Child and Adolescent Psychiatric Disorders

Continuum of care for youth

-Family support

-School counselor

-Pediatrician or pediatric nurse practitioner

-Outpatient therapy

-Intensive outpatient/partial hospital

-Therapeutic school

-Inpatient hospital

-Residential setting

Biological and environmental etiology

-Early experiences, development of brain circuitry have combined effect on child’s central nervous system

-Environmental factors can change gene activity, increase risk for developing psychopathology later in life

-75% of adult psychiatric disorders have onset in childhood and adolescence

-Genetic associations for attention deficit/hyperactivity disorder, autism, Tourette syndrome, schizophrenia

-Brain plasticity- Critical periods of develop: development, strengthening of neutral connections in response to environmental stimuli

-Levels of dorsolateral prefrontal cortex not yet fully developed

Psychological etiology

-Developmental theories: Overall tasks of childhood essential to healthy development, eventual independent living, strong social relationships

-Development of psychiatric disorders: Combination of child’s own biological, psychological growth, interactions with family, environment, and culture; Not a single factor

Child and Adolescent Psychiatric Disorders

-Psychiatric disorder influence daily functioning by causing impairment in: family relationships, Peer relationships, School functioning

-Others respond inappropriately as a result of failure to understand, sympathize with responses

DSM5

-In prior versions of DSM, one chapter was devoted to infancy, childhood, and adolescents

-DSM5 aimed to take a developmental/lifespan approach throughout since many can have onset in youth

-Starting with dx thought to reflect developmental processes that manifest early in life (neurodevelopmental disorders and schizophrenia spectrum disorders)

-Followed by dx that more commonly manifest in adolescents and young adulthood (anxiety, depressive, and bipolar disorders)

-Ending with dx relevant in adulthood/later in life (neurocognitive disorders)

Anxiety disorders

-Often seen in children and adolescents

-Separation anxiety disorder: Onset as early as preschool, common onset in childhood, and less common in adolescents

-Selective mutism (less common): Onset usually before age 5 but may not come to attention until school begins

-Social Anxiety disorder

-Panice disorder

-Generalized Anxiety Disorder

Anxiety disorder: Social Anxiety disorder

-Median age of onset is 13 years

-75% have onset between 8-15 years

-DSM includes specific considerations for kids:

-Anxiety must occur in peer settings and not only with adults

-Fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking or failing to speak in social situations

-Have a hard time verbalizing their anxiety

Anxiety disorder: Panic disorder

-Median age of onset is 20-24 but can begin in childhood/adolescence

-May not be diagnosed in childhood but many retrospectively recall anxiety attacks dating to childhood- may not be unexpected

-Adolescents may have less worry about having another attack than adults

-Important to ask them to describe a panic attack (emotion dysregulation vs panic attack), describe symptoms

Anxiety disorder: Generalized Anxiety Disorder (GAD)

-Many adults repost onset “all my life”

Primary difference across age groups is focus of worries:

-Kids: school, sports, performance, etc

-Older adult: family well being and own physical health

Common themes of worry in kids:

-Quality of performance or competence at school or sporting events, punctuality, catastrophic events (earthquakes, nuclear war), perfectionistic, requires excessive reassurance

Depressive Disorders

-Overall, the criteria for depression in youth is similar to that in adults

-May be some developmental differences in presentation that complicate diagnosis

-In preschool children, absence of joyful play observd by caregivers

-In school-aged children, irritability, temper tantrums, low frustration tolerance, and somatic symptoms

-Adolescents may more commonly present with sad mood, neuronegative symptoms, and suicidality

Bipolar disorders

-Diagnosed as bipolar with first episode of mania or hypomania

-Most often begins with one or more episodes of depression: can be difficult to distinguish as bipolar, higher risk for bipolar in those with onset in adolescence, those with psychotic symptoms and those with family history of bipolar disorder

