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CHAPTER 37 • Mental Disorders of Childhood and Adolescence

BOX 37.9 Trauma-Informed Approaches: Childhood Adversity in Youth Entering Residential Care Background

the court system because of fighting, truancy, speeding tickets, car accidents, petty crimes, substance misuse, or suicide attempts. They may be hostile, sarcastic, defensive, and provocative. At the same time, they may appear calm, outgoing, and engaging. Inconsistencies, distortions, and misrepresentations of the truth are com mon when interviewing these children and adolescents, so obtaining a clear history may be difficult. Therefore, instead of asking whether an event or behavior occurred, it may be better to ask when it occurred. These adoles cents are adept at changing the subject and diverting discussions from sensitive issues. They often use denial, projection, and externalization of anger as defense mech anisms when asked for self-disclosure. The assessment, which may take several sessions, should be conducted in a nonjudgmental fashion. High levels of marital conflict, parental substance misuse, and parental antisocial behav ior often mark family history. After patient and staff safety are established, improving communication and coping skills should be the patient’s priorities. The nurse can help the patient develop insight into the need for enhanced communication and positive coping. Taking Action: Nursing Interventions Children with oppositional defiant disorder or conduct disorder who also have specific neurodevelopmental dis orders should be placed in appropriate programs for reme diation. If a diagnosis of ADHD or depression emerges from the evaluation, appropriate pharmacotherapy should be considered (see previous discussion of ADHD and later discussion regarding depression). In planning inter ventions for patients with oppositional defiant disorder or conduct disorder, the focus is on problematic behaviors. Therapeutic progress may be slow, at least partly because these patients often lack trust in authority figures. Interventions The nurse must consider patterns of childhood adversity when working with children and adolescents with behav ioral issues. This screening information can better inform interventions for children and their families. Source: Gordon, C. T., Nguyen, P. T., Mitchell, A. K., & Tyler, P. M. (2023). Profiles of childhood adversity and associated psychopathology in youth entering residential care. Psy chological Trauma: Theory, Research, Practice & Policy , 15 , S82–S91. Planning Recovery and Wellness Outcomes: Generating Solutions

Etiology The etiologies of oppositional defiant disorder and con duct disorder are complex. More attention has been paid to conduct disorder, probably because it is the more seri ous of the two. Models used to understand aggressiveness (see Chapter 20) are useful in examining these childhood disorders, which appear to have both genetic and envi ronmental components (Tesli et al., 2024). Exposure to childhood adversity is known to increase a child’s risk for internalizing and externalizing issues (Gordon et al., 2023). See Box 37.9. EVIDENCE-BASED NURSING CARE FOR CHILDREN WITH DISRUPTIVE Records of over 2,000 youth entering a family-style res idential program were reviewed to examine profiles of patterns of childhood adversity. Five profiles were found: (1) Low Exposure, (2) Familial Dysfunction, (3) Neglect/ Emotional Abuse, (4) High Exposure without Sexual Abuse, (5) High Exposure with Sexual Abuse. Overall, female children were more likely than male children to have profiles of Neglect/Emotional Abuse and High Exposure with Sexual Abuse. Each of the five profile pat terns were associated with different clinical outcomes. The nurse gathers data from multiple sources. Adolescents with disruptive behavior disorders are at high risk for physical injury as a result of fighting and impulsive behavior. Sexual promiscuity is common in conduct dis order, resulting in an increased frequency of pregnancy and sexually transmitted infections. An important aspect of assessment is to rule out comorbid conditions that may partially explain or com plicate the individual’s lack of behavioral control. These conditions include ADHD, learning disabilities, chemi cal dependency, depression, bipolar disorder, or anxiety disorders. Children and adolescents who are chronically depressed may be irritable and easily frustrated. Given the tendency of adolescents to act out their frustra tion, chronic depression may exacerbate their behavior. Conduct issues can also elevate the risk for depression because young people who regularly elicit negative atten tion from parents and teachers and are constantly at odds with their environment may become despondent. Adolescents with conduct issues are usually brought or forced into the mental health system by family, school, or BEHAVIOR DISORDERS Recognizing Cues: Relevant Assessment Information

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