Pediatric Primary Care: Practice Guidelines for Nurses, 2nd Ed.

CHAPTER 35

Mental Health Disorders

Kim Walton and Susan J. Kersey

I. ANXIETY DISORDERS

Anxiety disorders, 300

 

Overanxious disorder in children, 313

Compulsions, 307.9

 

Panic disorder, 300.01

Dermatitis, 692.9

 

Post-traumatic stress disorder (PTSD), 309.81

Diarrhea, 787.91

 

Restlessness, 799.2

Dizziness, 780.4

 

School problems, 312.9

Fatigue, 780.79

 

Separation anxiety, 309.21

Headaches, 784

 

Shortness of breath, 786.05

Irritability, 799.2

 

Sleep disturbance, 780.5

Muscle tension, 729.82

 

Sweating, 780.8

Nausea, 787.02

 

Temper tantrums, 312.1

Obsessive compulsive disorder

 

Tiredness, 780.89

 (OCD), 300.3

   

A. Presentation of anxiety disorder; includes both physical and emotional characteristics.

B. Etiology.

1. Biochemical changes in brain.

a. Possible genetic vulnerability.

b. Post-traumatic stress disorder (PTSD) present in children who survive severe or terrifying physical or emotional event. Also occurs when witnessing an event that the child perceives as threatening; this includes domestic violence.

c. Separation anxiety, note relative frequency in children of mothers with panic disorder.

C. Occurrence.

1. Most common mental illness group occurring in children and adolescents.

2. Estimated prevalence of any anxiety disorder among children and adolescents is 13% in 6-month period.

D. Clinical manifestations.

1. Generalized anxiety disorder (also known as overanxious disorder in children).

a. Characterized by at least 6 months of persistent, excessive anxiety/ worry over everyday events; difficult to control the worry.

b. Anxiety and worry are associated with at least one of following:

• Restlessness.

• Being easily fatigued.

• Difficulty concentrating.

• Irritability.

• Muscle tension.

• Sleep disturbance.

c. Symptoms must cause significant distress or impairment in functioning.

2. Obsessive compulsive disorder (OCD).

a. Obsessions: recurring thoughts or images that are disturbing, intrusive, cannot be controlled through rational reasoning.

• Common obsessions:

i. Contamination.

ii. Fear of harm to self/family member.

iii. Worry about acting on aggressive impulses.

iv. Concern about order and symmetry.

• Thoughts or images are not simply excessive worries about real-life problems.

•Attempts to ignore or suppress such thoughts or images with some other thought/action.

b. Compulsions: repetitive behaviors that one feels obliged to complete. Performance of compulsive behavior, at least temporarily, decreases anxiety, thereby reinforcing behavior.

• Common compulsions:

i. Handwashing.

ii. Cleaning rituals.

iii. Requesting reassurance.

iv. Ordering and arranging.

v. Complex touching habits.

vi. Checking, counting, and repetition of routine activities.

• Behaviors are aimed at preventing or reducing distress.

c. Obsessions or compulsions must be time consuming (take > 1 hour a day), cause marked distress, interfere with daily activities.

d. Often seen with comorbidities.

e. Strong familial component.

f. Immune response to streptococcal infections.

3. PTSD.

a. Must have exposure to traumatic event with both of following:

• Actual or threatened death/serious injury or threat to physical integrity of self/others.

• Response involving intense fear, helplessness, horror. May be expressed as disorganized/agitated behavior in children.

b. Traumatic event is persistently reexperienced in one or more of following ways:

• Recurrent, intrusive, distressing thoughts of event. In young children, may include repetitive play.

• Recurrent distressing dreams. In children, may be frightening dreams without recognizable content.

• Acting or feeling as if trauma were reoccurring. In young children, may include trauma-specific reenactment, often through play.

• Intense psychologic distress on exposure to internal/external cues reminiscent of traumatic event.

• Physiologic reactivity on exposure to internal/external cues reminiscent of traumatic event.

c. Persistent avoidance of stimuli, numbing of general responsiveness with 3 or more of following:

• Efforts to avoid thoughts, feelings, or talking about trauma.

• Efforts to avoid activities, places, people that arouse memories.

