Child and Adolescent Mental Health

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.

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

Etiology of MH Problems Genetics: strong for depression, Anxiety, OCD, Tic disorders, ADHD, bipolar Environment: Abuse and neglect, (actually causes a change in 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 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 Children

Content 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 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and Disruptive Behavior Disorders ADD – Attention Deficit Disorder (Hyperactive type) – Attention Deficit Disorder (Withdrawn type) Oppositional Defiant Disorder Conduct Disorder

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

ADD The Frontal Lobe Subtle Dysfunction in the Frontal Lobe – Reduced metabolic activity – Hypoperfusion

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

Medication: Stimulants – Ritalin (methylphenidate) – Dexedrine (dextroamphetamine) – Adderall (D,L dextroaamphetamine) Also used for weight loss Extended release Ritalin LA; Metadate CD, Concerta and decrease dosing to once daily Adderall XR Vyvanse is also extended release

Medication issues for Stimulants 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-Stimulant Tricyclic Antidepressants – Imipramine, Desipramine, Clomipramine – Concern about cardiac conduction Clonidine (Catapress) – Developed as an antihypertensive – Reduce norepinephrine activity in the brain

Non-Stimulant: Atomoxetine/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 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 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 Disorders Impairment across multiple domains (impairment is global) – Psychological Impairment – Social Impairment – Academic Impairment – May meet the standard for Mental retardation

Pervasive Developmental Disorders Characterized by impairments across all domains of development – Delayed social development – Stereotypical behaviors Hand-flapping Rocking and spinning – Peculiar preoccupations Moving objects Water – Rigid and intolerant of change

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

Pervasive Developmental Disorders Autistic Disorder Asperger’s Disorder Pervasive Developmental Disorder NOS

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

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

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

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

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)

Other Psychiatric Disorders Childhood Schizophrenia- 2 cases per 100,000 Anxiety Disorders: Separation anxiety 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, cont’d Bipolar Disorder and Schizophrenia – adolescence (rare earlier onset) 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 Younger Populations In Children –Lack of cognitive maturity effects expression irritable or resistant aggression In Adolescents –Both: risk-taking behavior –boys; aggressive behavior or acting out –girls; anxiety, eating disorders, and or self-cutting. –2 symptoms to be concerned about: difficulty concentrating negative statements about themselves and their place in life (peer group, family, school); like “I’m stupid”

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

Nursing Interventions for Attention Problems Simple instructions for children with attention problems – 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 history and how successful Listen, support groups, books Communicate with teachers, School

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

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

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?

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

Psychotherapy Individual Therapy Group Therapy Family Therapy – Passes to go home prior to being discharged

Community Resources Support groups, camps, web resources, and literature

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