Mental Health

Introduction• Mental status is the total expression of a

person's emotional responses, mood, cognitive functioning, and personality. Altered mental status can affect motivation, initiative, goal formulation and planning, and self-monitoring.

• This lesson provides an overview of the assessment of the mental status as a context for diagnosis and treatment of mental disorders and for health promotion. We'll cover these topics:

• History • Physical examination • Common screening and diagnostic tests • Health-promotion behaviors

Incidence• The cerebral cortex is primarily responsible for a

person's mental status • All human brain cells are present at birth, but it

takes the first years of life for them to fully develop and myelinize

• Through adolescence, intellectual maturation continues with greater capacity for information and vocabulary development; abstract thinking develops during this period

• No decline in general intelligence is evident in older adults

PathophysiologyRisk factors for depression• Women are at greater risk than men • Adolescents are at greater risk than younger or older

individuals • The children of parents with depression are likely to

experience the disorder themselves • A history of trauma, sexual abuse, physical abuse, physical

disability, alcoholism, or loss of a spouse or child increases risk

• Low self-esteem, distorted perceptions of others' views, inability to acknowledge personal accomplishment, and a pessimistic outlook increase the likelihood of depression

Risk factors for anxiety• A 20% risk exists in those with blood relatives with the

disorder • People who are sleep-deprived are at greater risk • Financial concerns, health, relationships, and school or work

problems increase the likelihood of anxiety

HistoryCurrent complaint• Assess dress, mood, affect, body posture, tone of voice,

and conversation flow • Look for disorientation, confusion, depression, and anxiety • Ask key questions about the patient's perception of onset

(abrupt or insidious), time of day, duration, precipitating factor or event, associated problems, associated symptoms (e.g., insomnia, mood swings), and factors that aggravate or relieve the symptoms

• Ask other questions that may be helpful in assessing emotional status

• Determine the patient's coping behaviors and support system

• In a child, assess speech and language, behavior, performance of self-care activities, and learning or school difficulties

• In an older adult, assess changes in mental function (e.g., cognition, thought process, memory, confusion, depression)

HistoryMedical history• Neurological disorder • Psychiatric illness or hospitalizationFamily history• Psychiatric disorders • Substance abuse • Alzheimer disease • Learning disordersMedication history• Maternal use of illicit drugs or alcohol during pregnancy

(if the patient is a child) • Use of alcohol, tobacco, and drugsPsychosocial history• Recent life changes, both positive and negative

Physical Examination

Examination• Conduct a short screening examination involving

the assessment of appearance and behavior, cognitive abilities, emotional stability, and speech and language

• Perform a complete physical examination, including vital signs, with particular attention to the cardiovascular and neuroendocrine systems

• Use an assessment tool such as the ABC Stamp-Licker mnemonic to assist in this examination

Physical Examination

Diagnostic procedures• Mini-Mental State Examination and the Short

Portable Mental Status Questionnaire • Primary-care evaluation of mental disorders

(better known as the PRIME-MD test to screen for the five most common psychiatric disorders)

• Hamilton or Zung Anxiety Scale • Beck or Zung Depression Scale • Laboratory tests, generally ordered to rule out

physiologic causes for the presenting symptoms

Physical Examination

Differential diagnosis• Depression • Bipolar disorder • Anxiety disorders (e.g., posttraumatic stress

disorder, obsessive-compulsive disorder, generalized anxiety disorder, and panic disorder)

• Psychotic disorders (e.g., schizophrenia, delusions)

• Substance-abuse disorders • Delirium and dementia

Education• Reinforce health-promotion behaviors as appropriate • Explain the importance of self-awareness • Teach ways to develop self-awareness, including

monitoring stress warning signs, learning and practicing relaxation techniques, using alternative and complementary therapies, and keeping a journal

• Stress the importance of a healthy diet, physical activity, and adequate sleep

• Teach cognitive restructuring and assertive-communication techniques

• Ensure patients have adequate social support • Encourage patients to engage in humor, spiritual

practice, and healthy pleasures • Encourage patients to clarify their values and beliefs and

to set realistic goals

Introduction

Anxiety is a normal reaction to stress that helps one cope. Excessive anxiety, however, can result in an inability to function within society, necessitating social service support. For patients with anxiety disorder, the most effective nursing approaches must reflect understanding and calm.

In this lesson, we'll review the following anxiety disorders:• Anxiety in children • Panic disorder • Posttraumatic stress disorder • Obsessive-compulsive disorder • Generalized anxiety disorder

Incidence• Fear is a cognitive (thinking) process that involves intellectual appraisal,

whereas anxiety is an emotional (feeling) response to appraisal of the environment

• Anxiety is a high level of physical and emotional distress • Anxiety is the oldest, most recognizable and prevalent mental disorder and

is one of the most common reasons for seeking medical and psychiatric treatment

• Anxiety disorders affect approximately 15% of the general population • Anxiety disorders accounted for nearly one third of the nation's total mental

health–care costs in 1990, at approximately $46.6 billion • Symptoms can render an individual unable to function at home, work, or

school • Persons with anxiety disorder often have dual diagnoses • Anxiety disorder, particularly panic disorder, is more common in women

than in men • The median age of onset is the early twenties • A correlation exists between anxiety and cardiac problems, hypoglycemia,

and seizure disorders • Between 1.5% and 3% of persons will experience panic disorder at some

time in their lives • Approximately 6% of children experience anxiety

Pathophysiology

Generalized anxiety disorder (GAD)• Characterized by unrealistic and excessive worrying • It is difficult for people with this disorder to distinguish

normal worrying or apprehension from unrealistic worry and to control the worry

• Excessive anxiety and worry (apprehensive expectation) are considered GAD when they occur more days than not for at least 6 months with regard to a number of events or activities (for example, school or work)

• Anxiety and worry are associated with three or more symptoms (only one item is required in children)

• Anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

PathophysiologyPanic disorder• All anxiety disorders can have a component of panic • Symptoms are at the extreme end of the anxiety

continuumPanic disorder without agoraphobia• Characterized by sudden and unexpected onset of

intense anxiety and apprehension and is associated with profound fear or sense of impending danger

• Unless treated, attacks are recurrent • Four or more symptoms develop abruptly and peak

within 10 minutesPanic disorder with agoraphobia• Characterized by global incapacitation and avoidant

behaviors • Stems from anxiety about being in places or situations

from which escape might be difficult or help may not be available

Pathophysiology

Social phobia• Fear of social or performance situations where the

person is exposed to unfamiliar people or to possible scrutiny by others

• The individual fears that he or she will act in a way that will be humiliating or embarrassing

