Case Study
Patient Demographic: Name: Jackson Clinical Issues: Behavioral problems Diagnostic Category: Depressive Disorders Provisional Diagnosis: F34.8 Disruptive Mood Dysregulation Disorder Age: 11 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Not Assessed Ethnicity: White Marital Status: Not Applicable Modality: Individual Therapy Location of Therapy : Private Practice  
Mental Status Exam: Appearance: The client is dressed in clothes associated with anime. He is well groomed and appears to be a few years younger than his chronological age. Orientation: The client is oriented X3. Mood: The client's mood is dysphoric. Affect: The client's affect is restricted. Speech: The client's speech is soft and hesitant. Thought Process: The client's thought process is slow and labored. Thought Content: The client's thought content is pessimistic and focused on negative themes. Perception: The client's perception is intact. Insight: The client's insight is poor.
Presenting Problem: First session You are a therapist in private practice specializing in working with children. The client is an 11-year-old male. His mother brought him to therapy because of the "latest incident at school," wherein he had an angry outburst and threatened to come to school with a gun and shoot everyone, including himself. The mother states that the police were notified, and the client was suspended from school for a week. The client was unwilling to discuss his emotions or the incident at school. He became agitated and defensive whenever the topic was brought up and now will not talk to you. He seemed to be in a state of denial, minimizing the impact of the incident at school. You observe a bald spot on the top of the client's head, indicating that the client has been pulling his hair out. The client was evasive when asked about the bald spot on his head and became increasingly anxious. He could not articulate why he was pulling his hair out and seemed embarrassed, avoiding the topic. He has difficulty identifying and expressing emotions outside of anger. His mother reports that he lashes out at home with family and classmates at school, aggressively arguing and making threats. He had difficulty engaging in self-reflection and could not make meaningful connections between his behavior and the consequences that may follow.  His mother is extremely frustrated and worried that this school will also expel him. She is upset with the lack of progress his previous therapist made with her son and is now considering residential treatment options. The mother has been receiving conflicting diagnoses from previous therapists and is seeking a definitive diagnosis from you. Halfway through the session, you ask to speak with the client by himself for a few minutes. The mother exits the room, leaving you alone with the client. You take notice of his anime shirt and ask him more about anime. He quickly starts talking and making eye contact.  Second session After your initial session with the client, the school performed a risk assessment and concluded that the client could return to school. You have requested to meet with the client and his mother every week. Today is your second session, during which time you spend the first thirty minutes talking with the mother and the second half talking with the client. During your conversation with his mother, she shared that she believes her son might have Autism. She says she has been debating whether to tell you this because she is "concerned about the stigma associated with Autism" and the possibility of her son being treated differently. She has been anxious about her son's issues and wants to have him tested to get him the "right help."  Jackson's mother appeared very anxious during the session. She shared concerns that he may have Autism but has hesitated to disclose this for fear of stigma. She has been struggling with getting him properly assessed and finding adequate support. Her anxiety around Jackson's issues was evident in her tense body language and rapid speech. She is worried about her son's well-being and future. However, the stigma she associates with an Autism diagnosis seems to be preventing her from getting Jackson the help he likely needs.  You recognize that Jackson's mother feels overwhelmed and alone trying to understand her son's difficulties. Her eagerness to have him tested indicates she believes an Autism diagnosis would provide answers and open up access to services. Yet she is torn about the potential labeling and discrimination Jackson could face. Her desire to protect her son's privacy competes with her need to get him help. This is causing Jackson's mother significant inner turmoil. She presented today as a caring parent under great strain.  In the second part of the session with the client, you find him disinterested and bored until you start talking about gaming. Then, he appears to perk up and becomes talkative. When you ask why he thinks he is here, he tells you about an incident at school. A student in another room texted his entire class, saying he was "short." This angered him, and he left the classroom and started a fistfight with that student, resulting in disciplinary action.  Jackson told this story with clenched fists, still visibly upset. He explained that the school was unfair and justified his violent reaction by stating he has Autism. This suggests Jackson feels his neurodiversity excuses poor behavior. Rather than take responsibility, he blamed external factors for the altercation. Jackson's body language and tone indicated he remained defensive and saw himself as the wronged party.  Jackson believed his Autism diagnosis makes aggression an inevitable response in certain situations. By citing Autism as the cause of his actions, he abdicated any sense of personal responsibility. Without intervention, he may continue acting out when provoked and making excuses based on his diagnosis. There is a risk that Jackson will not develop appropriate coping skills or learn to navigate his interpersonal conflicts. He appears fixed in the view that others are at fault, while his neurodiversity pardons any misdeeds.
Other Contexts: The client's biological father was diagnosed with Bipolar I Disorder. The biological father is unaware of the client's existence although the client knows that his step-father is not his biological father. The client has transitioned from school to school. Each time his behavioral problems have escalated. This is his third school. The client's issues have become so severe that his parents have been called to the school multiple times. They have been unable to get him to listen to them or follow directions. His outbursts are becoming more frequent and aggressive, and his refusal to do work or cooperate has become a problem for his teachers.  The school has tried various approaches to try and help the client, but he has been resistant to them. He has been put on a behavior plan but has not followed through. The administration has also tried talking to him on multiple occasions to try and get him to open up, but he has been unresponsive.  The administration has now exhausted all of its options and is at a loss as to what to do. They are willing to give him one more chance, but they will be forced to find another solution if he does not improve. Previous Counseling: The client has been seeing a pediatric psychiatric nurse twice a month for two years for his frequent temper outbursts at home and school. His irritable and angry mood is a daily occurrence, with verbal rages and physical aggression occurring three or more times a week. He is currently taking Respidol for emotional regulation. The medication affects his appetite and energy level. 

Question: Which short-term goal would you prioritize as you develop a treatment plan for the client?
(A): Decrease angry outbursts and behaviors
(B): Decrease his defiance toward his mother
(C): Decrease bullying
(D): Decrease anxiety

Correct Answer: Decrease angry outbursts and behaviors
Explanation: You are considering the diagnosis and his school behaviors which have led to expulsions. Decreasing angry outbursts and subsequent behaviors is the most critical goal on which to work. Therefore, the correct answer is (D)
Competency: treatment planning