psychiatric nursing

1. History taking on Childhood and adolescent
Psychiatric Disorders
Presented by,
Sudipta Debnath
Junior Lecturer
CON,CMC,Vellore

2. Whom should I talk to first???
• For young children:
– 1 or >1 initial interviews of parents without the
child may be appropriate
– But child should be interviewed alone also at some
point of time .
• Adolescents:
– Include them from the starting with/without
parents

3. History of presenting illness

4. Intellectual disability
• Conceptual skills:
– language; reading and writing; and money, time and
number concepts;
• Social skills:
– interpersonal skills, social responsibility, self-
esteem, gullibility, naivety (i.e. wariness), follows
rules/obeys laws, avoids being victimized, and
social problem-solving;
• Practical skills:
– activities of daily living (personal care),
occupational skills, use of money, safety, health
care, travel/transportation, schedules/routines.

5. • Assessment of
– Nonsymbolic (e.g., gestures, vocalizations,
problem behaviors) and/or symbolic (e.g., words,
signs, pictures) communication;
– Play;
– Social interaction and social communication;
– speech production;
– Safe swallowing;
• Impairment in vision, hearing, speech or mobility
should be mentioned
• History of medical, educational, and vocational status
as well as caregiver and client/patient perspectives on
the problem.

6. ADHD (Attention Deficit Hyperactivity
Disorder)
• Inattentive, (often):
– Fails to give close attention to details or makes
careless mistakes in schoolwork, work, or other
activities
– Difficulty sustaining attention in tasks or play
activities
– Does not seem to listen to what is being said
– Does not follow through on instructions and fails
to finish schoolwork
– Has difficulties organizing tasks and activities

7. • Hyperactivity :
–Fidgeting with or tapping hands or feet,
squirming in seat
–Leaving seat in classroom or in other
situations in which remaining seated is
expected
–Running about or climbing excessively in
situations where this behavior is
inappropriate (in adolescents, this may be
limited to subjective feelings of restlessness)
–Difficulty playing or engaging in leisure
activities quietly

8. –Unable to be or uncomfortable being still for
extended periods of time (may be
experienced by others as “on the go” or
difficult to keep up with)
–Excessive talking
–Blurting out answers to questions before the
questions have been completed
–Difficulty waiting in lines or awaiting turn
in games or group situations
–Interrupting or intruding on others (for
adolescents may intrude into or take over
what others are doing)

9. • Other
– Amount of distress or impairment in social, academic,
or occupational functioning
– Often avoids or strongly dislikes tasks (such as
schoolwork or homework) that require sustained mental
effort
– Often loses things necessary for tasks or activities
(school assignments, pencils, books, tools, or toys)
– Often is easily distracted by extraneous stimuli
– Often forgetful in daily activities

10. Autism (RED flags)

11. Depression
• Depressed mood - For children and adolescents, can be an
irritable mood
• Diminished interest or loss of pleasure
• Weight change or appetite disturbance ( / )- For children,
this can be failure to achieve expected
• Sleep disturbance
• Psychomotor agitation or retardation
• Fatigue or loss of energy
• Feelings of worthlessness or inappropriate guilt
• Decreased concentration or indecisiveness
• Refusing to attend school or poor school performance
• Suicidal ideation or thoughts of death

12. • Impulsive, risk-taking, or self-injurious behaviour.
• Somatic complaints (e.g., headaches and
stomachaches), particularly for younger children
• Early and recent negative life events
• Psychosocial and academic problems (including
bullying, social withdrawal, avoiding school)
• Neglect of the child or sibs
• Physical, sexual and psychological abuse
• Harassment by peers
• Substance use/abuse (including nicotine)

13. Conduct disorder
• History of sibling violence, abuse of family pets, and
cruelty to animals outside of family
• Age of onset
• History of symptoms
• Difficulties during infancy, including temperament
• Behavior during the preschool years, especially
– oppositional and/or aggressive behaviour,
– attention and impulse control (ADHD symptoms),
– attachment problems involving parent or caregiver

