Child and Youth Mental Health & Illness Key Concepts PDF

Objectives Describe Foundational aspects of the screening, assessment, treatment planning approaches for mental health conditions affecting children, youth, and older adults Introduce Developmental considerations for mental health promotion for children/youth and older adults Examine Mental hea...

Objectives Describe Foundational aspects of the screening, assessment, treatment planning approaches for mental health conditions affecting children, youth, and older adults Introduce Developmental considerations for mental health promotion for children/youth and older adults Examine Mental health conditions in the context of children/youth and older adults Child & Youth Mental Health & Illness Key Concepts 7 Discussion For children & youth what are key factors that promote mental health? Key Factors that Promote Mental Health for Children & Youth Positive Adult Relationships Secure Attachment Supportive Home/School/Community Environment General Health (nutrition, safety, security, social and physical development) Supportive Social Networks Positive Childhood & Adolescent Experiences How does racism, poverty, social justice issues, colonization, systemic inequities impact these factors? What are examples? “It Takes a Whole Village to Raise a Child” Nigerian Proverb Community • Connected and positive community environments • Social support and connection Families & Siblings • Important role as protectors, nurturers, mediators, mentors for surviving & thriving Secure Attachment • Bond between parent/guardian begins in infancy • When secure allows child to explore the world without fear of rejection 10 Discussion How and in what ways has the Pandemic Affected the Mental Health of Children & Youth? Common Childhood Challenges/Stressors • Attachment – disrupted • Grief - Loss/Death • Family Separation/Divorce • Sibling relationships • Physical illness • Adolescent risk-taking behaviours 12 Grief & Loss in Childhood Key Points Grief and loss are common types of stress for children and adolescents Subjective experience that accompanies the perception of loss. (Death of family member, moving schools, transitions in relationships) Children respond to loss and grief based on their developmental stage**** Learning to mourn losses can lead to renewed appreciation of value of relationships 13 Grief and Loss Developmental Considerations Preschool aged • React more to parents’ distress • Need reassurance • Avoid euphemisms (e.g., “he went to sleep”) School aged • Express grief through somatic complaints, regression, behaviour problems, withdrawal, hostility • May experience complicated grief Adolescents • May have an idealized/romantic idea of death • If a parent is dead, may assume parental role Physical Illness Perception of an event will influence the family’s ability to cope. Chronic physical illness is linked to emotional/behavioural problems. Common childhood reactions include: • • • • • Regression Sleep and feeding difficulties Behaviour problems Somatic complaints Depression Protective Factors Individual attributes, such as problem-solving skills, sense of self-efficacy, accurate processing of interpersonal cues, positive social orientation, and self-regulation A supportive family environment, including attachment with adults in the family, Sibling relationships, low family conflict, and supportive relationships Environmental supports, including those that reinforce and support coping efforts and recognize and reward competence 16 Risk Factors for Poor Mental Health • • • • Poverty and homelessness § 14% of children in Canada live in poverty. § Recent immigrant families had a lowincome rate of 39.3%. • A national study found that, in 2009, an estimated 29,964 youth (ages 16 to 24 years) and 9,459 children (under the age of 16 years) stayed in emergency shelters across the country Child abuse and neglect (Table 29-3) Children in care (Box 29-3) Children with parents who are struggling with substance use disorders or mental illnesses. 17 Adolescent Risk-Taking Behaviours • Many adolescents experiment with risk-taking behaviours, such as smoking, alcohol, unprotected sex, truancy or delinquent behaviours, and running away. • LGBTQ+ youth face additional challenges of stigma, exclusion, and anxiety • Interventions: • Intervene at peer level, educational programmes, peer counselling, alternative recreation activities 18 Promotion & Prevention Intervention Approaches Individual level Mental health promotion Psychoeducation Community Level Systems Level Social skills training Bibliotherapy 19 Mental Illness Among Children and Adolescents The Mental Health Commission of Canada (MHCC) estimates that 1.2 million children and youth are affected by mental illness in our country. Over 800,000 Canadian children and youth experience significant mental health issues. For Canadians aged between 15 and 34, suicide is the leading nonaccidental cause of death. * Indigenous youth experience higher rates 20 Indigenous Youth Experience of Suicide in Rural Community https://youtu.be/xiAZ_3T _5hQ Psychiatric Disorders in Children/Adolescents Schizophrenia spectrum and other psychotic disorders •Most often substance induced or Brief Psychotic Disorder Bipolar and related disorders Depressive disorders Anxiety disorders Obsessive–compulsive disorders Trauma- and stressor-related disorders Neurodevelopment disorders of childhood Disruptive, impulse control, and conduct disorders Motor disorders Elimination disorders 22 Schizophrenia Spectrum and other Psychotic Disorders Schizophrenia: • Onset often in early adolescence as prodrome or first episode onset Brief psychotic disorder Treatment • Related to substance use or other unknown cause or illness • Anti-psychotic medications (2nd generation atypical ie. Olanzapine, Risperidone) • Symptom management • Psychosocial Supports and Counselling Bipolar and Related Disorders • First presents during adolescence • Symptoms include periods of mania (extreme optimism, euphoria, and feelings of grandeur; rapid, racing thoughts and hyperactivity; a decreased need for sleep; increased irritability; impulsiveness and possibly reckless behaviour; and alternate periods of depression) • Treatment intervention: • lithium carbonate, mood stabilizers (carbamazepine) 24 Depressive Disorders • Major depressive disorder • Disruptive mood dysregulation disorder • Treatment interventions Cognitive–behavioural therapy (CBT) • Mindfulness • • Nursing care: ruling out concerns of suicidality 25 Anxiety Disorders The most prevalent mental illness in Canadian children between 4 and 17 years of age Assessment: Does the child: q Often seemed worried? q Consistently avoid age-appropriate situations or activities? q Have frequent episodes of stomach aches, headaches, or hyperventilation? q Have daily repetitive rituals? 26 Generalized Anxiety Disorder • Characterized by excessive anxiety and worry about many events or activities. • GAD affects an estimated 1 out of 150 school-aged children in Canada. • Risk for developing GAD includes a genetic predisposition. • Psychodynamic theory and cognitive–behavioural theory. • Treatment interventions: • CBT • Pharmacotherapy 27 Separation Anxiety Disorder • Manifested by excessive anxiety on separation from home or a major attachment figure before adulthood. • Includes school phobia • The prevalence of separation anxiety disorder is estimated at 4% of schoolaged children. • Both environmental and genetic factors affect the risk for separation anxiety disorder: • Treatment interventions: • Individual psychotherapy, behavioural treatment, and pharmacotherapy 28 Trauma- and Stressor-Related Disorders • It is well documented that early chronic stress or trauma affects how the developing brain grows and evolves • Causes: • Physically or emotionally absent parent • Erratic or inconsistent caregiving • Abuse • Neglect • Violence in the home or community • War or disasters 29 Child Abuse • Duty to report in cases where there is report of neglect, physical, or sexual abuse of child. • Are the child's immediate circumstances unsafe? Does the child have to be taken into care or removed to a safe place? • For current cases, what is the assessed risk of repeat abuse? What are the issues that merit intervention on a priority basis? • For ongoing cases, to what extent are interventions working? What is the current situation of the child, the family, and any substitute care arrangement? 30 Reactive Attachment Disorder • Typically identified prior to the age of 5 years • Four types: • Secure; insecure avoidant; insecure ambivalent/resistant; and disorganized • May experience lifelong struggle with relationships 31 Disinhibited Social Engagement Disorder • Blatant disregard of social inhibition when approaching strangers verbally and physically. • The prevalence of this disorder remains unknown; however, in high-risk populations, the incidence is about 20% of children. • Causes similar to RAD. 32 Neurodevelopmental Disorders of Childhood • Significant developmental delays or deficits in one or more of following areas: • Attention, cognition, language, affect, or social and moral behaviours • Developmental delay is the development of a child that is outside the norm, including delayed socialization, communication, peculiar mannerisms, and idiosyncratic interests. 33 Autism Spectrum Disorder (ASD) • Delayed and divergent language development, echolalia, and a tendency to be extremely concrete in the interpretation of language • Stereotypic behaviour • Self-injurious behaviour • May or may not have an intellectual disability but commonly show an uneven pattern of intellectual strengths and weaknesses. • Nursing care: positive relationship with child and family • Connection to assessment, early intervention support services 34 Continuum of Care for ASD • Promoting interaction • Ensuring predictability and safety • Self-care • Supporting family • Support groups 35 Specific Learning Disorders and Communication Disorders Specific learning disorders Communication disorders • Are among the most common neurodevelopmental disorders in children and are defined as difficulties in learning and using academic skills • Interventions focus on building self-confidence and family support • Involve deficits in speech, language, and communication. • Interventions focus on fostering social and communication skills, identifying and addressing low self-esteem, and making referrals for specific speech or language therapy. Attention Deficit Hyperactivity Disorder • Associated with functional impairments such as school challenges, peer problems, and family conflict. • Treatment interventions • Psychoeducation for the child and family • Behavioural and/or occupational interventions for the child • Individual and family support, counselling, and therapy • School accommodations • Medication management 37 Motor Disorders: Tourette’s Disorder • Motor disorders include developmental coordination disorder, stereotypic movement disorder, and tic disorders. • Epidemiology • The prevalence of Tourette's disorder is estimated to be from 3 to 8 per 1,000 in school-aged children, with boys being affected more than girls at a 2:1 to 4:1 ratio. • Treatment interventions • Behaviour therapy and the alpha-2-adrenergic antagonists are the first line of therapy for children with tic disorders. 