Practicum Journal: Voluntary and Involuntary Commitment

Practicum Journal: Voluntary and Involuntary Commitment

Assignment 1: Practicum Journal: Voluntary and Involuntary Commitment

PMHNPs may find themselves working in a wide variety of settings—each having their own unique challenges and inherent legal issues. For instance, what do you do in your state of practice when you are providing a therapy/treatment session and a client reports active suicidal ideation? What do you do if you are covering inpatient psychiatric consults and are called to see a patient in the ICU who overdosed on prescription medication requiring intubation? What do you do if you are a PMHNP on an inpatient unit and a client who admitted themselves on a voluntary basis suddenly states that they have decided to sign themselves out of the hospital so that they can go home to kill themselves? These are just some of the legal questions that PMHNPs must know the answers to specific to their state of licensure/practice.

In this Assignment, you investigate your state’s laws concerning voluntary and involuntary commitment. You also analyze a case to determine if the client is eligible for involuntary commitment.

Scenario for Week 7 Case:

You are a PMHNP working in a large intercity hospital. You receive a call from the answering service informing you that a “stat” consult has been ordered by one of the hospitalists in the ICU. Upon arriving in the ICU, you learn that your consult is a 14 year old male who overdosed on approximately 50 Benadryl (diphenhydramine hydrochloride) tablets in an apparent suicide attempt. At the scene, a suicide note was found indicating that he wanted to die because his girlfriend’s parents felt that their daughter was too young to be “dating.” The client stated in the suicide note that he could not “live without her” and decided to take his own life. Although he has been medically stabilized and admitted to the ICU, he has been refusing to talk with the doctors or nurses. The hospital staff was finally able to get in touch with the clients parents (using contact information retrieved from the 14 year old’s cell phone). Unbeknown to the hospital staff, the parents are divorced, and both showed up at the hospital at approximately the same time, each offering their own perspectives on what ought to be done. The client’s father is demanding that the client be hospitalized because of the suicide, but his mother points out that he does not have “physical custody” of the child. The client’s mother demands that the client be discharged to home with her stating that her son’s actions were nothing more than a “stunt” and “an attempt at manipulating the situation that he didn’t like.” The client’s mother then becomes “nasty” and informs you that she works as a member of the clerical staff for the state board of nursing, and if you fail to discharge her child “right now” she will make you “sorry.” How would you proceed?

Learning Objectives

Students will:
  • Evaluate clients for voluntary commitment
  • Evaluate clients for involuntary commitment based on state laws
  • Recommend actions for supporting parents of clients not eligible for involuntary commitment
  • Recommend actions for treating clients not eligible for involuntary commitment

To Prepare for this Practicum:

  • Review the Learning Resources concerning voluntary and involuntary commitment.
  • Read the Week 7 Scenario in your Learning Resources.
  • Research your state’s laws concerning voluntary and involuntary commitment.

The Assignment (2–3 pages):

  • Based on the scenario, would you recommend that the client be voluntarily committed? Why or why not?
  • Based on the laws in your state, would the client be eligible for involuntary commitment? Explain why or why not.
  • Did understanding the state laws confirm or challenge your initial recommendation regarding involuntarily committing the client? Explain.
  • If the client were not eligible for involuntary commitment, explain what actions you may be able to take to support the parents for or against voluntary commitment.
  • If the client were not eligible for involuntary commitment, explain what initial actions you may be able to take to begin treating the client.



Practice Parameter for the Assessment and Treatment of Children and Adolescents With

Tic Disorders Tanya K. Murphy, M.D., Adam B. Lewin, Ph.D., Eric A. Storch, Ph.D., Saundra Stock, M.D.,

and the American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Quality Issues (CQI)

Tic disorders, including Tourette’s disorder, present with a wide range of symptom severity and associated comorbidity. This Practice Parameter reviews the evidence from research and clinical experience in the evaluation and treatment of pediatric tic disorders. Recommendations are provided for a comprehensive evaluation to include common comorbid disorders and for a hierarchical approach to multimodal interventions. J. Am. Acad. Child Adolesc. Psychiatry, 2013;52(12):1341–1359. Key Words: tic disorders, Tourette’s disorder, treatment, Practice Parameter

his Parameter is intended to guide the practice of medical and mental health pro-T fessionals that assess and treat youth with

tic disorders including Tourette’s disorder. Child and adolescent psychiatrists are often not the first point of contact for the assessment and treatment of tic disorders, but more often are involved when comorbid conditions arise or when tics develop while treating another neuro- developmental disorder. Given the increased complexity in assessing the medical and psychi- atric well-being of children presenting with these tic disorders and related comorbid conditions, as well as recent developments in evidence-based pharmacologic and behavioral treatments, a com- prehensive and developmentally sensitive Prac- tice Parameter is needed. The recommendations in this Parameter are applicable to children, adoles- cents, and young adults.

