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Mental Health
Chapter 11 Childhood and Neurodevelopmental Disorders
| Question | Answer |
|---|---|
| Biological factors: Genetic | Hereditary factors are implicated in numerous childhood-onset psychiatric disorders. |
| Psychological factors: Temperament | -Temperament refers to the overall mood, attitude, and behavior that a child habitually uses to cope with the demands and expectations of the environment. -Temperament and behavioral traits can be powerful predictors of future problems. -traits such as shyness, aggressiveness, and rebelliousness, for example, may increase the risk for substance use problems. |
| Psychological factors: Resilience | The phenomenon of resilience is the capacity to recover quickly from difficulties: -The resilient child has the following characteristics: 1. Adaptability to changes in the environment 2. Ability to form nurturing relationships with other adults when the parent is not available 3. Ability to distance self from emotional chaos 4. Social intelligence 5. Good problem-solving skills 6. Ability to perceive a long-term future |
| Environmental factors: Witnessing violence | -Children who have experienced abuse are at risk for identifying with their aggressor and may act out, bully others, become abusers, or develop dysfunctional interpersonal relationships in adulthood. -Neglect and abuse Neglect is the most prevalent form of child abuse in the United States. Adverse Childhood Experience (ACE) - Is a risk factor of a childhood disorder |
| Child and Adolescent Psychiatric Mental Health Nursing: Assessment | - A nurse should be prepared to make an independent judgment about what to assess and how to assess it. -In all cases, a physical examination is part of a complete assessment for children and adolescents with serious mental problems who require hospitalization. -Nurses use play activities such as therapeutic games, drawings, and puppets for younger children who have difficulty responding to a direct approach. |
| Developmental assessment | -A developmental assessment will look at milestones such as the age a child starts walking, talking, or toilet training. A child or adolescent who does not have a psychiatric disorder matures with only minor regressions, coping with the stressors and developmental tasks of life. -The Denver II Developmental Screening Test is a popular assessment tool that lists 125 items. This tool covers four areas: social/personal, fine motor function, language, and gross motor function. |
| General Interventions for Children and Adolescents: Behavioral interventions | Behavioral interventions reward desired behaviors to reduce maladaptive behaviors. |
| Play therapy | -Play therapy is an intervention that allows children to express feelings such as anxiety, self-doubt, and fear through the natural use of play. Example: Using the sand tray - most kids will hide snake figures which indicates sexual abuse. -Trauma is often stuck in the nonverbal parts of the brain—amygdala, thalamus, hippocampus, or brainstem. Playing out memories helps move them to verbal frontal lobes. |
| Family interventions | -the family is critical to improving the functional capacity of a young person with a psychiatric illness. |
| Disruptive behavior management: Time-out | Asking or directing a child or adolescent to take a time-out from an activity Is an excellent intervention that promotes self-reflection and encourages self-control. It is a less restrictive alternative to seclusion and restraint. |
| Disruptive behavior management: Quite Room | A unit may have an unlocked room for a child who needs an area with decreased stimulation for regaining and maintaining self-control. This is lease restrictive than restraints. -Use the least restrictive first; this is implemented in specific settings like therapeutic schools. |
| Disruptive behavior management: Seclusion and restraint | -The registered nurse assigned to the patient is often the one to make the decision to restrain or seclude a child. A physician, nurse practitioner, or other advanced-level practitioner must authorize this action according to facility policy and state regulation. The patient’s family should be notified of any incident of seclusion or restraint. -this is implemented in specific settings like therapeutic schools. |
| Patients in seclusion or restraints | Patients in seclusion or restraints must be monitored constantly and not be left alone. Vital signs and range of motion in extremities must be monitored at a set interval. Hydration, elimination, comfort, and other psychological and physical needs should be monitored and addressed as needed. |
| Advanced Practice Interventions: Group therapy | Younger children: uses play and ideas Grade-school children combine play, learning skills, and talk Adolescents: identifying emotions, modifying responses, learning skills and talking, focusing largely on peer relationships, and addressing specific problems |
| Advanced Practice Interventions : Cognitive-behavioral therapy (CBT) | Replacing negative, self-defeating thoughts with more realistic and accurate appraisals to improve the functioning |
