Chapter 26: Children & Adolescents

Welcome back to the Deep Dive.

Today, we're doing something a little, um, a little different.

Yeah, we are.

We're pulling the fire alarm, metaphorically speaking.

We're calling this the Last Minute Lecture Edition.

I like that.

Because we have a stack of clinical texts right here, specifically Chapter 26 of Essentials of Psychiatric Mental Health Nursing.

Right.

And our mission for you today is to translate this from, you know,

dense academic theory into actual usable clinical judgment.

It's a really necessary translation, honestly.

I mean, we know we have listeners who are nursing students who are just, you know, cramming for boards right now.

Oh, for sure.

But we also have people who just need to understand the mechanics of the developing brain.

So this isn't just about passing a test for you guys.

It's about understanding the internal architecture of the children and adolescents that, uh, that we interact with every single day.

And the stakes for that interaction are just incredibly high.

I was looking at the prevalence data in the introduction of the chapter, and it honestly stops you in your tracks.

It really does.

One in five children and adolescents will experience a mental health disorder before they turn 18.

Yeah, one in five.

But the statistic that really underscores why we're doing this deep dive is the root system.

80 % of adult mental health issues begin in childhood.

Right.

And that is the critical reframe right there.

We tend to think of childhood problems as phases.

Like they'll just grow out of it.

Exactly.

Things that just wash away with puberty.

But the data says otherwise.

We aren't talking about temporary glitches here.

We're talking about the foundation being poured for adult psychiatric health.

So if you have a crack in the foundation now and you build a skyscraper on top of it, that building is going to be incredibly unstable at age 40.

Yeah.

And yet there's this massive gap in treatment.

The text highlights that only about 20 % of young people with these conditions actually receive the care they need.

It's wild.

So you have this huge population walking around with these untreated structural fractures.

Which leads directly to comorbidity.

And that's a term we're going to use a lot today.

Sure.

It's rarely just one thing.

The text points out that if a child has ADHD,

there is a 50 % chance they have a co -occurring condition.

Like anxiety or a disruptive disorder.

Exactly.

Right.

And if we look at high -functioning autism, that number jumps to 74%.

74 %!

That complicates the clinical picture so significantly.

I mean, you can't just treat the noisy symptom, right?

No, you really can't.

If you treat the hyperactivity, but you miss the underlying anxiety that's actually driving it, you aren't solving the problem.

And the text connects this to physical health too, which I found fascinating.

It mentions that youth with asthma are three times more likely to have an anxiety disorder.

It makes complete physiological sense though.

I mean, if your primary mechanism for survival - Remember breathing.

Breathing, exactly, is threatened.

Your sympathetic nervous system is going to be on high alert all the time.

It really validates the holistic nursing approach.

You cannot treat the lungs in room 302 and the brain in room 304.

Right.

It's the same patient.

So let's get into the machinery of why this happens.

The text introduces the interaction model, which kind of moves us past that old nature versus nurture debate and suggests it's more of a, I don't know, a collision.

Or maybe a braid.

You have biological vulnerability, genetic programming, and then the environment just hits those factors.

Okay.

Let's look at the genetics first then, because the heredity rates here are undeniable.

We see strong familial links in autism, bipolar disorder, schizophrenia, and ADHD.

Yeah.

The specific stat for ADHD was that 75 % of children with the diagnosis have a family member with a mental health disorder.

75%.

That really challenges the common societal narrative that ADHD is just a result of, too much screen time or lazy parenting.

It really does.

It places the disorder firmly in the realm of biology.

But the text does add nuance there.

It mentions that while there are over a thousand genetic changes linked to autism, about 40 % of the risk factors are actually non -genetic.

So genetics loads the gun.

Right.

What the environment pulls the trigger.

Okay.

So that environmental piece brings us to the concept of temperament.

This basically defines the child's default setting, right?

Their activity level, their sensitivity, their adaptability.

And the text discusses the difficult child risk factor, which sounds a little harsh, but it's a clinical term.

It is, and it refers to the fit.

