Case Study
Patient Demographic:  Initial Intake: Age: 8  Gender: Male  Sexual Orientation: N/A Ethnicity: Caucasian  Relationship Status: N/A  Counseling Setting: Through agency inside school and via telehealth  Type of Counseling: Individual
Mental Status Exam: Avery presents as fair, with some stains on his t-shirt. His mood is euthymic but with anxious affect as evidenced by hyperactivity, some pressured speech and fidgeting of the hands and feet as he cannot sit still. There is no evidence of suicidal or homicidal ideation and no reported hallucinations or delusions. The initial assessment revealed no significant trauma, other than not having his biological father around his entire life. Avery reports feeling tired often but overall happy. Mom reports his appetite is very good, but his diet could be better. He also has headaches at times in school or when he comes home.
Presenting Problem: Diagnosis: Attention-deficit hyperactivity disorder, combined type (F90.2)
 

Avery is an 8-year-old Caucasian male that has been referred to you by his school counselor because of emotional breakdowns, failing grades and falling asleep in class. You set up an initial assessment session with Avery and his parents in person at the school’s conference room and learn that he refers to his biological mother as “dad” and her wife as “mom”, and that he has a twin brother with Autism. Mom tells you Avery sees a psychiatrist for medications but frequently has them changed because she feels they are not working. Mom reports Avery has trouble sleeping at night, hits and kicks her and his brother when he’s angry and steals food from the kitchen and hides it in his room. She must ask him multiple times to complete a task and he often will not comply or forget each time he is told. Dad adds that Avery is very smart and does well in most subjects in school but struggles with reading comprehension and worded math problems. Avery is already on an IEP (Individualized Educational Plan) in school to better support his unique learning needs. They ask for your help in regulating his affect and behaviors.
Other Contexts: Family History:
Avery is very close with his two mothers and does not seem to notice that he does not have his father present in his life. His mother mentions that he has made several remarks recently about wanting to be a girl. Avery’s brother is high functioning on the autism spectrum but has poor communication and coping skills, increasing Avery’s stress level at home due to their constant fighting. Both parents work full-time and take shifts in caring for the children, often sleeping at odd hours of the day and therefore have trouble keeping Avery on a regular schedule. Avery has some extended family on both sides and sees them occasionally. Dad reveals she was also diagnosed with ADHD and Dyslexia growing up and had trouble in school.

Question: What is the best response for how to guide this parent while building the therapeutic alliance?
(A): "Don't worry, you're doing a great job and he will grow out of this phase eventually."
(B): "I will educate you on the Behavioral Parent Management Training approach and we will explore the benefits of these techniques together."
(C): "Use negative reinforcement to deter his behavior and CBT for addressing negative patterns."
(D): "You have to implement stronger boundaries in order for my interventions to be effective."

Correct Answer: "I will educate you on the Behavioral Parent Management Training approach and we will explore the benefits of these techniques together."
Explanation: Parent behavior management training is an evidence-based treatment teaching parents how to manage difficult childhood behaviors (defiance, outbursts, noncompliance). Validating and encouraging a parent like in answer a) is positive, a positive attitude to have however dismissing the behavior or the parent's role in reinforcing the behavior is not clinically best practice when you are responsible for treating the child conducting those behaviors. Answer b) is an aggressive response to a parent who is actively seeking advice and support, however the need for stricter boundaries may be something the parent should consider. Negative reinforcement and CBT (cognitive behavioral therapy) techniques are also appropriate to teach the parent, but this response assumes the parent understands these terms. It is also best practice to collaborate with the parent on what interventions they have already tried already, and work towards empowering them to select their own options as this approach tends to be the most effective. Therefore, the correct answer is (D)
Competency: counseling skills and interventions