Infant, Child, and Adolescent Clients
UNITY
I dreamed I stood in a studio and watched two sculptors there. The clay they used was a young child’s mind and they fashioned it with care. One was a teacher; the tools she used were books and music and art. One a parent with a guiding hand and gentle loving heart. Day after day the teacher toiled with touch that was deft and sure, while the parent labored by the side and polished and smoothed it o’er. And when at last their task was done, they were proud of what they had wrought. For the things they had molded into the child could neither be sold nor bought. And each agreed they would have failed if they had worked alone, for behind the parent stood the school and behind the teacher, the home.
—Author Unknown
Learning objectives
After studying this chapter, you should be able to:
Explain the limitations involving the study of the genetics of behavioral disorders in children.
Articulate the relationship between the psychosocial process of attachment and child development.
Identify the seven groups of children considered to be at high risk for mental health disorders
Differentiate the four types of mental retardation.
Distinguish attention-deficit hyperactivity disorder from conduct disorder.
Articulate the etiology and clinical symptoms of attention-deficit hyperactivity disorder in adults.
Distinguish autistic disorder from Asperger’s disorder and Rett’s disorder.
Compare and contrast clinical symptoms of oppositional defiant disorder and conduct disorder.
Develop an assessment tool for childhood and adolescent depression.
Propose at least three nursing interventions for each of the following clients:
a 15-year-old girl with conduct disorder
a 12-year-old boy with clinical symptoms of depression
a 7-year-old boy with attention-deficit hyperactivity disorder
a 4-year-old girl with autistic behavior
a 3-year-old girl with separation anxiety disorder
a 9-year-old boy with childhood psychosis
Formulate a list of pharmacologic agents approved for use in the treatment of children and adolescents.
Key Terms
Asperger’s disorder
Attachment theory
Attention-deficit hyperactivity disorder
Autistic disorder
Conduct disorder
Encopresis
Enuresis
Mental retardation
Oppositional defiant disorder
Rett’s disorder
Scapegoat
Tic
Tourette’s syndrome
Psychiatric care for children continues to be a growing crisis in America. Since the inception of child and adolescent training programs, there has been a shortage of child and adolescent psychiatrists. In 1993, the American Medical Association predicted that the number of youths needing psychiatric services would continue to increase and that the supply of child and adolescent psychiatrists would not keep up with the demand. This prediction has come true. Currently there is a severe shortage of child and adolescent psychiatrists to service the growing needs of this population. For example, attention-deficit hyperactivity disorder (ADHD), one of the most common mental disorders in children and adolescents, affects an estimated 4.1% of youth’s ages 9 to 17 years in a 6-month period. Autism affects an estimated 1 to 2 cases per 1,000 individuals. The prevalence of oppositional defiant disorder and conduct disorders among school-aged children is approximately 2% to 16%. Over 5 million youths, by the age of 16 years, have met the diagnostic criteria for substance use disorder. Furthermore, approximately 103,000 short-term psychiatric hospitalizations (of less than 30 days) of youths under age 15 occur yearly (National Institute of Mental Health, 2005). Table 29-1 lists the most current statistics regarding the prevalence of mental or addictive disorders exhibited by children and adolescents. Table 29-2 compares the prevalence of critical mental health related problems between adolescent males and females.
In 2000, the Surgeon General’s report on children’s mental health, National Action Agenda for Children’s Mental Health, drew attention to the crisis in children’s mental health services. The agenda reflects the culmination of several activities and incorporates recommendations from federal agencies, clinicians, professional and advocacy organizations, and other mental health advocates (Imperio, 2001). The report listed eight goals to improve mental health services to children. Summarized, they include:
Promoting public awareness of and reducing stigma associated with children’s mental health issues
Developing, disseminating, and implementing scientifically proven prevention and treatment services in the field of children’s mental health
Improving the assessment and recognition of mental health needs in children
Eliminating racial/ethnic and socioeconomic barriers to mental health care
Improving the infrastructure for children’s mental health services
Increasing access to and coordination of quality mental health care services
Training providers (eg, family practitioners or primary care physicians) to recognize and manage mental health issues, and educating mental health providers in scientifically proven prevention and treatment services
Monitoring access to and coordination of quality mental health care services
Diagnosing childhood and adolescent psychiatric disorders is not an easy task. The etiology of mental health and psychiatric disorders is multifactorial; that is, there is no single cause. Several risk factors (eg, overprotective or controlling parents, behavior problems in the toddler or preschool period, lack of resilience, and gay or bisexual orientation) have been identified as placing children and teens at risk for mental health disorders. In addition to the shortage of child and adolescent psychiatrists noted earlier, the problem of diagnosing and treating young clients is further compounded by the scarcity of trained clinicians such as psychiatric–mental health clinical nurse specialists,
advanced nurse practitioners, clinical child psychologists, and social workers. Inadequate screening and referral is a major contributing factor to misdiagnosis, leaving approximately 70% of affected children and teens without proper diagnosis and treatment (Kaplan, 2000; Sadock & Sadock, 2003).
advanced nurse practitioners, clinical child psychologists, and social workers. Inadequate screening and referral is a major contributing factor to misdiagnosis, leaving approximately 70% of affected children and teens without proper diagnosis and treatment (Kaplan, 2000; Sadock & Sadock, 2003).
