Adolescent Psychiatric Nursing



Adolescent Psychiatric Nursing


Audrey Redston-Iselin





Adolescence is a time of transition—an age when the person is not yet an adult but is no longer a child. Psychiatric nurses treating adolescents focus on their movement toward adulthood, considering social, emotional, and physical aspects of their adjustment in their family, school, and peer groups. Many mental health disorders begin in adolescence, and if they are not diagnosed and treated, they continue into adulthood, often becoming chronic illnesses.



Developmental Stage


Adolescence is a unique stage of development that occurs between the ages of 11 and 20 years, when a shift in growth and learning occurs. The adolescent must cope with physical, cognitive, and emotional changes that can be stressful and lead to behaviors that are uniquely adolescent. Different views of adolescence are described in Table 36-1. Tasks that should be accomplished during adolescence include the following:





Biological View of Adolescence


One of the fundamental features of adolescence is the series of biological changes known as puberty. These changes transform the young person physically from a child into a reproductively mature adult. This process is so basic to adolescent development that many people identify puberty as the beginning of adolescence. Puberty involves a set of biological events that produce changes throughout the body. The biological changes fall into two categories: hormonal and brain development.


In both genders, increases in hormone production lead to the development of reproductive capability and a mature physical appearance. Physical changes include pubic hair growth, breast development, and menarche in girls and genital development, pubic hair growth, voice change, and the emergence of facial hair in boys. A spurt in height and weight occurs in both genders. Although all adolescents experience the changes of puberty, there are large individual differences in the timing of these changes and the pace at which they take place. Hormone levels can influence the behavior of teens and result in emotional extremes such as mood swings and emotional outbursts.


Brain growth continues in adolescence. Although the number of neurons does not increase, the support cells that brace and nourish the neurons begin to proliferate. Growth of the myelin sheath around nerve cell axons continues at least until puberty, enabling faster neural processing. Simultaneously, the number of interconnections between adjacent neurons decreases, probably reflecting the disappearance of redundant or inappropriate neural connections. This fine-tuning of the neural system coincides with the development of formal operational thought, described by Piaget as adult cognitive thinking. Physical response to stress in teens occurs more rapidly than in adults because the prefrontal cortex, the area of the brain that calmly assesses danger and calls off a stress response, is not fully developed.



Assessing the Adolescent


Nursing care of adolescents begins with a thorough assessment of their health status. Data collection by the nurse is based on current and previous functioning in all aspects of an adolescent’s life (American Academy of Child and Adolescent Psychiatry, 2005). A variety of approaches and tools may be used, but data collection should include the information listed in Box 36-1. These data are collected from adolescents and significant others through interviews, examinations, observations, and reports. The nurse also may ask the following questions of the adolescent’s family:




One outcome of the nursing assessment should be the identification of teenagers at high risk for problems. Nurses need to understand the difference between constructive and age-appropriate exploration and engagement in activities that are potentially dangerous and threaten the adolescent’s physical and emotional well-being. Focus should be on how the teenager is functioning in all areas of their lives. The Youth Risk Behavior Surveillance System (Centers for Disease Control and Prevention, 2010) conducted a national school-based survey of students in grades 9 to 12. The data reveal many threats to the health and well-being of teenagers, as seen in Box 36-2.



BOX 36-2   2009 NATIONAL YOUTH RISK BEHAVIOR SURVEY OVERVIEW




• 10% of students had driven a car or other vehicle one or more times when they had been drinking alcohol during the 30 days before the survey.


• 17% of students had carried a weapon (e.g., gun, knife, or club) on at least 1 day during the 30 days before the survey.


• 31% of students had been in a physical fight one or more times during the 12 months before the survey.


• 20% of students had been bullied on school property during the 12 months before the survey.


• 14% of students had seriously considered attempting suicide, and 6.3% of students had attempted suicide one or more times during the 12 months before the survey.


• 19% of students smoked cigarettes on at least 1 day during the 30 days before the survey.


• 42% of students had had at least one drink of alcohol on at least 1 day during the 30 days before the survey.


• 21% of students had used marijuana one or more times during the 30 days before the survey.


• 46% of students had ever had sexual intercourse.


• Among the 34% of currently sexually active students, 61% reported that either they or their partner had used a condom during last sexual intercourse, and 23% reported that they or their partner had used birth control pills or Depo-Provera to prevent pregnancy before last intercourse.


• 12% of students were obese, and 16% of students were overweight.


