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: As you are concluding your conversation with Avery's parents, they ask if you can also treat his twin brother Marc, who has autism spectrum disorder and is non-verbal. You should reply?
(A): "It is unethical to provide counseling for a family member of an existing client."
(B): "I can't treat him or help you with that, but Google some local autism resources."
(C): "I am happy to conduct an assessment, but I also might refer you to an ABA Specialist."
(D): "Of course I can treat him! Let me check my calendar and we will get him right in!"

Correct Answer: "I am happy to conduct an assessment, but I also might refer you to an ABA Specialist."
Explanation: It is best practice to offer or assess each client on your own prior to agreeing to or denying services. To better understand Marc's needs, conducting an assessment can help you to rule out which conditions you can or cannot support. You should also prepare your clients to know that external support from other specialists might be an option you provide depending on the client's needs that may be outside of your scope of practice. It is not unethical to treat more than one member of the same family depending on the circumstances and situation, specifically when it comes to child siblings; often the parents of children in counseling will prefer the same counselor to meet with their different children and resolve family dynamics issues and provide insight to the parent. The situation must be screened for boundary issues and unethical dual relationships or roles. Answer d) sounds supportive and encouraging but could be giving a family false hope if agreeing to provide services without properly screening through initial assessments. Therefore, the correct answer is (A)
Competency: treatment planning