Case Study
Patient Demographic: Client Age: 9 Sex: Male Gender: Male Sexuality: Unknown Ethnicity: Caucasian Relationship Status: Not Applicable Counseling Setting: School Type of Counseling: Individual Presenting Problem: Severe Temper Outbursts Diagnosis: Disruptive Mood Dysregulation Disorder (DMDD), Provisional (F34.81)
Mental Status Exam: Mental Status Exam: The client’s affect is irritable and angry. He sits with his arms crossed and exhibits poor eye contact. His appearance is somewhat disheveled. Mother reprimands the client multiple times, requesting that he “sit up straight” and “answer the lady’s questions.” The client mumbles responses at his mother’s prompting and is otherwise minimally engaged. The client reports that he “gets mad” daily and feels unjustly “blamed for everything.” His motor activity is somewhat fidgety. Speech and language skills are developmentally appropriate. The client states he “sometimes” feels sad and denies feeling worried or scared. His appetite is good and his sleep is poor. The mother attributes his sleep difficulties to the client staying up late playing video games.
Presenting Problem: You are a school-based mental health clinical counselor conducting an initial intake evaluation. A 9-year-old 3rd-grade male is accompanied by his mother, who reports that the client has been in several school and neighborhood altercations. She states she is at her “wit’s end” with him and is about to lose her job due to constant calls from his school. The client’s teacher reports that the client has daily temper outbursts, and his mother says that his mood is irritable for most of the day, every day. The client was recently suspended from school for flipping over his desk when his teacher told him he lost recess privileges. The mother first noticed these behaviors when her son was in kindergarten. The client recently kicked a hole in his wall after losing a video game. His grades are poor, and the school is currently evaluating him for special education services. The client was reluctant to take part in the intake. He shrugged his shoulders when asked if he would agree to participate in counseling.
Other Contexts: You have attempted to arrange a family session with the mother, but she is unable to take off work to attend. The client arrives for his second session eager to share that he is “on green” this morning, which means the client’s behavior for the day has been good. You praise him for staying in his seat and keeping his hands and feet to himself. The client responds well to your praise. When engaging in a feelings identification activity, the client identifies feeling unhappy and worried when his father doesn’t show up for scheduled visitation. The client explains that his parents frequently argue about “how to take care of me” and “sometimes push each other.” He quickly abandons the feelings activity and asks if he can go back to class. You deny the client’s request to leave and instead give him the option of selecting another activity. The client refuses to do so and begins to kick your file cabinet repeatedly. He proceeds to knock papers off your desk. When redirected, the client’s behavior escalates

Question: Given the severity of the client’s emotional and behavioral difficulties, as well as the disruptive behavior displayed during this session, what would be your next best step?
(A): Arrange for an alternative school placement.
(B): Initiate an immediate psychiatric medication evaluation.
(C): Refer the family for intensive in-home family therapy services.
(D): Conduct a crisis risk assessment.

Correct Answer: Conduct a crisis risk assessment.
Explanation: The client, who initially had a good morning, quickly becomes inconsolable and destructive when recalling his parents’ domestic violence. Conducting a crisis risk assessment prioritizes safety concerns, making it an essential step in providing vital services to a client with multiple risk factors (eg, bullying, trauma, attachment, poor school performance, hopelessness, and mood instability). A comprehensive risk assessment helps determine the intensity of treatment services required to meet the client’s current needs. A referral to a psychiatrist or to an in-home treatment provider would likely be part of a crisis plan of care but are inadequate as stand-alone interventions. An appointment with a psychiatrist may take time to secure, and parental consent is required before placing a child on medication. Also, certain medications take time to build up in the client’s system before symptom reduction occurs. As part of a crisis plan, a referral for intensive in-home therapy may be helpful as the mother’s work schedule compromises her availability. However, wrap-around services, such as intensive-in-home treatment and a referral for case management, are likely to be identified and prioritized after analyzing the risk assessment results. The client is already in the process of being evaluated for special education; therefore, you cannot unilaterally arrange for an alternative school placement. Federal laws require the client to be placed in the least restrictive environment, with specific procedural standards outlined in PL 94-142 (the Individuals with Disabilities Education Act). Therefore, the correct answer is (B)
Competency: intake, assessment, and diagnosis