Assessments to Identify Health Problems and Propose Strategies for Treatment - Case Study Example

Case Plan Name Institution Introduction Interventions for patients require systematic and purposeful planning. This ensures that the patient’s wellbeing and safety is protected (DePanfilis & Salus, 2003). To develop an effective case plan, it is important that the caseworker understands the factors contributing to the patient’s health problems so that purposeful interventions can be adopted. This understanding would require the caseworker to identify problematic behaviours, risks, strategies need and interventions with clearly outlined goals, tasks and outcomes (Perkinsons, 2012). Once the caseworker identifies these issues, he/she is in a better position to develop strategies to address the patient’s problem, have a clear guide for behavioural change, develop a benchmark for measuring progress, and to develop a framework for decision making in case management (DePanfilis & Salus, 2003). This paper discusses the development of a case plan for Brad’s case scenario. It will describe his health issues, assessment tools, modalities and aspects of the case plan such as goals, interventions and evaluation. Background of the Patient Brad has a number of issues. Firstly, he has a drinking problem. Brad has a problem with excessive drinking and had his driving license revoked for driving under the influence (DWI). The drinking could be a symptom of alcohol dependence. Secondly, Brad has had attention deficit hyperactivity disorder (ADHD) since the age of nine. His academic performance has been declining and has changed his behaviour such as being more verbally aggressive and sleeping all day. Brad’s mother argues that Brad’s drinking has contributed to these behavioural changes and will affect his future. She also brings up an accident caused by Brad’s drunk driving adding that Brad should talk about the accident. On his first session, Brad looked healthy and well kempt. However, he has problems making eye contact, does not see the reason for the session, defends his drinking and minimises the consequences of his drinking (such as the charge for drink driving). He claims he is not an alcoholic like his father but does not question why he experiences memory loss or is aggressive when he is drunk. Proceeding with this Session The caseworker can proceed with this session and others by drafting a diagnostic summary of the patient. The diagnostic summary uses information from the patient’s background to identify his current needs and state. According to Perkinsons (2012), the information in a diagnostic summary is very important for members of an intervention team such as nurses, psychologists, counsellors, family therapist, psychiatrists, physicians and other health workers involved in patient care. The diagnostic summary helps these healthcare workers to discuss the patient’s problems and to develop the most effective treatment plan. A diagnostic summary for Brad would detail his key health problems, the sources of these problems and the proposed solutions. Brad seems to have two key problems: alcohol dependence and ADD. His alcohol dependence is evidenced by Sandra’s claim of excessive drinking, drinking under the influence charge and paternal alcoholic dependence. Paternal alcoholic dependence may have increased Brad’s genetic predisposition to developing alcohol dependency. Brad confirms that there is a history of alcohol dependency in the family. Brad is also defensive about his drinking when he compares his drinking with his friends’ drinking. He suggests that his friends share the same drinking experiences and therefore his drinking should not be a problem. Brad’s ADD is evidenced by difficulty with schoolwork, memory loss and inability to control his emotions (such as anger). These are a few symptoms of ADD. According to Pelt (2010), the symptoms of this condition include difficulty initiating or finishing projects, underestimation of time to complete a project or task, difficulty in focusing during meetings, procrastination, impulsivity, distractibility, disorganisation and inability to control emotions. People with ADD and ADHD have low academic and work performance because they are unable to demonstrate self-efficacy and self-control in a controlled environment. Impulsive aggression is a key symptom in ADHD, which is associated with intermittent explosive disorder (Pliszka, 2009). Brad’s declining academic performance could be due