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Patient Management Exercise For Child and Adolescent Psychiatry
B. Harrison Levine, M.D., M.P.H.; Ronald C. Albucher, M.D.
FOCUS 2004;2:543-549.
View Author and Article Information

CME Financial Disclosure
B. Harrison Levine, M.D., M.P.H., Department of Psychiatry, University of Michigan Health System

No affiliations with commercial supporters.

Ronald C. Albucher, M.D., Clinical Assistant Professor of Psychiatry, University of Michigan Medical School, and Assistant Chief, Psychiatry Service, Ann Arbor VA Health System

No affiliations with commercial supporters.

Disclosure of Unapproved or Investigational Use of a ProductAPA policy requires disclosure by CME authors of unapproved or investigational use of products discussed in CME programs. Off-label use of medications by individual physicians is permitted and common. Decisions about off-label use can be guided by the scientific literature and clinical experience.

Copyright 2004 American Psychiatric Association

This patient management exercise is designed to test your comprehension of material presented in this issue of FOCUS as well as your ability to evaluate, diagnose, and manage clinical problems. Answer the questions below, to the best of your ability, on the basis of the information provided, making your decisions as you would with a real-life patient.Questions are presented at "decision points" that follow a paragraph that gives information about the case. One or more choices may be correct for each question; select your choices on the basis of your clinical knowledge and the history provided. Read all of the options for each question before making any selections.You are given points on a graded scale for the best possible answer(s), and points are taken away for answers that would result in a poor outcome or delay your arriving at the right answer. Answers that have little or no impact receive zero points. On questions that focus on differential diagnoses, bonus points are awarded if you select the most likely diagnosis as your first choice. At the end of the exercise you will add up your points to obtain a total score.

Abstract Teaser
Figures in this Article

You are a child psychiatrist at a large medical center and occasionally take weekend call from home for the psychiatric emergency room. You receive an urgent phone call at 8:00 p.m. from the psychiatric emergency room resident. Ms. A, a 14-year-old ninth-grade student at a prestigious private all-girl school, is there, accompanied by her parents. According to the resident, Ms. A admits to taking "a big handful" of aspirin two nights earlier but did not tell anyone and was not treated. Tonight, after she had made superficial cuts on her right wrist with a razor blade, her parents brought her to the emergency department. Because the cuts did not require sutures, the attending emergency physician transferred her to the psychiatric emergency room for evaluation. The patient’s parents insist that their daughter is probably just worried about her end-of-year exams and is otherwise fine and that she needs to go home. The psychiatric resident feels that the girl is ambivalent about being suicidal, and he is not convinced that she is safe to go home. He is calling to ask for your opinion on whether Ms. A should be admitted.

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Decision Point A

Given this history, which of the following would you do? (Select the best answer.)

  • A1.____ Ask to speak with the parents. Tell them that they are probably right about their daughter’s anxiety and should take her home for the night, then bring her to your office tomorrow after school for an appointment.

  • A2.____ Ask to speak with the parents. Tell them you cannot assess their daughter from home and that you are deferring to the judgment of the resident, who thinks their daughter should be admitted for safety.

  • A3.____ Ask to speak with the parents. Tell them their daughter is not at great risk of suicide, that the cutting was merely a gesture. Tell them it is okay to take her home and tell them to call your secretary in the morning and make an appointment for sometime within the week.

  • A4.____ Refuse to speak with the parents. Tell the resident that you agree the patient should be admitted for safety. Ask him to politely tell the parents that they may call you tomorrow at your office to discuss the case.

  • A5.____ Refuse to speak with the parents. Speaking with the parents will only intensify Ms. A’s feelings of mistrust.

Ms. A is admitted to the hospital’s child and adolescent psychiatry locked ward and placed on close observation. The resident explained to the parents that you, as the attending psychiatrist, would see her the following morning. Because they were in a hurry to go home and did not know whether they would be available to come in early the next day to sign consent forms, the resident sought consent for use of several medications that you might wish to prescribe for their daughter, depending on your evaluation. They agreed and anxiously signed consent forms for use of fluoxetine, lorazepam, ziprasidone, and chlorpromazine.

