Final Exam: NR605/ NR 605 (Latest Update 2024/ 2025) Diagnosis & Management in Psychiatric-Mental Health Across the Lifespan I Practicum Review |Weeks 5-8 Covered|Questions and Verified Answers| 100% Correct- Chamberlain

Final Exam: NR605/ NR 605 (Latest Update 2024/ 2025) Diagnosis G Management in Psychiatric-Mental Health across the Lifespan I Practicum Review |Weeks 5-8 Covered| Questions and Verified Answers| 100% Correct- Chamberlain / Exams & Certification / By admin Final Exam: NR605/ NR 605 (Latest Update 2024/ 2025) Diagnosis & Management in Psychiatric-Mental Health across the Lifespan I Practicum Review |Weeks 5-8 Covered| Questions and Verified Answers| 100% CorrectChamberlain Final Exam: NR605/ NR 605 (Latest Update 2024/ 2025) Diagnosis & Management in Psychiatric-Mental Health across the Lifespan I Practicum Review |Weeks 5-8 Covered| Questions and Verified Answers| 100% Correct- Chamberlain Q: Behavioral theory Answer: -Personality is a result of the interaction between an ind. and their environment. -focus on observable and measurable behavior -Skinner associated with the concept of operant conditioning, using rewards and punishments to increase or decrease a behavior -PavlovRussian Physiologist, father of behaviorism, associated with classical conditioning, Pavlov dog, Q: Cognitive theory Answer: -Study of mental processes and complex behaviors -Albert Bandura combines concepts of observing, thinking, and behaving. -Tying external behaviors in with internal mental processes that facilitate them learning, memory, language development, mental problem solving. Q: Cognitive Distortions Answer: -faulty, exaggerated, or irrational thinking patterns cause ind’s to inaccurately perceive reality lead to (-) emotions & psychopathological states, including depression & anxiety Q: common cognitive distortions Answer: -Should statement “I shouldn’t yell at my kids. I should always be able to keep my temper. I’m the adult here.” -All-or-nothing thinking “I got an A- on the biology exam! I never get below an A. I am such a complete failure!” -Catastrophizing “I know my relationship is in trouble. If my girlfriend leaves, I know I’ll never find someone else and will be alone forever.” -Filtering “I just read my student evaluations for the term. While they’re almost allpositive, one student felt that I was insensitive and never responded promptly even though I answered every email within 24 hours. I’m a terrible teacher.” -Overgeneralization “Every single time I work the night shift at the hospital, they always give me the worst assignments! It’s always a nightmare!” -Mind reading “I was at lunch with my friend today. She kept looking at her phone the whole time. I just know she didn’t want to be there and is bored with our friendship.” -Emotional reasoning “I started a diet on Monday and was doing well until they brought in pizza for lunch on Thursday. I feel like I’ll never be able to succeed at this, so I’m giving up.” Q: Cognitive Techniques for Stabilization Answer: -Socratic dialogue (SD) -Decatastrophizing Q: Socratic dialogue (SD) Answer: -hallmark of CBT -helps facilitate guided discovery -therapist guides the client through a series of questions & answers to draw out the client’s automatic thoughts & assumptions collaboratively examine the logic underlying the assumptions ID thought processes that may be creating problems -can be used to:facilitate cognitive reappraisal information processing emotional regulation support tx processes Q: Socratic questions Answer: -Socratic questions What is the evidence your belief is true? What is the evidence your belief is not true? -Alternative Explanation Socratic Questions Is there another point of view? Are you paying attention to only one aspect of the situation? Are you misinterpreting the evidence? Are you making assumptions? -Impact of the automatic thought Socratic Question What is the effect of believing “If I’m not perfect then I’m a failure?” -Distancing Socratic Question What would you advise a friend who told you something similar? -Problem solving Socratic Question What would be good to do now? What would you like to do about this situation? Q: Decatastrophizing Answer: -Catastrophic thinking common for clients with anxiety focusing on most (-) outcome of a situation -Decatastrophizing cognitive restructuring technique used to explore fears help challenge catastrophic thinking-examining the outcome the client considers to be the “worst possible” developing a plan of action to address that outcome to decrease anxiety Q: Valerie is a 34-year-old who presents for therapy with symptoms of anxiety and depressive disorder. She has been in a relationship with her partner for the past 12 years. She feels like her partner makes all the decisions in the relationship, and when Valerie’s opinions differ, she does not feel comfortable sharing her thoughts. She states, “If my partner can’t figure out what my needs are after so many years, I don’t know how we can save this relationship.” What can you use to assist the client? Assertiveness training Bibliotherapy Contingency management Behavioral rehearsal Answer: Assertiveness training Rationale: Assertiveness training can assist clients who are experiencing symptoms of depression, anxiety, and low self-worth. It may help clients learn how to express their point of view in a respectful manner. The client and therapist may use role-play to practice verbal and nonverbal behaviors and improve assertiveness. Q: Dustin is a 24-year-old who presents for therapy with symptoms of anxiety. He has a remote position with a large company and rarely meets with colleagues or clients in person. When he does have an in-person meeting, he states “I feel like an idiot whenever I Page G of 83 open my mouth. I’m always tripping over my words, and I feel so awkward.” What can you use to assist the client? Assertiveness training Powered by cognitive-behavioral therapy -focus on how well individuals can adapt cognitively and functionally to their environments -short-term, structured, goal-oriented form of psychotherapy -stresses necessity of challenging maladaptive thoughts that lead to behavioral problems -first emerged in 1955 -most widely practiced psychotherapy -help clients recognize and address cognitive distortions by Albert Ellis, widely known as the grandfather of cognitive behavior therapy -Beck originally trained in psychoanalysis, pioneered cognitive therapy in the 1960s, through his research on depression also developed the popular Depression Inventory instrument CBT Relationship to Nursing Theory -Orem’s self-care deficit nursing theory provides a framework to view CBT as a supportive intervention fosters effective self-care behaviors -Roy’s Adaptation Theory Page 7 of 83 premise that individuals use coping mechanisms to adapt to stimuli, both internal and external share underpinnings with CBT. Indications for CBT -treatment of a wide range of diagnoses depression anxiety disorders substance use disorders eating disorders severe mental illness PTSD Principles of CBT include: -way an ind cognitively structures thoughts about self & the world determines how the ind feels & behaves -Dysfunctional thoughts are rooted in irrational assumptions -Dysfunctional thinking and learned patterns of maladaptive behavior contribute to psychological problems -Ind’s can learn more adaptive behaviors which can relieve symptoms & improve quality of life -CBT is (+) & stresses collaboration & active participation -CBT includes action plans in the form of therapy homework Role of the Psychotherapist in CBT -using a structured, collaborative approach to help clients recognize and reevaluate cognitive distortions -help clients: better understand the behaviors of others develop improved coping skills Page 8 of 83 -Psychoeducation -Homework to help clients reinforce & build on what was learned during the therapy session motivational interviewing (MI) -helps