CH is a six-year-old boy with a history of neglect and isolation and parental drug use. He presents with his foster mother for concerns of inattention, hyperactivity, irritability, tantrums, and restless sleep.
NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template
Week 4: Case Study SOAP Note
Subjective:
CC (chief complaint): “I’m here because Wendy told me I need to see the doctor”
HPI: CH is a six-year-old boy with a history of neglect and isolation and parental drug use. He presents with his foster mother for concerns of inattention, hyperactivity, irritability, tantrums, and restless sleep. He’s been living in his current foster home since July 1, 2023. Past history of ADHD combined type, unspecified trauma disorder, oppositional defiant disorder, and autism spectrum disorder. Previous medication trials include guanfacine XR doses of 1-3 milligrams daily. Methylphenidate 2.5 milligrams. CH refrains from physical affection including hugging or touching unless he initiates it. He does not seek comfort for injury but can be consoled when upset. His response is consistent between his foster mother and his relationship with his biological mother who he sees during supervised visits.
He’s easily upset by inconveniences that can become tantrums that last for several minutes. He responds to therapeutic intervention including reflection by taking time in the corner to calm down. Triggers are identifiable. He demonstrates manipulative behavior including bargaining.
He falls asleep easily and sleeps through most of the night. Denies enuresis and infrequent nightmares. Foster mother reports that he is restless in his sleep and will thrash around to the extent that he will fall out of bed. He self-soothes by rocking and humming.
CH engages with the biological children of the foster family although has demonstrated rough play appropriate for his age. He denies aggressive intent and spiteful or vindictive feelings toward others. Foster mother voices concern regarding quote obsession with penis including touching, talking about it, and showing others.
Substance Current Use: CH tested positive for opioids at birth and exhibited signs of neonatal abstinence syndrome with high suspicion of substance exposure in utero. He required NICU and morphine to manage symptoms.
Medical History:
· Current Medications: Guanfacine ER 2 milligrams QHS, Abilify 2 milligrams QAM
· Allergies: NKDA
· Reproductive Hx: Puberty not reached. Not sexually active
Social History: CH was removed from his mother’s custody at the age of five months due to neglect. Police were called to the home by neighbors and he was found in the hallway on the floor with needles drugs and paraphernalia around the home. He lived with his maternal grandparents and his eight-year-old brother until March of 2022 when the grandparents were no longer able to provide care. CH was separated from his brother and placed into care for 16 months with one family who was unable to meet his needs and reported that he was engaged in physically risky behaviors, did not understand social cues, became overstimulated quickly, and was defiant. He has been in his current placement for three months with his foster mother foster father their two biological children and a foster brother close in age. Foster parents deny the above-noted behaviors From previous placement.
Family History: Biological father is unknown. CH has supervised visitation with his biological mother. Biological family medical and other health history is unknown.
· 13-year-old maternal half-brother in the custody of grandparents since the age of 2
· 8-year-old maternal half-brother who resides in another foster home.
· 3-year-old maternal half-sister who lives with father.
ROS:
· GENERAL: denies fever, malaise
· HEENT: denies headache, earache, red eyes, nasal drainage/congestion, sore throat
· SKIN: intact, denies sweating, bruising, bleeding, injury, rash
· CARDIOVASCULAR: denies chest pain, activity intolerance
· RESPIRATORY: denies SOB, cough
· GASTROINTESTINAL: denies n/v/d, constipation
· GENITOURINARY: denies urinary pain, frequency, enuresis
· NEUROLOGICAL: denies pain/weakness/dizziness
· MUSCULOSKELETAL: denies weakness, stiffness
· HEMATOLOGIC: denies bruising/bleeding
· LYMPHATICS: denies swelling
· ENDOCRINOLOGIC: denies heat/cold intolerance
Objective:
Ht: 46.5 in., Wt: 48 lbs., AIMS: 0
Diagnostic results:
CMP, lipid panel, TSH, prolactin level- pending
Assessment:
Mental Status Examination: He is alert and oriented to person, place, time, and event and is dressed appropriately for the occasion and time of year. Speech and language, memory, and thought process are appropriate/intact and age-appropriate. His mood is appropriate and has a full range of affect. He denies auditory or visual hallucinations. His thought process is linear, logical, and goal-directed. He engages with fidgets and toys during the interview.
Diagnostic Impression:
Post-traumatic stress disorder, unspecified 309.81(F43.10)- The diagnostic criteria for children six years and younger for PTSD is specific to exposure to actual or perceived death, serious injury, or sexual violence. The methods of how exposures are perceived include directly witnessing the event as it occurs to themselves or others and experiencing repeated or extreme exposure to the violence or traumatic episode. Out-of-home placement such as foster care can precipitate emotional dysregulation related to stressful exposures (Baldwin et al., 2019). Symptoms include intrusive thoughts and distressing memories of the event which can include frightening dreams or flashbacks where the patient may not be able to recall specific detail. This can all also present and reenactment play or marked physiological reactions to triggers. Other key indicators include persistent avoidance of stimuli associated with the traumatic event and negative alterations in cognition and mood associated such as the inability to remember specific details of the event.
