ADOLESCENT DISORDERS

INTRODUCTION
Adolescence is a time of transition an age when the person is not yet an adult but
is no longer a child. The issues raised during adolescence are central to personal
development. Psychiatric nurses treating adolescents focus on their movement
toward adulthood, considering social, emotional and physical aspects of their
adjustment in their family, school and peer groups.

CONCEPT OF ADOLESCENCE
Adolescence is a time of rapid physiological and psychological change of
intensive readjustment to the family, school work and social life and of preparation
of adult roles.
It starts with puberty and ends with the achievement of an adult work role.
It usually begins between 11 and 16 years in boys and between 9 and 16 years in
girls.

DEFINITION
Adolescence is the process of growing up to the period of life from puberty to
maturity.
-Webster’s Dictionary.

DEVELOPMENTAL MODEL
The Developmental theories of adolescence are
a. Cognitive development
b. Psychosocial development
c. Psychodynamic model
d. Learning model

a. Cognitive development:
Jean Piaget described 4 distinct stages in the cognitive development
from birth to adolescence.

i. Sensory motor stage [from birth to 18 months] wherein the child acquires
numerous basic skills with limited intellectual capacity and is primitive.
ii. Preoperational or intuitive stage: roughly starting from at about 18 months
and ending at 7 years, where the child learns to communicate and uses
reason in an efficient way.
iii. Concrete operations stage where the child becomes capable of appreciating
the constancies and develops the concept of volume but thinking is still
limited in some respect.
iv. Formal operations stage [from 12 years through adulthood] in which the
child develops the ability to ponder and deliberate on various alternatives
and begins to approach the problem situation in a truly systematic manner.

b. Psychosocial development:
Identity and its precedents in development are the backbone of
Erickson’s psychological developmental theory. Erickson lays more stress on the
social than the biological features in the process of development. This theory is
more humanistic and optimistic and emphasizes the importance of ‘ego’ rather
than ‘id’.

[Link] model
It focuses on adolescent development under various dimensions such as
psychosexual, psychosocial, cognitive, object relations, structural and moral.

d. Learning model:
Three major learning paradigms are classical conditioning, operant
conditioning and observational learning. The concepts of generalization and
discrimination illustrate how learning theory can account for individuality of
response styles an dbehaviour.

DEVELOPMENTAL PHASES OF ADOLESCENCE

A. Early Adolescence
It is probably the most stressful of all developmental transitions. It is
generally acknowledged that within the years from 11 to 15, a period of rapid and
drastic biological change will be experienced. There are 2 major psychosocial
challenges that confront early adolescents.
 The transition from elementary to junior high school
 The shift in role status from child to adolescent

The early adolescent begins to search for new behaviour values and
reference persons and to renegotiate relationship with parents.
At this time, they are particularly receptive to new ideas and risk taking.

B. Middle Adolescence:
It generally encompasses the ages 15 to 17. The middle adolescents
are capable to generalize, think abstractly and introspect usefully which are linked
to experience.
The middle adolescent is beginning to orient more to the larger society and
to learn about and to question the workings of society, politics and government.
C. Late Adolescence:
The ages represented are 17 years through the early 20s.
It represents a definitive working through of the recurrent themes of body
image autonomy, achievement, intimacy and sense of self that when integrated
come to embody the sense of identity.
The challenge of intimacy and the establishment of a stable, mature,
committed, intimate friendship are perceived as critical challenge.

FACTORS INFLUENCING DEVELOPMENT:

1. Genetic Factors: genetic influences in psychiatry characterized by
 The inheritance of traits or tendencies rather than specific
abnormalities
 Polygenic inheritance that is to say more than one gene being
influential
 The threshold effect
2. Neurological Factors:
 Brain damage: various degrees of injury to brain.
 Mental retardation: various degrees of intellectual deficit and
general mental handicap.
 Epilepsy: this may or may not be associated with brain damage,
mental handicap and psychiatric problems.
 Neurological disorder: Brain disorder including neurodegenerative
disorders.

3. Constitutional and Temperamental Factors:

If by personality , it is meant that more or less characteristic, coherent and
enduring set of ways of thinking and behaving that develops through childhood
and adolescence, then by constitution it means those inherited [genetic] and
acquired physiological qualities that underlie personalities.

4. Family and Social Influences:

i. Attachment, separation and loss
ii. Parental care and control
iii. Parental mental disorder
iv. Parental criminal behaviour
v. Family size and structure
vi. Family patterns of behaviour
vii. Adoption, fostering and institutional care
viii. The effects of schools
ix. Social and transcultural influences
ASSESSNG THE INDIVIDUAL
1. Basic information: name, age, address, school and domestic situation, by whom
referred, the date, factors affecting authority to proceed.
2. Main problems for key people [patient, family]
3. Details of the problems and their development
4. Developmental history from pregnancy to the patient
5. Social and personality development
6. Physical health and mental condition
7. Family history and family disorders and problems
8. Family assessment
9. Individual assessment: mental and physical
10. Psychological assessment performed or indicated
11. Physical investigations performed or indicated
12. Diagnostic statement
 Multiaxial categories
 Diagnostic formulation
13. Note action taken: appointments made, explanations given, letters sent etc.
 Peers:
Lack of
Substance friends, Home:
abuse: antisocial Acting out
regular use, Secretive
large amt ness

School:
Sexual:
Truancy,
Prmiscuity,
underachie
pregnancy,
vement,
sexual abus
disrup
High risk
adolescent
Appearance
Antisocial
Poor
behaviour;
hygiene,
Delinquenc
dressing

Functional:
Sleep and Medical:
eating Chronic
Problems, Mood: illness,
eating Depression, handicap
problem anxiety,
hostility

MALADAPTIVE RESPONSES
Behaviours that impede growth and development may require nursing
intervention. The nurse should consider the nature of the adolescents’ maladaptive
responses and the harm resulting from them. If the difficulty is significant and
ongoing intervention may be needed.

1. Inappropriate Sexual Responses

Sexual behaviors can be the cause of many teenage problems. Sexual
activity is often not as much an outlet for sexual passion as an attempt to
achieve closeness with another person.
Adolescents tend to use their sexuality to sublimate other needs, such
as those of love and security and personal anxiety about sexual adequacy
and peer group pressure may lead the adolescent to have inappropriate
sexual relations.
 The nurse must explore the meaning of adolescents’ sexual behaviour
by asking the following questions.
 Does the adolescent desire sexual gratification or punishment?
 Do the adolescents goals much the situation or is self deception
present?
 Is the adolescent demanding adult privileges while acting
irresponsibly dependent?
 To what extent is the sexual behavior experimental a defense against
depression or a way of expressing anger toward others?
 Is the sexual behaviour a way to avoid anxiety producing fantasies?
 How close is the relationship to a mature one?