individuals prepare for change -person-centered, evidence-based approach to behavior change -using a collaborative, goal-oriented communication style -empowers clients to draw on their meanings & capacities to facilitate change addressing issues with ambivalence and resistance -grew out of William R. Miller’s clinical practice working with clients with substance use disorders in the 1980s collaborated with Stephen Rollnick to write book: Motivational interviewing Indications for MI -reduction of substance use and health promotion -improving medication adherence in clients with schizophrenia MI Guiding Principles -acceptance -empathy -compassion -respect of client autonomy -acknowledgment of the client’s strengths & efforts -Spirit of MI Partnership, compassion, acceptance, evocation MI Role of the Psychotherapist Page U of 83 represented by the mnemonic RULE: Resist the righting reflex Understand the patient’s motivation Listen to the patient Empower the patient OARS Communication skills for MI: -Open questions cannot be answered with a yes or no, require elaboration -Affirming provide encouragement, are (+) comments on a client’s strengths or efforts -Reflecting mirror the content or feelings explicitly or implicitly stated by the client convey empathy, demonstrate listening, highlight emotions & beliefs, • provide opportunities for the client to elaborate on their concerns empower clients to take control of the conversation recommended to use at least two reflections for every question -Summarizing links together what has been stated to help the client organize their experiences MI Phases of the Change Process -engagement Page 10 of 83 establishment of trust & a helping relationship between the therapist & client uses reflections that communicate understanding -focusing identification of the direction or target of the change uses open-ended questions -evoking identifying the client’s motivation for change and evoking hope uses reflections and summaries -planning creating a plan for change acceptance and commitment therapy (ACT) -helps individuals accept life’s challenges while focusing on their values and goals learning how to relate to thoughts & feelings which impact life rather than changing those thoughts & feelings -referred to as a “third wave” CBT therapy -Accepting reactions and being present -Choosing a valued direction -Taking action -Used for: depression, anxiety, substance use, chronic pain, transdiagnostic combinations of conditions solution-focused therapy (SFT) Page 11 of 83 -future-oriented approach -helps client ID problems & construct solutions that will result in change -postmodern thinking reality is shaped by multiple and conflicting “truths” & constructed through human interaction there are as many stories of meaning as there are people involved -fourth force of psychotherapy transpersonal, going beyond the ideas of humanness, identity, and selfactualization -client is considered to be the expert of their lives -focus from the problem to the solution -grew out of the work at the Brief Family Therapy Center in Milwaukee in the 1970s influenced by many psychotherapists, work at the Mental Research Institute in California, and the philosophies of Buddhism and Taoism solution-focused therapy Key Concepts and the Role of the Psychotherapist -Solutions talk Shift talk from problems to solutions -Positive orientation Shift focus from problems to new possibilities -Looking for what is working Focus on the exceptions within problem patterns Indications for SFT -used for individual or group therapy across settings Page 12 of 83 marriage, family, and child therapies trauma postpartum depression depression eating disorders severe mental illness how SFT is used to alleviate anxiety 4-Step Approach for Overcoming Anxiety -Identify the meaningful parts of life that the anxiety is blocking. -Shift the focus away from the anxiety itself toward the meaningful goal. -Create a list of positive messages that would motivate you toward that goal. -Be gentle with yourself – you’re not alone. Many of the people you meet may be working through something similar. Behavioral theory -Personality is a result of the interaction between an ind. and their environment. -focus on observable and measurable behavior -Skinner associated with the concept of operant conditioning, using rewards and punishments to increase or decrease a behavior -Pavlov Russian Physiologist, father of behaviorism, associated with classical conditioning, Pavlov dog, Cognitive theory Page 13 of 83 -Study of mental processes and complex behaviors -Albert Bandura combines concepts of observing, thinking, and behaving. -Tying external behaviors in with internal mental processes that facilitate them learning, memory, language development, mental problem solving. Cognitive Distortions -faulty, exaggerated, or irrational thinking patterns cause ind’s to inaccurately perceive reality lead to (-) emotions & psychopathological states, including depression & anxiety common cognitive distortions -Should statement “I shouldn’t yell at my kids. I should always be able to keep my temper. I’m the adult here.” -All-or-nothing thinking “I got an A- on the biology exam! I never get below an A. I am such a complete failure!” -Catastrophizing “I know my relationship is in trouble. If my girlfriend leaves, I know I’ll never find someone else and will be alone forever.” -Filtering “I just read my student evaluations for the term. While they’re almost all Page 14 of 83 positive, one student felt that I was insensitive and never responded promptly even though I answered every email within 24 hours. I’m a terrible teacher.” -Overgeneralization “Every single time I work the night shift at the hospital, they always give me the worst assignments! It’s always a nightmare!” -Mind reading “I was at lunch with my friend today. She kept looking at her phone the whole time. I just know she didn’t want to be there and is bored with our friendship.” -Emotional reasoning “I started a diet on Monday and was doing well until they brought in pizza for lunch on Thursday. I feel like I’ll never be able to succeed at this, so I’m giving up.” Cognitive Techniques for Stabilization -Socratic dialogue (SD) -Decatastrophizing Socratic dialogue (SD) -hallmark of CBT -helps facilitate guided discovery -therapist guides the client through a series of questions & answers to draw out the client’s automatic thoughts & assumptions collaboratively examine the logic underlying the assumptions ID thought processes that may be creating problems Page 15 of 83 -can be used to: facilitate cognitive reappraisal information processing emotional regulation support tx processes Socratic questions -Socratic questions What is the evidence your belief is true? What is the evidence your belief is not true? -Alternative Explanation Socratic Questions Is there another point of view? Are you paying attention to only one aspect of the situation? Are you misinterpreting the evidence? Are you making assumptions? -Impact of the automatic thought Socratic Question What is the effect of believing “If I’m not perfect then I’m a failure?” -Distancing Socratic Question What would you advise a friend who told you something similar? -Problem solving Socratic Question What would be good to do now? What would you like to do about this situation? Decatastrophizing Page 1G of 83 -Catastrophic thinking common for clients with anxiety focusing on most (-) outcome of a situation -Decatastrophizing cognitive restructuring technique used to explore fears help challenge catastrophic thinking -examining the outcome the client considers to be the “worst possible” developing a plan of action to address that outcome to decrease anxiety Valerie is a 34-year-old who presents for therapy with symptoms of anxiety and depressive disorder. She has been in a relationship with her partner for the past 12 years. She feels like her partner makes all the decisions