You visit Ms. A the next morning. During your interview with her, she speaks slowly and has poor eye contact. She reports that she feels "depressed" and "angry with her parents." You ask her why, and she replies, "They have unreasonable expectations of me. They never let me do what I want to do. They just keep grounding me for every little thing." She is tearful and her voice becomes louder. You note that her fists are clenched tightly. You ask how she is doing in school. She responds that she gets "B’s mostly, a couple of A’s." You ask about other activities. She says that she is on the school soccer team, takes extra French lessons outside of school, and has taken piano lessons since age 4 and that her mother recently encouraged her to volunteer at the hospital’s oncology department. At this, her eyes well up with tears: "I hate working in the hospital," she says. "Those patients, they’re are all just dying, and it makes me want to die too. I hate my life."

She reports that she has been sleeping "a lot" and as a result has fallen behind on some of her school assignments, which is unlike her. She says that she used to like all of the activities and schoolwork, but now "everything is such a chore. I feel like blowing it all off just to piss off my parents." She has lost about 10 pounds in the past 2 months without dieting or changing her routine. She says that her appetite is less than it usually is and she doesn’t know why, other than that she is "too busy feeling like my life is crappy and I’d rather not live." She says it has been more difficult for her to stay focused on her schoolwork over the past month and she has to try harder to accomplish the same tasks that she once found easy.

You ask how often she has thought about killing herself, and she replies that she thinks about it every day. She tells you that she recently took "a big handful" of aspirin. It made her sick to her stomach, but she did not tell anyone. "My parents grounded me when I didn’t make the varsity soccer team, too." She shows you her right wrist, which is bandaged. "I didn’t cut deep enough. That was stupid."

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Decision Point B

Given this presentation, what is your next step? (Rank the following in the order in which you would perform them. Points are taken away for incorrect answers.)

  • B1.____ Ask if she has ever used drugs or alcohol.

  • B2.____ Ask if anyone in her family has any psychiatric problems.

  • B3.____ Ask if her schoolwork is too hard for her. Determine whether she is developmentally appropriate for her grade level.

  • B4.____ Ask if she has mood swings often and if she has bad premenstrual symptoms.

  • B5.____ Ask if there is any suicidal ideation or specific plan to kill herself.

  • B6.____ Order lab work to obtain a thyroid-stimulating hormone level, CBC, blood chemistry profile (CHEM-7), and a urine drug screen.

  • B7.____ Ask if she is sexually active and determine her level of sexual behavior.

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Decision Point C

You make a preliminary diagnosis of a mood disorder. In children and adolescents, which of the following symptoms of depression is less likely to be considered in the diagnostic criteria for adult depression? (Rank as many as appropriate, in order of their likelihood.)

  • C1.____ Loss of interest or pleasure

  • C2.____ Sadness

  • C3.____ Emptiness

  • C4.____ Irritability

  • C5.____ Hypersomnolence

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Decision Point D

When reviewing the important symptoms of depression, "SIGECAPS" is a helpful mnemonic. In the following, match each letter with the word it represents. (Answers may be used once, more than once, or not at all.)

  • D1. S ____

  • D2. I ____

  • D3. G ____

  • D4. E ____

  • D5. C ____

  • D6. A ____

  • D7. P ____

  • D8. S ____

  • Ideation (suicidal or homicidal)

  • Paucity of speech

  • Interest (decreased)

  • Excessive or disproportionate guilt

  • Intellectual deficits

  • Energy level

  • Sleep

  • Psychomotor agitation or retardation

  • Excitability

  • Altered consciousness

  • Substance use

  • Concentration

  • Appetite

  • Gregariousness

  • Cognition

  • Suicidal ideation

  • Somnolence

You are paged by the desk clerk. Ms. A’s mother has arrived and has brought a knapsack containing a laptop computer for her daughter. She tells you that "it is imperative" that her daughter get the computer so that she won’t fall behind in her schoolwork. She remarks that "this sort of thing has been going on lately with her. I don’t know why she feels the need to pull these stunts except to hurt us." She holds out the knapsack for you to take. "I really must be going," she says. "My husband is double-parked."

