Child and Adolescent Psychiatric Disorders

Child and Adolescent Psychiatric Disorders

Disorders of Focus

  • Intellectual Developmental Disorder

  • Autism Spectrum Disorder

  • Attention Deficit Hyperactivity Disorder (ADHD)

  • Disruptive Behavior Disorders:

    • Oppositional Defiant Disorder

    • Conduct Disorder

  • Tourette’s Disorder

  • Separation Anxiety Disorder

Problematic Behaviors Exist If They:

  • Are not age-appropriate

  • Deviate from cultural norms

  • Impair functioning

Why Are These Difficult to Assess?

  • Varying developmental stages

    • Every child grows at different rates

  • Cultural influences

  • Overlap of symptoms

Intellectual Developmental Disorder

  • Formerly known as Mental Retardation (IDD)

  • Onset prior to age 18

  • Characterized by:

    • Impaired intellectual performance

    • Deficits in adaptive skills across multiple domains

Diagnosis

  • IQ Score ≤ 70 (or clinical assessment if testing is not possible)

  • Adaptive functioning deficits in at least two areas:

    • refers to the person’s ability to adapt to requirements of activities of daily living and the expectations of their age and cultural group

      • Communication

      • Self-care

      • Home living

      • Social/interpersonal skills

      • Use of community resources

      • Self-direction

      • Functional academic skills

      • Work, leisure, health, and safety

Predisposing Factors

  • Genetic Factors (~5%) - Down Syndrome

    • Inborn errors of metabolism

    • Chromosomal disorders

    • Single gene abnormalities

  • Embryonic Development (~30%)

    • Maternal alcohol/drug use

    • Maternal illnesses/infections during pregnancy

    • Pregnancy/birth complications

  • Perinatal Factors (~10%)

    • Fetal malnutrition, viral or other infections during pregnancy

    • Trauma or complications during delivery that deprive the infant of oxygen

    • Premature birth

  • Medical Conditions (~5%)

    • Infections (e.g., meningitis, encephalitis)

    • Poisonings (e.g., lead exposure)

    • Physical trauma (e.g., head injuries, drowning)

  • Sociocultural Factors (~15-20%)

    • Deprivation of nurture and social stimulation

    • Impoverished environments associated with poor prenatal/perinatal care and inadequate nutrition

    • Severe mental disorders, such as autism spectrum disorder

Degrees of Severity

  • Mild (IQ 50-70): Independent learning with support; academic skills up to 6th grade

  • Moderate (IQ 35-49): Limited independence; academic skills up to 2nd grade

  • Severe (IQ 20-34): Needs complete supervision; elementary hygiene skills

  • Profound (IQ < 20): Fully dependent; minimal speech or socialization

Nursing Diagnoses

  • Risk for injury

  • Self-care deficit

  • Impaired verbal communication

  • Impaired social interaction

  • Delayed growth and development

  • Anxiety

  • Defensive coping

  • Ineffective coping

Nursing Care Plan

  • Focus on safety, self-care, and communication

  • Encourage family involvement

  • Assess strengths as well as limitations

  • Develop plans that encourage independence

Goals

  • No physical harm

  • Self-care needs met

  • Socially appropriate interactions

  • Manageable anxiety levels

  • Adaptive coping skills

Autism Spectrum Disorder (ASD)

Overview

  • Characterized by:

    • Social difficulties

    • Communication impairments

    • Restricted/repetitive behaviors

  • Prevalence: 1 in 54 children

  • More common in boys

  • Onset in early childhood

  • Chronic condition with persistent challenges

Nursing Diagnoses

  • Risk for self-mutilation

  • Impaired social interaction

  • Impaired verbal communication

  • Disturbed personal identity

Nursing Interventions

  • Protection from self-harm (PRIORITY)

  • Enhance social functioning

  • Promote verbal communication

  • Strengthen personal identity

Medications

  • Risperidone

    • Side effects: Drowsiness, increased appetite, nasal congestion, constipation, dizziness, weight gain

  • Aripiprazole

    • Side effects: Sedation, fatigue, weight gain, vomiting, tremor

Alternative Interventions

  • Consistent caregivers

  • Individualized education plans

  • Behavior modification for positive reinforcement

  • Speech, physical, or occupational therapy for improved functionality

Attention Deficit Hyperactivity Disorder (ADHD)

Overview

  • Characterized by inattention, impulsiveness, and hyperactivity

  • 3 Presentations:

    • Inattentive Presentation

    • Hyperactive-Impulsive Presentation

    • Combined Type

Symptoms

Inattentive Presentation:

  • Careless mistakes

  • Difficulty sustaining attention

  • Forgetfulness

  • Poor organization

Hyperactive-Impulsive Presentation:

  • Fidgeting

  • Excessive talking

  • Difficulty remaining seated

  • Blurts out answers

  • Hyperfocus

Combined Presentation:

  • Symptoms of both inattention and hyperactivity/impulsivity

Impairments

  • Occupational difficulties

  • Criminal behavior

  • Traffic accidents

  • Divorce and relationship issues

  • Financial instability

  • Higher mortality rates

Planning Care

  • Behavior Management Strategies:

    • Sticker charts and frequent positive reinforcement

    • Ensure attention by removing distractions

    • Show unconditional acceptance of the child

    • Teach and demonstrate social skills

    • Set firm but compassionate limits

    • Use short and simple instructions

    • Encourage positive self-talk

    • Staff and teachers may complete behavior rating questionnaires (e.g., Connors, SNAP-IV)

Psychopharmacological Interventions

  • CNS Stimulants: first-line treatment

    • Examples: Dextroamphetamine, methamphetamine, lisdexamfetamine, methylphenidate, dexmethylphenidate, dextroamphetamine/amphetamine mixture

