Mental Health Lecture Salem State College

1. Mental Health LectureSalem State College Kristine Ruggiero, CPNP, MSN, RN Child Health Nursing: Partnering with Children and Families; Ch 34 pp1369-1384; 1396-1401

2. Mental Health • Sense of personal well-being involving successful engagement in activities and relationships and the ability to adapt to and cope with change.

3. Mental Health • Many children who need services don’t receive them • 25% of children in the US suffer from mental illness that impairs functioning at home or school • Only 30% of those children receive MH services • Many of these interventions are not comprehensive, multidisciplinary or evidence-based • MH issues are among the top 2 leading causes of hospitalization in 10-21 year-olds • Indicates children are not receiving adequate MH services

4. Mental Health Assessment • Appearance • Behavior • Development • History • Prenatal, natal and post-natal hx • Assessment: • Include a valid, reliable tool to assess behavioral/ mental health problems

5. Mental Health Disorders in Children • Pervasive Developmental Disorders • Autistic disorder • Asperger’s syndrome • Rett’s disorder • Childhood disintegrative disorder • Pervasive developmental disorder NOS • Attention Deficit Disorders • Cognitive Disorders • Trisomy 21 • Fragile X • FAS

6. Pervasive Developmental Disorders • Aka “Autistic Spectrum Disorders” • 5 types • Begin in early childhood • Characterized by impaired social interactions and communication, with restricted interests, activities, and behaviors • about 2 or more/ 1,000 are dx w/ ASD • 4X more common in males

7. Pervasive Developmental Disorders • It can be difficult to know at first if a child has a pervasive developmental disorder (PDD). PDDs are a wide spectrum of social and communication disorders, including autism, that can be complicated to diagnose. • However, there are acknowledged criteria for determining if a child has a PDD and there are ways to help children with these disorders at an early age. Typically, the symptoms should be recognizable before a child is 3 years old. Although a toddler's behaviors might seem to fit the criteria, they also might just be part of a youngster's developing personality.

8. Autistic Disorder • Autism and Genetics: • Some genetic contribution • Familial incidence • Monozygotic twins: 60% autism: 92% PDD • Dizygotic twins: 0% autism: 10-30% PDD • Sibling risk: 4-7% • Increased risk with genetic differences • Fragile X, Williams Syndrome, Angleman’s

9. Autistic Disorder • Impaired social, communication and behavioral development usually noted in the first year of life • Impaired social interaction • Stereotypy (rigid obsessive behavior) • Head banging, twirling, flapping hands • Impaired Communication • Speech delay or language difficulty (often 1st symptom) • Echolalia (parroting of what is heard) • Use of “you” in place of “I“ • Restricted or repetitive patterns of behaviors

10. Autism specific characteristics • Difficulty mixing with other children • Inappropriate laughing • Little or no eye contact • Insensitive to pain • Prefers to be alone • Spins objects • Physical over-activity or extreme under activity • Insistence on sameness • No real fear of dangers • Sustained odd play • Echolalia • May not want to cuddle • Not responsive to verbal cues • Tantrums • Uneven gross or fine motor skills • Difficulty expressing needs

11. Autistic Disorder • Onset prior to age 3 • Remember this disorder occurs on a spectrum • Clinical Therapy: • Early intervention is key to maximize outcomes…this means early assessment and dx is key to treatment!...Screening tools in primary care! • Interventions focus on improving behaviors and communication skills, PT and OT, structuring play interactions with other children, educating parents of child’s needs • Combination of behavioral and cognitive tx

12. Behaviors and ASDs • Strong preference for routine • Perseveration • Focus on same nonfunctional activity for hours • Restricted range of interests • Stereotypical behaviors • Spinning, hand flapping

13. Red Flags for Autism Spectrum Disorder • No Babbling at 12 months • No gesturing (pointing, waving) at 12 months • No single words at 16 months • No 2-word phrases at 24 months • Any loss of language/ social skills at any age

