Child Psychiatric Nursing

Child Psychiatric Nursing

Sally Raphel

Although one of five children has a clinically significant psychiatric disorder, only one third of them receive treatment. The ratio of dollars saved in later life to each dollar spent treating children early is 28 to 1 (Kluger, 2010). The Global Burden of Disease Study indicates that by the year 2020, childhood neuropsychiatric disorders will increase by more than 50% internationally to become one of the five most common causes of morbidity, mortality, and disability among children in the world (Murray and Lopez, 1996; Mental Health America, 2011).

Child Psychiatric Care

Children and youth with mental health problems have lower educational achievement, greater involvement with the criminal justice system, and fewer stable and long-term placements in the child welfare system than children with other disabilities. Research shows that one half of all lifetime cases of mental illness begin by age 14 (Kessler et al, 2009).

When treated, children with mental health problems do better at home, at school, and in their communities. The statistics regarding child mental health are alarming.

• Every 33 seconds, a child is abused or neglected.

• Every 36 seconds, a child is born without health insurance.

• Every 39 seconds, a child has a child.

• Every 3 hours, a child is killed by firearms.

• Children and youth in elementary school with mental health problems are more likely to be unhappy at school, absent, suspended, or expelled.

• Fifty percent of children in the child welfare system have mental health problems.

• Seventy percent of youth in the juvenile justice system have a diagnosable mental disorder.

• Alcohol and drug use begins by 8 years of age in some children and can be a significant problem by age 12 years. Among eighth graders, 41% have had at least one drink of alcohol, 20% of them report having been drunk, 25% have smoked cigarettes, and 16% have used marijuana (Carter Center, 2008).

Adding to these concerns is the increase in school-related shootings and other violent behavior displayed by young children in family and community settings.

Another disturbing issue is the prognosis of a child who has been diagnosed with a psychiatric illness. Mental illness that develops before age 6 years can interfere with critical aspects of a child’s emotional, cognitive, and physical development. For example, there is an association between conduct disorder in a child and the development of antisocial personality disorder later in life. Prior anxiety, behavior, and mood disorders all increase the likelihood of the child having psychiatric problems as an adult.

Prevention, early identification, and treatment of children at risk is essential to reduce the risk for psychiatric disorders reaching into their adult lives. Although the number of children receiving care has significantly increased in the past decade, youth and families continue to suffer because of missed opportunities for prevention of psychiatric disorders and early interventions in behavioral problems.

Causative Factors

Genetic factors (nature) and childhood environment (nurture) are predisposing and precipitating causes for the development of a psychiatric illness. For example, traumatic events can have a profound impact on children (Sadock and Sadock, 2007). The symptoms of posttraumatic stress disorder (PTSD) in children are those of increased arousal, including hypervigilance, irritability, anxiety, physiological hyperactivity, impulsivity, and sleep difficulty. These symptoms are often misdiagnosed as attention deficit hyperactivity disorder (ADHD), conduct disorder, anxiety disorder, and mood disorder.

After traumatic events, many factors influence the intensity of symptoms, including the nature of the trauma, whether body integrity was threatened, the threat posed to the child’s self-system and security, and the nature of the family support system (Copeland et al, 2010).

The type of symptoms a child experiences is often related to the family history. Specifically, if a family member has a history of anxiety disorder, the child may experience symptoms that are more anxious in appearance. However, if family members have a strong history of alcoholism and sociopathy, symptoms may be more related to a conduct disorder. A genetic predisposition to certain symptoms is inherited, and these symptoms can be stimulated as a response to a stressful event in the environment.

The neurophysiology activated during acute stress is usually rapid and reversible. The brain has mechanisms that down-regulate the stress reaction after the threat has passed, returning the brain to its prior level of functioning. However, if the stress is prolonged, severe, or repetitive, the resulting increases in neurotransmitter activity are often not reversible. This process has a significant impact on the development of the child’s brain.

A trauma-induced brain response can result in abnormal patterns, time, and intensity of catecholamine activity in the developing brain. Young children who are exposed to a high rate of stress-induced trauma are at risk for developing permanent changes in neuronal organization, making it more difficult for them to learn and to control their behavior.

