CMH5215 - Child and Adolescent Mental Health Case Study - Nursing Assignment Help

Assignment Task

Introduction
Appropriate management of mental health conditions can be an important deterministic factor in the development of children and adolescents. This paper will discuss the role of child and adolescent mental health services and their management in the development of clients, specifically focusing on their emotional development. It will do this through analysis of the case study of an adolescentreferred to as ‘Ian’ with his respective treatment plan for a diagnosis of complex PTSD. This paper uses Ian’s case study due to its representation of both the positive and negative influences that mental health services can have on emotional development. For confidentiality purposes, the exact age, treatment location and other identifying information will be withheld.
The paper will first outline the context of the case study – the author's bias and the client’s initial presentation to the service along with the indications for ongoing service involvement. It will then outline the role services have for nurses within the formulation of Ian’s treatment plan. With the context fully established, this paper will then provide recommendations for treatment options that will best support Ian’s healthy emotional development following his initial presentation. This will involve highlighting the relation between treatment of complex PTSD and clients’ emotional development. It will thenoutline multidisciplinary treatment recommendations to help determine the success of this treatment. As part of this, this paper will outline collaborative care planning in treatment pathways. In this way, this paper will illustrate the role of mental health services’ treatment of mental health conditionson clients’emotional development.
Author’s context
To establish context for the case study, it is first necessary to identify the author’s role and personal field of practice. This paper’s author works within a locked mental health unit catering for the cohort of voluntary and involuntary mental health patients between the ages of 16-24. Separation by developmental period as opposed to mental health act status means this client base can vary greatly in treatment needs and acuity. The author’s role within the wardteam is that of a clinical nurse - commonly coordinating shifts, care coordinating or providing guidance to other members of the nursing team. This outlines the author’s perspective concerningthe case study.
Referral and initial presentation
Thepreface of this case study is the details of Ian’s referral path to the treating service. Ian’s initial referralbelied the acuity of the case and the complexity of his eventual treatment pathway. Ian first presented on referral from an emergency departmentfollowing a suicide attempt via overdose. He was given a brief admission for risk containment purposes and assessment purposes. Following an initial diagnostic formulation of a moderate depressive episodeand connection with community support for ongoing assertive follow-up, he was then discharged for care in the community. However, over following months Ian began experiencing behavioural disturbances of escalating severity unmanageable in the community –significant non suicidal self-harm (cutting), recurrent suicide attempts and dissociative episodes with violent behaviouroften requiring police attendance in community. A more detailed assessment by Ian’s team revealed symptomology consistent with complex post-traumatic stress disorder (complex PTSD). This change in presentation, along with increased risk level necessitated a reformulated treatment pathway. This task fell to Ian’s inpatient team both due to the frequency of inpatient contact and the difficulty maintaining consistent appropriate outpatient support from services due to his acuity. This shows both the manner in which Ian was referred and how the author’s mental health service took a directive role in creating a long-term treatment pathway for Ian.
Development of a treatment plan    
As part of examining the role of mental health services on clients’ emotional development, it is important toexamine the influence of individuated clinical specialist roles on a patients’ treatment plan. This paper will highlight this influence using the role of nursing, shown in the context of that author’s role in the development of Ian’s treatment plan. There are two aspects to this influence: the impact of nursing assessment during care plan formulation and the incorporation of nursing perspectives within the finalised treatment plan. 
Nursing assessment represents a key component of the treatment plan formulation for children requiring treatment from mental health services. Child mental health assessment is a challenging task. Children with mental health issues often have difficulties communicating symptomology,will display symptoms differently depending on environmental factors (De Los Reyes et al., 2015), and even collateraltestimony sourced from parents may not be accurate due to frequent discrepancies between parents’ and children’s relative concerns over internalised symptoms like nightmares or anxiety(Achenbach, 2011).Once referred to an inpatient setting, patients will have more frequent interactions with nurses than other disciplines(Cleary et al., 2012). Whilst it is not within the scope of nurses to diagnose, this degree of contact allows specialist nurses to place high-level inferences towards the presence of psychiatric conditions as well as improving the team’s understanding of psychosocial circumstances in a manner that greatly improves diagnostic accuracy (Dogra & Leighton, 2009). The value of nursing assessment was shown in Ian’s example by the initial nursing identification of aberrations in ward-based interpersonal interactions potentially indicative of complex PTSD (Cloitre et al., 2014), contributing to the diagnostic picture and allowing a more accurate treatment plan.
More broadly after diagnosis, nurses offer beneficial inputduring treatment plan formulation. Dogra and Leighton (2009, p. 56) highlighted sixroles for nurses within the treatment of child and adolescent mental health patients: creator of a therapeutic environment, socialising agent, counsellor/parent surrogate/teacher (depending on the setting), technician, case manager and advocate. The experience from each of these roles allows nurses to provide unique care perspectives that can enrich the development of a treatment plan. In the example of Ian’s case, an inpatient nurse with reliable rapport providedperspective with suggestions on incorporationof individualised trauma-informed strategies, an essential component of theinpatient management of complex PTSD(Butler et al., 2011). This is a representation of how nurses use their experience and roles to assist in the formulation of treatment plans, and the degree to which services’incorporation ofmental health nurse input into treatment plans can affect treatment provided.