14. Nursing Assessment and Diagnosis • Nursing assessment: Early and frequesnt developmental screening is KEY! • Nursing Dx include: • Impaired verbal communication • Impaired social interaction • Disturbed thought processes • Risk for injury • Risk for caregiver role strain

15. Early Intervention Services • State program run by DPH • Services for children 0-3 • Children who are at risk d/t • Biological factors • Environmental factors • Psychological factors

16. Asperger’s Syndrome • Clinical manifestations: • Impaired social interactions w/ normal language development for age; pitch, tone and other speech characteristics may be abnormal. • Verbal skills involving spelling and vocabulary are high with concept formation, language flexibility, and comprehension low. • So, the child w/ Asperger’s can have normal language development and normal or above normal cognition, but will have impairments in social interactions and functioning

17. Asperger’s Syndrome • Treatment: • Applied Behavior Analysis • Positive Reinforcement • Language and communication therapy • Social skills training • Medications: • No tx for core sxs of social and relationship problems • Meds target some secondary sxs: hyperactivity, aggression and anxiety • Common drug used= Risperidone • Decreases abberant behavior (aggression, hyperactivity)

18. Rett’s Disorder • Early development appears normal and sxs appear b/t 6-18 months • Affects only girls (X-linked dominant disorder) • Ataxia, hangwringing, intermittent hyperventilation, dementia, and growth retardation show progressive increase.

19. Childhood Disintegrative Disorder • Fist 2-5 years of development appear normal followed by deterioration in many areas of functioning. Behaviors finally stabilize at some point w/o further deterioration. • Clinical therapy: • Focuses on areas of developmental function that show abnormality. • IEPs for school

20. Pervasive Developmental Disorder NOS • PDD NOS: severe social impairment w/o meeting DSM criteria for other types of autistic spectrum disorders. • Clinical Tx: • Focuses on building social skills

21. Attention Deficit Hyperactivity Disorder • Background: The term attention deficit is misleading. In general, the current predominating theories suggest that persons with ADHD actually have difficulty regulating their attention; inhibiting their attention to nonrelevant stimuli, and/or focusing too intensely on specific stimuli to the exclusion of what is relevant. In one sense, rather than too little attention, many persons with ADHD pay too much attention to too many things, leading them to have little focus.

22. ADHD • Frequency: • In the US: The prevalence of ADHD in children appears to be 3-7%. ADHD is associated with significant psychiatric comorbidities. • Approximately 50-60% of individuals with this disorder meet DSM criteria for at least 1 of the possible coexisting conditions, which include learning disorders, restless-legs syndrome, depression, anxiety disorder, antisocial personality disorder, substance abuse disorder, conduct disorder, and obsessive-compulsive behavior. • The risk of a person having ADHD if his or her family member has ADHD or one of the disorders commonly associated with ADHD is significant.

23. ADHD • According to the DSM IV, the essential features of ADHD include: • persistent and developmentally inappropriate pattern of inattention, impulsivity, and/ or hyperactivity • presence of sxsb/f 7 y.o.a • Impairments apparent in at least two different settings (ie home and school) • Interference w/ social, academic, or occupational function • Sxs are not d/t some other psychiatric disorder

24. ADHD • Occurs 4X more often in boys • Multifactorial etiology • Genetics • Environment • Biologic risk • Three subtypes • ADD (primarily inattentive) • ADHD (primarily hyperactive-impulsive) • Combined

25. ADHD • In obtaining the PMHx, it is important to thoroughly review the social hx, • including school performance, substance abuse, and violence in the home, etc.

26. Treatment for ADHD • School or education interventions • The age of the child at initial diagnosis and the severity of the symptoms of ADHD likely affect the extent to which the child benefits from working with education specialists. • Psychotherapeutics • For adolescents, ADHD coaching, participating in a support group, or both can help normalize the disorder and assist them in obtaining well-focused peer feedback and general information. • affected children and their families. • Behavioral modification and family therapy are usually necessary for optimal care.