| Neurodevelopmental Disorders: Communication Disorders | Communication disorders are manifested in deficits in language, speech, and communication. These deficits result in impairments in academic achievement, socialization, or self-care. |
| Speech disorders | Problems in making sounds |
| Language disorders | -Difficulty understanding or in using words in context and appropriately -May be evident by inability to follow directions -Expressive language disorder (How the child tries to express themselves) -Receptive - (How they understand language) |
| Motor Disorders | Developmental coordination disorder is based on (1) impairments in motor skill development, (2) coordination below the child’s developmental age, and (3) problems interfering with academic achievement or activities of daily living. Symptoms include delayed sitting or walking or difficulty jumping or performing tasks such as tying shoelaces. |
| Developmental coordination disorder | Impairments in motor skill development Coordination below the child’s developmental age |
| Stereotypic movement disorder | Repetitive, purposeless movements for 4 weeks or more -Interventions for stereotypic movement disorder focus on safety and prevention of injury. Helmets may be required for children who have the potential for head injury |
| Tic disorders | Sudden nonrhythmic and rapid motor movements or vocalizations --Tics are sudden, nonrhythmic, and rapid motor movements or vocalizations. Motor tics usually involve the head, torso, or limbs, and they change in location, frequency, and severity over time. |
| Provisional tic disorder | Single or multiple motor and or vocal tics for less than 1 year |
| Persistent motor or vocal tic disorder | Single or multiple motor or vocal tics Cannot have both for more than 1 year |
| Tourette’s disorder | Multiple motor tics and at least one vocal tic for more than 1 year |
| Treating tic disorders: Behavioral techniques | - Behavioral techniques can reduce tic expression. They are referred to as habit reversal, and the most promising form is called comprehensive behavior intervention for tics (CBIT). It works by helping the patient become aware of the building up of a tic urge and then using a muscular response in competition to or incompatible with the tic. |
| Medications for treating tics | First-generation antipsychotics: Haloperidol (Haldol) and Pimozide (Orap) Second-generation antipsychotic: Aripiprazole (Abilify). Another second-generation drug: Risperidone (Risperdal) - does not have FDA approval but is commonly used for tic disorders. Alpha 2-adrenergic agonists used to treat hypertension are also prescribed for tics - While less effective and far slower acting than the antipsychotics, they have fewer side effects. |
| CNS Stimulants to treat tics | Central nervous system stimulants, like those used to treat ADHD, can increase the severity of tics, so medications must be carefully monitored in children with coexisting ADHD. |
| Specific Learning Disorder : Dyslexia | Reading - Most Common |
| Specific Learning Disorder : Dyscalculia | (math) |
| Specific Learning Disorder : Dysgraphia | (written expression) |
| Intellectual Development Disorder (IDD): | Used to be called Mental Retardation Individuals with moderate intellectual developmental disorder progress academically to about the second grade. These people can learn to travel in familiar areas and perform unskilled or semiskilled work. With supervision, the person can function in the community, but independent living is not likely. |
| People with IDD is Deficit in: | Intellectual functioning Social functioning Daily functioning This disorder is on a spectrum |
| Deficit - Intellectual functioning | Intellectual functioning: Deficits in reasoning, problem-solving, planning, judgment, abstract thinking, and academic ability |
| Deficit - Social functioning | • Social functioning. Impaired communication and language, interpreting and acting on social cues, and regulating emotions |
| Deficit - Daily functioning | • Daily functioning. Practical aspects of daily life are impacted by a deficit in managing age-appropriate activities of daily living, functioning at school or work, and performing self-care. |
| Application of the Nursing Process: Assessment guidelines | -Assess for delays in cognitive and physical development or lack of ability to perform tasks or achieve milestones in relation to peers. -Gather information from family, caregivers, or others actively involved in the child’s life. -Assess for delays in cognitive, social, or personal functioning, focusing on strengths and abilities. -Assess for areas of independent functioning and the need for support/assistance to meet requirements of daily living (examples are hygiene, dressing, or feeding). |
| Application of the Nursing Process: Assessment guidelines continued | -Assess for physical and emotional signs of potential neglect or abuse. Be aware that children with behavioral and developmental problems are at risk for abuse. -Assess for the need of community resources or programs that can provide resources and support the child’s need for intellectual and social development and the family’s need for education and emotional support. |
