Childhood and Adolescent

Psychiatric Disorders
 Epidemiology
 1 in 5 children & adolescents in U.S. suffer
from major psychiatric disorder
 15-30% prevalence rate for depression in

adolescents
 Suicide is 3rd leading cause of death, ages

15-24
 Suicide is 6th leading cause of death, ages 5-

15
 Lack of mental health providers for these age

groups; premature termination of treatment

 Comorbidities

 ADHD occurs in 90% of juvenile-onset bipolar

disorder; 90% oppositional defiant disorder;
50% with conduct disorder
 Childhood depression: increased comorbidity

with anxiety disorders, ADHD, oppositional

defiant disorders, and conduct disorders
 Learning disabilities
 Risk Factors
 Neglect and abuse
 Genetic link
 Parental dysfunction
 Children witnessing violence in the home,

community
 Bullying
 Poverty
 Exposure to alcohol and drugs
 Lead exposure
 Psychosocial Adversity
 Parent with history of substance abuse or
psychiatric disorder
 Sexual, physical, emotional abuse
 Family discord
 Not all children exposed to psychosocial

trauma develop a psychiatric disorder

 Foster-care placement
 Parental criminality
 Overcrowding, poverty
 Family Systems

 Rules, cultural practices, rituals,

communication patterns have an impact on
the child’s development
 Child’s developmental patterns can influence

the family system and vice versa

 Instability v. stability
 Resilience

 Adaptability to changes in environment

 Ability to form nurturing relationships with

other adults
 Ability to distance oneself from emotional

chaos
 Effective social skills
 Problem-solving abilities
Neurodevelopmental Disorders
 Intellectual disability: deficits in:
1. intellectual functions
2. adaptive functioning, performance skills
3. onset occurs during developmental stages,

prior to age 18
4. functional deficits in conceptual, practical,
and social domains
 Autism Spectrum Disorder
 Specific deficits in social communication and
social interaction manifested by:
1. deficits in social-emotional behaviors
2. deficits in nonverbal communication
behaviors used for social interaction (eye contact,
body language)
3. deficits in developing and maintaining
relationships
4. Severity is based on social communication
impairments and restricted, repetitive patterns of
behavior
 Asperger’s Disorder
 Now included in autism spectrum disorder
 No significant delays in cognitive & language

development, age-appropriate skills

 Etiology unknown
 Common in males, familial link with high

occurrence in fathers
 Social deficits, aversion to touch
 Restricted & repetitive patterns of behavior &

idiosyncratic interests (obsessive-compulsive

 traits)
 Nursing Diagnoses for Autism
Spectrum Disorder

 Examples:

 Risk for self-mutilation

 Impaired social interaction
 Impaired verbal communication
 Disturbed personal identity
 See care plan in Townsend text, p. 740-741)
Pharmacological Interventions
 FDA approved medications:
 Risperidone (Risperdal), 5-16 years of age
 Aripiprazole (Abilify), 6-17 years of age
 Specific behaviors: aggression, deliberate self-

injury, temper tantrums, mood lability

 Dosage is based on the weight of the child and the

clinical response.
 Risperdal: 2.5mg daily (15-45 kg)

3.5mg daily (>45 kg)

Abilify: 2.0mg daily; no more than 15mg
daily
 Attention –Deficit/Hyperactivity
Disorder (ADHD)
 More common in males (3:1); prior to age 12
 DSM 5 criteria: 6 or more symptoms persist for

at least 6 months with maladaptive behaviors:

1. Inattention

2. Hyperactivity and impulsivity

3. Intrusive behavior

4. Difficulty waiting one’s turn

5. Talks excessively

6. Inattention to social cues

7. Fidgeting, climbing, unable to sit still

 ADHD
9. Avoids, dislikes, reluctant to engage in tasks
requiring sustained mental effort
10. Does not follow through on instructions
11. Difficulty organizing tasks and activities
12. Loses important items
13. Easily distracted by extraneous stimuli
14. Forgetful in daily activities
15. “On the go,” “Driven by a motor”
 ADHD
 Occurrence in 9% of school-age children
(CDC)
 80% genetic imbalance of catecholamine

