Diagnostic Assessment and Plan of Care Discussion Paper

Clinical Encounter

C.K., an 8-year-old Caucasian kid, is brought to the clinic by his parents after the latest school reports indicate that his academic performance has deteriorated. Parents said that C.K has had a lengthy history of academic challenges. He had to retake grade 1 due to a lack of attendance. During his first couple of years of school, he would weep every morning as he left the house, clutch to his mother, and beg to be allowed to remain at home. When his parents are late, he feels quite worried and begins to fear whether anything awful has occurred to them. He has trouble falling asleep since he is preoccupied with his parents’ wellbeing and cannot stop thinking about it. C.K. had a hard time completing his homework assignments. It became necessary for his mother to sit with him for extended amounts of time after school to assist him with his assignments. When it comes to school, C.K. has a habit of misplacing items like his books and pens. He is introverted and timid, and he does not disrupt or speak over others. Also highlighted by his parents was the fact that he is quickly bored and has difficulties maintaining concentration for more than a couple of minutes at a time. He is frequently distracted, especially when there is a lot of commotion or someone moves nearby Diagnostic Assessment and Plan of Care Discussion Paper.

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Additionally, his parents are worried about his hyperactivity, impulsiveness, inability to remain focused, grumpy mood, frequent restlessness, unrest, fidgeting, and forgetfulness in his daily tasks. Several teachers expressed similar issues, including absentmindedness in class, inability to finish home assignments, a continual need for reassurance, and repeated absences from school due to C.K.’s feeling too fatigued in the mornings. He also seems to have lost interest in the majority of the activities that he used to enjoy. C.K. has never undergone treatment and does not use any drugs at this time. It was discovered that the patient suffered from attention deficit hyperactivity disorder (ADHD) with comorbid generalized anxiety disorder and moderate depression.

Pathophysiology

Attention deficit hyperactivity disorder (ADHD) is a prevalent mental disease in children characterized by the common manifestations of attention problems, impulsivity, and hyperactivity. According to the latest research, these children no longer seem to “grow out” of their illness. Certain ADHD symptoms do decrease with age, but several children who are diagnosed with the disorder never reach the same degree of functionality as their healthy counterparts when they reach adulthood. A high proportion of children with ADHD have co-occurring mental problems – most often anxiety and depressive disorders – which exacerbate their symptoms and are typically linked with a worse prognosis (Weiping & Lixiao, 2016)Diagnostic Assessment and Plan of Care Discussion Paper.

The association between ADHD and anxiety seems to be strong, as shown by the fact that it exists in all demographics, including children treated by primary care physicians. Various psychological and biological explanations have attempted to explain this co-existence. On the basis of neurophysiology, anxiety in ADHD may partly alleviate impulsive and reaction inhibition deficiencies, exacerbate mental processing impairments and could be substantially distinct from pure anxiety (Weiping & Lixiao, 2016). The co-morbid condition is associated with higher levels of unpleasant affective states and disrupted social behavior, as well as lower levels of fearful/phobic behaviors. Anxiety in children with ADHD may have a significant impact on how the illness presents and progresses. When combined with ADHD or anxiety, the co-morbid illness is related to higher attentional issues, school phobia, and mood disturbances, as well as poorer degrees of social interaction.

It has not been possible to fully characterize the pathophysiology of this complicated comorbid disease. According to the research, attention deficit hyperactivity disorder (ADHD), anxiety disorders, and depression are distinct illnesses that are related by complicated dopaminergic activation problems at the region of the ventral striatum and nucleus accumbens, which are impacted by the amygdala and hippocampus (Reimherr et al., 2017). In PET examinations of individuals with Generalized anxiety disorder, the availability of serotonin and dopamine transmitters (DAT and 5-HTT) in the striatum was shown to be considerably decreased, whereas the availability of 5-HTT was not found to vary between healthy individuals and patients. Children with ADHD have been shown to have reduced availability of DAT in the striatum (Weiping & Lixiao, 2016).

