Case Study
Patient Demographic: Client Age: 9 Sex: Male Gender: Male Sexuality: Unknown Ethnicity: Caucasian Relationship Status: Not Applicable Counseling Setting: School Type of Counseling: Individual Presenting Problem: Severe Temper Outbursts Diagnosis: Disruptive Mood Dysregulation Disorder (DMDD), Provisional (F34.81)
Mental Status Exam: Mental Status Exam: The client’s affect is irritable and angry. He sits with his arms crossed and exhibits poor eye contact. His appearance is somewhat disheveled. Mother reprimands the client multiple times, requesting that he “sit up straight” and “answer the lady’s questions.” The client mumbles responses at his mother’s prompting and is otherwise minimally engaged. The client reports that he “gets mad” daily and feels unjustly “blamed for everything.” His motor activity is somewhat fidgety. Speech and language skills are developmentally appropriate. The client states he “sometimes” feels sad and denies feeling worried or scared. His appetite is good and his sleep is poor. The mother attributes his sleep difficulties to the client staying up late playing video games.
Presenting Problem: You are a school-based mental health clinical counselor conducting an initial intake evaluation. A 9-year-old 3rd-grade male is accompanied by his mother, who reports that the client has been in several school and neighborhood altercations. She states she is at her “wit’s end” with him and is about to lose her job due to constant calls from his school. The client’s teacher reports that the client has daily temper outbursts, and his mother says that his mood is irritable for most of the day, every day. The client was recently suspended from school for flipping over his desk when his teacher told him he lost recess privileges. The mother first noticed these behaviors when her son was in kindergarten. The client recently kicked a hole in his wall after losing a video game. His grades are poor, and the school is currently evaluating him for special education services. The client was reluctant to take part in the intake. He shrugged his shoulders when asked if he would agree to participate in counseling.
Other Contexts: The client is seen for the first time since the initial intake due to being suspended the previous week. He displays an angry affect, sits with his arms closed, and faces the wall. You begin to establish rapport by engaging the client in a game. The client starts to open up and discloses that he feels angry every day and attributes this to his mom “always bothering” him and “everybody always picking” on him. He believes that his teacher doesn’t like him, and he is unhappy that his desk is no longer with the other students but instead right next to the teacher. He states that when he feels angry, his heart races, he clenches his fists, and he feels a tightness in his chest.  You and the client’s mother develop an incentive chart for the client. The mother uses a token system to reward skills learned in family therapy, and she uses planned ignoring when the client displays maladaptive behaviors

Question: You and the client’s mother develop an incentive chart for the client. The mother uses a token system to reward skills learned in family therapy, and she uses planned ignoring when the client displays maladaptive behaviors. This is an example of which one of the following?
(A): Exposure and response prevention (ERP)
(B): Contingency management (CM)
(C): Motivational interviewing (MI)
(D): Habit reversal training (HRT)

Correct Answer: Contingency management (CM)
Explanation: CM is based on the principle of operant conditioning and involves shaping desired behaviors. CM uses “if, then” contingencies to provide or withhold rewards in response to predetermined behaviors (eg, “if” the client stops playing video games after being asked the first time, “then” he can stay up 15 minutes past his bedtime). A token economy is a form of CM that uses positive reinforcement and extinction. Tokens serve as behavioral reinforcements and are administered when the targeted or desired behavior occurs. When the client displays maladaptive behavior, the mother ignores the behavior. Planned ignoring removes the desired response (eg, attention) through extinction. MI is a collaborative approach used to help clients resolve ambivalence and increase motivation. ERP is used with children experiencing anxiety or panic disorder; it involves incrementally exposing the child to anxiety-related triggers in a safe setting to reduce or eliminate anxiety-related responses (eg, rituals). HRT is an intervention used with children who have tics or Tourette’s syndrome. HRT techniques include identifying sensations occurring directly before the tic to respond to that urge in a new way. Therefore, the correct answer is (B)
Competency: treatment planning