Mental Health & Cognitive Disorders in Children

risk factors for mental health issues

Biologic or genetic characteristics, Nutrition, Physical Health, Developmental ability, Environmental and family interactions, Child’s individual temperament, Parents & Care-givers responses to child’s behavior

Adverse Childhood Experiences (ACES)

Traumatic experiences that occur before age 18 and are remembered into adulthood. (abuse, neglect, seeing domestic violence)

ACES These kids are at RISK for

Alcohol abuse, Depression, Suicide attempts, Ischemic heart disease, Early initiation of smoking, Early initiation of sexual activity, Teen pregnancy, Poor academic performance

PROTECTION against MENTAL ILLNESS

Academic achievement, High self-esteem, Emotional self-regulation, Good coping skills and problem-solving skills, Engagement and connections in school or with peers, Supportive family members, Presence of mentors

What is the NURSE’S responsibility ACES

Awareness/Assessment, Screening, Anticipatory guidance, Trauma Informed Care

NURSE’S responsibility Practice with principles of

safety, Peer support, Voice and choice, Trustworthiness, Transparency, Collaboration, Empowerment

ACE Health History

PMH – Birth and prenatal, (stress, high cortisol, decreased neurodevelopment), family history, Developmental milestone delays, changes in family structure

ACE Behavior Changes

regression, increase or decrease sleeping and eating, school performance, trisk taking, changes in friendships, less interest in activities.

Tools for the Nurse SCREENING

CRAFFT use of alcohol & substance use. Patient Health Questionnaire-2 item screen (PHQ-2) Depression, HEEADSSS Home, Education, Drugs, Sexuality, Suicide, Safety, Poverty Screening (WE CARE) survey, ASK Suicide Screening Questions

How do we talk to the PARENTS about ACES

Mood disorders are biologic conditions NOT personality flaws. Psychiatric medication administration & adverse effects. Encouragement and praise to parents,Support throughout the lengthy process Refer the family to local support resources. Coping strategies (for parents – grounding, open comminication with child, support groups)

The most common pediatric Mood Disorders… Depression s/s

Change in mood. Loss of interest in activities once enjoyed, Significant change in appetite or weight, Difficulty sleeping or oversleeping, Physical agitation or slowing, Fatigue or loss of energy, Feelings of worthlessness or guilt (unique somatic symptoms)

Depression Pharmacological Treatment

Delayed therapeutic effect once initiated. Close dosage monitoring/adjusting due to rapid growth! All psychiatric medications have a black box warning for suicide in the pediatric population.

SSRIs SE

Lower BP, insomnia, N/V, decreased appetite, Serotonin Syndrome (High BP, Temp, HR)

SSRIs

Fluoxetine, Sertraline, Escitalopram

Anxiety s/s

Lasts > 4 weeks. Struggles with social and academic relationships. Separation, Generalized, Panic disorders, PTSD, Obsessive Compulsive disorder. Recurrent Irrational Persistent, Excessive worrying

Atypical somatic complaints for anxiety and depression in children

headache, stomach aches, or nightmares.

Anorexia Nervosa Who’s at risk?

Body image distortion, social media, school age and adolescents

Anorexia precautions

Nutritional guidelines, No bathroom for 30 minutes after eating, Daily weight, Sitter present for 1:1 supervision, No caloric labels on foods.

Anorexia Nervosa Complications

Fluid electrolyte imbalance, Decreased blood volume, Cardiac arrhythmias, Esophagitis, Rupture of the esophagus or stomach, Tooth loss , Menstrual problems, Mortality rate as high as 18%

Anorexia Nervosa Complications Fluid electrolyte imbalance

Hypokalemia , Hyper or Hypo natremia, Hypomagnesemia, hypophosphatemia

Hypokalemia s/s

constipation, N/V, fatigue, arrhythmias, weak twitching muscles, Rhabdo, Nephropathy, polyuria, polydipsia

Hyper or Hypo natremia

concentration from dehydration, neuro effects, HA, confusion

Hypomagnesemia

Nystagmus, seizures, confusion

Hypophosphatemia

osteopenia, Rhabdo, edema, seizures,

Suicide Who’s at risk?