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Decision Point E

Given this information, how do you respond? (Rank as many as appropriate, in order of their likelihood. Points are taken away for incorrect answers.)

  • E1.____ Tell the mother that you would be happy to deliver the computer to her daughter and that she should hurry, because the police in this area love to write tickets.

  • E2.____ Tell the mother that you would be happy to deliver the computer to her daughter, but that you want to speak with her and her husband about what happened.

  • E3.____Tell the mother that you cannot deliver the computer to her daughter because the ward has a policy against bringing in electronic devices, including laptop computers, for safety reasons. None of the children have them.

  • E4.____Tell the mother that you are concerned about her running off so quickly when her daughter has just tried to kill herself. Would she like to talk about it?

  • E5.____Tell the mother that you are concerned about her daughter, but that she is now in a safe place. Strongly suggest a meeting between you and both parents so you can determine what caused their daughter to make an attempt on her life twice in one week.

  • E6.____Ask the mother if she could meet with you now. Tell her to have her husband park the car properly and meet you in your office in 15 minutes. Her daughter has made a serious attempt on her life, and she should not leave without discussing the matter.

  • E7.____Ask the mother for consent to treat her daughter and, as applicable in your state, for specific consents for psychotropic medications and releases to speak with her pediatrician and her psychiatrist.

After 2 days on the ward, your patient feels more relaxed. She occasionally smiles, and she interacts with the other patients, but she still has a somewhat restricted affect. She begins complaining that she is not getting her schoolwork done and that "my parents are going to kill me." She denies that she is currently suicidal but cannot rule it out for the future. She is still sleeping excessively and did not make it to her morning group session, which kept her from advancing up the scale of earned privileges on the ward. She complains that she wants to go outside and is frustrated that she can’t. She no longer wants to talk about "my problems" and asks, "Is that all I’m going to do here? Talk about problems? Why do you think I have problems? Talk to my parents! They’re the ones with problems!"

You later ask her about substance use, and she admits to having tried marijuana and beer in the past but insists that it is not a problem for her. "Everyone does it," she says. "I mean at parties. I’ll have a beer or two, not enough to get trashed like some of my friends. My parents would kill me if I came home drunk. And I don’t like pot. I don’t like how it makes me feel."

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Decision Point F

Given this information, what are your next steps? (Rank as many as appropriate in order of their likelihood. Points are taken away for incorrect answers):

  • F1.____ Agree that she is not likely using drugs or alcohol in a way that is dangerous and leave this subject alone for now. Instead, concentrate on peer relationships and how they affect her own decision making.

  • F2.____ Agree that she is not likely using drugs or alcohol in a way that is dangerous and leave this subject alone for now. Instead, scold her gently for not attending all of her group sessions and tell her that she will not be able to leave the ward until she improves her behavior.

  • F3.____ Send for a urine drug screen if this has not already been done. If the urine drug screen is positive for any drugs, consider placing Ms. A in a discovery group or a similar group that helps young teens learn about drugs, the dangers of their use, and how to avoid being in situations where drug use might occur.

  • F4.____ If the urine drug screen is positive for any drugs, do not tell Ms. A’s parents. This information is entirely confidential, and revealing it might destroy the therapeutic bond with your patient.

  • F5.____ If the urine drug screen is positive for any drugs, have the social services department invite Ms. A’s family in to discuss alcohol and/or drug abuse and treatment options and other issues.

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Decision Point G

Depressed patients who exhibit difficulty concentrating can be misdiagnosed as having attention deficit hyperactivity disorder (ADHD). Match the following symptoms and signs with depression, ADHD, both, or neither. (Your score will be determined by the number of questions for which "both" is the correct answer.)

