Psychiatric Nursing:

1
Psychiatric Nursing

• Care of children
• Adolescents

2
Concepts R/T

• Growth and Development
• Developmental Stages
• Development of Defense Mechanism

3
Nursing Application

• The importance of meeting the needs of each
  developmental stage.
• Interference with normal developmental process
  during the hospitalization.
• Nursing consideration

4
Major Theories of Development

• Stages of Growth and Development
• Freuds - psychosexual development.
• Ericksons - psychosocial development
• Piagets - cognitive development.

5
CHILD PSYCHIATRIC NRSG

• Scope of the problem 10/ 8-12 million
  school-aged children suffer from persistent and
  serious mental problems.
• 15-20 has milder problems at home and school (
  relationship, adjustment problems, etc).
• Only 1/5 of children receive required mental
  health services.

6
Prevalence of MentalAddictive D. in Children
Adolescents(9-17)

• Type of disorder Percentage
• Anxiety D --------------------- 13
• Disruptive D ------------------- 10
• Mood D ------------------------- 6.2
• ADHD --------------------------- 4.1
• Autism ------------------------- 1-2 cases per
  1.000
• Conduct D --------------------- 2-16,
• Substance rel. D --------------- 2 over 5 mil
  by age 16
• Other --------------------------- 20.9
• -- Source U.S. Dept of Health Human Service,
  99

7
Prevalence of Critical Adolescent Mental Health
related Problems

• Problem Male
  Female
• Disabling sadness, unhappiness,Depre. 33
  34
• Suicide attempts requiring medical TX -- 2.1
  3.1
• Drinking and driving ----------------------
  17 9.5
• Alcohol consumption prior to age 13 y -- 24
  34
• Physical fights -------------------------------
  43 33
• Carrying a weapon at school -------------- 10
  3
• Chlamydia Trachomatis --------------------
  15.7 12.2
• --Source Elster, et al03. Health care of
  adolescent males Overview, rationale,
  recommendation. Adolescent medicine. State of the
  Art Prof. Review, 14(3), 525-540

8
Contributing Factors

• Factors that contribute to psychiatric disorders
  in children
• Biological/Genetic
• Psychosocial and Environmental

9
Therapeutic Role of the Nurse Children
Adolescent care

• Issues concerning Psychiatric care for children
  and adolescents
• Recognition of needs for mental health promotion,
  early identification, tx for children and
  adolescents
• Age specific mental status assessment, Dx, and Tx
  of children and adolescents.
• Cont. research on new and innovative Tx
  modalities for children with MI

10
Developmental Disorders

• 1. Mental Retardation
• 2. Pervasive Developmental disorders
• Autistic disorder
• Asperser's disorder
• Pervasive developmental disorders NOS
• 3, Specific Developmental Disorders
• Learning disorder
• Communication disorders

11
Developmental Disorders PDD

• 2. Pervasive Developmental Disorders PDD
• AUTISTM
• Retts Disorder
• Childhood Disintegrative Disorder
• Aspergers Disorder
• PPD -NOS

12
PDD AUTISTIC DISORDER

• Characteristics Withdrawal into self.
• Marked abnormal or impaired develop. In social
  interaction, communication, and restricted
  repertoire of activity and interests that are
  bizarre.
• Onset prognosis Prior to age 3
• Most cases it runs a chronic course.

13
Clinical manifestation Autism

• Profound disturbance in cognitive functioning.
• Affect is flat and aloof
• Language is delayed and deviant.
• Stereotypical behaviors rocking, hand flapping,
  insistence on sameness.
• Preoccupation with peculiar interests.

14
PDD Retts Disorder

• Onset of Retts after the period of normal
  development all of the following
• Apparently normal prenatal perinatal
  development
• Apparently normal psychomotor development through
  the first 5 months
• Normal head circumference at birth.