• The disorder threatens a person's social, interpersonal, and occupational functioning

• Exposure to the feared social situation almost invariably provokes anxiety, a panic attack, or both

• The person recognizes that the fear is excessive or unreasonable but either avoids situations that provoke anxiety or endures them with intense distress

PathophysiologySpecific phobia• Specific phobias are triggered by common

objects or situations that generate fear • Fear is marked and persistent, excessive, or

unreasonable and is cued by the presence of anticipation of a specific object or situation

• Exposure to the phobic stimulus almost always provokes an immediate anxiety response

• The person recognizes that the fear is excessive or unreasonable but either avoids the triggers or endures them with intense distress

• Specific phobias interfere with a person's normal routine

PathophysiologyObsessive-compulsive disorder (OCD)• Obsessive thoughts, impulses, or images are

intrusive, recurrent, and persistent and cause marked anxiety and impairment in function

• Compulsive behaviors satisfy a need for symmetry or order

• Behaviors serve to decrease the anxiety related to the obsession but cause marked impairment in function

• Patients recognize that the symptoms are unreasonable

• OCD behaviors are characterized as those that cause marked distress, are time-consuming (take more than 1 hour per day), or significantly interfere with the person's normal routine

Pathophysiology

Acute stress disorder• Episodes result from exposure to a traumatic and

overwhelming event • Disturbances last for at least 2 days but no longer than 4

weeks and occur within 4 weeks of the traumatic event • Response involves intense fear, helplessness, or horror • During or after experiencing the distressing event, the

individual has three or more dissociative symptoms • Patient persistently reexperiences the traumatic event in

at least one way and markedly avoids the stimuli that arouse recollections

• Causes clinically significant distress or impairment in social, occupational, or other important area of function

Pathophysiology

Posttraumatic stress disorder (PTSD)• Similar to acute stress disorder except that it has more

symptoms that are of longer duration • Symptoms may occur immediately after the event or

later • Preexisting emotional problems are believed to increase

risk • In addition to acute stress disorder symptoms, patients

experience intense psychological distress on exposure to internal or external cures that resemble an aspect of the trauma

• Patients have two or more persistent symptoms of increased arousal that are not present before the trauma

• The patient persistently avoids the stimuli associated with the trauma in three or more ways

Pathophysiology

Older-adult disorders• Anxiety disorders are the most common psychiatric condition of older

adults • Triggers are related to advanced age, including physiologic factors • Extent of disorder is influenced by such factors as the quality of the

patient's support system and drug interactions (polypharmacy) • High risk of suicideAnxiety in childhood and adolescence• Separation-anxiety disorder is the most common childhood anxiety

disorder; affects girls more than boys • Social phobia is caused by a fear of performance situations in which a

child fears embarrassment, exhibits unwarranted distress over appropriateness of behavior, and is unable to relax or settle down

• PTSD is common in children who have been abused • OCD consists of repetitive, ritualistic behaviors and thoughts, is highly

refractory, presents with a chronic and episodic course, and may reflect a pediatric autoimmune neuropsychiatric disorder

PathophysiologyTheoretical perspectives• Psychoanalytic (Freudian): As the level of anxiety increases,

the use of ego-defense mechanisms may become necessary • Cognitive-Behavioral: Anxiety develops as a result of one's

faulty thinking or cognitive distortions about one's life and environment

• Existential: How one views the meaning of one's life affects one's sense of mastery and coping; a life perceived as meaningless or chronically inadequate produces anxiety

• Developmental: The Attachment Theory describes the maladaptive anxiety that develops when a child does not move through the stages of normal separation anxiety

• Psychophysiological: The loss of neuromodulation is hypothesized to be at the core of inescapable stress, and neuroregulators such as dopamine and serotonin are implicated as the cause of anxiety

• Continuum: Anxiety progresses from pure euphoria (total absence of anxiety) to mild anxiety, moderate anxiety, severe anxiety, and panic anxiety

History

Current complaint

• Symptoms

• Precipitating factor or event as the patient perceives it

• Patient's perception of when the problem started and its duration

• Aggravating and relieving factors

• Other questions to aid assessment

• Coping behaviors and support systems

History

Medical history• Most people with anxiety have a long history of

symptoms, especially during stress, but they may not call the symptom anxiety

• Ask whether the patient can remember a time when he or she was not bothered by chronic worrying and, if so, when

• Ask for three or four symptoms and examples of panic, obsessive thoughts and compulsive behaviors, avoidance, hypervigilance, sympathetic arousal, flashbacks, and dissociation and determine whether the patient has experienced any of them

• Ask when the patient first experienced these symptoms

History

Family history• High incidence of anxiety in other family

members

Medication history• Medications that can cause anxiety symptoms • Current use of alcohol, tobacco, and drugs

Psychosocial history• Recent life changes, both positive and negative

Physical Examination

Examination• Conduct a comprehensive physical examination,

paying special attention to the cardiovascular and neuroendocrine systems

• Conduct a mental-status examination using such assessment tools as the ABC Stamp-Licker mnemonic, the Mini-Mental State Examination and the Short Portable Mental Status Questionnaire, PRIME-MD screening test, and Zung or Hamilton Anxiety Scale

Physical Examination

Diagnostic procedures to rule out physiologic causes

• Electrocardiography • Complete blood count with differential and

electrolyte levels • Thyroid-function test • Liver-function profile • Urinalysis with drug screen • Chest radiography

Physical ExaminationDifferential diagnosis• Neurologic and endocrine diseases • Mitral-valve prolapse • Carcinoid syndrome • Pheochromocytoma • Irritable bowel syndrome • Gastritis • Vitamin B12 deficiency • Perimenopause • Substance abuse • Unresolved grief • Depression • Adjustment disorder to changes or life circumstances • Somatization disorder

TreatmentNonpharmacologic• The most critical intervention is to establish

rapport and trust in a quiet, calm, and supportive manner

• Psychotherapeutic treatment assesses maladaptive response and teaches and enhances coping skills

• Psychotherapy can consist of individual therapy, family therapy, or a combination thereof

• Specific psychotherapeutic modalities address mild to moderate anxiety, moderate anxiety, and severe anxiety or panic

