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NRSG262 child and adolescent health Goals of child and adolescent health  To improve the health and well-being of children and young people  To improve the accessibility and appropriateness of health services for children and young people  To improve the quality of health services provided to children and young people  To promote partnerships within the health system and with other public and community based agencies which impact on the health of children and young people How healthy are Australia children?  Mortality – favourable trend  Chronic conditions – prevalence of asthma has decreased, cancer and type 1 diabetes has remained the same  Disability – 7% of all Australian children  Dental health – 80% of children have access to fluoridated water = favourable trend. However dental decay is the most common chronic condition of childhood. How healthy are Australia children?  Mortality - injury and poisoning – 2/3 of deaths  Chronic conditions – prevalence of asthma has decreased to 11%, cancer survival improving but type 1 diabetes increasing Mental health – 9% high or very high levels of psychological distress  Disability – 7% of Australian young people – Communicable diseases – up to 4 fold increase in notifications  Dental health – decay twice as high for 15 year olds as 12 year olds Preventable mortality  Injury – Leading cause of mortality and morbidity after the first year of life  Aboriginal Child Health – Aboriginal and Torres Strait Island children are at greater risk although they are a small proportion of the population (4.9%)  Sudden Infant Death Syndrome – 58 per 100,000 deaths in 1997‐99 to 25 per 100,000 in 2010‐2012 Morbidity  Birth Defects – Neural tube defects (eg spina bifida), structural defects, visual and hearing impairments  Low Birth Weight – 2500 grams= 6.4% (very low birth weight 15 years • Major concerns:  Dietary habits  Substance use (particularly cigarettes)  STIs  Effects of poverty  Onset of prenatal care  Psychological development or maturity Adolescent nutrition Nutritional needs  Marked variation in dietary needs of adolescents

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Pregnant adolescents continue to exhibit food preferences, eating behaviours and lifestyle habits as non-pregnant peers: o Frequent snacking o High intake of fat & sugar o Low intake of calcium, iron, zinc, folic acid & vitamins Pregnant adolescents should be encouraged to have a diet with sufficient nutrients to meet their own growth needs and that of their unborn child

Adolescent Birth  Younger adolescents (12 – 15 years) o Smaller stature & incomplete growth can lead to prolonged labour due to Cephalopevic disproportion (CPD) o Higher rates of interventions & Caesarean births  Critical point between CPD and adequacy is around 15 years of age in the average adolescent  Older adolescents (15 – 21) o Often have labours that are shorter than average, particularly if they have given birth previously Adolescent Responses to Labour and Childbirth  Very young adolescents (< 14 years) have fewer coping mechanisms and less experience to draw on than older adolescents  Because cognitive development is incomplete, may have fewer problem solving capabilities  Ego integrity may be more threatened by the experience  May be more vulnerable to stress & discomfort  May be more childlike and dependent on others Adolescent Postnatal Expectations Adolescents often have unrealistic expectations for the infant in regard to:  Feeding breast or artificial feeding?  Crying  How much is normal?  Sleeping  How much is normal?  Ongoing demands of parenthood  Adolescents may need extra assistance from midwives initially to learn to care for their baby  Then receive ongoing support when they return home from nurses  Many children of adolescents are raised by a grandparent WEEK 4 MENTAL HEALTH FOR CHILDREN AND FAMILIES Mental health The National Mental Health Strategy & National Prevention  Strategy recognises:  The need for effective action to promote mental health; and  The need to prevent the development of mental health problems in children The National Standards for Mental Health Services focus on:  How services are delivered  Whether they comply with policy directions  Whether they meet expected standards of communication and consent  Whether they have procedures and practices in place to monitor and govern particular areas—especially those which may be associated with risk to the consumer, or which involve coercive interventions. Key principles The key principles for the National Standards of Mental health strategies are consistent with national policy and requirements for the delivery of mental health services in Australia and are embedded in the Standards. Key principles that have informed the development of the Standards include:

