Mental health in children

What is mental health?

• Sense of personal wellbeing involving

successful engagement in activities and

relationships and the ability to adapt to and

cope with change. cope with change.

Mental Health in children

• 25% of children in US have MH issues that

impair their ability to function in home or at

school

• Many who need services do not receive them. • Many who need services do not receive them.

• Goal of treatment is to assist child & family to

achieve & maintain optimal level of

functioning through interventions that reduce

risk factors and enhance coping.

Statistics close to home

• Massachusetts

• Salem

– Survey of teachers in Salem 19% children with

Behavioral Health DisordersBehavioral Health Disorders

• ADHD

• Anxiety

• Depression

– 2/3 of educators feel insufficiently trained in BH

Mental Health Assessment

• Appearance

• Behavior

�Development

• Life events• Life events

• History

– Prenatal events

Assessment

• Tools exist for many behavioral health

problems

– Use a valid, appropriate, agency approved tool to

validate any subjective ideas about behavioral/ validate any subjective ideas about behavioral/

mental health problems

– Removes bias in assessment

Planning and Implementation

treatment modes

• Group therapy

– Supportive

– Effective with adolescents

• Individual Therapy• Individual Therapy

– Cognitive therapy

• Family therapy

Planning and Implementation

Therapeutic strategies

• Play therapy

• Art therpay

• Behavior and cognitive therapy

• Visualization and guided imagery• Visualization and guided imagery

• Hypnosis

Inpatient care

• Nursing responsibilities

– Medication administration with careful attention

to therapeutic action and side effects

– Ensure safety– Ensure safety

– Collaborate regarding medical concerns

– Involve the family

Discussion of mental health disorders

in children

• Pervasive developmental disorders

• Attention deficit disorders

• Cognitive disorders

• Violence• Violence

• Abuse

Pervasive Developmental Disorders

• Begin in early childhood

• Characterized by impaired social interactions

and communication

• Restricted interests, activities, behaviors• Restricted interests, activities, behaviors

• Unusual ways of learning

• 4x more likely in boys than girls

Pervasive Developmental disorders

• Autistic Disorder

• Asperger’s syndrome

• Rett’s disorder

• Childhood disintegrative disorder• Childhood disintegrative disorder

• Pervasive developmental disorder NOS

Other medical disorders that should be

ruled out before a diagnosis is made

• Hearing loss

• EEG

• Metabolic screening

• MRI• MRI

• C T

• Genetic testing

Autistic disorder

• Impaired social, communication, and

behavioral development usually noted in the

first year of life

Clinical therapy involves early

intervention

•OT

•PT

•Speech

Autistic disorder

• Impaired social interaction

• Impaired communication

• Restricted repetitive and stereotyped patterns

of behavior, interests or activitiesof behavior, interests or activities

• Onset prior to age 3 years

• Not better accounted for by Rett’s disorder or

childhood disintegrative disorder

Spectrum disorder

RememberToddler language development

• Concrete use of single words (labeling)

– Combining words to express ideas

• Expanded phonology (range of sounds)

• Expanded semantics (meanings of words)• Expanded semantics (meanings of words)