15
Retts Clinical syndrome

• Deceleration of head growth between ages 5months
  -48months.
• Loss of previously acquired purposeful hand
  skills (5-30months)with subsequent development of
  stereotyped hand movements(wringing or hand
  washing),
• Loss of social engagement early in the course -
  may develop later.
• Poor coordinated gait or trunk movement
• Severely impaired expressive/receptive language,
  severe psychomotor retardation

16
PDD Childhood Disintegrative Disorder

• A) Apparently normal development for at
  least the first 2 yr. after birth.
• B)Clinically signif. Loss of
• previously learned skills before age 10 in at
  least two of these Expressive or receptive
  language
• Social skills or adaptive behavior
• Bowel or bladder control, play, motor skills
• C) Impairment in social interaction,
• communication, restricted, repetitive patters of
  behavior, mannerisms. ,

17
PDD Aspergers disorder

• Less likely become mentally retarded,
• Verbal intelligence is higher than performance
  intelligence, therefore,
• They are clumsy, problem initiating social
  interaction,
• Impaired reading social cues,
• Tendency to interpret language in concrete term.
  

18
PDD-NOS

• This is a residual category not otherwise
  specific, such as Autism and Aspergers.
• Age of onset and severity of speech, language
  deficit, social skills, etc. are not as severe as
  the others.

19
Assessment PDD

• Developmental Hx - parent report
• Direct observation of child
• Cognitive assessment
• Educational Testing
• Diagnostic instruments
• Medical work-up
• Psychological work-up
• Rating Scale

20
Developmental Screening

• List the following 5 behaviors as red flags for
  further evaluation
• 1. Not babble or coo by 12 months
• 2. Not gesture (point, wave, grasp) by 12m
• 3. Not say single words by 16 months
• 4. Not say two-word phases by 24 months
• 5. Loss of any language or social skill.
• - Natl Ins of Child HealthHuman Development. -

21
Screening Instruments

• Autism Diagnostic Interview- (ADI-R)
• Childhood Autism Rating Scale (CARS)
• Checklist for Autism in Toddlers(CHAT)
• Autism Screening Questionnaire
• Screening Test for Autism in Two-year-old

22
Medical work-up

• Complete physical exam.
• VS, HT, WT.
• Neuro exam, MRI, EEG
• Hearing, vision screening
• Lead level, other labs
• Hepatic, cardiac baselines prior to starting
  medications.

23
Psychological Work-up

• IQ assessment
• LD testing
• Baseline assessment of target symptoms

24
Presentation Assessment

• Social impairments
• Communication impairments
• Repetitive/Restricted behavior

25
Assessment Functional Behavior

• A clear description of the problem behavior
• Development of hypotheses of function of the
  behavior
• Develop Tx plan(behavior modification) based on
  predicted outcome
• teach skills to replace old behavior
• modify environment to reduce need to use old
  behavior - collect data to eval. Outcome.

26
Rating Scales

• Heterogeneity clinical presentation of PDDs
  requires- measurement of predominant sympt. As a
  guideline for tx
• No comprehensive scale available.
• Several rating scales for other dx groups are
  used for PDDs. E.g. next slide

27
Rating scales

• Aberrant Behavior Checklist(ABC)
• To measure tantrums, aggression, self-inj -
• Childrens Yale-Brown OC Scale(CY-BOCS) To
  measure repetitive, and compulsive behavior
• Connors Rating Forms To measure attention,
  impulse control and hyperactivity.

28
Intervention Strategies

• Ind./Family education prog need resources
  -long-term.
• School structured, well managed. Safety
• Facilitating Success write/draw rules be
  consistent. Use activity based, multi-model
  learning if poss.
• Dealing with problem behavior (-) contingencies
  dont work. Incentives explicit instruction
  more successful.

29
Pharmacological TX

• Drugs that have primary effects on the core
  social impairment of autistic other PDDs have
  not been developed.
• More recent studies
• Atypical antipsychotic and SSRI
• Psycho stimulants

30
References

• Text Pediatric psychopharmacology Principles
  and practice (2003) ch 42, Andres Martin, et al
• Article Am Academy of Child Adolescent
  Psychiatry. Practice Parameters for the Assess.
  Tx of children with autism, PDD, J Am Acad. of
  Child Adolesc Psychiatry. 993832S-54S.
• Books Klin, et al, Child Adolesc Psych Clinics
  of North Am. Elsevier Science, 2003.
• Klin, a., et al. Asperger Syndrome. Guilford
  Press2000.