Mental health services should promote an optimal quality of life for people with mental health problems and / or mental illness.  Services are delivered with the aim of facilitating sustained recovery.  Consumers should be involved in all decisions regarding their treatment and care, and as far as possible, the opportunity to choose their treatment and setting. Key Principles cont.  Consumers have the right to have their nominated carer(s) involved in all aspects of their care.  The role played by carers, as well as their capacity, needs and requirements as separate from those of consumers is recognised.  Participation by consumers and carers is integral to the development, planning, delivery and evaluation of mental health services.  Mental health treatment, care and support should be tailored to meet the specific needs of the individual consumer.  Mental health treatment and support should impose the least personal restriction on the rights and choices of consumers taking account of their living situation, level of support within the community and the needs of their carer(s). Finally, the Standards describe care that will be delivered in accordance with each of the nine (9) domains from the Key Performance Indicators for Australian Public Mental Health Services (2015) as follows: 1. Effectiveness: care, intervention or action achieves desired outcome in an appropriate timeframe. 2. Appropriateness: care, intervention or action provided is relevant to the client’s needs and based on established standards. 3. Efficiency: achieving desired results with the most cost-effective use of resources. 4. Accessibility: ability of people to obtain health care at the right place and right time irrespective of income, physical location and cultural background. 5. Continuity: ability to provide uninterrupted, coordinated care or service across programs, practitioners, organisations and levels over time. 6. Responsiveness: the service provides respect for all persons and is client orientated. It includes respect for dignity, cultural diversity, confidentiality, participation in choices, promptness, quality of amenities, access to social support networks, and choice of provider. 7. Capability: an individual’s or service’s capacity to provide a health service based on skills and knowledge. 8. Safety: the avoidance or reduction to acceptable limits of actual or potential harm from health care management or the environment in which health care is delivered. 9. Sustainability: system or organisation’s capacity to provide infrastructure such as workforce, facilities, and equipment, and be innovative and respond to emerging needs. 

Perinatal Mental Health Psychiatric diagnoses are 4 times greater in the perinatal period Could it be ...  Grief? – Adjustment disorder?  Anxiety?  Mood disorder?  Personality disorder?  Psychosis?  Substance related? Tocophobia Tocophobia – fear of pregnancy or childbirth Predisposing factors  Sexual abuse  Termination of pregnancy  Instrumental/operative birth  Foetal distress, severe pain  Perineal tearing Consequences  Termination of pregnancy, sterilisation Associated with

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Hyperemesis gravidarum Depression (including AND/PND) & PTSD 18/01/2018

Predicting Postnatal Depression  Screen in pregnancy  30% – 40% of women with PND display symptoms in pregnancy – routine screening – EPNDS (Edinburgh Post Natal Depression Scale) o Level of placental CRH (Corticotrophin-releasing hormone) at 25 weeks gestation may help predict postnatal depression  Assess for non biological risk factors & explore possible interventions o Low self-esteem, antenatal anxiety, low social support, negative cognitive style, major life events, low income, history of abuse etc. Management Strategies 1. Psychological therapy & support 2. Pharmacology 3. Social support 4. Complementary therapy Psychological Therapy & Support  Psychotherapy  Information support  Debriefing  Home visits Pharmacology  Selective serotonin reuptake inhibitors (SSRI) o Taken by 5% – 9% of pregnant women & 10% of lactating women o Increase the extracellular level of serotonin by inhibiting its reuptake into the pre‐ synaptic cell, increasing the level of serotonin in the synaptic cleft available to bind to the postsynaptic receptor  Tricyclics  Benzodiazepines  Antipsychotic Antidepressants During Lactation  Only small amounts pass into breast milk o Drugs of choice - Sertraline, Paroxetine & Nortriptyline o Adverse effects reported – Fluoxatine & Citalopram  Low dose does not assure the infant will be unaffected o Immature hepatic & renal function o Infant blood-brain barrier is also immature o No studies of long term effects  Antidepressants can delay lactation & inhibit the sucking reflex  Need to balance against negative effects of maternal depression Improving Breast Feeding Safety  Breast feed immediately before drug intake to minimize infant exposure to medication o When mother’s plasma concentration is at its lowest  Give lowest effective dose of medication  Observe child for adverse effects such as GI symptoms, sedation, agitation, poor feeding, or poor weight gain  Consult healthcare provider to discuss whether breastfeeding should be continued Evidence Based Practice Although each case requires a risk-benefit decision, in light of available data, potential benefits of breast feeding seem to outweigh the risks of exposure to SSRIs