Etiology

Both genetic and social variables impact the incidence, prevalence, and intensity of attention deficit hyperactivity disorder (ADHD) in children, as well as the co-occurrence of anxiety and depression symptoms in children who have ADHD. According to some research, the degree of heritability for ADHD can be as high as 0.7 to 0.8 in certain individuals (Bélanger et al., 2018). A negative feedback loop, according to other research, exists in which harsh input from parents regarding a child’s ADHD conduct stresses family bonds, worsening ADHD symptoms and increasing the likelihood that the child would acquire comorbid mental illnesses. Additionally, poor adaptive abilities and cognitive impairments in parents might be passed down to their children, increasing the likelihood of anxiety, depression, and other mental problems in the children. Because of the relatively high frequency, the frequent lifetime disability, and the periodic occurrence of other mental and behavioral illnesses, attention deficit hyperactivity disorder (ADHD) is regarded as a significant public health and clinical concern (Bélanger et al., 2018)Diagnostic Assessment and Plan of Care Discussion Paper.

Incidence and Prevalence

Adolescent attention deficit hyperactivity disorder (ADHD) is regarded as significant public health concern since it hinders the functioning of the person and may have an impact on both the social and family surroundings. In school-age children, the prevalence of ADHD has been estimated to be between 3 and 7 percent; however, internationally, the prevalence has been estimated to be 5.29 percent (Gumus et al., 2017). It has been noted that youngsters with ADHD have comorbidities such as anxiety disorders (AD) in 15 percent to 50 percent of cases, and mood disorders (MD) in 3 percent to 75 percent of cases (Gumus et al., 2017). Recent research has shown that the existence of comorbid conditions has an impact on the general features, intensity, and long-term prognosis of ADHD, as well as the responsiveness to treatment and subjective quality of life of individuals.

When it comes to schoolchildren, generalized anxiety disorder (GAD) is one of the most frequent mental diseases. Anxiety is a defensive and protective feeling that may be characterized as uneasiness coupled with the anticipation of harm. Anxiety can manifest itself differently depending on one’s personal experiences. The symptoms of AD are marked by dread or agitation, which may result in significant suffering and impairment of functioning. When comparing untreated ADHD patients to control groups, researchers discovered that anxiety and depression disorders are more common in untreated ADHD patients (Gumus et al., 2017)Diagnostic Assessment and Plan of Care Discussion Paper.

Determinants of Health

According to global research, there is a link between social variables and the diagnosis of ADHD, just as there is with many other diseases and disorders. These social variables are known as the social determinants of health, which are described as factors in the contexts in which individuals are born, reside, study, play, work, worship, and grow that have an impact on a broad variety of health, functional, and quality-of-life outcomes and hazards. The social determinants of health that have been demonstrated to be associated with ADHD comprise household income, parents ’ education level, access to medical care, and children’s insurance status (Simoni and Drentea, 2016). Biological and genetic variables may potentially play a role in the development of attention deficit hyperactivity disorder in youngsters.

People from poor origins have been linked to a higher prevalence of psychiatric conditions (Russel, Ford, & Russel, 2015). Additionally, research has indicated that both biological variables and sociocultural contexts might play a role in the diagnosis of attention deficit hyperactivity disorder and its comorbidities (Rowland et al., 2017). Despite the fact that ADHD has a 76 % heritability rate, it has been discovered that familial and surrounding variables have a key part in the etiology of the remainder 24 percent of cases. Mother’s age at birth, household size, family hardship, and smoking while pregnant have all been associated with ADHD in children. Nevertheless, the social determinants that are most regularly identified and analyzed include parental social standing, access to health care, and medical insurance, all of which are generally referred to as socioeconomic position.

Among the measures of socioeconomic position considered by Rowland et al. (2017) were family income and parental educational attainment. They discovered that children from low-income families were 6.2 times more likely than other children to be diagnosed with attention deficit hyperactivity disorder. This number was produced among people who did not have a family background of ADHD, demonstrating the statistically significant relationship between income and the incidence of this illness in the absence of confounding factors (Rowland et al, 2017). This information also points to the fact that social and environmental determinants are more powerful among children who are less genetically susceptible to disease. With a family income of less than $20,000 per year, children with ADHD are more likely to be diagnosed than those with more money (Rowland et al, 2017). In the end, these data show that there is a considerable relationship between family income and the diagnosis of ADHD with comorbid anxiety and depression.

