Answer to colleaguee

Celestina Igbinosun

College of Nursing-PMHNP, Walden University

PRAC 6675: PMHNP Care Across the Lifespan I

Robert Daun PMHNP

06/21/2023

 

 

 

 

 

 

 

 

Case Study Objectives:

1. Outline the clinical presentation of a child with Autism.
2. Develop differential diagnosis for children with Autism
3. Develop appropriate treatment plans for children with Autism
4. Recommend health promotion and education for patients and families of children with Autism.

 

 

Subjective:

CC: “My head keeps telling me to run away from home.”

HPI: K. W., an 11-year-old African American Female, presents to the clinic with her mother and junior brother for a follow-up to discuss previous psychiatric evaluation for concentration difficulty, attempt to run away from home, medication management, and recent referral for family psychotherapy. At her last appointment a week ago, Abilify was increased to 5mg PO daily, and Zoloft was increased to 50mg PO daily. On initial intake to the clinic, the patient was having difficulties with concentration and was inattentive; she mentioned she daydreams a lot and does not feel like doing anything. Her school grades were poor, and she is homeschooled. The patient was easily distracted, did not follow through on instructions, and was forgetful when completing tasks. Also, the patient ran away in the middle of the night, was picked up by law enforcement, and returned home to a safe environment. She stated she ran away from home because she felt she did not belong. The patient was started on Guanfacine 0.5mg PO daily, which showed improvement, and then increased to 1mg, which has been very effective. The patient was adopted by a Caucasian couple with two other adopted AA children. The patient’s birth mother was addicted to drugs and alcohol, which she kept consuming throughout pregnancy. The patient was delivered at 27 weeks gestation and was adopted as a baby because her birth mother did not want her baby. The patient recently began her menstrual cycle, and according to her adoptive mother, the attitude/behavior of the patient changed. Two weeks ago, when she presented to the clinic, she had been hospitalized for eight days at Children’s National Medical Center for attempting to run away from home by jumping off a three-story apartment building in the middle of the night. The hospital performed tests, and the patient was diagnosed with Autism and confirmed that she was functioning at a 4-year-old level.

The patient was in a wheelchair with a cast on her right arm and right leg because she broke them during the jump. The patient admits she has “hard times” and cannot handle her tantrums; she feels irritable and gets upset quickly, always thinking her life is stupid, always sad, and does not feel like playing with her younger brother. She mentioned that she feels guilty putting the family through all this because she did not like being away from home for eight days with limited visiting hours. She admitted that voices in her head keep telling her to run away from home, and she cannot stop the voices. Recently, with a cast on her arm and leg, she tried to run away by attempting to climb through a vent in her room, not comprehending that she would not fit into the vent hole. Fortunately, her brother saw her doing it in the middle of the night and alerted their parents. As a result, the patient’s mom now sleeps by the door of the patient’s room to avoid her running away from home. The patient admits to seeing things no one else sees. The patient reported that the last psychotherapy session was terrible because she yelled at her parents and brother and said mean things to them. The patient wants to know why she was given up at birth and was adopted. Her mom informed the patient several times that her biological mother could not care for her, so she decided to give her away, but the patient did not seem to comprehend. As per her mom, patient asked why her skin color is different from her adopted parents, and she has explained to the patient a couple of times that it is different because her biological mom is dark-skinned like the patient.

Substance Current Use: Patient denies use of caffeinated drinks, alcohol, or illicit drugs. The patient’s biological mother abused alcohol and drugs during pregnancy, and the patient was delivered at 27 weeks gestation. The patient’s biological father also abused drugs and alcohol and committed a crime that sent him to jail.

Medical History: Fetal Alcohol Syndrome; Intellectual Developmental Disorder; Attention Deficit Hyperactivity Disorder, inattentive type; Major Depressive Disorder and Autism.

 

• Current Medications: Guanfacine 1mg PO daily (ADHD); Zoloft 50mg PO daily(MDD); Abilify 5mg PO daily(Autism); Melatonin 3 mg PO qhs (Insomnia) & Benztropine 0.5mg PO daily (prevention for EPS).
• Allergies: No known drug or food allergies. Denies seasonal allergies.
• Reproductive Hx: Last menstrual cycle 05/29/2023. The patient is not sexually active and is not on contraceptives.

Psychosocial History: The patient was raised by adoptive parents since she was a baby.