Ian’s treatment pathways and effects on emotional development
Emotionaldevelopment within the treatment pathway
Before providing recommendations for Ian’s treatment pathway, it is necessary toillustrate the relevance of Ian’s goals of care to this paper’s examination of mental health services’ impact on emotional development.If left untreated or under-treated, Ian’scomplex PTSD represents a serious threat to his normal emotional development. Complex PTSD can be conceptualised as a developmental maladjustment to chronic trauma(Sar, 2011).In contrast to PTSD, an anxiety-based disorder with avoidance and hypervigilance, complex PTSD involves more global effects secondary to trauma impeding development ofemotion regulation and self-concept as well astriggering broader relational difficulties(Cloitre et al., 2014). As Ian had experienced the trauma event in early adolescence, it disrupted a developmental stage in which he was already vulnerable due to his developing perspective-taking skills and the process of learning relationship individuation (Lawson & Quinn, 2013). Neurologically, the sustained chronic stress from that trauma response potentially affected the formation of Ian’s amygdala, hippocampus and prefrontal cortex(Romeo, 2017). In terms of emotional development, this disruption willmanifest in affect and behavioural dysregulation as well asimpedance of Ian’s ability to develop emotional coping skills(Lawson & Quinn, 2013). This combines to predispose Ian to maladaptive measures of managing the underlying emotional disturbances, including self-harm, substance abuse or increased aggressive behaviours (Chu, 2011, p. 25).Successful treatment of complex PTSD aims to both treat the anxiety aspect and address areas of impairmentthat complex PTSD causes in emotional functioning (Lawson & Quinn, 2013). The effect of complex PTSD on emotional development is compounded by the multi-faceted psychological effects of the loss of functioning caused by the disorder, so the longer it remains untreated the more difficult it is to normalise long-term emotional functioning(Chu, 2011, p. 116). This shows Ian’s future emotional development pathway as being directly linked to the efficacy of the treatment pathway provided by mental health services.
Best practice treatmentoptions for complex PTSD
To best understand the implications of mental health service provision on Ian’s emotional development, it is first worth outlining the current best practice multidisciplinary treatment options for PTSD treatment in adolescents.The most effective treatment for PTSD in children is psychotherapy with Trauma-Focused Cognitive Behaviour Therapy(T-F CBT)  or ‘exposure therapy’ as the predominant therapy model with the greatest empirical support(Lawson & Quinn, 2013). T-FCBT is recommended as first line treatment for complex PTSD by theUK National Institute for Health and Care Excellence as well as the American Academy for Child and Adolescent Psychiatry (Smith et al., 2013). This therapy involves repeated exposure to the traumatic memory through discussion in a controlled environment with coaching in distress tolerance (Deblinger et al., 2011), and can be both culturally adapted and made suitable for younger children using a narrative structure (Hayes et al., 2017). However, psychotherapy involves the child or adolescent repeatedly revisiting traumatic and distressing memories andtherefore comes with a risk of worsening symptoms or even triggering ‘iatrogenic suicide’ (Bryan et al., 2016). Premature therapy work also will encounter challenges with respect to the relational dysfunction of those with complex PTSD(Cloitre et al., 2012). Chu (2011, pp. 102-129) proposed a staged treatment plan for complex PTSD consisting of three phases: initial stabilisation including safety and symptom control, confronting and working through traumatic memories, with a final stage of recovery through continued rehabilitation. Though this phased treatment pathway prolongsthe disruption of the complex PTSD to his emotional development, it represents the most pragmatic and realistic pathway for Ian’s safe recovery and eventual emotional normalisation.
A secondary consideration for Ian’s treatment is pharmacotherapy options. Pharmacotherapy in children risks interfering with natural psychological development, with the National Institute for Health and Care Excellence (2018) stating that psychotropic pharmacotherapy is to be avoided for children under 18 with PTSD.However, the Royal Australian and New Zealand College of Psychiatrists (2020)provides a recommendation of selective serotonin reuptake inhibitors (SSRIs) as a psychotherapy adjunct.SSRIshave a low side effect profile, may help reduce the degree of reactivity to anxiety-provoking stimuli, and are often more acceptable to patients than initial psychotherapy (Forbes et al., 2007). Benzodiazepines are frequently prescribed for anxiety or dysregulation disorders but offer no long-term benefits, actively interfere with the ‘habituation’ aspect of exposure therapy treatments (Rosen et al., 2013), and when used in children as part of long-term care can lead to increased emotional dysregulation in adult life (Vinkers et al., 2010). Ian may benefit from stabilisation on an SSRI regime prior to phase 2 psychotherapy treatment, pending discussion of whether potential disruption to emotional development from medication is outweighed by clinical risk.
