Case Study
Patient Demographic: Name: Timmy Clinical Issues: Developmental processes/tasks/issues Diagnostic Category: Neurodevelopmental Disorders Provisional Diagnosis: F84.0 Autism Spectrum Disorder, Level 2 Age: 13 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: Black Marital Status: Not Applicable Modality: Family Therapy Location of Therapy : School  
Mental Status Exam: The client speaks using only a few words. There is no report of echolalia or other repetitive or overly formal use of language. You ask him to say "hi," and he opens his mouth wide, smiles, and laughs. He sustains direct eye contact with you for about two seconds. When you ask him to show you where his mother is, he points to her, looks back at you, and begins to laugh again. There are no reported or observed preoccupations and no reported or observed sensory symptoms to date.
Presenting Problem: First session You are a mental health therapist in a school setting. The client is referred to you by your school district to complete an evaluation. The client and his mother enter the session. The mother is prompting the client in a "toddler-like" voice to sit in the seat. The mother tells you that the client is becoming increasingly "violent" in the home setting, and she and her husband are not equipped to teach their son the skills he needs to regulate his emotions. In addition, she states that he needs some social exposure to others. He is nonresponsive to subtle social cues and has difficulty when others cannot understand his needs. She states that they need professional help and requests assistance in getting him "the education he deserves". You listen carefully to the mother's concerns and ask additional questions about her son's behavior, both at home and in school, as well as any history of mental health treatment or diagnoses.    You explain to the client’s mother that you will provide an assessment of her son’s social and emotional needs and use evidence-based interventions to help him develop effective strategies for regulating his emotions and interacting with others. You review your therapy procedures in detail, including your expectations regarding how often the client and family should come for sessions and what to expect in terms of treatment outcomes. You also discuss any potential risks associated with therapy and the importance of open communication between family members, the client, and yourself during treatment. The mother expresses her understanding of your expectations and agrees to follow through with treatment. You encourage her to ask questions if she has any concerns or needs clarification about any part of the therapy process.  Fourth session You have arranged for the client to have a one-on-one aid at school. You review his progress with his team of teachers and give them necklaces with visual cues to help communicate with him. The aid brings the client in for his weekly session with you today. The client sits and stares. At times he will rock and make loud noises. You hand him a stress ball and model for him how to squeeze it. The client starts to giggle as he squeezes the stress ball. You show the client the picture of a person laughing. You clap for the client and tell him "good job." The client mimics you and starts to clap. You ask the client if he would like to try playing a game with you. He nods his head in agreement and looks at you with anticipation. You choose a simple matching game with different shapes, colors, and sizes. Through this game, you encourage him to take turns and practice communication skills. As the session progresses, you provide verbal praise for his efforts and watch as he slowly builds a sense of trust in you. You create opportunities for him to share small stories about himself and encourage him to express his feelings through drawings or writing exercises. Through these activities, you provide a safe and comfortable environment for him to explore his emotions and interact with others.    Following your session with the client, you contact his mother with an update on his progress. You discuss the importance of continuing therapy on a regular basis and explain what kinds of progress she can expect to see as time goes on. You also provide her with resources such as books, websites, and support groups that she can use to help reinforce the skills her son is learning in therapy. Finally, you outline a plan for continuing treatment and develop a timeline for when the family should check back in for sessions. The client's mother expresses her appreciation for your assistance and her agreement to follow through with the treatment plan.  Ninth session The client's one-on-one aide presents to this session with the client. The client is crying and having difficulties following the aid's directives in the hallway. You walk into the hall and show the client a picture with "a quiet sign." You open your door, and he reluctantly walks in and begins to kick the toy bins. You show him the "no" visual sign and shake your head no. You sit on the floor quietly until he joins you on the floor. You pull out a deck of visual cue cards and place them in front of him. He points to a picture of a boy being mean to another classmate, then starts to cry harder.    You allow some extra time for the client to process his emotions. You then explain to him that it is not okay to kick the toy bin, and that he can use his words or draw pictures of what he feels instead. You provide reassurance that you are there to help him learn how to control his feelings in a better way. You then select some calming activities such as squeezing the stress ball and playing a matching game. As he begins to gain control of his emotions, you reinforce positive behaviors with verbal praise and approval. Throughout the session, you actively listen and provide opportunities for him to express himself in whatever manner is comfortable to him. You end the session by drawing a picture of yourself and your client, with both of you smiling together. You explain that this is what happens when you work together to find positive ways to cope with emotions.
Other Contexts: The client has a close-knit family, and his parents strive to support their son in any way they can. They have little outside support, however, and have been overwhelmed by their child's needs. The client has been home-schooled and lacks social skill development. Parents report that lately he refuses to do school work; as he gets older they will not have the skills to teach him what he needs to know academically. They feel it is now best for him to learn how to thrive socially and emotionally in a public school setting. 

Question: What will work best in facilitating trust and safety at school for this client?
(A): Role play the bullying and explore appropriate responses with the visual cards
(B): Contact the client's parents and school regarding the potential bullying issues
(C): Allow the client to take the stress ball with him to class
(D): Monitor the client's routine to provide more supervised relational time

Correct Answer: Contact the client's parents and school regarding the potential bullying issues
Explanation: Addressing the bullying directly would be the most appropriate choice to facilitate trust and safety at school for this client. Therefore, the correct answer is (A)
Competency: professional practice and ethics