in the relationship, and when Valerie’s opinions differ, she does not feel comfortable sharing her thoughts. She states, “If my partner can’t figure out what my needs are after so many years, I don’t know how we can save this relationship.” What can you use to assist the client? Assertiveness training Bibliotherapy Contingency management Behavioral rehearsal Assertiveness training Rationale: Assertiveness training can assist clients who are experiencing symptoms of depression, anxiety, and low self-worth. It may help clients learn how to express their point of view in a respectful manner. The client and therapist may use role-play to practice verbal and nonverbal behaviors and improve :// Page 17 of 83 Dustin is a 24-year-old who presents for therapy with symptoms of anxiety. He has a remote position with a large company and rarely meets with colleagues or clients in person. When he does have an in-person meeting, he states “I feel like an idiot whenever I open my mouth. I’m always tripping over my words, and I feel so awkward.” What can you use to assist the client? Assertiveness training Bibliotherapy Contingency management Behavioral rehearsal Behavioral rehearsal Rationale: Behavioral rehearsal can assist clients who experience anxiety with social skills or interactions with others. Rehearsal may be conducted using guided imagery where the client pictures themselves responding appropriately, or the client and therapist may choose to explore a behavioral rehearsal using role-play. Corinne is a 46-year-old who presents for therapy with symptoms of depression. The therapist recommends that Corinne read Cognitive Behavioral Therapy in 7 Weeks by Dr. Seth J. Gillihan between sessions. What can you use to assist the client? Assertiveness training Bibliotherapy Contingency management Behavioral rehearsal Bibliotherapy Rationale: CBT therapists may prescribe specific readings or self-help books related to the client’s condition as an adjunct to in-session :// Page 18 of 83 Tina is a 52-year-old who presents with depression and obesity. She has struggled with her weight for the last several years. The therapist implements a series of rewards when Tina adheres to treatment goals. What can you use to assist the client? Assertiveness training Bibliotherapy Contingency management Behavioral rehearsal Contingency management Rationale: Contingency management reinforces or rewards positive behavioral changes. The client and therapist can work together to identify appropriate rewards; for instance, Tina may choose to reward herself for maintaining an exercise regimen by scheduling a relaxation massage. Amina is a 40-year-old who presents for therapy. She reports that she has felt “depressed” most of her life but never sought mental health services. She discloses that she was a victim of childhood incest and neither reported the abuse nor discussed it with anyone before this time. She feels that the time is right to do therapy. The psychiatric mental health nurse practitioner (PMHNP) selects solution-focused therapy (SFT) to create a warm and supportive climate in which the client can identify her resources to create a shift from the past to the present, integrate her memories, and empower herself beyond her victimization. Which of the following provider statements or question prompts are congruent with SFT? Select all that apply. “What needs to happen today so that when you leave, you’ll think this was a good session?” “I can see that things have been difficult for you. How have you managed to Page 1U of 83 carry on and prevent things from becoming worse?” “How bad is the problem? What would it take to move one point higher?” “Between now and the next time we meet, observe what happens in your life that you want to continue.” “What needs to happen today so that when you leave, you’ll think this was a good session?” “I can see that things have been difficult for you. How have you managed to carry on and prevent things from becoming worse?” “How bad is the problem? What would it take to move one point higher?” “Between now and the next time we meet, observe what happens in your life that you want to continue.” Rationale: Joining questions helps the therapist to connect with and accommodate the client’s world. Coping questions help the client to identify resources that may have gone unnoticed. Scaling questions helps the client to pay attention to what they are doing and how they can take steps that lead to the changes they desire. Future-oriented questions help the client to shift their focus from problems to envisioning a better life. group therapy first appeared in the _ 1940s -grew out of the need to efficiently treat large groups of psychiatrically disturbed soldiers following World War II figures in group therapy -Joseph Moreno Page 20 of 83 psychodrama to enable veterans to participate in group dramatizations, reenact or role-play scenarios in their past and present learn to better manage fears and anxieties -Wilfred Bion identified fundamental patterns that could disrupt group work -Samuel Slavson used psychoanalytic approaches in working with groups of disturbed children and adolescents psychodrama Therapy in which clients act out personal conflicts and feelings in the presence of others who play supporting roles Stages -the warm up getting to know each other -the drama the enactment -sharing Group therapy -form of psychotherapy -group of clients meets to discuss problems or concerns under the guidance of a therapist -one to two hours per week either online or in-person -may be designed to address a specific problem or diagnosis or may be more general -benefit, provides opportunity to expand access to care & efficiency Page 21 of 83 therapists can provide tx to several clients at once more cost-effective than individual therapy Mindfulness- and cognitive-based group therapy has shown efficacy for schizophrenia spectrum disorders Group therapy has also shown efficacy in helping clients with physical diagnoses such as neurological conditions, chronic pain, and cancer Principles of Group Therapy Existential psychoanalyst Irvin Yalom identified eleven principles that underpin group therapy: 1. Instillation of hope 2. Universality 3. Imparting information 4. Altruism 5. Corrective recapitulation of the primary family group 6. Development of socializing techniques 7. Imitative behavior 8. Interpersonal learning 9. Group cohesiveness 10. Catharsis 11. Existential factors catharsis the process of releasing, and thereby providing relief from, strong or repressed emotions. Altruism Page 22 of 83 unselfish regard for the welfare of others Nikki typically pouted through group meetings. When asked about her silence, she said she felt other members were favored and that she wanted to quit the group and do therapy on her own. Over time, she saw that her feelings stemmed from her jealousy of her sister and was able to address her feelings. Which principle of group therapy is this an example of? Corrective recapitulation of the primary family group Rationale: Corrective recapitulation of the primary family group helps group members work through unresolved family issues, such as sibling rivalry. Group therapy helps members process unresolved family conflicts. Kesha told the group that the most important aspect of therapy was just having a group of people she could talk to, that wouldn’t walk out on her. Which principle of group therapy is this an example of? Group cohesiveness Rationale: Group cohesiveness occurs when members feel they belong and are unconditionally accepted by the other members. Group cohesion correlates with positive outcomes. At home, Tuan used communication strategies he observed in group therapy to try to improve his relationship with his daughter. Which principle of group therapy is this an example of? Imitative behavior Rationale: Learning from the therapy of others helps members experiment or try on new behaviors. Van