Child and Adolescent Child and Adolescent Mental HealthMental Health

Cognitive developmentCognitive 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 Mental Health Problems of school Age Childrenschool Age Children

10-13% of children have serious MH problems

655,000 Texas children

Etiology of MH ProblemsEtiology of MH Problems

Genetics: strong for depression, Anxiety, OCD, Tic disorders, ADHD, bipolar

Environment: Abuse and neglect, (actually causes a change is the structure of the brain) – Fetal Alcohol Syndrome, Brain damage, poverty of

thought ( mental retardation) Neurological Anomalies

– Developmental disorders- MR-IQ below 70 , Axis II– Pervasive developmental disorders-Autism, Asperger’s,

PDD-NOS, Etc.

Resiliency in ChildrenResiliency in Children

Psychosocial disadvantage: multiple risk factors– Do not develop a psychiatric disorder– Well-adjusted adult

Environmental and constitutional elements – Not well understood– Relative or community cares for the child– Absence of Neglect– Ability to internalize and define themselves

Foster resiliency– Predictable family environment

Structure Therapeutic milieu

Resiliency in ChildrenResiliency in Children

ContentContent Developmental Disorders Attention Deficit and Disruptive Behavior Disorders

Internalization Disorders TIC Disorders Psychotic Disorders Other Psychiatric Disorders

– Eliminations Disorders– Psychotic Disorders– Mood Disorders

Depression Bipolar Disorder

Psychopharmacology Cognitive Behavioral Therapy

Developmental DisordersDevelopmental 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 and Disruptive Attention Deficit and Disruptive Behavior DisordersBehavior Disorders

ADD– Attention Deficit Disorder (Hyperactive type)– Attention Deficit Disorder (Withdrawn type)

Oppositional Defiant DisorderConduct Disorder

Attention Deficit Hyperactive Attention Deficit Hyperactive Disorder (ADHD)Disorder (ADHD)

Inattention ImpulsivityOveractivity

– Restless overactive distractible reckless disruptive

– Up to 11% of school age children– Psychological adversity

ADHDADHD

The Frontal LobeSubtle Dysfunction in the Frontal Lobe

– Reduced metabolic activity– Hypoperfusion

Treatment ADHDTreatment ADHD

Problem in the Frontal lobe, which is responsible for planning, attention, regulation of motor activity-Brain under active

Not enough dopamine available

Medication: StimulantsMedication: Stimulants

Medication: Stimulants – Ritalin (methylphenidate)– Dexedrine (dextroamphetamine)– Adderall (D,L dextroaamphetamine)

Also used for weight loss

Extended release Ritalin LA; Metadate CD, Concerta and Vyvanse decrease dosing to once daily

Adderall XR is also extended release

Medication issues for Medication issues for StimulantsStimulants

Non-extended release – Administer regular

stimulants just prior to meals to decrease anorexia

– Require noon dosing and a smaller dose in the evening to prevent rebound

– Last dose is given at 1600

Side effects– Anorexia– Weight loss– Lowers the seizure

threshold– Abnormal movements– Labile mood– Insomnia,– Hyper-focused

over focused on details

– Agitation

Non-StimulantNon-Stimulant

Tricyclic Antidepressants– Imipramine, Desipramine, Clomipramine– Concern about cardiac conduction

Clonidine (Catapress) – Developed as an antihypertensive– Reduce norepinephrine activity in the brain

Non-Stimulant: Non-Stimulant: Atomoxetine/StratteraAtomoxetine/Strattera

Has a different mode of action, not a schedule II drug

Capsule form of 10,18,25,40,60 mg

Effects reuptake of Norepinephrine

Side effects– 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; ventolin inhalers can increase

– Drug interactions: Paxil and Prozac

Disruptive Behavior DisordersDisruptive Behavior Disorders

Oppositional Defiant Disorder– 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 DisordersDisruptive Behavior Disorders

Conduct Disorder– More serious violations of social standards

– Higher than expected rates of ADHD, depression and learning disorders

Associated with Antisocial Personality Disorder (if the child does not make changes in behavior)

Pervasive Developmental Pervasive Developmental DisordersDisorders

Impairment across multiple domains (impairment is global)– Psychological Impairment– Social Impairment– Academic Impairment

– May meet the standard for Mental retardation

Pervasive Developmental Pervasive Developmental DisordersDisorders

Characterized by impairments across all domains of development– Delayed social development– Stereotypical behaviors

Hand-flapping Rocking and spinning

– Peculiar preoccupations Water moving objects Women’s noses Water Second story window

– Rigid and intolerant of change

PDD’sPDD’s

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

Pervasive Developmental Pervasive Developmental DisordersDisorders

Autistic Disorder

Asperger’s Disorder

Pervasive Developmental Disorder NOS

Autistic DisorderAutistic 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 DisorderAutistic Disorder Communications

– Delayed and deviant– Abnormal intonation– Pronoun reversals– Echolalia

Insistence on sameness and preoccupation with peculiar interests– Fans– Air conditioners– Train schedules– Windows– Water

The vaccination controversy

Asperger’s DisorderAsperger’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 Pervasive Developmental Disorder NOSDisorder NOS

Does not meet criteria for more specific type of PDD

Traits of both Autism and Asperger’s

Tic DisordersTic 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 Medications:

– haloperidol (Haldol)– clonidine (Catapress)

Other Psychiatric DisordersOther Psychiatric Disorders

Childhood Schizophrenia- 2 cases per 100,000

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, Other Psychiatric Disorders, cont’dcont’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 Depression Symptoms Specific to Younger PopulationsYounger 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 life (peer group, family, school); like “I’m stupid”

PharmocotherapyPharmocotherapy

Antidepressants– 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’dPharmacotherapy, 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’dPharmacotherapy, cont’d

Antipsychotic Agents– For aggressive behavior, self-injury, tics,

psychotic symptoms Typicals: Highly correlated with EPSEs (rarely

used) Atypicals: Weight gain problematic; fatty livers

(Zyprexa prn)

Nursing InterventionsNursing Interventions

Simple instructions; Do not say-”Clean your room” say- “Put the dirty clothes in the hamper”, Then,” Make your bed”

Teaching the family about ADHDAssess family HX and how successfulListen, support groups, booksCommunicate with teachers, School

Cognitive Behavioral TherapyCognitive Behavioral Therapy

Milieu Negative Reinforcement Positive Reinforcement Extinction Consistency Points Levels Cost Response

Social Skills TrainingSocial Skills Training

Recognize the impact of their behavior– Fail to recognize the impact on others

InstructionsRole Playing Positive Reinforcement

Problem-Solving SkillsProblem-Solving Skills

Misinterpret the intentions of others– Perceiving hostility when none is intended– Teaches a different interpretation of the behaviors of

others– Options for a response

Each option is evaluated for the consequence

– What to say: What happened? What did you do? How did that work for you? What can you do next time?

Parent TeachingParent Teaching

Importance of clear limitsPositive reinforcement

– Praise– Positive attention– Tangible rewards

Point SystemsMild punishment

– Time out

PsychotherapyPsychotherapy

Individual Therapy

Group Therapy

Family Therapy– Passes to go home prior to being discharged

Community ResourcesCommunity Resources

Support groups, camps, web resources, and literature

The EndThe End