WILKES NSG 526 exam 3
A helpful technique for managing feelings is known as the COMMUNICATION TRIAD. The triad provides a specific syntax and order for clients to identify and express their feelings and seek relief. The sentence" consists of three parts: An ------------ statement to identify the prevailing feeling A nonjudgmental statement of the --------------- What the client would like ------------- or what would restore comfort to the situation
"I" emotional trigger differently
The PMH-APRN must emphasize with clients that they begin with the: 1.) "I" statements (i.e. I get mad when you treated me that way) or 2.) condition (you treated me that way and I got mad) Why?
"I" statements because condition becomes accusatory, provokes defensiveness
Biological Theory Neurotransmitter Secretion - There is growing support for the existence of certain abnormalities in neurotransmitter secretion (Hankin & Abela, 2005). Dopamine and serotonin (5-HT) have been of major interest in a number of disorders. For instance, studies suggest that ------------- levels may be elevated in autism but depleted in childhood depression. However, it is often unclear whether the dysfunction in neurotransmitter levels causes the disorder, or whether the disorder may create nervous system changes that cause the neurotransmitter abnormality.
-5-HT (serotonin) elevated in autism, depleted in depression -
The Office of the U.S. Surgeon General produced a report indicating that the unmet mental health needs of children and their families is a public health crisis (Department of --------- and Human Services [DHHS], 2001). The report calls for a national action agenda to promote mental health in children and treat more effectively their mental disorders. Among the many important goals in this national agenda are plans to: Improve assessment and recognition of children's mental health needs. Eliminate ------------- and socioeconomic disparities in access to care. Educate mental health providers as well as front-line, primary care providers to better recognize and manage children's mental health issues.
-Health and Human Services -racial/ethnic -
The treatment approaches most commonly used by child and adolescent psychiatric-mental health professionals are: -child-parent ---------------therapy ---------- therapy ------------- behavioral therapy --------- therapy, and medication.
-child-parent psychotherapy -play therapy -cognitive behavioral therapy -family therapy, and medication.
Psychodynamic theory also holds that the child is born with instincts or drives for the --------------- of needs to ensure survival. L--------- is described as the psychic energy that makes the child try to meet these needs. If the needs are not satisfied during development, the child may become so fixated on meeting the needs that they influence much of his or her -----------
-gratification -Libido -behavior.
Borderline BPD Pharmacologic Interventions - --------- medication is better for people with BPD. Clients with BPD may be taking several medications, particularly if they have a comorbid disorder, such as a mood disorder or substance abuse. Pharmacotherapy is used to control emotional dysregulation, impulsive aggression, ------------- disturbances, and anxiety as an adjunct to psychotherapy
-less cognitive
Attachment Theory: These various patterns can be seen in children by ----- months of age and eventually stabilize into cognitive frameworks that influence all of their intimate relationships in adulthood. While the primary attachment relationship is seen as central to the development of these life patterns, other significant relationships and the child's own degree of resilience or temperamental ------------- are recognized as important mediators in developing secure or insecure attachment patterns.
12 vulnerability
Paranoid, Schizoid, and Schizotypal personality disorders are Cluster --------- which aligns with which one?------------------- 1. (Anxious, Fearful) 2. (Odd or Eccentric) 3. (Dramatic, Emotional, Erratic)
A Odd/Eccentric
--------- instability (rapid and extreme shift in mood) is a core characteristic of BORDERLINE-BPD and is evidenced by erratic emotional responses to situations and intense sensitivity to criticism or perceived slights. For example, a person may greet a casual acquaintance with intense affection, yet later, be ---------- with the same acquaintance. Persons with BPD also have difficulty recognizing negative facial affects of others and experiencing negative emotions, particularly sadness, a------- and d-----------
Affective aloof sadness, anger, disgust
Paranoid Schizoid Schizotypal Antisocial Borderline Histrionic Narcissistic Avoidant Dependent Obsessive-compulsive personality disorders Which one: Characteristics: has superficial ---------, violates ---------- of others, exploits others, lies, cheats, lacks guilt or remorse, is ----------, acts out, and lacks empathy. As clients these individuals are extremely manipulative and ------------- Nurses must establish and adhere to a plan of care, and maintain clear ------------ if they are to minimize client manipulation and acting out.
Antisocial (cluster B) charm rights impulsive manipulative and aggressive. boundaries
Paranoid Schizoid Schizotypal Antisocial Borderline Histrionic Narcissistic Avoidant Dependent Obsessive-compulsive personality disorders Which one: Characteristics: social inhibition, feelings of ------, hypersensitivity to criticism, preoccupation with fear of rejection and ----------, and self perceived to be socially inept. Low self-esteem and hypersensitivity grow as support networks decrease. Demands of workplace often ----------. Project that caregivers will harm them through disapproval and perceive ------------ where none exists. Nurses can teach socialization skills, provide positive feedback, and build ------------
Avoidant (cluster C) inadequacy overwhelming rejection self-esteem.
antisocial, borderline, histrionic, and narcissistic personality disorders are Cluster --------- which aligns with which one?------------------- 1. (Anxious, Fearful) 2. (Odd or Eccentric) 3. (Dramatic, Emotional, Erratic)
B Dramatic, Emotional, Erratic
Paranoid Schizoid Schizotypal Antisocial Borderline Histrionic Narcissistic Avoidant Dependent Obsessive-compulsive personality disorders Which one: Characteristics: unstable, intense relationships; --------- disturbances; impulsivity; self----------; rapid mood shifts; chronic e--------; intense fear of abandonment; splitting; and anger. A major defense is splitting (alternating between idealizing and devaluing). Self-mutilation and suicide-prone behavior are often-used impulsive self-destructive behaviors. ----------- is intense and pervasive and help with ---------- management is an important intervention. Relationship building, safety, and -------- setting are other foci.
Borderline (cluster B) identity self-mutilation emptiness Anger/Anger limit setting
avoidant, dependent, obsessive-compulsive personality disorders are Cluster --------- which aligns with which one?------------------- 1. (Anxious, Fearful) 2. (Odd or Eccentric) 3. (Dramatic, Emotional, Erratic)
C Anxious, Fearful
Borderline treatment strategies: ----------- is a psychosocial treatment developed by Marsha M. Linehan specifically to treat individuals with borderline personality disorder.
