CASE REPORT

Submitted to

Mam. Tayyabasafder

Submitted by
Madiha jahangir

3rd Semester

DEPARTEMET OF PSYCHOLOGY
NATIONAL UNIVERSITY OF MODERN LANGUAGES
ISLAMABAD
 APPROVAL SHEET
CASE REPORT (Psy-526)

BY

Madiha Jahangir

_____________________________________

Internship Instructor

Department of Applied Psychology

National University of Modern Languages Islamabad

7th may, 2018

National University of Modern Languages, Islamabad, Pakistan

 CERTIFIES

CASE REPORT

BY

Madiha Jahangir

This report is submitted to National University of Modern Languages in partial fulfillment of the
requirement for the degree of M.Sc. in Applied Psychology

APPROVED

BY

___________________________________

Prof Dr. AnisulHaque

Head, Department of Applied Psychology

Contents
APPROVAL SHEET........................................................................................................................................II
ACKNOWLEDGMENT VI
CASE REPORT # 1 1
CASE SUMMARY: 1
DEMOGRAPHIC DATA:
2
REASON FOR REFERRAL 2
PRESENTING COMPLAINTS: 3
TARGET SYMPTOMS: 3
ASSESSMENTS: 3
INFORMALASSESSMENT: 3
BEHAVIROAL OBSERVATION : 3

HISTORY OF PRESENT ILLNESS:

4

FAMILY HISTORY:
4

PERSONAL HISTORY 4
EDUCATIONAL HISTORY: 4
OCCUPATIONAL HISTORY 4
SEXUAL AND MARITAL HISTORY: 4
PERMOBID PERSONALITY: 4
HISTORY OF PRESENT ILLNESS: 4
FORMAL ASSESSMENT: 5
Mini mental status examination: 5
Incomplete sentence RISB: 5
DIAGNOSIS: 5
PROGNOSIS: 5
CASE REPORT # 2.....................................................................................................................................6
CASE SUMMARY:.....................................................................................................................................7
DEMOGRAPHIC DATA..............................................................................................................................8
REASON AND SOURCE OF REFFERAL:.....................................................................................................8
PRESENTING COMPLAINTS:....................................................................................................................8
TARGET SYMPTOMS:...............................................................................................................................9
 FAMILY HISTORY:.......................................................................................................................................
GENERAL HOME ATMOSPHERE:...........................................................................................................13
PERSONAL HISTORY:..............................................................................................................................13
EDUCATIONAL HISTORY:.......................................................................................................................13
OCCUPATIONAL HISTORY:.....................................................................................................................13
SEXUAL AND MARITAL HISTORY:..........................................................................................................14
PERMOBID PERSONALITY:....................................................................................................................14
INFORMAL AND FORMAL ASSESSMENT:..............................................................................................14
INFORMAL ASSESSMENT:.....................................................................................................................14
Clinical assessment...........................................................................................................................14
Behavioral assessment......................................................................................................................14
Mental status examination...............................................................................................................14
FORMAL ASSESSMENT:.........................................................................................................................15
SIMPLE LINES.....................................................................................................................................15
House tree person HTP.....................................................................................................................15
Incomplete sentence RISB.................................................................................................................15
Back Depression Inventory BDI.........................................................................................................15
Drug Abuse Screening Test DAST-10.................................................................................................15
DIAGNOSIS:...........................................................................................................................................15
PROGNOSIS:..........................................................................................................................................16
CASE FORMULATION.............................................................................................................................16
MANAGEMENT PLAINS:........................................................................................................................16
REPORT # 3................................................................................................................................................17
CASE SUMMARY:...................................................................................................................................18
DEMOGRAPHIC DATA............................................................................................................................19
REASON AND SOURCE OF REFFERAL:...................................................................................................20
PRESENTING COMPLAINTS:..................................................................................................................20
TARGET SYMPTOMS:.............................................................................................................................20
FAMILY HISTORY:...................................................................................................................................20
MEDICAL HISTORY:................................................................................................................................21
GENERAL HOME ATMOSPHERE:...........................................................................................................21
PERSONAL HISTORY:..............................................................................................................................21
EDUCATIONAL HISTORY:.......................................................................................................................21
 SEXUAL AND MARITAL HISTORY:..........................................................................................................21
PERMOBID PERSONALITY:....................................................................................................................21
HISTORY OF PRESENT ILLNESS:.............................................................................................................21
INFORMAL AND FORMAL ASSESSMENT:..............................................................................................22
INFORMAL ASSESSMENT:.....................................................................................................................22
Clinical assessment...........................................................................................................................22
Behavioral assessment......................................................................................................................22
Mental status examination...............................................................................................................22
FORMAL ASSESSMENT:.........................................................................................................................22
House tree person HTP.....................................................................................................................22
Child autism rating scale CARS..........................................................................................................22
Attention deficit hyperactivity disorder rating scale ADHD..............................................................22
Applied behavior analysis ABA.........................................................................................................23
DIAGNOSIS:...........................................................................................................................................23
PROGNOSIS:..........................................................................................................................................23
CASE FORMULATION.............................................................................................................................23
MANAGEMENT PLAINS:........................................................................................................................23
ANNEXURES..............................................................................................................................................24