TreatmentPharmacologic• Benzodiazepines are prescribed by many as a second-

line treatment for anxiety disorders or for depression with comorbid anxiety; however, they are short-acting, have numerous adverse effects, interact adversely with other medications, and carry other warnings

• Nonbenzodiazepine antianxiety agents are also used, but they are not effective for acute crises because of their delayed onset of action

• Antidepressants are prescribed for primary anxiety or in cases involving depression as an integral factor in the anxiety; because of temporary side effects, antidepressants may initially worsen anxiety before exerting their full effect

Education and Follow-Up

Education• Teach deep breathing and stress-reduction exercises • Teach effective coping behaviors • Explain the appropriate use of medication • Alert patients to the availability of various treatment

resources • Explain options for treatment • Teach the avoidance of foods that contain stimulantsFollow-up• Follow up weekly to evaluate the patient's response • Progress is made when the patient accomplishes certain

tasks

Referral

• Certain situations and findings necessitate referral to a mental-health specialist: psychotic paranoid thought processes, panic level of anxiety, suicidal or homicidal ideation, escalation of symptoms to the point of refusal of treatment, failure of standard treatment, comorbid psychiatric diagnoses

• Refer the patient to Alcoholics Anonymous or Narcotics Anonymous if alcohol or drug abuse is a contributing factor

Introduction

• Depression is an emotion that affects a person's entire perception of life. Left untreated, depression can result in suicide or harm to others. For example, without treatment a woman with postpartum psychosis may harm her infant.

• In this lesson, we'll review the following mood disorders:

• Major depressive disorder • Dysthymia • Postpartum depression

Types of Depression• Depression is a disturbance in mood or affect that occurs as a

single episode or recurring episodes • It frequently occurs along with other mental-health disorders, as well

as drug and alcohol abuse, addiction, and withdrawal • Major depressive disorder (unipolar depression) is characterized by

depressed mood and loss of interest or pleasure in all or almost all activities

• Dysthymia is a chronic depressed mood for most of the day, nearly every day, for 2 years or longer, with impaired function; it is less intense than major depressive disorder but has a longer duration

• Depression with seasonal pattern (seasonal affective disorder) is the relationship between the onset of a major depressive episode (or bipolar disorder) and a recurrent and particular time of the year in the absence of obvious seasonal stressors such as examinations or holidays

• Adjustment-disorder depression is the onset of depression symptoms in response to an identifiable event within the preceding 3 months, excluding posttraumatic stress disorder

• Postpartum depression is a type of adjustment disorder that occurs during the first few days or weeks after childbirth that must be recognized and attended to as a priority

Incidence• Between 10 million and 14 million Americans suffer from some form of mood

disorder • Depression is the most common reason for seeking mental health treatment,

accounting for 75% of hospitalized psychiatric patients and 6% to 8% of all outpatients in the primary-care setting

• Depression is twice as common in women as in men • Approximately 24% of people have first-degree relatives with depression • Depression in women tends to be less common with age, but incidence increases

in women older than age 50 with hypothyroidism • In men, incidence tends to increase with age • Depression affects 2% of prepubertal children and 5% to 8% of adolescents • Older adults are at high risk for depression because of the multiple losses and

health problems that often occur at this stage of life • The incidence of depression increases after a person has experienced a

depressive episode • No significant relationship has been found between race and mood disorders • Suicide is a risk for all patients with a mood disorder • The incidence of postpartum depression is 8% to 26%, and recurrence in

subsequent pregnancies is common • Between 30% and 70% of new mothers experience postpartum blues, the mildest

of a range of postpartum mood problems • Children of women with postpartum depression experience cognitive and social

problems in development and are more likely to have frequent illnesses during childhood

Pathophysiology

• Various theories have been formulated to explain the cause and dynamics of mood disorders

• It is believed that these disorders are a syndrome with common features and a variety of causative factors

• The genetic/biologic theory states that there is a functional deficiency of GABA and the neurotransmitters serotonin, dopamine, norepinephrine, and acetylcholine, with a probable genetic component

• The psychodynamic theory focuses on perceived loss and the unresolved grieving that occurred in the early child-parent relationship

• The cognitive theory states that schemas direct the way in which people experience others and themselves

• The family theory states that developmental events and experiences within a family system can lay the groundwork for depression

• The kindling theory hypothesizes that stress lowers the sensitization threshold, resulting in the neurochemical deficits associated with depression

Pathophysiology

Factors increasing susceptibility• Marital status (single, divorced, or widowed) • Seasonal changes (increased susceptibility in

spring and fall) • Previous episode of depression • Age younger than 40 years • Postpartum state • Physical illness • Inadequate social support • Substance abuse • Ineffective psychosocial functioning

Pathophysiology

Risk factors for suicide• White race • Physical illness • Substance abuse • Male sex • Increasing age • Solitary lifestyle • Previous suicide attempts • Less education • Relationship conflicts • Family history of suicide • Loss of income or employment • Impaired impulse control • In adolescents, drugs and alcohol abuse, rebellious behaviors such

as violence or running away from home, marked depression, or feeling of pressure by the family to succeed

HistoryCurrent complaint• Use the clinical interview to detect the impaired emotional,

behavioral, cognitive, and physical responses that are characteristic of depression

• Look for the emotional and physiologic symptoms of depression unique to children, adolescents, adults, older adults, and women in the postpartum period

• Look for warning signs of suicide, particularly in adolescents • Try to identify the predisposing and precipitating factors or events as

perceived by the patient • Determine the patient's perception of when the problem started and

its duration • Determine what aggravates and relieves the symptoms • Ask whether the patient would describe himself or herself as a

nervous person or a worrier • Explore traumatic events in the patient's past • In a woman who has recently given birth, identify abnormal bonding

behavior and evidence that the woman may harm her infant • Determine the patient's coping behaviors and support systems

History

Medical history• Most people with depression have a long history of symptoms,

especially during stress, but they may not call the symptom anxiety • Ask whether the patient can remember a time when he or she was

not bothered by the blues or chronic worrying and, if so, when • Describe three or four symptoms and examples of excessive

worrying and depression and ask the patients whether he or she has experienced any of them

• Determine the first time the patient experienced these symptoms • Obtain a complete personal history of panic attacks • Ask about past feelings of hopelessness, helplessness, or despair,

how the patient coped with them, and whether symptoms of avoidance, hypervigilance, sympathetic arousal, flashbacks, or dissociation occurred within the same time frame

