Assignment: Decision Tree (Week 5: Anxiety Disorders In Childhood and Adolescence)

Learning Resources

Required Readings

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

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

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

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

· “Anxiety Disorders”

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

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)

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

Note: All Stahl resources can be accessed through the Walden Library using the link. This link will take you to a login page for the Walden Library. Once you log in to the library, the Stahl website will appear.

To access information on the following medications, click on The Prescriber’s Guide, 5th Ed. tab on the Stahl Online website and select the appropriate medication.

Required Media

https://youtu.be/Gm3FLGxb2ZU

https://youtu.be/TO8aITpMG5E

Laureate Education (Producer). (2017c). Anxiety disorder, ODC, or something else? [Multimedia file]. Baltimore, MD: Author.

YMH Boston. (2013b, May 22). Vignette 3 – Asking about depression in a preventive services visit [Video file]. Retrieved from https://www.youtube.com/watch?v=TO8aITpMG5E

Note: The approximate length of this media piece is 3 minutes.

YMH Boston. (2013d, May 22). Vignette 5 – Assessing for depression in a mental health appointment [Video file]. Retrieved from https://www.youtube.com/watch?v=Gm3FLGxb2ZU

Note: The approximate length of this media piece is 3 minutes.

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)

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)

Decision Point Two

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

Decision Point Two

Begin Fluvoxamine controlled release 100 mg orally in the morning

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks

Tyrel’s mom reports that Tyrel took the medication for the first week, but she stopped giving it to him after that because “he was so drugged up.” She reports that Tyrel was impossible to wake up, and missed an entire week of school due to his sedation from the medication.

She reports that during that week, the frequency of handwashing decreased because “poor Tyrel was too doped up to wash his hands.” However, she reports that 2 days after she stopped giving him the medication, he resumed handwashing behaviors.

Begin Zoloft 50mg orally daily.

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 notices that he is still handwashing frequently, but thinks that the frequency has decreased “a bit.”

She also reports that Tyrel has not fully embraced returning to school, but that his attendance has improved.

Tyrel’s mom is concerned about the decrease in Tyrel’s appetite. She reports that he has been having some decreased appetite and has complained of feeling “sick to his stomach.”

Decision Point Three

Tyrel’s mom to continue the current medication dose and educate her that the side effects will abate with time

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. Assignment: Decision Tree (Week 5: Anxiety Disorders In Childhood and Adolescence)

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.

Recall that it is generally not appropriate to treat the side effects of one medication with another medication, especially when those side effects can be overcome by changing to a different preparation of the medication (in this case, immediate release), or can be minimized by a change in timing of the medication (in this case, changing the medication to bedtime). In some cases, medications are used to treat side effects of medication (for example, propranolol is often used to treat tremors associated with lithium); but these types of “exceptions” are few and far between. Always try to treat side effects by a different preparation, or different administration time. Avoid polypharmacy whenever possible.

Decision Point Three

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

Discontinue Zoloft and begin Fluvoxamine controlled release 100 mg orally every morning.

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.

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.

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. Assignment: Decision Tree (Week 5: Anxiety Disorders In Childhood and Adolescence)