 
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High positive scores (+3 and above) indicate a decision that would be effective, would be required for diagnosis, and without which management would be negligent. Lower positive scores (+2) indicate a decision that is important but not immediately necessary. The lowest positive score (+1) indicates a decision that is potentially useful for diagnosis and treatment. A neutral score (0) indicates a decision that is neither clearly helpful nor harmful under the given circumstances. High negative scores (−3 and above) indicate a decision that is inappropriate and potentially harmful or possibly life-threatening. Lower negative scores (−2) indicate a decision that is nonproductive and potentially harmful. The lowest negative score (−1) indicates a decision that is not harmful but is nonproductive, time-consuming, and not cost-effective.

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Decision Point A

  • A1. 2 points Although it is not necessary for the attending psychiatrist on call to speak directly with a patient or the patient’s parents, you should consider doing so if they wish to speak with you or if you find that the resident and/or social worker was unable to establish a suitable rapport for assessing the situation. In this exercise, the parents are allegedly quite upset, do not fully comprehend the gravity of their daughter’s suicide attempt, and may be making matters worse for their daughter by fighting with the treatment team. Telling them that they are right about their daughter’s anxiety would be inappropriate at this juncture because you do not know the current situation firsthand; however, you can offer reassurance, reflect back to them their frustration with their child’s behavior, and help them better understand the issue of suicide and the need to take it seriously. The child should certainly be seen right away, but judging whether she should be admitted has less to do with the temper of her parents than the assessment of her mental status, the seriousness of her suicidal intention, and her overall safety. If she is deemed safe to go home, then her parents should closely monitor her overnight and follow up with you the next day. If she is not deemed safe to go home, then she should be admitted.

  • A2. 5 points The resident is your proxy and you must put your faith in his judgment of whether or not this child is safe. If the resident feels the child is at risk of harming herself, then she should be admitted. Speaking with the parents would be appropriate. You could also consider coming in to the hospital to obtain information firsthand.

  • A3. −5 points The resident feels that the child is not safe. You should trust his judgment or come in to the hospital to see the child yourself and discuss her situation with the psychiatric emergency room team. Waiting a week to see this patient would not be appropriate.

  • A4. −2 points While it would be appropriate to admit the patient, refusing to speak with her parents if they ask to talk with you would seem insulting to them and damage your hopes of gaining their trust. After all, you are admitting their daughter to a psychiatric ward because of a suicidal gesture they do not fully comprehend or appreciate.

  • A5. −5 points The parents may be agitated, but you should talk with them, because they may be confused about their daughter’s psychiatric condition. Furthermore, given that the resident feels that the child will require admission, waiting until your next open appointment would not be appropriate.

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Decision Point B

  • B1. 4 points Children, especially adolescents, are often experimenting with, abusing, or dependent on drugs and/or alcohol, and a mood disorder is often comorbid with the substance use disorder. Although determining which came first can be a puzzle, knowing about the substance use will help you arrive at an appropriate diagnosis and determine the best course of treatment. When a substance use problem is present, it should be treated in order to remove it as an obstacle to the patient’s recovery from the mood disorder. Whether or not this patient is currently using alcohol or drugs, she has admitted to prior use.

  • B2. 3 points This is always a good question to ask, because mood disorders and other psychiatric conditions are inheritable.

  • B3. −2 points Asking if here courses are too hard for her would quickly cast you in the role of another parental figure who doesn’t understand her. Earning B’s and A’s in classes, learning French, taking piano, and volunteering clearly indicate a high level of achievement (perhaps overachieving).

  • B4. 2 points Ms. A is at the age when she should be menstruating, and hormonal changes can cause or contribute to mood disturbances. This information should be obtained as part of your evaluation, but it is secondary to issues of safety, including suicide and substance abuse.

  • B5. 5 points This is the most important area of assessment and should guide treatment planning. High-risk indicators for continuing risk of suicide include the following:

    • The patient presents immediately after committing a serious suicidal act.