            She lives with her adoptive parents, an older adopted sister (16 years old), and a younger adopted brother (10 years old).

She is homeschooled and in 5th grade

No history of physical or sexual abuse

The patient has never met biological parents

Family Psychiatric History: Biological mother is addicted to drugs and alcohol.

            Biological father: Alcohol use disorder and currently incarcerated.

            Adopted mother does not have any history of biological parents families.

ROS:

• GENERAL: No weight loss or gain, no fever or chills. The patient is in a wheelchair due to a fall.
• HEENT: Patient denies any visual issues. No hearing difficulties. Denies any congestion or sneezing. She denies running nose or sore throat.
• SKIN: No wounds or bruises noted. She has no rash and denies any itching.
• CARDIOVASCULAR: She denies any chest pain.
• RESPIRATORY: She denies any difficulty with breathing
• GASTROINTESTINAL: Patient denies any stomach issues, no nausea, or vomiting. Appetite is good.
• GENITOURINARY: Patient denies any problems with urination or bowel movement. Last bowel movement was last night.
• NEUROLOGICAL: Patient has no complaint of headache or feeling of dizziness. No history of seizures.
• MUSCULOSKELETAL: Patient’s right arm and right leg are in a cast due to a fall.
• HEMATOLOGIC: No signs of bleeding and no reports of anemia.
• LYMPHATICS: No swelling to neck, armpits, or groin areas.
• ENDOCRINOLOGIC: Patient denies cold or heat intolerance.

Objective:

Diagnostic results: Vital signs: BP 100/49, HR-78, R-18, T-98.1, Sat. 99% Room air.

Lab work from Children’s National Medical Center: Comprehensive metabolic profile – WNL; Complete blood count with differential – WNL; Thyroid stimulating hormone – WNL; Lipid profile – WNL.

Screening test: PHQ-9 = 18/27 (moderately severe depression)

GAD-7 = 10/21 (moderate anxiety)

Assessment:

Mental Status Examination: She is an 11-year-old African American female who appears her stated age. She came to the clinic in a wheelchair with a cast to her right arm and right leg, accompanied by her adopted mother and junior brother. The patient appeared well-dressed for the weather. Patient’s motor activity is restricted to the wheelchair. Her speech is clear, incoherent, and got loud in her tone when speaking to mom. She speaks over mom and provider without seeking for permission. Her thought process is not logical, and her reasoning is impaired. The patient does not comprehend that she could be hurt while trying to run away from home, and regardless of the broken extremities, the patient made another recent attempt to run away from home. She admitted that voices in her head kept telling her to run away from home and that she will succeed this time. There is no evidence of looseness of association or flight of ideas. Her mood is sad, and she cried at the clinic for a bit, irritable, and her affect is flat. When asked why she was crying, she stated her behavior is not her fault, it’s the voices in her head. The patient admitted to having auditory and visual hallucinations. No evidence of delusional thinking.

The patient denies any suicidal or homicidal ideations, but her actions say otherwise, she is a high risk for self-harm. She is alert and oriented. Her recent and remote memory is intact. The patient’s concentration is good, and her insight is poor. Appetite is good. As per mom, patient wakes up frequently at night and has difficulty falling back asleep. The patient is not comprehending why she was adopted and why her biological mother would give her away. She does not understand why her skin color differs from her adoptive parents. No reports of seizures in the past or present. Patient denies decreased need for sleep, increased energy, excessive talking, racing thoughts, or grandiosity.

Diagnostic Impression: Autism Spectrum Disorder F84.0

According to DSM-5, important characteristics of autism spectrum disorder are continuous impairment in the exchange of social communication and interaction and similar patterns of behavior and interest (APA, p.60, 2022). These symptoms are present at a young age and can stagnant a child’s everyday functioning. This is one of the patient’s diagnoses from the Children’s national medical center while at the hospital for 8 days. Patient was observed and monitored closely while hospitalized. Patient has a history of fetal alcohol syndrome, which predisposes her to the autism spectrum.

 

Attention Deficit Hyperactivity Disorder, predominantly inattentive F90.0

The diagnostic criteria are the continuous inattention format that obstructs an individual’s functioning or development (APA, p.70, 2022). Inattention presents in ADHD as straying off task, lack of abiding by instructions or completing assigned work, unable to concentrate, and being disorganized (APA, p.70, 2022). I agree with this diagnosis because prior to starting Guanfacine patient lacked focus, was inattentive, daydreamed, and had poor school grades.

