Objective 12- child and adolescents

MENTAL ILLNESS IN CHILDREN AND ADOLESCENTS IN CANADA

  • Statistics: Many children and adolescents experience mental illness in Canada, yet many remain unnoticed and undiagnosed.

  • Suicide: The leading cause of death among adolescents (Statistics Canada, 2022).

  • Refer to Box 27-2 for characteristics of mental health conditions in children and adolescents.

Disorders of Children and Adolescents

  • Neurodevelopmental Disorders:

    • Intellectual Development Disorder

    • Neurodivergent Disorders:

    • Autism Spectrum Disorder (ASD)

    • Down Syndrome

    • Attention Deficit Hyperactivity Disorder (ADHD)

    • Learning Disorder

    • Motor Disorder

  • Conduct Disorders:

    • Conduct Disorder (CD)

    • Oppositional Defiant Disorder (ODD)

  • Affective Disorders: Including Anxiety and Depression (with a focus on suicide risk).

ETIOLOGY OF MENTAL DISORDERS

Biological Factors

  • Genetics: Relevant in disorders such as Autism, Schizophrenia, ADHD, and Bipolar Disorder.

  • Brain Development: Myelination of brain fibers in early childhood is crucial for information processing.

  • Neurotransmitters: Important role of norepinephrine and serotonin in mental health.

  • Temperament: Involves aspects like resilience and adaptability to change.

Environmental Factors

  • Influence of poverty, abuse, divorce, and foster care on mental health.

Cultural Factors

  • The impact of societal values and beliefs on behaviors related to mental health.

NEURODEVELOPMENTAL DISORDERS

Common Types

  1. Intellectual Development Disorder

  2. Communication Disorder

  3. Learning Disorder

    • Assessment should include:

      • Obtaining family history and developmental milestones.

      • Assessment of developmental stage and interaction abilities.

      • Use of semi-structured interviews.

      • Collaboration with other disciplines is often necessary.

Box 27-3: Types of Assessment Data

INTERVENTIONS AND TREATMENTS

  • Focus on deinstitutionalization of care.

  • Recommended interventions include:

    • Providing environmental stimulation.

    • Offering familiar comfort objects (e.g., toys, blankets).

    • Assisting with Activities of Daily Living (ADLs).

    • Employing cognitive therapy.

    • Implementing protective measures if the child exhibits aggression or violence.

    • Providing family education and utilizing community resources.

    • Promoting collaborative management strategies.

AUTISM SPECTRUM DISORDER (ASD)

Etiology

  • Etiology remains unknown; symptoms typically manifest within the first three years of life; however, few cases are diagnosed before school age.

  • Prevalence: Approximately 1 in 66 children/youth are affected in Canada.

Symptoms/Signs (S/S)

  • Difficulty with verbal/non-verbal communication.

  • Language delays including babbling and echolalia.

  • Lack of imaginative play.

  • Minimal response or participation; poor eye contact during social and play activities.

  • Indifference to affection or physical contact.

  • Stereotypical behaviors and fixation on routines.

  • Difficulty adjusting to changes in routine.

  • Statistically more common in males (3 times) compared to females, with girls often facing greater intellectual challenges.

Assessment Strategies

  • No specific screening tools currently exist for ASD.

  • Review physical health and neurological status, including assessment of sleep and appetite patterns.

  • Evaluate psychosocial activity patterns, communication skills, and behavioral triggers.

  • Observe for signs of agitation and repetitive behaviors.

  • Investigate flexibly the child's response to changes in routine.

  • Note: There is no correlation between immunizations and the onset of ASD. Earlier diagnosis and intervention generally lead to more positive developmental outcomes.

Treatment/Interventions

  • Management should adapt to varying levels of severity of ASD.

  • Ensuring a safe, consistent, and structured environment.

  • Encouragement of social interactions through intensive, one-on-one interventions.

  • For outbursts, implement cooling periods and reduced stimulation strategies.

  • Collaborative management involving counseling, family support, and resources.

  • Consideration of medications as necessary.

ATTENTION-DEFICIT HYPERACTIVITY DISORDER (ADHD)

Etiology

  • Biological Factors:

    • Genetic predispositions and neurodevelopmental influences.

    • Dysregulation of neurotransmitters (dopamine and serotonin).

  • Developmental Factors:

    • CNS infections (e.g., meningitis) and brain injuries.

  • Psychosocial Factors:

    • Factors such as poverty and abuse can contribute to the disorder.

Symptoms

  • Inattention: Difficulty listening and easily distracted.

  • Hyperactivity: Characterized by fidgeting and excessive talking.

  • Impulsivity: Includes behaviors like interrupting and blurting out.

Assessment

  • Conduct a comprehensive assessment through history taking, observations, and interviews to identify behaviors related to inattention, hyperactivity, and impulsivity.

  • Collaborate with families, schools, and caregivers due to the absence of definitive diagnostics.

Interventions and Treatment

  • Adopt a firm and consistent approach.

  • Use of familiar objects for comfort during treatment.

  • Engage in play therapy for younger children.

  • Ensure proper nutrition, sleep, and environmental organization to minimize distractions.

  • Provide psychotherapy through individual and family-based therapies.

  • A multidisciplinary approach is essential, involving collaboration with families and schools.

  • Educate families on social skills correlating with ADHD.

Medications

  • Methylphenidate (Ritalin): - Highly effective, however, poses a risk for abuse.

  • Alternative options include Concerta, Vyvanse, Adderall XR (only available in Canada), and Atomoxetine (Strattera).