DBT
Mix and match DSM-5 TR and the Clinical Picture of Cluster A Disorders DSM-5 TR and the Clinical Picture of Cluster B Disorders DSM-5 TR and the Clinical Picture of Cluster C Disorders with (Anxious, Fearful) (Odd or Eccentric) (Dramatic, Emotional, Erratic)
DSM-5 TR and the Clinical Picture of Cluster A Disorders (Odd or Eccentric) DSM-5 TR and the Clinical Picture of Cluster B Disorders (Dramatic, Emotional, Erratic) DSM-5 TR and the Clinical Picture of Cluster C Disorders (Anxious, Fearful)
Paranoid Schizoid Schizotypal Antisocial Borderline Histrionic Narcissistic Avoidant Dependent Obsessive-compulsive personality disorders Which one: Characteristics: inability to make daily decisions without advice and reassurance, need of others to be responsible for important areas of life, anxious and helpless when alone, and submissive. Solicit care taking by ----------. Fear abandonment if they are too competent. Experience anxiety and may have co-existing ------------
Dependent (cluster C) clinging co-existing depression.
The Four Modules of DBT are -Mindfulness -Interpersonal Effectiveness -Emotion Regulation -Distress Tolerance Which one Reducing vulnerability, Taking opposite action, also related to distress tolerance
Emotion regulation
T or F a child's biologic makeup could influence his or her psychosocial outcomes but not the reverse.
F
T or F There should be reflection at every play session
F There should be a few sessions of play observation without any reflective comment, to allow the child to gain comfort in the play, before eliciting any anxiety that may arise as a result of reflection.
T or F In BPD, there are not any concerns with failure to engage in active problem solving. (meaning the patient becomes ----------) -but the funny thing is --------------- are rarely taken
F hopeless, relying on others for help suggestions
Mutual Storytelling - Mutual storytelling is a psychodramatic technique developed by -------- (1971) to help young children express themselves verbally. The child is asked to make up a story with a beginning, middle, and ending. At the end of the story, the child is asked to state the lesson or -------- of the story. The PMH-APRN determines the psychodynamic meaning of the story and selects one or two of its important themes. Using the same characters and a similar setting, the PMH-APRN -----------, providing a healthier resolution. The lesson of the story is also reformulated to help the child become consciously aware of the better resolution. If the child has trouble starting a story, the PMH-APRN can assist by beginning the story with "---------------- in a faraway land there lived a ... " and then asking the child to continue. After the child has identify main characters, the PMH-APRN may need to keep prompting
Gardner moral retells the story Once upon a time recorded
Paranoid Schizoid Schizotypal Antisocial Borderline Histrionic Narcissistic Avoidant Dependent Obsessive-compulsive personality disorders Which one: Characteristics: center of attention; flamboyant; seductive or provocative behaviors; s-------, rapidly shifting ---------; dramatic expression of emotions; overly concerned with --------- others; exaggerates degree of intimacy with others; self-----------; preoccupied with own appearance. Experience depression when a---------- of others is not given. Suicide gestures may result in client entry into the health care system. A thorough assessment of suicide potential must be undertaken, and support offered in the form of clear ---------- of psychotherapy.
Histrionic (cluster B) shallow emotions impressing self-aggrandizing (promoting oneself as being powerful or important) admiration parameters
Personality disorders were originally classified as Axis ---------- diagnoses in the DSM-IV-TR.
II
The Four Modules of DBT are -Mindfulness -Interpersonal Effectiveness -Emotion Regulation -Distress Tolerance Which one teach assertiveness, saying no. Focus on changing something or resisting something. Self-respect
Interpersonal
The biosocial viewpoint proposed by Marsha --------- and colleagues sees BORDERLINE-BPD as a multifaceted problem, a combination of a person's innate emotional vulnerability and his or her inability to control that emotion in social interactions (emotional dysregulation) and the environment (Linehan, 1993). The emotional dysregulation and aggressive impulsivity entail both social learning and ---------- regulation. Much of the neurobiological research is directed at neurotransmitter functions involving s----------, n--------- d--------, a--------, gamma-aminobutyric acid (GABA), and v---------- (Joyce et al., 2006; Gollan, Lee, & Coccaro, 2005). In fact, restoring balance in these systems permits more consistent neural firing between the ---------- system and the ----------and prefrontal cortex. When these pathways are functional, the person has greater capacity to think about his or her emotions and modulate beh
Linehan biologic regulation serotonin, norepinephrine, dopamine, acetylcholine, gamma-aminobutyric acid (GABA), and vasopressin limbic/frontal
Rett's disorder has been found to be an X-linked dominant inheritance disorder associated with mutations in the MECP2 gene (City of Hope, 2008). In addition, there is evidence that other milder mutations in the MECP2 gene may predispose to ------------ and ---------retardation. Information on DNA testing for the MECP2 gene is available at the website of the City of Hope's Clinical Molecular Diagnostic Laboratory.
MECP2=autism and mental retardation
The Mental Status Examination (MSE) judges: -Appearance ------------- Activity -Self-concept -Behavior ----------- Interaction -General Intelligence -Fund of Knowledge -Orientation -Recent Memory -Re--------- Memory -A--------- Reasoning and Analogies -Arithmetic Calculations -Writing/s---------- -Reading -Fine Motor Skills -Gross Motor Skills -Attention Span -Insight and Judgment -C------------ -Mood/f------------- -Thought process/content -Speech/language
Motor Social remote Abstract spelling Comprehension feelings
Paranoid Schizoid Schizotypal Antisocial Borderline Histrionic Narcissistic Avoidant Dependent Obsessive-compulsive personality disorders Which one: Characteristics: grandiosity, fantasies of power or brilliance, need to be a-------, sense of entitlement, arrogant, patronizing, rude, overestimates self and underestimates others. This behavior covers a fragile ego. In health care setting demand the ------- of everything. When client is corrected, when boundaries are defined, or when limits are set on client's behavior, client feels --------------, degraded, and empty. To lower anxiety the client may launch a --------- The nurse should gently help the client identify attempts to seek and become ---------, exhibit grandiose behavior, and sense of entitlement.