31
References cont.

• Natl. Organizations Autism Society of Am
• 7910 Woodmont Ave., suite 650 Methesda, MD
  20814.1-800-3-AUATISM.
• Hittp//www.autism-society.org
• Aspergers Syndrome Coalition of the US,inc
• p.o.box 49267. Jacksonville, FL32240
• http//www.asperger.org
• The Autism Research Inst. In San Diego, CA
• hittp//wwwautismresearchinstitute.com

32
References cont.

• Siegel, et at. The world of the Autistic Child
  understanding TX Autistic spectrum disorders.
  Oxford Univ.. Press 1998.
• Frith, Uta. Autism and Aspergers synd.
• University Press 1992
• Gray, Carol. The New Social Stories Book
• Illustrated Edition. Future Horizons 2000.

33
DISRUPTIVE BEHAVIOR DISORDRS(DBD)

• 1. ATTENTION-DEFICIT HYPERACTIVE
  DISORDER(ADHD).
• 2. CONDUCT DISORDER
• 3. OPPOSITIONAL DEFIANT DISORDER

34
ADHD General Statistics

• Most common neurobehavioral childhood disorder
• Affect 3-5 of children Adolescents
• Age of onset it typically 3 y.o.(not detected)
• Mean diagnostic age is 8-9 y.o.
• Approx. 50-60 of those with ADHD have symptoms
  persisting into adulthood( Hyperactivity dec.
  inattention continues)
• ---- Goodman, et al, 1998 -----

35
Etiology of ADHD

• Genetic Origins/Biological family Hx, Prenatal
  or perinatal issues, toxins.
• Brain structure and functional abnormality.
• Neurochemical/Neuroanatomical changes
• CNS Insults
• Psychosocial/Environmental stressors

36
DISRUPTIVE BEHAVIOR DISORDER ADHD

• Core symptoms
• Impulsivity
• Inattention
• Hyperactive
• Onset and prevalence.

37
ADHD Inattention

• Fail to give close attention to details or makes
  careless mistakes
• Has difficulty sustaining attention in tasks
• Does not follow through on instructions
• Has difficulty organizing tasks
• Avoids, reluctant to engage in tasks that require
  sustained mental effort
• Loses things, easily distracted, forgetful

38
ADHD Impulsivity

• Blurts out answers before the question is
  finished.
• Has difficulty awaiting turn
• Interrupts or intrudes on others

39
ADHD Hyperactivity

• Fidgets and is unable to stay seated
• Inappropriate running/climbing
• Difficulty engaging in leisure activities quietly
• On the go like a motor running
• Talks excessively
• DSM IV --

40
ADHD subtypes

• ADHD, combined type
• ADHD, predominantly inattentive type
• ADHD, predominantly hyperactive-impulsive type (
  see DSM- IV criteria)

41
ADHD Diagnosis

• Review DSM-IV Classification
• Diagnosis is made from multiple sources
• Parental, teacher, caregiver information
• Medical and other professional staff inform.
• A comprehensive psychiatric and medical
  evaluation of the child.
• Social functioning
• Most be present before the age of 7 y.o.
  symptoms must last greater than 6 months

42
Differential DX ADHD

• Organic disorder
• Sensory disorders
• Medication induced ( antihistamines,
  phenobarbital, beta-agonists).
• Seizure disorder
• Learning D
• Thyroid abnormality

43
Co morbidities

• Most common
• ADHD Conduct disorder - 8-12
• ADHD Oppositional Defiant D. gt40
• ADHD Axis 1 conditionDepression 50
• ADHD Mania/hypomania 22
• ADHD Anxiety -30
• ADHD Learning difficulty -10-92
• ADHD TIC disorder 8-34 -Girls have higher
  levels of comorbid mood anxiety D

44
ADHD Myths

• ADHD does not affect occupational status in long
  run
• A child can outgrow ADHD
• Children are just lazy. They can concentrate if
  they just put their mind to it
• Stimulant medications are addictive
• More children are dx in the US with ADHD than any
  other country.

