Author: Taryn A. Myers, Ph.D., Virginia Wesleyan College
Please note: Clinical Choices allows you to enhance and test your understanding of the disorders and treatments covered in your textbook, in a simulated case study environment. It is not intended to replicate an actual intake interview or therapy session or provide training on therapeutic techniques. Clinical Choices is for educational purposes only and is not intended as a substitute for clinical training.
The receptionist hands you the intake paperwork prior to your intake interview with your new client, Gabriel, and mentions that his parents have brought him in after several meetings with the staff at Gabriel’s school about his behavior. Click on the button below to review the paperwork before you begin the interview.
Gabriel: Case #11017
Client Name: Gabriel
Parent/Guardian Name(s) (if minor): Emily & Mateo
Age: 6 years old
Ethnicity: Biracial (Caucasian & Latino)
Occupation: Elementary school student
Current living situation: Lives with parents
Why are you seeking services at our clinic?
We have received numerous complaints from Gabriel’s teachers about his outbursts in class. They called us in for several conferences and told us that Gabriel won’t listen to instructions from adults, and also that he is struggling with his schoolwork.
You will now ask Gabriel and his parents a number of questions you would typically ask during the intake interview. As you conduct the interview with Gabriel and his parents, begin to think about his symptoms, what his diagnosis might be, and later, what type of treatment might be most helpful to him. Click the “play” button below the illustration to hear Gabriel’s and his parents’ responses to your questions. To read the transcript for these answers, click on the “transcript” button. Take notes in the box provided as you listen to Gabriel’s and his parents’ responses.
“Hi Gabriel, It’s good to meet you. I’m a doctor, but I’m not the kind of doctor who will give you shots or anything like that. Instead, we’re going to talk about what’s going on with you at home and at school. Mom and dad – Emily and Mateo, right? – it’s nice to meet you, too. What we are doing today is called an intake interview. I’m going to have you tell me why you are here today, and I’m going to ask you some questions that I ask everyone who comes here. This information will tell me how best to help you. This may mean continuing to come to see me here at this clinic, or you may meet another doctor. Let’s start. Gabriel, why do you think you are here today?”
Gabriel: [sulky] Don’t know. They made me come. Who are you?
Mom: [embarrassed] Gabriel, darling, be nice to the doctor! I am very worried about Gabriel. He seems to be getting more and more disobedient. His first-grade teacher has called us in for several conferences. Apparently Gabriel is constantly being sent to the principal’s office for causing distractions in class and refusing to do what she asks him to do. [to Gabriel, pleading:] Gabriel, honey, stop fidgeting, please.
Dad: He’s also being disrespectful to his classmates, He distracts and annoys them in class, apparently. [sternly] This behavior is completely unacceptable!
Mom: His teacher also says that he can’t sit still and he daydreams instead of paying attention in class – just like he is now. Gabriel, please…sit still. I know it’s hard for kids his age to pay attention, though, so maybe this is just normal?
Dad: [accusing] It’s not normal. You coddle him… you let him get away with all kinds of things!
Check Your Notes
What brought you in?
- Feels his parents made him come
- Seems to have difficulty sitting still
- Mom is worried about his increasing disobedience
- Teacher has called parents in for conferences
- Dad says child is disrespectful; distracts and annoys his classmates
- Teacher reports Gabriel fidgets and daydreams instead of focusing
“Emily, Mateo, what other concerns are you having at this time? How does Gabriel act at home?”
Gabriel: [rudely] Nothing! What’s it to you?
Dad: As you can see, he’s so argumentative and stubborn. What a pain!
Mom: Well, it has been hard to get him off the tablet, get ready for bed and go to bed at a reasonable hour. He also won’t make his bed, which is the one chore we are trying to get him to do.
Dad: Hard! How about nearly impossible! We have a battle every night about giving up that iPad, taking a bath and brushing his teeth. He won’t even put his pajamas on by himself! Then, once we put him to bed, he won’t stay there! It’s getting to be more and more of a struggle.
Gabriel: [rudely] Why do I have to put on pjs? You just make me take ‘em off again when I wake up!
Mom: I have to bribe him with an extra dessert to get the iPad, so he can get ready for bed. That seems to work. Getting him to do his reading is a huge ordeal! His teacher says he seems to be slow to catch on with reading, so she asked us to have him read for half an hour at home. I give him more time on the iPad as a reward for reading.