Natural Antidepressants  Rhodiola rosea (aka golden or arctic root) o Adaption plant for treating lethargic depression o Combined with conventional antidepressants to alleviate side effects  Chromium (commonly used nutritional supplement) Beneficial effect on eating-related atypical symptoms of depression, seasonal affective disorder  Inosital o A sugar alcohol & a structural isomer of glucose, vitamin B8 o May be useful in the treatment of bipolar depression when combined with mood stabilisers  5-Hydroxytryptophan (5-HTP) o Aromatic amino acid produced by the body from the essential amino acid Ltryptophan, involved in the synthesis or serotonin o Produced commercially from African plant o Used for 30 years to treat depression Social Support  Family  Friends  Support groups  Indigenous support workers Complementary Therapy  Infant massage – benefits all members of the family, including fathers  Exercise (to improve mood) o Psychological theories distraction hypothesis, mastery hypothesis, social interaction o Biological mechanisms endorphins, neurotransmitter (monoamines), nor epinephrine, serotonin, dopamine o Thermogenic effect reduces muscle tension, bolsters the immune response, may increase uptake of monoamines Effects of maternal depression on children Infants Passivity Anger Low weight gain Insecure attachment Attention and arousal problems

Toddlers Passive noncompliance Less independence Lower performance Less interaction with others on verbal and memory tests Less creative play

Specific Mental Health Disorders in Infancy  Feeding & eating disorders  Pervasive developmental disorders  Relationship problems or attachment disorders  Anxiety disorders or separation anxiety  Motor skills disorders Effects of maternal depression children School age Impaired adaptive functioning Depressive disorders Anxiety disorders Attention disorder Lower IQ

Adolescents Depressive disorders Anxiety disorder Substance abuse Conduct disorders Attention disorder Learning difficulties

Specific Mental Health Disorders in Childhood Usually grouped into: Internalising behaviour  Mood  Sleep  Thoughts  Parents often report ‘something is not quite right’ Externalising behaviour  Aggressive and delinquent behaviours  Under controlled behaviours Specific Mental Health Disorders in Adolescence  First onset psychosis  Eating disorders  Mood disorders  Anxiety disorders Mental health “Approximately 28% of young Australians are depressed, anxious, involved in antisocial behaviour and/or high alcohol consumption” Strategies to Assist Young People  The ‘whole school’ model focuses on the ways schools can enhance protective factors for students: o Mutually respectful, inclusive, safe & supportive environment free from prejudice & discrimination o Ensuring the whole curriculum, across all subjects areas, promotes wellbeing by enhancing respect for diversity, providing opportunities for participation, achievement, communication & relationship building o Working in partnership for the wellbeing of the total school community  The ‘Promoting Better Mental Health’ initiative aims to help young people with mental health problems & drug & alcohol problems  This initiative supported by the establishment of a National Youth Mental Health Foundation o Focus on early identification & intervention for young people (12 – 25 years) at risk of developing mental health problems o Or those showing early signs of mental health problems o Or associated drug & alcohol problems Indigenous child health  Early childhood is one of three identified priority areas under the whole of government arrangements for Indigenous affairs  The Healthy for Life program aims to improve the health of ATSI mothers, infants & children; & those affected by chronic diseases, through specific activities in maternal & child health & chronic disease in over 80 sites across Australia o The program aims to develop a whole‐of‐life approach to break the cycle of poor health from childhood to adulthood  Indigenous Child Health Check introduced in June 2005 in the Northern Territory, but the program has been extremely controversial  

Suicide in Aboriginal communities continues to escalate • In 2007 suicide was three (3) times as prevalent among Aboriginal people as among other Australians o Hanging was the most common method o Occurred most frequently among those aged 15 – 34 (ABS 2014)

Current Service Models  The development of Child & Adolescent Mental Health Services (CAMHS) has been essential to meet the needs of this specific age group

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However, there has been a growing call for the need a separate system dealing with youth psychiatry Rationale: youth–onset mental disorders are the most serious health problems of their development period, both in mortality & morbidity

