Chapter 34: Children & Adolescents in Psychiatric Nursing

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Welcome back to the Deep Dive.

Today we are opening a file that I think a lot of people, even those deeply embedded in the medical field approach, with a mix of curiosity and honestly a bit of trepidation.

Oh, absolutely.

We are taking a magnifying glass to chapter 34 of Psychiatric Nursing, the seventh edition, and the title is simple enough.

Children and Adolescents.

But the content.

Anything but simple.

It's elaborate.

You are so right.

It is a deceptively complex topic.

I think there is this prevailing instinct, not just in the general public, but even among early career medical professionals, to view children as just little adults.

Right.

You know, the mindset, if a child is acting out, they're just having a bad day or they need a nap or, you know, maybe they just need better discipline.

But this text, it grabs you by the shoulders immediately and says no.

It really does.

It frames child psychiatry not as a smaller version of adult psychiatry, but as a highly specialized high stakes field.

We aren't just talking about behavioral quirks or temper tantrums.

Not at all.

We are looking at a massive tangled web of genetics, biology, environmental factors, and some truly heartbreaking life circumstances.

It's heavy, but it's fascinating.

It is a collision of nature and nurture in the most literal sense.

And for the nursing students listening to this deep dive, or really anyone trying to understand the developing brain,

this is where the rubber meets the road.

This is it.

This is where you see how delicate human development really is.

So let's set our mission for this deep dive.

We are going to act as your study companion.

We know this textbook can be dense.

Incredibly dense.

So we are going to walk through this chapter chronologically, stripping away the academic density to find the core insights.

We'll break down the major disorders, dissect the specific clinical examples provided in the text.

Which are incredibly vivid, by the way.

They really are.

And we will end with the nursing interventions, the framework they call me, meds, and milieu.

I love that framework.

It's such a useful mnemonic for students.

And just a quick disclaimer before we get into the weeds, we're sticking strictly to the provided text.

We are covering the seventh edition material.

That means we will be discussing the transition to DSM -5 criteria, the specific case studies mentioned in this chapter, and the medication guidelines as they are presented here.

So if you are ready, let's dive into section one, foundations and resilience.

The chapter doesn't start with a dry definition.

It starts with a story.

It does.

It introduces us to a nine -year -old boy named Billy.

And Billy is, well, Billy is in trouble.

Right, the case of Billy.

And this is a perfect opener because it illustrates the diagnostic trap that is so easy to fall into with kids.

How so?

You see a set of behaviors and you think you know what you're looking at.

You just connect the dots.

Let's look at the facts presented.

Billy is nine.

His behavior is, frankly, dangerous.

He is a fire setter.

The text says he admitted to setting fires in a mailbox,

a trash can, and even an alley.

Which, pause there for a second.

If you are a clinician seeing fire setting on a chart for a nine -year -old, your alarm bells are ringing for conduct disorder.

That is serious, aggressive, antisocial behavior.

Fire setting is one of those triad symptoms that makes everyone nervous.

But it doesn't stop there.

He is aggressive toward his siblings.

He has destroyed his own bedroom, literally tearing apart his safe space.

Which is so significant.

He refuses to go to school.

And physically, he is not sleeping well.

He can't concentrate.

He's a tornado of energy and destruction.

So you have a constellation of symptoms.

Aggression, destruction, insomnia, and inattention.

Now, usually when you're building a diagnosis, you look at the family history to find a clue.

A genetic roadmap.

Exactly, a genetic roadmap.

And in Billy's case, the history is loud.

It is very loud.

The text notes that his father and an uncle both have bipolar disorder.

So naturally, my brain, and I assume most students' brains, connects those dots.

Of course.

You see the high energy, the destruction, the lack of sleep, and the genetics.

You think, okay, this is early onset bipolar disorder.

It seems like an open and shut case.

That would be a very logical leap.

A very reasonable assumption.

But this is why assessment in children is so critical and so difficult.

Despite that screaming family history, and despite the aggression, what is Billy's actual diagnosis in the text?

Attention deficit hyperactivity disorder, ADHD.

That feels like a curve ball, doesn't it?

It really does.

It feels like we ignored the genetic evidence.

Why wouldn't it be bipolar?

Well, what the text is illustrating here is the massive overlap in symptoms.

A child who is manic might look agitated and destructive, but a child with severe ADHD who is impulsive and hyperactive.

