Psychiatric Disorders of Childhood and Adolescence - Comprehensive Notes

Erikson's Developmental Stages

  • Infancy (Birth to 1 year):
    • Crisis: Trust vs. Mistrust
    • Virtue: Hope
    • Danger: Withdrawal
  • Toddler (1 to 3 years):
    • Crisis: Autonomy vs. Shame/Doubt
    • Virtue: Will
    • Danger: Compulsion/Obsessiveness
  • Preschool (3 to 5 years):
    • Crisis: Initiative vs. Guilt
    • Virtue: Purpose
    • Danger: Inhibition
  • School Age (6 to 12 years):
    • Crisis: Industry vs. Inferiority
    • Virtue: Competence
    • Danger: Inertia
  • Adolescence (12 to 18 years):
    • Crisis: Identity vs. Diffusion/Identity Confusion
    • Virtue: Fidelity
    • Danger: Role Repudiation
  • Young Adult (19 to 35 years):
    • Crisis: Intimacy vs. Isolation
    • Virtue: Love
    • Danger: Exclusivity
  • Adulthood (35 to 65 years):
    • Crisis: Generativity vs. Self-Absorption
    • Virtue: Care
    • Danger: Stagnation/Rejectivity
  • Old Age (65 and older):
    • Crisis: Integrity vs. Despair
    • Virtue: Wisdom
    • Danger: Disdain

Child and Adolescent Mental Health

  • Children are more likely to be mentally healthy if they have normal physical and psychosocial development.
  • An easy temperament allows adaptation to change.
  • Secure attachment prohibits fear of rejection.

Assessment Process

  • The assessment process for children and adolescents is similar to that for adults, with some key differences:
    • Use more specific, fewer open-ended questions because children are concrete thinkers.
    • Use simple phrases (narrower vocabulary).
    • Corroborate information with an adult.
    • Use artistic and play media.
    • Be aware of possible problems with accurate sequencing of events (less specific sense of time, less developed memory).

Techniques for Data Collection: Clinical Interview

  • Clinical interview: primary tool; dependent on the developmental level of each child.
  • Establish a treatment alliance.
  • Child and parent observation.
  • Separate child and parent interviews.
  • Discussion with the child yields more information about internalizing symptoms.
  • Discussion with parents yields more information about externalizing symptoms.
  • Development of rapport is crucial.

Development of Rapport

  • Preschool Children:
    • Difficulty putting feelings into words and thinking concretely.
    • Use of play is helpful.
    • Assessment tools: drawings.
  • School-Aged Children:
    • Ability to use constructs, provide longer explanations.
    • Rapport through competitive games; thinking-feeling-doing game.
  • Adolescents:
    • Egocentric with increased self-consciousness, fear of being shamed.
    • Communicate respect, cooperation, honesty, and genuineness.
    • Explain what information will be shared with parents; direct, candid approach.
    • Promote the adolescent's feeling of control.

Separation and Divorce

  • Half of the marriages in the United States end in divorce.
  • It creates changes in family structure.
  • Children are at increased risk for emotional, behavioral, and academic problems.
  • The first 2 or 3 years after marital breakup tend to be the most difficult.
  • Stepfamilies develop, creating a renewed risk for problems.

Separation and Divorce: Protective Factors

  • Structured home and school environment.
  • Education.
  • Regular and predictable visitations.
  • Reduction of conflict between parents.
  • Continuance of usual routines.
  • Limit setting.
  • Family counseling.

Bullying

  • Deliberate attempts to harm someone, usually unprovoked; imbalance of strength.
  • Cyber-bullying is on the increase.
  • Increased risk for becoming bullies: children with insecure attachments; with distant or authoritarian parents; and who have been physically, sexually, or verbally abused.
  • Victims of bullies: low self-esteem and relationship difficulties.

Risk Factors for Psychopathology

  • Poverty and homelessness: increased risk for physical health problems, mental health problems, and educational underachievement.
  • Child abuse and neglect: family stress, drug or alcohol abuse, unstable parent, lack of social support.
  • Substance-abusing families: poor school performance, emotional problems.
  • Out-of-home placement: stages of coping (protest, despair, detachment); coping styles such as detachment, rage, depression, antisocial behavior, low self-esteem, chronic dependency.