recently joined group therapy for sexual abuse survivors and listened to Page 23 of 83 others talk about their feelings of shame, guilt, rage, and uncleanliness which mirror his feelings. Which principle of group therapy is this an example of? Universality Rationale: Being part of a group of people who have the same experiences helps members feel that they are not alone and what they are going through is universal. A feeling of universality is a fundamental step in healing for clients burdened by shame, stigma, and self-blame. Stasia joined group therapy following the recent death of her child. Group members helped her to anticipate feelings associated with significant days in her first year of bereavement, such as birthdays, anniversaries, and holidays. Which principle of group therapy is this an example of? Imparting information Rationale: Group members help one another by sharing information. Information about the natural cycle of bereavement can help Stasia realize there is a sequence of pain and a lessening of distress as the stages are experienced. Madison told the group how she shoplifts clothes, makeup, and other items when life feels out of control. She noticed that she felt better after sharing. Which principle of group therapy is this an example of? Catharsis Rationale: Sharing feelings and experiences with group members can help relieve pain, guilt, or stress. Group members may benefit from witnessing a peer in emotional catharsis. Sindhu is typically withdrawn in group therapy. She developed a large axillary lymph node and underwent a biopsy. She arrived at the next meeting Page 24 of 83 animated and wanted to plunge into her feelings of fear about the implications of her diagnosis. Which principle of group therapy is this an example of? Existential factors Rationale: Existential factors include the ultimate concerns of the human condition—death, isolation, freedom, and meaninglessness—and may be the basis of psychiatric problems. Experiencing an existential event such as possible illness may mobilize awareness that each individual is responsible for their lives, actions, and choices. Inmates in group therapy were asked to share one thing they valued about each of the other group members. Which principle of group therapy is this an example of? Interpersonal learning Rationale: Group members gain a deeper understanding of themselves through interacting with others and receiving feedback. Jamilla just began group therapy for an eating disorder and shared that she has overwhelming shame. Another group member, Jessamine, has been in the group for a while and talked openly about how she has overcome her body shame and shame around eating, which was encouraging to Jamilla. Which principle of group therapy is this an example of? Instillation of hope Rationale: Sharing insight and resources among group members are important sources of realistic, therapeutic hope. Seeing others who are coping or recovering gives hope to those at the beginning of the process. Aroon joined therapy because of his isolation and loneliness. After joining, he monopolized the conversation talking about the weather and other :// Page 25 of 83 One of the group members told him, “If you talk about feelings, I want to listen to you, but if you just talk about things like the weather, I just want to walk away.” Which principle of group therapy is this an example of? Development of socializing techniques Rationale: Group members learn from each other about basic social skills and how to overcome maladaptive social tendencies. When Raub, initially started in group therapy, he felt anxious and isolated. Over time, he became more comfortable. Recently, a new member, Anita joined the group. She appeared anxious and rarely spoke. Raub reached out to her and shared his experience with joining the group, which helped Anita feel better and gain confidence. Which principle of group therapy is this an example of? Altruism Rationale: Altruism plays an important part in the healing process. People need to feel they are needed and useful. They also need to transcend themselves to consider something greater than their self-absorption. Group Leadership -starting a group first step, ID the purpose & types of clients likely to benefit from the group -Groups may be led by single leaders or co-leaders -Leaders responsible for: articulating ground rules and expectations ask that clients not socialize outside of group sessions to avoid alliances that could disrupt group dynamics Page 2G of 83 Types of Groups -Psychoeducational Groups -Support Groups -Self-Help Groups -Acute Inpatient Therapy Group Psychoeducational Groups -most common types of therapeutic groups -provide education to clients & families about a variety of psychiatric & mental health topics -may provide info about a pt dx as well as encouragement to remain committed to a tx plan -may include info about addiction, medication, self-care, and recovery -may teach pts how to avoid maladaptive behaviors how to engage in (+) behavioral change -less focused on developing relationships between group members -role of the therapist educator support client engagement, incorporating diff learning styles Support Groups -focus on providing members with an opportunity to interact and share personal experiences, feelings, or coping strategies with others who may be going through similar circumstances serious illness, grief, or loss -formal or informal -may be led by professional or nonprofessional leaders Self-Help Groups -typically comprised of participants experiencing a common issue or concern Page 27 of 83 provide a venue for members to share struggles and successes and to help members feel less alone -not considered a form of psychotherapy though they often help support members’ efforts to change -substance-centered Twelve Step groups Alcoholics Anonymous Narcotics Anonymous Al-Anon -Other focuses bipolar disorder, substance use disorder, or cancer Grief -members may participate for months to years -do not have a professional formal leader Acute Inpatient Therapy Group -not an independent, freestanding entity group has a complex relationship with the inpatient ward -challenges: client turnover variety of psychiatric diagnoses and concerns therapist’s time with clients is limited Boundaries blurred, clients spending much time outside group together -Opportunities: engaging pts in therapeutic process helping pts see that engagement can be helpful assisting pts in problem identification decreasing isolation allowing pts to help others reducing ward-based anxiety or tension Page 28 of 83 who identified the five phases of group development? Tuckman (1965) -Phases of group formation are useful in documentation and in assessing the group’s productivity. Phases of Group Formation -Forming -Storming -Norming -Performing -Adjourning Forming -getting acquainted and orientation to the group process. -Most interactions are social as members get to know each other. Storming -phase is one of transition and is often marked by conflict, anxiety, and ambiguity as members define themselves by testing or acting out behaviors and define group norms. Norming -marked by group cohesion and the formation of the therapeutic alliance. -The group develops standards of behavior. Performing -Encompasses individual and group growth. -Members experiment with new ideas or behaviors. -Conflict may emerge but is dealt with constructively. Adjourning -Involves closure for the group or an individual that :// Page 2U of 83 -Achievements are reviewed and feelings are explored about what worked (and what didn’t), and any feelings of loss. Selena feels apprehension and asks herself: “What does the group offer me?” “What is expected of me?” “Will I fit in?” What phase of group development? Forming Adjourning Performing Storming Norming Forming Rationale: The forming phase involves getting acquainted and orientation to the group process. Most interactions