NRNP 6644 Week 9 Medication Decision Paper Example

Medication Decision Paper: Waiting Six More Weeks Before Sertraline in a Fifth Grader With Separation Anxiety Disorder, With the Case for Starting Now Argued in Full

Student Name

College of Nursing, Walden University

NRNP 6644: Psychiatric Mental Health Advanced Practice Nursing Care of Children Through Young Adults

Instructor Name

Month Day, Year

Medication Decision Paper: Waiting Six More Weeks Before Sertraline in a Fifth Grader With Separation Anxiety Disorder, With the Case for Starting Now Argued in Full

The Decision

Sertraline is not started today; therapy continues for six more weeks with added parent sessions, and the decision is reviewed at that point or sooner if a named trigger occurs. Composite patient: the same fifth grader, diagnosed in week 5, now after eight weekly sessions of cognitive behavioral therapy with graded exposure.

Where he is now: mornings with crying or pleading have fallen from 4 or 5 a week to about 2; absences fell from 11 in the first semester to 2 in the past 4 weeks; nurse visits to about one every two weeks. SCARED child total is 24 and parent total 29, down from 33 and 38 (Birmaher et al., 1997). He still comes to his parents' room some nights and has not yet tried a sleepover. His parents asked at this visit whether medicine would speed things up.

The Case for Starting Sertraline Now, Argued Fully

The strongest argument for starting is the evidence. In the Child/Adolescent Anxiety Multimodal Study, children and adolescents aged 7 to 17 with separation, generalized, or social anxiety disorder were randomized to therapy, sertraline, both, or placebo; response rates at 12 weeks were 80.7% for the combination, 59.7% for therapy alone, 54.9% for sertraline alone, and 23.7% for placebo (Walkup et al., 2008). Adding sertraline to therapy was the most effective option in that trial, and he is partway through therapy now.

Second, his symptoms still cost him: two hard mornings a week, a sleepover he wants and has not managed, and an evening argument between his parents most weeks. Third, antidepressants show their largest benefit over placebo in anxiety disorders other than obsessive-compulsive disorder; a meta-analysis of pediatric trials found a number needed to treat of 3 for these conditions (Bridge et al., 2007). Fourth, his parents are asking, and a clinician who turns down a family's reasonable request needs a better reason than habit.

If he were not improving, or if his absences were rising, these arguments would carry the decision.

Why Waiting Is Chosen

He is improving on therapy alone, on every measure, and eight sessions is short of the 12 weeks over which the trial's therapy arm was judged. The parent work on accommodation has only just begun, and reduced accommodation is itself an effective route for childhood anxiety (Lebowitz et al., 2020). Starting a medicine now would make it impossible to tell, at the next review, whether gains came from the medicine or from the therapy and parent work that were already moving. The functional cost of six more weeks is real but bounded: he is attending school most days, and waiting does not put him at risk.

Factors Specific to a Child

Safety: antidepressants carry an FDA boxed warning for suicidal thoughts and behavior in young people. In the pooled trial data, the added risk of reported suicidal ideation or attempt across all indications was 0.7%, with a number needed to harm of 143, and no completed suicides; within non-OCD anxiety disorders the difference was not statistically significant (Bridge et al., 2007). The risk is small but would require weekly contact early in treatment. Tolerability: stomach upset, sleep change, and restlessness would be hard to separate from his existing stomachaches without careful baseline notes. Growth: height and weight would be recorded at baseline and at each visit if a medicine is started, as for any child on a daily medicine. School: his teacher's reports of nurse visits and clock-watching are one of the measures, so any decision is judged partly by what school sees.

Consent and Assent, Recorded Apart

Guardian consent: both parents were present. Explained in plain English: the trial results, the likely benefit, the boxed warning and what it would mean for visit frequency, the common side effects, and the plan to wait six weeks and review. Both parents agreed to the plan to wait and asked that medicine be reconsidered at the review. Recorded with the date and both names.

Child assent: explained to him separately, in words he chose to repeat back: "There's a medicine that can turn the worry down, but we're going to keep practicing first and see." He asked whether it would make him sleepy; I answered. He said he wanted to keep trying "the brave steps" first. His agreement is recorded apart from his parents', in his words.

Monitoring and the Review Point

Monitoring: the parent's daily morning log; attendance and nurse visits from the school counselor every 2 weeks; SCARED child and parent versions at 4 and 6 weeks.

Review at six weeks, with the decision reopened sooner if any trigger occurs: two or more absences in a week for two weeks running; a return of daily morning distress; new low mood, loss of interest, or hopelessness; or SCARED totals rising above their current levels. At the six-week review, if mornings have not fallen to one a week or fewer, sertraline is offered again with the same consent and assent process.

References

Birmaher, B., Khetarpal, S., Brent, D., Cully, M., Balach, L., Kaufman, J., & Neer, S. M. (1997). The Screen for Child Anxiety Related Emotional Disorders (SCARED): Scale construction and psychometric characteristics. Journal of the American Academy of Child & Adolescent Psychiatry, 36(4), 545-553. https://doi.org/10.1097/00004583-199704000-00018

Bridge, J. A., Iyengar, S., Salary, C. B., Barbe, R. P., Birmaher, B., Pincus, H. A., Ren, L., & Brent, D. A. (2007). Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: A meta-analysis of randomized controlled trials. JAMA, 297(15), 1683-1696. https://doi.org/10.1001/jama.297.15.1683

Lebowitz, E. R., Marin, C., Martino, A., Shimshoni, Y., & Silverman, W. K. (2020). Parent-based treatment as efficacious as cognitive-behavioral therapy for childhood anxiety: A randomized noninferiority study of Supportive Parenting for Anxious Childhood Emotions. Journal of the American Academy of Child & Adolescent Psychiatry, 59(3), 362-372. https://doi.org/10.1016/j.jaac.2019.02.014

Walkup, J. T., Albano, A. M., Piacentini, J., Birmaher, B., Compton, S. N., Sherrill, J. T., Ginsburg, G. S., Rynn, M. A., McCracken, J., Waslick, B., Iyengar, S., March, J. S., & Kendall, P. C. (2008). Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. The New England Journal of Medicine, 359(26), 2753-2766. https://doi.org/10.1056/NEJMoa0804633