Adverse Childhood Experiences (ACE)

  • Traumatic events that occur during childhood, typically before the age of 18.
  • ACEs are common.
  • About 64% of adults in the United States reported they had experienced at least one type of ACE before age 18. Nearly one in six (17.3%) adults reported they had experienced four or more types of ACEs.
  • Examples of ACEs:
    • Physical, emotional, or sexual abuse
    • Neglect (physical, emotional, or medical)
    • Witnessing domestic violence
    • Substance abuse in the household
    • Mental illness in a parent or caregiver
    • Parental separation or divorce
    • Incarceration of a parent
  • Higher ACE scores are more likely to experience:
    • Chronic diseases (heart disease, stroke, cancer).
    • Mental health problems (depression, anxiety).
    • Substance use disorders.
    • Poor academic performance.
    • Relationship problems.
  • ACEs are costly.
  • ACEs-related health consequences cost an estimated economic burden of 748 billion annually in Bermuda, Canada, and the United States.
  • Prevention is key.

Intervention Approaches

  • Prevention
    • Allow maximal autonomy; keep the family intact
    • Provide appropriate level of care
    • Early intervention programs
    • Psycho-educational programs
    • Social skills training

Children Psychiatric Disorders

  • Often lack abstract cognitive ability and verbal skills
  • Constantly changing and developing
  • Behaviors depend on age development
  • Have some of same diagnosis as adults

Intellectual Disability

  • Causes
    • Hereditary
    • Early alterations in embryonic development
    • Pregnancy/Perinatal problems
    • Medical conditions (Lead poisoning)
  • Behaviors
    • Some passive/dependent
    • Aggressive and impulsive
    • Mild/Moderate cared for at home
    • Severe may require residential placement

Intellectual Disability (ID) - Levels of Severity

  • Mild:
    • 85% of ID Population
    • Can generally learn reading, writing, and math skills between third- and sixth-grade levels.
    • May have jobs and live independently.
  • Moderate:
    • 10% of ID Population
    • May be able to learn some basic reading and writing.
    • Able to learn functional skills such as safety and self-help.
    • Require some type of oversight/supervision.
  • Severe:
    • 5% of ID Population
    • Probably not able to read or write, although they may learn self-help skills and routines.
    • Require supervision in their daily activities and living environment.
  • Profound:
    • 1% of ID Population
    • Require intensive support.
    • May be able to communicate by verbal or other means.
    • May have medical conditions that require ongoing nursing and therapy.

Neurodevelopmental Disorders

  • Attention Deficit Hyperactivity Disorder
  • Autism spectrum disorders
  • Asperger's Disorder
  • Childhood disintegrative disorders
  • Rett's Disorder
  • Pervasive developmental disorders

Autism Spectrum Disorders

  • Previously called pervasive developmental disorders.
  • Characterization
    • Pervasive and usually severe impairment
    • Reciprocal social interaction skills
    • Communication deviance
    • Restricted stereotypical behavioral patterns
    • Can range from mild to very severe behaviors/limitations

Autism Disorder

  • More prevalent in boys than girls.
  • Identified usually by 18 months to 3 years of age.
  • Limited eye contact.
  • Few facial expressions toward others.
  • Limited gestures.
  • Limited capacity to relate to others.
  • Little intelligent speech.
  • Stereotyped motor behaviors.

Autism Disorder Continued

  • 80% early onset in infancy
  • 20% normal growth and development till age 2/3
  • Genetic link
  • Controversy continues with vaccines
  • Tends to improve with the use of language/communication
  • Social skills rarely improve to be completely independent

Autism Spectrum

  • Asperger syndrome
    • Severe and sustained impairment in social interaction and restricted, repetitive patterns of behavior, interests, and activities.
    • Age-appropriate language and intelligence.
    • "Milder form of autism"

Goal of treatment

  • Reduce behavioral symptoms
  • Promote learning and development
  • Comprehensive/individualized treatment plan
  • Special education/language therapy
  • Cognitive behavioral therapy

Interventions cont.

