Mental Health of Children & Adolescents
Characteristics of Mentally Healthy Child/Adolescent
Trust others; sees the world as safe.
Behavioral developmentally appropriate.
Positive Self-Concept / developing identity.
Can learn and master new tasks.
Expresses self in creative and spontaneous ways.
Develops and maintains satisfying relationships.
Child and Adolescent Mental Health
Statistics suggest a high number of mental health problems in children, particularly those in:
Foster care system
Juvenile justice system
Families with alcohol and drug abuse
Early identification and treatment are vital to reduce the risk of mental health issues.
Trauma in Childhood
Neuroplasticity can be impacted by genetics and childhood environment (traumatic events).
Children exposed to trauma are at risk for developing permanent neurological changes, making it difficult to learn and control behaviors.
Adverse Child Experiences (ACEs)
Include abuse, neglect, witnessing domestic violence, death of a caregiver, etc.
A higher number of ACEs typically results in poorer health outcomes.
Nursing Assessment
A therapeutic alliance must be established with the child and the family.
Key areas of assessment:
Developmental history
Family history
Stress and trauma history
Strengths of the child
MSE (Mental Status Exam)
Cultural sensitivity and knowledge of ages and stages are important.
Assess the child for nine ego competency skills:
Establishing relationship trust
Handling separation and independence
Handling interpersonal conflict
Dealing with frustration
Feeling good
Delaying gratification
Relaxing and playing
Cognitive processing
Sense of direction or purpose
Disorders
Generalized Anxiety Disorder (GAD)
Obsessive Compulsive Disorder (OCD)
Intellectual Developmental Disorder (IDD)
Autism Spectrum Disorder (ASD)
Attention-Deficit/Hyperactivity Disorder (ADHD)
Tourette’s Disorder
Oppositional Defiant Disorder (ODD)
Conduct Disorder
Major Depressive Disorder (MDD)
Generalized Anxiety Disorder (GAD)
Excessive anxiety or worry about multiple events or activities.
Cannot control the anxiety.
No focused trigger to the anxiety.
Must persist for > 6 months and be present > 50% of the time.
Significant impact on life – home, work, school.
Symptoms of GAD
Restlessness or feeling keyed up or on edge.
Being easily fatigued.
Ruminative thinking.
Difficulty concentrating or mind going blank.
Irritability.
Muscle tension.
Sleep disturbance.
Obsessive Compulsive Disorder (OCD)
Obsessions: recurrent and persistent thoughts, impulses, or images that are intrusive and cause marked anxiety or distress.
Compulsions: repetitive behaviors or mental acts that the person feels driven in response to an obsession to reduce distress.
The obsessions and compulsions impact life, school, home, and /or work
Intellectual Developmental Disorder (IDD)
Defined: disorder with onset during the developmental period that includes both intellectual and adaptive functioning deficits in conceptual, social, and practical domains.
General intellectual functioning is measured by both clinical assessment and a person’s performance on IQ tests.
Adaptive functioning refers to the person’s ability to adapt to requirements of activities of daily living and the expectations of his or her age and cultural group.
Predisposing Factors to IDD
Genetic factors (~5 %): Inborn errors of metabolism, chromosomal, single gene
Sociocultural Factors and Other Mental Disorders (~15-20%): Deprivation of nurturance and/or social stimulation, Impoverished environments, Inadequate nutrition
Disruptions in embryonic development (30%): Toxicity (ETOH, drugs), Maternal illnesses, infections, complications during early pregnancy
Pregnancy and perinatal factors (~10 %): Fetal malnutrition, infections during later pregnancy, Birth trauma/complications that deprive the infant of O2 / premature birth
General Medical Conditions Acquired in Infancy or Childhood (~5 %): Meningitis, encephalitis, lead poisoning, physical trauma (head injuries)
Autism Spectrum Disorder (ASD)
Defined: A broad range of conditions characterized by challenges with social skills, repetitive behaviors, speech and nonverbal communication, as well as by unique strengths and differences.
Prevalence: about 1 in 59 children (CDC)
More common in boys (4x).