They look agitated and destructive too.

Exactly.

The fire setting might be impulsivity, I wonder what happens if I light this, rather than the malice you see in conduct disorder.

The not sleeping might be hyperactivity, rather than the decreased need for sleep you see in mania.

It's a subtle but critical difference.

So the takeaway for the listener is that you cannot rely on family history alone as a diagnostic tool.

Not at all.

Just because dad has bipolar doesn't mean the son's hyperactivity is mania.

Precisely.

Symptoms can mimic each other, and often children can have vulnerabilities to multiple things.

The diagnosis frames the treatment,

so getting it right, differentiating between can't sit still and manic episode, is vital.

That word vulnerability comes up a lot in this first section.

The text pivots from Billy to this broader, almost philosophical idea of resilience, because not every kid with or even a tough genetic deck ends up with the disorder.

This is the nature versus nurture debate, but with a hopeful twist.

The text asks a fundamental question.

Why does one child who grows up with parental addiction, poverty, or foster care placement transcend those adversities to become a competent adult, while another child might crumble under the same weight?

What is the magic test?

Is there a recipe for resilience?

Like, can we bake this into kids?

Can we manufacture it?

The text is very honest here.

It explicitly says there is no recipe for resilience.

It's not a simple formula.

So no easy answers.

No.

You can just add two cups of good parenting and get a resilient kid.

However, they do identify key ingredients that seem to protect children.

Things that show up again and again in resilient individuals.

Let's list them, because I think these are vital for anyone working with kids to recognize if we can spot these, we can maybe nurture them.

Okay, first, an easygoing temperament.

And that is largely biological.

Some kids are just naturally more adaptable, less reactive to stress.

So some of it is just the luck of the draw, genetically?

To a degree, yes.

Second, the ability to form supportive relationships with adults.

And the text clarifies this doesn't necessarily mean parents.

Correct.

And this is so important, says an adult.

It could be a teacher who takes an interest, a coach, a grandparent, a neighbor.

Just one stable anchor who sees the child and validates them.

Just one person can make that difference.

One person.

Third is family resources.

Let's be real, poverty makes everything harder.

Having resources buffers stress.

It just does.

And fourth, and this is a big one, emotional intelligence.

Now, emotional intelligence is a buzzword we hear in corporate seminars all the time.

But how are they defining it here for a child?

They are specifically talking about the capacity to delay gratification and to understand other people's signals.

Delaying gratification.

That is the famous marshmallow test, isn't it?

It is.

Can you wait for the bigger reward?

If a child can pause, read the room and wait, they are much better equipped to handle stress than a child who needs immediate satisfaction.

That ability to regulate that impulse is a huge protective factor.

It means they can navigate social complexities and manage their own frustration.

But sadly, we know that many children don't just face stress, they face trauma.

The chapter dives deep into AC's adverse childhood experiences.

This is something that has revolutionized how we think about public health.

You truly have.

This is a critical area of modern psychiatric study.

The text cites a statistic that stops you in your tracks.

What is it?

About 45 % of all childhood onset psychiatric disorders are associated with the presence of multiple childhood adversities.

I want to double -click on that word, multiple.

It's not just one bad thing happening.

No, it's the accumulation.

It's the pile -up.

Physical abuse plus poverty.

Neglect plus a parent in prison.

It's the cumulative weight that breaks the system.

The straw that breaks the camel's back.

Exactly.

And these aren't just mental scars.

The text explains that these hardships are associated with adult physical health problems and even earlier death.

The body keeps the score.

They give a clinical example of this link between childhood trauma and adult presentation, the case of Alan.

This one really highlights why taking a history is so important.

Alan is a fascinating case because he shows up as an adult.

He is a 30 -year -old patient.

He comes to the clinic asking for help with depression and nightmares.

So if you are a nurse doing an intake and you're in a rush, you might just chart depression, prescribe an antidepressant, and move on.

And you would fail him.

You'd be treating a symptom, not the disease.

Because a careful history revealed the root cause.

Which was?

Alan had endured years of physical and sexual abuse by older male cousins when he was a child.

So the nightmares weren't just bad dreams.

No, they were re -experiencing symptoms.

His diagnosis wasn't just depression, it was post -traumatic stress disorder,

PTSD.

The nightmares had persisted from adolescence into his 30s.

He had been living with that trauma loop for decades.