metabolism in cerebral cortex

 Deficits in prefrontal cortex (response

inhibition area)
 Dietary factors: sugar, food additives, food

allergies
 Lead poisoning
 Fetal alcohol syndrome, maternal smoking
 ADHD
 DNA sequencing: abnormal regulation of
dopamine transport gene and dopamine
receptor resulting in abnormal dopamine
transmission
 Effective treatments involve dopamine and

norepinephrine to improve executive

functioning; regulation of arousal for
improved performance
 Ritalin increases extracellular levels of

dopamine
 Areas of Brain Affected
 Prefrontal cortex: maintains attention,
organization, executive function; modulates
behavior inhibition
 Basal ganglia: regulates movements;

interruption can cause inattention and

impulsive behavior
 Hippocampus: learning and memory
 Limbic system: regulation of emotions
 Reticular activating system: center of arousal

and motivation
 Assessment of ADHD

 Comprehensive testing:
1. Medical, social, family histories
2. Developmental stages
3. Educational progress
4. Psychosocial impairment
5. Diagnosis of primary psychiatric disorders
6. Neurological testing
Stimulants: Use in the Treatment of
ADHD
 Block dopamine and norepinephrine reuptake
with increasing catecholamine release
 Decrease fatigue, enhance wakefulness,

mood elevation, increase in speech/motor

activity, stimulate respiratory center, depress
appetite
 Considered first-line therapy
 Potential for chronic abuse
 Stimulants
 Methylphenidate (Ritalin): most common
agent: short, intermediate, and long-acting
dosing; Methylin ER, Concerta
 Dexmethyphenidate (Focalin): short and

long-acting (Focalin XR)

 Mixed amphetamine salts (Adderall): short

and long-acting (Adderall XR)

 Dextroamphetamine (Dexedrine, Dextrostat):

short and intermediate acting

 Lisdexamfetamine (Vyvanse): once daily
Adverse Effects of CNS Stimulants
 Can exacerbate bipolar/psychotic conditions
 Can cause sudden death from undiagnosed

cardiac conditions
 Can inhibit or decrease growth of about

1cm/year along with weight loss of 3kg/year

 Monitor growth patterns; use drug holidays

during the time periods when school is not in

session
 G.I. s/s; headache; irritability; abnormal

movements; hypertension; psychosis

(hallucinations); anxiety; dependence
 Non-Stimulants for ADHD
 Atomoxetine (Strattera): SNRI – only increases
norepinephrine; effective in clients with
anxiety, insomnia, substance use disorders;
less growth suppression; takes 2-4 weeks to
work; black box warning for severe liver
injury and suicidal behavior
 Antipsychotics are used to control aggression

or explosive behaviors.
 Non-Stimulants
 Bupropion (Wellbutrin): weak dopamine and
norepinephrine inhibitor; less toxicity in overdose;
less appetite suppression; contraindicated in
seizure disorders; can cause a rash and nausea
 Tricyclic antidepressants (TCAs): imipramine,

desipramine, nortriptyline
 Clonidine (Catapres) & guanfacine (Intuniv, Tenex):

alpha-2-adrenergic agonists: reduce sympathetic

outflow from central nervous system: palpitations,
bradycardia, constipation, dry mouth, sedation are
potential side effects
 Nursing Diagnoses for ADHD
 Examples:

 Risk for injury

 Impaired social interaction
 Low self-esteem
 Noncompliance (with task expectations)
 See care plan in Townsend text, p. 746-748
Oppositional Defiant Disorder
 Pattern of angry/irritable mood,
argumentative/defiant behavior, or
vindictiveness lasting at least 6 months as
evidenced by at least 4 symptoms, and
exhibited during an interaction with a person
who is not a sibling
 Behaviors cause significant functional

impairment in home, social relationships,

school (APA, 2013)
Oppositional Defiant Disorder
 Usually evident by 8 years of age: behaviors
can be evident at 10-11 months
 Common in males until puberty; equal

numbers male/female after puberty

 Behaviors should be outside of the normative

developmental range
 Substantial overlap with ADHD
 Associated with anxiety and mood disorders
 Nursing Diagnoses
 Examples:

 Defensive coping
 Noncompliance
 Low self-esteem
 Impaired social interaction
 See care plan in Townsend text, p. 756-758
 Conduct Disorder
 Characterized by more serious violations of
social standards (aggression, vandalism,
cruelty to animals, stealing, lying, truancy)
 Persistent behaviors violate the rights of

others and societal norms (APA, 2013)

