1

FIELD WORK REPORT

Carried out at, GRACE OPEN SCHOOL & Training Centre Mysore.

Field work report submitted in partial fulfilment of the requirements for

the award of Master of Science Degree in psychology prescribed by
University of Mysore

Submitted by
Shalom S
Reg no: P01ZZ21S0311

Under the supervision of:

Dr. Sampath Kumar.
Professor.

DEPARTMENT OF STUDIES IN PSYCHOLOGY

UNIVERSITY OF MYSORE
MANASAGANGOTRI
MYSURU-570006

MARCH 2023
FIELD WORK REPORT
2

Carried out at, GRACE OPEN SCHOOL & Training Centre Mysore.

Field work report submitted in partial fulfilment of the requirements for

the award of Master of Science Degree in psychology prescribed by
University of Mysore

Submitted by
Shalom S
Reg no: P01ZZ21S0311

Under the supervision of:

Dr. Sampath Kumar.
Professor.

DEPARTMENT OF STUDIES IN PSYCHOLOGY

UNIVERSITY OF MYSORE
MANASAGANGOTRI
MYSURU-570006

MARCH 2023
`
3

DECLARATION

I, SHALOM S, with registration number P01ZZ21S0311, hereby declare that this field work
was carried out by me at GRACE OPEN SCHOOL & TRAINING CENTRE, under the
supervision of Dr. SAMPATH KUMAR, Professor, University of Mysore, in partial
fulfilment for the requirements of Master of Science in psychology in University of Mysore
and has not been submitted to any other University for the award of any Degree or Diploma.

Date: Signature of the student

Place: SHALOM S
4

CERTIFICATE

I hereby certify that this field work has been successfully carried out by SHALOM S, with
registration number P01ZZ21S0311, at, GRACE OPEN SCHOOL & TRAINING
CENTRE, under my guidance and supervision. This field work is submitted in partial
fulfilment for the Master of Science in Psychology and has not been submitted to any other
University for the award of any Degree or Diploma.

Signature of the chairman Signature of the supervisor

(Dr. Sampath Kumar) (Dr. Sampath Kumar)
Department of psychology, Department of Psychology,
University of Mysore, University of Mysore,
Manasagangothri. Manasagangothri.
5
6

ACKNOWLEDGEMENT

I express my sincere gratitude to Dr. Sampath Kumar, chairman and professor, Department
of studies in psychology, University of Mysore for giving me the opportunity to carry out my
field work in Grace Open School, Training centre.
I sincerely thank Sir. Shibu A Joseph and Madam. Swapna Joseph (Counselling psychologist
cum Social Worker) for granting me permission to be an intern in the school and guiding me
throughout the course.

I am extremely grateful to all my family members & Respected Teachers, who encouraged
me and had been with me whenever I needed them. I also express my gratitude to my friends
for their motivation, support, timely assistance and encouragement.
7

INDEX
SECTION PAGE
TITLE NO.
01 INTRODUCTION
FIELDWORK
Definition of Internship
Objective of Internship
Case History Taking
Mental Status Examination
About DSM & ICD
About the institution

02 CASE HISTORY
Case 1- Attention Deficit Hyper-Activity Disorder

 Introduction
 Case History
Case 2- autism spectrum disorder

 Introduction
 Case History
Case 3- Intellectual Disability

 Introduction
 Case History
Case 4- Functional Dysphonia

 Introduction
 Case History
Case 5- Learning Disability

 Introduction
 Case History
03 FIEDWORK SUMMARY

REFERENCE

APPENDIX
8

SECTION – 01
INTRODUCTION
9

FIELD WORK

INTRODUCTION

Fieldwork in Psychology is an independent learning experience, where students volunteer or

are employed in work directly related to psychology.
According to American psychological Association, field work in clinical practice education is
a practicum in which the student supplements and applies classroom theory by taking
responsibility for actual cases under the tutelage of experienced, qualified supervisors.
As Dornan, Borshuizen, King and Scherpbeir (2007) suggest, individuals who participate in
hands-on learning experiences acquire two important qualities:

1) practical competence and skills

2) a state of mind characterized by confidence, motivation, and a sense of professional
identity.
Both of these characteristics strengthen students’ credentials for future employment, and
help to identify the type of career they are most interested in.
For students considering graduate study in clinical or counselling psychology or other
practice-related fields (such as social work, or mental health counselling) field work
experiences can help understand which types of clinical or mental health related issues we
enjoy working with (or don’t enjoy working with!). It can give students exposure to
various clinical populations, and a behind the scenes glimpse into the tasks and roles of
psychologists and other mental-health practitioners, fieldwork experiences can also be useful
to students who are not considering careers in psychological service provision.

DEFINITION OF INTERNSHIP
An internship is a professional learning experience that offers meaningful, practical work
related to a student’s field of study or career interest. An internship gives a student the
opportunity for career exploration and development and to learn new skills.
10

OBJECTIVES OF INTERNSHIP

 CAREER DIRECTION: While an individual is working under any psychological

field or setting, his/her strengths and weaknesses and whether he/she is suitable for
that particular nature of work can be very well understood. Gaining hands-on
experience that can help the individual choose the path of career is one of the most
important objectives of a psychology internship.

 INCREASED COMPETENCE: Increasing individual competence by developing

skills, values and ideas is the essential part of a psychology internship, developing
competence in a variety of areas, such as increasing the experience with
multiculturalism and diversity, developing individual’s knowledge of ethical
practices, learning to maintain professional relationships and become more competent
in providing direct services, such as counselling, psychotherapy and crisis
intervention.

 ENHANCED MARKETABILITY: Internships increases individual marketability

when it comes to the time to look for a job. It draws a line between those who have
gained valuable hands-on experience and the others. Completing an internship shows
an employer that a person is able to apply the theories and models learned in the
classroom to a real or practical situation.

 FORMATION OF WORK HABITS: Internships are great platforms for individuals

to develop good work habits, completing the tasks before leaving for the day, show
accountability and responsibility and reporting the day-to-day work to the supervisors.
Internships help individuals to undergo a transition from student to a professional.

IMPORTANCE OF INTERNSHIP
 Internships allow individual to apply what is learned in a practical setting. This helps
prepare for what to expect in the field and increases confidence in the work.
 Internships provide opportunities to learn new skills, practice old ones and develop a
deeper understanding of the chosen field.
 An internship can help build individual professional network and show a strong work
ethic.
 Internships increase the chances of an individual acquiring employment right after
graduation as individual possesses the practical knowledge about the field.
11

CASE HISTORY TAKING

According to American Psychological Association, case history also knows as patient history,
a record of information relating to a person’s psychological or medical condition. It is used as
an aid to diagnosis and treatment, a case history usually contains test results, interviews,
professional evaluations, and sociological, occupational, and educational data.
Case history is an imperative method to observe human behaviour. It is a technique through
which the questions hidden in the subconscious and concealed from the individual can be
estimated by a professional researcher as well as a therapist that can assess the real problem
faced by the individual or group under study. Case history is a detailed account of the facts
affecting the development or condition of a person or group under treatment or study,
especially in medicine, psychiatry, or psychology.
The general framework for case history taking is as follows:
1.Personal data:
Name, Age, Gender, Education level, marital status, Religion, Type of family, Socio
economic status, Residential address.
2. Complaints and their duration

Record the complaints in a chronological order.

3. History of present illness

Give detailed and coherent account of the symptoms from the onset to the time of
consultation including their chronological evolution and course. Specific attention must be
paid to the following.