Other psychiatric disorders, such as ADHD, also show the interaction of genetics and environment. Children with ADHD usually exhibit excessive activity and have difficulty paying attention. These behaviors are often tolerated by a family, but when the children begin school, it can be problematic if these behaviors interfere with academic performance and peer relationships. As in PTSD, children with ADHD often have a range of symptoms, including symptoms that overlap with anxiety disorders, mood disorders, oppositional defiant disorder, and conduct disorder.

Although the exact cause of ADHD is unclear, it is believed that environmental factors, such as lead ingestion, prenatal and perinatal complications, socioeconomic factors, genetic factors, and brain dysfunction resulting from brain damage, may contribute to the development of the illness. Although no single finding explains the cause of this disorder, there is agreement that it has a neurobiological basis. By the time a child and family seek treatment, the child may have developed secondary mental health problems, such as low self-esteem and poor socialization (Van Cleave, 2008).


A child’s individual characteristics and early life experiences, as well as protective factors in the social and physical environment, contribute to resilience, the child’s ability to withstand stress. Resilient children are active, affectionate, and good natured. They are also humorous, confident, competent, realistic, flexible, and assured of their own inner resources and support from outside sources.

Resilient children have a strong sense of personal control, take age-appropriate responsibility, and exercise self-discipline. When faced with stressors, they show the capacity to recover quickly from temporary collapse and attempt to master stress rather than retreat or defend against problems.

Although developmental consequences of living in chaotic and stressful environments can be devastating for some children, not all children are harmed or develop psychiatric disorders (Coker et al, 2009; Vericker et al, 2010; Yoo et al, 2010). It has been estimated that 80% of children exposed to powerful stressors do not have developmental damage. Children from similar family and community environments can have the same negative experience (e.g., poverty, parental psychiatric and substance abuse disorders, violence, war, dislocation) but not experience the same degree of emotional or physical problems.

Specific protective factors make some children more resilient than others (National Research Council, 2009). A sense of autonomy is one resiliency factor. Another is adaptive distancing, which occurs when a child is able to distance oneself from too close involvement with a dysfunctional family, transcend a difficult past, and select healthy alternatives as they become available. Other protective factors include the following:

Resilient children have parents who model resilience, care for them in a routine and stable way, and are available to them with reassurance and encouragement during times of trouble. These support persons help children understand and process stress and trauma. Resilient children have the ability to make sense of threatening situations and understand what is happening in their environment, which then helps them cope with stress.

A Framework for Nursing Practice

To be effective in the psychiatric care of children, nurses must have knowledge of child growth and development. Nursing interventions should be based on meeting the developmental needs of the child and not on parental, societal, or academic standards. Nurses should identify realistic, well-defined goals, respond to the social needs of the child, advocate for the child, and develop a comprehensive treatment plan that identifies and integrates the child’s needs and family resources. This must be done with the realization that the behavior of children is largely culturally based and must be viewed from a sociocultural perspective.

Organizing child psychiatric nursing care around ego competency skills is an effective and culturally sensitive way of planning and implementing nursing interventions for children regardless of psychiatric diagnosis or setting. The nine skills that all children need to become competent adults include the following (Strayhorn, 1989):


The first goal of the nurse is to establish a therapeutic alliance with the child and the parents. If the child’s verbal communications are vague or unclear, the nurse needs to ask for additional explanation. A child often does not respond to a problem-centered line of communication. In this case, the nurse should start with discussing more general aspects of the child’s life, such as family members, school, or friends. Strategies for communicating with children are identified in Box 35-1.

Children with internalizing disorders, such as depression or anxiety, are often the best informants about their affective states. Children with externalizing disorders, such as ADHD or conduct disorder, are typically poor informants and usually less cooperative in an interview. They tend to blame others, thereby requiring reports from parents, teachers, day care, or school personnel to obtain information about problems and progress.

