Occupation Based Practice: Mental Health

Case Study: Dylan

1. Learning issues should: be discussed in depth; organized and effectively communicated (posters, diagrams,

video) have a brief handout for each group member with the student’s name and title of

learning issue topic have at least one peer reviewed journal reference, APA format

2. Bring resources to class to help answer simple questions.

3. Peer feedback on level of group members' participation will be recorded using the CBL Log on each day and collected on last day of CBL

4. The presentation guidelines are as follows: 30 minutes (no more, no less) Visual demonstration of some sort (video, power point, skit, hand puppets, whatever) Choose two goals and a total of three interventions (include adaptations for each). One of the interventions

should be educational with an instructional design and materials appropriate for your client. Incorporate your OBM and frame of reference(s) into your presentation, justifying from scholarly sources

why you chose the interventions and the therapeutic use of self strategies Put a copy of your treatment plan (using the General Psychosocial Treatment Plan Template) on the class

wiki- notice that this is a general template- make it specific for your client Interventions should be evidence-based (and properly referenced by APA)

Three-day Case Agenda

Day One [bring text books, class notes, etc]1. Discuss snacks, breaks, agenda2. Read the case and list learning issues on the board3. Answer any learning issues that can be resolved through current resources4. Assign learning issues to group members5. Record group member feedback

Day Two [bring supplies for presentation, camera, etc.]1. Agenda2. Report on learning issues (approximately 15 minutes each) provide handouts to group

members3. Decide on occupation based model to use4. Select frame of reference(s)5. Complete treatment plan using template 6. Plan presentation7. Record group member feedback

Day Three1. present project to class (30 minutes)2. turn in group member feedback forms

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Case Study: Dylan

Dylan is a 15 year old Byrd high school student. He lives with his mother, Melinda and his

stepfather, Scott, in a quiet suburban neighborhood in Shreveport. He has a younger sister, Amanda,

age 12 who attends Middle Magnet. Scott works in middle management in manufacturing and

Melinda is an LPN at a local hospital.

As a young boy, Dylan often accompanied his biological father, John, on fishing and hunting trips.

Dylan enjoyed spending time with his father, although John typically began drinking early in the

day and was fairly inebriated by evening. When drunk, Dylan's father became verbally and

physically abusive, cursing and slapping his son. One night when Dylan was 10, he and his father

returned home after a fishing trip. John had been drinking as usual and had given Dylan a black eye

during an argument about John's driving. When Melinda asked John how Dylan got the bruise, John

flew into a rage and left the house. That was five years ago and Dylan has not seen his father since.

He blames himself for the breakup of the family, although he has never admitted this to himself or

anyone else.

Dylan appeared to accept the disappearance of his father well and when his mother met and

married Scott, the family expected Dylan to adjust just as easily. Melinda works the three to eleven

shift at the hospital and Scott works late, but is usually home with the children in the evenings.

Amanda did not adjust well when her father left, and she seems to seek Scott's attention as much as

possible. Dylan spends most of his time in his room playing video games or skateboarding alone

around the neighborhood. He often sneaks out of the house at night, but Scott and Melinda are not

aware of this. He does not perform well at school and has been suspended several times for missing

class and talking back to teachers. Dylan was diagnosed with ADHD in the first grade but Melinda

decided not to use medications, feeling the side effects were too harmful.

ISSUE:

What is your impression of Dylan?

Describe the family dynamics.

How do boys and girls differ in their response to stress?

How did Amanda and Dylan respond to the divorce and

remarriage?

What are the pros and cons of ADHD medication?

Please do not turn the page until the group is ready

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Last Saturday morning, Melinda woke Dylan up and told him to take out the trash, a chore that

should have been done the day before. An argument ensued, and Dylan angrily took the trash out

and then used his sling shot to shoot out the windows of the house. When Scott came out to

confront him, Dylan aimed the sling shot at Scott, screaming and cursing at him. Melinda eventually

resorted to calling the police, who arrested Dylan. At the police station, Dylan tested positive for

methamphetamines and cannabis. He was subsequently released to Brentwood Hospital, an

inpatient substance abuse treatment facility.