 Table 29.1 Prevalence of Mental or Addictive Disorders in Children and Adolescents Ages 9 to 17 Years | ||||||||||||||
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 Table 29.2 Prevalence of Critical Adolescent Mental Health–Related Problems | |||||||||||||||||||||||||||
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This chapter focuses on etiology of disorders of infancy, childhood, and adolescence, which usually occur as a result of complex reactions during one’s early developmental stages. The clinical symptoms and diagnostic characteristics are also presented. Using the nursing process, care of children and adolescents is discussed. (See Chapter 24 for information regarding developmental theories.)
History of Child and Adolescent Psychiatry
Most historians of child and adolescent psychiatry trace its beginning in the United States to the year 1899, when Illinois established the nation’s first juvenile court in Chicago. In 1909, a group of influential, socially concerned women, who wanted to understand the origin, prevention, and treatment of behavior that contributed to juvenile delinquency, created the Juvenile Psychopathic Institute. They hired William Healy, a neurologist, to be the program director. He formed teams composed of a psychologist, neuropsychiatrist, and social worker to study brain functioning and intelligence quotient (IQ) of clients with behavioral disturbances. Although research was a primary goal, the institute’s board of directors also expected the teams to focus attention on the social factors, attitudes, and motivations of juveniles (Schowalter, 2006).
Around 1911, the noted Swiss psychiatrist Eugene Bleuler, who was also studying behavior, introduced the term autism to describe an individual’s exclusion of the outside world and virtual withdrawal from social life. Shortly thereafter, in 1922, behavioral symptoms now associated with ADHD were documented and given a diagnosis of “Post-Encephalitic Behavior Disorder.” The first edition of Child Psychiatry, published by an American physician, Leo Kanner, in 1935 was very influential in the field of psychiatry. In 1943, Kanner published a paper in which he described autistic behavior as a specific childhood mental health disorder. The following year, Hans Asperger of Vienna, Austria, published a paper in which he described a similar condition that later became known as Asperger’s syndrome. These landmark papers featured the first theoretical attempts to explain such complex disorders (About.com, 2006; National Alliance for Autism Research, 2006; Schowalter, 2006).
During the 1940s, World War II also played an important part in the research of child and adolescent psychiatry. Background histories about soldiers who had behavior problems as children or adolescents and were prematurely discharged, disciplined, wounded, or killed in action were researched. The findings provided important statistical information about the etiology of childhood and adolescent mental illness. The movement toward subspecialization in the field of child and adolescent psychiatry accelerated in 1943 when the American Psychiatric Association (APA) converted its section on Mental Deficiency to the Section of Child Psychiatry (Schowalter, 2006).
The American Academy of Child Psychiatry was founded in 1953. In 1983, the academy published Child Psychiatry: A Plan for the Coming Decades. Recommendations were made to focus on the understanding and treatment of mental illnesses in children. In 1986, the academy expanded its name to American Academy of Child and Adolescent Psychiatry. The academy continues to conduct research in an attempt to improve understanding of developmental psychopathology of children and adolescents with mental illnesses.
Etiology
Several theories (eg, genetic, biologic) have been proposed for the different psychiatric–mental health disorders affecting infants, children, and adolescents. In addition, attachment theory and psychosocial and environmental risk factors pertaining to the development of disorders of infants, children, and adolescents have been discussed in the literature.
Theories
The more common psychiatric–mental health disorders occurring in infants, children, and adolescents include mental retardation, pervasive developmental disorder, ADHD, childhood psychosis, anxiety disorders, depression, and disruptive behavior. The theories underlying the causes of these disorders are presented here.
Mental Retardation
Mental retardation is a term used to describe individuals who exhibit subaverage intelligence, as measured by a standardized IQ test, and deficits in adaptive functions (eg, activities of daily living). The etiologic factors associated with the development of mental retardation have been identified as genetic (eg, chromosomal and inherited conditions), developmental (eg, prenatal exposure to toxins and infections), and acquired syndromes (eg, perinatal trauma and sociocultural factors). For example, although Down syndrome (also known as trisomy 21) is a general medical condition, it is a form of mental retardation caused by the chromosomal abnormality. Phenylketonuria is a genetic, metabolic disorder characterized by the inability to convert phenylalanine to tyrosine. Abnormal accumulation of chemicals interferes with brain development and, if untreated, can result in mental retardation. Mental retardation has also occurred when fetuses were exposed to radiation, syphilis, oxygen deprivation, poor maternal nutrition, alcohol, or drugs in utero.
In approximately two thirds of all individuals with mental retardation, the probable cause can be identified. It is not unusual for a comorbid mental disorder to be present (Sadock & Sadock, 2003).
Pervasive Developmental Disorders
Pervasive developmental disorders (also called autism spectrum disorders) are characterized by severe deficits and impairment in reciprocal social interaction and communication, and include the presence of stereotyped behavior, interests, and activities. Genetic or biologic theories of Rett’s disorder, autistic disorder, and Asperger’s disorder are presented.
Rett’s Disorder
Rett’s disorder is an X-linked, progressive neurodevelopmental disorder. Although it was once thought to only occur in girls, there are now several case reports with boys. The gene for this disorder has been found (Baker, 2000). For families who have an identified mutation in the gene, genetic testing may be considered for prenatal diagnosis. That is, for those families who have a child with Rett’s disorder or someone in the family with Rett’s disorder and the identified gene, genetic testing will be done to help with a possible prenatal diagnosis.