Typically underdiagnosed in in girls/women
Onset: early childhood
Often chronic
Predisposing Factors of ASD
Neurological Implications: Imaging studies
Genetics: Strong evidence
Prenatal & Perinatal Influences: Advanced parental age, Gestational Diabetes, Gestational bleeding, Low birth weight, Complications (hypoxia at birth), Exposure to toxins (air pollution and pesticides)
Attention Deficit Hyperactivity Disorder (ADHD)
Essential features of ADHD include developmentally inappropriate degrees of:
inattention
hyperactivity
impulsiveness
ADHD Causes
Pre and perinatal complications
Environment
Lead ingestion
Socioeconomic factors
Genetics
Brain dysfunction and damage
Neuroanatomical changes
Pharmacological Interventions for ADHD
CNS Stimulants:
Amphetamine: Dextroamphetamine/amphetamine (Adderall)
Miscellaneous: Methylphenidate (Ritalin, Concerta)
Side Effects: insomnia, restlessness, anorexia, weight loss, CV effects (HTN, chest pain, palpitations, tachycardia, dysrhythmias), psychosis, withdrawal
Warnings/Nursing Implications:
Administer last dose at least 6 hours before bedtime
Carefully monitor CV functioning during treatment
Psychiatric symptoms may worsen – monitor carefully (mania)
Potential for abuse high (controlled substance)
Long-term use can result in temporary slowing of growth & development
Nursing Implications in ADHD
Weigh weekly while on therapy with CNS stimulants due to potential for anorexia, weight loss, & interruption of growth and development.
Attempt a drug “holiday” periodically under direction of the physician to determine effectiveness of the medication and need for continuation.
TIC Disorder / Tourette’s Disorder
The essential feature is the presence of multiple motor tics and one or more vocal tics.
Can cause distress or interfere with social, occupational, or other important areas of functioning.
Tourette’s Disorder - Types of Tics
Simple motor tics: eye blinking, neck jerking, shoulder shrugging, and facial grimacing
Complex motor tics: squatting, hopping, skipping, tapping, and retracing steps
Vocal tics: words or sounds such as squeaks, grunts, barks, sniffs, snorts, coughs, and, in rare instances, a complex vocal tic involving the uttering of obscenities
Palilalia: repeating own words or sounds
Echolalia: repeating words or sounds of others
Pharmacological Intervention for Tourette’s Disorder
Pharmacological intervention for Tourette’s disorder is most effective when combined with other therapy, such as:
Behavioral therapy
Individual psychotherapy
Family therapy
Common medications used include haloperidol (Haldol), risperidone (Risperidal) & guanfacine (Intuniv), clonidine (catapres).
Used for severe symptoms or symptoms that impede functioning
Other Pharmacological Interventions Used for ADHD & Tourette’s
CENTRALLY ACTING ALPHA-AGONISTS: Guanfacine (Intuniv) or Clonidine.
Side Effects: CNS depression (sedation, fatigue, drowsiness); CV effects (hypotension, bradycardia); weight gain
Warnings/Nursing Implications:
Do not discontinue abruptly due to rebound BP effects
Use cautiously in patients with CV disease
Avoid use of ETOH and other CNS depressants
Oppositional Defiant Disorder (ODD)
Defined: A persistent pattern of an Angry/Irritable Mood Argumentative/Defiant Vindictiveness.
More frequent occurrence than is usually observed in individuals of comparable age and developmental level.
Interference with social, educational, or vocational activities.
Comorbidities: ADHD, Anxiety, and Depressive Disorders
ODD Symptomatology
Passive-aggressive
Stubbornness
Procrastination
Disobedience
Carelessness
Negativism
Running away
School avoidance/ underachievement
Testing of limits
Resistance to directions
Deliberately ignoring the communication of others
Unwillingness to compromise
Temper tantrums
Fighting
Argumentativeness
Conduct Disorder
Persistent pattern of behavior in which the basic rights of others and major age-appropriate societal norms or rules are violated.
Classic characteristic is the use of physical aggression in the violation of the rights of others.