  • Collaborating with family
  • Promoting interaction
  • Ensuring predictability and safety
  • Managing behavior
  • Supporting the family

Pharmacologic treatments

  • Antipsychotics
    • Haloperidol/Risperidone/Aripiprazole
    • Target symptoms: temper tantrums, aggression, self-injury, hyperactivity, and stereotyped behaviors
  • Other medication
    • Naltrexone (ReVia), Clomipramine (Anafranil), clonidine (Catapres), and stimulants
    • Target symptoms: diminish self-injury and hyperactive/obsessive behaviors

Assessment and intervention

  • Classroom behavior, school performance, teacher rating
  • Standardized instruments
  • Developmental history; medical history
  • Eating, sleeping, and activity patterns
  • Hyperactivity
  • Modifying nutrition
  • Promoting sleep
  • Administering and teaching about pharmacologic agents
  • Behavioral programs: rewards for positive behavior

Stimulants

  • Methylphenidate (IR and SR)
    • Ritalin-IR
    • Sustained release- Concerta
  • Dextroamphetamines (IR and SR)
    • Lisdexamfetamine
    • Vyvanse
  • Amphetamines- (IR/SR)
    • Adderall

Disruptive Behavior Disorders

  • Characterized by persistent patterns of behavior that involve anger, hostility, and/or aggression toward people and property
  • Oppositional Defiant Disorder (ODD)
  • Intermittent explosive disorder (IED)
  • Conduct disorder

Disruptive Mood Dysregulation Disorder (DMDD)

  • DMDD symptoms usually begin before the age of 10. A child with DMDD experiences:
    • An irritable or angry mood most of the day, almost every day.
    • Severe temper outbursts (verbal or behavioral) that are out of proportion to the situation. These usually happen three or more times per week.
    • Issues with daily functioning due to irritability in more than one environment, such as at home, at school, or with their peers.

Oppositional Defiant Disorder (ODD)

  • Enduring pattern of uncooperative, defiant, disobedient, and hostile behavior toward authority figures
  • Diagnosed only when behaviors are more frequent and intense and affect functioning
  • More often in boys; prevalence in girls is growing
  • Limited ability to see consequences of behavior (both positive and negative)
  • Prognosis varies with age of onset, symptom severity, and comorbid psychiatric disorders
  • Treatment based on parent management training models of behavioral interventions

Interventions

  • Limit setting
    • Inform of rule/limit
    • Explain consequence if breaks rules/limits
    • State expected behaviors
  • Improving coping skills and self-esteem
    • Validate worth even if behavior is unacceptable
    • Practice problem-solving techniques
  • Promoting social interaction
    • Role model appropriate social interactions.
  • Providing education for the client/family
    • Teaching is effective if behavior stops

Anxiety Disorders: Separation Anxiety Disorder

  • Fear and anxiety developmentally inappropriate
  • Worry about harm to or permanent loss of major attachment figure
  • School phobia as a common manifestation of anxiety
  • Onset usually between 7 and 9 years
  • Risk factors: parents with anxiety disorder (one or both), parental depression
  • Nursing management

Anxiety Disorders: Obsessive-Compulsive Disorder

  • Intrusive thoughts (obsessions), ritualized behaviors (compulsions), or both
  • More than half of children have a comorbid disorder (tics, mood or anxiety disorder)
  • Treatment: cognitive behavior therapy, psycho-education, cognitive training, exposure and response preventions, relapse prevention, SSRIs
  • Nursing management: distinguish between normal and pathologic; interventions based on developmental needs; antidepressants and close monitoring ("black box warning")

Mood Disorders

  • Depression accounts for the largest percentage
  • Females more commonly affected
  • Children are more likely to show suffering through behavior rather than expression of feelings.
  • Therapeutic relationship, education, and support
  • Medications
    • Antidepressants for depression (use of SSRIs requiring frequent monitoring)
    • Mood stabilizers or antipsychotics for bipolar disorders

Childhood Schizophrenia

  • Diagnosed by same criteria as in adults
  • Poorer premorbid functioning than later (adult) onset
  • Nursing management similar to that for an adult with the disorder
  • Antipsychotics for symptoms
  • Parent education
  • Long-term management