TO REPLY WITH A COMMENT TO EACH POST WITH TWO REFERENCE PER POST APA WITH CITATION ABOVE 2013. THE SECOND POST WILL BE GIVING TOMORROW.

Post 1

Questions

1. How does not seeing your dad make you feel?   It is well understood that familial structure and exposure to marital discord are key risk factors in children with disruptive behavioral disorders (DBDs).
2. Do you believe your behavior is “ok” and acceptable?    Many children may have little insight into their behavior, the consequences, and how their behavior affects those around them.  Evaluating their perspective is valuable in that the feedback can be included in their treatment plan and goals. 
3. What in your daily life upsets you the most?    Workups of children with ADHD incorporates assessment for comorbid anxiety, depression, and developmental and learning disorders (Hamed, Kauer, & Stevens, 2015).  Evaluating daily anxiety causing factors such as school work, home environments, trauma, etc. can give the practitioner insight into clear diagnosis, treatment, and services appropriate for the client.

Feedback

     The most important people in the client’s life that could provide valuable feedback are her mother, grandmother, and teacher because they have the most contact with the client.  The grandmother is important to interview as she may have different experiences with the client while in her care.  The grandmother can also be asked about the mother’s behaviors and temperament during her childhood and adolescent years, especially considering the mother is exhibiting obvious symptoms of ADHD in her adult life.  Studies have shown a mean heritability rate of 75% in family studies of behavioral disorders (Wilens & Spencer, 2010).  The client’s teacher can provide a overview on any specific triggers preceding her tantrums and outbursts in class, and relationships with peers.  The mother should be asked about the severity of the client’s behavior and tantrums at home, relationship with sister, and level of disobedience as these assessments may indicate progression into more severe behavioral disorders suggesting prompt attention (Committee to Evaluate the Supplemental Security Income Disability Program for Children with Mental Disorders, 2015).  

Physical Exams and Diagnostic Tests

     When diagnosing ADHD and other DBDs, a thorough physical evaluations is needed to rule out medical causes.  A structural MRI could document diffuse abnormalities in children with ADHD.  A study found, individuals with ADHD may have smaller total cerebrum, cerebellum, and four cerebral lobes that do not change over time; in adults, imaging studies have shown smaller anterior cingulate cortex, thought to be the region that regulates ability to focus on tasks and choose between options, and smaller dorsolateral prefrontal cortex, which controls memory and ability to process new information (Wilens & Spencer, 2010).  EEG should also be considered as one study found EEG’s show more Beta activity than Theta/Alpha activity in children medication responders compared to non-medication responders, strongly suggesting a biological correlation to the behaviors in ADHD (Hamed et al., 2015).  Blood chemistry, thyroid levels, and ferritin levels have also been linked to the diagnosis of ADHD.  

Differential Diagnoses

• ADHD (most likely):  Based on criteria outlined in the DSM-5, symptoms of inattention, hyperactivity, and impulsivity should be observed in at least different setting  and present for 6 months or longer; symptoms must result in impairment of social, academic, or other functioning; and symptoms must not be better explained or attributed to other physical or mental health condition, or social situation (Brown, Samuel, & Patel, 2018).
• Oppositional Defiance Disorder (ODD):  Defined as a longstanding pattern of hostile, defiant, or disobedient behavior.  Children with ODD experience more school failures, suspensions, and expulsions; home relationships are often disrupted; and they are less successful at per relationships (Committee to Evaluate the Supplemental Security Income Disability Program for Children with Mental Disorders, 2015).  Characterized by temper tantrums, arguing with parents and other adults, defiance, refusal to comply with directives, deliberately annoying others, and being spiteful and vindictive.
• Conduct Disorder:  A disruptive behavioral disorder with higher incidence in adolescence years, that includes some antisocial behaviors such as lying or stealing.  Severity of symptoms often rise with age and can co-occur with substance abuse disorders.  Adolescents with the disorder demonstrate  more school failure, drug abuse, and arrests than adolescents without the disorder.  It has been suggested that children with ADHD can progress to conduct disorder without proper treatment and intervention (Committee to Evaluate the Supplemental Security Income Disability Program for Children with Mental Disorders, 2015).