This is so crucial for parents to understand.

If you have a family culture that is loud,

spontaneous, and high energy, and you introduce a child whose temperament is slow to warm, highly sensitive to noise, and rigid about routine, you have friction.

Yeah.

It's not that the child is bad or the parents are doing it wrong.

It's just a mismatch.

And that friction creates the risk.

Exactly.

If the caregiver cannot adapt their style to meet the child's temperament, you risk insecure attachment.

And insecure attachment is the absolute breeding ground for anxiety and behavioral disorders.

But on the flip side of that risk is resilience, which I think is the most hopeful concept in the entire chapter.

Oh, absolutely.

Because the text defines resilience not as a fixed trait you're born with, like eye color, but as a skill set.

That is the headline for any educator or nurse listening right now.

Resilience is the ability to adapt to stress.

And it can be learned.

Learned.

Yes.

It involves specific thought patterns and behaviors.

So part of the clinical role isn't just fixing what's broken.

It's teaching the child how to bend without breaking in the future.

That's powerful.

Let's deepen the technical analysis for a moment.

The text dives into biochemical factors.

Now, we usually hear about serotonin in the context of depression, but the breakdown of ADHD subtypes and their specific genetic drivers was totally new to me.

It links specific behaviors to specific transporter genes.

Yeah, this is the kind of detail that separates just a general understanding from actual clinical expertise.

The text links the inattentive type of ADHD to the norepinephrine transporter gene.

But if you looked at the hyperactive impulsive type, that is linked to the dopamine transporter gene.

And what about the combined type?

The choline transporter gene.

Wow.

So this completely explains the variability in medication response.

I've seen cases where a parent asks, you know, why did Ritalin work for my nephew, but it's doing absolutely nothing for my son.

Right.

And it's likely because they are dealing with a completely different neurochemical target.

Yeah.

Stimulants target dopamine.

Non -stimulants like Stratera target norepinephrine.

So if you're treating a norepinephrine kid with a dopamine drug, you are going to see the clearance of symptoms.

It just emphasizes that psychiatric nursing is chemistry, not just behavior management.

Speaking of chemistry, we need to talk about how the environment physically alters that chemistry.

The text brings up neuroplasticity.

Yes.

In childhood, the brain is clastic.

It's moldable.

It's in a state of rapid construction.

Neurons are firing and wiring together based on input.

The brain is basically asking one fundamental question all the time.

Is the world safe or is the world dangerous?

And if the input is trauma or chaos or fear, then the brain wires itself for survival.

It builds a superhighway straight to the amygdala.

The fear center.

Right.

And it neglects the roads to the prefrontal cortex, which is what controls reasoning and impulse control.

This is the mechanism behind the ACE study, right?

Adverse childhood experiences.

Most people know the acronym, but the text really details the specific dose -response relationship.

It's strictly mathematical.

You tally the events.

Abuse, neglect, a parent in prison, domestic violence.

As the ACE score goes up, the risk of negative health outcomes just skyrockets.

And not just mental health.

A high ACE score correlates with early heart disease and respiratory distress in adulthood.

That is the big takeaway for you.

Trauma isn't just a memory.

It's a biological injury that degrades the body over decades.

Which brings us to the disorders themselves.

The text categorizes these systematically, starting with neurodevelopmental disorders.

And the first one is intellectual disability or ID.

There has been a really significant shift in how this is diagnosed.

It used to be strictly about the IQ number.

Like if you were below 70, you had the diagnosis.

Right.

But the text says we've moved to functional adaptation.

Which is a much more humane and practical metric, honestly.

It really is.

The question is no longer just how well do you take a test.

It is how well can you navigate the world?

Right.

We look at conceptual skills, social skills, and practical skills.

Can you manage money?

Can you interpret a social cue?

Can you take a bus safely?

And they break it down into four severity levels.

Let's run through these so you can visualize the spectrum.

Okay.

So mild is the vast majority, about 85%.

Okay.

These individuals can often live independently.

They hold jobs.

They marry.

