Week 13: Children and Adolescents

Aspects of a mental health clinical interview for a child or adolescent

• Establish a Therapeutic Alliance

  • greet, speak, recognize, demonstrate

• Child and Parent Observation

• Separate Child and Parent Interviews

• Development of Rapport

Establishing a therapeutic alliance for kids and adolescents

• children are often very scared of coming to a hospital; distraction techniques for an assessment could include magic tricks and seeing how much the kid is paying attention — paying attention is good, wandering eyes is bad and shows that there I something else going on

• Talk to kids normally (not in a baby voice), show respect, and talk with them (do not chart at the same time)

Differences in Child and Adolescent MH assessment compared to adult’s assessment

• tailor the assessment to the child’s developmental and cognitive levels 

• Corroborate information with parents, teachers, etc.

• Additional testing as needed (cognitive, neuropsychological)

• Records (e.g., school performance)

Developing rapport with a child or adolescent when doing a clinical interview

• maintain appropriate eye contact

• speak slowly, clearly, and calmly

• show friendliness and acceptance using warm and expressive tone

• react objectively

• show interest and empathy (be genuine)

• make interview collaborative

Developing rapport with preschool children

Building rapport with school-aged children

Building rapport with adolescents

Building rapport with parents

Child and adolescent safety assessment 

Ask straightforward questions

• Have you ever hurt yourself?

• Have you thought about hurting yourself?

• How would you hurt yourself?

• What do you think would have happened?

How can mental health of children and adolescents be supported?

• supportive social networks

• positive childhood and adolescent experiences

• good physical health

• positive social development

• easy temperament (adaptable, low intensity, and positive mood)

• secure attachment through the emotional bonds formed between them and their parents at an early age.

How do developmental delays impact children and adolescent mental health? 

Developmental delays slow the child’s progress and also can interfere with the development of positive self-esteem

Adverse Childhood Experiences (ACES)

potentially traumatic events that can occur in childhood which can have significant, lasting negative effects on a person's health, well-being, and opportunities in life

What are the 3 types of ACES?

• Abuse

• Neglect 

• Household challenges 

What are the 3 types of abuse a child may face? 

• Emotional 

• Physical 

• Sexual 

What are 2 types of neglect that children may face?

• Emotional 

• Physical 

What household challenges may a child face?

• Witnessing violence against a parent or caregiver, especially the mother

• Living with someone who has a substance use disorder (alcohol or drugs)

• Living with someone who has a mental illness or attempted suicide

• Parental separation or divorce

• Having a household member go to prison or jail

• A household member is a victim of domestic violence.

Long-term impacts of ACEs

The number of ACEs a person experiences as a strong, dose- response relationship with a higher likelihood of negative outcomes later in life

• Physical health problems

• MH issues 

• Behavioral challenges

• Social and economic issues

Physical Health problems that may occur after experiencing ACEs

Increased risk for chronic diseases like heart disease, cancer, diabetes, and autoimmune disorders

Mental Health problems that may occur later in life after experiencing ACEs

Higher rates if anxiety, depression, PTSD, and suicide attempts

Behavioral challenges that may occur later in life after experiencing ACEs

increased likelihood of risky behaviors, such as smoking, substance misuse, and risky sexual behaviors, often adopted as coping mechanisms 

Social and economic challenges that may occur later in life after experiencing ACEs

Difficulties with social development, impaired school performance, and lower education or employment potential 

Common problems associated with child and adolescent MH issues

• Loss

• Death and grief

• Divorce

• Sibling relationships

• Bullying

• Physical illness

• Risk-taking behaviors (e.g., drug use, self injurious behavior)

Risk factors for MH struggles in children/adolescents

• Poverty and homelessness

• Child abuse and neglect

• Witnessing violence

• Substance abuse

• Mental illness in families

• Parental separation

• Foster care/out of home placements

• Genetics

Protective factors against MH struggles in children/adolescents

• Resilience

• Supportive social networks

• Secure attachments

• Positive experiences

• Good physical health

• Normal social development

• Access to resources

Interventions for children/adolescents must focus on these 3 things:

• Changing peer dynamics

• Values clarification

• Building self-esteem

Family interventions for child/adolescent MH

• Strengthen family relationships

• Improve communication

• Support problem-solving

• Reduce stress and boost coping

• Consider cultural context

Most common disorders occurring in children/adolescents

• Neurodevelopmental disorders

• Mood disorders

• Eating disorders

• Anxiety disorders

• SUD

Trauma Informed Care “4 R’s”

• Realizes the widespread impact of trauma and understands potential paths for recovery

• Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system

• Responds by fully integrating knowledge about trauma into policies, procedures, and practices

• Seeks to actively resist re-traumatization

6 key principles of Trauma Informed Care that providers must account for

1. Safety (physical and emotional)

2. Trustworthiness and transparency

3. Peer support

4. Collaboration and mutuality

5. Empowerment, voice, and choice

6. Cultural, historical, and gender issues

Intellectual Disability

Intellectual and adaptive functioning in conceptual, social, and practical domains

Intellectual Disability criteria

• Intellectual deficits (reasoning, problem-solving, academics) confirmed by testing and clinical assessment.

