How to solve a nursing case on Pediatric Anxiety and OCD (Answered)

Case Study: Cora is a seven-year-old girl, the second of two children of a middle-class family living in a suburban area of a northwest city. Cora has one sister that is two years older than her. Her mother’s pregnancy was normal, with no complications and Cora’s birth was normal. Cora had colic the first three months, cried extensively, and was difficult to comfort. After three months she became passive and cried very little with comfort from her mother. Her growth and development appeared to be normal. She met all the developmental milestones in her first three years. She interacted normally with her sister and parents, except that she would become tearful and anxious when her parents would get a babysitter.

At age four, she was in nursery school and appeared to function normally except during the first month when Cora had difficulty when her father would drop her off at school. The nursery school was a small private school with a lot of personal attention given to each child. Although shy, she made friends and liked going to nursery school after she became adjusted to the new setting. Her parents liked the school so much that they decided to keep Cora in kindergarten at this school with her same teachers and friends. However, tuition at the school became a problem after Cora’s mother became sick with lupus and was unable to work.

At age six, Cora’s parents enrolled her in first grade at the public elementary school in their neighborhood. For the last two weeks, she has refused to go to school and has missed six school days. She began routinely brushing her hair before bed and insisted on making sure each side was brushed with an even number of strokes. She also had her mother tuck her in bed on the right side and her father come after on the left side each night. She would become very tearful and upset if the routine was not followed. She is awake almost all night worrying about going to school and asks the same questions over and over about the environment, teachers, and other students. As the start of the school day approaches, she cries and screams that she cannot go, chews holes in her shirt, pulls her hair, digs at her face, punches the wall, throws herself on the floor, as well as experiences headaches, stomachaches, and vomiting. Over the past two weeks, she has become gloomy, has stopped reading for fun, and frequently worries about her mother\’s Lupus and that she may die. She asks her every night if she has dreamed about her funeral. In addition, Cora is phobic of dogs, avoids speaking and writing in public, and wets the bed every night.

Her parents immediately made an appointment to see her PCP. Her doctor conducted a thorough physical exam, found no physical abnormalities, and then referred her to you, a Family PMHNP.

Family history of mental health includes the following: mother has a history of panic disorder; her father has a history of treatment with medications for ADHD as a child, and she has a cousin diagnosed with Asperger’s syndrome.

Instructions
For your assignment, write a paper that addresses the following prompts using evidence-based references to support your answers:

1. Summarize the case.
2. What is your provisional diagnosis, as well as the possible differentials?
3. Justify your answer with DSM-5 criteria (be short, brief, and to the point).
4. Is Cora too young to diagnose, or is there a basis for early identification and intervention?
5. What psychiatric scales or assessment tools might you use with this patient? With the parents? List and describe briefly.
6. What would be your treatment plan for medications, if any? If you do choose to offer medication as part of the treatment plan, please address the following medications issues:
Target symptoms
Receptors affected
Psychiatric and system effects
Possible parental concerns
7. What would be your school-based treatment plan, if any?
8. What would be the implications for the families of children and adolescents with these diagnostic pictures?
9. How does the mother’s health play into the picture of Cora’s diagnosis? What type of therapy would you recommend for Cora (and her family) to work through her issues?
10. Identify resources for patients/families with this diagnosis in the form of community groups, web-sites, advocacy, as well as treatment resources available in your service area.
11. What are you worried about (if anything)? Consider this question in terms of treatment, assessment, alliance, compliance, effectiveness, safety, and other factors.

SOLUTION to Pediatric Anxiety and OCD

Summarize the case.

Cora is a seven-year-old girl brought to the PMHNP with primary complaints of refusal to go to school. For the last two weeks, the patient has missed six school days and the mother reports that she stays awake all night worrying about schooling. As the day starts, she cries and screams, pulls her hair, punches the wall, and experiences headaches, stomachaches, and vomiting. Additionally, she has become gloomy, stopped reading for fun, and constantly worries that her mother might die following a diagnosis of Lupus. On top of these symptoms, she routinely brushes her hair before bed, has her mother tuck in her bed on the right side and her father later on the left in the exact order. Cora had anxiety issues when she was young as she could cry when their parents got a babysitter and had difficulty when dropped off at school. She has a phobia of dogs, avoids speaking and writing in public, and wets the bed every night.