Narcissistic (cluster B) admired best humiliated counterattack. perfect
Play Therapy - ------------ play is normally viewed as the best way to begin play therapy. The ------------- and themes that emerge in play provide a core of information for assessment and subsequent treatment. They give us the same type of information that we gather through verbal communication with adults. Remember that ---------- (such as aggressive behavior toward a father doll) can have several meanings and should never be interpreted in a standardized fashion. Always consider the way a symbol is used in the play before interpreting a symbol's subjective meaning to a child, as it may relate to the particular context of the child's life. The PMH-APRN's impressions must be ------------ or refuted based on a variety of different types of information collected over time. There is a general belief that toys with ----------- meaning and diverse uses foster symbolic play more effectively because they allow the child
Nondirective symbols symbols (multiple meanings) verified ambiguous identity NONDIRECTIVE play first
Paranoid Schizoid Schizotypal Antisocial Borderline Histrionic Narcissistic Avoidant Dependent Obsessive-compulsive personality disorders Which one: Characteristics: preoccupied with rules, perfectionist, too busy to have ---------, rigid control, and s----------- relationships. Complains about others' i-------------- and gives others directions.
Obsessive-compulsive personality disorders (cluster C) friends superficial inefficiencies
Cognitive Behavioral Theory Cognitive theorists emphasize that psychopathology results from particular mental sets or cognitive schemata that involve distortions of reality. Children's experiences with the environment create these schemata, or ways of viewing the world, which then influence what is perceived and how it is processed and understood in all future interactions. Biased or inaccurate ways of thinking or processing information can take a number of forms; for instance: Interpreting things as worse than they are over---------- Selective ------------ Disqualifying the positive Jumping to conclusions P------------ events that are not actually related to the child. Treatment is thus focused on a reeducation or relearning process aimed at the child's --------- beliefs and their related behaviors (Stallard, 2005). This process can occur individually or in a group situation.
Overgeneralizing selective perception Personalizing irrational (group or 1:1)
Biological Theory Neuroendocrine Reactivity - A related biological vulnerability is the child's neuroendocrine reactivity. The hypothalamic-pituitary-adrenal axis regulates the nervous system's release of stress hormones such as cortisol. The feedback mechanism controlling these hormones appears dysfunctional in certain psychiatric disorders. For instance, children with ---------- show excessive secretion of stress hormones, with neurotoxic effects on brain development and function (van der Kolk, 2003).
PTSD excessive stress hormones (cortisol)
Paranoid Schizoid Schizotypal Antisocial Borderline Histrionic Narcissistic Avoidant Dependent Obsessive-compulsive personality disorders Which one Characteristics: suspicious of others; fear others will exploit, harm, or deceive them; fear of -------- in others (fear personal information will be used against them); misread compliments as -----------; hypervigilant; prone to counterattack; hostile; and aloof. Psychotic episodes may occur in times of -------. Nurses should give ------------- explanations of tests, history taking, and procedures, side effects of drugs, changes in treatment plan, and possible further procedures, to counteract client fear.
Paranoid (cluster A) confiding manipulation stress straightforward (as with all of cluster A)
Therapeutic Interventions - Regardless of the specific purpose of play therapy, the PMH-APRN's interventions should involve a combination of ----------- and interpretation to help the child gain greater awareness of the unconscious issues that are becoming apparent. -------------- involves simple commenting on what is happening in the child's play-for example, "The boy doll is hitting the father doll again." Such a statement includes no interpretation but has the potential to help the child become more aware of what is happening in the play. ----------- is the major intervention used by more inexperienced clinicians, including the generalist nurse. It is also the mainstay for clinical specialists during their initial work with the child.
REFLECTION and interpretation Reflection Reflection
Three activities associated with thought stopping are effective: Taking a quick deep breath when the behavior is noted (this also stimulates relaxation) Visualizing a stop sign or saying "---------" when possible (this allows the person to hear externally and internally) Deliberately replacing the undesired behavior with a positive alternative (e.g., instead of ruminating about an angry situation, think about a neutral or positive self-affirmation). The sequencing and combining of the steps puts the person back in -----------
STOP control.
Paranoid Schizoid Schizotypal Antisocial Borderline Histrionic Narcissistic Avoidant Dependent Obsessive-compulsive personality disorders Which one Characteristics: --------- close relationships, is socially -----------, has poor occupational functioning, and appears cold, -------, and detached. Social awareness is lacking and relationships generate ----- and confusion in the client. Nurses should strive for s------- and clarity to help decrease client anxiety.
Schizoid (cluster A) avoids isolated aloof fear simplification (as with all of cluster A)
Paranoid Schizoid Schizotypal Antisocial Borderline Histrionic Narcissistic Avoidant Dependent Obsessive-compulsive personality disorders Which one Characteristics: ideas of ------------; ------------ thinking or odd beliefs; perceptual distortions; vague, ---------speech; frightened, suspicious, ---------- affect; distant and ---------- social relationships. These clients tend to be frightened and suspicious in social situations. ------------ can ease their anxiety.
Schizotypal (cluster A) reference magical stereotyped blunted strained Explanations (as with all of cluster A)
Psychodynamic Theory - Psychodynamic theory originated with ------------ in his conceptualization of psychoanalysis but has evolved substantia1ly since its original formulation (Gabbard, 2004). Much of ---------- speculation regarding psychosexual stages of development has been rejected, but many components of his ----------theory continue to serve as a foundation for assessment and treatment in child psychiatry (Muratori et al., 2002 A central component of this theory is the concept of psychic --------- which proposes that the child's initial perceptions of the world are defined substantially during the first 5 to 6 years of life and will influence the child's later views and behavior in a causal way. While this stance seems almost a given in today's world, the concept was unheard of when ----------- first proposed it.
