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Case Report no. 1

Sadia Shafiq

BS Clinical Psychology, GIFT University

PSY314-Clinical Internship II

Ma’am Iqra Sherazi

13-12-2021
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Summary of the case

HA is a nine years old boy. He belongs to a well settled family. He is deaf
and has severe muscle weakness, eye-sight problem and mood issues. He performs
some certain actions repeatedly and produces certain kind of sounds frequently. His
parents have had a cousin marriage. His sister and maternal aunt are also deaf and
his father has muscle problems. He has average motor abilities and poor speech
patterns. He mostly remains reserved but often gets hyperactive, mischievous and
quarrelsome with others.

Identifying data

Name HA
Age 8 years
Gender Male
No. of Siblings 4
Birth order 4th
School’s Name National Institute for deaf
Source and reason for referral

The client was referred to trainee clinical psychologist for psychological

assessment and management of her problems i.e., mood swings, hyperactivity,
repetitive actions and sounds.
Presenting Complaints
Table 1

Presenting Complaints Reported by Client’s Teacher

Duration Presenting complaints

By birth ‫پٹھوں کا مسلہ ہے اور لڑکھڑا کے چلتا ہے۔‬
‫موڈ خراب ہو تو کچھ بھی نہیں کرتا ورنہ سن لیتا ہے۔‬

2 years ‫ایک ہی حرکت کو بار بار دہراتا ہے۔‬

5 years ‫بہت موڈ سونگس آتے ہیں۔‬

Initial Observation
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The client was physically weak. His speech was very poor, almost none. He
was not responding and he seemed to be quiet and reserved. His appearance was fine
i.e. his clothes were neat and hair were combed.

History of Present Illness

The client has been suffering from severe muscle weakness since his birth. He
exhibits very poor concentration and responding abilities. He rarely communicates and
responds, that too with small gestures. Reportedly, he has been showing symptoms
like repetitive actions and sounds, mood swings and hyperactivity since about five
years.
Background information
a) Personal History.
The client was born on 10 th May, 2013 with normal delivery. He had
delayed milestones. He started walking at the age of 3, with staggering leg.
Later on, his eyesight started getting lower. He has been taking the
prescribed medication by Children’s hospital.
b) Educational History.
The client was administered in this institute at the age of three. He was
there in institute as a trainable child and not an educatable one.
Apparently, He can write, if guided properly. But he can not understand or
comprehend anything. His speech and listening abilities are almost none.
c) Family History.
The client belongs to a financially stable family. His parents were cousins
and had an arranged marriage. He has four siblings, two brothers and two
sisters. He is the 4 th child of his parents. His father has muscle weakness.
His younger sister and maternal aunt are deaf.
History of Psychiatric Illness
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Provisional Formulation
The client has been showing symptoms like yelling a certain sound, performing same
action repeatedly, hyperactivity. He might be experiencing Tourette’s syndrome or
Provisional tic disorder.
Psychological Assessment
Client’s assessment was done through:
 Clinical Interview
 Subjective Ratings of Problem
 Reinforcer Identification

Clinical Interview.
The client’s interview was conducted in the presence of his instructor. He was
completely blank during the interview, initially. He was not responding to any
stimulus. He was quiet and reserved. Later on, behavioral observation suggested that
he was continuously teasing a fellow, sitting beside him. He was continuously moving
his hands in the same direction, with a yelling sound from his throat.
He was asked to write some alphabets with dotted lines which he done nicely.
But he had no understanding of what he was writing. He was asked to take his cap
and coat off, but he was unable to do so.
Subjective Ratings of the Problems.
Table
Subjective Rating of the Problems by Client (Pre-assessment)
Problems Rating
Behavioral patterns 2
Discipline 5
Art 0
General outlook 5
Self-help skills 0
Language and skills 0
Fine and gross motor skills 2
Cognitive skills 1

Reinforcer Identification.
The client was totally dependent on his own mood. But he was a little bit interested
in writing on his notebooks and getting appreciation on his work.
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Formal Assessment using Portage guide

Areas of development Obtained scores
Self-care skills 6 months.9days
Motor development 1 year,7 months
Cognition 7 months.8days
Language 1 month
Socialization 7 months

Global Developmental level=Total no. of years/Total areas

=3.6/5

=0.72 years =8 months

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Case Formulation
HA is 8 years old. He has four siblings, three brothers and two sisters. He has
delayed milestones. He is deaf and dumb and has severe muscle weakness. His sister
and maternal aunt are also deaf. He is unable to speak and communicate. He remains
reserved and quiet usually, but sometimes becomes hyperactive and starts teasing
others by his mischievous acts. His problematic behavior was first noticed at the age
of three.
He has been taking medicines prescribed to him by a professional at Children’s
hospital. His motor ability is fine. But he cannot comprehend and communicate.
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Precipitating Factors

Pre-Disposing Factors Poor physical health.

Father’s illness

Presenting complaints
Muscles weakness.
Mood swings.
Repetitive actions and sounds. Maintaining Factors
Lack of awareness in parents.
Lack of facilities and proper
treatment.
Poor social support.

Assessment

 Clinical Interview
 Subjective Ratings of Problems
Management
 Reinforcer Identification
1. Proper guidance about
sign language with
speech and language
therapy.
2. Enough social and
parental support.

Figure 1. Pictorial presentation of Case Formulation

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Diagnosis
Tourette’s Disorder 307.23 (F95.2)
Child’s Progress
No progress has been seen till now in the client.
Intervention Plan
The intervention plan was on the basis of problems of client such as problems
in response, and concentration and uncontrolled motor and vocal movements. The
management plan was based on education and behavioral model.
Short Term Goals
 Short term goal is to make the client able to control his mood swings and
repetitive actions and movements.
Long Term Goals
Long term goals of the intervention and management plan is to develop
necessary behavioral and cognitive abilities in the client by providing him better
training opportunity so that his uncontrolled and repetitive actions may get lesser and
he may do better in his daily routine.
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 References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596