| Autism Spectrum Disorders | Autism spectrum disorder is a complex neurobiological and developmental disability that typically appears during a child’s first 3 years of life. Autism spectrum disorder affects the normal development of social interaction and communication skills. It ranges in severity from mild to moderate to severe. |
| Autism Spectrum Disorders deficits: | Deficits in social relatedness and relationships Stereotypical repetitive speech Obsessive focus on specific objects Over-adherence to routines or rituals Hyper- or hypo-reactivity to sensory input Extreme resistance to change Appears in early childhood -Restricted, repetitive patterns of behavior, interest or activities. -Rigid with expectation example texture of food. |
| Autism Spectrum Disorders - Application of the Nursing Process: Assessment | 1. Assess for developmental delays, uneven development, or loss of acquired abilities. Use baby books and diaries, photographs, videotapes, or anecdotal reports from nonfamily caregivers. 2. Assess the child’s communication skills (verbal and nonverbal), sensory, social, and behavioral skills (including presence of any aggressive or self-injurious behaviors). 3. Assess the parent-child relationship for evidence of bonding, anxiety, tension, and fit of temperaments. |
| Autism Spectrum Disorders - Application of the Nursing Process: Assessment continue | 4. Assess for physical and emotional signs of possible abuse. Be aware that children with behavioral and developmental problems are at risk for abuse. 5. Ensure that screening for comorbid intellectual disability has been completed. 6. Assess the need for community programs with support services for parents and children, including parent education, counseling, and after-school programs. |
| Autism Spectrum Disorders - Application of the Nursing Process: Implementation: Applied Behavior Analysis (ABA) | -Applied Behavior Analysis (ABA) encourages positive behaviors and discourages negative behaviors. The child’s progress is tracked and measured. |
| Autism Spectrum Disorders - Application of the Nursing Process: Implementation: The Early Start Denver Model (ESDM) | -The Early Start Denver Model (ESDM) is also evidence based. Developmental considerations focusing on one-on-one interactions, joint play, and activity routines with the adult and child are used as teaching opportunities. |
| Autism Spectrum Disorders - Application of the Nursing Process: Implementation: The Early Intensive Behavioral Intervention (EIBI) | -The Early Intensive Behavioral Intervention (EIBI) has the strongest evidence for improving language and cognitive skills in children with autism spectrum disorder. This long-term (several years), intensive (up to 40 hours a week) approach combines operant conditioning (reinforcement and negative consequences) and ABA. |
| Psychobiological interventions | -Pharmacological agents target specific symptoms and may be used to improve relatedness and decrease anxiety, compulsive behaviors, or agitation. -There is no medications that treat autism. The doctor will treat the multiple symptoms and behavior. -The medications will be different depending on what is being treated. |
| Psychobiological interventions: Second-generation antipsychotics | The second-generation antipsychotics: Risperidone (Risperdal) - (5-16 years) Aripiprazole (Abilify) - (6-17 years) -These drugs improve irritability that is expressed in severe temper tantrums, aggression, and compulsive behavior. By reducing irritability, they may also improve relatedness. Side effects are significant and include extrapyramidal side effects, somnolence (drowsy), and weight gain. |
| Psychobiological interventions: Antidepressants: Selective serotonin reuptake inhibitors (SSRIs) | -Other medications may be used off-label. -Selective serotonin reuptake inhibitors (SSRIs) may improve mood and reduce anxiety, which provides the patient with a higher degree of tolerance for new situations and social interactions. |
| Psychobiological interventions: -Naltrexone | -Naltrexone, a drug used for addictive disorders, may reduce disability repetitive and self-injurious behaviors. -Used in ADHD |
| Autism Spectrum Disorders - Application of the Nursing Process: Evaluation | Autism spectrum disorder causes deficits in communication and social skills in the individual with a range of individual severity. The DSM-5 classifies autism spectrum disorder in three levels depending on the degree of assistance and support the individual requires: • Level 1 requires support • Level 2 requires substantial support • Level 3 requires very substantial support |
| Attention Deficit Hyperactivity Disorder (ADHD) | -Individuals with attention-deficit/hyperactivity disorder show an inappropriate degree of inattention, impulsiveness, and hyperactivity. -Some children are inattentive but not hyperactive. In this case, the diagnosis is still ADHD and is then further classified as primarily inattentive type (previously known as ADD). -Symptoms present in at least 2 settings |
| Attention Deficit Hyperactivity Disorder: Assessment | Attention-Deficit/Hyperactivity Disorder 1. Gather data from parents, caregivers, teachers, or other adults involved with the child. Ask about the level of physical activity, span, talkativeness, frustration tolerance, impulse control, and the ability to follow directions and complete tasks. Also, assess these areas through your own observations and note any developmental variance in these behaviors. |
