Mental Health Fall '12

1. Renee Franquiz RN, MSN

2.  Catergories of Mental Health Issues
 Growth &Developmental - Stages and Norms
▪ Aspergers, Autism, MR
 Behavioral Disorders
▪ ADHD, Opposition/Defiance, Conduct, Separation Anxiety
 Clinical Disorders
▪ BiPolar, Depression, Suicide
 Diagnosis
 Ability to communicate; Wide range of “normal”
 Pathologic
 Not age Appropriate
 Deviates from Cultural Norms
 Impairs Adaptive Functioning

3.  Overview  Dx - Autism Spectrum DSM-IV Criteria
 Effects 2:10,000 with higher  Two of the following
incidence in males (4:1 ▪ Impaired Non Verbal Communication
ratio) ▪ Failure to develop peer relationships
 Autism Spectrum – No
▪ Lack interests in other people
cognitive or language
▪ Lack of social/emotional reciprocity
impairment
 One of the following
 Suspicions in pre-school
years ▪ Preoccupation with a restricted interest
 Socially “awkward” to an that is abnormal in intensity
extreme ▪ Inflexible adherence to routines or
 Difficulty continues into rituals
adulthood ▪ Repetitive motor mannerisms
 Etiology – unknown; ▪ Persistent preoccupation with parts of
genetic d/t familial an object
tendency

4. MEDICAL MANAGEMENT NURSING INTERVENTIONS
 Social Skills Training  Collaborative Care
 role play social situations  Team member role as a nurse
 Cognitive/Behavior w/medical management
Therapy
 Talk Therapy  Independent Nursing Care
 Medications  Where else and how else
 Co-morbidities might you come in contact
with these children and their
 Physical Therapy families?
 Family Coping
 Support groups

5.  Developmental disorder of brain function which effects:
 Communication – language delay, echolacia
 Social Interaction- lack of reciprocity, responsiveness,
relationships
 Repetitive Behaviors – head banging, clapping, rocking, rituals
and routines
 Manifests b/t 24-48 mos age; 6:1000 with 4x males
 Cause is unknown; evidence supports multiple causes
 Biologic – Abnormal brain structure, Brain Hypoplasia,
Seratonin
 Genetic – Twins, familial
 Environment – Thimerosal; intranatal exposures; Food
Additives/Dyes

6.  DSM-IV Criteria page 382 in Textbook
 Impaired Verbal Communication
 Establishment of trust
 Able to communicate needs and desires
 Impaired Social Interaction
 Establishment of trust
 Engagement in social interaction
 Risk for Harm to Self
 No Harm to self
 Engage in alternate behaviors

7.  Est’b of therapeutic relationship – trust
 Limit Number of caretakers/Decrease stimuli
 Provide w/familiar or security objects
 Maintain a routine/Avoid abrupt changes
 Anticipate Needs
 Positive praise and reinforcement for desired behavior
 Protect from Self-Harm
 Distract
 Devices
 Ongoing Behavior Management Therapy
 Social Training
 Verbal Skills
 Parent Support
 Autism Society of America

8.  Definition
 Deficit in general intellectual functioning as measured
by IQ
 DSM-IV Criteria on page 377 in Textbook
 Etiology (Biologic and or Social)
 Hereditary– Genetic, Chromosomal, Metabolic D/O
 Perinatal Exposure– Infections, Ingestions
 Acquired– Infection, Safety/TBI, Child Abuse, Sx,
Social deprivation/neglect

9.  Mild - IQ 50 – 75
 Slower to talk and perform adls; mental age of 8-
12 year old; likely to achieve skills for self-
maintenance with support
 Moderate – IQ 36 -49
 Noticable delays, simple speech, mental age of
3-7 years; simple tasks with supervision; not
capable of self-maintenance
 Severe – IQ 20 – 35
 Marked delay, limited communication; mental
age of a 1-3 years; requires continuous
supervision
 Profound – IQ below 20
 Minimal purposeful actions; infantile

