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Pages:
3 pages/β‰ˆ825 words
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4 Sources
Style:
APA
Subject:
Health, Medicine, Nursing
Type:
Coursework
Language:
English (U.S.)
Document:
MS Word
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Total cost:
$ 17.5
Topic:

SOAP Note and Treatment Plan for Children With ODD and ADHD

Coursework Instructions:

Complete a SOAP Note and treatment plan based on the information provided:
Case Vignette—Joshua
Presenting Situation Joshua is a 12 year old boy who attends Middle School as a 6th grader. Joshua has been in placement with his grandmother for several months. His behavior has been on the decline since his middle sibling was recently placed in the home with him. He was strongly reactive to any signs that his sister was receiving more attention than he was. He becomes easily angered, his moods shift from constricted to volatile, with frequent angry outbursts, that carryover to and interfere with school. Joshua shows multiple signs of arousal (e.g., difficulty sleeping, impaired concentration, edginess and irritability). He was recently diagnosed with oppositional defiant disorder and ADHD although he doesn’t yet have an IEP. In school, he is taking the following classes: Remedial Reading, Math, 6th grade Science, Art, Social Studies and P.E. His favorite class is Art and the Remedial Reading class is his least favorite. He is at least two years behind in reading. When he is in a happy mood, Joshua is talkative and social with his peers.
Joshua’s grandmother, who has her own history of childhood trauma, has become more depressed and overwhelmed by his emotional outbursts and she has had difficulty providing consistent caretaking to either of the children, including sending them to school. She is reluctant to make contact with the school as it just adds one more overwhelming responsibility to her life.
Trauma History
Joshua has been in the care of his Grandmother since he was 18 months old at which time Child Protective Services removed him from his parents’ care due to neglect, physical abuse and parental substance abuse. When initially interviewed by CPS the mother acknowledged that she was under tremendous stress due to an often violent relationship with her husband. She admitted that caring for Joshua was difficult because he was often irritable and rejecting of her attempts to console him. At other times, he was very restless and clingy toward the mother, especially when the father was present. She also said Joshua was “slow to develop.” The mother admitted that she and her husband had a history of drug and alcohol abuse. At age 5, an attempt to reunify Joshua with his parents failed when he was once again removed from their care due to a report made by his Kindergarten of seeing bruises on Joshua’s legs and arms. He was placed back in care with his grandmother and has been with her since. His parents have separated and he only sees his mother at family events and holidays. He has had no contact with his father since the second set of allegations was substantiated when he was 5.

Coursework Sample Content Preview:

SOAP Note and Treatment Plan Term Paper
Student's Name
University
Course
Professor’s Name
Date
SOAP Note and Treatment Plan Term Paper
Joshua's SOAP Note
Patient Name: Joshua Age: 12 Gender: Male
Subjective
Joshua is a twelve-year-old boy who attends middle school as a sixth grader and was in placement with his grandmom for various months. Joshua's conduct has declined since his sister was put in the home with him. Joshua portrays impulsivity, hyperactivity, and mood swings that shift from constricted to volatile, with constant angry flare-ups that spill over to interfere with school. Recently Joshua was diagnosed with the oppositional defiant disorder (ODD) and attention deficit hyperactivity disorder (ADHD). In addition, Joshua portrays attachment issues as indicated by the mother that he was agitated and clingy towards the mom, mostly when the father was present.
Past medical history: Joshua is struggling with issues related to childhood trauma. Since he was eighteen months, Joshua has been under his grandmother's care because the child protection services (CPS) removed him from his parents' care because of maltreatment, physical abuse, and parental drug abuse. When CPS interviewed the mother, she admitted to neglecting Joshua because of the stress she experienced with her violent husband.
Current medications: Joshua is presently not taking any medicines.
Allergies: Joshua is not allergic to drugs, foods, or environmental factors.
Family and social history: Joshua has a history of trauma and drug abuse. Joshua's grandmom has a childhood trauma history. Joshua's parents have an account of substance abuse which has made them unable to care for their child because of the physical violence they subject him.
Objective
Joshua is diagnosed with ODD and ADHD. He has multiple arousal indications comprising irritability, difficulty sleeping, edginess, and impaired focus. In addition, Joshua has a trauma history containing parental drug abuse, neglect, and physical abuse.
Neurologic readings: He is talkative and interacts with peers when in a happy mood.
Psychological readings: Has inconsistent mood. He is restless, has emotional outbursts, and cannot concentrate for an extended period.
Assessment
The differential diagnosis indicates the following issues:
* ADHD because Joshua meets the DSM-5 ADHD diagnostic criteria
* ODD
* Autism spectrum disorder
The treatment goal is to assist Joshua in managing his ODD and ADHD. This will entail helping Joshua control his emotions, augmenting his focus and sleeping habits, as well as offering him support and stability.
Plans
* Trauma-focused cognitive behavioral therapy (TF-CBT) for Joshua, his grandmother, and his parents. TF-CBT will aid Joshua in lessening adverse emotional and behavioral reactions following his trauma. TF-CBT aims to tackle twisted or disturbing beliefs and attributions linked to traumas and offer a supportive environment whereby Joshua will be heartened to talk about his traumatic encounter and learn skills and assist him in coping with their normal life stressors (Kemp et al., 2020).
* Alternative therapies such as Joshua consuming a nutrition-balanced diet a...
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