Chapter 28

1. Disorders of Children and Adolescents Chapter 28

2. Epidemiology • One in five children and adolescents in the United States has a major mental illness. • Two-thirds of all young people with mental health problems are not getting treatment.

3. Comorbidities • Attention deficit hyperactivity disorder (ADHD) • Juvenile-onset bipolar disorder • Oppositional defiant disorder • Conduct disorders • Childhood depression • Conduct or oppositional disorders • Anxiety disorders

4. Risk Factors • Parent who has a mental disorder • History of abuse • Physical or sexual • History of neglect • Witnessed violence • Injury, toxic exposure, physical complications in utero or during prenatal period

5. Etiology • Biological factors • Genetic • Brain development and biochemicals • Temperament • Resilience • Environmental factors • Cultural considerations

6. Assessing Development and Functioning Assessment data (Box 28-2) Data collection Mental status examination Developmental assessment Suicide risk Cultural influences

7. Assessing Signs of Abuse • Risk indicators: • History of previous injuries • Inconsistencies in physical exam and report of injury • Delay in seeking treatment • Risk factors: • Experiences of significant loss • Family discord • Abuse or neglect • Psychiatric problems such as depression

8. Assessing Intellectual Impairment • Intellectual impairment • Mild (IQ 50/55–70) • Moderate (35/40–50/55) • Severe (20/25–35/40) • Profound (below 20/25) • Deficits in adaptive functioning • Communication • Social/interpersonal skills • Safety

9. General Interventions Family therapy Group therapy Milieu management Behavioral therapy Seclusion and restraint Quiet room Time-out

10. General InterventionsContinued Cognitive-behavioral therapy Play therapy Mutual storytelling Therapeutic games Bibliotherapy Therapeutic drawing Psychopharmacology

11. Specific Developmental Disorders • Learning disorders • Major problem is reading • Motor skills disorders • Impairment in development of motor coordination • Communication disorders • Impairments in language expression, understanding of language, phonology, or stuttering

12. Pervasive Developmental Disorders • Autistic disorder • Impairment in communication and imaginative activity • Impairment in social interactions • Markedly restricted, stereotypical patterns of behavior, interest, and activities • Asperger’s disorder • Rett’s disorder

13. Pervasive Developmental Disorders: Diagnoses and Outcomes

14. Attention Deficit Hyperactivity Disorder and Disruptive Behavior Disorders • Attention deficit hyperactivity disorder • Inattention • Hyperactivity • Impulsivity • Oppositional defiant disorder • Conduct disorder • Childhood onset and adolescent onset

15. Attention Deficit Hyperactivity Disorder Assessment • Relationship between child and parents/caregivers • Developmental competencies • Level of physical activity, attention span, talkativeness Nursing Diagnosis • Risk for self-directed or other-directed violence • Defensive coping • Impaired social interaction

16. Attention Deficit Hyperactivity DisorderContinued Outcomes Identification • Remains safe • Learns effective coping methods • Develops friendships with peers

17. Attention Deficit Hyperactivity DisorderContinued Implementation • Pharmaceutical agents (Table 28-5) • Behavior modification • Family counseling • Special education programs • Cognitive-behavioral therapy • Play therapy

18. Anxiety Disorders • Anxiety is part of normal development • Anxiety is a problem when: • An individual fails to move beyond the fears associated with a particular problem • It interferes with normal functioning over an extended period of time • Two anxiety disorders of children and adolescents: • Separation anxiety disorder • Posttraumatic stress disorder

19. Separation Anxiety Disorder and Posttraumatic Stress Disorder Assessment • Anxiety and conflict between child and parents • Recent stressors • Parents’ understanding of developmental norms • Parenting skills • Child’s developmental level • Symptoms of anxiety and coping style

20. Separation Anxiety Disorder and Posttraumatic Stress Disorder Continued Nursing Diagnosis • Anxiety • Ineffective coping Outcomes Identification (Table 28-6)

21. Separation Anxiety Disorder and Posttraumatic Stress DisorderContinued Implementation • Protect child from panic levels of anxiety. • Provide emotional support to help child progress developmentally. • Increase child's self-esteem and feelings of competence. • Help child accept and work through traumatic event. • Teach coping skills. • Cognitive therapy • Focused on underlying fears and concerns

22. Mood Disorders Most frequently diagnosed mood disorders: • Major depressive disorder • Dysthymic disorder • Bipolar disorder

23. Tourette’s Disorder • Motor and verbal tics • Causes marked distress • Causes significant impairment in: • Social functioning • Occupational functioning • Average age of onset of motor tics is 7 years of age; can appear as early as 2 years of age

24. Adjustment Disorder • Psychological response to an identifiable stressor • Symptoms develop within 3 months of stressors • Cause impairment in school and social relationships • Subtypes classified according to presenting symptoms

25. Feeding and Eating Disorders • Pica • Rumination disorder • Feeding and eating disorder of infancy or early childhood

26. Elimination Disorders • Encopresis • repeated passing of feces by the child into inappropriate places • Enuresis • repeated voiding of urine into the bed or clothes

27. Selective Mutism • Persistent failure to speak in specific social situations • Rare disorder slightly more common in girls • Child may be excessively shy, fearful of embarrassment, withdrawn, clinging, and negative; or have temper tantrums or oppositional behavior, especially at home

28. Stereotypic Movement Disorder Pattern of repetitive and nonfunctional motor behavior May be self-injurious or life-threatening Frequently associated with mental retardation but may also occur in children with severe sensory deficits

29. Psychopharmacology • Actions and side effects differ for children and adults • Developmental considerations • Rates of absorption • Excretion • Sites of action • Toxicity • Benefits must outweigh risks

30. Stimulants • Most frequently prescribed to treat ADHD • May affect growth • Include: • Methylphenidate (Ritalin) • Permoline (Cylert) • Dextroamphetamine sulfate (Dexedrine)

31. Antidepressants • Used to treat depressive disorders, anxiety disorders, enuresis, bulimia, and ADHD • SSRIs now the medication of choice for depression, anxiety, and OCD • Fewer side effects • Include fluoxetine (Prozac), paroxetine (Paxil), citalopram (Celexa), sertraline (Zoloft), fluvoxamine (Luvox)

32. Antipsychotics Used to treat psychosis, bipolar disorder, aggression, Tourette’s disorder, schizophrenia Atypical antipsychotics have fewer side effects and are more effective than typical antipsychotics Include: risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel)

33. Mood Stabilizers and Anxiolytics • Mood stabilizers: • Lithium carbonate (Lithobid) used for severe aggression and agitation but must be used with caution • Anticonvulsants: carbamazepine (Tegretol) and valproic acid (Depakote) • Anxiolytics: used infrequently

34. Nurse Generalist Applies knowledge of mental and physical health needs Assesses psychological and physical needs Understands significance of laboratory tests and results Administers and monitors medications Provides case management

35. Advanced Practice Nurse Is a specialist May be primary caregiver Provides counseling Manages medications Works with children and families

36. Self-Awareness Working with children with emotional problems may activate personal feelings about one’s own unresolved family problems or issues. Assessing one’s own attitudes and behavior will contribute to self-awareness and enhance personal growth and development.