Their academic level typically tops out around mid -elementary, but socially they function really well.

Then we have moderate.

That's about 10 % of cases.

Development is noticeably slower.

They might read at a first or second grade level.

They can handle daily living, like dressing and eating.

But they usually need a supervised living situation or significant support for complex tasks.

Like finances or healthcare decisions.

Exactly.

Then severe drops to about three to four percent.

Right.

Here speech is quite limited.

They require daily supervision and support for almost all activities.

And finally, profound.

Just one to two percent.

These individuals are often nonverbal and may have significant sensory or physical impairments.

They require constant lifelong care.

The text uses a really interesting vignette of an eight -year -old boy to illustrate how these diagnoses can be tricky.

He was small for his age, had wide -set eyes, and was initially treated for ADHD because he just couldn't focus.

But the ADHD treatment failed.

And this is where the deep dive skill comes in for nurses.

You have to look at the physical assessment.

The wide -set eyes, the thin upper lip, the small stature.

Those are classic markers of fetal alcohol syndrome, FAS.

Exactly.

The behavior looked like ADHD, but the root cause was organic brain damage from alcohol exposure in utero.

If you miss the physical signs, you miss the diagnosis completely.

That makes a lot of sense.

Moving to the biggest umbrella in the section, autism spectrum disorder, or ASD.

This diagnosis has basically absorbed what we used to call Asperger's and Pervasive Developmental Disorder.

It's a consolidation.

We look for deficits in two main buckets now.

Social and emotional communication.

And repetitive or restricted behaviors.

And that second bucket is where we see stimming.

Right.

Self -stimulatory behavior.

It's a way for them to regulate sensory input.

It can be mild, like tapping fingers or humming.

Or it can be severe and frankly dangerous, like headbanging or biting.

The text again uses a three -level severity scale here.

Level one requires support.

You see social awkwardness, difficulty switching between tasks, maybe some organization issues.

Level two requires substantial support.

The verbal and non -verbal deficits are really obvious to a casual observer.

They get very distressed when routines change.

And level three.

Level three requires very substantial support.

Severe deficits in verbal communication,

extreme distress at change, and very limited social initiation.

Usually just needs base communication.

The vignette for ASD in the chapter describes a four -year -old girl in a sandbox.

She isn't driving the toy cars around.

She's just spinning the wheels over and over.

That's the repetitive play.

She's also flapping her arms when overwhelmed and repeating words she hears, which is called echolalia.

Right.

But the clinical red flag that usually brings parents in is the lack of connection.

She resists hugs.

She doesn't bring a toy to show her mom.

That absence of joint attention is the real hallmark.

Next is ADHD.

We covered the genetics, but the clinical presentation is worth distinguishing.

We know the classic symptoms,

inattention, hyperactivity, impulsivity.

But the text makes a really critical point about how this evolves into adulthood.

Right.

The hyperactivity often goes underground.

A seven -year -old boy might climb the curtains.

A 25 -year -old woman isn't going to climb the curtains, but she will feel an intense internal restlessness.

Her mind is climbing the curtains.

That's a great way to put it.

It's so important not to rule out ADHD just because the patient is sitting still in front of you.

We should also briefly touch on specific learning disorders and motor disorders before we move on.

Dyslexia and dyscalculia are mentioned.

Right.

And the key there is that they are not related to intelligence.

But if they go untreated, there's a massive risk for school dropout and depression.

And for motor disorders, Tourette's involves both motor and vocal tics.

Yes.

And it can be severe, like flinging themselves out of a chair.

Or it can be highly embarrassing vocalizations, which really impacts their social life.

And developmental coordination disorder is basically extreme clumsiness, right?

Like trouble riding a bike or writing.

Exactly.

Okay.

Let's shift gears to mood, anxiety, and trauma disorders.

There is a specific controversy highlighted here regarding bipolar disorder in children.

Oh, yeah.

It is a diagnostic minefield.

Because tantrums and mood lability are, well, they're normal for kids and teens.

Exactly.