• Ask whether the patient has experienced a cerebrovascular accident, myocardial infarction, or other chronic debilitating illness

History

Family history

• Depression (including treatment strategies and outcomes)

• Suicide attempts

• Mental illness

• Mother, grandmother, or female siblings who may be described as nervous people or worriers

History

Medication history: Drugs that may increase depression - or contribute to depression

• Cardiovascular drugs • Anti-Parkinsonian drugs • Chemotherapeutic agents • Hormones, including oral contraceptive pills, glucocorticoids, and

anabolic steroids • Anticonvulsants • Withdrawal from amphetamines or cocainePsychosocial history• Discuss the patient's support systems and coping techniques • Determine whether there is substance abuse • Ascertain the patient's perceived losses and current stressors • Critically assess the suicide risk, asking specific and clear questions

regarding suicidal thoughts, history of past suicide attempts, presence of a plan for suicide, and access to a means of suicide

Physical Examination

Examination• Assess the patient's general appearance,

making note of poor eye contact, tears, downcast mood, inattentiveness to appearance

• Note lack of spontaneous speech, monosyllabic, long pauses, slow low monotone

• Assess mental status, including memory, affect, judgment, cognitive abilities, thought content, and sadness in preschool and school-age children

• Check the thyroid gland for enlargement • Assess the patient's neurological status

Physical Examination

Diagnostic procedures• No conclusive diagnostic physical examination findings or laboratory

tests for depression exists, but certain abnormal results have been noted in a few tests

• Abnormal sleep electroencephalogram (EEG) results are seen in about 50% of all outpatients with depression

• The dexamethasone-suppression test is sometimes employed to help establish a diagnosis of depression

• Thyroid-function studies are often ordered to rule out hypothyroid disorder

• Many clinicians use various rating scales designed to measure the patient's mood to help make a diagnosis of depression

• Postpartum-depression checklists such as the Edinburgh Postnatal Depression Scale help facilitate diagnosis

• In children, a complete blood count helps rule out anemia, electrolyte determinations rule out electrolyte or renal problems, and an EEG rules out seizure disorder

Physical ExaminationDifferential diagnosis• Organic mood disorder • Schizophrenia • Grief • Delirium • Dementia • Substance abuse • Endocrine disorders • Liver failure • Chronic fatigue • Renal failure

TreatmentNonpharmacologic treatment• The initial and primary goal of nonpharmacologic treatment

is to ensure the safety of the patient • Determine the lethality of the patient's suicidal ideation or

plan and establish a no-suicide contract with the patient • Avoid excessive cheerfulness, which could cause the patient

to feel that his or her problems are being discounted • Help the patient contact immediate support systems; if the

patient is clearly suicidal and unwilling to enter into a contract not to harm him- or herself, consider immediate hospitalization

• Encourage exercise (e.g., 10-minute walk) • Recommend psychotherapy to treat depression, either

alone or in combination with medication • Electroconvulsive therapy can be used to treat the most

severe forms of psychotic depression that do not respond to other forms of therapy

TreatmentPharmacologic treatment• Antidepressants are effective in the treatment of all types of depression,

ranging from dysthymia to severe depression • Appropriate agents include the tricyclic antidepressants, monoamine

oxidase inhibitors (MAOIs), and the selective serotonin-reuptake inhibitors (SSRIs)

• The choice of medication is based on the consideration of certain factors • Dosages in children and older adults should be half the normal starting

dosage • When stopping a medication, taper the dosage to avoid the discontinuation

syndrome that may result when a medication is stopped abruptly • Safety and adverse effect profiles make the SSRIs the preferred first-line

drugs in most cases of depression • Tricyclic antidepressants have a higher potential for fatal overdose and

require an electrocardiogram (ECG) before administration to avoid cardiotoxic effects, particularly in children

• MAOIs are reserved for treatment when other medications have failed; in general, nurse practitioners do not prescribe them

• Antidepressant drugs have been found to slightly increase the risk of suicidal thoughts and behavior in children and adolescents with depression, although the American Psychiatric Association has stated that the study in question does not clarify the relationship between suicidal thinking and behavior

Education• Tell patients that most antidepressant medications take 4 to 6

weeks to produce any significant results but that benefits may be seen in as little as 2 weeks

• Inform the patient and family of the adverse effects of medication, with special emphasis on the effects that patients must report

• Relay dietary and activity restrictions related to the prescribed medications

• Warn patients against discontinuing antidepressants suddenly and ensure that they can recognize withdrawal symptoms

• Discuss with the patient and family when to seek professional help • Teach the patient and family to report signs of worsening

depression or suicidal thoughts • Advise family members not to leave a woman alone with her infant

when she is exhibiting symptoms of delusions, hallucinations, or the illogical thought patterns of psychotic depression, and remind the woman's partner that postpartum depression is likely to recur in subsequent pregnancies

• Reinforce effective coping behaviors, nutrition, exercise, rest, and socialization

• Emphasize the need for family members to make the patient feel like a valued and important member of the family

Follow-Up

• Follow up weekly with patients who are depressed and taking antidepressant medications

• If you see improvement after 5 to 6 weeks, decrease the follow-up to 2 times a month, then monthly, and so on

• At each visit, reiterate that counseling combined with antidepressant therapy is critical to obtaining the most improvement

• Understand that the relapse rate is 50% during the first 6 to 18 months

• Understand the most common reasons for continued depression and maintain patients on medication accordingly

• Know that each successive episode of depression suggests that psychosocial events have little or no role in the disorder as the disorder becomes more firmly established

Referral

• Refer the patient to a mental-health specialist for counseling

• Refer any patient whose illness is difficult to diagnose and treat, including infants and toddlers and patients with significant comorbidities or bipolar disorder

• Seek immediate consultation for anyone who is actively suicidal

• Seek immediate consultation for woman with at-risk newborns

Summary

• In this lesson we've reviewed the causes, risk factors, assessment, and treatment of mood disorders such as major depressive disorder, dysthymia, and postpartum depression. There is no known way to prevent depression, but early intervention can help protect a person from harming him- or herself or others.

Introduction

• Bipolar disorder, formerly referred to as manic-depressive disorder, is characterized by the occurrence of at least one manic, mixed, or hypomanic episode. These episodes cause extreme shifts in a person's mood, energy, and ability to function. Through intervention and management, the nurse practitioner can help patients with this disorder minimize the effects of these episodes on relationships, self-esteem, and job or school performance.

