Case Study
Patient Demographic: Age: 9 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private practice Type of Counseling: Individual counseling Presenting Problem: The client has been engaging in behavior that has gotten him suspended from school several times over the past year, which also causes significant distress for the client’s family at home. Diagnosis: Conduct disorder, childhood-onset type, with limited prosocial emotions, severe (F91.1)
Mental Status Exam: Mental Status Exam: The client was minimally engaged in the session. The client’s behavior was withdrawn, argumentative, and la
Presenting Problem: You are a professional counselor, and you specialize in working with children and adolescents. The client comes to this session with his parents. You review informed consent with the client and his parents and begin to ask the client about what brings him to counseling. The client responds by saying “shut the hell up” and leaves the room to go to the lobby. The client’s father gets up and follows him out, and after a few minutes they return. The client sits down and faces away from you. The client does not engage in the intake session aside from cursing at his parents when they report specific behavioral incidents and he disagrees with them about the facts of the events. The client’s parents say that he has had “bad behavior” over the past 2 years and that his behavior has “gotten worse” over the past 5 months. The parents outline the following behavioral problems that the client engages in, in all settings: bullying, physical fighting, kicking and throwing items at his dog, intentionally breaking others’ property, lying to others to get items or have access to activities, stealing items from others, truancy, and leaving the house at night without permission or supervision.
Other Contexts: You meet with the client alone, and he appears to be more comfortable with you because he comes in and starts talking about a video game that he plays. You share that you have played that video game before. During the session, the client mentions that his parents got his first report card of the year and found out that he was failing most of his classes. He started to say that he was worried that his dad was going to hit him because of his grades. You ask if his father hits him often, and he replies that he does several times a week. You try to inquire about the manner of hitting his father uses because a certain level of corporal punishment is legal in the state that you work in. The client says that he is not going to talk any more about this. You remind the client that you likely will need to report this to child protective services and he says, “I don’t care” in response. You spend the rest of this session processing his relationship with his parents, and he discloses that he does love them, but that they are not his real parents. You meet with the client’s parents near the end of the session, and, while talking with them, they report that he was neglected while in foster care because the foster parent was “just in it for the money.”  Based on the information discussed in this session, you decide to begin supporting the parents in improving their son’s attachment with them

Question: Based on the information discussed in this session, you decide to begin supporting the parents in improving their son’s attachment with them. All of the following would be beneficial homework assignments, EXCEPT:
(A): Assigning reading homework for the parents regarding positive attachment
(B): Having intentional weekly family time
(C): Creating a reward system for behavior to create consistency and structure
(D): Assigning intentional one-on-one activities with each parent and the client

Correct Answer: Creating a reward system for behavior to create consistency and structure
Explanation: Consistency and structure are important for anyone, but they are especially for someone with conduct disorder. Although a reward system may be beneficial in treating behavior related to conduct disorder, it is not an intervention that is focused on enhancing the parents’ understanding of attachment and is therefore the least appropriate option in meeting that goal. In fact, reward systems can potentially strain attachment. Reading related to positive attachment would be beneficial for the parents and likely would include information on attachment-enhancing activities such as intentional one-on-one activities and consistent family time. Therefore, the correct answer is (C)
Competency: counseling skills and interventions