And this brings up the medication management aspect early on.

How did they treat Alan?

Because standard depression meds might not fix the nightmare.

Joe, they won't.

It required a two -pronged approach.

They used sertraline, which we know as Zoloft, for the depressive symptoms.

But they also used a drug called prazosin specifically for the nightmares.

Prazosin?

That's usually a blood pressure medication, isn't it?

It is.

But it works on the brain, too.

It blocks norepinephrine, that adrenaline spike.

It helps suppress those adrenaline -fueled nightmares.

That's a key clinical nugget treating the specific symptom of trauma, not just the general mood.

That is fascinating.

So we have looked at childhood trauma, but the text goes back even further.

It says, mental health starts in the womb.

This section on prenatal influences is absolutely gripping.

We tend to think of mental illness as developing after birth, maybe in the teenage years.

Sure.

But the text argues that the environment and uterus sets the stage.

The wiring is happening then.

And they use a historical event to prove this.

Boxtownie 4 -1, the Dutch Famine of 1944.

I had never heard of this in a medical context before.

It is a tragic, perfect storm for research.

You had World War II, a harsh winter making canals impassable in the Netherlands,

and the retreating German army destroying food supplies.

That's a total blockade.

It was a blockade.

The text notes that by early 1945, adults in Amsterdam were living on a ration of just 580 calories per day.

580 calories?

That is starvation level.

That's a fraction of what a body needs to function, let alone grow a baby.

Exactly.

And for pregnant women, the downstream effects on their unborn children were profound.

Researchers tracked the offspring of the mothers who were pregnant during this famine.

And what did they find?

They found these children had significantly higher rates of depression, and even more specifically, schizophrenia.

Wait, so if the mother starved during that critical developmental window, the child was more likely to develop schizophrenia as an adult?

Yes.

It connects biology and environment in a way that is hard to ignore.

It suggests that nutritional deprivation alters the way the fetal brain wires itself, creating a vulnerability that might not explode until decades later.

That's incredible.

It really underscores that society's health affects the next generation's mental health.

That is incredibly heavy.

And it's not just famine.

The text pivots to something more common in the US.

Prenatal substance exposure.

It states that prenatal alcohol exposure is the most common cause of non -genetic mental retardation in the United States.

That is a staggering statistic, the most common cause.

And it's preventable.

Entirely preventable.

And it mentions secondary disabilities too.

Right.

It's not just cognitive delay.

These kids suffer from school failure, mood disorders, substance abuse issues of their own.

It's a ripple effect that starts before the child is even born.

It emphasizes the need for prenatal care as a psychiatric intervention.

So having established that foundation resilience, trauma, and prenatal factors, the chapter moves into the specific disorders.

And the first big one is depression.

Which apparently used to be a bit of a myth.

Yeah.

The text mentions that conventional wisdom once held that young people simply didn't experience mood disorders.

The idea was that they were too young or their personalities weren't formed enough to be depressed.

Like what do they have to be sad about?

They don't pay taxes.

Exactly.

But we know now that is patently false.

The numbers are clear.

Approximately 12 .5 % of youth experience some form of depression by age 18.

A huge number.

And about two -thirds of those experience severe impairment.

This isn't just the blues.

This is stopping them from functioning.

And there is a gender dynamic here that shifts, right?

There is.

Before puberty, rates of depression between boys and girls are pretty similar.

But after puberty...

Girls surge ahead.

They become two times more likely to be depressed than boys.

Does the text explain why that shift happens?

Is it just hormones?

It offers a few theories beyond just biology.

It suggests girls rely more on close emotional communication for self -definition.

They're also more concerned about social evaluation.

So peer relationships are more central to their identity.

Exactly.

So when those relationships fracture, or when social judgment happens, which is practically the definition of junior high, the impact is deeper.

The social stakes are higher for them.

That makes sense.

Now, if I am a nursing student standing in a clinic, what does a depressed child look like?

Because the text says it's different from a depressed adult.

This is crucial for assessment.

An adult might sit in your office and say, I feel empty.

Or I have no hope.

A child often doesn't have the vocabulary for that.

So they show it differently.

They express depression through somatic complaints.

Somatic meaning physical.

Exactly.

Tummy aches, headaches,

my legs hurt.

They might say they feel unloved or bad.

And interestingly, the text notes they are less likely to experience psychosis, hallucinations, or delusions than adults with depression.

