N129 Mental-Health Mnemonics

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N129 Mental-Health Mnemonics



Mental Health

• 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

• 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

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

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

Medical history
• Neurological disorder
• Psychiatric illness or hospitalization
Family history
• Psychiatric disorders
• Substance abuse
• Alzheimer disease
• Learning disorders
Medication history
• Maternal use of illicit drugs or alcohol during pregnancy
(if the patient is a child)
• Use of alcohol, tobacco, and drugs
Psychosocial history
• Recent life changes, both positive and negative

Physical 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

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,
• Substance-abuse disorders
• Delirium and dementia

• 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 assertivecommunication 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

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


Fear is a cognitive (thinking) process that involves intellectual appraisal,
whereas anxiety is an emotional (feeling) response to appraisal of the
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
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
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

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

Panic disorder
• All anxiety disorders can have a component of panic
• Symptoms are at the extreme end of the anxiety
Panic 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 minutes
Panic disorder with agoraphobia
• Characterized by global incapacitation and avoidant
• Stems from anxiety about being in places or situations
from which escape might be difficult or help may not be

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

Specific 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

Obsessive-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
• 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

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

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
• Preexisting emotional problems are believed to increase
• 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
• 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

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

Theoretical 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
• 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

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

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,
• 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

Family history
• High incidence of anxiety in other family
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
• 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
• Electrocardiography
• Complete blood count with differential and
electrolyte levels
• Thyroid-function test
• Liver-function profile
• Urinalysis with drug screen
• Chest radiography

Physical Examination
Differential 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

• The most critical intervention is to establish
rapport and trust in a quiet, calm, and supportive
• 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

• Benzodiazepines are prescribed by many as a secondline 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
• 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
• Explain options for treatment
• Teach the avoidance of foods that contain stimulants
• Follow up weekly to evaluate the patient's response
• Progress is made when the patient accomplishes certain

• 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

• 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
• 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
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


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


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

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

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

Current 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

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

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

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 cocaine
Psychosocial 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
• 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
• 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
• 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 Examination
Differential diagnosis
• Organic mood disorder
• Schizophrenia
• Grief
• Delirium
• Dementia
• Substance abuse
• Endocrine disorders
• Liver failure
• Chronic fatigue
• Renal failure

Nonpharmacologic 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

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

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

• 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
• 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
• 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

• Refer the patient to a mental-health specialist for
• 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 atrisk newborns

• 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.

• Bipolar disorder, formerly referred to as manicdepressive 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.


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
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

• 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, secondmessenger abnormalities, and mitochondrial dysfunction
• Recent studies focus on the involvement of the prefrontal
cortex, amygdala, and hippocampus


Determine whether the patient is experiencing a manic episode on
the basis of duration and the presence of three or more signs or
Determine whether the patient is experiencing a depressive episode
on the basis of duration and the presence of five or more signs and
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
• 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 exist
Differential diagnosis
• Bipolar disorder is often poorly diagnosed, misdiagnosed, or
• 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 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.
• Psychotherapy, including cognitive-behavioral
therapy (CBT) or insight therapy
• Electroconvulsive therapy (ECT)
• Crisis intervention

• 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

• 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
• 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

Follow-Up and Referral
• Follow-up of the patient with bipolar disorder, generally
conducted by a psychiatrist, depends on a variety of
• 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
• 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

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

• 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


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

Current complaint
• Aversive behaviors, particularly with respect to
• 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

Medical history
• Birthweight and gestational age
• Mother's prenatal, perinatal, and neonatal
• 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
• Risk of lead exposure
• Food allergies

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 siblings
Medication history
• Maternal medication use or sedation during labor

Psychosocial 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
• 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 Examination
Diagnostic procedures
• Laboratory tests to differentiate physiologic (organic) from nonorganic
• 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

• 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
• No drugs are indicated for FTT unless an underlying
disease is found

• 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 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
• 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

• 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:
• 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

Attention Deficit–Hyperactivity
Disorder: History
Current complaint
• Symptoms: uninhibited behavior, inability to sustain
attention, impaired impulse control, excessive movement
• Onset of symptoms
Medical 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
• Injury events
• Sleep disorders
• Other history relevant to risk factors

Attention Deficit–Hyperactivity
Disorder: History
Family history
• Parents or siblings with ADHD or similar
Medication 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
• 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
• 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 hyperactivityimpulsivity, 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

Attention Deficit–Hyperactivity Disorder:
Physical Examination
Differential diagnosis
• As many as one-third of children have one or more coexisting
• Oppositional defiant disorder (ODD) has a 35% prevalence with
• Conduct disorder (CD) has a 26% prevalence with ADHD
• Generalized anxiety disorder (GAD) has a 26% prevalence with
• Depressive disorder has an 18% prevalence with ADHD
• Learning disabilities are present in 12% to 60% of patients with
• 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:
The best approach is a multidisciplinary team, but a consistent primary
provider is essential. The nurse practitioner may serve as the case
• 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
• 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:
• 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 norepinephrinereuptake 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:

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
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
• 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 approach
• 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
• 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:
• 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
• Certain risk factors for children and parents are
associated with behavior problems
• Protective factors exist for both the child and the

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: History
Medical 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: History
Medication 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 hyperactivity
Psychosocial history
• Relationships with siblings and friends
• Behavior in a variety of settings (e.g., school, play, home,
organized sports, youth organizations, after-school
• 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
• Observe the interaction between parents and
• Note the child's response to direction and
• Observe the child's affect and behavior during
• 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:
• 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
• Appropriate parental intervention is important
• Parenting classes, parent support groups, and
social services can be helpful
• 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
• 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
Encourage parents to spend as much one-on-one time with the child as

Behavior Problems in Children:
• 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 selfdestructive 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
• Consider consultation or referral for other indications

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