The presence of ADHD may be partly inherited, according to some studies, although genetics is not the only factor in determining whether someone has ADHD. Moreover, brain trauma, low birth weight, early delivery, and adverse environmental stressors during pregnancy have all been associated with the development of attention deficit hyperactivity disorder. However, much as in the case of genetic inheritance, all of these variables do not explain each and every ADHD diagnosis Diagnostic Assessment and Plan of Care Discussion Paper.

Diagnostic Assessment

The 8-year-old male’s history and physical examination are required for the diagnosis of ADHD. This is the gold standard for diagnosing ADHD. This includes an evaluation of the child’s developmental history, validation of normal sight and hearing, and an examination of the child’s family history for ADHD, learning disabilities, or mental disease. Diagnosing attention deficit hyperactivity disorder (ADHD) in youngsters requires meeting certain criteria. The youngster should show 6 or more indications of inattention, or 6 or more indications of impulsivity and hyperactivity, in order to be diagnosed with ADHD. According to the DSM-V criteria, the following clinical manifestations must also be present in order for the child to be diagnosed with ADHD:

  • Displayed symptoms on a consistent basis for at least six months
  • Began to display signs and symptoms before the age of twelve
  • Been exhibiting symptoms in at least two separate situations — for instance, at school and home – to eliminate the chance that the behavior is just a response to specific educators or parental supervision.
  • Indications that render their lives significantly more difficult on a social, intellectual, and/or professional level
  • Symptoms that are not simply components of a developmental issue or tough period, and that are not made clearer by another ailment.

The Childhood Behavior Checklist (CBCL) may help in the detection of attention deficit hyperactivity disorder (ADHD) with comorbid generalized anxiety disorder and mild depression. With this comprehensive diagnostic questionnaire, practitioners may screen children and adolescents for a wide variety of mental disorders, such as anxiety disorders, attention deficit hyperactivity disorder (ADHD), and oppositional defiant disorder. It is particularly effective when numerous mental health disorders are being examined at the same time using this technique. Since it aids in the identification of comorbid illnesses, the CBCL is strongly advisable for use in the first evaluation of ADHD as it aids to rule out comorbidities (Janiczak et al., 2020). Subscales of the CBCL may then be utilized to identify particular diagnoses, which can assist in the detection of ADHD. The Conners Abbreviated Symptom Questionnaire (CASQ is another strongly suggested rating instrument that may be used to aid in the diagnosis of ADHD. It is a quick rating scale with ten items that are filled by the child’s parents and teacher, with an overall score higher than 15 especially suggesting ADHD (Janiczak et al., 2020)Diagnostic Assessment and Plan of Care Discussion Paper.

Diagnostic tools like the Screen for Child Anxiety Related Emotional Disorders (SCARED) and the Spence Children’s Anxiety Scale (SCAS) may assist in the detection of a co-occurring generalized anxiety disorder (Janiczak et al., 2020). The Center for Epidemiological Studies Depression Scale for Children (CES-DC) would be used to test for moderate depression in the aforementioned patient. There are 20 items on CES-DC, and the results are used to determine whether or not someone is experiencing depressed symptoms (Janiczak et al., 2020). Apparently, at this point, there are no diagnostic tools present to detect children who have comorbid anxiety and depression as well as ADHD. A neuropsychological evaluation is appropriate in detecting learning disorders.

Diagnostic Differential

Generalized Anxiety disorder: Generalized anxiety disorder (GAD) is characterized by excessive, overwrought worry and stress over ordinary life occurrences for no apparent cause. It is common for children who have signs of generalized anxiety disorder to always anticipate misfortune and to be overly concerned about matters such as wellbeing, family, and school (Friesen et al., 2021). All of these symptoms are presented by the patient. The main diagnosis would have been this one if the patient had not shown signs of hyperactivity, impulsiveness, and a general lack of attention, thus this is ruled out as a possibility.

