Module 3 - Pediatric Mental Health Flashcards
Many __ ___ can lead to or resemble mental health disorders
learning disabilities
Many disorders occur ___ making diagnosis difficult
concurrently
What are some etiologies for mental health disorders in children?
Physiologic
Chronic Physical Illness or Disability
Family Dynamics
Environment
What are some examples of physiologic etiologies for mental health disorders?
Genetics
Structural Brain Abnormalities
Prenatal Influences
What are some examples of Family Dynamic etiologies for mental health disorders?
Child abuse
Dysfunctional Family System
Poor Role Modeling
What are some examples of environmental etiologies for mental health disorders?
Poverty
Homelessness
What are some treatment options for mental health disorders in children?
Cognitive, Behavioral, Group, Family, Play, Art, Music Therapy
Quiet Room
Time Out
Seclusion and/or Restraint
Psychopharmacology
What kind of therapy is most commonly used for mental health disorders in children?
Behavioral Therapy - if you start teaching and learning new behaviors early you can change them
Early Intervention
A federally mandated program implemented at the state level via LHD
Testing and Services are provided for free to try and prevent further developmental delay (if its already noted)
Many outcomes can be significantly improved if …
treatment is started early ! do not wait !
What sort of management can be done to treat mental health issues in children?
Community Based Treatment (Primary, Secondary, Tertiary)
Hospital Based Treatment
Specialized Units for Children and Adolescents
Primary Prevention Community based Treatment for Mental health in children
prenatal care
teaching about risk factors
parenting skills classes
Secondary Prevention Community based Treatment for Mental Health in children
Early detection and testing
school and community nurses, NPs, and teachers
Pediatricians
Tertiary Prevention Community based Treatment for Mental Health in Children
minimizes effect of disorder via individual, family, group therapy and behavioral modification
What Assessments should be done by the nurse for a child’s mental health status?
H&P - History and Physical (look at stressors and significant data)
PMH
FH
What are some examples of things to investigate in child PMH
prenatal and birth history
injuries
mood issues
medications
suicide and self injury
mood and actions at home
mood and action with friends
What are some examples of things to investigate in child FH
note strengths and weaknesses of family system
who do they live with
educational level
willingness to learn/participate in services
abuse issues? - Alcohol, physical, emotional
depression/anxiety issues?
What is important to do when assessing a child’s mental health status?
Become a detective - take things in visually like appearance, behavior, and developmental stage, but also ask open ended questions and learn during play
Try to get the family and the child to open up a little to learn about home life and family situations
Observe behaviors
Important Mental Health Disorders in Pediatrics
Developmental Disorders / Learning Disabilities
Pervasive Development Disorders (Autism)
ADD/ADHD/Behavioral Disorders
Mood Disorders
Anxiety Disorders
Intellectual Disabilities
What forms can developmental and learning disabilities take
Sensory Integration (Sensory issues)
Auditory Processing Difficulties (trouble hearing words or understanding)
Visual processing difficulties
Dyslexia
Speech/Language Delays etc
With developmental and learning disabilities, it is important to know what?
that they exist and can be misdiagnosed as other more common disorders
Pervasive Developmental Disorders (PDD)
GROUP of conditions that involve DELAYS in development of many basic skills
It is an umbrella term / group of conditions
Essentially, autism spectrum
PDD is more common in what gender?
Male
Children with PDD are …
confused in their thinking and generally have problems understanding the world around them
PDD exists as a spectrum of…
autism that goes from mild autism to Asperger’s Syndrome
PDD is a very large…
umbrella term for many things
Autism
A range of complex neurodevelopment disorders
What is Autism characterized by (generally)?
- Social impairments
- Communication Difficulties
- (sometimes) Receptive Patterns of Behavior (rocking, twirling, self abuse behavior)
S/S Of Autism
can engage in rigid, repetitive, machine like movement/obsessive behavior
Impaired social interaction
Unresponsive to people
unable to respond to social/emotional cues (cant pick up on a situation)
aversion to touch and extreme stimuli
at risk for self injury (hitting head, scratching, etc)
A pattern of restricted interests, activity and behaviors
Autistic Disorder
impaired social, communicative, and behavioral development
It is a complex disorder of brain development
When do Autism symptoms tend to emerge?