45
Meds Rx for ADHD Stimulant

• Block uptake of DA kept it at the synapse.
• This causes a greater release of DA in the
  synapse.
• 70 respond to the first stimulant agent given
  improve core symptoms
• Stimulants are comparable in efficacy but
  differences in response rate occur to various
  compounds.

46
Stimulants Primary drugs

• Methyl-phenidate( RitalinmetadateER, CD
  Concerta,Methylin)
• Dextro-amphetamine (Dexedrine Dextrostat)
• Amphetamine/Dextro-amphetamine(Adderall)
• Dexmethyl-phenidate(FocalinNot common)
• FDA o.k. to Rx ADHD for children 6ygt
• FDA o.k. to Rx ADHD for children 3ygt

47
Stimulants Considerations

• Short-acting stimulants
• Long-acting stimulants cause less potential for
  abuse, if taken QD, no dosing outside the home,
  less abuse potential.
• Considerations
• Duration, potency, Drug absorption
• Dosing

48
Methylphenidate

• Available in multiple reparations
• Retalin 5,10,20mg Regular acting,20mg Extended
  release(ER), Ritalin LA 10,20,30,40mg with 50/50
  IR/ER beads ratio.
• Side Effects Anorexia/Wt loss, insomnia, abd.
  Pain, nervousness, mild inc. HR, BP, dysphoria,
  Tics, irritability, depression, rebound( less
  common with long-acting)
• Tolerance with need for dose advance or switch
  to alternative medication.

49
Stimulant RX

• Problematic Side Effects
• Precautions with stimulants
• Contraindications
• Controversies

50
Other Meds Rx for ADHD

• Secondary Co-therapy with stimulants or
  monotherapy if stimulant cant be used.
• A) Atomoxetine (Strattera -not stimulant)
• B) Alpha-2 Agonists( Clonidine Tenex)
• C) Antidepressants TCA -not effective.
• SSRI, NSSRI( lexapro WellbutrinZoloft Prozac.
  Effexoretc), Depakote
• Other (PemolineCylertstimulant)
• Modafinil (Provigil)only for narcolepsy.

51
Other meds Rx ADHDcont

• Alpha 2 agonist Clonidine,Tenex
• StratteraConcerta( ADHD medication for pts. New
  to medication - august 2003)
• Start with concerta then add with Strattera - non
  stimulant that takes months to get therapeutic
  effect. ( Co-therapy strategy).

52
Nursing consideration

• ADHD with other co-morbid condition
• School issues- advocate for the child in the
  school. Social skills training
• Help parents and the significant others
• Mono-therapy, co-therapy and the efficacy
• Side effects and impact on normal growth and
  development.
• Always Tx anxiety before the ADHD

53
Disruptive Behavior disorder(DBD)CONDUCT
DISORDER

• Pervasive, repetitive, and persistent pattern of
  behavior in which basic rights of others or
  social norm/rules are violated.
• Physical aggression is common.
• DSM-IV subdivides
• CHILDHOOD-ONSET TYPE
• ADOLESCENT-ONSET TYPE.
• See DSM-IV Classification
  

54
DBD Oppositional Defiant

• Shows a pattern of negativistic, defiant,
  disobedient, and hostile behavior toward
  authority figures.
• Behaviors serious enough to interfere social,
  academic, or occupational functioning.
• Typically begins by 8 years of age, not later
  than early adolescence.
• A developmental antecedent to CONDUCT disorder.

55
Nursing Assessment

• Thorough family Hex and background
• Symptomatology data
• Follow DSM-IV Dx criteria and S.S. listed
  under the category of disorder

56
Nursing Dx 1

• Risk for injury R/T impulsive and accident-prone
  behavior and the inability to perceive self-harm.
• Outcome The child will have no physical harm at
  all time.

57
D. TIC DISORDERS

• Types and Features of Tic disorders
• TRANSIENT Motor and or phonic tics.
• CHRONIC Either motor or phonic tics for more
  than 1 year.