Cultural Competence

Cultural competence is essential to the delivery of mental health services to children and their families. Cultural issues and communication among the child, family members, and clinician are a critical part of the care provided and the success of the child’s outcomes. Culturally relevant clinical standards and implementation guidelines have been developed (U.S. Department of Health and Human Services, 2000). They help mental health professionals working with African Americans, Hispanics, American Indians/Alaskan Natives, and Asian/Pacific Island Americans.

To ensure cultural competence, the nurse must understand the child’s background, communicate effectively across cultures, and formulate treatment plans in partnership with the child and family. The nurse must develop knowledge, understanding, skills, and informed attitudes about differences related to the following:


Assessment of the child requires a biopsychosocial approach that includes biological development, medical illness, cognitive and personality characteristics, cultural context, and the child’s family, school, and social environment. The goals of assessment are to determine the child’s emotional, cognitive, social, and linguistic development and to identify the nature of relationships with family, school, and social milieu. The parts of a psychiatric assessment are shown in Box 35-2.

Multiple sources of information can be used when forming an assessment, including family (e.g., parents, caregivers), school and day care personnel (e.g., teachers, parents, counselors, principals), sitters, after-school program staff, athletic coaches, scout leaders, and bus drivers. An understanding of the child’s competencies related to the child’s stage of development is critical to forming a well-grounded diagnosis.

Key Areas

Establishing a therapeutic alliance with the child begins during assessment. Playing with or watching the child play with age-appropriate toys or games is an effective way to observe interactions with parents, caregivers, or others. Several key areas of assessment merit further discussion.

• Developmental history includes demographic information, a description of the presenting problem, identification of recent stressors in the family or home, and a history of the child’s prenatal, neonatal, and first year of life, including developmental milestones. The child’s general behavior, sexual behavior, and past and present personality traits should be recorded. Whether a child is seen as shy, timid, unfriendly, aggressive, risk taking, fearful, or morose is important.

• Family history involves collecting information about all members of the child’s family. This will add to understanding the context of the child’s current problems. Data about family members’ psychiatric diagnoses and psychological and social functioning can be key to determining the child’s resources. A family genogram can be a useful tool in gaining an understanding of family issues that span multiple generations (see Chapter 10).

• Stress and trauma history is significant to the child’s current situation when there has been caretaker absence, abandonment, or neglect; physical, sexual, or emotional abuse; placement in a foster home; or parental divorce or separation.

• Strengths of the child relate to the ability to cope and adapt, resilience, and ego strengths. These can enhance the possible treatment outcomes. A strength-based assessment identifies the resources the child has available internally and externally. It focuses on prior and current achievements, no matter how small. These resources can then be reinforced by the nurse and treatment team.

A mental status examination (MSE) should be completed. A standard format is followed with regard to appearance, orientation, general interaction, speech and language, motor ability, intelligence, and memory (see Chapter 6). The nurse also must assess cognitive, reading, and writing abilities; social relatedness; judgment; and insight.

For each area of the child MSE, the differences as compared with the adult version are significant. For example, it is critical to observe the child from a developmental perspective (e.g., depression may be confused with shyness). Social relatedness also is important (e.g., observation of personal boundaries and the child’s view of the emotional state of others), particularly behaviors when separating from a parent. Alertness is significant because sleepiness could be a medication side effect or a symptom of depressive disorder.

Perceptions and hallucinations, if expressed, must be evaluated along with the child’s level of concrete thinking. For example, a child may report seeing something the interviewer does not see, which with clarification, is a picture on the wall behind the interviewer. An evaluation of thought content may reveal suicidal or homicidal tendencies, delusions, or unusual preoccupations. Mood should be explored for sadness or anxiety.

Ego Competency Skills

The nursing assessment focuses on the specific skills that all children need to become competent adults. Regardless of the psychiatric diagnosis, a child should be assessed for mastery of the following nine ego competency skills.

Handling Joint Decision Making and Interpersonal Conflict.

Children who have not been allowed to participate in joint decision making or who have not been rewarded for cooperating may be deficient in this skill. A child with oppositional defiant disorder may use aggression instead of negotiation to respond to interpersonal conflict. However, learning the skill of joint decision making is critical for success in interpersonal relationships. The following questions are used to evaluate this skill:

Celebrating Good Feelings and Feeling Pleasure.

