Ch. 22 & 23- Common Child and Adolescent Mental Health Disorders

Mild (50-70) IQ

capable of independent living with assistance during stressful times Academic skills to 6th grade level As adult, can achieve vocational skills for minimum self-support Capable of developing social skills. Functions well in a structured, sheltered setting Pyschomotor skills usually not affected; some have problems with coordination

Attention Deficit Hyperactivity Disorder (ADHD)

***Characterized by: inattentiveness, overactivity, impulsiveness *Essential feature of ADHD: persistent pattern of inattention and/or hyperactivity and impulsivity *Onset and clinical course (across the lifespan): -Infants & Toddlers- fussy, poor sleeping patterns, temperamental, toddler is often always on the go, into everything, always running through house, can't sit still -Often diagnosed when child starts school- largest part of diagnosis, disruptive in class, can't complete tasks, forget or lose things, can't follow directions -Continues into adolescence- impulsive behaviors (cutting class), risky behaviors (speeding tickets, drugs, breaking curfew, sexual permiscuity) -Secondary complications: low self-esteem and peer rejection -New studies show that ADHD can persist into adulthood- about 50% of people with childhood will have ADHD continue through adulthood, might be restlessness or nervousness, low frustration tolerance, lack of friends at times, depression may be more prevalent, 70-75% of them have another psychiatric comorbidity (most common is MDD, bipolar, social phobia and/or alcohol dependence)

Conduct Disorder

*Characterized by persistent behavior that violates societal norms, rules, laws, and the rights of others. *Physical aggression is common and peer relationships are disturbed. *Symptoms are clustered into 4 areas: -Aggression to people and animals -Destruction of property -Deceitfulness and theft -Serious violation of rules -Little empathy, no remorse for their behavior, shallow or superficial emotions, don't ever feel bad, unconcerned about performance in school or at home *Prevalence: 1 in 10 percent; males 2:1 *Comorbidities: -ADHD, mood disorders, learning disorders, and substance use disorders -Higher chance of antisocial personality disorder later in life *About 30% of ODD patients move on to have conduct disorder

Disruptive Behavior Disorders

*Characterized by persistent patterns of behavior that involve anger, hostility, and/or aggression toward people and property. *Types: -Oppositional defiant disorder (ODD) -Conduct disorder -Intermittent explosive disorder (IED)

Autism Spectrum Disorders

*Characterized by pervasive and usually severe impairment of social interaction skills, communication deviance, and restricted stereotypical behavioral patterns *Characteristics: -Present by early childhood; affects boys more than girls -Diagnosed along a spectrum -80% are early onset (delays starting in infancy) -20% have normal growth and start to delay at 2-3 years old *Objective data: (Box 22.1, p. 428) -Little eye contact- major identifier -Few facial expressions -Limited gestures to communicate -Limited capacity to relate to peers or parents- parent might report they don't bond to me, don't want to be held -Lack of spontaneous enjoyment -Apparent absence of mood and affect -might hand flap, rock, or spin in circles

ODD

*Characterized by: enduring pattern of uncooperative, defiant, disobedient, and hostile behavior toward authority figures (anyone that tries to limit them) without major antisocial violations -Table 23.1, p. 449- acceptable characteristics and abnormal behaviors, typically begins by 8 years old but usually by the age of 12, often seen with comorbidity of ADHD, anxiety or mood disorders, more prevalent in boys than girls, may see conduct disorder and/or antisocial personality disorder as an adult -Acceptable Characteristics: psychosomatic complaints, unpredictable behavior, eagerness for peer approval, competitive in play, erratic work and leisure patterns, critical of self and others -Unacceptable Characteristics: fears, anxiety, and guilt about sex, health and education, defiant, negative, hypochondriacal complaints, etc. Background assessment data: -Passive-aggressive behaviors: stubbornness, procrastination, disobedience, carelessness, negativism, testing of limits, resistance to directions, unwillingness to cooperate -Initially attitude is directed toward parents, but later, relationships with peers and teachers become affected -Children don't see this as being a problem, think everyone else is the problem, impaired problem solving abilities,

Autism Spectrum Disorders: Plan of Care

*DSM Criteria: -Persistent deficits in social communication and social interaction -Restricted, repetitive patterns of behavior, interests, or activities -Symptoms must be present in early developmental period -Symptoms cause clinically significant impairment in social, occupation, or other important areas of current functioning -Disturbances are not better explained by intellectual disability ****Severity is based on social communication impairments and restricted, repetitive patterns of behavior**** KNOW THIS *Outcomes: -Exhibits no evidence of self-harm -Interacts appropriately with at least one staff member -Is able to communicate so that they can be understood by at least one staff member *Goals of treatment: reduce behavioral symptoms; promote learning & development, supporting parents *Treatment: -Special education, language therapy, one on one relationships, consistency -Medication for target symptoms (aggression, self-injury, temper tantrums, quickly changing moods)- not going to give an antipsychotic every time someone has autism just know that this is a possibility **Risperdal Ability

Conduct Disorder Cont.

