Mental Health Across the Life Span
Risky Behaviours/Qualities
- self harm - aggression - vulnerable (needy) - running away - delinquency - substance abuse - perpetrator - too trusting - sexualized behaviour - disinhibited - impulsivity
Child Factors
- sleep - eating - temperament - personality - adaptability - needs - growth - development - communication
Presentation of mental health problems: children
- somatic complaints - poor sleep/nightmares - in play - aggression/isolating - blanking out - dysregulation - regression
Family functioning
- dynamics - interactions - bonds - living arrangements
Mental Health Snapshot
- 1 in 5 Canadian children/adolescents have significant mental health problems - Suicide is the second leading cause of death for youth aged 10-24 in Canada - 24% of all deaths among 15-24 year olds - 12.8% of all deaths among 10-14 year olds
Early Onset
- 50% of all lifetime cases of mental illness begin by age 14 - Another 25% by age of 24
Intellectual Disabilities
- IQ - standard diagnosis can also be in developmental
ADHD
- tends to change over time in its presentation - hyperactivity tends to decrease over life span
at any one time (prevalence)
1-3 % of children have depression 3-9% teenagers have depression
Disruptive Behaviour Disorders (DBDs)
1. ADHD - Executive functioning and inhibition (filtering) - Co-morbidities - Restlessness - Short attention span, inability to wait - two types: inattentive and combined (inattentive and hyperactivity) 2. Oppositional Defiance Disorder - About control and self-protection - Never appearing weak or vulnerable or powerless - Different approach then just kids acting badly - Consequences ineffective 3. Conduct Disorder • Develops often from ODD as child becomes teen • Similar signs as antisocial personality disorder begin to emerge • Adults with APD often have childhood history of CD
Disruptive Behaviour Disorders
1. ADHD 2. Oppositional defiance disorder 3. Conduct disorder
PANDAS/PANS
Paediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections - Paediatric Acute Onset neuropsychiatric Syndrome - Sudden Onset OCD or tic disorder with other socio-emotional changes, behavioural changes, motor skill changes - controversial: pathogenesis unclear and treatment with antibiotics
Sensory Modulation
Sensory Modulation (when too high, too low, too fast or too slow) - it is the ability to regulate their response to input
ODD (Oppositional Defiant Disorder)
- A different approach needed as children and teens don't respond to typical behaviour strategies - Lack flexibility, adaptability and frustration tolerance - It's about control
children
- ADHD - aggression - anxiety - ASD - adjustment - abuse and trauma - ODD behaviour
Schizophrenia
- Age of onset in males is typically around age 18 - Age of onset in females is typically around age 25 - Because males tend to have an earlier onset, their prognosis is usually poorer, as females are able to move through many significant milestones before being challenged by this significant illness (i.e. completing college or university) - The behavioural changes often associated with the prodromal period in a first episode psychotic event often do not appear as frank psychotic symptoms such as hallucinations or delusions - The earlier the presentation of psychotic symptoms, and the longer the delay in diagnosis and treatment, the poorer the prognosis
Interactions with Child with ODD
- Allow children/youth to maintain dignity and self respect - Avoid threats, power struggles, consequences pile up - Heavy on clear rules and limits - Structure, Consistency, and Predictability - Covert, subtle approach to both praise and criticism - Make it about the behaviour, not the person - Be brief, and blunt - Use as few words as possible - Tell instead of ask - Limit options to ones that are both good options - avoid lectures or trying to talk it out - If child/youth is neutral or positive: you are positive - If the child/youth is negative: you are neutral - Control your emotions, show nothing - Do not engage ... if they think they have even hooked you they will escalate it - Your emotions feeds their behaviour - Build rapport and a relationship - but on a personal level rather than as a patient, be interested in their life
Sensory Interventions
- Analogous to those who find it comforting to relax under quilt or blanket - Example: weighted vest which gives deep pressure
Autism Spectrum Disorders
- Asperger syndrome removed from DSMV - Difficulties in social emotional reciprocity and reciprocal communication - Difficulties in non-verbal communication for social purposes - Difficulties with understanding relationships - Restricted or repetitive patterns of activities, interests, or behaviours - Two of: stereotyped movements, insistence on sameness, preoccupation, hypo/hyper sensory response
Autism Spectrum Disorder
- Aspergers is included under this disorder
ADHD Treatment
- Attentional Blink Task - Stroop Effect: state the colour of each word (not the word) - Time and organizational management skills - Behavioural regulation skills - Self monitoring skills - Social skills - lags in perspective taking, social conventions
Conduct disorder
- develops often from ODD as child becomes teen - similar signs as antisocial personality disorder begin to emerge - adults with APD often have childhood history of DBDs
Developmental Considerations
- Characterized by periods of transition and reorganization - Very dynamic, few static periods - waxing and waning of symptoms - Diagnosis, state versus trait - Normal and abnormal ... same behaviour with differing intensity or frequency - Developmental history - Difference from range of developmental norms - Regressions - Changes against individual baseline
Challenges for Children and Teens because they are still developing ...