• Increased symbolic understanding

• Expanded pragmatics

– Conversation & language as social tools

Behaviors and Autism Spectrum

disorders

• Strong preference for routine

• Perseveration

– Focus on same nonfunctional activity for hours

• Restricted range of interests• Restricted range of interests

– Trains, dinosaurs,

• Stereotypical behaviors

– Spinning, hand flapping, visual regard

Play and Autism

• Lack of or impaired imaginative play

• Purposeless or idiosyncratic play

– Lining up toys– Lining up toys

– Sensory exploration of objects/toys

• Preoccupied with parts/aspects of object

– Repetitive car wheel spinning

– Flashing/beeping interest exclusively

Red Flags for Autism Spectrum

Disorder

• No babbling at 12 months

• No gesturing (pointing, waving) at 12 months

• No single words at 16 months

• No 2 word phrases at 24 months• No 2 word phrases at 24 months

• Any loss of any language/social skills at any

age

Autism and genetics

• Some genetic contribution

• Familial incidence

– Monozygotic twins: 60% autism; 92% PDD

– Dizygotic twins: 0% autism; 10-30% PDD– Dizygotic twins: 0% autism; 10-30% PDD

– Sibling risk: 4-7%

• Increased risk with genetic differences

– Fragile X, Williams syndrome, 15 duplication,

Angelman’s

Autism specific characteristics

• Difficulty mixing with other children

• Inappropriate laughing

• Little or no eye contact

• Insensitive to pain

• Insistence on sameness

• No real fear of dangers

• Sustained odd play

• Echolalia

• May not want cuddling• Insensitive to pain

• Prefers to be alone

• Spins objects

• Inappropriate attachment to objects

• Physical over activity or extreme under activity

• May not want cuddling

• Not responsive to verbal cues

• Difficulty expressing needs

• Tantrums

• Uneven gross or fine motor skills

Nursing Assessment and diagnosis

• Impaired verbal communication

• Impaired social interaction

• Disturbed thought processes

• Risk for injury• Risk for injury

• Risk for caregiver role strain

Autism disorder

• Click to start

www.autismspeaks.org/sponsordevents/autis

m_every_day.phpautism speaks

Early intervention services

• State program run by Department of Public

Health

• Services children 0-3

• Children who are at risk due to • Children who are at risk due to

– Biological factors

– Environmental factors

– Psychological factors

Asperger’s Syndrome

• Neurological disorder that, like others on the

spectrum, is marked by difficulties in

communication and social interaction The set

of characteristics easily identified with the of characteristics easily identified with the

conditon was first identified by Austrian

pediatrician Hans Asperger.

Differences between aspergers and

traditional autism

• Impairment in social interactions

• Restricted, repetitive, or stereotyped

behaviors

• Significant impairment in functioning• Significant impairment in functioning

• No significant general delay in language

• Normal cognition, curiosity, adaptation

(normal IQ, meet milestones on time)

• Not schizophrenia or other PDD

Treatment of Aspergers

• Applied Behavior Analysis

• Positive reinforcement

• Language and communication therapy

• Social Skills training• Social Skills training

• Hippotherapy

• Martial arts therapy

• Medications

Pharmacotherapy

• No treatment for core symptoms of social and

relationship problems in autism

• Medications do target some secondary

symptoms: hyperactivity, self-injurious symptoms: hyperactivity, self-injurious

behavior, aggression, anxiety

• Since most require long-term treatment

periodic attempts to discontinue or decrease

medication is prudent

Risperidone for Autism

• Decrease in aberrant behavior

– Aggression

– Streotypic and hyperactive behavior

• Adverse Effects• Adverse Effects

– Weight gain

– Tremor

– Fatigue

Retts syndrome

• Occurs only in girls

• Genetic disorder

• Deceleration of head growth followed by loss of hand skills and the appearance of stereotypic hand wringing between the ages of 5 months and hand wringing between the ages of 5 months and 4 years

• Social skills and expressive/receptive language loss between ages 2-3

• Development of ataxia, apraxia, broad-based/jerky gait, breathing problems

ADHD

• According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), the essential features of ADHD include:

1. persistent and developmentally inappropriate pattern of inattention, impulsivity, and/or hyperactivity;

2. presence of symptoms before 7 years of age;2. presence of symptoms before 7 years of age;

3. impairments apparent in at least two different settings (e.g., home and school);

4. interference with social, academic, or occupational function; and

5. symptoms are not due to some other psychiatric disorder

ADHD

• Occurs more often in boys

• Multifactorial etiology

– Genetics

– Environment– Environment

– Biologic risk

• Three subtypes

– ADD (primarily inattentive)

– ADHD (primarily hyperactive-impulsive)

– Combined

ADHD diagnosis

• Physical exam

• Teacher/parent rating scales

– Vanderbilt

– Conner– Conner

• Psychoeducational testing

What else could it be?

• Depression

• Anxiety

• Learning disabilities

• Oppositional defiant disorder• Oppositional defiant disorder

Are there co-morbidities?

• Learning disabilities

• Tourette syndrome

• Oppositional defiant disorder

• Conduct disorder• Conduct disorder

• Anxiety and depression

• Bipolar disorder

ADHD treatment

• Stimulants

– Work on neurotransmitter dopamine

• Nonstimulants

– Work on neurotransmitter norepinephrine– Work on neurotransmitter norepinephrine

• Behavioral therapy

• Accomodations

– Provide an environment that best fits the needs of the child

– Focus on being proactive rather than reactive

What approach works best?

