Chapter 32
Disorders of Children
and Adolescents
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Prevalence
• One in five children and adolescents in the
United States has a major mental illness.
• Two thirds of all young people with mental
health problems are not getting treatment.
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Suicide
• Third leading cause of death among
individuals aged 15 to 24 years
• Sixth leading cause of death for
5- to 15-year-olds
• For every older teen or young adult who
takes his or her own life, 100 to 200 of their
peers attempt suicide.
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Comorbidity:
Common Associated Disorders
Attention deficit hyperactivity disorder (ADHD)
• Juvenile onset bipolar disorder
• Oppositional defiant disorder
• Conduct disorders
Childhood depression
• Conduct or oppositional disorders
• Anxiety disorder
• ADHD
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Relevance of Family History
Child raised by a depressed parent is at risk
for developing:
• Anxiety disorder
• Conduct disorder
• Alcohol dependence
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Relevance of Family History
Child raised by parent without effective coping
strategies is at risk for developing:
• Learned helplessness
• Anxiety
• Apathy
• Inability to learn how to master environment
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Relevance of Family History
• An emotionally unavailable parent places
the child at risk to be unable to make
emotional attachments.
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Relevance of Family History
Abused and neglected children are at risk for:
• Emotional, intellectual, and social handicaps
• Identification with aggressor and
development of bullying behavior
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Today’s Challenges for
the Psychiatric Nurse
• Increase in the number of children with acute mental disorders
• Decrease in the amount of time for hospital treatment
• Majority of children hospitalized diagnosed with conduct
disorder related to lack of adequate parenting and family
support (“functional orphans”)
• Care has moved into the community
– Homes, schools, group homes, homeless shelters
• Mental health needs of children and adolescents steadily
increasing
– Decreased funding and resources
– Decreased access to care
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Cause of Mental Illness
• A number of factors influence a child's or
adolescent's mental health, so interventions
need to be multimodal.
• Younger children are more difficult to
diagnose than older children.
• Boundaries between normal and abnormal
are less distinct in younger children.
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Vulnerability to
Emotional and Mental Disorders:
Result of Child’s Attributes
Genetic
• Direct genetic link
Biological
• Neurotransmitters: Epinephrine, serotonin,
dopamine
Temperament
• Constitutional factor with genetic link
• Style of behavior used to cope with the
environment
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Vulnerability to
Emotional and Mental Disorders:
Result of Child’s Attributes
Social and environment
• Familial risk factors
– Severe martial discord
– Low socioeconomic status
– Large families and overcrowding
– Parental criminality
– Maternal psychiatric disorders
– Foster care placement
• Traumatic life events
• Physical and sexual abuse
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The greater the number of stressors,
the greater the incidence
of mental disorders.
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Vulnerability to
Emotional and Mental Disorders:
Result of Child’s Attributes
Culture and ethnic
• Culture shock
• Cultural conflicts
• Lack of cultural role models
• Difference in cultural expectations
• Presence of stressors
• Lack of support from dominant culture
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A disproportionate number of
minority children labeled as having
mental and learning disorders suffer
from this stigma throughout life.
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Characteristics of the Resilient Child
• Adaptive temperament
• Ability to form nurturing relationships
with surrogate parental figures
• Ability to distance self from emotional
chaos in parents and family
• Good social intelligence and problem-solving
skills
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Characteristics of Mental Illness
in a Child or Adolescent
• Personality development has been hindered
or arrested by a variety of biopsychosocial
factors, resulting in impairments in physical
and cognitive capabilities.