Early Intervention  Evidence suggests that young people are poorly informed about mental health issues, including knowledge of key symptoms of mental disorders, & when and how to find help  This is worrying, given that early diagnosis of potentially serious psychiatric disorders in young people is essential in order to inform the choice of treatment & to predict outcome or prognosis Strengthening Medicare  Through the Strengthening Medicare initiative, GPs are being paid an additional Medicare rebate of $5 for each bulk billed service they provide to Commonwealth concession card holders & children aged under 16 years  This initiative has increased access to care, particularly for those in low socioeconomic groups, including students Research & Information  Children’s Headline Indicators are designed to focus the policy attention of Governments on a set of priority issues for children’s health, development & wellbeing  Mechanism to assist policy & planning by measuring progress on a set of indicators, which should change over time in response to prevention & early intervention strategies Research & Information The Longitudinal Study of Indigenous Children (LSIC)  Footprints in Time: the Longitudinal Study of Indigenous Children  Aim for ATSI peoples’, communities & government departments to gain a better understanding of Indigenous children’s health, education, family relationships, community, culture & housing  Study will span remote, regional & urban areas  Target babies aged less than 12 months; & four to five-year-olds WEEK 5 PATHOPHYSIOLOGY OF BONE GROWTH AND FRACTURES IN CHILDREN Children’s anatomical and physiological characteristics  Young children have more cartilage than bone o Ossification gradually occurs through to puberty o Thicker periosteum that limits displacement of bone / cartilage  Bone may bend instead of fracturing o Child may even be able to use a # arm and walk on a # leg if the periosteum is intact (Ball, Bindler & Cowen, 2014) Healing is more rapid in children  Bone growth is still occurring  Rapid replacement of bone cells  High level of activity stimulates bone growth and remodeling Fractures in Children  Children’s bones are more easily damaged than an adult o E.g. by twisting, minor falls o Less bony so less force is required to cause fracture o Active mobility and lack of coordination contribute to frequency of factures in children  Fractures are less likely to be accompanied by soft tissue damage o They are not so obvious Treatment  Alignment- depends on age.

Distance of the fracture from the end of the bone The amount of angulation. The younger the child and the closer to the epiphyseal plate, the greater the chance of deformity. Treatment of peadiatric hip fractures has the following goals:  Anatomic reduction  Maintenance of reduction until complete healing  Minimisation of complications associated with the injury and its treatment  The most important factors determining the outcome of treatment in these injuries are as follows: o Age of the child o Type of fracture o Degree of displacement of the fracture fragments o Length of time since injury   

Types of fractures

Growth Plates and Fractures  Growth plates in long bones are the weakest area o Weaker than supporting ligaments o Forces that would cause a sprain in an adult may cause a fracture in children  Fractures can occur across physes (Growth plate), epiphyses and metaphyses growth implications?  Salter-Harris classification for fractures involving growth plate Recent Research Meta Analysis Extensive analysis of research publications on growth plate fractures found that  52% of distal femoral growth plate fractures had some form of growth disturbance  22% of all distal femoral growth plate fractures developed a leg length discrepancy of > 1.5 cm  Greater incidence of growth disturbance in children treated with fixation but a decreased incidence of significant growth disturbance   in other words, the treatment worked to limit growth disturbance! X-ray Children’s fractures do not always show on X-ray  As they have more cartilage than bone  Sometimes an angulation shows Diagnosis is made on history and clinical signs  E.g. point tenderness and deformity  As well as an understanding of typical #s in children X-ray evidence will show:  As healing occurs and callus forms in 3 – 4 weeks Fractures in Infancy Causes:

 Birth Trauma (esp. clavicle)  Injury  Child abuse  Rough handling, twisting, pulling Other than from MVAs, true accidents are rare in infancy   injuries / fractures should be thoroughly investigated for abuse  Or Osteogenesis Imperfecta Abuse is indicated by: X-ray showing  Fractures at various stages of healing  Periosteal bleeding in long bones  Usually caused by rough handling, twisting and pulling of limbs  No explanation or hospital visit for injury, yet evidence on xray 3-6 weeks after injury o When callous has formed/healing occurred  Explanation or story of injury does not fit / or is inconsistent with clinical picture Toddler fracture  Toddlers ligaments ar...