*Etiology: **Biological influences: -Genetic risk with family members who have conduct disorder and/or parents with antisocial personality disorder, substance abuse, mood disorder, schizophrenia, or ADHD. **Psychosocial influences: -Peer relationships: skills acquired with this affect the child's long-term adjustment -Poor peer relations during childhood consistent with the etiology of later deviance **Family influences: -Parental rejection -Inconsistent management with harsh discipline -Early institutional living -Absent father -Inadequate communication patterns *Risk factors: -Prenatal exposure to alcohol -Child abuse -Poor family functioning, marital discord, poor parenting, and a family history of substance abuse and psychiatric problems are all associated with development of conduct disorder, socioeconomic factors can compound with other things and be a risk

ADHD Etiology and Assessment

*Etiology: -Cause remains unknown—thought to be multiple factors -Genetic link -Brain changes- norepi and dopamine appear to be depleted, decreased metabolism in the frontal lobes *Risk factors: -Family history of ADHD -Male relatives with antisocial personality disorder (starting to see link to) or alcoholism -Female relatives with somatic symptom disorder -Lower socioeconomic status -Male gender -Family discord, neglect, divorce, NAT *Assessment: -Typically cannot sit still and squirms and wiggles -Speech is unimpaired, but child interrupts and blurts out answers -Mood often labile; anxiety frustration, and agitation are common -Ability to pay attention is markedly impaired (attention span can be 2-3 seconds) -Lower self-esteem, tougher time making friends, might jump conversation

neurodevelopmental disorders

*Intellectual disability: disorder with onset during the developmental period that includes both intellectual and adaptive functioning deficits in conceptual, social, and practice domains. *Essential feature: below-average intellectual functioning; IQ <70, accompanied by significant limitations in: have to have deficits in intellectual functioning and the ways in which they adapt (relationships with parents, etc.) -Communication -Self-care -Home living -Social/interpersonal skills -Work -Leisure -Health and safety DSM Criteria: Three criteria must be met: -Deficits in intellectual functions such as: Reasoning, Problem solving, Planning, Abstract thinking, Judgment, Academic learning, Learning from experience, Confirmed by both clinical assessment and individualized, standardized intelligence testing -Deficits in adaptive functioning that results in failure to meet development and sociocultural standards for person independence and social responsibility. Without ongoing support the adaptive deficits limit functioning in 1 or more activities of daily life: Communication Social participation Independent living Across multiple environments (home, school, work, and community) -Onset of intellectual and adaptive deficits during the developmental period.

ADHD Medications

*Medications are often effective in decreasing hyperactivity and impulsiveness and improving attention. *Most common: methylphenidate (Ritalin) and amphetamine compound (Adderall); antidepressants (2nd choice) *Medications: (Table 22.1, p. 434) *Nursing interventions: **CNS Stimulants -To prevent insomnia, give last dose at least 6 hours before bedtime. -Monitor for appetite suppression or growth delays -May take 2 weeks for full effect **Antidepressants (2nd choice) -Strattera: give with food, monitor for appetite suppression, relieve dry mouth with liquids, monitor liver function *Antihypertensives: ex. Clonidine, must watch for antihypertensive type side effects

ADHD Outcomes and Treatment

*No one treatment is typically effective *Comorbidities: high as 84%, most commonly ODD, conduct disorder in 33%, 10-20% depression, bipolar *Goals of treatment: manage symptoms; reduce hyperactivity and impulsivity; increase child's attention -Combination of medications, behavioral, psychosocial, and education interventions -Nursing interventions: (p. 435)- look at these *Home and school strategies: -Behavioral and environmental strategies-quiet environment, safety, simplifying instructions (breaking things down into steps), structure their routine -Parental education: support groups, medication administration and side effects, special school services, behavioral approaches to be used at home, balance of praising child and correcting behavior, the need for structure and consistency in daily routine and behavioral expectations *Communication: -Explanations should be short and clear (no belittling or punitive) -State expectations clearly and give specific feedback

Intellectual Disability: Plan of Care

*Nursing diagnoses: -Selection depends largely on the degree of severity of the condition and client's capabilities, Ex. Risk for injury (altered physical ability), self-care deficit, impaired verbal communication or social interaction *Outcomes Identification: -Timelines are individually determined, ex. Experiences no physical harm, has had self-care needs fulfilled *Planning/implementation: -Involve the family- essential to this because they know the individual so much better, work on working with other and maintaining anxiety -Often focused on: Safety- especially if acting out and this is how they communicate, self-care, communication, and social interaction, consistency of staff *Evaluation: -Should reflect positive behavioral changes