If you diagnose every moody 14 -year -old with bipolar, you are over -medicating an entire generation.

So how do we distinguish actual depression in a child versus an adult?

In adults, we look for sadness, lethargy, the blues.

In children, depression wears a disguise.

Yeah.

It looks like anger.

Yeah.

It looks like irritability.

Or it looks somatic, stomach aches, headaches.

A child acting out in class might not be bad.

They might be clinically depressed.

Wow.

And to address the over -diagnosis of bipolar, the DSM -5 introduced a new label, right?

Disruptive Mood Disregulation Disorder, or DMDD.

Yes.

And this was a very necessary correction.

DMDD is for children with an onset before age 10 who have severe recurrent temper outbursts, like three more times a week.

Wow.

And a baseline mood that is persistently irritable or angry, it captures that volatility without tagging the child with a bipolar diagnosis, which implies episodic mania.

The vignette here describes a 12 -year -old girl visiting the school nurse repeatedly for stomach aches.

This is a classic somatic presentation.

And the nurse did the exact right thing.

She didn't just give her an antacid and send her back.

Right.

She asked, what is happening at home?

And it turns out the girl was overhearing her parents argue about getting a divorce.

The stomach ache was just the physical manifestation of her anxiety.

So the intervention wasn't a pill?

No, it was listening and using guided imagery.

Speaking of anxiety, let's talk about separation anxiety.

Context is absolutely key here.

A 10 -month -old screaming when mom leaves the room is totally normal.

Expected even.

Right.

An eight -year -old refusing to go to school, having nightmares about kidnapping or vomiting when separated from their parents.

Yeah.

That is separation anxiety disorder.

It impairs their development.

Then there is selective mutism, which is often misunderstood as defiance, I think.

Completely.

People say the kid refuses to talk.

No.

The child is unable to talk due to paralyzing anxiety in specific social situations like school, even though they might be chatter boxes at home.

It's a freeze response.

Exactly.

An anxiety freeze response.

Under the anxiety umbrella, the text also places obsessive compulsive -related disorders, specifically trichotillomania and excoriation.

Right.

Trichotillomania is hair pulling, scalp, eyebrows, eyelashes.

And excoriation is skin picking.

Both often begin in childhood and are more common in females.

And these are tension reduction behaviors, right?

Yes.

The child feels a mounting anxiety, pulls the hair or picks the skin, and feels a temporary release.

So it becomes this neurological loop.

And finally in this section, a disorder that links directly back to that concept of neuroplasticity and early attachment we talked about.

Reactive attachment disorder, or RED.

This is honestly one of the most heartbreaking diagnoses.

You see a child who is emotionally inhibited and withdrawn.

They rarely seek comfort when they're distressed.

And if you offer them comfort?

They don't respond to it.

What creates that level of withdrawal in a child?

Profound neglect.

We see this in children who spent their early years in orphanages with really high child -to -staff ratios, or in foster care systems where they were just moved constantly.

So they never had a consistent caregiver.

Right.

They learned a fundamental lesson very early on.

Adults are not safe and they will not help me.

So they stop asking.

They stop signaling.

Their brain has wired itself around the complete absence of care.

That's devastating.

It really is.

Let's move to the physical manifestations of distress.

Feeding and elimination disorders.

Pica is one that often surprises people.

Yeah, pica is the persistent eating of non -nutritive substances.

Dirt, paint chips, hair, chalk.

Is it always psychological?

Can be a mineral deficiency, but often in this psychiatric context, it's associated with intellectual disability or severe neglect.

The text also mentions rumination disorder, which is regurgitating, re -chewing, and re -swallowing food.

And avoidant restrictive food intake disorder, which is a failure to meet nutritional needs, but it's not body image focus, like anorexia.

Exactly.

It might be sensory aversion to textures or fear of choking.

Then we have elimination disorders, enuresis, which is bedwetting, and encopresis.

Right.

Enuresis is urine and it's considered a disorder after age five.

And enuresis is passing feces in inappropriate places, and that's considered abnormal after age four.

