1. Child and Adolescent Mental Health

2. 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.

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

4. 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.

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

6. 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

7. 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

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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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.

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

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

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

19. 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

20. 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

21. 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

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

23. 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)

24. 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

25. 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?

26. 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”

27. 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

28. 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

29. 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

30. 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

31. 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

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

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

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