• In this lesson, we'll cover the data collection, diagnosis, and management of bipolar disorder.

Incidence• Various mood states can be placed on a continuum from severe depression to

severe mania. Bipolar disorder manifests itself differently in adults, older adults, and children and adolescents.

• An estimated 1% to 2% of the general population has bipolar disorder • More than 90% of individuals with bipolar disorder have at least one major

depressive episode • Bipolar disorder I affects men and women at equal rates, whereas evidence exists

that bipolar II may be more common in women than men • Age of onset of bipolar disorder peaks between 15 and 25 years • Bipolar disorder is more likely to affect the children of parents who have the illness • Some people have their first symptoms during childhood; others experience them

late in life • About 50% of patients with acute mania do not realize that they are experiencing

manic symptoms • The estimated prevalence of mania in older adults is 5% to 19% • Early episodes may occur in response to stressful events, whereas later episodes

may be unconnected to stressful events • The longer a person has the disorder, the shorter the time until the next episode;

therefore, as the patient has more episodes, he or she spends more and more time ill • The more episodes a person has, the more likely new episodes will occur • Bipolar disorder is often not recognized as an illness and years elapse before the

disorder is properly diagnosed and treated • Twenty-five percent of individuals with untreated bipolar disorder commit suicide

Pathophysiology• The cause of bipolar disorder is unknown, and no useful

biological markers or laboratory tests exist • Bipolar disorder cannot be cured • The disorder is thought to be an interaction of genetic

factors (in people who are genetically predisposed to the illness) and life experiences such as stressful events, sleep deprivation, and circadian-rhythm disturbances

• Medical conditions associated with bipolar disorder include those of the hypothalamo-pituitary-adrenal axis, thyroid disorders, and neurotransmitter/receptor imbalances, particularly dopaminergic problems, second-messenger abnormalities, and mitochondrial dysfunction

• Recent studies focus on the involvement of the prefrontal cortex, amygdala, and hippocampus

History• Determine whether the patient is experiencing a manic episode on

the basis of duration and the presence of three or more signs or symptoms

• Determine whether the patient is experiencing a depressive episode on the basis of duration and the presence of five or more signs and symptoms

• Assess the patient for a mixed state (signs and symptoms of mania and depression occur together and last most of the day, nearly every day, for at least 1 week)

• Assess for hypomania on the basis of the extent of functional impairment rather than on the severity of symptoms

• Check for the presence or absence of other signs and symptoms • Prepare a bipolarity index rated on episode characteristics based on

signs and symptoms, age of onset of first affective episode or syndrome, and course of illness and associated features

• Assess the patient for common triggers of affective instability

Physical Examination

Examination• Conduct a mental-status examination, using such assessment tools

as the ABC Stamp-Licker mnemonic, the Mini-Mental State Examination, the Short Portable Mental Status Questionnaire, the PRIME-MD screening test, and the Zung or Hamilton Anxiety Scale

Diagnostic procedures• No diagnostic procedures for bipolar disorder existDifferential diagnosis• Bipolar disorder is often poorly diagnosed, misdiagnosed, or

undiagnosed • Individuals who exhibit psychotic symptoms may be misdiagnosed

with schizophrenia or another severe psychopathology • The criteria set forth in the American Psychiatric Association's

Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) criteria do not take into account age of onset, family history, or course of illness

• The first episode of depression is frequently the initial presentation and is misdiagnosed as unipolar mood disorder

Treatment

Treatment for bipolar disorder is directed toward stopping episodes of depression and mania or preventing or lessening their severity. The treatment path depends on whether the episode is manic or depressive.

Nonpharmacologic• Psychotherapy, including cognitive-behavioral

therapy (CBT) or insight therapy • Electroconvulsive therapy (ECT) • Crisis intervention

TreatmentPharmacologic• Mood stabilizers are the cornerstone for acute and

preventive treatment • First-line medications such as divalproex plus lithium,

divalproex plus lamotrigine, or carbamazepine act as the foundation for monotherapy or combination therapy

• For severe depression, combine a standard antidepressant (e.g., fluoxetine [Prozac], sertraline [Zoloft], paroxetine [Paxil], bupropion [Wellbutrin], nefazodone [Serzone], or venlafaxine [Effexor]) with divalproex (Depakote) or lithium

• For rapid cycling, use divalproex as monotherapy • Antipsychotics are a first-line combined treatment for

psychotic depression and an adjunct therapy for mania and depression with or without psychosis

Education

• Assure the patient that although bipolar disorder cannot be prevented or cured, it can be managed and controlled

• Encourage the patient to be honest about symptoms and family history and explain that keeping secrets about the disorder only increases the severity of illness

• Encourage family members to join organizations to educate themselves and the significant other who may have bipolar disorder and explain that talking to others with bipolar disorder who have experienced the same issues can be helpful

• Tell the patient that a psychiatrist or other mental-health professional can respond to doubts and concerns about the diagnosis of bipolar disorder

• Teach the patient how to keep mood and life charts to track patterns that will aid understanding of what exacerbates the episodes

• Explain the medications that the patient has been prescribed and teach the importance of complying with the treatment regimen

• Teach the importance of keeping therapy and medication appointments

Follow-Up and ReferralFollow-up• Follow-up of the patient with bipolar disorder, generally

conducted by a psychiatrist, depends on a variety of factors

• It is important to watch for signs of psychosis, mood swings, violence, and self-harmful behaviors

• Close follow-up is needed if the patient is not responding as well hoped to the prescribed therapy

Referral• Refer the patient with a diagnosis of bipolar disorder

made at the primary-care level for psychiatric evaluation and medication management

• Refer the patient for psychotherapy and support groups to help him or her cope with problems that arise in function, work, finances, relationships, and compliance issues

Introduction• Although no consensus exists on the definition

of failure to thrive (FTT), the term generally refers to infants and young children whose weight is below the third percentile on National Center for Health Statistics (NCHS) growth standards or whose weight trajectory has decreased by two major growth percentiles.

• Because most brain growth occurs during the first 6 months of life, FTT in a child's first year is ominous. Left untreated, it can result in developmental delays and social and emotional problems.

