Autism Spectrum Disorder

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Week 3: Autism Spectrum Disorder, ADHD, ODD, and ICD

“I can’t believe I am sitting here talking to this lady. Mom thinks I am nuts just because I will not do what she asks. She does not care about me. She only cares about my little brother and that man that keeps coming around. I don’t care anything about her. That is why I throw things and won’t do what she asks. I don’t care about anyone. Those kids at school who used to be my friends don’t know anything. I am so much smarter than they are.
Jacob, age 11”

There are many mental disorders that occur early in the life course. The DSM-5 describes neurodevelopmental disorders such as autism spectrum disorder and ADHD and disruptive, impulse-control, and conduct disorders, such as oppositional defiant disorder and conduct disorder. These disorders are examined together with a particular emphasis on comparing and contrasting presenting features. Diagnosis of these various conditions can rarely be made in a single office setting and often require a comprehensive approach involving multiple stakeholders, including the child, as well as his or her parents, teachers, and other significant figures in the child’s life and mental health professionals, such as psychologists who can conduct comprehensive neuropsychological testing.

The PMHNP must coordinate and integrate several sources of information to arrive at an accurate diagnosis of these disorders. Early and accurate diagnosis is essential to developing an effective treatment plan, which will have the potential to minimize the impact of these disorders on the child’s developmental trajectory. When one considers appropriate diagnosis from this perspective, the importance of diagnostic accuracy becomes quite apparent. Autism Spectrum Disorder

This week, you begin exploring disorders that occur early in the life course by working with your group to develop a Parent Guide. You also examine a case to determine a differential diagnosis and treatment plan that incorporates both psychotherapy and psychopharmacology.

Learning Resources

Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.

REQUIRED READINGS

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

Standard 5E “Pharmacological, Biological and Integrative Therapies” (page 59)

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 3, “Contributions of the Sociocultural Sciences” (pp. 131–150)

Chapter 31, “Child Psychiatry” (pp. 1152–1181, 1244–1253)

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

“Neurodevelopmental Disorders”

“Intellectual Disabilities”

“Communication Disorders”

“Disruptive, Impulse-Control, and Conduct Disorders” Autism Spectrum Disorder

Volkmar, F., Siegel, M., Woodbury-Smith, M., King, B., McCracken, J., & State, M. (2014). Practice parameter for the assessment and treatment of children and adolescents with autism spectrum disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 53(2), 237–257. Retrieved from http://www.jaacap.com/article/S0890-8567(13)00819-…

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.

Review the following medications:

Irritability in autism	Attention-deficit/hyperactivity disorder
aripiprazole risperidone	armodafinil amphetamine (d) amphetamine (d,l) atomoxetine bupropion chlorpromazine (hyperactivity) clonidine guanfacine haloperidol (hyperactivity) lisdexamfetamine methylphenidate (d) methylphenidate (d,l) modafinil reboxetine

Note: Many of these medications are FDA approved for adults only. Some are FDA approved for disorders in children and adolescents. Many are used “off label” for the disorders examined in this week. As you read the Stahl drug monographs, focus your attention on FDA approvals for children/adolescents (including “ages” for which the medication is approved, if applicable) and further note which drugs are “off label.”

REQUIRED MEDIA

Laureate Education (Producer). (2017b). A young girl with difficulties in school [Multimedia file]. Baltimore, MD: Author.

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 51, “Autism Spectrum Disorder” (pp. 665–682) Autism Spectrum Disorder

Assignment 1: Practicum: Decision Tree

For this Assignment, you examine the client case study in this week’s Learning Resources. Consider how you might assess and treat pediatric clients presenting with symptoms noted in the case.

Note: This Assignment is the first of three assignments that are based on interactive client case studies. For these assignments, you will be required to make decisions about how to assess and treat clients. Each of your decisions will have a consequence. Some consequences will be insignificant, and others may be life altering. You are not expected to make the “right” decision every time; in fact, some scenarios may not have a “right” decision. You are, however, expected to learn from each decision you make and demonstrate the ability to weigh risks versus benefits to prescribe appropriate treatments for clients.

Learning Objectives

Students will:

Evaluate clients for treatment of mental health disorders
Analyze decisions made throughout diagnosis and treatment of clients with mental health disorders

The Assignment:

Examine Case 1. 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.

At each Decision Point, stop to complete the following:

Decision #1: Differential Diagnosis
- Which Decision did you select?
- Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
- What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
- 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
- Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
- What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
- 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
- Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
- What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
- 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.

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Case #1 A young girl with difficulties in school chool BACKGROUND In psychopharmacology you met Katie, an 8-year-old Caucasian female, who was brought to your office by her mother (age 47) and father (age 49). You worked through the case by recommending possible ADHD medications. As you progress in your PMHNP program, the cases will involve more information for you to sort through. For this case, you see Katie and her parents again. The parents have reported that the medication given to Katie does not seem to be helping. This has prompted you to reconsider the diagnosis of ADHD. You will consider other differential diagnoses and determine what information you need to accurately assess the DSM-5 criteria to make the diagnosis of ADHD or another disorder with similar diagnostic features. When parents bring their child to your office, they may have read symptoms on the internet or they may have been told by the school “your child has ADHD”. Your diagnosis will either confirm or refute that diagnosis. Katie’s parents reported that their PCP felt that she should be evaluated by psychiatry to determine a differential diagnosis and to begin medication, if indicated. The PMHNP makes this diagnostic decision based on interviews and observations of the child, her parents, and the assessment of the parents and teacher. To start, consider what assessment tools you might need to evaluate Katie. Autism Spectrum Disorder