Pharmacological Agents

     Dexedrine Spansule 5mg daily is sustained-release amphetamine used to treat adults and children age 6 years and older with ADHD.  The drug has up to an 8-hour duration of clinical action, making its use preferable over IR formulations (Stahl, 2014b).  Most stimulants are highly and equally efficacious hence the label as first-line treatment for ADHD.  The side effect profile consists of cardiovascular, CNS, and hormonal effects requiring pre-assessment and monitoring throughout therapy.  Also, the once a day dosing is beneficial to children because it eliminates the interruption of the school day to take noon dose, maintains confidentiality, and increases likelihood of compliance (Shier, Reichenbacher, Ghuman, H., & Ghuman, J., 2013).  Compared to Atomoxetine, a selective norepinephrine reuptake inhibitor used to treat ADHD in adults and children over the age of 6, amphetamines have a more robust response (Shier et al., 2013).  Atomoxetine carries the FDA warning for the potential to increase suicidal ideation children and adolescents and is metabolized through the CYP2D6 pathway in which a small percentage of the Caucasian population are poor metabolizers, therefore dose adjustments may be required (Brown et al., 2018).

Lessons Learned

     Recommendations for treatment usually accompany the diagnosis of ADHD and have since been a source of controversy.  Although stimulant use to treat ADHD shows effectiveness in 65-75% of children after their first trial of use, the potentially dangerous side effects contribute to the indecisiveness of parents and children which affects treatment and compliance (Hamed et al., 2015). Approaching the diagnosis and suggested treatment should be done tactfully, as many parents have negative information and perceptions of the ADHD diagnosis.  As the practitioner, it is imperative that the challenges associated with assessing and treated ADHD are known.  The concerted effort to successfully treat children with ADHD involves family, caregivers, educators, and healthcare professionals alike. 

                                                                                                                                                               REFERENCES

Brown, K., Samuel, S., & Patel, D. (2018).  Pharmacological management of attention deficit hyperactivity disorder in children and adolescents: A review for practitioners.  Translational Pediatrics, 7(1): 36-47.  doi: 10.21037/tp.2017.08.02.

Committee to Evaluate the Supplemental Security Income Disability Program for Children with Mental Disorders (2015).  Mental disorders and disabilities among low-income children.  Washington, DC: National Academies Press (US). 

Hamed, A., Kauer, A., & Stevens, H. (2015).   Why the diagnosis of attention deficit hyperactivity disorder matters.  Frontiers in Psychiatry, 6: 168.  doi: 10.3389/fpsyt.2015.00168.

Shier, A., Reichenbacher, T., Ghuman, H., & Ghuman, J. (2013).  Pharmacological treatment of attention deficit hyperactivity disorder in children and adolescents: Clinical strategies.  Journal of Central Nervous System Disease, 5: 1-17.  doi: 10.4137/JCNSD.S6691.

Stahl, S. (2014b).  The prescriber’s guide (5th ed.).  St. Louis, MO: Cambridge University Press.

Wilens, T. & Spencer, T. (2010).  Understanding attention deficit/hyperactivity disorder from childhood to adulthood.  Postgraduate Medicine, 122(5): 97-109.  doi: 10.3810/pgm.2010.09.2206.

 . First, consider potential two factors that may affect your heart rate, and prepare two level conditions (Low condition and High condition) for each factor. For example, posture (sitting or standing) and workload (no workload and walking for 3 minutes) may be two potential factors. (10 points) 2. Write your statistical hypotheses (Null and Alternative) and explain them. (10 points) 3. Construct a design of experiment for your two factors and five replicates. (15 points) 4. Conduct your experiment and obtain your original data for all replications in random order. Take a picture of your data collection sheet and include it in the report appendix. (10 points) 5. Input the data properly into excel for 2 way ANOVA analysis. (10 points) 6. Construct graphs that compares heart rate in your Factor-A, Factor-B, and their interaction. Visually inspect them and write your findings about the three graphs. (15 points) 7. Analyze the obtained data by Two-way ANOVA method in Excel. Interpret the P-value, and state which hypothesis your data supports. (15 points) 8. Interpret the analysis result in terms of cardiovascular system. Why do your factors significantly (or not significantly) affect the measurement of your heart rate? Write a half page essay based on our lecture slides, textbooks or internet sources. Give your references. ( 