Learning disorder: This condition is defined by the majority of the symptoms that the patient presented with, including difficulty paying attention, misplacing items, and inability to finish home assignments. Nevertheless, the neuropsychological evaluation indicated that the child is unfocused in all areas, rather than just one specific area. The results were utilized to rule out the possibility of a learning disorder.

ADHD with comorbid generalized anxiety disorder and moderate depression (Primary Diagnosis): This is a chronic condition that affects the majority of children and, in many instances, advances to adulthood as time passes (Sayal et al., 2018). Hyperactivity, concentration difficulties, impulsive conduct, excessive concern, depressed mood, and a general lack of interest in everyday tasks are all characteristics of this condition. The patient arrived with symptoms of all three disorders: attention deficit hyperactivity disorder (ADHD), generalized anxiety disorder (GAD), and depression. The severity of his depression symptoms was determined to be moderate. Additionally, neuropsychological testing was performed to rule out the presence of any other neuropsychological disorders, and the findings validated the initial diagnosis of ADHD with comorbid generalized anxiety disorder and moderate depression Diagnostic Assessment and Plan of Care Discussion Paper.

Plan of Care

In children with ADHD who also have comorbid illnesses such as generalized anxiety disorder or depression, non-stimulant medication and behavioral therapy are the most effective treatments. Atomoxetine was prescribed at a starting dosage of 0.5 mg/kg once a day, and the dose was raised after three days to a total daily dose of 1.2 mg/kg given as a single dose in the morning. The dosage cannot be more than 1.4 mg/kg/day (Clemow et al., 2017). In addition, the parents were encouraged to enroll the kid in 15 one-hour sessions of cognitive-behavioral therapy. Parents were educated about the signs and symptoms of ADHD, as well as the usual causes of ADHD and its comorbidities, as well as available treatments. They were also given recommendations on individualized education and were linked to support and advocacy groups for children, including children with ADHD, and for their families. A number of online resources for ADHD and comorbid disorders were suggested, and pamphlets on ADHD and comorbid disorders were provided to the parents.

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Desired Outcomes

With the above treatment plan, it is expected that the patient will achieve the following outcomes:

  • Better relations with his parents, siblings, teachers, and friends.
  • Improved schooling (for example, finishing schoolwork or homework assignments).
  • Increased freedom in self-care or homework (e.g., getting ready for school in the morning without clinging to his mother).
  • Increased self-confidence (e.g., increase in feeling that she can get her work done).
  • Verbalization of dread, worry, and other negative emotions.
  • Response to relaxation exercises with a lowered anxiety level.
  • Reduced worry about parents’ well-being.
  • A revived interest in activities he used to enjoy.

Evaluation

Nursing goals were met as evidenced by:

  • The client was able to have better relations with his parents, siblings, teachers, and friends
  • The client was able to finish schoolwork or homework assignments.
  • He was able to have freedom in self-care or homework
  • He was able to have increased self-confidence (e.g., an increase in feeling that she can get her work done).
  • He was able to verbalize his dread, worry, and other negative emotions.
  • He was able to respond to relaxation exercises with a lowered anxiety level.
  • He was able to have reduced worry about his parents’ well-being.
  • He was able to revive his interest in activities he used to enjoy Diagnostic Assessment and Plan of Care Discussion Paper.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. https://www.amberton.edu/media/Syllabi/Fall%202021/Graduate/CSL6798_E1.pdf

Bélanger, S. A., Andrews, D., Gray, C., & Korczak, D. (2018). ADHD in children and youth: Part 1—Etiology, diagnosis, and comorbidity. Paediatrics & Child Health, 23(7), 447-453. https://doi.org/10.1093/pch/pxy109

Clemow, D., Bushe, C., Mancini, M., Ossipov, M., & Upadhyaya, H. (2017). A review of the efficacy of atomoxetine in the treatment of attention-deficit hyperactivity disorder in children and adult patients with common comorbidities. Neuropsychiatric Disease and Treatment, 13, 357-371. https://doi.org/10.2147/ndt.s115707

