Case Study
Patient Demographic:  Initial Intake: Age: 8  Gender: Male  Sexual Orientation: N/A Ethnicity: Caucasian  Relationship Status: N/A  Counseling Setting: Through agency inside school and via telehealth  Type of Counseling: Individual
Mental Status Exam: Avery presents as fair, with some stains on his t-shirt. His mood is euthymic but with anxious affect as evidenced by hyperactivity, some pressured speech and fidgeting of the hands and feet as he cannot sit still. There is no evidence of suicidal or homicidal ideation and no reported hallucinations or delusions. The initial assessment revealed no significant trauma, other than not having his biological father around his entire life. Avery reports feeling tired often but overall happy. Mom reports his appetite is very good, but his diet could be better. He also has headaches at times in school or when he comes home.
Presenting Problem: Diagnosis: Attention-deficit hyperactivity disorder, combined type (F90.2)
 

Avery is an 8-year-old Caucasian male that has been referred to you by his school counselor because of emotional breakdowns, failing grades and falling asleep in class. You set up an initial assessment session with Avery and his parents in person at the school’s conference room and learn that he refers to his biological mother as “dad” and her wife as “mom”, and that he has a twin brother with Autism. Mom tells you Avery sees a psychiatrist for medications but frequently has them changed because she feels they are not working. Mom reports Avery has trouble sleeping at night, hits and kicks her and his brother when he’s angry and steals food from the kitchen and hides it in his room. She must ask him multiple times to complete a task and he often will not comply or forget each time he is told. Dad adds that Avery is very smart and does well in most subjects in school but struggles with reading comprehension and worded math problems. Avery is already on an IEP (Individualized Educational Plan) in school to better support his unique learning needs. They ask for your help in regulating his affect and behaviors.
Other Contexts: Family History:
Avery is very close with his two mothers and does not seem to notice that he does not have his father present in his life. His mother mentions that he has made several remarks recently about wanting to be a girl. Avery’s brother is high functioning on the autism spectrum but has poor communication and coping skills, increasing Avery’s stress level at home due to their constant fighting. Both parents work full-time and take shifts in caring for the children, often sleeping at odd hours of the day and therefore have trouble keeping Avery on a regular schedule. Avery has some extended family on both sides and sees them occasionally. Dad reveals she was also diagnosed with ADHD and Dyslexia growing up and had trouble in school.

Question: Regarding Avery's comments about desired gender, which of the following courses of action is the most clinically appropriate?
(A): Do nothing unless Avery or his parents bring it up again as part of a problem
(B): Add diagnosis of gender dysphoria and include gender confusion as part of goals
(C): Do nothing because gender dysphoria for children his age is unsubstantiated
(D): Refer parents to a support group for children coping with transgender issues

Correct Answer: Do nothing unless Avery or his parents bring it up again as part of a problem
Explanation: Avery was referred for counseling to address symptoms resulting from his primary diagnosis of ADHD and both of his parents are requesting help with dysregulation related to this issue only. Neither parent has expressed concern or problematic behavior resulting from gender identity confusion, merely it was mentioned as a remark that was made. While gender dysphoria can very well be a legitimate concern for a child his age, begin the treatment planning process focusing on presenting problems related to the diagnosis. Should Avery or his parents bring up gender confusion later in counseling, the issue can certainly be addressed and explored at that time. While the counselor may have a personal theory of its connection to Avery's behavioral problems, it is best practice to first rule out known existing conditions. Referrals to support groups or other referrals, should only be made when the counselor deems it appropriate outside of clinical counseling, once the problem and need have been thoroughly assessed. Therefore, the correct answer is (C)
Competency: professional practice and ethics