• Inability to recall important aspect of event.

• Diminished interest/participation in activities.

• Feelings of detachment/estrangement.

• Restricted range of affect.

• Sense of foreshortened future.

d. Persistent symptoms of arousal with two or more of following:

• Difficulty falling asleep/staying asleep.

• Irritability or outbursts of anger.

• Difficulty concentrating.

• Hypervigilance.

• Exaggerated startle response.

e. Duration of symptoms for > 1 month.

f. Disturbance causes significant distress or impairment in functioning.

g. Diagnosis may be acute (symptoms < 3 months), chronic (symptoms ≥ 3 months), or delayed (onset of symptoms at least 6 months after stressor).

4. Separation anxiety.

a. Onset of excessive anxiety on separation from home/major attachment figure beyond what is expected for developmental level as evidenced by 3 or more of following:

• Recurrent excessive distress on separation from home or major attachment figure.

• Persistent/excessive worry about losing or harm coming to major attachment figure.

• Worry that untoward event will lead to separation (e.g., getting lost or kidnapped).

• Reluctance or refusal to go to school.

• Fearful or reluctant to be alone.

• Reluctance or refusal to go to sleep without being near attachment figure or to sleep away from home.

• Repeated nightmares with themes of separation.

• Repeated physical complaints when separation occurs or is anticipated.

b. Symptoms must be present for at least 4 weeks and must begin before age 18.

c. Symptoms must cause significant distress/impairment at home, school, with friends.

E. Physical findings.

1. May present with symptoms of sleep disturbance, tiredness, school problems, restlessness, irritability, somatic complaints (sweating, nausea, diarrhea, shortness of breath, dizziness, headaches).

2. For OCD, parents generally bring children in due to increase in temper tantrums, decline in school performance, food restriction, dermatitis. Children rarely request help; may be secretive about thoughts, behaviors.

F. Diagnostic tests.

1. None. Requires interview with child and parent/caregiver.

2. Consider collateral contact with school personnel, especially with separation anxiety.

3. Assess recent life stressors (family move, death, divorce, new school setting, etc.).

G. Differential diagnosis.

Anxiety disorder, 300

 

Post-traumatic stress disorder (PTSD),

Attention deficit hyperactivity disorder

 

 309.81

 (ADHD), 314

 

Separation anxiety, 309.21

Obsessive-compulsive disorder (OCD),

 

Stress reaction, acute, 308.9

 300.3

   

1. Attention deficit/hyperactivity disorder (ADHD).

2. Differentiate among anxiety disorders such as PTSD, separation anxiety, generalized anxiety disorder, OCD.

3. Consider acute stress reaction if exposed to traumatic event, symptoms present < 1 month.

H. Treatment.

1. May require use of medications to reduce anxiety symptoms. Consider use of selective serotonin reuptake inhibitors (SSRIs). These may include:

a. Fluoxetine (Prozac): starting dose of 5 mg/day; increase to 15-30 mg/ day for children; 10-40 mg/day for teens.

b. Fluvoxamine (Luvox): starting dose of 25 mg/day; increase to 50-200 mg/day for children; 150-300 mg/day for teens.

c. Sertraline (Zoloft): starting dose of 25 mg/day; increase to 50-100 mg/ day for children; 50-200 mg/day for teens.

2. May also consider a tricyclic medication, such as clomipramine (Anafranil): starting dose of 10 mg/day; increase to 75-100 mg/day for children; 100-200 mg/day for teens.

3. Cognitive behavioral therapy to help identify anxiety triggers, awareness of physiologic responses to anxiety. Develop plan for coping, evaluation of success of strategies.

4. Family therapy to address ways family can support the child. Must allow 6-8 weeks before full benefit will be obtained. Follow black box warning regarding increase monitoring of SI.

I. Follow up.

1. Follow-up appointment to monitor effectiveness of medications, address side effects of medications, compliance issues.

2. Collaboration with family, mental health treatment provider, school personnel to assess success of treatment approaches and medications.

J. Complications.

1. Poor school performance.

2. Poor self-esteem, social skills, avoidance of peers.

3. Potential for family stress and conflict.

4. Development of comorbid diagnosis of substance abuse or major depression.

K. Education.

1. Parent/caregiver and child need education about nature of anxiety, ways to identify, evaluate, change anxious thoughts.

