Chapter 33: Emotional & Behavioral Conditions in Children

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Welcome back to the Deep Dive.

Today we are taking a bit of a detour from the usual rounds.

Yeah, a little bit.

We spend so much time talking about the tangible things in nursing.

You know, the broken bones, the fevers, rashes, all the things you can see and measure.

Exactly, the things you can measure with a ruler or a thermometer.

But today we are looking at the invisible stuff.

We are diving into chapter 33,

the child with an emotional or behavioral condition.

Which I would argue can be the most challenging part of pediatric nursing.

Why do you say that?

Because you can't always see the wound, you know, but the pain is just so incredibly real.

Exactly.

And I know for a lot of our nursing students listening, especially the whole Last Minute Lecture crew, this chapter can be a bit of a stumbling block.

It feels subjective.

Totally.

Physical symptoms are, well, they're easier to see and treat.

Emotional ones, it's a really complex landscape.

You're dealing with everything from neurodevelopmental issues to behavioral struggles, eating disorders.

And even, you know, the most critical, life -threatening situations like suicide.

It's a heavy load.

It is.

But I think the mission for this deep dive is pretty simple.

I agree.

We want to take the clinical definitions from your textbook and really translate them into practical, on -the -floor nursing knowledge.

We aren't just here to help you memorize definitions for a test.

No, this is about trying to figure out how to spot the signs, to understand the why behind them.

And I think most importantly, know exactly what to do when you have a child in front of you who is really struggling.

Mentally or emotionally, yeah.

So we're going to map this out logically.

We'll just follow the structure of chapter 33.

Makes sense.

We'll start with the foundation.

So your role is the nurse and how to assess a family.

Then we'll look at the toolkit, you know, the therapies available.

And from there, we can get into the specific conditions.

Right.

Neurodevelopmental disorders like autism,

behavioral issues like ADHD and OCD, then eating disorders.

And we'll finish up with the critical safety issues like suicide and substance abuse.

It's a pretty comprehensive roadmap.

Let's get started.

Let's start at the very, very beginning.

The nurse's role.

Why are we as nurses so critical in this whole process?

I mean, typically people think of psychiatrists or psychologists for mental health.

Right.

They handle mental health stuff.

And we aren't psychiatrists.

No, we absolutely are not.

But just think about the logistics of health care for a second.

A psychiatrist might see a patient for what?

30 minutes, maybe an hour.

If they're lucky.

And maybe once a month.

Exactly.

So who is there for the other 23 hours of the day if that child is inpatient?

Or who sees the family every single time they come in for a vaccination or a sore throat or a well child check?

A nurse.

The nurse.

The text specifically calls the nurse the frontline observer.

I like that phrase.

Me too.

You have the greatest amount of contact with the family.

You are the one who sees how a mother looks at her child when she thinks no one else is watching.

Or how a toddler reacts to being held.

Yes.

Do they snuggle in or do they just arch their back and pull away?

Assessing those child -parent relations is a massive part of the job because you are seeing them in their raw, you know, unguarded moments.

But that observation, it feels so subjective sometimes.

To spot something that's wrong, you really, really need to have a solid baseline of what's right.

That is the golden rule here.

You absolutely must understand normal growth and development to spot the deviations.

All those other chapters on development.

They're the foundation for this one.

If you don't know that a two -year -old typically throws tantrums and says no a lot, you might mislabel a completely normal toddler as having a behavioral disorder.

Right.

But conversely, if you see that exact same behavior in a seven -year -old, well, that's a deviation.

You have to know the norm to identify the pathology.

Context is absolutely key.

Okay.

So once we suspect something might be off, we have to talk about the rule book.

If you're going into mental health, you hear this acronym constantly.

The DSM -5.

The Diagnostic and Statistical Manual of Mental Disorders, fifth edition.

It's published by the American Psychiatric Association.

And it's basically the standard.

It is the standard resource.

Yeah.

It defines all the mental disorders.

It sets the criteria you need for a diagnosis.

And practically speaking, it's used for billing.