Childhood-onset type
Adolescent-onset type
Frequently childhood CD results in adult antisocial personality disorder
Conduct Disorder - Common Behaviors
Use of drugs and alcohol
Sexual permissiveness
Low self-esteem manifested by a “tough-guy” image
Problems with inattentiveness, impulsiveness, & hyperactivity
Use of projection as a defense mechanism
Lack of feelings of guilt or remorse
Inability to control anger
Low academic achievement
Aggression towards people and/or animals
Other Pharmacological Interventions
ATYPICAL ANTIPSYCHOTICs: FDA approved for the treatment of Autism Spectrum disorder, Conduct disorder & Tourette’s
Risperidone (Risperdal) for children 5-16 years
Targeted for the following symptoms: Aggression, Deliberate self-injury, Temper tantrums, Quickly changing moods
Side effects: hyperglycemia/diabetes, weight gain, high cholesterol, orthostatic hypotension, anticholinergic effects, agitation, dizziness, sedation, insomnia, tremor
Caution for severe rare reactions: EPS (Extrapyramidal Symptoms)!
Separation Anxiety
Excessive fear or anxiety concerning separation from those to whom the individual is attached.
May result in tantrums, crying, screaming, complaints of physical problems (GI disturbances and headaches), clinging behaviors.
Interferes with social, academic, occupational, or other areas of functioning.
Most commonly diagnosed at ages 5-6 years.
Depression
Signs and symptoms of adolescent depression.
Treatments.
Goals.
Suicide Risk Factors
Risk factors for childhood suicide include:
Depression
Sexual abuse
Prior suicide ideation or plan
Being bullied
Substance abuse
Impulsive or aggressive behavior
Access to firearms
History of suicide in the family
Suicide is the 2nd leading cause of death for 15 to 24-year-olds.
The most common factor is the lack of or loss of a meaningful relationship.
Should be asked directly if having thoughts of harm.
New Data from a 2022 CDC Report
CDC released official mortality data that showed 45,222 firearm-related deaths in the US in 2020 for children ages 1-19.
Firearm homicides increased by 33.4%.
Firearm suicides increased by 1.1%.
New Peak.
13.5% increase from 2019 to 2020. In 2016, firearm-related deaths were 2nd only to motor vehicle crashes. Drug overdoses and poisoning increased by 83.6% from 2019 – 2020, becoming the 3rd leading cause of death in this age group.
Acetaminophen (Tylenol) Overdose
Common medication of choice for intentional OD due to accessibility.
Symptoms of toxicity (can take up to 12 hours): abdominal pain, irritability, weakness, loss of appetite, jaundice, diarrhea, nausea, vomiting, convulsions, coma.
Nursing Interventions/Treatment:
Diagnostics: acetaminophen level, electrolytes, kidney function tests, amylase, lipase, liver function tests, CBC, and coagulation factors.
If toxicity is suspected or confirmed: Antidotal therapy including N- acetylcysteine (Mucomyst) can be administered or activated charcoal (if within one hour of ingestion).
Supportive care: fluids, anti-nausea medications
Substance Use
Frequently used:
Alcohol (most used)
Marijuana
Opioids
Cocaine
Stimulants
Nicotine
Some reasons for use:
Rebelliousness
Feeling vulnerable
To decrease anxiety
Wish for closeness
Nursing Interventions Review
The main treatments for childhood mental health disorders:
Medication
Social skills training
Behavior management (milieu management)
Cognitive therapy for communication and problem-solving
Parent education – a nurse can model communication, reinforcement, and behavior management techniques so the parent can practice these techniques at home.
Coping skills – exercise, journaling, deep breathing
Setting goals – the accomplishment of goals is rewarding for a child. Provide positive feedback even when the goals are small.
Parent groups/Family therapy, group therapy, individual therapy
Characteristics of Mentally Healthy Child/Adolescent
Trust others; sees the world as safe.
Behavioral developmentally appropriate.
Positive Self-Concept / developing identity.
Can learn and master new tasks.
Expresses self in creative and spontaneous ways.
Develops and maintains satisfying relationships.
Child and Adolescent Mental Health
Statistics suggest a high number of mental health problems in children, particularly those in:- Foster care system
Juvenile justice system
Families with alcohol and drug abuse
Early identification and treatment are vital to reduce the risk of mental health issues.
Trauma in Childhood
Neuroplasticity can be impacted by genetics and childhood environment (traumatic events).
Children exposed to trauma are at risk for developing permanent neurological changes, making it difficult to learn and control behaviors.