Mental health changes, Vocalizing thoughts of suicide or “I hate myself”, Wanting to give clothing or belongings away, Depression or other mental illness, Family history , Poor school performance, Prior attempt, Substance abuse, LGBTQ, Isolation/ having no friends, Change in behavior, Incarceration

Suicide The Care Plan

Monitor for verbal & non-verbal cues, It is essential to ask directly if they are thinking of suicide . Build rapport, Suicidal comments usually made to someone perceived as supportive, Determine the suicide plan

Therapies for Mood Disorders Older

Behavioral therapy, Cognitive behavioral therapy, Group therapy, Individual therapy

Therapies for Mood Disorders younger

Play therapy, Family therapy

Cognitive Disorders usally discoveres

around age 5

Autism

A Neural developmental disorder A spectrum that ranges from mild to severe. Discovered around age 3,

Cause of autism

Genetic makeup, Chemical and Physical changes in the brain, In utero Virus or Toxin exposure

How Autism is diagnosed?

Checklist for Autism in Toddlers (CHAT) Ages and Stages Questionnaire, Modified Checklist for Autism in Toddlers (M-CHAT), Social Communication Questionnaire (SCQ), Pervasive Developmental Disorders Screening Test-II (PDDST-II), Screening Tool for Autism in Toddlers and Young Children (STAT), ARI Diagnostic Checklist

Autism Diagnostic Barriers

Expenstive (screening free), takes up to 4m to 1 year to diagnosis

The steps for initiating screening

Start with the parents! (monitor for delays in development and report) The Primary Care Provider - Routine Developmental screening, Pediatrician (ASD specific screening), Specialist (Developmental hx and neurological assessments), Early intervention -support services.

Routine Developmental screening is done at

9 months, 18 months, and 30 months.

ASD specific screening done at

18 months and 24 months

The RED Flags for Autism Language/Communication

Speech delay &/or loss, No babbling by No pointing or gestures by 12 mo. No single words by 16 mo. No 2-word utterances by 24 mo. Delayed developmental milestones.

Nursing Care Plan Autism?

STRUCTURE & CONSISTENCY, In the hospital - Private room, Decreased stimulation, Parent to stay with child, Consistent Nursing Staff

ADHD Signs

Inattentive, Impulsive , Distracted, Hyperactive

At Risk for ADHD

Disruption in learning ability, socialization and compliance Comorbidities are common ( Oppositional Defiant Disorder, Anxiety, Depression, Learning disability.

ADHD What’s happening in the brain?

Differences in the volume of grey and white matter. Differences in brain region activation during various tasks. Neurotransmitter imbalances = Decreased attention span, Poor self-regulation , Poor impulse control

Types of ADHD Predominantly Inattentive Presentation

Easily distracted, Doesn’t follow through, Difficulty organizing tasks

Types of ADHD Predominantly Hyperactive-Impulsive Presentation

Fidgets or squirms, Can’t stay seated, Blurts out answers

Types of ADHD Combined Presentation

Inattention and hyperactivity, Symptoms of both types

ADHD Management

Behavioral interventions (Non-pharmacological first), Set limits and hold child responsible for behavior. Do not argue, bargain, or negotiate about the limits set. Provide consistent caregivers and establish a daily routine. Use a low-pitched voice and remain calm. Redirect the child’s attention when needed. Ignore inappropriate behaviors. Praise the child’s self-control efforts. ,Use restraints only when necessary.

ADHD- Stimulants

Methylphenidate (Ritalin), Dextroamphetamine (Adderall), Guanfacine (Tenex, Intuniv)

Psycho-stimulant medications

can increase neurotransmitter availability and focus.

Methylphenidate (Ritalin) MOA

ADHD- Stimulant Increases synaptic levels of dopamine and norepinephrine

Methylphenidate (Ritalin)

Child should be 5 Monitor for weight loss, Give in AM with or after breakfast / side effect is difficulty sleeping

Dextroamphetamine (Adderall)

Monitor for weight loss Give in AM with or after breakfast/ side effect is difficulty sleeping

Guanfacine (Tenex, Intuniv) MOA

Centrally acting alpha 2 adrenergic receptor agonist. Can also treat high BP

Guanfacine (Tenex, Intuniv

Child should be at least 6. Side effects could include drowsiness & dizziness

FETAL ALCOHOL SYNDROME

Results from in utero alcohol exposure, Poor coordination, skeletal abnormalities, Microcephaly, Failure to thrive, Hearing loss

FETAL ALCOHOL SYNDROME Typical facial features

low nasal bridge with short upturned nose, flattened midface, long philtrum with narrow upper lip

Down Syndrome

Genetic disorder (Trisomy 21). Full or partial extra copy of chromosome 21 in each cell. Mental and physical changes, cognitive disabilities, lower IQ, change in physical appearance

Down Syndrome Screening occurs before birth! At-risk moms

(advanced maternal age) blood test & ultrasound in the first trimester. Chorionic villus sampling, amniocentesis & percutaneous umbilical blood sampling.

