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Pediatrics Unique in 2020:

Autism and Adolescence

Behavioral Health

Rhonda Conner-Warren PhD, RN,CPNP -PC

Assistant Professor Health Programs

Michigan State University College of Nursing

Nursing Grand Rounds

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Disclaimer

I don't have anything to disclose.

This presentation is free of financial and commercial

interest.

This program serves to promote any understanding

and discussion.

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Objectives

Discuss autism and adolescent behavioral/cognitive concerns during the Covid eraDiscuss

Discuss evidence-based management of autism in children and adolescentsDiscuss

Discuss medication options in treating children with autism or behavioral health issuesDiscuss

Participants will discuss cognitive-based therapy, the importance of psychoeducationDiscuss

Identify referrals when/where appropriateIdentify

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What is unique about you since Covid?

Answer this question in the chat

z Key points

Considerations for children in the COVID era

Treatment medication/cognitive behavioral

Community resources for parent and child

z Children's mental health

There are about 40 million children under

the age of 14 that exhibit some form of

mental of behavioral disorders.

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There are disparities regarding mental health disorders

Uninsured children have higher rates of unmet needs then publicly

supported children Latino children have a greater rate of unmet

needs

Latino adolescents have higher rates of suicidal thoughts,

depression and, anxiety

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Autism Spectrum Disorder

ASD

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Autism Spectrum Disorder

Characteristics

Persistent deficit in social communication and social interaction

across multiple contexts

Deficits emotional reciprocal relationships

Deficit in verbal and nonverbal communication behaviors

Deficits in developing, maintaining and understanding

relationships

Attention deficit disorder

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When these symptoms occur in primary care

The first question is what we do, when we suspect something’s not quite right!

Examination of overall health state: Vision, hearing, growth and

development.

Routine testing consist of assessing for language or abnormal use of

language

Testing for social reciprocity

Restrictive, repetitive patterns of behavior, interests or activities

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Adolescent Development

ADD?

“During adolescence, this is a time when kids are really

primed to want to explore their environment, to seek out

new experiences. And being stuck at home with your

parents isn’t really the best way to fulfill those

developmental needs,“ Schacter,2020

https://www.wxyz.com/rebound/coronavirus-stress/kids-teens-could-be-feeling-pandemic-related-

stress-heres-how-parents-can-help

Many have inconsistent performance at work or in their

careers; have difficulties with day-to-day

responsibilities; experience relationship problems; and

may have chronic feelings of frustration, guilt or blame.

https://chadd.org/understanding-adhd/

zCOVID 19

Since March in Michigan 55% of households are living with children birth -

17 have reported 55% of income loss. https://datacenter.kidscount.org/data/tables/10877-adults-living-in-households-with-children-who-lost-employment-income-since-march-13-

Morbidity: black and Hispanic children are more likely to have severe cold

outcome.

Hispanic ethnicity, black race and children with underlying conditions were

more commonly reported among children hospitalized and admitted to

coping ICU. https://www.nbcnews.com/health/health-news/covid-19-twice-likely-teens-younger-kids-n1241244

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Behavioral and cognitive challenges during COVID-19

Social Distancing

The closure of respite services

The closure of schools

Key milestones prom, sporting events and graduation

The decrease in social interactions with family and friends and

within your community.

Recently given hope and it has been taken away.

As an outcome on behavioral health mental health issues that

had been an increase in mental health challenges

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Outcomes of social distancing

School age Adolescent

zMental Health–Related Emergency Department Visits Among Children Aged <18 Years During the COVID-19 Pandemic —United States, January 1–October 17, 2020 (Morbidity and Mortality Weekly Report (MMWR)

Adolescents aged 12–17 years accounted for the largest

proportion of children’s mental health–related ED visits during

2019 and 2020

Mental health concerns in Children might be exacerbated by

stress related to the pandemic and abrupt disruptions to daily life

associated with mitigation efforts, including anxiety about illness,

social isolation, and interrupted connectedness to school

https://www.cdc.gov/mmwr/volumes/69/wr/mm6945a3.htm#:~:text=During%20weeks%2012%E2%80%9342%2C%202020%2C%20the%20proportion%20of%20mental,years%20remain

ed%20similar%20in%202020.

z Evidence Based Management

Testing

Medication

Cognitive behavioral Therapy

z Is it truly attention deficit?Testing

The only way to be certain of this diagnosis is to have children tested.

We also need reports from the child’s teacher in this case some providers

may actually use electronic versions of the form following all hit the

guidelines making it easier for the teacher to submit information that can tell

us how well the child is performing online or historical.

Assessment tools: The Connor scale, Vanderbilt, CBASC, MSEE, CB CL

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ADHD-Testing

DSM-IV criteria looks at the symptomology.