• 11% of students went without eating for 24 or more hours to lose weight or to keep from gaining weight during the 30 days before the survey.


• 5% of students took diet pills, powders, or liquids to lose weight or keep from gaining weight during the 30 days before the survey.


• 4% of students vomited or took laxatives to lose weight or to keep from gaining weight during the 30 days before the survey.


A profile of the high-risk adolescent is presented in Figure 36-1. Teenage behaviors that contribute to death and injury include smoking, poor diet, lack of physical activities, alcohol and drug abuse, unprotected sex, violence, suicide, homicide, and automobile crashes. Several high-risk behaviors, including substance use, delinquency, risky sexual behavior, and self-injury among adolescents, have been linked to victimization involving interpersonal violence. This includes experiencing sexual or physical assault and witnessing domestic or community violence (Danielson et al, 2006).



A number of other factors combine to impact adolescent risk-taking behavior, including age, socioeconomic status, education, race, gender, self-esteem, autonomy, social adaptation, vulnerability, impulsivity, and thrill-seeking activity. The issues of body image, identity, independence, social role, and sexual behavior can produce adaptive or maladaptive responses as the adolescent attempts to cope with the developmental tasks at hand.


Nurses who work in schools and community settings can engage in screening and early nursing intervention with high-risk teenagers to promote adaptive responses and prevent the development of future problems (Gance-Cleveland and Mays, 2008). They can teach coping skills that can promote healthy adaptation and integrated adult functioning.




Body Image


Physical growth is uneven and sudden, rather than smooth and gradual, and it causes a change in body image. Chronological age is not a true guide for physical maturation because growth often occurs in spurts and individual differences exist. Because school classes and extracurricular activities are usually grouped by age, the adolescent must face being with others who vary greatly in physical development and interests. This explains why adolescents often imitate behavior to fit in with one’s peers. The greater a person’s difference from the rest of the group, the greater is the adolescent’s anxiety.


Adolescents continuously reevaluate themselves in light of these physical changes, particularly the onset of primary and secondary sex characteristics that are so pronounced. They tend to compare themselves and their physical development with their peers. They are very concerned about the normality of their physical status. The physical changes of puberty cause adolescents to be self-conscious about their changing bodies. They may even be reluctant to have medical examinations because they fear abnormalities will be found.



Identity


In response to the physical changes of puberty, adolescents experience heightened periods of excitement and tension. They use defenses against these feelings that were helpful in childhood and experiment with new, more adult-like attempts at mastery. Thus in their attempt to cope, adolescents sometimes act like adults and at other times behave like children.


For example, adolescents can show behavior marked with experimentation and test the self by going to extremes. This can be useful in establishing self-identity. The rebelliousness or negativism of the adolescent shows a movement toward individuation and autonomy that is more complex but similar to the 2-year-old child’s “no.” Adolescents also may assert themselves by acting in a negative or contrary manner when relating to parents and other authority figures whom they believe are not allowing them to be separate and unique. This is seen in the following clinical example.



Adolescents often use the peer group to separate themselves from their parents and form their own identity. Exploratory behavior allows the adolescent to try on new roles and find what fits. The peer group is often used as a means to try these new roles in the safety of the group. Parenting styles that encourage individuality and relatedness to families are associated with support of adolescent identity exploration.


Adolescents expressing high levels of identity exploration have parents who express mutuality and separateness, encourage family member differences, and are aware of clear boundaries between themselves and their teenagers. These adolescents also are more likely to have positive approaches to peer and social relationships and more developed skills in initiating, diversifying, sustaining, and deepening peer friendships.



Independence


Adolescents have an unconscious desire to give in to their dependency needs, but adolescence also is a time of movement toward independence. Adolescents may show this ambivalence by responding to petty annoyances and irritations with intense outbursts. They see the process of gaining independence as being free of parental control. They do not see gaining independence as a gradual learning process but as an emancipation accomplished by acting differently.


They believe that acting like an adult equals being an adult. They expose themselves to situations beyond their capabilities and then become overwhelmed and frightened. They seek reassurance in an attempt to reduce their anxiety by returning to childlike ways and being dependent on those with whom they feel most secure, usually their parents. This accounts for the inconsistency of adolescent behavior.


Well-adjusted adults usually use a problem-solving approach and do not feel threatened when inexperience requires dependency on others. Teens, however, often feel threatened as if they are regressing into childhood. They therefore deny their need for their parents. They sometimes criticize their parents for treating them as children, but at other times, they complain that their parents are not helpful enough.


