Demographic Information:

Name : XYZ

Age : 8

Gender: Female

Education : 3 Grade

No. of siblings: 2

Birth order: 2nd

Marital Status: Single

Residence : Rawalpindi

Informants: Parents

Reason and source of Referral:

The patient came with her parents to the CDA Hospital, Islamabad due to the
complaints of headache, low energy mood, numbness, weight loss and extreme vomits.

Presenting Complaints:

 Headache
 Numbness
 Low energy mood
 Weight loss
 Extreme vomits

Family History:

The client was born in an upper middle class family of 1 brother and 1 sister. Her father was a
banker and mother was a teacher. Her family environment was very friendly. She is the eldest
in sibling and all family loved her very much. She was very friendly.
Past Personal History:

Her birth was normal without any complication. Mother explained that client had always
been a very ‘busy’ child, but that this had never been a problem for her parents as they were
both very active people. Client did not sleep particularly well as a baby, and still finds it
difficult to settle down when she goes to bed. Clients also remained in hurry when she did
homework and did another activity at home. She was very friendly and cooperative.
History of present illness:

Client problem started 12 month back when her mother note the change in behavior that
client has been struggling with her schoolwork and had fallen significantly behind in some
subjects. There had also been some difficulties in friendship groups and client is often
involved in arguments in the playground. On a positive note, her teacher is pleased to report
that she was doing exceptionally well at sport. Mother had noticed that client has become
more and more disorganized over the past 12 months. She had lost many items of school
equipment and was often late leaving the house for school and for social events, as it took her
so long to get ready. Client was often restless and finds it difficult to concentrate, even on
things that she found enjoyable; for example, it was unusual for her to be able to sit and
watch a film through to its conclusion. Client mother remembered that she was a lot like this
when she was a child, and had not been particularly worried until now. Both parents was
concerned about the fact that client was struggling academically but were more worried about
the fact that she appears to be having problems making and keeping friends.
Pre-morbid Personality:

Client did not sleep particularly well as a baby, and still finds it difficult to settle down when
she goes to bed. Clients also remained in hurry when she did homework and did another
activity at home. She was an intelligent student but always remained in hurry .He fight with
his class fellow and all his copies and books remain dirty and disorganized. Client family
records show no any psychotic history in the family.

Psychological Assessment:

Informal Assessments: Following measures were used as an informal assessment.

 Behavioral Observation

 Clinical interview

 MMSE
Behavioral Observation:

The client was a child of 8 years old and had neat and tidy clothes .she did not settle down on
seat and seems to be in hurry. He did not sit on the seat for one minute. Touch different
things on the table and shake his hand and legs. Client moved around all over the room.
Client change the topic again and again.

Clinical interview:

The interviews were conducted to understand the nature, severity and etiology of the patient
problems. At first, rapport was built and patient was assured that information provided by
him would keep confidential. The client was extremely talkative and flight of ideas noticed in
client. All of the information about client collected from the patient.

Mental state Examination:

Her recent and remote memory seemed to be intact as she could recall most of the past and
present events. She had good orientation of place and person .she knew about her name, name
of the other patients and name of city where she lived.

Tentative Diagnosis: ?

Case Formulation:

The patient came with her parents to the CDA Hospital, Islamabad due to the complaints of
headache, low energy mood, numbness, weight loss and extreme vomits. The client was born
in an upper middle class family of 1 brother and 1 sister. Her father was a banker and mother
was a teacher. Her family environment was very friendly. She is the eldest in sibling and all
family loved her very much. She was very friendly. Her birth was normal without any
complication. Mother explained that client had always been a very ‘busy’ child, but that this
had never been a problem for her parents as they were both very active people. Client did not
sleep particularly well as a baby, and still finds it difficult to settle down when she goes to
bed. Clients also remained in hurry when she did homework and did another activity at home.
Client problem started 12 month back when her mother note the change in behavior that
client has been struggling with her schoolwork and had fallen significantly behind in some
subjects. There had also been some difficulties in friendship groups and client is often
involved in arguments in the playground. Her teacher is pleased to report that she was doing
exceptionally well at sport. Mother had noticed that client has become more and more
disorganized over the past 12 months. She had lost many items of school equipment and was
often late leaving the house for school and for social events, as it took her so long to get
ready. Client was often restless and finds it difficult to concentrate, even on things that she
found enjoyable. After applying the above mentioned psychotherapies the patient was able to
deal with problem effectively .The patient was assured that if she has these problems again
she can contact with the psychotherapist with confidence and trust.

Therapeutic suggestions:
 Family therapy
 Cognitive behavior therapy
 Medication

Prognosis:

The client parent was interested and client was improving day by day and client was following the
routine