Mental and Emotional Disorders in Children and Adolescents

Children have certain developmental tasks to master in the various stages of development (learning to trust, control primary instincts, and resolve basic social roles).

Concepts and principles related to mental and emotional disorders in children and adolescents:
1. Most emotional disorders of children are related to family dynamics and the place the child occupies in the family group.
2. Children must be understood and treated within the context of their families.
3. Many disorders are related to the phases of development through which the children are passing. (Erik Erikson’s developmental tasks for children are trust, autonomy, initiative, industry, identity, and intimacy.)
4. Children are not miniature adults; they have special needs.
5. Play and food are important media to make contact with children and help them release emotions in socially acceptable forms, prepare them for traumatic events, and develop skills.
6. Children who are physically or emotionally ill regress, giving up previously useful habits.
7. Adolescents often act out their underlying feelings of insecurity, rejection, deprivation, and low self-esteem.
8. Strong feelings may be evoked in nurses working with children; these feelings should be expressed, and each nurse should be supported by team members.

Assessment of selected disorders:
1. Autistic disorders (previously called childhood schizophrenia):
  1. Disturbance in how perceptual information is processed; normal abilities present.
    1. Behave as though they cannot hear, see.
    2. Do not react to external stimulus.
    3. Mute or echolalic.
  2. Lack of self-awareness as a unified whole- may not relate bodily needs or parts as extension of themselves.
  3. Severe difficulty in communicating with others-may be mute and isolated.
  4. Bizarre postures and gestures (banging head, rocking back and forth).
  5. Disturbances in learning.
  6. Etiology is unknown.
  7. Prognosis depends on severity of symptoms and age of onset.
2. Developmental disorders (brain injury) characteristics:
  1. Hyperactivity.
  2. Explosive outbursts.
  3. Distractibility.
  4. Impulsiveness.
  5. Perceptual difficulties (visual distortions, such as figure-ground distortion and mirror reading; body-image problems; difficulty in telling left from right).
  6. Receptive or expressive language problems.
3. Elimination disorders (functional enuresis)-related to feelings of insecurity due to unmet needs of attention and affection; important to preserve their self-esteem.
4. Separation anxiety disorders of childhood (school phobias)-anxiety about school is accompanied by physical distress. Usually observed with fear of leaving home, rejection by mother, fear of loss of mother, or history of separation from mother in early years.
5. Conduct disorders-include lying, stealing, running away, truancy, substance abuse, sexual delinquency, vandalism, and fire setting; chief motivating force is either overt or covert hostility; history of disturbed parent-child relations.

Analysis/nursing diagnosis:
1. Altered feeling states: anxiety, fear, hostility related to personal vulnerability and poorly developed or inappropriate use of defense mechanisms.
2. Risk for self-mutilation related to disturbance in self-concept, abnormal response to sensory input, and history of abuse.
3. Altered interpersonal processes:
  1. Impaired verbal communication related to cerebral deficits, withdrawal into self, inability to trust other.
  2. Altered conduct/impulse processes: aggressive, violent behaviors toward self, others, environment related to feelings of distrust and altered judgment.
  3. Dysfunctional behaviors: age-inappropriate behaviors, bizarre behaviors; disorganized and unpredictable behaviors related to inability to discharge emotions verbally.
  4. Impaired social interaction: social isolation/ withdrawal related to feelings of suspicion and mistrust, lack of bonding, inadequate sensory stimulation.
4. Personal identity disturbance related to lack of development of trust, organic brain dysfunction, maternal deprivation.
5. Altered parenting related to ambivalent or dissonant family relationships and failure of child to meet role expectations.
6. Sensory/perceptual alterations: altered attention related to disturbed mental activities.
7. Altered cognition process: altered decision making, judgment, knowledge, and learning processes; altered thought content and processes related to perceptual or cognitive impairment and emotional dysfunctioning.

Nursing care plan/implementation in mental and emotional disorders in children and adolescents:
1. General goals: corrective behavior-behavior modification.
2. Help children gain self-awareness.
3. Provide structured environment to orient children to reality.
4. Impose limits on destructive behavior toward themselves or others without rejecting the children.
  1. Prevent destructive behavior.
  2. Stop destructive behavior.
  3. Redirect nongrowth behavior into constructive channels.
5. Be consistent.
6. Meet developmental and dependency needs.
7. Recognize and encourage each child’s strengths, growth behavior, and reverse regression.
8. Help these children reach the next step in social growth and development scale.
9. Use play and projective media to aid working out feelings and conflicts and in making contact.
10. Offer support to parents and strengthen the parent-child relationship.
11. Health teaching: teach parents methods of behavior modification.