Healthy children raised in a nurturing environment naturally experience good feelings and pleasure. However, children who are depressed or anxious many not be able to celebrate good feelings or experience spontaneous pleasure. In a maladaptive environment, shame is often used to control children’s behavior, and they feel guilty for having angry or unacceptable thoughts. Consequently, they may lose the ability to celebrate life and feel pleasure. The following questions are used to evaluate this skill:

Brain Imaging

Brain imaging can be used to track neuronal maturation of the child. Through brain imaging, physiological and developmental brain abnormalities can be identified. The main findings of neuroimaging studies were that brain abnormality locations fell into three groups of psychiatric diagnoses: (1) affective disorders associated with frontal-limbic changes; (2) psychiatric disorders with cognitive changes associated with cortex changes; and (3) psychomotor disorders associated with basal ganglia abnormalities (Mana et al, 2010).

A neuroradiologist can describe the degree of myelinization of an infant or toddler, the relative size of the ventricles, or the presence of atrophy visualized in routine brain magnetic resonance imaging (MRI) protocols. These techniques are being used in the study of ADHD, schizophrenia, anorexia nervosa, obsessive-compulsive disorders, autism, affective disorders, and Tourette syndrome (Shaw, 2010). Techniques used with proper release signed by a parent include MRI, functional MRI, magnetic resonance spectroscopy, magnetoencephalography, positron emission tomography (PET), and single-photon emission computed tomography (SPECT) (see Chapter 5).

Scientists have found that ADHD, childhood onset of bipolar disorder, and lead intoxication may have many similarities in presentation, and neurobiological tests cannot always give accurate classification of their important differences. These techniques may provide powerful tools for clinicians to use in following the course and treatment effects and predicting outcomes for children with neurodevelopmental conditions and disorders, such as autism and depression. This is supported by the major progress seen in the research on autism spectrum disorder since 2000 (Guttman-Steinmetz et al, 2009; Lichtenstein et al, 2010; McGuinness and Lewis, 2010).


Psychiatric Diagnoses

Children with psychiatric illness experience disabling symptoms that are responses to biological alterations, traumatizing situations, or maladaptive learning. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) (American Psychiatric Association, 2000) classifies disorders usually first evident in infancy, childhood, or adolescence. Children also can experience a number of psychiatric illnesses common to adults.

The most common psychiatric disorders seen in children are ADHD, depression/bipolar disorder, anxiety, conduct disorder, and autism. Table 35-1 summarizes the symptoms, assessment, developmental factors, and nursing implications for each of these disorders and other psychiatric disorders of children.