are social as members get to know each other. Garrick expresses frustration that Simone fidgets in her seat and appears disinterested while he’s talking. He shouts: “Can’t you sit still for just a minute? What’s wrong with you?” What phase of group development? Forming Adjourning Performing Storming Norming Storming Rationale: The storming phase is one of transition and is often marked by conflict, anxiety, and ambiguity as members define themselves by testing or Page 30 of 83 acting out behaviors and define group norms. Kara is excited about the topic the group is discussing but respectfully waits for David to finish speaking before expressing her enthusiasm. What phase of group development? Forming Adjourning Performing Storming Norming Norming Rationale: The norming phase is marked by group cohesion and the formation of the therapeutic alliance. The group develops standards of behavior. Chimene emulates the therapist’s communication techniques when responding to another member of the group. What phase of group development? Forming Adjourning Performing Storming Norming Performing Rationale: The performing stage encompasses individual and group growth. Members experiment with new ideas or behaviors. Conflict may emerge but is dealt with constructively. Leonard expresses how much he appreciates the other members of the group Page 31 of 83 and how much he will miss meeting with them. What phase of group development? Forming Adjourning Performing Storming Norming Adjourning Rationale: The adjourning phase involves closure for the group or an individual that left. In this phase, achievements are reviewed and feelings are explored about what worked (and what didn’t), and any feelings of loss. Contraindications for Group Therapy -paranoid -significant brain injury -acutely psychotic -Delusional clients may incorporate the group into their delusions -aggressive clients may pose a threat to others indications for couples, and family therapies presence of relational difficulty is the primary indication Family Therapy -type of therapy that seeks to improve the functioning of a family as a unit -Types of families: traditional nuclear family Page 32 of 83 single-parent blended extended alternative institutional family family by choice or chosen family (provides love and support but may not be recognized by the legal system) Family Therapy: Underlying Assumptions -Individuals are best understood within the context of the family system. -The whole family is viewed as the client. -The behavior of one family member influences all family members and the behavior of the family influences each member. -Symptoms are viewed as an expression of family dysfunction. -Problematic behaviors may serve a purpose for the family and may be unintentionally maintained. -Attempts at change are best accomplished by working with the family as a whole. Approaches to Family Therapy -Systemic -Structural -Strategic -Emotionally Focused Systemic Approach to Family Therapy -multigenerational framework family is a complex, self-regulating unit that seeks to maintain homeostasis -change in functioning of one member affects functioning of other members Page 33 of 83 -Family systems therapy seeks to change systemic factors that produce dysfunction in the family using a psychodynamic approach goal, help members increase their self-differentiation, reduce emotional turmoil applications for systemic family therapy -attachment problems -child abuse -childhood disruptive behavior disorders -psychosexual problems -intimate partner violence -substance use disorders -mood and anxiety disorders -adjustment to illness or disability systemic family therapy Therapeutic techniques -promoting self-statements -transforming dysfunctional generational patterns -decreasing anxiety and interrupting conflict -detriangulating family members -reestablishing connections between family members Couples Therapy -designed to improve the interactions between two individuals who are in conflict with one another conflicts: emotional, sexual, economic, or social elements -therapist helps the couple: ID & address maladaptive behavior or communication patterns finds shared resources for problem-solving encourages personality growth & development -goal of therapy: alleviate emotional distress & promote well-being of Page 34 of 83 the partners both together and individually Four principles of couple counseling 1. Build a balanced connection 2. Identify patterns of connection 3. Identify patterns of disconnection 4. Create new experiences of intimacy Commonly used evidence-based psychotherapies for the tx of trauma: -Trauma Resiliency Model (TRM) -eye movement desensitization and reprocessing (EMDR) -dialectical behavior therapy (DBT) Trauma Resiliency Model (TRM) -biologically based or bottom-up psychotherapy -helps support clients in processing acute or cumulative trauma once preliminary stabilization skills have been learned eye movement desensitization and reprocessing (EMDR) -bottom-up psychotherapy -helps clients in accessing & processing traumatic memories dialectical behavior therapy (DBT) -cognitive or top-down approach -support self-regulation after trauma Primate/Human Brain (Cortex) -Responsible for: Higher mental functions -Core functions: Regulating attention, feelings, and desires, complex reasoning, abstract thoughts, imagination, language, empathy -Basic “need”: Connection and attachment to others Page 35 of 83 -When need is met: We feel LOVE -When need is not met: We experience HEARTACHE Mammalian Brain (Subcortical region) might think of it as the little mouse part of the brain. -Responsible for: Feelings and memory formation -Core functions: Emotions, learning and memory, reward/motivation -Basic “need”: Satisfaction and approaching rewards -When need is met: We feel CONTENTMENT -When need is not met: We experience FRUSTRATION Reptilian Brain (Brain stem and cerebellum) -Responsible for: Survival and maintenance -Core functions: Regulating heartbeat, breathing, and other vital organs -Basic “need”: Safety and avoiding harm -When need is met: We feel PEACE -When need is not met: We experience FEAR Trauma -any incident or series of events that overwhelm an individual’s ability to cope -What happens inside us as a result of what happens to us -may be emotionally disturbing or life-threatening -may have enduring effects on emotional, psychological, physical, and spiritual well-being -70% of adults in U.S. report having had a traumatic experience that at increased risk of experiencing a traumatic event gay, lesbian, bisexual, transgender, people of color, low education & socioeconomic status experiences that may be traumatic include: -physical, sexual, and emotional abuse Page 3G of 83 -childhood neglect -living with someone with mental health or substance use disorders -a sudden separation from a loved one (death, divorce, separation) -poverty -racism, discrimination, and oppression -violence in the community, war, or terrorism -disasters, natural and man-made -serious, invasive, distressing medical illness and procedures Neurobiology of a Traumatic Event: disrupts the limbic system, amygdala, orbitofrontal cortex, and anterior cingulate gyrus -amygdala or “fear center” of the brain stores the physical impact of negative emotions. interferes with the hippocampus, which is involved with the recall of memory causes the prefrontal cortex to function less effectively, and the brain goes into survival mode What happens in the brain during a potentially traumatic event -brain stem directly connected with the retina retina sends visual info to the brain stem before higher levels of brain are aware of threat. -predator moves closer, periaqueductal gray initiates a fight or flight response activates the sympathetic nervous system Heart rate goes up. Blood flow to muscles increases. Blood pressure increases. Pupils dilate -person may enter the freeze response, or feigned death periaqueductal