Evaluation/outcome criteria:
1. Destructive behavior is inhibited.
2. Demonstrates age-appropriate behavior on developmental scale.

Emotional Disturbances in Children

Stage	Disturbance	Assessment: Symptoms or Characteristics	Analysis: Behavior Related To:	Plan/Implementation:
Oral (birth-1 year)	Feeding disturbances	Refusal of food.	Rigid feeding schedule. Psychological stress. Incompatible formula. Physiological: pyloric stenosis.	Pediatric evaluation, especially if infant is not gaining weight or is losing weight. Rule out physiological etiology or incompatible formula. Evaluate feeding style of caretaker. Is baby on demand feeding? Is caretaker sensitive to infant's needs or communications about holding, hunger, or satiation?
		Colic. Crying is usually confined to one part of day and starts after a feeding. Commonly lasts from first to third month.	Periodic tension in infant’s immature nervous system, causing gas and sharp intestinal pains.	Reassure parents and teach about condition and how to relieve it with hot water bottle, rocking, rubbing back, pacifier, which may soothe infant.
	Sleeping disturbances	Infant resists being put down for sleep or going to sleep.	Need for parental attention. A pattern formed during period of colic or other. Emotional disturbance related to anxiety.	If it is attention-getting strategy, suggest parental lack of response for a few nights to break pattern. If emotional disturbance is suspected, evaluate infant-caretaker interaction and refer for psychotherapeutic intervention.
	Failure to thrive	Infant does not grow or develop over a period of time.	Psychological: inadequate caretaking. Physiological: heart, kidneys, central nervous system (CNS) malfunction.	If it is attention-getting strategy, suggest parental lack of response for a few nights to break pattern. If emotional disturbance is suspected, evaluate infant-caretaker interaction and refer for psychotherapeutic intervention.
	Severe disturbances	Autistic psychosis: Very early onset; lack of response to others; bizarre, repetitive behavior; normal to above normal intelligence; failure to develop language or use communicative speech. Autism is one of the most severe and debilitating psychiatric disturbances.	Uncertain etiology; regression or fixation at earlier developmental stage, before child differentiates “me” from “not me.” A “nature versus nurture” controversy over the causative factors. These are variously thought to be: Environment only: Infant is tabula rasa and all disturbance is directly attributable to the environment (primarily the parenting). Heredity only: For genetic, biochemical, or other predetermined reasons, some infants will be psychotic regardless of the environment.	The severely disturbed child requires intensive psychotherapy and often milieu therapy available in residential or day care programs. Therapy is usually indicated for parents also. Nurses can work on a primary level of prevention by assessing parenting skills of prospective parents and teaching them these skills. On a secondary level of prevention, nurses can be knowledgeable about and teach others the early signs of childhood psychosis, making appropriate referrals. The earlier the intervention, the better the prognosis.
			Combination of environment and heredity plus the interaction between them: A susceptible infant, less than optimal parenting, and negative interaction between parent and infant will combine to produce disturbance.	On a tertiary level of prevention, nurses work with severely disturbed children and their families in child guidance clinics and residential and day care settings. Health teaching would include play activities that foster support, acceptance, and a nonthreatening mode of communication and interaction with a significant other.
		Symbiotic psychosis: Identified later than autistic type, usually between 2 and 5 years of age. These children seem to be unable to function independently of the caregiving parent. A situational stress, such as hospitalization of parent or child or entry into school, may precipitate a psychotic break in the child.	The same "nature versus nurture" controversy with respect to the origin of symbiotic psychosis. The child progresses beyond the selfabsorbed autistic stage to form an object relationship with another (usually the mother). Having progressed to this stage, the child then fails to differentiate his or her own identity from that of the mother.
Anal (1-3years)	Elimination disorders (disturbances related to toilet training)	Constipation	Diet. Child withholding due to history of one or two painful, hard bowel movements. Psychological causation: child withholds from parents to express anger, opposition, or passage through a very independent development stage.	Evaluate diet and consistency of stools. Fecal softener may be prescribed if necessary. In all cases, help parent avoid making an issue of constipation with the child. Enemas are contraindicated. If child is withholding, work with parents around not forcing rigid toilet training on child. Most children are more cooperative about toilet training at 18-24 months.