-Youth symptomatology: Same DSM5 criteria, Irritability as key mood state requires an additional manic/hypomanic symptom to meet for the condition

-Think Tasmanian Devil, Really important to distinguish episodic nature of manic symptoms (vs ADHD)

-Cyclothymia duration 1 year for kids compared to 2 years for adults

-Mania in adolescents is frequently associated with psychotic symptoms, markedly labile moods, mixed manic and depressive features

Bipolar Disorders: Mania in younger children

-Changes in mood, energy levels, and behavior are often markedly labile and erratic rather than persistent

-Irritability, belligerence and mixed manic-depressive features are more common than euphoria

-Children with juvenile mania most often present with mixed episodes (primarily irritability and explosiveness), with chronic impairment, including some patients for whom the illness represents their baseline functioning

Neurodevelopmental disorders

-Characterized by developmental deficits that impair functioning in multiple areas

-Usually manifest before a child begins school

-Intellectual disability

-Communication disorders: language disorder, speech sound disorder, childhood-onset fluency disorder (stuttering), social (pragmatic) communication disorder

-Autism spectrum disorder

-Attention-deficit hyperactivity disorder (ADHA)

-Specific learning disorder (with impairments in reading, written expression, math)

-Motor disorder: developmental coordination disorder, stereotypic movement disorder, Tic disorders

Neurodiversity

The concept that there is natural variation in how people’s brains work, with no single “correct” way, and that a wide range of perceptions and responses to the world should be accepted and encouraged, including those of children with ADHA, autism, and learning differences

-Strives to shine a light on the strengths and benefits of this diversity

-Often brings creativity

-Includes hyperfocus and novel perspectives, which are associated with autism

Neurodiversity Movement

-Judy Singer: an Australian sociologist who is herself on the autism spectrum

-A social justice movement, to promote equality of “neurological minorities”- people whose brains work in atypical ways (ASD, ADHD, learning differences)

-These differences should not be viewed as deficits, but rather as normal and potentially valuable variations on the way brains work

Autism Spectrum Disorder

-Two overall categories of symptoms: Impairment of social interactions, communications; Restricted, repetitive behaviors, interests

-DSM-5 now groups previously separate disorders into one ASD diagnosis

-Levels of severity of ASD recognized by degree to which assistance is needed

Autism Spectrum Disorders DSM5 Criteria

Persistent deficits in social communication and social interaction across multiple contexts, as manifested by all of the following, currently or by history:

-Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back and forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions

-Deficits in nonverbal communicative behaviors used for social interaction, ranging, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures to a total lack of facial expressions and nonverbal communication

-Deficits in developing, maintaining, and understanding relationships ranging from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers

Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least 2 of the following, currently or by history:

-Stereotyped or repetitive motor movements, use of objects or speech

-Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior

-Highly restricted, fixated interests that are abnormal in intensity or focus

Symptoms must be present in the early developmental period

Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning

These disturbances are not better explained by intellectual disability

Screening for ASD

-Determine family history, as this will confer increased risk

-Inquire about parental concerns in regards to child development

-Ascertain whether certain developmental milestones have been achieved

-AAP suggests the following “red flags” for indication of immediate evaluation: non babbling or pointing or other gestures by 12 months; no single words by 16 months; no 2-word spontaneous phrases by 24 months; loss of language or social skills at any age

Symptom presentation for ASD: Persistent deficits in social communication and interaction

-Lack of social smile development

-Lack of anticipatory posture when being picked up by a caregiver

-Poor eye contact

-Atypical attachment behavior

-Deficit in spontaneous play: Although, the individual may compensate in other social situations, attempts to engage in conversation but asks inappropriate questions

-Issues with inferring feelings or emotional states of those around them

-Lack of social overtures: pointing, eye contact, engaging in coversation

Symptom presentation for ASD: Restricted, repetitive patterns of behavior, interests, or activities

-Restricted and muted developmentally expected exploration

-Toys and objects may not be used typically, but instead manipulated in a ritualistic manner (spinning the wheels on a toy, over and over again)