to difficulty in prioritising and following through on assignments. Brad’s verbal aggression is another sign of poor emotional control evidenced in people with ADD. His agitation, reckless behaviour (driving while drunk) and lack of motivation (such as unwillingness to wake up in the mornings) are symptoms of ADD. Pelt (2010) and Quinn (1997) agree that recklessness, agitation, memory lapses, lack of motivation and risk taking behaviour are symptoms of ADD in adults. Presenting the Issues These health issues are summarised in the form of a problem list in figure 1. A problem list is important because it provides written evidence of the patient’s symptoms (reports from the patient and family) and signs seen by the caseworker (such as physical appearance and body language). Once the problem list has been defined, the next step is to formulate objectives and goals for the patient’s treatment. Writing goals for the patient’s treatment plan helps caseworkers to conform to standards of patient care (Erickson, 2011). Assessment Tools A number of assessment tools could provide an accurate diagnosis of Brad’s health problem. These tools include the Alcohol Use Disorders Identification Test (AUDIT), DSM-IV-TR Psychoactive Substance Abuse test and cognitive capacity screening. AUDIT is an effective test for screening and assessing alcohol dependence. It is an effective tool because it helps clinicians to identify a patient with AD who needs intensive treatment. The tool uses World Health Organisation algorithms to develop the best scores for males and females with unhealthy alcohol dependence. The algorithm recommends a score of seven and eight for women and men respectively (Babor, Higgins-Biddle, Saunders & Monteiro, 2001). Johnson, Lee, Vinson and Seale (2012) propose a lower cut off for alcohol dependence as five and three for men and women respectively. They argue that this lower score increases the likelihood of detecting unhealthy drinking (such as binge drinking), increase specificity of the dependence and lowers the occurrence of false positive screening results. The higher specificity of Johnson et al.’s (2012) AUDIT score would help the caseworker to understand the emotional impact of alcohol dependency diagnosis and encourage him/her to provide higher service level or to prescribe suitable antidipsotropic medication. Furthermore, AUDIT screening would be useful in Brad’s scenario because the scores give an estimate of the patient’s past (12-month) alcohol dependence (Rubinsky, Kivlahan, Volk, Maynard & Bradley, 2010). Alternatively, the caseworker can use Addiction Severity Index (ASI) to determine the degree of alcohol dependence as well as disorders of past alcohol abuse (Saitz, 2010). However, AUDIT is argued to be more effective for screening alcohol use and disorders of alcohol use (Johnson et al., 2012; Rubinsky et al., 2010). Brad’s ADD may have progressed into adulthood. Longitudinal studies of children with attention deficit or attention deficit hyperactivity disorder (ADHD) show that 2.5 percent to 4.9 percent of the cases progressed into adult ADD/ADD (Franke et al., 2012). Genetic testing of the 9/9 genotype and the 9-6 halotype would confirm Brandy’s ADD. This is because both molecules are associated with adult ADD/ADHD (Franke et al., 2012). Alternatively, a brain magnetic resonance image (MRI) could be used to detect abnormalities in gray matter such as lower volume in the caudate, cerebellum and patumen regions. These brain abnormalities are associated with the persistence of ADD into adulthood (Seidman et al., 2011). Lastly, the caseworker may use the fourth edition of the Diagnostic and Statistic Manual of Mental Disorders (DSM-IV) for ADD diagnosis. This tool provides the criteria for diagnosing two symptoms of ADD/ADHD (Willcut, 2012). These symptoms are the level of inattention and the impulsivity of the patient. The score can be combined with MRI results to confirm the patient’s brain dysfunction such as disruption of neural activities (for instance arousal or inhibition) that are associated with inattention (Willcut et al., 2012). The findings should confirm the symptoms of ADD in adults, which are inattention, restlessness, emotional instability, memory lapses, and impulsivity (Simon & Zieve, 2013) Modalities Modalities for Brad’s treatment include pharmacological treatment for alcohol dependence and ADD and behavioural management (Monti, Kadden, Rohsenow, Cooney & Abrams, 2002). For Brad’s alcohol