Sigmund Freud Freud's (stages of development rejected) PERSONALITY theory still valid psychic determinism, Freud
Cognitive Behavioral Theory - The origins of cognitive behavioral theory stem from ---------'s behavioral learning school of thought. However, current views integrate more recent cognitive theory and social learning theory traditions (Friedberg & McClure, 2002). The basis of this theory is the importance of the environment in the child's psychological development. The environment encompasses everything to which the child is exposed, including the immediate caregiving environment (the family, school, and neighborhood), as well as the larger socio-cultural milieu within which values and expectations are developed. Infants are viewed as coming into the world with a relatively "blank slate," and they develop personality by being conditioned to respond in certain ways by others in the environment. ---------- is important as well, whereby children learn by watching others and what happens to those people as a result of t
Skinner's Modeling
Child Behavior - The focus on the child aims to identify specific difficulties in the child's temperament or behavior and help manage these difficulties more effectively. Tem------ is the constitutional makeup of the child at birth, specifically the child's behavioral and psychophysiological attributes. For instance, infants who have been exposed to drugs in utero may be very sensitive to stimulation from lights, sounds, or touch; may cry frequently and be difficult to console; and have trouble developing regular patterns of sleep. An infant with such a tem--------- will need help to develop better regulation of ---------- patterns and responses to distress through a variety of activities that reduce stimulation and help calm and soothe the infant. In this way, the child may feel less distressed and begin to feel more secure with people. The PMH-APRN may also work to improve a child's interpersonal skills or capaci
Temperament temperament sleep rewards Parents watch NURSE work with kid (child behavior)
Purposes of Play Therapy Another purpose of play therapy is -------------, the reliving through play of past events and their related feelings. Through ----------, the child gradually can assimilate previous experiences that have been traumatic or painful. Assimilation occurs through the release of related emotions, as well as through integrating what happened into the child's ongoing view of himself and the world. The basis of this integration is the opportunity, through play, to gain mastery over an experience in which the child most likely had no control. Mastery comes from reenacting the event in the child's ----------, working through the feelings that were part of the experience, and modifying, over time, how it happened and what the outcome may have been. Another frequent use of play therapy is to help the child try out other ways of relating to the world or responding to situations. At about ---------year
abreaction (reliving past events) abreaction child's own way 3
Perinatal Complications - Perinatal complications, including perinatal -----------, congenital anomalies, and intrauterine exposure to drugs and alcohol, have also been associated with psychiatric disorders (Delobel-Ayoub et al., 2006; Linares et al., 2006).
asphyxia
Chronic Illness - Of equal importance is the effect of chronic illness on the adolescent's mental health. Asthma, head injury, diabetes, epilepsy, and many of the less common chronic physical diseases can result in depression. Equally at risk for depression are adolescents with various learning disabilities or specific neuropsychiatric illnesses, such as a------------ disruptive behavior disorders; t-------- disorders; e-------- disorders; anxiety disorders, including o------- and post-traumatic stress disorder (PTSD); and schizophrenia and related conditions (American Psychiatric Association [APA], 2000).
attention deficit/hyperactivity disorders (ADD/ADHD); tic eating OCD are all at risk for depression
Biologic Theory - Neurobiological Factors - There is considerable evidence for the role of neurobiological factors in the development of disorders such as a-------- disorder and childhood-onset s------------ Children with these disorders have more physical anomalies, neurologic soft signs, and brain abnormalities on electroencephalograms (EEGs) and in computed tomography (CT) and magnetic resonance imaging (MRI) scans. -Similarly, ----------- poisoning, -------- trauma, and i--------- in childhood have all been implicated as possible causative factors. These problems are considered potential causes of the mental disorder.
autistic schizophrenia. lead CNS infections
Personality disorders were originally classified as Axis II diagnoses in the DSM-IV-TR. Axis II classification was intended to focus attention on ----------I patterns that might be overlooked in the light of the more pronounced disorders of Axis I.
behavior
Humanistic-Interactionist Theory - As an PMH-APRN, you not only need knowledge about developmental theories and psychobiology, you must also integrate humanistic-interactionist principles into assessment and interventions to develop a trusting, caring interpersonal relationship with children and adolescent clients. The adolescent developmental period is a time when identity, values, and goals are in a state of flux. You should take into account not only the immediate situation but also the impact of the developmental stage; the social, ethnic, and cultural factors; family influences; and psychodynamic conflicts on the adolescent's behavior. To accomplish this, explore the meaning of the identified problem or ----------
behavior.
It is not unusual for people with --------- to direct their actions in accord with the wishes of other people. For example, one woman with ----------- describes herself: "I am a singer because my mother wanted me to be. I live in the city because my manager thought that I should. I become whatever anyone tells me to be. Whenever someone recommends a song, I wonder why I didn't think of that. My boyfriend tells me what to wear."
borderline-BPD borderline-BPD
Purposes of Play Therapy - Play therapy can serve many purposes. A major use is for ----------, the release of strong emotions in order to provide relief from the inner tension they may be causing the child. It is also believed that expressing emotions, interactions, and relationships, even though they may not be conscious for the child, provides some kind of ---------- relief. ------------ can be facilitated through many forms of play, including drawings, doll play, ---------modeling, or the -----------out of certain feelings through pounding toys or punching dolls or bags.
catharsis cognitive Catharsis clay acting
Biologic Theory - Advanced practice psychiatric/mental health nursing in the 21st century requires that you integrate a biologic focus into your practice, to accommodate both --------- client needs and an expanding biologic knowledge base. An appreciation of hormonal changes, growth spurts, stress and ------------ function, chronic illness, depression, and other mental disorders can help you evaluate children and adolescents from a more effective and comprehensive perspective. There are many hypotheses regarding the particular biologic characteristics that may make children and adolescents vulnerable to developing certain psychiatric disorders (Hankin & Abela, 2005). While the exact relationship between various biological factors and mental illness is not yet understood, several hypotheses are discussed in this unit.
changing immune f(x)
Therapeutic Games - The use of therapeutic games is ideal for children who have difficulty talking about their feelings and problems. Playing a game with a child facilitates the development of a therapeutic alliance and provides an opportunity for conversation. The game might be as simple as ---------, but specific therapeutic games are more effective in eliciting children's fears and fantasies ----------- (1979) developed a series of therapeutic games for children, one of which, Board of Objects, can be used with children --------- to 8 years of age. The game pieces are small items (people, animals, various objects) that are placed on a ---------. The players roll dice. One side of each is colored red. If a -------- side lands face up, the player selects an object. To get a reward chip, the player must say something about the object; if the player tells a ------- about object, he or she gets two reward chips. The c
checkers Gardner 4-8 checkerboard RED side faceup=player selects object story =2 chips child
Play Therapy - Play therapy is -----------centered (Landreth, 2002) and typically builds on the foundation of the psychodynamic, object-relations, and attachment theories described earlier in this Unit. Although play therapy is used as part of most assessment protocols and to treat a variety of mental health problems, it is quite helpful for the following diagnoses: ------------ disorder ------------ behavior disorders -----------disorders reactive ---------- disorder. Play therapy can be used by PMH-APRNs with children who are around ----- years of age or older. The generalist nurse does ----------- play with children, but not play therapy. The generalist nurse uses -------------, but not interpretation (discussed later in this Unit).
