Chapter 33: Emotional & Behavioural Conditions in Children

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Welcome back to The Deep Dive.

Today we are opening a file that I think for a lot of people is pretty intimidating.

We're looking at Chapter 33 of Lifer's Introduction to Maternity and Pediatric Nursing in Canada.

It is a heavy one, isn't it?

It really is.

The title is The Child with an Emotional or Behavioral Condition.

And I think for a lot of nursing students or really anyone entering the field,

this is where the clinical skills meet the human condition in a way that's, well, it's just messy.

It is.

It's not like setting a broken bone.

Not at all.

No, absolutely not.

We're moving away from the purely physiological, though the biology is definitely there and we'll get to that.

And we're stepping into the mind, the family dynamic and really the future of these children.

It's arguably one of the most critical areas in pediatric nursing today.

It is.

The stakes feel incredibly high.

They are.

And to really set the stage, we had to look at the numbers.

The text opens with a statistic that should honestly make everyone stop and pay attention.

I agree.

We are looking at approximately one in five children.

One in five?

That's 20 percent.

That's a huge portion of the pediatric population.

Right.

And we should be clear.

The text specifies these aren't just kids having a bad day or going through like a moody phase.

This isn't just being a teenager.

No.

These are children who are experiencing significant impairments because of their emotional or behavioral symptoms.

So when you say impairment, what does that actually look like on the ground?

What does that mean for them?

It means the symptoms are severe enough that they interfere with daily life.

I mean, it affects everything.

Their home life, their performance at school, their relationships with their peers.

Their whole world, really.

Their whole world.

It's a ripple effect.

If a child is suffering from an untreated behavioral condition, it doesn't just stay inside their head.

It spills out.

It spills into the classroom, onto the playground and right into the living room.

So if I'm a nurse walking onto a pediatric floor, this isn't some niche issue.

I have to expect that this is going to be, well, everywhere.

It's pervasive.

And to understand it, we really have to look at where it comes from.

The source material highlights some really profound risk factors.

The obvious ones that come to mind are, of course, abuse and neglect.

And they're mentioned right at the top.

It makes sense, right?

Trauma literally rewires the developing brain.

Of course.

So children who've been abused or neglected are at a significantly higher risk for developing emotional, intellectual and social problems.

But there's also a familial link that's a bit more nuanced.

This is the part about learned helplessness, right?

I found this concept just fascinating in a really tragic way.

It is tragic.

Can we unpack the mechanism there?

Because it almost sounds contagious.

In a behavioral sense, it is.

The text explains that a child with a parent who is suffering from depression is at a much higher risk for anxiety, for mood disorders, or even substance use later on.

And it's not just genetics.

Genetics plays a role, for sure.

But the mechanism here is largely observational.

It's what they see every single day.

So they're just watching how their parents handle the world.

Precisely.

If a parent is suffering from severe depression,

they might be unable to model effective coping strategies.

They might withdraw or just give up when they're faced with stress.

And the child sees that.

The child sees that.

And they develop what the text calls learned helplessness.

So they basically learn that their actions don't matter, that they're powerless.

Exactly.

They learn that they have no control over their environment.

If my parent, my protector, the person who runs my world, if they can't master their environment because of their illness, the child internalizes that inability.

So they learn apathy.

They learn apathy.

They

essentially learn to be helpless because that's the only model of adulthood they've seen up close.

That puts an incredible amount of pressure on that family dynamic.

It's not about bad parenting.

It's a transmission of a deficit in coping.

That's a perfect way to put it.

It's a transmission of a deficit.

And that's why we see the big three disorders showing up so frequently in kids.

The big three.

Mood disorders, anxiety disorders, and neurodevelopmental disorders, specifically ADHD.

We're also going to be touching on autism spectrum disorder and substance use disorders.

Okay.

So we have a massive slate to cover today.

So our mission is to guide you, the learner, through what the text calls the continuum of care, essentially how the system is supposed to work.

Then we'll break down the nurse's specific role, which is really unique in mental health.

And then we're going to do a deep clinical dive into those conditions.

Depression, suicide,

anxiety,

ADHD,

autism, and substance use.

All right.

Let's start with the big picture, the framework.

The text refers to a continuum of services.

