A significant number of children and adolescents have mental disorders. The Methodology for the Epidemiology of Mental Disorders in Children and Adolescents (MECA) study revealed that 21% of those ages 9 to 17 years had a diagnosable mental or addictive disorder associated with at least minimum impairment; 11% had significant impairment, and 5% had extreme functional impairment (Shaffer, 1999).

Disorders may improve or worsen depending on several factors, including the fluidity of development itself. Environmental factors often play a major role in the improvement or worsening of disorders in any age group. In this age group, for example, an affected child may improve as parental, sibling, school, and peer relationships improve or positively change. On the other hand, disorders may develop or worsen if an adolescent finds little or no relief from real or perceived traumatic stressors.

Environment is not the sole source of more severe disorders, and the child is not cured if only the psychosocial environment changes. In some cases the environment is healthy, but disorders still occur or continue. For example, mental disorders with identified genetic components, including autism, bipolar disorder, schizophrenia, and attention deficit/hyperactivity disorder (ADHD), may erupt in seemingly normal environments (National Institute of Mental Health, 1998).

Prevalence

The prevalence of certain mental disorders is remarkable in children and adolescents (Table 7-1). Anxiety disorders occur more often than any other mental disorder in this age group. ADHD is the most common behavioral disorder of childhood. Development at all levels is interrupted when mental disorders occur in a young person’s life, as evidenced by developmental delays, prolonged developmental periods, and other deviance from standard norms of performance at home, in school, and in relationships.

**TABLE 7-1** Prevalence of Mental Disorders in Children and Adolescents Ages 9 to 17 Years
Category	Percentage
Anxiety disorders	13.0
Mood disorders	6.2
Disruptive disorders	10.3
Substance use disorders	2.0
Any disorder	20.9

Suicides

Statistics for suicidal activity in younger populations remain fairly constant, and the numbers continue to be difficult to accept. According to the Centers for Disease Control and Prevention (1999), during the last decade the following numbers of children and adolescents committed suicide according to age groups:

▪ 1.6:100,000 population for ages 10 to 14 years

▪ 9.5:100,000 population for ages 15 to 19 years

□ Four times more boys than girls commit suicide in this group

□ Twice as many girls attempt suicide in this group

▪ 13.6:100,000 population for ages 20 to 24 years

These numbers have changed across time. Since the 1960s the number of male suicides in the 15- to 19-year-old group has tripled, whereas the female numbers have remained constant. The rate for white adolescent males reached a peak in the late 1980s (18:100,000 in 1986) and declined somewhat by the end of the 1990s. Hispanic high school students are more likely than other students to attempt suicide. African American male suicides increased from 1986 (7.1:100,000) to 1997 (11:100,000). Male American Indian adolescents and young adults in American Indian health service areas had the highest rate in the United States (62:100,000) (Wallace et al., 1996).

Box 7-2 lists additional epidemiologic information for this age group. Statistics show that even among the younger U.S. population, mental disorders take a substantial toll on quality of life and on life itself.

BOX 7-2

Epidemiologic Factors in Disorders of Infancy, Childhood, and Adolescence

▪ From 10% to 12% of all children have mental or emotional disorders severe enough to be disabling as adults.

▪ Only 5% to 7% receive adequate mental health intervention.

▪ Disorders of boys outnumber those of girls 2:1 before adolescence; girls equal or outnumber boys during and after adolescence.

▪ Emotional disturbances increase in children ages 9 to 12 years and 13 to 16 years.

▪ Prolonged stressors increase incidence and prevalence.

▪ Parental marital discord/divorce

▪ Overcrowded living conditions

▪ Low socioeconomic status

▪ Parental psychiatric condition or trouble with the law

▪ Family breakup, separation; foster home placement of child or adolescent

▪ Child abuse (physical, emotional, sexual)

ASSESSMENT AND DIAGNOSTIC CRITERIA

Many mental disorders that affect adults also occur in children and adolescents, including anxiety disorders, mood disorders, substance use disorders, and schizophrenia. With a few exceptions, symptoms of these disorders are the same in young people as they are in adults.