- Communication skills - Social and interpersonal skills - Emotional regulation - Behavioural regulation - Inhibition cognitively
Anxiety in younger children
- Crying, tantrums, emotional outbursts - Picking, pulling and chewing - Stomach aches, headaches, vomiting - Impulsivity, distractibility, "on edge" - Avoidant, refusal to follow direction, anger - Difficulty with change, transitions, adaptation, flexibility - Hyper, silly, laughing, or smiling inappropriately - Difficulty identifying feeling as anxiety or worry - Fantasy, imagination, "live in their heads"
Risk Scenarios: you are the nursing student meeting with this patient (in ER or on the floor)
- Do you think they are high risk to hurt themselves? - What risk factors are present? What factors decrease risk? - Physiological risk? Psychological risk? - What other questions would you want to ask the patient? - What information do you need? - What should the nursing care plan be?
Developmental Disabilities
- can have normal intellect or intellectual disabilities
Aggression
- children don't have good communication skills
Early Onset Bipolar Disorder
- Elevated and expansive mood - Decreased need for sleep - Racing and pressure speech - Grandiose delusions - Involvement in risk behaviours - Increased physical and mental activity - Poor judgement 1. Type 1 easier to identify but rare in childhood 2. Type II overlaps with teen development and is harder to tease out: disorganized mood - unrelated to life events or rapid cycling
Childhood anxiety - developmental?
- Fear and worry are normal aspects of specific stages of development - Separation anxiety in toddlers - Fear of dark or monsters in young children - Fear of things that are scary or new (thunderstorms, going to the hospital etc.) - Fear of failure or rejection in adolescence - Does it interfere with functioning or impair other aspects of typical development (social, academic, family functioning, emotional well-being)? - Does it persist beyond the expected developmental stage?
Suicide Risk Factors: prior to admission
- History of serious self harm, attempts, or attacks on others - Recent losses/adjustments to major stressful life events - Substance abuse - Diagnosis (depression with substance abuse, BPD, non-affective psychotic disorders, anxiety) - Sexual abuse history - Chronic medical condition - Highest Risk Factor: Females (MDE) Males (Prior Attempt) - Recent break up or family dispute/perceived loss of support, relationship of bonds (76% of teens who attempted suicide reported this factor) - reactive response to stress - Positive bonds (i.e. close ties with family/friends/community/groups)
What do sensory processing problems look life?
- Inappropriate and inconsistent responses to sensory stimulation - Difficulty organizing and analyzing information from the senses - Limited ability to respond to sensory information in an appropriate manner - Difficulty using sensory info to plan and execute actions - May be present with problems with moods (anger, sadness), behaviour (hyperactivity), cognitive problems (distractibility) - In other words, the overwhelmed or underwhelmed nervous system can resemble or be part of many other conditions, i.e. ADHD, bipolar etc.