 Associated with anxiety, depression, ADHD,

learning disabilities, substance abuse

 Onset: more males; before age 10
 Adolescent onset: more females become

aggressive & act out with peer group

 Conduct Disorder
 At least 3 criteria in the past 12 months:
1. Aggression to people and animals
2. Destruction of property
3. Deceitfulness or theft
4. Serious violations of rules

Direct correlation to later diagnosis of

antisocial personality disorder.
 Nursing Diagnoses
 Examples:

 Risk for other-directed violence

 Impaired social interaction
 Defensive coping
 Low self-esteem
 See care plan in Townsend text, p. 761-762
Intermittent Explosive Disorder
 Recurrent behavioral outbursts representing a
failure to control aggressive impulses as
manifested by either of the following:
 1. Verbal aggression twice weekly for 3

months
 2. Three outbursts involving damage or

destruction of property and/or physical

assault involving injury against animals or
individuals occurring within a 12-month time
period
Intermittent Explosive Disorder
 3. Aggressiveness is grossly out of proportion
to the provocation or psychosocial triggers
 4. Outbursts are not premeditated, but

impulsive, without trying to achieve an

objective
 5. Outbursts cause marked distress in the

person, impairment in functioning, and

associated with financial/legal consequences
 6. Chronological age is at least 6 years
 7. Rule out other disorders
 Nursing Diagnoses
 Examples:

 Risk for injury

 Risk for other-directed violence
 Ineffective coping
 Low self-esteem
 Separation Anxiety Disorder

 Excessive distress when separated from or

anticipates separation from home or parental
figure
 Excessive worries of getting lost, being

kidnapped, harm to parents, damage to home

 Fear of being home alone or in situations

without significant adults

 Separation Anxiety Disorder
 Refusal to sleep unless near a parental figure,
or refusal to sleep away from home
 Refusal to attend school or other activities

without parental figure

 Exhibits physical signs and symptoms of

anxiety
 Diagnosed around age 5 or 6
 Depression accompanies anxiety
 Genetic and environmental factors;

temperament; stressful life events

 Nursing Diagnoses
 Examples:

 Anxiety (severe)
 Ineffective coping
 Impaired social interaction
 See care plan in Townsend text, p. 765-766
 Obsessive-Compulsive Disorder
 Can be identified in children as young as 5 years
of age
 2-3% of adolescents
 Attempts to resist ritualized behaviors typically
increase anxiety and intensify the urge to
perform the compulsion
 Common obsessions in children and adolescents
include the fear of harm to self or family;
contamination; worry about acting on unwanted
aggressive impulses; concern about order
 OCD
 Common compulsions: hand washing,
cleaning rituals, ordering and arranging of
objects, checking
 Behavior interferes with daily activities at

least 1 hour per day

 Young children may not be able to articulate

the aims of these behaviors

 Associated with anxiety disorders,

depression, dysthymia
 Nursing Diagnoses
 Examples:

 Ineffective coping
 Anxiety
 Disturbed body image
 Major Depressive Disorder
 Children might be less able to verbalize their
feelings and exhibit increased irritability
 Males at slightly higher risk in younger age

groups; more common in females in

adolescence
 Apathy, anger, sadness, crying, isolation,

risky behaviors, suicidal gestures

 Bipolar Disorder
 Difficulty differentiating between ADHD and
bipolar disorder in children and adolescents
 Children who exhibit mania are significantly

impaired between manic episodes

 Mood instability, impulsive behaviors,

hyperactivity
 Approximately 4-6% of adolescents present with

core symptoms
 Less likely than adults to experience psychosis;

hallucinations more common than delusions if

psychosis occurs
 Adjustment Disorder
 Emotional responses to an identifiable stressor
that do not meet criteria for DSM 5 psychiatric
disorders.
 Begins within 3 months of the stressor and
lasts no longer than 6 months after the stressor
has ended.
 Impairs school performance and social
relationships.
 Usually does not require hospitalization
 Symptoms include anxiety and depressed mood
 Tourette’s Disorder
 Multiple motor tics and one or more vocal tics
that have persisted for more than one year
 Average age of onset before 18 years
 More prevalent in boys: 3-to-8 per 1000
 Inherited developmental disorder of

neurotransmission, structural brain

dysfunction, environmental factors
 Duration may be lifelong; periods of

remission; symptoms can resolve

 Tourette’s Disorder
 Motor tics: usually involve the head, but can
involve the torso and limbs
 Motor tics can change in location, frequency,

and severity over time (tongue protrusion,

touching, squatting, hopping, skipping,
twirling, retracing steps)
 Vocal tics: spontaneous production of words

and sounds.
 Rule out physiological effects of a substance

(cocaine) or another medical condition.