| Attention Deficit Hyperactivity Disorder: Assessment continued. | 2. Assess social skills, friendship history, problem-solving skills, and school performance. Gather this data from the family or caregiver and one or two additional sources. 3. Assess for comorbidities such as anxiety and depression. 4. Assess for any indicators of learning disorders, autism spectrum disorder, or intellectual disabilities. 5. Gather data on eating and sleeping patterns and monitor these regularly for the child treated with stimulants. |
| Attention Deficit Hyperactivity Disorder - Psychosocial interventions: Modeling | A method of learning behaviors or skills by observation and imitation that can be used in a wide variety of situations. It is enhanced when the modeler is perceived to be similar (e.g., age, interests) and attending to the task is required. |
| Attention Deficit Hyperactivity Disorder: Implementation - Psychosocial interventions: Role Playing | A counseling technique in which the nurse, the patient, or a group of youngsters acts out a specified script or role to enhance their understanding of that role, learn and practice new behaviors or skills, and practice specific situations. It requires well-developed expressive and receptive language skills. |
| Attention Deficit Hyperactivity Disorder: Implementation - Psychosocial interventions: Redirection | A technique used after an undesirable or inappropriate behavior to engage or re-engage an individual in an appropriate activity. It may involve the use of verbal directives (e.g., setting firm limits), gestures, or physical prompts. |
| Attention Deficit Hyperactivity Disorder: Implementation - Psychosocial interventions: Clarification as intervention | Breaking down a problem situation that a child experiences can help the child understand the situation, the roles of others, and his or her own motivation for the behavior. This can be done verbally and using worksheets depending on the age and functional level of the child. |
| Attention Deficit Hyperactivity Disorder: Implementation - Psychosocial interventions: Use of Restructuring | Changing an activity in a way that will decrease the stimulation or frustration (e.g., shorten a story or change to a physical activity). This requires flexibility and planning and an alternative if the activity is not going well. |
| Psychopharmacology: Medications for aggressive behaviors: CNS Stimulant | Paradoxically, we treat the symptoms of ADHD with stimulant drugs. Responses to these drugs are often dramatic and can quickly increase attention and task-directed behavior while reducing impulsivity, restlessness, and distractibility CNS Stimulant: Methylphenidate (Ritalin and others) - Used for age 6-12. Mixed amphetamine salts (Adderall) are the most widely used stimulants because of their relative safety and simplicity of use. These medication can cause: Cardiac issues, suppress appet |
| CNS Stimulant for ADHD | Central Nervous System Stimulants are potent and powerful medications. They are used to stimulate the neurotransmitters in the brain. The increase neurotransmitters is to the level of their peers. -Initially there is a lower level of a neurotransmitter in the brain hence will take a stimulant to increase the levels. -Stimulants increase dopamine levels, which boost concentration and lessen impulsive hyperactive behaviors: |
| CNS Stimulant for ADHD: Side Effect | -Not surprisingly, insomnia is a common side effect while taking stimulant medications. -Treating with the minimum effective dose is essential. -Administering medications, no later than 4:00 in the afternoon. -The extended-release formulations of these medications have improved dosing and scheduling. (8 hours) |
| A nonstimulant Psychopharmacology: Medications for Aggressive behaviors: Antidepressant - Selective norepinephrine reuptake inhibitor (SNRI) | Selective norepinephrine reuptake inhibitor, Atomoxetine (Strattera), is approved for childhood and adult ADHD. (for children > 6 years of age) -Therapeutic responses develop slowly, and it may take up to 6 weeks for full improvement. -This medication is preferable for individuals whose anxiety is increased with stimulants. -It is also useful for those with comorbid anxiety, active substance uses disorders or tics. |
| A nonstimulant Psychopharmacology: Medications for Aggressive Behaviors: Centrally Acting Alpha-2 Adrenergic | Two Centrally Acting Alpha-2 Adrenergic Agonists: Clonidine (Kapvay/Catapres) and Guanfacine (Intuniv/Tenex), -Decrease impulsivity and insomnia, and increase emotional regulation -Reduce agitation, restlessness, irritability. Lowers blood pressure • Work best in combination with a stimulant |
| A nonstimulant Psychopharmacology: Medications for aggressive behaviors Centrally acting alpha-2 adrenergic : Side Effect: | Clonidine carries more side effects: somnolence, fatigue, insomnia, nightmares, irritability, constipation, respiratory symptoms, and dry mouth. The most common side effects of guanfacine are: somnolence, lethargy, fatigue, insomnia, nausea, dizziness, hypotension, and abdominal pain. |