Childhood: early years
- Intellectual development - Behavioural development - Language development - Parent-child relationships - Relationships with other children
Sensory seeking
- Loud, physical, like to touch and be touched (not gently), on the move, like to chew on things, hyperactive, impulsive, jump and bump, repetitive loud noises, like bright colours & things that move, like extremes (hot/cold, spicy, adrenaline) - Clumsy, poor body awareness - Sensory under responsive - need high sensory input
Medication for ADHD
- Methylphenidate (Ritalin, Concerta) = stimulant + catecholamines and dopamine reuptake inhibitor - Amphetamine (Dexedrine, Adderall + Vyvanse) = stimulant and NT reuptake inhibitor - Atomoxetine (Strattera) = selective norepinephrine reuptake inhibitor
Anxiety in Children
- Mimics symptoms of ADHD - Emotional distress - upset, tantrums, crying, anger, outbursts - Excessive time spent consoling, encouraging throughout the day - Somatic - Refusal and avoidance - with inability to explain why - Shy follower - difficulty saying no to peers, sharing opinion or asking for needs, wants peers to like them - Social withdrawal (may need scripts or role playing) - Repetitive questions seeking reassurance or answers
Differential Diagnosis
- conduct disorders - oppositional defiant disorders - anxiety disorders - post traumatic stress disorder - social phobia
Rapid growth and development
- Periods of high sensitivity and vulnerability - Heavily dependent on others to learn emotional regulation and expression -"meaning makers" - Development of secure interpersonal relationships - Exploration and mastery - Context = family, community, culture
Social Pragmatics Disorder
- Persistent difficulties in social use of verbal and non-verbal communication - Appropriate for social context - Change communication to match context - Regulating self in conversation, following conversation, conventions of conversation and language - Understanding what is not explicitly stated
Interventions for ODD and CD
- Positive approach to behaviour (decrease harsh approach) - Collaborative Problem Solving - Involve child/youth in the process and invite their input on the unsolved problems - Lagging skills and addressing skill deficits - Using reflection to add empathy to the discussion - CBT - Social skills training - Home environment? May need alternate setting
Infant Mental Health
- Prenatal to age 3 - Sets the stage for the rest of life - Foundation of mental health, relationship formation - ¾ of all brain development happens between third trimester and age 2 - Relationship between mother/fetus and mother/baby - A lot of stress on new parents (i.e. societal pressures) - Expectations vs. realities
Disruptive Behaviours Disorders: Attention Deficit Hyperactivity Disorder
- Restlessness - Short attention span, inability to wait - Easily distracted - Impulsiveness - Poor concentration - Failure to complete tasks - Onset before age 12 - Inattentive Type - Combined Type (hyperactivity and inattentiveness) - Diagnosis: neurocognitive testing - not checklists
ADHD Med Education
- Stimulate nerve cells - Short term effect on symptoms - not treating cause - Short acting - 4 hours, long acting 6-12 hours - May require med trials to get best fit of drug and dose - individual dependent - Rebound effect - as dose wears off - Fatigue, low mood, restlessness - May use long and short acting simultaneously - Booster in afternoon/evening for homework - Decreases appetite and consolidated sleep - Effective immediately - Plateau effect - drug/dose often no longer works after 2 years - Side effects: tics (not common) - Abuse potential
Sensory avoidant
- Strong dislike for certain textures and tastes, particular about tags, certain types of fabrics, bothered by loud noises, lights, certain sounds, withdraw from touch, avoid risks, anxious in loud or stimulating environments, picky eaters, dislike getting dirty, wet, messy, sensitive to smells, get motion sick, dislike heights, meltdowns, refusals when overwhelmed - Sensory over responsive - find sensory input overwhelming
Building Rapport
- defiant/oppositional - indifferent - tells you what you want to hear - attachment - boundaries
Nursing Assessment
- demographics - presenting problems - social history - patient's psychiatric and medical history - mental status exam - specific risk assessment (suicidal/homicidal)
Depression in children and adolescents
- Symptoms may present as similar or different to those in the adult population - Increased sleep yet decreased energy, hyper insomnia - Increase or decrease in appetite and/or weight - Increase in activity - Decrease in concentration and declining academic performance - Irritability, anger and acting out behaviour (mood changes) - Increase in somatic complaints - Loss of interest and pleasure in everyday things (anhedonia) - Hopelessness and discouragement - Substance abuse - Low self-esteem, negative thoughts - Social isolation, withdrawal (from friends last) - Suicidal ideation or self-harm behaviours (cutting)
Behind Behaviour
- To build a wall - Fear or threat - Basic needs - Learned behaviour - Poor interpersonal skills - Executive functioning deficits - Neurobiology - Cognitive Distortions - Current life stressors - Sleep and Nutrition - Personality - Availability of supports - Attachment - Substance Use - Other comorbidities or developmental barriers
Questions to Ask about Anxiety in Children/Adolescents
- What has been the hardest part for you? - Is there anything worrying you? - Is there anything making you feel sad? - If you had 3 wishes that would make tomorrow better than today, what would they be? - What does feeling better look like? What would be different in your day? - Can you tell me about your favourite things? Things you don't like? Things that make you feel scared? Feel angry?
