Case Study - III

EXPRESSIVE LANGUAGE DISORDER

SOCIO-DEMOGRAPHIC DATA

Name : SB

Age : 12 Years Old

DOB : 19/02/2011

Gender : Female

Education : 7th Standard

Place : Mundakutti

Religion : Muslim

Mother Tongue : Malayalam

Socio economic status : Middle class

Residence : Semi urban

No. of family members :5

Family Type : Nuclear

REFERRAL

Source of referral: Doctor

Reason for referral: Poor academic performance

INFORMATION

a) Informant: SA

Relation: Mother

b) Reliability of information: Reliable

c) Adequacy of information: Adequate

d) Consistency of information: Consistent

Purpose of present visit: For skill training and routine evaluation

PRESENTING COMPLAINTS

According to the child,

● Difficulty in studying
● Facing difficulty in remembering thing
● Unable to talk to clearly

According to the informant,

● Poor communication skills

● Find difficulty to pronounce the words fluently and clearly
● Forgetting the things studied previously
● Difficulty in reading
● Difficulty in writing
● Difficulty in understanding
● Poor academic performance
● Showing unusual fear while talking
● Doesn’t express her needs
● Making incomplete sentence
 ● Unable to know get ready
● Unable to play rule based games

NATURE OF ILLNESS

Mode of Onset : Gradual onset

Course of Illness : Continuous course

Duration of Illness : Since birth

Progress of Illness : Improving

Precipitating Factor : Nill

Perpetuating Factor : Nill

HISTORY OF PRESENTING ILLNESS

The child SB, is a 12 years old female studying in 7th standard Echom School, Wayanad.
She was referred to the clinical psychology department for routine evaluation and skill
training. Some of the complaints reported by the mother include, poor communication
skill, unable to pronounce words fluently and clearly, forgetting the things studied
previously, difficulty in reading, difficulty in writing, difficulty in understanding, poor
academic performance, unable to complete sentence, unable to know how to get ready
and doesn’t know how to express her needs. According to the informant, she said the
child is having difficulty in communication. She doesn’t know how to make a proper
sentence. Most of the time her sentences become incomplete. Mother of the child
reported that, while asking her to tell what all the things happened in the school, the child
will tell some things that happened in school but it is incomplete and the listeners can’t
understand what exactly she is talking about. Her sentence will be like this, if the teacher
asks her to bring a pen to class, the patient will report it like this “sir said pen”. So, the
listeners don’t know whether sir told her to bring the pen to class or whether he asked her
to buy another pen. If we ask more about that she will start talking but she will stop it
immediately and show the fear to complete or continue it. Also, while speaking her
speech clarity is poor. Sometimes it is difficult to understand the words she is saying.
Patients’ academic performance was very poor. Mother of the child added that, till UKG
she was able to study well. But 1st standards onwards she started showing difficulties in
studying. Also, while copying the things to her notes her letters become reversed till 5th
standard for example “b” becomes “d”. She shows interest in studies when asked to study
and she will study for long but she forgets things very fast that she has studied earlier.
Also, teachers of the child reported that she had difficulty understanding the things taught
in the class. Informant reported that she is having difficulty in writing, reading and in
calculations. Mainly she is unable to read sentences and she doesn’t know how to write
things without looking. She can recognise the signs in calculation; however, she doesn’t
know how to do that.

The child “SB” doesn’t play with other children when they are playing rule-based games
such as snake and ladder, ludo and all. The informant of the child mentioned that she
doesn’t express her needs even though she wanted it. She usually seems very silent and
whenever her mother asks her whether she needs something, she keeps silent and she
doesn’t show stubborn behavior. But after reaching home she seemed to be very gloomy
all day for not buying it. Even though the patient mother mentioned that she knows how
to dress up, however, she doesn’t know how to brush her hair, and she faces difficulty
while tying her shoe lays. All these reasons led her mother to bring her to Louise mount
hospital on 24th June 2023, for routine evaluation and skill training.

NEGATIVE HISTORY

The child has no suggestive history of neurological disturbances, seizures, or head injury.

TREATMENT HISTORY
For presenting illness: The child’s mother has consulted the clinical psychologist Dr.
Linjo C. J and Anwin Soye (consultant psychologist) for these presenting complaints and
is currently getting skill training and counseling for five months.