 Onset
 Precipitating factors
 Course of illness:
 Associated disturbances

4. Family history

Give a description of the family members. The description should include information as to
whether they are living or dead, age education, occupation, marital status, personality and
relationship with the patient. Describe the socio-economic condition of the family, leadership
pattern, role functions and communication with the family. Enquire about the physical and/or
psychiatric illness in the family and record in detail.
12

5. Personal history

 Birth and early development

Record the details of prenatal, natal and post-natal period; was the birth at full term? Whether
delivered in hospital or at home? Any complications during delivery? Any physical illness in
post-natal period? Ascertain whether milestones of development were normal or delayed.

 Behaviour during childhood

 Physical illness during childhood
 Education
 Occupation
 Menstrual history
 Sexual history
 Marital history
 Use and abuse of alcohol, tobacco and drugs

6. Premorbid personality

In this description of the personality prior to the beginning of the mental illness.
 Social relations
 Intellectual activities
 Moods
 Character
 Interpersonal relationships
 Energy and initiative
 Fantasy life
 Habits
13

MENTAL STATUS EXAMINATION

The mental status examination is a structured assessment of the patient's behavioural and
cognitive functioning. MSE is usually conducted after taking the personal history and is done
mainly to obtain the information about the client’s level of functioning and self-presentation.
It is helpful for organizing subjective and objective information to use in diagnosis and
treatment.
MSE consists of the following components:
 General behaviour
 Psychomotor activity
 Speech
 Thought
- Form, stream, possessions, content.
 Mood
 Perception
 Cognitive functions:
Orientation
Attention and concentration
Memory Intelligence
Judgement
Insight

 Summary
 Diagnosis
 Treatment

ABOUT ICD AND DSM

International Classification of Diseases (ICD) was developed by the World Health
Organization and adapted for use in the American health care system. The latest version of
the ICD, ICD-11, was adopted by the 72nd World Health Assembly in 2019 and came into
effect on 1st January 2022. Uses of the ICD are diverse and widespread and much of what is
known about the extent, causes and consequences of human disease worldwide relies on use
of data classified according to ICD. The ICD has been revised periodically to incorporate
changes in the medical field. ICD-11 is not just ICD-10 with some new categories. Rather,
ICD-11 is a different and more powerful health information system, based on formal
ontology, designed to be implemented in modern information technology infrastructures, and
flexible enough for future modification and use with other classifications and terminologies.
14

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a guidebook widely
used by mental health professionals, The DSM is published by the American Psychiatric
Association and has been revised multiple times since it was first introduced in 1952. The
most recent edition is the fifth, or the DSM-5. It was published in 2013. It provides a resource
to help healthcare providers diagnose these mental health disorders. It provides clear, highly
detailed definitions of mental health and brain-related conditions. It also provides details and
examples of the signs and symptoms of those conditions. The APA released a revised version
of the fifth edition in March 2022. The DSM-5-TR uses more specific language to avoid
reader confusion and DSM-5-TR also made changes aimed at reducing racial and cultural
biases. DSM-5-TR includes the fully revised text and references, updated diagnostic criteria
and ICD-10-CM codes since DSM-5 was published in 2013.

DIFFERENCES BETWEEN ICD AND DSM

The ICD is produced by a global health agency with a constitutional public health mission,
while the DSM is produced by a single national professional association. DSM and ICD are
code sets which are nearly identical in many ways and permits classifying the diagnosis for
healthcare and insurance processing processes. Both DSM and ICD allow cross walking from
old to new versions. This allows the new version to have some definitions from the former
versions. ICD and DSM share several similar codes for diagnosis. However, the specificity of
defining each condition is where they differ. It may appear that the DSM-5 is redundant and
unnecessary in light of the ICD-10 coding system. However, the DSM-5 gives mental health
professionals criteria and definitions to classify diseases through a common language, while
ICD-10 assigns a code that is used for reimbursement in claims processing.

ABOUT THE INSTITUE

GRACE OPEN SCHOOL & TRAINING CENTRE of GRG GRACE TRUST is a non-profit
organisation and a self-financed institute established since 2011 in Mysore, Karnataka by a
group of likeminded people. It’s growing in quality and quantity making the best of the
limited available resources. The students come from far and near states of India. About 75
children are the daily beneficiaries of the school and the number goes up.

At GRACE OPEN SCHOOL, we focus on providing life skill training, remedial education,
academic training, counselling, and behavioural modification therapies for the
a) Children with Autism,
b) Children with Mental Retardation
c) Children with Behavioural disorders
d) Children with Down syndrome,
e) Children with Learning Disability
f) Children with Developmental Disorders
g) School Dropouts and we also give training for the Rural Village children and informal
education for Women.
15

We provide psychological counselling for Families, Youth, Students, Professionals, drug

addicts, alcoholics and all the needy people. We also reach out to the poor, sick, elderly
people in meeting their basic needs and other supporting services.

SECTION- 02
CASE PRESENTATION
16

CASE 01
ATTENTION DEFICIT HYPER-ACTIVITY DISORDER
17

CASE-01

INTRODUCTION

ATTENTION DEFICIT HYPER-ACTIVITY DISORDER (ADHD) Attention-

deficit/hyperactivity disorder (previously known as attention deficit disorder or ADD) is a
neurobehavioral disorder characterised by core symptoms of inattentiveness, distractibility,
hyperactivity, and impulsivity. ADHD is thought to be the most common childhood mental
health disorder, with estimates of its prevalence in children ranging from 5 to 11 percent.
ADHD in adulthood is thought to be less common, with approximately 2 to 5 percent of
adults diagnosed.

SYMPTOMS AND DIAGNOSIS

The symptoms of ADHD fall into two distinct categories in attention and
hyperactivity/impulsivity. Hallmarks of ADHD include difficulty sustaining attention, easily
becoming distracted, and not paying attention to details or instructions. They also include
making careless mistakes at work or school, the inability to finish projects, and losing or
forgetting things. Problems of hyperactivity and impulsivity include feeling restless, moving
around when it is inappropriate to do so, fidgeting or squirming, and talking excessively or
interrupting others at inappropriate times.

CAUSES AND RISK FACTOR

The causes of ADHD are not fully understood. As with other mental health and behavioural
disorders, genes likely play a role, but recent research also implicates exposure to
environmental toxins such as pesticides or lead, as well as prenatal cigarette smoking or
alcohol intake. The belief that eating too much sugar causes the condition has not held up in
research, though refined sugar may exacerbate hyperactive behaviour in certain cases.

"Poor parenting" is not to blame for ADHD, but parenting styles and strategies can have an
effect on children's self-regulating abilities. Children who are exposed to inconsistent
discipline, or who suffer from neglect, may find it more challenging to rein in their impulses
or direct their attention later on.

TREATMENT

Medication and behavioural treatments are both widely used to treat ADHD. While
medication is often the first-line treatment, patients who receive behavioural treatments-
typically therapy. parent training, or neuro feedback often ultimately need less medication or
are able to stop using it entirely. At the same time, several influential studies have concluded
that the two treatment approaches may work best in tandem.

The best treatment plan for ADHD is unique to the individual, and typically includes a mix of
medication, therapy, and/or lifestyle changes. Effective treatment should address both the
underlying symptoms-like impulsivity or distractibility-as well as the resulting behavioural
and social challenges (such as difficulties making friends, managing time, and poor self-
esteem).
18

MEDICATIONS

The most commonly used ADHD medications are stimulants such as Ritalin and Adderall.
Non-stimulants like Strattera or certain classes of antidepressants can be used for those who
don't respond to stimulants or cannot tolerate them.

Whatever medication is used, it's important to receive the correct dosage, since ADHD
medications, and stimulants in particular, can worsen other conditions that may co-occur with
ADHD, including bipolar disorder, obsessive-compulsive disorder, and anxiety.

