Childhood and Adolescence Stages

Focused SOAP Note

Introduction

Childhood and adolescence are important stages when it comes to mental health since this is the time when the brain develops rapidly. During childhood and adolescence, various cognitive and socio-emotional skills are acquired and they significantly influence their mental health. Generally, mental health problems in the pediatric population include various behavioral, emotional, and mental disorders that can affect this population. For the last 7 weeks, I have interacted with various patients with mental health problems, including pediatric patients. This SOAP note focuses on a pediatric patient who presented accompanied by her parents. The parents reported that the child was manifesting abnormal behaviors as she could talk to unreal people.

Identifying Data

XX is a 15-year-old African American female, born within the US. She lives with both his parents and his younger sister. She is in 6th grade.

Subjective

Chief Complaint: “Our daughter is showing behaviors that are not normal for a teenager like her. She keeps talking to imaginary people. Her behavior is really scaring us.”

History of Presenting Illness

Parents of XX reported concerns about their daughter’s behavior, which they described as “abnormal for a 15-year old”. They reported that she keeps talking to imaginary people and her behavior is normally calm. According to the parents, when she was younger, she would throw anger tantrums and was irritable, but lately, she has become passive. Her mother reports that even though young children have imaginary friends, she is supposed to have outgrown such behaviors. Her mother reports that the daughter claims to have “vampires” for friends and spirits that speak in her mind. The client (XX) admits that there are television programs exclusively for her. The parents reported that XX has been assessed several times by the GP, who told them that she was mentally okay. Her parents also added that they have been always concerned as she lagged behind in terms of developmental milestones, especially when younger.

Initially, when XX began school, her academic performance was good and she would keep up with her peers. However, teachers were concerned about her isolative behavior. The teachers also noted that her social skills were below average as they did not meet her peer’s social skills. At first, the school counselor suggested that XX was having attention deficit hyperactivity disorder, and hence recommended a mental health evaluation. The parents further reported that their daughter’s grades were okay until two years ago when she joined high school and educational demands increased. Teachers suggested that XX should hold her in junior school, but the parents refused. They now regret their decision as their daughter currently seems “more lost than ever” academically. When the father produced the homework XX had completed, the assignment did not appear to have any clarity as it appeared as a jumble of ideas and thoughts. The mother reports that XX’s grandmother had serious mental problems. After further probing, she started crying and said, “my mother had schizophrenia and major depressive disorder, what if my little girl is schizophrenic?”

Throughout the interview, XX appeared pleasant but very distant. On asking about her friends, she answers that “I am the type that does not have friends. I do not like such kinds of people.” On enquiring, if she is upset about friends, she says, “no, I am not upset with my friends, they like me to be their friend, but I just don’t want to be friends with them”. When the client was asked if she thinks she has control over the thoughts of other people with her mind, she gazes towards the doors and says, ‘my parents do not like me talking about these things so I try not to think about them because my parents can read my mind and get upset. They think I am crazy or something.”

Past Psychiatric History

XX’s social skills were below the appropriate milestones during her childhood. During childhood, the school counselor indicated that she was having ADHD.

Hospitalizations: No previous hospitalization.

Medication: No medication for the current symptoms

Psychotherapy: No psychotherapy for the current symptoms

Substance Use and History: No history of substance abuse or alcohol intake

Family Medical History: Maternal grandmother has a history of schizophrenia and major depressive disorder. Her father was diagnosed with an anxiety disorder during high school.

Psychosocial History: X X, was born and raised in Texas, USA. She lives with both her parents. She is the firstborn in a family of three children. She has a good relationship with her siblings. She does not have close friends.

Relationship: N/A

Educational Level: High-school

Medical History: N/A

Current medications: N/A

Reproductive History: LPM 12th June 2021. Regular menstrual cycle.

Objective

Vital signs: Temp 37.0 o C; RR 18; Blood pressure 123/88; HR 82; Weight 41 kgs

The client appeared appropriately developed and groomed for her age. She ambulates with an upright gaze that is also steady. She does not illustrate any notable mannerisms, tics, or gestures. No apparent psychomotor retardation/agitation.

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Assessment

Mental Status Exam

The client is alert and oriented to time, event, person, and place. Her speech is coherent, spontaneous, goal-directed, and coherent. Her self-reported mood is “good”. However, her affect appeared somehow constricted. XX’s eye contact was minimal during the entire interview and sometimes she would appear preoccupied. During the interview, XX endorsed seeing and hearing strange things that she communicates with. “Those things are from another world and they come to visit me as they are my custodians”. No evident overt paranoia. She reported delusion of reference as she believes that there are television programs only for her and people in television want her to punish “bad” people. However, she denied any homicidal or suicidal ideation.

