Psychosocial Problems in Children and Families

Learning Objectives

After studying this chapter, you should be able to:

• Identify risk factors for emotional and behavioral disorders that emerge in childhood and during adolescence.

• Recognize symptoms, behaviors, and characteristics for emotional and behavioral disorders.

• Identify the individual and familial factors and behaviors that correlate to childhood depression, suicide, or suicide attempts.

• Develop a nursing care plan for a child at risk for suicide and the child’s family, as well as for the support of a family with a child who has committed suicide.

• Discuss the incidence, risk factors, symptoms, and nursing interventions for children with eating disorders and their families and describe their nursing care.

• Identify the primary symptoms and manifestations of children with attention-deficit/hyperactivity disorder and describe their nursing care.

• Identify signs and symptoms of substance abuse disorders and develop a nursing care plan.

• Describe the major types of abuse and neglect seen in children, their contributing factors, and nursing care for abused children and their families.

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Clinical Reference

Overview of Psychosocial Disorders of Childhood

Psychosocial or mental illness refers to disorders that affect personal and social functioning or cause acute distress. Psychosocial disorders are disturbances in mood, emotion, cognition, or behavior. To be considered disorders, these disturbances must be of sufficient intensity and duration to disrupt or impair the ability to engage in developmental life tasks and to impair social and emotional functioning. In this sense, the concept of “mental health” is partially culturally defined; it includes the ability to engage in activities of daily living, to manage normal levels of stress, and to have meaningful interpersonal relationships. Disorders that impair mental health are characterized by disruption or alteration in thinking, mood, or behavior.

Mental health and mental illness are not mutually exclusive states, but rather a continuum. Mental health disorders may result from biologic, neurologic, cultural, societal, or psychological causes. Disorders may be triggered by trauma or stressful events. A child without underlying mental illness may experience life events that trigger mental health disruptions, and these may require treatment. Likewise, a child who has a mental illness may exhibit areas of psychological dysfunction, while at the same time showing areas of good or outstanding functioning.

Psychosocial disorders disrupt normal functioning for the affected child and the family. Children may lose interest in play and school activities, and relationships with family and friends are usually impaired. Children may exhibit learning deficits related to behavior in school or inability to concentrate on learning. Some disorders manifest through somatic complaints, such as recurrent abdominal pain, or headaches with no physical cause are common. Recurrent thoughts of death or suicide are sometimes reported. Hospitalization may be required. All of these occurrences have a powerful effect on parents, siblings, friends, and the child’s school environment.

The first section of this chapter provides an overview of the emotional and behavioral disorders that may emerge during childhood and adolescence. It also discusses issues pertaining to suicide, because these emotional and behavioral disorders present a risk for the emergence of suicidal impulses or thoughts. The second section of this chapter surveys substance abuse and eating disorders. Finally, nursing care related to the child and family in which child abuse or neglect is occurring is described.

PSYCHOSOCIAL DISORDERS TYPICALLY MANIFESTED IN CHILDHOOD

• Mood disorders: Depression, dysthymia, adjustment disorder, bipolar disorder

• Anxiety disorders: Social anxiety disorder, separation anxiety disorder, posttraumatic stress disorder, phobias, obsessive-compulsive disorder

• Attention-deficit/hyperactivity disorder

• Eating disorders: Anorexia nervosa, bulimia nervosa

Data from American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., Text revision). Washington, DC: Author.

Precipitating Factors

Neuroscientists have identified complex interactions among inherited predispositions, emotional and behavioral factors, life stressors, and environmental events (Weissman, Wickramaratne, Nomura, et al., 2006). Emotional and behavioral disorders may be manifested as disturbances in feeling (e.g., depression, anxiety), in body function (e.g., constipation, encopresis, enuresis), in somatic symptoms (e.g., headaches, stomachaches), in behavior (e.g., conduct disturbance, school avoidance, passive-aggressive behaviors), or in performance (concentration problems, test-taking difficulties). The manner in which a child responds to stress depends on multiple factors within these interactions (American Academy of Child and Adolescent Psychiatry [AACAP], 2007b).

Factors that influence the development of psychosocial disorders include genetic predisposition, age, developmental level, temperament, parental mental health, coping and adaptive abilities within the family, precipitating traumatic experiences, duration of stressors in the environment, stability and support within the family, and social supports outside the immediate family. Exposures to trauma, and posttraumatic stress disorder (PTSD), have been correlated to the development of anxiety and mood disorders (U.S. Department of Veterans Affairs, 2010).

Diagnostic Evaluation

When a child presents with symptoms that may be indicative of a psychosocial disorder, the nurse, as part of a multispecialty team, will gather information about physical condition, developmental level, cognitive ability and specific symptoms. In addition to the overall assessment, a structured mental status examination of the child is usually indicated. Laboratory and diagnostic tests may also help provide some insight into differential diagnosis and determine whether pharmacologic and psychological interventions are likely to be effective.

Accurate diagnosis is complicated by the fact that wide ranges of emotional, cognitive, and social ability are normal because the brain develops at a different pace for each child. This means that emotional and behavioral responses can be inconsistent and unpredictable. For this reason, the nurse needs to attend to the environment where the child will be interviewed. The nurse should plan time to establish a relationship as a caregiver and to establish a level of trust and comfort. Repeated assessments in a variety of situations and across time will provide the most accurate sense of what is “normal” for an individual child.