• Medication alone

• Intense therapy alone

• Combination

• Community care (nothing different)• Community care (nothing different)

COMBINATION

Stimulant side effects

• Decreased appetite

• Headaches

• Difficulty sleeping

• Tics

Things to remember about ADHD

meds

• Medication for ADHD help many children

focus and be more successful at school, home

and play. Avoiding negative experiences now

may actually help addictions and other may actually help addictions and other

emotional problems later

• About 80% of children who need medication

for ADHD still need it as teenagers. Over 50%

need medication as adults

Cognitive deficits

• Mental retardation is not something you have, like blue eyes, or a bad heart. Nor is it something you are, ike short, or thin.

• It is not a medical disorder or a mental • It is not a medical disorder or a mental disorder

• Mental retardation is a particular state of functioning that begins in childhood and is characterized by limitation in both intellectual and adaptive skills.

Cognitive Deficits

• Generally measured by IQ (<70=MR)

• Affects 3% of population. Occurs before age

18.

• Causes• Causes

– Prenatal errors in development

– Pre or postnatal changes in biologic environment

– External forces leading to CNS damage

Mental Retardation

• In 1967 there were 194,650 people living in public institutions

• Massachusetts Consent decree deinstitutionalized individuals living in state deinstitutionalized individuals living in state schools

• Established community services

• PL94-142 all children have right to a free appropriate public education to all children with disabilities.

Cognitive deficits

• Trisomy 21

• Fragile X

• Fetal Alcohol syndrome

Trisomy 21

• One in every 733 live births– More frequent in older mothers

• Wide range of intellectual abilities

• Medical risks– Cardiac– Cardiac

– Immunologic

– ENT

– GI

– Thyroid disorders

– Alzheimers

Trisomy 21 characteristics

• Single transverse palmar crease

• Almond shape to the eyes (epicanthal fold)

• Upslanting papebral fissures

• Shorter limbs• Shorter limbs

• Poor muscle tone,

• Larger than normal space between the big and second toe

• Protruding tongue

• Low set ears

Trisomy 21

prenatal diagnosis

• Maternal alpha feto protein, nonspecific test,

increase indicates risk

• Amniocentesis

• Chorionic villus sampling• Chorionic villus sampling

• In 2002 study found that 91-93% of

pregnancies with a diagnosis of down

syndrome were terminated.

Fragile X

• Most common known cause of inherited

mental retardation worldwide

• DNA analysis of FMR1 gene

– Disease severity related to the number of CGG – Disease severity related to the number of CGG

trinucleotide repeats in FMR1 gene

• Normal is 6-44 repeats

• Full mutation is >200 repeats

Fragile X

clinical manifestations

• Cognitive (IQ)

– Ranges: mental retardation to learning disabilities

– 85-90% males with mental retardation

– 70% girls with borderline/ mental retardation– 70% girls with borderline/ mental retardation

• Behavioral

– Sensory defensiveness

– ADHD-like features

– Autistic-like features

Fetal Alcohol Spectrum Disorder

• Alcohol use during pregnancy is the leading

known preventable cause of mental retardation

and birth defects in the United States

• Affects an estimated 40,000 infants each year • Affects an estimated 40,000 infants each year

(more than spina bifida, down syndrome and

muscular dystrophy combined)

• FASD is an umbrella term describing the range of

effects that can occur in an individual whose

mother drank alcohol during pregnancy.

Fetal Alcohol spectrum disorder

• FAS

• Partial FAS

• Alcohol related neurodevelopmental disorder

• Alcohol-related birth defects• Alcohol-related birth defects

Effects of fetal alcohol spectrum

disorder• Specific facial characteristics

• Growth deficits

• Mental retardation

• Heart, lung, kidney deficits

• Hyperactivity and behavior problems• Hyperactivity and behavior problems

• Attention and memory problems

• Poor coordination r motor skill delays

• Difficulty with judgment and reasoning

• Learning disabilities

FAS nursing care

• Help parents or caregivers acknowledge and understand the reality of their child’s situation

• Be nonjudgmental, building an alliance with caregivers and nurturing both their strengths and the strengths of the affected childthe strengths of the affected child

• Staying abreast of treatment research in related areas

• Refer to specialized medical services

• Follow-up on all referrals and coordinate care as needed