Summary of the case

The following case is of 10 years old girl who is the elder child of here family. She belongs to a middle
class family background. According to her mother she was the first child who got care, love and
pampered child. She was admitted in school in early childhood in Islamic University School with normal
children but she was week can’t give attention to academics and has no focus on things. She also had
speech issue as her speech was delayed and can’t express her feeling and thoughts through speech. She
has no attention span, focus, and learning. She has proper sitting and appearance was according to
school requirements.

Along with this she feel irritated in social gatherings and avoid them as she thinks cant adjust with
others as said by her mother or even when she goes with her family in gatherings, she try to come back
as early as possible. She has trouble in sleep sometimes but often has normal sleep. She has no
behavioral issues and has memory issues as she can’t memorize things and she feels trouble in learning,
problem solving. She can perform some task by her own like changing clothes, shoes, can eat
independently but has trouble in combing her hairs which her mother do. She is only comfortable with
her close family members and enjoy with them. She is closer to her mother and take care of her two
little sisters.

She learnt to talk later, trouble in speaking and explaining her thoughts and has no cognitive abilities,
perception. She has trouble in picking new things in her old school as her mother told that before
admitting her to Special Educational Academy, she faced a lot of trouble in old school as all students
there were normal and she was the one who can’t perform well in school. Later when she got to know
about her disability she admitted here in this school where she improved here speech. She follows
command and fulfills the task give to her

Furthermore, client was observed in different school sitting i.e. OT, music class, and sensory room. Her
behavior was observed in class room to see her attention, academic and interaction with other
children’s.

For assessment, client was assessed through formal and informal assessment. Formal assessment
includes HFD and CPM. Along with this informal assessment was down through Clinical Interview and
MSE.
Identifying data
Name : AM

Age : 10

Birth order : 1st born

Siblings : 2 sisters

Socioeconomic status : Middle class

Gender : Female

Resident : Rawalpindi

Head of family : Father

Family structure : nuclear

Source and reason of referral

Client was referred by her class teacher and psychologist to do in-depth study on her. The reason to
referral was to get to know about her case to know about her symptoms observe her behavior in class
and therapy rooms to know about her how she perform on different places and does she has any grip on
things and has interest in any of them .To know the proper reasons of her disability due to which she
can’t focus on thing, give attention on academics and what are the difficulties she face in her daily life. In
short to focus on her and study her in-depth to get to know more about her and try to make her
independent in daily life activities.

Presenting complaints
Verbatim of client mother

She is a shy child and had problem in speech due to which she faces problem in communication. She
had delayed millstones. In early childhood is admitted to normal school were she faced trouble in
academic. Along with this she had faced difficulty interacting with peers as she had problem in speech
and was not able to speak like other children of her age fellow. She didn’t pay attention and can’t
memorize things. Furthermore, client has problem in expressing her thoughts and feeling. Additionally
she avoids going in social gatherings.
 History of present illness
The child is 10 years old. She belongs to middle class family system. She was born with
normal delivery. They were no complication in her mother’s delivery and at time of birth.
But she was unable to accomplish her developmental milestones as her all milestones were
delayed. She likes to be with her family and avoid social gathering as she get irritated and
hesitate in social gatherings.

Developmental Milestone

Developmental task Achieved age of milestones Age when achieve

First cry After After 2 minutes of

Neck birth 3 birth After 3 months
holding months 1 year
Sitting without support 8 After 2 years
months
Walking without support After 3 years
2 years
Monosyllables little After 5 years
1.5 years
speech Small/ full After 6 years
2.5 years
sentence Complete After 5
2.5
speech years Not
years
Bowl and bladder control yet
4
Taking bath without help
years
11
years

Personal History
Client is involved in different activities in school and home, As she told that she love to spend her time
with friend in school and in home she watches cartoon with her siblings and love to eat different thing
and her favorite is rice. She is comfortable with those who are close to her like family members, teaches
and her one friend in school. Client has issues in learning, speech as she can’t express her feelings most
of the time by words, she just smile while saying two to three word sentence.

Family history
Client belongs to a middle-class family background. She is the first born child and has two younger
sisters. She lives in nuclear family system of 6 family members. Client father is the only person who
works and is head of family .As she is the elder child she try to take care of her to younger sisters. She
has issues in family gatherings and she try to avoid them. She mentioned that she love her mother and is
attached to her and spend her most of time with here. She told that when she went to her aunty house
she enjoy a lot there as she is also one of favorite person of her. With whom she love to stay and in last
two sessions she always mentioned about her visit to Lahore where her aunt lives. Which shows that
client like to spend her time with her other family members too

Education history
Client has changed two schools as she was facing many problem like can’t concentrate, focus, pay
attention and also has trouble in learning and speech. Due to which teachers scold her and her
complains were coming as was not capable to perform good in academics. As in early childhood her
family admitted her in normal school (Islamic University, SLS). She told that her classmates were also not
nice as all of them make fun of mine which made me feel bad and uncomfortable and also all teachers
there scold me too. But in this school every one is nice and i have one friend here, my teachers are also
nice and i love to spend time here.

Medical history
She is not on any type of medication.

Social History
Since childhood client has problem in speech due to which she can’t express he feeling to others. Client
is comfortable with her family members and get irritable in social gathering. Furthermore client has no
friends as she says that everyone in her old school make funs of mine due to which she doesn’t like
friends. Adding to this she said my mother is my friend.
Behavioral Observation
The client was assessed through clinical interview. In start she was not comfortable but with time she
cooperated during interview as she answered all things except few.

Psychological assessment
In psychological assessment format and informal test were applied in client. Through initial observation
her behavior was observed and applied MSE and Clinical Interview and in formal did HFD and CPM.

I. Informal

MSE:
Psychological Assessment mental status examination MSE was used as a tool to describe appearance,
behavior, cognition, speech and mood of the client. It indicates client mental functioning and
orientation. It involves the following indicators.