Between 2-3 years but can be evident from early toddler stage
Asperger’s Syndrome
Mild end of the autism spectrum
Social skills and interactions impaired, but high intellectual functioning
How does Asperger’s Syndrome differ from regular autism?
LATER ONSET
MILD END
Similar social interaction and repetitive behavior problems - but often called eccentric or loner
NO Language delay
Speech may be monotone, poor “give and take” in a conversation
Egocentric
Egocentric
low empathy for others
possessed by Asperger’s Syndrome
Nursing Interventions for Children with Autism
Gradual and Gentle Interaction (Create a safe and stable environment)
Enhance communication (learn triggers or what they like)
Coach on socialization - collaborative activities
Help parents decrease feelings of blame, provide education and resources
Use Childs established routine and decrease stimuli while hospitalized (learn from parent what works, communication cutes, self injury habits)
Use diversion for acting out and increased anxiety (appropriate activities)
Provide child with familiar objects
Change is often challenging
MEDICATIONS may be needed for aggression
Know the childs cues!!!
Autism Prevalence and the Vaccine Debate
10 epidemiologic population based studies concluded there is no evidence of a causal association between vaccines and autism
No evidence to date that children with neurodevelopmental disabilities, including autism, in the US have increased mercury concentrations or environmental exposures
Examples of Attention Deficit and Disruptive Behavior Disorders
ADHD
CD
ODD
ADHD
Attention Deficit - Hyperactivity Disorder (ADHD)
Disorder that makes it difficult for children to control their behavior
Can be both attention deficit and hyperactivity (or more one than the other)
ADHD goes beyond the normal…
hyperactive child, this is inappropriate attention or impulsiveness consistently
What is one of the most common chronic conditions of childhood? How many children does it impact?
ADHD - 4 to 12% of School Aged Children
Due to how common ADHD is, what often happens?
Other things are often misdiagnosed as ADHD
Characteristics of ADHD
Inappropriate degrees of inattention, impulsiveness, and/or hyperactivity
Trouble paying attention to details
Making careless mistakes
Trouble concentrating on one activity at a time
Talking constantly even at inappropriate times
Running around in a disruptive manner
Fidgeting and Squirming
Having trouble waiting turn
Being easily distracted
Impulsively blurting out answers
Misplacing school assignments
Seeming not to listen, even when directly addressed
When does ADHD onset begin and how long must it last for a diagnosis?
before age 7, last at least 6 months
Stress can cause ADHD like symptoms so we need to watch and make sure
ADHD has a high incidence of what?
COMORBIDITY (this can lead to a lot of issues)
ex: ODD, Anxiety disorders, mood disorders, developmental learning disorders like dyslexia
What is the focus of therapy for ADHD
MANIPULATE ENVIRONMENT TO DECREASE STIMULI (#1)
Minimize hyperactivity and impulsivity
Increase attention span
Prevent potential future problems (ex: substance abuse, conduct disorders, etc)
Assist family to establish regular scheduled times for eating, sleeping, homework, etc
Provide emotional support
Promote self-esteem, rewards for positive behavior
Why is one type of ADHD meds stimulants?
Stimulants cause an increase in dopamine levels that actually boost attention ability - it is a NT associated with motivation, pleasure, attention, and movement
Therefore, it can boost concentration and focus while reducing hyperactive and impulsive behaviors
When should ADHD meds be given?
In the morning to help get through the day (and may need a second dose for evening and homework time)
Side Effects of using Stimulants for ADHD medications
Difficulty Sleeping
Loss of appetite (big one) - we need to make sure they are growing well height and weight wise so give them suggestions for nutrition dense food options
Tachycardia
Tics (Rare)
Upset Stomach
Examples of Stimulant ADHD Meds
Adderall
Concerta
Ritalin
Why can non-stimulants be used as ADHD medication?
It boosts the levels of norepinephrine and has some anti depressant features
Non-stimulant ADHD meds lack which side effect?
Tic side effects
What is more effective, Stimulant or Non-stimulant ADHD meds?
Stimulant
Non-stim does not always work as well so you may need several types of meds and dosages until you get the right one that works for them
Side Effects of Non-stimulant ADHD meds?
