Childhood psychosis is extremely rare; however, children that present with psychosis must be carefully assessed and evaluated with appropriate interviewing of parent, child, and use of assessment tools.

For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat clients presenting with early onset schizophrenia.

The Assignment:

Examine Case 3. 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.

(N: B. A CASE STUDY WITH ANSWER SAMPLE IS ATTACHED WITH THIS ASSIGNMENT)

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.

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.

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 #3
A young girl with strange behaviors

BACKGROUND

Carrie is a 13-year-old Hispanic female who is brought to your office today by her mother and father. They report that they were referred to you by their primary care provider after seeking her advice because Carrie’s behavior has been difficult to manage, and they don’t know what to do.

SUBJECTIVE

Carrie’s parents report that they have concerns about her behavior, which they describe as sometimes “not normal for a 13-year-old.” They notice that she talks to people who aren’t real. Her behavior is calm and “passive.” Her parents noted that when she was younger, she was irritable at times, but have noticed that this has given way to passivity. Her parents state that they understand that it’s normal for younger children to have “imaginary friends,” but they feel that at

Carrie’s age, she should have grown out of these behaviors. Carrie’s parents report that she has friends that are half-cat and half-human, and “spirits” who speak with her “in her head.” She also reports that the people on television know when she is home and that they have certain shows “just for her.”

Carrie’s parents report that they have taken her to her pediatrician who has given her a “clean bill of health.” Carrie’s parents note that they had some early concerns as she was lagging in meeting developmental milestones. Initially, when she first started school, Carrie managed to keep up with her peers in terms of academic performance, but she was noticed by her teachers to be isolative. It was also noted by her teachers and guidance counselor that Carrie’s social skills do not seem to match what they see in other children her age. Initially the school counselor suspected that Carrie may have been suffering from attention deficit hyperactivity disorder (primarily inattentive type), but now is not certain and has recommended a psychiatric evaluation. Her grades were “ok” in school up until last year when she left junior high school, and entered high school, where the academic demands began to increase. Carrie’s teachers had wanted to hold her back a grade, but her parents acknowledge that they were “insistent” that this did not happen. Now they are describing some regrets over this as Carrie seems “more lost than ever” in her schoolwork. Carrie’s mother produced a copy of a paper that Carrie had to submit as a homework assignment. You attempt to read the assignment, but there does not appear to be any clarity to the work, and it can best be described as a hodge-podge of thoughts and ideas.

Carrie’s parents want you to know that although they are concerned about Carrie, they are opposed to giving her medications that would turn her “into a zombie.” Carrie’s mother also confides that her husband’s grandfather spent “a few years in the nut house.” When you probe further, she began crying and said, “He was schizophrenic … what if Carrie is schizophrenic?”

During your interview with Carrie, she seems pleasant, but somewhat distant. When you ask her about her friends at school, she shrugs her shoulders and says, “I don’t really have any. I don’t like those people.” You inquire if she is sad or upset that she doesn’t like them, to which she states “no, why should I be? I guess they would be friends with me if I asked, but I’m not interested. I could make them be my friends if I wanted, but I don’t … but if I wanted them to, all that I have to do is make up my mind that they will be my friend and they would have to.” When you ask Carrie if she believes that she can control the thoughts of others with her mind, she puts her index finger up to her mouth and looks toward the door. “My mom gets upset when I talk about these things. I try not to think about them either because if she is close enough, she could read my thoughts and they upset her. She may think that I’m into witchcraft or something.”

When you ask Carrie about the homework assignment that you read, she explains that her teacher “is just miserable. She doesn’t understand how I think—I think high, she just can’t get it.”

OBJECTIVE

The client is a 13-year-old Hispanic female client who appears appropriately developed for her age. She is dressed appropriately for the current weather and ambulates with a steady upright gait. She does not appear to be demonstrating any noteworthy mannerisms, gestures, or tics. No psychomotor agitation/retardation apparent.

