Case Study
Patient Demographic: Client Age: 25 Sex: Male Gender: Male Sexuality: Bisexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Telehealth Type of Counseling: Individual counseling Presenting Problem: The client is experiencing difficulty focusing on work due to a childhood diagnosis of attention-deficit/hyperactivity disorder (ADHD) and thinks that if he cannot keep up with work, he is going to get fired. Diagnosis: Attention-deficit/hyperactivity disorder (ADHD), predominantly inattentive presentation (F90.0)
Mental Status Exam: Mental Status Exam: The client is oriented to person, place, time and situation. The client is engaged and participates fully in the intake session. The client does not appear anxious. The client has a flat af
Presenting Problem: You are a licensed counselor working in your own private practice and providing telehealth sessions to clients. The client states that he is having trouble keeping up with tasks at work. The client reports that he wakes up and does not want to go to work because he knows he will not get much done. The client is often late to work, and although he is typically the only one in the office, his employer comes to work every now and then, and he worries that he will get caught arriving late. He says that he procrastinates on tasks but, often near the end of the day, finds motivation to complete the tasks and stays late to do so. In addition to his trouble at work, the client says he thinks that he does not do much that makes him happy. He expresses the desire to write stories and play guitar more because these activities used to make him happy, but he has trouble finding motivation to engage in them at the present.
Other Contexts:    fect. Family History: The client reports a strained relationship with his parents, but he says that he does not want to talk about them because they are not the reason that he is in therapy. The client says that he has a younger sister (age 23) and that they are not close. The client reports that he currently has a girlfriend.  The client self-reported his ADHD diagnosis, and you want to confirm this diagnosis

Question: The client self-reported his ADHD diagnosis, and you want to confirm this diagnosis. All of the following are appropriate steps to take to confirm the diagnosis, EXCEPT:
(A): You request records from the client related to the diagnosis in order to confirm it.
(B): You collaborate with the client’s PCP to diagnose the client.
(C): As a licensed therapist, you are authorized to diagnose ADHD like you would diagnose other mental health diagnoses.
(D): You give a provisional diagnosis of ADHD in order to continue to assess for ADHD on your own.

Correct Answer: As a licensed therapist, you are authorized to diagnose ADHD like you would diagnose other mental health diagnoses.
Explanation: ADHD is a mental health diagnosis, but it is also a medical diagnosis because it is a developmental disorder. You need to receive records from the PCP and historical documentation regarding symptomology to confirm this diagnosis. Do not attempt to diagnose ADHD on your own. You can also give a provisional diagnosis while you work through narrowing down the client’s diagnosis. This is a difficult diagnosis to confirm on your own, especially through telehealth sessions, and you should collaborate with other medical/mental health professionals who have seen this client in person. Therefore, the correct answer is (A)
Competency: professional practice and ethics