Assessment of a Child with Autism - Essay Example

?Assessment of a Child with Autism Introduction Mental health issues are one of the most debilitating conditions which any person can go through. Physically, its symptoms may not be clearly apparent to the patient and to other people. However, mentally and emotionally, its impact can be extensive and debilitating to the patient. For children, the impact of these mental health issues is especially significant because it can compromise their development from a very early age and it can prevent them from ever achieving their expected milestones. This paper shall discuss the case of an 8-year old autistic boy, including his Child and Adolescent Mental Health Services (CAMHS) assessment in my placement as a school nurse. The basic CAMHS assessment shall first be presented. This shall be followed by the case study, where the patient case shall be presented, including the evidence base and the assessment tool used. My actions and decisions in relation to the case shall also be evaluated based on appropriate literature support. Best practice for this case would also be included in the case study. The formulation of the study shall also be established, followed by a reflection of this case. At all times, the confidentiality of the patient was protected in accordance with the Nursing and Midwifery Code which basically requires: the respect of people’s right to confidentiality; ensures that people are informed about how and why data is being shared to those who will be providing care; and disclosing information if it is believed that someone may be at risk of harm. Finally, after all the above elements are established, this paper shall end with a conclusion which shall serve as a summary of the paper as well as an overall evaluation of the topic. Basic CAMHS Assessment In a generic CAMHS assessment, the patient’s presenting issues, history, strengths, as well as perceived needs would be reviewed (NHS Information Centre, 2012). A discussion on the services which the client would need would also be considered. During the interview with the patient, an objective feedback of the patient and his issues, as well as his treatment plan would also be discussed (CAMHS, 2009). The CAMHS also discussed that there is a need to assess children and determine if based on the standards set by the Children Order, they are in need; in need of protection; and are looked after children. Children in need are those who are unlikely to achieve or maintain standard health or development without provisions for social services; or whose health needs are significantly impaired; or who are disabled (NHS Information Centre, 2012). Those who need protection are those who are being physically or sexually abused by family or by other people (NHS Information Centre, 2012). Finally, those who are assessed as looked after children are those who have been placed in care of a Trust for a variety of reasons including abandonment or physical abuse. Based on the above standards, assessments should look like general physical, emotional, social, and mental checklists on the child (Lidz, 2003). The child’s family must also be assessed and evaluated based on their relationship with the child and their interactions with the child (Carr, 2006). There is a need to establish which category the child would fit into and based on such assessment, what type of services he needs. A generic assessment must be comprehensive, holistic, and accurate (Thambirajah, 2007). It must also include an assessment of the child’s family and environment in order to determine factors which are impacting on the child’s condition. In our setting, the basic assessment is carried out by the school nurse in the community setting (NICE, 2011). Our basic assessment of children often comes from referrals from the teachers handling the students. These teachers often note symptoms from their students which may indicate that the child may be suffering from some form of mental health issue (NICE, 2011). After referral to the school nurse, the child is often reviewed based on the assessment standards. This review is based on his mental and physical condition and factors which are impacting on his condition. This basic assessment would also serve as basis for further referral of the patient to a mental health professional (NICE, 2011). My role with regard to assessment within my clinical context is to interview the client and his family. My role is to assess the client’s general physical condition, as well as to converse with the client and evaluate his basic socialization skills (NICE, 2011). My role is also to assess the patient’s needs and to gather data which would help the mental health professionals in deciding whether the child is a child in need, a child in need of protection, or a looked after child (NICE, 2011). My task is also to assess symptoms which may help health professionals establish if the child is suffering from a mental illness and the type of mental illness he is suffering. Case Study This is the case of Client A, an 8 year old patient who was referred to the community centre by his teacher due to symptoms which included the following difficulties: engaging in social interactions, pretend play, and in communication; as well as the following symptoms: irritability to sight, sound, and touch; unusual distress with changes in routine; strong attachments to objects; slow development of language; lack of empathy; tantrums, and other symptoms which indicate the possible presence of a mental disorder. The client was generally behind his age-mates in relation to important development milestones which he should already have reached. Upon meeting the client and his mother, I immediately noted how the mother was overly protective of her son and how she was already