Practicum: Decision Tree
Decision One
The first decision is to diagnose the patient with early-onset schizophrenia. The reason for selecting the decision is because the symptoms match with the DSM criteria for early-onset schizophrenia (Driver et al., 2020). The disease, also known as childhood schizophrenia occurring among children and teenagers. It involves a range of problems including emotions, behavior, and thinking (Driver et al., 2020). Children with the disease experience hallucinations, delusions, and disordered thinking and behavior. The symptom impairs the ability of a child to function at home or school. The disease affects the developmental milestones of children. Although the disease presents various diagnostic challenges and treatments, psychiatrists can match the presenting symptoms with the DSM-5 for early-onset schizophrenia (Driver et al., 2020). The symptoms can vary over time with periods of worsening and remission of symptoms.
Early-onset schizophrenia is when the symptoms of the mental condition appear before the 13th birthday. Parents describe the health of their children as unusual (Hakulinen et al., 2019). For example, the case study indicates that the child has been seeing and talking to imaginary friends. The patient has delusions since she has imaginary friends who are half-cat and half-human. She has spirits who speak to her in her head. She also reports that people on the television know when she is at home and that the television programs are designed for her. The parents complain that the patient is not meeting the developmental milestones like other children in her age. Her academic performance has been on the decline. Another symptom is social isolation. During the interview, she states that she is not interested in having friends. According to the DSM-5 criteria for early-onset schizophrenia, patients experience social isolation (Han et al., 2017). Another symptom according to DSM-5 is the poor performance of children with early-onset schizophrenia in school. The children fail to meet their daily expectations or complete their homework. The symptoms are evident in the life of the 13th-year-old girl present for a psychiatric assessment and treatment.
The expectation for the diagnosis is to begin treatment for the patient. Accurate diagnosis is effective in the successful treatment of mental conditions. Matching the presenting symptoms with those of the patient is pertinent to diagnosis and treatment (Han et al., 2017). It is important to begin treatment to ensure recovery and resumption of the normal activities in school and at home. The desire of the parents is for the child to attain the developmental milestones, embrace rightful thinking and behavior without delusions and hallucinations.
There is no difference between what I was hoping to achieve and the first goal. The goal was to match the symptoms with the DSM-5 for accurate diagnosis (Han et al., 2017). It was important to eliminate the other two options based on accurate analysis.
Decision Two
The client returned to the clinic after four weeks. The second decision was to refer the patient for psychological testing although there is no specific test for early-onset schizophrenia. Subjecting a patient to a battery of comprehensive tests will examine the personality and cognitive functioning (Hakulinen et al., 2019). The testing is important to examine the underlying intellectual abilities of the patient (Hakulinen et al., 2019). The testing is important to further evaluate and explain the difficulties the patient is experiencing in school.
The tests administered in the psychological testing include Minnesota Multiphasic Personality Inventory, Kaufman Adolescent and Adult Intelligence Test, Rorschach test, Whitaker Index of Schizophrenic Thinking (WIST) test, Wide Range Achievement Test – 4th Edition (WRAT-4), and the Millon Adolescent Clinical Inventory (MACI) (Jerrell et al., 2017). The consulting psychologist opined that according to the tests, the patient could have early-onset schizophrenia.
Carrying out a battery of tests is important in identifying the symptoms and eliminating the possible conditions that present similar symptoms (Jerrell et al., 2017). For instance, Minnesota Multiphasic Personality Inventory is used to examine personality type and psychopathology. Millon Adolescent Clinical Inventory is effective in assessing the mental condition of teens by assessing their health and behaviors unique to their age bracket and making reliable diagnostic (Newton et al., 2018). Teenagers experience diverse changes in their mood and functionality which make the diagnosis of mental conditions difficult. It is similar to the children who experience diverse changes in their cognitive functions as they grow up (Newton et al., 2018). Taking several tests improves the accuracy to arrive at a diagnostic decision.
