Assignment: Practicum: Decision Tree (Due in Week 4)

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

o Which Decision did you select?

o Why did you select this Decision? Support your response with evidence 

and references to the Learning Resources.

o What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.

o Explain any difference between what you expected to achieve with 

o Decision #1 and the results of the Decision. Why were they different?

· Decision #2: Treatment Plan for Psychotherapy

o Why did you select this Decision? Support your response with evidence and references to the Learning Resources.

o What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.

o Explain any difference between what you expected to achieve with 

o Decision #2 and the results of the Decision. Why were they different?

· Decision #3: Treatment Plan for Psychopharmacology

o Why did you select this Decision? Support your response with evidence and references to the Learning Resources.

o What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.

o 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: In APA Format and proper citation, Support your rationale with a minimum of three academic resources/references no more than five years old. Include introduction and conclusion.

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: 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:

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 two:

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

RESULTS OF DECISION POINT TWO

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:

Increase Risperdal to 1mg po BID

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.