But the risk is still life -threatening.

Absolutely.

Suicide is the third leading cause of death among adolescents.

That is a stat every nurse needs to memorize.

The third.

And the text explicitly links this to the rise of internet bullying, which we will touch on later.

Let's look at the clinical example for depression, Tanya.

The text calls this case young and pregnant.

This poor girl.

It is a heartbreaking case.

Tanya is 14 years old.

She was an A and B student, but her grades dropped to Ds and Fs.

Pause there.

That academic drop, that is a major red flag, isn't it?

Huge.

When a good student suddenly fails, you have to look for a psychiatric or social cause.

It's often the first visible sign.

She also couldn't concentrate.

Her mom described her as having extreme anger, which is another symptom we see in kids.

How interesting.

Depression manifesting as irritability or rage rather than sadness.

And the trigger for all this was a relationship.

A very traumatic one.

She started dating a 16 -year -old, got pregnant at 14, and the baby died shortly after birth.

That alone is enough to cause major depression, losing a child at 14.

But it got worse.

The boyfriend moved on.

He and his new girlfriend would call Tanya and taunt her.

That is just cruel, pure cruelty.

But, and this speaks to that vulnerability we discussed,

Tanya got pregnant again by the same boy.

Oh, no.

And she lost that baby, too.

So she is dealing with double bereavement, betrayal, bullying, and hormonal shifts, all at 14.

Correct.

The mother brought her in to get on an antidepressant.

The diagnosis was major depression with a rule out for postpartum depression.

And the treatment.

They prescribed Estilapram or Lexapro, 20 milligram daily.

This highlights the role of SSRIs in treating adolescent depression, but also the massive need for follow up.

Right.

You can't just give the pill and walk away with a history like that.

Moving on from depression, we hit a disorder that I think confuses a lot of people when it comes to kids, bipolar disorder or BPD.

This is a controversial and difficult diagnosis in pediatrics.

The presentation differs significantly from adults.

In adults, we think of the highs, grandiosity, hypersexuality, not sleeping for days because they are writing a novel or re -shingling the roof at 3 a .m.

Exactly.

Classic mania.

But in kids, the text emphasizes that the symptoms are often more understated and negative.

So what do you see?

You see irritability as the prominent symptom.

Mood instability, temper tantrums, impulsivity.

Which sounds a lot like.

ADHD.

And that is the problem.

There is a high rate of overlap.

Throwing a tantrum could be manic, or they can be frustrated because they can't focus, or they could be both.

Let's look at the case of Willie to see how this plays out.

The text titles this, wanting to die.

Willie is an eight -year -old boy.

He was brought in by the sheriff after fighting at school.

He says he wants to be dead.

That is chilling from an eight -year -old.

It is.

Now looking at his history,

his father has BPD and schizophrenia.

Another strong genetic link.

Very strong.

Willie's IQ is 72, which is borderline intellectual disability.

So you have cognitive struggles, family history, and aggressive behavior.

What was the diagnosis?

They diagnosed him with both ADHD and BPD.

Both.

So he gets hit from both sides.

Yes.

And this leads to what we call polypharmacy, using multiple drugs to treat one patient.

The text calls it the cocktail.

Let's list what Willie is taking.

It's quite a list for an eight -year -old.

It really is.

He's on clonidine for impulse control.

Methylphenidate, or Concerta, for the ADHD.

Oxtarbazapine, or Trileptal, for mood instability.

A mood stabilizer.

Exactly.

And risperidone, or risperidil, for aggression and unrealistic thinking.

That is four heavy -hitting psychiatric medications.

It is.

And the text raises a very specific nursing consideration here.

It serves as a warning.

What's the warning?

If you treat a child who actually has bipolar disorder with just stimulants for ADHD, or just antidepressants, you can cause a paradoxical reaction.

What does that mean?

What's a paradoxical reaction?

Yeah, it means the drug might make them worse.

Stimulants increase dopamine.

If you give that to a manic brain, you're prowing gas on the fire.

It can trigger extreme irritability, or even full -blown mania.

The text suggests that if a child isn't responding to stimulants or antidepressants, and there's a family history of bipolar,

the clinician should suspect DPD is the primary cause.

That's a key takeaway.

If the meds are making them wilder, re -evaluate the diagnosis.

Don't just up the dose.

Precisely.