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Characteristics of a
Mentally Healthy Youth
• Trusts others
• Views world as safe and supportive
• Correctly interprets reality
• Self-concept positive and realistic
• Able to cope with anxiety and stress
• Attains age-appropriate developmental levels
• Develops creative ways of self-expression
• Has good friends
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Essential Assessment Data
• History of present illness
• Developmental history
• Maturation level
• Neurological status
• Medical history
• Family history
• Mental status
• Characteristics of play
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Methods of Collecting Data
• Structured questionnaires
• Behavioral checklists
• Genograms
• Semi-structured interview with
child or adolescent
• Play activities
• Observation of interaction between
child and family/caregivers/peers
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Suicide Risk Assessment in Children
and Adolescents
• Suicidal thoughts, threats, or attempts
• Circumstances and motivation at the time
of suicidal thoughts and behaviors
• Moods or feelings
• Concepts about suicide and death
• Experiences with suicide and death
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Pervasive Developmental Disorders
• Autism
• Asperger's syndrome
• Rett’s disorder
• Childhood disintegrative disorder
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Autistic Disorder: Standard Autism
• A behavioral syndrome resulting from abnormal
brain function of unknown etiology
• Usually first observed before 3 years of age
• Presenting symptoms:
– Impairment in communication and imaginative activity
– Impairment in social interactions
– Markedly restricted stereotypical patterns of behavior
and interest
• Prognosis related to:
– Overall intellectual level
– Development of social and language skills
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Asperger's Syndrome:
High-Functioning Autism
• Usually first observed after 2 years of age
• Mild mental retardation to normal
• Seizure disorder common
• Outcome fair to poor
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Rett’s Disorder:
Mid-Childhood Autism
• Observed only in females
• Onset before 4 years of age
• Severe mental retardation
• Associated with seizure disorder
• Outcome very poor
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Childhood Disintegrative Disorder:
Delayed Onset but Severe Autism
• Onset between 2 and 10 years of age
• More common in males
• Outcome very poor
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Pervasive Developmental Disorders:
Assessment Guidelines
• Developmental assessment
– Spurts or lags
– Unevenness
– Loss of previously acquired abilities
• Relationship assessment (child, parents, caregivers)
– Bonding
– Anxiety
– Tension
• Risk for abuse
– Higher with children with behavioral or developmental problems
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Pervasive Developmental Disorders:
Diagnoses and Outcomes
Nursing Diagnosis
Outcome Criteria
Impaired social interaction
Follows simple rules
of interactive games
with peers
Impaired verbal communication
Speech understood
by strangers
Delayed growth and
development
Expresses emotions
during play activities
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Pervasive Developmental Disorders:
Interventions
Children with Disabilities Act
Mandates education and treatment
• School
– Therapeutic nursery schools
– Special education classes in public schools
• Parents taught how to:
– Modify child's behavior
– Foster development of skills
•
Pharmacological agents
– Haloperidol
– Fenfluramine
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ADHD: Symptoms
• Inattention
• Hyperactivity
• Impulsivity
• Low tolerance for frustration
• Temper outbursts
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ADHD and the Nursing Process
Assessment
• Relationship between child and parents/caregivers
• Developmental competencies
• Level of physical activity, attention span,
talkativeness
Nursing Diagnosis
• Risk for self-directed or other-directed violence
• Defensive coping
• Impaired social interaction
• Chronic low self-esteem
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ADHD and the Nursing Process
Outcomes
• Remain safe.
• Learn effective coping methods.
• Develop friendships with peers.
• Develop self-esteem.
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ADHD and the Nursing Process
Interventions
• Behavior modification
• Special education programs
• Psychotherapy
• Play therapy
• Pharmaceutical agents
– Methylphenidate
– Mixed amphetamine
– Concerta
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Oppositional Defiant Disorder:
Symptoms
• Disorder usually evident before 8 years of age
• Stubborn
• Argumentative
• Testing of limits
• Refusal to accept blame
• Deviant behavior with authority figures
• No serious violations of basic rights of others
• Symptomatic behavior most evident at home
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Oppositional Defiant Disorder
and the Nursing Process
Assessment
• Issues that result in power struggles
• Severity of defiant behavior
• Impact on child's life in various environments
Nursing Diagnosis
• Ineffective coping
• Impaired social interaction
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Oppositional Defiant Disorder
and the Nursing Process
Outcomes
• Client will acknowledge existence of symptomatic
behavior.
• Client will acknowledge effect on family from the
behavior.
