1. Child and Adolescent Mental Health

2. Module Content Mood and Anxiety Disorders Attention Deficit and Disruptive Behavior Disorders Developmental Disorders: Autism Spectrum Bullying Psychopharmacology Cognitive and Behavioral Therapies

3. Cognitive Development Moves from concrete thinking to “formal operations” –i.e. Abstract thinking 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.

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

5. Mental Health Disorders In Children Many conditions overlap-make diagnosis and treatment a challenge Examples: ADHD with Bipolar Disorder Obsessive-compulsive Disorder with Disruptive Behavior Disorders

6. Etiology of Childhood Mental Health Problems Concept: Vulnerability vs. Resilience

7. Etiology of MH Problems:  Genetics: strong for Depression, Anxiety, OCD, Tic disorders, ADHD, Bipolar disorder Neurological Anomalies Prenatal Infection or Toxicity e.g. Fetal Alcohol Syndrome (FAS)

8. Etiology, cont’d Psychosocial Adversity Parent(s) with mental illness, drug or alcohol addiction, criminal behavior Abuse and neglect Family and/or community stress or trauma Poverty

9. Etiology, cont’d Other Environmental Factors Lead poisoning, Accidents/Brain injury, etc.

10. Mood Disorders Mood Disorders Depression: risk increases when a parent is depressed. Symptoms may differ from adult depression, e.g. Poor school performance Behavioral problems cont’d

11. Depression Symptoms Specific to Younger Populations In Children: Lack of verbal skills affects expression Irritable or resistant. May have somatic sx. In Adolescents: Blues in boys: aggressive behavior or acting out Blues in girls: eating disorders, and/or self-injury.

12. Suicide in Younger Populations Risk for suicide:  each year after puberty Child abuse:  risk for suicide X30 3 rd leading cause of death in males 11-14 Population with greatest  in rate = Hispanic females 12-17

13. Mood Disorders, cont’d Mood Disorders, cont’d Bipolar D/O —Primarily dx. in adolescence Evidence is growing for early bipolar sx. Sx. in children: irritability, impulsivity, temper tantrums Highly susceptible to mania caused by prescribed antidepressants and stimulants

14. Anxiety Disorders Trauma-Related (PTSD) Separation Anxiety Disorder Social Anxiety Disorder Pediatric OCD Behaviors may manifest as oppositional or resistent

15. Attention Deficit/ Hyperactivity Disorder (ADHD) Up to 11% of school age children Correlates with psychological adversity Dx: >6 months, before age 7 Types:  Inattentive Disorganized, poor-follow through  Impulsive and Over-active Restless, distractible, reckless, disruptive

16. Co-Morbidity 0f ADHD with Other Childhood Disorders

17. Etiology of ADHD: Neurobiological Theories Frontal Lobe Dysfunction: area of brain responsible for planning, attention, regulation of motor activity “ Underactive Brain” Reduced metabolic activity Not enough Dopamine Hypoperfusion

18. ADHD: Other Possible Neurobiological Factors Defective inhibitory mechanisms Dysfunctional Reticular Activating System (inability to regulate incoming stimuli and to attend to stimuli)

19. ADHD Issues-Etiology Exposure to chemicals? TV and electronic media?

20. Pharmacotherapy for ADHD Stimulants: methylphenidate (Ritalin, Concerta), dextroamphetamine (Dexedrine), and mixed amphetamine (Adderall), pemoline (Cyclert) Extended release--Ritalin LA/Concerta/Metadate CD, Adderall XR--decrease dosing to once daily

21. Non-Stimulant Medications for ADHD Affect norepinephrine release or reuptake: clonidine (Catapres) guanfacine (Tenex, Intuniv) atomoxetine (Strattera)

22. Stimulant Medication Issues  Rebound effects common, esp. with multi- dose forms Side effects: anorexia, weight loss, abnormal movements/tics, labile mood, insomnia, agitation Potential for drug abuse dextroamphetamine with l-lysine (Vyvanse) psychostimulant that reduces abuse potential

23. Stimulant Medication Issues, cont’d Ethical issue: Are stimulants over- prescribed?

24. Disruptive Behavior Disorders Disruptive Behavior Disorders Oppositional Defiant Disorder (ODD) Argumentative, disobedient, fighting, explosive anger Conduct Disorder (CD) More serious behavioral violations e.g. aggression, violence, torture of animals, etc. May be criminal in nature e.g. arson, stealing, etc. Frequently comorbid with ADHD, learning problems, mood and anxiety disorders

25. Developmental Disorders include: Mental Retardation Low IQ with learning dysfunction Pervasive Developmental Disorders Autistic Disorder Asperger’s Disorder Specific Developmental Disorders, e.g. Learning Disorder Communication Disorders

26. Autism and Asperger’s D/O Autism and Asperger’s D/O Viewed as being on the same spectrum, differentiated by severity of symptoms and impairment