Setting

Inattentive symptoms

Hyperactive/impulsivity symptoms

Combination the child may be considered mild, moderate, or severe

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Medical Treatment

Physical assessment

Address the behavioral in medication treatment.

Then address Attention Deficit Disorder

Evaluation/reevaluation off medication used medications used

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Medication Management

Stimulants the gold standard

SNRI-Strattera that can also be used to treat the comorbidity of anxiety.

Concerns with the medications is the issue of use and miss use

zHomeopathic treatments

Omega-3s for ADHD

One study suggested that a subgroup of boys with ADHD are deficient in omega-3

fatty acids compared with those who have no symptoms of the condition.

Zinc, Iron, and Magnesium for ADHD

Zinc synthesizes dopamine and augments the effects of methylphenidate2. Low

levels of this mineral correlate with inattention.

Iron is also necessary for making dopamine. In one small study3, ferritin levels (a

measure of iron stores) were low in 84 percent of ADHD children compared to 18

percent of the control group. Low iron levels correlate with cognitive deficits and

severe ADHD.

https://www.additudemag.com/homeopathy-for-adhd-popular-remedies-scientific-evidenc

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Nursing care

Here are some of the nursing actions that must be addressed

Baseline of the patient’s physical health status height, weight and CBC, Liver

enzymes.

Know if the patient states having externalizing behaviors with aggression

zThe contingency plan

If the parent has access to a local clinic counselors can develop

additional relationships with both outside clinics to have the child’s blood

pressure, weight checked and if necessary laboratory test.

Contingency therapy continues to have emphasis on environmental and

social aspects

They may also consider positive and negative issues occurring in the

patient’s life to consider how their functioning in their behavior

z Education

504 plan

IEP

A comfort timing in an timing out of the classroom

Flexibility with assignment and logins

About time for breaks

Resource room online promote that connectedness and support

z Recommendations for your health

Ensuring availability of and access to developmentally appropriate

mental health services for children outside the in-person ED.

Implementation of technology-based, remote mental health services

and prevention activities to enhance healthy coping and resilience in

children might effectively support their well-being throughout response

and recovery periods.

z Recommendations for your home

Stay physically active

Choose a creative activity

Address the nutritional needs/access

Sleep hygiene-Melatonin

Mindfulness/relaxation activity

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Cognitive behavioral therapy(CBT)

Cognitive behavioral therapy (CBT) is a common type of talk therapy

(psychotherapy). You work with a mental health counselor (psychotherapist

or therapist) in a structured way, attending a limited number of sessions.

CBT helps you become aware of inaccurate or negative thinking so you can

view challenging situations more clearly and respond to them in a more

effective way.

https://www.mayoclinic.org/tests-procedures/cognitive-behavioral-therapy/about/pac-20384610

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Be on the lookout

Stressed-out children

Adolescents who drink and smoke

Children abusing prescription medication

Aggressive children

z Resources

Testing on line resources:

www.cdc.gov/ncbddd/autism/hcp-screening.html

https://adhdonline.com/

Family Support

•https:/Autsimspeaks.org

•https:/ www.cdc.gov/ncbddd/autism/autism-spectrum-disorder-in-teenagers-adults.

•Parent-Child Interaction Therapy (PCIT) http://www.pcit.org/

z Resources

Families

CHADD: https://chadd.org/understanding-adhd

Providers

https://www.depressioncenter.org/mc3rule

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Words of

encouragement !

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References

Cognitive Behavioral Therapy https://www.mayoclinic.org/tests-procedures/cognitive-behavioral-therapy/about/pac-20384610

Dolan MA, Fein JA; Committee on Pediatric Emergency Medicine. Pediatric and adolescent mental health emergencies in the emergency medical services system. Pediatrics 2011;127:e1356–66

Golberstein E, Wen H, Miller BF. Coronavirus disease 2019 (COVID-19) and mental health for children and adolescents. JAMA Pediatr 2020;174:819–20

Gurwitch RH, Salem H, Nelson MM, Comer JS. Leveraging parent-child interaction therapy and telehealth capacities to address the unique needs of young children during the COVID-19 public health crisis. Psychol Trauma 2020;12(S1):S82–4

Leeb RT, Bitsko RH, Radhakrishnan L, Martinez P, Njai R, Holland KM. Mental Health–Related Emergency Department Visits Among Children Aged <18 Years During the COVID-19 Pandemic — United States, January 1–October 17, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1675–1680. DOI: http://dx.doi.org/10.15585/mmwr.mm6945a3

Schacter, H.(2020) https://www.wxyz.com/rebound/coronavirus-stress/kids-teens-could-be-feeling-pandemic-related-stress-heres-how-parents-can-help