MENTAL STATUS EXAM

Carries is alert and oriented × 4 spheres. Her speech is clear, coherent, goal directed, and spontaneous. Carrie self-reports her mood as “good.” However, her affect does appear somewhat constricted. Her eye contact is minimal throughout the clinical interview and at times, Carrie seems preoccupied. Carrie is oriented to person, place, and time. She endorses hearing and seeing strange “things that I talk to. They don’t scare me; they come to see me from another world.” No overt paranoia is appreciated. She does report delusions of reference (she believes that the people on TV play programs “just for her” and at times, television commercials were designed to tell her what to do), as well as other delusional thoughts (as described above). Carrie denies any suicidal or homicidal ideation.

At this point, please discuss any additional diagnostic tests you would perform on Carrie.

Decision Point One

BASED ON THE INFORMATION PROVIDED IN THE SCENARIO ABOVE, WHICH OF THE FOLLOWING DIAGNOSES WOULD THE PSYCHIATRIC/MENTAL HEALTH NURSE PRACTITIONER (PMHNP) GIVE TO CARRIE?

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.

Early Onset Schizophrenia

Schizoaffective Disorder

Schizotypal Personality Disorder

                                                        Answer Chosen:  

Early Onset Schizophrenia

Decision Point Two

BASED ON THIS DIAGNOSIS, SELECT YOUR CHOICE OF ACTIONS:

Refer for psychological testing

Begin Clozaril 100 mg orally daily

Begin psychotherapy using a psychodynamic approach

                                               Answer Chosen:

Refer for psychological testing

RESULTS OF DECISION POINT TWO

·  Client returns to clinic in four weeks

·  Although there are no specific psychometric tests available for schizophrenia, the consulting psychologist administered a comprehensive psychological battery of tests in order to assess personality and cognitive functioning as well as to identify any underlying intellectual disabilities that could account for the difficulty Carrie is having in school. Tests administered included the Minnesota Multiphasic Personality Inventory; Kaufman Adolescent and Adult Intelligence Test; Rorschach test; Whitaker Index of Schizophrenic Thinking (WIST) test; Wide Range Achievement Test – 4th Edition (WRAT-4); and the Millon Adolescent Clinical Inventory (MACI). The consulting psychologist opined that early-onset schizophrenia was strongly suspected in this client.

Decision Point Three

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

Begin Clozapine 100 mg orally daily

Begin family interventions

Begin Lurasidone 40 mg orally daily

                                               Answer Chosen

Begin Lurasidone 40 mg orally daily

Guidance to Student

It is not always necessary to procure a consult with a psychologist. However, psychologists by virtue of their advanced training and licensure are able to conduct comprehensive psychological testing on clients more advanced than those tests that could be conducted by the psychiatric/mental health nurse practitioner. In this case, we would like to know if the poor academic performance was the result of an intellectual disability, versus poor premorbid intellectual functioning that is often seen in schizophrenia.

In terms of treatment decisions, Clozapine is FDA-approved for treatment-resistant schizophrenia. Since the child has not yet been treated with any agent, we have no way of knowing if her schizophrenia is treatment resistant. Additionally, if we were to use Clozapine, the starting dose is approximately 25 mg in adults (perhaps 12.5 mg in a child, depending on body weight). Clozapine 100 mg would most likely cause significant side effects that both the child and parents would find objectionable, thus making compliance an issue.

Although not FDA-approved for use in children, Lurasidone is used as an off-label drug in this population. There are no legal prohibitions against any prescriber using drugs “off-label”; however, attention must be given to the concept of informed consent. When working with children/adolescents, the PMHNP must explain pros/cons, discuss therapeutic endpoints/goals of treatment, etc. The parent/guardian must have all of the information needed to make an informed consent. Therefore, Lurasidone would be the best choice. Additionally, Lurasidone may be the preferred antipsychotic, as it appears to have the least impact on body weight and lipid profile.

Recall that with any antipsychotic medication, you should determine fasting plasma glucose levels, monitor weight and BMI during treatment, as well as blood pressure and fasting triglycerides.

Family interventions are important as well, as they do have a positive benefit on symptom relapse and admission/readmission to the hospital. Family interventions should include teaching about the disease, medications, and anticipatory guidance.

