Case study:vulnerable aggregates

For the purposes of this course guide, only a few vulnerable aggregates have been selected for discussion. You are encouraged to extend your thinking beyond this preliminary list to include the kinds of clients you meet or expect to meet in your own practice. As you read the scholarly papers posted in the forum, further issues related to vulnerable aggregates will emerge.

New mothers, perhaps more than any other aggregate, look to Registered Nurses for support and guidance throughout their pre- and post-natal experiences. Opportunities to promote mental health exist in childbirth education classes, inpatient care throughout the birthing process, and pre-school vaccination clinics. One notable example is the primary prevention strategy mentioned previously where television advertisements promoting entirely substance free pregnancies are hoped to deter the onset of Fetal Alcohol Syndrome (FAS).

According to the Pacific Post Partum Support Society (http://www.postpartum.org/), both in Canada and internationally, an estimated one out of every six women experiences troubling depression or anxiety after the birth or adoption of a child. This is referred to as postpartum depression and can be a tremendously stressful time for the family. Many factors contribute to a difficult postpartum adjustment or depression including sleep deprivation, financial stress, grief over an unexpectedly difficult birth, a traumatic family history, and the high expectations of the mother and the society in which she lives. Instruments such as the Edinburgh Postnatal Depression Scale can help nurses identify potential problems and facilitate help through prompt referral and follow up.

Children and Adolescents

Knowing the differences between normal developmental milestones and psychopathology are essential when helping children and their parents. For example, repeated incidents of behaviours such as intentionally setting fires or maliciously hurting animals or other children are NOT normal. Research suggests that children who experience major losses, such as death or divorce, are at risk for the development of psychopathology (Boyd, 2008). Similarly, children whose parents engage in unhealthy lifestyles are also at risk. Issues of attachment with parents or significant others often emerge with younger children. Issues of seeking identity and independence through high risk behaviours such as drug use, unprotected sex, and delinquent behaviours often emerge with adolescents. Adolescents are considered an at risk population for suicide. Telephone hot lines are valuable resources for children and adolescents.

Recent advances in the psychiatric field, many of which are controversial, have created diagnostic “labels” for behaviours previously often considered simply a “phase” or “just part of growing up.” Standardized data collection instruments that involve parents, teachers, health professionals and the children themselves can assist with diagnosis and differentiating patterns of aberrant behaviour from isolated incidents of mischief.

DSM IV classification distinguishes among childhood disorders through categories such as developmental, externalizing, internalizing, and “other” behaviour. Developmental categories include Mental Retardation (below-average intellectual functioning as evidenced by an IQ score under 70) and Pervasive Developmental Disorders (PDD) including communication and learning disabilities. Autism, one common PDD, is a long-term disability where individuals seem detached and experience profound difficulty engaging and interacting with others. Children with autism often engage in repetitive behaviours such as incessant head banging.

Externalizing categories include the disruptive behaviour disorders: Attention Deficit Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder and Conduct Disorder. Attention Deficit Hyperactivity Disorder (ADHD) is defined by the presence of inattention, impulsiveness and frequently, hyperactivity. Today, ADHD is a common disorder of children and adolescents and affects more boys than girls. Treatment approaches include combinations of medication (usually stimulants such as methylphenidate – Ritalin), parent/teacher training, and child behaviour programs. Primary features of Oppositional Defiant Disorder include persistent disobedience, argumentativeness, and tantrums. Conduct Disorder is characterized by lying, truancy, stealing, and fighting.

Internalizing categories include Depression and Anxiety disorders. Major Depressive illness in children presents in parallel ways as Major Depression does in adults and is often treated with anti depressant medication. However, the use of psychotropic medication of any kind with children and adolescents, whose bodies and minds are continuing to develop, remains an issue that requires further research. Separation Anxiety and Obsessive Compulsive Disorders may emerge in children as well.

Other disorders of children and adolescents include encopresis (repeated passage of feces into inappropriate places), enuresis (repeated voiding of urine into inappropriate places), Tourette’s (vocal or motor tics) and in rare cases, childhood schizophrenia.

A variety of treatment approaches exist and children and their families are generally best advised to consider a combination of treatment possibilities. Family therapy, nutritional counseling, play therapy, alternative medicine, bibliotherapy and psychopharmacology may all offer help.

The Elderly

Once again, knowing the differences between normal developmental transitions expected within the aging process and psychopathology is essential when helping our elders. Losses associated with declining physical abilities, the death of spouse and friends, and a need for assisted living will evoke sadness. Also, preparing for death through actions such as writing a will, giving away prized possessions, and discussing the experience of death and afterlife beliefs are all anticipated.