BEHAVIOURAL TREATMENT

Behavioural therapy is thought to be the most effective non-medical approach for children
with ADHD. It typically trains parents to respond consistently to their child's negative
behaviours and help them set and meet goals, while teaching the child coping techniques and
social skills. A common refrain in the ADHD community, "pills don't teach skills," highlights
the fact that while medication may control symptoms of hyperactivity or inattention, it cannot
necessarily help a child learn how to behave appropriately or break negative habits.
Behaviour therapy aims to fill that gap.
19

CASE – 01

ATTENTION DEFICIT HYPER-ACTIVITY DISORDER

Socio-demographic Information

 Name: ABC

 Age: 10years

 Gender: Female

 Date of Birth: 12/01/2010

 Informant: Parents

 Socio-economic status: Middle Income Group

 Reliability and adequacy of information: Fair

Presenting Complaints

 Aggressive behaviour

 Complaints of rude attitude at school.

 Difficulty in paying attention

 Cannot sit in place for more than two minutes

 Does not finish homework given by teachers

Duration: Since 2yrs

History of Presenting Complaints

Client was rude with family members and not getting involved in any social settings it has
been clearly noticed in a family function that the client is more aggressive for no reasons. (
when the client was in 4th standard) aggressive behaviours found constantly for no reason
and also poor in academic performance. Being rude, fighting with friends, being ill mannered
towards grandparents, not paying attention in class, showing aggressive behaviours with
friends in neighbourhood, not completing homework assigned to her by teachers and that she
was hyperactive most of the time especially in the home environment.

Treatment history: No

Past history: Normal

20

Family history: Normal

Physical/ Mental illness: Absent

Living arrangement: Joint

Care given: Parents

Genogram:

The client hails from a joint family setup which includes her parents and paternal
grandparents. The client is the third and the youngest child in the family. The client's father is
a businessman, and the mother is a homemaker.

Personal History: Client is the youngest daughter in their family with formal parenting with
two elder brothers.

Birth and Development History

 Mother's state of health: Normal

 Delivery term: Normal

 Mode: C-Section

 Birth cry: Immediate

 Place of birth: Hospital

 Child's condition: Normal

 Early childhood illness (within first 28 days): No

 Developmental milestones: Normal

 Socialisation: Good
21

 School history: Attending Behaviour problems (if any specify): Very hyperactive at
home and school environment. She is very rude towards her grandparents and friends.

 School: Government School

 Occupation: No

 Menstrual History: No

 Age at Menarche: No

 Details of Cycle: No

 LMP: No

 Premorbid Personality: Well adjust

 Temperamental History: Slow to warmup

Mental Status Examination

 Eye to eye contact and Rapport: Abnormal

 Dressing and appearance: Normal

 Psychomotor activity: Increased

 Memory: Normal

 Speech: Spontaneous Yes (Irrelevant)

 Intelligence: Normal

General Observations:

 Appearance: Normal

 Speech: Normal

 Behaviour: Restless and impulsive

 Eye contact: Avoidant

 Mood: Irritated spells often

22

Cognition

Memory: Good

Attention: Poor

Judgement: Confused

Assessment

Psychological test finding:

 Developmental Screening Test (DST)

According to the DST, the developmental age of the child was found to be around 9 ½ to 10
years and the chronological age is calculated to be 10 years

 Problematic Behaviour Checklist (PCB)

The test findings reported a degree of problematic behaviour with a score of 26 indicating
that the client has indications of attention deficit hyperactivity disorder.

 Gesell's Drawing test (GDT)

The test findings concluded that the client has 100 IQ as she could draw the items till the
vertical diamond.

 Learning Developmental Checklist (LDC)

By administering the LDC, it was found that the client could read and write till the grade
level of II. The client was able to recite the mathematical tables of 8 fluently, count till 600
and reverse count from 20 to 0.

The client furthermore could perform simple addition, subtraction, multiplication and
division up to 2 digits correctly indicating that the client has no issues in academics.

Supervisors Observation:

 Toilet trained

 Fine motor coordination

 Adequate self-help skills.

Diagnostic Formulation and Summary:

A 10-year-old girl was brought to the institution by her parents with chief complaints of
being rude, fighting with friends, being ill mannered towards grandparents, not paying
23

attention in class, showing aggressive behaviours with friends in neighbourhood, not

completing homework assigned to her by teachers and that she was hyperactive most of the
time especially in the home environment. The client was sent to psychological assessment
wherein firstly the Developmental Screening test was administered, and the results showed
that the client had a mental age of 9½ to 10 years which ruled out mental retardation. She was
then administered the Gesell's Drawing test and the IQ was calculated to be 100 for 10 years
indicating normal intelligence. The problematic behaviour checklist was then administered
and the client scored 26, indicating high level of problematic behaviour present in the client.

When the Learning Developmental Checklist was administered to the client, it was concluded
that academically no problems were found. During the administration of tests, it was
observed that the client was always in a hurry without completely listening to the instructions
and could not sit with a calm posture. The client was then sent to the intervention session
where the client was diagnosed with ADHD. The client was recommended for behaviour
therapy and the parents were suggested with certain management techniques to manage the
child such as giving rewards for good behaviour or if the client completed the desired task. It
was also suggested that the client be joined and take part in sports due to excessive energy.
The parents were advised for regular follow up and revaluation.

DIAGNOSIS: Provisional

ICD 10- F90.0 Hyperkinetic Disorder, Unspecified SPECTRUM

DSM 5- Attention Deficit Hyper-Activity Disorder

Recommendation:

 Psychoeducation for parents for parents

 Behaviour therapy

Parents were suggested to follow certain techniques for managing the behaviour of child such
as-
 Daily routines

 Clear rules and expectations

 Attending to their demand

24

CASE – 02
AUTISM SPECTRUM DISORDER
25

CASE-2

AUTISM SPECTRUM DISORDER

INTRODUCTION

Autism Spectrum Disorder (ASD) is a developmental disorder that involves impairments in

social interaction and communication, challenges with sensory process, and repetitive
behaviours. The term "spectrum" reflects the fact that symptoms vary across different
individuals, ranging in type and severity.

People with autism may appear indifferent and remote and can have difficulty forming
emotional bonds with others. They may have unusual responses to sensory experiences — the
noise of a leaky faucet, for example, might become extremely disruptive.

Autism is found in many different countries and across racial, ethnic, religious, and economic
backgrounds. Its prevalence has been estimated at roughly 1 percent of the world population.
In a study by the Centres for Disease Control and Prevention (CDC), 1 in 59 U.S. children
were identified as having ASD. The earlier the disorder is diagnosed, the sooner a child can
be helped through treatment interventions.

SYMPTOMS

The DSM-5 diagnostic criteria for autism spectrum disorder include:

Persistent deficits in communication and social interaction. These may include:

 Lack of responsiveness during social interactions.

 Abnormalities in the use of gestures, eye contact, or facial expressions.

 No interest in peers or difficulty understanding relationships.

Restricted and repetitive behaviours and interests, such as:

 Specific movements or spoken phrases.

 Insistence on "sameness" and routines.

 Intense, limited interests in particular objects. . Low or high levels of sensitivity to the
sensory environment, including sights, sounds, or smells.

DSM-5 further describes three levels of severity for symptoms related to social
communication and restricted, repetitive behaviours.

 Requiring substantial support: Inflexible behaviour and difficulty dealing with

change; behaviours interfere with functioning in a range of contexts.
26

 Requiring support: Inflexibility significantly interferes with functioning in one or

more contexts; challenges with organising and planning limit the ability to be
independent.

CAUSES

The specific causes of autism are not fully understood, but research indicates that genes
interact with aspects of the environment to determine whether an individual has autism.
Recent evidence suggests that the disorder may be caused by random genetic mutations, as it
is associated with advanced maternal and/or paternal age at conception; such mutations
would likely account for the great variability of impairment and neural systems involved.