• In this lesson, we'll cover the data collection, diagnosis, and management of failure to thrive

Incidence• FTT occurs in children younger than 5 years; the

average age at diagnosis is 16 weeks • Boys and girls are affected equally • Approximately 5% to 10% of all low-birthweight children

are identified as failing to thrive • FTT accounts for 3% to 5% of all pediatric admissions of

infants younger than 1 year; as many as 50% lack underlying medical conditions

• Organic causes account for about 25% of FTT cases, whereas approximately 50% have nonorganic causes; the remaining cases are a result of combined (organic and nonorganic) causes

• Approximately a third of children with nonorganic FTT are developmentally delayed and have social and emotional problems

Pathophysiology• FTT is a descriptive rather than a diagnostic term • FTT can have organic, nonorganic, and mixed causes • Cystic fibrosis is the leading cause of organic FTT • Lack of bonding to the primary caregiver is the most common cause

of nonorganic FTT • FTT often results in developmental delays, delayed growth,

decreased immune response, cognitive delays, and academic failures (the 4-month-old in the image shown here was brought to the emergency department because of congestion; once there, she was found to be underweight and exhibited severe developmental delay, including marked loss of subcutaneous tissue, denoted by the wrinkled skinfolds over the buttocks, shoulders, and upper arms)

• Height/weight ratios and body-mass index (BMI) and other weight criteria are used to identify children with FTT

• Height is not affected unless FTT is prolonged or all growth is delayed, as it is in children with growth-hormone deficiency

• Parental stressors increase a child's susceptibility to FTT • Protective factors involving both parents and infants are known

History

Current complaint• Aversive behaviors, particularly with respect to

eating • Poor suck reflex; infant turns away from bottle • Excessive spitting up • Poor eye contact • Difficulty cuddling • Frequent crying or whining • Difficulty comforting • Associated symptoms such as frequent diarrhea

or vomiting

History

Medical history• Birthweight and gestational age • Mother's prenatal, perinatal, and neonatal

history • Illnesses since birth, particularly underlying

disease processes including cardiac, respiratory, hyperthyroidism, cancer, or recurrent infections

• Altered growth potential that may indicate prenatal insult, genetic disorder, or endocrine dysfunction

• Risk of lead exposure • Food allergies

History

Family history• Heights and weights of parents, grandparents,

and siblings • Family history of malabsorption problems (e.g.,

cystic fibrosis, lactose intolerance, other inborn errors of metabolism)

• Childhood history of parents (parents who give a history of being poorly parented are at high risk of having an infant with FTT)

• FTT in siblingsMedication history• Maternal medication use or sedation during

labor

HistoryPsychosocial history• Thorough feeding history • Stool patterns • Possible parasite exposure • 24-hour dietary recall (3 to 7 days is best) • Caloric intake (calculated from recall) • Parent/infant bonding • Factors that impair attachment behavior (e.g.,

mother's illness, separation of infant from mother, financial stressors)

• Parental illiteracy (can play a part in FTT)

Physical Examination

Examination• Assess the child's general appearance; measure

height and weight, BMI, and head circumference; and, if the child is 3 years or older, take vital signs

• Check the status of the fontanelles and look for oral defects and thyroid enlargement

• Listen for heart murmurs • Note whether the abdomen is protuberant • Look for signs of muscle wasting and other evidence of

malnourishment (e.g., decreased fat pads in cheeks or buttocks, poor muscle tone)

• Look for hypotonia and assess gag and swallow reflexes, muscle strength, sensation, and deep tendon reflexes

• Observe parent/infant interaction • Perform the Denver Developmental screening to help identify

developmental delays • If possible, watch the infant as he or she feeds

Physical ExaminationDiagnostic procedures• Laboratory tests to differentiate physiologic (organic) from nonorganic

causes • Complete blood count • Lead screening • Sweat chloride screening • Renal, liver panel, and electrolytes testing • Growth-hormone testing • Albumin/total protein testing • Calcium phosphate and phosphatase testing • Thyroid panel • Stool testing for parasites • Tuberculosis testing • HIV screening • Urinalysis • Reflux and malabsorption testing • Bone-age determination (if height is poor)Differential diagnosis• Organic problems • Nonorganic problems

TreatmentNonpharmacologic• Every effort should be made to enhance a therapeutic

alliance between the infant and the caregiver • Parents must be followed closely in the home to observe

feeding behaviors and parent-child interaction and to promote bonding

• FTT is usually managed on an outpatient basis, if possible, unless other factors necessitate hospitalization

• An interdisciplinary approach involving health care and nutritional, mental-health, and social services is optimal

• Caloric intake should be increased according to the child's age

Pharmacologic• No drugs are indicated for FTT unless an underlying

disease is found

Education

• Teach the parents or caregiver about child nutrition and appropriate feeding techniques

• Demonstrate ways to comfort the baby • Explain expected normal infant behaviors • Identify community resources that are available

to the caregiver • Stress that the disruption in normal parent-child

bonding that causes FTT affects the entire family and discuss ways to strengthen family unity

• Direct efforts to alter feeding at all caregivers

Follow-Up and Referral

Follow-up• Follow the child with FTT weekly until his or her weight has reached

the fifth percentile and continue monthly visits until adequate weight gain is maintained for at least 3 consecutive months

• FTT is subject to a high rate of relapse; ensure that caregivers are able to carry out remedial efforts over time

• Referral• Refer the caregiver to home health/social services if appropriate to

assess environmental factors • Refer the caregiver to Women, Infants, and Children (WIC) if

appropriate • Refer the caregiver to parenting classes, if appropriate • Refer the caregiver to a nutritionist • Contact child-protective services if FTT is a result of parental

neglect • For children with obvious signs of malnutrition or those

unresponsive to efforts to increase growth, consult with a physician to determine the need for hospitalization

Introduction

• Attention deficit–hyperactivity disorder (ADHD) is the current term applied to specific developmental disorders of both children and adults that are characterized by deficits in sustained attention, impulse control, and the regulation of activity level to situational demands.

• Common childhood behavior problems, as perceived by a supervising adult to deviate from acceptable norms, include temper tantrums, hitting, kicking, biting, noncompliance, back talk, fighting, arguing, yelling, breath holding, and refusing to go to bed.

• In this lesson we'll explore these behavior disorders and possible solutions.