2. Teen Pregnancy:
Pregnancy in adolescents is a complicated issue. Some adolescent
girls have low self esteem and fears. To ease these fears, they may become
pregnant.
Pregnancy in adolescent may have other origin. It can occur
accidentally after sexual exploration.
Pregnancy for unmarried adolescent may also be associated with
sexual promiscuity. If it is, the girl may be ostracized.

3. Runaways:
Many of the young people who have left or been forced from
dysfunctional abusive families only to face a life on streets. That can bring more
problems such as poverty, substance abuse, physical and sexual assault,
pregnancy, injury or illness, HIV infection, psychological and emotional problems
trouble with the law and suicide.
Running away might be a cry for help or an attempt to escape from
unbearable living situations, including child abuse and family abuse.
Adolescent runaway often rejected by their parents since birth and
parent may alternate between extreme punitive measures and a laissez faire
attitude toward the adolescent.
They usually runaway from disappointment toward something viewed as
favourable and supportive. Often the adolescent becomes involved in dangerous
activities after running away. Most runaway adolescents want to return home if
they believe their parents really want them.

4. Violence
Violence can also be a maladaptive way of coping with adolescent
anxiety and frustration as evident in a rage response
Many teenagers are violent because of periods of over stimulation or
strong desires for emotional contact.
 Much anxiety of adolescent is related to the fear that they may be
unable to control their destructive aggression.
They require the recognition of their fear and reassurance of external
limits.
These defenses against aggressive outburst should reinforced and supported.

5. Hypochondriasis
Adolescents are preoccupied with their bodies and body sensations. They
are uncomfortable with their bodies because of the rapid changes in size, shape
and functions.
It occurs when the adolescent has intensity of anxiety about personal health.
Hypochondriasis may be a way of avoiding activities that expose other stressful
fears.
Fears such as inadequacy at school, either socially or in school woek may
be a projection of general fears of inadequacy.
This can be tackled by reassurance that these changes are normal.

5. Occult Involvement:
Adolescents risk taking behaviour is also evident in the involvement of
teenagers in the occult. People particularly prone to this involvement tend to be
alienated from their family, be socially isolated and have poor skills for interacting
with others.
These adolescent depend on external rewards to make them feel good.
Satanism, the worship of satan is the dark side of the occult.
Adolescent behaviors that are often associated with involvement in the
occult include the following
 Sleep disturbances, including insomnia and nightmares
 Suicidal ideation with overwhelming feelings of guilt
 Chemical dependency and drug use.
 Voyeurism, nudity and sexual activity that includes thrill seeking
 Feelings of learned helplessness
 Excessive fantasy role play- including dungeos and dragons and various
computer games.
 Ritualistic use of objects such as knives and black clothing
 Strong preference for heavy mental music with hidden messages that
ridicule society.

6. Suicide:
The leading cause of death [behind accidents and homicides] for
teenagers. The warning signs and risk factors associated with teen suicide include
 Depression
 Previous suicide attempts
 Recent losses
  Frequent thought about death
 Use of drugs or alcohol
A teenager planning to commit suicide may also give verbal hints such as
‘nothing matters’ or ‘I won’t be a problem for you anymore’.
They may also give away favorite possessions or become suddenly cheerful
after a long period of sadness.

MENTAL ILLNESS AFFECTING TEENAGERS

Being a teenager is not easy. Adolescents feel all kinds of pressure – to do
well in school, to be popular with peers, to gain the approval of parents, to make
the team, to be cool. In addition many teenagers have other special problems.
Adolescents may be hurt or confused by their parental divorce, or they may
have to learn how to live with a parents’ alcoholism or mental illness.

Emotional and Psychotic disorders

 Anxiety
 Physical Abuse
 Sexual Abuse
 Post Traumatic Stress Disorder
 Attention Deficit / Hyperactivity disorder
 Bipolar Disorder [Manic - Depression]
 Depression
 Learning Disorders
 Obsessive Compulsive Disorder
 Psychosis
 Schizophrenia
 Tourettes’ Syndrome
Substance Use Disorders
Juvenile Delinquency
Eating Disorders

ANXIETY DISORDERS
Anxiety and fear are an inherent part of the human condition and in times
of danger are often adaptive.
Anxiety disorders are characterized by irrational fear or worry causing
significant distress/impairment in functioning and their relative prevalence reflects
this shifts in content.

Epidemiology:
Anxiety disorders are among the most common psychiatric disorders in
youth
Etiology:
 Genetic vulnerability
 Temperament that exhibits behavioural inhibition
 Insecure attachment
 Stressful or traumatic life events
 High social adversity
 Over protective/critical/punitive parenting

Organic causes of Anxiety:

 Medical condition
 Hyperthyroidism
 Cardiomyopathy
 Arrhythmias
 Respiratory and neurological diseases
 Substances
 cocaine
 alcohol
 amphetamines
 cannabis
 SSRIs
 LSD
 Ecstasy

Presentation of Anxiety in Children and Adolescents:

Particularly in children, it is difficulty to obtain a history of cognitive,
emotional and physical symptoms. Often somatic symptoms are the only feature
that the child will be able to readily describe.
Behavioural presentations include over activity, inattention, sleep
disturbance, separation difficulty, regression, school refusal, social withdrawal,
aggression, ritualistic behaviours and somatisation.

Types:
The three types of anxiety disorders are described in DSM IV. They are
i. Avoidant disorder of childhood or adolescent:
In this disorder, there is persistent and excessive shrinking from
contact with unfamiliar people that is of sufficient severity to interfere with social
functioning in peer relationships.
The duration is of atleast of 6 months and is coupled with a clear desire for
social involvement with familiar people, such as family members and other
familiar figures are warm and satisfying.
ii. Overanxious disorder
This essentially consists of excessive and unrealistic anxiety or worry for a
period of 6 months or longer. Adolescents with the disorder tend to be extremely
self conscious, worry about future events, or about meeting expectations.

iii. Separation Anxiety Disorder

It is clinically syndrome with predominant feature or excessive
anxiety on separation from the major attachment figures home or other familiar
surroundings.
Excessive anxiety concerning separation from home or from those to
whom the child is attached. The youngsters may develop excessive worrying to
the point of being reluctant or refusing to go to school being alone or sleeping
alone.
Repeated nightmares and complaints of physical symptoms [such as
headaches, stomachaches, nausea or vomiting] may occur.

Panic disorder with or without agoraphobia, agoraphobia without history of panic

disorder, social phobia, simple phobia, obsessive compulsive disorder, post
traumatic stress disorder and generalized anxiety disorder can occur as described
in DSM IV

Panic disorder:
The presence of recurrent unexpected panic attacks and persistent worries
about having attacks.
Panic attack refers to the sudden onset of intense apprehension, fearfulness
or terror, often associated with feelings of impending doom.
There may also be shortness of breath palpitations, chest pain, discomfort,
choking or smothering sensations and fear of going crazy or losing control.

Phobia:
Persistent irrational fear of a specific object, activity or situation [such as
flying heights and animals receiving an injection, seeing blood]. These intense
fears cause the child or adolescent to avoid the object, activity or situation.