Don't double down on the wrong path.

Okay, let's shift gears to anxiety disorders.

The text says this occurs in about 10 % of youth.

And again, girls outpace boys here.

The text also notes that childhood anxiety often foreshadows adult anxiety.

So it's not something they just grow out of.

No, it's a chronic trajectory for many.

They break it down into a few types.

We have OCD, PTSD, and general anxiety.

Right.

With pediatric OCD, it's similar to Adults' obsessions are the thoughts, and compulsions are the rituals.

But the text links it to specific traits,

perfectionism, and intolerance for uncertainty.

It also often co -occurs with oppositional defiant disorder.

Then there is PTSD.

They use a powerful example of cause here.

Yes.

They mention Hurricane Katrina, a child whose life was in danger and who lost their home.

The greater the magnitude of the stressor, the higher the risk.

And panic disorder.

This usually shows up later.

Typically in adolescents.

And we have a clinical example for this.

Brady.

Brady is a 17 -year -old senior honor roll student.

On the surface, he looks like he has it together.

But underneath, he is falling apart.

He tells the clinician, I can't breathe.

That somatic symptom again, it keeps coming back.

Exactly.

His panic attacks ramped up to one or two a week.

He describes an inability to sit still.

He says pacing is a matter of life and death.

That description really struck me.

It's not just I'm fidgety.

It's if I stop moving, something terrible will happen.

That is the essence of severe anxiety.

He has tingling, racing heart, sweating.

He was diagnosed with anxiety disorder with agoraphobia.

A fear of being in situations where escape might be difficult.

Right.

So now he's avoiding things.

His world is shrinking.

And the treatment.

Sirtuline, Zoloft again, starting low at 25 milligrams and titrating up.

And cognitive behavioral therapy, or CBT.

It seems like Sirtuline is a workhorse in child psychiatry based on these cases.

It is certainly a common first line treatment mentioned in this text for both depression and anxiety.

Now we move to the big one.

The most common childhood psychiatric disorder, ADHD.

Affecting about two million U .S.

children.

That's a huge number.

The text defines it as a complex brain disorder involving subtle abnormalities in the CNS, the central nervous system.

And it's likely a group of conditions, not just one thing.

We know the symptoms, inattention, hyperactivity, defiant behaviors.

But for students, the diagnostic criteria are vital.

Yes.

You can't just diagnose a kid because they were hyper one day.

Right.

What are the rules?

First, the behavior must last at least six months.

Okay.

So it has to be persistent.

Persistent.

Second, it must appear before age seven.

And third, and this is the big one, it must create trouble in multiple settings.

So not just at home, but at school too.

That multiple settings part is key.

If they are an angel at school and a terror at home, it might not be ADHD.

Exactly.

It might be family dynamics or something else.

If the brain is truly wired for ADHD, the symptoms should travel with the child everywhere.

Let's talk about Burt.

He is our ADHD clinical example.

Burt is seven.

He is fidgety, talks uncontrollably, and has poor grades despite having normal intelligence.

That's a classic sign.

The gap between potential and performance.

It really is.

And the family history is there again.

Always look at the family.

Yes.

His brother, father, and aunt all have ADHD.

His mother has MS.

How are they treating Burt?

They are using methylphenidate, specifically Concerta.

They increased his dose to 54 milligram, but they also added clonidine.

Why clonidine?

Isn't that a blood pressure med?

We've seen a couple of those now.

It is, but in psychiatry, it's an alpha -2 agonist.

The text explains it beautifully.

It works by tricking the brain.

I like that.

It makes the presynaptic neuron think there's enough norepinephrine, so it releases less.

This helps lower that hyperarousal.

For Burt, it was specifically added to help with insomnia, to help him settle down at night.

I love that explanation of tricking the brain.

It makes the mechanism of action much easier to remember.

It does.

And sadly, the text notes that while the best treatment includes parent and teacher management, in reality,

many cases default to medication only because of a lack of resources.

Which brings us to a diagnosis that has seen a lot of changes recently.

Autism spectrum disorders, or ASD?

This is a critical section for nursing students, because the DSM -5 changed the landscape significantly.

Goodbye, Asperger's.

Essentially, yes.

The categories of Pervasive Developmental Disorders and Asperger's Disorder were subsumed into the single category of Autism Spectrum Disorder.

So it's a spectrum now, not separate boxes.