DSM-IV-TR Criteria

Various categories of mental disorders have been identified for infants, children, and adolescents according to Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR) criteria (see DSM-IV-TR box; see also Appendix L).

MENTAL RETARDATION

Mental retardation refers to a deficiency in intellectual function coupled with an impairment of adaptive function. Intellectual function is measured by standardized intelligence tests that yield an intelligence quotient (IQ); individuals scoring below 70 are considered to be mentally retarded (Table 7-2). IQ is believed to be a relatively stable factor that generally is unaffected by remediation.

**TABLE 7-2** Categories of Severity for Mental Retardation
Category	Intelligence Quotient
Mild	50-55 to about 70
Moderate	35-40 to about 50-55
Severe	20-25 to about 35-40
Profound	Below 20-25

Adaptive function is the individual’s ability to perform effectively, consistent with expectations for age and culture in the following areas: communication, daily living skills, social skills, social responsibility, and independence.

Etiology

The specific etiology of mental retardation may be directly attributable to one or more factors (Box 7-3). A combination of factors (biologic, psychosocial, environmental) appears to be influential in many cases.

BOX 7-3

Etiology of Mental Retardation ^*

BIOLOGIC FACTORS

▪ Chromosomal (e.g., Down syndrome)

▪ Metabolic (e.g., phenylketonuria)

▪ Prenatal factors (e.g., rubella, cytomegalovirus, toxoplasmosis)

▪ AIDS, syphilis, other viruses/infections

▪ Enzyme deficiencies

▪ Accidents (e.g., head trauma, near-drowning)

PSYCHOSOCIAL FACTORS

▪ Lower socioeconomic groups

▪ Social deprivation

▪ Inadequate medical care

▪ Lack of intellectual/language stimulation

▪ Living with parent who has psychiatric disorder

*Cases with no known cause are usually mild. Etiology is attributed to a combination of biologic, psychologic, psychosocial, and environmental factors.

DSM-IV-TR

American Psychiatric Association
Mental Disorders of Infancy, Childhood, and Adolescence

Mental Retardation ^*

^*These diagnoses are coded on Axis II.

▪ Mild mental retardation

▪ Moderate mental retardation

▪ Severe mental retardation

▪ Profound mental retardation

▪ Mental retardation, severity unspecified

Learning Disorders

▪ Reading disorder

▪ Mathematics disorder

▪ Disorder of written expression

▪ Learning disorder NOS

Motor Skills Disorder

▪ Developmental coordination disorder

Communication Disorders

▪ Expressive language disorder

▪ Mixed receptive expressive language disorder

▪ Phonologic disorder

▪ Stuttering

▪ Communication disorder NOS

Pervasive Developmental Disorders

▪ Autistic disorder

▪ Rett’s disorder

▪ Childhood disintegrative disorder

▪ Asperger’s disorder

▪ Pervasive developmental disorder NOS

Attention Deficit and Disruptive Behavior Disorders

▪ Attention-deficit/hyperactivity disorder

▪ Conduct disorder

▪ Oppositional defiant disorder

Feeding and Eating Disorders of Infancy or Early Childhood

▪ Pica

▪ Rumination disorder

▪ Feeding disorder of infancy or early childhood

Tic Disorders

▪ Tourette’s disorder

Elimination Disorders

▪ Encopresis

▪ Enuresis

Other Disorders of Infancy, Childhood, or Adolescence

▪ Separation anxiety disorder

▪ Selective mutism

▪ Reactive attachment disorder of infancy or early childhood

▪ Inhibited type

▪ Disinhibited type

▪ Stereotypic movement disorder

Epidemiology

Approximately 1% of the U.S. population is mentally retarded, and the disorder is about 1.5 times more common in boys than in girls. The diagnosis is made before 18 years of age; the highest incidence occurs during school years, with a peak between ages 10 and 15 years. The percentages of the retarded population can be categorized as follows: mild, 85%; moderate, 10%; severe 3% to 4%; and profound, 1% to 2%.

