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11.
Case Study 2 Initial Intake Age: 8 Gender: Male Sexual Orientation: N/A Ethnicity: Caucasian Relationship Status: N/A Counseling Setting: Through agency inside school and via telehealth Type of Counseling: Individual Presenting Problem: Attention and concentration deficits Diagnosis: Attention-deficit hyperactivity disorder, combined type (F90.2)Presenting Problem: Avery is an 8-year-old Caucasian male that has been referred to you by his school counselor because of emotional breakdowns, failing grades and falling asleep in class. You set up an initial assessment session with Avery and his parents in person at the school’s conference room and learn that he refers to his biological mother as “dad” and her wife as “mom”, and that he has a twin brother with Autism. Mom tells you Avery sees a psychiatrist for medications but frequently has them changed because she feels they are not working. Mom reports Avery has trouble sleeping at night, hits and kicks her and his brother when he’s angry and steals food from the kitchen and hides it in his room. She must ask him multiple times to complete a task and he often will not comply or forget each time he is told. Dad adds that Avery is very smart and does well in most subjects in school but struggles with reading comprehension and worded math problems. Avery is already on an IEP (Individualized Educational Plan) in school to better support his unique learning needs. They ask for your help in regulating his affect and behaviors. Mental Status Exam: Avery presents as fair, with some stains on his t-shirt. His mood is euthymic but with anxious affect as evidenced by hyperactivity, some pressured speech and fidgeting of the hands and feet as he cannot sit still. There is no evidence of suicidal or homicidal ideation and no reported hallucinations or delusions. The initial assessment revealed no significant trauma, other than not having his biological father around his entire life. Avery reports feeling tired often but overall happy. Mom reports his appetite is very good, but his diet could be better. He also has headaches at times in school or when he comes home. Family History: Avery is very close with his two mothers and does not seem to notice that he does not have his father present in his life. His mother mentions that he has made several remarks recently about wanting to be a girl. Avery’s brother is high functioning on the autism spectrum but has poor communication and coping skills, increasing Avery’s stress level at home due to their constant fighting. Both parents work full-time and take shifts in caring for the children, often sleeping at odd hours of the day and therefore have trouble keeping Avery on a regular schedule. Avery has some extended family on both sides and sees them occasionally. Dad reveals she was also diagnosed with ADHD and Dyslexia growing up and had trouble in school. Which of the following is not a behavioral definition of ADHD?
a. Impulsivity as evidenced by frequent intrusions into other\'s personal business
b. Susceptibility to distraction by extraneous stimuli and internal thoughts
c. Frequent disruptive, aggressive, or negative attention-seeking behaviors
d. Exhibiting a marked impairment or extreme variability in intellectual and cognitive functioning
This definition describes a facet of autism spectrum disorder; answers a) through c) all correctly fall underneath the symptoms of attention-deficit hyperactivity disorder.
Incorrect answer. Please choose another answer.
12.
Which instrument is the most appropriate for further screening Avery’s diagnosed symptoms?
a. Vineland Adaptive Behavior Scales (VABS)
b. Screen for Childhood Anxiety Related Emotional Disorders (SCARED)
c. Conners Parent and Teacher Rating Scale (CPTRS)
d. Child Behavior Assessment Instrument (CBAI)
The CPTRS measures the presence and severity of behaviors related to ADHD exploring inattention, hyperactivity, learning problems and social skills, filled out by parents and teachers. It also helps point out where further testing may be needed or monitor how well medication is working for children already diagnosed with ADHD, as is the case with Avery. The VABS measures how a child’s daily living skills compare to those of other kids his age, helpful for screening diagnoses of autism spectrum disorder, Asperger’s syndrome, and developmental delays. This instrument would be more helpful for use with Avery’s brother in this case, but no evidence suggests Avery is having developmental issues. The SCARED is a child and parent self-report instrument used to screen childhood anxiety disorders ages 8-18 years old and could be used to identify anxiety issues, however the question asks about Avery’s already diagnosed conditions. The CBAI helps identify young children at risk of behavioral problems in community settings, which is not the most appropriate choice for this case study.
Incorrect answer. Please choose another answer.
15.
First session, two weeks after the intake session You visit with Avery back in the school’s conference room during his math class. He tells you he does not like that class and is happy to be out of it, saying “I am too stupid. It’s too hard.” Throughout the session Avery abruptly interrupts you and races off to gather a different activity off the shelf or wants to switch topics of conversation. You call mom afterwards to touch base with how his moods and behaviors have been in the past two weeks. She reports that he is still stealing foods and hiding them, fighting with his brother, and having trouble sleeping. She asks what she should be doing at home to resolve the behaviors. What is the best response for how to guide this parent while building the therapeutic alliance?
a. "Don't worry, you're doing a great job and he will grow out of this phase eventually."
b. "You have to implement stronger boundaries in order for my interventions to be effective."
c. "Use negative reinforcement to deter his behavior and CBT for addressing negative patterns."
d. "I will educate you on the Behavioral Parent Management Training approach and we will explore the benefits of these techniques together."
Parent behavior management training is an evidence-based treatment teaching parents how to manage difficult childhood behaviors (defiance, outbursts, noncompliance). Validating and encouraging a parent like in answer a) is positive, a positive attitude to have however dismissing the behavior or the parent’s role in reinforcing the behavior is not clinically best practice when you are responsible for treating the child conducting those behaviors. Answer b) is an aggressive response to a parent who is actively seeking advice and support, however the need for stricter boundaries may be something the parent should consider. Negative reinforcement and CBT (cognitive behavioral therapy) techniques are also appropriate to teach the parent, but this response assumes the parent understands these terms. It is also best practice to collaborate with the parent on what interventions they have already tried already, and work towards empowering them to select their own options as this approach tends to be the most effective.