What is your provisional diagnosis, as well as the possible differentials?

My provisional diagnosis for Cora is separation anxiety disorder (Code 309.21/F93.0).

Differentials for the patient include:

Adjustment disorder with disturbance of emotions and conduct (Code 309.4/F43.25)

Specific phobia (Code 300.29/F40.218)

Obsessive compulsive disorder (OCD) (Code 300.3/F42)

Justify your answer with DSM-5 criteria (be short, brief, and to the point).

Separation anxiety is assigned to individuals who have problems separating from people they feel strongly attached to. Patients usually present with symptoms like distress at the experience of separation, excessive fear of being alone, anxiety about sleeping, and physical complaints (American Psychiatric Association, 2013). For children, they may fail to go to school and present with somatic symptoms like stomachache and vomiting. To diagnose this condition in children, symptoms must persist for more than 4 weeks in children and adolescents (American Psychiatric Association, 2013). For the past two weeks, Cora has experienced these symptoms and are most likely associated with separation anxiety.

Adjustment disorder is a short-term illness characterized by exaggerated reactions to stressful or traumatic events. Symptoms in children may include loss of interest in daily activities, crying easily, anxiety, agitation, and impulsive behavior (American Psychiatric Association, 2013). Specific phobia is another potential diagnosis for Cora as she is phobic to dogs. The condition is characterized by deep and persistent fear of an object resulting in symptoms of anxiety. Symptoms like nausea, vomiting, and upset stomach indicate specific phobia disorder (American Psychiatric Association, 2013). Lastly, OCD involves experiences of intrusive thoughts, images, or impulses that create a high degree of emotional distress (American Psychiatric Association, 2013). Symptoms may include repetitive behaviors and recurrent thoughts that cause distress or anxiety.

Is Cora too young to diagnose, or is there a basis for early identification and intervention?

Cora is not too young to diagnose because separation anxiety is the most common anxiety disorder in children younger than 12 years. The prevalence of the disease is estimated to be 4.1% among children and 6.6% among adults (American Psychiatric Association, 2013). Cora is seven years old and separating from her parents is a difficult situation observed to cause her symptoms.

What psychiatric scales or assessment tools might you use with this patient? With the parents? List and describe briefly.

I will use the separation anxiety scale for children (SASC) to diagnose Cora’s condition. The item is suitable for the assessment of children aged 6 to 18 years and is used to determine if an individual has separation anxiety (Hu et al., 2020). The scale contains 34 items that are self-reported divided into six subscales. There are five items fear of being alone, fear of abandonment, fear of physical illness, being worried about calamitous events, frequency of the events, and nine items on the safety signals index (Hu et al., 2020). This item will identify crucial aspects to diagnose Cora with separation anxiety disorder.

What would be your treatment plan for medications, if any? If you do choose to offer medication as part of the treatment plan, please address the following medications issues:
Target symptoms
Receptors affected
Psychiatric and system effects
Possible parental concerns

Treatment of separation anxiety can involve both pharmacological and nonpharmacological approaches. My plan for the treatment of Cora will involve prescription with a selective serotonin reuptake inhibitor (SSRIs) as they are considered first-line therapy (Bushnell et al., 2018). This class includes drugs like escitalopram, fluoxetine, sertraline, and paroxetine.

SSRIs function by increasing the level of serotonin neurotransmitters in the brain. These drugs inhibit serotonin transporter at the presynaptic axon terminal thus increasing the amount of serotonin that remains in the synaptic cleft to stimulate receptors for a more extended period (Bushnell et al., 2018). The target receptors for these drugs are presynaptic 5-HT1A which enhances the extracellular 5-HT receptors.