gray activates the parasympathetic nervous system as Page 37 of 83 well Muscles get tight and freeze. Both gaze and breath may freeze, not a cognitive choice -predator doesn’t move away, the person may shutdown completely Heart rate drops. Respiratory rate drops. Some people stop breathing. Muscles become limp. Metabolism shuts down. Endorphins released. state of “no pain”. They are no longer aware of their surroundings During inescapable trauma differences between the freeze and shutdown trauma responses -Freeze The client is HYPERaroused. The muscles are tense and full of energy, but can’t release it. In this stage, there are similar levels of sympathetic and parasympathetic activation. Increased heart rate/blood pressure. The client might say, “I feel stuck,” “I can’t move,” or “I feel like I am encased in cement.” Eyes widen. The body is ready to return to fight/ flight as soon as the threat passes. -Shutdown/Collapse The client is HYPOaroused. The muscles are flaccid and loose. The parasympathic nervous system is dominant. Decreased heart rate/blood pressure/temperature. The client may not be able to speak at all. Blank stare. Sensory info stops at the thalamus. It doesn’t reach the cortex (so it’s not integrated). The client is less aware of their internal and external :// Page 38 of 83 Endorphins release to numb pain. Dynorphins release, which can make the client feel detached from their body. Can result in fainting. impact of trauma on Semantic Memory -What it is: The memory of general knowledge and facts. -Example: You remember what a bicycle is. -How trauma can affect it: Trauma can prevent information (like words, images, sounds, etc.) from different parts of the brain from combining to make a semantic memory. -Related brain area: The temporal lobe and inferior parietal cortex collect information from different brain areas to create semantic memory. impact of trauma on memory -Explicit Memory Semantic Memory Episodic Memory -Implicit Memory Emotional Memory Procedural Memory impact of trauma on Episodic Memory -What it is: The autobiographical memory of an event of experience – including the who, what, and where. -Example: You remember who was there and what street you were on when you fell off your bicycle in front of a crowd. -How trauma can affect it: Trauma can shutdown episodic memory and fragment the sequence of events. -Related brain area: The hippocampus is responsible for creating and recalling Page 3U of 83 episodic memory. impact of trauma on Emotional Memory -What it is: The memory of the emotion you felt during an experience. -Example: When a wave of shame or anxiety grabs you the next time you see your bicycle after the big fall. -How trauma can affect it: After trauma, a person may get triggered and experience painful emotions, often without context. -Related brain area: The amygdala plays a key role in supporting memory for emotionally charged experiences. impact of trauma on Procedural Memory -What it is: The memory of how to perform a common task without actively thinking about it. -Example: You can ride a bicycle automatically without having to stop and recall how it’s done. -How trauma can affect it: Trauma can change patterns of procedural memory. For example, a person might tense up and unconsciously alter their posture, which could lead to pain or even numbness. -Related brain area: The striatum is associated with producing procedural memory and creating new habits. Exposure to repeated stress leads to dysregulation of the _ nervous system Adverse Childhood Experiences (ACEs) -Neglect Physical Emotional -Abuse Page 40 of 83 Physical Emotional Sexual -Household Dysfunction Mental illness Substance abuse Divorce Parent treated violently Incarcerated relative 4 or more ACEs -heart disease 240% -cancer 190% -drug abuse 1030% -stroke 240% -suicide attempt 1120% -obesity 160% -depression 460% 6 or more ACEs -life expectancy decreases by almost 20 years Help regulate ANS -Therapies -breathing exercises -yoga, dance, play -helping others -creating art -singing, humming -spending time in nature Page 41 of 83 -awe and gratitude Effects of Trauma on Health and Relationships For many capacity to respond to common stressors, experience pleasure, & maintain emotional stability are compromised -emotional distress, dissociation, or disconnection with the present lead to unhealthy behaviors, substance use, self-harm, risky conduct develop stress-related medical problems Four Key Ways Collapse/Submit Can Present in a Client 1. Compliance / Obedience 2. Treatment-Resistant Depression 3. Interpersonal Conflict 4. Social Avoidance / Desire to Isolate Compliance / Obedience: -might be simply going through the motions of life on autopilot. -may feel detached from bodily experiences feelings no longer guide their actions -Ex: domestic violence pt may no longer be aware of fear, which keeps the person in the situation Treatment-Resistant Depression: -Experiencing ongoing, inescapable traumatic stress can lead to treatmentresistant depression -defining feature of this kind of depression is learned helplessness. -important to consider the client’s history (for example, did they experience chronic, inescapable stress?). Interpersonal Conflict: Page 42 of 83 A patient in collapse/submit might have difficulty engaging with others and/or setting boundaries. Social Avoidance / Desire to Isolate: -Collapse/submit can make it difficult for a patient to engage in basic daily activities making meals or personal hygiene. may withdraw socially activated responses: or _ fight or flight avoiding responses: / shutdown/collapse Kahara cannot sit still in class and constantly fidgets in her seat. activated responses (fight or flight) or avoiding responses (shutdown/collapse). Activated response (fight or flight) Connie loudly over shares personal information in public settings. activated responses (fight or flight) or avoiding responses (shutdown/collapse). Activated response (fight or flight) Genevieve is chronically late or misses meetings. activated responses (fight or flight) Page 43 of 83 or avoiding responses (shutdown/collapse). Avoiding response (shutdown/collapse) Eunjee is very directive and controlling of how things should be done. activated responses (fight or flight) or avoiding responses (shutdown/collapse). Activated response (fight or flight) Marshawn hides his belongings and tends to sneak things. activated responses (fight or flight) or avoiding responses (shutdown/collapse). Avoiding response (shutdown/collapse) Norland often sleeps through class or appears zoned out. activated responses (fight or flight) or avoiding responses (shutdown/collapse). Avoiding response (shutdown/collapse) Rhye talks about violence or intense events without emotions. activated responses (fight or flight) or avoiding responses (shutdown/collapse). Avoiding response (shutdown/collapse) Page 44 of 83 Leon is easily defensive or reactive at meetings. activated responses (fight or flight) or avoiding responses (shutdown/collapse). Activated response (fight or flight) Circuits in the lower brain, responsible for: emotional reactions and the defense system With trauma-informed therapy, the client can: “unlearn” their body’s response to trauma, manage symptoms, process feelings, heal and recover Brain-based approaches to help clients after trauma Top-down approaches Bottom-up approaches Top-down approaches -Encourage different ways of thinking, focus on cognitive interventions -Cognitive-Behavioral Therapy (CBT) -Dialectical-Behavior Therapy (DBT) -Mindfulness-based Cognitive Therapy (MBCT) Bottom-up approaches -Ways to cope with emotions and defenses -Eye Movement Desensitization and Reprocessing (EMDR) -Yoga -Trauma Resiliency Model (TRM) memory reconsolidation techniques are good for the _ hippocampus Page 45 of 83 The Trauma Resiliency Model (TRM) -bottom-up approach to psychotherapy -help pt process acute or cumulative trauma once