Sleepiness
Headache
Mood Swings
Nausea
Loss of Appetite
Oppositional Defiant Disorder (ODD)
While all children are defiant at times, especially toddlers saying no and early adolescents, this is much more so and is a pattern of uncooperative, defiant, and hostile behavior
What is ODD a combination of?
Internal Depression/Anxiety along with externalizing aggression/temper tantrums
What are some treatments for ODD
Therapy
Social Skill Training
Parenting Classes
Medications
(We want to work on managing this with a combination of things, and do so quickly because this could spiral out of control; we need strict action = consequences laid down)
Signs and Symptoms of ODD
Frequent temper tantrums
Excessive arguing with adults
Often questioning rules
Active defiance and refusal to comply with adult requests and rules
Deliberate attempts to annoy or upset people
Blaming others for his/her mistakes or misbehaviors
Often being touchy or easily annoyed by others
Frequent anger and resentment
Mean and hateful talking when upset
Spiteful attitude and revenge seeking
Conduct Disorder
Much worse than ODD
Great difficulty following the rules, often viewed as “bad” rather than mentally ill
These are the kids on the edge of even more serious aggression or criminal acts
Those with Conduct Disorders are likely to have what if they are not treated?
ongoing and increasingly serious problems if they go untreated
Signs and Symptoms of Conduct Disorders
Lying, Aggression, Even criminal acts
No remorse
Aggression to people and animals - bullies, threatens, starts fights, cruel to animals
Destruction of Property - fire starting, vandalism
Deceitfulness, Lying, or Stealing - money, shoplifting, breaking into house or car, lying to avoid obligations or get something
Serious violations of the rules - running away, truant, staying out past parents limits
What are the 2 subtypes of Conduct Disorders?
- Childhood Onset
- Adolescent Onset
What are some treatments for Conduct Disorders?
Intense behavioral and psycho therapy - the tx of choice for CD
Positive reinforcement
Arrange organized, supervised activity
HAVE TO SET STRICT BOUNDARIES AND CONSISTENT CONSEQUENCES
Pharmaceuticals - Anti depressants, mood stabilizers
Tourette’s Syndrome
INVOLUNTARY motor movements and/or vocalizations (TICS) - consistent and uncontrollable!
Tics could be motor or verbal
It is a neurobiological disorder
What are some signs/symptoms of Tourette’s Syndrome
TICS
Snorts
Throat Clearing
Facial Twitching
Arm Jerking
Kicking
May show sudden rage - frustration
Verbal tics
Co-morbidities - like depression
What alters the frequency and intensity of Tourette’s syndrome?
It can be up or down between people
Also, symptoms may worsen with anxiety
Are kids with TICS always diagnosed with Tourette’s?
No, some kids have tics that are not true Tourette’s and it will go away with a stressor’s leaving - true Tourette’s is consistent and remains
Anxiety Disorders
Generalized Anxiety Disorder
Panic Disorder
Phobias
Separation Anxiety Disorder
Obsessive Compulsive Disorder
Post Traumatic Stress Disorders
Generalized Anxiety Disorders
tend to being in childhood and continue into adolescence - anxiety is a normal part of development but if we fail to move beyond fear that is when problems begin
This lasts at least 3 months
What behaviors might generalized anxiety include
Bedwetting
Sucking Thumb
Regression
(for at least 3 months)
Separation Anxiety Disorder
Fear of being separated from the person to whom the child is most attached
It is an abnormally excessive or age inappropriate fear (toddlers and infants have this normally, but a 5 year old should be able to be dropped off without significant distress)
What can untreated separation anxiety lead to?
other generalized anxiety disorders or relationship difficulty later
What are some symptoms of Separation Anxiety Disorder
Refusal to attend school
Somatic complaints
Severe anxiety regarding separation
Worry about harm coming to significant caretaker
Clinging
Crying
Tantrums
Nursing Interventions for Separation Anxiety Disorder
Maintain a calm manner
Teach parents about consistency in expectations
Therapy - family and/or child
Education and resources for the parents
Medications MAY be needed (but they might just need better coping skills)
Ex: Get the kid back in school ASAP and keep a routine!!
Obsessive Compulsive Disorder
Ritualistic behaviors (similar to those displayed in adults) that are highly specific and a high anxiety issue for children
What some signs or symptoms of OCD in a child?
