Assignment: Practicum: Decision Tree

BACKGROUND

In psychopharmacology you met Katie, an 8-year-old Caucasian female, who was brought to your office by her mother (age 47) and father (age 49). You worked through the case by recommending possible ADHD medications. As you progress in your PMHNP program, the cases will involve more information for you to sort through.

For this case, you see Katie and her parents again. The parents have reported that the medication given to Katie does not seem to be helping. This has prompted you to reconsider the diagnosis of ADHD. You will consider other differential diagnoses and determine what information you need to accurately assess the DSM-5 criteria to make the diagnosis of ADHD or another disorder with similar diagnostic features.

When parents bring their child to your office, they may have read symptoms on the internet or they may have been told by the school “your child has ADHD”. Your diagnosis will either confirm or refute that diagnosis.

Katie’s parents reported that their PCP felt that she should be evaluated by psychiatry to determine a differential diagnosis and to begin medication, if indicated. The PMHNP makes this diagnostic decision based on interviews and observations of the child, her parents, and the assessment of the parents and teacher.

To start, consider what assessment tools you might need to evaluate Katie.

· Child Behavior Check List

· Conners’ Teacher Rating Scale

The parents give the PMHNP a copy of a form titled “Conner’s Teacher Rating Scale-Revised” (Available at: https://www.ncbi.nlm.nih.gov/projects/gap/cgi-bin/GetPdf.cgi?id=phd000099.1 ). This scale was filled out by Katie’s teacher and sent home to the parents so that they could share it with their provider. According to the scoring provided by her teacher, Katie is inattentive, easily distracted, makes careless mistakes in her schoolwork, forgets things she already learned, is poor in spelling, reading, and arithmetic. Her attention span is short, and she is noted to only pay attention to things she is interested in. She has difficulty interacting with peers in the classroom and likes to play by herself at recess.

When interviewing Katie’s parents, you ask about pre- and post-natal history and you note that Katie is the first born with parents who were close to 40 years old when she was born. She had a low 5 minute Apgar score. The parents say that she met normal developmental milestones and possibly had some difficulty with sleep during the pre-school years. They notice that Katie has difficulty socializing with peers, she is quiet at home and spends a lot of time watching TV.

SUBJECTIVE

You observe Katie in the office and she is not able to sit still during the interview. She is constantly interrupting both you and her parents. Katie reports that school is “OK”- her favorite subjects are “art” and “recess.” She states that she finds some subjects boring or too difficult, and sometimes hard because she feels “lost”. She admits that her mind does wander during class. “Sometimes” Katie reports “I will just be thinking about something else and not looking at the teacher or other students in the class.”

Katie reports that her home life is just fine. She reports that she loves her parents and that they are very good and kind to her. Denies any abuse, denies bullying at school. She offers no other concerns at this time.

Katie’s parents appear somewhat anxious about their daughter’s problems. You notice the mother is fidgeting with her rings and watch while you are talking. The father is tapping his foot. Other than that, they seem attentive and straight forward in the interview process.

MENTAL STATUS EXAM

The client is an 8-year-old Caucasian female who appears appropriately developed for her age. Her speech is clear, coherent, and logical. She is appropriately oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. She demonstrates no noteworthy mannerisms, gestures, or tics. Self-reported mood is euthymic. Affect is neutral. Katie says that she doesn’t hear any ‘voices’ in her head but does admit to having an imaginary friend, ‘Audrey’. No reports of delusional or paranoid thought processes. Attention and concentration are somewhat limited based on Katie’s short answers to your questions.

Decision Point One

BASED ON THE INFORMATION PROVIDED IN THE SCENARIO ABOVE, WHAT IS YOUR DIAGNOSIS FOR KATIE?

In your write-up of this case, be certain to link specific symptoms presented in the case to DSM–5 criteria to support your diagnosis.

Decision Point One

299.00 Autism Spectrum Disorder (ASD), mild and co-occurring; 300.23 Social Anxiety Disorder

RESULTS OF DECISION POINT ONE

Decision Point One

BASED ON THE INFORMATION PROVIDED IN THE SCENARIO ABOVE, WHAT IS YOUR DIAGNOSIS FOR KATIE?

In your write-up of this case, be certain to link specific symptoms presented in the case to DSM–5 criteria to support your diagnosis.

299.00 Autism Spectrum Disorder (ASD), mild and co-occurring; 300.23 Social Anxiety Disorder

315.0 Specific Learning Disorder with Impairment in Reading and 315.1 Impairment in Mathematics

314.00 Attention Deficit Hyperactivity Disorder, predominantly inattentive presentation

Client returns to clinic in four weeks

You have selected Autism Spectrum Disorder along with co-occurring Social Anxiety Disorder. Based on this choice, outline the remainder of the diagnostic evaluation that you will conduct on this child and their parents. Be sure to include standardized assessment instruments that you would administer

Decision Point Two

BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.

Based on your diagnosis and the parents’ concerns, you decided to begin Risperal 0.5 mg po BID

RESULTS OF DECISION POINT TWO

Decision Point Two

BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.

