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: Disagreeing with Lottie's mom's opinion on her medication needs, you decide to speak with her later about it. How should you explain to mom the reasons for your psychiatric referral?
(A): She will not be successful without medication.
(B): Medication will also resolve her oppositional defiance.
(C): Untreated symptoms of ADHD are hindering growth.
(D): You can't get her to do your assignments.

Correct Answer: Untreated symptoms of ADHD are hindering growth.
Explanation: Lottie has endorsed that medication was once helpful to her, and that she wants to return to using it. She is clearly having undesired difficulty with her symptoms and is not progressing in treatment as she should. You recall the family's insurance is now active and can therefore possibly cover the cost of medications, should a psychiatric evaluation warrant them. Submitting a referral for her evaluation is appropriate and her mother's refusal to do so without good reason could be considered neglect. Medication will not necessarily resolve Lottie's ODD symptoms but can aid in her impulse control. Lottie can become successful with interventions other than use of medication, but her unwillingness to do work with you in session is not criteria for prescribing medication. The consequence of not working on assignments could be a lack of growth, which is why in speaking to Lottie's mom, who may be resistant to the idea of medication, the idea of submitting a referral for her evaluation should be prioritized. Either way, without properly treating ADHD, it will be much harder to isolate and treat symptoms from other disorders. Therefore, the correct answer is (D)
Competency: intake, assessment, and diagnosis