Interventions
• Outpatient treatment with individual, group, and
family therapy
• Focus of therapy on parenting issues
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Conduct Disorder: Symptoms
• Behavior not within age-appropriate
societal norms
• Aggression toward people and animals
• Destruction of property
• Deceitfulness or theft
• Serious violation of rules
• Violates rights of others
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Conduct Disorder:
Symptoms in Childhood Onset
• Occurs before 10 years of age
• Usually in males
• Physically aggressive
• Poor peer relationships
• Lacks feelings of guilt or remorse
• Low self-esteem and tolerance for frustration
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Conduct Disorder:
Symptoms in Adolescent Onset
• Acts out misconduct with peer group
• School discipline problems
• Boys: fight, steal, vandalize
• Girls: truant, run away, abuse substances,
engage in prostitution
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Conduct Disorder and the
Nursing Process
Assessment
• Disruptive behavior
• Level of anxiety, aggression, anger, hostility,
impulsivity, ability to understand impact of behavior
• Inability to empathize with others
Nursing Diagnosis
• Risk for other-directed violence
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Conduct Disorder
and the Nursing Process
Outcome
• Maintains self-control without supervision
Interventions
• Inpatient hospitalization for crisis
intervention
• Transfer to therapeutic foster home
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Interventions for Controlling
Aggressive Behavior
• Pharmacological agents
• Cognitive-behavioral therapy
• Behavior modification
• Assess parents' knowledge of disorder.
• Provide information as needed.
• Assess impact of patient's behavior on family life.
• Discuss setting realistic behavioral goals.
• Refer parents to local self-help group.
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Techniques for Managing
Disruptive Behaviors
• Planned ignoring
• Use of signals or gestures
• Physical distance and touch control
• Redirect child's attention to an activity
• Give additional affection
• Use humor as a diversion
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Techniques for Managing
Disruptive Behaviors
• Appeal to child's developing self-control
• Give early help to a child who is easily frustrated
• Clarify situation and motivation for behavior
• Change activity to decrease stimulation or
frustration
• Remove child from situation
• Set limits
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Anxiety Disorders
• Anxiety is part of normal development
• Anxiety a problem when:
– An individual fails to move beyond the fears associated
with certain developmental stages
– Development is in response to physical or psychological
stressors and interferes with normal functioning
• Two anxiety disorders of children and adolescents:
– Separation anxiety disorder
– Posttraumatic stress disorder
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Separation Anxiety Disorder:
Symptoms
• Excessively anxious when separated from
parents and/or home
• Excessive anxiety when anticipating separation
• Fear of being lost or kidnapped
• Refusal to sleep without a parental figure nearby
• Refusal to attend school without parent
• Physical symptoms as a response to anxiety
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Separation Anxiety Disorder:
Specific Assessment
• First-degree relative with social anxiety
disorder or panic disorder
• Depression
• Child's previous and current ability to
separate from parents
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Posttraumatic Stress Disorder:
Symptoms in Preschool Children
• Irritability, angry outbursts, temper tantrums
• Relive traumatic event in play or drawings
• Nightmares/night terrors
• Loss of previously learned skills
• Somatic symptoms
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Posttraumatic Stress Disorder:
Symptoms in School-Aged Children
• Nightmares
• Irritability
• Difficulty concentrating
• Hypervigilance
• Omen formation
Specific Assessment
• Exposure to extreme traumatic event
• Internalized or externalized anxiety
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Separation Anxiety Disorder and
Posttraumatic Stress Disorder
and the Nursing Process
Assessment
• Anxiety and conflict between child and parents
• Recent stressors
• Parents' understanding of developmental norms
• Parenting skills
• Child's developmental level
• Physical, behavioral, and cognitive symptoms of
anxiety
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Separation Anxiety Disorder
and Posttraumatic Stress Disorder
and the Nursing Process
Nursing Diagnosis
• Anxiety (severe)
• Fear
• Ineffective coping
• Delayed growth and development
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Separation Anxiety Disorder
and Posttraumatic Stress Disorder
and the Nursing Process
Outcomes
• Anxiety level will be reduced to mild.