Screening questionnaires and assessment tools are increasingly used as part of a developmental and psychosocial evaluation, and some have demonstrated reliability with children. A frequently used test that has demonstrated reliability is the Child Behavior Checklist (CBCL), which is given to parents to complete. This test assesses a variety of emotional and behavioral problems (Beers, 2010). In addition, a structured mental status examination conducted by a skilled child interviewer will provide important information for planning nursing care.

MENTAL STATUS EXAMINATION OF CHILDREN

• Appearance: Noting appropriateness of dress and grooming, ability to engage in greeting behaviors, eye contact, dress, gestures, posture, tics, other repetitive movements; physical presentation, such as age, stature, race, age-appropriate behaviors

• Speech: Fluency, tone, volume, vocabulary, age appropriateness, ability to articulate feelings

• Mood or affect: Predominant feelings, mood fluctuations, congruence between observed mood and verbalization of mood state

• Manner of relating to the examiner: Exploration of the child’s understanding of the purpose of the interview, approach or avoidance behaviors, use of play materials available, verbalizations, ability to sit and talk and attend to the interview or to tasks

• Intellectual skills: Problem-solving abilities, conceptualization of causality, body image, memory, judgment, general fund of knowledge, insight (findings are compared with developmental norms)

• Play: Capacity for imaginative thinking and play, ability to interact during play

• Sensory and motor development: Fine and gross motor skills, symmetry and coordination of movement, hand and eye dominance, right-left discrimination

• Perceptions and thought content: Presence or absence of suicidal-homicidal ideation, intent, plan; delusions or illusions; hallucinations

EVIDENCE-BASED PRACTICE

In 2009, the Institute of Medicine (IOM), with the National Research Council, issued a consensus report that strongly called for health care providers and clinicians to address primary prevention approaches in regard to mental health disorders in children (National Research Council and Institute of Medicine, 2009). The report recognizes that half of all mental, emotional, and behavioral (MEB) disorders are recognizable by age 14, and three quarters are evident by age 24 (p. 15). The report suggests that a prevention focus requires a shift to implementing mental health promotion and illness prevention strategies before the onset of illness, and before the child shows signs or symptoms. Identification of populations at risk, early recognition of emerging signs (thought to occur up to 2 years before diagnosis), and interventions with families as well as children have the potential to decrease severity of illness.

The IOM report (2009) is a level 1 systematic review that not only looked at randomized controlled trials and other evidence-based literature, but also solicited evidence from experts in the care of children with MEB problems. Levels of prevention for the mental health of all children are defined in this report to include the following:

1. Mental health promotion: Population-based interventions designed to enhance children’s interactive competencies and self-esteem with the goal of achieving appropriate developmental milestones

2. Universal prevention: Interventions, such as school based programs about mental health issues, which are available to all children

3. Selective prevention: Interventions targeted to children at risk (e.g., those with dysfunctional family situations, or family history of mental health problems)

4. Indicated prevention: Strategies that address issues with children who are beginning to exhibit signs of concern

Interventions for the prevention of mental, emotional, and behavioral disorders include such approaches as parenting programs for parents of young children, prevention of depression, and the use of psychoeducation, cognitive-behavioral strategies, and family or community-based interventions (IOM).

This report has enormous implications for the role of the professional nurse. As a nurse, think about specific strategies you could implement that will recognize and encourage the developmental competencies of children, support the mental health and parenting abilities of parents, promote prevention and health promotion in schools, and advocate for social justice in protecting populations from poverty and violence.

Reference: O’Connell, M., Boat, T., & Warner, K. (Eds.). (2009). Preventing mental, emotional, and behavioral disorders among young people: Progress and possibilities.Washington DC, National Academies Press. Retrieved from www.nap.edu.

Recent research conducted and reported by the Institute of Medicine (2009) promotes a shift in the approach to childhood mental health issues from identification and treatment to an overall mental health promotion and illness preventive approach. Although this chapter is organized according to mental, emotional, and behavioral disorders, nurses need to think about facilitating preventive measures and mental health promotion for all children beginning in infancy.

Emotional Disorders

Nurses caring for children frequently encounter moods or behaviors that compromise a child’s ability to function at appropriate developmental levels and successfully establish interpersonal relationships. Research consistently shows that most psychosocial disorders are caused by a combination of predisposing or inherent factors and environmental factors that trigger symptoms.

Psychosocial disorders often occur in children who have a familial or genetic predisposition toward the disease. This predisposition may become apparent if physical or emotional stressors create a vulnerability for manifestation of the disorder. In addition to genetic and familial traits, contributors to a psychosocial disorder include physical problems, such as head injuries, sleep disorders, birth defects, physical injuries, and chronic illness. Environmental stressors, such as inconsistent or contradictory child-rearing practices, marital conflict, neglect, or traumatic events may also precipitate the development of a psychosocial disorder. Some cognitive, emotional, and behavioral manifestations are associated with genetic syndromes, such as fragile X syndrome. Other disorders, such as fetal alcohol syndrome (FAS), are associated with prenatal or infancy deficiencies or substance abuse by pregnant women (O’Donnell, Nassar, Leonard, et al., 2009). Still other disorders are related primarily to an inaccurate or inappropriate relationship between the child and significant others in the social environment.

