Please respond to your peerâ€™s posts, from an FNP perspective. To ensure that your responses are substantive, use at least two of these prompts:
- Do you agree with your peersâ€™ assessment?
- Take an opposing view to a peer and present a logical argument supporting an alternate opinion.
- Share your thoughts on how you support their opinion and explain why.
- Present new references that support your opinions.
Please be sure to validate your opinions and ideas with citations and references in APA format. Substantive means that you add something new to the discussion, you arenâ€™t just agreeing. This is also a time to ask questions or offer information surrounding the topic addressed by your peers. Personal experience is appropriate for a substantive discussion and should be correlated to the literature.Be sure to review your APA errors in your reference list, specifically you have capitalization errors in some words of the titles. Also, be sure you are italicizing titles of online sources.
Question number one-
- As a primary care provider working with children with mental health disorders you understand there are special health needs to be assessed and an increased frequency regarding health exams. What information do you want to assess in children who are diagnosed with ADHD and managed on stimulant medications? What is the frequency for evaluation?
Samantha B’s Response
Attention-deficit/hyperactivity disorder (ADHD) is the most common behavioral disorder in children, and the prevalence is increasing (Felt, Christner, Kochhar, & Harrison, 2014). The practitioner should evaluate for ADHD in children with behavioral concerns such as inattention, hyperactivity, impulsivity, oppositionality or poor academic progress using validated assessment tools with observers from several settings and self-observation, if possible (Felt et al., 2014). Practitioners who inherit a patient with a previous ADHD diagnosis should review the diagnostic process, and current symptoms and treatment needs (Felt et al., 2014). The American Academy of Pediatrics provides the National Initiative for Children’s Healthcare Quality Vanderbilt Assessment Scale for free, and this should be used for assessment at home, school, and in the practitionerâ€™s office (Felt et al., 2014).
Management for this condition include life style modification, behavioral treatment, and pharmacological treatment, ant the practitioner must manage this in addition to a psychiatrist. Behavioral treatments are recommended for preschool-aged children and may be helpful at older ages (Brahmbhatt et al., 2016). Effective behavioral therapies include parent training, classroom management, and peer interventions (Brahmbhatt et al., 2016). Medications are recommended as first-line therapy for older children (Brahmbhatt et al., 2016). Psychostimulants, such as methylphenidate and dextroamphetamine, are most effective for the treatment of core ADHD symptoms and have generally acceptable adverse effect profiles (Brahmbhatt et al., 2016).
Adverse effects of stimulant medication are generally dose dependent and include reduced appetite, abdominal discomfort, headache, irritability, anxiousness, sleep problems, and a small reduction in height velocity that may attenuate with time and/or reverse after discontinuation of treatment (Storebo, 2018). National guidelines recommend that practitioners consider electrocardiography and/or cardiology referral before initiating psychostimulants in patients with a history of heart disease, palpitations, syncope, or seizures, or with a family history of sudden cardiac death, Wolff-Parkinson-White syndrome, hypertrophic cardiomyopathy, or long QT syndrome. Height, weight, heart rate, blood pressure, symptoms, mood, and treatment adherence should be recorded at follow-up visits (Storebo, 2018). Monthly visits may be required until medication dosing and timing are optimized (Storebo, 2018). When an acceptable regimen is determined, follow-up is recommended at least every three months during the first year, and two or three times per year thereafter to assess control of symptoms, treatment adherence, and the presence of comorbid conditions (Storebo, 2018).
