Case Study
Patient Demographic: Client Age: 8 Sex: Female Gender: Female Grade: 3rd Ethnicity: African American Counseling Setting: School-based Type of Counseling: Individual and Family Presenting Problem: Defiance Diagnosis: Oppositional Defiant Disorder 313.81 (F91.3)
Mental Status Exam: Mental Status Exam: The client displays an angry affect and sits with her arms crossed. She is well dressed and well groomed. The client’s PGM repeatedly prompts her to say, “yes ma’am” and “no ma’am” when answering questions. The client sits slumped in her chair. She agrees to color in a feelings thermometer that reflects increased anger, sadness, and fear. Her insight is poor. The client often refuses to eat school lunch, and the PGM reports that the client is a picky ea
Presenting Problem: You are a school-based mental health counselor conducting an initial intake with an 8-year-old African American female in the 3rd grade. The client presents today with her paternal grandmother (PGM), the client’s legal guardian. The PGM states that the client is argumentative, refuses to take responsibility for her actions, and has a tantrum when she receives a consequence for her behavior. She reports that the client is restricted from “every single privilege indefinitely.” The client has been told she can regain privileges once she “learns to act her age.” The client states she is treated unfairly and “blamed for everything” at home and school. The client’s teacher reports that she has difficulty following directions, is easily annoyed by her classmates, and frequently loses her temper. The client’s grades are poor, and she is below grade level in reading. However, she enjoys art and proudly reports that one of her pictures came in 1st place and is hanging in the library.
Other Contexts:    ter. F amily History: The client’s paternal grandmother received legal guardianship when the client was in 1st grade due to parental neglect. The client’s mother and father have had ongoing issues with substance abuse. The client’s father is currently incarcerated for drug-related offenses. The PGM reports that the client’s mother continues to “run the streets” and shows up periodically asking for money. The PGM states that the client’s mother abused drugs while pregnant and that the client was born prematurely. In addition, the client’s father had similar school difficulties and dropped out of high school in the 10th grade. History of Condition: The client’s disruptive behavior began in early childhood. When the client was four years old, her tantrums were so severe that she disrupted two daycare placements and was not allowed to return. In kindergarten, the client was given a stimulant by her primary care provider to assist with symptoms of ADHD. The PGM says she is no longer on the medication and believes the client chooses to misbehave, explaining, “she is strong-willed, just like her father.” The client’s school records show she has an individualized education plan (IEP) and receives limited services for developmental delays in reading and written expression

Question: Given the client’s clinical presentation, how would you structure the first individual session with the client?
(A): Identify maladaptive cognitions.
(B): Establish treatment plan goals.
(C): Engage her in a therapeutic art activity.
(D): Process grief and loss issues.

Correct Answer: Engage her in a therapeutic art activity.
Explanation: Given the client’s clinical presentation, the best approach for your first session is to engage her in a therapeutic art activity. During the initial intake, the client proudly shared that her artwork came in 1st place. Focusing on the client’s strengths rather than the client’s clinical pathology helps establish a therapeutic alliance. The client has little to no contact with her parents, exhibits ODD behaviors at home and school, and is academically below grade level. Thus, the client’s social, emotional, and academic needs likely contribute to strained relationships with authority and have a higher probability of eliciting negative feedback. Identifying maladaptive cognitions is incorrect due to the client’s cognitive functioning. Establishing treatment plan goals is best accomplished after collecting relevant information from the client’s teacher and grandmother. Processing grief and loss issues, as it pertains to separation from her parents, is important but will likely be more effective after establishing the therapeutic alliance. Therefore, the correct answer is (D)
Competency: counseling skills and interventions