-Lack imitative, imaginative or pantomime play (concrete, literal)

-Monotonous and rigidity

-Enjoyment of spinning, banging, watcher water flowing

-Lining up objects, counting objects, attachment to an inanimate object

-Sterotypies, mannerisms, grimacing

Symptom presentation for ASD: Disturbances in language development and use

-Language deviance, language delay

-Minimal or absent babbling

-Vocalization of noises (clicks, screeches, nonsensical syllables) in a stereotyped fashion

-Echolalia: automatic, non-voluntary repetition of words, phrases, or sounds spoken by other people

-Stereotyped phrases (over and out!)

Symptom presentation for ASD: Response to sensory stimuli

-Interest in the sound of a clock or wristwatch

-Laying on the floor (enjoys the sensation of the carpet)

-Dislikes tags on clothing

-May not respond to an injury or seek comfort

Symptom presentation for ASD: Irritability and instability of mood and affect

Can include aggression, self-injurious behaviors, and severe temper tantrums

Pharmacological interventions for ASD

No pharmacological intervention will treat autism, but some are FDA-approved or utilized off-label to manage symptoms of ASD

Pharmacological Interventions for ASD: Irritability

-Risperidone (Risperdal)

-Aripiprazole (Abilify)

Pharmacological Interventions for ASD: Hyperactivity, impulsivity, and inattention

-Methylphenidate products are recommended

-Clonidine or Guanfacine may also be beneficial

Pharmacological Interventions for ASD: Sleep disturbances

-Melatonin may be helpful

-Clonidine

Pharmacological Interventions for ASD: GI distress

-Constipation: Lifestyle intervention, Miralax

-GERD: lifestyle interventions, PPIs

-Chronic abdominal pain: lifestyle interventions, dietary triggers

-Chronic diarrhea: lifestyle interventions, rule out celiac disease, consider probiotics

Non-Pharmacologic interventions for ASD

-Social skills training

-Behavioral therapy and cognitive behavioral therapy

-Management of insomnia:

-Removal of reinforcement and attention for being awake (gradual extinction of staying wake behavior)

-Graduated bedtime

Nursing Interventions for ASD: Self-injury

-Work with the individual on a 1:1 basis

-If self-injury occurs, attempt to assess for underlying anxiety, and triggers for anxiety

-Intervene with diversion or replacement activities and offer self to the individual las anxiety rises

-Use protective devises for self-injury (padded hand mitts, arm overs)

Nursing Interventions for ASD: Impaired social interactions

-Assign specific caregivers to the individual and convey warmth/acceptance

-provide individual with familiar objects

-Provide positive reinforcement

Nursing Interventions for ASD: Impaired verbal communication

-Maintain consistent caregivers

-Anticipate and fulfill the individual’s needs

-Seek clarification and validation

-Give positive reinforcement

Nursing Interventions for ASD: Issues with personal identity, delays in development

-Assist the individual in autonomy

-Allow the individual choices

Attention Deficit Hyperactivity Disorder (ADHD)

Core symptoms

• Inattention

• Hyperactivity

• Impulsivity

Diagnosed when symptoms persist for more than 6 months across at least 2 settings

Neurobiology of ADHD

Generally, low levels of both dopamine and norepinephrine are seen in patients with ADHD, particularly in the prefrontal cortex

DSM5 Criteria ADHD

1. Core Symptoms (A): Persistent Inattention and/or Hyperactivity-Impulsivity for 6+ months.

• Kids (under 17): 6+ symptoms required.

• Adults (17+): 5+ symptoms required.