		Encopresis (soiling).	Child’s expression of anger or hostility. It is usually directed toward the parent with whom the child is experiencing conflict and is rarely physiological.	Medical evaluation, then assessment and intervention in the child-parent relationship. Therapy for child and parent may be indicated.
	Excessive rebelliousness	Frequent temper tantrums, fighting, destruction of toys and other objects, consistent oppositional behavior.	Fear caused by inconsistency in handling the child, the setting of rigid limits, or the parents’ refusal or inability to set limits, which can all create insecurity and fear in the child. Excessive rebelliousness, usually indicating a frightened child; should not be confused with expression of negativism normal at around age 2, which is a necessary (though trying) developmental stage.	The nurse should offer parent counseling if necessary. When working with the child, the nurse needs to be receptive and sympathetic while establishing and maintaining firm limits.
	Excessive conformity	Lack of spontaneity, anxious desire always to please all adult authority figures, timidity, refusal to assert own needs, passivity.	Very rigid control established in an attempt to handle fears. Harsh toilet training, resulting in an overcompliant child. These children need help as much as overrebellious children, but they get it less frequently because their behavior is not a “problem”—that is, it is not difficult for parents to tolerate.	Excessive conformity can lead to compulsive, ritualistic, or obsessive behavior later. The nurse needs to be able to identify such a child, then work with the child and parents to encourage self-expression in the child. Referral for psychotherapy may be necessary to help the child deal with repressed anger.
		Enuresis. Ordinarily refers to wetting while asleep (nocturnal enuresis), though some enuretic children wet themselves during the day also. Enuresis is a symptom, not a diagnosis or disease entity.	Faulty toilet training (especially if child wets during the day also) or. Psychological stress. Physiological etiology, such as genitourinary (GU) tract infections or CNS disease, is rare. The child under 4 years old is usually not considered enuretic but is included in this section because bladder training is part of toilet training. Etiology is uncertain.	Many approaches have been tried with varying degrees of success. These include fluid restriction, behavioral intervention (in which a buzzer wakes the child when the child starts to wet), and psychotherapy. Educating parents in bladder training techniques and attitudes can help solve the problem on a primary level. It is important when working with enuretic children or their parents to suggest ways to help the child overcome feelings of shame and guilt. These feelings are often exacerbated by well-meaning but misguided parents.
Oedipal (3-6 years)	Excessive fears	Child will be frightened even in nonthreatening situations. Nightmares and other sleep disturbances occur. Usually, child will be very “clingy" with parents in an attempt to gain reassurance.	Anxiety as the causative factor. Anxiety can be induced by many things, such as: Parental failure to set appropriate limits. Physical or psychological abuse. Illness Fear of mutilation. Imaginary worries that are common at this age; e.g., a 4-year-old who is suddenly afraid of the dark, or dogs, or fire engines is not necessarily suffering from excessive fears.	If possible, identify and deal with the factors that are producing the anxiety. Offer child calm reassurance. Nightlight and open doors can help allay night fears, but counsel parents that it is unwise to allow the child to sleep with the parents, which may make the child feel that the oedipal retaliation has succeeded. With the hospitalized child, the nurse needs to be aware of and work with the mutilation fears common at this age. Fears around certain procedures (e.g., injections) can often be resolved by helping the child play out fears.
	Excessive masturbation	Touching and fondling of sometimes in a preoccupied or absentminded manner.	Insecurity. Exploration and stimulation of the genital area, which is normal and common in this age group. However, if it is compulsive, the behavior is a signal that the child is insecure.	Assess the child’s masturbating activity. When does it occur and why? Then help the child develop other strategies for coping with anxiety. Answer questions about sexuality in an open manner.
			Occasionally, a specific fear. For example, a boy viewing a baby sister’s genitals may have castration fears. These can be dealt with directly.	Counsel parents that threats and shaming are contraindicated, and help parents deal with their feelings about masturbation.
	Regression	Resumption of activities (such as thumb sucking, soiling and wetting, baby talk) characteristic of earlier developmental levels.	Child’s attempt to regain a more comfortable, previous level of development in response to a threatening situation (such as a new baby), or A response to difficulty resolving oedipal conflicts.	Counsel parents not to make an issue of behavior. Offer child emotional support and acceptance, though not approval of regressive behavior.