ACKNOWLEDGMENT

Starting with the name of Allah who is merciful and beneficial for us.All that is on earth is to
perish.And there is abiding forever is the Entity of your Lord Majestic and VenerableWhich then,
of the favours of your Lord wills O Jinn and men you twain will deny?. All the credit goes to
ALLAH ALMIGHTY.I would like to express my deepest appreciation to all those who provided
me the possibility to complete this report. A special gratitude I give to our case report Instructor,
Mam Tayyabasafdar, whose contribution in stimulating suggestions and encouragement, helped
me to coordinate my case reports especially in writing this report.A special thanks goes to our
Head of department HOD Dr. Anis-ul-Haq.
 Furthermore I would also like to acknowledge with much appreciation the crucial role of
the staff of Numl University and AL-NAFEES medical college and hospital.Who gave the
permission to use all required equipment and the necessary materiasl to complete the task “Dr.
Faisal”. Who help me to assemble the parts and gave suggestion about the task. Last but not
least, many thanks go to my parents head of the project, I have to appreciate the guidance given
by other instructors as well as theteachers especially in our project presentation that has
improved our presentation skills thanks to their comment and advices.
 CASE REPORT # 1

CASE SUMMARY:
K.H is 49 year old married Man educated up till 8 th and was happy 3th
born child of his family. His problem start from 1970 at that time doctor

1
didn’t take notice then again he went to the doctor in 2004 he was diagnose
with generalize anxiety disorder and get cured. Now from 3 month back he
was feeling intense fear of death and the same symptoms. K.H couldn’t bear
the fear and he was referred to AL-Nafees hospital for treatment by the
doctor and after different tests application such as HTP, RISB, PANS, and BDI.
Result showed that he was suffering from generalized anxiety disorder.

2
DEMOGRAPHIC DATA
NAME: Khalid

AGE: 49

GENDER: Male

EDUCATION: Middle 8th class

OCCUPATION: Government job

PARENTS: Died

NO. OF SIBLINGS: 8

MALE: 7

FEMALE: 1

BIRTH ORDER: 3rd

MARITAL STATUS: Married

FAMILY STUCTURE: Nuclear

NO. OF CHILD: 4

MALE: 1

FEMALE: 3

HEAD OF FAMILY: Self

EARNING MEMBER: 1

HERITAGE: Land

Language: Hind-koh

INFORMER’S NAME: Self and Munaza

BELONG TO: Lathrar, Kotlisatian

BROUGHT BY: Sister and brother

3
REFERED BY: Dr.Saif from lathrat.

REASON AND SOURCE OF REFFERAL:

The client was into the complains of disturbed sleep, intense fear,
crying spell and many more for which he was referred to the trainee
psychologist at AL-Nafees hospital for further reporting and treatment by her
family from Lathrar. KotliSatian, Islamabad.

PRESENTING COMPLAINTS:
‫مو ججودہ علماات‬

1) ‫مجھے بھت خوف اور گبھراٹ ھؤتی ھے۔‬

2) ‫خوف پۃ کابو پانا مشکل ھو جاتا ھے۔‬

3) ‫کام کرنے میں دل نہی لگتا۔‬

4) ‫کوئی بھی کام کروتہکاوٹ بہت جلدی ھو ھاتی ھے۔‬

5) ‫ہہرچچییز مییں چڑچڑاہٹ محسوس ہوتی ہے۔‬

5) ‫نیند کم آتی ھے۔‬

6) ‫بھوک کم لگتی ھے۔‬

TARGET SYMPTOMS:
1). Excessive anxiety and worry

2). Finds it difficult to control the worry.