10.  Risk for Injury
 No physical harm
 Self Care Deficit
 Self Care needs fulfilled
 Impaired Communication
 Means of communication established
 Impaired Social Interaction
 Interacts with others
 Impaired Growth and Development
 Maximize developmental capacity

11.  Physical Needs
 Provide for ADLs
 Encourage Self-Care
 Safety
 Create a safe environment
 Protect from self harm – devices
 Establish means/ method for communication
 Early intervention/special education programs to
maximize potential
 Support families and help in setting realistic goals
 Counsel adolescent/family on sexual maturity and
responsibility, marriage, childbearing and vocation

12. OVERVIEW ETIOLOGY
 Key Symptoms  Biologic
 Inattentiveness  Genetic – familial
 Hyperactive-Impulsive  Biochemical – alterations in
 Difficult to Dx before age 4 dopamine, serotonin, norepi
 Issues emerge with school  Anatomical variations – lobe size
 More common in boys  Intrauterine exposure – Substances
 Majority persist as adults  CNS disorders – sz, infection
 Subtypes
 Combined  Environmental
 Inattentive type  Lead
 Hyperactive-Impulsive type  Food Additives , dyes, sugars

13.  DSM-IV Criteria on page 387 in textbook
 Inattentive
 Unable to listen; Inattentive; forgetful
 Disorganized; Poor follow through
 Procrastinates; Loses things
 Hyperactive
 Restless; Excessive motor actvitiy
 Difficulty with quiet activities
 Talks excessively
 Impulsive
 Interrupts
 Blurts out
 Difficulty waiting turns

14.  Risk For Injury
 No physical harm
 Impaired Social Interaction
 Interacts with others
 Low self-esteem
 Positive self regard
 Noncompliance
 Participates in therapeutic activities

15.  Protect from injury/provide safe environments for
physical activity
 Set boundaries; identify unacceptable behaviors
and consequences
 Provide structure and routines – feenback
systems
 Convey acceptance and provide opportunities for
success
 Limit distractions in the environment
 Empower child to manage own behavior
 Medication Therapy

16.  Dextramphetamin - Dexedrine
 Methamphetamine - Desoxyn
 Combo – Adderall
 Methylphenidate – Ritalin
 Dexmethylphenidate – Focalin
 Anorexia, Insomnia, Weight Loss, Decreased Growth
 Atomoxetine – Strattera
 Same as above, increase BP/Pulse, sexual Dysfunction
 Bupropion – Wellbutrin
 CNS stimulation, anorexia, weight loss

17.  Administer after meal(s); monitor growth and
weight
 Administer in AM, or 6 hours before bedtime
 Use cautiously in clients with CV D/O
 Monitor LFTs
 Monitor for new psychotic D/O
 Monitor OTC that may contain similar
components
 Medication “holiday” to assess behaviors off
therapy

18. OVERVIEW ETIOLOGY
 Patterns of behavior that  Biologic
violate the rights of others  Genetics
 Physical Aggression if  Biochemical – Serotonin, Nor-
Common epi, Testosterone – inconclusive
 Most common reason for  Temperament – “difficult”
psychiatric referral Strong willed
 Higher Incidence Males  Psychosocial
 Child Onset – less than 10 y,  Peer socialization
aggression, disturbed  Family
relationships
▪ Marital discord, changing parent
 Adolescent Onset – After figures, absent fathers
10y, less aggressive, better ▪ Harsh discipline, permissiveness
relationships ▪ Parenteral rejection; Parent MH
D/O, early institutionalization

19.  DSM-IV Criteria on page 395 in textbook
 Physical Aggression - “Tough Guy”
 People and Animals
 Initiates; Weapons
 Rape
 Destruction of Property
 Fire Setting
 Lying/Stealing – Lacks Remorse
 Rules Violations
 Curfew Issues
 Runaway
 School Truancy – ability exceeds achievement

20.  Risk for other directed violence
 No harm to others
 Impaired Social Interactions
 Interacts in socially appropriate ways
 Defensive Coping
 Accepts feedback and responsibility
 Low Self-Esteem
 Positive self regard; discontinuation of
exploitation