Of course.

The money part.

Always.

If a condition isn't in the DSM -5, it's very, very hard to get insurance to pay for the treatment.

So it's essentially the dictionary for mental health.

Ideally.

But you know, the text makes a really important distinction here that students need to be aware of.

The DSM -5 is great for adults and for older children.

But.

But for infants and very young children, it's not always the best fit.

Their brains are still developing so incredibly rapidly that adult criteria don't always apply.

Okay.

So what do we use instead for the little ones?

There are age -appropriate alternatives mentioned in the chapter.

One is the DC2 .0 -3R.

What does that stand for?

That's the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood.

That's a mouthful.

It is.

But it focuses specifically on that zero to three age range.

It allows for a much more nuanced look at developmental delays that might not fit a strict DSM category just yet.

Okay.

So we've got our observation skills.

We have a rule book.

But nursing is fundamentally about care.

And in pediatrics, you aren't just caring for the child.

No, you're caring for the entire family unit.

Exactly.

And the text outlines a specific strategy for communicating with parents.

It's an acronym, which is always helpful for

H -E -L -P.

H -E -L -P.

It's a great framework for that first interaction when things are tense.

So let's break it down.

H.

H is for hope.

Parents of children with behavioral conditions are often just exhausted.

They're terrified.

They feel judged by everyone.

I can only imagine.

So you need to offer hope.

Not, you know, false promises, but the real hope that with management and support, things can actually improve.

Okay.

E is for empathy.

You have to demonstrate that you feel their situation.

You have to validate their struggle.

Not just say, I understand, but show it.

And L is for loyalty.

This means you show up for them.

You advocate for them.

You are on their team, not against them.

And finally, P is for participation.

You need them involved in the plan of care.

You can't just hand down orders from on high.

Parents need to feel like partners in the treatment or it won't work.

That participation piece feels huge.

Yeah.

But there's a massive nursing tip in this chapter about how we interact with parents that I think is just crucial.

It's about how we treat them, especially when the family dynamic seems well off.

This is so critical and it can be really hard for nurses.

You will encounter dysfunctional families.

You will see parenting styles you deeply disagree with.

Oh, for sure.

But the text is explicit about this.

Never, ever discredit the parents' values to the child.

Even if we think they're wrong.

Even if you are struggling.

And here's why.

That child identifies with their parent,

consciously and unconsciously.

The parent is their anchor.

Their anchor.

Exactly.

So if you, the nurse, attack or discredit that parent, you are threatening the child's fundamental security.

You're creating anxiety.

You cannot help a child by tearing down their foundation.

Even if that foundation is a little shaky.

Wow.

You have to support the child without alienating the parent.

It's a fine line.

That is such a powerful perspective.

Yeah.

It's not about approving of the parent's behavior.

Not at all.

It's about protecting the child's sense of self.

Precisely.

And knowing when you're out of your depth is a huge part of that protection.

You have to know your resource management.

Meaning?

When do you refer to parenting classes?

When is it time to call in NAMI, the National Alliance for the Mental Ill?

When should you loop in the school psychologist?

A good nurse knows their community resources and acts as a bridge to them.

Speaking of resources and professionals, let's move on to session two, the toolbox.

We tend to throw around titles like psychologist and psychiatrist almost interchangeably in casual conversation.

Oh, all the time.

But in a clinical setting, knowing who is, who really, really matters.

It does because their scopes of practice are completely different.

So let's clarify the hierarchy that the chapter presents.

First up, a psychiatrist.

This is a medical doctor, an MD.

They specialize in mental disorders and crucially, because they are doctors, they can prescribe medication.

That's the key difference.

It is.

If the treatment plan involves drugs, a psychiatrist is almost always involved.

Okay.

So psychiatrist equals meds, basically.

Generally.

Yeah.

Then you have a psychoanalyst.

This is usually a psychiatrist, but sometimes a psychologist who has advanced training specifically in psychoanalytic theory.

Like Freud and that kind of thing.

Think Freud.

Yeah.