And enuresis carries a serious physical risk too.

It does.

Often it starts with retention.

The child holds the stool, maybe it hurts to go, or they're super anxious about using the school bathroom.

So they hold it.

They hold it.

The stool builds up and the colon literally stretches.

That's called mega colon.

Oh, wow.

And when it stretches that much, the nerves lose the ability to signal the need to go.

So then they have leakage, which they truly cannot control.

And then they get teased at school.

They get teased, which increases the anxiety, which increases the retention.

It's a vicious physical and psychological cycle.

The text also touches on gender dysphoria here.

And it really frames it around the nurse's role in reflection.

How would you react if your child disclosed this?

It's an important exercise in empathy because parents vary so wildly from total acceptance to absolute rigidity.

And the nurse needs to navigate that family dynamic without judgment.

We've covered the internal disorders.

Now we have to look at the behaviors that usually involve the authorities.

Disruptive, impulse control, and conduct disorders.

We really need to distinguish between ODD and CD.

OK, so oppositional defiant disorder, or ODD, is exactly what it sounds like.

It's a pattern of angry, irritable mood and defiant behavior.

They argue with authority figures.

They refuse to comply with rules.

They deliberately annoy people.

It goes beyond normal limit testing.

Yes, but, and this is the vital distinction, they generally do not violate the basic rights of others or major societal norms.

Whereas conduct disorder, CD, crosses that line completely.

CD is dangerous.

This involves aggression to people or animals.

The text lists examples like using a weapon, a bat, a brick, a broken bottle, physically cruel behavior to animals, setting fires, stealing while confronting a victim, forced sexual activity.

It's much more severe.

It's the precursor to antisocial personality disorder in adulthood.

OK, the text provides a very detailed evidence -based practice case study that really helps synthesize all of this.

Let's walk through it for everyone listening.

We have a 16 -year -old male with ASD.

Right, he is nonverbal, he uses a wheelchair, and he has repetitive behaviors like wearing specific masks and hats.

And the crisis was that he started lashing out, biting himself and hitting his elderly parents.

And they just couldn't physically handle him anymore.

Right.

Now, the easy answer would have been to just sedate him.

But that's not what happened.

No.

They used the nursing process.

They assessed the context.

They realized the aggressive behavior spiked right after his favorite care aide left the agency.

So it was a grief and frustration.

Exactly.

So the plan involved safety and informatics.

First, they changed the care aide to find a better fit.

But the real breakthrough was the informatics piece.

They introduced an electronic communication device, a tablet.

And the outcome?

The aggression dropped significantly.

He was able to proudly use the device to tell them what he wanted.

It proves that so often, behavior is just frustrated communication.

You give the patient a voice, and you don't need the restraint.

That's an incredible example.

It leads us perfectly into the final section, the application of the nursing process.

How do we actually do this work?

The assessment of a child is very different from an adult.

Very different.

You can't just sit in two chairs and ask, so tell me about your week.

Right.

You have to meet them where they are.

Children are concrete thinkers.

They don't do abstract analysis.

And their primary language is play.

That's why we use play therapy.

Exactly.

You observe what the dolls are doing.

Is the daddy doll hitting the mommy doll?

Are they acting out a trauma?

That is your assessment data.

Box 26 .1 in the chapter outlines the mental status assessment specifically for children.

It highlights looking at general appearance and activity level, but also coordination.

Coordination is a subtle, but really powerful clue.

Tiptoe walking, for example, is a soft sign often seen in autism.

Clumsiness or inability to ride a bike might indicate the developmental coordination disorder we talked about.

And the speech category covers more than just vocabulary.

Right.

We listen for that echolalien we mentioned, repeating words, or pronoun reversal, like referring to themselves as you instead of I.

The box also mentions assessing affect and relating, like eye contact and ability to separate from parents.

And, of course, the themes of play.

So based on all that data collection, which involves interviewing parents, teachers, and the child separately, by the way.

Very important detail.

You move to diagnosis.

