Case Study
Patient Demographic: Initial Intake: Age: 9 Gender: Female Sexual Orientation: Heterosexual Race/Ethnicity: Caucasian/Non-Hispanic Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual
Mental Status Exam: Lottie presents as excited, over-stimulated and hyperactive, unable to sit still and does not take breaks from talking. Her appearance is highly disheveled with stained clothes and unbrushed hair. Lottie nervously walks around your office touching and commenting on everything. You ask her nicely to ask you before she touches your things, but she refuses and continues to do so. Lottie deflects from every question posed in your assessment. She denies SI/HI, hallucination, or delusion, which you were surprisingly able to find out from her.
Presenting Problem: 
Diagnosis: Attention Deficit Hyperactivity Disorder, predominantly hyperactive type (F90.1), Oppositional defiant disorder (F91.3), Reaction to severe stress (F43.9)
 

Lottie is a 9-year-old girl in the fourth grade who has been referred to you by officials in her elementary school. You are a counseling intern of a private practice that specializes in adult personality disorders, but your supervisor accepted Lottie as a new client because Lottie’s mother is a former client of her agency, and she requested her daughter be seen by your practice as opposed to a school-based counselor. Lottie’s mother does not want Lottie’s peers to know she is in therapy. Lottie has been doing well in school academically but has not been able to behave appropriately for years, according to the referral report. Lottie bounces up and down in her chair constantly, makes impulsive noises throughout the day, and engages in inappropriate behaviors daily. Some of the behaviors listed include invading the personal space of her peers, licking and eating school supplies to garner reactions from fellow classmates, hiding on the playground and refusing to emerge, and many other behaviors. Lottie follows basic classroom directions but needs constant reminding or guiding that the teacher does not have time for. Lottie breaks down into hysterical emotional fits when she does not get her way and her behaviors have been spreading the school staff too thin to be capable of managing without intervention. This session is conducted with only Lottie in the room; her mother insists on waiting in the car outside so she can make some phone calls. She mentions her Medicaid has just been reactivated to pay for sessions.
Other Contexts: Family History:
Lottie lives at home with her mother and mother’s boyfriend, as well as their 1-year-old son Davie who is her half-brother. You learned from speaking with her mother beforehand that Lottie’s biological father was a drug addict and homeless, and he was recently shot and killed, about four months ago. Lottie knows and understands what happened. During the intake session you ask her to draw a picture of something important to her. She likes this assignment and draws you a picture of her father’s homeless camp where she last saw him. She explains to you the details surrounding his murder and mature, intimate details of her mother’s broken relationship with him. “How do you know all of this, Lottie?” you ask her, concerned. “Oh, my mother told me. She tells me everything.”

Question: Speaking with Lottie's mother after session, you mention her comment about getting in trouble for admitting to feeling unsafe. Lottie's mother assures you she is safe, saying she has told stories in the past which led to unsubstantiated reports and cancelled investigations. What should you do?
(A): Continue to monitor the situation.
(B): Confront Lottie about the storytelling.
(C): Ask to have a session at Lottie's house.
(D): File a report anyway out of safety concerns.

Correct Answer: Continue to monitor the situation.
Explanation: Lottie's mother's explanation of storytelling is plausible, especially considering what you already know of Lottie's behaviors. However, it does not mean you should remove your attention from this factor while counseling Lottie. Continued safety questions, learning more about Lottie's traumatic past, and continual communication with her mother are all healthy and appropriate actions to take as you further assess their situation. Having a home visit is a clinical choice between you, your supervisor, and your client, but it does not yet seem warranted in this case as Lottie continues to be capable of coming into the office for sessions and you have not had many sessions yet with her. You still do not have enough information to substantiate any reporting. Confronting Lottie about storytelling is a choice you can make if you witness the storytelling yourself, however it seems Lottie's response to your safety question was her way of applying her own efforts to no longer tell stories. Therefore, the correct answer is (C)
Competency: counseling skills and interventions