58
TOURETTES DISORDER

• Present multiple motor tics and one or more vocal
  tics(APA94).
• They may appear simultaneously or at different
  periods during the illness.
• Causes marked distress or interference with ADL
  and other important functioning.
• Onset before age 18 and is more common in boys.
  Prognosis chronic, lifelong.

59
Internalizing Disorders

• 1. Anxiety Disorders
• 2. Mood Disorders
• 3. Feeding/Eating Disorders
• a) Pica b) Rumination, c) Obesity
• 4. Gender Identity Disorders

60
Internalized D. Anxiety Ds

• Separation anxiety
• Overanxious
• OPD
• PTSD

61
Internalized D. Mood Ds

• Major Depression
• Bipolar D
• Prevalence of Depression in a pediatric
  population
• Presenting problems (S.S. unique to the age
  group)
• Risk of suicide with depression

62
Etiology of Depression among children
adolescents

• Depression in child under 6 usually R/T severe
  neglect or abuse
• Biological /genetic
• Multifactorial environmental issues (family
  dysfunction, poverty, poor parenting)
• Presence of other disorders

63
Risk for suicide

• Prevalence
• Adolescents risk for suicidal thoughts,
  attempts, and completion.
• Factors R/T risk for completing a suicide
• Contagious chain-reaction, being male, subs.
  Abuse, overall poor copying style, high inviorn.
  Stress, impaired comm with adults and peers,
  inconsistent or chaotic family support.

64
Suicide Prevention Strategies

• Early identification of depressive illness
• Identify target population
• Poss contagious chain reaction
• Suicide prevention Enlist the help of others -
  parents, signif. Others, friends
• Model Tx Outpt tx, Inpt tx,

65
Treatment of Depression

• First line of TX is early identification of
  suicidality and prevention.
• Identify and treat substance abuse
• Identify and treat co-morbid problems
• Psychotherapy ind. Family, CBT
• Psychotropic medication management

66
Current Controversy Nursing consideration

• Inadequate pediatric drug trials
• Lack of clarity of child psychopathology
• Limited number of child psychiatry researchers-
  lack of incentives?
• Dramatic increase in use of SSRIs and other
  drugs without FDA approval

67
Rx antidepressant to children with depre illness

• SSRIs ( current controversy) and TCAs
• Inc. suicidality in use of Effexor Paxil.
• Suicidality Classification Project
• FDA hearings on safety of antidepressants
• Psychosocial intervention
• Implications for nursing practice

68
Using SSRIs safely in children and adolescents

• Monitor suicidality (before, during, after)
• R/O bipolar disorder
• Understand start low, go slow tactics minimize SE
• May require taper 1-3 weeks to avoid
  withdrawal/discontinuation syndromes in children
  and adolescents - should know the drug you are
  administering to children

69
Internalized D. cont.

• Feeding/Eating Disorders
• Pica
• Rumination
• Obesity
• Gender Identity disorder

70
Internalized D. cont.

• Elimination Disorders
• Enresis
• Encopresis

71
Psychosocial Tx

• Individual
• Family
• Peer group
• Treatment Settings
• Inpatient Most restricted expensive.
• Residential Tx program
• PHP

72
References Managing depression in child./adoles

• Birmaher et al. 2002. Course outcome of child
  adolescent major depressive disorder. Child
  Adolescent Psychiatric Clinics of North Am. 11,
  619-638
• Brown Univ. (2003). FDA approves fluoxetine for
  pediatric depres., OCD. Brown Univ. Child
  Adoles. Psychopharmacology Update, 5,4.
• Elliott, et at (2003). Depression in the child
  and
• adolescent. Pediatric Clinics of N Am.50,
  1093-106.

73
References cont.

• Kissinger, M.K. 2003. Are antidepressants right
  for kids? Nursing Spectrum (New York-New Jersey
  Metro Edition).15.
• Pfeffer, C.R. 2002. Suicide in mood disordered
  children and adolescents. Child and adolescent
  Psychiatric Clinics of North America, 11.639-48
• Manas-Lammers, L.A. 2002. The challenge of
  childhood depression and ADHD. Journal of the Am.
  Academy of Physician Assistants, 15, 31-4.