Mild Mental Retardation

Approximately 85% of the retarded population belong in the mild category and often are not noticed as “different” from the general population of schoolchildren until well into the school years. They usually can learn vocational and social skills sufficient to support themselves and academic achievement is limited to the sixth-grade level.

Moderate Mental Retardation

The 10% of retarded individuals in the moderate group can learn to take care of themselves with supervision. They may be able to perform at jobs in sheltered environments or in the regular job market under strong guidance. They usually are educable to about a second-grade level and live in group homes or with family because of the need for careful supervision.

Severe Mental Retardation

The 3% to 4% of retarded individuals in the severe group are recognizable early in life because they fail to develop adequate motor skills or speech for communication. They may eventually learn to talk, tend to basic hygiene, and perform simple tasks with close supervision.

Profound Mental Retardation

Approximately 1% to 2% of the retarded population is included in the profound category. They have very limited sensorimotor function, may have other physical handicaps, and require constant care and supervision. With supervision, they may learn to perform simple tasks.

LEARNING DISORDERS

A diagnosis of learning disorder is noted when an individual is unable to achieve designated scores on standardized tests of reading, math, or writing proficiency for specified ages, level of education, and IQ. Additionally, the lack of these skills hinders progress in school and interferes with activities that require the skills. Disturbances in sensory, perceptual, or cognitive processing may underlie the learning disorder and are often found in conjunction with other medical conditions, such as fetal alcohol syndrome, birthing traumas, or neurologic disorders. The individual with deficient learning skills frequently has low self-esteem and self-concept, negative self-worth, and inept social skills.

Reading Disorder

The defining characteristic of reading disorder, commonly referred to as dyslexia, is the inability to achieve specific scores on standardized tests that measure reading comprehension, speed, and accuracy. Additionally, the skill deficiency interferes with school progression and daily living activities in which the skills are required. When reading aloud, the child may omit, substitute, or distort content, and the process is usually slow. Reading disorder is usually associated with math and writing disorders.

Mathematics Disorder

Mathematics disorder is noted when an individual is unable to achieve specific scores on standardized tests that measure mathematics competence. The deficiency interferes with progress in school and daily activities in which the skills are important. Competence in mathematics includes several skills, such as recognizing and naming math symbols and signs, changing written problems into math symbols, understanding math concepts and terms, learning tables, and following sequences. Math disorder is often associated with writing and reading disorders.

Disorder of Written Expression

The defining characteristics of disorder of written expression are the inability to achieve standardized test scores and the resulting interference with school progress and daily activities that require writing skills. The disorder is manifested by difficulty organizing content into paragraphs; multiple errors in grammar, spelling, and punctuation; and poor handwriting. Written expression disorder is usually associated with reading and mathematics disorders.

MOTOR SKILLS DISORDER

The primary motor skills disorder in children involves impaired developmental coordination.

Developmental Coordination Disorder

The defining characteristic of developmental coordination disorder is impaired motor coordination. The diagnosis, however, is made only in the absence of an underlying medical condition and only if the impairment significantly interferes with progress in school or with daily activities. The impaired developmental coordination is age specific, for example, crawling and walking in infants, climbing and buttoning in toddlers, and throwing or catching a ball and printing words in school-age children.

COMMUNICATION DISORDERS

Expressive and Receptive Language Disorders

Expressive language disorder is noted when expressive language development is impaired. Manifestations of the disorder are poverty of speech, short sentences, omission of parts of sentences, limited variety of speech, and use of unusual wording.

Receptive language disorder is coupled with expressive language disorder, as noted by results on standardized assessment tests. Symptoms are the same as for expres-sive language disorder. The DSM-IV-TR diagnosis for these children is mixed receptive-expressive language disorder.