Psychosocial disorders, for many years, have been generally classified into two broad categories: emotional disorders and behavioral disorders. Emotional disorders are characterized by fear, sadness, depression, worry, and somatic complaints. The emotional disorders in the discussion that follows include anxiety, mood, and PTSDs. Behavioral disorders refer to problems with attention and behavior, such as attention-deficit/hyperactivity disorder, and are discussed later in this chapter.

Anxiety Disorders

Anxiety is a normal human emotion, the body’s adaptive response to change or challenges. Anxiety can be expected during times of transition or times of achieving developmental milestones. Most people can identify anxiety as an uncomfortable feeling of worry, dread, fear, or apprehension that occurs in response to external or internal stimuli. Symptoms and displays of anxiety are expected and normal in children at specific times in development. For example, infants and children up to preschool age often show intense distress at times of separation from their parents or family members (see Chapter 35). In addition, it is common for young children to have short-lived fears related to darkness, storms, animals, and imaginary situations (see Chapters 7 and 8).

Anxiety is generally considered to occur in two subtypes: state and trait. State anxiety refers to transitory feelings of apprehension, tension, or worry. These feelings vary in intensity and often have an identifiable event contributing to them, and the anxiety fluctuates over time. Trait anxiety describes a condition of anxiety that is prevalent, stable over time, and less likely to be associated with a specific triggering event.

Predispositions to anxiety result from a confluence of genetic factors, petrochemical and hormonal imbalances, parental patterns of coping with stress, and societal influences (AACAP, 2007a). The amygdala has a central role in the physical response to stress and fear, and some disorders may relate to amygdala activity (Stein & Stein, 2008).

Nurses caring for children often must differentiate normal or expected anxiety from the chronic conditions of anxiety, which should be treated. The identification, treatment, and management of an anxiety disorder can have a positive effect on children’s enjoyment of their lives, their social and educational success, and their adjustment to adult life.

Exposures to trauma and PTSD have been linked to the development of anxiety disorders (U.S. Department of Veterans Affairs, 2010). Differentiation of normal anxiety from anxiety disorders is made when worry and distress become overwhelming or interfere with the child’s ability to attend to tasks of daily functioning such as work, school, or home life. Symptoms such as muscle tension, increased respiratory rates, headaches, heightened startle reflex, tremors, and increased perspiration can be identified during the history and physical examination. Although school-age children typically express anxiety or fear of body harm or potentially real worries (e.g., thunder, lightning), adolescents may exhibit anxiety regarding social situations and acceptance (see Chapter 9).

Social Anxiety Disorder

Social anxiety disorder (social phobia) is the most common of the anxiety disorders and usually shows its first symptoms in childhood or early adolescence. It is also a disorder that, untreated, has wide-reaching effects on the child’s ability to make friends, successfully transition to school, play sports, be part of a peer group during adolescence, and make the transitions to dating and to college. Research on adult populations has correlated the diagnosis with lower educational level, increased workplace difficulties, and difficulty engaging in intimate relationships such as marriage. Some research indicates that anxiety disorders may create social isolation that precedes depression and predisposes to substance abuse (Stein & Stein, 2008).

Social anxiety disorder generally responds well to treatment, and several different treatment approaches have been shown to be effective. Symptoms of social anxiety may be generalized or may be focused on specific triggers. Generalized social anxiety disorder is characterized by fearfulness or discomfort in many social situations. Nongeneralized social disorder (also called performance anxiety) is characterized by severe anxiety about discrete situations or tasks, such as public speaking and socializing at parties, that people without social anxiety disorder can manage (Stein & Stein, 2008).

Social anxiety can be misinterpreted as shyness. The child may seem aloof from groups of children, or uninvolved in social situations. Children may avoid social or performance situations to such a degree that their daily routine is affected (e.g., by refusing to participate in physical education exercises or by failing to raise their hands to ask a question in class). Social phobia can result in social isolation for the child who has difficulty establishing and maintaining peer relationships.

Separation Anxiety

The essential hallmark of separation anxiety is disabling anxiety about being apart from one’s parents or another significant person to whom the child is attached, or anxiety about being away from home. It may develop spontaneously or under stress (e.g., in temporary relation to a move or a death in the family) and may last for several years, with symptoms developing and remitting in a cyclical pattern. Children with separation anxiety frequently fear that if they are apart from their parents, harm will come to the parent or themselves. Separation anxiety occurs in approximately 4% to 5% of children and young adults (Rosenberg, Vandana & Chiriboga, 2011). Separation anxiety disorders in childhood are associated with increased risk for the subsequent development of panic disorders and depression (Rosenberg et al., 2011).

School refusal is related to separation anxiety disorder (AACAP, 2007a) and may also be related to a social anxiety disorder. Persistent reluctance or refusal to go to school or elsewhere may be the primary reason families seek intervention for separation anxiety disorder. Unlike truants, who are relatively fearless and avoid school to pursue other interests, children with separation anxiety stay home or attempt to remain with their parents. The child may complain of physical symptoms, cry, bargain, plead, or even exhibit panic symptoms as school time approaches. Symptoms resolve quickly if the child is allowed to stay home, but will reappear the next morning. Sometimes the child may simply refuse to leave the home. Consideration of this diagnosis should rule out precipitating factors such as fear of bullying, fatigue, boredom, learning challenges, upsetting incidents that occur in the school setting, or upsets that are occurring in the home.