Oppositional defiance disorder
- about control and self-protection - never appearing weak or vulnerable or powerless - different approach then just kids acting badly - consequences ineffective
In treating adolescents with depression, caution must be used when ...
- administering anti-depressants (SSRI's) - psychoeducation, psychotherapy, CBT, group therapy and family therapy are important treatment modalities for this age group
Nursing Role
- advocacy - assessment (atypical) - education and guidance - supports and services - normalizing - assistance
Assessment: Contextual
- alone - with friends - with family - specific family members or parents or siblings - with pressure/expectations - at night/bedtime - at school - when frustrated
Adolescents
- anxiety - depression - eating disorders - substance abuse - early onset psychosis/mania - abuse and trauma - ODD and CD - suicidal ideation - ASD and aggression - personality traits
Anxiety Disorders
- anxiety disorders are experienced in the youth population at the highest rate of any mental illness in this age group - translates into such disorders as: GAD, phobias, PTSD, social anxiety disorder, OCD, panic disorder
Common disorders starting in childhood and adolescence
- autism spectrum disorder (ASD) - learning and communication disorders (LCD) - attention deficit hyper activity disorders (ADHD) - conduct disorder (CD) - child/adolescent anxiety (CAA) - child/adolescent depression (CAD) - tic and tourette's disorders (TTD) - elimination disorders (ED)
Children and Teens also lack ...
- autonomy/control/agency - life experience - understanding beyond immediate context - resources (depends on adults)
Working with children/youth
- be genuine and sincere - be on their level - relate - don't take it personally - respect - set clear expectations and limits - understand what the behaviour is trying to communicate - assess from every direction - involve the family - keep child/youth's perspective in mind - tailor your language
Social skills, school and friends
- bullying - assertiveness - relationships - authority
Reactive Attachment Disorder
- did not learn how to attach in childhood, due to neglect - an aversion to touch and physical affection - rather than producing positive feelings, touch and affection are perceived as a threat - control issues: will go to great lengths to remain in control and avoid feeling helpless - they are often disobedient, defiant and argumentative - anger problems - anger may be expressed, directly in tantrums or acting out or through manipulative, passive-aggressive behaviour - difficulty showing genuine care and affection - an underdeveloped conscious
Presentation of mental health problems in adolescence
- disengagement - delinquency - withdrawal, irritability, anger - changes in peers/dress/lifestyle - poor sleep - internalizing "fake it" - self injuring - substance use - risk taking
ADHD
- executive functioning and inhibition (filtering stimuli) - co-morbidities (i.e. anxiety)
Infant Mental Health: Attachment and Memory Resilience
- facilitating supportive adult-child relationships - building a sense of self-efficacy and perceived control - providing opportunities to strengthen adaptive skills and self-regulatory capacities - mobilizing sources of faith, hope and cultural traditions
Strengths and Needs Assessment
- family functioning - social skills, school, friends - identity, self concept - risk behaviours/qualities - developmental level
Childhood: later years
- friendships - self concept - thinking skills - developing logic - moral development - regulation and expression skills - perceptive
Contextual Risk Factors
- gender identity and sexual orientation - gender non-conformity - aboriginal - social determinants of health - intergenerational trauma - higher psychological distress and stress - experiences of violence/abuse - lack of support - school failure - family conflict - substance use - psychiatric illness/disorder - homelessness - friends and acquaintances who had suicide attempts - relationship ending - disconnection/loneliness
Memory can be re-triggered later on in life
- how they manage stress etc. - even though they were very young (i.e. 1-1.5 years old) - resilience is ongoing and across cultural contexts; there is a threshold to resilience and it is subject to change
Adolescent years
- independence and parental conflict - self concept: unrealistically high expectations and poor self confidence - concerned with appearance and one's body: self vs. others - strong emphasis on the peer group - development of self identity - abstract and existential thinking
Developmental Level
- intellectual level - thought content and process - MSE = mood, affect, anxiety, insight, judgement, motivation, behaviours - strengths - supports, caregiver needs and strengths
How is Depression in Adults different than in Youth? S&S of depression in youth
- irritable mood often more prominent, mood swings - have less insight into poor moods, more likely to think its normal, teen angst - often don't recognize symptoms of depression - more likely to "externalize" i.e. have behavioural problems - less likely to seek help from adults, but usually will talk to peers - stressors: bullying, pressure, struggling with identity/fitting in, school, home, peers - withdraw from peers last (keep up social persona) - risk taking behaviour - change appearance and lifestyle
Learning Disabilities
- just what they are able to process and produce (dyslexia) - intellect is not affected
Depression - what else might it be?