Past illness:

Psychiatric: At the age of 4 the patient's mother consulted Dr. Afsal N C, (pediatrician,
Kalpetta) for her delay in speech and drawing behavior. Then Dr. Afsal referred the
patient to Dr. Linjo C.J (clinical psychologist) and after taking treatment she showed
significant improvement. Then she started taking speech therapy from Pranja institute in
Kainatty, Kalpetta for one month in the year of 2021. Then later they started taking
speech therapy from the Govt. hospital Manthanvady in the year of 2022 and they get
therapy for one year and the mother of the child reported that, taking therapy from Govt.
At Mananthavady, the child shows reluctance to continue the treatment and the hospital
authorities are not giving proper care to the child and most of the time they shout against
the child and beat the child. Then the parents discontinued the speech therapy from Govt.
hospital and again they consulted Dr. Linjo C.J and then referred to Louise mount
hospital, chennanolde in the month January 20203.

FAMILY HISTORY

Consanguinity between parents: Absent

Family History of Psychiatric Illness / Mental Retardation / Suicide / Substance

Dependence / Epilepsy: Child’s father brother daughter also have issues regarding, poor
speech, difficulty in studying (reading, writing) and she has facing difficulties in doing
her basic things alone.

Family of origin:

The child SB belongs to a nuclear family: father,mother,maternal grandmother, sister and

brother. She is hailing from a middle-class family. The patient’s both parents are alive.
The head of the family is her father. The child is the firstborn in her family. Her father,42
years old, has business in Riyadh. He completed secondary education. Her mother, 32
years old, is a homemaker. She completed her PUC. The child’s younger sister is 8 years
old and she is studying in 2nd standard. She also has a younger brother who is 4 years old
who is studying in LKG. The child is more attached to her mother.The current attitude of
the family members towards the child’s illness is good and they want to provide her with
good treatment and they are careful about the child. The family follows cultural and
religious values.

Family Interaction Pattern:

● Communication - Direct
● Leadership - The child’s father
● Decision making - Mutually discussed by father and mother. But the final
decision is made by Father
● Role - Adequate
● Family Rituals - Dinner together
● Cohesiveness - Present
● Family burden - None
● Expressed Emotions - Warmth and love
PERSONAL HISTORY

BIRTH HISTORY

During the pregnancy period, the mother had a normal state of health. It was also a
normal birth. The child was a full-term baby weighing 3.45 kilogram. The child had a
normal birth cry. She was a wanted child. There are no other pre- or postnatal
complications reported.

MILESTONE DEVELOPMENT

The child attained head control when she was 4 months of age, started turning over when
he was 4 months of age, crawling when she was 8 months of age, started sitting alone
when she was 10 months of age and started walking when she was 2 years. The child
started babbling at 6 months, started her first word at 2.5 years, and started her first
sentence at 4 years of age.
EDUCATIONAL HISTORY

The child started going to school at the age of 4 years. Her academic performance during
LKG, and UKG was good. But her academic performance started going down from 1st
standard onwards. She did her schooling till 4th standard from Moon light L.P school,
Mundakutty. After 4th standard she changed the school from Moon Light to Echom. Now
the child is studying in 7th standard. The child’s relationship with teachers and peers is
satisfactory.

Highest grade : 7th standard

Academic performance : Poor (as reported)

Peer relationship : satisfactory

Hobbies & Interests : Watching videos

Behaviors at home and school

She likes to play with other children and also likes to make new friends. But she faces
difficulties while playing rule based games. At home, she likes to play with her siblings
and she doesn’t quarrel with them. If they quarrel she keeps silent. She cares and plays
with her siblings well. She likes all her family members.

MENTAL STATUS EXAMINATION

GENERAL APPEARANCE AND BEHAVIOR:

● Appearance : Well-kept and tidy

● Touch with the surroundings : Present
● Cooperativeness : Cooperative with effort
● Eye to Eye Contact : Established and maintained
● Rapport : Established with effort
● Attitude Towards Examiner : Cooperated with effort
 ● Psychomotor activity : Normal

ATTENTION AND CONCENTRATION

Digit forward

1, 7

3, 9, 4

7, 2, 6, 4

9, 1, 3, 8, 7

4, 9, 3, 7, 6, 1

2, 7, 5, 3, 1, 9, 4

9, 4, 6, 2, 5, 8, 3

Digit forward is 4

Digit backward

2, 8

4, 1, 9

5, 3, 7, 4

7, 1, 3, 9, 2

Digit backward is 3

Attention and concentration are not aroused and sustained.