dependence, it is important first to determine his consumption rate and assess medical and behavioural issues that could be contributing to alcohol use. If the AUDIT scores show a high level of alcohol dependence, advise the patient to abstain and refer to a specialist such as a psychologist or behavioural therapist. If Brad shows low alcohol dependence or moderate drinking, then the caseworker should advice him to reduce his drinking and have a drinking goal. Another modality is the CAGE method where the caseworker asks Brad whether he has cut down on drinking, is annoyed by criticism about his drinking, feels guilty about it and relies on a drink in the morning (eye opener) (U.S. Department of Health and Human Services, 1995; Jarvis, Tebbutt, Mattick & Shand, 2009). The International Centre for Alcohol Policies (2014) also recommends behavioural modification, social support groups (such as alcoholics anonymous) and pharmacological treatment for patients with alcohol dependence. Counselling would help Brad understand that alcohol increases the risk of developing coronary heart disease and causes psychomotor impairment that led to his accident 4years ago. ADD is a chronic condition that requires ongoing, long-term treatment and adjustment of interventions (Simon & Zieve, 2013). Modalities for Brad’s ADD include medication (stimulants, non-stimulants and antidepressants) and behavioural therapy. Stimulants such as methylphenidate and amphetamine-dextroamphetamine are primary drugs for treating ADD/ADHD. They stimulate the patient’s central nervous system by increasing dopamine production and produce a calming effect (Simon & Zieve, 2013). However, the drugs may worsen behaviour in patients with psychotic disorders, increase hostility and increase cardiovascular problems in patients with heart conditions. The blood pressure test listed in the problem list in figure 1 would help clinicians determine whether using stimulants would exposes Brad to cardiovascular problems. Alternatively, non-stimulant drugs such as atomoxetine can be prescribed to increase dopamine and norepinephrine levels. However, these drugs can cause liver injury, suicidal thinking, reduce appetite and drowsiness. Lastly, the Food and Drugs Administration (FDA) has not approved the use of antidepressants in ADD/ADHD treatment. Nevertheless, antidepressants such as bupropion and tricyclics can be used (Simon & Zieve, 2013). Case Plan Objectives: i. Enrol Brad in a support group for people with ADD and alcohol dependence ii. Ensure Brad shares his feelings in the support groups iii. Brad maintains a diary of his alcohol dependence and thought process iv. Brad completes the 12-step program for alcohol use v. Ensure Brad takes his medication as prescribed vi. Ensure Brad maintains weekly psychiatric appointments Goals: i. Help Brad to learn the skills for maintaining a sober life ii. Help Brad to develop the skills of healthy communication iii. Teach Brad to express his anger or negative feelings without showing aggression iv. Help Brad to develop positive attitude and commitment to sobriety v. Train Brad to develop organizational skills vi. Teach Brad to cope with ADD symptoms Interventions: i. Group therapy a. Teach coping and social skills, 12-step program, information/resources on his condition and a platform for sharing with others with similar conditions. Responsibility: Support group leaders, psychiatrist, ii. Cognitive-behavioural therapy a. Private sessions to discuss the patient’s feelings, review diary records, equip with coping skills, address Brad’s thinking b. Formulate a relapse plan- monitor withdrawal symptoms Responsibility: Psychiatrist; physician, caseworker (to monitor attendance) iii. Pharmacotherapy a. Patient should adhere to medication dosage and frequency. Responsibility: Physician, psychiatrist, nurse and caseworker; family to monitor iv. Psycho-education a. Provide information and support for family members; improve Brad’s interpersonal relationships; equip Sandra to deal with the challenges of her son’s ADD and alcohol dependence. Evaluation: The caseworker should monitor Brad’s progress by collecting information about his medication intake, attendance to meetings (psychiatrist and group sessions) and shares in group therapy. It is important to ensure that the patient demonstrates awareness of his problem, understands how this problem has a negative effect on his life (academic, interpersonal and physical effects), takes responsibility for