Phonologic Disorder

Phonologic disorder is evidenced by nonuse or misuse of sounds of speech for an expected age, as evidenced by sound omissions, sound substitutions, or sound distortions. Examples include omitting the last consonant (“truh” instead of “truck”), use of the letter b instead of p (“bretty”), and use of “ax” for the word “ask.” The individual’s cultural background with its specific sound differences must always be assessed in this regard to avoid misdiagnosis.

Stuttering

The defining characteristic of stuttering is impaired flow and pattern of speech, resulting in discontinuous sentences. Manifestations are varied and may include repeated words or sounds (“can-can-can-can-I.”), prolonged sounds (“the ssssssssun is warm”), pauses in speech, and other impairments.

PERVASIVE DEVELOPMENTAL DISORDERS

The term pervasive is used to describe the category of disorders in which several areas of development—social interaction, verbal and nonverbal communication, behavior, and activity—are severely affected. Pervasive developmental disorders result in severely impaired social function.

Autistic Disorder

Autistic disorder, known in the past as infantile autism, Kanner’s syndrome, childhood schizophrenia, and symbiotic psychosis, usually manifests before age 3 years, with a lifelong course. Changes can occur in some individuals, however, including improvement of social and language skills at about 5 to 6 years, improvement or decline in cognitive/social skills at puberty, and escalation of negative behaviors (e.g., aggression, opposition) at puberty.

Individuals with autistic disorder rarely are able to become totally independent because of their impaired IQ, language skills, and social skills. Therefore most affected individuals require a lifelong structured environment and close supervision. Four to five per 10,000 births are affected by autistic disorder.

Etiology

Biologic and prenatal, perinatal, and postnatal situations and conditions (e.g., anoxia at birth, encephalitis, chromosomal anomaly, phenylketonuria, maternal rubella) may cause brain dysfunction.

Autistic disorder is a severe form of pervasive developmental disorder. Symptoms include the following:

1. Impaired social interaction (two of the following must be present for diagnosis):

a. The client is unaware of feelings or needs of others; treats other people as objects.

b. At distressful moments, fails entirely to seek solace from others or seeks comfort in unusual ways.

▪ Rather than wanting hugs, may walk in circles or stereotypically repeat a phrase.

c. Does not imitate significant others’ actions (waving good-bye), or imitates out of context of situation.

d. Demonstrates impaired social play or total lack of it.

▪ Plays alone or engages others only as objects.

e. Demonstrates severely impaired ability to form peer relationships.

▪ Shows no interest in others or lacks awareness or understanding necessary to interact socially.

2. Impaired verbal and nonverbal communication (one of the following must be present for diagnosis):

a. The client demonstrates total lack of any mode of communication.

b. Engages in abnormal nonverbal communication: inappropriate and out-of-context posturing, facial expression, gazing, gesturing.

▪ Fails to smile at or move toward parents or significant others when greeted.

▪ Does not cuddle when held; may stiffen instead.

c. Fails to engage in imaginative play.

d. Demonstrates abnormal speech process; uses monotone; singsong quality; unusual pitch, rhythm, rate.

e. Demonstrates abnormal speech content/form: repetition of speech of other persons, television, or radio (echolalia); irrelevant or idiosyncratic use of words, (“want to run the dasher” meaning “I want to take a bath”).

f. Displays inability to begin or successfully maintain conversations with others.

3. Unusual or bizarre activities and interests (one of the following must be present for diagnosis):

a. The client demonstrates ritualized, stereotyped behaviors: head banging, rocking, body spinning, hand/arm flapping.

b. Displays intense preoccupation with specific objects.

▪ Flicks light switches on and off persistently.

▪ Watches toy spin for hours without playing with it.

▪ Rubs or spins one part of a toy instead of using as intended.

▪ Carries one object constantly (jar lid, particular piece of clothing).

c. Demonstrates need for sameness in environment and routine.

▪ Becomes upset when furniture is moved from usual spot.

▪ Must take same route every time when traveling to grandparent’s house.

d. Lacks variety of interests or is preoccupied with one interest.

▪ Looks through one book only, repeatedly.

