Classes of Psychotropic Drugs

Sedative-Hypnotic Sleep Agent MOA

Gaba receptor with sedative effects. No anti-anxiety, anticonvulsant, or muscle relaxant effects. Rapid onset and short half-life.

Hallucinations

Intervention requires knowledge of the content

Lithium

Stabilizes electrical activity of the cells of the brain (mood stabilizer). Used for bipolar and is very effective, but has narrow therapeutic index.

Genetic Influences on Schizophrenia

seems likely. Schizophrenia and schizophrenia-like symptoms occur at an increased rate among relatives of patients with schizophrenia.

Etiology of Schizophrenia

Schizophrenia most likely occurs as a result of a combination of factors including: genetic and nongenetic factors (e.g., viral infection, birth injuries, nutritional factors).

Benzodiazepines

Sleep inducing potential: flurazepam (Dalmane), temazepam (Restoril), triazolam (Halcion), estazolam (Prosom), and quazepam (Doral). Anxiety reducers: lorazepam (Ativan) and alprazolam (Xanax)

Communication with catatonia excited

During the excited phase, the person talks or shouts continually. Verbalizations may be incoherent. Staff communication should be clear and directed. The major concern is safety of patient and others.

Assessment Guidelines for ADHD and disruptive behavioral disorders

1. Assess quality of relationship between child and caregiver. 2. Assess caregiver's understanding of growth and development, parenting skills, and handling of problematic behaviors. 3. Assess cognitive, psychosocial, and moral development for lags or deficits.

Assessment Guidelines for Conduct Disorder

1. Assess seriousness of disruptive behavior, when it started, and attempts to manage it. 2. Assess levels of anxiety, aggression, anger, and hostility toward others and ability to control destructive impulses. 3. Assess moral development for ability to understand impact of hurtful behaviors on others, for empathy and feeling remorse.

Assessment Guidelines for Oppositional Defiant Disorder

1. Identify issues that result in power struggles, when they begin, and how they are handled. 2. Assess severity of defiant behavior and its impact on child's life at home, school, and with peers.

Assessment Guidelines for ADHD

1. Observe for level of physical activity, attention span, talkativeness, ability to follow directions, and impulse control. 2. Assess difficulty in making friends and performing in school. 3. Assess for problems with enuresis and encopresis.

SNDIs

Mirtazapine (Remeron)

TCAs

Nortriptyline (Pamelor), amitriptyline (Elavil), and imipramine (Tofranil)

Risk Factors

A child with a parent who has depression has risks of developing an anxiety disorder, conduct disorder, and alcohol dependence. Children who have been abused and neglected are at great risk for developing emotional, intellectual, and social handicaps. ______ include severe marital discord, low socioeconomic status, large families and overcrowding, parental criminality, maternal psychiatric disorders, and foster care placement. Child abuse and stressful life events relate to increased incidence of accidental injuries, anxious children, depression, and suicidal behaviors. Traumatic life events can lead to insecure attachments, posttraumatic stress disorder (PTSD), conduct disorders, delinquency, and impaired social and cognitive function. Abused children are at risk for dissociative identity disorder (DID).

Development and Functioning

A mentally disturbed child is one whose personality development is impaired, whereas a mentally healthy child progresses with only minor setbacks or difficulties.

Prognostic Considerations of Schizophrenia

A patient with abrupt onset of symptoms with good premorbid functioning usually has a more favorable prognosis than a person with a slow onset over a period of 2 or 3 years. Childhood history of withdrawal, seclusive, eccentric, and tense behavior are unfavorable diagnostic signs. The younger the patient is at onset, the more discouraging the prognosis.

Oppositional Defiant Disorder

A recurrent pattern of negativistic, disobedient, hostile, defiant behavior toward authority figures, without serious violations of the basic rights of others. Such a child may exhibit the following characteristics: loses temper, argues with adults, actively defies, refuses to comply, deliberately annoys people, blames others for mistakes, is easily annoyed by others, is angry or resentful, spiteful, or vindictive.

Behavioral Therapy

Desired behavior is rewarded; undesirable behavior is ignored or has limits set to prevent it. A point system awards points for age-appropriate desired behaviors, and points are collected and used to obtain a specific reward. A level system has increasing levels of privileges that can be earned.