his actions, understands what behaviour he needs to change (drinking and driving), and practices this change (such as abstaining from drinking) (Fisher & Harrison, 2009; Perkinson, 2012). The caseworker needs to review the interventions with the treatment team and make changes where necessary such as admission if the patient’s experiences alcohol withdrawal difficulties. Conclusion The diagnostic summary shows Brad’s major issues are alcohol dependence and adult ADD. Appropriate assessments and interventions seek to identify the degree of these health problems and propose strategies for improving his physical and mental wellbeing. The caseworker plays a vital role in ensuring that Brad complies with the treatment plan and ensuring that other healthcare workers work together and remain committed to Brad’s wellbeing. The caseworker also has a role in monitoring the objectives of the case plan and evaluating the changes shown by the patient throughout his treatment. References Babor, T, Higgins-Biddle, J., Saunders, J., & Monteiro, M. (2001). AUDIT, the alcohol use disorders identification test: Guidelines for use in primary health care (2nd edn). Geneva: World Health Organisation. DePanfilis, D., & Salus, M. (2003). Child protective services: A guide for caseworkers. Darby, PA: Diane Publishing. Jarvis, T., Tebbutt, J., Mattick, R., & Shand, F. (2009). Treatment approaches for alcohol and drug dependence: An introductory guide (2nd ed). West Sussex, England: John Wiley & Sons. Erickson, C. (2011). Addiction essentials: The go to guide for clinicians and patients. New York: WW Norton & Co. Fisher, G., & Harrison, T. (2009). Substance abuse: information for school counselors, social workers, therapists and counselors (4th ed). Boston, MA: Pearson Education. Franke, B., Faraone, S., Asherson, P., Buitelaar, J., Bau, C., Ramos-Quiroga, A., … Reif, A. (2012). The genetics of attention deficit/hyperactivity disorder in adults: A review. Molecular Psychiatry, 17, 960-987. International Centre for Alcohol Policies. (2014). Alcohol dependence and treatment. ICAP Blue Book Module. Retrieved from http://www.icap.org/PolicyTools/ICAPBlue Book/BlueBookModules/17AlcoholDependenceandTreatment/tabid/177/Default.aspx Johnson, J.A., Lee, A., Vinson, D., & Seale, P. (2012). Use of AUDIT-based measures to identify unhealthy alcohol use and alcohol dependence in primary care: A validation study. Alcoholism: Clinical and Experimental Research, 1-7. Monti, P. , Kadden, R., Rohsenow, D., Cooney, N., & Abrams, D. (2002). Treating alcohol dependence: A coping skills training guide (2nd ed). New York: Guilford Press. Pelt, J. (2010). Adult ADHD- hidden diagnosis. Social Work Today, 10(3), 14-15. Perkinson, R. R. (2012). Chemical dependency counselling: A practical guide (4th ed). Thousand Oaks, CA: Sage Publications. Pliszka, S. R. (2009). Treating ADHD and cormobid disorders: Psychosocial and psychopharmacological interventions. New York: Guilford Press. Quinn, P. O. (1997). Attention deficit disorder: Diagnosis and treatment from infancy to adulthood. Bristol, PA: Brunner/Mazel. Rubinsky, A., Kivlahan, D., Volk, R., Maynard, C., & Bradley, K. (2010). Estimating risk of alcohol dependence using alcohol screening scores. Drug Alcohol Dependency, 108(1-2): 29-36. Saitz, R. (2010). Alcohol screening and brief intervention in primary care: Absence of evidence for efficacy in people with dependence or very heavy drinking. Drug Alcohol Revisited, 29(6), 631-641. Seidman, L., Biederman, J., Liang, L., Valera, E., Monuteaux, M., Brown, A., …, Makris, N. (2011). Gray matter alterations in adults with attention deficit/hyperactivity disorder identified by voxel based morphometry. Biological Psychiatry, 69(9): 857-866. Simon, H., & Zieve, D. (2013). Attention deficit hyperactivity disorder. Retrieved from http://umm.edu/health/medical/reports/articles/attention-deficit-hyperactivity-disorder U.S. Department of Health and Human Services. (1995). The physician’s guide to helping patients with alcohol problems. Retrieved from http://kobiljak.msu.edu/CAI/OST517 /PhysicianGuide.html Willcutt, E. G. (2012). The prevalence of DSM-IV attention-deficit/hyperactivity disorder: A meta-analytic review. Neurotherapeutics, 9, 490-499. Willcutt, E., Nigg, J., Pennington, B., Solanto, M., Rhode, L., Tannock, R., … Lahey, B. (2012). Validity of DSM-IV attention-deficit/hyperactivity disorder symptom dimensions and subtypes. Journal of Abnormal Psychology, 121(4), 991-1010. Read More