Up to half of autistic children are also mentally retarded at a moderate, severe, or profound level. Interestingly, some children with autistic disorder possess unusual or extraordinary abilities or “islands of genius.” For example, a severely retarded person who is unable to make correct change in a store may be able to calculate an extraordinary range of numbers but is unable to understand their significance. An individual may be able to play a musical instrument and, without ever taking lessons or being able to read music, will often play complex compositions.

Rett’s Disorder

Defining characteristics of Rett’s disorder (Rett syndrome) are a period of normal functioning prenatally, perinatally, and up to age 5 months, followed by development of multiple deficits. The child has decelerated head growth, loss of acquired hand skills and child begins stereotyped movements of hand-wringing or handwashing. Socialization changes occur and child loses interest in interacting with others. Severe problems occur in coordination and in receptive and expressive language development.

Childhood Disintegrative Disorder

Childhood disintegrative disorder is marked by a period of normal development for up to 2 years, followed by severe loss of skills before age 10. Loss of skills includes two of the following five areas: language (receptive and expressive), socialization, control of bowel or bladder, play, and motor skills. This disorder has been known in the past as disintegrative psychosis, dementia infantilis, and Heller’s syndrome.

Asperger’s Disorder

Defining characteristics of Asperger’s disorder (Asperger’s syndrome) are marked and prolonged impairment in socialization and the development of stereotyped, repetitive behaviors. The individual fails to use social regulators such as smiling directly at others or looking in to a person’s eyes when talking. There is a lack of sharing with others, and age-appropriate relationships do not develop. Behaviors and interests are frequently stereotyped, rigid, and repetitive (e.g., incessant hand tapping, preoccupation with daily air flights into the city) and of little or no interest to others. Social interaction is severely impaired.

DSM-IV-TR

American Psychiatric Association
Attention Deficit and Disruptive Behavior Disorders

Attention deficit/hyperactivity disorder

▪ Combined type

▪ Predominantly inattentive type

▪ Predominantly hyperactive-impulsive type

Conduct disorder

▪ Childhood-onset type

▪ Adolescent-onset type

▪ Unspecified onset

Oppositional defiant disorder

Disruptive behavior disorder not otherwise specified

ATTENTION DEFICIT AND DISRUPTIVE BEHAVIOR DISORDERS

The DSM-IV-TR box lists attention deficit and disruptive behavior disorders as defined by the DSM-IV-TR.

Attention-Deficit/Hyperactivity Disorder

Children with ADHD are often referred to as being hyperactive. They have developmentally inappropriate problems in maintaining attention and are impulsive and hyperactive. These difficulties may manifest as inability to stay with a task to completion, listen to the teacher, and complete chores at home. Children with ADHD comment out of turn or cannot wait for a turn, do not follow directions, interrupt others continually, have difficulty staying in a seat, and are constantly “on the go.”

Subtypes

Some individuals with ADHD demonstrate symptoms of both inattention and hyperactivity-impulsivity. Others demonstrate one pattern more than another, as follows:

▪ Combined type

▪ Predominantly inattentive type

▪ Predominantly hyperactive-impulsive type

Conduct Disorder (Solitary Aggressive Type)

Conduct disorder is characterized by persistent patterns of serious misconduct at home, at school, and in the community. Manifestations of conduct disorder include violation of the basic rights of others and basic rules, laws, or norms (verbal and physical aggression toward other people, animals, and property); stealing; rape; assault; lying; cheating; truancy from school; use of drugs and alcohol; callous disregard for others’ feelings; blaming others for own transgressions; and lack of appropriate empathy, remorse, or guilt. If maladaptive behavior persists into adulthood, conduct disorder is changed to a diagnosis of antisocial personality disorder.

Oppositional Defiant Disorder

A pattern of defiance, hostility, and negativity characterizes oppositional defiant disorder. Behaviors may include loss of temper; arguments with adults; defiance and refusal to adhere to adult rules; displays of anger, resentment, or vindictiveness; swearing and use of obscenities; and deliberately annoying others.

