WORKING WITH CHILDREN
Emily K. Johnson
EXPECTED LEARNING OUTCOMES
After completing this chapter, the student will be able to:
1. Discuss the major theories related to growth and development in children
2. Identify normative versus non-normative behavioral patterns in relation to developmental milestones
3. Describe the major mental health disorders found in children
4. Identify the primary treatment options available for mental disorders found in children
5. Apply the nursing process from an interpersonal perspective that addresses the developmental needs of children experiencing mental health disorders
Childhood behavior varies significantly with developmental stage, psychosocial environment, and genetic influence. Due to differences between childhood and adult behavior, emotional problems and mental health disorders in children can be difficult to determine. As with adults, psychiatric diagnoses in children are made by skilled professionals trained to observe particular signs and symptoms. However, in children, the signs and symptoms must be considered in the context of developmental level and physical and social environment. The signs may be significantly different from those seen in adolescents and adults. Moreover, a young child’s inability to express symptoms clearly makes the determination even more challenging. For example, children with depression may display significant irritability (Stringaris, Maughan, Copeland, Costello, & Angold, 2013) and express nonspecific physical complaints. Children commonly find it more difficult to verbalize to an adult that they are feeling sad. As a result, reports from parents, other caretakers, and/or teachers are often used to supplement information gathered during a psychiatric assessment. Accurate diagnoses and effective treatment require a solid knowledge base involving childhood development, specific diagnostic criteria, and assessment techniques.
The following chapter addresses the unique and challenging issues involved in working with children who have a mental disorder. Major theories related to growth and development are reviewed and some of the more common mental health disorders are described. The nursing process is applied from an interpersonal perspective to provide a framework when caring for a child with a mental health disorder.
GROWTH AND DEVELOPMENT THEORIES
In all scientific fields, theory guides clinical practice and forms the basis for reasoning behind particular treatments. Chapter 10 provides an in-depth discussion of theories in general, including those specifically related to mental illness; this chapter describes the major theories related to an individual’s development through the life span. These theories help to provide a foundation from which to explain the reasons why particular disorders affect particular individuals and to assist in understanding the appropriate treatment options and care.
Piaget’s Theory of Cognitive Development
Knowledge and understanding of cognitive, emotional, and psychological growth is imperative to the assessment and nursing care of children. COGNITIVE DEVELOPMENT refers to one’s ability to understand the world, including interaction with stimuli and objects in the environment, social interactions related to thinking patterns, and how one receives and stores information (Bornstein & Lamb, 1999). Perhaps the most influential theory associated with cognitive development is that of Jean Piaget, a Swiss theorist who began studying childhood development in the 1920s using his own children as subjects (Sadock & Sadock, 2007). Although this method provided grounds for criticism, his observations of his children’s errors in reasoning formed Piaget’s theory of cognitive development.
Piaget identified four major developmental stages that children progress through when moving from infancy and continuing into early adolescence. Table 21-1 summarizes these four stages.
The first stage is known as the sensorimotor stage and spans from birth until age 2 years. Significant growth in this stage occurs as an infant is born with little knowledge beyond instincts and reflexes. Soon after, the newborn’s cognition develops into exploration of the environment, curiosity, and mental representation (problem solving using previously experienced events and/or objects; Bornstein & Lamb, 1999). Key features of the sensorimotor stage include CIRCULAR REACTIONS and OBJECT PERMANENCE. Circular reactions initially involve motor reflexes, such as thumb sucking and hand grasping. These then develop into object manipulation that invokes a response from people or the environment (rattle shaking). By 18 months, a circular reaction no longer involves initiating behavior to elicit a response but rather to produce a different outcome, such as trying to place a block in a hole until it fits and falls through. Object permanence refers to the ability of the child to realize that an object is no longer visible despite the fact that it still exists (Bornstein & Lamb, 1999). For example, a child will attempt to lift a blanket that he or she knows is covering a toy instead of believing that the toy has disappeared.