Generalized Anxiety Disorder:

Excessive anxiety and worry about events or activities such as school. The
adolescent has difficulty in concentrating, irritability muscle tension and sleep
difficulties.

General Principles of Management:

 Use ABC [antecedents, behaviour, consequences] approach to help child
and family understand what happens when the child feels anxious.
 Show how others reactions are influencing anxiety
  Stress reduction including relaxation
 Psycho education re anxiety, e.g connection between physical, cognitive
and emotional components.
 Age appropriate CBT approaches
 Anxiolytic drugs.

PHYSICAL ABUSE;
Physical abuse occurs when a person responsible for a child’s or
adolescent’s welfare causes physical injury or harm to the child.
Examples of abusive treatment of children include hitting, with an object,
kicking, burning, scalding, punching and threatening or attacking with weapons.
Children and adolescents who have been abused may suffer from
depression, anxiety, low self esteem and inability to build trusting relationships,
alcohol and drug abuse learning impairments and conduct disorders.

SEXUAL ABUSE
Teenage sexual abuse occurs when an adolescent is used for gratification of
an adult’s sexual needs or desires. Severity of sexual abuse can range from
fondling to forcible rape.
The most common forms of sexual abuse encountered by girls include
exhibitionism, fondling, genital contact, masturbation and vaginal, oral or anal
intercourse.
Boys may be sexually abused through fondling, mutual masturbation,
fellatio and anal intercourse.
Adolescents who have been sexually abused may also suffer from
depression, anxiety, PTSD, feelings of worthlessness and helplessness, learning
impairments and destructive behaviours.

POST-TRAUMATIC STRESS DISORDER

A syndrome characterized by a triad of symptoms intrusive re-experiencing
of a traumatic event; avoidance and hyper arousal.

Traumatic Event:
Requires exposure to a situation or event which is catastrophic or highly
threatening.

Clinical Presentation in Young Children

Identification of PTSD in children presents particular problems but can
improved by asking the child directly about their experiences
 Compulsive repetitive play representing part of the trauma and failing to
relieve anxiety
 Recurrent recollections of the event.
  Nightmares, night terrors and difficulty going to sleep.
 Constriction of play
 Social withdrawal
 Restricted affect
 Loss of acquired developmental skills especially language regression and
toilet training.
 Decreased concentration and attention
 New aggression
 New separation anxiety

Treatment
a. Offer trauma focused CBT to older children with severe post traumatic
symptoms or with severe PTSD in first month after the event.

Interventions more than 3 months

 Offer children and young people a course of trauma focused CBT adapted
as needed to suit their age, circumstances and level of development.
 For chronic PTSD in children and young people resulting from a single
event, consider offering 8 – 12 sessions of trauma focused psychological
treatment. When the trauma is discussed, longer treatment sessions [90
minutes] are usually necessary
 Psychological treatment should be regular and continuous [usually atleast
once a weed] delivered by the same person.
 Do not routinely prescribe drug treatments for children and young people
with PTSD.
 Involve families in the treatment of children and young people where
appropriate, but remember that treatment consisting of parental
involvement alone is unlikely to be of benefit for PTSD symptoms.
 Inform parents [and where appropriate, children and young people] that is
no good evidence for the efficacy of their forms of treatment such as play
therapy, art therapy or family therapy.

Nursing interventions:
 Establish trusting relationship
 Encourage the patient to express her grief, complete the mourning process
 Use crisis intervention techniques as needed
 Assist in regaining control over angry outbursts by identifying how anger
escalates
 Encourage move from physical to verbal expressions of anger
 Teach the patient about perceived medications and adverse effects and
advise her not to discontinue medication without physician consultation

ATTENTION DEFICIT HYPERACTIVITY DISORDER

 ADHD is characterized by three core symptoms of inattention,
hyperactivity and impulsiveness.

DSM IV recognizes 3 subtypes;

 A combined subtype where all 3 features are present
 An inattentive subtype
 A hyperactive impulsive subtype

Etiology:
o 80% of cases are generally inherited
o Risk of ADHD in sibilings in 2 – 3 times increased
o Rates are increased in low birth weight babies
o Babies born to mothers who used drugs, alcohol or tobacco during
pregnancy
o Following head injury
o Genetic and metabolic disorders

Clinical features
A. Inattention: careless with detail, fails to sustain attention, appears not
to listen, fails to finish tasks, poor self- organization, loses things,
forgetful, easily distracted, avoids tasks requiring sustained
attention.
B. Hyperactivity: Most evident in structured situations, fidgets with
hands or feet, leaves seat in class, runs/climbs about cannot play
quietly, ‘always on the go’
C. Impulsiveness: Talks excessively, blurts out answers, cannot await
turn, interrupts others, intrudes on others.

Problems associated with ADHD

Short term:
Sleep problems, low self esteem, family and peer relationship problems,
reduced academic achievement, increased risk of accidents

Longer term:
Development of comorbid problems, reduced academic and employment
success, increased criminal activity and antisocial personality disorder.
A poorer prognosis is associated with social deprivation, high expressed emotion,
parental mental illness, predominantly hyper active impulsive symptoms, CD
learning difficulty, and language disorder.

Assessment:
 Interview family and child
  Observe child preferably in more than one situation
 Collateral information from school
 Physical examination including neurological examination

Management:
 Psychoeducation
 Medication
 Methyl Phenidate- A central nervous system stimulant
licensed for treatment of ADHD in children over 6 years.
 Atomexetine- A non stimulant NA reuptake inhibitor licensed
for the treatment of ADHD. Taken once daily, providing 24
hour cover, may up to 6 weeks to have a full effect.
 Dexamfetaimine- A central nervous system stimulant licensed
for the treatment of ADHD in children whose symptoms are
refractory to other drug.
 Behavioural interventions- e.g. encouraging realistic expectations,
positive reinforcement of desired behaviours, [small immediate
rewards], consistent contingency management across home and
school, breakdown tasks, reduce distractions
 School intervention
 Voluntary organizations e.g. ADDISS- Attention Deficit Disorder
Information and Support Services

BIPOLAR DISORDER IN ADOLESCENTS:

The prevalence in adolescents is approximately 1%. Familial factors are
important with a 4 times greater risk of mood disorder in offspring of parents with
BPD.

