As Assistant Secretary for Health and Surgeon General of the US, Dr. David Satcher (2001) stated, “The burden of suffering experienced by children with mental health needs and their families has created a health crisis in this country…children are suffering needlessly because their emotional, behavioral, and developmental needs are not being met…it is time we as a nation took seriously the task of preventing and treating mental illness in youth.”
This was Dr. Satcher’s address to the report of the Surgeon General’s Conference on Children’s Mental Health. Not much has changed since that Conference due to many factors, which are still not partially or fully attained. This conference was the accumulated knowledge from many sectors of society, which concluded that the obstacles to delivery of mental health services are many, including: inadequate public awareness, fragmented services, racial/ethnic disparities, and more. The Conference also pointed out our country is facing a public crisis in mental health for infants, children and adolescents.
The World Health Organization (WHO) stated that “by the year 2020, childhood neuropsychiatric disorders will rise proportionately by over 50 % internationally, to become one of the five most common causes of morbidity, mortality, and disability among children.” But yet, most people do not recognize that mental health is a critical component of health and wellness.
Approximately 1 in 5 (20%) of children and adolescents may have a mental health disorder, and often these children have more than one disorder. (U.S. Dept of Health and Human Services, 1999). Failure to recognize and treat mental illness can cause a cascade of events for a child with deleterious effects. It reduces the child’s quality of life and ability to develop into a mature healthy member of society. These children can face school failure and drop out, possible substance abuse and addiction, incarceration, delinquent behavior and violence.
Modern psychopharmacology and health insurance reforms’ push to keep patients in the community has fashioned forward thinking home care agencies to incorporate and employ mental health nursing services. We are the “glue” that encourages compliance and communication, monitors for mental health symptoms, and provides a liaison with treating Psychiatrists, mental health clinics, and outpatient day treatment programs, all in the attempt to keep individuals stable and in the community.
In order for the home care mental health nurse to be of help to children and adolescents within her area of practice, one must know the issues, which interfere with children getting mental health services.
Parents may feel guilty that the child may be mentally ill and ignore early symptoms of mental illness. Due to lack of education and knowledge of mental illness symptoms in children and adolescents, parents may conclude that the child is impudent and punish the child for their inappropriate behavior, which can cause low self-esteem in both the child and parent. Parents themselves may be suffering from mental illness and/or substance abuse, and not be able to cope or respond to the child’s issues. There may also be lack of resources- money, availability of mental health resources, and a nurturing parental figure in the household.
Primary care physicians, due to required immunizations and physicals for day care and public schools, are also providers that are critical for early identification of children with mental illness, and often give counseling and prescribe psychotropic drugs, however, families do not view this as mental health services, and may not be getting the appropriate treatment.
Since children have to attend school, schools should be the place where early diagnosis would be most likely to happen, however this is not the case. Cole (2001) states, “Students with mental health needs are usually identified only after teachers cannot manage their behavioral problems. Therefore, less than 1% of children are diagnosed with depression, attention deficit hyperactivity disorder (ADHD), and post-traumatic stress disorder secondary to abuse. Consequently, these students are mistakenly treated for primary learning or language disorders. National data indicate that 22% of children ages 5 and younger live in poverty, which is a scientifically proven risk factor for mental illness. Other risk factors are prematurity, family stressors (divorce, death, illness).” Teachers, since they see the child for hours, days and months, need to be educated and evaluated on their ability to detect early signs of major mental illnesses in children, and have the support and ability to refer the child to a specialist when appropriate.
The home care mental health nurse may come upon the child or adolescent with mental health symptoms in two different venues. (1) Where the child is the primary problem. A Pediatrician, Pediatric Psychiatrist, Social Worker, school system or Clinic may have referred the child. The early problems may be parenting, sibling, and developmental, or school related issues. (2). The parent as the primary problem and its impact on the mental health of the child, either due to parental decompensation of mental or physical illness or biological issues. In either case, the home care mental health nurse will play a key role in early detection, education of parents and child, referral to appropriate services, monitoring of compliance to the plan of care, evaluation of the plan of care, and communication with all services and professionals involved.