Although relatively safer due to their selective ability, SSRIs are not without risks. The FDA has a black box warning on the risk for suicidality among pediatric and young children (Bushnell et al., 2018). They can also lead to arrhythmias as they prolong QT interval and common side effects like sleep disturbance, weight gain, anxiety, and dizziness can be observed. Cora’s parents may be worried about starting her on antidepressants at a young age. The need for close monitoring for side effects and suicidal thoughts may also be a worry of Cora’s parents.
7. What would be your school-based treatment plan, if any?

The first intervention that may be effective for Cora is group cognitive behavioral therapy CCBT). CBT and exposure therapy are helpful in improving relationships and decreasing anxiety (Caldwell et al., 2019). In addition to group therapies at school, training Cora’s parents will help in adjustment with Cora’s anxiety (Caldwell et al., 20190. Actions like preparing Cora for school ahead of time, establishing daily school routines, and creating distractions can help in her adjustment.

What would be the implications for the families of children and adolescents with these diagnostic pictures?

Anxiety and depression are the most frequently observed psychiatric conditions in children and adolescents. These conditions can cause disability and affect the entire lives of children if not well-managed. Separation anxiety in children causes worries in families, extra expenses in taking care of the child, and lost productive hours for parents. Families and parents should be trained to take care of their children by practicing simple goodbyes, commenting on positive progress, and ignoring negative behavior during routine detachment.

How does the mother’s health play into the picture of Cora’s diagnosis? What type of therapy would you recommend for Cora (and her family) to work through her issues?

Cora’s mother has Lupus disease that is observed to be a contributing factor to Cora’s separation anxiety. She constantly worries about her mother’s death and perhaps how she might cope thereafter. To address this challenge, I will use family therapy which is an evidence-based CBT for children with separation anxiety (Lippert et al., 2019). The family will receive psychoeducation that will help them to learn how to recognize irrational beliefs about separation and expand their coping skills.

Identify resources for patients/families with this diagnosis in the form of community groups, web-sites, advocacy, as well as treatment resources available in your service area.

Cora and her family can utilize local therapists for education and management of the condition. Local pharmacies are available to aid in dispensing medication alongside websites like the National Institute for mental health and the American Academy of Child and Adolescent Psychiatry.

11.What are you worried about (if anything)? Consider this question in terms of treatment, assessment, alliance, compliance, effectiveness, safety, and other factors.

At this point, I might be worried about the family’s approach to the use of medications to manage Cora’s condition. They may opt for CBT and family therapy which will be difficult to manage Cora’s condition. The increased risk for suicidality with the use of SSRIs is among the greatest worries especially if Cora’s mother’s health will deteriorate sooner.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Bushnell, G. A., Compton, S. N., Dusetzina, S. B., Gaynes, B. N., Brookhart, M. A., Walkup, J. T., Rynn, M. A., & Stürmer, T. (2018). Treating pediatric anxiety: Initial use of SSRIs and other antianxiety prescription medications. The Journal of Clinical Psychiatry, 79(1), 16m11415. https://doi.org/10.4088/JCP.16m11415

Caldwell, D. M., Davies, S. R., Hetrick, S. E., Palmer, J. C., Caro, P., López-López, J. A., … & Welton, N. J. (2019). School-based interventions to prevent anxiety and depression in children and young people: A systematic review and network meta-analysis. The Lancet Psychiatry, 6(12), 1011-1020.

https://doi.org/10.1016/S2215-0366(19)30403-1

Hu, Y., Cai, Y., Tu, D., Guo, Y., & Liu, S. (2020). Development of a computerized adaptive test for separation anxiety disorder among adolescents. Frontiers in Psychology, 11, 1077. https://doi.org/10.3389/fpsyg.2020.01077

Lippert, M. W., Pflug, V., Lavallee, K., & Schneider, S. (2019). Enhanced family approaches for the anxiety disorders. Innovations in CBT for childhood anxiety, OCD, and PTSD: improving access & outcomes. Cambridge University Press, Cambridge, 182-205. https://psycnet.apa.org/doi/10.1017/9781108235655.009

How to solve a nursing case on Pediatric Anxiety and OCD (Answered)

SOLUTION to Pediatric Anxiety and OCD

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