I kind of visualize this as a pyramid or maybe a ladder.

A ladder is a great analogy.

The core concept here is that you want to prevent harm and you want to ensure that the intensity of the care matches the severity of the need.

So it's proportional.

It has to be proportional.

You don't want to send a child with mild test anxiety to a locked down residential facility, right?

And you certainly don't want to treat a suicide attempt with just a pamphlet on stress management.

It has to fit.

But before a family even gets their foot on that ladder, there's a huge barrier to entry, isn't there?

The text mentions that just deciding to start treatment is really complicated.

It's incredibly complicated.

And the biggest hurdle mentioned in the text is stigmatization.

Stigma, of course.

Caregivers are often terrified.

They worry that if they seek help, they're labeling their child for life.

They worry that a diagnosis will marginalize them in school or in the community.

So they're afraid of what the neighbors will think, what the teachers will think.

Absolutely.

So you have this huge fear of stigma acting as a massive deterrent to even opening the door to the continuum of care.

And while they're waiting, I assume the problems aren't getting any better.

Usually they're getting worse, but let's assume they cross that threshold.

Let's walk through the hierarchy of services, the rungs on that ladder, starting at the bottom.

Level one, the foundation.

The text calls this health promotion, prevention, and harm reduction.

Right.

And ideally, this is where we want to do the most work.

The text makes a really powerful point here.

The 80 % statistic.

The 80 % statistic.

80 % of adults with mental illness experience their first symptoms in childhood.

That is just a staggering number.

It is.

It tells us that childhood is the critical window.

If we target prevention and health promotion here, you know, building resilience, creating safe environments, teaching coping skills,

we are potentially preventing a lifetime of struggle.

Okay.

But if prevention isn't enough and symptoms start to emerge, we move up a step.

We move up to community -based services.

This is your general practitioner, your family doctor, your pediatrician, the pediatric nurse practitioner.

This is the first line of medical defense.

And what if the presentation is more complex?

What if the family doctor says, look, this is beyond my scope?

Then we move to level three, specialized community services.

These are your local mental health and addiction services.

They handle the more detailed assessments, crisis management, and system navigation.

They are the experts in the community.

Okay.

So things are getting more serious.

Then we get to the acute level.

Right.

Level four is specialist acute inpatient services.

This is for severe, difficult to treat symptoms.

It often requires hospitalization because safety is at rest.

And finally, the very top of the ladder.

That's level five, long -term care, residential settings.

This is for children with what the text calls unremitting symptoms.

Unremitting meaning?

Meaning symptoms that just won't go away despite multiple attempts at treatment at the lower levels.

These are the most intensive environments for the most complex cases.

So that's the machinery of the system.

But where does the nurse fit into all of this?

I mean, what is our core goal as a nurse?

The text defines the nurse's goal as promoting an optimal level of functioning for the family and the child.

And notice I said family and child.

They can't separate them.

You cannot.

You can't treat a child in a vacuum.

But this brings up a massive challenge for the nurse, which is the whole developmental context.

This seems really, really tricky.

How do you distinguish between a phase and an actual disorder?

You know, if a teenager is moody and sleeping a lot, are they depressed or are they just fifteen?

That is the million -dollar question in pediatrics, isn't it?

Children change so rapidly.

Is this behavior a developmental lag?

Is it a response to a specific event that will pass?

Or is it a disorder?

And the risk, as the text points out, is that wait -and -see approach.

Exactly.

Waiting for them to grow out of it.

Parents and even some clinicians might hope it's just a phase, but that can lead to delayed treatment.

And that means prolonged distress for the whole family, and the child is losing crucial developmental time.

Correct.

Now, speaking of the family, there's a specific nursing tip in the text that I think is absolutely vital.

It warns nurses against discrediting the parents.

Okay, let's talk about that, because I can see how that could happen.

It's a trap that, you know, well -meaning students often fall into.

You see a child in distress, and maybe you see a parent who isn't handling it well.

Maybe the parent is anxious or angry, or they seem checked out.

And your instinct might be to side with the child, to be the hero for the kid.

Right.

You might start to view the parent as the problem, but the text is very, very fond on this.

Do not discredit the parents.

Why, though?

Even if the parent is making mistakes.