MOTOR DISORDERS

Etiology

  • The etiology is largely unknown although common in childhood.

  • Stereotypic Movements: Involves repetitive movements such as rocking or waving, typically noticeable by age 3 and may persist for years.

Interventions

  • Safety promotion and injury prevention are crucial.

  • Distraction techniques can be helpful; typically, medications are not prescribed except in severe cases such as Tourette's Disorder (TD).

Tourette's Disorder

  • Characterized as the most severe tic disorder, often co-occurring with ADHD and OCD.

  • Onset: Typically around ages 4-6; more common in boys.

  • Individuals can suppress tics for brief periods.

Assessment for Tourette's Disorder

  • Review developmental milestones, mental status examination (MSE), and assess social interactions, since tics can impact social and academic performance.

Treatment

  • Behavioral therapy, particularly habit reversal therapy.

  • Medications are prescribed only if the tics cause distress, with low doses of Abilify showing effectiveness.

DISRUPTIVE, IMPULSE CONTROL & CONDUCT DISORDER

Included Disorders

  • Oppositional Defiant Disorder (ODD)

  • Conduct Disorder (CD)

Etiologies

  • Developmental factors affecting behavior.

  • Psychosocial and environmental influences.

  • Socio-cultural contexts.

Symptoms of ODD

  • Patterns of disobedience, argumentativeness, hostility, anger outbursts.

  • Trouble with friendships and a tendency to blame others for issues without violating rights of others.

Symptoms of Conduct Disorder (CD)

  • Typically presents before age 10.

  • Aggressive behavior towards people and animals; property destruction; deceitful behavior.

  • School invasions (truancy/failure) and juvenile delinquency.

  • Characterized by callousness and lack of empathy, often leading to intimidation of others.

ASSESSMENT FOR ODD & CD

  • Conduct thorough assessment on history, behavioral triggers, cognitive abilities, and child’s self-assessment regarding their behavior.

  • Evaluation of social skills and communication, and inquiring about substance misuse.

Interventions

  • Create a safe environment to build rapport and trust.

  • Employ behavioral therapeutic techniques (including role-playing).

  • Establish clear expectations and limits.

  • Include family education about limits, therapy expectations, substance regulation, and medication management.

Medications

  • Prescriptions typically aimed at managing outbursts and co-morbid conditions, including stimulants or mood stabilizers like Risperidone.

BULLYING

  • Defined as repetitive behavior demonstrating an imbalance of power, featuring:

    • Harmful actions

    • Repetitive nature

    • Disproportionate power dynamic.

Types of Bullying

  1. Physical

  2. Verbal

  3. Relational

  4. Cyberbullying

Nursing Roles in Bullying

  • Early assessment for signs of bullying.

  • Screening and collaboration with families and schools.

ANXIETY DISORDERS

Prevalence

  • Higher prevalence than all other mental health disorders, with normal fears becoming problematic when they affect daily functions.

Risk Factors

  • Genetic influences, family conflicts, divorce, poverty, trauma, and mental illness.

Symptoms of Separation Anxiety Disorder

  • Commonly develops in infants less than 1 year of age, involving physical symptoms like headaches and stomachaches, persistent worry about separation from caregivers.

Generalized Anxiety Disorder

  • Affects approximately 10% of children with symptoms including difficulty concentrating, restlessness, and sleep disturbances.

Assessment of Anxiety Disorders

  • Investigate onset, recent behavioral changes, relationship with caregivers, and coping mechanisms.

Interventions

  • Develop a safe environment that promotes emotional support.

  • Foster psychosocial needs and coping skills.

  • Implement Cognitive Behavioral Therapy (CBT) and other psychotherapies.

  • Hospitalization or day treatment may be warranted in severe cases.

Medications for Anxiety

  • Possible use of SSRIs (Fluoxetine (Prozac) or anti-anxiety medications).

  • Utilize resources such as Bridge the Gap and family education programs.

MOOD DISORDERS

Influencing Factors

  • Genetic, neurotransmitter, and environmental influences alongside puberty.

Symptoms

  • Similarities to adult mood disorders: sadness, hopelessness, anhedonia, withdrawal, and mood alterations.

  • In children, 'acting out' is commonly seen with behaviors rather than verbal expression of feelings.

Assessment for Mood Disorders

  • Assess mood, feelings, severity and duration of symptoms, recent stressors, coping strategies, and any familial psychiatric history.

Interventions

  • Establish rapport through safety measures.

  • Suicide assessments are key, along with assessments of psychological and physical health aspects.

  • Therapeutic options include psychotherapy, SRIs (e.g., Celexa and Paxil).

SCHIZOPHRENIA IN CHILDHOOD

  • Early onset of Schizophrenia is rare (<1% of children) and typically develops in late adolescence due to neurostructural/neurochemical changes.

Symptoms

  • Hallucinations (less severe than in older individuals, typically visual), delusions, and disorganized speech.

Assessment and Interventions

  • Assessment includes history taking, behavioral changes monitoring, and thorough physical health evaluations.

  • Recommended treatments: medications, safe environments, family support, and educational resources.

CONTINUUM OF CARE

  • Inpatient or day programs ensuring:

    • Individual or family therapy.

    • Peer relationship development through group therapy.

    • Art and music therapy for expression.

    • Behavioral modifications to address and alter harmful behaviors.

    • Collaborative community and school interventions.

  • Refer to drug treatment guidelines for child/adolescent disorders.

  • Utilize national resources such as Kids Help Phone for additional support.