Separation Anxiety Disorder in Children

Assignment: Decision Tree (Due in Week 7)

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.Separation Anxiety Disorder in Children

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

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 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.

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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 #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.

Psychiatric Mental Health Nurse Practitioner Role I: Child and Adolescent

Introduction

The provided case study is about an 8-year-boy named Tyrel and presented accompanied by his mother due to various psychiatric symptoms. The mother reported that the son had become excessively worried and nervous and he spent a lot of time worrying about germs. The client washed his hands constantly because he did not want to become sick again. The client is also irritable and experiences sleep disturbances. The symptoms have interfered with his academics as he becomes nervous around his classmates. He has also stopped interacting with his best friend. His bilateral hands are dry. Tyrel reveals about having constant and uncontrollable thoughts about dirty hands. He also admits to being very nervous and scared and reports that washing his hands is what makes him feel better. However, handwashing only offers temporary relief and he starts being scared again and until he cleans his hands again. The MSE indicates that Tyrel is alert and well-oriented. His self-reported mood is “good” and “anxious”. His mood is affect. No apparent paranoid or delusional thought processes. He also denies suicidal thoughts and visual/auditory hallucinations. The findings from the lab analysis are okay, while the antistreptolysin O antibody titer is above the normal parameters. From the subjective and objective data, this paper will make a diagnosis for the client and select the appropriate treatment decisions for the client. All ethical considerations relevant to the client’s treatment will be discussed.Separation Anxiety Disorder in Children

Decision Point One

The diagnosis of Tyrel is obsessive-compulsive disorder (OCD). OCD was chosen as his diagnosis because the symptoms manifested by Tyrel meet the DSM-5 diagnostic criteria of OCD. According to American Psychiatric Association (2013), symptoms of OCD include obsessions/compulsions like persistent urges and thought accompanied by repetitive behaviors like fear of contamination and performing ritualistic behaviors of persistent hand-washing in order to eradicate germs. These symptoms lead to the impairment of an individual’s normal functioning (Davide et al., 2020). Similarly, Tyrel has persistent thoughts about his hands becoming contaminated with germs and as a result, he performs hand-washing constantly to get rid of the germs. His worry about germs and being sick, followed by constant hand-washing has impaired his functioning as indicated by him stopping to play with friends and no longer attending school. Nonetheless, symptoms such as social withdrawal and not attending school need to be assessed further in order to confirm or rule out any comorbidity. The reason why generalized anxiety disorder and PANDAS were not chosen as the diagnoses for Tyrel is that the client’s symptoms are not consistent with DSM-5 diagnostic criteria of generalized anxiety disorder and PANDAS.

Selection of obsessive-compulsive disorder as the client’s diagnosis hoped that this is the correct diagnosis and thus the appropriate treatment plan for Tyrel will be developed.

When diagnosing the patient, the ethical principle of beneficence was applied to ensure that the correct diagnosis was chosen to ensure the right treatment plan was developed. The confidentiality of the client’s diagnosis was also maintained (Roberts & Williams, 2015).

Decision Point Two

Fluvoxamine immediate release 25 mg during bedtime was prescribed for Tyrel. The reason for selecting fluvoxamine is because the pharmacological agent is n SSRI that increases serotonin and thus improves the mood and thus improves the OCD symptoms (Lenze et al., 2020). Fluvoxamine is supposed to be administered at bedtime since the medication has a sigma-1 antagonist and hence it is a sedative. The decision to have fluvoxamine administered in the morning was not considered due to the sedative effects of the medication (Garland et al., 2016). Zoloft was not prescribed since fluvoxamine is well-tolerated better when compared to Zoloft.

Prescription of fluvoxamine expects that Tyrel would manifest a good response to the medication as manifested by decrease the OCD symptoms. This would manifest by the client showing reduced fear of germs and reducing the frequency of washing his hands. The expected symptom improvement is due to Fluvoxamine’s efficacy in the treatment of OCD symptoms (Garland et al., 2016). It is also hoped that Tyrel would not experience side effects from the medication.

The treatment outcome was that Tyrel manifested significant improvement as the frequency of washing his hands had reduced. The anxiety levels also reduced as Tyrel appeared more relaxed. The mother also reported that Tyrel had started to partially attend school and playing with the friend. The improvements are attributable to Fluvoxamine’s efficacy in the treatment of OCD symptoms (Garland et al., 2016). No side effect was reported.Separation Anxiety Disorder in Children

The ethical principles of informed consent and beneficence were applied when selecting fluvoxamine. Informed consent was sought from the mother before the medication was prescribed (Roberts & Williams, 2015). Moreover, fluvoxamine was selected because it is the medication expected to bring out the best treatment outcomes for Tyrel.