14. • Context in which the child exhibits the problem
behaviour (alone or in a group)
• Specific events associated with the onset of the
behaviour problems, including injury or illness
• Corporal punishment of the child
• Physical and sexual abuse history (as victim and/or
perpetrator)
• Legal history
• Treatment history of child, history of hospitalizations,
adoptions and placements in foster care and out-of-
family care
• Parents' perception of the child's strengths and
weaknesses

15. To the child:
• Specific questions about changes in mood, with
special attention for signs of depression or anxiety
disorder and level of self-esteem
• Peer relationships
• Evidence of self-injury, suicidal and homicidal
thoughts and behaviour
• Specific questions about sexual or physical abuse,
sexual behaviour and promiscuity, substance abuse

16. Oppositional defiant disorder
• History of temper tantrums for his or her
developmental level
• Argumentativeness
• Often actively refuses adults’ requests or defies rules
• Often apparently deliberately, does things that annoy
other people
• Often blames others for his or her own mistakes or
misbehaviour
• Is often ‘touchy’ or easily annoyed by others
• Is often angry or resentful
• Is often spiteful or resentful.

17. Past history
• Onset of symptoms
• Pattern and duration
• Impact in functioning
• RED Flags
– h/o seizure
– Regression in development
– >97th or <3rd percentile in any of growth curve
– Sudden onset
– Altered LOC, severe fatigue, cognitive changes,
headache, nausea and weight changes
– Acute onset of OC symptoms or tics...particularly
following pharyngitis (PANDAS)

18. Birth history
• Consanguinity
• Planned/unplanned pregnancy
• Use of assistive reproductive technologies
• Pregnancy : exposure to
– Teratogens
– Alcohols, tobacco, illicit substance
– Medications
– h/o rashes, fever
• Previous neonatal deaths or acute life threatening
episodes in siblings
• Previous spontaneous abortions (>2)

19. Developmental history
• Early developmental history
– Fine and gross motor development
– Coordination: age of
• Neck holding
• Tooth eruption
• Sitting
• Standing and
• Walking
– Speech and language: age of
• First words
• First sentences
• Receptive and expressive languages
• Bowel and bladder control
• Type of play
• Any regression

20. Emotional development and
temperament
• Few questions that can be asked for inquiring about this
are:
– In the first few weeks & months of his/her life, how
was he like?
– Was he a very quiet/ moderably so?
– How did the child respond to changed circumstances?
– How would you know that the baby liked/disliked
something?
– Could you divert him easily & stop him crying?
• Also ask the adolescent about any antisocial/delinquent
behavior:
– Have you done anything that you now look back on
and think was pretty dangerous?

21. School history
• Age of beginning
• School changes: if any, reason
• Attendance
• academic strength and weaknesses
• Motivation to learn
• Attitude towards authority
• IPR with peers/teachers
• WARNING signs of school violence
– Social withdrawal
– Excessive feelings of isolation, rejection
– Feelings of being persecuted
– Expression of violence in writings /drawings
– Uncontrolled anger

22. –Substance abuse
–Severe destruction of property
–SIBs/ suicidal threats
–Severe rage for minor reasons
–Patterns of impulsive and chronic hitting,
intimidating & bullying behaviors
–Physical fights

23. Personal history
• Peer relations
• Hobbies and interests
• Conscience and values
• Substance abuse
• Unusual and traumatic life events
– Sexual/physical abuse
– Domestic violence
– Exposure to any disaster
– Any life changes

24. Family history
• h/o any neuropsychiatric illness
• Family functioning
– Coping styles
– Communication patterns
• Parent-child interactions
• Parental functioning
– Parental attitude, hope, fear, expectation regarding child
– Attachment towards child
– Boundaries and alliances within the family
– Child’s way of fitting in the system
• Social & environmental conditions