Differential Diagnosis

Early Onset Schizophrenia

According to the DSM-5 diagnostic criteria, symptoms of early-onset schizophrenia consist of negative symptoms, hallucinations, delusions, disorganized speech, and disorganized behavior (Coulon et al., 2020). According to the American Psychiatric Association (2013), a person is supposed to exhibit two or more of such symptoms to be diagnosed with schizophrenia. XX manifests three of these symptoms and they consist of the negative symptoms as demonstrated by constricted affect, hallucinations as manifested by the client hearing, seeing and communicating with strange and imaginary people, and delusions as manifested by the client asserting that television programs are exclusively made for her. Negative symptoms in individuals having schizophrenia also encompass flat affect, lack of interest, lack of motivation, and reduced social interactions (Budisteanu et al., 2020). XX lacks interest in interacting with her peers and friends, exhibits constricted affect, as well as blunt affect. There is also a family history of schizophrenia as the mother reported that the father had a diagnosis of schizophrenia. Therefore, from the symptoms, the client is manifesting and the family history of schizophrenia, this supports the diagnosis of early-onset schizophrenia for XX.

Schizoaffective Disorder

Schizoaffective disorder is also a possible diagnosis for XX. According to the DSM-5 diagnostic criteria, this disorder is characterized by symptoms of schizophrenia such as delusions or hallucinations, as well as symptoms of a mood disorder such as mania or depression (American Psychiatric Association, 2013). Mania symptoms include periods of high energy, reduced need to sleep, and engaging in risky activities, while depression symptoms include anhedonia, worthlessness, hopelessness, sleep disturbances, sadness, appetite changes, social isolation, among other symptoms (Freudenreich, 2020). The symptoms can exist at the same time or during different times, where periods of symptom improvement follow cycles of severe symptoms.

However, even though XX manifests symptoms such as delusions and hallucinations, she does not manifest mania symptoms such as high energy levels or engaging in risky behaviors. Additionally, the client does not manifest many symptoms of depression such as appetite changes or severe sadness. Psychotic symptoms such as delusions and hallucinations are the main symptoms for XX and thus the diagnosis of schizoaffective disorder is less likely.

Schizotypal Personality Disorder

According to the DSM-5 diagnostic criteria, schizotypal personality disorder is characterized by five or more of the following symptoms: lacking close friends apart from the family members; flat emotions; social anxiety; unusual thinking; paranoid thoughts; delusional beliefs of special powers; wrong interpretation of events; dressing peculiarly; social anxiety and peculiar speaking style (American Psychiatric Association, 2013). Additionally, adolescents manifest increased social anxiety and engagement in solitary activities. Children and adolescents also manifest reduced academic performance and have poor social skills when compared to their peers.

Even though individuals with this disorder may manifest psychotic episodes with hallucinations or delusions, the episodes are infrequent. Moreover, people with schizotypal personality disorder can be made to differentiate between reality and their distorted ideas. XX manifests frequent hallucinations and delusions and she is unable to differentiate between her distorted ideas and reality (Pattamanusorn et al., 2020). In addition, the client was dressed appropriately for her age, does not manifest increased social anxiety or peculiar speaking style since her speech is clear, goal-oriented, and coherent. Therefore, the diagnosis of schizotypal personality disorder for XX is less likely.

Treatment Plan

Individual Psychotherapy, Cognitive Behavioral Therapy (CBT)

Through individual psychotherapy, the client will be taught how to deal with and handle her behaviors and thoughts (Nuño et al., 2019). As a result, she will be able to learn about her diagnosis and its impacts, and also the differential between reality and what is not real. Individual psychotherapy will also help her to handle her thoughts and behaviors.

The CBT will help change the client’s thinking and behavior that may trigger negative emotions (Health Quality Ontario, 2018). For example, during CBT sessions she will be trained on how to deal with hallucinations and delusions. The client will also be trained on how to identify the triggers to the psychotic episodes and times when delusions and hallucinations flare-up and how to reduce or stop the psychotic symptoms (Sønmez et al., 2020). During the CBT sessions, the client will be taught how her feelings, thoughts, and behaviors affect each other. XX will thus be taught strategies to modify and alter negative thoughts and react to them in a different way; this changes the unwanted feelings and problematic behaviors. Through CBT, the client will be taught to test the reality of her perceptions and thoughts, manage symptoms and ignore any voices. As Bighelli et al (2018) explain, CBT can also assist individuals with schizophrenia to develop problem-solving skills, improve social skills, decrease the severity of symptoms, and also reduce the risk of symptoms’ relapse.

As a health promotion activity, XX will be encouraged to take part in community outreach programs in order to improve her social skills. The client will also be encouraged to engage in activities such as exercises and her hobbies in order to keep her mind engaged. She will also be educated to take a healthy diet such as reducing high intake of sugars and stimulants and increase intake of essential fats, fruits, and vegetables.

As an educational strategy, the client’s parents and siblings will be educated on the importance of always being supportive to XX. This is because a strong support system has been shown to improve symptoms of schizophrenia and also helps in treatment adherence (Hestmark et al., 2020).

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Pharmacotherapy

The recommended medication is Lurasidone 40 mg daily. Lurasidone is recommended for treating schizophrenia in the pediatric population and it has a good safety profile. The medication also has few side effects, low sedative effects, and does not have significant weight gain. The medication does not interfere with the cognitive ability and functioning of the patients (Goldman et al., 2017). Therefore, Lurasidone is appropriate for this client.