Case Analysis Guide

1.) Describe what is going on by noting:

a. Who are the key actors? What do we know about each of them?

b. What are the key systems involved? What do we know about each?

c. What does the problem seem to be? What are the underlying problems/issues?

d. What are the key sources of tension? What has lead up to this decision moment? What has changed to make this particular moment such a difficult one to negotiate?

2.) Explore the key sources of tension by considering:

a. What roles do different actors play in creating/sustaining a tension? 

i. How can you make sense of these roles? How does an actor’s background, attributes, culture, beliefs, etc., shape his/her perceptions? His/her behaviors? It may help spur your thinking to consider: How might things be different if a male actor were female? If a Black actor were white?

b. What roles do systems play in creating/sustaining a tension (issue/problem)?

i. How can you make sense of these roles? How does a system’s structure, organization, functionality, resources, location, rules, norms, expectations, etc., shape the kinds of experiences the key actors are having?

c. How do interactions among actors and systems relate to a tension?

3.) Assess how additional knowledge and/or theory could deepen your understanding of the key sources of tension, and integrate that additional knowledge:

a. What is known about people with the attributes of the key actors? (e.g. developmental stages, cultural differences, gender differences, life transitions, people experiencing particular types of stressors, etc.) – look for both theories and empirical evidence!

b. What is known about systems like those at the center of this case? (e.g. bureaucratic systems, hierarchical versus flat organizational structures, segregated neighborhoods, the impact of high job stress and low resources on worker productivity, strengths-based versus deficit-based service environments, etc.) – look for both theories and empirical evidence!

c. How does this additional knowledge shape your thinking about the key sources of tension?

4.) Develop a problem formulation that focuses attention on the central tension/issue that must be addressed if the decision-maker is to move things forward in a productive way, while clarifying the key individual and systems factors that are most salient to why/how this issue has come to be.

5.) Develop alternative strategies that the decision-maker could realistically use to address the central issue. Be sure that each strategy begins in the specific moment/situation in which the decision-maker finds him/herself – that is, if the decision-maker is in the midst of a heated argument, do not suggest a strategy that will start tomorrow, assuming that somehow he/she has gotten through the argument. Your strategy will often extend from the current moment into the near future, but you must articulate your strategy for getting from where things are right now, to a point where the key issue has been resolved enough to move forward productively.

6.) Look for evidence to support your strategies – what does the research literature tell us is likely to work? What does theory predict will happen if a particular strategy is selected? What does your own practice experience tell you about the pros and cons of each strategy?

7.) Choose the best strategy, and justify that choice.

Please make sure it is APA style and one thousand words or less or  one page and a half. Please make sure that you list 3 recommendations, which needs to be in numerical order. Then you must pick one recommendation out of the 3 and state why you chose that specific recommendation.

The first 2 attachments are Case Analysis examples on how they should be done and the third is the actual case analysis that needs to be written on.

 Required Components of Case Analyses- Introduction-Briefly identify the major elements (i.e., who, where, what) of the case. Problem Statement-Give a specific and concisely written formulation of the problem to guide analysis and problem-solving. Not a question but a statement of the problem. Usually no more than two sentences.  Contextual Analysis-Summarize internal and external issues that created or sustain the problem (i.e., why). Depending on the system level, these may include: cultural, economic/resource, political/legal, organizational, social, and ethical issues, interpersonal relationships, and intrapsychic and biological conditions. Use and cite professional sources (and include APA-style references). Alternative Strategies-Identify three or more possible solutions to the problem. These solutions should be plausible, distinct and non-contingent (i.e., not interdependent). Briefly note advantages and disadvantages of each possible solution for addressing the problem. Recommendation-Justify your preferred strategy, explaining why you selected that particular one, how it best resolves the problem, and how you will determine its effectiveness. Be sure your recommended strategy can be plausibly supported by resources available in the case context. Ways of Knowing –Self-reflectively identify the source for your thinking about this case. For example, did you base it on previous experience, intuition, specific theories, personal values, authority, empirical research, previous discussion of similar problems, or something else.