3). Loss of interest.

4). Being easily fatigued.

5). Irritability.

6). Sleep disturbance.

(7. Loss of appetite.

4
FAMILY HISTORY:
Client parents has died. He has eight siblings including himself. Seven
are male and one female and his birth order is third. His brother died 2
month before. He was married twenty six year before. Now he has three
daughter and one son. Client has good relationship with his family. No one in
the family have psychotic issues.

MEDICAL HISTORY:
Client had no such medical history but 3 month ago he met road side
accident by bicycle which cause severe injury. He is diabetic for more than 6
years but not evidence of B.P issues.

GENERAL HOME ATMOSPHERE:

General home environment was not strict. The client belong to a low
socio-economic background.

PERSONAL HISTORY:
The patient had no pre and post-natal birth complications. His delivery
was normal and mother condition was also well. All the development
milestones were supervened at proper time. In 1970 he was tense due to
family problems and legacy problem among his family member. Which lead
him to intense worry stage. At that time he went to the doctor but he didn’t
take it seriously and gave him medicines of nerve relaxing. Again in 2004
same symptoms appear. At that time he went to the doctor in PIMS. For first
time he was diagnosis anxiety disorder there. He took medicines for long
time then left them. Without any recommendation. For any important
decision he accept services of Nazimsahab.

EDUCATIONAL HISTORY:
He first attended school at the age of 5 year. He was an average student but
obedient one. His relation with his friends was good and long-term. Under his
peer-pressure he left school at 8th grade.

5
OCCUPATIONAL HISTORY:
Client was nayabkasnslar at National Art Gallery. He was working there
for more than 15 years. He has good professional relations with his
coworkers and officers. He was satisfied with is job and incentives awarded
during that years. Due to recent problem he left that job.

SEXUAL AND MARITAL HISTORY:

Client has successful marital life with his only wife. Otherwise no such
other sexual history was manifest by client.

PERMOBID PERSONALITY:
Before the onset of the illness client was active worker. As the client
was in national art gallery he was active thinker and participate as well.

HISTORY OF PRESENT ILLNESS:

Information was given by client himself and Munaza .Sister of client.
According to them symptoms appear after the death of client elder brother.
Client has good emotional attachment with him. It was a great loss for him.
He was died due to heart attack 6 month ago. When he think of him client
face anger outburst, intense fear, worry and mood disturbance as well. He
complained about marked disturbance in apatite and sleep. He also show
flatness of effects.

INFORMAL AND FORMAL ASSESSMENT:

Both formal and informal assessment was done to root out the real
cause of abnormality.

INFORMAL ASSESSMENT:
Clinical assessment
For exploring the important factor of client’s behavior and
psychological analysis a clinical unstructured interview was conducted.

Behavioral assessment

6
 He was dressed properly. He was also giving answer properly but
to memory problem he was giving late answer to some questions not
all.

Mental status examination

Client was neat in his appearance, behaving well cooperative.
Have no impairment in orientation. Language and perception was clear.
He was having memory issues. He was not making proper eye contact
and also restless. He have suicidal ideation and anger outburst.

FORMAL ASSESSMENT:
House tree person HTP
Client draw all the three things. Interpretation show that client do
not have much interest in social life, he is avoidant, dependent, low
self-esteem and confuse. Shading show the sign of anxiety. Person
without limbs show that client have conflict about them.

Mini mental status examination MMSE

In MMSE, client have scored 28 which showed that degree of
impairment is questionably significant. May have clinically significant
but mild deficits. Likely to affect most demanding activities of daily life.

Incomplete sentence RISB

In RISB, client scored 145 which showed the degree of
maladjusted. His statements represented maladjusted behavior.
1‫مجھے افسوس ہے کہ موت آجائےگئ‬ ‫۔‬-
2‫دوسرے لوگ اچھےنہیں لگتے‬ ‫۔‬-
3‫میں سب سے بہتر ہوتا اگر میں ٹٹھیک ہوتا‬ ‫۔‬-
4‫میں ذیادہ پریشان رہتا ہوں‬ ‫۔‬-

Test
Complete picture of blood CP and thyroid test was done in order
to find out that weather its anemia or due to thyroid secretion which
cause ablution.