FEEDING AND EATING DISORDERS OF INFANCY OR EARLY CHILDHOOD

Defining characteristics of feeding and eating disorders are disturbances in feeding and eating during the early years of a child’s life. Chapter 10 discusses anorexia nervosa and bulimia nervosa, eating disorders that occur in adolescence or adulthood.

Pica

The defining characteristic of pica is the persistent eating of substances that have no nutritive value. This behavior is inappropriate for the specific developmental level or cultural practice. Poverty, developmental delay, neglect, and inadequate parental supervision increase the risk of pica. Specific ingested substances vary with age (Table 7-3). This disorder tends to increase when associated with mental retardation.

**TABLE 7-3** Age-Significant Substances for Pica
Age Group	Substances
Infants, young children	Paint, plaster, string, hair, cloth
Older children	Sand, insects, animal droppings, pebbles, leaves
Adults	Clay, soil

Rumination Disorder

Defining characteristics of rumination disorder are repeated regurgitation and rechewing of food that has been swallowed by an infant or child who had normal functioning before the occurrence of this behavior. The child brings food back up into the mouth without retching and either rechews and reswallows or expels the food. Malnutrition may occur with weight loss or failure to gain weight. Children with rumination disorder have a 25% mortality rate.

Feeding Disorder of Infancy or Early Childhood

The defining characteristic of feeding disorder of infancy or early childhood is a persistent failure to eat adequate amounts of food, with resultant failure to gain weight, or loss of weight, before age 6 years.

TIC DISORDER

A tic is a stereotyped vocalization or motor movement that occurs rapidly and suddenly in a nonrhythmic manner (Table 7-4; see DSM-IV-TR box on p. 286).

**TABLE 7-4** Tic Manifestations
Motor Tics	Vocal Tics
Simple
Coughing	Throat clearing
Neck jerking	Grunting
Eye blinking	Sniffing
Shoulder shrugging	Snorting
Facial grimaces	Barking
Complex
Grooming behaviors	Repeating words out of context
Jumping	Obscene words, swearing (coprolalia)
Foot stomping	Repeating own words (palilalia)
Facial gestures	Repeating others’ words (echolalia)
Smelling an object	Imitation of others’ behaviors (echopraxia)

Tourette’s Disorder

Defining characteristics of Tourette’s disorder (Tourette’s syndrome) are multiple motor and vocal tics that present several times a day at irregular intervals. Frequently, individuals with Tourette’s disorder experience obsessions and compulsions, hyperactivity, self-consciousness, and depression in addition to the tic disorder.

DSM-IV-TR

American Psychiatric Association
Tic Disorders

Tourette’s disorder

Chronic motor or vocal tic disorder

Transient tic disorder

▪ Single episode

▪ Recurrent

Tic disorder not otherwise specified

ELIMINATION DISORDERS

Enuresis

The defining characteristic of enuresis is repeated urination voluntarily or involuntarily during the day or night into bed or clothing, past the age of expected continence (5 to 6 years). Physical causes must be ruled out before this diagnosis is made.

Primary enuresis refers to the disturbance when it is not preceded by a year of urinary continence. Secondary enuresis refers to the disturbance when at least 1 year of continence precedes the disorder.

Nocturnal enuresis, the most common type, occurs during rapid eye movement (REM) sleep, usually in the first third of total sleep, at night. Diurnal enuresis occurs during the day and is more common in females. The diurnal type may result from reluctance to use public toilets.

Encopresis

The defining characteristic of encopresis is repeated defecation voluntarily or involuntarily into clothes or areas other than appropriate toilet facilities. Physical causes must be ruled out before the diagnosis is made (see DSM-IV-TR box).

OTHER DISORDERS OF INFANCY, CHILDHOOD, OR ADOLESCENCE

The DSM-IV-TR box lists other disorders of infancy, childhood, or adolescence as defined by the DSM-IV-TR.