Panic Disorder

Panic disorder (panic attacks) is distinguished from other anxiety disorders by the rapid onset of physical, cognitive, and emotional symptoms. The child’s ability to cope may be quickly overwhelmed by the marked discomfort that includes physical symptoms such as cardiovascular (palpitations, chest pain) and respiratory (shortness of breath) distress, and psychological symptoms characterized by a strong feeling of impending doom or fear that the child is dying (Rosenberg et al., 2011).

Before considering panic disorder, organic causes should be ruled out. These include hyperthyroidism, hyperglycemia, temporal lobe epilepsy, and extreme caffeine intake, as well as other disorders. However, the presence of mitral valve prolapse does not exclude the diagnosis of panic disorder (Kaplan & Saddock, 2007) and both should be noted. The diagnosis of panic disorder is more frequently seen in adolescents than in children (Queen, 2010).

Posttraumatic Stress Disorder

PTSD is a disabling psychosocial disorder that follows a traumatic or overwhelming experience. Population studies estimate that exposure to at least one traumatic event is experienced by 14% to 43% of children and adolescents (U.S. Department of Veterans Affairs, 2010). The development of PTSD is correlated to severity of trauma, proximity, repeated experience of trauma, and social supports. PTSD affects approximately 6% of children younger than 18 years but less than 1% of preschoolers (U.S. Department of Veterans Affairs, 2010). A number of studies have linked the development of PTSD to sexual or physical abuse (Cutajar, Mullen, Ogloff, et al., 2010), but PTSD also occurs as a sequel to other traumatic events, such as experience of a natural disaster, life-threatening accidents, loss of a parent, or severe injury.

PTSD is characterized by three main clusters of symptoms: intrusive symptoms, arousal symptoms, and avoidance symptoms (Cutajar et al., 2010). Intrusive symptoms include nightmares, flashbacks (terrifying memories), and a feeling of depersonalization. Arousal symptoms include trouble sleeping, agitation, exaggerated startle response, or regressive behavior. Avoidance symptoms are characterized by avoidance of people, places, or triggers that remind the child of the perpetuating traumatic event. Other symptoms of PTSD include intense fear, helplessness, or horror, along with physiologic symptoms of increased arousal. For example, the child may demonstrate determined avoidance of stimuli associated with the traumatic event but may have persistent nightmares or flashbacks. Children may reenact the event during play. Adolescents may exhibit antisocial or aggressive behaviors and may be at risk for using substances that they perceive will alleviate their feelings of distress (U.S. Department of Veterans Affairs, 2010). PTSD interferes with the child’s developing brain and ability to concentrate, may contribute to sleep problems, and may cause the child to be hypervigilant or agitated.

Obsessive-Compulsive Disorder

Affecting approximately 1% of children (Massachusetts General Hospital, 2010), obsessive-compulsive disorder (OCD) manifests as repetitive unwanted thoughts (obsessions) or ritualistic actions (compulsions), or both. Obsessions are recurrent intrusive thoughts, feelings, and ideas. Compulsions are behaviors or actions that are repetitive and recurrent. Compulsions are designed to relieve the anxiety that the child usually realizes is irrational. Because young children cannot adequately describe their uncomfortable thoughts or concerns, severe temper tantrums, particularly when a ritual has been interrupted, may be the predominant symptom (Massachusetts General Hospital, 2010).

Children often go through transient stages of obsessive thinking or compulsive behavior, usually at times of anxiety or stress, and these transient symptoms do not warrant the diagnosis. This is usually manifested by the need to count, or to check and recheck locks on doors.

OCD is considered when obsessions and compulsions are intractable, disturbing to the child, and interfere with activities and relationships. Several studies link OCD to depressive disorders, with the prefrontal cortex, the basal ganglia, and the limbic system as areas that are affected (Kaplan & Saddock, 2007).

Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS) refer to the abrupt onset of OCD symptoms or tic disorder symptoms (see Chapter 54) following a group A beta-hemolytic streptococcal infection. Research suggests that the disease is not caused by the bacteria, but rather by the antibodies that respond to the infection (Schrag, Gilbert, Giovannoni, et al., 2009). Some researchers speculate that PANDAS may be an element in subsequent development of other psychosocial disorders (Kerbeshian, Burd, & Tait, 2007).

Although the relationship between streptococcal infection and OCD has been described in several studies, recent evidence varies as to the strength of the relationship and what factors contribute to the development of the disorder following exposure to strep (Shulman, 2009).

Mood Disorders

Mood disorders are characterized by lowering of mood, or cycling between low mood and mania. Mood disorders are classified on the basis of severity of symptoms, the course of the illness, and the presence or absence of mania. The mood disorders include major depressive disorder, dysthymic disorder, bipolar disorder, and adjustment disorder.

Major Depressive Disorder and Dysthymic Disorder

Major depressive disorder (MDD) and dysthymic disorder (DD) are diagnoses that have become increasingly prevalent in the adolescent age-group. Recent estimates for both disorders combined indicate a prevalence rate of 14% of 13- to 18-year-olds. Among that age-group, severe depression is estimated to have a prevalence of 4.7% (Merikangas, He, Burstein, et al., 2010). The prevalence rate of depression among girls shows nearly three times the rate of depression in boys. In addition, the depression rates appear to increase with age; approximately 4% of children younger than 13 years of age are considered to be depressed, with a rate increase of 11.6% among 16-year-olds (Merikangas et al., 2010).