Dad: That’s the main problem - Emily spoils that kid. He’s smart, too… don’t let him fool you…he’s figured out how to get more and more time on the iPad… [aside, to Gabriel:] Son, what have we said about keeping your behind in your seat?
Mom: [martyred] Go ahead, blame me, if it makes you happy, Mateo. Everything is always my fault. If you spent more time with Gabriel and treated him with respect instead of like a drill sergeant he would not be rebelling. His soccer coach is just like you. Gabriel is just a kid, for heaven's sake! It’s hard for kids to sit still in a classroom or stand in one place for a stupid soccer game.
Dad: Don’t even get me started on soccer! – [harshly] Gabriel, come back here…sit still and pay attention when adults are talking!...He was rude to his soccer coach – again -- at Saturday's game. The coach put him on the sidelines for three minutes. He’s been fooling around at practice instead of doing drills. Then his coach dropped him from the team. The final straw was when he was goalie and refused to stay in the box and pay attention to the game. He drew pictures in the dirt or jumped up and down. I was so angry I had to leave the game. What an embarrassment!
Check Your Notes
- Doesn’t seem to respect adult authority
- He has a hard time sitting still
- Dad says he is argumentative & stubborn
- Won’t give up the iPad and fights bedtime activities → won’t stay in bed
- Mom bribes him to give up the iPad and get ready for bed
- Resists and has trouble reading → at school and at home
- Dad thinks it is because mom spoils him
- Dads notes that Gabriel has figured out how to manipulate mom to get more time on the iPad
- Mom feels blamed and thinks dad is too harsh
- Gabriel was kicked off soccer team for fooling around and not paying attention
Think about what is fact and what is opinion from what Gabriel and his parents have told us.
Which of the following diagnoses is a potential explanation for Gabriel’s behaviors at home and school? Check all that apply. To review the diagnostic criteria for each disorder, click on the disorder name.
|wCfH0QtRgXJ8o+c+||Separation anxiety disorder|
|bI0LPa9lfHQ+dYqk||Disruptive mood dysregulation disorder|
|bI0LPa9lfHQ+dYqk||Oppositional defiant disorder (ODD)|
|bI0LPa9lfHQ+dYqk||Conduct disorder (CD)|
|bI0LPa9lfHQ+dYqk||Attention deficit/hyperactivity disorder (ADHD)|
|bI0LPa9lfHQ+dYqk||Specific learning disorder|
|wCfH0QtRgXJ8o+c+||Autism spectrum disorder|
Think about all of the symptoms Gabriel’s parents mentioned. There is more than one correct answer.
“How do you react when Gabriel doesn’t listen to you or misbehaves?”
Dad: Ugh. Don’t even get me started about his behavior at home. Six years old, and he already has a chip on his shoulder! It’s unbelievable!
Mom: He talks back pretty regularly.
Dad: He knows better than to argue with me, of course, because I will let him have it – a good hard smack on the behind shuts him up. But you ought to hear him and Emily go at it!
Mom: He argues constantly with me… about playing with iPad or my phone, about doing his reading, picking up his toys, getting ready for bed…everything is a struggle.
Dad: It’s because you treat him like your brother instead of your son. The way you argue, you sound more like siblings than mother and son.
Mom: [to Gabriel] Gabriel, come away from that bookshelf… stop that…sit down in your seat, please. [to therapist] I try to make reasoned arguments with him, but it doesn’t always work!
Dad: He never listens. You can’t reason with him.
Check Your Notes
How do parents react when Gabriel talks back?
- Dad spanks him
- Mom argues with him and tries to reason with him
- Has a hard time sitting still and is getting into everything
“What is it like for you at school, Gabriel? Do you get in trouble sometimes?”
Gabriel: Yeah. The teacher doesn’t get it. The other kids get me in trouble. Yesterday, I was finishing up my picture book drawings and I needed the silver marker… and this girl wouldn’t share. [loudly] She’s supposed to SHARE! I tried to take it from her …and her drawing got ripped. Too bad for her – she should have SHARED!Not my fault! Other kids talk and then Miss Martin gets mad at me! [whiny] School is boring… I don’t want to read all day long. Too boring!
Mom: His teacher said she tries to get him back on task, and he talks back to her.
