Four Psychiatric Medications and a Third Foster Home: An Integrated Review for a 10-Year-Old Boy, Tapering What the Trauma History Does Not Support and Starting Trauma-Focused CBT With His Foster Mother
[Student Name]
University of Phoenix
PMH/505: Psychiatric Management Of Children And Adolescents
Week 8 Assignment
[Instructor Name]
[Date]
The patient is a composite written for a model paper.
DeShawn, 10, entered foster care at 7 after neglect and exposure to domestic violence. He has lived in three foster homes. His current foster mother, Ms. R., has cared for him for four months. He takes methylphenidate for ADHD, risperidone for aggression, sertraline for anxiety and clonidine for sleep, prescribed by different clinicians over three years. He has gained 12 kg in two years. He still has nightmares, startles easily and hits when other children come near his belongings. His caseworker asks for a medication review. What follows describes the integrated assessment and plan.
The National Picture
Raghavan et al. (2005) found that 13.5% of children in a national probability sample of the child welfare system were taking psychotropic medications, a rate two to three times that of children in the community. Zito et al. (2008), studying youth in foster care in one state, found that 41.3% of those taking psychotropic medication received three or more classes at once and 15.9% received four or more, most often antidepressants, ADHD drugs and antipsychotics, and that such combined treatment lacked evidence of effectiveness and safety. DeShawn's four medications fit this pattern.
Reframing Through Trauma
DeShawn's history of neglect and domestic violence, his nightmares, startle, hypervigilance and aggression when his space is invaded are consistent with posttraumatic stress disorder. Many of the behaviors attributed to ADHD, aggression and anxiety can be explained by trauma. His medications treated labels applied at different times by clinicians who did not have his full history.
Gathering the Full Picture
With consent from the child welfare agency, I obtain records from his previous clinicians and schools. Ratings from Ms. R. and his teacher show high trauma symptoms and moderate inattention. His teacher notes that he concentrates well in math, which he enjoys, and loses focus when classmates are close to him. He is interviewed alone and describes "bad pictures" of his mother being hurt.
Four medications had been added for four labels; one history explained most of what they were treating.
Trauma-Focused CBT
Cohen et al. (2004) randomly assigned children with PTSD symptoms related to sexual abuse, many of whom had experienced multiple traumas, to trauma-focused CBT or child-centered therapy. Children receiving TF-CBT improved more in PTSD, depression, behavior problems, shame and abuse-related attributions, and their parents improved more in depression, distress, support of the child and parenting practices. The authors concluded the results supported TF-CBT for children with multiple traumas.
TF-CBT for DeShawn
DeShawn and Ms. R. begin weekly TF-CBT. Components include psychoeducation, relaxation, affect regulation, cognitive coping, a trauma narrative, in vivo exposure to reminders, conjoint sessions with Ms. R. and enhancing safety. Ms. R. learns about trauma responses and praise and consistent routines that help him feel safe.
Medication Review
Each medication is reviewed for its original reason, current benefit and risk. Risperidone, started for aggression that appears trauma-related, has caused substantial weight gain; it is the first to taper, reducing slowly over eight weeks while TF-CBT begins. Clonidine for sleep is continued for now, since it may help hyperarousal and nightmares. Sertraline is continued, since SSRIs may help trauma symptoms. Methylphenidate is reassessed after trauma symptoms improve, since inattention may resolve with them.
Why Taper Risperidone First
Risperidone carries the largest risk, has the weakest link to his true problem and has caused the most harm, with 12 kg of weight gain. Tapering it while TF-CBT begins lets the therapy address the aggression's cause as the medication is withdrawn. A slow taper avoids withdrawal dyskinesias and rebound irritability.
One Change at a Time
Changing one medication at a time allows each effect to be judged. Ms. R. and the teacher record behavior weekly during the risperidone taper. If aggression increases, the taper pauses.
His Foster Mother as Co-Therapist
In TF-CBT, the caregiver is an active participant. Ms. R. attends part of every session and learns what DeShawn is working on so she can reinforce it at home. When he becomes agitated, she uses the calming skills he learned, such as slow breathing, rather than sending him to his room. Cohen et al. (2004) found that caregivers in TF-CBT improved in their support of the child and parenting practices, which strengthens the placement as well.
