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: Which objective is most efficient for addressing Lottie's behavior issues?
(A): Discuss feelings about having ADHD and learn acceptance and coping.
(B): Identify behaviors causing difficulty and list consequences of problem behaviors.
(C): Teach replacement behaviors and practice using them.
(D): Learn how ADHD affects behavior and verbalize understanding of symptoms.

Correct Answer: Identify behaviors causing difficulty and list consequences of problem behaviors.
Explanation: With co-occurring ADHD and ODD, Lottie is going to have a hard time taking suggestions in treatment of her conditions. Cognitively she is impaired and behaviorally she is resistant to suggestions. Without an understanding of how or why some of her behaviors are problematic, Lottie may not develop the desire or motivation to modify her behaviors. With little insight into what is causing her difficulty, Lottie will also not be willing to make changes. Discussing feelings about her conditions, learning acceptance, and coping strategies, and better comprehending the clinical issues underlying her symptoms, are all healthy objectives in counseling with Lottie; however, the most efficient method to directly help affect positive change for her is to target what Lottie endorses she is struggling with and help her see the effect of her choices. She may then be more willing to work on interventions aimed towards modifying inappropriate actions or improving skills needed to compensate for deficits. Therefore, the correct answer is (D)
Competency: counseling skills and interventions