child-centered posttraumatic stress disorder disruptive behavior disorders mood disorders reactive attachment disorder. 3 or older generalist= THERAPEUTIC play but not play therapy generalist uses REFLECTION, not interpretation
The treatment approaches most commonly used by child and adolescent psychiatric-mental health professionals are: -child-parent psychotherapy -play therapy -cognitive behavioral therapy -family therapy, and medication. Which one should be considered by the PMH-APRN when a parent or caregiver has beliefs that a caregiving style may be contributing to the child's mental health problems
child-parent
Cognitive Behavioral Therapy - The approaches used in cognitive behavioral therapy stem from cognitive behavioral theory, described earlier in this Unit. Two major differences exist between this modality and traditional play therapy: 1.) First, cognitive behavioral approaches focus on the child's ----------- rather than ----------- issues. 2.) Second, emphasis is placed on more effective coping in the ---------- rather than on mastery over ---------- feelings associated with the child's past experiences. Cognitive behavioral approaches have been particularly successful in treating problems associated with depression ---------- disorder A--------- an----------- in children ------ and older (Martin & Pear, 2007). Behavioral techniques, without the cognitive component, are also widely used to address therapeutic goals for ------ to 6-year-old children and those with mental -----------, learning and communication
conscious rather than unconscious present RATHER than mastery over unresolved feelings depression conduct disorder ADHD, anxiety 7 and older 3-6 retardation tic elimination
A personality disorder is defined as "an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's ------------, is pervasive and -----------, has an onset in adolescence or early adulthood, is stable with time, and leads to distress or impairment"
culture inflexible
Biological Theory Genetic Predisposition - Twin and adoption studies continue to provide evidence in support of genetic etiology for many disorders, including pervasive developmental disorders, schizophrenia, and depression. Adopted children and their biologic parents show a much stronger likelihood of both having these disorders than adoptive parents and children. In addition, when cone twin has a disorder, the other is much more likely to have the disorder than is another sibling, parent, or other relative. There is also strong evidence of a familial pattern for both major ----------- and dysthymia, with clear support for a genetic, biochemical etiology (Hankin & Abela, 2005).
depression
Attachment Theory - Attachment theory builds on the psychodynamic concepts of psychic ---------- and the impact of --------- processes. As in object-relations theory, -----------s are viewed as the organizing principle for the development of psychological well-being in the child. However, the concept of ---------- within the relationship is the main focus of attachment theory. Attachment theory was originally described by ---------- and later extended by Ainsworth and others (Hankin & Abela, 2005).
determinism unconscious relationships security Bowlby/Ainsworth
Child-Parent Psychotherapy - Child-parent psychotherapy should be considered by the PMH-APRN when a parent or caregiver has beliefs that a caregiving style may be contributing to the child's mental health problems (Timmer, Urquiza, Zebell, & McGrath, 2005). It can also be very effective when the child has temperament or behavioral characteristics that are creating special challenges for a parent. There are many approaches to child-parent psychotherapy, depending on the clinician's theoretical perspective. It is used with a wide variety of problems, including pervasive de----------disorders, fe------ disorders, disruptive behavior disorders, --------treatment, and re--------- attachment disorder (Landreth & Bratton, 2006). In child-parent psychotherapy, the nurse works closely with both the primary caregiver (usually the mother) and the child, focusing on three components: the child's be---------, the parent's attit
developmental feeding maltreatment reactive behavior feelings interaction
Developmental Theory - An understanding of developmental theory helps you identify ---------- in adolescent growth and development processes and intervene appropriately. The theories of Freud, Erikson, and ----------- provide considerable insight into the adolescent's struggle to attain adulthood. The development of an adolescent's sense of identity entails a preoccupation with self----------. It also entails a connection between future role and past experiences. In the search for a new sense of sameness and continuity, many adolescents must repeat the crisis resolutions of earlier years to integrate these past elements and establish the lasting ideals of a final identity. According to Erikson, these crisis periods or stages are reviews of the adolescent's sense of t-------, a---------, i--------, and i-------, in that order. Equally important for an adolescent's development is c--------Piaget's research reveal
deviations Sullivan self-image. trust, autonomy, initiative, and industry cognition. formal (3rd stage) 12-14, adult level self-reflective
The thinking of people with BPD is di-------------- They either think in black and white (per is good or bad) or their thinking becomes dis--------------- Another cognitive dysfunction common in BPD is dis--------, or times when thinking, feeling, or behaviors occur outside a person's awareness
dichotomous. (divided into two parts) disorganized dissociation
Borderline Identity d----------- occurs when a person lacks aspects of personal identity or when personal identity is poorly developed (Erikson, 1968). Four factors of identity are most commonly disturbed: -r--------- absorption (narrowly defining self within a single r--------) -painful in----------- (distressed sense of internal disharmony) -in----------- (lack of coherence in thoughts, feelings, and actions), -lack of --------------
diffusion role/role incoherence inconsistency commitment
The Four Modules of DBT are -Mindfulness -Interpersonal Effectiveness -Emotion Regulation -Distress Tolerance Which one bear pain skillfully, acceptance of reality is not approval of reality. distracting, self--------------, improving the ----------, and thinking of pros and ---------- Acceptance skills include radical acceptance, turning the mind toward acceptance, and willingness versus will---------
distress tolerance distracting self-soothing improving moment pros/cons willfulness.
borderline personality These dysfunctions could be caused by a number of events, including trauma, e--------, and A----------. People with BPD manifest psychotic-like symptoms, including p---------- thinking, dissociation, depersonalization, and de-------. These symptoms seem to be associated with intense ------------
epilepsy ADHD paranoid derealization. anxiety.