Presentation:
 It depends on the phase of the disorder
 A hypomanic/manic child may present as overactive, dull or self belief,
grandiose and challenging of authority. They are often irritable and can
become aggressive or violent
 Poor concentration affects school performances
 Over spending, sexual disinhibition and risk taking behaviour may feature
 Psychotic symptoms may be present
 Mixed affective stales are also significant

Diagnosis:
NICE recommends
The adult criteria are used but
i. Mania must be present
ii. Euphoria must be present most days most of the time for 7 days
iii. Irritability is not a core diagnostic criterion
Do not diagnose solely on the basis of a major depressive episode in a child with a
family history of bipolar disorder, but follow up such children carefully
For older or developmentally advanced adolescents use adult criteria
Do not diagnose bipolar II in younger adolescents/children

Assessment:
 Individual and family
 Thorough developmental history, family history, mood disorder, pattern of
mood changes
 Impact of disorder on life-family, friends, school etc
 Collateral information from school
 Physical examination and appropriate investigation
 Level of risk- suicide, exploitation, violence
 Capacity/consent/legislation

Management:
Involve parents or carers in developing care plans so that they can give informed
consent, support treatment goals and help ensure adherence.

Consider inpatient or day patient admission to age appropriate services or more

intensive community treatment for patients at risk of suicide or other serious harm.

Acute mania: Consider antipsychotic, valproate [not girls] or lithium. Before

starting and therafter, check height, weight and prolactin levels. Start at lower
doses than for adults. If there is inadequate response to antipsychotic can add
valproate or lithium.

Depression: If mild, monitor and support. If depression is moderate to severe,

offer psychological therapy first. If no response at 4 weeks consider fluoxetine
starting at 10 mg daily. If this fails, consider sertraline or citralopram. Consider
augmentation with antipsychotic if psychotic symptoms present.

Longterm: Consider atypical antipsychotic that is associated with less weight gain
and does not increase prolactin levels. As second line, consider lithium for female
patients and valproate or lithium for male patients.

Psychological interventions include psychoeducation and support to individual and

family, more formal therapy. E.g. motivational interviewing, CBT, family therapy.
Education and vocational training including school liaison, additional support etc.

DEPRESSION IN ADOLESCENTS

Risk factors:
 Female
 Post pubertal
 Parental history of depression
 Personally undesirable life events resulting in permanent change of
interpersonal relationships in friends or family.
 Past history of depressive symptoms
 High trait levels of neuroticism or emotionality
 Ruminative style of thinking

Etiology:
 Vulnerability [genes, endocrine, early family factors]
 Interacts with social stressors [poverty, family discord] to provoke
depression at time of life stress.

Clinical Features
 Mood changes: Unpleasant mood- may not be described as sadness
but as grumpy, irritable or down also anhedonia.
 Thought changes, reduced self esteem, confidence, concentration
and self efficacy. Hopelessness, guilt indecisive suicidal thoughts
must be taken seriously, rarely psychotic symptoms.
 Physical / behavioural changes: reduced energy, motivation, self
care, fatigue, apathy, withdrawal appetite and sleep change, aches
and pains, self harming and suicidal behaviour. Results in
impairment of functioning – school, social, family etc.

Assessment:
 Family and individual interviews. Assess whether depression is
present, contributing factors to development and maintenance,
presence of comorbidity, suicide risk.
 Collateral from teachers, GP, social services etc
 Consider use of rating scales. E.g. moods and feelings questionnaire
 Physical examination and laboratory investigations.

Treatment:
Mild depression
 Up to 4 weeks of ‘watchful waiting’- stay in contact with family
  If symptoms continue, offer 2-3 months of individual non directive
supportive therapy, group Cognitive Behavioural therapy [CBT] or guided
self help [GSH]

Moderate severe depression

 Offer individual CBT, interpersonal therapy or family therapy for atleast 3
months as a first line treatment
 If unresponsive after 4-6 sessions multidisciplinary review and consider
alternative/additional psychotherapy including child psychotherapy

Pharmacotherapy
 Fluoxetine is the only antidepressant with a favourable risk benefit ratio and
should be prescribed first
 In psychotic depression consider augmentation with atypical antipsychotic

ECT
Only consider ECT for young people [12 – 18 years] with very severe
depression and either life threatening symptoms or intractable and severe
symptoms that have not responded to other treatments.

CONDUCT DISORDERS:
The conduct disorders are characterized by a repetitive and persistent
pattern of antisocial, aggressive or defiant behaviours which violate age
appropriate societal norms. Conduct disorders can be divided in to conduct
disorder and oppositional defiant disorder.

Clinical Features
 Aggression/cruelty to people and/or animals
 Destruction of property, deceitfulness, theft
 Fire setting, truancy
 Running away from home
 Severe provocative
 Disobedient behaviour
These behaviours result in significant impact on family and peer relationships and
schoolings

Etiology
 Social disadvantage
 Poverty
 Low socio economic class
 Overcrowding
 Homelessness
 Social isolation
  Truancy
 unemployment
 Parenting
 Parental criminality
 Parental psychiatric disorder
 Substance misuse
 Inconsistent and critical parenting style
 Parental conflict
 Teenage pregnancy
 Single parenthood
 Child
 Low IQ
 Neuro developmental problems
 Brain damage
 Epilepsy
 Difficult or under controlled temperament
 Attachment problems
 Poor interpersonal problems

Assessment
o See family and child
o Obtain a full history with collateral from school, social worker and legal
system
o Identify causal, risk and protective factors.

Management of Conduct Disorder:

 Parent management training
 Functional family therapy
 Multi systemic therapy – family based including school and
community
 Child interventions – social skills, problem solving, anger
management, confidence building.

Oppositional Defiant Disorder

An enduring pattern of negative, hostile and defiant behaviour, without
serious violations of societal norms or the right of others.
Behaviour may occur in one situation only and tends to be most evident in
interactions with familiar adults or peers.

Prevention strategies and Policy Implications

 Preschool child development programs
 School programmes
  Community programmes
 Social and economic restructuring

Preschool Child Development Programmes

Identifying parents and families at risk and instituting home visits and
support

School Programmes
Identify children at risk and institute classroom enrichment, home visits and
parent teacher training.

Community Programmes
Identify children and adolescent through their involvement with social
agencies and institute interventions such as enhanced recreation programmes,
parent training and adult monitoring of youth.

Social and Economic Restructuring

To reduce poverty and to improve family and community stability.

OBSESSIVE COMPULSIVE DISORDER

OCD is characterized by recurrent obsessions and / or compulsions that
cause impairment in terms of time, distress, or interference in functioning.

Clinical features
Obsessions: Intrusive, repetitive and distressing thoughts/images, common
themes, contamination, harm coming to others, sexual, aggressive, religious

Compulsions: Repetitive, stereotypes unnecessary behavior common rituals-

washing, checking, repeating, ordering, reassurance seeding rituals may involve
parents.

Rituals are part of normal development, especially in 3 – 7 age group. More likely
to be OCD, if the rituals or thoughts distress the child, they take up a lot of time
and if they interfere with the child’s everyday life.
Multiple obsessions and compulsions are common. Poor insight commoner
in child cases.