Adverse Child Experiences (ACEs)
Include abuse, neglect, witnessing domestic violence, death of a caregiver, etc.
A higher number of ACEs typically results in poorer health outcomes.
Nursing Assessment
A therapeutic alliance must be established with the child and the family.
Key areas of assessment:- Developmental history
Family history
Stress and trauma history
Strengths of the child
MSE (Mental Status Exam)
Cultural sensitivity and knowledge of ages and stages are important.
Assess the child for nine ego competency skills:- Establishing relationship trust
Handling separation and independence
Handling interpersonal conflict
Dealing with frustration
Feeling good
Delaying gratification
Relaxing and playing
Cognitive processing
Sense of direction or purpose
Disorders
Generalized Anxiety Disorder (GAD)
Obsessive Compulsive Disorder (OCD)
Intellectual Developmental Disorder (IDD)
Autism Spectrum Disorder (ASD)
Attention-Deficit/Hyperactivity Disorder (ADHD)
Tourette’s Disorder
Oppositional Defiant Disorder (ODD)
Conduct Disorder
Major Depressive Disorder (MDD)
Generalized Anxiety Disorder (GAD)
Excessive anxiety or worry about multiple events or activities.
Cannot control the anxiety.
No focused trigger to the anxiety.
Must persist for > 6 months and be present > 50% of the time.
Significant impact on life – home, work, school.
Symptoms of GAD
Restlessness or feeling keyed up or on edge.
Being easily fatigued.
Ruminative thinking.
Difficulty concentrating or mind going blank.
Irritability.
Muscle tension.
Sleep disturbance.
Obsessive Compulsive Disorder (OCD)
Obsessions: recurrent and persistent thoughts, impulses, or images that are intrusive and cause marked anxiety or distress.
Compulsions: repetitive behaviors or mental acts that the person feels driven in response to an obsession to reduce distress.
The obsessions and compulsions impact life, school, home, and /or work
Intellectual Developmental Disorder (IDD)
Defined: disorder with onset during the developmental period that includes both intellectual and adaptive functioning deficits in conceptual, social, and practical domains.
General intellectual functioning is measured by both clinical assessment and a person’s performance on IQ tests.
Adaptive functioning refers to the person’s ability to adapt to requirements of activities of daily living and the expectations of his or her age and cultural group.
Predisposing Factors to IDD
Genetic factors (~5 %): Inborn errors of metabolism, chromosomal, single gene
Sociocultural Factors and Other Mental Disorders (~15-20%): Deprivation of nurturance and/or social stimulation, Impoverished environments, Inadequate nutrition
Disruptions in embryonic development (30%): Toxicity (ETOH, drugs), Maternal illnesses, infections, complications during early pregnancy
Pregnancy and perinatal factors (~10 %): Fetal malnutrition, infections during later pregnancy, Birth trauma/complications that deprive the infant of O2 / premature birth
General Medical Conditions Acquired in Infancy or Childhood (~5 %): Meningitis, encephalitis, lead poisoning, physical trauma (head injuries)
Autism Spectrum Disorder (ASD)
Defined: A broad range of conditions characterized by challenges with social skills, repetitive behaviors, speech and nonverbal communication, as well as by unique strengths and differences.
Prevalence: about 1 in 59 children (CDC)
More common in boys (4x).
Typically underdiagnosed in in girls/women
Onset: early childhood
Often chronic
Predisposing Factors of ASD
Neurological Implications: Imaging studies
Genetics: Strong evidence
Prenatal & Perinatal Influences: Advanced parental age, Gestational Diabetes, Gestational bleeding, Low birth weight, Complications (hypoxia at birth), Exposure to toxins (air pollution and pesticides)
Attention Deficit Hyperactivity Disorder (ADHD)
Essential features of ADHD include developmentally inappropriate degrees of:- inattention
hyperactivity
impulsiveness
ADHD Causes
Pre and perinatal complications
Environment
Lead ingestion
Socioeconomic factors
Genetics
Brain dysfunction and damage
Neuroanatomical changes
Pharmacological Interventions for ADHD
CNS Stimulants:- Amphetamine: Dextroamphetamine/amphetamine (Adderall)
Miscellaneous: Methylphenidate (Ritalin, Concerta)
Side Effects: insomnia, restlessness, anorexia, weight loss, CV effects (HTN, chest pain, palpitations, tachycardia, dysrhythmias), psychosis, withdrawal
Warnings/Nursing Implications:- Administer last dose at least 6 hours before bedtime
Carefully monitor CV functioning during treatment
Psychiatric symptoms may worsen – monitor carefully (mania)
Potential for abuse high (controlled substance)
Long-term use can result in temporary slowing of growth & development
Nursing Implications in ADHD
Weigh weekly while on therapy with CNS stimulants due to potential for anorexia, weight loss, & interruption of growth and development.