Review the case study and answer all questions with a scholarly response using APA and include 2 scholarly references.

Inflammatory Bowel Disease:  

The patient is an 11-year-old girl who has been complaining of intermittent right lower quadrant pain and diarrhea for the past year. She is small for her age. Her physical examination indicates some mild right lower quadrant tenderness and fullness. 

Studies 

Hemoglobin (Hgb),: 8.6 g/dL (normal: >12 g/dL)
 

Hematocrit (Hct),:   28% (normal: 31%-43%)
 

Vitamin B12 level,:  68 pg/mL (normal: 100-700 pg/mL)
 

Meckel scan,; No evidence of Meckel diverticulum
 

D-Xylose absorption:  60 min: 8 mg/dL (normal: >15-20 mg/dL)  and  120 min: 6 mg/dL (normal: >20 mg/dL) 

Lactose tolerance:  No change in glucose level (normal: >20 mg/dL rise in glucose)
 

Small bowel series:  Constriction of multiple segments of the small intestine 

Diagnostic Analysis  

The child’s small bowel series is compatible with Crohn disease of the small intestine. Intestinal absorption is diminished, as indicated by the abnormal D-xylose and lactose tolerance tests. Absorption is so bad that she cannot absorb vitamin B12. As a result, she has vitamin B12 deficiency anemia. She was placed on an aggressive immunosuppressive regimen, and her condition improved significantly. Unfortunately, 2 years later she experienced unremitting obstructive symptoms and required surgery. One year after surgery, her gastrointestinal function was normal, and her anemia had resolved. Her growth status matched her age group. Her absorption tests were normal, as were her B12 levels. Her immunosuppressive drugs were discontinued, and she is doing well. 

Critical Thinking Questions 

1. Why was this patient placed on immunosuppressive therapy?
    
2. Why was the Meckel scan ordered for this patient?
    
3. What are the clinical differences and treatment options for Ulcerative Colitis and Crohn’s
   Disease? (always on boards)
    
4. What is prognosis for patients with IBD and what are the follow up recommendations for
   managing disease?
    

I chose mindfulness-based stress reduction (MBSR) in treatment to reduce chronic pain because I believe that health should be a comprehensive, total body state, not just a physical one. Chronic pain is an ailment many people suffer daily, including my family members who live with rheumatoid arthritis or fibromyalgia. My purpose in this research was to discover a mind-body approach to use in my advanced practice to benefit those with chronic pain effectively. Ideally, people with daily pain will be able to utilize MBSR as a practice to control their pain levels and their feelings and responses to the negative symptoms associated with their disorders. As an advanced practice nurse, I will refer my patients to a helpful course that ensures their physical and psychological needs are met. MBSR has been proven to be a beneficial nonpharmacologic therapy to manage chronic pain symptoms. By using the stress reduction and meditation aspects of the treatment in addition to their traditional care, patients will be able to treat all aspects of their health. 

Aiken et al. (2016) measured the outcomes of patient mortality, ratings of care, care quality, patient safety, adverse events, and nurse burnout or job dissatisfaction. These factors were measured to determine if more professional nurses versus associate nurses in a workplace are associated with more favorable outcomes for patients and nurses. The researchers analyzed these factors through reports obtained from hospitals’ patient discharge data, hospital administrative information, and nurse and patient surveys. In my theoretical research, I would plan to measure the outcomes of patient-reported pain levels and quality of life. Through surveys before, during, and after an 8-week MBSR course, the efficacy of the treatment could be observed.