2. Child needs to learn to recognize physiologic symptoms of anxiety, use of positive “self-talk.”

3. Relaxation training may be beneficial.

II. EATING DISORDERS

Abdominal pain, 789

 

Hair loss, 704

Anorexia nervosa, 307.1

 

Hypotension, 458.9

Arrhythmias, 427.9

 

Hypothermia, 996.1

Brittle nails, 703.8

 

Insomnia, 780.52

Bulimia nervosa, 783.6

 

Lethargy, 780.79

Cold intolerance, 788.9

 

Leukopenia, 288

Constipation, 564

 

Metabolic acidosis, 276.2

Dehydration, 276.5

 

Metabolic alkalosis, 276.3

Dental caries, 525.09

 

Mild anemia, 285.9

Dental enamel erosion, 521.3

 

Nausea, 787.02

Dry skin, 701.1

 

Scars, 709.2

Eating disorders, 307.5

 

Sinus bradycardia, 427.89

Enlarged parotid glands, 240.9

 

Vomiting, 787.03

Expected weight gains, 783.41

 

Weakness, 780.79

Fatigue, 780.79

 

Weight loss, 783.21

Fluid and electrolyte imbalances, 276.9

   

A. Serious, sometimes life threatening; tend to be chronic, usually arise in adolescence.

B. Etiology.

1. Combination of genetic, neurochemical, psychodevelopmental, sociocultural factors.

a. Increased risk among first-degree biological relatives of individuals with disorder. Often co-occurs with other mental health problems such as depression, anxiety, substance abuse, personality disorders.

C. Occurrence.

1. > 90% of all eating disorders occur in females.

2. Estimated 0.5% of adolescent females have anorexia nervosa; 1-5% meet criteria for bulimia nervosa.

3. Rarely begins before puberty, most common in ages 14-18 years.

4. Onset may be associated with stressful life event.

D. Clinical manifestations.

1. Anorexia nervosa.

a. Most severe consequence with mortality rate from starvation, suicide, electrolyte imbalance.

b. Characterized by refusal to maintain minimally normal body weight for age and height (< 85% of expected weight).

c. Intense fear of gaining weight or becoming fat.

d. Significant disturbance in perception of shape or size of body; sees self as overweight even when dangerously thin.

e. In postmenarchal females, presence of amenorrhea.

2. Bulimia nervosa.

a. Repeated episodes of binge eating characterized by:

• Eating in discrete period of time (e.g., within 2 hours), amount of food larger than most people would eat during same period of time and under similar circumstances.

• Sense of lack of control over eating during episode.

c. Recurrent inappropriate compensatory behaviors to prevent weight gain such as self-induced vomiting, misuse of laxatives, diuretics, enemas, other medications, fasting, excessive exercise.

d. Occurrence of both of above behaviors, on average at least twice a week for 3 months. Individuals place excessive emphasis on body shape, weight in self-evaluation.

E. Physical findings.

1. Anorexia nervosa.

a. Reported by family members, individual presents with weight loss or failure to make expected weight gains.

b. Leukopenia, mild anemia are common.

c. May present with signs/symptoms of dehydration, sinus bradycardia, arrhythmias.

d. May present with constipation, abdominal pain, cold intolerance, lethargy, hypotension, hypothermia, dry skin, dental enamel erosion.

2. Bulimia nervosa.

a. Typically presents within normal weight range to slightly overweight.

b. May present with complaints of abdominal pain, nausea, hair loss, brittle nails, fatigue, insomnia, or weakness.

c. Fluid and electrolyte imbalances: metabolic alkalosis from vomiting or metabolic acidosis from laxative abuse.

d. Loss of dental enamel, increased frequency of dental caries.

e. Enlarged parotid glands.

f. Possible calluses/scars on dorsal surface of hand from repeated selfinduced vomiting.

F. Diagnostic tests.

1. Ask all preteens, adolescents screening questions about eating patterns, satisfaction with body appearance.

2. Monitor height, weight, body mass index (BMI) on all visits.

3. Laboratory studies: complete blood count (CBC), electrolyte measurement, liver function tests, urinalysis, thyroid-stimulating hormone (TSH) test.