Attempt a drug “holiday” periodically under direction of the physician to determine effectiveness of the medication and need for continuation.
TIC Disorder / Tourette’s Disorder
The essential feature is the presence of multiple motor tics and one or more vocal tics.
Can cause distress or interfere with social, occupational, or other important areas of functioning.
Tourette’s Disorder - Types of Tics
Simple motor tics: eye blinking, neck jerking, shoulder shrugging, and facial grimacing
Complex motor tics: squatting, hopping, skipping, tapping, and retracing steps
Vocal tics: words or sounds such as squeaks, grunts, barks, sniffs, snorts, coughs, and, in rare instances, a complex vocal tic involving the uttering of obscenities
Palilalia: repeating own words or sounds
Echolalia: repeating words or sounds of others
Pharmacological Intervention for Tourette’s Disorder
Pharmacological intervention for Tourette’s disorder is most effective when combined with other therapy, such as:- Behavioral therapy
Individual psychotherapy
Family therapy
Common medications used include haloperidol (Haldol), risperidone (Risperidal) & guanfacine (Intuniv), clonidine (catapres).
Used for severe symptoms or symptoms that impede functioning
Other Pharmacological Interventions Used for ADHD & Tourette’s
CENTRALLY ACTING ALPHA-AGONISTS: Guanfacine (Intuniv) or Clonidine.
Side Effects: CNS depression (sedation, fatigue, drowsiness); CV effects (hypotension, bradycardia); weight gain
Warnings/Nursing Implications:- Do not discontinue abruptly due to rebound BP effects
Use cautiously in patients with CV disease
Avoid use of ETOH and other CNS depressants
Oppositional Defiant Disorder (ODD)
Defined: A persistent pattern of an Angry/Irritable Mood Argumentative/Defiant Vindictiveness.- More frequent occurrence than is usually observed in individuals of comparable age and developmental level.
Interference with social, educational, or vocational activities.
Comorbidities: ADHD, Anxiety, and Depressive Disorders
ODD Symptomatology
Passive-aggressive
Stubbornness
Procrastination
Disobedience
Carelessness
Negativism
Running away
School avoidance/ underachievement
Testing of limits
Resistance to directions
Deliberately ignoring the communication of others
Unwillingness to compromise
Temper tantrums
Fighting
Argumentativeness
Conduct Disorder
Persistent pattern of behavior in which the basic rights of others and major age-appropriate societal norms or rules are violated.
Classic characteristic is the use of physical aggression in the violation of the rights of others.- Childhood-onset type
Adolescent-onset type
Frequently childhood CD results in adult antisocial personality disorder
Conduct Disorder - Common Behaviors
Use of drugs and alcohol
Sexual permissiveness
Low self-esteem manifested by a “tough-guy” image
Problems with inattentiveness, impulsiveness, & hyperactivity
Use of projection as a defense mechanism
Lack of feelings of guilt or remorse
Inability to control anger
Low academic achievement
Aggression towards people and/or animals
Other Pharmacological Interventions
ATYPICAL ANTIPSYCHOTICs: FDA approved for the treatment of Autism Spectrum disorder, Conduct disorder & Tourette’s- Risperidone (Risperdal) for children 5-16 years
Targeted for the following symptoms: Aggression, Deliberate self-injury, Temper tantrums, Quickly changing moods
Side effects: hyperglycemia/diabetes, weight gain, high cholesterol, orthostatic hypotension, anticholinergic effects, agitation, dizziness, sedation, insomnia, tremor
Caution for severe rare reactions: EPS (Extrapyramidal Symptoms)!