Buproprion (Wellbutrin)

Acts as NE reuptake inhibitor but also inhibits nicotinic acetylcholine receptors which induces the addictive action of nicotine. A/E: tremor, insomnia, anorexia. Antidepressant.

Side Effect Treatments

Acute dystonic reaction - Antiparkinson agent (IM) Akathisia - Benadryl (po) TD - No treatment, AIMS test to follow progression Anticholenergic toxicity - ER treatment begin with cooling blanket

ADHD

Affected children show inappropriate inattention, impulsiveness, and hyperactivity. May be associated with oppositional defiant or conduct disorder or Tourette's. Symptoms: 1. Inattention 2. Hyperactivity 3. Impulsivity

Psychotherapy

Although medication maintenance has been shown to be the single most important factor in prevention of relapse, a combination of medication and psychosocial interventions lowers the relapse rate even further. Patient concerns that can be addressed are relationship problems, family concerns, depression, losses, and medication.

Quiet Room

An unlocked room used for removing a child from the situation to regain self-control with staff support is called the quiet room. The feelings room, which is carpeted and supplied with soft objects that can be punched or thrown, and the freedom room, which contains a large ball for throwing or kicking, are alternative approaches.

Doxepin (Silenor)

Antidepressant used at a low dose that treats insomnia by blocking histamine.

Adjuncts to Antipsychotic Drug Therapy

Antidepressants may be ordered for coexisting depression. Antimanic agents may be useful for suppressing episodic violence and may help alleviate comorbid depression. Benzodiazepines may be ordered during the acute phase to reduce agitation.

Psychopharmacological Interventions

Antipsychotics allow patient management in the community as well as in the hospital. Noncompliance with medications usually precedes relapse. Maintenance is required for 1 year after one episode, 2 years after two episodes, and probably lifelong after three episodes.

Third Generation Antipsychotics

Aripiprazole (Abilify)- partial agonist, lowering or raising dopamine in areas of the brain as needed. Side effects are insomnia and akathisia

Assessment Guidelines: Pervasive Developmental Disorders

Assess for developmental spurts, lags, uneven development, and loss of previously acquired abilities. 1. Assess quality of relationship between child and caregiver for evidence of bonding, anxiety, tension, fit between temperaments. 2. Be aware that children with behavioral and development problems are at risk for abuse.

Alterations in Speech

Associative looseness: loosely associated, haphazard, illogical, confused speech that can sometimes be decoded. Neologisms: newly coined words having meaning only for the patient. Echolalia: pathological repeating of another's words. Clang association: meaningless rhyming of words. Word salad: mixture of words meaningless to the listener.

Comorbidity

Attention deficit hyperactivity disorder (ADHD), a prominent _________ condition in emotionally disturbed children, occurs in 90% of individuals with juvenile-onset bipolar disorder, 90% of children with oppositional defiant disorder, and 50% of children with conduct disorder. Childhood depression is also associated with a high incidence of ___________.

Bain Development and Biochemical Factors

Dramatic changes occur in the brain during childhood and adolescence. Alterations in neurotransmitters play a role in causing depression, mania, and ADHD. Elevated testosterone levels have been studied and may have a role in mediating responses to environmental stress.

Psychological and Environmental Factors of Schizophrenia

Birth and pregnancy complications (e.g., viral infection, poor nutrition, exposure to toxins) place individuals at increased risk for developing schizophrenia as adults. Although there is no indication that stress causes schizophrenia, stress may precipitate it in a vulnerable individual. Other risk factors include birth during the winter, birth in an urban area, low socioeconomic status.

Alterations in Behavior

Bizarre behaviors take the form of stilted, rigid demeanor, eccentric dress or grooming, and rituals. Extreme motor agitation—running about in response to inner or outer stimuli. Stereotyped behaviors—motor patterns that have become mechanical and purposeless. Automatic obedience—performing commands in a robotlike fashion. Waxy flexibility—excessive maintenance of a posture for long periods of time. Stupor—remaining motionless and unresponsive. Negativism—active negativism involves the patient doing the opposite of what is suggested; passive negativism involves not doing the things one is expected to do, such as getting out of bed, eating, and so forth. Agitated behavior—related to difficulty with impulse control; because of cognitive deterioration, patients lack social sensitivity and may act out impulsively.

