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Course: Mental Health Nursing

Topic: Disorders of Infancy, Childhood and Adolescents

The Nurses International Community

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Module Goals

Learners will be able to:

List mental disorders related to infancy, childhood and adolescents.
List the symptoms that are reported by clients.
Identify the clinical manifestations of disorders.
Discuss evidence-based management.
Identify the appropriate nursing interventions.

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Mental Disorders in Early Childhood

Childhood mental and developmental disorders encompass neurodevelopmental, emotional, and behavioral conditions that have broad and serious adverse impacts on psychological and social well-being.

Approximately 17% of all children have a mental disorder in early childhood (up to the age of 6 years).

Von Klitzing, Döhnert, Kroll, & Grube, 2015

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Types of Disorders

Relationship Disorders: Reactive Attachment Disorders.
Feeding Disorders
Disorders of Motor Regulation/ Hyperactivity (Attention Deficit Hyperactivity Disorders, (ADHD).
Affect Disorders: Anxiety and Depression
Oppositional Defiant Disorders (ODD)
Post Traumatic Stress Disorders (PTSD)
Conduct disorder
Autism
Intellectual disability

Von Klitzing, Döhnert, Kroll, & Grube, 2015

CDC, 2021

Scott et al., 2016

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Relationship Disorders: Reactive Attachment Disorders

Prevalence of about 1% in the general population.
Key features

Emotional withdrawal.
Inhibited relationship behaviors.
Indiscriminate.
Disinhibited relationship behaviors.

Risk factors
Mental illness (particularly addiction) in the parents.
The disintegration of the family.
Teenage parenthood, poverty, and transgenerational traumatization.

Von Klitzing, Döhnert, Kroll, & Grube, 2015

Image by, Ph

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Relationship Disorders: Reactive Attachment Disorders

Risk factors

Excessive parental domination, little autonomy for the child.
Lack of parental involvement (insensitivity or neglect).
Abuse toward a small child.
Primary residence in foster home/orphanage.

Von Klitzing, Döhnert, Kroll, & Grube, 2015

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Critical Thinking Question

Which of the following is a risk factor for developing a reactive attachment disorder?

More than five siblings
A multigenerational household
Same-sex parents
Inadequate parental care
A single parent

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Feeding Disorders

Types

Feeding disorder of state regulation

Stagnation or loss of weight
Difficulty maintaining a calm and alert state (sleepy, agitated, or distressed).

Feeding disorder related to relationship with caregiver

Lack of interaction during feeding (caregiver provides no eye contact, smiling, or vocalization).
Complex disturbance of mother-child relationship and failure to thrive.

Von Klitzing, Döhnert, Kroll, & Grube, 2015

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Feeding Disorders

Infantile anorexia

Refusal of food and failure to thrive.
Minimal signs of hunger or interest in food.
Mealtimes are used for exploration and interaction with caregivers rather than for eating.

Sensory food aversions

Avoidance of foods with a particular taste, structure, or smell.
Commonly occurs at the introduction of semisolid food.
Preferred foods eaten without problems.
Nutritional deficits, impaired oral motor function.

Von Klitzing, Döhnert, Kroll, & Grube, 2015

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Feeding Disorders

Feeding disorder associated with a concurrent medical condition

Difficulty finishing meals (presence of heart or lung disease).
Stagnation or loss of weight.

Feeding disorder associated with gastrointestinal insults

Food refusal after single or repeated aversive.
Stimulation of the upper gastrointestinal tract (gagging, vomiting, reflux, cannulation, suction).

Von Klitzing, Döhnert, Kroll, & Grube, 2015

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Critical Thinking Question

In which condition does a child eat preferred food without any problems?

Anorexia nervosa
Sensory food aversion
Feeding disorder with concurrent medical condition
Feeding disorders with gastrointestinal insults

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Disorders of Motor Regulation/ Hyperactivity

Attention Deficit Hyperactivity Disorder (ADHD):

A neurodevelopmental disorder characterized by inattention and disorganization, with or without hyperactivity-impulsivity, causing impairment of functioning.
Have trouble paying attention, controlling impulsive behaviors or being overly active.