Correct.

The new criteria require persistent deficiencies in social communication and interaction, plus restricted and repetitive behaviors.

And the text notes, they changed the rule on those repetitive behaviors.

In DSM -IV, you only needed one symptom of fixed interest or repetitive behavior.

In DSM -5, you need at least two, so the bar is a little higher there.

They also relaxed the age criteria a bit, didn't they?

They did.

It used to be symptoms before age three.

Now, the criteria acknowledge that symptoms might be present early, but might not fully manifest until social demands increase.

Like when school gets harder or peer groups get more complex.

Exactly.

Which is so helpful for those higher functioning kids who hit a wall later on.

The text highlights three major commonalities across the spectrum.

Let's run through them.

Go for it.

One, arrested social skills.

Withdrawal, lack of reciprocity.

Two, speech and language delays or strange pitch and intonation.

Three, narrow interests, spinning objects, obsession with mechanical things.

And we can't forget sensory issues.

No, this is huge for nurses.

Distress over clothing tags, buttons, textures.

A hospital gown might be torture for a child with ASD.

That's a really practical point.

The prevalence has skyrocketed, a 20 -fold increase since the 80s.

Which sparks the debate.

Is it better assessment or a real increase?

The text leaves that open, but is very firm on one thing.

Vaccines.

Yes.

Let's be clear on this.

The text states clearly that the theory that the MMR vaccine causes autism is not supported by research.

Full stop.

Good to know.

Let's look at the case of Trey.

Trey was diagnosed at two.

But his story starts with something physical.

Seizures.

Atonic seizures, where his head would just drop.

Yes.

His parents struggled to find a neurologist who could stop them.

Eventually they did, but Trey is now seven and in special education.

His behaviors are classic ASD.

Yes.

Flapping,

obsession with trucks, and a high -pitched, unintelligible voice.

And for medication.

He is taking resperidone.

This is an atypical antipsychotic.

It's not treating psychosis in the traditional sense.

It's treating the tantrums, aggression, and self -injury.

Okay, moving from biological disorders to a behavioral phenomenon that causes massive mental health issues.

Bullying.

This section starts with a history lesson.

The study of bullying really began in Norway in 1983, after three boys committed suicide.

A researcher named Olwais defined it.

How does he define it?

Repeated negative actions, unequal power, intentional, and unprovoked.

All four have to be there.

And the nurse has a front -row seat to this.

Because often bullied kids don't say, I'm being bullied, they go to the nurse with a stomach ache.

Somatic symptoms again.

It's the language of distress for kids.

It really is.

The text breaks down the types of bullying.

Verbal is the most frequent.

Name -calling, slurs, the obvious stuff.

But then there's relational bullying.

This one is insidious.

This is shunning, ignoring.

The goal is to disrupt peer relationships.

The text notes it's more common in girls and is very hard for adults to spot because it's quiet.

It's the meme -girls dynamic.

Exactly.

And of course, physical bullying and the modern monster.

Cyberbullying.

Yeah.

19 .4 % of students reported being cyberbullied.

The text points out why it is so damaging.

Yeah.

It is 2047.

There's no escape.

You go home and it follows you on your phone.

It's in your pocket, in your bedroom.

Exactly.

The consequences are deadly.

The text links bullying to school violence.

The Secret Service study mentioned is chilling.

They found that in 37 acts of targeted school violence, three quarters of the attackers had been bullied.

Three quarters.

It's a massive factor.

And the clinical example, Alex Moore, shows the other side of that coin.

Suicide.

Alex was 15.

She committed suicide by jumping from an overpass.

She had been teased about her weight.

She left a note saying she was going to see Jesus.

That is just devastating.

It is.

And it underscores that bullying is a medical issue, a nursing issue, not just a school principal issue.

So we have covered the problems.

Now we need the solutions.

The text introduces the framework, psychotherapeutic management, or ME, meds and milieu.

This is the core of the nursing rule.

Let's start with ME, the nurse -patient relationship.

The text talks about mental health literacy.

Which is basically combating ignorance and stigma.

But this section also highlights a crisis in care, the void.

This part made me angry.

It talks about parents having to use safe haven laws just to get care.

It is a desperate situation.

Safe haven laws are meant for abandoning newborns, but parents are surrendering older children to state custody because they can't afford or access psychiatric treatment.

They are giving up their parental rights just to get their child help.