• Adaptive deficits (personal independence, social responsibility) limiting daily functioning.

• Onset during developmental period.

3 most common causes of intellectual disabilities that happen before birth

• Fetal alcohol syndrome (and other teratogens)

• Genetic + chromosomal conditions

• Infections

Factors that impact developmental disabilities

• Genetic factors

• Parental health/behaviors during pregnancy

• Birth complications (e.g., prematurity)

• Infections before or shortly after birth

• Exposure to environmental toxins (e.g., lead)

What countries are most likely to have intellectual disabilities?

Low and middle income countries

Comorbidities psychiatric disorders in children

• ADHD

• Anxiety

• Mood/depression

• Behavior

Aspects of a developmental assessment that should be focused on for children/adolescents

• Adaptive skills

• Intellectual status

• Social functioning

What are the overall goals for nursing interventions for children with intellectual disabilities?

overall goals are optimal level of functioning for the family and eventual

independent functioning within a normal social environment for the child

Autism Spectrum Disorder (ASD)

persistent deficits in social communication and social interaction with others across multiple contexts as manifested by deficits in:

1. Social-emotional reciprocity

2. Nonverbal communicative behaviors used for social interaction

3. Developing, maintaining, and understanding relationships

AND

Restrictive, repetitive patterns of behavior, interests, or activities, as manifested by 2 of the following:

1. Stereotyped or repetitive motor movements, use of objects, or speech

2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of behavior

3. Highly restricted, fixated interests or focus

4. Hyper- or hypo- reactivity to sensory input or unusual interest sensory aspects of the environment

3 risk factors for ASD

• Genetics Parenteral health or chromosomal conditions

• Heritability

• Environmental

Best practices for communicating with an Autistic child

• Be aware of cultural expressions

• Have a gentle, calm manner

• Form an alliance by following the child’s lead in preferences or interests

• Use visual clues (pictures, hand gestures, colors) to convey messages [visual learners]

• Keep spoken communication simple and short

• Decrease sensory stimuli

• Provide structure and predictability in daily activities

• Form an alliance with primary caregivers (experts in communicating with their child)

Interviewing preschool age children

• Think concretely or magically

• Join their world of play

• For kinds under 5 observe free place with other children

Interviewing school-aged kids

• Ability to think concretely

• Can provide longer explanations

• Use competitive board games — explains cognitive functioning and emotional processing (e.g., how to the react if they are losing)

Interviewing adolescents

• Capacity for abstract thought

• Complex social world

• Often believe that subjective experiences are real and align with reality

• Rejection or hostility is common

• Rapport development thought communication + respect

• Likely defensive in front of parents

ADHD common comorbidities

• Autism

• MDD and anxiety

• Disruptive Mood Dysregulation Disorder

• Learning Disabilities

• Tic disorders

• OCD

ADHD risk factors

• Biological — genetics

• Environmental — low birth weight; mother smoking/drinking alcohol while pregnant; neurotoxin exposure

• Psychosocial — history of child abuse/neglect

ADHD physical health assessment

• ID and explore problems

• Developmental course

• ID factors that have worsened or improved child’s problems

• Medical history

ADHD psychosocial assessment

• School performance

• Behavior at home and/or discipline issues

• Comorbid psychiatric disorders

• Family functioning and situation

Physical interventions for children with ADHD

• Sleep + self care

• Dietary changes

Psychosocial interventions for children with ADHD

• Behavioral programs

• Cognitive behavioral techniques

• Family treatment

• School programs

Methylphenidate MOA

CNS stimulant the blocks reuptake of dopamine and norepinephrine

Amphetamine (Adderall) MOA

Promotes release of dopamine and norepinephrine

Stimulant side effects

• RISK FOR ABUSE!

• Cardiac complications

• Growth effects

• Decreased appetite

• Insomnia

• Dry mouth

• Nausea

Non-stimulant medication

Doesn’t prevent reuptake of dopamine = not a stimulant

Atomoxetine MOA

Non-stimulant medication that prevents the reuptake of norepinephrine

Atomoxetine side effects

• Possible suicidal ideation

• HA

• GI issues

• Decreased appetite

• Moody/irritable

Guanafacine and Clonidine MOA

Alpha-2 receptor agonists — acts like NE and binds to A2 receptors, which decreases SNS activity

• Alpha-2 receptors are inhibitory, so binding to them will decrease neuronal firing

Alpha-2 receptor agonist side effects (Guanfacine and Clonidine)

Due to decreased SNS activity:

• Fatigue

• Sedation

• Decreased BP