27. Autistic Disorder (Autism) Autistic Disorder (Autism) Early Age of onset 30 months of age Constant delayed development May or may not have low intellectual function

28. “Triad of Autism” #1 Impaired Social Skills and Relatedness Aloof and indifferent to others Prefer inanimate objects to human contact Unable to understand social cues Cont’d

29. Autistic Disorder “Triad” #2 Alteration in Communication  Delayed  Restricted  Abnormal intonation  Pronoun reversals  Echolalia  May be nonverbal

30. Autistic Disorder “Triad” #3 Restricted, Repetitive and/or Stereotypical Behaviors or Interests Rocking, hand flapping, spinning Insistence on sameness Preoccupation with peculiar interests

31. Autism You Tube http://www.youtube.com/watch?v=FDMMw G7RrFQ (Autism Every Day 7 min. docu.) http://www.youtube.com/watch?v=FDMMw G7RrFQ http://www.youtube.com/watch?v=mc1H0a Vqn20 (Toddler boy 5 min.) http://www.youtube.com/watch?v=mc1H0a Vqn20

32. Asperger’s Disorder Asperger’s Disorder Less severe form of autism Less likely to be mentally retarded Higher performing: language development may be ok Communication handicap is less severe Concrete interpretation of language Stilted and abnormal intonation

33. Asperger’s Disorder, cont’d Clumsy Social Interactions are impaired Problems reading social cues Preoccupation with matters of private interest Obsessive, repetitive routines and rituals

34. Aspergers’s You tube http://www.youtube.com/watch?v=V0DBHx S5Zv0&feature=related (2 teens) http://www.youtube.com/watch?v=V0DBHx S5Zv0&feature=related

35. Other Characteristics of Autism Spectrum Disorders Hypersensitivity to sensory stimuli Difficulties with transitions or change

36. Etiology of Autism Spectrum D/Os Multiple causes are proposed: Genetic-Highly heritable Infection Intrauterine Childhood

37. Autism Issues The vaccination controversy

38. Bullying Pattern of harm/abuse of power over another person that is repetitive and has not been provoked Reporting is low Diagnosis is difficult About half of all US children have been victims

39. Bullying May be carried out by individuals or groups Types: Verbal-name calling, racial slurs, malicious false gossip Physical attacks Cyberbullying-use of electronic media to invade privacy, defame or embarrass

40. Results of Bullying: Emotional problems, school refusal Substance use Suicide Revenge on persons or institutions

41. Interventions for Bullying School nurse is often the first responder Interventions need to be institution-based and community-based Education

42. General Nursing Interventions for Children: A Behavioral Focus  Simple step-by-step instructions Daily routines “It’s 5:00; play time is over.—Please put away all the toys.---We’ll wash hands now because it’s dinner time.—You washed your hands, so we’re ready to go to the table.” Short term rewards/re-enforcers

43. Nurse-Client Communications Nurse-Client Communications Communication Examples for Children: “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” “Because you didn’t hit today, you may choose the group snack tonight”

44. Milieu Management Milieu Management Communicate expectations for behavior Set limits on destructive, aggressive and inappropriate sexual behavior Support independence as appropriate Rights of the group vs. individual rights

45. Other Cognitive and Behavioral Therapies Problem Solving Skills- reinterpretation of environment to reduce negative thinking CBT: 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

46. Cognitive and Behavioral Interventions, cont’d  Social Skills Training- e.g. for Asperger’s Prompting and sensory reinforcement: Autism

47. More Nursing Interventions 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

48. Pharmocotherapy Interventions Antidepressants SSRIs : fluoxetine (Prozac)  sertraline (Zoloft)  fluvoxamine (Luvox)  paroxetine (Paxil) citalopram (Celexa) escitalopram (Lexapro)  Also used for OCD

49. Pharmacotherapy: Antidepressants SSRIs, cont’d Activating effects may precipitate hypomania, mania or suicide TCAs – many SE’s; lethal doses have occurred

50. Pharmacotherapy, cont’d Antipsychotic Agents For aggressive behavior, self-injury, psychotic symptoms, mood stabilization Typicals: Highly correlated with EPSEs Atypicals: FDA approved = risperidone/Risperdal and aripiprazole/Abilify Weight gain problematic; fatty livers (risperidone/Risperdal)

51. Pharmacotherapy, cont’d Antianxiety agents- best choices buspirone/Buspar clonazepam/Klonipin Mood Stabilizers-dose based on weight Lithium-age 12 and older Atypical antipsychotic agents

52. Issues in Pharmacotherapy Issues in Pharmacotherapy Few drugs are FDA approved Most not tested on children Children metabolize and excrete differently from adults Children may have narrower therapeutic range for some drugs

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

54. Community Resources Community Resources Support groups, camps, web resources, literature (e.g. workbooks), parenting classes