2. Age Limit (B): Several symptoms must have started before age 12.

3. Places (C): Symptoms must show up in 2 or more settings (e.g., home and school/work).

4. Impact (D): Clear proof that symptoms disrupt daily life, school, or work.

5. Rule-Out (E): Symptoms are not better explained by another mental health condition (like anxiety or depression).

Symptoms of Inattention (ADHD)

1. Missing small details or making careless mistakes in school, work, or activities.

2. Struggling to keep attention on tasks or lectures.

3. Seeming not to listen when spoken to directly.

4. Failing to finish instructions, chores, or work duties.

5. Having trouble organizing tasks, timing, or belongings.

6. Avoiding or disliking tasks that require long-term mental effort (like paperwork or reading).

7. Losing things needed for daily life (keys, phone, school supplies, wallet).

8. Easily getting distracted by outside sights or sounds.

9. Being forgetful in daily routines (running errands, keeping appointments).

Symptoms for Hyperactivity and impulsivity (ADHD)

1. Fidgeting, tapping hands/feet, or squirming in a seat.

2. Getting up and leaving a seat when staying seated is expected.

3. Running or climbing in situations where it is not appropriate (or internal feelings of extreme restlessness in adults).

4. Struggling to play or relax quietly.

5. Being constantly "on the go" or acting as if driven by a motor.

6. Talking excessively.

7. Blurting out answers before a question is finished.

8. Having a hard time waiting for a turn (e.g., in a line).

9. Interrupting or intruding on others (e.g., cutting into conversations or games)

ADHD Symptom Presentation

-Onset of the disorder is in childhood- hence, the diagnosis criteria states that symptoms must be present prior to age 12

-Delays in motor language, and social development are not diagnostic but frequently co-occur with ADHD

-Academic performance is often impaired due to inattentive symptomatology

-Social relationships are sometimes impaired due to hyperactive symptomatology

-Typically, parents initially noticed increased activity during toddlerhood

-Inattentive symptoms may become more evident when the child enters school, as expectations and demand exceed capabilities

-Motor activity reduced with time: Adults have less than adolescents

ADHD is a highly comorbid disorder

Must also assess for:

-Oppositional defiant disorder

-Conduct disorder

-Depression

-Anxiety

-Substance use disorder

-Bipolar disorder

In which specific patient demographic is behavioral therapy primarily recommended as a first-line nonpharmacological intervention for ADHD, and what are its core principles?

Target Group: Recommended for pre-school aged children (4–5 years) and/or those with mild symptoms.

Core Principles: Increasing desired behaviors and decreasing undesired behaviors based on learning principles, cognitive theories, and contingency management.

Why is parent education and training considered critical/integral in ADHD management, and what key perspective shift must parents make regarding the child's behaviors?

Perspective Shift: Behaviors are not "voluntary" but are instead symptoms of ADHD.

Training Focus: Helping parents develop usable behavioral interventions utilizing positive reinforcement

Describe the setting and unique mechanism used during Parent-Child Interaction Therapy (PCIT) for ADHD.

Setting: Parent and child are in a playroom while the therapist observes from an adjoining room through a one-way mirror and/or live video feed.

Mechanism: The parent wears a "bug-in-the-ear" device through which the therapist provides live, in-the-moment coaching.

What are the primary in-school support mechanisms and key collaborative strategies used to manage ADHD in the academic environment?

Formal Plans: Individualized Education Plans (IEPs) and 504 plans.

Strategies: Collaborating closely with teachers and support personnel, and managing student workload (especially during adolescence) to mitigate the recurrence of symptoms or feelings of being overwhelmed.

What are practical home/environmental strategies parents can implement to help structure a child with ADHD?

• Maintaining a daily schedule

• Keeping distractions to a minimum

• Providing specific and logical places for schoolwork, toys, and clothes

• Setting small, reachable goals

• Rewarding positive behavior using a "token economy"

• Using charts and checklists to stay "on task"

• Limiting choices

What methods are recommended for calm discipline in children with ADHD, and what critical psychological risk must clinicians monitor for when children/adults struggle to succeed?

Calm Discipline: Time-out, distraction, and removing the child from the situation.