The interaction between adolescent changes in autonomy and family relationships is important. Three parenting styles have been described in relation to whether they help or hinder independent functioning in adolescence:



• Traditional parents tend to value a sense of continuity and order. They accept the value judgments that come from previous generations. Adolescents from these families tend to be more attached to their parents, conforming, and achievement oriented. Often they avoid major conflicts in their teenage years.


• Authoritarian parents are oriented toward shaping, controlling, and restricting the adolescent to fixed standards. Obedience is seen as a virtue. Power and responsibility are not shared with the adolescent. Harsh discipline is used to curb autonomous strivings that are viewed as willfulness. The approach here is often punitive, and it can result in problems with the adolescent’s development of autonomy.


• Democratic parents do not believe that their standards are always right. They tend to be supportive and respond to the specific situation with solutions that promote the adolescent’s autonomy. They foster stimulation and challenge. This parenting style combines limit setting with negotiation, encouraging the teenager’s participation in the disciplinary process. It is shown to predict greater independent functioning in adolescents.




Social Role


Adolescents respond intensely to people and events. They may be totally invested in one interest and then suddenly change to something else. They are easily hurt and disappointed by others. They have a tendency toward hero worship and crushes, but with little evaluation of the people to whom these feelings are directed. They often mimic each other’s dress, speech, language, and thoughts. These relationships help in the development of self-identity and establishment of a social role by allowing for exploration.


The peer group is very important because within the security of the peer group, adolescents can attempt to resolve conflicts. With peers they can test out their thoughts and ideas and, through mutual sharing, they can try to find answers. The peer group also can explore other ways of dealing with problems and offer its members companionship, protection, and security. In the peer group, adolescents can accept dependency, not as a child but as one of the group, testing ideas and trying new values. Within the safety of the peer group, they can observe, comment on, and evaluate the activities of others. Adolescents usually are very loyal to their friends. Group security is sometimes so important that it is pursued at all costs, even if it involves destructive behavior.


Adolescents react to many stimuli and drain off the tension created by new drives and impulses by investment in many interests. They do this with great intensity, which is why adolescents are susceptible to fads. This is often seen in their dress, music, or hobbies. Close relationships with the opposite gender provide adolescents with security (often by “going steady”) and a person with whom to discuss problems and evaluate solutions. This reciprocal relationship enhances self-esteem by demonstrating sexual attractiveness and indicates that one is lovable.




Sexual Behavior


Adolescents use fantasy to discharge sexual tension. However, they may feel guilt and shame about sexual feelings or fantasies. Fantasies usually are an attempt to find solutions and evaluate consequences. Masturbation is another way in which adolescents discharge sexual tension. The value of masturbation may be lessened if shame and guilt accompany it. Male adolescents often fear discovery of evidence of ejaculation, and females often fear changes in their genitalia as a result of masturbation. Mutual masturbation can help to dispel anxieties about sexuality by assuring adolescents that they are sexually adequate.


More teens are engaged in sexual activity, including intercourse and oral sex, than ever before and at an earlier age. Some believe that this is a result of media and music influences, inattentive parents, and early pubescence. Society gives very mixed messages to adolescents about sex, encouraging teens to wait to have sex or at least to be safe from disease or pregnancy with condom use. Whatever the cause, there is rising concern about the emotional and physical consequences of early sexual activity.


Although 5% to 10% of U.S. youth acknowledge homosexual experiences and 5% feel that they could be gay, homosexual experimentation is common during late childhood and early adolescence. Experimentation may include mutual masturbation and fondling of the genitalia and does not by itself cause or lead to adult homosexuality. Specifically, nurses need to be aware of the following:



Societal acceptance of homosexuality varies among cultures. Destructive attitudes toward homosexuality can result in homosexual adolescents repressing their desires by withdrawing and becoming asexual. The developmental process of identity formation can be jeopardized and healthy emotional adjustment inhibited. Sexuality and sexual identity are discussed in detail in Chapter 25.



Maladaptive Responses


Behaviors that impede growth and development may require nursing intervention. The nurse should consider the nature of the adolescent’s maladaptive responses and the harm resulting from them. If the difficulty is significant and ongoing, intervention is needed. It has been found that early adolescent problem behavior is associated with a high risk for adult pathology (National Research Council, 2009).


