Child and Adolescent Mental Health

Cognitive Development Moves from concrete thinking to “formal operations” -Abstract thinking Level of thinking allows the person to transfer information from one situation to another, deal efficiently with complex problems, and plan realistically for the future. Physical development precedes cognitive development The last part of the brain to mature is the prefrontal cortex Adolescence is a time of profound change in brain function.

Mental Health Problems of School Age Children 10-13% of children have serious MH problems 655,000 Texas children

Etiology of MH Problems Genetics: strong for Depression, Anxiety, OCD, Tic disorders, ADHD, Bipolar Environment: Abuse and neglect, (actually causes a change in structure of the brain) Intrauterine: Fetal Alcohol Syndrome Other: Poverty, Lead poisoning, Brain injury, etc.

Etiology, cont’d Neurological Anomalies Developmental disorders- MR-IQ below 70 , Axis II Pervasive developmental disorders-Autism, Asperger’s, PDD-NOS, Etc.

Main Content Developmental Disorders Attention Deficit and Disruptive Behavior Disorders Pervasive Developmental Disorders TIC Disorders Psychotic and Mood Disorders Elimination Disorders Psychopharmacology Cognitive Behavioral Therapy

Developmental Disorders Mental Retardation IQ< 70 Pervasive Developmental Disorders Autistic Disorder Asperger’s Disorder Pervasive Developmental Disorder NOS Specific Developmental Disorders Learning Disorder Communication Disorders Speech and language disorders are strongly associated with psychiatric disorders

Attention Deficit Hyperactivity Disorder (ADHD) Inattention Impulsivity Overactivity Restless overactive, distractible, reckless, disruptive Up to 11% of school age children Psychological adversity

Etiology of ADHD: Neurobiology Frontal Lobe Dysfunction: area of brain responsible for planning, attention, regulation of motor activity “Underactive brain” Reduced metabolic activity Not enough Dopamine Hypoperfusion

Pharmacotherapy for ADHD Stimulants: methylphenidate (Ritalin), detroamphetamine (Dexedrine), and mixed amphetamine (Adderall) Extended release--Ritalin LA; Metadate CD and Concerta--decrease dosing to once daily Adderall XR is also extended release

Stimulant Medication Issues Dose regular stimulants just prior to meals to decrease anorexia Non-extended release require noon dosing and a smaller dose in the evening to prevent rebound Side effects: anorexia, weight loss, abnormal movements, labile mood, insomnia, over focused on details, agitation

Other Medications for ADHD clonidine (Catapres) also used: reduce norepinephrine activity in the brain atomoxetine (Strattera) Has a different mode of action from amphetamines, not a schedule II drug Capsule form of 10,18,25,40,60 Mgm Affects reuptake of Norepinephrine

Side Effects of Strattera Most common: dyspepsia, nausea, vomiting, fatigue, appetite decreased, dizziness, and mood swings Less common: insomnia, sedation, depression, tremor, itching, dry eyes, sexual dysfunction Adverse events: Increased heart rate and blood pressure--albuterol inhalers can increase CV effects Drug interactions: Paxil and Prozac

Disruptive Behavior Disorders Oppositional Defiant Disorder (ODD) Enduring pattern of disobedience Argumentative Explosive (Impulsive) Frequently in conflict with adults Tendency to blame others Comorbid Diagnosis with ADHD, anxiety and mood disorders

Disruptive Behavior Disorders, cont’d Conduct Disorder More serious violations of social standards Higher than expected rates of ADHD, depression and learning disorders Associated with adult Antisocial Personality Disorder dx.