| Psychopharmacology: Medications for Aggressive Behavior: Mood Stabilizers | Mood stabilizers such as lithium and anticonvulsants reduce aggressive behavior and are recommended for impulsivity, explosive temper, and mood lability. |
| Application of the Nursing Process: Evaluation | For the family and child with ADHD, the evaluation will focus on the symptom patterns and severity. -For those with ADHD, the inattentive type, the focus of the evaluation will be academic performance, activities of daily living, social relationships, and personal perception --For those with ADHD, hyperactive-impulsive type, or combined type, the focus will be on academic performance, social skills and relationships, impulse control, and behavioral responses. |
| Atomoxetine & ADHD | This drug is an Antidepressant - A nonstimulant selective norepinephrine reuptake inhibitor: Do not give Atomoxetine when treating a patient with ADHD who is experiencing depression and anxiety -This drug increase the incidence of suicidal ideation. - It can be given given to all ages 6-65 who have ADHD and is given once a day |
| Psychopharmacology: Medications for Aggressive Behavior in ADHD | -To control aggressive behaviors, pharmacological agents—including stimulants, mood stabilizers, alpha-adrenergic agonists, and antipsychotics—are used. -Antipsychotic medication is useful for managing aggressive or violent behavior in some children diagnosed with ADHD. If medication were prescribed for a child with an anxiety disorder, it would be a benzodiazepine. |
| Which statement demonstrates a well-structured attempt at limit setting? a. “Hitting me when you are angry is unacceptable.” b. “I expect you to behave yourself during dinner.” c. “Come here, right now!” d. “Good boys don’t bite.” | A |
| Cognitive-behavioral therapy is going well when a 12-year-old patient in therapy reports to the nurse practitioner: a. “I was so mad I wanted to hit my mother.” b. “I thought that everyone at school hated me. That’s not true. Most people like me and I have a friend named Todd.” c. “I forgot that you told me to breathe when I become angry.” d. “I scream as loud as I can when the train goes by the house.” | B |
| Which activity is most appropriate for a child with ADHD? a. Reading an adventure novel b. Monopoly c. Checkers d. Tennis | D |
| What assessment question should the nurse ask when attempting to determine a teenager’s mental health resilience? Select all that apply. a. “How did you cope when your father deployed with the Army for a year in Iraq?” b. “Who did you go to for advice while your father was away for a year in Iraq?” c. “How do you feel about talking to a mental health counselor?” d. “Where do you see yourself in 10 years?” e. “Do you like the school you go to?” | A,B,D, |
| Which factors tend to increase the difficulty of diagnosing young children who demonstrate behaviors associated with mental illness? Select all that apply. a. Limited language skills b. Level of cognitive development c. Level of emotional development d. Parental denial that a problem exists e. Severity of the typical mental illnesses observed in young children | A,B,C |
| Pam, the nurse educator, is teaching a new nurse about seclusion and restraint. Order the following interventions from least (1) to most (5) restrictive: a. With the patient, identify the behaviors that are unacceptable and consequences associated with harmful behaviors b. Placing the patient in physical restraints c. Allowing the patient to take a time-out and sit in his or her room d. Offering a PRN medication by mouth e. Placing the patient in a locked seclusion room | A-1 B-5 C-3 D-2 E-4 |
| Child protective services have removed 10-year-old Christopher from his parents’ home due to neglect. Christopher reveals to the nurse that he considers the woman next door his “nice” mom, that he loves school, and gets above average grades. The strongest explanation of this response is: a. Temperament b. Genetic factors c. Resilience d. Paradoxical effects of neglect | C |
| April, a 10-year-old admitted to inpatient pediatric care, has been getting more and more wound up and is losing self-control in the day room. Time-out does not appear to be an effective tool for April to engage in self-reflection. April’s mother admits to putting her in time-out up to 20 times a day. The nurse recognizes that: a. Time-out is an important part of April’s baseline discipline. b. Time-out is no longer an effective therapeutic measure. c. April enjoys time-out and acts out to get some | B |
| Adolescents often display fluctuations in mood along with undeveloped emotional regulation and poor tolerance for frustration. Emotional and behavioral control usually increases over the course of adolescence due to: a. Limited executive function b. Cerebellum maturation c. Cerebral stasis and hormonal changes d. A slight reduction in brain volume | B |
| In pediatric mental health, there is a lack of sufficient numbers of community-based resources and providers, and there are long waiting lists for services. This has resulted in: Select all that apply. a. Children of color and poor economic conditions being underserved b. Increased stress in the family unit c. Markedly increased funding d. Premature termination of services | A,B,D |
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