27. Treatment of ADHD • Medications: • Stimulants: • Amphetamines (Adderall) • Methylphenidate (Ritalin, Concerta) • Pemoline (Cylert) • Dextroamphetamine (Dexedrine) • Nonstimulants • Bupropion (Wellbutrin) • Atomoxetine (Strattera)

28. ADHD • For children, a major side effect of some of the stimulant medication for treatment of ADHD is what?

29. Nursing Interventions for ADHD • Monitor G+D; if child is receiving methylphenidate growth may be slowed • Give one instruction at a time to a child w/ ADHD • Give meds in morning and at lunch to avoid interfering w/ sleep • Ensure adequate nutrition • Provide consistency and routine w/ schedule (teach parents)

30. Cognitive Disorders • Learning disabilities • Trisomy 21 • Fragile X • Fetal Alcohol Syndrome

31. Learning Disabilities • Prefer to call them Learning Differences • Affects 5% of school children • They involve neurologic conditions in which the brain cannot receive or process information in the “normal” manner. • Often the impairment is only in 1 or 2 types of learning making the dx difficult • Children should have IEPs established w/ realistic goals • Nurses role: ID of children w/ learning disabilities, help to access services for child/family w/in the community

32. Mental Retardation • Mental retardation is not something you have, like blue eyes, or a bad heart. Nor is it something you are like short or thin. • It is not a medical disorder or a mental disorder. • Mental retardation is a particular state of functioning that begins in childhood and is characterized by limitation in both intellectual and adaptive skills.

33. Mental Retardation • MR is defined as significant limitation in intellectual functioning and adaptive behavior. • IQ below 70-75 • Mild retardation occurs in 3-6 per 1,000 people • MR affects about 3% of the population. Occurs b/f age 18 • Causes: • Prenatal errors in the development of the CNS • Prenatal or postnatal changes in the biologic environment of the person • External forces leading to CNS damage

34. Trisomy 21 • One in every 733 live births • More frequent in mothers over 35 years of age • Wide range of intellectual abilities • Medical risks • Cardiac • Immunologic • ENT • GI • Thyroid disorders • Alzheimer’s

35. Trisomy 21 prenatal diagnosis • Triple screen: newest test for Down’s syndrome • Maternal alpha feto protein, nonspecific test, increase indicates risk • Amniocentesis • Chorionic villus sampling • In 2002, a study found that 91-93% of pregnancies w/ a dx of Down’s syndrome were terminated

36. Trisomy 21 characteristics • Single transverse palmar crease • Almond shape to the eyes (epicanthal fold) • Upslanting paperbral fissures • Shorter limbs • Poor muscle tone • Larger than normal space b/t the big and second toe • Protruding tongue • Low set ears

37. Fragile X Syndrome • Most common known cause of inherited mental retardation worldwide • DNA analysis of FMR1 gene • Disease severity r/t the number of CGG trinucleotide repeats in this gene • Normal= 6-44 repeats • Full mutation> 200 repeats

38. Fragile X Syndrome • Clinical Manifestations: • Cognitive (IQ) • Ranges: mild learning disabilities to mental retardation • 95-90% males w/ MR • Behavioral • Sensory defensiveness • ADHD-like features • Autistic-like features

39. Fetal Alchohol Spectrum Disorder • Alcohol use during pregnancy is the leading known preventable cause of mental retardation and birth defects in the US • Affects an estimated 40,000 infants each year (more than spina bifida, down’s syndrome, and muscular dystrophy combined) • FASD is an umbrella term describing the range of effects that can occur in an individual whose mother drank alcohol during pregnancy

40. Effects of fetal alcohol spectrum disorder • Specific facial characteristics • Growth deficits • Mental retardation • Heart, lung, kidney deficits • Hyperactivity and behavior problems • Attention and memory problems • Poor coordination and motor skills delay • Difficulty w/ judgment and reasoning • Learning disabilities

41. Nursing care for the child w/ mental retardation • Once the dx has been made, a functional assessment of the child should be performed • Assess the availability of services for the child and family • Possible Nursing Diagnosis include: • Delayed growth and development r/t neonatal condition • Imbalanced nutrition: less than body requirements r/t inability to ingest sufficient food • Self-care deficit: dressing, toileting, bathing r/t developmental disability