Repeatedly perform routines or think thoughts over and over until they become a ritual
Cant control the deep need to the ritual again and again
The anxiety and rituals get in the way of daily life
What is commonly used to treat OCD in children?
Medications - to calm and focus the child
Sometimes therapy to learn coping skills, letting go, and lower anxiety
When is COD more common in children?
more so in littler kids than older ones.
What are 2 important mood disorders in children?
Suicide
Depression
Mood Disorders are often associated with what in children?
Behavioral Issues
Social Skill Deficits
Family Dysfunction
poor achievement
Mood disorders were recognized as occurring in children…
only recently! It is not just in teenagers, grade schoolers too!
S/S of Depression in Children
Poor school grades
Withdrawal from activities previously enjoyed
Sleep and appetite disturbances
Somatic complaints
Decreased energy
Difficulty concentrating
Low self esteem
Feelings of hopelessness
Warning signs of Suicide in Teens
Sudden withdrawal
Violent behaviors
Drug and alcohol use
Unusual neglect of personal appearance
Truancy
running away
excessive fatigue
poor response to praise
talks about suicide
gives away possessions
How do children under 12 committing suicide differ from it occurring in teens?
MAY DO SO IMPULSIVELY (less thought) - so it ends up being often recorded as an accident
Tend not to give warning signs as adolescents and adults do
Careful monitoring for an treatment of depression is critical
Many child suicides are recorded as …
accidents
Because of the differences between how children deal with suicide to others, what is highly important to do?
Careful monitoring for and treatment of depression critical
Nursing Interventions for Mood Disorders
BE SUPPORTIVE
Medications when needed
Monitor for Side Effects of Meds
Provide Community Resources, Education
Promote Self-Esteem
Maintain Hopefulness
Provide a safe environment
Use Suicide Precautions
Change approach based on the mood disorder or the effect of certain medications. - Be gentle with them
Fetal Alcohol Syndrome (FAS)
Completely preventable syndrome of cognitive problems and physical abnormalities
Caused by drinking while the child is developing in the womb
What sort of delays and issues can occur d/t FAS
Developmental Delays
Behavioral Disorders
Intellectual Disabilities
What are some characteristic physical abnormalities in FAS children?
Wide eye placement
Small thin upper lip
Flat nasal bridge
Upturned nose
“Classic Look”
Anorexia Nervosa
Distorted body image d/t fear of obesity, thus leading to dramatic weight loss
They strain to keep a “perfect” body - high expectation type of image
What group is anorexia nervosa most common in?
Females aged 12-18 years old
What are some signs and symptoms of Anorexia Nervosa?
Fear of Obesity
Dramatic Weight loss
Distorted body image
anemia
amenorrhea (body just stops everything)
dry brittle hair
nails
laxative and enema use frequently
electrolyte imbalance
High expectation of body type image
What is a highly useful treatment for Anorexia Nervosa?
Behavior Modification Model - meet a goal and get a reward/privilege
Bulemia
Distorted body image with much of the characteristics of anorexia, but involves binge eating and then vomiting
Signs and Symptoms of Bulemia?
Many anorexia s/s
Binge eating (high calorie food in short time) followed by induced vomiting
Could be normal weight or even overweight
Electrolyte imbalances
Body slows itself (like with many eating disorders) - body slows itself down (constipation, bradycardia, low BP)
What are some interventions for eating disorders?
Behavioral modification therapy (rewarded for corrected behavior; ex: gains weight each week = add privileges)
Family therapy
Monitor clinical status - weight, intake, vital signs - so we can get them into a proper facility
PICA
Ingestion of non nutritional substances (ex: clay, chalk, plants, paint chips, hair…)
It is a nervous anxiety issue for them that soothes them, but they need therapy
How long does PICA need to occur for diagnoses?
For at least one montyh
Treatment for PICA?
Feeding Therapist, Psychologist, etc
They might use PICA as a soothing behavior, but they need therapy
What is the overall goal for pediatric mental health?
SUPPORT AND UDNERSTANDING
(remember that is a patient has these issues, it frames how you set the goals, go forward, reevaluate goals more often, meet their needs, etc)