There is also evidence that the disorder may be caused by failure of embryonic brain cells to
undergo normal patterns of migration during early development, affecting later brain
structure and wiring of nerve-cell circuits that control social skills, language, movement, and
other abilities.

A sex imbalance in the number of affected children (four times more males than females)
suggests the disorder may also be related to fetal exposure to abnormally high levels of
testosterone in utero; many of the traits of autism are said to reflect male cognitive and
behavioural preferences, such as orientation to detail rather than the big picture, affinity for
things rather than social experience, facility for math and numbers, and even linguistic
impairment; children with autism can accumulate a large vocabulary without being able to
sustain a conversation.

A belief that autism is caused by standard childhood immunisation with mercury-containing

vaccines persists despite many studies discrediting the link and retraction of the original
research paper linking autism to immunisation.

TREATMENT

There is no cure for ASD, but early treatment can help mitigate the challenges associated
with it. The National Institute of Mental Health advises that there is not one best treatment for
all cases of ASD, but medical professionals can confer with diagnosed individuals and their
families to determine an approach that works.

Therapeutic and educational interventions can help people with ASD learn important social
and practical skills and reduce harmful behaviours.

Applied Behavioural Analysis (ABA) focuses on improving specific behaviours such as

communication, hygiene, and competence in domestic or job-related tasks and minimising
negative behaviours, such as self-harm.

While existing drug-based treatments do not address the primary symptoms of ASD, a doctor
may prescribe medication to help alleviate challenges such as aggression, hyperactivity,
anxiety, or depression.
27

CASE-2

AUTISM SPECTRUM DISORDER

Socio-demographic Information

 Name: DEF

 Age: 3 years and 11 months

 Gender: Female

 Date of Birth: 20/01/2016

 Informant: Mother

 Socio-economic status: Lower

 Reliability and adequacy of information: Fair

 Duration: past 3 Months

Presenting Complaints

 No expressive speech

 Repetition of words and actions

 Aggressiveness

 Temper tantrums

 Poor socialisation and communication

History of Presenting Complaints

An anxious and concerned mother visited the institute on complaints of reduced speech by
her child and that she is very aggressive and not responding to basic commands by family
such as calling her name, knowing what water is, etc.

The child does not play or socialise with other children and is found to be all by herself.

The child was asked basic questions like where her mother and identification of various body
parts is. It was concluded that the mental age of the child is 2 years.

Family History: The client hails from a joint family setup which includes her parents and
maternal grandparents. The client is the third and the youngest child in the family. The
28

client's father is an engineer who works in USA and lived there for 2 years; and the mother is
a homemaker.

Genogram:

The client hails from a joint family setup which includes her parents and maternal
grandparents. The client is the third and the youngest child in the family. The client's father is
an engineer who works in USA and lived there for 2 years; and the mother is a homemaker.

Birth and Development History

 Mother's state of health: Normal

 Delivery term: Normal

 Mode: C-section

 Birth cry: Delayed

 Place of birth: Hospital

 Child's condition: Abnormal

 Early childhood illness (within first 28 days): Absent

 Developmental milestones:

 Global delay Socialisation: Poor

 School history: Not attending

 Behaviour problems (if any specify): Aggressive and obsessive with food choice

 Consanguinity: Present
29

 Physical/ mental illness: Absent

Supervisors Observation:

 Toilet control not achieved

 Expressive speech not achieved

 Can identify body parts

 Can scribble

Psychological Test Finding:

• Problematic Behaviour Checklist (PCB)

The checklist was completed by the child's mother. It was found that the intensity of the
problematic behaviour was 32.

It was also observed that the child had obsession with specific food and clothes, banging
objects, self-injuring behaviour, pulling hair, repetition of words and actions, rolling and
crying on floor, fear of certain objects, people and animals.

Mental Status Examination

General Observations:

 Appearance: Normal

 Speech: Unclear

 Behaviour: Impulsive

 Eye contact: Inconsistent

 Mood: Anxious

Cognition

 Memory: Clear

 Attention: Not clear

 Judgement: Not clear

30

Diagnostic Formulation and Summary:

An anxious and concerned mother visited the institute on complaints of reduced speech by
her child and that she is very aggressive and not responding to basic commands by family
such as calling her name, knowing what water is, etc. The child does not play or socialise
with other children and is found to be all by herself. The child was asked basic questions like
where her mother and identification of various body parts is. It was concluded that the mental
age of the

child is 2 years.

The child was sent to detailed psychological assessment and PCB was scored with the help of
the mother. The results showed a score of 32, indicating high level of problematic behaviour
present in the client. The client was then sent to the intervention session where the client was
diagnosed with autism.

The client was recommended for speech therapy, behaviour therapy and safety skill training
to help her adapt and cope well. While the mother was given psychoeducation on autism and
how the child could be trained to take care of herself eventually and if the training proves to
be helpful, she could even start working, but the mother was cautioned that it would take a lot
of effort to reach there. The mother was further suggested for follow up and revaluation after
6 months to check the progress.

ICD 10-F84.0 Childhood autism CASE 3

Recommendation:

 Safety skill training.

 Behaviour therapy

 Speech therapy.
31

CASE- 03
INTELLECTUAL DISABILITY
32

CASE-03

INTELLECTUAL DISABILITY

INTRODUCTION

It is defined as an intellectual functioning level (as measured by standard tests for intelligence
quotient) well below average and significant limitations in daily living skills (adaptive

functioning).

 Description of MR

According to the 'Centre for Disease Control and Prevention', in the 1990s, mental retardation
is prevalent in 2.5 to 3% of the general population. Mental retardation begins in childhood or
adolescence before the age of 18.

 It persists throughout adulthood. Intellectual functioning level is defined by

standardized tests (Wechsler-Intelligence Scales) that measure the ability to reason in
terms of mental age (intelligence quotient or IQ). Diagnosis of mental retardation is
made if an individual has an intellectual functioning level well below average and
significant limitations in two or more adaptive skill areas.

 Mental retardation is defined as IQ score below 70 to 75.

 Adaptive skills are the skills needed for daily life. Such skills include the ability to
produce and understand language (communication); home-living skills; use of
community resources; health, safety, leisure, self-care, and social skills; self-direction;
functional academic skills (reading, writing, and arithmetic); and work skills.

 In general, mentally retarded children reach developmental milestones such as

walking and talking much later than the general population.

 Symptoms of mental retardation may appear at birth or later in childhood. Time of

onset depends on the suspected cause of the disability.

 Some cases of mild mental retardation are not diagnosed before the child enters pre-
school.

 These children typically have difficulties with social, communication, and functional
academic skills.

 Children who have a neurological disorder or illness such as encephalitis or

meningitis may suddenly show signs of cognitive impairment and adaptive
difficulties.
33

 Categories of Intellectual Disability

Mild Intellectual Disability

Approximately 85% of the mentally retarded population is in the mildly retarded category.
Their IQ score ranges from 50 to 75 and they can often acquire academic skills up to the
sixth- grade level. They can become self-sufficient and, in some cases, live independently,
with community and social support.

Moderate Intellectual Disability

About 10% of the mentally retarded population is considered moderately retarded.

Moderately retarded individuals have IQ scores ranging from 35 to 55. They can carry out
work and self- care tasks with moderate supervision. They typically acquire communication
skills in childhood and can live and function successfully within the community in a
supervised environment such as a group home.

Severe Intellectual Disability

About 3 to 4% of the mentally retarded population is severely retarded. Severely retarded

individuals have IQ scores of 20 to 40. They may master very basic self-care skills and some
communication skills. Many severely retarded individuals can live in a group home.