Adolescents are diagnosed with the various Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) psychiatric illnesses described in Chapters 15 through 25 of this text. The nursing interventions described in these chapters can be implemented with adolescents, along with the various treatment modalities described in Chapters 26 through 32. Evidence-based treatment strategies for adolescents have been identified that take into account the particular developmental issues and the unique challenges of establishing a therapeutic alliance with an adolescent (Evans et al, 2005).


Approximately one in every four or five youth in the U.S. meets criteria for a mental disorder with severe impairment across their lifetime. A national survey found that anxiety disorders were the most common condition (31.9%), followed by behavior disorders (19.1%), mood disorders (14.3%), and substance use disorders (11.4%). The median age of onset was earliest for anxiety (6 years old), followed by 11 years for behavior disorders, 13 years for mood, and 15 years for substance use (Merikangas et al, 2010).



Inappropriate Sexual Activity


Sexual behaviors can be the cause of many teenage problems. Some of the negative outcomes as a result are described in Box 36-3 (Centers for Disease Control and Prevention, 2009). Sexual activity is often not as much an outlet for sexual passion as an attempt to achieve closeness with another person. Adolescents tend to use their sexuality to sublimate other needs, such as those for love and security and personal anxiety about sexual adequacy. Peer group pressure also may lead to the adolescent to inappropriate sexual relations.



Some adolescents engage in sexual relations as a means of punishing themselves. Their promiscuity elicits external control and criticism from others. Others have poor self-esteem and assume promiscuity makes them popular. Some have had poor role models and imitate destructive adult sexual acting out behaviors as seen in the following clinical example.



The additional risk of sexually transmitted diseases, including human immunodeficiency virus (HIV), makes sexual experimentation more problematic because of its potential short-term and long-term effects. Adolescents’ needs for exploration and sexual gratification, as well as their feelings of invincibility, put them at great risk for HIV infection and other sexually transmitted diseases.


Despite educational efforts, many adolescents are misinformed about the transmission of these illnesses and effective preventive strategies. Some believe “it can’t happen to me” or think that having only one partner ensures their safety. Unprotected sex is the area of highest risk. Oral, anal, and vaginal contacts all pose a risk because they involve the transfer of body fluids that can contain viruses. Alcohol and drug use increases the risk potential of adolescents because they are more likely to have unplanned and unprotected sex. This may be a result of these substances reducing their inhibitions.



Teen Pregnancy


Pregnancy in adolescence is a complex issue. Some adolescent girls have low self-esteem and fears of inadequacy. To ease these fears, they may become pregnant. Occasionally, an emotionally deprived adolescent hopes to give her child what she believes she has never received. More often, she may hope to receive from the child what she has not been given.


Some teens see pregnancy as a way to change their circumstances, become independent from parents, or escape a dysfunctional family situation. Sometimes being pregnant is an effort to force the parents to agree to a marriage that may be inappropriate, as shown in the following clinical example.



Pregnancy in adolescence can occur accidentally after sexual exploration. The adolescent may be unaware of contraceptive methods or may have delayed obtaining contraceptives. Research suggests that most teenage girls delay seeking contraceptives and become pregnant because they are unwilling or unable to make conscious decisions about their sexual and contraceptive behavior.


Regular contraceptive use among sexually active adolescents requires that they believe that they can become pregnant and that using contraceptives is safe and the only way to prevent pregnancy. They also must have access to reliable, affordable contraceptives and must have a positive self-concept that allows them to make conscious decisions about their sexual and contraceptive behavior. They must want to postpone childbearing. Nurses are in an ideal position to educate teens about contraception and abstinence.


If pregnancy for unmarried adolescents is associated with sexual promiscuity, the girl may be ostracized. Pregnancy sometimes occurs within a close, caring relationship. Peer groups can be supportive of a girl who becomes pregnant as a result of a meaningful relationship but intolerant of one whose pregnancy is the result of promiscuity. The circumstances and the adolescent’s level of maturity need to be assessed. In some cultures, out-of-wedlock pregnancies are an accepted part of adolescence.


The most influential factor that discourages teens from having early intercourse is their connection to a parent, especially the mother. Mothers who are clear about their values and communicate them to their teenagers in a nonpunitive way have the most influence on teens postponing intercourse.


Decisions involving abortion, placement of the baby, and marriage are difficult to make. Attitudes and laws influencing these decisions are diverse. Forcing the adolescent to have the baby or have an abortion can be traumatic. Some families include the baby as another sibling. Negotiating school, social life, and baby care is a difficult challenge.