There appear to be numerous possible contributors to depression. These include genetic predisposition, familial situation, life events, physical or psychological trauma, or head injury components. In young children, depression may be related to abuse or neglect or other situational triggers. An episode of MDD increases the risk for subsequent episodes. Depression often manifests as a co-morbidity with substance abuse, so children who report depression should be assessed for substance abuse as well. The distinction between MDD and DD is based on the level of depression and the effect on the adolescent’s functioning.

DD is considered to be a chronic lowered level of mood that is persistent. Children or adolescents who exhibit a less severe but depressed or irritable mood for at least 1 year meet the criteria for DD. Children with DD are generally able to continue overall functioning, but energy and motivation may be low (National Institute of Mental Health [NIMH], 2010d).

By contrast, MDD is a debilitating and severe depression, creating significant risk factors. Clinical signs and indicators include angry outbursts, irritability, loss of interest and enjoyment in usual activities, decreased energy, altered appetite, altered sleep patterns, decreased self-esteem, disengagement from family and friends, and thoughts of suicide. If the clinical presentation lasts at least 2 weeks (or longer), the child meets the criteria for MDD. Children and adolescents who are diagnosed with MDD should be carefully assessed for risk of self-harm, suicide, or aggression toward others.

Adjustment Disorder

Adjustment disorders are maladaptive reactions to identifiable traumas or stressors. The Diagnostic and Statistical Manual of Mental Disorders (4th ed., Text revision) (DSM-IV-TR) (American Psychiatric Association [APA], 2000) sets two conditions that are considered to be essential for the consideration of the diagnosis: The response to the stress or trauma must be “abnormal” (that is, beyond the level of stress that most children would display), and in addition, the child must experience significant impairment in social and developmental functioning (APA, 2000). In the case of adjustment disorders, the stressors act as precipitating events.

Adjustment disorders are characterized by less severe mood disturbance, fewer overall symptoms, and a self-limiting course (generally 3 months or less). Manifestations of adjustment disorder include depression, anxiety, mixed depression and anxiety, and disturbance of conduct.

The incidence of adjustment disorders is difficult to estimate, because other diagnoses are frequently co-morbid. Caretakers should be alert for signs of social isolation, withdrawal from socialization or affection, and suicidal thinking. Early identification, support, and intervention can be a powerful resource in minimizing the length and severity of mood disruption.

Bipolar Disorder

Onset for bipolar disorder occurs most often in late adolescence or early adulthood (NIMH, 2010b). Bipolar disorder is characterized by chronic, fluctuating, and extreme mood disturbances. Depression and lowered mood alternate with episodes of elation, irritability, anger, and aggression. The child or adolescent experiencing a manic mood state may be overly elated, grandiose, easily distracted, irritable, and aggressive, and may also demonstrate increased risk-taking behavior, talk rapidly, and not be able to sleep (NIMH, 2010b). Impaired social relationships are common.

When these mood fluctuations have been present for 1 year and are not related to a physical or developmental condition, bipolar mood disorder may be diagnosed. However, normal mood swings that accompany some developmental stages, particularly early adolescence, may confound the ability to make an accurate diagnosis. Recent findings indicate that most children with rapidly shifting moods are experiencing normal developmental or personality states. This means that the diagnosis of bipolar disorder has been incorrectly assigned to children who are “difficult” (Findling, Youngstrom, Fristad, et al., 2010).

In young children, bipolar disorder most often manifests in a rapid cycling form, with swiftly changing and extreme mood swings (NIMH, 2010a). Other signs include irritability, anger, aggressive behavior, rapid speech, sleep disturbances, psychosomatic complaints, sadness, decreased energy, and suicidal ideation (NIMH, 2010a). Bipolar mood disorders affect approximately 1% to 5% of adolescents (NIMH, 2010b).

Parents of children who have bipolar disorder are more likely to have bipolar disorder themselves. A recent National Institutes of Mental Health study (NIMH, 2010b) found that 33% of such parents had the disorder.

Etiology and Physiology of Emotional Disorders

The contributing factors to emotional disorders include biologic, environmental, and traumatic.

Biologic Factors

Research supports the view that emotional disorders have biologic components that affect both brain structure and function; it is also possible that some overwhelming events may interrupt brain development (Kerbeshian et al., 2007). Biologic factors that contribute to mental disorders include genetic determinants, genetic predispositions (risk factors), traumatic brain injury, and disease states that affect brain function (Fay, Yeates, Drotar, et al., 2009). Other factors can influence behavior by affecting a child’s physiologic processes. Stress perception, such as PTSD, and certain mood disorders, such as depression, are associated with increased cortisol levels over time, with emerging evidence that these increased cortisol levels may contribute to alteration in structural brain development (Fay et al., 2009).