    • The patient is displaying dangerous psychotic symptoms suggestive of a high suicide risk.

    • The patient mentions suicidal planning or intent in the interview, suggesting that he or she is seriously planning imminent suicide (or corroborative sources supply information suggestive of such planning).

  • B6. 4 points Standard of care

  • B7. 4 points This is an important line of questioning with any adolescent female, particularly when considering the use of psychotropic medications. Could she be pregnant? Additionally, you want to know if there is any history of sexual, emotional, or physical abuse.

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Decision Point C

  • C1. 0 points

  • C2. 0 points

  • C3. 0 points

  • C4. 5 points

  • C5. 0 points

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Decision Point D

 
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Decision Point E

  • E1. −5 points The patient was admitted to the ward because of a suicide attempt. She is there to recover from the event, to learn from it, to be further evaluated by the team, and to participate in group and individual milieu activities—not to continue with her schoolwork. Considering the story, it is regrettable that the mother is insistent about this issue. She should be told that it is not in her daughter’s best interest to focus on schoolwork right now and that the family needs to understand what is going on in terms of the recent suicide attempts.

  • E2. −3 points You will not give the computer to the patient (as explained above), but you do want to speak with her parents.

  • E3. 3 points This would be an appropriate response. You would want to make an effort at this point to arrange to speak with the parents at some point in the near future, not necessarily at that moment.

  • E4. 1 point Although you may think this, you should be careful not to draw the mother into a confrontation about the suicidal behavior. You should assume that she is distressed by the incident. Use a more tactful approach to invite the parents to meet with you to discuss the incident and their daughter’s mental health and to allow you to answer any of their questions.

  • E5. 3 points This is appropriate. You are making it clear that her daughter is safe and that you want to involve the patient’s parents in the treatment process.

  • E6. −3 points Unless the mother makes the specific request to speak with you directly, you should make a future appointment.

  • E7. 5 points

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Decision Point F

  • F1. −3 points Any substance use before the child’s brain is fully developed, possibly around age 21–23, is also going to affect the child in ways that later use will not. It is okay to acknowledge that children and adolescents are naturally inquisitive and that some experiment with potentially harmful activities. This helps attenuate the child’s shame or guilt and may help elicit more information. Continue to explore this topic as well as the patient’s peer relationships.

  • F2. −5 points See F1. Additionally, the patient should be attending all of her milieu activities unless there is a good reason not to, but you would want to make that clear in a way that does not invoke more guilt for “failing” another authority figure. Moreover, it is inappropriate to “scold” the patient for anything.

  • F3. 5 points

  • F4. −2 points Since the patient is a minor, you must involve her parents in the treatment process. However, in some states minors may confidentially receive treatment for substance use without parental consent.

  • F5. 3 points It would be a good idea to have the family involved in recovery. Again, if the state allows for the patient to receive confidential treatment without parental consent, then the patient must agree to family involvement.

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Decision Point G

Depressed patients who exhibit difficulty concentrating can be misdiagnosed as having attention deficit hyperactivity disorder (ADHD). Match the following symptoms and signs with depression, ADHD, both, or neither. (Your score will be determined by the number of questions for which "both" is the correct answer.)

 
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Your total

 
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American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington DC, American Psychiatric Association,  2000
 
Sadock BJ, Sadock VA: Kaplan and Sadock’s Synopsis of Psychiatry, 9th ed. Philadelphia, Lippincott Williams & Wilkins,  2003
 
Shea SC: The Practical Art of Suicide Assessment. Hoboken, NJ, Wiley,  2002
 
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References

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington DC, American Psychiatric Association,  2000
 
Sadock BJ, Sadock VA: Kaplan and Sadock’s Synopsis of Psychiatry, 9th ed. Philadelphia, Lippincott Williams & Wilkins,  2003
 
Shea SC: The Practical Art of Suicide Assessment. Hoboken, NJ, Wiley,  2002
 
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