Autistic Disorder
Autistic disorder refers to a disorder of development consisting of gross and sustained impairment in social interaction and communication accompanied by restricted and stereotypical patterns of behavior. On the basis of recent genetic analyses, behavioral and brain chemistry studies, and imaging analyses of autistic children, approximately 70% of idiopathic autism cases appear to be an inherited form of an affective disorder (Sadock & Sadock, 2003).
Researchers have hypothesized that there are two distinct forms of autistic disorder. The first type is caused by bilateral brain damage early in life. The second type, which is a more common form, is not associated with brain damage, neurologic findings, or biologic markers. Children with the more common form exhibit very low levels of serotonin on the left side of the brain in the area responsible for language. Symptoms of autism are thought to occur when serotonin levels in the left hemisphere of the brain do not reach a critical level in early childhood (APA, 2000; Sadock & Sadock, 2003). According to recent research, concrete evidence proves that several mutations within the serotonin transporter (SERT) gene, which regulates serotonin levels, constitute a risk factor in autism (Neuropsychiatry Reviews, 2005).
Recent research, based on the premise that not being able to detect autism until a child is close to the age of 3 years eliminates a valuable window of treatment opportunity, is focusing on hematologic changes (ie, unique immune responses) of children ages 2 to 5 years with autism. This study is ongoing. In another study, researchers have isolated the regions of an autism gene on chromosomes 7 and 21. These regions are
linked to susceptibility of a type of autism characterized by developmental regression, the loss of previously acquired sociocommunicative skills (Spittler, 2005).
linked to susceptibility of a type of autism characterized by developmental regression, the loss of previously acquired sociocommunicative skills (Spittler, 2005).
Smith-Lemli-Opitz syndrome (SLOS), a genetic disorder that often presents as a “mild case of autism,” is included in the classification of pervasive developmental disorders. It is caused by a defect in the cholesterol metabolic pathway and may exist alone or as a comorbid condition in children with autism. Research has shown that some autistic children with SLOS benefit from cholesterol treatment, which lessens behavioral symptoms associated with autism (Little, 2005).
Asperger’s Disorder
Although the cause of Asperger’s disorder—a disorder similar to autism characterized by impaired behavior and social interaction but with no impairment in communication—is unknown, family studies suggest a possible relationship to autistic disorder. The similarities between the two disorders support the presence of genetic, metabolic, infectious, and perinatal contributing factors. Although definitive data regarding the prevalence of Asperger’s disorder are lacking, the disorder appears to be diagnosed much more frequently in males (at least five times more) than in females (APA, 2000; Sadock & Sadock, 2003).
Attention-Deficit Hyperactivity Disorder
Attention-deficit hyperactivity disorder (ADHD), one of the best-researched disorders in medicine, is characterized by prominent symptoms of inattention and/or hyperactivity–impulsivity. Although overall data on the validity of its existence are far more compelling than for most mental disorders, a major limitation in the study of the genetics of such disorders in children has been the overlap of one or more syndromes such as anxiety, depression, or conduct disorder. The rate of overlap is greatly increased with ADHD.
Given that any child has a 10% possibility of being diagnosed with ADHD, overlap with other syndromes can occur merely by chance (Baren, 2000; Flick, 2002; Myers, Eisenhauer, & Ryan, 2003).
ADHD is a heterogeneous behavioral disorder with multiple etiologies. The symptoms have been attributed to neuromaturational delay, catecholamine deficits, altered glucose metabolism in the brain, and frontal lobe dysfunction. For example, genetic influences such as rare mutations in the human thyroid receptor gene on chromosome 3, dopamine transporter gene on chromosome 5, and D4 receptor gene on chromosome 11 have been identified in studies of twins and families (Biederman, 1999). Additionally, severe central nervous system infections such as Reye’s syndrome and meningitis; perinatal insults such as substance abuse during pregnancy, poor maternal nutrition, premature labor, and anoxia; and brain injuries during or after birth are also considered to be causes of ADHD (Baren, 2000).
ADHD in Adults
Until the 1970s, it was believed that ADHD was strictly a childhood disorder, and that children outgrew it in adolescence. Recent research supports the diagnostic continuity of ADHD throughout the life cycle. Estimates suggest that ADHD affects approximately 5% of adults (or about 8 million American adults). Although the hyperactivity component may diminish, the attention and impulsive aspects can persist into adulthood. To be diagnosed with ADHD, an adult must have a childhood onset on clin-ical symptoms that are persistent during adulthood. According to a 10-year follow-up study of male subjects with ADHD, the chance of boys retaining ADHD into manhood was 56% (McDonnell & Dougherty, 2005; Waite, 2004; Zoler, 2004).
Childhood Psychosis
Although there is clearly a genetic component, genetic predisposition alone does not explain the development of childhood schizophrenia. Early-onset schizophrenia and schizophrenia-like disorders (such as schizoaffective, schizoid personality, and schizophreniform disorders) are due to neuropathology, which includes neurostructural changes, neurochemical influences, and changes in brain metabolism. Intrauterine stress, neuropsychological abnormalities, communication style, life events, and stress are important etiologic factors as well.