Additional tests are necessary to examine the reason for the changes in the mental condition of teenagers. Blood tests are necessary to rule out possible causes of the unusual behavior and thinking patterns. The blood test will hormonal, chromosomal, and disorders related to growth failure (Jerrell et al., 2017). For instance, diabetes or lack of thyroid hormones can undermine appropriate growth patterns. The test can determine if a patient has an intellectual disability that results in poor performance in school. The physical examination can be used to rule out possible causes of failing to achieve the growth milestones (Jerrell et al., 2017). The psychologist should also collect comprehensive medical history to ascertain any relationship with the past. For instance, the mother indicates the grandfather had schizophrenia, a factor that could increase the risk of early-onset schizophrenia (Newton et al., 2017). Research shows that although the cause of schizophrenia is not known, genetic factors play a major role in the family tree (Jerrell et al., 2017).
There is no difference between the expectations I had while carrying a battery of tests and the results. One of the suspected conditions was early-onset schizophrenia due to the history of the condition in the family. It was important to carry diverse tests to examine other causes of different symptoms.
Decision Three
The third decision was to begin Lurasidone orally daily. The drug is used for the treatment of schizophrenia in adults, but it can be used for off-label purposes (Goldman et al., 2017). One of the precautions is to reduce the drug to almost by half such as 20mg orally daily depending on the weight of the child. The practitioner should monitor the reactions and determine whether to increase, decrease, or change the dosage (Goldman et al., 2017). There is no legal prohibition on the prescription of drugs used in adults to treat schizophrenia. The practitioner needs to take precautions to avoid side effects triggered by a high dose. The prescription should take into consideration the informed consent of the parent or guardian (Arango et al., 2019). The practitioner should educate the parent to ensure they understand the drug will be used off-label. Another reason why Lurasidone is the best option is that it has little impact on the body weight and lipid profile (Arango et al., 2019). Drugs that affect the weight of a child or adult record low adherence (Arango et al., 2019). Patients stop taking the drugs when they realize they are leading to an increase in weight.
It was not prudent to prescribe Clozapine 100mg orally daily. Clozapine is only essential to treat resistant schizophrenia (Kim et al., 2017). Since the patient is receiving treatment for the first time, it is not clear if the disease is resistant to treatment. Beginning Clozapine can undermine the efficacy of the treatment and other drugs that may follow in the future (Kim et al., 2017). Another consideration is that prescribing 100mg can affect the health of the patient severely due to the side effects. Practitioners should consider the weight of a child while prescribing off-label drugs (Kim et al., 2017).
During the prescription, it is important to determine the fasting plasma glucose levels. Antipsychotic medication can affect patients in different ways (Arango et al., 2019). Healthcare workers should determine the BMI and weight of a patient. In every clinic, it is crucial to measure the weight of the patient (Arango et al., 2019). Other essential factors include blood pressure and fasting triglycerides.
The next intervention is family intervention. The family needs to know the cause of the behavior of the child and how to live with the child until they recover. Family interventions help prevent relapse (Camacho-Gomez & Castellvi, 2020). Some of the family interventions include educating the family about the disease to prevent stigma and how to encourage the child to take medication. Adhering to the medication is effective in reducing the risk of relapse (Camacho-Gomez & Castellvi, 2020). Anticipatory guidance or proactive counseling is used to address the significant changes that occur in children (Camacho-Gomez & Castellvi, 2020). The counseling helps the parents to anticipate emotions, thinking, and behavior patterns and respond effectively.
Ethical Considerations
Treatment of mental conditions in children required adherence to the nursing ethical principles to avoid undermining the quality of care or attracting legal suits. One of the considerations is the principle of informed consent (Martinez-Martin & Kreitmair, 2018). Prescription of off-label drugs to children requires the approval of a patient. A practitioner should inform the parent about the therapeutic endpoints (Martinez-Martin & Kreitmair, 2018). Another consideration is beneficence and maleficence, which takes into consideration the risk of harming a patient. A psychiatrist should avoid decisions that can undermine the safety of a patient (Bastos & Alberti, 2021). Monitoring the patient’s weight and other reactions after four weeks is critical to determine the best responses. The information about the health of the child should remain confidential. Confidentiality according to the HIPPA laws prohibits practitioners to reveal identity or information about a patient’s sickness (Bastos & Alberti, 2021). However, during the treatment, the practitioner can explain the limits of disclosure. A nurse must observe fidelity, which involves being faithful and true to professional responsibilities (Bastos & Alberti, 2021). One of the responsibilities is to provide safe off-label drugs by lowering the dosage and monitoring the responses.
