Case Study
Patient Demographic:  Initial Intake: Age: 14 Gender: Male Sexual Orientation: Heterosexual Race/Ethnicity: Hispanic - Mexican American Relationship Status: Single Counseling Setting: School-based Type of Counseling: Individual
Mental Status Exam: Raul presents as irritable and anxious, with congruent mood and affect. Raul is casually dressed, appears to be overweight for his age and height, and is sweating with nervous hand motions. Raul has difficulty making eye contact, takes long pauses prior to answering questions, and often asks you to repeat the question after a long pause. Raul denies SI/HI or hallucination/delusion. He refers to an incident in his past he considers to be “trauma” but is uncomfortable discussing with you. When asked about his father, he sheds a tear which he immediately wipes away and returns to a scowl on his face with arms crossed, saying “there’s nothing to talk about.” Raul does admit to several instances of aggression with others such as “shoving a kid,” “kicking a desk” and “cursing out the principal.” You ask if he has ever been on medication for ADHD. He says, “No, I don’t think so. My doctor told my mom a few times to fill out some forms, but I don’t think she ever did.”
Presenting Problem: Diagnosis: Attention-deficit hyperactivity disorder, predominantly inattentive type (F90.0), Conduct disorder, unspecified (F91.9)
 

You are a counseling intern working for an agency that sends counselors into grade schools to work with their students on longer-term mental health issues. Raul is referred to you by his assistant principal for multiple in classroom infractions of interrupting, bullying, and being a “class clown.” In meeting with Raul and his mother, she shares that the principal accused Raul of bullying kids on the bus, and defacing property. She says, “Kids will be kids, they’re probably just too sensitive.” Raul’s mother works full-time and has an active social life, leaving Raul to stay at home alone frequently after school or on weekends. His mother appears very casual and does not seem concerned about Raul’s behaviors. She does mention Raul’s diagnosis of ADHD was given by his pediatrician, but he has never received psychiatric services. In front of his mother, Raul is quiet and acts well-behaved; after his mother leaves, he tells you he gets frustrated with her for leaving him alone but would never admit it to her directly. He refuses to state that he feels lonely, sharing that he spends most of his alone time playing live video games with other people across the country. He also denies bullying other kids.
Other Contexts: Education History:
Raul’s teachers inform you of his behaviors throughout his freshman year in high school, that have according to them been ongoing since Raul’s middle school years. Raul is often reported for being inappropriate in class by making impulsive remarks to try and get others to laugh, disrupting the class, or falling asleep and appearing distracted. The school is concerned with his academic progress and has discussed moving his status up a higher-level Tier so he can be monitored further and made available to special programming geared towards students in jeopardy of failing.
 
Family History:
Raul lives with his mother and occasionally one of his mother’s boyfriends who come and go intermittently. Raul has one older sister who lives in the next town. Raul’s father lives in Mexico with several of his half and step siblings with whom Raul has minimal contact. Raul’s father is unable to enter the U.S. and has been absent most of Raul’s life. Raul reports his father is an alcoholic, but that where he lives, they “don’t think of things like that” because that is what his father told him. Raul’s grandmother also lives in Mexico but has been a continual presence in his life via phone calls, mail, and is his primary caretaker when he does visit Mexico, which has occurred twice.

Question: Reflecting on your conversation with mom, you recall that Raul's primary pastime is playing video games. What can this piece of information help you understand about Raul?
(A): He uses dissociation for coping.
(B): He can be motivated through use of gaming language.
(C): Video games worsen his ADHD symptoms.
(D): He doesn't really have ADHD.

Correct Answer: He uses dissociation for coping.
Explanation: If the only activity Raul engages in on his own time involves a distraction from his reality, it is reasonable to assume this is what he turns to for escape, release, comfort, enjoyment, and/or safety. This is vitally helpful in treatment planning and providing interventions to help Raul learn to accept his reality, adapt to his circumstances, and cope with his distress, to prepare him for a successful future in an unpredictable world. One can control several factors in video gaming, giving a false sense of security and predictability as one navigates the rules of the game. When met with unprecedented challenges or failure, the consequences are minimal and thus capable of being managed with little effort. Gamers may experience and feel losses or frustrations in games passionately, resulting in large expressions of emotions and often impulsive behavior such as throwing their controller across a room; these are expressions of much deeper emotional conditions that have found a rather controllable outlet. While overstimulation may negatively affect an individual with ADHD, some games have been proven to support certain cognitive functions that can help with certain ADHD conditions when well-managed with boundaries and a balance of other activities. The ability to hyper-focus on gaming does not rule out ADHD; some people think if a child can focus on something like their video games, they could not possibly have ADHD. However, the deficits in the disorder relate to how well a child can pay attention to low interest activities or content. Children with ADHD can develop an obsession with high-interest activities due to their cognitive processing inflexibility. There is no evidence to support answer c) would be effective, although use of this idea in interventions would not be harmful. Therefore, the correct answer is (D)
Competency: intake, assessment, and diagnosis