More than 50% of adults with bipolar disorder experience the onset in childhood or adolescence. Biologic contributions include genetic factors, neuropathology, and neurotransmitter abnormalities (Hendren, 1997). Box 29-1 summarizes possible causes of psychosis in childhood. Chapters 21 and 22 provide additional information regarding theories related to the development of bipolar disorder and schizophrenia.
Mood Disorders
Although the cause of childhood mood disorders, such as depression or bipolar disorder, is unknown, the evidence
is strongest for a transaction between biologic, personality, and environmental factors. Biologic factors include genetic heritability, dysregulation of central serotonergic or noradrenergic systems, hypothalamic–pituitary–adrenal (HPA) axis dysfunction, and the influence of prepubertal sex hormones (Jeffrey, Sava Bianca, & Winters, 2005). Recent studies of pediatric clients also point to a possible neurobiologic marker (eg, reduced glutamatergic concentrations in the anterior cingulated cortex) in the pathogenesis of major depressive disorders as well as obsessive–compulsive disorder. Future studies are warranted and necessary because alterations in glutamatergic concentrations can be reversed with effective treatment (Romano, 2004). Studies of adults with depression point to a genetic predisposition and environmental influence. The children of depressed parents are three times more likely to develop a mood disorder than their peers with unaffected parents. Possible risk factors include a history of abuse, neglect, trauma, or loss of significant other. Although divorce and the loss of a loved one can place a child at risk, these factors do not necessarily trigger the onset of depression. Learning disabilities may also contribute to childhood depression (National Institute of Mental Health, 2003). Chapter 21 provides additional information regarding the development of mood disorders in children and adolescents.
is strongest for a transaction between biologic, personality, and environmental factors. Biologic factors include genetic heritability, dysregulation of central serotonergic or noradrenergic systems, hypothalamic–pituitary–adrenal (HPA) axis dysfunction, and the influence of prepubertal sex hormones (Jeffrey, Sava Bianca, & Winters, 2005). Recent studies of pediatric clients also point to a possible neurobiologic marker (eg, reduced glutamatergic concentrations in the anterior cingulated cortex) in the pathogenesis of major depressive disorders as well as obsessive–compulsive disorder. Future studies are warranted and necessary because alterations in glutamatergic concentrations can be reversed with effective treatment (Romano, 2004). Studies of adults with depression point to a genetic predisposition and environmental influence. The children of depressed parents are three times more likely to develop a mood disorder than their peers with unaffected parents. Possible risk factors include a history of abuse, neglect, trauma, or loss of significant other. Although divorce and the loss of a loved one can place a child at risk, these factors do not necessarily trigger the onset of depression. Learning disabilities may also contribute to childhood depression (National Institute of Mental Health, 2003). Chapter 21 provides additional information regarding the development of mood disorders in children and adolescents.
Box 29.1: Possible Causes of Psychosis in Childhood
| Metabolic and Infectious Causes | Neurologic Causes | Drug-Induced Causes |
| Adrenal cortical hypofunction Thyroid and parathyroid disease Porphyria Endocrinopathies Wilson’s disease Encephalitis, meningitis, AIDS | Head trauma Multiple sclerosis Seizure disorder Brain tumor Congenital malformations Huntington’s disease Neurosyphilis | Prescription drugs, stimulants, corticosteroids, anticholinergics Drug interactions Nonprescription drugs, cocaine, phencyclidine (PCP), hallucinogens, solvents Heavy metals |
Anxiety Disorders
Children and teens experience stress and anxiety in their lives, just as adults do. Kids Health Kids Poll, a survey of 875 children conducted from May 10 to June 7, 2005, identified the top ten triggers of stress in children ages 9 to 13 years. Identified triggers included grades/school/homework (36%), family (32%), friends/teasing/gossip (21%), siblings (20%), mean/annoying people (20%), parents (14%), yelling/loud noise (9%), fighting (9%), sports (8%), and lack of autonomy (7%) (Foley & Keller, 2006). Although events such as starting school, moving, or the loss of a parent precipitate stress, a specific stressor need not be the precursor to the development of an anxiety disorder. As a group, anxiety disorders affect 20% of youth up to age 18 years; however, clinical symptoms are generally evident around the age of 11 years (Bryant & Cheng, 2005). The most common diagnoses include separation anxiety disorder, social phobia, school phobia, panic disorder in adolescents, and generalized anxiety disorder.
Insufficient data exist regarding the etiology of anxiety disorders in very young children. Studies do not prove whether anxiety is the result of biologic or environmental factors or both (Anxiety Disorders Association of America, 2003). Psychosocial risk factors,
including attachment theory, are discussed in the next section. Chapters 19 and 20 provide additional information regarding theories related to the development of anxiety disorders.
including attachment theory, are discussed in the next section. Chapters 19 and 20 provide additional information regarding theories related to the development of anxiety disorders.
Disruptive Behavior Disorder: Conduct Disorder
Conduct disorder is classified as a disruptive behavior disorder that is characterized by a pattern of behavior that violates the basic rights of others or major age-appropriate norms or rules (APA, 2000). No single factor can account for the etiology of conduct disorder. Rather many risk factors are considered to contribute to development of this disorder including parental and family, sociocultural, psychological, and school-related factors (Perepletchikova & Kazdin, 2005; Sadock & Sadock, 2003). Psychosocial risk factors, including attachment theory, are discussed in the next section.