4. Electrocardiogram.

G. Differential diagnosis.

AIDS, 042

 

Major depression, 311

Anxiety disorder, 300

 

Substance abuse, 995.5

Brain tumors, 348.8

 

Weight gain, 783.1

GI disease, 569.9

 

Weight loss, 783.21

1. Rule out other possible medical causes for significant weight loss/failure to gain weight (GI disease, brain tumors, malignancies, AIDS, etc.), although these do not present with distorted body image.

2. Comorbid diagnosis of substance abuse, major depression, anxiety disorder.

H. Treatment.

1. Anorexia nervosa.

a. Requires comprehensive treatment plan including medical care, monitoring, psychotherapy, nutritional counseling, medication (when appropriate). Involves three phases:

• Restoring weight loss due to severe dieting, purging.

• Treating psychologic disturbances such as distorted body image, low self-esteem, interpersonal conflicts.

• Achieving long-term remission, rehabilitation.

b. Treatment with medication, such as SSRIs; consider only after weight gain established.

c. Acute inpatient hospitalization may be required to restore weight, address fluid and electrolyte imbalance or cardiac disturbances. May require nutrition via nasogastric tube/IV therapy.

d. Intensive treatment may be needed in specialized day treatment program or intensive outpatient program.

e. Refer for cognitive behavioral therapy and family therapy.

2. Bulimia nervosa.

a. Requires comprehensive treatment plan including medical care, monitoring, psychotherapy, nutritional counseling, medication (when appropriate).

b. Primary goal: reduce/eliminate binge eating, purging behavior.

• Establish pattern of regular, nonbinging eating.

• Improve attitudes related to eating disorder.

• Encourage healthy, not excessive exercise.

• Resolution of co-occurring disorders such as depression, anxiety.

c. Treatment approaches may include individual, group/family therapy.

d. Cognitive behavioral therapy: useful to address cognitive distortions related to body image and to develop adaptive coping skills.

e. Antidepressant medications, especially SSRIs, have been found to be effective.

I. Follow up.

1. May need weekly visits to monitor weight, lab work.

2. To achieve long-term remission and rehabilitation, treatment must include ongoing behavioral therapy, continued assessment of weight and physical health status.

3. Ongoing assessment of anxiety/depressive symptoms.

4. Collaboration between family and mental health provider to assess effectiveness of treatment approaches.

5. Pharmacologic support has found conflicting evidence as benefit.

J. Complications.

Anorexia nervosa, 307.1

 

Fluid and electrolyte imbalances, 276.9

Bulimia nervosa, 783.6

 

Gastric rupture, 537.89

Cardiac arrhythmias, 427.9

 

Loss of dental enamel, 521.3

Cardiac complications, 429.9

 

Potential for development of depression, 311

Dehydration, 276.5

 

Potential for suicide, 300.9

Dental caries, 525.09

 

Renal failure, 584.9

Depression, 300.4

 

Starvation, 994.2

Esophagitis, 530.1

 

Ulceration of esophagus, 530.2

Family stress and conflict, 308.9

 

Vomiting, 787.03

1. Anorexia nervosa.

a. Starvation, fluid and electrolyte imbalances, dehydration.

b. Cardiac complications.

c. Renal failure.

d. Potential for suicide.

e. Development of anxiety/depression.

f. Potential for family stress and conflict.

2. Bulimia nervosa.

a. Dental caries, loss of dental enamel.

b. Potential for development of depression, substance abuse.

c. Gastric rupture from acute gastric dilatation secondary to vomiting.

d. Esophagitis and ulceration of esophagus.

e. Potential for cardiac arrhythmias.

K. Education.

1. Educate family on potential complications of disorder, as well as how to best support adolescent in treatment.

2. Adolescent and family may benefit from nutritional counseling.

III. MOOD DISORDERS

Appetite changes, 783

 

Mania, 296.9

Attention deficit/hyperactivity disorder

 

Mood disorders, 296.9

 (ADHD), 314.01

 

Oppositional behavior, 313.81

Bipolar disorder, 296.7

 

Self-harm, 300.9

Depression, 311

 

Sleep, 307.4

Fatigue, 780.79

 

Stomachache, 789

Headache, 784

   

A. Etiology.

1. Close family member with depression or bipolar disorder may be single largest contributor to likelihood of disorder in child.