Down Syndrome - For moms not at risk

blood tests alone by 16-20 weeks of gestation.

Down Syndrome - Blood tests

maternal serum alpha-fetoprotein, triple screen and quad screen

S/S of Down Syndrome

Almond shaped eyes that slant up, A short neck, Small ears , A protruding tongue, Small white spots on the colored portion of the eye, Small hands and feet, A palmar crease, Poor muscle tone or loose joints

Down SyndromLife Expectancy

60 Years

Fragile X ( Martin-Bell syndrome)

May not be any physical manifestations in early years,Often coincides with autism spectrum and ADHD behaviors.

Fragile X

FMRI gene mutation, Macroochildism, Intellectual disability, Large face, prominent mandible, larges ears, extensible joints, X linked Dominate (cannot be passed from male to male)

Forms of Child Abuse

Physical Abuse, Sexual Abuse, Neglect, Munchausen syndrome by proxy, Substance Abuse, Shaken baby syndrome

Munchausen Syndrome by Proxy

Caregiver fabricates signs and symptoms of illness in child (the proxy) to gain attention from medical staff Child may undergo needless and painful procedures and treatments—10% of cases may be fatal to the child

Munchausen Syndrome by Proxy Red flags

Child with one or more illnesses that do not respond to treatment or that follow a puzzling course; a similar history in sibling, Symptoms that do not make sense or that disappear when the perpetrator is removed or not present; the symptoms are witnessed only by the caregiver, Physical and laboratory findings that do not fit with the reported history, Repeated hospitalizations failing to produce a medical diagnosis, transfers to other hospitals, discharges AMA, Parent who refuses to accept that the diagnosis is not medical

S/S of Physical Abuse

Bruising, Multiple fractures, Child is afraid of parent or caregiver, Missed medical appointments, Anxious, Lacks social skills and has few friends, Poor hygiene , Dressed inappropriately for social situation, Retinal hemorrhages and skull fractures (infants)

TEN-4-FACESp

Bruising Clinical Decision Rule for Children < 4 Years of Age

When is bruising concerning for abuse in children <4 years of age?

If bruising in any of the three components (Regions, Infants, Patterns) is present without a reasonable explanation, strongly consider evaluating for child abuse and/or consulting with an expert in child abuse.

Bruising TEN — REGIONS

Torso | Ears | Neck

Bruising FACES

Frenulum, Angle of Jaw, Cheeks (fleshy part), Eyelids, subconjunctivae

Bruising 4 months and younger — INFANTS

Any bruise, anywhere

Patterned bruising — PATTERNS

Bruises in specific patterns like slap, grab or loop marks

Bruising See the signs

Unexplained bruises in these areas most often result from physical assault. TEN-4-FACESp is designed to increase objectivity and function as a screening tool to improve the recognition of potentially abused children with bruising who require further evaluation.

Abuse The Responsibility of the NURSE

If you suspect  stay calm and conversational. , Ask non-leading questions such as “What happened?” , Where were you when it happened?” , Be polite and non-judgmental., Document! Report to your charge nurse who can report to CPS (child protective services)

Shaken Baby Syndrome

Subdural hematoma is the most common type of injury, Retinal hemorrhages occur in more than 50% of victims. It’s estimated that 20-25% of caregivers are not aware of the consequences

Shaken Baby Syndrome S/s?

fussy, irritable, unresponsive, lethargic, irregular breathing, poor feeding, low energy, no tracking in pupils, bulging fontanels, subdural hematoma, bruising

Down Syndrome Co-Morbidities

Heart defects, Vision and hearing impairments, Obstructive sleep apnea, Gastrointestinal issues, Leukemia, Hypothyroid, At Risk for infections of , Skin, Bladder, Respiratory

Shaken Baby Syndrome plan of care?

remove from parent, neuro, feeding, airway, seizure prevention