Neurobiologic theories state that conduct disorders may be a result of decreased noradrenergic functioning or high serotonin blood levels. Medical and metabolic explanations given for the development of a conduct disorder include encephalopathy, phenylketonuria, lead poisoning, hyperthyroidism, fragile X syndrome, Lesch-Nyhan syndrome, Tourette’s syndrome, brain tumors, or head trauma. Some teenagers with conduct disorder have been found to be exposed to cocaine in utero. The most salient contributor to their behavior lies in the brain, in which abnormalities and atrophy can be confirmed by magnetic resonance imaging and electroencephalogram (Bates, 1999; Sadock & Sadock, 2003).
Attachment Theory
John Bowlby, a British psychoanalyst (1907–1990), formulated a theory about the psychological concept of attachment. His Attachment theory states that normal attachment in infancy is crucial to a person’s healthy development. He differentiates attachment from bonding. Attachment, according to Bowlby, occurs when there is a warm, intimate and continuous relationship with the mother in which both the infant and mother find satisfaction and enjoyment. Attachment is also referred to as the emotional tone between children and their caregivers and is evidenced by the child’s clinging to the caregiver. Bonding occurs during skin-to-skin contact between a mother and infant or when other types of contact, such as voice and eye contact occur (Sadock & Sadock, 2003; Wikipedia.org, 2006.).
Charles Zeanah, professor of psychiatry and neurology at Tulane University Medical School, New Orleans, believes the quality of early attachments is a good predictor of later social adaptation. Children who have difficulty with attachment often exhibit anxiety and aggressive behavior and are more likely to have difficult relationships with parents, peers, and teachers. Attachment problems often overlap with other diagnoses including autism, conduct disorders, and depression. Separation anxiety disorder, avoidant personality disorder, depressive disorders, and borderline intelligence have also been traced to negative attachment experiences (Sadock & Sadock, 2003; Sullivan, 2004).
A meta-analysis of attachment studies indicates that about 15% of children in a general population sample exhibit disorganized attachment. The percentage is much higher, however, in a high-risk sample where there is poverty, neglect, or abuse. In those samples, up to 82% of children may exhibit disorganized attachment (Sullivan, 2004).
Psychosocial Risk Factors
Seven specific groups of children, many of whom experienced maternal or caregiver deprivation (detachment), are considered to be at high risk for psychiatric–mental disorders. The summary that follows reflects the risk factors identified by the United States Congress, Office of Technology Assessment (USCOTA; 1986).
Children in Families With Conflict or Divorce
Scapegoat is a term used to describe the role within a family of a person who receives the angry, hostile, frustrated, or ambivalent emotions experienced by various family members. The scapegoat, usually a child, is singled out by family members who project their feelings onto this person. As a result, the child may resort to acting-out behavior in an attempt to cope, decrease anxiety, receive love and attention, or preserve self-esteem.
Placing too much responsibility on a child, making him or her a “little adult” in the absence of an adult partner, creates an abnormal family role that can also lead to a behavior disorder. Such a child might be expected to baby-sit siblings, help with adult tasks, or even fulfill the role of the absent adult. The child does not have the opportunity to progress through the normal stages of growth and development. Children of divorce may exhibit low self-esteem and ineffective coping skills and lack social support.
Children Who Experience Poverty
Children who live in poverty are generally denied access to health care, child care, nutrition, adequate housing, and school and play environments. Social isolation occurs. Family functioning is compromised because parents in poverty live under chronic stress, which exposes children to other risk factors (eg, crime or illicit drug use or abuse) for psychiatric–mental health disorders.
Children of Minority Ethnic Status
According to 1990 statistics from the National Center for Children in Poverty, children ages 18 years and younger from culturally diverse groups constituted
approximately one third of the U.S. and Canadian populations (Li & Bennett, 1994). These children lived in families in which there was racial, ethnic, and/or religious diversity. Nearly 50% of African American children and more than 40% of young Hispanic children live in poverty. These children experience adverse effects related to their ethnicity because of poverty and racism. Learning disabilities, deteriorating grades, and lack of developmental assets such as self-esteem and coping skills often place these children at risk (Andrews & Boyle, 2003).
approximately one third of the U.S. and Canadian populations (Li & Bennett, 1994). These children lived in families in which there was racial, ethnic, and/or religious diversity. Nearly 50% of African American children and more than 40% of young Hispanic children live in poverty. These children experience adverse effects related to their ethnicity because of poverty and racism. Learning disabilities, deteriorating grades, and lack of developmental assets such as self-esteem and coping skills often place these children at risk (Andrews & Boyle, 2003).
Children Who Are Abused
Child abuse, which can be physical, emotional, or sexual, places children at risk for emotional and behavioral disorders possibly resulting in death. Clinicians who routinely provided care for children saw an average of four to six victims of abuse and neglect each year (United States Department of Health and Human Services [USDHHS], 1999). It is estimated that more than 2.4 million cases of suspected child abuse and neglect are reported yearly to state child protective agencies in the United States. Estimates of abuse continue to rise yearly.
Child abuse can occur in the home, where the abusers are parents or parent substitutes; in institutional settings, such as daycare centers, child-care agencies, schools, welfare departments, correctional settings, and residential centers; and in society, which allows children to live in poverty or be denied the basic necessities of life. (Chapter 33 discusses child abuse in more detail.)