Brahmbhatt, K., Hilty, D. M., Hah, M., Han, J., Angkustsiri, K., & Schweitzer, J. B. (2016). Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder During Adolescence in the Primary Care Setting: A Concise Review. The Journal of adolescent health : official publication of the Society for Adolescent Medicine, 59(2), 135â€“143. doi:10.1016/j.jadohealth.2016.03.025
Felt, B., Christner, J., Kochhar, P., & Harrison, R. (2014). Diagnosis and management of ADHD in children. American Family Physician . Retrieved from https://www.aafp.org/afp/2014/1001/p456.html
StorebÃ¸, O. J., Pedersen, N., Ramstad, E., Kielsholm, M. L., Nielsen, S. S., Krogh, H. B., Gluud, C. (2018). Methylphenidate for attention deficit hyperactivity disorder (ADHD) in children and adolescents – assessment of adverse events in non-randomised studies. The Cochrane database of systematic reviews, 5(5), CD012069. doi:10.1002/14651858.CD012069.pub2
Amanda D’s response
You have just finished seeing a 10-year-old girl for complaints of somatic pains, refusal to engage in activities, mood swings, and sleep disturbances. You perform a depression screening which reveals a high score for depression. You diagnose her with Depression NOS and initiate monotherapy with sertraline.
What are your recommendations for her parents?
Successful management of childhood depression involves participation from the childâ€™s parents (Steele, & Doey, 2007). The parents should be educated regarding the childâ€™s medication regimen, possible medication side effects, and medication schedule (Gordon, & Melvin, 2014). Depression is commonly triggered by stressful life events such as; divorce of parents, difficulty at school, social dysfunction, and family conflict (Pinfield, 2017). I would recommend that they work to develop a daily routine for the patient and limit exposure to stressful events. I would recommend that the parents develop a nightly bedtime routine to foster an appropriate sleep schedule. Insomnia has been identified as a risk factor for the development of depression (Boysan, 2016). Bedtime has been recognized as a time of increased anxiety for children that suffer from insomnia (Boysan, 2016). I would encourage the parents to limit â€œscreen timeâ€ at least 1 hour before bedtime to reduce stimulus.
When will you have her return to clinic?
Reviewed literature suggests that pediatric patients which are placed on a selective serotonin reuptake inhibitor (SSRI) should be monitored weekly for the first 4 weeks of therapy, then biweekly for 2 months, and monthly until stable (Scahill, Hamrin, & Pachler, 2005). I would have this patient return to the clinic weekly for four weeks to monitor the efficacy of the medication, potential medication side effects, and assess her overall wellness.
What is your plan if she discloses suicidal ideation?
My first priority is the safety of the patient and her family. If this patient were to disclose suicidal ideation I would gather more information. I would assess the patientsâ€™ level of suicide risk. I would ask if she has attempted suicide in the past. If so, how? I would ask if she has a plan to end her life, if so how? I would inquire if she had the means to carry out her plan. For example, if she stated she had the intent to shoot herself, I would ask if she had access to a firearm. Risk of suicide is increased when the patient begins to exhibit characteristics such as giving away possessions, has a mental health history, has a family member that has committed suicide, and the patient exhibits psychotic thinking (Steele, & Doey, 2007). If after further assessment I felt that this patient was a danger to herself or others, I would facilitate her transport to an inpatient facility for close observation and management. It has been my experience (although quite limited) that pediatric patients do not distinguish thoughts of suicide from thoughts of self-harm. The difference between suicide and self-harm is intent. Often, suicidal patients feel that there is â€œno way outâ€ and want to end their life. Patients with thoughts of self-harm view harming themselves as a coping mechanism.
Boysan, M. (2016). Developmental implications of sleep. Sleep and Hypnosis (Online), 18(2), 44-52.
Gordon, M., & Melvin, G. (2014). Risk assessment and initial management of suicidal adolescents. Australian Family Physician, 43(6), 367-72.
Pinfield, J. (2017). Recognizing and diagnosing depression in children and young people. Nursing Standard (2014), 31(48), 51.
Scahill, L., Hamrin, V., & Pachler, M. E. (2005). The use of selective serotonin reuptake inhibitors in children and adolescents with major depression. Journal of Child and Adolescent Psychiatric Nursing, 18(2), 86-9.
Steele, M. M., & Doey, T. (2007). Suicidal behavior in children and adolescents. Treatment and prevention. Canadian Journal of Psychiatry, 52(6), 35S-45S.