One focus of exploration in the etiology of emotional disorders relates to the role of neurotransmitters. Neurotransmitters are chemical molecules that facilitate communication among neurons. Neurotransmitters conduct electrical impulses across nerve synapses. Normally, these neurotransmitters are synthesized in a presynaptic nerve, are released into the synaptic space, and bind to receptors in the postsynaptic nerve, where they excite, inhibit, or modify nerve action. The neurotransmitters are then released again by the postsynaptic nerve back into the synaptic space, where they are either destroyed or taken back into the presynaptic nerve for future use (reuptake) (Takashi, 2010). A deficit in some neurotransmitters in the synaptic space, particularly the monoamines norepinephrine and serotonin, has been implicated in the etiology of emotional disorders. In children with mood or anxiety disorders, available serotonin is decreased, either from decreased release or increased reuptake (Takashi, 2010); this particularly affects neurotransmitters in areas of the brain that regulate cognition, feelings and emotions, and motivation (prefrontal cortex and limbic system).

One other important area of exploration is into the hypothalamic-pituitary-adrenal axis, which regulates stress hormones. Theoretically, stress early in life can contribute to an exaggerated level of stress hormones with subsequent excessive stress response. The increase in stress hormones contributes to the symptoms seen particularly in children with anxiety disorders. In addition, children with OCD have heightened metabolic activity in areas of the brain associated with strong emotions (Takashi, 2010).

Environmental Factors

A family history of depression (particularly parental) is a significant risk factor for depression in children or adolescents, which increases the risk for suicide (NIMH, 2010e). Emotional and behavioral theories emphasize the importance of the interaction within the family system and quality of relationships with siblings (Waldinger, Vaillant, & Orav, 2007). There is evidence that children with a history of verbal, physical, or sexual abuse; frequent separation from or loss of loved ones; drug use; incarceration; lower socioeconomic status; homosexuality; chronic illness; behavioral disorders; and dysfunctional families are more likely than peers with healthy family patterns to have anxiety or depressive disorders (NIMH, 2010b).

Traumatic Brain Injury

Growing evidence points to the secondary development of mood disorders in children and adolescents who have sustained traumatic brain injury (TBI), including concussion. The impact of damage resulting from brain injury depends on a number of factors, including the extent, location, and treatment of the injury (Fay et al., 2009). One significant factor is the maturational stage of the brain at the time the damage occurs. Another physiologic factor is the length of time the brain tissue is impaired (as a result of swelling, hemorrhage, or tissue destruction). Finally, the specific area of the brain that is damaged may determine the precise areas of deficit.

The range of severity of TBI may be mild, with only a brief change in mental status, or it may be severe, causing functional long-term changes that can affect emotions, sensations, memory, or cognition. Damage may be cumulative over consecutive injuries (Centers for Disease Control and Prevention [CDC], 2010a).

Manifestations

Disruption in emotional state, including sadness, worry, fear, and somatic complaints, is often prominent in the clinical presentation of emotional disorders, which include both anxiety disorders and mood (depressive) disorders. In addition, suicide risk is increased, particularly with mood disorders.

Anxiety disorders and mood disorders may present with mixed features (i.e., depression and anxiety are both present), which complicates establishing an accurate diagnosis. For example, the child who is anxious may be withdrawn, tearful, unwilling to engage in play, or prone to acting aggressively toward others. These same symptoms typically occur in children who are depressed. Moreover, it is often difficult to differentiate between normal mood changes that are the result of normal developmental maturation and adaptation and abnormal, persistent mood disturbances.

Generally, however, mood disturbance is more intense and persistent and interferes with social relations and daily functioning. Finally, the child or adolescent can have both anxiety and a mood disorder. Mood disorders are also varied and are specified according to the intensity or duration of depressive symptoms or the particular behaviors displayed by the child. For these reasons, careful assessment by a specialist in psychosocial disorders and the use of screening tools is essential.

Therapeutic Management of Children with Emotional Disorders

The management of depression and anxiety in the pediatric population is focused toward providing immediate symptom relief, stabilizing the family situation, and planning for supports that will help mitigate the intensity and frequency of recurrences. Interventions will vary based on the age, developmental level, and social support available to the child.

Recurrence of symptoms is common, with every recurrence increasing the likelihood of future events. For this reason, accurate identification, appropriate intervention, and long-term follow-up are essential to protect the child’s physical, intellectual, and social development, because poor health behaviors and social isolation accompany the disorders.

Nursing Care

The Child with an Emotional Disorder

Assessment

In addition to the diagnostic methods described earlier in this chapter (see Diagnostic Evaluation) a thorough physical and developmental history should be obtained from the child and/or the family, with attention paid to previous episodes of the presenting problem. Children may initially be most comfortable having parents present, but when the child is comfortable with the nurse, a private interview should also be offered. Presenting emotional symptoms, physical symptoms (e.g., headaches, stomachaches), and precipitating events should be identified. Initial assessment should also include descriptions of the child’s moods, patterns of daily activity, stressors, and coping style (Briggs-Gowan & Carter, 2008).

It is important to gain information regarding risk for self-harm or suicide, particularly if the child shows symptoms of depression. Assessment of risk for self-harm and suicide includes questions about ideation (thoughts), impulses, or plans. Assessment of previous suicide attempts is essential because this raises the risk of future attempts (Wintersteen, 2010).

Family history provides a contextual framework for understanding the child’s symptoms. This should include identification of extended family members who may share living arrangements, and questions about the family interaction patterns. Family (particularly parental) history of psychosocial disorder, mood or anxiety disorder, or substance abuse are all risk factors for a child’s development of a psychosocial disturbance. Parents or caregivers should be asked to describe changes in the child’s behaviors and when these changes began. Other areas of inquiry include the child’s ability to engage in routine activities or play and to interact with friends, and school performance (Wintersteen, Diamond & Fein, 2007).