7
Back anxiety inventory BAI
In BDI, client scored 39 which showed that the client is suffering
from moderate anxiety. Showing the symptoms of
1‫۔ بد ترین حالت کا خوف‬-
2‫۔ گبراہٹ رہنا‬-
3‫۔بغیرگرمی کے پسیا آنا‬-
4‫۔غصے کا آنا اور آپے سے باہر ہوجانا‬-

DIAGNOSIS:
300.02 Generalized Anxiety Disorder.

PROGNOSIS:
Insight was developed. Prognosis was favorable because his family was
supportive and he himself was willing to get well soon.

CASE FORMULATION:
A new University of Wisconsin-Madison imaging study shows the brains of people with
generalized anxiety disorder (GAD) have weaker connections between a brain structure that
controls emotional response and the amygdala, which suggests the brain's "panic button" may
stay on due to lack of regulation. This research showed that my case is valid.

MANAGEMENT PLAINS:
 Deep breathing.
 Relaxation technique.
 Cognitive behavioral therapy CBT.

8
CASE REPORT # 2

9
CASE SUMMARY:
Y.A is 34 year old married Man educated up till 8 th and was happy 3th born child of his
family. His problem start when he first went to uncle’s marriage party and for the first time use
marijuana. Then he start using other drugs as well. Y.A couldn’t bear the craving for drug. At that
time client become addicted and become aggressive and even can’t control himself if not found.
He was referred to AL-Nafees hospital for treatment by the doctor and after different tests
application such as HTP, MSE, RISB, BDI and DAST. Result showed that he was suffering from
Alcohol withdrawal disorder.

10
DEMOGRAPHIC DATA
NAME: Yasir

AGE: 34

GENDER: Male

EDUCATION: Middle 8th class

OCCUPATION: Carpenter and mechanic

PARENTS: Alive

NO. OF SIBLINGS: 7

MALE: 3

FEMALE: 4

BIRTH ORDER: 3rd

MARITAL STATUS: Married

FAMILY STUCTURE: Joint

NO. OF CHILD: 3

11
MALE: 0

FEMALE: 3

HEAD OF FAMILY: Father

EARNING MEMBER: 3

HERITAGE: Land

Language: Pakhtoon

INFORMER’S NAME: Self

BELONG TO: Sawabi, Khaberpakhtoonkhow KPK.

BROUGHT BY: Father and brother

REFERED BY: Uncle

REASON AND SOURCE OF REFFERAL:

The client was into the complains of disturbed sleep,fear, aggression and many more for
which he was referred to the trainee psychologist at AL-Nafees hospital for further reporting and
treatment by his family from Sawabi, Khaberpakhtoonkhow KPK.

PRESENTING COMPLAINTS:
‫ماوجودہ علماات‬

1) ‫ غصہ اور جارحیت کی کیفیت رہتی ہے۔‬،‫چڑچڑاپن‬

2) ‫خوف بہت آتا ہے۔‬

3) ‫نیند بہت آتی ہے۔‬

4) ‫بھوک بھی کم لگتی ہے۔‬

5)‫مازاج مایں خوشی ماحسوس نہی ہوتی ہے۔‬

6) ‫ بخاراور سرکا دردکافی رہتا ہے۔‬،‫پیٹ کا درد‬

TARGET SYMPTOMS:
1). Irritability, anger and aggression.

12
2). Anxiety.

3). Sleep disturbance.

4). Decreases appetite.

5). Depressed mood.

6). Physical symptoms abdominal pain, fever and headache.

FAMILY HISTORY:
Client’s both parents were alive. He has seven siblings including
himself. Three male and four female and his birth order is third. He was
married twenty six year before. Now he has three daughter. Client has good
relationship with his family. Mother had psychotic issues since her
adolescence.

MEDICAL HISTORY:

Client reported that three year past he suffer dramatic event of self-
burning. Which was very painful for him. Client was admitted to the burn
hospital of Peshawar. Where he felt hallucinations about hygiene.

GENERAL HOME ATMOSPHERE:

General home environment was not strict. The client belonged to
meddle socio-economic background. They have their own house and land
heritage.