                                                                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. 1268–1283)

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

• “Schizophrenia Spectrum and Other Psychotic Disorders”

McClellan, J., & Stock, S. (2013). Practice parameter for the assessment and treatment of children and adolescents with schizophrenia. Journal of the American Academy of Child & Adolescent Psychiatry, 52(9), 976–990. Retrieved from http://www.jaacap.com/article/S0890-8567(13)00112-3/pdf

Giles, L. L., & Martini, D. R. (2016). Challenges and promises of pediatric psychopharmacology. Academic Pediatrics, 16(6), 508–518. doi:10.1016/j.acap.2016.03.011

Hargrave, T. M., & Arthur, M. E. (2015). Teaching child psychiatric assessment skills: Using pediatric mental health screening tools. International Journal of Psychiatry in Medicine, 50(1), 60–72. Retrieved from http://search.proquest.com.ezp.waldenulibrary.org/docview/1702699596?accountid=14872

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

Required Media

Laureate Education (Producer). (2017b). A young girl with strange behaviors [Multimedia file]. Baltimore, MD: Author. (THE ATTACHED CASE STUDY IS THE MEDIA)

PLEASE PART OF THE CONTRACT IS TO HAVE IT DONE IN 12 HOURS. THANKS

Question 1. 1. Which of the following best describes the pain associated with osteoarthritis? (Points : 2)
Constant, burning, and throbbing with an acute onset
Dull and primarily affected by eposure to cold and barometric pressure
Begins upon arising and after prolonged weight bearing and/or use of the joint
Begins in the morning and limits continued ambulation

Question 2. 2. Your 63-year-old Caucasian woman with polymyalgia rheumatica (PMR) will begin treatment with corticosteroids until the condition has resolved. You look over her records and it has been 2 years since her last physical eamination and any laboratory or diagnostic tests as she relocated and had not yet identified a health-care provider. In prioritizing your management plan, your first orders should include: (Points : 2)
Recommending she increase her dietary intake of Calcium and Vitamin D
Ordering once a year bisphosphonate and a proton pump inhibitor
Participate in a fall prevention program
Dual-energy -ray (DEA) scan and updating immunizations

Question 3. 3. In providing health teaching related to dietary restrictions, the nurse practitioner should advise a patient with gout to avoid which of the following dietary items: (Points : 2)
Green leafy vegetables
Beer, sausage, fried seafood
Sugar
Gluten and bread items

Question 4. 4. A 33-year-old female reports general malaise, fatigue, stiffness, and pain in multiple joints of the body. There is no history of systemic disease and no history of trauma. On physical eamination, the patient has no swelling or decreased range of motion in any of the joints.She indicates specific points on the neck and shoulders  that are particularly affected. She complains of tenderness upon palpation of the neck, both shoulders, hips, and medial regions of the knees. The clinician should include the following disorder in the list of potential diagnoses: (Points : 2)
Osteoarthritis
Rheumatoid arthritis
Fibromyalgia
Polymyalgia rheumatica

Question 5. 5. A 46-year-old female complains of fatigue, general malaise, and pain and swelling in her hands that has gradually worsened over the last few weeks. She reports that pain, stiffness, and swelling of her hands are most severe in the morning. On physical eamination, you note swelling of the metacarpophalangeal joints bilaterally. These are common signs of: (Points : 2)
Osteoarthritis
Rheumatoid arthritis
Scleroderma
Sarcoidosis

Question 6. 6. Which of the following statements about osteoarthritis is true? (Points : 2)
It affects primarily weight-bearing joints
It is a systemic inflammatory illness
The metacarpal phalangeal joints are commonly involved
Prolonged morning stiffness is common

Question 7. 7. The most appropriate first-line treatment for an acute gout flare is (assuming no kidney disease or elevated bleeding risk): (Points : 2)
Indomethacin 50 mg thrice daily for 2 days; then 25 mg thrice daily for 3 days
Doycycline 100 mg twice daily for 5 days
Prednisolone 35 mg four times a day for 5 days
Ice therapy