TCA MOA

Block reuptake of NE and serotonin; therefore, increasing the levels at the synapse. Also block muscarinic receptors which can lead to anticholinergic side effects. Can also block histamine receptors, causing sedation and drowsiness. Adherence issues. High potential for lethal overdose.

SGAs

Clozapine (Clozaril)- low potential for EPS, but high potential for bone marrow suppression and agranulocytosis. Risperdone (Risperdal)- highest potential for EPS. Causes weight gain, sexual dysfunction, and sedation. Quetiapine (Seroquel)- weight gain and metabolic syndrome. Olanzapine (Zyprexia)- metabolic syndrome. Ziprasidone (Geodon), Paliperidone (Invega), iloperidone (Fanapt), lurasidone (Latuda), and asenapine (Saphris).

Cultural Considerations

Culture shock and cultural conflicts related to assimilation issues put immigrant children at risk for mental and learning disorders. Differences in cultural expectations, stresses, and support or lack thereof by the dominant culture have a profound effect on development and the risk of mental, emotional, and academic problems.

Alterations in Thinking

Delusions: fixed false beliefs (with themes of ideas of reference, persecution, grandiosity, unusual bodily function, jealousy, being controlled). About 75% of patients with schizophrenia experience delusions at some time during their illness. Other common delusions include: thought broadcasting (the belief that one's thoughts can be heard by others), thought insertion (the belief that thoughts of others are being inserted into one's mind), thought withdrawal (the belief that thoughts have been removed from one's mind), and delusions of being controlled (belief that one's body or mind is controlled by an outside agency). Concrete thinking: impaired ability to use abstract concepts. Interpretation is literal.

Affective Symptoms

Depression recognition during assessment is crucial because depression affects a majority of people with schizophrenia. It may herald a psychotic relapse, increase the likelihood of substance abuse or suicide, or may be associated with impaired functioning.

Cultural Influences

Eye contact, expression of feelings, and patterns of speech differ from culture to culture. Cognitions must be evaluated in light of cultural beliefs. Folk medicine practices for the culture are also considered.

Family therapy with schizophrenia

Family therapy further reduces relapse rate when a psychoeducational approach is used. This format expands patients' and relatives' social networks, expands problem-solving capacity, and lowers emotional overinvolvement of families.

Group Therapy

For younger children, _____________ takes the form of play; for grade-school children, it combines play and talking. For older children and adolescents, group therapy takes the form of talking.

Benzo MOA

Gaba receptors inhibit cellular excitation, resulting in a calming effect. Can also be used as anticonvulsants and for alcohol withdrawal.

Milieu Management

Goals are to provide physical and psychological security, promote growth and mastery of developmental tasks, and ameliorate psychiatric disorders. Therapeutic factors include an environment with boundaries and limits, a reduction in stressors, opportunities for expression of feelings without fear of rejection or retaliation, available emotional support and comfort, assistance with reality testing and support for weak ego functions, interventions in impulsive or aggressive behavior, opportunities for learning and testing new adaptive behaviors, consistent constructive feedback, reinforcement of positive behaviors and development of self-esteem, corrective emotional experiences, role models for making healthy identifications, opportunities to be spontaneous and creative, and experiences leading to identity formation.

Alterations in perception

Hallucinations are sensory perceptions for which there is no external stimulus. Auditory hallucinations are most common among patients with schizophrenia. Voices may tell the patient what to do (commanding) or speak to or about him or her (usually derogatory). Behavioral indications of the presence of auditory hallucinations include tilting head as if listening and answering back. Hallucinations may also be visual, olfactory, gustatory, or tactile. Personal boundary difficulties may also be referred to as loss of ego boundaries. Examples include depersonalization—the person feels he has lost his identity or that the body has changed; and derealization—a false perception that the environment has changed.

Genetic

Hereditary factors are implicated in autism, bipolar disorder, schizophrenia, attention deficit problems, and mental retardation. Direct genetic links are noted in Tay-Sachs disease, phenylketonuria, and fragile X syndrome.

Environmental Factors

If parents are abusive, rejecting, or overly controlling, the child may suffer detrimental effects at the developmental point at which the trauma occurs.