	Stuttering	Articulation difficulty characterized by many stops and repetitions in speech pattern.	Anxiety. Frustration. Insecurity. Excitement. Stuttering ususally occurs when the affected child feels anxious, frustrated, insecure, or excited. Parental concerns and attention to stuttering focuses attention on it and increases anxiety. The origins of stuttering are not understood. It is common around 2-3 years of age and is not a cause for concern at that time.	Speech therapy is usually indicated. Psychotherapy may also be indicated, if stuttering is an expression of anxiety and conflict, persisting beyond age 6.
Latency (6-12 years)	Attention deficit disorder (hyperactivity and hyperkinesis)	Both hyperactivity and hyperkinesis are occasionally observed in schoolchildren; characterized by a short attention span, restlessness, distractibility, and impulsivity.	An organic disturbance of the CNS, of uncertain origin, as the basis of hyperkinesis. Because the primary symptom-difficulty with attention span-is the same as that presented by the hyperactive child, the hyperactive child is frequently and incorrectly labeled hyperkinetic. Attempts by hyperactive child to control anxiety through reducement (and can attend when interested or relaxed). Does not fit smoothly into environment, but problem may be with the environment rather than the child. In other words, the school situation requires a high degree of conformity. The child who does not fit the mold is not necessarily emotionally disturbed.	For the hyperkinetic child, psychopharmaceutical intervention-usually Ritalin-is most often employed. Psychotherapy and special education classes may also be indicated. Ritalin is also frequently prescribed for the hyperactive child-which raises the issue of whether an individual should be medicated to fit more smoothly into the environment. Therapy can help the hyperactive child decrease anxiety and increase selfesteem, thus reducing the symptoms.
	Withdrawal	Reduced body movement and verbalization, lack of close relationships, detachment, timidity, and seclusiveness.	Need to withdraw as a defensive behavior, through which the child controls anxiety by reducing contact with the outer world. Like	Offer positive reinforcement when child is more active. Help child assert self and experience success at certain tasks.
			the overcomplaint child, the withdrawn child is frequently not identified as needing help because this behavior is not a “problem."	The nurse needs to work with parents who are overprotective. Therapy may be useful to work through anxiety and provide child with a chance to form a trusting relationship with another.
	Psychophysiological symptoms	The child experiences physical symptoms (such as vomiting, headaches, eczema, asthma, colitis) with no apparent physiologic cause.	Conversion of anxiety into physical symptoms.	After medical evaluation has established lack of physiological etiology, psychotherapy is usually indicated. Family therapy may be treatment of choice because dysfunctional interpersonal family dynamics are common in these cases. The nurse can also provide the child with a healthy interpersonal relationship. Nurses are frequently in a position to talk to parents and teachers about the importance of mental health counseling for children with physical symptoms.
	Separation anxiety disorders (school “phobia”)	Sudden and seemingly inexplicable fear of going to school. These children often do not know what it is they fear at school. Frequently occurs after an illness and absence from school or birth of sibling.	An acute anxiety reaction related to separation from home (not actually a phobia).	If the child is allowed to stay home, the dread of returning to school usually increases. The child and parent should have psychiatric intervention quickly (before the problem becomes worse) to help the child separate from the parent.
	Learning disabilities	Failure or difficulty in learning at school.	Emotional disorders, which cause school failure. Feelings of inferiority, discouragement, and loss of confidence from school failure. Learning disabilities may be caused by many factors or combinations of factors, including anxiety, poor sensory or sensorimotor integration, dyslexia, receptive aphasia.	A comprehensive evaluation is essential. Ideally, this would include assessments by a pediatric neurologist, a mental health worker such as a psychiatric nurse or psychiatrist, a learning disabilities teacher specialist, and possibly an occupational therapist trained to work with sensory integration. Treatment is then based on the specific problem or problems.
	Conduct disorders	Behavior that is nonproductive; that is repeated in spite of threats, punishments, or rational argument; and that usually leads to punishment. Persistent stealing and truancy are examples.	Conflicts that are expressed and communicated through behavior rather than verbally. Child knows what he or she is doing but is unaware of the underlying motivations for the problem behavior.	Counseling or therapy for the child by a child psychiatric nurse or other mental health worker can allow the child to resolve the basic conflict, thus making the problem behavior unnecessary.