B. Occurrence.

1. For depression, prevalence is 2% in children, 6% in adolescents, with lifetime prevalence in adolescents estimated to be 20%.

2. 1% of adolescents 14-18 years of age meet criteria for bipolar disorder. Recent reports indicate a 40-fold increase in the diagnosis of bipolar disorder in children and teens.

C. Clinical manifestations.

1. Major depression.

a. Characterized by five or more of the following symptoms present daily for at least 2 weeks:

• Persistent sadness or irritable mood.

• Loss of interest in activities once enjoyed.

• Significant change in appetite or body weight.

• Difficulty sleeping or oversleeping.

• Psychomotor agitation or slowing.

• Loss of energy.

• Feelings of worthlessness or inappropriate guilt.

• Difficulty concentrating.

• Recurrent thoughts of death or suicide.

b. Other signs associated with depression include:

• Frequent, vague, nonspecific physical complaints such as stomachaches, headaches, muscle aches, tiredness.

• Frequent absences from school or poor school performance.

• Talk of or efforts to run away from home.

• Outbursts of shouting, complaining, unexplained irritability or crying.

• Being bored or lack of interest in playing with friends.

• Alcohol or substance abuse.

• Social isolation, poor communication, difficulty with relationships.

• Fear of death.

• Extreme sensitivity to rejection/failure.

• Increased irritability, anger, hostility.

• Reckless behavior.

2. Bipolar disorder.

a. Bipolar I: experiences alternating episodes of intense mania and depression.

b. Bipolar II: experiences episodes of hypomania (markedly elevated or irritable mood with increased physical and mental energy) between recurrent periods of depression.

c. Bipolar not specified (NOS): being used more to describe bipolar spectrum symptoms. Next edition of Diagnostics and Statistical Manual of Mental Disorders to include Temper Dysregulation Disorder that will better capture developmental aspect of symptoms.

d. Manic symptoms include:

• Severe or rapid changes in mood: extremely irritable or overly silly, elated mood.

• Overly inflated self-esteem, grandiosity.

• Exaggerated beliefs about personal talents/abilities.

• Increased energy, decreased need for sleep; able to go with very little/no sleep for days without tiring.

• Talks too much, too fast, changes subjects too quickly.

• Distractibility, hyperactivity: attention shifts from one thing to another quickly.

• Increased sexual thoughts, feelings, behaviors, or use of explicit sexual language.

• Increased goal-directed activity or physical agitation.

• Excessive involvement in risky, daredevil behaviors/activities.

e. Depressive symptoms include:

• Pervasive/overwhelming sadness, crying spells.

• Sleeping too much or inability to sleep.

• Agitation, irritability.

• Withdrawal from activities formerly enjoyed.

• Drop in grades, inability to concentrate.

• Thoughts of death and suicide.

• Low energy.

• Significant loss of appetite.

f. May also present: explosive/destructive rages, separation anxiety, defiance of authority, bedwetting, night terrors, strong and frequent cravings, impaired judgment, impulsivity.

g. Presents with depressive symptoms and also exhibits ADHD-like symptoms that are very severe: Refer to mental health professional for further evaluation, particularly if family history of bipolar disorder.

D. Physical findings.

1. Specifically ask about thoughts of suicide or self-harm: suicide is third leading cause of death among 10-24-year olds.

2. Major depression may present with multiple, vague somatic complaints (e.g., headache, stomachache, fatigue, sleep, appetite changes).

3. Bipolar disorder may present with symptoms of ADHD, depression, mania, oppositional behavior.

E. Diagnostic tests.

1. Several screening tools useful for children/adolescents, including Children's Depression Inventory for ages 7-17 and Beck Depression Inventory for adolescents. Positive screens indicate need for comprehensive diagnostic evaluation by mental health professional.

