Case Study
Patient Demographic:  Initial Intake: Age: 16 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: African American Relationship Status: Single Counseling Setting: Community Health Type of Counseling: Individual
Mental Status Exam: The client presents as a thin young woman, whose weight is appropriate for her age. Her clothing is appropriate for her age and to the situation. She identifies her mood as happy and her affect is congruent. The client shows some retardation in movement but no spasticity or physical or abnormal movements. The client appears open and honest in her responses, though responses are short. She responds to closed questions without pause but appears to struggle to answer open-ended questions as evidenced by staring and smiling without speaking or saying “I don’t know.” On examination, the client shows little insight into her mother’s concerns and uses childlike judgement when responding to hypothetical questions. The client denies suicidal or homicidal ideations or intent, delusions, or hallucinations, but does admit to playing a game with children at her maternal grandmother’s house where they attempt to see ghosts in the bathroom mirror.
Presenting Problem: You are a counselor in a community health setting which includes in-office sessions as well as home visits. Your client is a 16 year-old female who presents with a history of academic difficulties, problems following rules at home, and fighting with her sister, which recently included threatening to cut her sister with a kitchen knife. Her mother tells you that the client has always had some problems in school but they are getting worse. Her teachers say that she doesn’t pay attention and struggles with simple concepts, but is always polite and friendly to others. When asked to tell you how she thinks things are going, she answers “good” and smiles. You notice that she often smiles while her mother is talking but when her mother talks about the problems at home, the client looks away from both of you and stares out the window. The client’s mother reports that the client does not clean her room, has to be told to attend to her hygiene, and does not complete chores when they are assigned, such as cleaning out the refrigerator or vacuuming the living room. Mother reports that the client stays at home alone or with her two younger sisters when her mother or mother’s boyfriend are at work or away from home during the day.
Other Contexts: Family History:
The client is the oldest of three children born to her mother. Her siblings have different fathers and her youngest sister’s father currently lives in the home and is identified as “mom’s boyfriend” or “Robert.” Client’s mother reports no family history of mental health disorder or substance abuse. The client reports that she often spends several nights a week with her grandmother “to give Mom a break” and plays games and spends time with the neighborhood children. The client states that her grandmother “makes me sit and she reads the Bible to me” for several hours each day. She reports that she likes spending time at her grandmother’s house because she and her sister watch “scary movies” including movies about monsters, murders, and witchcraft.

Question: Using the information provided, which action is most appropriate in working with this client?
(A): Obtaining release of information to talk with client's school, physician, and family members.
(B): Referring the client for testing and possible accommodations due to her academic difficulties.
(C): Assessing the client for early childhood or current traumatic events.
(D): Helping the client's mother set appropriate guidelines and rules for this client.

Correct Answer: Obtaining release of information to talk with client's school, physician, and family members.
Explanation: Each of the responses are appropriate, however the most important will be to obtain a release of information to talk with others involved in working with this client. The intake information is being provided from the mother and the client appears limited in her responses. The counselor will gain a more holistic view of the client through speaking with the client's teachers to best understand the client in her academic setting, understanding any physical or psychological concerns that may have been previously identified by her physician, and speaking with grandmother as she is the client's caregiver for part of each week. Based on discussions with the client's school and physician, testing may be required. It will also be appropriate to assess for trauma and mother may need assistance with setting appropriate guidelines for this client, however these will need to occur after more data is gathered from additional sources. Therefore, the correct answer is (C)
Competency: professional practice and ethics