All mental health nurse professionals must have knowledge of the most common mental health disorders in children and adolescents and their symptoms, in order to be effective in early detection.
Anxiety Disorders are the most common mental health diagnosis. 13% of 9-17-year-olds have either anxiety disorders or phobias and fears of objects or situations. (A) GAD or Generalized Anxiety Disorder, seen as excessive, unrealistic worry, (B) Panic Disorder, seen as attacks with physical symptoms of palpitations and dizziness. (C) OCD or Obsessive- Compulsive Disorder, Where the child is “trapped” by repetitive thoughts and behaviors, such as repeated hand washing.
Post-Traumatic Stress Disorder, which is usually, exhibited by “flashbacks” from exposure to a psychological distressing event, such as abuse, exposure to violence, natural disasters, or war.
Severe Depression: Only in recent years have experts agreed that children can suffer from severe depression. 2% of children and 8% of adolescents may have major depression. Symptoms in children may include: (A) Affect changes- such as sadness, crying and worthlessness. (B) Loss of interest in playing and school activities, truancy, and poor school performance. (C) Physical signs may include appetite, weight, and sleeping habit changes. (D) Attitude changes may include a negative outlook pertaining to themselves and the future. (E) Suicidality. Suicide is the third leading cause of death in adolescents. 90% of children who commit suicide have a mental health disorder. 6.9% of 9-12th graders have attempted suicide. Any child or adolescent with depression is at risk for suicide and need to be monitored for suicidal thoughts and actions. (F) Substance Abuse- 43% of youths with a mental health disorder also abuse drugs and alcohol. .19.7% of 9-12th graders have tried marijuana. Adolescence is very stressful, and poor coping skills can lead to drug and alcohol use to escape problems. These substances can reduce impulse control, making it easier to attempt suicide.
Bipolar Disorder or Manic Depression: A child or adolescent who demonstrates extreme mood changes, from highs (excited behavior), e.g. manic phase, to lows, e.g. depression, may have bipolar disorder. These extremes may follow with periods of moderated mood. When having manic behavior, the child may be hyper verbal, show a reduced need for sleep with poor judgment and impulsiveness. Adults with this disorder often experience their first symptoms during their teen years and are approximately 1 % of the population.
Attention Deficit/ Hyperactivity Disorder (ADD and ADHD): ADD is when the child has difficulty focusing attention and/or is easily distracted, and does not have the hyperactivity component, whereas ADHD does include it. ADHD occurs in up to 5 % of children. These children have difficulty remaining still and keeping quiet.
Learning Disorders: These children have difficulty processing information. They may have problems with spoken or written language, coordination, attention or self-control.
Conduct Disorder: Children with this disorder tend to violate the rights of others and rules of society. They act out their impulses in destructive or inappropriate ways. A child may start out lying or stealing and move on to more serious crimes such as vandalism, aggression, and violence. 1-4% of children 9-17 years old have Conduct Disorder.
Eating Disorders: Society, culture and the Media send powerful messages about the ideal, thin body, by which our youth feel they must attain, in order to be powerful, sexy and successful in life. This sets up children and adolescents to only value themselves for the body image that they project, and can lead to poor self-esteem, poor body image and potential eating disorders. (A) Anorexia nervosa-extreme weight loss, fear of eating and food rituals. (B) Bulemia- Binging and Purging by induced vomiting, laxatives, enemas, and compulsive exercising to prevent weight gain. Anorexia mostly effects girls (.5-1% of adolescent girls). Bulemia is 1-3% of all adolescents. (C) Obesity- The causes are multifactorial- poor lifestyle choices, genetics, less structured family life, etc. The changing roles of parents in our society, where both are needed to sustain the household financially has impacted the way a family spends their time and effort. Many rely on fast and convenience foods as a quick and easy way to feed children in the evenings, rather than a meal that is home cooked. These fast and easy foods are much higher in fat, sugar and salt. The after-school time is when children can be more active, doing fun activities outside. However, due to parents working, children may be required to go home, lock the door, and stay at home until the first parent arrives home. This encourages sedentary activities and unmonitored snacking. The lack of proper adult/parent availability does not lend itself for time to talk about their daily stresses and concerns. This may lead to emotional eating to fend off their mood. These children are at increased risk for mental disorders. In one study, 13-14-year-old girls were four times more likely to suffer from self-esteem issues. Low self-esteem apparently leads to loneliness, sadness, nervousness, poor body image, and are at high risk for substance abuse, smoking, and depression, which, if left untreated, may contribute to the cause or effect of obesity. In a recent University of Minnesota study, overweight children who are teased by family and other children, 26% had considered suicide, and 9% attempted suicide. In another study Schwimmer, et al (2003), obese children rated their quality of life with scores as low as young cancer patients on Chemotherapy.