Even then.

Because first, on a practical level, the parents are your primary source of A five -year -old can't give you a detailed history of their behavioral changes over the last six months.

The parent can.

Okay, that makes sense.

But more importantly, and this is crucial,

the parents are the child's security system.

They are the child's foundation.

So if you undermine the parent, you're shaking the child's entire sense of safety.

You got it.

If a healthcare provider undermines the parent's values or their authority, it threatens the child's sense of security, and it actually increases their anxiety.

So your goal isn't to tear the parents down.

Your goal is to help them regain confidence in their role.

You need them on the team.

You have to build them up.

That is such a nuanced and important point.

It's about putting the child's security above your own need to be right.

Okay, let's dive into the clinical conditions.

The big three.

First up, mood disorders.

Also known as affective disorders, these are really characterized by pain and suffering.

But in kids, it doesn't always look like sadness, does it?

No, and that is a major, major misconception.

Children often can't articulate psychological pain.

They don't have the vocabulary to say, I'm feeling existential dread.

So they act out their concerns instead.

Exactly.

The text mentions specifically that while an adult might present with classic sadness, a child is more likely to show irritability, anger, or even somatic symptoms.

I want to pause on somatic symptoms.

Somatic means of the body, right?

That's right.

So if a child is depressed or anxious, they might not cry.

They might have headaches all the time.

They might have stomach aches.

The kid who's always in the school nurse's office.

The one with the tummy ache that has no physical cause.

As a nurse, you need to be thinking about emotional distress.

The body is speaking what the mouth cannot.

And the triggers for this can be things that might seem small to an adult.

Totally.

Poor grades, moving to a new house, losing a pet.

To a child, these are monumental events, and they can trigger dependent or disruptive behaviors.

Let's look at box 33 .2 in the text.

It lists the signs and symptoms.

Beyond the sadness and the tummy aches, what stands out to you in that list?

Well, look for social isolation.

The child who stops playing with friends.

Look for extreme sensitivity to ejection.

A small comet sends them into a spiral.

Changes in eating or sleeping are classic signs too.

Classic.

And there's one word the text highlights that I think is really interesting.

Boredom.

Boredom.

How is that a sign of depression?

Persistent boredom.

I'm bored.

Everything is boring.

Nothing is fun.

That is often the child's way of describing anhedonia.

Anhedonia, which is the inability to feel pleasure.

Exactly.

They have lost interest in the things they used to love.

To a kid, that just feels like boredom.

That is a major red flag for a nurse to pick up on.

Okay, so we've identified potential depression.

We can't just guess, though.

How do we screen for this?

No, we use standardized tools.

In adolescence, so ages 12 to 18, we use the PHQ -9.

It's a pretty standard patient health questionnaire.

And for the younger kids?

For ages 7 to 17, there's the CDI -2, the child depression inventory.

What's really interesting and useful about the CDI -2 is that it triangulates data.

Triangulates.

What does that mean?

It means it doesn't just ask the child how they're feeling.

It takes input from the parent and from the teacher as well.

So you get a 360 -degree view of how the child is functioning in different environments.

Exactly.

And there's also the MFQ, the mood and feelings questionnaire.

There are parent and child versions, but the text notes that for the child version, the child needs to be verbal enough to identify feelings like unhappiness or restlessness.

Okay, so we've done our screening.

We have a diagnosis.

How do we treat it?

It's almost always a combination approach.

First, you have the psychosocial interventions.

About therapy.

Right.

Specifically cognitive behavioral therapy or CBT.

We're teaching problem -solving and emotion management.

We're also working on strengthening that parent -child relationship.

And then there's the pharmacological side, the medications.

Yes.

SSRI, selective serotonin reuptake inhibitors.

Fluoxetine is a common one that's mentioned.

But we have to stop here and discuss a critical, critical safety warning.

This is the black box warning.

The black box equivalent.

Yes, we must monitor these children so closely.

SSRIs can cause agitation and paradoxically, they can increase suicidal thoughts in adolescents.

Wait, can you explain that?

That seems so counterintuitive.

Why would an antidepressant make someone more suicidal?

It's a terrifying paradox.

One of the leading theories is about the gap between energy and mood.

You see, severe depression often causes what we call psychomotor retardation.