Incorrect answer. Please choose another answer.
18.
Second session, two weeks after the first session You decide to meet with Avery’s parents again together and in person along with Avery’s school counselor briefly before having your next session with Avery. The school counselor reports Avery’s emotional responses to difficulties in class have not been as severe as in past weeks, but that he is still falling asleep during morning classes. Dad mentions that Avery is often up late playing video games despite their attempts to get him to sleep. Mom adds they have settled on a medication regimen that has reduced Avery’s physical aggression, but that he is less communicative now and “spaces out” more. In meeting with Avery, he presents as more focused on your intervention attempts but when you ask how he has been feeling he reports “I don’t feel anything, really.” Which type of therapy encompasses teaching emotion regulation and distress tolerance that would be helpful for Avery in case of future behavioral outbursts?
a. Cognitive Behavioral Therapy
b. Dialectical Behavioral Therapy
c. Applied Behavior Analysis
d. Holistic Therapy
Emotion regulation and distress tolerance are taught facets from the school of Dialectical Behavioral Therapy (DBT) which would be helpful for Avery in learning how to manage his emotions, tolerate frustration and regulate his affect. This is especially a good choice for a client who has little insight into their problem (either from a maturity standpoint, age, cognitive ability, or to help with personality disorder) and needs help controlling their bodily reactions immediately without necessarily understanding the underlying reasons why they react the way they do. Cognitive behavioral therapy (CBT) approaches will also be useful for Avery but focus on identifying and changing negative beliefs and thought patterns that contribute to maladaptive behaviors, which is critical for long term change. Applied Behavior Analysis (ABA) is the preferred intervention for autism, and holistic therapies can be considered to provide additional support but are not all clinically evidence-based and do not directly apply to the interventions listed in the question.
Incorrect answer. Please choose another answer.
19.
Second session, two weeks after the first session You decide to meet with Avery’s parents again together and in person along with Avery’s school counselor briefly before having your next session with Avery. The school counselor reports Avery’s emotional responses to difficulties in class have not been as severe as in past weeks, but that he is still falling asleep during morning classes. Dad mentions that Avery is often up late playing video games despite their attempts to get him to sleep. Mom adds they have settled on a medication regimen that has reduced Avery’s physical aggression, but that he is less communicative now and “spaces out” more. In meeting with Avery, he presents as more focused on your intervention attempts but when you ask how he has been feeling he reports “I don’t feel anything, really.” In response to Avery’s parents telling you how difficult it is to get him to sleep, you reply saying “I completely understand it must be difficult! I am here to help however I can.” This is an example of:
a. Reverse reflection and deflection
b. Non-judgmental stance
c. Development of conflict resolution strategies
d. Empathic responding using validation and therapeutic alliance
This is an example of showing empathy by validating a client’s feelings and reinforcing the therapeutic relationship by reminding them of your commitment to give your clinical resources to help alleviate their distress. Answer a) is a fabricated counseling skill. All clinical services should be provided from a non-judgmental position, offering unconditional positive regard as best practice. Developing resolution to their conflicts is at times a collaborative process along with the client, as well as it is a teaching process, that will continue throughout the course of their treatment. If the response were to include strategies, there would be instructions and SMART goals involved. This response was merely using core counseling attributes as a skill to enhance the client’s trust and comfort their apparent frustrations.
Incorrect answer. Please choose another answer.
20.
Second session, two weeks after the first session You decide to meet with Avery’s parents again together and in person along with Avery’s school counselor briefly before having your next session with Avery. The school counselor reports Avery’s emotional responses to difficulties in class have not been as severe as in past weeks, but that he is still falling asleep during morning classes. Dad mentions that Avery is often up late playing video games despite their attempts to get him to sleep. Mom adds they have settled on a medication regimen that has reduced Avery’s physical aggression, but that he is less communicative now and “spaces out” more. In meeting with Avery, he presents as more focused on your intervention attempts but when you ask how he has been feeling he reports “I don’t feel anything, really.” As you are concluding your conversation with Avery’s parents, they ask if you can also treat his twin brother Marc, who has autism spectrum disorder and is non-verbal. You should reply:
a. "I am happy to conduct an assessment, but I also might refer you to an ABA Specialist."
b. "I can't treat him or help you with that, but Google some local autism resources."
c. "It is unethical to provide counseling for a family member of an existing client."
d. "Of course I can treat him! Let me check my calendar and we will get him right in!"
It is best practice to offer or assess each client on your own prior to agreeing to or denying services. To better understand Marc’s needs, conducting an assessment can help you to rule out which conditions you can or cannot support. You should also prepare your clients to know that external support from other specialists might be an option you provide depending on the client’s needs that may be outside of your scope of practice. It is not unethical to treat more than one member of the same family depending on the circumstances and situation, specifically when it comes to child siblings; often the parents of children in counseling will prefer the same counselor to meet with their different children and resolve family dynamics issues and provide insight to the parent. The situation must be screened for boundary issues and unethical dual relationships or roles. Answer d) sounds supportive and encouraging but could be giving a family false hope if agreeing to provide services without properly screening through initial assessments.
Incorrect answer. Please choose another answer.