    • Side Effects: Insomnia, anorexia, weight loss, tachycardia, slowed growth, constipation, GI upset, dry mouth, tics, rare psychosis

    • Nursing Education: Administer immediately after breakfast to reduce appetite suppression

  • Alpha Agonists:

    • Examples: Clonidine, Guanfacine

    • Used For: Alternative for patients intolerant to stimulants or in combination for severe ADHD

    • Side Effects: Drowsiness, dizziness, fatigue, headache, GI upset, dry mouth

  • Selective Norepinephrine Reuptake Inhibitor (SNRI):

    • Example: Atomoxetine

    • Key Considerations: Avoid in patients with cardiovascular issues or recent MAOI use

  • Selective Serotonin Reuptake Inhibitor (SSRI):

    • Example: Bupropion

    • Caution: Avoid in patients with seizure history

    • Side Effects: Worsening depression, unusual behavior changes, suicidal thoughts, anxiety, insomnia, irritability

Disruptive Behavior Disorders

Oppositional Defiant Disorder (ODD)

  • Characteristics:

    • Onset ~ age 8

    • Passive-aggressive behavior, procrastination, temper tantrums, resistance to change

    • Testing of limits, refusal to comply with requests

  • Outcomes:

    • Noncompliance with therapy

    • Ineffective coping

    • Low self-esteem

    • Impaired social interaction

  • Interventions:

    • Structured therapeutic activities

    • Rewards and consequences system

    • Realistic goals with positive reinforcement

    • Emphasize acceptance of the child, not the behavior

    • Role-play acceptable behaviors

    • Evaluate and adapt care plan as needed

Conduct Disorder

  • Characteristics:

    • Common in males

    • Aggressive behavior, destruction of property, deceitfulness/theft

    • Serious violation of rules, lack of guilt/remorse

    • Early substance use and sexual activity

    • High risk of developing antisocial personality disorder

  • Predisposing Factors:

    • Neurological issues, school problems, parental psychological factors, divorce, major stressors

    • Family factors: large family, absent father, parental antisocial traits

  • Outcomes:

    • Priority: Risk for directed violence toward others

    • Impaired social interaction

    • Defensive coping

    • Low self-esteem

  • Interventions:

    • Early intervention and redirection of violent behaviors

    • "Show of strength" with adequate staff presence if needed

    • Firm limit setting

    • Use medications, mechanical restraints, or isolation if necessary

    • Encourage group programs for peer feedback and accountability

    • Separate the child’s behavior from their identity

Tourette’s Disorder

Characteristics:

  • Onset: As early as age 2, commonly between 6-7 years

  • Presence of multiple motor tics and one or more vocal tics

  • Tics may appear simultaneously or independently

  • Symptoms often diminish with age

Assessment:

  • Motor Tics: Eye blinking, neck jerking, facial grimacing

  • Complex Tics: Hopping, knee bends, twirling

  • Vocal Tics: Barking, sniffing, coughing, obscene language

  • Tics are compulsive but can be temporarily suppressed

Outcomes:

  • Risk for self-directed or other-directed violence

  • Impaired social interaction

  • Low self-esteem due to tic-related embarrassment

Interventions:

  • Monitor for agitation and self-destructive behavior

  • Provide safe outlets for frustration

  • Use a matter-of-fact approach

  • Show unconditional acceptance

  • Evaluate and adjust interventions as needed

Psychopharmacological Interventions:

  • Alpha Agonists: First-line treatment; also helps with ADHD, anxiety, insomnia

    • Less side effects

  • Antipsychotics: Control severe tics and vocal utterances (prefer atypical agents for reduced side effects)

Separation Anxiety

Characteristics:

  • Onset usually by age 5 or 6; more common in girls

  • Excessive anxiety about separation from home or loved ones

  • Common symptoms: refusal to attend school, “shadowing” parents, frequent worrying, tantrums, crying, clinging, somatic complaints

Assessment:

  • SCARED Tool: Differentiates between separation anxiety, school anxiety, and generalized anxiety

Planning/Interventions:

  • Anxiety Prevention:

    • Create a calm, safe environment

    • Assure the child’s safety and build trust

    • Explore parent/child fears about separation

    • Set realistic goals with gradual exposure

    • Use positive reinforcement for desired behavior

    • Ignore undesired behaviors

  • Ineffective Coping Interventions:

    • Discuss stressful events with the child

    • Support development of new coping strategies

Assessment Findings

  • School refusal: Common, especially in adolescence.

  • Younger children may “shadow” their parents.

  • Worrying is common, often about separation.

  • Specific phobias: Fear of heights, elevators, cars, etc.

  • Anticipation of separation may cause tantrums, crying, screaming, and clinging behaviors.

  • Somatic complaints such as stomachaches, headaches, etc.

Planning/Interventions

Anxiety Prevention

  • Create a calm environment.

  • Ensure safety and establish trust with the child.

  • Explore fears (both the child’s and the parent’s) related to separation.

  • Set realistic goals: Gradually expose the child to separation with new coping skills.

  • Positive reinforcement for desired behaviors.

  • Ignore undesired behaviors.

Ineffective Coping

  • Related to unresolved separation conflicts and inadequate coping skills, evidenced by somatic complaints.

  • Intervention: Discuss stressful events and connect them to physical symptoms (involving parents in the discussion).

  • Connect unmet expectations to physical symptoms.

  • Role-play adaptive coping skills with the child and parents.

Impaired Social Interaction

  • Related to reluctance to be away from attachment figure.

  • Develop trust with the child.

  • Support social interaction with others and give positive feedback.

  • Gradually introduce group activities.

  • Set attainable personal goals with the child.

General Therapeutic Approaches for All Diagnoses

  • Behavior Therapy

  • Family Therapy

  • Group Therapy

  • Psychopharmacology