TABLE 35-1


Mental retardation (MR) Beginning before age 18 years, MR involves low intelligence and resulting difficulties requiring special help for child in coping with life. Based on intelligence quotient (IQ):
Mild: 55-70
Moderate: 40-55
Severe: 25-40
Profound: less than 25
Many causes detected through laboratory studies
Tools to measure IQ and developmental quotient (DQ) vary.
A child with associated physical features is diagnosed earlier.
Denver and Bayley scales for ages 1-42 months are helpful.
Safety needs must be closely monitored.
Self-esteem is usually low and requires frequent reevaluation and enhancement.
Higher-functioning child usually has a sense of humor, and some have a rich fantasy life.
Pervasive developmental disorders (PDDs):
Rett disorder
Childhood disintegrative disorder
Asperger disorder
Development is slow, sometimes never comes.
Inability to socialize, communicate, and control motor movements.
Aspects of these disorders overlap many others.
Neurological disorders must be explored with careful attention to gross and fine motor coordination.
The degree of disability varies, but the effects on child and family are profound and permanent. The child may use language inappropriately and ask personal questions that require redirection.
Learning disorders:
Written expression
Academic problem
Learning disorder NOS
Child is found to be substantially below expected skill level and has more difficulty than normal in learning specific academic skills.
Consideration is given to intelligence level, age, and experience with appropriate education.
Often some history points to the problem and correct diagnosis.
An interview with a child experiencing reading difficulty is also used to examine for accompanying disorders (e.g., ADHD, communication disorder).
Unlikely to be evident until school age. Take time and support child from a strength-based perspective to assist self-esteem issues.
Build on child’s achieved communication skills, and consult with educational specialist for specific methods.
Motor skills disorders: Developmental coordination disorder A child whose motor coordination is seriously below expectation for intelligence and age.
Very young child may have delayed milestones or older child may have fine motor difficulty in sports or handiwork.
Cause is unknown.
Rule out physiological, genetic, neurological, or other contributors.
Criteria for pervasive developmental disorder do not fit symptoms.
The target symptoms are not from medical condition such as cerebral palsy or muscular dystrophy. Fit play interventions to age and development.
Observation in varied activities gives data to build a care plan.
Communication disorders:
Expressive language
Mixed receptive/expressive
Selective mutism
Communication disorder NOS
Impair a child’s ability to communicate with others.
Most are not commonly known and often go unrecognized.
Encourage child to talk uninterrupted for prolonged periods to get samples of speech rate, repetition, dropped sounds, lack of prosody.
Use story telling or have child recount an event as a nonthreatening subject.
Mild case may be missed until teens.
Younger child with MRELD can appear deaf; older child shows confusion.
Stuttering begins in early childhood, and self-esteem issues are important.
Need a clear sense of use of symbols and ability to comprehend and follow commands given without gestures.
Movement and tic disorders:
Developmental coordination
Transient tic
Chronic motor or vocal tic disorder
Tourette disorder
Stereotypic movement disorder
Tic disorder NOS
Tics can be motor or vocal, simple or complex.
Simple motor—grimaces, eye muscle twitches, abdominal tensing, or jerking of shoulder, head, or distal extremities.
Simple vocal—barks, coughs, throat clearing, sniffs, or single syllables called out.
Complex vocals have more organized patterns.
Usually suppressed during sleep; increase in intensity or frequency at times of stress, fatigue, or illness.
Present a wide range of symptoms on a continuum from occasional eye blinking to severe motor and vocal tics so severe they preclude normal classroom participation.
Motor tics appear as young as 2 years and usually involve the upper part of the face; vocal occur somewhat later.
Prognosis for transient tics is better; chronic motor or vocal tics wane within a few years and rarely last into adulthood.
Child with a tic feels out of control of own body. With Tourette disorder, the child has multiple motor tics in addition to vocal ones and may use socially inappropriate, vulgar language (coprolalia).
Nursing plan incorporates empathetic care, self-esteem enhancement, supportive environment to improve social relationships, and medication monitoring and teaching.
Disorders of intake and elimination:
Feeding disorder of infancy or early childhood
Other eating disorders—anorexia nervosa or bulimia nervosa
Intake: Child eats nonnutrient substances (e.g., dirt, paper), regurgitates and rechews food, or fails to eat adequately.
Elimination: Urinating on clothes or bed after age 5 years.
Repeated passage of feces in inappropriate places after age 4 years.
Enuresis is most often viewed as physiological condition with physical symptoms, not necessarily mental disorder. It does have emotional sequelae similar to obesity.
Symptoms of elimination disorders may be embarrassing.
Assess for pain, sensation of need to void.
A few years of maturation can separate the pathological situation from the developmental issue.
Normal toddlers put everything in their mouths. Pica should not be considered unless inappropriate eating lasts longer than 1 month in a child developmentally past the toddler stage.