And though modern analysis is obviously updated, they focus on the unconscious mind, past experiences.

Okay.

Then a clinical psychologist.

They have an advanced degree, a PhD or a Psi Psi ID.

They often do the heavy lifting on the psychological testing side of things, IQ tests, personality assessments, and therapy, and therapy, lots of therapy.

But in most places, they do not prescribe meds.

Got it.

And a counselor.

A counselor usually has a master's degree.

They might specialize in really specific areas like substance abuse counseling or school counseling.

They provide support and guidance, but they don't typically diagnose complex medical conditions or prescribe drugs.

Okay.

So that's the who.

Now let's talk about the what.

The text lists several different therapeutic modalities.

Some seem pretty obvious, but some are really specific to pediatrics.

Behavior modification is a huge one.

This is all based on stimulus and response, positive reinforcement.

So rewarding the behavior you want to see.

Exactly.

It's very effective for specific behavioral issues where you want to change a concrete action.

Then there's one called milieu therapy.

This one sounds fancy.

It does, but it just means environment.

Milieu therapy refers to the structured physical and social environment, usually in like a residential treatment center.

So the whole vibe of the place.

The vibe, the rules, the schedule, the safety of the space, that entire environment is designed to be therapeutic.

It teaches the child how to exist within a community.

And for the really little ones, I mean, a four year old isn't going to respond to that.

No, for them it's play therapy.

And this is so critical because a four year old cannot sit on a couch and explain their existential dread.

It's not going to happen.

Right.

They express it through play.

A child might out a traumatic event with dolls or draw a picture that reveals their deepest fears.

It lets the therapist interact with the child completely on their level.

We also have things like art and music therapy, expressive outlets.

Yeah.

And one I really like is bibliotherapy that's using books, right?

Yep.

Reading stories about other children who are in similar situations.

It helps the patient feel so much less alone.

It normalizes their experience.

So if a child's parents are getting a divorce.

Reading a book about a character who's also going through a divorce can be incredibly validating for them.

And finally, the text mentions intervention.

An intervention is a planned event.

It's when family, friends, sometimes professionals, all come together to get someone into counseling or treatment.

It can be confrontational.

It can be, or it can be supportive.

But the main goal is to break through denial and get that person to finally accept help.

Okay.

So we have our team and we have our tools.

Let's start applying them.

Section three covers neurodevelopmental dysfunctions.

So now we're talking about things that affect how a child's brain develops and processes information.

Right.

And we'll start with learning disabilities.

These are usually diagnosed when a child starts school and just hits a wall.

And the key definition here is that there's a gap.

A gap, exactly.

A gap between their intelligence and their achievement.

These kids are often smart average or even above average intelligence, but they aren't achieving at that level because there's a processing issue in the brain.

The big three mentioned in the chapter are dyslexia, dysgraphia, and dyscalculia.

Let's break those down.

Okay.

Dyslexia is language -based.

It involves difficulty sounding out words with word recognition, reading comprehension.

And the text is really clear on this.

Very clear.

This is not an intelligence deficit.

And an interesting note, it often co -occurs with ADHD, but it is not part of ADHD.

They are two separate conditions.

What about dysgraphia?

That's difficulty with writing and spelling.

And this isn't just, you know, messy handwriting.

It's a real struggle to organize thoughts on paper or to physically form the letters.

And dyscalculia must be math.

Yep.

Difficulty with mathematics and number concepts.

So what's the intervention here?

It's not like we're curing the brain wire.

No, you're not.

You're accommodating it.

So interventions involve using things like computers, calculators, creating distraction -free zones.

You're trying to bypass the bottleneck so their actual intelligence can shine through.

Okay.

Now let's move to a big diagnosis that nursing students will definitely, definitely encounter.

Autism spectrum disorders, or ASD.

This is a major topic in chapter 33 for sure.

ASD is this big umbrella term for a group of neurodevelopmental disorders.

What characterizes them?

Difficulties in social interaction, problems with communication, and repetitive behaviors.

It now includes things that used to be separate diagnoses like Asperger's.