However, clinical depressive and anxiety disorders can be overlooked with this population. Assessment for suicidal ideation and persistent feelings of fear and dread are often indicated. As we have emphasized throughout this course, careful observation and documentation translated into relevant assessment instruments can greatly assist clients. Extensive literature from nursing and other disciplines is available and you are encouraged to remain informed about mental health issues specific to vulnerable aggregates of elderly that you encounter in your own professional practice.

Survivors of Violence

In the 1800′s, it was the Society for the Prevention of Cruelty to Animals (SPCA) who first interceded on behalf of a child being beaten. Since then, throughout the world, agencies and organizations have been created to prevent and eliminate violence. However, individuals and groups continue to use violent means to impose power and control over others. Violence can include physical, emotional, and sexual harm and may be present in any area of life. Examples include spouse, child and elder abuse in families, sexual abuse including rape in interpersonal relationships, bullying behaviour in schools and workplaces, and acts of terrorism and torture perpetrated by one ethnic group on another.

Acts of violence are often associated with social isolation and substance abuse by the perpetrator. In some cases, perpetrators are protected rather than punished by groups they are affiliated with. Survivors may experience profound guilt and shame, making disclosure of abuse difficult. In fact, victims of abuse and torture may only disclose their experiences many years later. Survivors of violence value assurance that the experience was NOT their fault.

Health care and other professional groups in Canada and internationally have taken a zero tolerance position toward violence. For example, the Canadian Association of Registered Nurses has a clear policy advocating the elimination of violence in society (http://www2.cna-aiic.ca/CNA/documents/pdf/publications/PS57_Violence_March_2002_e.pdf). The College and Association of Registered Nurses in Alberta, in a joint position statement with the Association of Registered Psychiatric Nurses and the College of Licensed Practical Nurses, (http://www.nurses.ab.ca/pdf/Joint_Statement_on_Family_Violence.pdf) advocates zero tolerance of family violence. Trade unions also advocate zero tolerance of violence in the workplace. For example, the Canadian Federation of Nurses Unions, in conjunction with the Canadian Association of Registered Nurses, stipulate that zero tolerance of violence is a fundamental principle (http://www2.cna-aiic.ca/CNA/documents/pdf/publications/JPS95_Workplace_Violence_e.pdf). National and provincial professional associations and union sites continue to update members on expectations and opportunities for Registered Nurses to make a difference as advocates against violence.

The Discharged Mentally Ill

Since the move in the 1970s towards deinstitutionalizing individuals diagnosed with psychiatric illnesses, the criminal justice system and homeless shelters are all too often the primary providers for discharged mentally ill persons. Most research findings agree that the mentally ill account for 25% to 35% of the homeless population and that 50% of those who are homeless demonstrate symptoms of depression and or schizophrenia (Mohr, 2005). More individuals detained in jails are now known to have a chronic mental illness. Crimes leading to incarceration may result from symptoms of mental illness such as command hallucinations or diminished capacity to make clear judgments. The likelihood of arrest increases when mental illness is associated with drug and alcohol use. Other criminal behaviour may be an attempt to maintain daily needs and includes such acts as sleeping in an abandoned building and being charged with trespassing (Mohr, 2005). Some homeless individuals, including families with young children, victims of abuse, and those who face increasing poverty as a result of eviction and job loss, experience acute stress reactions as a result of their circumstances.

Managing medication with the discharged mentally ill is a priority. As we discussed earlier, compliance with psychotropic drugs that frequently produce devastating side effects is challenging. For clients experiencing hallucinations, compliance is further challenged when “voices” command the individual not to ingest the medication. Depot injections provided on weekly or monthly clinic visits can be helpful.

However, many medications such as lithium are not available by depot. Attending to tasks such as drinking extra water with lithium and applying sunscreen to prevent photosensitivity (sensitivity to the sun leading to profound sunburn) with neuroleptics are often neglected. For the homeless, carrying drugs of any sort increases the risk of assault and robbery because most medications have street value. Within the prison system, “cheeking” prescribed medications for re-sale occurs.

The process of returning from homelessness or the prison system to the community is a complex and anxiety-producing experience. Knowledge of agencies that exist and referral requirements are essential in preventing clients with psychiatric problems from “slipping through the cracks” within the Canadian health care system.

Specialized education programs exist within the field of psychiatric mental health nursing. For example, the Forensic Nurses? Society of Canada (http://www.forensicnurse.ca/) forensic means pertaining to the law) offer specific guidance for nurses working with clients also involved with the legal system.

The International Association of Forensic Nurses (http://www.forensicnurse.org/) offers further information on the sub-specialty as well.

Readings

Reading 1: Required – Online Resource
Locate one scholarly article regarding post-partum depression in Canadian women.

Learning Activity 1: Required – Article Summary

Post a summary of the Canadian article that you read for your reading requirement. Remember to include an APA style reference to identify your source and to comment on at leas two of your peers’ posts.

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