For a child who presents with symptoms of OCD or tic disorder, history of sore throats related to strep infection should be noted, along with whether OCD symptom onset was sudden or occurred after an illness (see PANDAS, this chapter).

Screening instruments and self-reporting instruments are increasingly used as part of outcomes measurement and are useful for differential diagnosis of depression and anxiety. As retest measures, they have shown some reliability in assessing treatment effectiveness (Briggs-Gowan & Carter, 2008; Queen, 2010).

Expected Outcome

The child will engage in appropriate play for developmental level, attend school, maintain educational progress, and continue positive relationship with peers.

Interventions

Social skills training or group therapy may be most helpful for social anxiety. Children will often try to avoid anxiety by limiting social interactions. This creates a cycle of avoidance and associated shame. Behavioral interventions for children with school phobias are directed toward keeping the child attending school, while offering interventions during school time to reduce anxiety symptoms, such as refusing to pick up the child from school, even if the child insists. This form of intervention is a type of desensitization therapy.

Controversy has surrounded the use of antidepressants. Most antidepressants were studied in adult populations, and evidence is emerging that children may not metabolize these substances in the same manner as adults. A black box warning about the potential for increased risk of suicidal ideation and behavior in children, adolescents, and young adults appears on all dispensed prescription antidepressants. Schneeweiss, Patrick, Solomon, et al. (2010) conducted an extensive study of antidepressant use and suicide thoughts or acts in more than 20,000 children and adolescents and found that increased suicide risk does not differ among various classes of antidepressants. Therefore the decision on prescribing a particular antidepressant should be based on its potential for therapeutic effect and not on its relative risk for suicide (Schneeweiss et al., 2010). It is not prohibited to use antidepressants to treat these disorders in children or adolescents; however, it is advised to keep a close watch on initiating any type of medication treatment in this population. With careful monitoring when drugs are introduced, use of selective serotonin reuptake inhibitors (SSRIs) for medication management is an appropriate and widely used treatment for depression and anxiety in children (Tishler, Reiss, & Rhodes, 2008; Walter & Demaso, 2011).

Children, parents, and clinicians may prefer to initiate psychotherapy before, and perhaps in lieu of, medications; however, the most effective treatment combines medication and the child and family’s exploration of situations and environmental factors that are related to the child’s symptoms (March & Vitiello, 2009). Individual therapy and family counseling are essential for children with suicidal ideation or persistent mood disturbances, and in these cases consideration for hospitalization is paramount to protect the child from harmful impulses. Additionally, severe and disabling anxiety warrants serious intervention (Connolly & Bernstein, 2007) and may require day treatment or hospitalization. If the child needs hospitalization, admission will generally be to a psychosocial unit where specialized nursing is available (AACAP, 2007b).

Day treatment programs have increasingly become an alternative to hospitalization. Hospital and day treatment settings use cognitive-behavioral therapies (CBTs) to increase coping skills and social skills and to provide tools that can be used to manage stress. The underlying principle of CBT is that individuals, by consciously becoming aware of stressful thoughts and feelings associated with various events or situations, can learn to analyze behaviors related to these thoughts or feelings and begin to think and behave in more positive ways. CBTs have shown benefit for all of the emotional disorders. They can be done individually or in groups. Other behavioral strategies for managing depression and anxiety include relaxation therapy, distraction strategies, self-talk, or cognitive strategies, as well as support from adults or friends who are safe and reassuring (Pull, 2007).

Evaluation

• Does the child exhibit an energy level that allows for interactions, play, and school?

• Does the child seem interested in people and events?

• Does the child communicate positive statements about self?

• Does the parent report that the child appears happier and more engaged?

• Does the child exhibit normal patterns of eating and sleeping?

• Can the parent describe the medication effects and side effects?

Suicide

Suicide is a major public health problem, the third leading cause of death among adolescents between 15 and 24 years old and the fifth among children 5 to 14 years old (National Center for Health Statistics, 2011). Suicide rates among adolescents in the United States have risen dramatically. Estimates of the prevalence of suicidal ideation are 10.5% in males and 17.4% in females. The prevalence of suicide attempts is 4.6% in males and 8.1% in females (CDC, 2010c).

Among young people, suicide incidence rises with age. Suicide by children younger than 10 years of age is uncommon. Children between the ages of 5 and 14 died by suicide at a rate of 0.7 per 100,000 and adolescents between 15 and 24 at a rate of 10.1 per 100,000. This compares to an overall rate of 11.9 per 100,000 people (National Center for Health Statistics, 2011). Other differences are also noted. For example, males are more likely to die by suicide than females, at a ratio of 4:1. Methods appear to vary by gender, with girls using poisons and boys using firearms most frequently (CDC, 2009).

Risk for suicide should be assessed by ascertaining prior suicide attempts, family history of suicide, history of depression, substance abuse, alcohol abuse, an overwhelming life stressor, access to methods, and history of arrest or incarceration (CDC, 2010b). Presence of risk factors does not mean that a suicide attempt is inevitable, but should raise the awareness of anyone who interacts with the child or adolescent.