It is important to remember that children both: Actively elicit and seek out certain res fain responses and ------------ Perceive what is given by the environment through the looking glass of their unique ------------
experiences genotype
Cognitive Restructuring - Cognitive behavioral treatment is a reeducation and relearning process involving the development of new ways of thinking about life and new behaviors that are more adaptive and more functional for the child. The cognitive aspects of therapy attempt to modify inaccurate or biased ways of processing information that result in distortions of what is actually occurring in the child's world (Martin & Pear, 2007; Stallard, 2005). The process of cognitive restructuring involves strategies such as ------------ what the child means by statements he makes, teaching him to question the "-----------" he's using to maintain any irrational beliefs, helping him identify other ------------ for what a situation might mean, listing --------- and disadvantages of a particular belief, and teaching him to use ----------- or directives to himself to help change or reframe a situation. For example, "Stop and w
finding out evidence options advantages self-talk
New research that has emerged from the Autism Genome Project Consortium at NIMH has implicated the brain's ------------ chemical messenger system and a previously overlooked site on chromosome --------. Based on studies of 1,168 families with at least two affected members, the research adds to evidence that tiny, rare variations in genes may heighten the risk for autism spectrum disorder (ASD; NIMH, 2008). Another Consortium study has identified a defect-a missing segment- on chromosome --------- (Weiss et al., 2008). None of the parents in this study had the chromosomal defect, leading researchers to conclude that some cases of genetically caused autism are due to a random accident while the egg or sperm is being formed and not to h------------
glutamate 11 16 (accident with egg/sperm) not to heritability.
Borderline-BPD Self-injurious behavior can be compulsive (e.g., hair pulling), episodic or repetitive (cutting wrists, arms, or other body parts) and is more likely to occur when the individual with BPD is depressed; has highly unstable interpersonal relationships, especially problems with intimacy and sociability; and is paranoid, hyper------- and re-----------
hypervigilant (alert, watchful), and resentful.
In the DSM-IV-TR, Borderline (BPD) is defined as "a pervasive pattern of ---------- of interpersonal relationships, self-image, and affects, and marked impulsivity that begins by early --------- and is present in a variety of begins by early ------------ and is present in a variety of diagnostic characteristics of BPD.
instability adulthood adulthood
Family Therapy - Family therapy goes beyond family involvement in the child's treatment to focus on treatment of the entire family (Nichols & Schwartz, 2005). This method is selected when i---------- among family members need attention in order to address specific problems exhibited by the child. The goal is to increase the likelihood that improvements in the child's mental health will occur and will be supported in the home with consistent and sustained family patterns (Diamond & Josephson, 2005). If children under age ----------- are involved in family therapy, the nurse may choose to -------- between having the child present and seeing the parents or other family members only. The child's presence provides information for clinical assessment, allows for direct comment on and discussion of the dynamics that occur among parents and children, and provides opportunities for the PMH-APRN to model effective interaction
interactions 7/alternate 2nd talk about ISSUES while child plays or engages in discussion as desired
Borderline patients need: ----------- medications ------------- enhancement Established ------------- (testing limits is a ---------- way of ) identifying
less sleep boundaries/natural
borderline personality disorder Associated brain dysfunction occurs in the -------- system and ---------- lobe and increases the behaviors of impulsiveness, parasuicide, and mood disturbance. A decrease in ---------- activity and an increase in ------noradrenergic receptor sites may be related to the irritability and impulsiveness common in people with this disorder It has also been hypothesized that an increase in ----------- may be responsible for transient psychotic states
limbic/frontal -decreased serotonin -increase α2 hypothesized that increase in DOPAMINE
Parental Attitudes and Feelings - Focusing on the parent's attitudes and feelings toward the child is essential, especially for caregivers whose feelings about the child or attitudes about parenting are distorted in some way. For example, distortions can occur as a result of a parent's own ------------ as a child or current mental illness. Interventions with the parent may include exploration of feelings about the parent's own ---------- and family relations and how they are affecting the care of the child. Parents who receive the PMH-APRN's empathy and support may experience less psychological distress and be able to rework the model they hold in their mind of their relationship with their child. The goal of these interventions is to increase the capacity of the parent to nurture the child and find ---------- in the role of caregiver.
maltreatment history satisfaction (attitude/feelings)
The Four Modules of DBT are -Mindfulness -Interpersonal Effectiveness -Emotion Regulation -Distress Tolerance Which one is the capacity to pay attention, non-judgmentally to the present moment. It is derived from teachings of the Buddha, the Zen tradition being perhaps one of its most well-known proponents. Living in the moment
mindfulness
Interaction Between Parent and Child. Child-parent psychotherapy provides interaction guidance in order to sensitize the parents to appropriate care giving practices. The PMH-APRN can do this by ----------- specific ways of interacting with the child, suggesting approaches for the parents to try, supporting and praising the use of positive interactions, and -------------- for the child so the parents become more aware of the child's potential experience during caregiving (e.g., "Oh, I feel so safe and loved when you snuggle me close like this ... ").The PMH-APRN can also teach the parent certain approaches that will help reduce a child's symptoms or encourage growth in an area where the child is having difficulties. Each of the components of child-parent psychotherapy attempts to enhance the goodness-of---------- between parent and child in order to increase their enjoyment in one another and provide the child with
modeling SPEAKING for the child goodness-of-FIT interactive
In a ------------ model, there is no certain etiology, no predictable set of risk factors, and no specific therapeutic approach having a standard effectiveness. The unique fit between a particular child and a particular set of life ------------- must be considered to understand the child's mental health problems and develop an appropriate
multicausal experiences
Some additional strategies for establishing the boundaries of the relationship include the following: Documenting in the client chart the agreed-on appointment expectations Sharing the treatment plan with the client Confronting violations of the agreement in a non--------- way Discussing the purpose of limits in the therapeutic relationship and applicability to other relationships.
non-punitive
Play Therapy put in order of how these are used: ----------------------------- -interpretation -observation -reflection The use of interpretation begins after rapport and trust have been established, and it can range from subtle to very direct. ------------ interpretations are more removed from the child and speak to the potential meaning behind the toy's behavior. For instance, "The boy doll is hitting the father doll because he's very angry at him." More ----------interpretations are used over time as the PMH-APRN develops greater confidence in the validity of the interpretations for the child. For example, "I wonder if you feel like the boy doll. You seem angry at your dad for leaving." Obviously, these more direct interpretations must integrate anything observed in the play with the total assessment of the child's issues and problems in the real world.