Friesen, K., & Markowsky, A. (2021). The diagnosis and management of anxiety in adolescents with comorbid ADHD. The Journal for Nurse Practitioners, 17(1), 65-69. https://doi.org/10.1016/j.nurpra.2020.08.014

Gumus, Y. Y., Memik, N. C., & Agaoglu, B. (2017). Anxiety disorders comorbidity in children and adolescents with attention deficit hyperactivity disorder. Noro Psikiyatri Arsivi, 52(2), 185-193. https://doi.org/10.5152/npa.2015.7024

Janiczak, D., Perez-Reisler, M., & Ballard, R. (2020). Diagnosis and management of comorbid anxiety and ADHD in pediatric primary care. Pediatric Annals, 49(10). https://doi.org/10.3928/19382359-20200922-01

Reimherr, F. W., Marchant, B. K., Gift, T. E., & Steans, T. A. (2017). ADHD and anxiety: Clinical significance and treatment implications. Current Psychiatry Reports, 19(12). https://doi.org/10.1007/s11920-017-0859-6

Rowland, A. S., Skipper, B. J., Rabiner, D. L., Qeadan, F., Campbell, R. A., Naftel, A. J., & Umbach, D. M. (2017). Attention‐deficit/Hyperactivity disorder (ADHD): Interaction between socioeconomic status and parental history of ADHD determines prevalence. Journal of Child Psychology and Psychiatry, 59(3), 213-222. https://doi.org/10.1111/jcpp.12775

Russell, A. E., Ford, T., & Russell, G. (2015). Socioeconomic associations with ADHD: Findings from a mediation analysis. PLOS ONE, 10(6), e0128248. https://doi.org/10.1371/journal.pone.0128248

Sayal, K., Prasad, V., Daley, D., Ford, T., & Coghill, D. (2018). ADHD in children and young people: Prevalence, care pathways, and service provision. The Lancet Psychiatry, 5(2), 175-186. https://doi.org/10.1016/s2215-0366(17)30167-0

Simoni, Z. R., & Drentea, P. (2016). ADHD, socioeconomic status, medication use, and academic ethic. Sociological Focus, 49(2), 119-132. https://doi.org/10.1080/00380237.2016.1107713

Weiping, X. I. A., & Lixiao, S. H. E. N. (2016). Comorbid anxiety and depression in school-aged children with attention deficit hyperactivity disorder (ADHD) and selfreported symptoms of ADHD, anxiety, and depression among parents of school-aged children with and without ADHD. Shanghai archives of psychiatry, 27(6), 356. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4858507/

Diagnostic Assessment and Plan of Care

This paper is a pediatric psych and should be written on an 8-years-old Caucasian male with diagnosis of ADHD with comorbid generalized anxiety disorder and moderate depression. It should be written by an experienced professional psychiatric nurse practitioner paper writer. Please do not assign this writing to a beginner and inexperienced writer Diagnostic Assessment and Plan of Care Discussion Paper.

Introduction

PMHNP’s must synthesize information and communicate it in the oral and written word. In this assignment, you will choose a patient you have interacted with during your clinical experience and provide a comprehensive overview to fully describe the encounter and the treatment/plan of care. The focus of the assignment will be on the psychiatric-mental health diagnosis, although your patient may have comorbid medical conditions that should be included in the paper.

Do not include any identifying patient information on your assignment. 

Purpose

The purpose of this assignment is to facilitate the learner’s ability to synthesize clinical information and comprehensively present assessment, diagnostic, and treatment information.

Assignment outcome

At the conclusion of this assignment, the learner will be able to:

  • Introduce the reader to the patient seen
  • Provide fully assessment information
  • Provide a diagnostic differential
  • Provide a psychiatric-mental health diagnosis (with rationale)
  • Describe the treatment and plan of care for this patient
  • Discuss your preceptor’s diagnosis/treatment/plan of care, and provides evidence for why student agrees or disagrees with such

Directions

In this assignment, you will choose a patient you have interacted with during your clinical experience and provide a comprehensive overview to fully describe the encounter and the treatment/plan of care. The focus of the assignment will be on the psychiatric-mental health diagnosis, although your patient may have comorbid medical conditions that should be included in the paper.