The second stage, the preoperational stage, takes place between ages 2 and 7 years. This stage is credited for development of motor skills and language. Key developmental features of the stage include SYMBOLIC PLAY and MAGICAL THINKING. Symbolic play involves the child’s ability to separate behaviors and objects from their actual use and instead use them for play (Bornstein & Lamb, 1999). For example, a child takes a wooden block and moves it through the air, stating that it is an airplane. To do this, the child must have a mental representation of an airplane and be able to replace reality (the object is a block) with the mental representation of an airplane. Magical thinking results from the child’s belief that a circumstance or event may be brought on by wishing for it or thinking about it. A child exhibiting magical thinking may feel responsible for a friend falling on the playground if the child had been mad at the friend earlier that day.
Birth to 2 years
12 years to adulthood
The third stage is the concrete-operational stage. Adult-like characteristics begin to emerge through flexible reasoning, logical thought, and organization. The stage begins around age 7 years and continues until age 11 or 12 years (Sadock & Sadock, 2007). Key features of this stage include REVERSIBILITY, in which the child realizes that certain things can turn into other things and then back again, such as water and ice, and CONSERVATION—the ability to recognize that despite something changing shape, it maintains the characteristics that make it what it is (clay). Both of the features of the concrete-operational stage are made possible by increased ability to understand spatial operations, distance, time, velocity, and space (Bornstein & Lamb, 1999).
According to Piaget, a child’s cognitive development occurs over four developmental stages from infancy through adolescence: sensorimotor, preoperational, concrete operational, and formal operational.
Finally, the formal operational stage is differentiated based on the child’s ability to think abstractly. Usually occurring around age 12 years, this stage transitions a child into adolescence as he or she demonstrates the ability to use logic and reasoning to hypothesize, problem solve, and comprehend information (Bornstein & Lamb, 1999).
Erikson’s Theory of Emotional and Personality Development
Various theories have been used to describe the development of emotional well-being and personality, but Erik Erikson’s stages of human development are commonly used. Although the stages progress throughout the life span, the majority of developmental “crises,” as Erikson calls them, occur within the first 20 years of life (Sadock & Sadock, 2007). Table 21-2 summarizes the major stages of Erikson’s theory.
Mastery of the initial stage is dependent on the child feeling nurtured and loved, ensuring the development of a sense of security, trust, and a basic optimism. Children who are mishandled, neglected, or abused often become insecure in their environment and mistrustful of others. Progression of development continues into the second stage in early childhood. A well-adjusted child emerges from this stage with a sense of pride and self-control instead of shame and self-doubt (Bornstein & Lamb, 1999). The child demonstrating normal development through this stage displays willpower through tantrums and stubbornness. This is not necessarily a sign of poor development, but rather an indication of testing wills and temperament. Children experiencing poor parenting may show a lack of independence, willpower, and self-esteem.
As children move into late childhood, this newfound independence from the previous stage progresses into self-directed behavior and ability to form goals. This progression is often demonstrated through play. According to Erikson, a healthy developing child will increase imagination through fantasy play, learn to cooperate with others, and lead as well as follow (Bornstein & Lamb, 1999). Children demonstrating poor development will continue to depend on adult figures, show restrictions in play and imagination, and fail to participate fully in groups.
Children moving into school-age development begin to master more formal skills as rules are enforced, structured activity increases, and the need for self-discipline becomes important. A child successful in this stage gains autonomy by showing competence in self-directed activities and appreciating reward for achievements (Bornstein & Lamb, 1999). However, failure at the school-age stage will reveal difficulty learning in traditional settings and subsequently a sense of inferiority.
According to Erikson, the majority of an individual’s emotional and personality development occurs during the first 20 years of that person’s life. This development forms the foundation for continued development in adulthood.
Over the rest of an individual’s life span, the remainder of Erikson’s stages emerges based on personality formation in the initial childhood stages. Failure to develop mastery at any stage may result in failure at subsequent stages. The progression through stages can be compared with building a house. The foundation is essential for the structure of the house as a whole, and each floor’s stability is dependent on proper construction of the floors below it. Through adulthood, an individual will discover intimacy through lasting friendships and marriage and generativity through lasting marriage, productivity, and child rearing. The individual will also learn to maintain integrity through experiencing aging and death (Sadock & Sadock, 2007). Inability to satisfactorily complete any of the adult stages leads an individual to show signs of isolation, egocentrism, and an overall dissatisfaction with life.