The next aspect of the treatment plan to examine is treatment setting. Inpatient settings provide more intensive therapy regimes than outpatient or day programs(Fowler et al., 2014). They also allow for greater risk containment, something that may be important for Ian during phases one and two of therapy (Chu, 2011, pp. 112-116). However, extended inpatient stays can jeopardise attempts to normalise development due to separation from supportive factors in the child’s environment, exposure to adverse events whilst on unit, and the disruption of family life from these stays(Darwish et al., 2006).Inpatient environments also run risks ofexposure and normalisation to maladaptive behaviourssuch as self-harm, drug usage and even emulation of new psychiatric symptoms through peer observation on inpatient wards (Haynes et al., 2011; Reavey et al., 2017). Another concern is the risk of seclusion and restraint, often used as an intervention to control dangerous behaviours on inpatient psychiatric units, as a trigger for re-traumatisation (Ross et al., 2014). Ian’s diagnosis, aggressive history and demographic place him at high risk for seclusion and restraint while an inpatient (Hendryx et al., 2010).Given these concerns, where able Ian’s psychotherapy should be done as an outpatient ideallywith inpatient stays limited to periods of intense therapy during the more risky phase 2 of therapy(Chu, 2011, p. 112). However, due to Ian’s level of acuity he may also benefit from a patient-controlled crisis admission plan – a planallowing brief admissions during patient-perceived periods of psychiatric risk shown to improve treatment success rates (Helleman et al., 2016). This framework of brief admissions for intense therapy work and a PCAP plan represents a compromise between safety and the risks of inpatient stays.
Collaborative formulation of treatment plans
The final component of the treatment recommendations for the case study is patient involvement in care planning. From an organisational perspective, patient collaboration in care planning is mandated under the National Safety and Quality Health Service standard “Partnering with Consumers”(Australian Commission on Safety and Quality in Health Care, 2017) as well as standard 2 of the ‘National standards for mental health services 2010’, “consumer and carer participation” (Government of Australia Department of Health, 2010). Ian’s involvement in care planning is especially pertinent given the relational challengesforpatients with complex PTSDand the essential nature of patient engagement in psychotherapy treatments (Meredith et al., 2016).A collaborative approach to treatment helps patients manage the challenges involved in maintaining their therapeutic relationships (Barrett & Fish, 2014, pp. 78-92). The team should aim to deliver care that is patient-centric with a focus on identification of Ian’s treatment goals, therapeutic alliance maintenance and shared-decision making (Thompson & McCabe, 2012). Applicable demonstrated strategies for this include encouraginghis participation in multidisciplinary meetings, use of mental health advocates, or the formulation of inpatient management plans formulated by Ian with nursing assistance(Brawer et al., 2010).
As with patient involvement, there are important motivators for team adherence to the principles of carer collaboration. Poor family engagement is a key determinant of drop-out rates within adolescent mental health services (De Haan et al., 2013). Family therapy, psycho-education to allow families to better support their children in the community, and direct parental presence during T-F CBT sessions are all options for integration of families into treatment plans with demonstrated positive effects on treatment outcomes in trauma therapy (Gutermann et al., 2016).Often services will have barriers to family involvement in the care of complex PTSD – patient unwillingness to discuss trauma with family, cultural views on mental health, parent invalidation of the traumatising event, fears of ‘blame’ by guardians, carer burnout, logistical unavailability, family views as to service efficacy, and even family as the trauma perpetrators are some of the obstacles services may encounter (Ellis et al., 2011). However, collaboration with family is essential for a successful treatment plan. Regardless, there are modifiable strategies for family engagement that services can choose to implement. Psycho-education, use of paraprofessional ‘carer support workers’ to increase engagement, flexibility in scheduling appointments, and use of empowering ‘strengths-based’ approaches when engaging withthe family during therapy are all approaches services may (or may not) utilise to ensure parental involvement (Gopalan et al., 2010).These recommendations can increase the collaborative aspects of Ian’s treatment plan dependant on service implementation.
This paper has shown how mental health services can impact a patient’s emotional development by using the context of a case study of a client with complex PTSD. It has first established context for the case study for clarity by providing the author’s perspective and the details of the initial referral. It has then reflected on the way mental health services incorporate contributions of individual healthcare disciplines to treatment plan formulations. It did this by examining how nurses contribute to treatment plan formulation, showing it in context of the case study and the effect on treatment effectiveness. The paper next provided recommendations for the treatment of the condition in the case study. It first outlined the way that emotional development related to treatment success in complex PTSD. The paper then used this as context for treatment recommendations from current literature relevant to the case study.Within these recommendations, the paper highlighted the importance of mental health services’ involvement of clients and family in treatment planning. In these ways, this paper has shown how mental health services can impact a patient’s emotional development.
 

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