Separation Anxiety

In this disorder, the child becomes excessively anxious when separated or anticipating separation from home or parental figure. Other characteristics include excessive worry about being lost or kidnapped or that parental figures will be harmed, fear of being home alone or in situations without significant adults present, refusal to sleep unless near a parental figure, refusal to attend school without a parental figure, and physical symptoms as a response to anxiety.

SNRI MOA

Increase levels of serotonin and NE by blocking reuptake. Main side effect is increased BP. Also helps with neuropathic pain.

Non-stimulant Medications for ADHD

Inhibit reuptake of NE. Atmoxetine (Strattera), guanfacine (Intuiv), and clonidine (Kapvay). Decreased appetitie, fatigue, and dizziness.

SSRI MOA

Inhibit reuptake of serotonin with less muscarinic and histamine blockade (no anticholinergic or sedating side effects). Main A/E include apathy and low libido.

Methods of data collection

Interviewing, screening, testing, observing, and interacting. Histories are taken, and structured questionnaires and genograms can be used.

Assessment guidelines: Schizophrenia

It is important to assess whether the patient has had a medical workup, including evaluation for the presence of psychosis, and whether the patient is dependent on alcohol or other drugs. Is the individual experiencing hallucinations or delusions? Is the patient's belief system founded in reality? Be sure to be alert for co-occurring disorders such as depression, anxiety, substance dependency, or a history of violence, and ask if the patient taking medications and is he or she adhering to the medication regimen as prescribed. It is also important is to assess the support for the patient (e.g., family, significant others) and assess the patient's global functioning.

SGA MOA

Lower risk for EPS, target positive and negative symptoms. Can cause metabolic syndrome. Predominantly dopamine and serotonin antagonists.

Removal and Restraint

May be used judiciously

Psychopharmacology

Medicating children typically works best when combined with another treatment such as cognitive-behavioral therapy (Sadock and Sadock, 2008).

Glutamate Blockade (For Alzheimer's)

Memantine (Namenda) decreases excess glutamate, which is thought to be destructive to neurons.

Epidemiology

One in five U.S. children and adolescents suffers from a major mental illness. The prevalence rate for depression in adolescence is about 15%, with up to 30% of adolescents reporting clinically significant levels of depressive symptoms at some point (Evan and Seligman, 2005). It is especially important to understand that the prevalence of some of the disorders of childhood and adolescence have been rising over successive generations.

Phase II (Stabilization) and Phase III (Maintenance)

Outcome criteria will focus on helping the patient to adhere to medication regimens, to understand the nature of the illness, and to participate in psychoeducational activities for patient and family.

Communication Guidelines of Paranoia

Paranoid patients are unable to trust others and are guarded, tense, reserved, and aloof. They often adopt a superior, hostile, and sarcastic attitude to distance others. They may disparage others and dwell on others' shortcomings. Staff must not react with anxiety or patient rejection. Frequent discussion with peers and clinical supervision are helpful. Readers are referred to the communication card.

Self-care needs with excited catatonia

Patient may exhibit gross hyperactivity (running, striking out, etc.). Exhaustion and collapse, as well as safety, are the primary concerns. IM administration of antipsychotic medication is usual. Provision of nutrition, fluids, and rest are of high priority. The patient may be destructive and aggressive in response to hallucinations or delusions. The reader is referred to the CD-ROM.

Communication with Catatonia withdrawn

Patients may actually appear comatose and mute. Although seemingly unaware of the environment, the patient is aware and may remember events accurately at a later date.

Self-care with disorganized schizophrenia

Patients need much help grooming insofar as they have no awareness of social expectations. They are often too disorganized to carry out ADLs.

Therapeutic Games

Playing a game with the child facilitates the development of a therapeutic alliance and provides an opportunity for conversation. Several therapeutic games exist that require the child to say something or tell a story about various objects in order to collect a chip. A more advanced game for older children requires talking, feeling, and doing activities.