Dad: He does exactly what he’s doing now and blames other kids. Not right, son.
Mom: Like the marker incident. He ripped that girl’s paper and said it was her fault for not letting him borrow her marker.
Gabriel: [interrupting, indignant] It WAS her fault!! She deserved it!
Dad: [raising his voice] Gabriel, stop yelling! Don’t interrupt when adults are talking.
Check Your Notes
- Gets in trouble
- Blames the other kids and his teacher
- Impulsive behavior (grabbing the marker)
- Distracted by other kids, but feels teacher blames him
- Finds reading boring
- He talks back to his teacher
- Does what he wants and blames other kids for the results of his actions
- Dad seems to have a temper
- Gabriel interrupts adults
What behavioral symptoms is Gabriel exhibiting? Check all that apply.
|bI0LPa9lfHQ+dYqk||angry and resentful|
|wCfH0QtRgXJ8o+c+||physical cruelty to people or animals|
|bI0LPa9lfHQ+dYqk||argues with authority figures|
|wCfH0QtRgXJ8o+c+||provoking physical fights|
|bI0LPa9lfHQ+dYqk||blames others for own misbehavior|
|bI0LPa9lfHQ+dYqk||spiteful or vindictive|
|wCfH0QtRgXJ8o+c+||using dangerous weapons|
Review your interview notes or listen to Gabriel and his parents again to review his symptoms.
Think about the symptoms you’ve identified: losing his temper, being angry, arguing with authority figures, annoying others, blaming others for his misbehavior, and being spiteful or vindictive.
“Gabriel, tell me about your family. What’s it like?”
Gabriel: [nastily] Why do you want to know?
Dad: [angry] Answer the question, son!
Gabriel: [muttering begrudgingly] It’s just me and mom and dad. They tell me what to do all the time! Mom especially. She’s ALWAYS there! Dad is always at work.
Dad: [calmer] We are a very stable, normal family. That’s why Gabriel’s behavior is so embarrassing.
Mom: Mateo works as a salesman. I work part-time in retail, so I can be home for Gabriel when he gets home from school.
Dad: You know you don’t have to work. I can provide for us.
Mom: Believe it or not, it’s something I enjoy. I like to get out of the house and have contact with other adults! Plus I think it sets a good example for Gabriel to see both of his parents working and taking responsibility. [to Gabriel:] Sit down, son.
Dad: Taking care of Gabriel is your most important job. If you were home all the time, maybe this wouldn’t be happening!
Mom: [defensively] I am home whenever he’s home! What would I do when he’s at school all day? Don’t get me wrong, Gabriel is the light of my life and I love my son, but I also want to work. I think I can do both well… enough.
Check Your Notes
- Only child
- Says his parents always tell him what to do
- His mom is always there
- His dad is always at work
- Dad states they are a stable, “normal” family
- Dad is salesman
- Mom works part-time in retail, so she can be home when Gabriel is home
Think about the remaining problems you have yet to explore.
“Can you tell me more about what it’s like for you at school? Are you having a hard time with your schoolwork?”
Gabriel: Why do you need to know all this stuff? I don’t know…sometimes when Miss Martin asks me stuff... I don’t know the answer… [defensively] it’s hard, okay? And reading … it’s sooooo boring. I can read, but it’s soooooo boring!
Dad: I think he just needs to pay attention! He never listens at home – it’s not surprising he doesn’t at school either!
Mom: [plaintively] He’s just a kid. It’s really hard for him to focus. He’s only 6, for goodness sake. [to Gabriel:] Gabriel, please put those toys back right now!
Dad: [firmly] His teacher seems to think it’s more than him just being a kid. He daydreams in class, hums constantly and distracts other children. Apparently he is rude … he interrupts the teacher and other kids. When he does know an answer, he doesn’t wait to be called on. He just blurts it out.
Mom: [defensively] He can read. When he can focus on reading, he reads pretty well for a child his age. He can sound out words no problem and he recognizes common words pretty quickly. [sighs] It’s just hard to get him to actually sit down and read! He won’t focus – he whines and complains and wanders off to do something else. Then he’ll misplace the book, and forget where he left it. Reading with him can be exhausting.