Children of Substance-Abusing and Mentally Ill Parents
The terms crack babies and fetal alcohol syndrome are used to describe the effects of maternal crack addiction and alcoholism on children. Children exposed to substance abuse in utero or to substances at any early age may experience altered physical development, decreased intellectual ability, behavior or conduct disorders, substance abuse, depression, suicide, and criminality (Johnson, 1997).
Children who live with substance-abusing or mentally ill parents also are at risk for parental abuse and the development of a psychiatric–mental health disorder if they remain in a dysfunctional family unit. Children of mentally ill parents are often neglected because of lack of bonding with parents after birth, and separation or detachment from the ill parent who is unable to function as a positive role model.
Children of Teenaged Parents
Teenage pregnancy is often the result of impulsive sexual behavior without any thought given to the consequences (USCOTA, 1986). In addition, the sexual act may occur while the teenager is under the influence of alcohol or other substances, placing the teenager and infant at risk for a sexually transmitted disease or acquired immunodeficiency syndrome (AIDS). Infants born to teenage mothers are likely to be premature and to present with health problems. The parenting skills of teenagers to deal with stressors of family life are generally lacking. As a result, the child is at risk for developmental disorders, behavior or conduct disorders, and emotional problems.
Children With Chronic Illness or Disability
Just as adults may develop psychiatric–mental health problems secondary to a chronic medical condition or disability, children are also at risk. For example, a child with a physical handicap due to a neuromuscular disorder is at risk for the development of an emotional or behavioral problem. A child taking medication to control asthma symptoms is at risk for the development of anxiety due to adverse effects of medication, or may exhibit behavior similar to conduct disorder due to low self-esteem or a disturbance in self-concept. Children of parents with a chronic illness or disability are also at risk for the development of psychiatric–mental health disorders. They may be subjected to unrealistic expectations (eg, serving as caretakers for the disabled parent) or they may be verbally or emotionally abused by a parent who is unable to cope with his or her medical condition.
Environmental Risk Factors
Two environmental factors that place children at risk for the development of psychiatric–mental health disorders include public schools and the community, also referred to as “neighborhood” or the inner city.
Public Schools
According to a public school education survey conducted in 1999, the National Public Radio (NPR)/
Kaiser/Kennedy School Poll, parents think the nation’s public schools have six major problems: the presence of undisciplined and disruptive students, lack of parental involvement, overcrowded classrooms, violence and lack of school safety, students’ use of alcohol and drugs, and inequality in funding among school districts. All of these factors can influence the development of psychiatric–mental health disorders in children and adolescents (NPR online, 2003).
Kaiser/Kennedy School Poll, parents think the nation’s public schools have six major problems: the presence of undisciplined and disruptive students, lack of parental involvement, overcrowded classrooms, violence and lack of school safety, students’ use of alcohol and drugs, and inequality in funding among school districts. All of these factors can influence the development of psychiatric–mental health disorders in children and adolescents (NPR online, 2003).
Behavioral Approaches
The public school setting is becoming an entry point of contact for behavioral health services in an attempt to prevent and reduce environmental factors that place children and youth at risk for the development of a psychiatric–mental health disorder. Partnerships between psychiatric–mental health clinical nurse specialists in the public-school setting and primary-care nurse practitioners can provide comprehensive services of early identification and timely intervention. When mental health services are provided within the school system, accessibility and efficiency of interventions increase, fragmentation decreases, and there is no unnecessary stigma that often surrounds referrals for mental health treatment (Hales, Karshmer, Monter-Sandoval et al., 2003).
Promotion of Positive Behaviors
The poem at the beginning of this chapter addresses the role of a positive parent–teacher relationship in child development. Barker (1995) lists the characteristics of a school environment that minimize risk factors and influence the development of normal, positive behavior in children and adolescents. The characteristics are summarized as follows:
Integration of the intellectually able and less able children provides for a well-balanced classroom, encouraging normal growth and development.
Acknowledgment and praise by teachers promotes the development of a positive self-concept.
Encouragement of participation in running the school fosters responsibility.
Moderate emphasis on academic achievement permits the child to participate in a variety of activities and to develop a well-rounded personality.
Good role-modeling by teachers promotes positive behavior in children.
A comfortable, pleasant, and attractive environment is conducive to the development of mentally healthy persons.
Neighborhoods
Neighborhoods can also influence the development of behavior disorders. Poor socioeconomic conditions in crowded inner cities produce higher rates of childhood psychiatric–mental health disorders than are seen in suburban areas. Delinquency, substance abuse, childhood depression, and antisocial personality are just a few examples of disorders prevalent in such neighborhoods.
Clinical Symptoms and Diagnostic Characteristics
Disorders usually evident in infancy, childhood, or adolescence have been classified by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) (APA, 2000). These disorders are as follows:
Mental retardation
Learning disorders related to reading, mathematics, and writing
Motor skills disorder related to coordination
Communication disorders
Pervasive developmental disorders
Attention-deficit and disruptive behavior disorders
Feeding and eating disorders
Tic disorders
Elimination disorders
Other disorders of infancy, childhood, and adolescence, such as excessive anxiety, selective mutism, or repetitive nonfunctional motor behavior
Several disorders such as personality disorders, dual diagnosis disorders, psychotic disorders, and substance-related disorders that are discussed in this text may be diagnosed in children or adolescents. Age-specific features have been included in each chapter. Specific content regarding eating disorders, adolescent suicide, and child abuse is discussed in separate chapters.