2. Requires intensive interview with child/adolescent and family as well as detailed family history.

F. Differential diagnosis.

Adjustment disorder, 309.9

 

Intermittent explosive disorder, 312.34

Attention-deficit/hyperactivity disorder

 

Oppositional defiant disorder, 313.81

 (ADHD), 314.01

   

1. Adjustment disorder.

2. ADHD.

3. Intermittent explosive disorder.

4. Oppositional defiant disorder.

G. Treatment.

1. Major depression.

a. Antidepressant medication may be indicated.

• Consider SSRI medications:

i. Fluoxetine (Prozac): starting dose of 5 mg/day; increase to 15-40 mg/day for children, 10-60 mg/day for teens.

ii. Fluvoxamine (Luvox): starting dose of 25 mg/day; increase to 50-200 mg/day for children, 100-300 mg/day for teens.

iii. Sertraline (Zoloft): starting dose of 25 mg/day; increase to 50-150 mg/day for children, 50-200 mg/day for teens.

• Following remission of symptoms, continue medications with therapy for at least several months given high rate of relapse, recurrence of depression. Gradually discontinue medications over 6 weeks or longer.

b. Short-term psychotherapy such as cognitive behavioral therapy (CBT).

• CBT based on premise that young people with depression have distorted view of themselves, world, future. CBT focuses on changing distortions through time-limited therapy.

• Continued therapy for several months after remission of symptoms may help consolidate skills learned, cope with after effects of depression, address environmental stressors, understand how young person's thoughts and behaviors could contribute to relapse.

2. Bipolar disorder.

a. Use of mood-stabilizing medications such as lithium (Eskalith, Lithobid, lithium carbonate), valproic acid (Depakote), carbamazepine (Tegretol), lamotrigrine (Lamictal), tiagabine (Gabitril).

• Start lithium at 25 mg/kg/day, gradually increase until serum level reaches therapeutic range of 0.9-1.1 mEq/L.

• Valproic acid (Depakote): start at 15 mg/kg/day, gradually increase until serum level reaches therapeutic range of 80-120 mg/mL.

• Carbamazepine (Tegretol): starting dose of 100 mg/day with increase to 300-800 mg/day in children, 800-1000 mg/day in teens; monitor for serum level to reach therapeutic range of 8-12 mcg/mL.

b.Consider polypharmacy with addition of antipsychotic medications, calcium channel blockers, antianxiety agents.

c. Do not use antidepressant medication alone; may lead to mania or rapid cycling.

d. Psychostimulant medications frequently used to treat ADHD may worsen manic symptoms.

e. CBT, interpersonal therapy, multifamily support groups essential part of overall treatment plan.

H. Follow up.

1. Monitor effectiveness of medications; address side effects, compliance issues.

2. Monitor closely for suicidal thoughts and/or behaviors. Note: FDA Black Box warning on use of SSRI antidepressants in children and teens.

3. Monitor blood levels to assess appropriate medication dosing.

4. Collaborate with family, mental health treatment provider, school personnel to assess success of treatment approaches.

I. Complications.

Conduct disorder, 312.9

 

Risk for suicide, 300.9

Poor psychosocial functioning, V71.02

 

Substance abuse, 995.5

1. Increased risk for suicidal ' text-align:justify; line-height:normal;background:white'>2. Increased risk for poor psychosocial functioning.

3. School truancy or poor academic performance.

4. Substance abuse.

J. Education.

1. Monitor effectiveness of medications.

2. Educate families on signs/symptoms of both depression and mania and signs/symptoms of suicidal ideation.

BIBLIOGRAPHY

American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: Author; 2000.

National Institute of Mental Health. Brief notes on the mental health of children and adolescents. Bethesda, MD: Author; 2002.

National Institute of Mental Health. NIH Publication No. 00-4744. Bethesda, MD: Author; 2002.

National Institute of Mental Health. NIH Publication No. 00-4778. Bethesda, MD: Author; 2002.

National Institute of Mental Health. NIH Publication No. 01-4901. Bethesda, MD: Author; 2002.

Scahill L. Child and adolescent psychiatric nursing. In NL Keltner, CE Bostrom, & T McGuinness, eds. Psychiatric nursing. 6th ed. pp. 459-468. St. Louis: Mosby; 2011.



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