MEMORY

a) Immediate memory
Q: I will ask you to listen to a list of five words. You have to reproduce it when I

ask you to do so.

Dog, pen, ball, flower, bulb

A: Dog, pen, ball

Immediate memory is impaired.

b) Recent memory

Q: What did you eat for breakfast today?

A: Chapati and fish curry.

Recent memory is intact.

c) Remote memory

Q: What is the name of the first school you joined?

A: Moon Light L.P school

Remote memory is intact.

Memory is intact.

INTELLIGENCE

a) General knowledge

Q: Who is the Chief minister?

A: Couldn't answer.

Q: Which is the capital city of Kerala?

A: Couldn’t able to answer

General knowledge is below average

b) Arithmetic skills

2+2= 4

9-5=4

12/3=

7*3=

Arithmetic skill is below average

c) Comprehension

Q: If your sister beat you, what would you do?

A: I won’t beat her.

Comprehension is average.

Intelligence is below average

ABSTRACT THINKING

a) Similarities and differences

Q: What are the similarities and differences between orange and mango?

A: Both are fruits. But different in shape.

Similarities and differences are understood at the functional level.

Abstract thinking is at a functional level.

ORIENTATION

Q: What is the time now?

A: Around 3 clock

Q: Where are you at present?

A: At Louis Mount Hospital

Q: Whom have you consulted now?

A: Dr. Linjo C.J

The patient is oriented to time, place and person.

VOICE AND SPEECH:

The child was unable to read and write things in sentences. The fluency was poor. Also,
the clarity of speech was poor.

● Intensity / Tone : Audible

● Reaction Time to Stimulus : Decrease
● Speed : Decrease
● Productivity / Volume : Normal
● Goal Directed/ Non goal directed : Goal directed

PERCEPTUAL DISTURBANCES

No perceptual disturbances were reported.

THOUGHT:

● Stream - Normal
● Possession - Normal
● Content - Normal
JUDGEMENT

a) Test judgment

Q: What will you do if you get money from the school?

A: I will give it to my teachers.

Test judgment is good.

b) Social judgment

Q: What will you do if a guest comes to your home?

A: I will come to them.

Social judgment is good.

MOOD/AFFECT:

a) Mood

Q: How are you feeling since the last two weeks?

A: I am fine.

b) Affect

Affect: Euthymic

DIAGNOSTIC FORMULATION

The child, SB, was brought to the hospital as part of skills training and routine evaluation.
Some of the complaints reported by parents include poor communication skills, difficulty
pronouncing words fluently, difficulty in reading and writing, and forgetting to study
related things easily. The child started babbling at 6 months, started her first word at 2.5
years, and started her first sentence at 4 years of age. In the child, the speech and walking
was attained with specific delay respectively.

M.S.E reveals that the child cooperated with the effort. The child has maintained eye-to-
eye contact. Rapport was established with effort. The psychomotor activity was normal.
She had decreased speed and reaction time also delayed, tempo, and volume of voice are
audible. The fluency was poor. Also, the clarity of speech was poor. The child’s mood
was fine. Attention and concentration were not aroused and sustained. Based on the
detailed case history, MSE, and assessments administered, he fulfills the criteria for
Expressive Language disorder (F80.1) as mentioned in ICD 10.

DIFFERENTIAL DIAGNOSIS

According to ICD-10, ICD-10 R41.83, Borderline Intellectual Functioning

Points in favor

● Difficulty in understanding
● Easily get distracted
● Poor interest in studies
● Poor concentration
● Inattention

PROVISIONAL DIAGNOSIS

According to ICD-10, F80.1 Expressive Language disorder

Points in favor:

● Expressive language skills below the child’s age

● Normal usage and understanding of non-verbal communication
● Lack of fluency and clarity in speech
 ● Absence of sensory, neurological, or physical impairments which can create
speech problems

TREATMENT PLAN

● Speech therapy can be given frequently

● Skill training can be given to the child to acquire independent self-care,
communication skills, attention, and concentration respectively.
● The child should be engaged productively so that attention and concentration can
be increased.
● Parental supervision in various activities of the child can improve his
communication as well as his study habits.
● Parental training should be given to encourage, monitor and help the child to
improve communication skills.
● Psycho education to the parents.