WK 9 discussion
The psychiatric mental health nurse practitioner (PMHNP) has a significant role to play in evaluating and treating their clients. There are many different approaches to Assessment and care for adolescent treatment. The purpose of this week’s discussion is to explain observations of a chosen client, including behaviors associated with the diagnostic and statistical manual of mental disorders (DSM-5). Additionally, discuss therapeutic approaches that can be used with this client, including possible psychotropic medications, if necessary. Finally, address the expected outcomes for the client based on the chosen therapeutic approaches.
Observations/DMS-5
For this discussion, I chose the young adolescent boy, who I would describe as argumentative, angry, and blames others for his behavior. He reports that another kid at school told him to take the gym teacher’s car for a drive, and states that the gym teacher left his keys in the car, trying to justify his actions (Laureate Education (Producer), 2013a). He feels that he should not be the one getting therapy; his parents should be (Laureate Education (Producer), 2013a). Based on his behaviors, he meets the criteria for Oppositional Defiant Disorder (ODD). Displayed by angry and irritable mood, losing temper often, easily annoyed, and is often resentful. He is argumentative or defiant with authority, adults at home, and school. He also displays vindictiveness. His behaviors are not due to substance use, and he has no other mood or other diagnosed psychiatric disorders. The (DSM-5) notes that oppositional defiant disorder (ODD) has an angry or irritable mood pattern, exhibits argumentative or defiant behaviors, and at times vindictive nature (American Psychiatric Association, 2013). The psychiatric mental health nurse practitioner (PMHNP) must address with the parents when the symptoms started, to gauge a timeline for a therapeutic care plan.
Therapeutic Approach
According to Wheeler (2014), the level of a child’s development influences what they can understand and how they understand it. The therapeutic approaches that could be effective for this client include individual cognitive behavior therapy (CBT), school-based training, functional family therapy, and parental management training (PMT) (Danforth, 2016). Cognitive behavior therapy (CBT) is aimed more at Helping the adolescent client in identifying and changing thought patterns that may lead to negative behaviors (Merrill, Smith, Cumming, & Daunic, 2017). Cognitive behavior therapy (CBT) techniques useful for oppositional defiant disorder (ODD) include identifying triggers and consequences of aggressive behaviors, learning to recognize and regulate anger, problem-solving and cognitive restructuring techniques, modeling and rehearsing socially appropriate responses that can replace anger, aggressive behaviors (Merrill, Smith, Cumming, & Daunic, 2017). Individual and family therapy supports modifying family functioning to change the problematic behavior by taking a multisystemic approach and interacting with the adolescent with family involvement in interventions and in setting goals (Wheeler, 2014). Parental management training (PMT) helps with developing parenting skills and structured interventions that will make the actions and experiences more manageable (Danforth, 2016). Parent’s roles in the therapy include bringing the child to treatment, insight into the behavior problems, creating an environment in between sessions conducive to practicing newly learned skills. Parents are also encouraged to recognize and praise their child’s efforts and reward the child for improvements in behaviors (Danforth, 2016).
Psychotropic Medications
Psychosocial approaches are first-line interventions for maladaptive aggression in youth; therefore, psychotropic medications are not required at this time. There are no medications that are food and drug administration approved for oppositional defiant disorder (ODD) alone. If the client was dealing with another form of mental health disorder, then other treatment remedies are available. If an oppositional child’s aggression cannot be controlled psychosocially, pharmacotherapy can be combined to produce better results, especially in areas of aggression and emotional dysregulation (Ghosh, Ray, & Basu, 2017). In pharmacotherapy, treating comorbid disorders is the first choice, according to Ghosh, Ray, and Basu (2017). If the disorder is not yet controlled, an atypical antipsychotic can be added, which can be titrated to get an optimal dosing schedule. If there is a nonresponse to the medication, the antipsychotic is changed; partial response would indicate the need to add a mood stabilizer to the antipsychotic medication regime (Ghosh, Ray, & Basu, 2017). Ghosh, Ray, & Basu (2017) note that prescribing more than one antipsychotic medication is not recommended. Methylphenidate has had the best results in treating aggression when there are comorbid disorders involved, such as attention deficit hyperactivity disorder (ADHD) (Martinez-Raga, Ferreros, Knecht, de Alvaro, & Carabal, 2017). Risperidone is an atypical antipsychotic that has the most reliable evidence in treating aggression in youth, followed by aripiprazole (Martinez-Raga et al., 2017).
Expected Outcomes
The expected outcomes through therapy approaches are to decrease the symptoms of oppositional defiant disorder (ODD) and to help the client and family recognize and manage them. The client will be able to identify and change the thought process associated with oppositional defiant disorder (ODD). Through family involvement, goal setting, and implementing interventions will prove to be more therapeutic for the client.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Laureate Education (Producer). (2013a). Disruptive Behaviors – Part 2 [Multimedia file]. Baltimore, MD: Author.
Danforth J. S. (2016). A Flow Chart of Behavior Management Strategies for Families of Children with Co-Occurring Attention-Deficit Hyperactivity Disorder and Conduct Problem Behavior. Behavior analysis in practice, 9(1), 64–76. https://doi.org/10.1007/s40617-016-0103-6
Ghosh, A., Ray, A., & Basu, A. (2017). Oppositional defiant disorder: current insight. Psychology research and behavior management, 10, 353–367. doi:10.2147/PRBM.S120582
Martinez-Raga, J., Ferreros, A., Knecht, C., de Alvaro, R., & Carabal, E. (2017). Attention-deficit hyperactivity disorder medication use: factors involved in prescribing, safety aspects, and outcomes. Therapeutic advances in drug safety, 8(3), 87–99. https://doi.org/10.1177/2042098616679636
Merrill, K. L., Smith, S. W., Cumming, M. M., & Daunic, A. P. (2017, February). A review of social problem-solving interventions: Past findings, current status, and future directions. American Educational Research Association, 87(1). https://doi.org/10.3102%2F0034654316652943
Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.