explaining why her son may be different from other children. I then assured the parent that there may indeed be nothing wrong with her child, but that it would not hurt to have him assessed. After gaining the mother’s informed consent, my assessment of the patient commenced. Using the CAMHS assessment tool, I evaluated the patient, his social interaction, his mental health and development, as well as his general sensory sensitivity (NHS Information Centre CAMHS, 2012). I also interviewed the mother about the child’s living environment, including his interactions with them (NICE, 2011). I also carried out one session of assessment with the child and his family. In order to ensure an accurate assessment of the child, I also carried out a session of assessment alone with him, without the protective eyes of his mother (NHS Information Centre, 2012). After assessing the patient for a possible ADHD or autism diagnosis, I then referred the family to a psychiatrist for further assessment (NICE, 2011). The CAMHS (2008a) also discusses how children with autism manifest strong difficulties in social situations and in terms of language and communication. This often affects the child’s overall development because he cannot adjust well to the school environment. This is unfortunate because the school is the place where the child can fully develop intellectually and socially (CAMHS, 2008a). This was clearly apparent with this patient who had trouble communicating and socializing in school with his teachers, classmates, and even his family. The NICE (2011) also helped to support the assessment process which I undertook with the client. This assessment included detailed questions on the parent’s concerns as well as details on the child’s experiences in his home life, education, and social activities (NICE, 2011). The child’s development history, specifically highlighting the child’s development and behavioural history was also reviewed and compared in relation to the ICD-10 standards on the possible autism diagnosis (NICE, 2011). The assessment process was carried out through an interactive process with the child, allowing for an evaluation of the child’s communication skills and behaviour. The NICE (2011) also specified a medical history check, including the patient’s prenatal and family history, as well as his past and present health issues. These were important aspects for me to evaluate because they helped me to rule out the child for any possible mental health disorders (Goodman and Scott, 2005). It also pointed me in a possible direction for the child’s mental health condition. I did not have proper mental health expertise to make the final diagnosis on the patient; hence, the referral to the psychiatrist. I used the CAMHS assessment which took up about four sessions (CAMHS, 2008b). In using the CAMHS assessment, I assessed the child’s current difficulties, his developmental history and possible gaps in said development, and his current family relationships and circumstances (NICE, 2011). These parts of the assessment provided a general background of the client, in terms of his development and relationship interactions. This assessment helped me reach a thorough understanding of the child’s strengths and his difficulties (Baron-Cohen, et.al., 2000). Moreover, with the assistance of the family, I was also able to gather more information about the client. I also used the functional assessment in order to establish client’s mental health condition (MHSIP, n.d). The Functional Assessment Scale provides an inventory measuring “functional impairment of children and adolescents...” (MHSIP, n.d). This scale includes role performance, thinking, behaviour toward self and others, substance abuse, basic needs, and family/social support. This assessment is considered a global assessment and in using this assessment, the assessor is often required to directly observe the impairment or the behaviour elements which indicate cognitive or behavioural issues (MHSIP, n.d). The best practice would be the application of the functional behaviour assessment in order to establish the child’s mental health condition (Child Welfare Group, n.d). This assessment tool can adequately establish whether or not the child’s mental health development matches his age and growth milestones. The functional assessment tool is the best practice for this case because it seeks to understand the family systems and interactions of the family in order to understand the patient’s condition. It also strengths-based, needs-based, and team-based processes in its assessment (Child Welfare Group, n.d). It includes the family in the assessment of the child and highlights the need for comprehensive child and family functions. This assessment also provides hints on possible interventions, because it flows naturally into service planning (Child Welfare Group, n.d). In general, the functional assessment tool is the best tool of assessment because it provides a big-picture as well as a long-term assessment of the child’s functioning. All in all, it also ensures information for the family and the health team. The functional assessment tool also helps specify the function of a behaviour which allows the practitioner to directly consider a function-based intervention (Love, et.al., 2008). Functional assessment also specifies treatments which are irrelevant. It identifies the means by which behaviour issues are gained; it helps in eventually understanding the behaviour issues; and it supports the development of holistic means of preventing these issues (Love, et.al., 2008). In reviewing the ICD-10, the child’s condition possibly falls under autism because he fulfils most of the symptoms for the disorder (WHO, 2007). According to the ICD-10, the onset of the symptoms must be seen at three years of age