Focus on the involuntary nature of the elimination problem, as well as the child’s hope for improvement.
Build a therapeutic alliance by using child’s own words for body functions and anatomy.
For eating disorders, direct observation of child and parents at mealtime may help. Most information will come in verbal reports from parent.
Watch for other oral behaviors, nail biting, and thumb sucking.
Attention deficit and disruptive behavior disorders:
Conduct disorder
Oppositional defiant behavior
Child antisocial behavior
Disruptive behavior NOS
ADHD: Child’s behavior comprises either attention deficits or hyperactivity and impulsivity.
Develops as a failure of brain mechanisms for self-control and inhibition of impulses or frontal lobe executive functions.
Conduct disorder: For 12 months or more, child has repeatedly violated rules, age-appropriate societal norms, or rights of others.
Explore problems of inattention, trouble keeping attention on task or play, listening ability, how child responds to and follows instructions, help needed organizing, is easily distracted, and avoids tasks requiring mental effort.
Appears “on the go,” has trouble sitting quietly, talks excessively, consistently squirms or fidgets, inappropriate running or climbing.
Greater emphasis placed on parent and teacher reports of child’s behaviors.
Conduct disorder: Before age 10 years, at least one problem of conduct.
Can be difficult to sort from normal toddler and preschool inattentiveness. Older child may report an inner restlessness. It is important that the nursing plan of care be based on multiple sources of data and reference resources. Talking with child and parent separately is sometimes helpful. Negativistic behaviors are always challenging.
Mood disorders:
Major depressive disorder
Bipolar I or II
Mixed episode
Hypomanic episode
Mood disorder caused by medical condition
Substance-induced mood disorder
A pattern of illness caused by abnormal mood.
Episode refers to any period of time the child is abnormally happy or sad or has uncontrollable mood swings.
Use of thorough Mental Status Exam to explore current level of functioning.
Explore family, particularly parental, history of mood disorder.
Environmental precipitants or traumatic events in young child.
Recurrence or rehospitalization within 2 years.
Very young child expresses depression through irritability, somatic complaints, or refusal to go to school.
Manic symptoms are often misread for hyperactivity of ADHD.
School age may have somatic complaints (headache, stomachache, abdominal pain).
Delusional content depends on developmental stage.
Because child has grown up with the disorder, child may not voluntarily discuss symptoms with parents or teacher.
Full assessment for self-harm and contract for safety.
Establish safe environment.
Monitor sleeping, eating pattern, and medications.
Educate child about effects of compliance.
Work with parents to foster support for child.
Anxiety disorders:
Panic disorder
Specific phobia
Social phobia
Obsessive-compulsive disorder
Posttraumatic stress disorder
Acute stress disorder
Generalized anxiety disorder
Anxiety caused by medical condition
Substance-induced anxiety disorder
Anxiety disorder NOS
Child presents with prominent anxiety symptoms. Symptoms produce disability or distress.
Co-morbidity is the rule. Anxiety symptoms can be found in a child with almost any other Axis I disorder (e.g., as part of mood disorder or in response to separation).
Fears are common in children, but in 2%-3% they cause a clinical level of distress.
Children usually only relive the traumatic incident in dreams (e.g., monsters or frightening images).
Children exhibit compulsions more frequently than obsessions.
Although equally affected, boys’ symptoms begin at an earlier age than girls’.
Children often lack the insight that they feel anxious and express symptoms by clinging, crying, or freezing in position.
Important to remember that anxiety is a normal, even useful, emotion that will change from one developmental stage to the next.
Young children are especially apt to experience PTSD symptoms by talking less and acting out their anxieties.
Be specific when interacting with a child, “Are there things that frighten you? What do you worry about most?” The fears can extend to include situations for parents, friends, siblings, or pets.
Avoidance and vigilant behaviors may be noted. This child does not volunteer a lot of information about thoughts or feelings.
Disorders of relationship:
Separation anxiety
Reactive attachment of infancy or early childhood
Parent-child relational problem
Sibling relational problem
Problems related to abuse or neglect
Inappropriate and excessive anxiety about separation from home or significant person.
Parent-child diagnosis (PCD) is relevant when clinically important symptoms or negative effects on functioning are linked with the way a child and parent interact.
Examine family history for duration and intensity of current problem. Is the interaction difficulty only with one adult (mother, father) and not all adults? All family members involved should be interviewed.
A most common occurrence in child mental health practice.
This area of problem behavior is not considered a mental illness but can become the focus of clinical attention.
Developmental stage and norms are key to understanding the family or interpersonal dynamics.
When attention span and activity levels are within normal range, ADHD and disruptive disorders can be ruled out.
Assess anger, spite, or loss of temper in exchanges with significant others.

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