Case Study
Patient Demographic: Initial Intake: Age: 9 Gender: Female Sexual Orientation: Heterosexual Race/Ethnicity: Caucasian/Non-Hispanic Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual
Mental Status Exam: Lottie presents as excited, over-stimulated and hyperactive, unable to sit still and does not take breaks from talking. Her appearance is highly disheveled with stained clothes and unbrushed hair. Lottie nervously walks around your office touching and commenting on everything. You ask her nicely to ask you before she touches your things, but she refuses and continues to do so. Lottie deflects from every question posed in your assessment. She denies SI/HI, hallucination, or delusion, which you were surprisingly able to find out from her.
Presenting Problem: 
Diagnosis: Attention Deficit Hyperactivity Disorder, predominantly hyperactive type (F90.1), Oppositional defiant disorder (F91.3), Reaction to severe stress (F43.9)
 

Lottie is a 9-year-old girl in the fourth grade who has been referred to you by officials in her elementary school. You are a counseling intern of a private practice that specializes in adult personality disorders, but your supervisor accepted Lottie as a new client because Lottie’s mother is a former client of her agency, and she requested her daughter be seen by your practice as opposed to a school-based counselor. Lottie’s mother does not want Lottie’s peers to know she is in therapy. Lottie has been doing well in school academically but has not been able to behave appropriately for years, according to the referral report. Lottie bounces up and down in her chair constantly, makes impulsive noises throughout the day, and engages in inappropriate behaviors daily. Some of the behaviors listed include invading the personal space of her peers, licking and eating school supplies to garner reactions from fellow classmates, hiding on the playground and refusing to emerge, and many other behaviors. Lottie follows basic classroom directions but needs constant reminding or guiding that the teacher does not have time for. Lottie breaks down into hysterical emotional fits when she does not get her way and her behaviors have been spreading the school staff too thin to be capable of managing without intervention. This session is conducted with only Lottie in the room; her mother insists on waiting in the car outside so she can make some phone calls. She mentions her Medicaid has just been reactivated to pay for sessions.
Other Contexts: Family History:
Lottie lives at home with her mother and mother’s boyfriend, as well as their 1-year-old son Davie who is her half-brother. You learned from speaking with her mother beforehand that Lottie’s biological father was a drug addict and homeless, and he was recently shot and killed, about four months ago. Lottie knows and understands what happened. During the intake session you ask her to draw a picture of something important to her. She likes this assignment and draws you a picture of her father’s homeless camp where she last saw him. She explains to you the details surrounding his murder and mature, intimate details of her mother’s broken relationship with him. “How do you know all of this, Lottie?” you ask her, concerned. “Oh, my mother told me. She tells me everything.”

Question: Lottie uses play to show how her father was killed. She notices you have let a tear out of your eye while observing her and says, "Why are you crying? Please don't!" What is the best clinical response?
(A): "Why not, don't you cry when you think about your dad?"
(B): "Lottie, what you shared was sad. I cried. But I am okay."
(C): "I just have irritated eyes, nothing to do with you."
(D): "I'm so sorry you saw that; I couldn't hold it back."

Correct Answer: "Lottie, what you shared was sad. I cried. But I am okay."
Explanation: Demonstrating to a child that a person can cry when something is sad, but that they can also be okay right afterwards, is a very powerful clinical lesson. Helping model for Lottie a healthy grief response and recovery is a great way for her to learn that she can do the same thing. Turning the response back onto her can be confrontational in a sensitive grief situation which may trigger a stronger response from her. This can be okay to ask, as in answer a), but do not miss the opportunity to first give a clinical response such as in answer d). It builds a more genuine therapeutic bond and offers sincere empathy, something Lottie desperately needs. Apologizing is setting the example that it is "not okay to cry when something is sad". Denying your feelings to her using excuses like in answer c) is in direct conflict with the skills you are working to show Lottie how to use, therefore it is not the best choice. Therefore, the correct answer is (D)
Competency: counseling skills and interventions