While CH is new to care and has not been able to articulate details of his exposures, his behaviors in connection with third-party accounts of his exposures support a diagnosis of PTSD. He was exposed to neglect from his mother and drug use and demonstrates an aversion to affection when initiated by others. His hyperfixation with his penis could also be a symptom of trauma that he is unable to articulate or recognize due to his age. He avoids triggers that are identifiable but were not identified during this exam due to time constraints. The occasionally rough play with toys also warrants further evaluation as this could represent reenactment from trauma. While CH does not describe nightmares, he is restless at night and can be heard rocking or humming and frequently thrashes around in his sleep, falling out of bed at times.
Reactive attachment disorder of childhood 313.89 (F94. 1)-
RAD is a condition that is characterized by marked disturbance in behavior demonstrated by inappropriate attachment for comfort and support. Children with this condition also display a blunted positive response of emotion to interaction with caregivers. CH demonstrates guarded behavior when interacting with caregivers and does not regularly seek comfort. When he does seek comfort, his response is minimal. Also consistent with with diagnosis as described in the DSM-V (American Psychiatric Association, 2013) is his past exposure to neglect which is a diagnostic requirement. While rare, RAD is most often identified in children who are institutionalized or in alternate care sites such as foster homes (Bruce et al., 2019). Differential diagnoses for this condition include ASD, intellectual disability, and depressive disorders. CH does not meet criteria for these other diagnoses.
Attention deficit hyperactivity disorder, combined type 314.01 (F90.2)-
CH demonstrates difficulty staying on task, sustaining attention, and impulsiveness including difficulty staying in the seat and waiting for a turn and interrupting. The DSM-V requires 6 or more criteria met for patients under the age of 17 and CH represents combined inattentiveness and hyperactivity (American Psychiatric Association, 2013). He denies AVH or symptoms of other conditions including psychotic disorders or mood disorders.
Reflections:
CH has had an extensive history of neglect and substance exposure since infancy. He does not currently display associated traits of autism spectrum disorder. Rocking and humming at night are likely self-soothing measures in response to extensive trauma and neglect and poor or nonexistent attachment formed with his mother as an infant. Behaviors such as not seeking comfort from others, lack of need for affection, behavioral issues, and attachment aversion appear to be social struggles related to a reactive attachment disorder.
If I could conduct the session again, I may have discussed sending the foster mom home with Vanderbilt forms to give to his teachers in school to help further assess for ADHD behaviors in the classroom. It may be appropriate to consider a Conners for the next appointment. Further assessment can help support a definitive diagnosis to better guide the treatment plan. There is no medication for PTSD, however, symptoms can be mitigated with medication as needed.
Case Formulation and Treatment Plan:
Continue current treatment Guanfacine ER 2 milligrams QHS, Abilify 2 milligrams QAM for symptoms of attention deficit hyperactivity disorder combined type, and add post-traumatic stress disorder to diagnoses. Guanfacine is an FDA-approved non-stimulant medication that is FDA-approved medication for the treatment of ADHD in children 6-17 years old and has a milder side effect profile compared to stimulant alternatives (Huss et al., 2018). His behaviors appear to be well managed with his current regimen of medications excluding the occasional tantrum. Lab work including CMP, lipid panel, TSH, and prolactin level to obtain baseline and monitor for potential metabolic changes related to Abilify. Request the Vanderbilt form from the classroom teacher and engage in weekly therapy services provided in school through community resources. No identifiable obstacles to adherence. Follow up in three weeks.
PRECEPTOR VERIFICATION:
I confirm the patient used for this assignment is a patient who 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. (2013). Diagnostic and statistical manual of mental disorders (5th ed.; DSM-5).
Baldwin, H., Biehal, N., Cusworth, L., Wade, J., Allgar, V., & Vostanis, P. (2019). Disentangling the effect of out-of-home care on child mental health. Child Abuse & Neglect, 88, 189–200. https://doi.org/10.1016/j.chiabu.2018.11.011 .
Bruce, M., Young, D., Turnbull, S., Rooksby, M., Chadwick, G., Oates, C., Nelson, R., Young-Southward, G., Haig, C., & Minnis, H. (2019). Reactive Attachment Disorder in maltreated young children in foster care. Attachment & Human Development, 21(2), 152–169. https://doi.org/10.1080/14616734.2018.1499211 .
Huss, M., Dirks, B., Gu, J., Robertson, B., Newcorn, J. H., & Ramos-Quiroga, J. A. (2018). Long-term safety and efficacy of guanfacine extended release in children and adolescents with ADHD. European Child & Adolescent Psychiatry, 27(10), 1283–1294. https://doi.org/10.1007/s00787-018-1113-4 .
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