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Child and Adolescent Mental Health. Module Content. Mood and Anxiety Disorders Attention Deficit and Disruptive Behavior Disorders Developmental Disorders: Autism Spectrum Bullying Psychopharmacology Cognitive and Behavioral Therapies. Cognitive Development.

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module content
Module Content

Mood and Anxiety Disorders

Attention Deficit and Disruptive Behavior Disorders

Developmental Disorders: Autism Spectrum



Cognitive and Behavioral Therapies

cognitive development
Cognitive Development

Moves from concrete thinking to “formal operations” –i.e. Abstract thinking

Physical development precedes cognitive development

The last part of the brain to mature is the prefrontal cortex

Adolescence is a time of profound change in brain function.

mental health problems of school age children
Mental Health Problems of School Age Children

10-13% of children have serious MH problems

655,000 Texas children

mental health disorders in children
Mental Health Disorders In Children
  • Many conditions overlap-make diagnosis and treatment a challenge
  • Examples: ADHD with Bipolar Disorder

Obsessive-compulsive Disorder with Disruptive Behavior Disorders

etiology of childhood mental health problems
Etiology of Childhood Mental Health Problems


Vulnerability vs. Resilience

etiology of mh problems
Etiology of MH Problems:

Genetics: strong for Depression, Anxiety, OCD, Tic disorders, ADHD, Bipolar disorder

Neurological Anomalies

Prenatal Infection or Toxicity

e.g. Fetal Alcohol Syndrome (FAS)

etiology cont d
Etiology, cont’d
  • Psychosocial Adversity
      • Parent(s) with mental illness, drug or alcohol addiction, criminal behavior
      • Abuse and neglect
      • Family and/or community stress or trauma
      • Poverty
etiology cont d1
Etiology, cont’d
  • Other Environmental Factors
    • Lead poisoning, Accidents/Brain injury, etc.
mood disorders
Mood Disorders

Depression: risk increases when a parent is depressed.

Symptoms may differ from adult depression, e.g.

Poor school performance

Behavioral problems cont’d

depression symptoms specific to younger populations
Depression Symptoms Specific to Younger Populations

In Children: Lack of verbal skills affects expression

Irritable or resistant.

May have somatic sx.

In Adolescents:

Blues in boys: aggressive behavior or acting out

Blues in girls: eating disorders, and/or self-injury.

suicide in younger populations
Suicide in Younger Populations
  • Risk for suicide:  each year after puberty
  • Child abuse:  risk for suicide X30
  • 3rd leading cause of death in males 11-14
  • Population with greatest  in rate = Hispanic females 12-17
mood disorders cont d
Mood Disorders, cont’d
  • Bipolar D/O —Primarily dx. in adolescence
    • Evidence is growing for early bipolar sx.
    • Sx. in children: irritability, impulsivity, temper tantrums
    • Highly susceptible to mania caused by prescribed antidepressants and stimulants
anxiety disorders
Anxiety Disorders
  • Trauma-Related (PTSD)
  • Separation Anxiety Disorder
  • Social Anxiety Disorder
  • Pediatric OCD
  • Behaviors may manifest as oppositional or resistent
attention deficit hyperactivity disorder adhd
Attention Deficit/ Hyperactivity Disorder (ADHD)

Up to 11% of school age children

Correlates with psychological adversity

Dx: >6 months, before age 7



Disorganized, poor-follow through

Impulsive and Over-active

Restless, distractible, reckless, disruptive

etiology of adhd neurobiological theories
Etiology of ADHD: Neurobiological Theories

Frontal Lobe Dysfunction: area of brain responsible for planning, attention, regulation of motor activity

“Underactive Brain”

Reduced metabolic activity

Not enough Dopamine


adhd other possible neurobiological factors
ADHD: Other Possible Neurobiological Factors