- normal teenage "stuff" - other mood/anxiety conditions - bipolar disorder - generalized anxiety disorder - ADHD - Alcohol or street drug problems - primarily behaviour/conduct problems - eating disorders
Identity, self concept
- perception of self and others - life events: stability, trauma, abuse, attachments, stressors, loss, changes - self care: sleeping, eating, routines, exercise, substance use, physical illness
Role of Families
- play key role - parents as experts, parents as partners - parent's own trauma/illness - parents connections/supports - caregiver strain: role strain - no blame game: adaptation to best meet needs of child and family; alternative approaches to parenting; support for parent mental health
Stigma: Mental illness or mental health problems
- poverty - discrimination - marginalization - trauma/abuse - bullying
Effects on Infant Mental Health
- pre-natal environment - parental stress - parental health and well-being - parental experience of being parented - parental capabilities and competencies - parental expectations - culture - supports and connections - home environment
Nursing Role Specifics
- prepare individual and group programs - do individualized assessment (risk and MHS) and care (talktimes) - provide safe environment and supervision - therapeutic relationship - admissions, transfers, and discharges - orders, meds, VS, intake, other nursing care - answer phones and doors - take patients for ECGs, EEG's, CT's, Offwards - meet with team for rounds, case conferences, and discharge feedbacks - engage, redirect, support, distract, de-escalate, intervene, monitor all patients - support and manage your patients in acute crisis - backup staff dealing with patients in acute crisis - meet/speak with families to support, educate, teach programs and discuss care, progress, passes
Stability
- residential instability concerns - removed - foster care - group homes - frequent moves - relational stability concerns - financial stability concerns
Nursing Interventions
- risk assessment - multi-component intervention - assessment of contributing factors - discussion areas where change can be made, supports accessed, or services provided - validate distress - outlets for expression - connection, belonging - safety plans - address impulsivity
Evidence
- school functioning - social functioning - forming and maintaining friendships - family relationships: parents and siblings - well being - growth and development
Healthy development during infancy
- secure attachments - meaningful interaction - protection from harm - affection and nurturing - responsive care - opportunity to experience and explore - respect - collaboration and cooperation - stable caregivers
Therapeutic Activities
- stress management - anger management - sensory processing - relationship building - safety - family conflict - peer conflict - conflict resolution - school - life stressors - art therapy - goal setting - play therapy - social stories
Attachment Disorders
- trauma, neglect or abuse during early childhood - lack the skills necessary to build meaningful relationships - have difficulty connecting to others and managing their own emotions - lack of trust and self worth, a fear of getting close to anyone, anger and a need to be in control - feels unsafe and alone
Anxiety
- very common in childhood
Adjustment Disorder
- when HCPs don't want to give them another diagnosis - it is contextual or situational
Three significant areas of development for this population
1. the onset and movement through puberty (biological) 2. the emergence of more advanced thinking (cognitive changes) 3. the transition into new social roles (social changes)
Child/Youth in Family Context
o Home and Community Environment o Culture o Parental mental health o Roles and responsibilities o Family structure o Family dynamics o Conflict o Attitudes and beliefs o Response to team o Level of involvement o Supports and resources o Strengths
ADHD Co-morbidities
• ODD • CD • Tics/Tourettes • Sleep disorders • Learning disabilities • Mood D/O • Substance use • Anxiety • OCD