That is the definition of a broken system.

A completely broken system.

And with the closing of residential facilities,

the wait lists for medication evaluations can be nine months long.

Speaking of medication, let's move to meds.

The text introduces a concept called prescription hygiene.

I love this term.

It's the philosophy of a conservative approach.

Basically,

remove meds to clarify effects before you add more.

So you know what's actually working.

Yes.

Don't just keep stacking them.

Minimize side effects.

Be thoughtful.

They also emphasize involving the family?

Yes.

Box 34 -3.

Use the family to track symptoms.

They're the ones seeing the child every day.

They're your best source of data.

Let's do a rapid -fire review of the drug classes mentioned for kids.

Depression.

QCAs, the tricyclics, are mentioned, but with Caution Narrow Therapeutic Index, Cardiac Risks.

Dysipramine is singled out for having caused deaths.

So very high risk.

Very.

SSRIs are the go -to, but with that black box warning.

Right.

The risk of suicidal thoughts.

And the text mentions a website, ssrestories .com, noting a perception that SSRIs can induce morally indifferent thinking.

That's a very specific phrase.

But Phleoxetine, Prozac, is approved for kids over eight.

Bipolar.

Goal is to stabilize mood and sleep first.

Lithium is approved for 12 and up.

Respiradone for 10 and up.

And weight -based dosing is crucial.

A 10 -year -old isn't a small adult.

Their metabolism is different.

Good point.

Anxiety.

Antidepressants, again.

Buspirone is mentioned.

And Clonazepam, or Clonopen, because it's less addicting than other benzos.

We have the stimulants.

Methylphenidate, Ritalin Concerta, and amphetamines, Adderall.

They activate the dopamine and noradinergic systems in the prefrontal cortex.

Essentially waking up the control center of the brain.

That's a perfect way to put it.

And the alpha -2 agonists we mentioned with BERT.

Guanadine and guanfacine.

Good for impulse control and aggression.

And finally, autism.

Atypical antipsychotics.

Respiradone, Aripiprazole.

Again, treating the tantrums and aggression, not the core symptoms of autism itself.

OK, the final M, milieu,

the environment.

Safety is priority number one.

Physical safety -removing sharps, glass.

But also psychological safety freedom from ridicule.

And protection from staff.

A sad but necessary point.

Background checks are essential.

Vulnerable children must be protected from predators in the system.

Then there is structure and norms.

Kids need predictability.

A schedule.

Clear expectations or norms like nonviolence and cleanliness.

It reduces anxiety when they know what the rules are.

Limit setting is a big one.

Clear rules.

No acting out.

No inappropriate sexual behavior.

The text warns nurses not to get bogged down in arguing with adolescents who split hairs.

Set the rule and enforce it.

Don't get into a power struggle.

No.

And finally, balance.

The text uses a great analogy here.

Music analogy, it says, you have a right to listen to music, but you do not have a right to play it so loud that I cannot hear my music.

It teaches the balance between independence and the rights of others.

That is a perfect way to explain boundaries to a teenager.

It really is.

We are coming to the end of our deep dive.

The chapter concludes with a sobering thought.

Mental illness changes a family forever.

It does.

It's not neutral.

Some families grow stronger, some disintegrate.

There is a final anecdote in the text that really stays with you.

The couple on the plane.

Yes.

They were flying coast to coast with their five -year -old autistic son.

They thought they could handle it.

You know, they prepared.

Right.

But shortly after takeoff, he had a meltdown.

Screaming, flapping, jumping.

And the reaction of the passengers.

Mixed.

Some were sympathetic.

Others judged them, accused them of poor parenting.

One person even threatened to sue because a dress got stained.

Oh, come on.

And the result?

The couple decided never to fly again.

Wow.

It shows how the world shrinks for these families when they don't have support or understanding.

As a powerful place to leave it.

We have covered resilience, the five major disorders.

Depression, BPD,

anxiety, ADHD,

autism, the tragedy of bullying, and the framework of me,

meds, and milieu.

It's a lot of material.

But remember,

assessment is key, safety is paramount.

And you are treating a developing human being, not just a set of symptoms.

To all the nursing students listening, hang in there.

This is tough material, but you are the ones who will be making that milieu safe for these kids.

This has been the Last Minute Lecture Team.

Thanks for listening.

Catch you on the next Deep Dive.