• Child will be able to sleep through the night
without nightmares.
• Child will attend school without objection.
• Child will be at an age-appropriate
developmental level.
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Separation Anxiety Disorder
and Posttraumatic Stress Disorder
and the Nursing Process
Interventions
• Protect child from panic levels of anxiety.
• Provide emotional support to help child progress
developmentally.
• Increase child's self-esteem and feelings of competence.
• Help child accept and work through traumatic event.
• Cognitive therapy
– Focused on underlying fears and concerns
• Behavior modification
– Reinforce self-control behaviors
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Mood Disorders
Most frequently diagnosed mood disorders:
• Major depressive disorder
• Dysthymic disorder
• Bipolar disorder
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Mood Disorders:
Symptoms of Depression
• Sadness
• Hopelessness
• Anhedonia
• Social withdrawal
• Thoughts of suicide
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Mood Disorders: Symptoms
In children
• Somatic symptoms
• Self-critical
• Feel unloved
In adolescents
• Psychomotor retardation
• Hypersomnia
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Mood Disorders: Factors Associated
with Child and Adolescent Depression
• Physical and sexual abuse
• Neglect
• Homelessness
• Parental marital problems
• Parent’s death, divorce, or separation
• Learning disabilities
• Chronic illness
• Conflict with or rejection by parents/peers
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Mood Disorders:
Complications of Depression
• School failure
• Drug and alcohol abuse
• Sexual promiscuity
• Running away
• Illegal and antisocial behavior
• Suicide
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Tourette's Disorder
• Age of onset 2 to 10 years
• Characterized by motor and verbal tics
Motor tics
Verbal tics
Eye blinking
Tongue protrusion
Touching
Barks
Grunts
Yelps
Squatting
Skipping
Clicks
Snorts
Sniffs
Coughs
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Tourette's Disorder
Other symptoms
• Obsessions
• Compulsions
• Hyperactivity
• Distractibility
• Impulsivity
• Low self-esteem
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Tourette's Disorder
Theory
• Genetic transmission
• 70% of females and 99% of males who have inherited
the gene develop the disorder
Prognosis
• Usually permanent
• Possible periods of remission
• Symptoms may disappear in early adulthood
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Adjustment Disorder: Symptoms
• Emotional response to an
identifiable stressor
• Decreased school performance
• Temporary changes in social
relationships
• Begins within 3 months of stressor
• Lasts no longer than 6 months after
cessation of stressor
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Adjustment Disorder: Subtypes
• Subtypes classified according to
presenting symptoms
• Adjustment disorder with:
– Anxiety
– Mixed anxiety and depressed mood
– Disturbance of conduct
– Mixed disturbance of emotions and conduct
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Feeding and Eating Disorders
• Pica
• Rumination disorder
• Feeding and eating disorder
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Pica
• Persistence in eating nonnutritive
substances
– Paint, plaster, string, pebbles, dirt, animal
droppings
• No aversion to eating food
• Frequently associated with mental
retardation
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Rumination Disorder
• Repeated regurgitation and rechewing
of food
• Lack of nausea, retching, or gastrointestinal
problems
• May occur with developmental delays
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Feeding and Eating Disorder
• Infant or child does not eat adequate
amounts of food
• Food is available
• No medical disorder or mental retardation
• Does not gain weight
• Experiences developmental delays
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Interventions for Child and
Adolescent Disorders
Family Therapy
• Parents actively involved in treatment
• Multiple-family therapy with families as
co-therapists
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Interventions for Child and
Adolescent Disorders
Group Therapy
• Play for younger children
• Play and talk for grade-school children
• Talking about peer relationships and
specific problems for adolescents
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Interventions for Child and
Adolescent Disorders
Milieu Therapy
• Basis for structuring inpatient, residential,
and day treatment programs
• Therapeutic environment provides:
– Physical and psychological security
– Promotion of growth
– Mastery of developmental tasks
– Treatment for psychiatric disorders
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Interventions for Child and
Adolescent Disorders
Behavioral Therapy