Marriage is another alternative. Forcing adolescents to marry to avoid societal stigma usually adds to their problems. However, if the couple is mature, they may do well in marriage. All the alternatives should be presented to the adolescent, with the consequences clearly stated. The adolescent should make her decision with the aid and support of her partner, her family, the nurse, and other involved health care professionals.


Teenage mothers who choose to have the baby may be at risk for posttraumatic stress disorder due to the birth experience. Vulnerable teens need to be assessed for past traumas. Nurses are in the position of minimizing the potential trauma of the birth experience by providing an educational program specifically directed toward teens that includes knowledge about labor and delivery, pain management, and postpartum care. This can help make the experience a less frightening one. Involvement of a positive caregiver and of the father can result in more positive outcomes for the teens and their babies (Anderson and McGuinness, 2008).




Mood Disorders


Depression


Adolescent depression is the most common mental health disorder, and it can be fatal (Box 36-4). The symptoms of depression in adolescence listed in Box 36-5 differ somewhat from those seen in adults (American Academy of Child and Adolescent Psychiatry, 2008). Adolescents have difficulty describing their emotional or mood states. Young teenagers often do not complain about the way they feel and instead act moody and irritable. Youth who develop depression between ages 14 and 16 years are at greater risk for major depression later in life.




Teens who are depressed have negative perceptions of their current lives and their future. These thoughts result in low self-esteem, a sense of hopelessness, and cognitive distortions that interfere with appropriate problem solving. Adolescents at greatest risk are those with a family history of depression.


Between the ages of 11 and 15 years, the rate of depression in girls rises rapidly, whereas only a slight increase in rate occurs in boys. Girls worry more than boys, feeling that they have less control over their environment and what is happening in their lives. Boys tend to focus more externally on their actions and activities. For both groups, however, symptoms of depression in adolescence strongly predict an episode of major depression in adulthood.


Interventions for depression in adolescence are similar to those for adults. Cognitive behavioral therapy (CBT) is an effective intervention for adolescents who are depressed. It identifies and modifies negative cognitions or thoughts that underlie depression (see Chapter 27). It also focuses on coping strategies to deal with situations that trigger emotional problems (Nelson and Tusaie, 2011).


Adolescents respond differently to medication because they do not show evidence of hypercortisolemia (excessive production of cortisol) as adults often do. Research shows that depressed adolescents do not respond well to the tricyclic antidepressants. Among the selective serotonin reuptake inhibitors (SSRIs), only fluoxetine is approved for adolescent depression, with care to monitor for suicidal ideation.


The mechanism of suicidal ideation with SSRI use is unknown. It is thought that serotonergic transmission includes behavioral activation in some teens, causing irritability, agitation, and impulsiveness. This resulted in black box warnings for the use of SSRIs with adolescents in 2004, which was revised in 2007 to include young adults up to age 24.


Depression in teens is a serious mental health issue that can result in suicide if not treated. A combination of CBT and medication produces the best results (Vitiello and Pearson, 2008). Adding CBT can enhance the effects of antidepressants by providing coping skills for managing conflicts and stressful events and by providing alternative constructive ways to deal with anger, frustration and loss. Coping skills, if used successfully, can promote healthy adaptation. Safety plans should be established and maintained. Reducing access to firearms and prescription and over-the-counter drugs and working on improving communication in the family can improve outcomes.



Bipolar Disorder


Originally thought to be rare, bipolar illness in teens is receiving more attention. Interventions for bipolar disorder in teens need to consider the level of development, ensuring that interventions are age appropriate. The risks and benefits of medication need to be carefully explained. Education distinguishing normal outbursts from extreme moodiness should be presented to parents, and the differences between adult and adolescent bipolar behavior must be clarified.


Adolescents have more frequent mood fluctuations that are less episodic in nature than adults. They also express their feelings differently, which must be understood in the context of their development if interventions by the nurse are to be successful. Consideration should be given to the fact that parental depression may interfere with interventions for teens with mood disorders.


Psychopharmacological treatment of teens with bipolar disorder is similar to adults in the use of mood stabilizers (e.g., lithium, divalproex, lamotrigine) and atypical antipsychotics (e.g., olanzapine, risperidone). They sometimes can be used together providing a synergistic effect.

Feb 25, 2017 | Posted by in NURSING | Comments Off on Adolescent Psychiatric Nursing
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