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

Question: Given the client’s ability to describe what happens when he feels angry, how would you proceed?
(A): Refer the client for a psychiatric medication evaluation.
(B): Have the client keep a journal and record the relationship between behavioral symptoms and negative self-talk.
(C): Teach the client relaxation techniques to use when experiencing associated physiological symptoms.
(D): Request that the client’s teacher move the client’s desk back with the other students.

Correct Answer: Teach the client relaxation techniques to use when experiencing associated physiological symptoms.
Explanation: Evidence-based practices for DMDD include cognitive-behavioral therapy and mindfulness-based interventions. Relaxation skills training is a mindfulness-based intervention. Since the client can identify physiological symptoms associated with feeling angry (eg, heart races, teeth clench, chest tightness), the next step would be to teach relaxation and other emotional regulation skills. Although medication can be prescribed to children with acute symptoms, this is generally initiated if therapy alone proves ineffective. Asking the client to keep a journal would not be appropriate for this client as there is currently no demonstration of insight or motivation. At present, requesting that the teacher move the client’s desk back with his peers is not in the client’s or the other students’ best interest. Therefore, the correct answer is (B)
Competency: counseling skills and interventions