• Based on principle that behavior that is
rewarded is more likely to be repeated
• Specific treatments include:
– Operant conditioning
– Point and level system
• Modifying disruptive behavior
– Increasing the structure of an activity
– Using all available resources
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Interventions for Child and
Adolescent Disorders
Removal and Restraint
• Seclusion
– Use is controversial
– Reflects staff's lack of confidence in their
ability to handle behavior
– Perceived as punishment by the
child/adolescent
– Experience of being overpowered by adults
terrifying for abused children
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Interventions for Child and
Adolescent Disorders
Removal and Restraint
• Quiet room
– Used to remove child from a situation for
self-control or control by staff
– Variations
• Feelings room
• Freedom room
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Interventions for Child and
Adolescent Disorders
Removal and Restraint
• Time out
– Intervening disruptive or inappropriate
behavior by removing child from activity
– Child regains self-control and reviews
episode with staff
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Interventions for Child and
Adolescent Disorders
Removal and Restraint
• Therapeutic holding
– Used to control destructive behaviors
– Prompt, firm, nonretaliatory protective
restraint
– Used to reduce the child's distress
– Produces relaxation and returns selfcontrol and trust in staff
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Cognitive-Behavioral Therapy
• Goal: Remove maladaptive responses and
replace with new cognitive and behavioral
competencies
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Play Therapy
Guiding principles:
• Accept child as he is and follow the child's lead.
• Establish warm, friendly relationship to help the
child express feelings.
• Recognize feelings and reflect them back so the
child can gain insight into behavior.
• Accept the child's ability to solve personal
problems.
• Set limits to provide reality and security.
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Dramatic Play
• Psychodrama
– Also referred to as theater
– Use of dramatic techniques to act out
emotional problems and try out new
behaviors
• Dramatic play
– Use of hand puppets, puppet shows, or
dramas to enable children to act out
problems and solutions
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Dramatic Play
• Mutual storytelling
– Child is asked to make up a story with a
beginning, middle, and end.
– At end of story, child is asked the lesson or the
moral of the story.
– Nurse then determines the psychodynamic
meaning of the story.
– Nurse then uses an important theme to retell
the story with the same characters and a
similar setting, providing a healthier
resolution.
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Therapeutic Games
• Ideal for children who have difficulty talking
about their feelings and problems
• Help development of a therapeutic alliance
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Bibliotherapy
• Use of children's literature to help child
express feelings in a supportive environment
• Book should reflect the situation or feelings
the child is experiencing
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Therapeutic Drawing
• Drawings capture thoughts, feelings, and
tensions child may not be able to express
verbally.
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Psychopharmacology
Medications that target specific symptoms
have the potential to:
• Increase the ability to cope
• Increase quality of life
• Enhance potential for growth
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Psychopharmacology
• Pervasive developmental disorders
– Antipsychotics
• Autistic disorder
– Antipsychotics
– Selective serotonin reuptake inhibitors (SSRIs)
• ADHD
– Stimulants
– Antidepressants
– α-Adrenergic agonists
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Psychopharmacology
• Conduct disorders
– Antipsychotics
– Stimulants
– Antidepressants
– Mood stabilizers
– α-Adrenergic agonists
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Psychopharmacology
• Anxiety disorders
– Panic and school phobias
• Antidepressants
• SSRIs
– Obsessive-compulsive disorder
• Antidepressants
• SSRIs
– Separation anxiety disorder
• Antidepressants
• SSRIs
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Psychopharmacology
• Anxiety disorders
– Social phobia
• Antidepressants
• Anxiolytics
– Posttraumatic stress disorder
• Atypical antipsychotics
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Psychopharmacology
• Anxiety symptoms
– Insomnia
• Antihistamines
• Depressive symptoms
– Major depression and dysthymia
• Antidepressants
• SSRIs
• Atypical antidepressants
– Psychotic symptoms
• Antipsychotics
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Chapter One