Assessment;
Family and individual assessment is done where possible. Young person
may be reluctant to discuss aspects of obsessions/compulsions.
Children’s Yale-Brown Obsessive Compulsive Scale may be useful both as
rating scale and to obtain clear picture of O/C
Treatment
 Consider guided self help for mild impairment in first instance.
 If more severely affected, offer developmentally appropriate CBT and ERP
[exposure response prevention] in group or individual format
 Involve family where possible in planning and process of treatment, and
school etc as necessary.
 Following multidisciplinary review, consider SSRI, in addition to CBT,
and ERP if no response. Monitor closely and advise of delay in onset of
action of up to 12 weeks.
 Augmentation with antipsychotic may be appropriate

PSYCHOSIS
Psychotic illness are rare in young children and a particular challenge in
both diagnosis and management. Imagined friends, transient, hallucinations under
stress and loose associations may all occur within the normal spectrum of
development.

Clinical features
 More often insidious than acute onset
 Associated with poor premorbid function with developmental delays
 Below average IQ
 Negative symptoms often precede positive and are prominent
 Poor premorbid functioning, negative symptoms
 ‘Disorganized’ clinical presentation

Assessment
 Detailed developmental history
 History from multiple informants including family and school
 Negative symptoms
 Physical examination and medical investigation
 Consider use of rating scale e.g. k-SADs

Management

Medication

A typical antipsychotic favored over typical clozapine useful in treatment

resistance.
Benzodiazepines or antipsychotic may be useful in managing acute behavioural
disturbance not responsive to non pharmacological measures.
 Supportive psycho educational and specific psychotherapeutic individual
work: E.g. CBT, social skills training, Family support, education and therapeutic
work as appropriate.

Ongoing risk assessment and management

Educational/vocational input: E.g. reintegration package to school

TOURETTE’S SYNDROME [Gilles de la]

A severe neurological disorder characterized by multiple facial and other

body tics, usually beginning in childhood or adolescence and often accompanied
by grunts and compulsive utterances, as of interjections and obscenities. It is also
called Gilles de la Tourette syndrome.
A developmental neuropsychiatric disorder characterized by multiple motor
and one or more vocal tics, present for atleast a year causing distress and impaired
function.
Motor tics often begin between the ages of 3 and 8, a few years before the
onset of vocal tics.
Typically tics vary over time with more complex tics emerging after some
years. Severity of tics, waxes and wanes, with exacerbations often related to
fatigue, emotional stress and excitement.
Tic severity usually peaks in early adolescence with most showing marked
reduction in severity by the end of adolescence.

Etiology
 Interaction of genetic and environmental factors
 Psychosocial stress
 Gestational and perinatal insults
 Heat, fatigue, post infectious and auto immune mechanisms

Assessment
 Assess degree of interference with child’s family
 Careful perinatal, developmental, family and medical history
 Screen for associated difficulties

Management
Psychoeducation for child and family and lifestyle adjustment
 What tics are
 Realistic expectations
 Stress reduction
  Caffeine reduction

Behavioural intervention
 Habit reversal training
 Awareness training
 Self monitoring of tics
 Relaxation training
 Competing response training
 Motivational techniques

Medications
1. Antipsychotics
2. α adrenergics

EATING DISORDERS
Eating disorders in children and adolescents include anorexia nervosa,
bulimia nervosa and their variants characterized by disturbed or inadequate eating
patterns associated with abnormal preoccupation with weight and shape.
Children and adolescents may also present with other types of clinical
eating disturbance including
1. Food Avoidance Emotional Disorder: Food avoidance and weight loss
unaccounted for by other psychiatric disorder and in the absence of
abnormal cognitions about weight/shape.
They know that they are underweight, would like to be heavier and may not
know why they find this difficult to achieve. Often they have other
medically unexplained symptoms can result in serious weight loss.

2. Selective eating characterized by long standing restriction of types of food

eaten. Rarely harmful but can result in social difficulties.

3. Pervasive refusal: A rare disorder defined as a profound and pervasive

refusal to eat, walk or engage in self care.
Eating disturbance may also be a feature of other disorders. E.g. depression,
OCD, or part of a physical disorder, where there is a psychological
component to presentation.

Anorexia Nervosa [AN]

Self induced weight loss associated with abnormal beliefs and
preoccupation regarding weight/shape.

Assessment
 Family and individual – often secrecy around behaviour
  Eating – intake, weight control measures, attitude to weight/ shape
 Assessment of factors contributing to and maintaining disorder. E.g. acute
life stress, obesity, parental weight concerns, peers, psychological factors
such as perfectionism and personal ineffectiveness
 Full physical assessment and investigations as appropriate. e.g. bloods,
ECG, bone density, ovarian ultrasound scan.

Management
Involves physical, psychological, educational and social aspects and will
usually require a multidisciplinary approach
 Treatment should normally involve whole family and the effects of
anorexia nervosa on other famiy members should be recognized
 Restoration of healthy weight allowing further growth and development and
treatment of physical coomplicaltions.
 Provide education on nutrition and healthy eating carers should be included
in any dietary education or meal planning
 Patients should be offered family interventions that directly address the
eating disorder and also individual sessions to provide support, improve
motivation and address core maladaptive thoughts, attitudes and feelings.
 Liaison with school. E.g. graded return if has been absent.
 Relapse prevention

Bulimia nervosa
 Disorder characterized by recurrent binges and purged sense of lack of
control and morbid preoccupation with weight and shape.
 Rarely occurs prepubertally, much commoner in girls often comorbid with
depression.
 Usually of normal weight.

Management
 Work with family to establish clear structures and boundaries strike a
balance between individual work.
 Adolescents with bulimia nervosa my be treated with CBT, adapted as
needed to suit their age, circumstances and level of development and
including the family as appropriate.
 Address physical health concerns e.g. due to frequent vomiting
 No clear evidence to support drug treatments in this age group, but
fluoxetine could be useful treatment in older adolescents.

SCHIZOPHRENIA
Schizophrenia is a severe, chronic, and disabling brain disease that affects
approximately 1 percent of the world's population,. Contrary to the popular
misconception, people with schizophrenia do not have a "split" personality.
Rather, they experience severe mental disturbances in which normal thoughts,
speech, and behavior are disrupted.

Causes:
Schizophrenia researchers generally believe the illness is caused by a combination
of genetic and environmental factors, and that, in people with a genetic
predisposition, the likelihood of schizophrenic episodes can be increased or
triggered by the use of street drugs, including marijuana.