Profound Intellectual Disability

Only 1to 2\%o the mentally retarded population is classified as profoundly retarded.
Profoundly retarded individuals have IQ scores under 20 to 25. They may be able to develop
basic self-care and communication skills with appropriate support and training. Their
retardation is often caused by an accompanying neurological disorder. The profoundly
retarded need a high level of structure and supervision

 Causes of Intellectual Disability

Prenatal causes (causes before birth)

 Chromosomal Disorders: Down's syndrome, fragile X syndrome, Prader Willi

 syndrome, Klinefelter syndrome. Single Gene Disorders: Inborn errors of metabolism

like galactose Mia, phenyl ketonuria, hypothyroidism, Mucopolysaccharidosis, Tay-
Sachs disease.

 Neuro Cutaneous Syndromes: Tuberous sclerosis, neurofibromatosis.

 Dysmorphic Syndromes: Laurence Moon Biedl syndrome

 Brain Malformations: Microcephaly, hydrocephalus, Myelomeningocele.

34

Abnormal maternal environmental influences

 Deficiencies: Iodine deficiency and folic acid deficiency, severe malnutrition.

 Substance use: Alcohol, nicotine, cocaine.

 Exposure to harmful chemicals: Pollutants, heavy metals, phenytoin, warfarin sodium

etc.

 Maternal infections: Rubella, toxoplasmosis, cytomegalovirus infection, syphilis,

HIV.

 Exposure to: Radiation and Rh incompatibility harmful drugs like thalidomide,

 Complications of Pregnancy: Pregnancy induced haemorrhage, placental dysfunction.

 Maternal Disease: Diabetes, heart and kidney disease

During delivery

Difficult and /or complicated delivery, severe prematurity, very low birth weight, birth
asphyxia, birth trauma.

 Neonatal period: Septicaemia, jaundice, hypoglycaemia, neonatal convulsions Infancy

and childhood: Brain infections like tuberculosis, Japanese encephalitis, bacterial
meningitis, Head trauma, chronic lead exposure, severe and prolonged malnutrition,
gross under stimulation

 Symptoms of Intellectual Disability

 Failure to meet intellectual developmental markers.

 Failure to meet developmental milestones such as sitting, crawling, walking, or

talking, in a timely manner

 Persistence of childlike behaviour, possibly demonstrated in speaking style, or by a

failure to understand social rules or consequences of behaviour

 Lack of curiosity and difficulty solving problems

 Decreased learning ability and ability to think logically.

 Trouble remembering things

 An inability to meet educational demands required by school

35

 Treatment

Treatment for Mental Retardation is not designed to "cure" the disorder. Rather, therapy
goals include reducing safety risks (e.g., helping an individual maintain safety at home or
school) and teaching appropriate and relevant life skills. Interventions should be based on the
specific needs of individuals and their families, with the primary goal of developing the
person's potential to the fullest.

Medications are required to treat co morbidities like aggression, mood disorders, self-
injurious behaviour, other behavioural problems and convulsions which occur in 40% to 70%
of cases
36

CASE - 3

MODERATE INTELLECTUAL DISABILITY

Socio-demographic Information

 Name: GHI

 Age: 11 years 7 months

 Gender: Female

 Date of Birth: 01/07 /2008

 Informant: Father

 Socio-economic status: Lower

 Reliability and adequacy of information: Fair

 Duration: 1yr

Presenting Complaints

 Dis fluent speech

 Inadequate speech and language

 Poor mental abilities

 Reading and writing difficulties

 Poor attention

Family History

The client hails from the nuclear family, she is the second and the last child to her parents and
the elder sister is normal.

 Consanguinity: Absent

 Physical/ mental illness: Absent

37

Genogram:

Birth and Development History

 Mother's state of health: Normal

 Delivery term: Normal

 Mode: C-section

 Birth cry: Immediate

 Place of birth: Hospital

 Child's condition: Normal

 Early childhood illness (within first 28 days): Absent

 Developmental milestones: Specific delay (Speech)

 Socialisation: poor

 School history: Attending

 Behaviour problems (if any specify): Nil

Supervisors Observation:

 The child is unable to identify colours

 She needs help with taking bath

 She cannot perform basic mathematical operations

38

Psychological Test Finding:

 Gesell's Drawing test (GDT)

The test findings concluded that the client has 40 IQ as she could not draw the items of 6
years and the mental age was calculated to be 5 years against her chronological age.

 Sanguine Form Board Test (SFBT)

The child could not complete the task within the given time in the first 3 trials and the after a
10-minute break; the shortest time taken to complete the task was 40 seconds.

MENTAL STATUS EXAMINATION:

 Memory: Poor

 Attention: Poor

 Appearance: Shabbily worn dress

 Eye contact: Restless and avoiding

 Judgement: Confused

Diagnostic Formulation and Summary:

An 11-year-old girl was assisted by her father on a complaint that she cannot understand what
they say and that her sentence is very broken or hard to interpret by the parents and that the
client cannot perform basic tasks, poor in self-help skills and partially dependent on father or
grandmother for daily activities. Assessment by the psychologist revealed that the client
could not take bath without help and always required assistance, was poor in mathematical
skills and could not identify the present day and date. It was initially concluded that the
mental age of the client is 6 years and was sent for detailed psychological assessment.

By administering the GDT and SFB, it was found that the client's mental age is 5 years and
IQ is 40; with the above indications the client was diagnosed with moderate mental
retardation.

The client was sent for counselling wherein her parents were suggested to take care of the
client and teach her the basic skill for everyday life such as eating, having bath, wearing
clothes, toilet skills, etc. A mental retardation certificate was issued to the client and was
advised to come after 4 months for revaluation and progress.

ICD 10-F71Moderate Intellectual Disability

RECOMMENDATIONS:

 Psychoeducation for parents

 Self-care training
39

 Counselling for the parents

Parents were suggested to follow certain techniques for managing the behaviour of child such

as;

• Training her for basic tasks

• Teaching her basic sense of touch

40

CASE-04
FUNCTIONAL DYSPHONIA
41

CASE 4

FUNCTIONAL DYSPHONIA

INTRODUCTION

A voice disorder occurs when voice quality, pitch, and loudness differ or are inappropriate for
à individual's age, gender, cultural background, or geographic location. A voice disorder is
present when an individual expresses concern about having an abnormal voice that does not
meet daily needs-even if others do not perceive it as different or deviant.

A number of different systems are used for classifying voice disorders. For the purposes of
this document, voice disorders are categorised as follows:

 Organic- voice disorders that are physiological in nature and result from alterations in
respiratory, laryngeal, or vocal tract mechanisms

 Structural- organic voice disorders that result from physical changes in the voice
mechanism (e. g., alterations in vocal fold tissues such as Edema or vocal nodules;
structural changes in the larynx due to aging)

 Neurogenic- organic voice disorders that result from problems with the central or
peripheral nervous system innervation to the larynx that affect functioning of the
vocal mechanism (e . g., vocal tremor, spasmodic dysphonia, or paralysis of vocal
folds)

 Functional- voice disorders that result from improper or inefficient use of the vocal
mechanism when the physical structure is normal (e.g., vocal fatigue; muscle tension
dysphonia or aphonia; Diploponia; ventricular phonation)

Voice quality can also be affected when psychological stressors lead to habitual, maladaptive
aphonia or dysphonia. The resulting voice disorders are referred to as psychogenic voice
disorders or psychogenic conversion aphonia/dysphonia (Stemple, Glaze 2010). These voice
disorders are rare. SLPs refer individuals suspected of having a psychogenic voice disorder to
other appropriate professionals (e.g, psychologist or psychiatrist) for diagnosis and may
collaborate in subsequent treatment.

Voice disorders are not mutually exclusive, and overlap is common. For example, the
etiology of nodules is functional, as they result from behavioural voice misuse. The voice
misuse results in repeated trauma to the vocal folds, which may then lead to structural
(organic) changes to the vocal fold tissue.

A. Signs and symptoms

The generic term dysphonia encompasses the auditory-perceptual symptoms disorders.