METHODOLOGY Information and treatment recommendations used in this Parameter were obtained by using the terms Tourette’s Disorder, Tourette syndrome, or Tic Disor- der, English Language, and Human Studies to search Medline, PubMed, PsycINFO, and Cochrane Library

This article can be used to obtain continuing medical education (CME) at


databases and by iterative bibliographic explora- tion of articles and reviews. Beginning with more inclusive and sensitive searches using the search terms noted above, multiple free text and relevant medical subject headings (MeSH terms), and the time period from January 1, 1965 to March 29, 2013, yielded 3,764 citations in Medline, 3,172 in PsycINFO, and 3 reviews in the Cochrane Library. The search was narrowed to the following desig- nations: Meta-Analysis (11 all, 2 child), Practice Guideline (5 all), Review (811 all, 296 child). The original search was also narrowed to the following designations: Treatment and 0-18 (1206), and Treatment and 0-18 and RCT (87). We selected 149 publications and 25 RCTs that enrolled pediatric subjects with an effective N � 20 for careful ex- amination based on theirweight in the hierarchy of evidence, the quality of individual studies, and their relevance to clinical practice. This Practice Parameter has been reviewed by acknowledged experts in the field, and their comments and sug- gestions are included.

CLINICAL PRESENTATION AND COURSE A tic is a sudden, rapid, recurrent, nonrhythmic movement or vocalization. Tics can be simple (rapid, meaningless) or complex (more purpose- ful, elaborate, or orchestrated), and transient or chronic. Chronic tic disorders (CTD), including Tourette’s disorder (TD) and persistent motor or

Y 1341http://www.jaacap.org


vocal tic disorder, are long-lasting neuropsychi- atric disorders, typically of childhood onset (<18 years). They are characterized by multiple motor and/or vocal/phonic tics that wax and wane in severity and are often accompanied by an array of behavioral problems, including symptoms of attention-deficit/hyperactivity disorder (ADHD) and obsessive compulsive disorder (OCD). Persistent motor or vocal tic disorder has tics limited to each of those domains whereas TD has both motor and vocal tics at some point in the illness.1

For either diagnosis, however, tics need to be present for at least one year. For tics present for less than 1 year, provisional tic disorder (formerly transient tic disorder) is used. Other specified tic disorder or unspecified tic disorder diagnoses are used for tic disorders that do not meet full criteria for TD, persistent tic disorder, or provisional tic disorder. In the case of the other specified tic disorder, clinicians specify the reason the full criteria were not met (e.g., atypical clinical pre- sentation or age of onset).1

The clinical manifestations of CTD2 may involve varying combinations of fluctuating tics. Simple motor tics are fast, brief movements involving 1 or a few muscle groups, such as eye

TABLE 1 Repetitive Movements of Childhood


Tics Sudden rapid, recurrent, nonrhythmic vocalizatio motor movement

Dystonia Involuntary, sustained, or intermittent muscle cont that cause twisting and repetitive movements, a postures, or both

Chorea Involuntary, random, quick, jerking movements, m often of the proximal extremities, that flow from to joint. Movements are abrupt, nonrepetitive, a arrhythmic and have variable frequency and in

Stereotypies Stereotyped, rhythmic, repetitive movements or pa of speech, with lack of variation over time

Compulsions A repetitive, excessive, meaningless activity or m exercise that a person performs in an attempt to distress or worry

Myoclonus Shock-like involuntary muscle jerk that may affect body region, 1 side of the body, or the entire b may occur as a single jerk or repetitive jerks

Habits Action or pattern of behavior that is repeated ofte Akathisia Unpleasant sensations of “inner” restlessness, ofte

prompting movements in an effort to reduce the sensations

Volitional behaviors

Behavior that may be impulsive or due to boredo tapping peers, making sounds (animal noises)

Note: ADHD ¼ attention-deficit/hyperactivity disorder; CTD ¼ chronic tic disor disorder; TD ¼ Tourette’s disorder.

JOURN 1342

blinking, shoulder shrugs, head jerks, or facial grimaces. Complex motor tics are sequentially and/or simultaneously produced relatively coordinated movements that can seem purpose- ful, such as tapping the bottom of the foot. Simple vocal/phonic tics are solitary, meaning- less sounds and noises such as grunting, sniffing, snorting, throat clearing, humming, coughing, barking, or screaming. Complex vocal/phonic tics are linguistically meaningful utterances and verbalizations such as partial words (syllables), words out of context (Oh boy!), repeated sen- tences, coprolalia, palilalia, or echolalia. Sensory phenomena that precede and trigger the urge to tic have been described and are referred to as premonitory urges.2 Patients with CTD can voli- tionally suppress tics for varying periods of time, particularly when external demands (e.g., social pressure) exert their influence or when deeply engaged in a focused task or activity. For this reason, teachers and family often perceive that when the child is not suppressing his/her tics that they are “choosing” to tic, that tics are intentional or are habits that can be easily stopped. Although parents may describe a rebound effect of increased frequency of tics at the end of the school day,