Symptoms of Childhood-Onset Schizophrenia

"The symptoms and behavior of children and adolescents with schizophrenia may
differ from that of adults with this illness. The following symptoms and behaviors
can occur in children or adolescents with schizophrenia:

 seeing things and hearing voices which are not real (hallucinations)
 odd and eccentric behavior, and/or speech,
 unusual or bizarre thoughts and ideas
 confusing television and dreams [with] reality
 confused thinking
 extreme moodiness
 ideas that people are "out to get them," or talking about them, (paranoia)
 severe anxiety and fearfulness,
 difficulty relating to peers, and keeping friends
 withdrawn and increased isolation
 decline in personal hygiene

The behavior of children with schizophrenia may change slowly over time. For
example, children who used to enjoy relationships with others may start to become
more shy or withdrawn and seem to be in their own world. Sometimes youngsters
will begin talking about strange fears and ideas. They may start to cling to parents
or say things which do not make sense. These early symptoms and problems may
first be noticed by the child's school teachers."
Treatment for Schizophrenia
"Treatment is aimed at reducing symptoms and preventing psychotic relapses and
is believed to be most effective when begun early in the course of the illness.
Schizophrenia is usually treated with antipsychotic medication. Once acute
symptoms have lessened, a combination of medicine and
psychosocial/rehabilitation interventions can be beneficial. Because schizophrenia
is a chronic condition, disease management is a life-long process."
LEARNING DISORDERS

Learning disorders are estimated to occur in five to fifteen percent of

children and adolescents with a male predominance between 3:1 to 5:1. That is,
males are more likely to have behavioral problems when they have learning
disorders and acting out behaviors may bring them to the attention of educational
authorities.

There are eight areas of neurodevelopmental function that relate to learning

disorders.

Attention impacts on the arousal of the central nervous system, mental energy
and the mobilization and distribution of mental efforts. Teens with attention
difficulties yawn, daydream and fidget. They have difficulties sustaining
concentration and as a result suffer from performance inconsistency.

Memory is increasingly important as children and teens progress through school.

Proficiency in both short term and long term memory is needed to retrieve skills,
facts and concepts.

Teaching in middle and high school is primarily through language. Teens who
have problems with language skills may have very significant learning disorders.

Visual-spatial ordering may present as difficulties for an adolescent in

organizing the position and shape of objects that he or she is viewing. This may
cause problems with word recognition, and spelling may emerge as a weakness

A teen with temporal-sequential ordering problems may have difficulties in

preserving the proper order to motor procedures, a narrative or mathematical
algorithms

Neuromotor dysfunction is a neurodevelopmental function that may be classified

into three separate pieces.

 Fine motor dexterity may affect a teen’s ability to do well in artistic and
crafts activities.
 Adolescents with gross motor delays may also have visual-spatial
information problems. For example, teens with this problem may not be
able to catch a thrown ball since they have difficulty forming a judgment as
to the ball’s trajectory in space.
 The third part to neuromotor dysfunction may include graphomotor
fluency problems. Teens with this problem may have illegible writing and
poor spelling. These adolescents may prefer printing to cursive writing.
Critical thinking skills, problem solving, brainstorming, creativity and other
executive functioning comes under the broader function termed higher-order
cognition. Teen with problems in these areas may have difficulty grasping new
concepts and underachieve.

The final neurodevelopmental function is social cognition. Teens with

dysfunction in social cognition may sustain verbal abuse, bullying and rejection.
They may seek a world of fantasy or relationships with animals or younger
children.

Causes:No one's exactly sure what causes learning disabilities. But researchers do
have some theories as to why they develop. They include:

Genetic influences. Experts have noticed that learning disabilities tend to

run in families and they think that heredity may play a role. Family history
of reading and spelling disabilities in teens with these particular learning
disorders.

Brain development. Some experts think that learning disabilities can be

traced to brain development, both before and after birth. For this reason,
problems such as low birth weight, lack of oxygen, or premature birth may
have something to do with learning disabilities. Young children who
receive head injuries may also be at risk of developing learning disabilities.

Environmental impacts. Infants and young children are susceptible to

environmental toxins (poisons). For example, you may have heard how lead
(which may be found in some old homes in the form of lead paint or lead
water pipes) is sometimes thought to contribute to learning disabilities.
Poor nutrition early in life may also lead to learning disabilities later in life.

Medical conditions: low-level lead intoxication, meningitis, AIDS, low

birth weight and recurrent ear infections may have an association with
learning disorders

Signs and symptoms:

Warning signs of learning disabilities in secondary school students occur as a
pattern of behaviors to a significant degree over time. They include the following:

Language/Mathematics/Social Studies

 Avoidance of reading and writing

  Tendency to misread information
 Difficulty summarizing
 Poor reading comprehension
 Difficulty understanding subject area textbooks
 Trouble with open-ended questions
 Continued poor spelling
 Poor grasp of abstract concepts
 Poor skills in writing essays
 Difficulty in learning foreign language
 Poor ability to apply math skills

Attention/Organization

 Difficulty staying organized

 Trouble with test formats, such as multiple choice
 Slow work pace in class and in testing situations
 Poor note-taking skills
 Poor ability to proofread or double-check work

Social Behavior

 Difficulty accepting criticism

 Difficulty seeking or giving feedback
 Problems negotiating or advocating for oneself
 Difficulty resisting peer pressure
 Difficulty understanding another person's perspective

Adolescents with learning disorders may develop self-esteem issues, chronic

fatigue, sadness and even suicidal ideation. Some lose motivation and ambition.

Diagnosis:

Any teen who is not functioning well in school deserves an evaluation. Ideally a
multidisciplinary team that consists of a pediatrician or adolescent medicine
specialist, a psychologist or psychiatrist and a psycho educational specialist,
performs the evaluation.

An evaluation consists of a complete medical history and physical examination as

well as some neurological and sensory testing.

Historical information on the teen’s academic performance, behavioral

adjustments and development issues should be obtained.
 The mental health specialist may identify family issues that could complicate the
learning disorder. And the psycho educational specialist may administer relevant
tests to obtain data in regard to reading, spelling, writing and mathematical
abilities.

The team works together to present a comprehensive report on the teen’s learning
disabilities.

Treatment:

Treatment for learning disabilities is based according to the teen’s specific issues.

Teens should be given an explanation of their learning disorder. Accommodation

can be utilized to bypass a specific problem. For example, if an adolescent has
difficulty with legible writing, then a word processor can be utilized. If there is
difficulty with oral presentations, then written works could be substituted. These
strategies do not cure the learning disorder, but they do help to minimize the
academic and social effects.

Remediation such as tutorial programs help to advance a teen with deficient

academic skills. Specialists in reading or math may be utilized to assist the teen.
Remediation usually occurs in a school’s resource room or learning center.

Other treatments could include modification in the curriculum, strengthening of a

teen’s strengths and individual or family counseling services. Occasionally
medication may be prescribed. This usually would be indicated for teens with
Attention Deficit Disorder. Teens with learning disabilities and depression or
anxiety may by prescribed medication also.

Prevention: Since most learning disabilities have no known etiology, there is no

prevention. However, early recognition and appropriate special education
intervention may help to prevent further problems from the learning disabilities.

SUBSTANCE ABUSE

Nationwide, substance use and abuse are significant problems for adolescents.
They carry serious consequences, causing 50% of the deaths in youth age 15 to 24
years.
Use of alcohol and drugs also contribute to assaults and rapes perpetrated
by adolescents. Alcohol is the most commonly used and abused substance by
youth.
Higher levels of adolescent alcohol use are associated with three most common
forms of mortality among adolescents
 Accidental deaths
 Homicides
 Suicides
The onset of drug use before age20 years predicts more sustained use over time.