Create an APA formatted paper that follows the rubric below. Turn this assignment into Turnitin and upload your PDF results from Turnitin into the appropriate dropbox in Learning Management System

Your paper should be 9-10 pages (without the cover page and reference page), double spaced, which is approximately 2250-2500 words Diagnostic Assessment and Plan of Care Discussion Paper.

Diagnostic Assessment and Plan of Care Rubric
Criteria 10 Points 9 Points 8 Points 0 Points
Pathophysiology Communicates a clear & precise overview of the pathophysiology for the chosen disorder including evidence-based guidelines. Communicates the associated pathophysiology but may be missing one important piece of data Communicates a brief & vague assessment of the disorder while missing important details of the pathophysiology No paper submitted or content missing
Criteria 10 Points 9.5 Points 8.75 Points 0 Points
Etiology Thoroughly describes all relevant factors to the etiology of the disorder Describes the etiology but omits one component that should be listed Describes the etiology but omits more than one component that should be included Diagnostic Assessment and Plan of Care Discussion Paper No paper submitted or content missing
Incidence and Prevalence Develops and provides a clearly written analysis of the incidence and prevalence of the disorder. Develops a clear analysis of the incidence and prevalence but did not support it by evidence Develops and provides a brief overview of the incidence and prevalence with more than one omission and lacks evidential support No paper submitted or content missing
Criteria 10 Points 9.5 Points 8.75 Points 0 Points
Determinants of Health Develops and demonstrates a clear & precise understanding of the determinants of health associated with the disorder. Determinants of health are described but not supported by evidence. A general overview of the determinants of health provided but it is not specific to the current case. No paper submitted or content missing
Diagnostic Assessment A complete diagnostic assessment is provided including the use of all appropriate screening tools. A diagnostic assessment is provided but one or more components is omitted. A brief diagnostic assessment is provided but no appropriate screening tools are listed. No paper submitted or content missing
Diagnostic Differential All appropriate diagnostic differentials are provided with supportive evidence-based information. Appropriate diagnostic differentials were provided but one may have been omitted. Appropriate differentials listed but one may have been omitted and is lacking evidence- based information Diagnostic Assessment and Plan of Care Discussion Paper No paper submitted or content missing
Comprehensive Plan of Care

 

 Complete comprehensive plan of care utilizing evidence-based guidelines and levels of evidence. Plan of care described with one component missing and or no levels of evidence. Plan of care listed without evidence-based guidelines. No paper submitted or content missing
Desired Outcomes

 

 Desired outcomes described to completion with use of evidence-based research to support. Desired outcomes described with one component missing Desired outcomes described with more than one component missing and/or no evidence-based research to provide support. No paper submitted or content missing
Evaluative Methods Complete description of all evaluative methods associated with the disorder to determine if the plan of care has been successful

 

 Description of evaluative methods but one component is omitted. Brief description of evaluative methods and does not tie into the specific plan of care Diagnostic Assessment and Plan of Care Discussion Paper. No paper submitted or content missing
Criteria 5 Points 3.5 Points 3 Points  0 Points
Grammar, spelling, and punctuation There are no errors in grammar, spelling, and punctuation There are a few minor errors in grammar, spelling, and punctuation that do not detract from the meaning Diagnostic Assessment and Plan of Care Discussion Paper There are major errors in grammar, spelling, and punctuation that do not reflect scholarly writing NA
APA and references The paper meets APA format guidelines and/or all references are peer reviewed, relevant, scholarly and contemporary, up to 5 years. There are minor APA format errors and/or references meet two requirements of relevant, scholarly or contemporary, up to 5 years. There are significant errors in format and/o references meet one requirement of relevant, scholarly or contemporary. NA

Diagnostic Assessment and Plan of Care Discussion Paper