NURSING QUALITY ALERT

Resources for People with Thoughts of Suicide

Resources for anyone who is having thoughts of suicide are available through the National Suicide Prevention Lifeline (1-800-273-8255); through its website (www.suicidepreventionlifeline.org), or from the American Association of Suicidology at www.suicidology.org/web/guest/home.

Of significant importance, gay, lesbian, bisexual, and possibly transgender adolescents are two to seven times more likely to attempt suicide than are their heterosexual peers (Suicide Prevention Resource Center, 2008). This appears to be linked to social stigma, feelings of isolation, and level of vulnerability and stress, such as lack of social and family support (Suicide Prevention Resource Center, 2008). Suicide ideation is also significantly higher in lesbian, gay, and bisexual (LGB) adolescents (Suicide Prevention Resource Center, 2008).

Suicide potential should always be assessed for a child with symptoms of a mood disorder, or multiple disorders (co-morbidity), or history of previous suicide attempts. Family history of psychosocial disorders (especially depression or a parent who has died by suicide) creates increased risk. Other significant risk factors are chronic medical illness, family violence, substance abuse, poor impulse control, poor school performance, homosexuality, and access to firearms in the household (Moscicki, 2009).

Underlying major depression, poor self-concept, and hopelessness appear to be the most significant factors contributing to suicide, regardless of age or sex. Long-standing family dysfunction is often present, with emotional detachment and isolation among family members. The suicide victim is typically a vulnerable individual who, under stress and unable to envision a solution, seeks and finds a way to die. In the case of children, risks are greatest when there is not adequate adult support to identify and intervene in the escalation of symptoms.

Most adolescent suicide attempts are impulsive: motivated by a desire to influence others, gain attention, communicate love or anger, or escape a difficult or painful situation. Suicide hotlines or drop-in centers can often serve to keep the young person safe until the impulse passes.

However, any verbalization or gesture of suicide should be taken very seriously and should never be ignored. The young person should be encouraged to discuss the thought specifically to determine whether there is a plan and the lethality of the plan (Wintersteen, 2010). Help should be obtained from qualified health professionals.

Suicide remains a rare phenomenon for young children, although a child who has lost a parent before the age of 13 has increased risk for mood disorder and suicide. Until about the age of 6 most children do not have a realistic concept of death, although they may express thoughts about harming themselves. However, children as young as 3 have tried to commit suicide and apparently understood what they were doing.

Knowledge regarding prevention of suicide is an essential role for the community health nurse and the school nurse, especially for nurses at the middle or high school level. It is imperative that school nurses educate school personnel about recognizing the subtle signs of an impending suicide attempt so intervention can occur. Considerations included in continuing education should be whom to contact if a teacher or other school worker suspects a child is considering suicide, who will interview and evaluate the child, and what personnel will notify the family. Often, schools have professional teams that perform the evaluation and make appropriate referrals. Suicide prevention and incidence reduction are two of the national goals described in Healthy People 2020 (U.S. Department of Health and Human Services [USDHHS], 2010).

Manifestations and Risk Factors

The risk for suicide should be considered if the following are present:

• Previous suicide attempts

• Past psychosocial hospitalization; overt signs of mental illness manifested as delusions or hallucinations

• A family member or friend who has committed suicide; exposure to violence in the home or social environment

• Death of a parent before the child reached 13 years of age

• Recent losses; these may include the death of a relative, a family divorce, a breakup, or any significant change or life event that disrupts the emotional status quo

• Preoccupation with death; statements about suicide or self-harm; suicidal clues, such as cryptic verbal messages, giving away personal items, and changes in expected patterns of behaviors (e.g., sudden calmness in a normally anxious teenager)

• History of risk-taking or self-abusive behaviors; use of alcohol or drugs to cope with emotions

• Overwhelming sense of guilt or shame; obsessional self-doubt

• Social isolation: the individual does not have social alternatives or the skills to find alternatives to suicide

• Handguns in the home, especially if accessible or loaded

• History of physical or sexual abuse

• Homosexuality, especially if the teen discovers same-sex orientation early in adolescence, experiences violence because of homosexual identity, or is rejected by family members as a result of sexual orientation

Therapeutic Management

Prevention

Recognition of risk factors for suicidal feelings by health care providers and at schools is one of the most significant prevention strategies. Children or adolescents who commit suicide have usually offered at least veiled information about their suicidal ideation or feelings of despair to classmates, teachers, or health care providers. Children or adolescents with suicidal ideation should undergo a thorough psychosocial evaluation by a mental health professional. The child may need pharmacotherapeutic agents, such as antidepressants or antipsychotic medications. The use of medications in children at risk for suicide requires close monitoring, and medications should be distributed in small doses because they could be used in a suicide attempt or act (AACAP, 2007b). The decision to discharge a child for observation or to hospitalize is based on the nature of the ideation, the access to methods, and the ability of the family to provide a supportive and safe environment (Tishler et al., 2008).

When Prevention and Intervention Fail

A suicide attempt or a death by suicide is a crisis event for all family members and friends. Counseling by a mental health specialist who is experienced in the area of suicide should be provided to all family members and the child’s immediate friends. It is important that these services be offered quickly, preferably within the first 24 hours. In the event of a death by suicide, counselors should remain available for at least 1 year after the event. Grieving and emotional adjustments often take several months and may peak around the anniversary of the suicide event. The experience of losing someone by suicide creates an increased risk that others may act on similar impulses.