Explain the therapeutic approaches I would take with this patient.
Respond to at least two of your colleagues by providing one alternative therapeutic approach. Explain why you suggest this alternative and support your suggestion with evidence-based literature and/or your own experiences with clients.
1:In this discussion I will be sharing my observation of a child exhibiting disruptive behaviors, along with the diagnosis I would give this child based on the DSM-5 diagnosis criteria. I will then explain the therapeutic approaches I would take with this patient. In addition to the therapy I would choose I will discuss any medications I would utilize with this patient. Lastly, I am going to cover the expected outcomes for the chosen therapy and treatment plan.
Attention Deficit Hyperactive Disorder
In observing the patient in the hyperactive case study, she is in the room talking fast and impulsively touching things. Attention deficit hyperactive disorder (ADHD) is a neurodevelopment impairment of attention levels, hyperactivity and impulsivity (American Psychiatric Association, 2013). ADHD generally starts in childhood resulting in impairments that can flow into adulthood. Many of these impairments are involved with doing poorly academically, challenges with behaviors, slow to find personal independence, and stressful interpersonal relationships (Modesto-Lowe, Charbonneau & Farahmand, 2017). Further reviewing this case study the patient wishes there was no more homework, expressing her life would be better if that happened. This would lead me to clue into that she may be struggling in school, this would be something as the Psychiatric Mental Health Nurse Practitioner (PMHNP) that is providing her therapy I would want to further explore in the sessions with her. The patient eludes to possible strained relationships with her parents and she mentions wanting to be invisible so she wouldn’t annoy anyone. This is another area that is important as it is sounding like she is struggling in her interpersonal relationships, as individuals with ADHD can.
Therapeutic Approach
When treating a child or adolescent who is struggling with ADHD it is recommended that behavioral and psychosocial approaches are in the treatment plan along with medication for those that are in the moderate to severe category. The behavioral support can be modifications in the classroom and behavioral training for parents. When providing therapy to a child or adolescent with ADHD the family dynamics and goals need to be taken into consideration (Wheeler, 2014). Keeping these components in mind I would use the common factors approach when providing therapy to this group of patients. Using the common factors approach allows me as the PMHNP to forming a trusting relationship with the family and patient. When I am working with the child I work in a straight forward manner, further building the relationship with them through respect, understanding and the willingness to help them (Wheeler, 2014). Along with therapy, medication is recommended for the most favorable treatment of ADHD. Medications that are used in the ADHD population are psychostimulants, guanfacine and atomoxetine. Prior treatment suggested patients discontinue these medications as they transitioned into adolescence and adulthood, however, it is now recommended patients continue with medication as part of their treatment plan (Modesto-Lowe, Charbonneau & Farahmand, 2017).
Expected Outcome
Having the knowledge that children and adolescents struggle in the known areas of academics, interpersonal relationships, challenging behaviors and struggles finding independence, my goal of treatment would be to help the patient have less struggles in these areas. Providing psychotherapy, behavior training and appropriate medication would lead to controlled behaviors that were originally a challenge, many times it involves a decrease in impulsive, angry outburst. In addition, the patient would being to move toward being more independent and feeling more in control of themselves. It has been shown that children who receive a multi-modal treatment plan had a substantial decrease in outcome measures (Masi, Milone, Manfredi, Brovedani, Pisano & Muratori, 2016). Being that I would provide this patient with a multi-modal treatment plan including psychotherapy, behavioral therapy and medication, I believe this patient would have a decrease in her symptoms.
References
Masi, G., Milone, A., Manfredi, A., Brovedani, P., Pisano, S. & Muratori, P. (2016). Combined pharmacotherapy-multimodal psychotherapy in children with Disruptive Behavior Disorders. Psychiatric Research, 238, 8-13. Retrieved from: https://doi-org.ezp.waldenulibrary.org/10.1016/j.psychres.2016.02.010
Modesto-Lowe, V., Charbonneau, V. & Farahmand, P. (2017). Psychotherapy for adolescents with Attention-Deficit Hyperactivity Disorder: A pediatrician’s guide. Clinical Pediatrics, 56(7), 667-674. Retrieved from: DOI: 10.1177/0009922816673308
Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.
2:After viewing the case studies, I chose to complete this post over the angry adolescent. My initial observations were that she is obviously angry about being at the therapy session and is not going to participate in the counseling session. She is a teenage, Caucasian female, who was made to start counseling by her parents and her probation officer. The patient states, in a loud and angry tone, that she does not want to be there, that the counselor is stupid and that she is not going to provide any information about herself. Therefore, the problem that the patient is having is unidentified. No history was given, other than she is popular in school, has good social skills, has a probation officer, and has anger issues, according to her parents and her probation officer. While listening to the patient speak, her mental status examination seems to be normal, as her appearance, manner of relating, use of language, mood and affect, content of speech, perceptions, abstracting ability, judgment and insight (Wheeler, 2014) are intact and are not abnormal. After the assessment, I would consider temper dysregulation disorder with dysphoria, which includes core features of pervasive irritable and/or sad mood and recurrent, severe anger outbursts (Axelson, 2010). The second diagnosis I would consider is disruptive mood dysregulation disorder, which requires frequent, persistent, severe temper outbursts out of proportion to the situation and developmental context in combination with persistent, angry/irritable mood between the temper outbursts (Rao, 2014). The therapeutic approach I may consider using for this angry adolescent is the common elements approach. This approach is an evidence-based, effective intervention for common childhood mental health problems, such as aggression, withdrawn behaviors, and attention problems by providing strategies of the actual intervention and providing a sophisticated decision tree model for moving common elements into practice (Walden, 2014). The ideal outcome for this patient would be for her to be able to control her angry independently and safely.
References
Axelson, D. (2010). Adding the Diagnosis of Temper Dysregulation Disorder to DSM-5. Retrieved from https://www.psychiatrictimes.com/view/adding-diagnosis-temper-dysregulation-disorder-dsm-5
Rao, U. (2014). DSM-5: disruptive mood dysregulation disorder. Asian journal of psychiatry, 11, 119-123. https://doi.org/10.1016/j.ajp.2014.03.002
Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.
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