Many texts present an excellent summary of psychological development, focusing on the developmental stage, motor and physical development, language or communication, cognitive behavior, interpersonal behavior, developmental crisis, and the most frequent disturbing behaviors in that particular developmental stage. The reader is referred to such texts on growth
and development for additional information because it is important in the assessment and treatment of disorders affecting infants, children, and adolescents.
and development for additional information because it is important in the assessment and treatment of disorders affecting infants, children, and adolescents.
Mental Retardation
The last two decades have seen enormous changes in services for children with learning and developmental difficulties such as mental retardation, who are referred to by the general public as “mentally or developmentally challenged.” Although onset occurs before the age of 18 years, the incidence is difficult to calculate because mental retardation sometimes goes unrecognized until middle childhood. Its prevalence rate has been estimated at approximately 1% of the population, with the highest incidence in school-age children peaking at ages 10 to 14 years. It occurs about 1½ times more frequently among men than among women. The trend toward deinstitutionalization has made family and community support a central issue (Sadock & Sadock, 2003).
Mental retardation is described in the DSM-IV-TR as the presence of subaverage general intellectual functioning (an IQ of approximately 70 or below) associated with or resulting in impairments in adaptive behavior. Table 29-3 lists the subtypes and associated severity of mental retardation. Clients with mental impairment experience or exhibit significant limitations in at least two of the following skill areas: communication, self-care, home living, social/interpersonal skills, use of community resources, self-direction, functional academic skills, work, leisure, health, and safety.
Associated features of mental retardation include irritability, aggressiveness, temper tantrums, stereotyped repetitive movements, nail biting, and stuttering. See Clinical Example 29-1.
Associated features of mental retardation include irritability, aggressiveness, temper tantrums, stereotyped repetitive movements, nail biting, and stuttering. See Clinical Example 29-1.
 Table 29.3 Severity of Mental Retardation | ||||||||||||||||||||
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Clinical Example 29.1: The Client With Severe Mental Retardation
MW, 18 years old, was born by a normal spontaneous vaginal delivery without any complications. Two months after birth, MW developed a temperature of 105°F and had a grand mal seizure. He was admitted to the neonatal intensive care unit with the diagnosis of fever of undetermined origin (FUO). Diagnostic tests revealed the presence of encephalitis. MW recovered, but his parents were cautioned about the possibility of central nervous system damage because of the severity of his illness. During early childhood, ages 1 to 5 years, MW was able to communicate with his parents to some extent but exhibited poor motor-skill development. He was unable to learn basic skills such as reading, writing, and arithmetic, and it became evident that he needed supervision in a controlled environment. Testing revealed MW’s IQ to be that of a person with severe retardation or mental impairment. At age 18 years, he continues to live at home with very supportive parents who have been able to teach him some self-care activities. He relates well to a pet cat, helps his mother with simple household chores, and helps his father with gardening and lawn care.
Pervasive Developmental Disorders
Five disorders are classified as pervasive developmental disorders: autistic disorder; Rett’s disorder; childhood disintegrative disorder; Asperger’s disorder (also referred to as Asperger’s syndrome); and pervasive developmental disorder, not otherwise specified. Between 70% and 85% of individuals with the diagnosis of developmental disability referred for psychiatric consultation have one or more untreated or undiagnosed medical problems influencing their behavior. Between 60% and 100% have experienced trauma, usually repeated incidents of abuse (Ryan & Sunada, 1997; Sobsey, 1997). A summary of autistic disorder and Asperger’s disorder follows.
Autistic Disorder
According to statistics provided by the Autism Society of America in 2002, an estimated 500,000 to 1.5 million individuals in the United States have the diagnosis of autistic disorder or some form of pervasive developmental disorder. The incidence of autism is one or two of 1,000 live births. The onset of the disorder is generally noted before the age of 3 years. However, in some cases, it is not detected until a child is much older. In addition, it is estimated that children having autistic-like behavior number 15 to 20 of 10,000. These statistics have increased during the last 5 years.
Autism is four to five times more likely to affect males than females. However, girls with autistic disorder are more likely to have more severe mental retardation. Autistic disorder knows no racial, ethnic, or social boundaries. It is incurable and is considered a life-long disability (Johnson & Dorman, 1998; Sadock & Sadock, 2003).
Sometimes referred to as early infantile autism, childhood autism, or Kanner’s autism, this disorder is characterized by qualitative impairments in social interaction and communication, and restricted repetitive and stereotyped patterns of behavior, interest, and activities. Before the age of 3 years, the child exhibits delays or abnormal functioning in social action, language as used in social communication, or symbolic or imaginative play.
Specifically, autistic children have an inability to establish a meaningful relationship because of their lack of responsiveness to others. They do not display an interest in or need for cuddling, touching, or hugging. They ignore people as if they were inanimate objects or not present in the environment.
Children with autistic disorder also possess gross deficits in language development, including mutism, echolalia, and the inability to name objects. Language deficits may also consist of pronominal reversal, or the use of the pronoun “you” when “I” should be used, and immature grammar.
