before starting SSRI.

• Discontinue fluoxetine 5 weeks before starting MAOI.

• Avoid concurrent TCA/St. John’s Wort use.

Warfarin → displacement → ↑ bleeding risk.

• Nursing Actions: Monitor PT/INR, assess for bleeding, dosage adjustment may be needed.

TCAs + Lithium → ↑ levels of both.

• Client Education: Avoid concurrent use.

NSAIDs + Anticoagulants → ↑ bleeding risk (platelet suppression).

• Client Education: Monitor for bleeding (bruising, hematuria), notify provider.

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Take with food to minimize GI upset.

Take in morning to reduce sleep disturbances.

Daily dosing required to establish plasma levels.

May take up to 4 weeks to achieve therapeutic effects.

Selective Serotonin Reuptake Inhibitors (SSRIs) Meds: DepreSSed moms need a SERT (special emergency reaction team) and PRAMS (pregnancy risk assessment monitoring system) for PAROXysmal FLU symptoms

Prototype Medication

• Paroxetine

Other Medications

• Sertraline

• Citalopram

• Escitalopram

• Fluoxetine

• 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.

Meds for ADHD

CNS Stimulants (stimulant gold standard)

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

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

SNRIs (stimulant intolerance or substance use disorder gold standard, no dopamine rush)

• Hallmark risk: suicidal ideation in adolescents; hepatotoxicity.

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

A2-Adrenergic Agonists (insomnia, tics, aggression)

• 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.”

Meds for Autism

2nd-3rd Gen (Atypical) Antipsychotics (severe irritability and aggression)

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

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

Meds for Depression/Anxiety (Children/Adolescent)

SSRIs (1st Line)

• 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.”

TCAs (2nd Line)

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

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

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

---

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

---

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

Concurrent use → ↑ effects

• OTC Cold & Decongestant Medications

• Caffeine/Sugar

Inhibits drug metabolism → ↑ drug levels

• Phenytoin, Warfarin, Phenobarbital

Hypertensive Crisis

• MAOI

---

Patch: Max 9 hours; rotate site.

• Must be flushed in the toilet and watched by two nurses

Pill: Latest can be given 4 PM

• Give on empty stomach (before breakfast/cafeteria to focus on eating)

CNS Stimulants

Nature: Neurodevelopmental; genetic.

Delays: Language and cognition.

Characteristics: Poor eye contact; repetitive actions (e.g., fidget spinners); strong preference for routine (near-OCD).

Also assess: Physical difficulties; risks; range of functioning.

• Risk of seizures (typically prescribed antiepileptic mood stabilizers)

High Functioning: Can do ADLs

Autism Spectrum Disorder

Deficits: Reasoning, abstract thinking, academic learning, learning from prior experience.

Function: Cannot maintain personal independence; poor ADLs; needs school support.

Intellectual Development Disorder

Difficulties: Reading, writing, math.

Performance: Well below age/intelligence/education level.

IEP: Interprofessional education/collab noted (supplemental resources)

• Extra reading classes 

• ASL

Specific Learning Disorder

Inattention: Difficulty paying attention, listening, focusing (poor grades)

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

Impulsivity: Difficulty waiting turns, frequent interruptions, acting without considering consequences

High risk of:

• Injury

ADHD

Domains: Aggression to people/animals; property destruction; deceit/theft; serious rule violations.

Epidemiology:

• Common: Males before 10

• After 10? Male/Females are 50/50

Functional impact: Criminal record; school problems.

Additional notes: Bullying/threats; believes aggression is justified; SI; runs away from home.

Conduct Disorder - Worsens at playground

Pattern: Recurrent violent/aggressive behavior; can hurt others/animals; property destruction

Demographics: Males vs females; age trends; more in younger vs older?

• Most common ages 13–21

• More common in males

Cycle: Aggressive overreaction to a trigger (not random), followed by:

• Shame/regret

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

Intermittent Explosive Disorder (IED)

Pattern: Frequent, severe anger outbursts (physical or verbal) not correlated to situation (random); age-inappropriate.

Age range: 6–18.

Disruptive Mood Dysregulation Disorder (DMDD)

Characteristics: Negative attitude, disobedience, hostility, defiant behavior, argumentative, limit-testing, refusal to accept responsibility.

Toward whom is defiance directed?

• At person best known; usually at home

Insight: Do they see themselves as defiant?

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

Frustration threshold: Typically low.

Potential progression: What can this lead to?

• Conduct disorder (worsens at playground)

Oppositional Defiant Disorder (ODD)  - Worsens in class

Impulse-Control Disorders Mnemonics

ODD future was STUBBORN and REBELLIOUS and parents feared the music would lead to misCONDUCT in the ALL GENDERS (10+)

RANDOM DMs from AI girls DID DESTROY my childhood (6-18)

he TRIGGERED BOMBS (IEDs) in ADOLESCENT communities without SHAME/REGRET

ODD future was STUBBORN and REBELLIOUS and parents feared the music would lead to misCONDUCT in the ALL GENDERS (10+)

Oppositional Defiant Disorder (ODD) is characterized by negative attitudes toward best known can lead to Conduct Disorder and actual damages, with an even male-female split after age 10.

RANDOM DMs from AI girls DID DESTROY my childhood (6-18)

Disruptive Mood Dysregulation Disorder (DMDD) is characterized by random age-appropriate outbursts from ages 6-18

he TRIGGERED BOMBS (IEDs) in ADOLESCENT communities without SHAME/REGRET

Intermittent Explosive Disorder (IED) is characterized by overreactions to triggers followed by shame/regret during the adolescent phase (13-21).