PERSONAL HISTORY:
The patient had no pre and post-natal birth complications. His delivery
was normal and mother condition was also well. All the development
milestones were supervened at proper time. Client was sensitive to his
environment and strict as well. He has issues with his cousins. Once they
shot each other. I his teen client fallen in love with a girl but that was one
sided love and the girl married someone else. On the wish of her parents.

13
After few years client also married to his cousin in 2004. Now he had three
daughters. Whom he love alote.

EDUCATIONAL HISTORY:
He first attended school at the age of 5 year. He was an average
student but obedient one. His relation with his friends was good and long-
term. Under his peer-pressure he left school at 8th grade. His teacher
complained that he had no interest in studies rather in painting and
calligraphy.

OCCUPATIONAL HISTORY:
Client was carpenter and mechanics. He started working at the age of
16. First he was a helper boy later on he became self-employed. After a while
in an incident his shop got burnt and he also faced some injuries which
traumatized him. He had good professional relations with his subordinates.
He was satisfied with his job. Due to addiction problem he left that his work
and live impaired life.

SEXUAL AND MARITAL HISTORY:

Client has successful marital life with his only wife. Otherwise no such
other sexual history was manifest by client.

PERMOBID PERSONALITY:
Before the onset of the illness client was active worker. As the client
wasself-employee he was active thinker and good problem solver as well.

HISTORY OF PRESENT ILLNESS:

Information was given by client himself and hospital authorities.

According to them symptoms appear like acute headache, constant fever,
abdominal pain, depressed mood and aggression. Client started using Ice
and marijuana frequently from past three month. He complained about
marked disturbance in apatite and sleep. He also showed marked confusion
in daily chores. At that time he was admitted to the hospital for 75 days.

14
INFORMAL AND FORMAL ASSESSMENT:
Both formal and informal assessment was done to root out the real
cause of abnormality.

INFORMAL ASSESSMENT:
Clinical assessment
For exploring the important factor of client’s behavior and
psychological analysis a clinical unstructured interview was conducted.

Behavioral assessment
He was dressed properly. He was also giving answer properly but
due to retention problem he was answering late of some questions not
all.

Mental status examination

Client was neat in his appearance, his behavior was withdrawal
and cooperative and have no impairment in orientation. Language was
little delay. He was having retention issues. Sometime he heard voices
which have no such evidence like hallucination. He was not making
proper eye contact and also restless. He have suicidal ideation and
anger outburst.

FORMAL ASSESSMENT:
SIMPLE LINES
Client was ask to draw straight lines which show that client was
addicted because they were not straight. Some lines were straight
because he use edges support to draw that.

House tree person HTP

Client draw all the three things. Interpretation show that client is
raged. He have sense of insecurity and want to get empowered on his
environment. Unstable personality, confuse things, not social, lack of
confidence, depression about oneself, overt and aggressive. He is also
paranoid.

15
Incomplete sentence RISB
In RISB, client scored 138 which showed the degree of
maladjusted. His statements represented maladjusted behavior.
1‫۔ کہ میں نشے میں مبتل تھا‬-
2‫۔مجھے نفرت ہے اپنے آپ سے۔‬
3‫۔ مجھے بہت برا لگتا ہے جب کوئی آگے سے بات نہ کرے۔‬

Back Depression Inventory BDI

In BDI, client have scored 22 which showed that degree of
impairment is questionably significant. May have clinically significant
but moderate depression. Likely to affect most demanding activities of
daily life. ‫ت‬ ‫ن‬ ‫ت ت‬ ‫ن‬
1‫ہی روسک تا‬ ‫اب مییں رون‬-‫ے رونے کی سکت ہہوتی تھی‬ ‫۔ مججھ مییں چنہل‬-
‫ت ت‬ ‫ن‬ ‫نہ ت‬ ‫ن ت‬ ‫ن‬ ‫ت‬
‫ت‬
2‫ے ت تگ آتا ھا‬ ‫ج‬
‫ہی تآتا جن سے چ ل‬ ‫ن‬
‫۔ م ی نیں ان چچییزوں سے ت تگ ن‬-
‫ہ‬
3‫ہے‬ ‫ہوگی‬ ‫ہ‬ ‫تم‬ ‫خ‬ ‫۔ ججنس مییں مییری دلچچ چسپی جتلکل‬-

Drug Abuse Screening Test DAST-10

In DAST, client scored 4 which indicate that the client’s degree of
problem related to drugs is at moderate level. And showed that client
is addicted.