Dysphonia is characterised by altered vocal quality, pitch, loudness, or vocal effort.

Signs and symptoms of dysphonia include

42

 Roughness (perception of aberrant vocal fold vibration);

 Breathiness (perception of audible air escape in the sound signal or bursts of

breathiness);

 Strained quality (perception of increased effort; tense or harsh as if talking and lifting
at the same time);

 Strangled quality (as if talking with breath held); Abnormal pitch (too high, too low,
pitch breaks, decreased pitch range);

 Abnormal loudness/volume (too high, too low, decreased range, unsteady volume),

 Abnormal resonance (hyper nasal, hypo nasal);

 Aphonia (loss of voice);

 Phonation breaks;

 Asthenia (weak voice);

 Gurley/wet sounding voice;

 Hoarse voice (raspy, audible aperiodicity in sound);

 Pulsed voice (fry register, audible creaks or pulses in sound);

 Shrill voice (high, piercing sound, as if stifling a scream); and

 Tremulous voice (shaky voice; rhythmic pitch and loudness undulations).

Other signs and symptoms include

 Increased vocal effort associated with speaking;

 Decreased vocal endurance or onset of fatigue with prolonged voice use;

 Variable vocal quality throughout the day or during speaking;

 Running out of breath quickly;

 Frequent coughing or throat clearing (may worsen with increased voice use); and

 Excessive throat or laryngeal tension/pain/tenderness of voice

43

B. Causes

Normal voice production depends on power and airflow supplied by the respiratory system;

Laryngeal muscle strength, balance, coordination, and stamina; and coordination among these
and the supraglottic resonators structures (pharynx, oral cavity, nasal cavity).

A disturbance in one of the three subsystems of voice production (ie., respiratory, laryngeal,
and subglottal vocal tract) or in the physiological balance among the systems may lead to a
voice disturbance. Disruptions can be due to organic, functional, and/or psychogenic causes.

Organic causes include the following:

Structural

 Vocal fold abnormalities ( e .g., vocal nodules, glottal stenosis, recurrent respiratory
papilloma, sarcopenia [muscle atrophy associated with aging])

 Inflammation of the larynx (e.g., arthritis of the cricoarytenoid or cricothyroid,

laryngitis, laryngopharyngeal reflux)

 Trauma to the larynx ( e .g., from intubation, chemical exposure, or external trauma)

Neurologic

 Recurrent laryngeal nerve paralysis

 Adductor/abductor spasmodic dysphonia

 Parkinson's disease

 Multiple sclerosis

Functional causes include the following:

 Phono trauma ( e .g.,yelling screaming, excessive throat-clearing)

 Muscle tension dysphonia

 Ventricular phonation

 Vocal fatigue ( e .g., due to effort or overuse)

Psychogenic causes include the following:

 Chronic stress disorders

 Anxiety
44

 Depression

 Conversion reaction (e.g., conversion aphonia and dysphonia)

The complementary relationships among these organic, functional, and

psychogenic influences ensure that many voice disorders will have contributions from more
than one etiologic factor. Recognising associations among these factors, along with patient
history, may help in identifying the possible causes of the voice disorder. Even when an
obvious cause is identified and treated, the voice problem may persist. For example, an upper
respiratory infection could be the cause of the dysphonia, but poor or inefficient
compensatory techniques may cause dysphonia to persist, even when the infection has been
successfully treated.

Intervention

Intervention is conducted to achieve improved voice production and coordination of

respiration and laryngeal valving.

Consistent with the WHO (2001) framework, intervention is designed to

 capitalise on strengths and address weaknesses related to underlying structures and

functions that affect voice production;

 facilitate the individual's activities and participation by assisting the person in

acquiring new communication skills and strategies; and

 modify contextual factors to reduce barriers and enhance facilitators of successful

communication and participation, and to provide appropriate accommodations and
other supports, as well as training in how to use them.

C. Treatment Options

The following subsections offer brief descriptions of general and specific treatments for
individuals with voice disorders. They are organised under two broad categories: physiologic
voice therapy (i.e., those treatments that directly modify the physiology of the vocal
mechanism) and symptomatic voice therapy (i.e., those treatments aimed at modifying
deviant vocal symptoms or perceptual voice components using a variety of facilitating
techniques).

Treatment selection depends on the type and severity of the disorder and the communication
needs of the individual. Clinicians are sensitive to cultural, linguistic, and individual variables
when selecting appropriate treatment approaches.

Physiologic Voice Therapy

Physiologic voice therapy is inherently a holistic approach to treatment. Physiologic voice

therapy programs strive to balance the three subsystems of voice production (respiration,
45

phonation, and resonance) as opposed to working directly on isolated voice symptoms. Most
physiologic approaches may be used with a variety of disorders that result in hyper- and
hypofunctional vocal patterns. Below are some of the physiologic voice therapy programs;

 Expiratory Muscle Strength Training (EMST)

 Lee Silverman Voice Treatment (LSVT)

 Phonation Resistance Training Exercise

 Resonant Voice Therapy

 Stretch and Flow Phonation

 Vocal Function Exercises (VFE)

 Symptomatic Voice Therapy

 Amplification

 Auditory Masking

 Biofeedback

 Chant Speech

 Confidential Voice

 Glottal Fry

 Inhalation Phonation

 Semi-Occluded Vocal Tract (SOVT) Exercises

 Straw Phonation

 Lip Trill

 Posture

 Relaxation

 Twang Therapy

 Yawn-Sigh
46

Case 4

FUNCTIONAL DYSPHONIA

Socio-demographic Information

 Name: JKL

 Age: 11 years 2 months

 Gender: Male

 Date of Birth: 07/12/2008

 Informant: Father and Mother

 Socio-economic status: Middle class

 Reliability and adequacy of information: Fair

 School: Government First Grade College 7th

Presenting Complaints

 Reduced loudness of voice

 Strained voice

 Loss of voice for 1 month

 A month ago, child was speaking and reading normally with a clear voice and tone.

 Absence of irritation/pain in the throat while speaking/while not speaking

 Client becomes aphonic if he speaks for some time

 No difficulty in swallowing solids/liquids

 Severity of the problem doesn't vary

Duration: past 2 weeks

History of Complaints: A 11-year-old boy was assisted by his parents to the institution
because he had suddenly lost his voice and could not speak for 2 weeks. The client was
nervous and scared of his parents which could easily be observed by his responses. So, the
parents were sent out and an attempt was made to make him talk, no sound was generated by
the client.
47

Treatment History: Not Specified

Past History: Normal

Family History: Normal

Care given: Parents

Genogram:

Client is the eldest child among three children. There is no significant history of Mental
Illness, Intellectual Disability, Seizure Disorder, Deaf, Dumb or Blindness. It is noted that the
member in the family shows clear and close relationship.

 Consanguinity: Absent

 Physical/ mental illness: No

Birth and Development History

 Mother's state of health: normal

 Delivery term: normal

 Mode: C-section Birth cry: Immediate

 Place of birth: Hospital

 Child's condition: Normal

 Early childhood illness (within first 28 days): No • Developmental milestones:

Normal

 Socialisation: Good

 School history: Secondary education/ Madrasa

 Behaviour problems (if any specify): No

48

MENTAL STATUS EXAMINATION:

 Appearance: Normal

 Speech: Normal

 Behaviour: Reserved and shy

 Mood: stable

 Memory: Normal. Attention: Good

 Orientation: Intact

 Insight: Present

Eye to eye contact and Rapport: No

PSYCHOLOGICAL TEST FINDING:

 Seguin Form Board Test

According to the SFB, the developmental age of the child was found too normal

 Bhatia Battery Test of Intelligence - short form (BBTI)

The test findings reported a normal level of intelligence.