they have learned preliminary stabilization skills -developed by Elaine Miller-Karas, Geneie Everett, and Laurie Leitch based on Peter Levine’s work in Somatic Experiencing Trauma Resiliency Model (TRM) Concepts -psychoeducation therapist help pt understand nature of trauma & normal responses how parts of the brain & autonomic nervous system function -key concept is the resilient zone (RZ) represents the optimal zone of arousal for a person in which there is a natural flow of energy and vitality greatest capacity for balanced thinking, feeling & handling the ups & downs of life in the RZ -goal: help clients recognize sensations associated with the RZ so they can return to the RZ when hyper- or hypo-aroused. Trauma Resiliency Model (TRM) Skills TRM uses a set of nine skills -first six are stabilization skills, standalone self-care model called the Community Resiliency Model (CRM) used throughout TRM therapy for self-care & emotional regulation -three additional TRM components titration, pendulation, and completion of survival response potential for destabilizing the client Page 4G of 83 -CRM Skills Tracking Gesturing Titration Resourcing & Resource Intensification Help Now! Pendulation Grounding Shift and StaY “What are you aware of now? Is this sensation pleasant, unpleasant, or neutral?” What CRM skill? Tracking Gesturing Titration Resourcing & Resource Intensification Help Now! Pendulation Grounding Shift and Stay Tracking Rationale: Tracking skills help the client to pay attention to sensations, name them, and distinguish sensations of distress from those of well-being. “What is it about you that helped you get through that?” What CRM skill? Page 47 of 83 Tracking Gesturing Titration Resourcing & Resource Intensification Help Now! Pendulation Grounding Shift and Stay Resourcing and Resource Intensification Rationale: Resource questions can be used to shift from thoughts or feelings of stress or trauma to resilience. “Place this weighted pillow in your lap and bring your attention to your body sitting in the chair.” What CRM skill? Tracking Gesturing Titration Resourcing & Resource Intensification Help Now! Pendulation Grounding Shift and Stay Grounding Rationale: Grounding provides a felt sense of contact in the present moment to provide a sense of safety, security, and control. “Let’s perform this movement together.” Page 48 of 83 What CRM skill? Tracking Gesturing Titration Resourcing & Resource Intensification Help Now! Pendulation Grounding Shift and Stay Gesturing Rationale: Soothing gestures can be used as a form of self-regulation. “Count backward as you walk around the room.” What CRM skill? Tracking Gesturing Titration Resourcing & Resource Intensification Help Now! Pendulation Grounding Shift and Stay Help Now! Rationale: Help Now! strategies decrease or increase activation within the nervous system when a person is hyper- or hypoaroused. “Shift your awareness by imagining your dog for at least 15 seconds.” Page 4U of 83 What CRM skill? Tracking Gesturing Titration Resourcing & Resource Intensification Help Now! Pendulation Grounding Shift and Stay Shift and Stay Rationale: Shift and Stay strategies relieve distress by shifting awareness from distressing sensations to more pleasant or neutral sensations. “Describe the sensation you’re having, then think about it as an object and focus on a single, small part of that object.” What CRM skill? Tracking Gesturing Titration Resourcing & Resource Intensification Help Now! Pendulation Grounding Shift and Stay Titration Rationale: Titration strategies help the client to slow the processing of trauma into small, manageable sensations to build tolerance and avoid overwhelming Page 50 of 83 sensations and retraumatization. “You’re feeling the tension in your chest. Focus now on feeling the parts of your body that are not tense and notice any sensations that arise when you make this shift.” What CRM skill? Tracking Gesturing Titration Resourcing & Resource Intensification Help Now! Pendulation Grounding Shift and Stay Pendulation Rationale: Pendulation is used along with titration and is often referred to as looping, switching between resourcing and titration, to help the client move between a state of arousal triggered by a traumatic event and a state of calm. Eye Movement Desensitization and Reprocessing therapy (EMDR) -used for neural network integration for processing traumatic and adverse life events -Most efficient trauma tx -Used for: PTSD, depression, SUDs, anxiety, panic disorder & phobias -developed by Dr. Francine Shapiro in the late 1980s -eight-phase psychotherapy focuses on earlier life experiences Page 51 of 83 present stressors or triggers desired thoughts & actions for the future phases of Eye Movement Desensitization and Reprocessing therapy (EMDR) 1. Client Hx & Tx Planning -Assess readiness for EMDR using Dissociative Experiences Scale 2. Preparation -Establish therapeutic alliance, provide psychoeducation about EMDR & relaxation strategies 3. Assessment -ID aspects of the target or an image to process that best represents the traumatic injury. 4. Desensitization -Create bilateral stimulation with eye movements, sound, and/or tapping. 5. Installing & Strengthening (+) Cognition -Use (+) cognition with repeated eye movements when the distress has been reduced. 6. Body Scan -ensure all aspects of the traumatic injury have been processed. 7. Closure -self-calming strategies to end session with the pt feeling safe, psychoeducation about journaling feelings that come up after session is over. 8. Re-evaluation -Determine if (+) results maintained & ID new targets that need processing. “window of tolerance” resilient zone (RZ) or therapeutic window -When you are in your Window of Tolerance, you feel like you can deal with Page 52 of 83 whatever’s happening in your life -You might feel stress or pressure, but it doesn’t bother you too much -ideal place to be -Working with a practitioner can help expand window of tolerance more able to cope with challenges How Trauma can Affect Your Window of Tolerance When stress & trauma shrink your window of tolerance, it doesn’t take much to throw you off balance. Hyperarousal -Anxious, Angry, Out of Control, Overwhelmed body wants to fight or run away Hypoarousal -Spacy, Zoned Out, Numb, Frozen body wants to shut down Areas of brain r/t traumatic experiences Amygdala -alarm system for stressful events Hippocampus -assists with learning including memories about safety & danger Prefrontal Cortex -controls behavior & emotion Page 53 of 83 Elisabeth is a 30-year-old who presents for psychotherapy. Elisabeth’s eightmonth-old daughter died suddenly in the night two years ago. The coroner determined the death was sudden infant death syndrome (SIDS). Elisabeth is a critical care nurse and is having difficulty understanding how her baby died so suddenly and without warning. She feels like she should have detected some symptoms of distress and feels guilty that her attempts at cardiopulmonary resuscitation (CPR) did not revive her baby. She also has disturbing memories of finding her baby dead in the crib. The psychiatric mental health nurse practitioner (PMHNP) selects EMDR as a psychotherapeutic approach. Which of the following responses are congruent with EMDR? Select all that apply. “Identify the 10 most disturbing experiences in your life?” “Imagine yourself in a safe train that is speeding by upsetting scenery.” “Choose a preferred statement, such as I did the best I could to counter your statement that the death is your fault.” “As you think about the death, how do the words I did my best feel now?” “Can a mother be guilty of her child’s death when there are no symptoms of distress?” “Think about the session an “Identify the 10 most disturbing experiences in your life?” “Imagine yourself in a safe train that is speeding by upsetting scenery.” “Choose a preferred statement, such as I did the best I could to counter your statement