You have no energy to do anything, not even to harm yourself.

You can't get out of bed.

Right.

The medication might start to restore their physical energy and motivation before it actually lifts their mood.

Oh, wow.

So suddenly the patient has the energy to carry out the suicidal plans they were previously too tired to enact.

That is the danger.

It means the first few weeks of treatment are the highest risk period.

You cannot just write the prescription and say, see in six months.

Close, intensive monitoring is absolutely essential.

Let's make this really practical.

The text provides nursing care plan 33 .1,

which is specifically for an adolescent who's been admitted after a suicide attempt.

I want to walk through the goals and interventions because they're so specific.

Let's do it.

This is the real how -to of psychiatric nursing.

Okay.

Goal number one in the care plan is positive self -image.

The intervention here is simple, but it can be really effective.

You have the teen list, two positive things about themselves every day.

And the rationale for that, what's it doing?

It forces them to interrupt that constant negative thought loop.

You're trying to rewire that negative self -talk by making them actively search for and identify their own strengths.

Goal number two, accepting positive statements.

The intervention for this one involves drawing.

You ask the patient to draw how I see myself on one side of the paper and how others see me on the other.

Why drawing?

Why not just talk about it?

Because sometimes the words are just too hard or they're too defensive.

Drawing can clarify emotions and it offers a release.

It gives the nurse and the patient a vehicle for discussion.

Tell me about this shape here that isn't just a direct interrogation.

That's a great technique.

Okay.

Goal number three, coping with feelings.

This one has a specific technique called the box.

I love this intervention.

It's so concrete.

You instruct the adolescent to draw a box and inside it they put things that bring them happy feelings.

Then you have them draw another box for things that cause sadness.

And what does that achieve for them?

It creates psychological distance.

The rationale is that drawings help adolescents distance themselves from the problem so they can see it more clearly.

It compartmentalizes the emotions so they aren't just a storm inside their head.

They're objects in a box on a piece of paper.

Right.

It makes the feelings manageable.

And finally, the most critical goal of all, safety and suicide prevention.

The intervention here is direct assessment.

You have to ask.

You ask directly about thoughts, about plans, and about means.

And you use something called a safety contract.

What is that exactly?

Is it a legal document?

No, not legal, but it's a written agreement.

The patient signs a paper agreeing to contact a nurse, a counselor, or a crisis line before they harm themselves.

Does a piece of paper really stop someone who's in that state of mind?

It can.

It's not foolproof, of course, but it puts a barrier, a moment of hesitation, between the impulse and the action.

It's that moment where they think, I promised I would call first.

That split second can save a life.

And of course, there's the environment itself.

Oh, absolutely.

You strip the environment of any and all risks.

You remove belts, glass objects, rope, shoelaces, anything that could possibly be used for self -harm.

That transitions us grimly, but necessarily, right into the topic of suicide itself.

And it's a topic we have to face.

It's the second leading cause of death in adolescents.

That statistic alone should make every listener pause and really take that in.

And the text mentions a gender difference here.

It does.

Boys die by suicide more often.

Girls tend to engage in non -lethal self -harm more often.

But obviously, both are absolute emergencies.

The text also emphasizes the specific and tragic context for Indigenous youth in Canada.

We need to talk about this.

We absolutely do.

This is a critical public health crisis.

First Nations youth are five to six times more likely to die by suicide than their non -Indigenous peers.

And for Inuit youth, the number is even higher.

It's devastating.

For Inuit youth, that number is up to 30 times more likely.

30.

We have to talk about the root causes mentioned in the text.

This isn't random.

This is historical.

No, it's not random at all.

The text explicitly links this to the ongoing impact of colonization, the horrific legacy of residential schools, the dismantling of cultural structures, and the weight of intergenerational trauma.

It's systemic.

So as a nurse, you have to understand that context.

You're not just treating an individual.

You are treating a generational wound.

That's exactly right.

So when we are assessing risk for any young person, what is the triad we need to be looking for?

The text outlines three things.

And if you see all three, alarms should be ringing.

Number one is a plan of action.

Do they know how they would do it?

Is it vague or is it specific?

Number two, the means to carry out the plan.

Do they have access to the pills, the gun, the rope?