Question 8. 8. A 34-year-old female presents with fever, general malaise, fatigue, arthralgias and rash for the last 2 weeks. On physical eamination, you note facial erythema across the nose and cheeks. Serum diagnostic tests reveal positive antinuclear antibodies, anti-DNA antibodies, elevated C-reactive protein and erythrocyte sedimentation rate. The clinician should include the following disorder in the list of potential problems: (Points : 2)
Fibromyalgia
Sarcoidosis
Systemic lupus erythematosus
Rheumatoid arthritis

Question 9. 9. Your 66-year-old male patient has recently started treatment for metabolic syndrome and is currently taking the following medications: an ACE inhibitor and beta blocker for treatment of hypertension. He is also taking a statin medication, simvastatin for hyperlipidemia, and a biguanide, metformin, for type 2 diabetes. The patient complains of myalgias of the legs bilaterally and blood work shows elevated serum creatine kinase. Which of the medications can cause such a side effect? (Points : 2)
Beta blocker
ACE inhibitor
Statin medication
Metformin

Question 10. 10. A 20-year-old male construction worker is eperiencing new onset of knee pain. He complains of right knee pain when kneeling, squatting, or walking up and down stairs. On physical eamination, there is swelling and crepitus of the right knee and obvious pain with resisted range of motion of the knee. He is unable to squat due to pain. Which of the following disorders should be considered in the differential diagnosis? (Points : 2)
Joint infection
Chondromalacia patella
Prepatellar bursitis
All of the above

Question 11. 11. A 17-year-old male complains of severe right knee pain. He was playing football when he heard a “pop” at the moment of being tackled and his knee “gave away” from under him. On physical eamination, there is right knee swelling and decreased range of motion. There is a positive anterior drawer sign. These findings indicate: (Points : 2)
Knee ligament injury
Osgood-Schlatter disease
Prepatellar bursitis
Chondromalacia patella

Question 12. 12. A 55-year-old patient complains of lower back pain due to heavy lifting at work yesterday. He reports weakness of the left leg and paresthesias in the left foot. On physical eamination, the patient has diminished ability to dorsifle the left ankle. Which of the following symptoms should prompt the clinician to make immediate referral to a neurosurgeon? (Points : 2)
Straight leg raising sign
Lumbar herniated disc on -ray
Loss of left sided patellar refle
Urinary incontinence

Question 13. 13. Your patient is a 43-year-old female golfer who complains of arm pain. On physical eamination, there is point tenderness on the elbow and pain when the patient is asked to fle the wrist against the clinician’s resistance. These are typical signs of: (Points : 2)
Carpal tunnel syndrome
Osteoarthritis of the wrist
Epicondylitis
Cervical osteoarthritis

Question 14. 14. Which of the following describes the pathology of De Quervain’s tenosynovitis? (Points : 2)
Irritation of a tendon located on the radial side of the wrist, near the thumb
Impingement of the median nerve, causing pain in the palm and fingers
Fluid-filled cyst that typically develops adjacent to a tendon sheath in the wrist
Ulnar nerve compression at the olecranon process

Question 15. 15. What is the most common cause of hip pain in older adults? (Points : 2)
Osteoporosis
Osteoarthritis
Trauma due to fall
Trochanteric bursitis

Question 16. 16. A 43-year-old female was in a bicycling accident and complains of severe pain of the right foot. The patient limps into the emergency room. On physical eamination, there is no point tenderness over the medial or lateral ankle malleolus. There is no foot tenderness ecept at the base of the fifth metatarsal bone. According to the Ottawa foot rules, should an -ray of the feet be ordered? (Points : 2)
Yes, there is tenderness over the fifth metatarsal
No, there is not tenderness over the navicular bone
Yes, the patient cannot bear weight on the foot
A and C

Question 17. 17. 38-year-old Asian male, Mr. Chen, with past medical history significant for prehypertension who has recently taken up softball presents with three to five weeks of shoulder pain when throwing overhead. Ice minimally alleviates pain. Medications: Naproen minimally alleviates shoulder pain. Allergies: Penicillin-associated rash. Family history: Brother has rheumatoid arthritis.

Which of the following musculoskeletal causes of shoulder pain would merit urgent diagnosis and management? (Points : 2)
Adhesive capsulitis
Septic subacromial bursitis
Impingement of the supraspinatus tendon
Calcific tendinopathy