DSM-IV-TR

American Psychiatric Association
Elimination Disorders

Enuresis (not due to a general medical condition)

▪ Nocturnal only

▪ Diurnal only

▪ Nocturnal and diurnal

Encopresis

▪ With constipation and overflow incontinence

▪ Without constipation and overflow incontinence

DSM-IV-TR

American Psychiatric Association
Other Disorders of Infancy, Childhood, or Adolescence

Separation anxiety disorder

▪ Early onset

Selective mutism

Reactive attachment disorder of infancy or early childhood

▪ Inhibited type

▪ Disinhibited type

Stereotypic movement disorder

▪ With self-injurious behavior

Disorder of infancy, childhood, or adolescence not otherwise specified

Separation Anxiety Disorder

When separated from the major figure of attachment (primary caregiver), the child may experience severe to panic levels of anxiety. Symptoms of separation anxiety disorder are unrealistic and persistent and include worry that the parent will not return or will have an accident while away, refusal to go to school, refusal to go to sleep when parent is not near, clinging behaviors, nightmares about separating from parent, physical symptoms (nausea, vomiting, headache, stomachache), or pleading not to be separated.

Selective Mutism

The defining characteristic of selective mutism is failure to speak when speaking is expected, even though the person speaks in other situations. For example, a child may not speak to playmates during school but talks at home. Before a diagnosis is made, the behavior must persist past the beginning of a new class (1 month) and must interfere with educational and social functioning.

Reactive Attachment Disorder of Infancy or Early Childhood

Reactive attachment disorder is characterized by age-appropriate but greatly disturbed social relationships, manifesting as either of two types, as follows:

▪ Inhibited type. Failure to respond to or initiate inter-actions with others: apathy; lack of spontaneity, visual tracking, curiosity, or playfulness.

▪ Disinhibited type. Indiscriminate socializing: over-familiarity with strangers, displays of affection toward them, or requests for attention from strangers.

Additionally, evidence exists for one of the following regarding negligent or punitive care of the child: (1) disregard of child’s needs for affection, comfort, and stimulation (emotional needs); (2) disregard of child’s needs for food, clothing, and shelter (physical needs); (3) disregard of protection from abuse or danger; or (4) frequent changes in primary caregivers, leading to unstable attachments.

Etiology

Reactive attachment disorder results from pathogenic care of the infant by the primary caregiver. Lack of bonding or poor parent-infant fit may result from problems that exist with one or both members of the dyad, such as poor parenting skills, low socioeconomic status, deprivation, presence of mental retardation, or a physical anomaly in the child.

Stereotypic Movement Disorder

Diagnosis of stereotypic movement disorder is made when an individual persistently and repetitively performs a nonfunctional motor behavior in a driven way. Examples of behavior include biting self, playing with fingers, head banging, waving hands, rocking, and picking at skin or body orifices. The disorder often occurs in conjunction with mental retardation or in individuals who are institutionalized and receive little stimulation.

INTERVENTIONS

When determining treatment for clients in this age group, several factors must be considered. A report of the child’s history and past experiences is a valuable tool for gaining correct perspective on present conditions. Knowledge of both normal growth and development and psychopathology are necessary before the nurse can understand the many factors that encompass the development, presence, absence, or continuance of mental disorders. Because of the inherent fluidity of development in this young age group, another consideration is the individual child’s capacity and ability to adapt to his or her own internal and external changes and discontinuities when they arise. Also, prevention on all levels plays an important role in treating this population.

Prevention Programs

Prevention programs regarding mental disorders in the younger population have proven statistically successful. For example, Project Head Start for preschool-age children is one of many programs that have demonstrated the importance of (1) early risk reduction, (2) prevention of onset, and (3) early intervention with children and their parents as important factors for ensuring mental health for U.S. children. Through provision of appropriately stimulating and supportive environments, children can make significant advances in knowledge, logic, and reasoning—areas previously thought to be predetermined. Several other national primary prevention programs support these data and the subsequent reduction in mental disorders.

Primary prevention in the form of parenting classes has proven valuable. Parents who learn the patterns of normal growth and development usually have reasonable expectations for their children and their performance. Treatment outlook is generally more favorable if parents have knowledge of healthy parenting skills when their child develops a mental disorder that alters the child’s thoughts, feelings, and behaviors and the family’s dynamics.