Risk factors for adolescent alcohol use

1. Societal community
 Laws and normative behavior
 Availability
 Extreme economic deprivation
 Neighborhood disorganization
2. school
 low commitment to school
 academic failure
 early persistent behaviour problems
3. family
 family members alcohol users
 family management practices
 family conflict
 low bonding to family
4. peers
 peer rejection in elementary grades
 associating with alcohol using peers
 friends with attitudes favourable to alcohol use
5. individual
 physiological
 alienation and rebelliousness
 early onset deviant behaviour
 problem solving coping skills

Stages of adolescent substance abuse

Chemical dependency is the result of a gradual process. It is important for the
nurse to remember that not all adolescents progress through these stages, but the
younger the user, the greater the risk for chemical dependency.
Specifically, first use of alcohol at age of 11 to 14 years greatly increases
the risk of development of an alcohol.

Stage I; Curiosity
Drugs None
Sources Available but not used
Feelings Curiosity
Behavior Risk taking, desire for acceptance
Treatment Optimal time, anticipatory guidance to develop good
coping skills and strong self esteem, clear family
guidelines on drug and alcohol use, drug education.

Stage II Experimentation
Drugs Tobacco, alcohol, marijuana
Sources House supply, friends, siblings
Frequency Weekend, use of recreational purposes
Feelings Excitement, pleasure few consequences, learning how
easy it is to feel good
Behavior Lying, little change
Treatment Drug education, attention to societal messages,
reduction of supply, strict, loving rules at home,
establishment of drug free alternative activities
Stage III Regular use

Drugs Tobacco, alcohol, marijuana, hashish or hash oil,

tranquilizers, sedatives, amphetamines
Sources Buying
Frequency Progresses to midweek use, purpose is to get high
Feelings Excitement followed by guilt
Behavior Mood swings, faltering, school performance, truancy,
changing peer groups, changing style of dress.
Treatment Drug – free self help groups, family involvement,
psychiatric counseling unhelpful unless, family therapy
and after care provided.

Stage IV Psychological or physical dependency

Drugs Tobacco, alcohol, marijuana, hashish or hash oil,

tranquilizers, sedatives, amphetamines, stimulants,
hallucinogen
Sources Selling to support the habit, possibly stealing or
prostitution in exchange for drug
Frequency Daily
Feelings Euphoric highs followed by depression, shame, guilt
and perhaps suicidal thoughts.
Behavior Pathological lying, school failure, family fights,
involvement with the law over curfew, truancy,
vandalism, shoplifting, driving under the influence,
 breaking and entering, violence.
Treatment Inpatient or foster care programs that require family
involvement and provide after care

Stage V: Using drugs to feel ‘normal’

Drugs Tobacco, alcohol, marijuana, hashish or hash oil,

tranquilizers, sedatives, amphetamines, stimulants,
hallucinogen, available drug including opiates.
Sources Any way possible
Frequency All day
Feelings Euphoria rare and harder to achieve chronic
depression.
Behavior Drifting with repeated failures and psychological
symptoms of paranoia and aggression, frequent over
dosing, blackouts, amnesia, chronic cough, fatigue.
Treatment Inpatient or foster care programs that require family
involvement and provide after care

JUVENILE DELINQUENCY
According to Dr. Sethna, Juvenile Delinquency involves wrong
doing by a child or a young person who is under an age specified by the law of the
place concerned.
From the legal point of view, a juvenile delinquent is a person who is below
16 years of age [18 years, in case of a girl] who indulges in antisocial activity.

Causes:
 defects of the family, like broken families, uncaring attitude of parents, bad
conduct of parent etc
 defects of the school, like harsh punishment by teachers, weakness in some
subjects, a level of education that is above the child’s capacity
 children living in crime dominated areas
 absent or defective recreation
 war and post war conditions

Psychological causes:
Personality characteristics [emotional instability immaturity], emotional
insecurity and mental illness.

Economic causes:
 Poverty leading to stealing, prostitution and other antisocial activities to
satisfy unfulfilled desires.

Reformatory measures.
 Probation, where the juvenile delinquent is kept under the supervision of a
probation officer, whose job is to help him get established in normal life.
 Institutions like reformatory schools, remand homes, certified schools,
auxiliary homes. These institutions provide for all round progress of the
delinquent
 Psychological therapies like play therapy, finger painting, and
psychodrama.

THERAPEUTIC APPROACH TO ADOLESCENT DISTURBANCE

Although there may be little scope or necessity for active psychiatric
treatment, systematic management of interpersonal, social, education, legal and
ethical problems may be necessary and can be challenging and time consuming.
These aspects of management call for full multidisciplinary team work,
consultation with other professionals and carefully integrated planning

Hospitalization and Residential care

Great care needs to be exercised in using residential resources in view of
the implications for adolescents of separation from home and the limited nature of
residential provisions

Non Psychiatric Residential Care of Adolescents

Disturbed adolescents may be placed in a miscellany of settings in addition
to facilities administered by the National Health Services, including schools and
units for maladjusted children, Independent boarding schools, and children’s
homes run by social service and voluntary agencies, observation and assessment
centers, community homes with education, remand homes, detention centers and
portals.

Psychiatric Inpatient Hospital Treatment

Steinberg et al have distinguished six needs related to requests for
admission, comprising the need for further work to be done with adults already
involved for detailed educational reappraisal for proper care and control for
physical containment for an emergency safe place, for psychiatric assessment and
treatment.

THERAPEUTIC WORK WITH ADOELSCENTS

Health education
 Basic health information can be given in such areas as smoking, drugs, sex
and contraception, suicide prevention and crime prevention.
Adolescents want information about what activities are healthy and
unhealthy, including facts about exercise, nutrition, dealing with anger, sexuality,
conflict resolution, where they can access help.
Among other techniques they use the process of normalization. i.e. by
educating them on normal adolescent behaviour and by interpreting the underlying
conflicts, the nurse prepares parents, teachers and other community members to
support adolescents and encourage healthy independent functioning.

Social skills training:

It is one psychoeducational approach that has been useful with youth who
are low self esteem, aggressive behaviour or a high risk for substance abuse.
Social skills training involves instruction, feedback, support and practice
with learning behaviours that help children to interact more effectively with peers
and adults

Bibliotherapy:
It involves the use of books and other reading materials to help individuals
cope with various life stressors. It is particularly potent form of intervention
because it empowers families to learn and develop coping mechanisms on their
own.
A wide variety of books are available to help children understand issues
such as death, divorce, chronic illness, step families, adoption and birth of a
sibling.
In addition many mental health organizations and public health agencies
have pamphlets designed to educate parents about various physical and
psychological problems.
In addition to providing concrete information and advice these reading
materials help to reduce anxiety by pointing out common reactions to the various
stressors so that the families do not feel alone.