It's all under one spectrum now.

The text lists some very specific red flags.

So if you're doing a well -tiled assessment,

what are the absolute must -knows that should make you think referral needed?

There are three huge ones listed that every single student should have memorized.

Okay, what are they?

One, no babbling or pointing by 12 months.

Pointing is a massive social milestone.

It's called joint attention.

What does that mean?

It means the baby sees something, points to it, and then looks at you to share that experience.

It's a social bid.

If a baby isn't doing it, that's a flag.

Okay, number two.

Two, no two -word spontaneous phrases by 24 months.

And the key word there is spontaneous.

Not just repeating what they hear, but putting two words together to mean something new, like more juice.

And the third one sounds really scary.

It is.

Number three is loss of previously attained skills.

If a child was talking and then stops, or if they were social and suddenly withdraw, that is a massive, massive red flag.

And socially, what does ASD look like in a child?

Well, you'll see little to no pretend play.

They might line up their toys in a perfect row instead of playing house.

A need for routine.

A very rigid adherence to rules and routines.

They often engage in solitary play.

And you'll see a lack of empathy or understanding of others' feelings, not because they're mean, but because they just can't read the social cues.

Exactly.

They struggle to read them.

So let's put this into practice.

You're the nurse on the floor.

You have a patient with ASD who's been admitted for something else, maybe a surgery or an infection.

How do you manage them?

The hospital is a sensory nightmare.

It really is.

You have to adapt your approach completely.

The text advises a slow paced approach.

Avoid any sudden movements.

Avoid loud noises.

These children can be so easily overstimulated.

And this is important.

Ask permission before touching, even for something as simple as vital signs.

Prepare them for what you are going to do.

I am going to put this cuff on your arm now.

And safety is always the number one priority.

Always.

You know, drug therapy isn't a cure for autism, but it might be used to manage specific behavioral problems like aggression or severe anxiety.

But your environment and your approach, those are your primary tools.

Let's move on to section four.

The text calls these the acting out and ritualistic disorders.

Let's start with OCD, obsessive compulsive disorder.

Right.

And we really need to distinguish this from just being, you know, need or organized.

It's not a personality quirk.

Not at all.

OCD is a cycle.

You have the obsession, which is a recurrent persistent thought.

My hands are dirty or something bad is going to happen to my mom.

And that thought causes huge anxiety.

Immense anxiety.

And that anxiety leads to the compulsion, which is the ritual or the activity they do to silence that thought.

Like washing hands over and over.

Exactly.

Washing hands, touching an object a certain number of times, checking locks.

And the text mentions a fascinating physiological link here.

What's that?

There's a potential connection to strep infection.

Strep, as in a sore throat.

Yes.

It's a condition called pan S that's pediatric acute onset neuropsychiatric syndrome.

Wow.

Basically, a group of beta hemolytic strep infection triggers an autoimmune response that affects the basal ganglia in the brain.

And it causes the sudden dramatic onset of OCD symptoms.

That is just wild.

It really shows why nurses have to look at the whole picture, the whole person.

It really does.

And structurally, it's important for you to know that OCD does not involve an impairment of cognitive function.

These kids are often incredibly bright.

But they're just hindered by these rituals.

Completely.

The rituals take up so much time and energy.

Treatment usually involves a combination of cognitive behavioral therapy or CBT and SSRIs like phylloxetine or sertraline.

Okay.

Now for the big one.

ADHD,

attention deficit hyperactivity disorder.

I feel like everyone thinks they know what this is, but let's look at the actual clinical definition.

Yeah, let's get specific.

Clinically, it's developmentally inappropriate degrees of attention, impulsivity and hyperactivity.

And there are time constraints on the diagnosis, right?

There are.

To diagnose it, the symptoms usually have to appear before age seven and they must last for more than six months.

It has to be persistent and across different settings like home and school.

And the text busts a really common myth here regarding intelligence.

Yes.

And this is so important.

Learning disabilities often occur with ADHD, but they are not part of it.