Medications

Medications are used to manage a variety of symptoms resulting from mental disorders of childhood and adolescence, primarily when other therapies do not adequately manage disruptive behaviors that may threaten to harm the child or others. Because these types of medications need frequent adjustment, parents need to work closely with the physician and pharmacist to provide the child with the optimal medication regimen. Often, the same medications used by adults with mental disorders are also prescribed for children and adolescents, with dose variation being an important factor. Antidepressants, anti-mania drugs, sedatives and hypnotics, and antipsychotics are used for this age group. Additionally, medications for managing symptoms of ADHD and other behavioral disorders are often prescribed for younger clients. (See Appendix H for more complete information on medication use for this age group.)

Therapies

Treatment for childhood mental disorders that also occur in adults follows the same general principles, primarily interpersonal therapeutic interventions and psychopharmacology. Medications are frequently used in children with mental disorders, with appropriate dosage modifications for individual age and size.

Interventions for severe and persistent mental disorders, such as severe mental retardation and pervasive developmental disorders, require intensive, specialized care and education of the child and family. Treatment focuses on promotion of the child’s language and social development and mastery, with reduction or elimination of behaviors that interfere with learning and functioning in the world.

Therapeutic Nurse-Client Relationship

Nurse-client relationship therapy is ideally suited for this age group (see Chapter 1). The nurse must consider the child’s chronologic and developmental stages, cogni-tive level, capacity and readiness for change, ability to engage in a therapeutic alliance, and skills that the child has developed in all areas. Modifications in the nurse-client relationship are made as a result of this assessment. The care plans in this chapter support the therapeutic alliance at various levels of intervention and offer other techniques for interacting with younger clients.

Cognitive-Behavioral Therapy

The nurse assesses and considers the child’s capacity for awareness of problematic areas and ability and willingness to participate in an interdisciplinary treatment program. Cognitive-behavioral therapies are currently popular for all age groups, including this population.

In cognitive therapy for children and adolescents the client may be assisted in the following steps: (1) recognize troublesome feelings such as anxiety, (2) identify and clarify thoughts associated with the feelings, (3) challenge irrational thoughts, (4) develop a plan to cope with the thoughts, (5) and evaluate the success of coping strategies. Cognitive and problem-solving approaches can often be modified for most ages, but the treatment team will consider the child’s capacity and ability to do this work.

Behavioral therapy is often useful in the treatment of children and includes such techniques as contingency management, systematic desensitization, and behavioral contracts. In all instances, priority interventions focus on safety of the child and the environment to prevent and manage violence directed toward self or others.

Contingency management uses behavioral principles of shaping, positive reinforcement, and extinction to alter behavior by manipulating its consequences. It is most successful when conducted in specialized settings with highly trained staff because consistency and other elements are crucial. Homes and most acute care facilities are usually not prepared to carry through with the rules and have too many distractions. Most settings that treat children incorporate behavior modification methods, but on a level that is less demanding than formal contingency management. Often a points and levels system or token economy is employed so that a child can earn privileges.

Systematic desensitization is used for children and adults to assist them to unlearn fears and phobias by presenting a feared stimulus with a non-feared stimulus. For example, a client taught to do relaxation techniques whenever a feared stimulus appears (e.g., spiders, heights) frequently learns to control the fear response by reciprocal inhibition.

Behavioral contracts can be adapted for any age group and often are successful adjuncts to other therapies for most mental disorders (Box 7-4). Behavioral contracts are concrete methods for predictability and are easily modified for younger children and for older adolescents, who frequently think of themselves as being more sophisticated. When followed carefully, contracts are successful because they shift the external locus of control (parent, therapist, teacher) to the child’s own internal locus of control. The child will agree to complete elements of the contract to reap the rewards and avoid the adverse consequences that were previously negotiated, decided, and agreed on by the child and the parent, teacher, or therapist.