Examples would be risk for deficient food intake for those feeding disorders, or impaired parenting, or risk for caregiver stress.

Right.

Which brings us to planning and implementation, specifically psychopharmacology.

The general rule here seems to be extreme caution.

Start low, go slow.

Children metabolize drugs differently, and their brains are still developing.

Medication is rarely the first line of defense.

It's usually combined with behavioral therapy.

For ADHD,

stimulants are the standard.

Ritalin, Adderall, Vyvanse, they improve focus.

They do that by increasing dopamine and norepinephrine levels in the brain.

For ASD, the text mentions antipsychotics like Respertil, or Abilify for aggression and irritability, and SSRIs for anxiety or obsessive traits.

Right.

And for depression and anxiety, SSRIs are the first line.

But we have to discuss the black box warning.

Yes.

This is crucial for nursing students.

It is non -negotiable knowledge for a nurse.

All antidepressants carry a warning that they may increase the risk of suicidal thinking and behavior in children and young adults during the first few months of treatment.

That honestly seems completely counterintuitive.

You give a drug to treat depression, and it increases suicide risk.

I know.

The theory is that the medication gives the patient the physical energy to act on their thoughts before it actually lifts the mood.

Oh, wow.

So the lethargy lifts, they can get out of bed, but the hopelessness remains.

That is a highly dangerous window.

Nurses must educate parents to watch for any sudden changes in behavior or increased agitation.

That is such an important distinction.

Just quickly on other meds, DDAVP is mentioned for Inuresis, bedwetting.

And for DMDD, there are no approved meds yet.

But they use off -label guanfacine or clonidine for outbursts or mood stabilizers.

Finally, let's look at the non -pharmacological interventions.

The text mentions milieu therapy, which is structuring the environment for safety and growth.

And behavior modification, like point systems to reward desired behavior.

Yes.

And it touches on restraints and seclusion, which are controversial and dangerous.

Their use is rare and strictly monitored.

But the most interesting part to me was time out versus time in.

This ties back to everything we discussed about attachment.

It does.

Time out is isolation.

It removes the child from the situation and the environment.

Time in is connection.

Right.

It involves the caregiver sitting with a distressed child, offering a calm presence and helping them co -regulate.

If we go back to neuroplasticity, time out teaches the brain.

When I'm overwhelmed, I am alone.

Time in teaches the brain.

When I am overwhelmed, help is available.

That is a profound difference in wiring.

It completely changes the trajectory of emotional development.

We also have therapeutic play.

The concept is that play is the work and language of childhood.

The text mentions dramatic play, like acting out problems, and therapeutic games, like the talking, feeling, and doing game.

Right.

It also mentions bibliotherapy, using books so the child identifies with characters going through similar things.

Right.

And drawing.

Drawing is an incredible window into the unconscious.

If a child draws a person with no hands,

it might indicate feelings of powerlessness or insecurity.

If the figures are huge with jagged teeth, you're looking at aggression or fear.

It allows the child to externalize what they literally don't have the vocabulary to verbalize.

We have covered a massive amount of ground today, from the specific transporter genes of ADHD to the interpretation of child's drawing.

We really have.

And it reinforces that the interaction model isn't just theory on a page.

You have to understand the biology, the genetics, the environment, and the emotional world of the child to be an effective psychiatric nurse.

And I want to leave you with a final provocative thought on that concept of neuroplasticity we discussed earlier.

If a child's brain is literally physically molded by environmental input, if it is wiring itself based on whether the world feels safe or dangerous,

then every single interaction you have as a nurse with a child matters.

Every time it inverses time out.

Absolutely.

Every time you choose to validate a feeling, instead of just dismissing a noisy behavior, you aren't just being nice.

You are physically helping to wire that child's brain for resilience in the future.

You are architectural engineers for the next generation.

That changes the weight of daily care completely.

It's not just behavior management, it's structural construction.

It really is.

Well, thank you so much from the Last Minute Lecture team for tuning into this deep dive.

Good luck with your studies, and we will see you on the next one.