 

Intellectual Developmental Disorder, moderate (IDD) F71

“This is a disorder with onset during the developmental period that includes deficits in general mental abilities and impairment in everyday adaptive functioning in comparison to an individual’s age, gender, and socioculturally matched peers (APA, p.38, 2022)”. This diagnosis is determined based on both clinical assessment and standardized testing of intellectual functions (APA, p.38, 2022). In this case study, the patient received an in-person individualized, standardized intelligence testing by a licensed psychologist before establishing care with this provider. The results showed intellectual developmental disorder. Research has shown that psychiatric disorders are thrice as prominent in children with IDD than those with typical development, especially ODD, ADHD, Anxiety disorder, ASD, and FASD (Siegel et al., 2020). This writer accepts this diagnosis because the patient’s symptoms match the diagnostic criteria mentioned in DSM-5.

 

Major Depressive Disorder F33.0

The diagnostic criteria of MDD are having a depressed mood in all or almost all activities for most of the day occurring for at least two weeks together with a change in appetite, sleep, change in energy level, feelings of self-condemnation, inability to think/concentrate/decide, suicidal ideation or suicide attempt (APA, p.185, 2022). This is a diagnosis I agree with because the patient portrays these symptoms according to DSM-5.

 

Differential Diagnosis:

Schizophrenia: This is a neurodevelopmental disorder, and childhood-onset schizophrenia is rare and should not be misdiagnosed because not every child with psychotic symptoms has schizophrenia (Kendhari et al., 2016). The symptoms portrayed with schizophrenia are composed of positive (hallucinations, delusions) and negative symptoms (cognitive deficits). According to DSM-5, the diagnostic criteria must include two or more of the following; i) Delusions; ii) Hallucinations; iii) Disorganized speech; iv) Catatonic behavior; or v) Negative symptoms, and one of the symptoms must include i, ii, or iii (APA, p.113-114, 2022). From our case study, we can conclude that the patient does not have childhood-onset schizophrenia at this time because hallucination is the only symptom patient portrays.

 

Schizoaffective Disorder The diagnostic criteria is “an uninterrupted period of illness during which there is a major mood episode (depressed mood) concurrent with criteria A1 (delusions, hallucinations, disorganized speech, catatonic behavior, negative symptoms) for schizophrenia (APA, p.121, 2022)”. This diagnosis is given when a patient has features of schizophrenia and mood disorder but does not meet the criteria for any of them. In this case study patient does not have schizoaffective disorder.

Reflections: The behavior/attitude displayed by this patient is in accordance with the diagnostic criteria presented in DSM-5 for the diagnostic impressions listed above. Reflecting on this case, trying to better assist the patient and family is a difficult call, especially since the patient is not comprehending what is being spoken to her. On the other hand, mom feels sad and wants to help her daughter but feels things are worsening. The patient admits that her adopted mother loves her, but sometimes patient feels adopted mom does not love her. The patient is unpredictable and uncomfortable being the only dark-skinned person in the family because her two adopted siblings are light-skinned. Having to deal with why she was given away at birth and the color of her skin seems to be a lot for the patient to handle now. What I would have done differently was to get the patient involved in psychotherapy beginning from her initial consultation. I would encourage in-person schooling to be attended by the patient at least twice a week to assist the patient in addressing her social developmental skills; isolating the patient is not a good idea. Schools have individual education plans that can accommodate children with developmental disorders while helping them achieve their full potential.

Autism does not discriminate, it cuts through all racial, ethnic, and socioeconomic groups, but its detection is uneven across these groups; research has proven that there are more children with Autism in the Caucasian race than Black or Hispanic (Hodges et al., 2020). The reason for these discrepancies could be related to the stigma, availability/affordability of healthcare, and language/cultural barriers (Hodges et al., 2020). The inability of everyone to access healthcare services is a significant contributor to the severity of psychiatric illness. In addition, cultural bias that prevents people from seeking help is a lousy contributor.

Case Formulation and Treatment Plan: The use of Guanfacine 1 mg has been beneficial to the patient because her focus and concentration have improved, which has led to better grades with her school work, so we will continue with the medication. The Abilify 5 mg was just increased a week ago from 2 mg, which means patient has been on Abilify for a total of 3 weeks, so we need to give it more time to see any benefits or change in patient behavior. Zoloft was recently titrated to 50mg a week ago from 25mg to address the major depressive disorder; since no adverse side effects have been reported, we will continue with the medication.

