Case Study
Patient Demographic: Client Age: 9 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private practice clinic Type of Counseling: Individual counseling with family involvement Presenting Problem: Behavioral problems and social skills issues Diagnosis: Autism spectrum disorder, without accompanying intellectual impairment (F84.0)
Mental Status Exam: Mental Status Exam: The client is oriented to person, place, situation, and time. The client appears clean and is wearing season-appropriate clothing; however, his parents report that he often wears the same outfit for several days because he gets frustrated with having to change his clothes and showering. The client was minimally involved in the intake session and was instead focused on reading a video game walk-through
Presenting Problem: You are a private practice, licensed counselor. The client is 9 years old and comes to the first session with his parents. The client has been previously diagnosed with autism via use of the Autism Diagnostic Observation Schedule-Second Edition by a psychologist, and you receive supporting documentation for this diagnosis. The client demonstrates difficulties with normal back-and-forth communication with peers, difficulty maintaining eye contact during the session, and difficulty with imaginative play with peers as reported by his parents. The client and his parents also report what they call “OCD behavior”—for example, he often lines up toys and insists that they “have to be this way”—and that he has trouble with changes in schedule, often becoming aggressive toward the parents if changes occur. The parents report that he is very rigid and that certain activities and play have to be done a certain way or he becomes upset, which affect the home, social, and school settings. The client’s intellectual quotient is above average for his age per the supportive testing provided. The parents report that the client’s difficulty with changing plans or daily changes causes him to become angry and confrontational.
Other Contexts: The client comes to the session, sits down, and is quiet. The parents report that prior to the session he was playing an online game and became so upset that he threw his video game console. The parents express frustration that they do not know what to do when this happens. You provide psychoeducation to the client regarding coping skills to manage frustration. You find out that the parents respond by removing access to video games, and this usually results in yelling back and forth with the parents and the client. The parents do typically encourage the client to listen to music because this appears to be very effective in calming him down. The client expresses frustration with the people that he was playing with by saying that they “cheated and are lying about it.” You support the client with cognitive reframing.  When the client becomes angry, the parents are unsure of what to do

Question: When the client becomes angry, the parents are unsure of what to do. Which of the following would be considered positive reinforcement of the client’s behavior?
(A): When the client resists becoming angry despite circumstances that usually generate his anger, the parents withhold a negative consequence (such as scolding) to encourage him to continue the appropriate behavior.
(B): The client does not become angry when he loses, and the parents provide praise.
(C): The parents remove the video game console and restrict his access to it over the next week.
(D): The parents ignore the client when he throws his video game console.

Correct Answer: The client does not become angry when he loses, and the parents provide praise.
Explanation: The parents are providing positive reinforcement when they provide praise when the client exhibits appropriate behavior. The parents removing a consequence (scolding) to increase appropriate behavior is negative reinforcement. The parents ignoring a behavior is considered extinction. The parents removing the console would be considered punishment for his behavior. Therefore, the correct answer is (A)
Competency: counseling skills and interventions