observation, reflection, interpretation Subtle direct
To receive a diagnosis of a personality disorder, an individual must demonstrate the criteria behaviors persistently and to such an extent that they impair the ability to function socially and ----------- In some people, the underlying feelings and behaviors may be intermittent and interfere interpersonally without impairment. Instead of having a personality disorder, the individual is said to have --------- of the disorder.
occupationally. traits
Behavioral Approaches - The behavioral aspects of therapy are based to a great extent on classical and ----------- conditioning techniques. The major classical conditioning technique is --------- desensitization, which involves the pairing of a negative stimulus (such as a feared situation or animal) with a positive stimulus (such as candy or relaxation exercises). The pairing is done in a ------------ way, so the child begins to handle situations that are increasingly fearful or aversive. For example, a child may initially look at pictures of a dog that scares him while having a favorite snack, and progress through a series of more frightening situations. Eventually, the child is asked to touch a dog and receive more positive rewards, such as a favorite snack, which counteract the negative impact. Examples of operant conditioning techniques are c----------- contracting, the use of tokens, m---------, and behav
operant systematic progressive -contingency contracting -modeling -role Contracting modeling modeling
Sleep Enhancement - Facilitation of regular sleep-wake cycles may be needed because of disturbed sleep patterns. Conservative approaches should be exhausted before recommending medication. Establishing a regular bedtime routine, monitoring bedtime snacks and drinks, and avoiding foods and drinks that interfere with sleep should be tried. If relaxation exercises are used, they should be adapted to the tolerance of the individual. Moderate exercises (e.g., brisk walking) 3 to 4 hours before bedtime activates both serotonin and endorphins, thereby enhancing calmness and a sense of well-being before bedtime. For clients who have difficulty falling asleep and experience interrupted sleep, it helps to establish some basic sleeping routines. The bedroom should be reserved for only two activities: sleep and sex. Therefore, the client should remove the television, computer, and exercise equipment from the bedroom. If the clie
physically and sexually furniture
Borderline Basically, DBT maintains that some people, due to invalidating environments during upbringing and due to biological factors as yet unknown, react abnormally to emotional stimulation. Their level of arousal goes up much more quickly, peaks at a higher level, and takes more time to return to baseline. This explains why borderlines are known for crisis-strewn lives and extreme emotional lability (emotions that shift rapidly). Because of their past invalidation, they do not have any methods for coping with these sudden, intense surges of emotion. DBT is a method for teaching skills that will help in this task. The treatment itself is based largely on behaviorist theory with some cognitive therapy elements as well. There are two essential parts of the treatment, and without either of these parts the therapy is not considered "DBT adherent." -Decreasing high-risk suicidal behaviors -Decreasing responses or beh
post-traumatic core mindfulness skills, emotion regulation skills, interpersonal effectiveness skills, and distress tolerance skills
Projective identification is believed to play an important role in the development of BORDERLINE-BPD and is a defense mechanism by which people with BPD protect their fragile self-image. For example, when overwhelmed by anxiety or anger at being disregarded by another, they defend against the intensity of these feelings by unconsciously b----------- others for what happens to them. They project their feelings onto a significant other with the unconscious hope that the other knows how to d-------- with it. Projective identification becomes a defensive way of interacting with the world, which leads to more r---------------
projective identification- BLAMING deal rejection.
Object-Relations Theory - Object-relations theory is built on the foundation of ------------ theory and is based on the work of Fairbairn, Winnicott, Klein, Mahler, Stem, and others (Kaslow & Magnavita, 2002). In this theory, an object is defined as a -------- or thing in the child's environment that has psychological significance to the child. A major assumption of the theory is that rather than being driven simply by physical needs or instincts that enhance survival, infants have an innate biologic need for -----------. These ------- increase in quality and complexity as a child develops.
psychodynamic person or thing relationships/relationships.
Brain Structure and Function - Finally, there is a growing body of research that suggests that early psychological trauma from severe neglect or abuse may create deficits or abnormalities in brain structure and function. It was previously thought that a child's biologic makeup could influence his or her ------------------- outcomes but not the reverse. Evidence now indicates that psychological trauma in the first few years of life can create changes in the size of the brain, the number of neuronal pathways affecting certain brain functions (such as emotion), and the amount at and function of neurotransmitters in the brain (van der Kolk, 2003).
psychosocial
Cognitive Behavioral Theory - The original views of behavioral theory were that positive and negative ---------- alone could condition a child's behavior. These views expanded to recognize the child's ability to deliberate consciously on what occurs and make certain choices about which behaviors are used. This process is called r--------- determinism. The environment provides information that influences the child in choosing how to behave, but interpretation of the ------------ is the determinant of the child's behavior, not the environment itself. However, without the environment, the child has no stimulus toward growth or development.
reinforcement reciprocal interpretation of the environment=behavior
Psychodynamic Theory: Because the ego and superego prevent the id from getting all needs met, Freud proposed that children attempt to cope with the anxiety associated with need deprivation through the unconscious mental processes known as defense mechanisms. Defense mechanisms commonly employed by children are re---------, re-------- formation, and pro-------------. The child comes to deal with the world through these distorted views in an attempt to defend against painful unconscious issues. However, the unconscious content continues to influence the behavior and conscious thoughts of the child, often in ways that severely impair his or her ability to function in life. Defense mechanisms are, therefore, considered to be symptoms of --------------
repression, reaction formation, and projection. mental health problems.
