Case #1: A young girl with difficulties in school

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Case #1: A young girl with difficulties in school

Case #1: A young girl with difficulties in school

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: ). 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: Case #1: A young girl with difficulties in school

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

RESULTS OF DECISION POINT ONE

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

RESULTS OF DECISION POINT ONE

  • Client returns to clinic in four weeks
  • You have selected 315.0 Specific Learning Disorder with Impairment in Reading and 315.1 Impairment in Mathematics. 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.

Comprehensive Integrated Psychiatric Assessment

The comprehensive integrated psychiatric assessment of a child or adolescent consists of gathering information from not only the child but from several sources, most notably the family members, caregivers, and the child’s teacher or school counselor. Because of this, the diagnostic assessment becomes more complicated. Issues of confidentiality, privacy, and consent must be addressed. Also, the PMHNP must take into consideration the impact of culture on the child.

In this Discussion, you review and critique the techniques and methods of a mental health professional as he or she completes a comprehensive integrated psychiatric assessment of an adolescent.

Learning Objectives

Students will:
  • Evaluate comprehensive integrated psychiatric assessment techniques
  • Recommend assessment questions

To Prepare for the Discussion:

  • Review the Learning Resources concerning the comprehensive integrated psychiatric assessment.
  • Watch the Mental Status Examination video.
  • Watch the two YMH Bostonvideos.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click submit, you cannot delete or edit your own posts and cannot post anonymously. Please check your post carefully before clicking Submit!

By Day 3

Based on the YMH Boston Vignette 4 video, post answers to the following questions:

  • What did the practitioner do well?
  • In what areas can the practitioner improve?
  • At this point in the clinical interview, do you have any compelling concerns? If so, what are they?
  • What would be your next question, and why?

Discussion: Parent Guide

Note: You and your group will use the wiki function to develop three Parent Guides (one in Week 3, one in Week 7, and one in Week 10). A wiki is a site that allows collaborative editing by all users. Each group will have its own place to communicate and collaborate on the assignments. Once your group has completed each assignment, one member should transfer the information to its final format and submit it through the group submission link in the Discussion. Do not delete the assignment from the wiki format, as your Instructor will review this area to determine each member’s participation.

Collaboration is essential to accurate diagnosis of the conditions under consideration in this week. For this week’s Discussion, you practice collaboration by working in a group on developing a “Parent Guide,” which will serve as a teaching tool for parents with children who have been diagnosed with a specific mental health disorder.

It is recommended that you make your project as attractive as possible and consider using the finished product as teaching tools for families that you will work with in your own practices.

Learning Objectives

Students will:

  • Analyze signs and symptoms of neurodevelopmental disorders
  • Analyze the pathophysiology of neurodevelopmental disorders
  • Analyze diagnosis and treatment methods for neurodevelopmental disorders
  • Evaluate Parent Guides

To Prepare for this Discussion:

  • Your Instructor will assign you to a group and a disorder by Day 1 of Week 2.
  • Review the resources concerning your assigned disorder.
  • Review the Blackboard Help website concerning wikis.
  • Use your group’s Discussion Board to design and develop the Parent Guide before posting to the group wiki. For further guidance, refer to the Accessing Group Discussionsinstructions below.

Using evidence-based research, design and develop a Parent Guide for your assigned disorder including:

  • Signs and symptoms
  • Pathophysiology
  • How the disorder is diagnosed
  • Treatment options

Provide a minimum of three academic references.

 

 

Assignment 1: Practicum: Decision Tree

For this Assignment, you examine the client case study in this week’s Learning Resources. Consider how you might assess and treat pediatric clients presenting with symptoms noted in the case.

Note: This Assignment is the first of three assignments that are based on interactive client case studies. For these assignments, you will be required to make decisions about how to assess and treat clients. Each of your decisions will have a consequence. Some consequences will be insignificant, and others may be life altering. You are not expected to make the “right” decision every time; in fact, some scenarios may not have a “right” decision. You are, however, expected to learn from each decision you make and demonstrate the ability to weigh risks versus benefits to prescribe appropriate treatments for clients.

Learning Objectives

Students will:
  • Evaluate clients for treatment of mental health disorders
  • Analyze decisions made throughout diagnosis and treatment of clients with mental health disorders

The Assignment:

Examine Case 1. You will be asked to make three decisions concerning the diagnosis and treatment for this client. Be sure to consider co-morbid physical as well as mental factors that might impact the client’s diagnosis and treatment.

At each Decision Point, stop to complete the following:

  • Decision #1: Differential Diagnosis
    • Which Decision did you select?
    • Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
    • What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
    • Explain any difference between what you expected to achieve with Decision #1 and the results of the Decision. Why were they different?
  • Decision #2: Treatment Plan for Psychotherapy
    • Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
    • What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
    • Explain any difference between what you expected to achieve with Decision #2 and the results of the Decision. Why were they different?
  • Decision #3: Treatment Plan for Psychopharmacology
    • Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
    • What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
    • Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
  • Also include how ethical considerations might impact your treatment plan and communication with clients and their families.

Note: Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement.

CASE NUMBER 1

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