MAOI MOA

Prevent the destruction of monoamines by inhibiting the action of MAO. Avoid foods with tyramine so as not to cause significant vasoconstriction. Contraindicated with other antidepressants and sympathomimetic drugs (OTC decongestants)

Melatonin Receptor Agonists

Ramelteon (Rozerem)

Buspirone (Buspar)

Reduces anxiety without sedation. No interactions or addiction

Delusions

Rely on empathy. Clarify the reality of patient's experience. Do not focus on delusional content. Do not use logic to refute delusion and do not argue. Clarifying misinterpretations is useful. Spend time with patient in reality-based activities.

Milieu needs of Paranoia

Risk for violence is present because the patient may respond with hostility or aggression to hallucinations or delusions. Homosexual urges may also be projected onto the environment.

FGA MOA

Strong dopamine antagonists (too much dopamine causes positive symptoms of schizophrenia). Also antagonists of ACh, NE, and histamine (which may cause side effects). Can cause EPS. Also increased prolactin leading to amenorrhea, galactorrhea, and gynecomastia. Blocking muscarinic receptors leads to anticholinergic side effects. Blocking NE causes vasodilation and orthostatic hypotension. Histamine blockage leads to sedation and weight gain.

Brain Structure Abnormalities

Studies suggest schizophrenia is a disorder of brain circuits. Structural cerebral abnormalities could cause circuit disruptions. Findings suggest that possible brain abnormalities might be enlarged lateral ventricles, cortical atrophy, third ventricle dilation, ventricular asymmetry, cerebellar atrophy, and frontal lobe atrophy. PET scans suggest reduced frontal lobe activity.

Comorbidity of Schizophrenia

Substance abuse disorders occur in approximately 40% to 50% of individuals with schizophrenia. It is associated with negative outcomes such as incarceration, violence, suicide, and HIV infection. Nicotine dependence may be as high as 80% to 90%. Other comorbid disorders include depressive symptoms, anxiety disorders, and psychosis-induced polydipsia.

Individual therapy

Supportive therapy is the modality found to be most helpful. Skills training to enhance social functioning, cognitive rehabilitation to improve information-processing skills, and cognitive content therapy to change abnormal thoughts or responses to hallucinations through coping strategies are also useful.

Modifying Disruptive Behavior

Techniques include planned ignoring; use of signals or gestures to remind a child to use self-control; using closeness or touch to calm; redirecting the child's attention toward an activity; giving additional affection; use of humor to help the child "save face"; direct appeals such as, "Please . . . not now"; extra assistance to avoid blowups due to frustration; clarifying the situation for the child; restructuring, such as shortening a story if the child becomes restless; and setting limits and giving permission to do what is expected.

Phase I (Acute)

The acute phase essentially involves crisis intervention, with patient safety and medical stabilization as the overall goal. If the patient is at risk for violence to self or others, initial outcome criteria would address safety issues (i.e., "Patient will remain safe while hospitalized"). Another appropriate focus would be on outcomes that reflect improvement in intensity and frequency of hallucinations, delusions, and increasing ability to test reality accurately.

Milieu needs for catatonia withdrawn

The continuum from decreased spontaneous movement to complete stupor is described and waxy flexibility explained. Readers are cautioned that the patient may move from stupor to an outburst of gross motor activity prompted by hallucinations, delusions, or neurotransmitter changes.

Phases of Schizophrenia

The course of the disease usually involves recurrent acute exacerbations of psychosis. It can be presented in three phases: the acute phase, the stabilization phase and the maintenance phase.

Cognitive Behavioral Therapy

The goal of this is to change cognitive and behavioral processes, thus reducing the frequency of maladaptive responses and replacing them with new competencies.

Self-Assessment

The intensity of the patient's emotions can evoke intense, uncomfortable, and frightening emotions in staff. If feelings are not worked through, feelings of helplessness can increase anxiety. Defensive behaviors may emerge to thwart patient progress and undermine nurse self-esteem. Slow patient progress can lead to frustration. Team evaluation of progress can assist with this.

Epidemiology of Schizophrenia

The lifetime prevalence of schizophrenia is 1% worldwide. Typical age of onset is during the late teens and early twenties. Men and women are equally represented but there are some differences.

Disorganized Schizophrenia

The most regressed and socially impaired patients carry this diagnosis. They show grossly inappropriate affect, bizarre mannerisms, grimaces, giggles, incoherent speech, blocking, and extreme social withdrawal. Onset is often early and insidious. The prognosis is often poor, the patient being able to live only in a structured and well-supervised setting.