Issues:

What are the risk factors associated with methamphetamine use?

What are the effects of meth and cannabis?

Why would these two drugs be found together in Dylan's system?

What services are provided at Brentwood Hospital? What is the typical length of stay?

Please do not turn the page until the group is ready.

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Medical Report

Pt. Name: Dylan Thomas DOB: 4/2/95 Sex: M Age: 15

Facility: Brentwood Insurance#: Cigna 6789

Diagnosis: I: Polysubstance abuse (305.9), ADHD (314.9) R/O Bipolar DO

II: deferred

III: none

IV: truancy, poor academic performance

V: GAF 61

Onset Date: 8/28/09 MD: Dr. Jones

Chief complaint

"The police thinks I have a problem with anger and drugs, so they sent me here."

History of present illness

Client stated that he went to a party the evening of 8/27/09 and snorted approximately a quarter gram of methamphetamine (pale yellow). He came home at 2 am and smoked 2 joints of MJ in order to sleep. Client stated that his mother woke him up at 7 am to take out the trash, a chore that he had neglected to complete for several days. Client stated that he felt 'very strung out' and angry as he took out the trash. He found a forearm slingshot outside and began shooting rocks at the house. Client stated he was just angry and did not think the rocks would break the windows. Client's stepfather came out of the house and according to client, confronted him by threatening physical violence. Client stated he pointed the slingshot at the stepfather in defense and that he had no real intention of actually shooting him with a rock. Client stated that his mother overacted "freaked out" by calling the police. The police conducted a urinalysis and found evidence of recent methamphetamine and cannabis use. Client court ordered to 30 days inpatient substance abuse treatment at Juvenile Detention or at a private facility of parental choice. Client's mother requested client transfer to Brentwood.

Client stated feeling depressed and worthless for 'a really long time.'

Beck Depression Inventory = 33, client verbalized suicidal ideation with no intent or plan. He stated that problems with school or parents make the depression worse. He stated frequent early morning wakening and difficulty getting to sleep. Physical examination revealed long thin scars on upper left abdomen. When confronted, client admitted pattern of cutting torso with razor blade to relieve feelings of dissociation, stating, "I feel like I'm not real, like this is all a really bad dream and I get scared so I have to cut myself, you know, to get some relief." See Social Services Report for Substance Abuse History

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Past medical history

No significant medical or psychiatric history other than diagnosis at age 6 of ADHD, James Pinkston PhD. See chart for copy of results. Usual childhood illnesses.

Medication

Client reports not currently taking any medications or OTC supplements

Allergies

none known to client or mother

Family history

According to intake report, client's mother stated that client's biological father was an alcoholic and possibly Bipolar. Father abandoned family when client was 10 after a domestic dispute and has not been in contact with the family since. Client's mother stated that the father was physically and verbally abusive when intoxicated. Mother re-married when client was 12. She stated that client has always had trouble at school (in school suspension 3x this year) but that the trouble worsened after her re-marriage. Mother denies any history of psychiatric illness on her side of the family, and she stated that she does not know about the father's family.

Client has a 12 year old sister in the seventh grade at Middle Magnet who performs well academically and has no psychiatric history. Client's maternal grandparents live in New Orleans and visit only occasionally due to poor health. Client's paternal grandparents were deceased prior to client's birth.

Social history

Client is in the ninth grade at Byrd High School. He repeated the second grade due to academic and behavioral problems. Client admitted to skipping classes and forging excuses. He stated that he has a few male friends at school and that he has a girl friend, but denies sexual activity.

Client stated that the family is Methodist but does not attend regular church services. He stated that his relationship with his parents is "stressful". He stated that his parent's expect too much from him academically and that he can never please them. Discipline takes the form of yelling and restriction to the home. However, client stated that his parents usually forget about the problem, typically his grades, within a few days.

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Perinatal and developmental history

Client's mother reports uncomplicated pregnancy and birth. Usual developmental milestones met, although client was a 'very active baby.'

Assets

Client is average to above average in intelligence. Polite and moderately cooperative in interview.