Begin Donepezil 10 mg po daily

Begin Abilify 5 mg orally daily

Begin Clonidine 0.1 mg po daily

Client returns to clinic in four weeks

Upon her return to the clinic in 4 weeks, Katie’s parents feel that Katie is calmer, but no changes in her school performance have been noted. Additionally, her parents have noticed that she seems more “tired” than usual, and report that she seems to ‘space out’ more often. They further report that she has been falling asleep during her usual television shows.

Decision Point Three

BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.

Decision Point Three

BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.

Increase Risperdal to 1 mg po BID

Augment current dose of Risperdal with Cognitive-Behavioral Therapy and Video Modeling/self-modeling therapy

Reconsider diagnosis

Guidance to Student

The information provided in the scenario is not suggestive of the diagnostic criteria for autism spectrum disorder (ASD) or co-occurring social anxiety disorder. Even if it were, Risperdal is not routinely used to treat autism-spectrum disorder- in fact, there are no FDA approved drugs for treatment of this disorder. Antipsychotics are only used to treat violent or self-injurious behaviors in ASD, and in those cases, used off-label. Antipsychotics did slow Katie down, but also gave her a other side effects, and did nothing to treat the primary presenting problems of inattention.

While CBT has evidence of efficacy in both autism spectrum disorder and social anxiety disorder, and while video modeling and video-self modeling therapy has some evidence for efficacy in ASD, these therapies will not, in and of themselves, help Katie as she does not have ASD with co-occurring social anxiety disorder.

Running Head: ASSIGNMENT 1 PRACTICUM-DECISION TREE

ASSIGNMENT 1: PRACTICUM-DECISION TREE4

Assignment 1: Practicum-Decision Tree

Student’s Name:

Course Name and Number:

Instructor’s Name:

Institution:

Date Submitted:

Practicum: Decision Tree

The Case Study: A young Girl with Difficulties at School

Katie is an 8 years old girl who was recommended ADHD medications for her mental condition. However, the medications offered seem not to work hence there is need for reconsideration of ADHD diagnosis using the DSM-5 criteria.

Decision #1: Differential Diagnosis

Selected Decision:

Attention Deficit Hyperactivity Disorder [ADHD]; Evidenced by Inattentive Presentation

Reason for Making Decision:

Having an age of 8 year, Katie has attained the developmental age. However, she presents symptoms of poor coordination as well as organization concerns. Furthermore, she exhibits inattentiveness in class, is easily distracted, cannot easily recall what she has already been taught, and short attention. She also experiences difficulties in arithmetic, .spelling, and reading. In addition to this, this girl has been reported to be responsive to the items she is quite hooked on. It has been reported that she has difficulties in her social interactions, especially in the classroom with other learners. She is mostly found playing alone during break time.

Based on the DSM-5 criteria for ADHD, patients with ADHD present persistent pattern of distractions. They are inattentive and hyperactive, for instance, cannot sit still, do not pay attention in class. These patients are exceedingly impulsive especially when answering queries. The symptoms that Katie presents are adequate conclude that she has inattention, but she does not qualify for hyperactivity-impulsivity (Somma et al., 2019).

With the symptoms presented by Katie, is paramount to conduct more inquiries with regard to her behavior in diverse settings such as school, while playing with her peers, and at home. The inquiries can be made by her teachers or her parents. In addition to this, it is important to establish whether Katie is suffering from any other mental condition for better clarifications of the symptoms she has presented so as to be sure of ADHD, and not any other condition whose symptoms imitate those of this disease. The information collected regarding Katie through the Conner’s Rating Scale Revised [CRS-R] should then be applied using the DSM-5 guidelines in order to support the diagnoses of ADHD (Izzo, Donati & Primi, 2018).

Anticipated Result with this Decision:

This decision aims at establishing that Katie has no other mental condition that could be used to clarify the symptoms she presented better as well as those that occur at the same time with ADHD. Furthermore, the decision aims aim at, in the best and simple way possible, explaining to the Katie’s parent that the symptoms of inattentiveness, impulsivity, and hyperactivity experienced by their daughter are due to ADHD (Somma et al., 2019). Moreover, the decision will help in ascertaining that the patient is appropriately diagnosed as provided by the DSM-5 standards of diagnosis (Sayal et al., 2018).

Difference Between What I Expected to Achieve with Decision #1 and the Decision Results:

There was no difference between the expectations of the decision and the actual results. I expected similar results of ADHD.

Decision #2: Treatment Plan for Psychotherapy

Why this Decision:

The patient should begin on Adderall XR 10mg orally daily. She should also eat small meals, severally in a day rather than bigger three meals.

Reason for Making Decision:

Adderall XR 10mg is used in the treatment of ADHD by changing quantities various natural substances in the brain. It is also a stimulant drug. Katie will highly benefit from this drug by increasing her attention paying-ability, controlling her antisocial behaviors, and remaining attentive on an activity she is engaged in (Brown, Samuel & Patel, 2018). The drug will also significantly contribute in supporting Katie’s skills of organizing tasks as well as her listening skills. This medication is orally taken with or without food. The medication is approved by FDA and it functions by increasing the brain’s dopamine and norepinephrine. This helps in minimizing any external signals that affect attention and concentration (Brown, Samuel & Patel, 2018).