Individuals with BPD develop dysfunctional beliefs and maladaptive schemas leading them to misinterpret environmental stimuli continuously, which in turn leads to ---------- and inflexible behavior patterns in response to new situations and people Because those with BPD have been conditioned to anticipate rejection and disappointment in the past, they become entrenched in a pattern of fear and anxiety regarding encountering new people or situations. They have fears that ------- is going to strike any minute. Early in life, clients with BPD develop maladaptive schemas or dysfunctional ways of interpreting people and events. The work of cognitive therapists is to ----------- these distortions in thinking patterns and replace them with realistic ones.
rigid disaster challenge (remember CBT)
Biological Theory Nervous System Responsiveness - Studies also indicate that problems with nervous system responsiveness may be related to certain psychiatric disorders. For example, children with schizophrenia have unusually -------- autonomic system reactivity when in baseline or resting states, and children with ADHD appear to have a ---------- excitability in the reticular activating system of the brain, requiring more stimulation in order to feel optimally aroused.
schizophrenia=high autonomic system ADHD=lowered excitability in reticular activating system
Attachment Theory: The ways the attachment figure responds to the child's attachment behaviors are considered critical to the foundation of the child's internal working models (Belsky, 2006). These models are ways of viewing relationships that will come to guide the child's evaluation of his or her own capacity to handle e stress, as well as the responses he or she expects of others in times of need. Four major patterns of attachment have been identified as resulting from the initial experiences with the primary attachment: s--------- insecure-a----------- insecure-r-------- dis----------- While the first three patterns reflect different internal working models, the --------- is viewed as a lack of any integrated or consolidated model to guide attachment behavior during situations where comfort or felt security is needed. --------- security is the emotional security a child feels when either physical or emotiona
secure insecure-avoidant insecure-resistant disorganized. disorganized Felt security
A person with BPD has not achieved the normal and healthy developmental stage of separation-individuation, during which a child develops a sense of s--------, a permanent sense of s----------others (object constancy), and integration of seeing both bad and good components of self (Jorgensen, 2006). Those with BPD lack the ability to separate from the primary caregiver and develop a separate and distinct personality or self------------- Psychoanalytic theory suggests that these separation difficulties occur because the primary caregivers' behaviors have been in--------- or insensitive to the needs of the child
self significant others identity inconsistent
The psychoanalytic views of borderline-BPD focus on two important psychoanalytic concepts: s------------ individuation and p----------- identification
separation projective
Milieu Therapy Based on Behavioral Approaches - Cognitive behavioral approaches, such as the ones just described, serve as the basis for most milieu therapy in child psychiatric inpatient settings. These settings are for children with more --------- mental health problems, who may require --------------- assessment to determine an exact diagnosis or intensive, consistent care for life-threatening or violent conditions. The use of behavioral interventions on inpatient units allows staff to give continuous feedback to the children about the appropriateness of their behavior. The children receive rewards such as verbal praise, a sticker, or ---------- for appropriate behavior. For example, children who have a problem hitting others all the time may receive a sticker and verbal praise for no hits hourly, until they associate their behavior with the reward. At that time, the need for feedback may decrease to a less-
severe around-the-clock points verbal time-out
Attachment Theory: Attachment refers to the ---------- bond of the child to another person (the attachment figure) who is perceived as strong or powerful and who can be turned to for ---------- and support in situations of perceived danger or adversity. Infants are viewed as coming into the world with an innate neurobiological structure called the a--------- b-------- system. This evolutionary-based adaptive system monitors and processes information regarding un-------, str---------, or potential -------- as well as the accessibility of the attachment figure during these situations. The infant appraises both the environmental conditions and his or her emotional state to determine how much proximity or contact is needed in order to feel --------. The child then uses attachment behaviors (p------------ or contact-promoting behaviors such as calling, approaching, or ----------) to acquire a sense of security.
socio-emotional protection attachment behavioral uncertainty, stress, or potential danger secure. proximity clinging
Biological Theory There has been great concern among parents, consumer advocacy groups, and health care professionals that vaccines given to infants may be linked to the increase in autism. Because of this concern, some parents have been reluctant to have their children protected from childhood diseases through vaccination. Two reasons are generally given for this concern. The first is the use of t-------- (a preservative in vaccines that contains trace amounts of ethylmercury). The second is related to the ------------ immunization schedule for infants. The data do not support the hypothesis that exposure to t------------ causes autism. The rate of autism has increased even with the exclusion of t----------- from childhood vaccines (Schecter & Getcher, 2008). Studies in Canada yield similar results. In fact, one study (Fombonne, Zakarian, Bennett, Mung, & McLean-Heywood, 2006) found that the increase was higher
thimerosol measles-mumps-rubella (MMR) thimerosal/thimerosal/thimerosal/thimerosal MMR
Psychodynamic Theory: The focus of treatment is attempting to bring repressed conflicts and issues into awareness so that they can be addressed and resolved. A primary way in which this occurs is through --------, a process whereby the child unconsciously directs feelings and desires from other relationships in life onto the therapist. So the relationship between therapist and child is used as a focus for interpretation and change.
transference
Object-Relations Theory - Initially infants are (differentiate or undifferentiate --------------) from the object they seek (the primary caregiver) and are in a state of diffuse, unorganized experiences. The child is totally dependent on the mother to organize the child's different experiences into an ------------. As the young child begins to (differentiate or undifferentiate --------------), that is, separate and develop a sense of his or her own self as an individual, the relationships with interpersonal "objects" in the world of the child are (externalized or internalized ----------) and become the internal mental representations that form the self. The differentiated self forms the basis for the child's future views of his or her own worth and the availability and responsiveness of others. Ultimately, it determines whether or not the child becomes healthy, strong, and creative. Development of the self is c
undifferentiate understandable whole. differentiate internalized repeat in relationships
Borderline They appear more competent than they actually are and often set --------- expectations for themselves.
unrealistically high
To receive a diagnosis of a personality disorder, an individual must demonstrate the criteria behaviors persistently and to such an extent that they impair the ability to function socially and occupationally. In some people, the underlying feelings and behaviors may be intermittent and interfere interpersonally without impairment. Instead of having a personality disorder, the individual is said to have traits of the disorder. Personality traits are defined as "prominent aspects of the personality that are exhibited in a wide range of important social and personal contexts" (APA, 2022, p. 735). Personality traits can also be noted without a -----------
without a formal diagnosis.
More than three fourths (77%) of the clients with diagnoses of BORDERLINE (BPD) are young --------- (mean age, mid-20s; Friedel, 2004a). Another reason is that childhood -----------, strongest risk factors for BPD T or F ---------------There is evidence of central nervous system dysfunction in BPD including possible structural changes. Magnetic resonance imaging studies of 21 female clients with both BPD and PTSD, compared with a matched healthy control sample, showed that women with BPD had a 16% (larger or smaller-------------) amygdale than did the healthy control subjects impulsive, ----------, and suicidal behavior
women sexual abuse T smaller aggressive
