Ava is a seven-year-old girl, the second of two children of a middle-class family living in a suburban area of a northwest city. Ava has one sister that is two years older than she is. Her mother’s pregnancy was normal, with no complications and Ava’s birth was normal. Ava had colic the first three months, cried extensively and was difficult to comfort. After three months, she became passive and cried very little with comfort from her mother. Her growth and development appeared to be normal. She met all the developmental milestones her first three years. She interacted normally with her sister and parents, except that she would become tearful and anxious when her parents would get a babysitter.
At age four, she was in nursery school and appeared to function normally except during the first month when Ava had difficulty when her father would drop her off at school. The nursery school was a small private school with a lot of personal attention given to each child. Although shy, she made friends and liked going to nursery school after she became adjusted to the new setting. Her parents liked the school so much that they decided to keep Ava in kindergarten at this school with her same teachers and friends. However, tuition at the school became a problem after Ava’s mother became sick with lupus and was unable to work.
At age six, Ava’s parents enrolled her in first grade at the public elementary school in their neighborhood. For the last two weeks, she has refused to go to school and has missed six school days. She began routinely brushing her hair before bed and insisted on making sure each side was brushed with an even number of strokes. She also had her mother tuck her in bed on the right side and her father come after on the left side each night. She would become very tearful and upset if the routine was not followed. She is awake almost all night worrying about going to school and asks the same questions over and over about the environment, teachers, and other students. As the start of the school day approaches, she cries and screams that she cannot go, chews holes in her shirt, pulls her hair, digs at her face, punches the wall, throws herself on the floor, as well as experiences headaches, stomachaches, and vomiting. Over the past two weeks, she has become gloomy, has stopped reading for fun, and frequently worries about her mother’s Lupus and that she may die. She asks her every night if she has dreamed about her funeral. In addition, Ava is phobic of dogs, avoids speaking and writing in public, and wets the bed every night.
Her parents immediately made an appointment to see her PCP. Her doctor conducted a thorough physical exam, found no physical abnormalities and then referred her to you, a Family PMHNP.
Family history of mental health includes the following: mother has a history of panic disorder; her father has a history of treatment with medications for ADHD as a child; and she has a cousin diagnosed with Asperger’s syndrome.
For your assignment, write a paper that addresses the following prompts using evidence-based references to support your answers:
1. Summarize the case.
2. What is your provisional diagnosis, as well as the possible differentials?
3. Justify your answer with DSM-5 criteria (be short, brief and to the point).
4. Is Ava too young to diagnose, or is there a basis for early identification and intervention?
5. What psychiatric scales or assessment tools might you use with this patient? With the parents? List and describe briefly.
6. What would be your treatment plan for medications, if any? If you do choose to offer medication as part of the treatment plan, please address the following medications issues:
1. Target symptoms
2. Receptors affected
3. Psychiatric and system effects
4. Possible parental concerns
7. What would be your school-based treatment plan, if any?
8. What would be the implications for the families of children and adolescents with these diagnostic pictures?
9. How does the mother’s health play into the picture of Ava’s diagnosis? What type of therapy would you recommend for Ava (and her family) to work through her issues?
10. Identify resources for patients/families with this diagnosis in the form of community groups, web-sites, advocacy, as well as treatment resources available in your service area.
11. What are you worried about (if anything)? Consider this question in terms of treatment, assessment, alliance, compliance, effectiveness, safety, and other factors.