Autism Spectrum Disorders: These children have problems interacting and communicating with others and are identified prior to age 3. The behaviors include; repetitive behavior such as banging their head, rocking, and spinning objects, poor awareness of others and are at increased risk for other mental disorders. Autism affects 1 in every 110 children.
Schizophrenia: Children have psychotic episodes with hallucinations, withdrawal, delusions, disordered thinking, and loss of contact with others and reality. Schizophrenia affects 5 out of 1,000 children.
As a home care nurse, in order to develop a plan of care for a child with a mental illness, he or she must be treated within a holistic paradigm. The child lives with other family members one (or two) of which is the primary caregiver. Along with earning trust with the child, it is of utmost importance to earn trust with the caregiver(s). Building upon a trustful therapeutic relationship will most likely make the difference between compliance or noncompliance. This person will play a key role in whether a child gets to MD or Clinic appts, obtaining and administering medications to the child and being alert to any changes in the child’s physical and mental status.
Other siblings in the home also need attention and support of the home care nurse. Other children may suffer from lack of attention of the caregiver, especially during a period of crisis. Giving some brief attention to them, and helping them understand, at their developmental level, what is happening to their sister/brother, may help allay fears and concerns.
Education of the child and caregiver is an ongoing part of the Home Care nurses visit. Anxiety of both the child and caregiver are to be expected. It is difficult to retain information when you are very anxious, so, it is better to allow the first part of the visit to be used for therapeutic interaction, followed by educational issues. Education regarding services, diagnosis, symptom management, emergency management, medications and administration, and need for continued follow up and treatment are some of the items addressed. Safety regarding medications and children is an issue, which may be solved with the use of a locked box to prevent accidental overdose. The learning must not be given all at once but based on comprehension and degree of importance.
Since the mental health home care nurse sees the child in the home, we have access to knowledge the other mental health caregivers do not. We can evaluate how the caregiver functions within the home. Is the caregiver organized, appear competent and willing to support the child? Does the caregiver have illnesses of her/his own to deal with? Is the caregiver employed? How will the caregiver take the child to his or her appts or obtain medications? Will the caregiver remember what to do in an emergency? How well are they adhering to the plan of care? All of this information is important to the treating Psychiatrist, Clinic, and Therapist to know in order to fashion a plan that will take into account the willingness and ability of the caregiver in the home.
The home care mental health nurse can be an invaluable tool in preventing, accessing, treating, and monitoring children and adolescents with mental health issues, in preventing relapses in children with mental health problems, supporting and encouraging the parents/caregiver to continue treatment and reinforcing good parenting skills, and preventing acute hospitalization of the child with a mental health disorder.
ENDNOTES
- American Psychiatric Assn., Obesity can be harmful to your child’s Mental Health. Research shows Significant risks and impact.
- Cole, M., (April 16, 2001). The Gridlock in Mental Health Services for Children. New York Nursing News.
- Marcus, L., and Baron, A. Childhood Obesity. The Effects on Physical and Mental Health. NYU Child Study Center.
- National Mental Health Information Center. SAMHSA Health Information Network. Children’s Mental. Health Facts. Children and Adolescents with Mental, Emotional, and Behavioral Disorders.
- United Way (2005). Overcoming Disease and Disabilities. Focused Care Council. Mental Health Issues in Children and Adolescents.
U.S. Department of Health and Human Services. (1999). Mental Health. A Report of the Surgeon General. Rockville, MD, U.S. Health and Human Services.