as the child manifests abnormal functions in terms of social interactions, language and imaginative play, among others. The fact that the child’s symptoms do not match other possible diagnosis also helps support an autism diagnosis (WHO, 2007). In order to manage this disorder, the child needs professional mental health. The early use of pharmacological treatment seems to be one of the best practices for this disorder (Bethea and Sikich, 2008). Drugs like Reelin and BDNF help in the child’s neurological development among autistic patients. The early use of SSRIs seems to ensure the reduction of serotonin synthesis, thereby increasing synapse refinement (Bethea and Sikich, 2007). Posey, et.al., (2008) also discuss how atypical antipsychotics help in the management of various symptoms which relate to autism. They manage specific symptoms, including irritability, aggression and self-injury (Posey, et.al., 2008). Antipsychotics have also proven to be useful tools in managing hyperactivity as well as repetitive activities. In effect, the use of this drug has been highly considered by practitioners as it has provided them with the necessary tools in managing patient symptoms. He needs to undergo therapy in order to properly address his main symptoms. His family also needs to undergo therapy in order to help them cope with the child’s disorder. The family needs to provide as much support for the child as possible in order to ensure that the child would have the necessary support system in coping with his disorder. Green, et.al., (2010) discuss that parent-mediated communication-focused treatment (PACT) in children with autism is one of the more effective options for children suffering from this disorder. In their study, treatment using the PACT proved to be favourable for the child, for the parent, and for securing patient-child shared attention. Based on the study’s findings, the authors recommend the use of PACT intervention in order to treat and reduce autism symptoms; moreover, benefits were especially apparent in improving parent-child social communication (Green, et.al., 2010). Cognitive behavioural therapy has also been suggested as an effective therapy for autism (Wood, et.al., 2009). A standard CBT program has been considered for the management of autism, aiming to assist the child in his social and adaptive skills. The study was able to achieve improved outcomes for the management of child anxiety and assisting the child in socially interacting with other children (Wood, et.al., 2009). This study provides support for the possible achievement of improved outcomes for autistic children after application of cognitive-behavioural therapy. Eikeseth, et.al., (2007) also supports findings on the impact of cognitive behavioural therapy for children. The study revealed that children manifested lower incidents of aberrant behaviour and also fewer incidents of social issues during follow-up. These children were also able to gain significantly during their first year of pre-treatment; they also scored higher gains in IQ and in terms of communication (Eikeseth, et.al., 2007). This brings strong support for the use of behavioural therapy for these children, helping them wade through their feelings and thoughts and to figure out how to prevent the usual patterns of behaviour observed in autism. Formulation Formulation is about trying to make sense of the data gathered in the assessment and using such data to assist the patient. Formulation is now being used in establishing diagnosis as the main standard in understanding people’s experiences; on the other hand, diagnosis often makes patients feel dependent on professionals to resolve their mental health issues (Psychology Solutions Partnerships, 2012). According to the Psychology Solutions Partnerships (2012), the best evidence can be drawn from the following points in order to establish a client formulation: school-based emotional and behavioural issues; clear formulation of client’s distressing feelings and thoughts; and therapeutic needs of clients with mental health issues. Based on the above discussion, a formulation of the child’s symptoms indicates that he may indeed be suffering from autism. According to the school-based information, the child does not socialize well with other children or students and his development in school is very much delayed. Behavioural information also indicates that the child is manifesting tantrums, socialization problems, and lacks empathy. Clear data can also be gleaned on the client’s feelings and thoughts. The data assessment indicates that the patient feels insecure because of his developmental delays and the various issues he is experiencing in school. In assessing the child’s needs, it can also be established that the child is in need of therapy in order to address his mental health issues and to assist him in coping with his symptoms, his developmental delays, and other related issues. The formulation of the child’s case as autism is based on a major developmental milestone – which relates to his school work and activities. The child manifests gaps in his school interactions and behavioural development and this clearly indicates a significant issue which points to a mental health disorder. A clear picture of the child’s distress is also apparent and the child’s delay in development is further implying a gap in the overall mental framework of the patient. In making sense of all these considerations, it can be observed that the child’s symptoms add up to autism. Using such a formulation actually helps in establishing a productive means of assisting the client (Psychology Solutions Partnerships, 2012). The formulation has helped to identify the specific symptoms which the client is experiencing and how each symptom can be addressed separately. Addressing