DIAGNOSIS:
Cannabis withdrawal 292.0.

PROGNOSIS:
Insight was fairly developed. Prognosis was favorable because his
family was supportive and he himself was willing to get well soon.

CASE FORMULATION
Cannabis is one of the most commonly used recreational drugs
worldwide. Psychoactive properties of the principal compound, δ-9-
tetrahydrocannabinol include euphoria, a sense of relaxation and increased
appetite. Chronic cannabis use has been associated with the development of
a withdrawal syndrome on abrupt discontinuation. Withdrawal symptoms
typically begin within 24 h of abstinence and manifest as irritability,
nervousness, sleep disturbances and decreased appetite. There is growing

16
evidence that supports the use of plant-derived and synthetic cannabinoids
for the treatment of cannabis withdrawal. In this case report, we present 20-
year-old woman who developed protracted nausea and vomiting secondary
to cannabis withdrawal and was successfully treated with nabilone. Nausea
and vomiting is not listed in the Diagnostic and Statistical Manual-5
diagnostic criteria for cannabis withdrawal syndrome and is an uncommon
symptom presentation.

MANAGEMENT PLAINS:
 Deep breathing.
 Progressive muscle relaxation technique.
 Roll play.
 Cognitive behavioral therapy CBT.

17
 REPORT # 3

CASE SUMMARY:
S.A is 23 year old unmarried mentally retarded young man, living meaningless life and
was 2nd born child of his family.at the time of birth he didn’t cry or sneeze like other normal
children. Later on he never produce any kind of sound and concentration was not develop. He
was referred to different hospital for treatment by the doctor and relatives. Now he is under
observation of qualified Psychologist and trained teachers of chambali institute of mentally
retarded and handicap students. After different tests application such as MMSE, ADHD rating
scale and CARS. Result showed that he was suffering from AUTISM SPECTRUM DISORDER.

18
DEMOGRAPHIC DATA
NAME: Sirmad ALI

AGE: 23

GENDER: Male

EDUCATION: Nil

OCCUPATION: Nothing

PARENTS: Alive

NO. OF SIBLINGS: 4

MALE: 1

FEMALE: 3

19
BIRTH ORDER: 2nd

MARITAL STATUS: Single

FAMILY STUCTURE: Nuclear

HEAD OF FAMILY: Father

EARNING MEMBER: 1

HERITAGE: Land

Language: Pakhtoon

INFORMER’S NAME: Father and teacher.

BELONG TO: Lahore, Punjab.

BROUGHT BY: Father

REFERED BY: Uncle.

REASON AND SOURCE OF REFFERAL:

The client was into the multiple complains of attention deficient, deficit in social-
emotional reciprocity, communication deficit. Aggression and many more for which he was
referred to the psychologist at hospital and then admitted to chambali institute of mentally
retarded and handicap. He was referred by doctors and family relatives.

PRESENTING COMPLAINTS:
‫ماوجودہ علماات‬

1) -‫خوشی اورغم کا اظہار باتوں مایں ظاہر نہیں ھوتا‬

2) ‫تعلقات کوبنانا رکھنا اور سمجھنا نہئ آتا۔‬

3) -‫روزمارہ کئ چیزوں مایں بھت ماحدود رھتا ہے‬

4) ‫مااحول مایں تبدئلی کو پسند نہی کرتا۔‬

5) -‫ھر وقت ایک ھی پینسل کے ساتھ رھتل ھے‬

6) ‫بہت کم چیزوں کا جواب دیتا ھے‬-

20
TARGET SYMPTOMS:
1). Deficits in social-emotional reciprocity.

2). Deficits in developing, maintaining and understanding relationships.

3). Highly restricted.

4).Insistence or sameness.

5). Highly resistive.

6). Hyporeactivity to sensory input. .

FAMILY HISTORY:
Client’s both parents were alive. He has four siblings including himself. One male and
three female and his birth order is second. One of his uncle from mother side also facing the
same problem. Which showed that this disorder runs in DNA of his mother family. There is no as
such disease or disorder history in his father’s family. All of his sisters are normal but youngest
one have mild learning disability as well.