Assessment Guidelines: Anxiety Disorders

The nurse will assess the quality of relationships, recent stressors, parent/caregiver's understanding of developmental norms; also assess developmental level and regression and assess for physical, behavioral, and cognitive symptoms of anxiety.

Residual Schizophrenia

The patient no longer has active-phase symptoms but evidences two or more residual symptoms (such as lack of initiative, marked social withdrawal, impaired role function, speech deficits, odd beliefs, magical thinking, and unusual perceptual events).

Other Neurochemical Hypotheses

The role of other neurotransmitter systems (norepinephrine, serotonin, glutamate, GABA, neuropeptides, and neuromedullary substances) are being studied. Newer drugs target serotonin and norepinephrine and may provide more information about causation. Phencyclidine use induces a schizophrenia-like state. This observation has renewed interest in the NMDA receptor complex and the possible role of glutamate in schizophrenia.

Self-Care needs of paranoia

These are usually minimal. Nutrition may be problematic if patient is suspicious that food has been tampered with. If this is the case, provide food in unopened containers. Suspicion may also interfere with sleep.

Prepsychotic Phase of Schizophrenia

These begin 1 month to 1 year before the first psychotic episode and include increased anxiety, evidence of a thought disorder (e.g., poor concentration), inability to keep out intrusive thoughts, attaching symbolic meaning to ordinary events, and misinterpretation of others' actions or words. In the latter part of this phase, the patient may experience emotional and physical withdrawal, hallucinations, delusions, odd mannerisms, preoccupation with religion, neologisms, or preoccupation with homosexual themes.

Pervasive Developmental Disorders

These disorders are characterized by severe and pervasive impairment of reciprocal social interaction and communication skills, usually accompanied by stereotyped behavior, interests, and activities. Mental retardation is often present.

Feeding and Eating Disorders

These disorders include pica (persistent eating of nonnutritive substances), rumination disorder (the repeated regurgitation and rechewing of food), and feeding and eating disorders of infancy or early childhood (failure to eat adequate amounts of food though available).

Milieu needs with disorganized schizophrenia

These highly regressed patients exhibit primitive behaviors that require a structured and protective milieu.

Communication with disorganized schizophrenia

These patients experience persistent and severe perceptual problems and frequently display looseness of associations, incoherence, clang association, word salad, and blocking.

Asperger's

This disorder is recognized later than autistic disorder. There are no significant delays in cognitive and language development or in self-help skills, but severe and sustained impairment in social interactions, development of restricted, repetitive patterns of behavior in interest and activities, and delayed motor milestones do occur. Social interaction problems are more noticeable when the child enters school, as are problems with empathy and modulating social relationships.

Undifferentiated schizophrenia

This illness is characterized by active signs of the disorder but with symptoms that do not clearly fall into one specific category. Undifferentiated schizophrenia often has an early and insidious onset, with disability remaining fairly stable over time.

Mutual Storytelling

This is a technique for helping young children express themselves verbally. The child is asked to make up a story. At the end of the story, the child is asked to give a lesson or the moral of the story. The nurse retells the story, selecting one or two of its important themes, and provides a healthy resolution.

Conduct Disorder

This is characterized by a persistent pattern of behavior in which the rights of others and age-appropriate societal norms are violated. Rates for males range from 6% to 16% and for females 2% to 9%. Predisposing factors are ADHD, parental rejection, inconsistent parenting with harsh discipline, early institutional living, absence of father, alcoholic father, and similar causes. Childhood-onset conduct disorder occurs prior to age 10 and is marked by physical aggression. The youth with adolescent-onset conduct disorder demonstrates less aggressive behaviors and more normal peer relationships, tending to act out misconduct with the peer group. Conduct disorders frequently progress to adult antisocial personality disorder. Types of behavior noted: (1) aggressive conduct that causes harm to other people or animals, (2) destruction of property, (3) deceitfulness or theft, and (4) serious violation of rules.

Rhett's Disorder

This is seen only in females, with onset before age 4 years. Characteristics include persistent loss of manual skills, development of stereotyped hand movements (hand wringing), problems with coordination and gait, severe psychomotor retardation, severe problems with expressive and receptive language, and loss of interest in social interactions.