Nightmares
His nightmares are addressed within the trauma narrative and with a bedtime routine that includes a nightlight and a comfort object. If they persist after the narrative phase, specific nightmare treatment will be added.
Metabolic Health
His weight gain is addressed with a nutritionist and increased activity, including a soccer program. Fasting glucose, lipids and A1c are checked.
Consent and the Agency
In foster care, consent for psychotropic medication often involves the child welfare agency or court. The plan is reviewed with his caseworker and the agency's consent process is followed. His biological mother, whose parental rights remain, is informed through the caseworker.
Placement Stability
Placement changes worsen trauma symptoms. The caseworker and I discuss the importance of keeping DeShawn with Ms. R., and she is offered respite and a foster parent support group to prevent disruption.
Methylphenidate Reassessment
After three months of TF-CBT, teacher and foster mother ratings of inattention will be repeated. If inattention has fallen with his trauma symptoms, a supervised trial off methylphenidate over a school break will test whether it is still needed.
Assent and His Voice
DeShawn is asked what he wants. He says he wants to stop "the medicine that makes me hungry" and to stay with Ms. R. His assent is sought for each change.
Contact With His Mother and Siblings
DeShawn has a younger sister in another foster home. Regular sibling visits are arranged through the caseworker, since sibling contact supports children in care. Contact with his mother follows the court's plan and is prepared for in therapy.
School
The school is informed about his trauma history, with consent, so staff can understand his reactions when classmates are close. He is given a personal space at his desk and a signal he can use to ask for a short break when he feels crowded, instead of hitting.
Coordinating Prescribers
Four medications from different clinicians led to a regimen no one had reviewed as a whole. From now on, one prescriber manages all his psychiatric medications, and the agency keeps a single medication record that travels with him if he moves.
Measuring Progress
A trauma symptom checklist, Ms. R.'s and the teacher's behavior ratings and his weight are tracked monthly.
Conclusion
DeShawn's four medications, reflecting a national pattern of polypharmacy in foster care, treated symptoms better explained by trauma. An integrated plan reframes his difficulties, begins trauma-focused CBT with his foster mother, tapers risperidone first and reviews each remaining medication in turn, while protecting his placement and including the agency, school and his own voice.
References
Cohen, J. A., Deblinger, E., Mannarino, A. P., & Steer, R. A. (2004). A multisite, randomized controlled trial for children with sexual abuse-related PTSD symptoms. Journal of the American Academy of Child and Adolescent Psychiatry, 43(4), 393-402. https://doi.org/10.1097/00004583-200404000-00005
Raghavan, R., Zima, B. T., Andersen, R. M., Leibowitz, A. A., Schuster, M. A., & Landsverk, J. (2005). Psychotropic medication use in a national probability sample of children in the child welfare system. Journal of Child and Adolescent Psychopharmacology, 15(1), 97-106. https://doi.org/10.1089/cap.2005.15.97
Zito, J. M., Safer, D. J., Sai, D., Gardner, J. F., Thomas, D., Coombes, P., Dubowski, M., & Mendez-Lewis, M. (2008). Psychotropic medication patterns among youth in foster care. Pediatrics, 121(1), e157-e163. https://doi.org/10.1542/peds.2007-0212
How this PMH 505 Week 8 example is structured
The PMH/505 Week 8 work usually closes with an integrated family-centered case. This paper brings together multi-informant assessment, trauma, polypharmacy and the family and agency systems around a child in foster care, showing how a coordinated plan can do more with fewer medications. Students search this week as PMH 505 Week 8, PMH505 Wk 8 or PMH/505 Wk 8; all three are the same assignment.
PMH/505 Week 8 questions, answered
What does PMH/505 Week 8 usually ask for?
Many sections close with an integrated case of a child or adolescent, requiring a full assessment, family and school involvement and a coordinated psychotherapy and medication plan.
How common is psychotropic polypharmacy in foster care?
In one state study, 41.3% of foster children taking psychotropic medication received three or more classes at once, and 15.9% received four or more.
What is trauma-focused CBT?
A structured therapy for children with trauma symptoms that includes the caregiver and teaches skills, builds a trauma narrative and addresses safety; a multisite trial found it improved PTSD, depression and behavior more than child-centered therapy.
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