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Assignment 1: Practicum: Decision Tree

Week 5: Anxiety Disorders in Childhood and Adolescence

“I don’t know why everyone is worried that I don’t want to go out with my friends anymore. I just like to stay home. There is nothing wrong with that. I go to school and get good grades, but I don’t know what to say to those other girls in my class. They ask why I can’t go to the mall with them on the weekend and I get all embarrassed. They don’t understand that I don’t know what to say to them. When I do say something, it is always wrong, or they laugh. I can just stay home and read my books.”

Emma, age 15

Anxiety disorders that plague many individuals in adulthood often have their origins in childhood and adolescence. By identifying those children and adolescents with anxiety disorders, the PMHNP can intervene and teach skills that the client can use to control anxiety throughout his or her life.

This week, you analyze case studies to determine the diagnosis and treatment of anxiety disorders.

Learning Resources

Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.

Required Readings

American Nurses Association. (2014).
Psychiatric-mental health nursing: Scope and standards of practice (2nd ed.). Washington, DC: Author.

• Standard 8 “Education” (pages 69-70)

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014).
Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.

• Chapter 31, “Child Psychiatry” (pp. 1253–1268)

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

• “Anxiety Disorders”

American Academy of Child & Adolescent Psychiatry (AACAP). (2012a). Practice parameter for the assessment and treatment of children and adolescents with obsessive-compulsive disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 51(1), 98–113. Retrieved from
http://www.jaacap.com/article/S0890-8567(11)00882-…

McClelland, M., Crombez, M., Crombez, C., Wenz, C., Lisius, M., Mattia, A., & Marku, S. (2015). Implications for advanced practice nurses when pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) is suspected: A qualitative study. Journal of Pediatric Healthcare, 29(5), 442-452. doi:10.1016/j.pedhc.2015.03.005

Review the following medications:

Note: Many of these medications are FDA approved for adults only. Some are FDA approved for disorders in children and adolescents. Many are used “off label” for the disorders examined in this week. As you read the Stahl drug monographs, focus your attention on FDA approvals for children/adolescents (including “ages” for which the medication is approved, if applicable) and further note which drugs are “off label.”

Required Media

Optional Resources

Thapar, A., Pine, D. S., Leckman, J. F., Scott, S., Snowling, M. J., & Taylor, E. A. (2015).
Rutter’s child and adolescent psychiatry (6th ed.). Hoboken, NJ: Wiley Blackwell.

• Chapter 60, “Anxiety Disorders” (pp. 822–840)
• Chapter 61, “Obsessive Compulsive Disorder” (pp. 841–857)

Assignment 1: Practicum: Decision Tree

For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat pediatric clients presenting symptoms of a mental health disorder.

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 2: 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.

By Day 7 of Week 7

Submit your Assignment.

Case #2

Decision Point One

Obsessive Compulsive Disorder

Decision Point Two

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

Begin Zoloft 50 mg orally daily

Begin Fluvoxamine immediate release 25 mg orally at bedtime

Begin Fluvoxamine controlled release 100 mg orally in the morning

ecision Point Two

Begin Fluvoxamine immediate release 25 mg orally at bedtime

RESULTS OF DECISION POINT TWO

• Client returns to clinic in four weeks
• Upon return to the clinic, Tyrel’s mother reported that he has had some decrease in his symptoms. She states that the frequency of the handwashing has decreased, and Tyrel seems a bit more “relaxed” overall.
• She also reports that Tyrel has not fully embraced returning to school, but that his attendance has improved. She reported that over this past weekend, Tyrel went outside to play with his friend from across the street, which he has not done in a while.

Decision Point Three

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

Increase Fluvoxamine to 50 mg orally at bedtime

Augment with an atypical antipsychotic such as Abilify

Augment treatment with cognitive behavioral therapy

Decision Point Three

Augment with an atypical antipsychotic such as Abilify

Guidance to Student

In terms of an actual diagnosis, the child’s main symptoms are most consistent with obsessive-compulsive disorder. There may also be an element of social phobia developing, but at this point, the PMHNP has not assessed the nature of the school avoidance—that is, why is the child avoiding school. Notice that nothing in the scenario tells us that the PMHNP has assessed this.

Fluvoxamine immediate release is FDA-approved for the treatment of OCD in children aged 8 years and older. Fluvoxamine’s sigma-1 antagonist properties may cause sedation and as such, it should be dosed in the evening/bedtime.

At this point, it would be appropriate to consider increasing the bedtime dose, especially since the child is responding to the medication and there are no negative side effects.

Atypical antipsychotics are typically not used in the treatment of OCD. There is also nothing to tell us that an atypical antipsychotic would be necessary (e.g., no psychotic symptoms). Additionally, the child seems to be responding to the medication, so there is no rationale as to why an atypical antipsychotic would be added to the current regimen.

Cognitive behavioral therapy is the psychotherapy of choice for treating OCD. The PMHNP should augment medication therapy with CBT. If further assessment determines that Tyrel has social anxiety disorder, CBT is effective in treating this condition as well.