A child with ADHD usually has average or even above average intelligence.

They just struggle to access it in a traditional setting.

Let's break down the three core symptoms.

Inattention, impulsivity, hyperactivity.

Okay.

So inattention, they're easily distracted.

They don't seem to listen when they're spoken to.

They make careless mistakes.

Impulsivity.

They disrupt the class.

They talk out of turn.

They absolutely cannot wait their turn in line.

They just act before they think.

And hyperactivity is the one everyone pictures.

It is.

They fidget.

They climb on things.

They act like they are driven by a motor.

They physically cannot sit still.

So what causes it is bad parenting.

No.

The leading theory is the dopamine hypothesis.

So disturbances in the dopamine system in the brain.

There are also links to the prenatal environment.

And interestingly, the text mentions a potential link to a high fat and sugar prenatal diet.

For treatment, we usually think of medication.

And it always seems so paradoxical to give a hyperactive child a stimulant.

It does seem completely backward, but it works on those dopamine pathways.

We use dopaminergic agonists.

Like Ritalin, Concerta, Adderall.

Yep.

Those are stimulants that paradoxically help the ADHD brain focus and filter out all the distractions.

They can be taken as oral pills or even skin patches now.

But pills can't be the only answer.

The text has a great health promotion box about classroom strategy.

If you're a school nurse, what are you telling the teacher?

You're advising them to structure the environment for success.

Seat the child in the front away from the windows or the door.

Minimize distractions.

Exactly.

Give clear instructions.

And this is key clear repeated instructions.

And you have to provide breaks.

You cannot expect a child with ADHD to sit still for 90 minutes straight.

So let them get up.

Let them stand up, stretch, or even deliver a note to the office.

Give them an outlet for that energy.

Okay.

Let's take a breath.

We've covered the brain wiring and the behavioral struggles.

Now we're moving into section five, eating disorders.

This is heavy stuff and unfortunately so common in the adolescent population.

It is a really serious topic.

And the text focuses on the two main diagnoses, anorexia nervosa and bulimia.

Let's start with anorexia nervosa.

Who is the

patient profile for this?

Adolescent girls are the most common demographic, though we're seeing it more in boys too.

Profile wise, we often see overachievers,

perfectionists,

straight A students.

And the text uses a really interesting word to describe them.

Obedient.

That's it.

Obedient.

You don't typically associate obedience with a psychiatric disorder.

But it ties directly into the core issue, which is control.

Anorexia is often a response to a feeling of a complete lack of control, sometimes in a dysfunctional family dynamic where the child feels powerless.

So they control the only thing they can.

The only thing they can, their food intake.

It's driven by an intense fear of gaining weight and a severe body image disturbance.

They look in the mirror and genuinely see obesity, even if they are starving to death.

Physically, what signs are we going to see as nurses?

Well, severe weight loss, obviously, but also amenorrhea, the stopping of the menstrual period.

That's a huge sign the body is shutting down non -essential functions to survive.

You'll see lanugo, which is this fine baby -like hair that grows on the back and limbs.

Why does that happen?

Because the body is trying to keep itself warm since it has lost all of its fat insulation.

You'll also see dry skin, low blood pressure, and a severe intolerance to cold.

So what's the nursing focus when a patient like this is admitted?

First and foremost, you have to keep them alive.

You correct electrolyte imbalances, you stabilize their weight.

But emotionally, and this is critical, you have to avoid being a food policeman.

What does that mean exactly?

It means you avoid those authoritarian approaches.

You don't want to get into a power struggle over food because that's exactly what the disorder feeds on.

So forcing them to eat.

It will just make them fight back or find ways to deceive you.

You have to focus on building trust.

You build a relationship.

You have to treat the person.

Not just the eating behavior.

Okay, let's contrast that with bulimia.

Bulimia is characterized by this cycle of binge eating followed by purging.

And purging can be self -induced vomiting, or it can be the misuse of laxatives or diuretics.

And personality profiles different too, right?

Very different.

Where the anorexic patient is often rigid and overcontrolled, the bulimic patient is frequently impulsive.