Freud’s Theory of Psychological Development
Like the development of emotional well-being and personality, a variety of theories exist to outline the psychological development of children. The most notable theories include Sigmund Freud’s theory of psychosexual development and Ivan Pavlov and B. F. Skinner’s behavioral theories.
According to Freud, if an individual does not resolve issues in an early stage, he or she becomes fixated in that stage. Fixation results in unhealthy behavior.
Freud’s psychosexual development theory is one of the best known theories in psychology. He identified five childhood stages: oral, anal, phallic, latent, and genital. Each of these stages is guided by the pleasure-seeking energy of the id. The id, commonly known as the LIBIDO, is the driving force behind specific behaviors (Bornstein & Lamb, 1999). Healthy psychosexual development occurs when each stage is successfully completed, whereas unresolved issues in a particular stage cause fixation and unhealthy behavior (Sadock & Sadock, 2007). Table 21-3 summarizes Freud’s theory. Refer to Chapter 10 for additional information about Freud.
Birth to 18 months
Oral gratification; anxiety occurs for the first time
18 months–6 years
Forming of peer relationships
Sullivan’s Theory of Interpersonal and Personality Development
Harry Stack Sullivan, a psychoanalytically trained psychiatrist, believed that children develop a self-system through childhood and adolescence (Rioch, 1985). This system develops over a period of six stages and is based on how an individual interacts with others. Table 21-4 summarizes Sullivan’s six stages.
According to Sullivan, the self-system is composed of personality traits that have been reinforced and maintained through interpersonal relationships, into adulthood, at which point they become rigid and dominant. A person has a need for satisfaction and security. If these needs are not met, anxiety develops (Sullivan, 1953). The purpose of the self-system is to decrease anxiety and sustain security (Rioch, 1985). (See Chapter 2 for additional information on Sullivan.)
According to Sullivan, children develop a self-system from infancy through late adolescence based on their interactions with others.
Behavioral Theories of Pavlov and Skinner
Behavioral theories of child development are based only on observable behaviors influenced by interaction with the environment. Development is a reaction to rewards, reinforcement, and punishment and is described in theories of classical conditioning and operant conditioning. Pavlov made famous the theory of CLASSICAL CONDITIONING with his experiment on salivation in dogs. Classical conditioning refers to a learned behavioral response to a stimulus.
Pavlov’s theory consists of four basic principles. The unconditioned stimulus is a naturally occurring event that elicits an unconditioned response, which is unlearned. The conditioned stimulus, although previously neutral, becomes a trigger for the conditioned response after associating with the unconditioned stimulus (Bornstein & Lamb, 1999). Simply put, Pavlov measured salivation (unconditioned response) in dogs when they were presented with food (unconditioned stimulus). He then rang a bell (unconditioned stimulus) multiple times as he presented the dogs with food; soon, the dogs would begin to salivate at the sound of the bell in expectation of receiving food (conditioned response). Pavlov’s theory became the basis of behavioral psychology and is often used in child therapies for phobias, anxiety, panic disorders, and behavioral modification (Bornstein & Lamb, 1999).
The behavioral theories of Pavlov and Skinner form the basis for many of the therapies used for childhood disorders.
Skinner’s behavioral theory involving OPERANT CONDITIONING holds that learning takes place through rewards (used to increase desired behavior) and punishments (to decrease undesirable behavior). Operant conditioning is used frequently throughout the life span but more commonly as a parenting technique and in the classroom (Bornstein & Lamb, 1999). Examples include time-outs for misbehavior, grounding for missing curfew, candy or praise for success in toilet training, stickers for perfect scores on spelling tests—the list could easily continue. (See Chapter 10 for a more in-depth discussion about the work of Pavlov and Skinner.)
OVERVIEW OF DISORDERS OF CHILDHOOD
Historically, mental illness in children was rarely studied because the general population believed that psychiatric illnesses did not occur in that population.