 Tourette’s Disorder
 Palilalia: repeating one’s own sounds or
words.
 Echolalia: repeating what others say.
 Coprolalia: uttering of obscenities; occurs in

less than 10% of cases.

 Corpropraxis: obscene gestures.
 Associated with depression, OCD, ADHD.
 CNS stimulants increase severity of tics.
 Nursing Diagnoses for Tourette’s
Disorder
 Examples:

 Risk for self-directed or other-directed

violence
 Impaired social interaction
 Low self-esteem
 See care plan in Townsend text, p. 752-753
 Medications Used for Tourette’s
Disorder
 Typical antipsychotics: haloperidol (Haldol) &
pimozide (Orap): suppress motor and vocal
tics by blocking D2 receptors
 Atypical antipsychotics: risperidone

(Risperdal), olanzapine (Zyprexa), ziprasidone

(Geodon): lower incidence of EPSEs
 Alpha agonists: clonidine (Catapres) &

guanfacine (Tenex, Intuniv): help with

symptoms of anxiety and insomnia
 Nursing Assessment Data for Child
and Adolescent Disorders
 Developmental and functional levels: any
impairments due to biological, psychosocial,
spiritual factors; ability to cope with stressors
and developmental tasks; ability to bond with
others in a mutually satisfying way
 History of present illness
 Developmental history: pregnancy, birth,

neonatal data; milestones; eating; sleeping;

elimination patterns
 Assessment Data
 Attachment behaviors
 Play activity
 Social and interpersonal skills
 Psychomotor language
 Cognitive skills
 Academic achievements
 Response to stress and changes in
environment
 Problem-solving and coping skills
 Energy level and motivation
 Assessment Data

 Risk Behaviors
 Neuropsychological assessment
 Medical history of family, child illnesses
 Substance use/abuse; addiction
 Mental status exam
 Problems with thinking, feeling, behaving
 Suicide Risk Assessment
 Major predictor: past/current suicide attempt
 Past suicidal thoughts, threats, attempts
 Existence of a plan
 Lethality of a plan
 Accessibility of methods for carrying out a

plan
 Changes in levels of energy
 Feelings of hopelessness, helplessness
 Circumstances, state of mind, motivation
 Suicide Risk Assessment
 Viewpoints about suicide and death
 Family/friends history of suicide
 Depression, anger, guilt, rejection
 Impulsive behaviors, poor judgment, poor

decision-making abilities
 Substance abuse
 Prescribed meds, adherence issues
 Changes in appetite, sleep, social

relationships, isolation
 Suicide Risk Assessment
 Preoccupation with morbid themes, music,
film, books, websites
 Early intervention is essential
 Cutting, reckless driving, binge drinking must

be taken seriously and evaluated by a mental

health specialist
 Interview child/adolescent/teen in his or her

native language to fully understand problems

 Interventions
 Individual and family therapy
 Group therapy
 Medications
 Milieu management
 Cognitive behavioral therapy
 Play therapy
 Storytelling
 Therapeutic games
 Art and music therapy
 Nursing Interventions
 Develop a trusting relationship
 Convey acceptance
 Identify which behaviors are acceptable and

not acceptable
 Assist to verbalize positive aspects of self
 Observe behavior through routine activities
 Monitor for self-destructive behavior
 Redirect violent behavior with physical outlets

for frustration
 Nursing Interventions
 1:1 time with assigned nurse
 Assure client of safety
 Assist client to establish and meet small
personal goals
 Attend groups with the client
 Set clear expectations and set limits as needed
 Help client to recognize triggers and work on
developing realistic coping strategies
 Establish a well-constructed discharge plan for
the client and family