Defective inhibitory mechanisms

Dysfunctional Reticular Activating System (inability to regulate incoming stimuli and to attend to stimuli)

adhd issues etiology
ADHD Issues-Etiology
  • Exposure to chemicals?
  • TV and electronic media?
pharmacotherapy for adhd
Pharmacotherapy for ADHD

Stimulants:methylphenidate (Ritalin, Concerta), dextroamphetamine (Dexedrine), and mixed amphetamine (Adderall), pemoline (Cyclert)

Extended release--Ritalin LA/Concerta/Metadate CD, Adderall XR--decrease dosing to once daily

non stimulant medications for adhd
Non-Stimulant Medications for ADHD

Affect norepinephrine release or reuptake:

clonidine (Catapres)

guanfacine (Tenex, Intuniv)

atomoxetine (Strattera)

stimulant medication issues
Stimulant Medication Issues

Rebound effects common, esp. with multi-dose forms

Side effects: anorexia, weight loss, abnormal movements/tics, labile mood, insomnia, agitation

Potential for drug abuse

dextroamphetamine with l-lysine (Vyvanse) psychostimulant that reduces abuse potential

stimulant medication issues cont d
Stimulant Medication Issues, cont’d
  • Ethical issue: Are stimulants over-prescribed?
disruptive behavior disorders
Disruptive Behavior Disorders
  • Oppositional Defiant Disorder (ODD)
    • Argumentative, disobedient, fighting, explosive anger
  • Conduct Disorder (CD)
    • More serious behavioral violations e.g. aggression, violence, torture of animals, etc.
    • May be criminal in nature e.g. arson, stealing, etc.

Frequently comorbid with ADHD, learning problems, mood and anxiety disorders

developmental disorders include
Developmental Disordersinclude:
  • Mental Retardation
    • Low IQ with learning dysfunction
  • Pervasive Developmental Disorders
    • Autistic Disorder
    • Asperger’s Disorder
  • Specific Developmental Disorders, e.g.
    • Learning Disorder
  • Communication Disorders
autism and asperger s d o
Autism and Asperger’s D/O

Viewed as being on the same spectrum, differentiated by severity of symptoms and impairment

autistic disorder autism
Autistic Disorder (Autism)

Early Age of onset

30 months of age

Constant delayed development

May or may not have low intellectual function

triad of autism
“Triad of Autism”

#1 Impaired Social Skills and Relatedness

  • Aloof and indifferent to others
  • Prefer inanimate objects to human contact
  • Unable to understand social cues


autistic disorder triad
Autistic Disorder “Triad”

#2 Alteration in Communication



Abnormal intonation

Pronoun reversals


May be nonverbal

autistic disorder triad1
Autistic Disorder “Triad”

#3Restricted, Repetitive and/or Stereotypical Behaviors or Interests

  • Rocking, hand flapping, spinning
  • Insistence on sameness
  • Preoccupation with peculiar interests
autism you tube
Autism You Tube (Autism Every Day 7 min. docu.) (Toddler boy 5 min.)

asperger s disorder
Asperger’s Disorder

Less severe form of autism

Less likely to be mentally retarded

Higher performing: language development may be ok

Communication handicap is less severe

Concrete interpretation of language

Stilted and abnormal intonation

asperger s disorder cont d
Asperger’s Disorder, cont’d
  • Clumsy
  • Social Interactions are impaired
    • Problems reading social cues
  • Preoccupation with matters of private interest
  • Obsessive, repetitive routines and rituals
aspergers s you tube
Aspergers’s You tube (2 teens)

other characteristics of autism spectrum disorders
Other Characteristics of Autism Spectrum Disorders
  • Hypersensitivity to sensory stimuli
  • Difficulties with transitions or change
etiology of autism spectrum d os
Etiology of Autism Spectrum D/Os

Multiple causes are proposed:

  • Genetic-Highly heritable
  • Infection
    • Intrauterine
    • Childhood
autism issues
Autism Issues
  • The vaccination controversy
  • Pattern of harm/abuse of power over another person that is repetitive and has not been provoked
  • Reporting is low
  • Diagnosis is difficult
  • About half of all US children have been victims
  • May be carried out by individuals or groups


  • Verbal-name calling, racial slurs, malicious false gossip
  • Physical attacks
  • Cyberbullying-use of electronic media to invade privacy, defame or embarrass
results of bullying
Results of Bullying:
  • Emotional problems, school refusal
  • Substance use
  • Suicide
  • Revenge on persons or institutions
interventions for bullying
Interventions for Bullying
  • School nurse is often the first responder
  • Interventions need to be institution-based and community-based
  • Education
general nursing interventions for children a behavioral focus
General Nursing Interventions for Children: A Behavioral Focus

Simple step-by-step instructions

Daily routines

“It’s 5:00; play time is over.—Please put away all the toys.---We’ll wash hands now because it’s dinner time.—You washed your hands, so we’re ready to go to the table.”

Short term rewards/re-enforcers

nurse client communications
Nurse-Client Communications

Communication Examples for Children:

“It is unsafe to jump down stairs 2 at a time”

“You walked down the stairs in a safe way”

“It is not OK to grab a toy from another child; you must ask”

“Because you didn’t hit today, you may choose the group snack tonight”

milieu management
Milieu Management
  • Communicate expectations for behavior
  • Set limits on destructive, aggressive and inappropriate sexual behavior
  • Support independence as appropriate
  • Rights of the group vs. individual rights
other cognitive and behavioral therapies
Other Cognitive and Behavioral Therapies
  • Problem Solving Skills- reinterpretation of environment to reduce negative thinking
  • CBT: Useful for long-term tx., e.g. for OCD, negative thinking in depression, anxiety
      • May be used in inpatient settings as part of milieu management
cognitive and behavioral interventions cont d
Cognitive and Behavioral Interventions, cont’d
  • Social Skills Training- e.g. for Asperger’s
  • Prompting and sensory reinforcement: Autism
more nursing interventions
More Nursing Interventions

Teach the family about disorders, symptoms and intervention techniques

Assess family HX: Listen; be objective when hearing what family has to say

Identify family strengths and successes

Communicate with teachers, school

Passes to go home prior to discharge

pharmocotherapy interventions
Pharmocotherapy Interventions


SSRIs : fluoxetine (Prozac) 

sertraline (Zoloft) 

fluvoxamine (Luvox) 

paroxetine (Paxil)

citalopram (Celexa)

escitalopram (Lexapro)

Also used for OCD

pharmacotherapy antidepressants
Pharmacotherapy: Antidepressants

SSRIs, cont’d

Activating effects may precipitate hypomania, mania or suicide

TCAs –many SE’s; lethal doses have occurred

pharmacotherapy cont d
Pharmacotherapy, cont’d

Antipsychotic Agents

For aggressive behavior, self-injury, psychotic symptoms, mood stabilization

Typicals: Highly correlated with EPSEs

Atypicals: FDA approved = risperidone/Risperdal and aripiprazole/Abilify

Weight gain problematic; fatty livers (risperidone/Risperdal)

pharmacotherapy cont d1
Pharmacotherapy, cont’d
  • Antianxiety agents-

best choices

    • buspirone/Buspar
    • clonazepam/Klonipin
  • Mood Stabilizers-dose based on weight
    • Lithium-age 12 and older
    • Atypical antipsychotic agents
issues in pharmacotherapy
Issues in Pharmacotherapy
  • Few drugs are FDA approved
  • Most not tested on children
  • Children metabolize and excrete differently from adults
  • Children may have narrower therapeutic range for some drugs
interventions psychotherapy
Interventions: Psychotherapy
  • Individual Therapy
    • Play therapy for children
  • Group Therapy
  • Family Therapy
community resources
Community Resources

Support groups, camps, web resources, literature (e.g. workbooks), parenting classes