Autistic Disorder

This is usually first observed before age 3 years. It is a behavioral syndrome resulting from abnormal left brain function (language, logic, reasoning). Language delay or absence, repetitive use of language, babbling, failure to imitate, lack of responsiveness, aversion to physical contact, preoccupation with repetitive activities

Time-Out

Time-out may require going to a designated room or sitting on the periphery of an activity until self-control is gained and the incident is reviewed with a staff member.

Family Therapy

To ensure optimal outcomes for children and adolescents, the family must be involved and educated. Both single-family therapy and multiple-family therapy are being used.

Anticonvulsants

Valproate (Depakote/Depakene)- A/E include thrombocytopenia, pancreatitis, and hepatic failure. Carbamazepine (Tegretol)- can cause anticholinergic side effects and Stephens-Johnson syndrome. Lamotrigine (Lamictal)- works well for depression associated with bipolar, but not for acute mania. Stephens-Johnson. Gabapentin (Neurontin), topiramate (Topamax), and oxcarbazepine (Trileptal)- not used for bipolar but do stabilize mood.

Self-care needs with catatonia withdrawn

When a patient is extremely withdrawn, physical needs take priority. The patient may need complete care, including hand or tube feeding, incontinence care, and passive exercise, as well as assistance with hygiene, dressing, and grooming.

PTSD

Younger children appear to react more with behaviors indicative of internalized anxiety, whereas for older children and adolescents, the anxiety is more often externalized.

Short-Acting Sedative-Hypnotic Sleep Agents

Zolpidem (Ambien), zaleplon (Sonata), and eszopiclone (Lunesta).

Etiology

_______ of mental illness in children and adolescents encompasses multiple factors; distinguishing among the genetic, psychosocial, and environmental factors makes diagnosis challenging.

Resilience

__________ is formed by the relationship between the child's constitutional endowment and environmental factors. Characteristics of a ________ child include temperament that adapts to environmental change, ability to form nurturing relationships with other adults when the parent is not available, ability to distance self from emotional chaos of the parent or family, good social intelligence, and ability to use problem-solving skills.

Temperament

__________ is the style of behavior the child habitually uses to cope with the demands and expectations from the environment. It is thought to be genetically determined and may be modified by the parent-child relationship.

Catatonia withdrawn

abnormal motor behavior. Onset is usually abrupt and the prognosis favorable. In the withdrawn phase, the patient may demonstrate posturing, waxy flexibility, stereotyped behavior, extreme negativism or automatic obedience, echolalia, and echopraxia.

Negative Symptoms

apathy, lack of motivation, anhedonia, poor social functioning, and poverty of thought are associated with insidious onset, premorbid history of emotional problems, chronic deterioration, CT scan showing atrophy, and poor response to antipsychotic therapy. Are the symptoms that most interfere with adjustment and ability to survive (e.g., ability to initiate and maintain relationships, initiate and maintain conversation, hold a job, make decisions, maintain adequate hygiene and grooming). Others include poverty of speech or speech content, thought blocking, anergia, anhedonia, avolition, affective blunting (minimal emotional response), inappropriate affect (incongruent response), or bizarre affect (grimacing, giggling, etc.).

Therapeutic Drawing

captures thoughts, feelings, and tensions a child may not be able to express verbally. Characteristics of human figures are general indicators of a child's emotions rather than indicators of psychopathology. A number of characteristics and their meanings are given in the text. The nurse may ask the child questions about the pictures and discuss emotions.

Paranoia

characterized by intense and strongly defended irrational suspicion. Projection is the most common defense mechanism used by paranoid patients. These patients usually feel frightened, lonely, and helpless. The paranoid facade is a defense against painful feelings.

SSRIs

fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), escitalopram (Lexapro), and fluvoxamine (Luvox)

FGAs

haloperidol (Haldol), thioridazine (Mellaril), fluphenazine (Prolixin), and chlorpromazine (Thorazine)

MSE

in children is similar to the adult assessment except that the developmental level is considered.

SNDI MOA

increases NE and serotonin transmission by blocking presynaptic receptors. Provides antianxiety and antidepressant effects and promotes sleep with minimal sexual side effects. Also antiemetic. Causes weight gain and sedation.