Conclusion
The patient in the case study presents various symptoms that undermine social interaction and academic performance. The possible disease the patient is suffering from is early-onset schizophrenia. Children with the disease experience hallucinations, delusions, and disordered thinking and behavior. The first decision is to diagnose the patient with early-onset schizophrenia. Early-onset schizophrenia is when the symptoms of the mental condition appear before the 13th birthday. The second decision was to refer the patient for psychological testing although there is no specific test for early-onset schizophrenia. The third decision was to begin Lurasidone orally daily. It is not safe to prescribe Clozapine since it is used to treat resistant schizophrenia. The treatment process should involve family intervention such as anticipatory guidance to help the family respond effectively to the behavior of the teenager. Healthcare workers should observe legal and ethical considerations to ensure they maintain professionalism in their treatment approach.
References
Arango, C., Ng-Mak, D., Finn, E., Byrne, A., & Loebel, A. (2019). Lurasidone compared to other atypical antipsychotic monotherapies for adolescent schizophrenia: a systematic literature review and network meta-analysis. European child & adolescent psychiatry, 1-11.
Bastos, A. D. D. A., & Alberti, S. (2021). From the psychosocial paradigm to religious morality: ethical issues in mental health. Ciência & Saúde Coletiva, 26, 285-295.
Camacho-Gomez, M., & Castellvi, P. (2020). Effectiveness of family intervention for preventing relapse in first-episode psychosis until 24 months of follow-up: A systematic review with meta-analysis of randomized controlled trials. Schizophrenia Bulletin, 46(1), 98-109.
Driver, D. I., Thomas, S., Gogtay, N., & Rapoport, J. L. (2020). Childhood-onset schizophrenia and early-onset schizophrenia spectrum disorders: An update. Child and Adolescent Psychiatric Clinics, 29(1), 71-90.
Goldman, R., Loebel, A., Cucchiaro, J., Deng, L., & Findling, R. L. (2017). Efficacy and safety of lurasidone in adolescents with schizophrenia: a 6-week, randomized placebo-controlled study. Journal of child and adolescent psychopharmacology, 27(6), 516-525.
Hakulinen, C., McGrath, J. J., Timmerman, A., Skipper, N., Mortensen, P. B., Pedersen, C. B., & Agerbo, E. (2019). The association between early-onset schizophrenia with employment, income, education, and cohabitation status: nationwide study with 35 years of follow-up. Social Psychiatry and Psychiatric Epidemiology, 54(11), 1343-1351.
Han, S., Huang, W., Zhang, Y., Zhao, J., & Chen, H. (2017). Recognition of early-onset schizophrenia using deep-learning method. In Applied Informatics (Vol. 4, No. 1, pp. 1-6). SpringerOpen.
Jerrell, J. M., McIntyre, R. S., & Deroche, C. B. (2017). Diagnostic clusters associated with an early onset schizophrenia diagnosis among children and adolescents. Human Psychopharmacology: Clinical and Experimental, 32(2), e2589.
Kim, J. S., Park, C. M., Choi, J. A., Park, E., Tchoe, H. J., Choi, M., … & Lee, S. H. (2017). The association between season of birth, age at onset, and clozapine use in schizophrenia. Acta Psychiatrica Scandinavica, 136(5), 445-454.
Martinez-Martin, N., & Kreitmair, K. (2018). Ethical issues for direct-to-consumer digital psychotherapy apps: addressing accountability, data protection, and consent. JMIR mental health, 5(2), e32.
Newton, R., Rouleau, A., Nylander, A. G., Loze, J. Y., Resemann, H. K., Steeves, S., & Crespo-Facorro, B. (2018). Diverse definitions of the early course of schizophrenia—a targeted literature review. NBJ Schizophrenia, 4(1), 1-10.