Currently, diagnosis in children is more common; subsequently, there is now inclusion of childhood mental illnesses in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013). The rates of childhood psychiatric diagnoses have been on a steady rise, with current data showing that one in five children aged 13 to 18 years have had a seriously debilitating mental disorder, either currently or at some point in their lives (Merikangas et al., 2010). Approximately 13% of children aged 8 to 15 years have met diagnostic criteria for a mental disorder in the last year according to the Centers for Disease Control and Prevention’s National Health and Nutrition Examination Survey (NHANES) 2015 update. Whether the increase is due to actual increases in childhood mental illness or related to increased comfort and acceptance with diagnoses from providers is unclear. Regardless, disorders of childhood are important to recognize and understand.
Previously, disorders of childhood were separated diagnostically to help providers identify unique signs and symptoms specific to children; however, as psychiatry and psychology move to a life-span approach to mental health, the various mental health conditions are now organized by how they manifest at each developmental stage (APA, 2013). As the practice of working with children evolves, through both clinical and scientific knowledge, changes continue to be made to identification and treatment of childhood disorders. A few of the more common disorders are described in this chapter.
AUTISM SPECTRUM DISORDERS
In the DSM-IV-TR, autism was combined with Rett’s disorder, childhood disintegrative disorder, and Asperger’s disorder as a grouping of diagnoses categorized as pervasive developmental disorders (PDD; APA, 2013). The category was largely debated as some practitioners felt that the disorders were not clearly differentiated, which would increase the possibility of diagnostic errors (Gupta, 2004). In the DSM-5, efforts were made to provide more precise descriptions of each disorder as research continued to support the presence of multiple symptoms and behaviors across a spectrum of severity. With this change, children still have to meet a set of diagnostic criteria, but are now grouped according to severity of social communication impairments and restricted, repetitive patterns of behavior (APA, 2013).
The term AUTISM literally means “living in self” and was first used in 1911 to describe poor social relatedness in schizophrenics. However, signs of autism are apparent in reports of children with distortions of the developmental process as early as 1867. In the early 1940s, autism was considered a subtype of childhood psychosis carrying the label “childhood schizophrenics of the pseudo-defective type” (Gupta, 2004). Over time, however, autism began to distinguish itself as a unique and independent disorder characterized by impairments in social interactions, ability to relate to others, communication problems, and types of repetitive behaviors.
Before the release of the third edition of the DSM, problems arose in the clinical setting because of similarities between autism and schizophrenia. The third edition included autistic disorder under the category of PDD, not under psychotic disorders. Although clinicians acknowledge the similarities between the diagnostic criteria, there are two significant differences:
Schizophrenia occurs after a period of normal development, whereas autism is likely to be present from birth (APA, 2013).
Positive symptoms such as hallucinations and delusions and higher intelligence levels are associated with schizophrenia but not autism (APA, 2013).
Over the past 30 years, the categories, diagnostic criteria, and subtypes of autistic disorder have undergone many changes due to increased research and diagnoses of the disorder. It is likely that features of autism will continue to change over the next 30 years. The severity of autism varies widely and can range in impact from mild to significantly disabling/severe.
Prevalence studies revealed that an average of 1 out of every 68 8-year-old children was identified as having autism spectrum disorder (ASD), with a five times higher rate in boys (1 in 42) than in girls (1 in 189; Baio, 2010). Over the past 10 years, there has been an increased focus on autistic disorders in the popular media, leading to research, speculations, and controversy about what causes autism. Heredity, environment, brain abnormalities, postnatal infection, and prenatal conditions may lead to an increased risk of autism, but the actual cause remains unknown.
Research demonstrates that genetic factors may play a role in the etiology of autism based on both twin and non-twin sibling studies, with a strong environmental component (Hallmayer et al., 2011). However, no specific genes have been identified. Current research is exploring a number of biomarkers associated with autism, which may aid in the discovery of specific genetic markers. Environmental influences thought to contribute to autism are assumed to be related to the interaction between the environment and genes, not environment alone (Anderson, 2015). Additionally, specific risk factors have not been identified.
Abnormalities in the structure and function of the brain are generally accepted as the underlying cause of autism. Sophisticated imaging techniques have shown that autistic children have disproportionate enlargement of the amygdala, which influences social interaction and processing (Nordahl et al., 2012). Abnormalities have also been noted in the areas of the brain associated with sensory perception, emotion, and empathy. Researchers have yet to identify a primary deficit associated with autism.