each symptom can help reduce the overall impact of the disorder, especially when the disorder as a whole has no available treatment. The formulation process was able to replace the diagnostic process in establishing a clear conceptualization of the client’s experiences (Psychology Solutions Partnerships, 2012). The areas for change and development in the client were identified. These areas included his communication, socialization skills and interactions. The client clearly lacked the necessary focus for a clear interaction with his friends, teachers, and clients; and this prevented him from making friends. Making friends is almost a given for school-age children. However, the child had trouble even connecting with other classmates and teachers. Formulation allowed the identification of these gaps in the client’s development and interactions (Psychology Solutions Partnerships, 2012). As a result, clearer solutions were made possible because of the comprehensive identification of client issues. Reflection In reviewing my actions in this case, I believe that the assessment process went well. I was able to assess the patient and his family while also applying appropriate ethical principles of confidentiality. I was also able to respect the family’s privacy and reservations about the assessment. I was able to carry out my assessment freely with the patient. There were moments when there was a difficulty in the communication process, but while using the simplest language, I was able to make myself understood. The family was also able to understand the process of assessment and were very cooperative in sharing information they thought would be essential for my assessment. There were however moments which did not go well. During the first part of the assessment, the client’s mother was present and she was overprotective of her son. This also made her son uncooperative. But when I asked a moment to talk with her son alone, the child became more cooperative. If allowed to re-do this case, I think my initial interview with the child would be carried out without the mother. This would have made the child more cooperative from the very beginning. In reflecting on my actions, I note that I was able to gather the necessary information from the client. The data I gathered made the formulation and assessment process easier. I was also able to gather such information, especially in relation to the useful data needed to make the mental health assessment of the client. As a result, the formulation process allowed for the clear diagnosis of autism. The diagnosis was accurately made and was well-supported by the observed symptoms. The assessment process was also less tedious because the client was not subjected to a long and repeated process of questioning. Less anxiety too was experienced by the client’s family who were interviewed comprehensively. What was bad about the experience was that it was difficult at times to get past the patient and his family’s defences. They felt defensive and close-minded at the very beginning and although they soon acknowledged the child’s mental illness, they believed that it was also just a stage which the child would eventually overcome even without therapy or treatment. I had to try my best to educate the family and the client on what the client’s condition and mental state was. But by utilizing a sympathetic and trustworthy demeanour, I was eventually able to convince the patient and his family about the seriousness of his condition and the importance of managing his autism the soonest time possible. I learned that in handling cases with children possibly manifesting mental health disorders, I should be prepared to meet a lot of resistance and denial from parents. It is after all their natural instinct to be protective of their children and to want to think that their children are healthy. It is a delicate balance which can however be managed appropriately through experience and by learning from other experts in mental health. Conclusion Based on the discussion above, the client is suffering from autism. In reviewing his symptoms, the CAMHS generic assessment, and ICD-10 standards were utilized. Based on these standards, he is suffering from autism. His communication, socialization, and development patterns are severely compromised and they need to be managed with psychopharmacological, as well as therapeutic remedies. The NICE also supports an NICE diagnosis and a strong support for the use of functional assessment is provided by studies which promote the proper evaluation of children as well as their families in their home settings. In applying the necessary tools, a better communication and socialization pattern is expected from the client. I believe that there are things that went well and some things which did not go well during my placement. I was able to gain the necessary data for a correct formulation; however, I was also able to cause some distress to the family during the assessment process. With the application of ethical and sympathetic models, I was able to gain the client’s and his family’s trust. This case taught me various ways in appropriately handling child-cases, especially where their parents are involved with their legitimate concerns. I found out that I must be ready to meet the challenge from parents and to do my job adequately in ensuring accurate assessment and formulation. References Baron-Cohen S, Wheelwright S, Baird G, Charman T, Swettenham J, Drew A, et al. (2000), Early identification of autism by the Checklist for Autism in Toddlers (CHAT). J R Soc Med, 93(10), pp. 521-5 Bethea, T. & Sikich, L. (2007), Early pharmacological treatment of autism: a rationale for developmental treatment, Biol Psychiatry, 61(4): 521–537. Carr, A. 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