And number three, an absence of resources for help.

Do they feel completely and utterly alone with no one to turn to?

And what are the warning signs we should be teaching families to look for?

Giving away possessions is a classic one.

Here, take my favorite guitar.

I won't need it anymore.

Changes in appearance, either neglecting hygiene or a sudden drastic change.

The text also mentions rage behaviors.

Yes.

Sometimes it doesn't look like sadness.

It looks like explosive anger.

Or a sudden unexplained deterioration in their school performance.

And the safety alert in the chapter is very clear.

It is.

Every single threat must be taken seriously.

There is no such thing as just looking for attention when it comes to a suicide threat.

You treat it as real every single time.

End of story.

I really like the communication tip the text offered for when a teen tells you they feel hopeless.

Yes, this is so important.

Do not contradict them.

If a teen says, I am worthless,

your first instinct might be to jump in with, no, you're not.

You're great.

Right.

That seems like the kind and supportive thing to say.

But it's not.

It's not helpful because it invalidates their feeling.

It tells them that you don't understand their reality.

Instead, you listen.

You validate that they are in pain.

So you say something like, I hear that you are hurting right now.

Or it sounds like you are feeling incredibly overwhelmed.

Exactly.

You join them in their reality first before you try to guide them out of it.

And another key point on communication, secrecy.

Right.

Never, ever promise secrecy.

You can't.

You just can't promise not to tell anyone if their life is in danger.

You have to be upfront and say, I can keep a lot of things private.

But if you tell me you are going to hurt yourself, I have to tell the team so we can keep you safe.

OK, let's move on to the second of the big three,

anxiety disorders.

Right.

And again, we all feel anxiety.

So the first step is to differentiate between normal developmental fears and a genuine disorder.

The text has a great table for this.

Table 33 .1.

It shows that, you know, a toddler fearing separation from their parent.

That's normal.

A seven -year -old fearing the dark.

Also normal.

Exactly.

But an anxiety disorder has four distinct features that set it apart.

Number one, it interferes with daily life.

Two, the reasons for the anxiety are often unclear.

Three, logical explanations don't reduce the worry.

You can't just logic a child out of an anxiety disorder.

It doesn't work.

And number R, which is the hopeful part, is that the symptoms are responsive to treatment.

Right.

There is help.

So let's run through the types quickly.

First is GAD or generalized anxiety disorder.

This is the child who worries about everything.

Everything.

Their grades, the safety of their family, world events, natural disasters.

These kids are often perfectionists.

The text uses the powerful image of a child erasing through the paper because their work has to be absolutely perfect.

And there are physical symptoms too.

Yeah.

Trembling, sweating, those stomach aches we talked about.

Next up, separation anxiety.

This is normal in toddlers, but it becomes pathological in school -aged children.

This can turn into what we call school phobia.

They aren't afraid of math class.

They are terrified that some harm will come to their parents if they are apart.

Then there's social anxiety.

This is an intense fear of embarrassment or being observed by others.

It is not just shyness.

Shyness is a personality trait.

This is a fear that paralyzes social interaction.

And panic disorder and OCD.

Panic disorder is characterized by intense unexpected periods of anxiety panic attacks.

Heart racing, feeling like you're dying.

And OCD is that cycle of obsessions, the intrusive, unwanted thoughts and compulsions, the behaviors like hand washing or checking that they do to try and reduce the distress caused by the thoughts.

And finally, PTSD.

Post -traumatic stress disorder, re -experiencing a trauma.

And the text has a specific important note on signs of sexual assault in children.

Things like unexplained bedwetting, new clinginess or intense secrecy.

Those are major red flags that require immediate and careful attention.

So what's the treatment for these anxiety disorders?

It's very similar to depression actually.

CBT is the gold standard.

You're working to replace negative, catastrophic thoughts with more realistic ones.

It requires homework, practicing those new skills in the real world.

HOFFMAN Mindfulness is also mentioned.

STACEY Yes, mindfulness and acceptance techniques.

Helping them learn to live in the moment without judgment.

And again, SSRIs can be very effective, especially when they're combined with therapy.

HOFFMAN Okay, let's hit the third big one.

The neurodevelopmental disorders.

Let's start with ADHD.