Decision Point Three

Fluvoxamine should be augmented using a psychotherapy treatment, cognitive behavioral therapy (CBT). The reason why CBT was chosen is because psychotherapy has been demonstrated to be effective in changing negative and maladaptive thinking patterns, feelings, and behaviors (Zhang et al., 2020). As a result, an individual then adopts a more adaptive and positive thinking pattern, which leads to positive behavior change. Moreover, through CBT, the client will be equipped with the appropriate coping skills to be able to handle different situations, including situations that evoke fear and anxiety. CBT is also expected to reduce the client’s social anxiety and thus he will resume school fully and interact with friends fully. Increasing fluvoxamine dose to 50 mg was not deemed appropriate since Tyrel is already showing a good response to fluvoxamine 25 mg and hence there is no clinical reason to titrate the dose upwards. Augmenting fluvoxamine 25 mg with an atypical antipsychotic such as Abilify was not deemed suitable since antipsychotics are not recommended to treat OCD.

The treatment goal for augmenting fluvoxamine with CBT hopes that Tyrel will continue having symptom decrease and finally achieve full symptom remission. This will manifest by Tyrel stopping having anxiety and fears about germs and becoming sick and stopping performing the ritualistic hand-washing behavior. This is because by augmenting fluvoxamine with CBT, CBT will improve the client’s response due to CBT’s effectiveness in altering the maladaptive and negative thoughts and thus facilitating positive behavior change (Wu et al., 2016).

Non-maleficence and beneficence were applied in this decision. The risks and benefits associated with every decision were analyzed and the treatment decision with minimal risks and maximum benefits was selected (Coombes et al., 2020). Moreover, augmenting fluvoxamine with CBT was considered to be the treatment decision with the best care outcomes for Tyrel.

Conclusion

The diagnosis for Tyrel of the compulsive-obsessive disorder. This is because the symptoms he manifests such as high levels of anxiety and nervousness, fear of germs, and ritualistic handwashing meet the DSM-5 criteria of OCD. The fear of germs is the obsession, while the constant hand washing is compulsive behavior. After the diagnosis of OCD, Fluvoxamine 25 mg at bedtime was chosen as the appropriate medication. This is because fluvoxamine is effective in treating OCD symptoms. After prescribing fluvoxamine 25 mg, after four weeks Tyrel manifested a good response to the medication as the anxiety levels and nervousness as well as his obsession against germs reduced. Moreover, the frequency of handwashing reduced and he also started attending school partially and socializing with his friend. For the third decision, it was decided that fluvoxamine would be augmented using CBT. This is because CBT is effective in improving OCD symptoms because it changes the negative thinking pattern and behaviors into a more positive thinking pattern and more adaptive behaviors. It is expected that augmenting fluvoxamine with CBT will lead to further symptom reduction for Tyrel. During the treatment of this client, informed consent was sought before the treatment process started. Additionally, the risks and benefits associated with all medication choices were analyzed as per the non-maleficence principle, while the medication with the best care outcomes for Tyrel was chosen. Separation Anxiety Disorder in Children

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References

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

Coombes, I., Markwell, A., Kubler, P., Redmond, A. M., McGurk, G., & Roberts, J. A. (2020). Principles of ethical prescribing for self and others: hydroxychloroquine in the COVID‑19 pandemic. AN INDEPENDENT REVIEW, 76.

Davide, P., Andrea, P., Martina, O., Andrea, E., Davide, D., & Mario, A. (2020). The impact of the COVID-19 pandemic on patients with OCD: Effects of contamination symptoms and remission state before the quarantine in a preliminary naturalistic study. Psychiatry Research, 291, 113213. https://doi.org/10.1016/j.psychres.2020.113213

Garland, E., Kutcher, S., Virani, A., & Elbe, D. (2016). Update on the Use of SSRIs and SNRIs with Children and Adolescents in Clinical Practice. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 25(1), 4–10.

Lenze, E. J., Mattar, C., Zorumski, C. F., Stevens, A., Schweiger, J., Nicol, G. E., … & Reiersen, A. M. (2020). Fluvoxamine vs placebo and clinical deterioration in outpatients with symptomatic COVID-19: a randomized clinical trial. JAMA, 324(22), 2292-2300.

Roberts, L. W., & Williams, N. (2015). Ethics Commentary: Obsessive-Compulsive and Related Disorders: Ethical Issues in the Care of Obsessive-Compulsive Disorder: Clinical Ethics Case Examples. Focus, 13(2), 191-194.

Wu Y, Lang Z & Zhang H. (2016). Efficacy of Cognitive-Behavioral Therapy in Pediatric Obsessive-Compulsive Disorder: A Meta-Analysis. Med Sci Monit, 1(22), 1646–1653.Separation Anxiety Disorder in Children