38 Elimination Disorders • Enuresis • • • Involuntary or intentional voiding of urine in inappropriate places. • At night (nocturnal) or during the day (diurnal) or both. The DSM-5 specifies bedwetting occurs: • At least twice per week for a duration of 3 months. • Child is at least 5 years of age. • Behaviour cannot be attributed to a medication side effect or to another medical condition. Treatment: • Behavioural interventions • Pharmacotherapy 39 Mental Health Assessment of Children and Youth Assessment: Psychological Domain • • • • • • • • Mental status Developmental assessment Psychosocial development Language Attachment Temperament and behaviour Self-concept Maturation 41 Interviewing Techniques • Interview the child and parent separately. • Approach should be developmentally and age appropriate • Children provide better information about internalizing symptoms (mood, sleep, suicide ideation). • Parents provide better information about externalizing symptoms (behaviour, relationships). 42 Approach to Interview informed by Developmental Stage Pre-School Children • Have difficulty putting feelings into words, thinking concrete • Use play; conduct assessment in playroom. School Aged Children • Able to use constructs, provide longer explanations • Establish rapport through competitive games. Adolescents • Ego-centric orientation, increased self-consciousness, fear of being shamed • Let them know what information will be shared with parents. Direct, candid approach. 43 Older Adult Mental Health Promotion & Assessment Late Adulthood Young-old: 65 to 74 years. Middle-old: 75 to 84 years. Old-old: 85 years and older. Nurses need to understand and respond well to the unique needs of this population. Changes With Aging • Aging is a gradual bio/psycho/social/spiritual process that may be viewed as both positive and negative. • Can lead to a loss of independence. • Friendships change, and losses occur. • • Many are faced with establishing new meaning in life. To have a sense of meaning and purpose is a critical factor in older adults’ mental health. • A protection against suicide and despair Box 31-1 46 Social Domain • • Functional status may decrease Retirement: • • • • • • Can lead to alterations in selfconcept Cultural impact Social activities change Added strains Residential care Assisted living 47 Social Support Transitions Lifestyle support. Developing regular exercise habits can help maintain physical and psychological well-being. Exercise promotion and nutrition counselling Community & Social Connection Spiritual Domain Spiritual needs are basic for all age groups and are requirements for establishing meaning and purpose, love and relatedness, and forgiveness. There is growing evidence of the significance that spirituality plays in successful aging. The process of spiritual assessment involves active listening, thoughtful observing, and sensitive questioning. Aging and Sexual Health • Healthy aging is an ongoing process of adaptation across the four primary bio/psycho/social/spiritual domains. • Sexual health serves as a good illustration. • Desire for intimacy does not go away. • Practicing safe sex is as important for older persons as for younger persons. • Some physical illnesses, disabilities, and medications can cause sexual problems. 50 Risk Factors for Geriatric Psychopathology • Chronic illness • Polypharmacy • Beers criteria • There is an increased risk of drug interactions because of polypharmacy in the elderly. • Bereavement and loss • Poverty • Suicide and the lack of social support • Linked to the rate of suicide in older adults 51 Bereavement and Loss • Older adults experience many losses. • Survivors are at higher risk for depression. • Facilitating meaningful engagement and connectedness can help older persons feel supported and understand that they are not alone. 52 Poverty • Older adults (particularly women) can be at higher risk for poverty than other age groups. • Poverty may result from: • Inadequate retirement income • Illness, discrimination against women in pension plans • Financial exploitation of older individuals 53 Suicide and the Lack of Social Support • Suicide is a leading cause of preventable death in Canada and worldwide. • More than 10 older adults over the age of 60 die by suicide every week in Canada, and “approximately 1,000 are admitted to Canadian hospitals each year as a consequence of intentional self-harm.” • Hanging and firearms are the most common method of suicide for men, while women tend to use self-poisoning or suffocation. • A lack of social support has been linked to the rate of suicide in older adults. 54 Mental Illness Prevention and Promotion • Preventing depression and suicide • Recognition and early intervention are the keys. • Reducing the stigma of mental health treatment • Work of the MHCC has recognized the critical importance of combating stigma and discrimination. • Use of medications • New medications helpful • Avoiding premature institutionalization 55 Mental Health Assessment of the Older Adult • Intellectual function, capacity for change, and productive engagement with life remain stable in the older adult. • As the population ages, there will be increased numbers of seniors with mental health illnesses and problems. • Mental health problems in older adults can be especially complex because of coexisting medical problems and treatments. • A mental health assessment is necessary when psychiatric or mental health issues are identified or when clients with mental illnesses reach their later years. 