MEDICAL HISTORY:
Father and teacher reported that he does not have any other severe medical problem
rather than autistic one. He always get flue very easily even every month.

GENERAL HOME ATMOSPHERE:

General home environment is helpful for him. The client belonged to meddle socio-
economic background. They have their own house and land heritage.

PERSONAL HISTORY:
The patient had both pre and post-natal birth complications. His delivery was not normal
and operation was done for this purpose. All the development milestones were not met properly.
He had deficits in communication, language and mote movement as well. Client was extreme
sensitive to change his environment. He have love of a green color pencil and his green color
specific lunch box. He was taking same kind of meal for more than 15 year which is bread and
butter socked in thin condense milk. He seldom respond to stimulus otherwise remain inert. At
the age of 3 year he started sporting his neck.

21
EDUCATIONAL HISTORY:
He is not a normal child. Before joining chamabali he was admitted to mentally retarded
institute where client didn’t not fit properly. Client has good understanding with his mother. It
was his mother decision to take admission in chamabali. He is there for seven year and no one
liston his voice. Client never try to make friends and more avoident.

SEXUAL AND MARITAL HISTORY:

Client has no such history but if someone ask for marriage then his answer was always
YES. Because according to his father client had colored dresses.

PERMOBID PERSONALITY:
As the client suffering from autism spectrum disorder from his birth so his personality is
avoidant.

HISTORY OF PRESENT ILLNESS:

Information was given by client’s father and teachers. According to them symptoms was
hypoactive, avoidant, highly restricted, highly resistive and do not form relationships.

INFORMAL AND FORMAL ASSESSMENT:

Both formal and informal assessment was done to root out the real cause of abnormality.

INFORMAL ASSESSMENT:
Clinical assessment
For exploring the important factor of client’s behavior and psychological analysis
a clinical unstructured interview was conducted. He was not giving answer to any
questions, making no eye contact and was not produced any single words during all that
time.

Behavioral assessment
He was dressed properly. He was not also giving answer properly even showed
inert behavior to certain stimulus. He was holding a lunch box that no one can touch that
even his teachers.

22
Mental status examination
Client was neat in his appearance, sitting on his chair doing nothing just bowed
his head down all the time. Have no orientation of time, day and month and if anything
go beyond his vision he thinks that it is vanish. Language was not develop. He has no
retention. He was not making eye contact and also restless. Client has not any kind of
ideation and anger outburst.

FORMAL ASSESSMENT:
House tree person HTP
Client didn’t draw any of the three things. Teacher ask me to draw any figure he
will color it. Already drew picture was given to him and he colored it for 2.5 hours. That
coloring was not also proper

Child autism rating scale CARS

Client autism rating scale was applied on the client and questions were ask from
his father. He scored 45 which lies severe autistic condition.

Attention deficit hyperactivity disorder rating scale ADHD

In ADHD rating scale client scored 37 which showed that he has some attention
deficits and also hyperactivity problems along with autistic symptoms.

Applied behavior analysis ABA

This technique was done to check the behavior of client. Several matching cards,
color matching shapes and word pronunciation was check to identify the causes of
behavior. Client didn’t answer any of the activity. He was pre-occupied with his color
pencil. Event frequently.

DIAGNOSIS:
Autism spectrum disorder comorbidity with ADHD

PROGNOSIS:
Insight was not developed. Prognosis was unfavorable because his family was supportive
and he himself do not know about his awn condition.

23
CASE FORMULATION
Autism Spectrum Disorder (ASD) is on the rise, with one in 68 children diagnosed with
ASD. Families of children with ASD speak of being Bothered feeling like outsiders in social
situ- actions. Because of ASD prevalence, all nurses need to understand current research, causes,
symptoms, diagnosis, treatment, and how to offer effective support. Nurses within the faith
community, especially parish/faith community nurses, can play a signify-cant role in creating a
welcoming and supportive environment for children with ASD and their families. This research
show that my case is valid.
MANAGEMENT PLAINS:
 Behavioral therapy.
 Social Skills Training and Speech-Language Therapy.
 Sensory Integration/Occupational Therapy.
 Applied Behavioral Analysis (ABA).

24
ANNEXURES

25