Separation Anxiety
Excessive fear or anxiety concerning separation from those to whom the individual is attached.
May result in tantrums, crying, screaming, complaints of physical problems (GI disturbances and headaches), clinging behaviors.
Interferes with social, academic, occupational, or other areas of functioning.
Most commonly diagnosed at ages 5-6 years.
Depression
Signs and symptoms of adolescent depression.
Treatments.
Goals.
Suicide Risk Factors
Risk factors for childhood suicide include:- Depression
Sexual abuse
Prior suicide ideation or plan
Being bullied
Substance abuse
Impulsive or aggressive behavior
Access to firearms
History of suicide in the family
Suicide is the 2nd leading cause of death for 15 to 24-year-olds.
The most common factor is the lack of or loss of a meaningful relationship.
Should be asked directly if having thoughts of harm.
New Data from a 2022 CDC Report
CDC released official mortality data that showed 45,222 firearm-related deaths in the US in 2020 for children ages 1-19.
Firearm homicides increased by 33.4%.
Firearm suicides increased by 1.1%.
New Peak.
13.5% increase from 2019 to 2020. In 2016, firearm-related deaths were 2nd only to motor vehicle crashes. Drug overdoses and poisoning increased by 83.6% from 2019 – 2020, becoming the 3rd leading cause of death in this age group.
Acetaminophen (Tylenol) Overdose
Common medication of choice for intentional OD due to accessibility.
Symptoms of toxicity (can take up to 12 hours): abdominal pain, irritability, weakness, loss of appetite, jaundice, diarrhea, nausea, vomiting, convulsions, coma.
Nursing Interventions/Treatment:- Diagnostics: acetaminophen level, electrolytes, kidney function tests, amylase, lipase, liver function tests, CBC, and coagulation factors.
If toxicity is suspected or confirmed: Antidotal therapy including N- acetylcysteine (Mucomyst) can be administered or activated charcoal (if within one hour of ingestion).
Supportive care: fluids, anti-nausea medications
Substance Use
Frequently used:- Alcohol (most used)
Marijuana
Opioids
Cocaine
Stimulants
Nicotine
Some reasons for use:- Rebelliousness
Feeling vulnerable
To decrease anxiety
Wish for closeness
Nursing Interventions Review
The main treatments for childhood mental health disorders:- Medication
Social skills training
Behavior management (milieu management)
Cognitive therapy for communication and problem-solving
Parent education – a nurse can model communication, reinforcement, and behavior management techniques so the parent can practice these techniques at home.
Coping skills – exercise, journaling, deep breathing
Setting goals – the accomplishment of goals is rewarding for a child. Provide positive feedback even when the goals are small.
Parent groups/Family therapy, group therapy, individual therapy
Adverse Child Experiences (ACEs)
Includes abuse, neglect, witnessing domestic violence, death of a caregiver, etc.
Generalized Anxiety Disorder (GAD)
Excessive anxiety or worry about multiple events or activities persisting for > 6 months and present > 50% of the time.
Obsessions (OCD)
Recurrent and persistent thoughts, impulses, or images that are intrusive and cause marked anxiety or distress.
Compulsions (OCD)
Repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession to reduce distress.
Disorder
Intellectual Developmental Disorder (IDD)
Disorder with onset during the developmental period that includes both intellectual and adaptive functioning deficits in conceptual, social, and practical domains.
Autism Spectrum Disorder (ASD)
A broad range of conditions characterized by challenges with social skills, repetitive behaviors, speech and nonverbal communication.
Attention-Deficit/Hyperactivity Disorder (ADHD)
Developmentally inappropriate degrees of inattention, hyperactivity, and impulsiveness.
TIC Disorder / Tourette’s Disorder
Multiple motor tics and one or more vocal tics causing distress or interfering with functioning.
Oppositional Defiant Disorder (ODD)
A persistent pattern of Angry/Irritable Mood, Argumentative/Defiant behavior, or Vindictiveness.
Conduct Disorder
Persistent pattern of behavior in which the basic rights of others and major age-appropriate societal norms or rules are violated.
Separation Anxiety
Excessive fear or anxiety concerning separation from those to whom the individual is attached.