Attention Deficit–Hyperactivity Disorder: Incidence

• ADHD has had a variety of labels • ADHD is one of the most common neurobehavioral

disorders of childhood, affecting 3% to 5% of children in the United States

• Approximately 4.4 million children 4 to 17 years of age were found to have ADHD in 2003; 2.5 million of these children received medication to treat the disorder

• Boys are affected more frequently than girls in the United States, with ratios ranging from 4:1 to 9:1, depending on the setting

• It is estimated that one child in every classroom in the United States needs help for the disorder

• Symptoms of ADHD continue in about 50% of adults who had ADHD as a child; data now suggest that diagnostic features of ADHD take a different form in adults

• ADHD is associated with common developmental disorders

Attention Deficit–Hyperactivity Disorder: Pathophysiology

• ADHD may have a biological basis (e.g., catecholamine metabolism in the cerebral cortex, which creates an imbalance in brain chemistry, particularly in neurotransmitters such as dopamine, norepinephrine, and serotonin)

• ADHD has a genetic component • Some people believe that toxins are responsible

for the development of ADHD, but no scientific proof exists

• Susceptibility to ADHD increases with certain factors

Attention Deficit–Hyperactivity Disorder: History

Current complaint• Symptoms: uninhibited behavior, inability to sustain

attention, impaired impulse control, excessive movement • Onset of symptomsMedical history• Prenatal, perinatal, postnatal, and infancy history and

developmental milestones and characteristic behaviors at each developmental stage

• Chronic health problems (e.g., asthma, diabetes, heart conditions)

• Injury events • Sleep disorders • Other history relevant to risk factors

Attention Deficit–Hyperactivity Disorder: History

Family history• Parents or siblings with ADHD or similar

symptomsMedication history• Methylphenidate (Ritalin) • Dextroamphetamine (Dexedrine) • Pemoline (Cylert) • Tranquilizers • Anticonvulsants • Antihistamines • Other prescription drugs

Attention Deficit–Hyperactivity Disorder: History

Psychosocial history• Relationships with siblings and friends • Behavior in a variety of settings (e.g., school,

play, home, organized sports, youth organizations, after-school programs)

• Physical or sexual abuse • Police involvement • Custody issues • Interaction between child and parent • School history (if patient is an adult, ask from a

perspective of past history)

Attention Deficit–Hyperactivity Disorder: Physical Examination

Examination• Test hearing and vision • Be alert to "soft neurological signs" (e.g., problems with

right-left discrimination, motor-overflow movements, sequencing difficulties)

• Conduct cognitive testing, including having the child recite serial sevens, span digits forward and backward to assess attention, and verbally solve math problems

• Determine whether the child has any developmental difficulties

• Use assessment tools such as the DSM-IV criteria and checklists or behavior rating scales developed by Connors, Wender, or Taylor to have teachers and others help assess the child's behavior in different environments

Attention Deficit–Hyperactivity Disorder: Physical Examination

Diagnostic procedures• No laboratory tests exist to aid the diagnosis of ADHD • DSM-IV criteria aid the diagnosis of ADHD in both adults and children • Criterion 1: six or more symptoms of either inattention or hyperactivity-

impulsivity, persisting for at least 6 months to a degree that is maladaptive and inconsistent with developmental level

• Criterion 2: presence of some hyperactive-impulsive or inattentive symptoms that caused impairment before the age of 7 years

• Criterion 3: some impairment from the symptoms in two or more settings (e.g., at home and at school or work)

• Criterion 4: clear evidence of clinically significant impairment in social, academic, or occupational function

• The symptoms do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder and are not better accounted for by another mental disorder (e.g., mood, anxiety, dissociative, or personality disorders)

• Although the APA criteria do not specifically address adults, it is clear that adults may have ADHD; some areas may be more pronounced in adults

Attention Deficit–Hyperactivity Disorder: Physical Examination

Differential diagnosis• As many as one-third of children have one or more coexisting

conditions • Oppositional defiant disorder (ODD) has a 35% prevalence with

ADHD • Conduct disorder (CD) has a 26% prevalence with ADHD • Generalized anxiety disorder (GAD) has a 26% prevalence with

ADHD • Depressive disorder has an 18% prevalence with ADHD • Learning disabilities are present in 12% to 60% of patients with

ADHD • Mental retardation is sometimes associated with ADHD • Understimulating environment is associated with ADHD • Developmentally inappropriate behaviors in active children are

frequently seen • Comorbidity frequently occurs • In adults, depression and substance abuse frequently accompany

ADHD; comorbidity is more likely the rule than the exception

Attention Deficit–Hyperactivity Disorder: Treatment

The best approach is a multidisciplinary team, but a consistent primary provider is essential. The nurse practitioner may serve as the case manager.

Nonpharmacologic• Properly done, parental training in the use of techniques for dealing

with the child's behavior is one of the best therapeutic approaches • Parents may benefit from counseling to help them accept that their

child has the disorder and to work through grief if it arises • Psychotherapy may be needed to help some children with ADHD

cope with the anxiety, depression, and self-esteem issues they are experiencing

• Family therapy is helpful in improving communication within the family and helping siblings deal with their concerns

• Social-skills training and peer-relationship training may be beneficial to children with ADHD because they demonstrate problems in social situations and are at high risk for peer rejection

• Some parents have found that a reduction in the use of artificial additives and the intake of simple sugars helps their children

Attention Deficit–Hyperactivity Disorder: Treatment

Pharmacologic• Central nervous system stimulants are very effective in

the management of symptoms, mainly shortened attention span and impulse control

• Medications consist of class 2 controlled substances, including methylphenidate (Ritalin and Ritalin-SR), which has a 77% positive response, and dextroamphetamine (Dexedrine and Dexedrine Spansules), which has a 74% positive response

• Atomoxetine (Strattera), a selective norepinephrine-reuptake inhibitor, is a noncontrolled substance approved for ADHD

• Selective serotonin-reuptake inhibitors (SSRIs), pemoline, and tricyclic antidepressants are usually considered second-line options after stimulants

Attention Deficit–Hyperactivity Disorder: Education

• Explain the symptoms and course of ADHD • Explain that treatment of ADHD is long-term and it is no longer

believed that children "outgrow" the disorder • Help parents understand the importance of learning how to cope

with behavioral difficulties rather than cure them • Teach parents techniques for dealing with the child's behavior that

help reduce negative behaviors and promote positive behaviors • Guide parents to modify the environment rather than the child and

explain that the child with ADHD functions best in a highly structured environment with clear rules, limits, and consequences

• Help parents develop techniques to enhance structure and organization, such as making lists and developing computerized schedules

• Explain that although no preventive measures exist, a healthy prenatal course (avoiding lead, alcohol, cigarette smoking, drug abuse, and malnutrition) may reduce the incidence of ADHD

