Transcript case studies

Trauma-Informed Care
CASE STUDY
WACPP
James Meyer MD
05-12-2015
Disclosure Statement
I, James Meyer, M.D., do not have any relevant
financial interest or other relationship(s) with a commercial
entity producing health-care related product and/or services.
I will indicate during this presentation when a
medication use or dosage is other than an FDA approved
treatment.
Case:
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Colt
Presents as a new patient with new
foster mom age 13 yrs for health
maintenance evaluation.
MA takes Colt for vitals and to get ready
for the evaluation.
As most children in foster care have
experienced some negative experiences
and you want to get some
understanding of Colt’s past history,
start by interviewing his foster mother
alone.
Case: Colt Past HX from
Foster Mom
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Has no medical documents.
Colt has been in her care for 2 weeks.
Social worker reported that Colt is in
foster care due to mom having been
arrested/facing long jail sentence for
drug trafficking and running a meth lab
in the home along with her current
boyfriend (X6 months).
Case: Colt Past HX from
Foster Mom
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Aware that mom was a teenager
when Colt was born with mental
health and AODA issues.
Biologic dad is not involved in Colt’s
life.
Many moves within the state.
Known to Social Services since quite
young with prior domestic violence.
Case: Colt Past HX from
Foster Mom
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Has attended many schools and
misses a lot. No known LD/ADHD.
Colt’s meds (unsure how long he
has been on these):
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trazodone 25mg at HS for sleep.
fluoxetine 20mg for depression
Case: Colt’s Behavior
Observations from Foster Mom
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Easily upset
Sullen/spends time alone
Seems nervous/jumpy
Struggles with focus/attention/school effort
Not easily engaging with peers
Nightmares and delay sustained sleep
Frequent complaints of fleeting aches/pains
without physical signs
Knows that he has smoked
Case: Aspects of Taking Past HX
from Colt
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You already know that Colt has
experienced many Adverse Childhood
Experiences (ACEs).
You want to give emotional support while
gathering information about the “bad
things” that have happened to him/his
family.
Try to avoid threatening and judgmental
questions.
Give Colt some control over parts of the
history and exam. Ok to not answer.
Case: HX from Colt
(interviewed alone)
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Talents and strengths- I’m a tough guy and
stand up for kids getting picked on. (He use
to get teased-new kid in class.)
Tell me something that you remember that
was fun that you did with your momFishing last summer, making a big ugly
snowmonster. (You must miss your mom!)
What comfort items did you take to foster
care? Box of treasures collected since
young. (You must really cherish those.)
Case: HX from Colt
(interviewed alone)
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Scariest life event? MANY: Police raiding
trailer was the worst. Dog bite was bad.
Lost a friend in home fire at age 9 years
and some physical fights with stepdad.
Do you feel safe now? Yes but always
wary and afraid something else will
happen.
Current worry? What is going to happen
to me? Will my mom get out of jail?
Case: HX from Colt
(interviewed alone)
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ROS- occasional headaches, muscle pains
but not seriously sick often.
Feels tense and irritable when pushed to
do things
Nightmares & remembering bad things.
Upset around dogs, people raising their
voices, hearing police siren.
Startles easily/feels on edge/jumpy.
Doesn’t like to talk about the bad things.
Case: HX from Colt
(interviewed alone)
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Avoid getting close to people/not trusting.
Dread what is going to happen next.
Hard to concentrate because mind is
busy.
Feels need to be alert/watch for danger
Hard to have fun. Always nervous or sad.
Feels guilty about things that happened.
Case: Past HX from Colt
(interviewed alone)
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Colt’s dad has not been involved in his
life since around age 4 years when
parents had a violent fight. He does not
know where he lives. Mom says bad
things about his dad (drug abuse and
many legal problems).
Mom divorced stepdad 3 years ago after
escalating verbal and physical fights
between Colt, stepdad & mom. No
contact now with stepdad. (Present ages
6-10yrs).
Case: Colt History
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Diet ok. Likes 2-3 caffeinated drinks/day
with occasional Monster/Rock Star energy
drinks.
No sports but active on bike/skateboard.
Sleep onset ok but nightmares and wakes
up.
First cigarette at age 10yrs and up to 10
cigs/day. Episodic use of alcohol with one
UAD offense. Used pot a few times.
HX of verbal abuse in home. Denies
sexual abuse. No sex but curious.
Case: Colt’s School History
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7th grade B’s to D’s
Colt has never liked school-puts in little
effort and misses about 20 days/year.
Mostly he does not want to go and uses
illness complaints to stay home.
Thinks does ok on achievement tests but
thinks he is a slow reader.
No belief that he has ADD/ADHD.
Prior suspension 6th grade for bringing a
knife to school.
Case: Colt Unknown PMHx
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Prenatal and peri-natal course. Suspect
prenatal alcohol or other drug exposures.
Early childhood development except for
slight speech delay.
Feeding issues, colic.
Hearing problems.
Head trauma, toxic ingestion , lead
exposure or fever with delirium.
Case: Colt Known PMHx
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Admission age 4 years after dog bites
to face (avoids dogs now and
frightened if hears a dog bark).
Surgery initial sutures and then one
plastic surgery one year later.
Diagnosed with depression several
years ago. RX’d with fluoxetine and
trazodone for sleep.
Case:
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Colt FHx
No major medical problems
Mom had depression/anxiety/temper
issues. Prior 2 DWI’s.
Dad with reported AODA and legal
problems.
Case: Colt’s Physical Exam
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WNL weight/height and vital signs
Normal exam, well groomed, a little standoffish but cooperative. Becomes upset with
recommended genital exam/pubertal eval
(exam omitted- can do in future when ready).
No suggestion of anemia, thyroid dysfunction,
obstructive nasal breathing, tics or other
medical conditions.
Labs: Considered unnecessary today.
Post-Traumatic Stress Disorder
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a traumatic stressor and subjective emotional experience of
fear, helplessness, or horror.
at least 1 re-experiencing symptom
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at least 1 avoidance symptom
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Sad, anxious, somatic symptoms, obsessions
at least 2 hyper-arousal symptoms
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Avoid talk about bad thing, anhedonia, emotionally numb/detached.
at least 2 symptoms that indicate negative alterations of
cognition or mood
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Thoughts stuck, flashbacks, nightmares, distress SXs
Irritability, poor concentration, poor sleep
significant impairment in functioning home, school, peers,
work
duration of symptoms: 1 month or more
DEPRESSION DX Mnemonic
Sadness and/or irritable plus:
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S- change in SLEEP
I- loss of INTEREST in usual activities
G- self critical and feelings of GUILT
E- change in ENERGY level
C- problems with CONCENTRATION
A- change in APPETITE
P- PSYCHOMOTOR agitation or slowing
S- thoughts of SUICIDE or self harm
Case: Colt
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Diagnosis- Affective Disorder with PTSD
Treatment Medication:
 Trazodone to 50mg at HS
 Fluoxetine increase toward 40mg
 Refer to therapy:
 Response to Distress
 Emotional Support
 Family Centered Care
Case:
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Colt F/U
Phone follow up at 2 weeks-no concerns.
Clinical visit F/U at 6 weeks:
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Adjusting well to current foster care.
Attending school and completing work with
positive praise/earned token awards.
Not smoking
Scheduled to start therapy
Sleeping without nightmares
Less secretive in general
Feels less stressed and tolerating higher
fluoxetine dosage.