Case Study
Patient Demographic: Client Age: 8 Sex: Male Gender: Male Sexuality: Unknown Ethnicity: Hispanic Relationship Status: Single Counseling Setting: Home Health Outpatient Therapy Type of Counseling: Individual with Family Involvement Presenting Problem: Behavioral Issues Diagnosis: Oppositional Defiant Disorder, Severe (F91.3)
Mental Status Exam: Mental Status Exam: The client was argumentative and did not engage in the entire intake session. The client was oriented to person, place, situation, and time. He was dressed appropriately for the weather and appeared well groomed. The client appeared clean and had appropriate hyg
Presenting Problem: You are a home health outpatient therapist working with an 8-year-old male in the home setting. The client’s parents will be actively involved in counseling due to the client’s age. The client was referred to receive counseling by his school social worker. He has been having behavioral issues in school that have led to difficulty staying in the classroom and is resultantly falling behind in academics. During the first session, the client refuses to engage and leaves the room. The client’s parents prompt him to return, and he calls them “jackasses” and leaves the room again. The parents finish the intake session with you and provide you with a report on their observations in the home and reports from the school social worker. The client reportedly often loses his temper and is generally easily annoyed or angered. The client has trouble taking direction from his teachers and parents. The client’s parents also state that he often blames his younger sister for things that he does and often tries to annoy her. The parents have trouble identifying any of the client’s friends and state that he does not get along with his peers.
Other Contexts: You arrive at the client’s house for the session, and he decides to meet with you in the family office and brings some toys with him. He sits on the floor, and you decide to sit on the floor with him and engage in play to continue building rapport. While playing, you begin to ask the client about what frustrates him about his parents, and, through processing, you identify that he desires some independence. You meet with the parents after the session and encourage them to give him some choices throughout his day so that he can have a sense of control. You state that they can be choices that may not be consequential, such as the order of the bedtime routine, so that the routine still happens but he has some control over the order of the process

Question: When addressing the client’s behavioral response to the denial of a snack, which one of the following would be the most appropriate behavioral intervention?
(A): Maintain boundaries and allow the client time to accept the decision that was made about waiting until the end of the session for the snack.
(B): Support the client in requesting the snack in a more appropriate manner and when he does, you provide the snack.
(C): The parents set a boundary that the client needs to wait until the session is over, so you support him in coping with the denial of his request.
(D): Support the client in calming down, and when he does, if he requests the snack in an appropriate manner, he may have it.

Correct Answer: The parents set a boundary that the client needs to wait until the session is over, so you support him in coping with the denial of his request.
Explanation: The most appropriate behavioral intervention should address the problem behavior, which, in this case, is the reaction to being denied a snack immediately (and not the manner in which he requested the snack). When the client engages in inappropriate behavior in order to gain access to something (in this case, the snack immediately rather than after the session), you should support him in coping with the decision that was made if clear boundaries are set. If the client had inappropriately requested the snack, then you could support the client in requesting the snack more appropriately and provide the snack when he does. Simply allowing the client to accept the decision that was made by his parents is not enough because you want to empower him to cope with his strong emotions. Therefore, the correct answer is (A)
Competency: counseling skills and interventions