Patient and mother were instructed on the possible adverse effects of the medications and encouraged to inform the provider if any are experienced;

• Guanfacine 1 mg PO daily (Attention Deficit Hyperactivity Disorder) – Dry mouth, hypotension, somnolence, headaches, dizziness, constipation, fatigue, abdominal pain, nausea, vomiting, and bradycardia (FDA, n.d.).
• Abilify 5 mg PO daily (Autism) – Sedation, fatigue, vomiting, somnolence, tremor, pyrexia, drooling, decreased appetite, salivary hypersecretion, extrapyramidal disorder, and lethargy (FDA, n.d.).
• Zoloft 50 mg PO daily (Major Depressive Disorder) – Nausea, diarrhea/loose stool, tremors, dyspepsia, decreased appetite (FDA, n.d.).
• Melatonin 3 mg PO qhs (Insomnia) – Abdominal cramps, daytime fatigue, dizziness, decreased alertness, drowsiness, headache, irritability.
• Benztropine 0.5 mg PO daily – (Drug-Induced Extrapyramidal Disorders) blurred vision, confusion, constipation, dry mouth/throat, nausea, psychosis, hyperthermia, and vomiting (FDA, n.d.).

Instructed patient and mother that patient can not stop any medication abruptly; if they decide to stop any medication, the provider should be made aware immediately.

Although this patient has no intention to hurt herself or others, she keeps putting herself at high risk of getting hurt.

Psychotherapy is highly recommended to help the patient address her thoughts which influence her behavior. Currently, she is getting family therapy once a week.

I would prefer to have her also get individual therapy once a week to give her more room to express herself and give the therapist the tools to assist her best. The patient’s mother is worried if patient’s condition will ever get better, and she is getting tired of the relentless challenges posed by the patient. Having the mom get a behavioral psychologist can help teach the patient effective ways to modify these challenging behaviors.

In addition, I will recommend parent management training for parents to learn appropriate methods to address problematic behaviors and encourage the appropriate behaviors in patient. Parent support groups are beneficial because they all share a familiar problem and can support each other in coping with the stress involved in raising a child with Autism.

The patient’s mother was given the emergency number: Emergency Services 911. Clients crisis line is 1-800-273-8255. Instructed mother to take patient to the nearest ER or call 911 if patient becomes suicidal or homicidal.

The patient had recent lab work completed while hospitalized, which was within normal limits, so no labs will be ordered.

Patient’s next visit is scheduled in 2 weeks to follow up on medication management.

Parent and patient instructed that the patient avoid any over-the-counter medications to avoid adverse reactions.

Online resources are provided to enable parents to understand this behavior and what to do on: American Academy of Child and Adolescent Psychiatry website (www.AACAP.ORGLinks to an external site.) and Autism Research Institute (https://autism.org).

 

Questions

1. What will your reply to the patient’s mother when she asks if this behavior will improve or worsen?
2. Is there something the provider needs to include? Is the patient misdiagnosed, or are the medications not enough?
3. What kind of psychotherapy would you recommend, and how often should the sessions be?

 

 

 

 

 

 

 

 

 

PRECEPTOR VERFICIATION:

I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.

 

Preceptor signature: ________________________________________________________

 

Date: ________________________

 

 

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental

            disorders (5th ed. text rev.).

Hodges, H., Fealko, C., & Soares, N. (2020). Autism spectrum disorder: definition,

            epidemiology, causes, and clinical evaluation. Transl Pediatr, 9(1), pp.S55-S65.

Kendhari, J., Shankar, R., & Young-Walker, L. (2016). A review of childhood-onset

            schizophrenia. Focus (Am Psychiatr Publ), 14(3), pp.328-332.

Siegel, M., McGuire, K., Veenstra-VanderWeele, J., Stratigos, K., & King, B. (2020).

            Practice parameter for the assessment and treatment of psychiatric disorders in

            Children and adolescents with intellectual disability (intellectual developmental

            Disorder). J Am Acad Child Adolesc Psychiatry, 59(4), pp.468-496.

US Food & Drug Administration. (n.d.). Drugs@FDA: FDA-approve drugs.

            https://www.accessdata.fda.gov/scripts/cder/daf/index.cfmLinks to an external site.

 

 

WK4Assgn_Igbinosun_C.Signed.pdf

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