Several early developmental problems, both prenatal and postnatal, have been linked to autistic disorders. For example, prenatal viral infections, such as rubella or cytomegalovirus, are thought to activate the maternal immune response. Presence of particular infections and activation of certain cytokines have been associated with the risk of ASDs (Brown, 2012). Additionally, gestational diabetes, teratogenic medications, pesticides, thyroid issues, folic acid deficiencies, and stress are other maternal influences that possibly contribute to autism. A large list of potential postnatal environmental causes of or associations with autism exists and includes everything from viral infections to lead exposure to excess rainfall. One issue related to the development of autism that has raised much debate is the use of vaccines. Box 21-1 describes this issue. Over the years, most research has not been able to demonstrate a statistically significant relationship among any of these factors and the development of autism. However, current research into the etiology of autism is showing many possibilities and may show promising results in the near future.
Genetics, environment, structural and functional alterations of the brain, and pre- and postnatal problems have been linked to autism.
Children with autism will show marked impairment in social interactions and communication that is sustained throughout childhood and beyond (APA, 2013). Although the individual may speak, there will likely be an inability to initiate or carry on a conversation. It is common for the pitch, intonation, rate, and rhythm of the speech to be abnormal and inappropriate to the context of conversation. Rhyming, ECHOLALIA (repeating spoken words like an echo), peculiar languages, and referring to themselves in the third person are common (APA, 2013). A child with autism will also display repetitive and restricted behavior. They may seem to exist in their own world where repetitive routines and fantasy are apparent. Occasionally, a child with autism may exhibit a particular talent in art, music, mathematics, or another area. They are known as savants.
By definition, these symptoms must be pervasive and sustained, and will present initially between 12 and 24 months of age. Parents can often trace abnormalities in social interaction back to birth or shortly afterward. The severity of symptoms through development may continue to change and can be affected by treatment but symptoms remain sufficient enough to cause impairment in functioning (APA, 2013).
At the less severe end of the spectrum, children may not experience a significant delay in early cognitive and language skills, and the preoccupation with objects and rituals that are common at the more severe end are less often observed. The less severe form of autism was formerly known as Asperger’s disorder. In addition, the social isolation is much less severe, and individuals may display motivation for approaching others despite the eccentric, verbose, and insensitive nature of their conversation (APA, 2013). It became quite difficult to differentiate those with Asperger’s and those with a mild form of autism as many of the symptoms were similar.
BOX 21-1: DO VACCINES CAUSE AUTISM?
Many studies have researched whether there is a relationship between vaccines and autism. The majority of scientific research has concluded that vaccines are not associated with autism and the risk of not immunizing children against disease supersedes the risk of potentially damaging ingredients in vaccines. In a 2007 court case, three families with autistic children sought compensation from the Vaccine Injury Compensation Program for allegedly triggering autism with a measles, mumps, and rubella (MMR) vaccine-containing thimerosol, a mercury-based preservative. The court ruled that the three cases presented did not prove a link between autism and particular childhood vaccines, citing insufficient evidence (Hitti, 2009).
Autism Speaks, a well-known autism advocacy organization, supports continuing examination of the factors contributing to autism and encourages increased scientific research to determine the cause. Celebrity influence from Jenny McCarthy and Holly Robinson Peete, both mothers who believe vaccines were the cause of autism in their children, has made the vaccine/autism debate increasingly sensitive. Both women, along with antivaccine groups, trace the emergence of autism in their children to the time when thimerosol-containing vaccines were administered.
Future research will likely focus on genetics and environment to determine the true etiology of autism. Until then, the debate continues in both science and the popular media.
Difficulty with communication, both verbal and nonverbal, can be associated with disorders other than ASD. When a child exhibits significant impairment in communication and social interactions, without the restrictive and repetitive behaviors associated with ASD, and without low cognitive ability associated with an intellectual/cognitive disorder, the diagnosis may be a social communication disorder (SCD; APA, 2013). Addition of this disorder to the DSM provides a basis for treatment, which was previously inconsistent and nonspecific.
ATTENTION DEFICIT HYPERACTIVITY DISORDER