DIAGNOSTIC FORMULATION AND SUMMARY:

A 11-year-old boy was assisted by his parents to the institution because he had suddenly lost
his voice and could not speak for 2 weeks.

The client was nervous and scared of his parents which could easily be observed by his
responses. So, the parents were sent out and an attempt was made to make him talk, no sound
was generated by the client.

The client was sent to psychological assessment. SFB and BBTI was administered on the
client. The results showed that the client has normal IQ.

The client was sent for intervention where it was found that the boy was forcibly sent to a
Madrasa school, and this seemed very traumatic as the client was severed from every
relationship and was expected to behave and live in a very orthodox lifestyle.

This overtime had a significant impact over his mental status and slowly began to speak
lesser and lesser over time after which he was completely unable to create sounds from his
mouth.

The caretakers informed the client's parents and even after coming home the client did not
recover his voice due to fear of going back to the Madrasa School.
49

The client was recommended for behaviour therapy and after the first session 90% of the
voice had been recovered.

The client seemed more vibrant and positive. The parents were suggested on not forcing the
child into anything and a follow up after 6 months.

ICD 10-R49.0 Functional Dysphonia

RECOMMENDATIONS:

 Psychoeducation for parents

 Behaviour therapy was performed on the client and the voice was recovered
successfully

Parents were suggested to follow certain techniques for managing the behaviour of child such

as;

 Not to force the child into something that he dislikes.

 Understand his wishes and needs

50

CASE 05
LEARNING DISABILITY
51

CASE 05

LEARNING DISABILITY

INTRODUCTION

A learning disability is a neurological condition which affects the brain's ability to send,
receive, and process information. Learning disabilities are not caused due to physical or
mental illness, economic condition, or cultural background; neither do they indicate that the
child is weak or lazy. A child with a learning disability may have difficulties in reading,
writing, speaking, listening, understanding mathematical concepts, and with general
comprehension.

Learning disabilities include a group of disorders such as dyslexia, dyspraxia, dyscalculia and
dysgraphia. Each type of disorder may coexist with another. The main types of learning
disorders include:

Dyspraxia: Dyspraxia affects a person's motor skills. Motor skills help us with movement
and coordination. A young child with dyspraxia may bump into things or have trouble
holding a spoon or tying his shoelaces. Later, he may struggle with things like writing and
typing. Other problems associated with dyspraxia include:

 Speech difficulties

 Sensitivity to light, touch, taste, or smell

 Difficulty with eye movements

Dyslexia: Dyslexia affects how a person processes language, and it can make reading and
writing difficult. It can also cause problems with grammar and reading comprehension.
Children may also have trouble expressing themselves verbally and putting together thoughts
during conversation.

Dysgraphia: Dysgraphia affects a person's writing abilities. People with dysgraphia may
have a variety of problems, including:

 Bad handwriting

 Trouble with spelling

 Difficulty putting thoughts down on paper

Dyscalculia: Dyscalculia affects a person's ability to do math. Math disorders can take many
forms and have different symptoms from person to person. In young children, dyscalculia
may affect learning to count and recognise numbers. As a child gets older, he or she may
have trouble solving basic math problems or memorising things like multiplication tables.
52

Experts say that there is no single, specific cause for learning disabilities. However, there are
some factors that could cause a learning disability:

Heredity: It is observed that a child, whose parents have had a learning disability, is likely
to develop the same disorder.

Illness during and after birth: An illness or injury during or after birth may cause learning
disabilities. Other possible factors could be drug or alcohol consumption during pregnancy,
physical trauma, poor growth in the uterus, low birth weight, and premature or prolonged
labour.

Stress during infancy: A stressful incident after birth such as high fever, head injury, or
poor nutrition.

Environment: Increased exposure to toxins such as lead (in paint, ceramics, toys, etc.)

Comorbidity: Children with learning disabilities are at a higher-than-average risk for

attentional problems or disruptive behaviour disorders. Up to 25 percent of children with
reading disorder also have ADHD. Conversely, it is estimated that between 15 and 30 percent
of children diagnosed with ADHD have a learning disorder.

While the causes of learning disabilities are not fully understood, several risk factors have
been identified. Other factors that may increase one's risk for a learning disability include
premature birth, very low birth weight, the use of nicotine, alcohol, or drugs during
pregnancy, and severe deficits in nutrition or exposure to lead in infancy.

The symptoms of learning disabilities are a diverse set of characteristics which affect
development and achievement. Some of these symptoms can be found in all children at some
time during their development. However, a person with learning disabilities has a cluster of
these symptoms which do not disappear as s/he grows older. Most frequently displayed
symptoms are short attention span, poor memory, difficulty following directions, inability to
discriminate between/among letters, numerals, or sounds, poor reading and/or writing ability,
eye-hand coordination problems; poorly coordinated, difficulties with sequencing, and/or
disorganisation and other sensory difficulties. Other characteristics that may be present
include performs differently from day to day, responds inappropriately in many instances,
distractible, restless, impulsive, says one thing, means another, difficult to discipline, doesn't
adjust well to change, difficulty listening and remembering, difficulty telling time and
knowing right from left, difficulty sounding out words, reverses letters, places letters in
incorrect sequence, difficulty understanding words or concepts, and/or delayed speech
development; immature speech.
53

Diagnosis

A. Difficulties learning and using academic skills, as indicated by the presence of at least one
of the following symptoms that have persisted for at least 6 months, despite the provision of
interventions that target those difficulties:
1. Inaccurate or slow and effortful word reading

(e.g., reads single words aloud incorrectly or slowly and hesitantly, frequently guesses words,

has difficulty sounding out words).

2. Difficulty understanding the meaning of what is read

(e.g., may read text accurately but not understand the sequence, relationships, inferences, or
deeper meanings of what is read).

3. Difficulties with spelling

(e.g., may add, omit, or substitute vowels or consonants).

4. Difficulties with written expression

(e.g., makes multiple grammatical or punctuation errors within sentences; employs paragraph
organisation; written expression of ideas lacks clarity). poor

5. Difficulties mastering number sense, number facts, or calculation

(e.g., has poor understanding of numbers, their magnitude, and relationships; counts on
fingers to add single-digit numbers instead of recalling the math fact as peers do; gets lost
during arithmetic computation and may switch procedures).

6. Difficulties with mathematical reasoning

(e.g., has severe difficulty applying mathematical concepts, facts, or procedures to solve
quantitative problems).

B. The affected academic skills are substantially and quantifiably below those expected for
the individual's chronological age, and cause significant interference with academic or
occupational performance, or with activities of daily living, as confirmed by individually
administered standardised achievement measures and comprehensive clinical assessment. For
be substituted for the standardised assessment individuals aged 17 years and older, a
documented history of impairing learning difficulties may

C. The learning difficulties begin during school-age years but may not become fully manifest
until the demands for those affected academic skills exceed the individual's limited capacities
(e.g., as in timed tests, reading or writing lengthy complex reports for a tight deadline,
excessively heavy academic loads).

D. The learning difficulties are not better accounted for by intellectual disabilities,
uncorrected visual or auditory acuity, other mental or neurological disorders, psychosocial
adversity, lack of proficiency in the language of academic instruction, or inadequate
educational instruction.
54

CASE 5

LEARNING DISABILITY

Socio-demographic Information

 Name: MNO

 Age: 10 years 10 months

 Gender: Male

 Date of Birth: 27/05/2009

 Informant: Mother

 Socio-economic status: Lower

 Reliability and adequacy of information: Fair

 School: sixth

Presenting Complaints

 Poor in reading and writing skills Poor academic performance

 Does not complete answer sheets during exam

 Poor handwriting

 More difficulty in Kannada and Hindi

 Does not like writing

 Poor attention and concentration

 No complaint of hearing

Duration: 3yrs

History of present illness

From past 3 years client is having issues in giving the best in academic also has poor
attention and concentration Before the client had good academic skills as the care giver
Informed.
55

Negative History: No

Treatment History: No

Physical/Mental illness: Absent

Treatment History: No

Past History: No

Family History: Normal

Living Arrangement: Nuclear family

Care given: Parents

Genogram:

Client is the youngest member in the family. Along with him, parents of the client have a 13-
year-old daughter. There is no significant history of Mental Illness, and Intellectual
Disability. Daughter has an excellent academic background. It is noted that the member in the
family shows clear and close relationship among siblings and parents.