that the death is your fault.” Page 54 of 83 “As you think about the death, how do the words I did my best feel now?” “Can a mother be guilty of her child’s death when there are no symptoms of distress?” Rationale: A client’s history of disturbing events that might be related to the trauma might also be targeted for processing (client history and treatment planning). Clients are taught ways to relax and calm themselves to cope with distressing arousal. A safe train speeding by distressing scenery may help the client feel safe during EMDR (preparation). Having the client identify a negative belief associated with the event and a preferred statement helps support positive cognition (assessment). Repeating positive cognition after distress strengthens positive cognition (installing and strengthening positive cognition). When processing is stuck, the therapist may pose a question to simulate the connection to a positive cognition (installing and strengthening positive cognition). Trying one thing different between sessions is congruent with Gestalt therapy, not EMDR. Dialectic Behavior Therapy (DBT) for Trauma form of cognitive-behavioral therapy incorporates elements of Zen Buddhism -developed by Marsha Linehan approach to treat individuals with chronic suicidal thoughts & BPD -may also be used with PTSD shares similar elements with BPD: hyperarousal, hx of invalidation, dissociation, affective instability often comorbid with personality disorder, depression, substance use -DBT shows efficacy as a component of: tx for complex trauma changing behavioral patterns r/t self-harm -dialectics is the balance between acceptance and change Page 55 of 83 The functions of dialectical treatment include: -enhancing client capabilities -motivating clients to use and expand capabilities -helping clients generalize capabilities beyond the therapeutic relationship -improving the therapist’s skills -structuring the environment to enhance the therapeutic process Four Treatment Modes of Dialectic Behavior Therapy (DBT) typically delivered as a 1-year outpatient treatment modality. -Mode 1: Individual therapy (1 hour per week) -Mode 2: Group skills training (2.5 hours per week) -Mode 3: Therapist consultation team (1 – 1.5 hours per week) -Mode 4: Phone coaching (as needed) Four skills of DBT -Mindfulness Being aware of the present moment without judgment Observing, describing, participating -Emotion regulation Understanding and reducing vulnerability to emotions changing unwanted emotions -Distress tolerance Getting through crisis situations without making things worse accepting reality Page 5G of 83 -Interpersonal effectiveness Getting interpersonal objectives met maintaining relationships increasing self-respect in relationships core skill of DBT which underpins the other three skills Mindfulness Sasha is a 22-year-old, single female who presents for psychotherapy. Sasha has a history of major depression and substance abuse disorder. She was previously prescribed various psychotropics medications that only increased her depression. She began self-medicating with her boyfriend’s pain medications to tolerate her depressive symptoms. The psychiatric mental health nurse practitioner (PMHNP) selects DBT as an adjunct to pharmacological interventions. DBT is selected to address Sasha’s problematic behavioral patterns and enhance her functioning. In the early phase of DBT, the PMHNP helps Sasha build skills in mindfulness to enhance her awareness and self-observation. Which of the following are the most appropriate exercises to enhance mindfulness skills? Select all that apply. abdominal breathing wise mind judgment diffusion assertive listening negotiating relaxation abdominal breathing wise mind judgment diffusion Page 57 of 83 Rationale: Mindful abdominal breathing, wise mind, and judgment diffusion are common mindfulness exercises. Assertive listening and negotiating are exercises to build interpersonal effectiveness and relaxation exercises are used to build distress tolerance skills. Sasha also has low distress tolerance. The PMHNP helps her build distress tolerance skills as a healthier alternative than self-medicating with her boyfriend’s pain medications. Which of the following are the most appropriate exercises to enhance distress tolerance? Select all that apply. reducing vulnerabilities relaxation recognizing emotions making a request self-soothing radical acceptance relaxation self-soothing radical acceptance Rationale: Radical acceptance, relaxation, and self-soothing exercises build skills in distress tolerance. Recognizing emotions and reducing vulnerabilities exercises build skills in emotional regulation. Making a request is an exercise to build interpersonal effectiveness. In the next phase of DBT, Sasha reports that she wants to be able to feel again since her emotions have been “numbed out” due to her substance abuse. The PMHNP uses skills in emotional regulation to help Sasha learn to control her feelings rather than being controlled by them. Which of the following are the most appropriate exercises to enhance emotional regulation? Select all that :// Page 58 of 83 problem-solving realistic goal setting passive versus aggressive behavior radical acceptance opposite action to emotion opposite action to emotion problem-solving Rationale: Opposite action to emotion and problem-solving exercises build skills in emotional regulation. Realistic goal setting is an exercise to enhance self-management. Radical acceptance builds skills in distress tolerance, whereas exercises in passive versus aggressive behavior build skills in interpersonal effectiveness. Psychotherapy with older adults considerations -higher prevalence of dementia •raises need for neuropsychological screening -higher prevalence of medical disorders req careful consideration of physical causes of symptoms & effects of meds Child Development: -Physical Development by three months, infants can lift their heads and clasp their hands by six months, they may roll over, sit with support, and reach for objects and transfer them from hand to hand by one year, infants can stand and start to take steps by one year, birth weight triples and height increases by 50% -Cognitive and Language Development Page 5U of 83 by two months, infants start to coo by six months, infants begin to babble by nine months, infants imitate sounds and know their name by one year, infants begin to say words and can follow one-step commands -Psychosocial Development by four months, infants socially smile by six months, infants enjoy their reflection in a mirror. by nine months, infants enjoy peekaboo and often develop stranger anxiety -Health History obtain information from the parent or caregiver observation and report of infant behavior and activity -Physical Exam perform as much of the exam with the infant in parent or caregiver’s lap as possible keep familiar toys or blankets with infant feed hungry infants before examining them use a toy or object or play for distraction -Health Promotion administer immunizations per the recommended schedule newborn screens: genetic and metabolic screening; hearing screen, screen for congenital heart disease; bilirubin screening anticipatory guidance: illness prevention; anticipated growth and development; and when to call for advice Child Development: Toddler (1 to 4 years) -Physical Development after age 2, growth is about 5 centimeters (cm) and gain about 2-3 kilograms (kg) per year gross motor skills develop from walking to running, jumping, climbing, Page G0 of 83 and riding a tricycle fine motor skills develop from beginning to feed self, to scribbling, to drawing a person and writing letters -Cognitive and Language Development by two years, toddlers can speak in two to three-word sentences and have a vocabulary of up to 300 words by four years, preschoolers form complex sentences -Psychosocial Development toddlers develop from pretend play, to parallel pl