Comorbidity Monitoring: Closely monitor for comorbid mental health issues because individuals with ADHD frequently become overwhelmed and frustrated when they are not succeeding.

What complementary and alternative medicine (CAM) dietary interventions are sometimes explored, and what other non-pharmacological modalities are listed for ADHD?

Dietary Therapy: Restricting gluten and eliminating artificial food coloring.

Other Modalities: Problem-solving strategies, organizational skills, and finding activities where the child can experience success (such as hobbies and sports).

Nursing Interventions for ADHD: Low self-esteem

-Assure goals are realistic

-Plan activities that provide opportunities for success

-Convey unconditional acceptance and positive regard

-Offer recognition of successful endeavors and reinforcement for attempts made

Nursing Interventions for ADHD: Issues with task expectations- low frustraction tolerance and limited attention span

-Provide environment with limited distractions

-Begin assistance on a 1:1 basis

-Begin with simple, concrete instructions

-Reward completion of each step of task, allow breaks for physical activities

-Gradually decrease the amount of assistance given

Pharmacological interventions for ADHD

-Recommended in children over the age of six with moderate to severe symptoms

-Stimulates

-Methylphenidate class

-Amphetamine salt class

-Bupropion

-Atomoxetine

-Noradrenergic agents

Stimulants: Adverse effects

-Anorexia, poor growth, weight loss

-Sleep disturbances

-Jitteriness

-Emotional lability (particularly when the medication is wearing off)

-Headache/dizziness

-GI symptoms

-Increased heart rate and blood pressure: must assess for family history of sudden cardiac death, EKG no longer routinely recommended

-Tics (new onset or worsening)

-Diversion or misuse: substance contracts, prescription drug monitoring programs, Random urine drug screens

-Psychosis

-Suicidal thinking

Stimulant: Guidance

-Should take in the morning after eating a meal

-Slow titration up to avoid over activation

-Some children and adults can take “drug holidays”

-Avoid taking late in the day (after 4pm or 5pm for immediate release) as insomnia may ensue

-Generally, should be avoided during and discontinued prior to pregnancy

-Therapeutic effects will be seen immediately

Methylphenidate Products

-Concerta

-Ritalin or Ritalin LA

-Focalin or Focalin XR

-Daytrana

-Methylphenidate (generic)

-Metadate CD or Metadate ER

-Methylin

-Quillichew ER or Quillivant XR

-Aptensio XR

-Cotempla XR-ODT

Amphetamine Products

-May increase risk for abuse/diversion, thus some consider second line

-Adderall, Adderall XR

-Dexdrine Spansule

-Dexedrine Spansule

-Zenzedi

-ProCentra

-Evekeo

-Adzenys-XR-ODT and Adzenys ER

-Dyanavel XR

-Mydayis

-Lisdexamfetamine (Vyvanse)

Bupropion (Wellbutrin)

-works similarly to stimulants as it is an antagonist at both norepinephrine and dopamine transporters

-Can improve symptoms of ADHD in adults

-Recommended for those at-risk for diversion

Atomoxetine (Straterra)

-SNRI

-MOA: blocks norepinephrine transporters, increases levels of both dopamine and norepinephrine

-FDA-Approved for ADHD in adults and children over the age of six years

-Slight therapeutic effect may be seen in as little as a few days, with full benefits continuing for 8-12 weeks

-Side effects: sedation, fatigue, decreased appetite, increased HR and BP, CNS effects, Rare priapism, GI symptoms, Sexual dysfunction, Activation of suicidality

-Generally, not recommended during pregnancy

-May be beneficial for patients with comorbid depressed symptoms

Nonadrenergic agents

-Are found in high concentrations in the CNS, and in the prefrontal cortex

-In the prefrontal cortex, regulates inattention, hyperactivity, and impulsivity

-Agonists at norepinephrine receptors can increase activity at postsynaptic receptors to enhance cognitive performance

-Clonidine (Kapvay)

-Guanfacine (Intuniv, Tenex)