That binge purge cycle is a coping mechanism for guilt, depression, or really low self -esteem.

There are some very specific physical signs for bulimia that nurses can catch.

Sometimes just during a routine exam.

Oh, for sure.

Erosion of tooth enamel is a big one.

It's caused by the stomach acid from frequent vomiting constantly washing over the teeth.

What else?

Muscle weakness from electrolyte imbalances.

And Russell's sign, that's calluses or scars on the knuckles from using their fingers to self -induce vomiting.

It's a classic sign to look for on their hands.

And the family dynamic is mentioned as well.

It is.

The text notes that the mother -daughter relationship is often distant or strained in cases of bulimia, which is a specific observation nurses should be aware of during their family assessment.

So the nursing approach here, is it the same as with anorexia?

Similar, but with a different flavor.

It has to be non -judgmental.

Supportive, but firm.

The text suggests using things like contracts and compromise rather than rigid authority.

You want them to feel a sense of agency in their own recovery.

Moving on to section six, mood disorders and suicide prevention.

This is arguably the most critical safety section of the entire chapter.

Absolutely.

And we have to start with depression in children because it looks so different than it does in adults.

How so?

Well, an adult with depression might look sad, stay in bed, cry.

A child often acts out.

They get irritable.

Irritable, maybe aggressive.

Their grades suddenly drop.

They start having a lot of somatic complaints.

My tummy hurts, my head hurts.

It's so easy to miss depression if you're only looking for sadness.

You have to look for that behavioral shift.

And if that depression deepens, we run the risk of suicide.

The statistics are just sobering.

It is the third leading cause of death in adolescents.

And there's a really important gender difference to know.

Boys complete suicide more often, usually because they choose more lethal means like firearms.

Girls, on the other hand, attempt suicide more often, typically using less immediately lethal means like an overdose or cutting.

So as a nurse, you are constantly doing a risk assessment.

What puts a kid in the danger zone?

What are you looking for?

You are looking for the trifecta, a plan, a means to carry it out, and a lack of resources or support.

Can you give an example?

Sure.

If a teenager has a specific plan like, I'm going to take these pills and they have access to the pills, that's the means and they feel completely alone.

That's the lack of support.

That is an immediate crisis.

What are some of the warning signs that parents and nurses should be looking for?

A flat effect, a sudden deterioration in their schoolwork, social isolation, and a classic one, giving away prized possessions.

Why that one?

If a teenager starts giving away their favorite video games, their clothes, something they love, that is a massive red flag.

They are, in their mind, settling their affairs.

So you suspect a child is suicidal.

What is the nursing intervention?

What do you do?

You ask directly.

There is this terrible myth that asking about suicide will plant the idea in their head.

That is completely false.

So what do you say?

You ask, do you have thoughts of harming yourself?

You need a direct answer.

And if they say yes?

You implement safety protocols immediately.

One tool the text mentions is the safe contract.

What's that?

It's a written agreement where the patient agrees to contact a specific person or a hotline before they harm themselves.

It's about putting a barrier, a moment of thought, between the impulse and the action.

I also love the drawing exercise the text suggests.

Oh, it's great.

Asking the child to draw how I see myself versus how others see me, or to draw boxes for happy things and sad things, it opens a door for communication that words sometimes can't.

It gives you real insight into their self -perception.

It does.

There is a specific medication warning here that is absolutely vital for patient teaching, especially regarding antidepressants.

Crucial for SSRIs.

When a patient first starts taking them, in the first few weeks, their energy level might improve before their mood does.

And that's a dangerous window.

The most dangerous.

Because they now have the energy to carry out a plan they previously didn't have the drive to execute.

So close, close monitoring in those first few weeks is completely non -negotiable.

And the text mentions something called the safe ET program.

Yeah, it's an acronym.

Identify risk, identify protective factors, suicide inquiry, determine risk level, and then document and follow up.

It's just a systematic way to make sure you don't miss anything critical in your assessment.

Okay.

Finally, let's talk about section seven.