Typical Disorders Where Present

n or Transient tics, TD, CTD

ractions bnormal

DYT1 gene, Wilson’s, myoclonic dystonia, extrapyramidal symptoms due to dopamine blocking agents,

ost joint nd tensity

Sydenham’s chorea, Huntington’s chorea

tterns Autism, stereotypic movement disorder, intellectual disability

ental avoid

OCD, anorexia, body dysmorphic disorder, hoarding disorder, trichotillomania, excoriation disorder

a single ody;

Hiccups, hypnic jerks, Lennox-Gastaut syndrome, juvenile myoclonic epilepsy, mitochondrial encephalopathies, metabolic disorders

n Onchophagia n Extrapyramidal adverse effects from dopamine

blocking agents; anxiety

m like ADHD, ODD, sensory integration disorders

ders; OCD ¼ obsessive-compulsive disorder; ODD ¼ oppositional defiant



research has not supported volitional suppressing of tics leading to tic rebound.3-5

Average age of onset of CTD is 7 years, with onset as early as a few months of age.6 The prevalence and severity of tic disorders has a peak around age 9 to 12 years,7 followed by a decrease in prevalence with age,7,8 with remission or marked attenuation of tic severity in most in- dividuals (65%) by age 18 to 20 years.2 The early presentation of CTD may be indistinguishable from bouts of transient tics, but then progresses to a more typical chronic waxing and waning course.8-10 Children with only OCD or tics may develop additional symptoms months or years later.10 Although some patients will have com- plete or partial remissions of their illness in early adulthood, others may continue to have a chronic and disabling illness for many years.11,12

Many youth with CTD experience impairment in daily functioning2,13 Youth with TD have been shown to experience greater psychosocial stress relative to healthy controls.14 Socially, many youth with tics experience peer difficulties that may further contribute to distress.13 With regard to home life, there is an increased risk for marital difficulties, substance abuse in parents, family conflict, poorer quality of parent–child in- teractions, and higher levels of parenting frustra- tion in families with a child with CTD, especially when associated with comorbid conditions.15

Many people with CTD seek mental health ser- vices to assist them in coping with CTD and related problems, such as stigma, anxiety, and depression.16 Not only has stress been linked to symptom exacerbations, but it has also been associated with increased depressive symptoms among youth with tics.14

EPIDEMIOLOGY The prevalence of CTD has been estimated as 0.5% to 3%,17 with approximately 7% of school age children having had tics in the previous year.18,19

It is estimated that the prevalence of transient tics is approximately 5%. This figure may be an underestimate, given that most cases of tics are mild and may be misdiagnosed or unrecognized by medical professionals.2 Prevalence rates for all tics (chronic or transient) range from 5.9% to 18% for boys and from 2.9% to 11% for girls.18 In gen- eral, CTD have a male preponderance, with a gender ratio of at least 2:1 or higher.11,20 Tic dis- orders have been reported in numerous Asian, Middle Eastern, and European samples. Although


ethnic differences in prevalence are understudied, the Great Smoky Mountains Youth Study and the CDC study found higher rates in white compared to African American youth.20,21

ETIOLOGY Although the pathophysiology of CTD is not entirely understood, there is evidence that motor programs at both a cortical and subcortical level are not properly modulated. Tics are proposed to be the result of dysfunctional cortico-striatal- thalamo-cortical circuits, prominently those sub- serving motor function. Magnetic resonance imaging (MRI) morphometric studies have demonstrated a loss of the normal asymmetry of the caudate nucleus and, in some studies, other regions as well.22,23 Functional neuroimaging studies have revealed a pattern of decreased activity in the basal ganglia, often with asym- metries that are not consistent from 1 study to the next (although a left-sided preponderance is often noted).23 Greater activity in sensorimotor regions (e.g., primary motor cortex, putamen) and reduced activity in the anterior cingulate and caudate during spontaneous tics have suggested deficient engagement of circuits that inhibit either tic behaviors or the sensorimotor urges.24

Other studies have revealed that during the performance of a motor task, a larger area of cortex was recruited in subjects with TD than in controls.25 Transcranial magnetic stimulation revealed that the cortical silent period was shortened and intracortical inhibition reduced; abnormalities that were particularly prominent when tics were present.26 Motor threshold and peripheral motor excitability, however, did not differ from that of controls.26 During tic sup- pression, there were significant changes in signal intensity in the basal ganglia and thalamus and interconnected cortical regions. These changes in signal intensity were inversely corre- lated with the severity of tic symptoms.27,28 Male predominance in CTD and childhood OCD may be due to influences of sex hormones on the neurodevelopment of these cortico-striatal- thalamo-cortical circuits, as reflected by a study of anti-androgens in the treatment of TD.29

Relatives of those with TD have repeatedly been shown to be at an increased risk for devel- oping tic disorders. Family studies suggest a 10- to 100 fold increase in the risk of CTD among first-degree relatives compared to rates in the general population.30 Twin st

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