Family therapy
The nurse needs to assess the level of family functioning and determine
how to best interact with and help the family of the adolescent.
Family therapy is particularly useful when disturbed family interaction is
interfering with the adolescent’s development.
Sometimes a series of family sessions may be enough and the adolescent may
benefit from either individual or group approaches to support the effort to separate
emotionally from the family

Group therapy
 Group therapy addresses adolescent’s need for peer support. The conflict
between dependence and independence with adults becomes somewhat diluted by
the presence of other adolescents.
It is valuable in teaching skills in relating and dealing with others. Group
therapy helps fulfill the adolescents’ need for a positive, meaningful peer group for
ego identity formation.

Individual therapy
A pact or contract between the nurse and adolescent is established and a
therapeutic relationship is initiated. This contract is a therapeutic alliance in which
a nurse aligns herself with the healthy, reality oriented pact of the adolescents’ ego
and moves toward an honest and critical understanding of the adolescents’
thoughts and behaviors.

Pharmacotherapy
For adolescents, it is particular challenge to determine which of the
changing and often tumultuous behaviors are target symptoms for
psychopharmacological interventions.

 The use of SSRI is generally preferred over tricyclic antidepressants in the

treatment of adolescents because of their lower side effect profile and their
relative safety in overdose.
 The use of benzodiazepines for anxiety is generally not recommended in
this age group because of the increase in drug experimentation by
adolescents and the negative side effects on learning and memory that these
drugs may have
 Lithium is generally well tolerated in this age group and is effective in the
treatment of mania, aggression and conduct disorder.
 Antipsychotic are the standard treatment for psychotic symptoms in
adolescents.

THERAPEUTIC WORK WITH ADOLESCENTS

Parental and Family Work

Some form of specific work with the parents or families of disturbed
adolescents is usually required and it may be an advantage to allocate a therapist to
work chiefly with them.
Most adolescents are likely to accept the family sessions are an appropriate
medium for dealing with issues that are public in the sense that they impinge on all
family members.
Social Liaison:
Information from the school or school psychological service may be
essential in assessment and planned liaison about aspects of management may be
useful therapeutically, as well as providing a way of monitoring progress.

Prevention of Adolescent Psychiatric Disorders

Prevention is important because treatment methods are not easily available
and by no means uniformly effective.
There are three levels of Prevention
 Primary prevention
 Secondary prevention
 Tertiary prevention

Primary Prevention:
It consists of planned programmes designed to reduce the incidence of
specific pathological conditions whether psychiatric illness or mental handicap.
Primary prevention involves the identification of risk factors and their
removing them in time. The risk factors, which are known to be significant,
include genetic factors. It also involves regular home visits, support education,
concrete services to those in need.

Secondary prevention
It involves early diagnosis and case findings, followed by intervention to
bring the disorder under control as rapidly as possible.

Tertiary prevention
It aims to limit the effect of the disorder, to prevent its getting worse and to
give support to the affected individual or family.
Generally, however primary and secondary prevention help in more
economic uses of scarce professional time.
JOURNAL ABSTRACT

Mental, Emotional And Behavioral Disorders Can Be Prevented In Young

People

ScienceDaily (July 30, 2009) — Around one in five young people in the U.S. have
a current mental, emotional, or behavioral disorder. About half of all adults with
mental disorders recalled that their disorders began by their mid-teens and three-
quarters by their mid-20s. Early onset of mental health problems have been
associated with poor outcomes such as failure to complete high school, increased
risk for psychiatric and substance problems, and teen pregnancy.
A new article by Mary E. Evans, RN, PhD, FAAN, published in the
Journal of Child and Adolescent Psychiatric Nursing assesses the recently
released government report on preventing these disorders among young people.
Dr. Evans' paper concludes that using certain interventional programs in schools,
communities and health care settings, risk for mental illness can be better
identified and treated.
The article highlights the fact that specific risk and protective factors have
been identified for many disorders. For example, certain thinking and behavioral
patterns are risks for the development of depression. Nonspecific factors that
increase risk for developing disorders also include poverty, marital conflict, poor
peer relations, and community violence. Also, certain neurobiological factors
contribute to the development of disorders in youth, but this is also influenced by
environmental factors.
A key risk factor for externalizing disorders is aggressive social behavior
that begins in early childhood. A number of interventions have been developed to
provide training in parenting skills to prevent the development of aggressive and
antisocial behavior. In addition, some preventive interventions have targeted
specific disorders such as depression and schizophrenia. Cognitive behavioral
treatment for high-risk adolescents has lowered the rate of major depressive
symptoms. Also, a number of community-based programs have been shown to be
effective in promoting healthy behaviors

Which measure of adolescent psychiatric disorder—diagnosis, number of

symptoms, or adaptive functioning—best predicts adverse young adult
outcomes?
Screening children and adolescents for psychiatric disorders can identify those at
high risk of adverse young adult outcomes. Future school and community
adjustment can be predicted as easily and accurately on the basis of a simple count
of psychiatric symptoms as by applying more complex diagnostic algorithms.
Screening youth for psychiatric symptoms in neighbourhood, school, or primary
care settings is a logical first step for early intervention to promote increased
school completion and decreased criminal activity in young adulthood.

BIBLIOGRAPHY
1. Gail Stuart, ‘Principles and Practice of Psychiatric Nursing’, 8 th Edition, Mosby
Publication.
2. Niraj Ahuja, ‘ A short Textbook of Psychiatry’, 5 th Edition, Jaypee Brothers
Publication, New Delhi.
3. Lalitha, ‘Textbook of Psychiatric Nursing’, 1st Edition, 2004, Bangalore.
4. Neeraja, ‘Essentials of Mental Health and Psychiatric Nursing’,1 st Edition,
Volume I, JayPee Publication.
5. James Scully, ‘Psychiatry’, 3rd Edition, B.I. Waverly Ltd, New Delhi
6. Prema,Graicy, ‘ Principles and Practice of Psychiatric Nursing’, 1 st Edition,
Jaypee Brothers Publication, New Delhi.
7. Straight A’s ‘Psychiatric and Mental Health Nursing’ , Lippincott Williams and
Wilkins Publication, United States,2006.
8. Oxford Hand Book of Psychiatry.

JOURNAL REFERENCE

1. Copeland WE, Shanahan L, Costello EJ, Angold A, Childhood and adolescent

psychiatric disorders as predictors of young adult disorders, Arch Gen
Psychiatry. 2009 Jul;66(7):764-72.
2. A Vander Stoep , N S Weiss , B McKnight ,S A A Beresford, P Cohen, Which
measure of adolescent psychiatric disorder—diagnosis, number of symptoms,
or adaptive functioning—best predicts adverse young adult outcomes?,
Epidemiol Community Health 2002;56:56-65 doi:10.1136/jech.56.1.56
3. Mental, Emotional And Behavioral Disorders Can Be Prevented In Young
People, ScienceDaily (July 30, 2009)

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