Conduct Disorder: Plan of Care

*Outcome identification: -No injury to others or damage to property. -Participate in effective problem solving and coping. -Use age-appropriate and acceptable behavior when interacting with others. -Verbalize age-appropriate statements about self *Interventions: (Nursing care plan, p. 453-455) **Decreasing violence/increasing compliance with treatment -Limit setting with consistent enforcement -Behavioral contracting; time-out **Improving coping skills, self-esteem **Promoting social interaction **Providing patient, family education Ex. Of diagnoses: Risk for self or others, destruction of property

ODD: Plan of Care

*Outcomes: -Compliance with treatment by participating without negativism -Accepts responsibility for his or her part in the problem -Takes direction from staff without become defensive -Does not manipulate other people -Want them to take ownership of their actions *Interventions: -Set structured plan of therapeutic activities. -Establish a reward system for therapy and consequences for noncompliance. -Convey acceptance of the client separate from the behavior -Provide immediate, nonthreatening feedback for passive-aggressive behavior -Set limits on manipulative behavior

Intellectual Disability

*Predisposing factors: -Genetics- about 5% of cases -Disruptions in embryonic development- 30% of cases, drugs and alcohol exposure, uncontrolled diabetes during pregnancy, maternal illnesses or infections -Pregnancy and perinatal factors-inborn errors of metabolism, down syndrome and Klinefelter's syndrome -General medication conditions acquired in infancy or childhood- 5%, infections such as meningitis or encephalitis, poisonings especially lead, physical trauma (head injuries, very high fevers, asphyxia) -Sociocultural factors and other mental disorders- 15-20%, coping mechanisms are decreased, not getting nurtured or loved from parents *Developmental characteristics of intellectual disability by degree of severity, measured by IQ level: Mild (50-70) Moderate (35-49) Severe (20-34) Profound (below 20)

Points to Consider

*Remember to focus on the client's strengths and assets, as well as their problems. *Avoid a "blaming" attitude toward clients and/or families; rather focus on positive actions to improve situations and behaviors. *Children and adolescents with ODD and conduct disorder may be diagnosed with antisocial personality disorders as adults. *Most at risk are clients with more severe conduct behaviors and early onset ( before age 10) of those behaviors. *Ask parents how they are doing. Offer to answer questions and provide support or make referrals to meet their needs as well as those of the client.

DSM Criteria: ODD

A. A pattern of angry/irritable mood, augmentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced at least 4 symptoms from the following categories: *Angry/irritable mood: -Often loses temper -Is often touchy or easily annoyed -Is often angry and resentful *Argumentative/defiant behavior: -Often argues with authority figures -Often actively defies or refuses to comply with requests from authority -Often deliberately annoys others -Often blames others for his or her mistakes or misbehavior *Vindictiveness -Has been spiteful or vindictive at least twice within the last 6 months -Has run away from home overnight at least twice. -Is often truant from school. B. The disturbance is associated with distress in the individual or others in immediate social context. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning. C. Behaviors do not occur exclusively during the course of a psychotic, substance use, depressive, or bipolar disorder. For children <5, the behavior should occur on most days for a period of at least 6 months. For children >5, the behavior should occur at least once per week for at least 6 months, If the individual is age 18 years or older, criteria are not met for antisocial personality disorder Specified by severity: Mild: symptoms are confined to only one setting (home, school, work, or with peers) Moderate: some symptoms are present in at least 2 settings Severe: some symptoms are present in three or more settings

An 11-year-old child, who has been diagnosed with oppositional defiant disorder (ODD), becomes angry over the rules at a residential treatment program and begins shouting at the nurse. Select the best method to defuse the situation. A. Assign the child to a short time-out. B. Administer an antipsychotic medication. C. Place the child in a therapeutic hold. D. Call a staff member to seclude the child.

A. Assign the child to a short time-out.

ADHD: DSM Criteria

A. Persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development as characterized by: *Both Inattention and hyperactivity: 6 or more symptoms persist for at least 6 months to a degree inconsistent with developmental level and that negatively affects social and academic functions Inattention: -Lack of attention to detail -Difficulty sustaining attention to task and play -Doesn't follow through on instructions -Difficulty organizing tasks and activities -Often loses things necessary for tasks or activities -Easily distracted by unimportant stimuli Hyperactivity: -Often fidgets with or taps hands or feet -Often runs about or climbs in situations where it is inappropriate -Is "often on the go" -Often talks excessively -Often blurts out answer before question has been completed Other Criteria: -Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years -Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (home, school, work, with friends and/or relatives, in other activities) -Clear evidence that the symptoms interfere with or reduce the quality of social, academic, or occupational functioning -Symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder

DSM Criteria: Conduct disorder

A. Repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated. *Manifested by at least 3 of the following 15 criteria in the past 12 months: **Aggression to People and Animals -Often bullies, threatens, or intimidates others -Often initiates physical fights -Has used a weapon that can cause serious physical harm to others -Has been physically cruel to people and/or animals -Has stolen while confronting a victim (e.g. mugging, purse snatching, extortion, armed robbery) -Has forced someone into sexual activity **Destruction of Property -Has deliberately engaged in fire setting with the intention of causing serious damage -Has deliberately destroyed others' property (other than by fire setting) **Deceitfulness or theft -Has broken into someone else's house, building or car -Often lies to obtain goods or favors or to avoid obligations (i.e. "cons" others) -Has stolen items of nontrivial value without confronting a victim (shoplifting but without breaking and entering) **Serious violation of rules -Often stays out at night despite parental prohibitions, beginning before age 13 B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning. C. If the individual is 18 years or older, criteria are not met for antisocial personality disorder. *Child onset: -Individuals show at least one symptom characteristic of conduct disorder prior to age 10. -Often includes more physical aggression towards others and disturbed peer relationships. -These children are more likely to have persistent conduct disorder and to develop antisocial personality disorder as adults. *Adolescent-onset type: -individuals show no symptoms characteristic of conduct disorder prior to age 10 years. -These adolescents are less likely to be aggressive and have more normal peer relationships. -They are less likely to have persistent conduct disorder or antisocial personality disorder as adults.

The nurse is assessing a 16-month-old child during a well-baby checkup. Which of the following behaviors would be consistent with autism spectrum disorder? Select all that apply. A. The child displays little eye contact with others. B. The child thrives on changes in routine. C. The child makes few facial expressions toward others. D. The child does not like repetition. E. The child answers questions verbally.

A. The child displays little eye contact with others. C. The child makes few facial expressions toward others.

A parent is concerned that his child might suffer from attention deficit hyperactivity disorder (ADHD). Which of the following behaviors reported by the parent would be consistent with this diagnosis? A. The child interrupts others. B. The child has been hoarding objects at school. C. The child has lots of friends. D. The child is excelling academically in school.

A. The child interrupts others.

A 16-year old adolescent diagnosed with conduct disorder has been in a residential program for three months. Which outcome should occur before discharge? A. The teen and parents create and consent to a behavioral contract with rules, rewards, and consequences. B. The teen completes an application to enter a military academy for continued structure and discipline. C. The teen is temporarily placed with a foster family until the parents complete a parenting skills class. D. The teen has an absence of anger and frustration for 1 week.

A. The teen and parents create and consent to a behavioral contract with rules, rewards, and consequences.

The child with ADHD has a nursing diagnosis of impaired social interaction. Which of the following nursing interventions are appropriate for this child? Select all that apply. A. Socially isolate the child when interactions with others are inappropriate. B. Set limits with consequences on inappropriate behaviors. C. Provide rewards for appropriate behaviors. D. Provide group situations for the child.

B. Set limits with consequences on inappropriate behaviors. C. Provide rewards for appropriate behaviors. D. Provide group situations for the child.

The child most likely to receive propranolol (Inderal) to control aggression, deliberate self-injury, and temper tantrums is one diagnosed with: A. Attention deficit hyperactivity disorder (ADHD) B. Post-traumatic stress disorder (PTSD) C. Autism spectrum disorder (ASD) D. Separation anxiety

C. Autism spectrum disorder (ASD)

Moderate (35-49) IQ

Can perform some activities independently. Requires supervision. Academic skill to 2nd grade level. As adult, may be able to contribute to own support in sheltered workshop. May experience some limitation in speech communication. Difficulty adhering to social convention may be interfere with peer relationships. Motor development is fair. Vocational capabilities may be limited to unskilled gross motor activities.

A 15-year-old adolescent is referred to a residential program after an arrest for theft and running away from home. At the program, the adolescent refuses to participate in scheduled activities and pushes a staff member, causing a fall. Which approach by the nursing staff would be most therapeutic? A. Neutrally permit refusals B. Coax to gain compliance C. Offer rewards in advance D. Establish firm limits

D. Establish firm limits

Severe (20-34) IQ

May be trained in elementary hygiene skills. Requires complete supervision. Unable to benefit from academic or vocational training. Profits from systematic habit training. Minimal verbal skills. Wants and needs often communicated by acting-out behaviors. Poor psychomotor development. Able to perform only simple tasks under close supervision.

Profound (<20) IQ

No capacity for independent functioning. Requires constant aid and supervision. Unable to profit from academic or vocational training. May respond to minimal training in self-help in done in the close context of a one-to-one relationship. Little, if any, speech development. NO capacity for socialization skills. Lack of ability for fine and gross motor movements. Requires constant supervision and care. May be associated with other physical disorders.