The Nurse’s Role

The nurse is often the person who has the greatest amount of contact with the family. Assessing child-parent relations is an important and ongoing aspect of care. To work effectively with the disturbed child, nurses first must understand the types of behavior considered within normal range. The Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision) (DSM-IV-TR) (American Psychiatric Association [APA], 2000) is a resource that defines mental disorders and is used by health professionals to aid in diagnoses of specific mental health conditions. Nurses are valuable members of the multidisciplinary health care team in that they work closely with hospitalized acutely ill children, long-term chronically ill children, and children in school. Nurses should keep a careful record of behavior and note relationships with members of the family. Such notations are meaningful to the physician and other staff members, who are as concerned with prevention of problems as they are with treating them.

Every day, everywhere, children are trying to cope with stress. Many succeed and grow stronger; some do not. Early childhood intervention programs are helpful in preventing major problems that affect growth and development. Parenting classes teach what to expect at various ages and stages. They also stress the importance of age-appropriate discipline and guidance. Parent groups provide education, socialization, and support. Other agencies provide a variety of services. Some services include the National Alliance for the Mentally Ill (NAMI), Family Service Association of America, Toughlove, and Youth Suicide National Center. Nurses must be aware of such resources to guide parents appropriately.

When parents request guidance, the nurse encourages them to seek help from their family physician or pediatrician or from a community mental health center. In the hospital, a psychiatric clinical nurse specialist (CNS) is an excellent resource. If the child is in school, the services of the school psychologist or guidance counselor may prove valuable. Some religious centers employ counselors who are available free of charge to parishioners. Families who lack adequate financial resources can be directed to the appropriate agencies. Some agencies not only provide emergency funds but also can establish a budgeting system for those receiving minimum wages. This is particularly helpful when the parents are young adolescents.

No matter how dysfunctional the parent-child relationship, most children consciously and unconsciously identify with parental values. Discrediting of the parents’ values by the health care provider threatens the child’s security and creates anxiety. The nurse reassures parents and helps them regain or maintain confidence in their parenting role. In addition, because children do not seek treatment on their own, the nurse should assist parents in becoming invested in the treatment modality. Finally, as a professional, the nurse supports organizations concerned with mental health, votes on issues that are pertinent to the welfare of children in the community, and offers services when needed.

Types and Settings of Treatment

The basic staff of the modern child guidance clinic is composed of a psychiatrist, a psychologist, a social worker, a pediatrician, and the nurse. Usually the child guidance clinic provides diagnostic and treatment services. It may be part of a hospital, school, court, or public health or welfare service, or it may be an independent agency.

The psychiatrist is a medical doctor who specializes in mental disorders. The psychoanalyst is usually a psychiatrist but may be a psychologist; all psychoanalysts have advanced training in psychoanalytic theory and practice. The clinical psychologist has an advanced degree in clinical psychology from a recognized university. Many of these specialists work in the school system with children, teachers, and families to prevent or resolve problems. A counselor is a professional with a master’s degree from an accredited institution. Many counselors specialize in a specific area, such as substance abuse or counseling of children. In most states, counselors must be licensed.

Children who do not respond well to individual outpatient therapy may require the type of care provided in residential treatment centers. Their home situations may be so disruptive that they might benefit from a change of environment. This alternative also provides a cooling-down period for the family. Family therapy is begun and includes all family members. The length of stay for the child varies from 1 to 3 weeks. Partial hospitalization programs in which the child attends therapy during the day and returns home at night are popular.

Intervention may involve individual, family, or group therapy; behavior modification; or milieu therapy. It may also involve a combination of these therapies. Behavior modification focuses on modifying specific behaviors by means of stimulus and response conditioning. Milieu therapy refers to the physical and social environment provided for the child. Art therapy, music therapy, and play therapy are particularly helpful in dealing with younger children who have difficulty expressing themselves. Recreation therapy is also valuable. Bibliotherapy, the reading of stories about children in a situation similar to the child’s situation, is also therapeutic. Creating an emotionally safe environment is basic to all forms of therapy.

Origins of Emotional and Behavioral Conditions

Early childhood experiences are critical to personality formation. Situations that disrupt family patterns can have a lasting impact on the child. Children who come from these dysfunctional families may experience any of the following: failure to develop a sense of trust (in their caregivers and environment), excessive fears, misdirected anger manifested as behavioral problems, depression, low self-esteem, lack of confidence, and feelings of lack of control over themselves and their environment. These and other manifestations may make children feel negative about themselves and the world. They experience guilt and may blame themselves when confronted with disappointment and failure.

Growing up can be painful even under the best circumstances. It is difficult for the child in the early school years to live up to so many rapidly developing standards. Guilt and anxiety develop. Finger sucking, nail biting, excessive fears, stuttering, and conduct problems are reflections of nervous tension.

Organic Behavioral Disorders

Environmental or Biochemical Behavioral Disorders