56 Mental Status Exam Appearance Dress appropriate to weather and season Behaviour Calm, vs agitated, etc. Mood & Affect Mood – as described by person Affect – Facial expression of emotion Speech Clear, coherent Thought Process Logical, organized vs disorganized, tangential Thought Content Logical and organized, goal directed vs. paranoid Perceptions No perceptual disturbances vs auditory hallucinations, visual hallucinations Cognition Memory,attention, Cognitive abilities, Orientation to Person, place, date, Time Insight Awareness of self and current health status Judgement Good judgment vs poor judgement 57 Neuro-Cognitive Disorders Key Concepts Cognition Memory • The ability to think and know; a relatively high level of intellectual processing in which perceptions and information are acquired, used, or manipulated • Facet of cognition; ability to recall or reproduce what has been learned or experienced Delirium • Acute cognitive impairment caused by medical condition Dementia • Chronic, cognitive impairment • Differentiated by cause, not symptoms Delirium: Clinical Course Fluctuating consciousness and attention with reduced ability to focus, sustain, or shift attention Marked by a decline in cognitive function Develops over a short period of time Usually reversible if underlying cause identified Serious, should be treated as an emergency Delirium: Diagnostic Criteria • Impairment in consciousness—key diagnostic criteria • Children—can be related to medications, endocrine–metabolic issues, or fever • Older adults—most common in this group, often mistaken as dementia • Postoperative delirium 61 Delirium: Epidemiology and Risk Factors • • • • • • Prevalence rates from 10% to 30% of patients In nursing homes, prevalence reaching 60% of those older than age 75 Occurs in 30% of hospitalized cancer patients 30% to 40% of those hospitalized with AIDS Higher for women than for men Common in elderly, postsurgical patients • Risk factors • Table 32-1 62 Delirium: Aetiology #1 Complex and usually multifaceted Most commonly identified causes: • • • • Medications, infections Fluid and electrolyte imbalances Advanced age, brain damage, dementia Sensory overload or underload, immobilization, sleep deprivation and psychosocial stress Dementia: Alzheimer’s Type • Degenerative, progressive neuropsychiatric disorder that results in cognitive impairment, emotional and behavioural changes, physical and functional decline, and ultimately death • Types • Early onset (65 years and younger) • Rapid progression • Late onset (over 65) • Stages: early, middle, late • Table 32-3 64 Diagnosis of Alzheimer Dementia Essential feature—multiple cognitive deficits and cognitive impairment Criteria include cognitive and/or behavioural symptoms that: • • • • • Interfere with the ability to function at work or at usual activities Represent a decline from previous levels of functioning and performing Are not related to delirium or a major psychiatric disorder Table 32-4 Box 32-5 Epidemiology • Age is the most acknowledged risk factor for developing AD. • It is estimated that dementia affects 1 in 14 people over the age of 65 and 1 in 6 over the age of 80. • Females are at higher risk, even discounting the fact that they tend to live longer. 66 Aetiology • Neuritic plaques (extracellular lesions) • β-Amyloid plaques • Alpha-synuclein • Neurofibrillary tangles • Oxidative stress and the role of antioxidants • Inflammation • Genetic factors 67 Priority Care Issues • Priorities will change throughout the course of the disorder. • Initially, delay cognitive decline. • Later, protect the patient from hurting him/herself. • Later, physical needs become the focus of care. 68 Pharmacologic Interventions • Cholinesterase inhibitors • Aricept (donepezil) • Exelon (rivastigmine) • Reminyl (galantamine) • N-methyl-D-aspartate antagonists • Antipsychotic agents • Antidepressant agents and mood stabilizers • Antianxiety medications (sedative–hypnotics) • Other medications 69 Dementia: Psychological—Nursing Interventions • Therapeutic relationship • Interventions for cognitive impairment Validation therapy • Memory enhancement • Orientation • Maintenance of language functions • Supporting visuospatial functioning • Interventions for psychosis • Management of suspicious, illusions, delusions • Management of hallucinations • 70 Dementia: Psychological—Nursing Interventions • Interventions for alterations in mood • Management of depression (do not force activities, but encourage them) • Management of anxiety by helping the patient deal with stress • Management of catastrophic reactions, minimizing environment distractions, speaking slowly, being reassuring 71 Dementia: Psychological—Nursing Interventions • Interventions for behaviour problems • Managing apathy and withdrawal: do not interrupt wandering behaviour, but identify pattern. • Determine if he or she is confused and cannot find way; walk with the patient, and then redirect. • Managing aberrant behaviour. • Reducing disinhibition. 72 Other Major Dementias • • • • Vascular neurocognitive disorder NCD (dementia) with Lewy’s bodies NCD (dementia) due to Parkinson’s disease Dementia caused by other general medical conditions: • NCD (dementia) caused by HIV infection • NCD (dementia) due to traumatic brain injury • NCD (Dementia) due to Huntington’s disease • NCD (Dementia) due to prion disease • Substance/medication-induced NCD (dementia) 73