Substance abuse and family impact.

Substance abuse in adolescence often starts with experimentation and can very quickly slide into dependence.

And we have two kinds of dependence.

Psychological and physical.

Right.

Psychological is the craving, and physical dependence is when you have actual withdrawal symptoms.

If the drug is stopped.

We need to talk about gateway substances.

These are the accessible ones, the things they can find at home.

Household products like inhalants or huffing, alcohol, tobacco.

They seem minor to some kids because they're legal or available.

But they prime the brain.

They absolutely prime the brain for stronger drugs down the road.

And there's some really specific scary drugs mentioned in the chapter.

Yeah, like bath salts.

And no, these are not for the tub.

Right.

They are synthetic stimulants, usually snorted or injected.

They cause euphoria,

but also intense hallucinations, paranoia, and seizures.

It's a very dangerous trend.

What about marijuana?

The concern specifically mentioned for nursing is bronchoconstriction.

So for a teenager with asthma, it can be incredibly dangerous.

And opiates.

Heroin, prescription painkillers.

The biggest risk here is rapid physical dependence and, of course, overdose.

But substance abuse doesn't just happen in a vacuum.

So often it's a family disease.

The text spends a good amount of time discussing children of alcoholics.

This is a really profound section.

The environment in an alcoholic home is just chaos.

It's unpredictable.

The rules change day to day, even hour to hour, depending on the parent sobriety.

And the kids experience role reversal.

Total role reversal, where the child has to act as the parent to the adult.

And to survive this chaos, the chapter says, children usually adopt one of four coping patterns or archetypes.

I think understanding these is so helpful for nurses to spot these kids.

Oh, absolutely.

Let's run through them really quick.

OK.

First, you have the flight.

This child just flees.

They literally stay away from home as much as possible, always at friends' houses, or they just emotionally bury all their feelings.

Number two is the fight.

This child is aggressive.

They're acting out.

They're basically mirroring the chaos that they see at home.

Third is the perfect child.

And this one is heartbreaking.

They are the obedient, straight -A student who never causes trouble.

They're trying to earn love or stabilize the family by being absolutely perfect.

And they often fly under the radar.

Completely.

Because they look like they're doing great, but inside they are suffering.

And fourth is the savior.

Or the super cooper.

They feel responsible for everyone and everything.

They try to fix the parent, fix the house, fix their siblings.

They are overly painfully responsible for their age.

So as a nurse, if you see a child who is just too good or too responsible, like an eight -year -old managing all the younger siblings in the waiting room, like a little pro, that could actually be a flag.

It definitely warrants a closer look.

Our role as nurses is to recognize these patterns.

And practically, we teach that child how to get help in an emergency.

We refer them to Al -Anon and Alateen Resources.

And you let them know it's not their fault.

You let them know they aren't alone, and the parent's addiction is not their fault.

Wow.

We have covered a massive amount of ground today.

I mean, from the H -E -L -P strategy to the tiny intricacies of autism red flags, from the physical signs of anorexia to the hidden signs of depression.

It's a lot to take in, but if we zoom out for a second, there is a common thread that runs through this entire chapter.

What's that?

Observation.

The nurse is the bridge.

Whether it is spotting that tiny red flag in a toddler who isn't pointing, or noticing the perfect child who is actually crumbling under the weight of an alcoholic parent, your power is in your observation.

You're the one who notices the things the textbook describes.

You are the one who is there.

You are the one who sees.

That's powerful.

And the final thought I want to leave with the listeners is this.

Children are resilient.

That is the good news in all of this.

It is.

With early recognition and with the right support, remember H -E -L -P.

Hope.

Empathy.

Loyalty.

Participation.

The outcomes can change so drastically.

You aren't just documenting symptoms.

You are intervening in a life's trajectory.

That's a great place to leave it.

Thank you so much for diving deep with us today.

Good luck with your studies.

Good luck on the floor.

And remember,

you might just be the one person who notices.

From the Last Minute Lecture team, thanks for listening.

We'll see you next time.