• • Child Behavior Check List Conners’ Teacher Rating Scale The parents give the PMHNP a copy of a form titled “Conner’s Teacher Rating ScaleRevised” (Available at: https://www.ncbi.nlm.nih.gov/projects/gap/cgibin/GetPdf.cgi?id=phd000099.1 ). This scale was filled out by Katie’s teacher and sent home to the parents so that they could share it with their provider. According to the scoring provided by her teacher, Katie is inattentive, easily distracted, makes careless mistakes in her schoolwork, forgets things she already learned, is poor in spelling, reading, and arithmetic. Her attention span is short, and she is noted to only pay attention to things she is interested in. She has difficulty interacting with peers in the classroom and likes to play by herself at recess. When interviewing Katie’s parents, you ask about pre- and post-natal history and you note that Katie is the first born with parents who were close to 40 years old when she was born. She had a low 5 minute Apgar score. The parents say that she met normal developmental milestones and possibly had some difficulty with sleep during the pre-school years. They notice that Katie has difficulty socializing with peers, she is quiet at home and spends a lot of time watching TV. SUBJECTIVE You observe Katie in the office and she is not able to sit still during the interview. She is constantly interrupting both you and her parents. Katie reports that school is “OK”- her favorite subjects are “art” and “recess.” She states that she finds some subjects boring or too difficult, and sometimes hard because she feels “lost”. She admits that her mind does wander during class. “Sometimes” Katie reports “I will just be thinking about something else and not looking at the teacher or other students in the class.” Katie reports that her home life is just fine. She reports that she loves her parents and that they are very good and kind to her. Denies any abuse, denies bullying at school. She offers no other concerns at this time. Katie’s parents appear somewhat anxious about their daughter’s problems. You notice the mother is fidgeting with her rings and watch while you are talking. The father is tapping his foot. Other than that, they seem attentive and straight forward in the interview process. MENTAL STATUS EXAM The client is an 8-year-old Caucasian female who appears appropriately developed for her age. Her speech is clear, coherent, and logical. She is appropriately oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. She demonstrates no noteworthy mannerisms, gestures, or tics. Self-reported mood is euthymic. Affect is neutral. Katie says that she doesn’t hear any ‘voices’ in her head but does admit to having an imaginary friend, ‘Audrey’. No reports of delusional or paranoid thought processes. Attention and concentration are somewhat limited based on Katie’s short answers to your questions. Decision Point One BASED ON THE INFORMATION PROVIDED IN THE SCENARIO ABOVE, WHAT IS YOUR DIAGNOSIS FOR KATIE? 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. 299.00 Autism Spectrum Disorder (ASD), mild and co-occurring; 300.23 Social Anxiety Disorder 315.0 Specific Learning Disorder with Impairment in Reading and 315. Autism Spectrum Disorder

1 Impairment in Mathematics Decision Point One Decision Point One BASED ON THE INFORMATION PROVIDED IN THE SCENARIO ABOVE, WHAT IS YOUR DIAGNOSIS FOR KATIE? 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. 299.00 Autism Spectrum Disorder (ASD), mild and co-occurring; 300.23 Social Anxiety Disorder 315.0 Specific Learning Disorder with Impairment in Reading and 315.1 Impairment in Mathematics 314.00 Attention Deficit Hyperactivity Disorder, predominantly inattentive presentation Decision Point One 314.00 Attention Deficit Hyperactivity Disorder, predominantly inattentive presentation RESULTS OF DECISION POINT ONE • • Client returns to clinic in four weeks You selected Attention deficit hyperactivity disorder, predominantly inattentive presentation. Based on this choice, outline the remainder of the diagnostic evaluation that you will conduct on this child and their parents. Be sure to include standardized assessment instruments that you would administer 314.00 Attention Deficit Hyperactivity Disorder, predominantly inattentive presentation RESULTS OF DECISION POINT ONE • • Client returns to clinic in four weeks You selected Attention deficit hyperactivity disorder, predominantly inattentive presentation. Based on this choice, outline the remainder of the diagnostic evaluation that you will conduct on this child and their parents. Be sure to include standardized assessment instruments that you would administer Decision Point Two Decision Point Two BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION. Begin Wellbutrin 75 mg orally daily Begin Strattera 25 mg orally daily Begin Adderall XR 10 mg orally daily Begin Adderall XR 10 mg orally daily RESULTS OF DECISION POINT TWO • • • • Client returns to clinic in four weeks Katie’s parents seem absolutely delighted upon their return stating that Katie is paying more attention in school, but note that there is still room for improvement, particularly in the afternoon They report that Katie’s teacher has reported that Katie is able to maintain her attention throughout the morning classes but come afternoon, she “daydreams.” Katie’s parents are also concerned about her decrease in appetite since starting the medication Decision Point Three Decision Point Three BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION. Autism Spectrum Disorder

Assure Katie’s parents that weight loss is common with stimulant medications used to treat ADHD Augment medication with family thearpy Add a small dose of immediate release Adderall in the early afternoon Add a small dose of immediate release Adderall in the early afternoon Guidance to Student Whereas weight loss is common with stimulant medication, this option does not address Katie’s parents’ concerns about the return of symptoms in the afternoon. Augmentation with family therapy is also a good idea as it can help Katie with her symptoms and further help her parents to understand the unique challenges that Katie experiences, as well as ways that they can help her with symptoms, however, this option does not address the return of inattentive symptoms in the afternoon. Adding a small dose of immediate relate Adderall in the afternoon can help Katie to maintain attention throughout the afternoon and into the early evening when she must do homework. This would be the best option. The decision answers are in red, … Autism Spectrum Disorder