Personal History

Birth and developmental history

 Mother's state of health: Normal

 Delivery term: Normal

 Mode: Normal

 Birth cry: Immediate

 Place of birth: Hospital

 Child's condition: Normal

56

 Early childhood illness (within first 28 days): Absent

 Developmental milestones: Specific delays (only related to reading, writing)

 Socialisation: Good

 School history: Client is enrolled only to Ideal Jawa Rotary School

 Behaviour problems (if any specify): No

 Consanguinity: Absent

 Physical/ mental illness: No

Supervisors and observation:

 Client is continuing his studies from the same school since kindergarten years.

 Neither negative school atmosphere, Supervisors and observation: nor change of

syllabus and medium of teaching is present

 Client fluently speaks in both Kannada and English

 Regardless of poor academic performance client enjoys attending school

 Presence of academic delay

Premorbid personality: Well, Adjusted

Temperamental History: Slow to Warmup

MENTAL STATUS EXAMINATION:

 Dressing and Appearance: Normal

 Eye to eye contact and Rapport: Normal

 Psychomotor Activity: Restless

 Speech: Spontaneous No

 Communicable: No

 Liability: Yes
57

Assessment

PSYCHOLOGICAL TEST FINDING:

 Standard Progressive Matrices (RPM)

On RPM he got a score of 35, giving a Grade 3 and above 50th percentile. This indicating
that he is of Intellectually Average.

 Learning Disability Checklist (LDC)

On LDC, he got Grade 2 level on Reading, and Grade 3 level Spelling and Arithmetic.

Cognition

 Psychomotor activity: Normal

 Speech: Age adequate speech and language development

 Thought: Coherent and age-appropriate thoughts, insights and judgment

 Mood: Stable mood and affect

 Perception: Age appropriate

 Orientation: Intact

 Attention and concentration: Normal

 Memory: Normal

 Intelligence: Average

 Insight: Present, client understands learning difficulties that he is experiencing

DIAGNOSTIC FORMULATION AND SUMMARY:

A mother bought her son to the institution reporting that he has been repeatedly scoring very
low marks in his exams conducted in school. The mother even mentioned that he cannot
complete his homework and need assistance in every sentence and problem he tries to solve.

The client was referred to psychological testing where RPM was administered; the client
scored 35 showing he is of average intellect. When LDC was administered it was observed
that the client had a hard time reading simple sentences and making meaning out of it,
similarly in spelling and arithmetic also indicating that he has issues in spelling words and
finds mathematical operations hard to understand. The questions had to be repeated several
times and explained to a very basic level.
58

The client was then sent to intervention and was suggested various techniques and methods to
cover up on the syllabus to catch up with his present class and score better. The mother was
advised for follow up and revaluation after 6 months based on the current recommendation.

Diagnosis: ICD 10-F81.3 Mixed Disorder of Scholastic Skills

DSM 5

 Difficult in Reading

 Writing

 Athematic

 Mathematical Reasoning Skills

RECOMMENDATIONS:

 Intensive attention needs to be paid if the child needs to catch back to his present
grade

 Starting basic concepts so that he registers the foundation which can be improvised
later.
59

FIELD WORK SUMMARY

The Internship was carried out by me at Grace Open School, Training centre Mysore. It
Was a beautiful place to be with those Children and observing the different
developmental issues they had. The children there were sincerely cooperating with the
teachers in attaining their formal education (some of the activities like puzzle board
activities, dance and games). Being there with those Children and taking classes for
them made me understand how difficult it was for them to understand concepts
compared to the Normal students.
But despite every single day’s difficulties, still the teachers were sharing
that there is HOPE for that child to improve. It is a school for grades from L.K.G,
U.K.G ,1st grade up to 12th grade, and further they would join various other courses
based on their interest. Despite the hopeless condition of each and every child, Sir &
Madam they have taken these Children and are working on the betterment of every
child’s life. I really understood that it wasn't that easy as understood theoretically but to
work in real life it needs our patience and tireless efforts and staying positive
throughout in all situations.
60

Appendix
FORMAT OF CASE HISTORY
Psychiatric Evaluation Performa (Unit 3) NIMHANS, Bangalore
Name:
Age:
Sex:
Education:
Occupation:
Marital Status:
Address:
Referred By:
Informant:
Reliability:
Adequate:
Presenting Complaints:
Duration:
History of presenting Complaints:

 Onset
 Course
Treatment History:
Past History:
Family History:
Living Arrangements:
Caregiver:
3 Generation Genogram:
Personal History:

 Birth and Development:

 Behaviour during Childhood
 Childhood physical illness:
61

 School:
 Occupational:
 Marital History:
 Habits:
Premorbid Personality:
 Fantasy life:
Mental Status Examination:

 General appearance and behaviour:

 Dressing and appearance:
 Consciousness
 Eye to eye contact and rapport
 Tics/mannerisms:
Psychomotor Activity:

 Speech:
 Tone/tempo:
 Reaction time:
 Prosody:
Thought:

 Stream:
 Possession:
 Content:
Mood:
 Subjective:
 Objective:
 Communicable:
 Appropriate:
 Reactivity:
Perception:
Cognitive function test:

 Orientation:
 Attention and Concentration:
 Memory:
 Immediate:
 Recent:
 Remote:
Intelligence:
 General Information:
62

 Comprehension:
 Arithmetic:
Abstraction:
 Similarities:
 Differences:
Judgement:
Insight:
Formulation/summary:
Diagnosis:
Recommendation.
63

Reference:
American Psychiatric Association (1980). Diagnostic and statistical manual of mental
disorders. 3rd ed. Washington: American Psychiatric Association.

American Psychiatric Association (1994). Diagnostic and statistical manual of mental

disorders. 4th ed. Washington: American Psychiatric Association.

American Psychiatric Association (2013). Diagnostic and statistical manual of mental

disorders. 5th ed. Arlington: American Psychiatric Association.

Andrews G, Slade T, Peters L (1999). Classification in psychiatry: ICD-10 versus DSM-

IV. Br J Psychiatry; 174:3-5.

Bub B (2004); The patient's lament: hidden key to effective communication: how to
recognise and transform Medical Humanities.

First MB, Pincus HA (1999). Classification in psychiatry: ICD-10 vs. DSM-IV. A

response. Br J Psychiatry; 175:205-9.

Jablensky A, Sartorius N, Hirschfeld R, et al (1983). Diagnosis and classification of

mental disorders and alcohol- and drug-related problems: a research agenda for the
1980s. Psyche Med; 13:907-21.

Sartorius N Principal Investigator. The WHO/Alcohol, Drug Abuse, and Mental Health
Administration Joint Project on Diagnosis and Classification. Cooperative agreement
UOIMH035883, from the National Institute of Mental Health to the World Health
Organization, 1983-2001
64

Smith R (2003); Thoughts for new medical students at a new medical school. BMJ.
20327(7429):1430-3.

World Health Organisation (1992). Manual of the international statistical classification

of diseases, injuries, and causes of death. Tenth revision of the international
classification of diseases. Geneva: World Health Organization.
World Health Organization (1993). ICD-10 Classification of mental and behavioural
disorders. Diagnostic criteria for research. Geneva: World Health Organization.