21.  Highly Resistant to Treatment – Requires intensive , persistent , long
term services
 Family Therapy
 Parenting Skills Training
 Communication
 Behavior Therapy
 Improved Decision Making/Problem Solving
 Anger Management
 Impulse Control
 Relationship Building
 Substance Use/Abuse
 Medications – manage behaviors (Sedation agents; Impulsiveness; Mood
Stabilizers)
 Prognosis - refractory

22. OVERVIEW ETIOLOGY
 Negative, disobedient,  Biologic
defiance towards authority  Genetics
 Stubborn, argumentative,  Biochemical – Serotonin, Nor-
temper epi, Testosterone –
 Interferes with social, inconclusive
school, and work  Temperament – “difficult”
 Do not violate rights of Strong willed
others
 Family
 Parenting Limitations
 Behaviors emerges in
 Impulsed Disordered Parent –
childhood
Serves as a Role Model
 Higher incidence in males
 Absent Parent

23.  DSM-IV Criteria on page 398 in Textbook
 Passive Aggressive – Negative, stubborn,
disobedient, testing, uncooperative,
argumentative
 Attitude directed toward parent(s)
 Project blame on others
 Poor relationships (limited friends), school
performance

24.  Impaired Social Interactions
 Interacts is socially appropriate ways
 Defensive Coping
 Verbalize responsibilities for behaviors
 Demonstrate effective Coping
 Low Self Esteem
 Positive self regard
 Noncompliance
 Participation in Therapeutic Activities

25.  Family Therapy
 Parenting Skills Training
▪ Avoid Power Struggles
▪ Set reasonable expectations - Structure
▪ Impose limits
▪ Follow Through – Consequences - Rewards
 Behavior Therapy
 Improved Decision Making/Problem Solving
 Anger Management
 Social Skills Building

26. OVERVIEW ETIOLOGY
 Excessive anxiety when  Biologic
separating or anticipating  Genetics
separation from home or  Temperament – Shy, cautious
parents  Environment
 May be triggered by a  Traumatic Event
trauma event; Most  Maternal Over Attachment
common on starting school  Overprotective Family
 Higher incidence in  Parent Role Model Fears
females
 May progress to panic D/O

27.  Separation reluctance
 Tantrums, crying, screaming, clinging
 Reluctance to attend school
 Follow parent around the house
 Inability to sleep away from home
 Worry, nightmares – during separation harm
will come to self or parent
 Phobias – fear of dark, ghosts, dogs

28.  DSM-IV Criteria on page 405 in textbook
 Anxiety
 Uses adaptive activity to manage anxiety
 Feels safe
 Demonstrates trust
 Ineffective Coping
 Demonstrate adaptive coping
 Impaired Social Interaction
 Spend time with others

29.  Establish calm atmosphere
 Reassure client of safety
 Explore fears and worries
 Establish gradual separation goals – desensitize
 Identify alternative adaptive coping
 Alternate parenting techniques
 Anti-anxiety medications – severe cases

30.  Suicide Overview
 Rates rise during adolescence
 3rd leading cause death 15-24 years old
 Greater risk due to impulsive behaviors;Risk
Taking
 Most common methods is firearm (49%)
 Trigger more often relationship issues

31.  Assessment
 Similar tools, methods and findings
 Desire to hurt self with a plan and the means
 Report – minors who seek health care for mental health
are considered emancipated
 Dx
 Risk For Suicide
 Hoplessness
 Interventions
 Physical Safety/Treat Co-Morbidities
 Suicide Precautions
 Therapy/Support

32.  Overview
 Approximately 4%-5% of children experience depression
 Etiology – usually a feeling of loss
▪ Genetic Predisposition
▪ Relationship Difficulties, Family Distruption, school Changes
 Behaviors
 May vary or similar to adults
 Morbid Thoughts; Excessive Worry, Sadness
 Changes in School Performance and Relationships
 Sleeping and Eating Disturbances
 Self Harm - slashing
 Management
 Similar to adults
 +/- Hospitalization
 AntiDepressants and Psychotherapy