Cognitive Symptoms

involves difficulty with attention, memory, problem solving, and decision making and represents a major disability associated with schizophrenia.

Tourette's

involves motor and vocal tics that cause marked distress and significant impairment in social and occupational function. Vulnerability is transmitted in an autosomal dominant pattern. Associated symptoms are obsessions, compulsions, hyperactivity, distractibility, and impulsivity. Low self-esteem is associated with tics

Bibliotherapy

involves using children's literature to help the child express feelings in a supportive environment, gain insight, and learn new ways to cope with difficult situations. Books are chosen by the nurse to reflect the situations or feelings the child is experiencing.

Seclusion

is rare. Other methods are more effective, especially early intervention before loss of control occurs. The child or adolescent will always perceive ________ as punishment, and the experience of being overpowered by adults is terrifying to one who has been abused.

MAOIs

isocarboxazid (Marplan), phenelzine (Nardil), selegiline (EMSAM) and tranylcypromine (Parnate)

EPS management

lowering dose and prescribing antiparkinsonian drugs such as trihexyphenidyl (Artane), benztropine (Cogentin), or diphenhydramine (Benadryl).

Dopamine Hypothesis

states excess dopamine is responsible for psychotic symptoms. This theory was based on the knowledge that antipsychotic drugs block some dopamine receptors, limiting the activity of dopamine and reducing psychotic symptoms. Other drugs (e.g., amphetamines), increase activity of dopamine and can simulate symptoms of paranoid schizophrenia in a patient without schizophrenia.

Mood disorders

may be similar to adult symptoms. Symptoms of depression in children often include somatic complaints, irritability, and social withdrawal. Psychomotor retardation and hypersomnia are more evident in adolescent depression. Associated factors include, among other things, physical and sexual abuse, neglect, death, divorce, learning disabilities, conflicts with or rejection by family or peers. Complications include school failure, drug or alcohol abuse, promiscuity, running away, suicide, and similar responses

Group therapy

may be used to develop interpersonal skills, resolve community problems, and teach use of community supports. Medication groups can help patients deal with side effects, alert staff to potential adverse or toxic effects, minimize isolation, and increase compliance.

Psychostimulants for ADHD

methylphenidates (Ritalin, Daytrana, Concerta) and dextroamphetamines (Adderall, Vyvanse). May cause agitation, exacerbation of psychotic thoughts, HTN, growth suppression, and high potential for addiction.

Associative Looseness

mirror patient thoughts. Don't pretend to understand when you can't. Tell patient you're having difficulty understanding, placing the problem with yourself (i.e., "I'm having difficulty understanding what you're saying" instead of "You're not making sense"). Look for and mention recurring themes. Emphasize what is going on in the environment, and involve the patient in simple reality-based activities. Tell patient when you do understand, reinforcing clear communication.

Neuroleptic Malignant syndrome

occurs in less than 1% of those taking standard antipsychotics, is potentially fatal, and is characterized by lowered level of consciousness, increased muscle tone, and autonomic dysfunction (including fever, hypertension, tachycardia, tachypnea, diaphoresis, and drooling).

Developmental Assessment

provides information about the child's current maturational level. When compared with chronological age, it identifies developmental lags and deficits. Abnormal findings are often related to stress, adjustment problems, or more serious disorders.

Adjustment Disorder

residual category used for emotional responses to an identifiable stressor that do not meet other DSM-IV-TR axis I criteria for another disorder. The disorder is characterized by decreased performance at school and temporary changes in social relationships occurring within 3 months of the stress and lasting no longer than 6 months after the stress has ceased.

Positive Symptoms

symptoms are florid psychotic symptoms such as hallucinations, delusions, bizarre behavior, and paranoia. Are associated with acute onset; normal premorbid functioning and normal functioning during remissions; normal CT scans; and favorable response to antipsychotics.

Acetylcholinesterase Inhibitors (For Alzheimer's)

tacrine (Cognex), donepezil (Aricept), galantamine (Razadyne), and rivastigmine (Exelon). Cognex can cause hepatic toxicity

SNRIs

venlafaxine (Effexor), desvenlafaxine (Pristiq), and duloxetine (Cymbalta).