• Ensure that teachers and administrative staff at the child's school understand the characteristics and management of ADHD and work with the child's teacher to develop educational approaches

Attention Deficit-Hyperactivity Disorder: Follow-Up and Referral

Follow-up• Involve the family in the development of the treatment

plan and adjust the plan as the child and family change • Adjust medications as the child grows • Continue to adopt a multidisciplinary approachReferral• Refer the parents for counseling, if appropriate, to help

them accept their feelings about their child with ADHD • Refer patients for psychotherapy to help them cope with

feelings of anxiety, depression, and low self-esteem • Refer families for family therapy, if appropriate • Refer children for social-skills and peer-relationship

training, if appropriate

Behavior Problems in Children: Incidence

• Behavior problems arise when a child's behavior is perceived by a supervising adult to deviate from acceptable norms

• Behavior problems may be specific to a situation or person • The mnemonic BASIC aids recall of the five areas of

adjustment in which a child with behavior problems has difficulty

• Most children display one or more problematic behaviors during the first years of life through adolescence

• Incidence of behavior problems is highest during preschool years, with 90% of mothers reporting at least mild concern

• Temper tantrums, which result when a child's emotions exceed the child's ability to control them, peak at 18 months of age and occur weekly in 50% to 80% of children ages 18 months to 3 years

• Behavior problems are often undiagnosed (that is, not addressed during health-care encounters)

Behavior Problems in Children: Pathophysiology

• The primary cause of behavior problems in children is unclear and irregular enforcement of parental expectations for behavior

• Parenting skills and the temperament of the child are both factors in the potential for behavior problems

• Certain risk factors for children and parents are associated with behavior problems

• Protective factors exist for both the child and the family

Behavior Problems in Children: History

Current complaint• Description of misbehavior(s), parent response,

and the effectiveness of that response • Age- and sex-appropriateness of response • Persistence of behavior • Precipitating events • Setting/situation specificity • Extent of disturbance • Type, severity, and frequency of symptoms • Change in behavior

Behavior Problems in Children: HistoryMedical history• Chronic illness of child • Attention deficit/hyperactivity disorder (ADHD) • Anxiety disorder or depressive disorder in parent • Alcohol abuse in parent • Oppositional defiant disorder (ODD)Family history• Family composition • Family dynamics • Discipline techniques • Illness • Developmental milestones • Behavior problems

Behavior Problems in Children: HistoryMedication history• Any medication use that suggests conditions covered in

the medical history • Use of over-the-counter agents to treat upper-respiratory

infection or allergies that could cause hyperactivityPsychosocial history• Relationships with siblings and friends • Behavior in a variety of settings (e.g., school, play,

home, organized sports, youth organizations, after-school programs)

• Physical or sexual abuse • Police involvement • Custody issues • Interaction between child and parent • School history (if patient is an adult, ask from a

perspective of past history)

Behavior Problems in Children: Physical Examination

Examination• Observe the interaction between parents and

child • Note the child's response to direction and

correction • Observe the child's affect and behavior during

play • Look for physical problems that could be

affecting behavior (e.g., conduct neurodevelopmental, vision, and hearing tests)

Behavior Problems in Children: Physical Examination

Diagnostic procedures• Use a behavior rating scale to help spot the

psychologically disturbed child • Select a scale on the basis of age and complaint • Consider having the scale applied by a supervising adult

other than the parents (e.g., a teacher)Differential diagnosis• Normal behavior of childhood • Major behavior problem • Psychological disturbance • Learning disorder • Ineffective parenting • Dysfunctional parenting • Child abuse

Behavior Problems in Children: Treatment

Nonpharmacologic• A behavior-management system should be

initiated as appropriate, maintaining open communication and support with the family during the weeks it may take to notice consistent change

• Appropriate parental intervention is important • Parenting classes, parent support groups, and

social services can be helpfulPharmacologic• Short-term use of antidepressants or antianxiety

agents may be indicated for parents • The child may need stimulants for ADHD

Behavior Problems in Children: Education• Establish a relationship with the family • Acknowledge the difficulty of addressing a child's

developmental issues • Determine a child's expected behaviors according to

developmental level and have the parents discuss and agree what constitutes misbehavior

• Identify parents as role models • Discuss appropriate parenting strategies, including a system

for behavior modification that identifies consequences for misbehavior and positive reinforcement of appropriate behavior

• Reinforce consistency among parents and all caretakers, in all circumstances, as key to a successful system

• Work with parents to improve family communication • Teach parents how to manage temper tantrums • Help parents eliminate unnecessary frustrations by instituting

predictable routines and consistent schedules

Behavior Problems in Children: Education

• Tell parents to increase praise and decrease punishment • Teach parents prospective intervention techniques when complaints

such as irritability, whining, or oppositional behavior occur as a result of fatigue, hunger, overstimulation, or boredom

• Help parents understand the nature of a difficult child's temperament if they have an older child who had a pleasant, relaxed behavioral style as an infant

• Suggest other ways to handle behavior issues • Help parents understand that fluctuating moods and feelings,

accompanied by a push for independence, often leave a toddler insecure and encourage them to react supportively

• Tell parents to reinforce an appropriate expression of strong emotions • With a child who has a history of biting or hitting, advise parents to

maintain a proximal presence so they can intervene promptly • For children with pervasive control difficulties, teach parents how to

identify early warning signs and prevent escalation of angry outbursts to meltdowns

• Encourage parents to spend as much one-on-one time with the child as possible

Behavior Problems in Children: Follow-Up

• Follow up by phone in 1 to 2 weeks; encourage parent to call sooner with questions/difficulties with implementing behavior management

• Schedule a return visit in 4 to 6 weeks • Repeat neurodevelopmental screening if any

developmental lags or deficits are noted • If misbehavior is still unmanaged after 4 weeks,

repeat neurodevelopmental screening • Consider a 6-month interval between well-child

visits until stability is maintained

Behavior Problems in Children: Referral

• Refer for parenting classes, parent support groups, and social services as needed

• Consider referral to a pediatrician, child psychologist, or both for some hyperactivity and learning disorders

• Consult with a physician regarding aggressive or self-destructive behaviors

• Report any suspected cases of child abuse to the appropriate authorities

• Refer complicated (multiple types) or major behavior problems (persistent, inappropriate for age/sex, increasing severity or frequency of symptoms) for evaluation by physician and possible psychiatric evaluation

• Consider consultation or referral for other indications