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).

Resilience

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.

Communication

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:

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.

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.

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).