Von Klitzing, Döhnert, Kroll, & Grube, 2015

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Disorders of Motor Regulation/ Hyperactivity

ADHD Sign and Symptoms:

A child with ADHD might:

Daydream a lot
Forget or loses things
Squirms or fidgets
Talks too much
Makes careless mistakes or takes unnecessary risks
Has a hard time resisting temptation
Has trouble taking turns
Has difficulty getting along with others

CDC, 2021

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Disorders of Motor Regulation/ Hyperactivity

Causes of ADHD

Genetics
Other possible causes and risk factors

Brain injury
Exposure to environmental risks (e.g., lead) during pregnancy or at a young age
Alcohol and tobacco use during pregnancy
Premature delivery
Low birth weight

CDC, 2021

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Critical Thinking Question

Which of the following is present in a child with ADHD? (Select all that apply)

Inattentive
Organized
Disorganized
Overly active

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Anxiety Disorders

A child does not outgrow the fears and worries that are typical in young children.
Types of anxiety disorders:

Separation Anxiety: Fearful when away from parents.
Phobia: Extreme fear about a specific thing or situation (dogs, insects, thunder, going to the doctor).
Social Anxiety: Afraid of school and masses of people.
General Anxiety: Excessive worry about about bad thing happening in the future.
Panic Disorder:

Repeated episodes of sudden and intense fear with symptoms such as a pounding heart.
Trouble breathing, feeling dizzy, shaky, or sweaty.

CDC, 2021

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Anxiety Disorders

Child may feel feel irritable and angry.

May have trouble sleeping.

Physical symptoms like fatigue, headaches, or stomachaches.

CDC, 2021

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Depression

Persistent sadness and hopelessness.
Behaviors include:

Feeling sad, hopeless, or irritable much of the time
Eating more or eating less
Changes in sleep patterns
Changes in energy (tired and sluggish or tense)
Difficulty paying attention
Self-destructive behavior

Extreme depression that may lead to suicidal ideation.

CDC, 2021

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Oppositional Defiant Disorders (ODD)

Usually starts between 8-12 years of age
Act defiantly around people they know well (family members or a teacher)
Examples of ODD behaviors include:

Often being angry or losing one’s temper
Constantly arguing with adults or refusing to follow rules
Resentful
Deliberately annoying others
Blaming other people for one’s own mistakes

CDC, 2021

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Conduct Disorders (CD)

Diagnosed in children under the age of 18 years.
Characterized by a pattern of antisocial behaviors that violate the basic rights of others.
Examples of CD behaviors include:

Breaking serious rules, such as running away, staying out late.
Being aggressive in a way that causes harm (bullying, fighting, or being cruel).
Lying, stealing, or damaging someone’s property.

CDC, 2021

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Critical Thinking Question

Which behavioral assessment in a child is most consistent with a diagnosis of conduct disorder?

Arguing with adults.
Gross impairment in communication.
Physical aggression toward others.
Refusal to separate from caretaker.

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Post Traumatic Stress Disorders

Some children who experience severe stress will be affected long-term.

Symptoms last longer than one month from such stress, which interferes with their relationships and activities, they may be diagnosed with post-traumatic stress disorder (PTSD).

CDC, 2021

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Post Traumatic Stress Disorders

Examples of PTSD symptoms include:

Reliving the event over and over in thoughts
Nightmares and sleep problems
Lack of positive emotions
Intense ongoing fear
Irritability and angry outbursts
Constantly looking for possible threats
Acting helpless, hopeless, or withdrawn
Avoiding places or people associated with the event

CDC, 2021

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Other Mental Disorder in Children

Autism:

A neurodevelopmental disorder characterized by:

Severe impairment in reciprocal social interactions, communication skills, and the presence of restricted and stereotypical behaviors.

Intellectual disability:

A generalized disorder that is characterized by:

Significantly impaired cognitive functioning and deficits in two or more adaptive behaviors.

Scott et al., 2016

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Risk Factors in Children and Adolescents

Life long:

Natural Disasters
Physical Illness
Malnutrition
Illness
Loss of caregivers
Exposure to Trauma
Genetic background
Toxins

Preconception:

Unwanted pregnancy
Inadequate spacing of children
Adolescent pregnancy
Consanguinity

Scott et al., 2016

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Risk Factors in Children and Adolescents

Prenatal and perinatal:

Inadequate prenatal care
Complications during pregnancy
Maternal cigarette and alcohol use
In utero exposure to pesticides and other toxins
Birth hypoxia and other obstetric complications
Maternal difficulties adapting to pregnancy or arrival of a newborn
Perinatal maternal mortality

Scott et al., 2016

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Risk Factors in Children and Adolescents

Infancy and early childhood

Maternal mental illness
Early emotional deprivation
Inadequate parenting
Developmental and behavioral problems

School-age children

School problems
Maternal mental illness
Bullying, Inadequate parenting
Developmental and behavioral problems
Risk- taking behaviors

Scott et al., 2016

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Risk Factors in Children and Adolescents

Adolescence

Maternal mental illness
Family, peers, or inadequate parenting
Substance abuse
Early sexual activity
Risk-taking behaviors
School problems

Scott et al., 2016

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Critical Thinking Question

Which of the following is considered a risk factor for childhood mental disorders? (Select all that apply)

Genetic vulnerability
Age
Social support
Intact family

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Interventions for Mental and Developmental Disorder

Child and Adolescent Mental Health Policies and Plans.
Child Protection Legislations.

