Case Study
Patient Demographic: Client Age: 8 Sex: Male Gender: Male Sexuality: Unknown Ethnicity: Hispanic Relationship Status: Single Counseling Setting: Home Health Outpatient Therapy Type of Counseling: Individual with Family Involvement Presenting Problem: Behavioral Issues Diagnosis: Oppositional Defiant Disorder, Severe (F91.3)
Mental Status Exam: Mental Status Exam: The client was argumentative and did not engage in the entire intake session. The client was oriented to person, place, situation, and time. He was dressed appropriately for the weather and appeared well groomed. The client appeared clean and had appropriate hyg
Presenting Problem: You are a home health outpatient therapist working with an 8-year-old male in the home setting. The client’s parents will be actively involved in counseling due to the client’s age. The client was referred to receive counseling by his school social worker. He has been having behavioral issues in school that have led to difficulty staying in the classroom and is resultantly falling behind in academics. During the first session, the client refuses to engage and leaves the room. The client’s parents prompt him to return, and he calls them “jackasses” and leaves the room again. The parents finish the intake session with you and provide you with a report on their observations in the home and reports from the school social worker. The client reportedly often loses his temper and is generally easily annoyed or angered. The client has trouble taking direction from his teachers and parents. The client’s parents also state that he often blames his younger sister for things that he does and often tries to annoy her. The parents have trouble identifying any of the client’s friends and state that he does not get along with his peers.
Other Contexts: The client appears to be more comfortable with you as he greets you at the door and starts talking with you about his favorite TV show as you walk back to the office. The client talks about how his parents give different consequences to him than his younger sister and that they also give her more attention than they give him. You empathize with the client about this because it must be frustrating being treated differently. You assist the client with processing further, and he identifies feeling like he is “bad.” But because he gets attention, he continues to push back against their authority. During this session, the client curses at his parents and they punish him by removing access to video games for the next week.  The parents are using punishment to alter behavior, and you want to educate them on positive reinforcement

Question: The parents are using punishment to alter behavior, and you want to educate them on positive reinforcement. Which would be an example of positive reinforcement to encourage appropriate behavior when the client is cursing?
(A): The parents encourage him to request what he wants or needs in a more appropriate manner.
(B): The parents walk away to demonstrate that they will not communicate with him when he curses at them.
(C): The parents wait until the client calmly and quietly requests what he needs and they praise him for appropriate communication.
(D): The parents provide a time-out in the client’s room to encourage more positive behavior.

Correct Answer: The parents wait until the client calmly and quietly requests what he needs and they praise him for appropriate communication.
Explanation: The parents praising appropriate behavior is positive reinforcement. Positive reinforcement involves adding something to increase desired behavior. The client desires attention from his parents, so providing positive praise would increase the likelihood of more appropriate communication. A time-out would be considered a punishment, which would focus on providing an adverse consequence to decrease a behavior. The parents walking away to demonstrate they do not approve of his behavior would not be positive reinforcement because they are not adding something to increase the target behavior. The parents’ encouragement to request what he wants or needs is helpful, but it is not positive reinforcement. Therefore, the correct answer is (B)
Competency: counseling skills and interventions