STACEY Attention Deficit Hyperactivity Disorder.

The key phrase here is developmentally inappropriate.

We're looking at developmentally inappropriate degrees of inattention, impulsivity and hyperactivity.

HOFFMAN What are the diagnostic criteria?

STACEY It typically begins before age seven, has to last for more than six months.

And this is key.

It must be present in at least two different settings.

HOFFMAN Two settings.

So usually home and school.

Why is that part so important?

STACEY Because if a child is wild and unfocused at home, but a perfect angel at school, it might not be ADHD.

It might be a behavioral reaction to something in the home environment.

ADHD is in the brain's wiring.

It travels with the child wherever they go.

HOFFMAN And what causes it?

STACEY The text points to the dopamine hypothesis.

It's essentially a neurochemical issue, a problem with dopamine regulation in the brain.

There are also links to prenatal alcohol or tobacco exposure and premature birth.

HOFFMAN Box 33 .6 in the chapter lists the manifestations.

STACEY Yeah, it's the classic list.

Fidgeting, talking too much, difficulty taking turns, always losing things.

And what I find important is careless mistakes.

It's not that they don't know the answer.

It's that their brain has already moved on, so they missed the details.

HOFFMAN Treatment for ADHD needs a multidisciplinary team.

STACEY You need everyone on the same page.

The parent, the child, the physician, the nurse, the teacher.

Medications are common, especially stimulants like methylphenidate or amphetamines.

HOFFMAN But the health promotion box gives some fantastic classroom strategies.

These are things a nurse can teach parents to advocate for with the school.

STACEY Absolutely, and they're so practical.

One, seat the child front and center.

It minimizes distraction.

HOFFMAN Two,

give instructions one at a time.

Don't say open your book, turn to page five, and do problems one through ten.

That's too much for their working memory to hold.

STACEY Right.

You say open your book, you wait, now turn to page five, break it down.

Color coding subjects is another great one.

HOFFMAN I love the secret cues idea.

STACEY Isn't that great?

The teacher and the student agree on a nonverbal signal, like a gentle touch on the shoulder, to refocus the child without embarrassing them in front of the whole class, and allowing physical outlets like squeeze balls or fidget toys.

HOFFMAN Now, let's talk about the other major neurodevelopmental disorder in the chapter,

autism spectrum disorder, or ASD.

STACEY Right.

And the key word there is spectrum.

It's a huge range that includes what we used to call ASD syndrome.

The core deficits are in two main areas, social interaction and communication, and repetitive behaviors or stereotyped interests.

HOFFMAN Early diagnosis is so, so important here.

What are the big red flags for parents and nurses to watch for?

STACEY Well, the early milestones are key.

If there is no babbling or pointing by 12 months, no two -word phrases by 24 months.

But the biggest red flag of all is regression.

HOFFMAN Regression, meaning losing skills.

STACEY Exactly.

A loss of previously attained skills.

If a child was waving bye -bye, maybe speaking a few words, and then suddenly stops, that is a massive warning sign that needs immediate investigation.

HOFFMAN And what about screening?

STACEY The mChat, the modified checklist for autism in toddlers.

The text recommends this screening be done at all 18 and 24 -month well -child visits.

HOFFMAN Once a child is diagnosed, box 33 .8 outlines the four essential components of management.

STACEY Yes, and these are the pillars of care for a child with ASD.

Number one is clarity.

Expectations must be crystal clear.

HOFFMAN Number two, consistency.

Everyone—family, school staff, health care providers—has to use the same approach.

STACEY Number three is simplicity.

The supports need to be practical and accessible.

And number four is continuation.

You have to keep the supports in place even as the behavior improves.

You don't just pull the rug out from under them.

HOFFMAN The text makes a point about how stressful hospitalization can be for a child with ASD.

STACEY It can be a complete nightmare for them.

It's a sensory minefield—bright fluorescent lights, loud beeping noises, strangers in uniforms trying to touch you.

HOFFMAN So what's the nurse's role in managing that?

STACEY You have to be their sensory shield.

You slow the pace down.

You minimize input dim the lights, lower the volume on machines if possible, and you always, always ask for permission before you touch them.

You have to respect their sensory boundaries or you will trigger a meltdown.