Mini-MSE: 29/30

Psychiatric Treatment Plan

Provisional Dg

I: Polysubstance abuse (305.9), ADHD (314.9) R/O Bipolar DO

II: deferred

III: none

IV: truancy, poor academic performance

V: GAF 61

Treatment: Bupropion 100 mg tidTrazodone 50 mg HSSuicide Precautions, inpatient activities, meals on unit only, no day passOccupational Therapy Eval and Treat

A Jones, MDA. Jones, MD

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ISSUES:

What is the classification system used to state Dylan's diagnosis? What does his diagnosis mean?

What are some of the legal issues associated with drug use? How will these issues impact Dylan's

treatment?

How common is the phenomena of 'cutting' in teens? What are the etiological theories of cutting?

What is the Beck Depression Inventory? What does Dylan's score mean?

What is a Mini-MSE? What does Dylan's score mean?

What are the indications, typical doses, side effects of the medications Dr. Jones has prescribed for Dylan?

Review the average length of inpatient stay for a substance abuse diagnosis. How will this impact

OT tx?

How does Dylan’s self-report differ from what really happened?

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Questionnaire on Drinking and Drug Abuse

For each of the following questions, mark an X in one or two columns, as appropriate. Please answer each question for the past six-month period only.

During the past six months have you: Yes, Alcohol

Yes,Drugs No

1. Felt guilty about your drinking or drug use? 2. Received a poor grade on an exam or paper because you were drinking or using drugs the night before?

3. Used alcohol or drugs before going to a class or before a test? 4. Cut a class or missed work after having several drinks or taking drugs?

5. Turned a class assignment in late because you were drinking or using drugs the day (night) before it was due?

6. Had anyone close to you complain about your drinking or drug use or suggest that you cut down on your drinking or drug use?

7. Engaged in sex after drinking or using drugs that you were later sorry for or embarrassed about?

8. Gotten “high” on alcohol or drugs before going out on a date? 9. Passed out from drinking or using drugs while out on a date or out with friends?

10. Gotten into conflicts with your friends or acquaintances after drinking or using drugs?

11. Drunk or used drugs and stayed at home instead of going out to be with others?

12. Lied to friends about your drinking or drug use? 13. Acted more quarrelsome or angry after drinking or using drugs? 14. Had a difficult time being with friends without drinking or using drugs?

15. Had a bad abdominal pain in the morning after drinking or using drugs?

16. Injured yourself badly enough after drinking or using drugs that you required medical attention?

17. Found that you could not remember what you did the night before when you were drinking or using drugs?

18. Missed morning classes because of alcohol or drug hangovers? 19. Drunk or used drugs when you felt lonely or depressed? 20. Become more depressed when drinking or using drugs? 21. Drunk or used drugs after blowing an exam or after other disappointments?

During the past six months have you: Yes, Alcohol

Yes,Drugs No

22. Been scared by your reaction to alcohol or drugs? 23. Run out of money because you spent too much on alcohol or drugs?

24. Gotten into trouble with the police or campus officials because of your behavior after drinking or using drugs?

25. Spent more money on alcohol or drugs than you think you should have?

26. Damaged personal or university property after drinking or using drugs?

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27. Driven a car when you knew you had had too much alcohol or drugs?

28. Been driving after drinking or using drugs and become involved in an accident?

29. Usually gulped the first two or three drinks or tried to “get high” quickly?

30. Chosen not to attend a social activity because there would have been no alcohol or drugs present?

31. Increased the amount of alcohol or drugs that you use? 32. Found that you are using more and enjoying less? 33. Gotten “high” with alcohol or drugs almost every day? 34. Drunk or used drugs in order to forget or feel better about problems?

35. Thought that you might have a drinking or drug problem? 36. Has answering the above questions caused you to think any differently about your drinking or use of drugs?