Unfortunately, appetite in Katie declined after taking this medication. It is therefore highly advisable that she eats small meal for several times in a day. The decreased appetite is a side effect of this drug. It makes her to skip some of her meals. This is dangerous as it can result in low blood sugar, which in turn reduces her ability to focus. It is also highly advisable that she eats her dinner a bit late in the evening after the effects of the medication have reduced.

Anticipated Result with this Decision:

I anticipate that Katie will correctly adhere to the medication as instructed in order for her to increase the ability to pay attention in class, remain attentive to the activities she is involved in, as well as improve on her social behaviors. Eating of small amount of food severally will help Katie in increasing her blood sugar level to normal hence she will remain focused in the course of the day.

Difference Between What I Expected to Achieve with Decision #2 and the Decision Results:

The decision I made and the actual results were not different. I expected the adverse effects of Adderall XR 10mg to be nausea, dry mouth, appetite loss, moodiness, difficulties with sleeping, and headaches. The side effects are mild in some individuals and they fade within the course of a few weeks or even months after a well managed treatment (Brown, Samuel & Patel, 2018).

Decision #3: Treatment Plan for Psychopharmacology

Decision Selected:

Add a small dose of immediate release Adderall in the early afternoon, in addition to family therapy.

Reason for this Decision :

The Katie’s condition and treatment response indicate that she is able to remain focused in class in the morning hours. Unfortunately, she daydreams in the afternoon, an indication that the symptoms come back in the afternoon. This implies that there is need for adjustment of her dose to the appropriate quantity that commensurate with her condition. It is therefore important to add some small quantity of Adderall in the early afternoon in order to make Katie remain attentive throughout the afternoon session. She should also be given some small quantity early evening for her to manage to finish her homework.

Combination of this medication with family therapy will be paramount in the treatment of Katie’s condition. Family therapy will support the family in fostering strong positive relationships. It will greatly reduce emotional tensions in the family as they take care of the child (Smith & Kaye, 2019). The family will therefore have time to address more critical areas such as effectively supporting Katie in her studies.

Anticipated Result with this Decision:

The addition of small quantities of Adderall in early afternoon and evening will greatly help Katie improve on her attentiveness and concentration in class. She will remain focused in the afternoon and in the evening. However, the combination of this drug with the family therapy mostly helps the family, but not Katie in improving on her attentiveness especially in the afternoon and evening. I anticipate that it will motivate the family towards appropriately supporting Katie and cooperating with the relevant in order to understand and address the problem she is suffering from.

Difference Between What I Expected to Achieve with Decision #3 and the Decision Results:

I expected that the small dose of Adderall medication added in the early afternoon and evening will greatly help Katie in remaining attentive in class and while doing her homework. I also anticipate that the Family Therapy will significantly motivate the parents to cooperate with the medical professional team in order to understand and address the challenges that their daughter is facing. The parents will also be supportive in eliminating the symptoms that Katie presents.

Ethical Considerations Impacts on Treatment Plan and Communication with clients and Families:

As a qualified professional nurse, I am expected to make sure I let the parent know the actual condition that the girl is suffering from. I am also expected to make sure I do the correct diagnosis of her condition, and do the appropriate medication prescription. Furthermore, I will have to let the parents know the side effects of the medication prescribed to Katie. In general, I will try and reduce information asymmetry as much as I can (Gavin & McNicholas, 2018).

Refernces

Brown, K. A., Samuel, S., & Patel, D. R. (2018). Pharmacologic management of attention deficit hyperactivity disorder in children and adolescents: a review for practitioners. Translational pediatrics, 7(1), 36.

Gavin, B., & McNicholas, F. (2018). ADHD: science, stigma and service implications. Irish journal of psychological medicine, 35(3), 169-172.

Izzo, V. A., Donati, M. A., & Primi, C. (2018). Conners 3–Self-Report Scale: An empirical support to the dimensionality of the content scales. Clinical child psychology and psychiatry, 23(4), 556-566.

Sayal, K., Prasad, V., Daley, D., Ford, T., & Coghill, D. (2018). Barriers to medication entitlements after diagnosis of ADHD–Authors’ reply. The Lancet Psychiatry, 5(1), 19-20.

Smith, B. A., & Kaye, D. L. (2019). Collaborative Care: An Effort to Increase Behavioral Health Adherence by Supporting the Primary Care Provider. In Psychiatric Nonadherence (pp. 165-176). Springer, Cham.

Somma, A., Carlotta, D., Boni, F., Arlotta, E., Masci, E., Busso, S., … & Fossati, A. (2019). Reliability and validity of the Structured Clinical Interview for DSM-5-Clinician Version (SCID-5-CV) Attention Deficit/Hyperactivity Disorder Criteria: preliminary evidence from a sample of 217 Italian adolescents. Cited in: EMBASE-Excerpta Medica Database• Index Copernicus• PsycINFO• SCOPUS• Google Scholar• Emerging Sources Citation Index (ESCI), a new edition of Web of Science, 3.https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6660/03/mm/decision_tree/index.html