HOFFMAN Okay, finally we need to address substance use disorders in adolescents.

STACEY A huge and growing problem.

We're talking about alcohol, cannabis, nicotine, but also prescription drugs like opioids and stimulants, and of course street drugs.

HOFFMAN Let's define some key terms first.

The book differentiates between tolerance and dependence.

STACEY Right.

Tolerance is basically physics.

You need more and more of the drug to get the same effect.

Your body gets used to it.

HOFFMAN Independence.

STACEY There are two types.

Physical dependence is physiological.

Your body adapts to the presence of the drug.

If you stop suddenly, you get withdrawal sickness.

Psychological dependence is the craving, the compulsive need to use the drug for a sense of well -being.

HOFFMAN The text describes alcohol as a family disease.

STACEY It does, largely because of the mixed messages kids can get.

If parents drink freely but then tell their kids not to, it creates a lot of confusion.

And we know alcohol is a that seriously affects judgment and inhibition.

HOFFMAN Cannabis.

This is a big topic in Canada since legalization with Bill C -45.

STACEY Legalization completely changed the landscape.

But the text is clear.

Legal doesn't mean harmless, especially for the developing adolescent brain.

Cannabis directly affects the endocannabinoid system, which regulates mood, memory, and pain.

HOFFMAN And what about for teens specifically?

STACEY The big concern is executive function.

Long -term use in adolescence is linked to and executive function is what exactly?

HOFFMAN Those are the high -level brain skills.

Planning, organizing, impulse control, emotional regulation, the adolescent brain is frantically trying to build and pave those neural highways.

The text suggests that cannabis use basically puts up roadblocks and creates potholes on those developing highways.

STACEY Okay, let's talk about opioids.

We are in the middle of a crisis.

HOFFMAN We are.

And the text mentions carfintanil.

It's a veterinary drug used to tranquilize elephants.

It is 10 ,000 times more potent than morphine.

STACEY 10 ,000 times.

And the scariest part is the lookalike pills.

HOFFMAN This is what's killing so many young people.

Fentanyl or carfintanil is pressed in illegal labs to look exactly like a legitimate prescription bill, like an Oxycontin.

A kid thinks they're taking a pill they recognize, maybe from a friend, but it's lethal.

One pill can kill.

STACEY So what should parents and nurses be looking for?

Box 33 .9 lists the signs of substance use.

Some big ones are sudden changes in friend groups, the use of incense or perfume to mask odors, carrying eye drops to hide red eyes from marijuana,

mouthwash to hide the smell of alcohol.

HOFFMAN And a really practical one for families.

STACEY Missing prescription medications from the whole medicine cabinet.

That's a huge red flag.

HOFFMAN So what is the nursing approach when you're dealing with an adolescent with a substance use disorder?

STACEY The approach is harm reduction.

This is the Canadian standard of care.

It means you meet people where they are.

You focus on safety first.

HOFFMAN So it's not quit or nothing?

STACEY No.

You might not get abstinence on day one, but you can keep them alive.

You can provide clean needles, naloxone kits, and education.

Then you work toward management or abstinence.

And on the other end, prevention is key building self -esteem early so kids don't feel like they need chemicals to cope with life.

HOFFMAN We have covered an incredible amount of ground today.

From that huge continuum of framework all the way down to specific interventions for depression, suicide,

anxiety, ADHD, ASD, and substance use.

STACEY It's a massive chapter, but it's also just the reality of pediatric nursing today.

This is the work.

HOFFMAN It is.

I want to leave our listeners with a thought from the text that really stuck with me.

It mentions that most adolescents don't choose treatment voluntarily.

They're coerced by their parents, by their schools, by the justice system.

STACEY That is such a profound and important point.

So my question to mull over is this.

How does that change the way a nurse has to build a therapeutic alliance?

If your patient doesn't want to be there, if they feel like a prisoner,

how on earth do you build trust?

HOFFMAN That's the million dollar question, isn't it?

It requires immense patience,

unconditional positive regard, empathy, and a complete refusal to judge.

You have to earn that trust every single shift, sometimes minute by minute.

STACEY Something to mull over.

Thanks for diving deep with us today.

This is a last minute lecture team signing off.

HOFFMAN Take care.