Check Your Notes
More about school:
- Hard to focus
- Doesn’t remember what teacher is saying, or doesn’t know the answers
- Finds reading boring
- Has a hard time sitting still and focusing in the office
- Dad thinks Gabriel just needs to pay attention
- Points out he never listens at home either
- Teacher reports he daydreams in class, hums constantly and interrupts others
- Blurts our answers before being called on
- Mom thinks he is just being a kid, behavior “normal” for 6 year old
- Gabriel can read well for his age, when he can focus
- Getting him to focus is hard - misplaces book, wanders off
- Reading with him is exhausting
Which of the following symptoms is Gabriel currently experiencing? Check all that apply. Use your interview notes to help you remember!
|bI0LPa9lfHQ+dYqk||difficulty sustaining attention|
|bI0LPa9lfHQ+dYqk||loss of items necessary for activities|
|bI0LPa9lfHQ+dYqk||failure to follow through on instruction|
|wCfH0QtRgXJ8o+c+||difficulty with understanding meaning of what is read|
|wCfH0QtRgXJ8o+c+||difficulty with mathematical reasoning|
|bI0LPa9lfHQ+dYqk||easily distracted by irrelevant stimuli|
|wCfH0QtRgXJ8o+c+||academic skills below those expected for his age|
|bI0LPa9lfHQ+dYqk||blurts out answers|
|bI0LPa9lfHQ+dYqk||frequent wandering from seat|
|wCfH0QtRgXJ8o+c+||skills do not meet demands for classroom work|
|bI0LPa9lfHQ+dYqk||frequent “on the go” activity|
|wCfH0QtRgXJ8o+c+||difficulties with spelling|
Think about the symptoms reported by Gabriel’s parents as well as his behavior during your interview.
Think about the following symptoms Gabriel exhibits in making your choice:
- difficulty sustaining attention
- easily distracted by irrelevant stimuli
- frequent wandering from seat
There is a common public belief that ADHD is overdiagnosed. However, in a 2007 review of the existing research, Sciutto and Eisenberg found that “there does not appear to be sufficient justification for the conclusion that ADHD is systematically overdiagnosed.” Why do you think people believe ADHD is overdiagnosed, and why would it be a concern?
From the File. You remember a former patient who shared symptoms similar to Gabriel’s. You review this case to help you as you think about Gabriel’s case.
Think about all of the possible factors that may contribute to these disorders.
Think about the type of therapy that would use problem-solving skills.
Which of the following are the two MOST COMMON treatments for ADHD?
In making your choice, think about the need to treat both brain chemical imbalances and Gabriel’s misbehaviors.
After additional testing to confirm a diagnosis of ADHD, you diagnosed Gabriel with both ADHD and ODD. Working with a child psychiatrist, he began taking Ritalin, beginning at age 6, after your diagnosis. Gabriel is now 10 years old and in the fifth grade. He has continued taking the medication, off and on, for the past four years. Gabriel’s parents refused to participate in behavioral/sociocultural treatment, as his father said it would be “a waste of time and money.” At school, Gabriel received an Individualized Education Program (IEP), which entitled him to services from the school district. The IEP recommended that Gabriel work with a school psychologist and receive extra time and a quiet environment for testing. Gabriel was uncooperative with the school psychologist, so he made little progress. His schoolwork did not improve, however, he was quieter at school. At home, he was just as defiant as ever.
He now he has a new reputation—class bully. He is known as a mean kid who will go out of his way to hurt the other boys in his class. His fights have led to suspensions from school, which means that his mother, Emily, has to take time off from work to stay home with him. Emily has given up—she has lost control over Gabriel's behavior. Mateo, Gabriel’s father, has only gotten angrier and stricter. Gabriel spends a lot of time grounded in his room.
Last week Gabriel took Mateo's cigarette lighter and set fire to papers in the trashcan in his room. Fortunately, the smoke detector went off and Emily and Mateo were able to put out the fire. Mateo was so angry that he ended up back-handing Gabriel in the face. Emily took Gabriel to her mother's for the rest of the day.
Things reached a new low today. Emily got a call from the principal to come to school. Gabriel pulled out a knife during recess and cut another student on the arm. The child had to be taken to the emergency room because the cut required stitches. The principal asked Emily to call Mateo to come in for a meeting with the principal, Gabriel’s teacher and the school psychologist. Emily is now worried that Gabriel will be expelled from school.
Think about the severity of Gabriel’s behavioral problems.
Real World Application
Watch the following video and answer the questions below.