Legislation to address child maltreatment requires the support of well-integrated systems that increase public awareness.

School-Based Interventions

Scott et al., 2016

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Interventions for Mental and Developmental Disorder

Voluntary Sector Programs:

Awareness of the issues faced by children with mental health difficulties and their families, as well as in reducing the associated stigma.

Health Care Platform Interventions

Screening and Community Rehabilitation for Developmental Disorders.

Scott et al., 2016

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Interventions for Childhood Mental and

Developmental Disorder

Parenting Skills Training:

Enhance the parental role through education and training.
Improving emotional and behavioral outcomes for children.
Increasing positive parent-child interactions.

Maternal Mental Health Interventions:

Target maternal mental health problems (perinatal period and early infancy)

Scott et al., 2016

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Interventions

Cognitive Behavioral Therapy (CBT):

Management of anxiety disorders in children.
Teach children to recognize their anxious feelings and the somatic experiences that accompany anxiety.
Identify the anxious thoughts and develop alternative thoughts

Example: positive self-talk and other coping strategies, and evaluate the differences.

Behavioral interventions

Relaxation training, modeling behaviors, and graded exposure to anxiety-provoking stimuli.

Scott et al., 2016

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Interventions

Psychosocial Treatments for Conduct Disorder:

Problem-solving skills therapy:

An individual-based intervention for children and adolescents that focuses on changing the way children interact with the significant others in their lives.

Multisystemic therapy:

Targets adolescents with disruptive behaviors.
Use of various therapies deemed appropriate by individual therapists.

Scott et al., 2016

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Method of Parent-Child Psychotherapy

Interactional guidance (McDonough):

Parent-child interactions are recorded on video, and the parents are then instructed, with the aid of video feedback, how to improve their interactive competence.

Child-centered psychotherapy (“watch, wait, and wonder”) (Cohen):

Mothers are helped, in a non-directive fashion, to open themselves to the opportunities for forming a relationship with their children and to establish interaction with them.

Scott et al., 2016

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Nurse’s Role

History
Assessment of the child
Identification of problems
Set goals
Provide care
Provide education to the child and parents
Reinforces the parent’s role
Facilitate group interactions and healthy behaviors
Participation and organization of the group
Evaluation of the care

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Critical Thinking Question

Which of the following is a common symptom of depression in preschool children?

Vivid dreams
Loss of interest in, and pleasure from play
Onychophagia
Secondary enuresis
Self-injurious behavior, e.g., head-banging

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Red Flags

Be alert to behaviors that may signal emotional needs

Feeling sad, hopeless, or irritable much of the time
Eating a lot or a lot less
Changes in sleep patterns
Changes in energy (tired and sluggish or tense)
Having a hard time paying attention
Self-destructive behavior

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Cultural Considerations

Cultures have differing practices with regard to child rearing. This may include types of punishment, expectations in school and in social situations. Certain emotions may be frowned upon in some cultures and encouraged in others.

The nurse should practice evidence based transcultural care.

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References:

Centers for Disease Control and Prevention (CDC). (2021). Children’s Mental Disorders. https://www.cdc.gov/childrensmentalhealth/symptoms.html

Centers for Disease Control and Prevention (CDC), (2021). Anxiety and Depression in Children. https://www.cdc.gov/childrensmentalhealth/depression.html#anxiety

Centers for Disease Control and Prevention (CDC), (2021). Behavior or Conduct Problems in Children. https://www.cdc.gov/childrensmentalhealth/behavior.html#defiant

Centers for Disease Control and Prevention (CDC). (2021). What is ADHD? https://www.cdc.gov/ncbddd/adhd/facts.html

Centers for Disease Control and Prevention (CDC). (2021). Post-traumatic Stress Disorder in Children. https://www.cdc.gov/childrensmentalhealth/ptsd.html

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References:

Centers for Disease Control and Prevention (CDC), (2021). Children’s Mental Disorders. https://www.cdc.gov/childrensmentalhealth/symptoms.html

Von Klitzing, K., Döhnert, M., Kroll, M., & Grube, M. (2015). Mental Disorders in Early Childhood. Deutsches Arzteblatt international, 112(21-22), 375–386. https://doi.org/10.3238/arztebl.2015.0375 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4496484/

Scott JG, Mihalopoulos C, Erskine HE, et al. Childhood Mental and Developmental Disorders. In: Patel V, Chisholm D, Dua T, et al., editors. Mental, Neurological, and Substance Use Disorders: Disease Control Priorities, Third Edition (Volume 4). Washington (DC): The International Bank for Reconstruction and Development / The World Bank; 2016 Mar 14. Chapter 8. Available from: https://www.ncbi.nlm.nih.gov/books/NBK361938/ doi 10.1596/978-1-4648-0426-7_ch8, https://www.ncbi.nlm.nih.gov/books/NBK361938/

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