Other symptoms include withdrawal, which may be mistaken for deafness; obsessive ritualistic behavior, such as rocking and spinning; obsessive attachments to particular objects, even mechanical objects; and anxiety or fear associated with harmless objects. The child may exhibit an obsessive desire for sameness;
that is, he or she becomes resistant to change and is severely distressed if environmental change occurs.
that is, he or she becomes resistant to change and is severely distressed if environmental change occurs.
Overactivity, distractibility, poor concentration, sudden unprovoked anger or fear, or aggressive outbursts also may occur. Autistic children do not experience delusions, hallucinations, incoherence, or looseness of association.
Intellectual functioning varies, because children who are autistic may function at a normal, high, or retarded level. Approximately 50% of autistic children have an IQ below 50 (APA, 2000). Memory may be exceptional, as observed in the behavior of an autistic child who plays several pieces of complicated classical music on the piano. See Clinical Example 29-2.
Asperger’s Disorder
Asperger’s disorder, incorporated into the DSM-IV in 1994, has been widely recognized as part of the mild end of the autistic spectrum. More commonly seen in boys, the typical child with this syndrome lives in the real world on his or her terms, has normal or higher intelligence, exhibits pedantic speech (overemphasis on detail when speaking) by age 5 years, is clumsy, has poor handwriting, and exhibits autistic-type behavior such as hand flapping or pacing when excited or upset.
Clinical Example 29.2: The Client With Autistic Disorder
TJ, age 16 years, was diagnosed with autistic disorder at age 2 years. He lives at home with his parents and attends a school for developmentally disabled children. His ability to communicate verbally is restricted to making guttural sounds at times. TJ requires constant supervision because of behavior such as head banging and biting himself. Custodial care is also necessary to feed and toilet TJ. He has occasional outbursts in which he hits others and attempts to bite them. TJ responds to music, which seems to have a soothing effect on him and he will stand on the basketball court for hours shooting baskets. Although he appears to be in his own world, TJ will unexpectedly respond to the voice of his classroom teacher by looking directly at her and nodding his head or making guttural sounds. His parents report that his conduct at home fluctuates from manageable behavior to hostile, aggressive outbursts, at which time he needs to be medicated to stabilize his behavior.
Verbal functioning is essentially normal, but range of interests is highly circumscribed and social deficits are striking. The child is unable to develop peer relationships, lacks the ability to exhibit social or emotional reciprocity (ie, is unable to respond emotionally to others), and displays an impaired ability to express pleasure in other persons’ happiness (APA, 2000; Sadock & Sadock, 2003).
Verbal IQ is higher than performance IQ. Developmental delay may not be apparent until preschool or school age when social deficits become apparent. Certain psychiatric disorders occur with unusual frequency in children with Asperger’s disorder, including bipolar disorder, ADHD, obsessive–compulsive disorder, and Tourette’s syndrome (Reed, 2001; Sherman, 2000).
Attention-Deficit and Disruptive Behavior Disorders
This category includes the diagnoses of ADHD and disruptive behavior disorders (childhood-onset type and adolescent-onset type) that manifest themselves in home, academic, or social environments. A summary of each follows.
Attention-Deficit Hyperactivity Disorder
Approximately 3% to 7% of prepubertal elementary school children have ADHD, and at least 25% of those children have a parent who also has ADHD. It is not unusual for the proper diagnosis in a child to lead to identification of ADHD or another psychiatric diagnosis in a parent and/or siblings. ADHD is more prevalent in boys, with a ratio ranging from 2 to 1 to as much as 9 to 1 (Glod, 2001; Myers et al., 2003; Sadock & Sadock, 2003).
Characteristics of ADHD include a short attention span, impulsivity, and distractibility. See the accompanying Clinical Symptoms and Diagnostic Characteristics box.
Although manifestations of symptoms are typically present before age 3 years and may cause life-long dysfunction, delayed or missed diagnoses are not unusual. ADHD appears to have many associated comorbid disorders including learning disability, depression, oppositional
defiant disorder, Tourette’s syndrome, general anxiety, conduct disorder, and bipolar disorder. Diagnosis is usually not made until the child enters school, when academic and social functioning may be impaired (Flick, 2002; Sadock & Sadock, 2003). See Clinical Example 29-3.
defiant disorder, Tourette’s syndrome, general anxiety, conduct disorder, and bipolar disorder. Diagnosis is usually not made until the child enters school, when academic and social functioning may be impaired (Flick, 2002; Sadock & Sadock, 2003). See Clinical Example 29-3.
Clinical Symptoms and Diagnostic Characteristics/ADHD
Clinical Symptoms
Lasting at least 6 months and occurring before the age of 7 years:
Stubbornness
Negativism
Temper tantrums
Obstinacy
Inability to tolerate frustration
Deficit in judgment
Poor self-image
Aggressiveness
Diagnostic Characteristics
Inattention
Failure to complete a task, pay attention, or listen
Distractibility
Inability to concentrate
Difficulty participating in activities for a period of time
Hyperactivity
Fidgeting
Inability to sit still
Running, climbing, or moving during sleep
Behavior indicating being in “high gear”
Impulsivity
Failure to think before acting
Frequent shifting from one activity to another (poor attention span)
Inability to organize work
Frequent disrupting of class or groups
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