Reflection Notes

The diagnosis for this client (schizophrenia) was quite perplexing because this disorder is not common among the pediatric population. It was somehow overwhelming to witness an adolescent with psychotic symptoms. I believe that the recommended treatment options will help the client achieve complete symptom remission. However, in the future, I would recommend psychological testing for a pediatric patient presenting with similar symptoms. psychological tests can help evaluate the personality, cognitive functioning and identify any intellectual disability. Moreover, comprehensive psychological testing can be useful in ruling out other causes of psychotic and other mental symptoms.

With a good support system from the family and adherence to the prescribed treatment, XX has a good prognosis. Therefore, it would be important to emphasize the significance of the parents supporting xx as she deals with the mental health issue.

Conclusion

The client, xx is a pediatric patient who presented with her parents. The parents reported that their daughter was exhibiting abnormal behavior as she could talk to unreal people and believed television shows were exclusively made for her. She also manifests other symptoms, apart from psychotic symptoms. The patient was diagnosed with early-onset schizophrenia. Both the objective and subjective data, as well as the mental status exam, support this diagnosis. individual psychotherapy, CBT is the recommended psychotherapy while Lurasidone is the recommended pharmacological choice.

References

American Psychiatric Association, A. P., & American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (Vol. 10). Washington, DC: American psychiatric association.

Bighelli, I., Huhn, M., Schneider-Thoma, J., Krause, M., Reitmeir, C., Wallis, S., … & Leucht, S. (2018). Response rates in patients with schizophrenia and positive symptoms receiving cognitive behavioral therapy: a systematic review and single-group meta-analysis. BMC psychiatry, 18(1), 1-10.

Budisteanu, M., Andrei, E., Linca, F., Hulea, D. S., Velicu, A. C., Mihailescu, I., Riga, S., Arghir, A., Papuc, S. M., Sirbu, C. A., Mitrica, M., Docu-Axelerad, A., Ghinescu, M. C., Dobrescu, I., & Rad, F. (2020). Predictive factors in early-onset schizophrenia. Experimental and therapeutic medicine, 20(6), 210. https://doi.org/10.3892/etm.2020.9340

Coulon, N., Godin, O., Bulzacka, E., Dubertret, C., Mallet, J., Fond, G., Brunel, L., Andrianarisoa, M., Anderson, G., Chereau, I., Denizot, H., Rey, R., Dorey, J. M., Lançon, C., Faget, C., Roux, P., Passerieux, C., Dubreucq, J., Leignier, S., Capdevielle, D., … Schürhoff, F. (2020). Early and very early-onset schizophrenia compared with adult-onset schizophrenia: French FACE-SZ database. Brain and Behavior, 10(2), e01495. https://doi.org/10.1002/brb3.1495

Freudenreich, O. (2020). Schizoaffective Disorder: Conceptually Flawed, Clinically Relevant. Psychiatric Annals, 50(5), 183–184.

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. https://doi.org/10.1089/cap.2016.0189

Health Quality Ontario (2018). Cognitive Behavioural Therapy for Psychosis: A Health Technology Assessment. Ontario health technology assessment series, 18(5), 1–141.

Hestmark, L., Romøren, M., Heiervang, K. S., Weimand, B., Ruud, T., Norvoll, R., … & Pedersen, R. (2020). Implementation of guidelines on family involvement for persons with psychotic disorders in community mental health centers (IFIP): protocol for a cluster-randomized controlled trial. BMC health services research, 20(1), 1-15.

Nuño, L., Guilera, G., Coenen, M., Rojo, E., Gómez-Benito, J., & Barrios, M. (2019). Functioning in schizophrenia from the perspective of psychologists: A worldwide study. PloS one, 14(6), e0217936.

Pattamanusorn, N., Wongpakaran, N., Thongpibul, K., Wongpakaran, T., & Kuntawong, P. (2020). Pathogenic beliefs among patients with a schizotypal personality disorder. Heliyon, 6(5), e03870.

Sønmez, N., Romm, K. L., Østefjells, T., Grande, M., Jensen, L. H., Hummelen, B., … & Røssberg, J. I. (2020). Cognitive behavior therapy in early psychosis with a focus on depression and low self-esteem: A randomized controlled trial. Comprehensive Psychiatry, 97, 152157.

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  • Select a patient (a child or adolescent) that you examined during the last 7 weeks.
  • Create a Focused SOAP Note on this patient using the template provided in the Learning Resources.
  • Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
  • Objective: What observations did you make during the psychiatric assessment?
  • Assessment: Discuss their mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and supported by the patient’s symptoms.
  • Plan: What was your plan for psychotherapy? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Also be sure to include at least one health promotion activity and one patient education strategy.
  • Reflection notes: What would you do differently with this patient if you could conduct the session again? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow up, discuss what your next intervention would be.
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