1. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 1 Chapter 23 Children and Adolescents

2. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 2 Disorders in Children and Adolescents: Prevalence and Comorbidity Prevalence –One in five children and adolescents in U.S. suffers from major psychiatric disorder causing impairment in functioning About 2/3 of those needing mental health services are not getting them 60% of all children in out-of-home care have moderate to severe mental health problems Comorbidity: often more than one psychiatric diagnosis present

3. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 3 Theory Related to Disorders in Children and Adolescents Child’s vulnerability to psychopathology –Complex interactions between biological, psychological, genetic, and environmental factors Genetics –Implicated in autism, bipolar disorder, schizophrenia, ADHD, and mental retardation

4. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 4 Theory Related to Disorders in Children and Adolescents Biochemical factors –Alterations in neurotransmitters Environmental factors –Abuse, severe marital discord, low socioeconomic status, overcrowding, parental criminality, maternal psychiatric disorders and foster care placement

5. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 5 Concept of Resilient Child Vulnerable child who does not develop psychiatric disorder has resiliency characteristics of: –Temperament that adapts to changes –Ability to form nurturing relationships with other adults –Ability to distance self from emotional chaos in family –Social intelligence –Ability to use problem-solving skills

6. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 6 Mental Health Assessment of Children Mental status assessment –Provides information about problems in thinking, feeling, and behaving Developmental assessment –Information about child’s current maturational level compared with chronological age as well as identifying developmental deficits Denver II Developmental Screening Test (used for infants and children up to age 6)

7. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 7 Mental Health Assessment of Children Methods of data collection –History collected from parents, caregivers, child or adolescent, and other family members –Interviewing (semistructured) in which child/adolescent is asked about life at home and at school –Use of activities such as games, drawings, puppets, and free play (especially for younger children)

8. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 8 Disorders in Children/Adolescents: Mental Retardation Most common developmental disorder, affecting approximately 1% of population Lack of intellectual development that impairs function, learning, communication, interpersonal skills, and social adjustment Degree of mental retardation assessed by intelligence quotient (IQ) –Mild, moderate, severe, profound

9. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 9 Disorders in Children/Adolescents: Pervasive Developmental Disorder (PDD) Severe, impaired social interaction and communication skills, accompanied by stereotyped behavior –Autistic disorder Impairment in communication and imaginative play, lack of responsiveness and interest in others, markedly restricted and stereotyped behaviors –Asperger’s syndrome Similar to autistic disorder, with later onset and less severe symptoms

10. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 10 Nursing Process: Assessment Guidelines for Developmental Disorders Assess for developmental spurts or lags, loss of previous abilities Assess quality of relationship between child and parent or caregiver Be aware that children with behavioral/developmental problems are at risk for abuse –Assess for abuse

11. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 11 Nursing Process: Diagnosis and Outcomes Identification Common nursing diagnoses –Defensive coping, Ineffective coping, Delayed growth and development, Risk for impaired parent/child attachment Outcomes identification –Long-term outcomes established: help child with PDD to reach full potential by fostering developmental competencies and coping skills

12. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 12 Nursing Process: Planning and Implementation for PDD Planning –Intervention takes place in therapeutic nursery schools, day treatment programs, and special education classes in public schools

13. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 13 Nursing Process: Planning and Implementation for PDD Implementation –Increase child’s interest in reciprocal interaction –Foster development of social skills –Facilitate expression of emotional responses –Foster development of communication, cognitive skills –Foster development of adequate self-concept and self-control

14. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 14 Anxiety Disorders in Children/Adolescents Most common mental disorder of children and adolescents (19% of ages 9 to 17) Characteristics similar to those in adults with exception of: –Separation anxiety disorder: excessive anxiety when separated from or anticipating separation from home/parent; can lead to refusal to attend school

15. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 15 Anxiety Disorders in Children/Adolescents –Posttraumatic stress disorder (PTSD) Children with this disorder tend to react with behaviors indicative of internalized anxiety consistent with developmental level

16. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 16 Nursing Process: Assessing for Anxiety Disorders Assess quality of child-parent-caregiver relationship Assess for recent stressors affecting child Determine developmental level and if regression occurred Assess for physical, behavioral, cognitive symptoms of anxiety

17. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 17 Nursing Process: Assessing for Anxiety Disorders Determine child’s previous and current ability to separate from parent/caregiver Determine problems of anxiety in caregiver Assess parent response to child’s anxiety Assess for potential exposure to traumatic event

18. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 18 Nursing Process: Diagnosis and Outcomes Identification Common nursing diagnoses for anxiety disorders –Anxiety, Fear, Delayed growth and development, Impaired parenting, Ineffective coping, Post-trauma syndrome Outcomes identification –Goals established to focus on underlying fears and concerns as well as reinforce self- control behaviors

19. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 19 Nursing Process: Planning and Implementation Planning for child with anxiety disorder –Directed toward providing services on outpatient basis, using cognitive-behavioral methods in individual, group or family therapy Implementation –Help reach full potential by focusing developmental potential and coping skills

20. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 20 Nursing Process: Planning and Implementation –Protect from panic levels of anxiety (act as parent surrogate) –Accept regression; give support for child to progress –Increase self-esteem and feelings of competence –Help child/adolescent work through traumatic events

21. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 21 Disorders of Children/Adolescents: Mood Disorders Symptoms of depression similar to adult symptoms with exception: –Children more likely to have somatic complaints, be self-critical, and feel unloved –Depression can also be expressed as irritability and can lead to aggressiveness

22. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 22 Disorders of Children/Adolescents: Mood Disorders Factors associated with depression in children –Physical and sexual abuse, neglect, homelessness, marital discord between parents, death, divorce, separation, learning disabilities, chronic illness, conflicts with family/peers

23. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 23 Nursing Process: Assessing for Mood Disorders Assess for: –Changes in mood or affect, cognition, social behavior, physical status –Major life-changing events –Maturational level/signs of regression –Quality of parent/caregiver relationship –Parent/caregiver understanding of child’s developmental issues –Family history of mood disorders

24. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 24 Nursing Process: Diagnosis and Outcomes Identification Common nursing diagnoses for child with mood disorder –Grieving, Hopelessness, Ineffective coping, Risk for injury, Risk for violence, Self-esteem disturbance, Social isolation Outcomes identification –Maintain safety is overall goal since risk for self-harm increased with mood disorders –Long-term outcome: help child or adolescent with mood disorder reach full potential

25. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 25 Nursing Process: Planning and Implementation Planning for mood disorders –Hospitalization for suicidal child/adolescent –Psychotherapy and antidepressants important Implementation –Provide for physical/psychosocial needs by acting as parent surrogate –Protect child from aggressive episodes

26. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 26 Nursing Process: Planning and Implementation –Help child explore feelings, thoughts, life events –Help child develop cognitive, coping, and social skills –Increase self-esteem –Help child accept/work through losses

27. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 27 Disorders of Children/Adolescents: Attention Deficit Hyperactivity Disorder ADHD difficult to diagnose before age 4 Characteristics –Inattention: difficulty paying attention to task at hand, easily distracted –Hyperactivity: fidgets, runs and climbs excessively, talks excessively –Impulsivity: blurts out answers before question is finished, has difficulty waiting one’s turn, interrupts and intrudes on others’ conversations/games

28. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 28 Nursing Process: Assessment Guidelines for ADHD Observe level of physical activity, attention span, control of impulses Assess difficulty in making friends and performing in school Assess for problems of enuresis and encopresis Assess for quality of child-parent-caregiver relationship

29. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 29 Nursing Process: Assessment Guidelines for ADHD Asses parent/caregiver’s understanding of growth and development, handling of problem behaviors Assess developmental level for lags or deficits

30. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 30 Disorders of Children/Adolescents: Disruptive Behavior Disorders Oppositional defiant disorder –Recurrent pattern of negativistic, disobedient, hostile, and defiant behavior toward authority figures without seriously violating rights of others (APA, 2000) Conduct disorder –Persistent pattern of behavior in which rights of others and age-appropriate societal norms or rules are violated Childhood onset: before age 10 Adolescent onset

31. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 31 Nursing Process: Assessing for Disruptive Behavior Disorders Assess for: –Quality of child-parent-caregiver relationship –Parent/caregiver’s understanding of growth and development, handling of problem behaviors –Developmental lags/deficits –Identify issues resulting in power struggles

32. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 32 Nursing Process: Assessing for Disruptive Behavior Disorders Assess for: –Severity of defiant behavior –Seriousness of disruptive behavior –Levels of anxiety, aggression, anger, and hostility toward others –Moral development and ability to feel remorse and guilt

33. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 33 Nursing Process: Diagnosis and Outcomes Identification Common nursing diagnoses for children with ADHD and disruptive behavior disorders –Risk for other-directed violence, Risk for caregiver role strain, Defensive coping, Risk for injury, Impaired social interaction, Ineffective coping Outcomes identification –Changing or modifying behaviors that cause problems with families, peers, and authorities

34. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 34 Nursing Process: Planning and Implementation Planning –Children with ADHD and disruptive behavior disorders are treated with behavior modification and medication for hyperactive/impulsive behaviors Implementation –Protect child from harm; provide for needs –Increase interpersonal relationship skills

35. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 35 Nursing Process: Planning and Implementation –Increase ability to control impulses –Foster identification with positive role models –Foster self-esteem, self-identity –Provide support, education, and guidance for parents/caregivers

36. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 36 Medications Used for ADHD and Disruptive Behavior Disorders ADHD –Psychostimulants: methylphenidate (Ritalin, Daytrana, Concerta) –Research ongoing because 30% of children do not respond to psychostimulants Disruptive behavior disorders –Antipsychotics, lithium carbonate, anticonvulsants, antidepressants, and ß- blockers have been used

37. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 37 Disorders of Children/Adolescents: Tourette’s Syndrome Motor and verbal tics that cause marked distress and significant impairment in social and occupational functions (APA, 2000) Nursing process –Assessment: assess obsessions, compulsions, hyperactivity, distractibility, and impulsivity

38. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 38 Disorders of Children/Adolescents: Tourette’s Syndrome –Nursing diagnoses: Anxiety, Impaired social interaction, Chronic low self-esteem, Social isolation –Implementation: help child, family, and school understand and cope with tic behaviors

39. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 39 Treatment for Disorders of Children/Adolescents Parental involvement: important in supportive and educative system –Single and multiple family therapy used Group therapy –Play therapy for young child, combination of play and talking therapy for older children Milieu therapy –Physical milieu provides for safe, comfortable place to live, play, and learn –Daily schedule exists to structure activities

40. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 40 Treatment for Disorders of Children/Adolescents Behavior modification –Rewarded behavior is likely to continue –Use of point/token systems to reward desirable behaviors Removal and restraint –Controversial modalities for use in children, usually perceived as punishment –Quiet rooms are acceptable alternatives –Time-out method useful for disruptive behaviors

41. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 41 Treatment for Disorders of Children/Adolescents Therapeutic holding –Prompt, firm, nonretaliatory protective restraint gently applied and leads to reduction in youth’s distress Cognitive-behavioral therapy –To change cognitive processes and behaviors Play therapy –Based on notion that play is work of a child

42. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 42 Treatment for Disorders of Children/Adolescents Forms of play therapy –Dramatic, therapeutic games, bibliotherapy, therapeutic drawing Other modalities –Music therapy –Movement and dance therapy –Recreational therapy