Social Worker Note: Client stated first drink at age of three or four from father's beer. He developed a taste for beer by the age of seven and often drank up to 10 oz while on fishing trips with his father. Since his father's disappearance, he stated drinking alcohol whenever the opportunity arises (~2 SEC 2-3x month). At age of 12, client smoked first joint and found that it helped him relax and interact more easily with friends. Since then he has used marijuana approximately 1-2x week, often prior to class. At age 13, client smoked first methamphetamine rock (1/4 gram), which he stated produced a focused euphoria- "I almost felt like I was normal, like this is how other people feel all the time." He stated that for the past year, he has attempted to either snort or smoke meth 1 or 2x week, when he has the money. The amount depends on the source, (rock ½ gram, powder 1/2 to 1 gram). He stated one experience with a bad source of powder (headache, nausea, burning nasal passages) and now tries to buy crystal meth when he can. Client stated motivation for drug and alcohol use as "relax with friends." The only negative consequence identified as "mixed up making out with a friend's girlfriend" after meth use.

Client stated first sexual experience at age of 14 and has had a number of different partners, always while under influence of substances. He stated that he and his current girl friend of 3 months are sexually exclusive however. He stated intermittent unprotected sex, which he did not see as a problem.

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Issues

Are there any inconsistencies between the psychiatrist's report and the social service's report? If

so, what might be the reason?

What is a typical amount of methamphetamine use at one time? How much does that cost? How might this impact Dylan's lifestyle and choices?

What are the effects of methamphetamine use? What is the pattern of Dylan's use?

What are the effects of marijuana use? Why might Dylan be using this?

What kind of withdrawal symptoms might Dylan display?

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Dr. Jones, Dylan's psychiatrist at Brentwood, referred Dylan to occupational therapy. Susan

Sepulveda, MOT responded to the referral and completed an initial OT evaluation.

Occupational Therapy Initial Note

Pt. Name: Dylan Thomas DOB: 4/2/95 Sex: M Age: 15 HD: R

Facility: Brentwood Insurance#: Cigna 6789

Diagnosis: I: Polysubstance abuse (305.9), ADHD (314.9) R/O Bipolar DO

II: deferred

III: none

IV: truancy, poor academic performance

V: GAF 61

Onset Date: 8/28/09 MD: Dr. Jones

Precautions: suicide precautions OT Eval: 8/28/09 OTR: Susan Sepulveda, MOT

S: "Leave me alone, I just want to sleep."

O: Client was arrested for physically threatening his stepfather on 8/26/09 and subsequently

tested positive for cannabis and methamphetamine use. Admitted to Brentwood on 8/26/09. Client

psychosocial and substance abuse history per Dr. Jones noted in client record. Client given

Adolescent Role Assessment and magazine collage task for initial occupational therapy evaluation

on 8/28/09.

ARA: see chartMagazine Collage Task: client verbalized minimal insight into reasons for drug addiction,

moderate insight into personal responsibility for actions. Themes consisted of drug use, escape to

rural setting, feelings of anger and frustration. Client able to think abstractly. Client verbalized poor

motivation to maintain abstinence and was resistant to identifying consequences of past drug use.

A: Client is in pre-contemplative stage of motivation according to the trans-theoretical model of

behavior change. He would benefit from structured OT group experiences designed to increase

motivation and interpersonal communication skills needed to maintain abstinence from drugs.

Since client identified family emotional strain as a contributing factor to relapse, OTR recommends

family involvement in OT and counseling groups.

P: Client will participate in OT psychoeducational group 1x week and OT skills group 3x week for 4

weeks.

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ADOLESCENT ROLE ASSESSMENT

I. Childhood-Play + 0 - III. Adolescent-Occupational Choice + 0 -1. Activities

2. Rules 18. Work N/A3. Interactions 19. Choice Stage 4. Fantasy 5. Role Models 6. Interests

II. Adolescent-SocializationA. Family

IV. Adulthood— Work

7. Interactions 20. Goals 8. Responsibilities 21. Fantasy 9. Economics

B. School10. Consistency 11. Responsibilities 12. Feedback 13. Role Models 14. Activities

C. Peers15. Activities 16. Time 17. Community

ASSESSMENT SUMMARYBehavioral Observations During OT eval, Dylan demonstrated fidgeting (drumming table with pencil, shifting in chair) and distractibility. He had to be redirected to interview 5x by OT. Depressed affect consistent with stated mood. Answers to questions tended to be short and concrete, he did not maintain eye contact with therapist for 80% of interview. Dylan expressed thoughts in logical, coherent manner with vocabulary appropriate for age and education.Summary of Client Answers:

Childhood Play: I liked to go out and play in the woods, a few friends. I wanted to be a NASCAR driver. My dad taught me how to clean fish, shoot BB gun. I taught myself how to ride a bike. I still like to ride skateboard, and be outside, but I don't get to go fishing or hunting since my dad left. Just hang out and play video games now

Adolescent: Yeah, I'm the black sheep, my parents hassle me, always nagging me about chores and how I could do better at school. My mom says I'm just like my dad.I get money for my birthday and Christmas, sometimes I just have to take it out of my mom's purse. I don't like to ask for money. They don't tell me how to spend my own money at least.I don't see why I should go to school- It's not like I am ever going to learn anything there that I will actually use. So, I skip out whenever I can. I just make up a doctors excuse and sign my mom's name on it.I'm supposed to look out for my sister but she doesn't even stay home after school, so I do whatever. I guess my friends are ok. Spend time watching TV, playing video games, dating, hanging out with friends, listen to music, get high.

Adolescent Occupational Choice: Don't work- I'd like to be a comic book writer. I have a whole collection of stuff I've drawn based on video games.

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Adult Work: I don't want to go to college, I think I can just submit my stuff to an online publisher- you can make a lot of money that way. I think money is important but not as much as having fun- people worry too much about work and then they don't ever get to do anything or see the world. I would change it so no one had to go to work or school. I'd get a place in Alaska and me and my friends would ride snowmobiles and hunt polar bears. I could build a house out of ice- of course I'd have to bring my girlfriend- Ashley Tisdale.

Goalssee OT treatment plan

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ISSUES:

What is the transtheoretical model of behavior change? What are some other treatment

frameworks and occupation-based models used in this setting?

What strengths and weaknesses of Dylan's do you see in the OT report that were not specifically identified? How would you prioritize treatment issues?

What are Dylan's goals? What would be your OT goals?

What role does OT play in this setting? How is this different from the role of social work or counseling?

How does Cigna reimbursement impact: pts length of stay in the hospital, OT services, aftercare?

What do suicide precautions typically mean in occupational therapy?

What are the roles and occupations would you expect of a 15 year old male?

What TX activities will address deficits in Dylan's performance skills during his hospitalization?

Please do not turn the page until the group is ready.

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Susan, Dylan's OTR, overhears a conversation between Dylan and some other clients in OT group.

Dylan was bragging about how he sold his mother's Xanax to obtain money for drugs. He also buys

large amounts of marijuana from a dealer and then re-sells smaller amounts to friends for a large

profit.

Issues

What should Susan do with this information?

How should the treatment team handle this?

How likely is it that Dylan is also using Xanax? What would be the effects of abusing this prescription drug?

What are the legal implications for Dylan's behavior? Is this a misdemeanor or a felony?

What are the ethical issues involved with the disclosure of this information? Should this be reported to the police? or to Dylan's mother?

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Objectives for CBL: Dylan

1. Identify social, psychological, physical and legal risks associated with drug use, particularly methamphetamines.

2. Describe typical patterns of behavior associated with marijuana and methamphetamines.

3. Identify client factors that will influence Dylan's treatment and recovery.

4. Summarize the types of activities you would expect of a 15 year old male.

5. Identify the areas of occupation and performance skills that may be impaired as a result of Dylan's diagnoses.

6. Describe influencing characteristics of Dylan's culture and value system.

7. Describe the family dynamics that might influence Dylan’s recovery and OT’s role in address these.

8. Identify relevant occupation based models and describe how these models could be applied to Dylan's case.

9. Identify relevant frames of reference and therapeutic strategies that can be used to guide specific OT interventions.

10. Identify appropriate OT goals and treatment that should be implemented within a 30 day inpatient stay.

11. Identify appropriate OT goals and treatment that should be implemented in an aftercare setting.

12. Describe the long term prognosis for Dylan.

13. Are there new learning objectives you wish to develop to enhance your understanding of this case?

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