Child and Adolescent Mental Health

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 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.

5. Resiliency in Children Resiliency 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

6. Content • Developmental Disorders • Attention Deficit and Disruptive Behavior DisordersInternalization Disorders • TIC Disorders • Psychotic Disorders • Other Psychiatric Disorders • Eliminations Disorders • Psychotic Disorders • Mood Disorders • Depression • Bipolar Disorder • 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 and Disruptive Behavior Disorders • ADD • Attention Deficit Disorder (Hyperactive type) • Attention Deficit Disorder (Withdrawn type) • Oppositional Defiant Disorder • Conduct Disorder

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

10. ADHD • The Frontal Lobe • Subtle Dysfunction in the Frontal Lobe • Reduced metabolic activity • Hypoperfusion

11. Treatment ADHD • Problem in the Frontal lobe, which is responsible for planning, attention, regulation of motor activity-Brain under active • Not enough dopamine available

12. Medication: 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

13. 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 Medication issues for Stimulants

14. Non-Stimulant • Tricyclic Antidepressants • Imipramine, Desipramine, Clomipramine • Concern about cardiac conduction • Clonidine (Catapress) • Developed as an antihypertensive • Reduce norepinephrine activity in the brain

15. 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 Non-Stimulant: Atomoxetine/Strattera

16. Disruptive 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

17. Disruptive 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)

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

19. Pervasive Developmental Disorders • 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

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

21. Pervasive Developmental Disorders • Autistic Disorder • Asperger’s Disorder • Pervasive Developmental Disorder NOS

22. 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

23. Autistic 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

24. 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

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

26. 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 • Medications: • haloperidol (Haldol) • clonidine (Catapress)

27. Other 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

28. 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?

29. 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 life (peer group, family, school); like “I’m stupid”

30. Pharmocotherapy • Antidepressants • 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 (rarely used) • Atypicals: Weight gain problematic; fatty livers (Zyprexa prn)

33. Nursing 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 ADHD • Assess family HX and how successful • Listen, support groups, books • Communicate with teachers, School

34. Cognitive Behavioral Therapy • Milieu • Negative Reinforcement • Positive Reinforcement • Extinction • Consistency • Points • Levels • Cost Response

35. Social Skills Training • Recognize the impact of their behavior • Fail to recognize the impact on others • Instructions • Role Playing • Positive Reinforcement

36. Problem-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?

37. Parent Teaching • Importance of clear limits • Positive reinforcement • Praise • Positive attention • Tangible rewards • Point Systems • Mild punishment • Time out

38. Psychotherapy • Individual Therapy • Group Therapy • Family Therapy • Passes to go home prior to being discharged

39. Community Resources • Support groups, camps, web resources, and literature

40. The End