Assign 2-WK7(C)

                                            Assignment: 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.

                                                          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. 

                                                                                Case #2
Anxiety disorder, OCD, or something else? 

                                                                    BACKGROUND
Tyrel is an 8-year-old black male who is brought in by his mother for a variety of psychiatric complaints. Shaquana, Tyrel’s mother, reports that Tyrel has been exhibiting a lot of worry and “nervousness” over the past 2 months. She states that she notices that he has been quite “keyed up” and spends a great deal of time worrying about “germs.” She states that he is constantly washing his hands because he feels as though he is going to get sick like he did a few weeks ago, which kept him both out of school and off the playground. He was also not able to see his father for two weekends because of being sick. Shaquana explains that although she and her ex-husband Desmond divorced about 2 years ago, their divorce was amicable and they both endeavor to see that Tyrel is well cared for. 
Shaquana reports that Tyrel is irritable at times and has also had some sleep disturbances (which she reports as “trouble staying asleep”). She reports that he has been more and more difficult to get to school as he has become nervous around his classmates. He has missed about 8 days over the course of the last 3 weeks. He has also stopped playing with his best friend from across the street. 
His mother reports that she feels “responsible” for his current symptoms. She explains that after he was sick with strep throat a few weeks ago, she encouraged him to be more careful about washing his hands after playing with other children, handling things that did not belong to him, and especially before eating. She continues by saying “maybe if I didn’t make such a big deal about it, he would not be obsessed with germs.” 
Per Shaquana, her pregnancy with Tyrel was uncomplicated, and Tyrel has met all developmental milestones on time. He has had an uneventful medical history and is current on all immunizations. 

                                                                OBJECTIVE
During your assessment of Tyrel, he seems cautious being around you. He warms a bit as you discuss school, his friends at school, and what he likes to do. He admits that he has been feeling “nervous” lately, but when you question him as to why, he simply shrugs his shoulders. 
When you discuss his handwashing with him, he tells you that “handwashing is the best way to keep from getting sick.” When you question him how many times a day he washes his hands, he again shrugs his shoulders. You can see that his bilateral hands are dry. Throughout your assessment, Tyrel reveals that he has been thinking of how dirty his hands are; and no matter how hard he tries to stop thinking about his “dirty” hands, he is unable to do so. He reports that he gets “really nervous” and “scared” that he will get sick, and that the only way to make himself feel better is to wash his hands. He reports that it does work for a while and that he feels “better” after he washes his hands, but then a little while later, he will begin thinking “did I wash my hands well enough? What if I missed an area?” He reports that he can feel himself getting more and more “scared” until he washes his hands again.  
        
                                                         MENTAL STATUS EXAM
Tyrel is alert and oriented to all spheres. Eye contact varies throughout the clinical interview. He reports his mood as “good,” admits to anxiety. Affect consistent to self-reported mood. He denies visual/auditory hallucinations. No overt delusional or paranoid thought processes were apparent. He denies suicidal ideation. 
Lab studies obtained from Tyrel’s pediatric nurse practitioner were all within normal parameters. An antistreptolysin O antibody titer was obtained for reasons you are unclear of, and this titer was shown to be above normal parameters. 

                                                   Decision Point One
BASED ON THE INFORMATION PROVIDED IN THE SCENARIO ABOVE, WHICH OF THE FOLLOWING DIAGNOSES WOULD THE PMHNP GIVE TO TYREL?
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.
 
Generalized Anxiety Disorder (GAD)
Obsessive Compulsive Disorder
Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (“PANDAS”)

 ANSWER CHOOSEN: 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
 
Discontinue Zoloft and begin Fluvoxamine controlled release 100 mg orally every morning 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. Zoloft is FDA-approved to treat OCD in children. However, between ages 6 and 12, it should be started at 25 mg orally daily. If starting doses are too high, the child may experience side effects that he associates with the medication and as such, may refuse to take the medication. Starting at too high a dose can result in unfavorable side effects (gastrointestinal side effects are notable in this drug), and we can see that Tyrel is experiencing nausea and decreased appetite. In this case, it is recommended to wait to see if the side effects dissipate. Decreasing the dose to 12.5 mg orally daily for about 3 or 4 days, then going back to 25 mg orally daily may help to overcome the unfavorable side effects. If side effects persist, the PMHNP may need to consider switching to a different medication.Fluvoxamine controlled release is not FDA-approved for use in children with OCD (see “Special Populations: Children and Adolescents” in the Fluvoxamine monograph of Stahl’s Prescriber’s Guide for further details). Fluvoxamine 100 mg orally daily may not be tolerated in the morning secondary to the drug’s sigma-1 antagonist properties, which can cause sedation. Dosing of Fluvoxamine should be such that the larger dose is given in the evening to minimize daytime sedation. It is also worth noting that nothing in the scenario tells us that the Zoloft will not be effective. 

ANSWER CHOOSEN: Begin Fluvoxamine immediate release 25  
mg orally at bedtime 

·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.

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

ANSWER CHOOSEN: Increase Fluvoxamine to 50 mg orally at 
 bedtime

 
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.

                                                 Learning Resources
Required Readings
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)00882-3/pdf 

McClelland, M., Crombez, M-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 Health Care, 29(5), 442–452. doi:10.1016/j.pedhc.2015.03.005

Stahl, S. M. (2014). Prescriber’s Guide: Stahl’s Essential Psychopharmacology (5th ed.). New York, NY: Cambridge University Press. 

SEE ATTACHED ASSIGNMENT OF DECISION TREE AND ASSIGNMENT EXAMPLE/SAMPLE