Pervasive Developmental Disorders Impairment across multiple domains (impairment is global) Psychological Impairment Social Impairment Academic Impairment May meet the standard for Mental retardation

Pervasive Developmental Disorders Autistic Disorder Asperger’s Disorder Pervasive Developmental Disorder NOS

PDD’s Are now viewed as being on the same spectrum, differentiated by severity of symptoms and impairment

Autistic Disorder Early Age of onset 30 months of age Constant delayed development Social relatedness is profoundly impaired Aloof and indifferent to others Prefer inanimate objects to human contact Stereotypical Behaviors Rocking and Hand flapping

Autistic Disorder, cont’d Alteration in Communication Delayed and deviant Abnormal intonation Pronoun reversals Echolalia Insistence on sameness and preoccupation with peculiar interests The vaccination controversy

Asperger’s Disorder Less likely to be mentally retarded Communication handicap is less severe Concrete interpretation of language Stilted and abnormal intonation Higher performing Social interactions impaired Impaired reading of social cues Clumsy Difficulty with transition Preoccupation with matters of private interest

Pervasive Developmental Disorder NOS Does not meet criteria for more specific type of PDD Traits of both Autism and Asperger’s

Tic Disorders Tourette’s Syndrome -Movement disorder defined by the presence of motor and phonic tics: Rare 1 to 2 per thousand Motor Tics-rapid, jerky movements of eyes, face, neck, and shoulders Phonic tics: grunting, throat clearing, and repetitive noises Can be words or obscenities Treatment: haloperidol (Haldol), clonidine (Catapres)

Other Psychiatric Disorders Childhood Schizophrenia- 2 cases per 100,000 Compare with Autism Anxiety Disorders: Separation anx. and OCD Elimination Disorders-often accompany other disorders or as response to stress Enuresis –bedwetting and/or incontinence during the day Encopresis—fecal incontinence, soiling or inappropriate depositing of feces Fecal impaction may cause or result

Other Psychiatric Disorders, cont’d Bipolar D/O and Schizophrenia—Primarily dx. in adolescence Depression: risk increases when a parent is depressed. How are the symptoms of depression in children and adolescents different from the symptoms seen in adults?

Depression Symptoms Specific to Younger Populations In Children Lack of verbal skills affects expression: may be irritable or resistant In Adolescents Blues in boys; aggressive behavior or acting out Blues in girls; anxiety, eating disorders, and or self-cutting. 2 symptoms to be concerned about: difficulty concentrating and negative statements about themselves and their place in it; like “I’m stupid”

General Nursing Interventions for Children: A Behavioral Focus Keep it simple, structured, and re-enforce good behavior “It is unsafe to jump down stairs 2 at a time” “You walked down the stairs in a safe way” “It is not OK to grab a toy from another child, you must ask” Simple step-by-step instructions Daily routine & short term rewards/re-enforcers

Other Interventions Cognitive-Behavioral Therapy Useful for long term tx. e.g. for OCD, negative thinking in depression, anxiety May be used in inpatient settings as part of milieu management “Reinforcement” concepts (negative/positive) Points and levels “Extinguishes” negative thinking Social Skills Training- e.g. for Asperger’s Problem Solving Skills- reinterpretation of environment

More Nursing Interventions Teach the family about disorders, symptoms and intervention techniques Assess family HX Listen; be objective when hearing what family has to say Identify family strengths and successes Communicate with teachers, school Passes to go home prior to discharge

Pharmocotherapy Antidepressants  Also used for OCD SSRIs : fluoxetine (Prozac)  sertraline (Zoloft)  fluvoxamine (Luvox)  paroxetine (Paxil) citalopram (Celexa) escitalopram (Lexapro) None are yet officially FDA approved!  Also used for OCD

Pharmacotherapy, cont’d SSRIs, cont’d Activating effects may precipitate hypomania, mania or suicide TCAs –have been used for many years but effectiveness not proven

Pharmacotherapy, cont’d Antipsychotic Agents For aggressive behavior, self-injury, tics, psychotic symptoms Typicals: Highly correlated with EPSEs Atypicals: Weight gain problematic; fatty livers

Interventions: Psychotherapy Individual Therapy Play therapy for children Group Therapy Family Therapy

Community Resources Support groups, camps, web resources, and literature