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CHILD PSYCHODIAGNOSTIC REPORT

Supervisor: Ms. Maria Tanvir

Submitted by :Nimra Tariq

25260

Laraib Nisar Kayani

23861

Mahnoor Naheed

23873

Faculty Of Science And Humanity

Depoartment of Applied Psychology

Academic year-Spring 2022

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DECLARATION:

I, Ms. nimra,laraib, mahnoor, do hereby solemnly declare that the work submitted

in this report is my own and has not been presented previously to any other

institution. The work has been carried out and completed at the Department of

Applied Psychology of Riphah International University, Gulberg Green Campus.

Student signature ……………………………

Supervisor signature ……………………………..

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Forwarding Sheet

The Clinical reports of us have been accepted in partial fulfillment of requirement of

the degree of Bachelors in Applied Psychology and are forwarded for further

necessary actions.

Supervisor Miss Ayesha Malik

…………………………
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Approval Sheet

The Clinical reports of us have been accepted in partial fulfillment of requirement

of the degree of bachelors in Applied Psychology (MSCP).

Supervisor ……………………

Miss Ayesha Malik

Head of Department ………………………

Dr Rabia Hanif
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Acknowledgement

In the name of Allah, the Most Merciful, the Most Compassionate, all praise to be

for Allah, the Lords of the worlds and prayers to Prophet Muhammad (PBUH).

I want to start by expressing my gratitude to Ma'am ayesha malik, my

supervisor, whose knowledge was crucial in completing the report. The positive

criticism I received from her helped improve my ideas, which raised the caliber

of my work.

Additionally, I want to convey my sincere gratitude to my family members, who

have continuously provided me with support and encouragement. Without their

understanding, I would not have been able to continue pursuing higher

education.
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Table of Contents

Case report # 1 3

Case summary

Bio Data…………………………………………………………………………………………..

Reason Refferal…………………………………………………………………………………..

Background

Family history…………………………………………………………………………………….

Personal History………………………………………………………………………………
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CASE 1
SUBSTACE INDUCED
PSYCHOTIC DISORDER
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Case summary:
The client is a 26 year old male. The client was refereed to a training psychologist by
his friend to experiencing of psychotic symptoms such as delusion and visual and auditory
hallucinations. The client has also been feeling anxious lately and find it difficult to interact
with people. The lack of social interaction has caused impairment in his work life. The client
is an alcohol addict with heavy dependency. After administering the psychological tests and
through interview, the client has been diagnosed with substance induced psychotic disorder
(F10.259). The treatment recommended for the disorder is medication, rehabilitation centre,
and CBT.

Identifying data:
Name: Mr. MA
Age: 26 Gender:
Male Siblings: 3
Birth order: 2nd

Education: post
graduation

Occupation:

Employee
Marital status:
single

Address:
Islamabad
Religion: Islam
Socio-economic status: Upper-middle class
Informant: Client’s friend
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Reason and source of referral:

The client was referred to a training clinical psychologist by his friend for psychological
assessment and management.
Presentation complaints:
Table 1
Frequency, intensity, duration table

Complaints Frequency Intensity Duration

‫مجھے لگتا ہے کہ میرے دونوں بھائ‬ 20 days a month 9/10 6 months

‫مجھے مارنا چاھتے ہیں۔‬

15-20 days a month 7/10 3 months

‫ مجھے اکثر موت کا سایا بھی نظر آتا ھے‬8-10 days a month 6/10 3 months

‫ مجھے لوگوں سے ملتے ھوۓ بہت‬Everyday 10/10 2 months

‫گبراہٹ ہوتی ھے۔‬

‫میں اکثر بہت سی چیزیں بھول جاتا ہوں۔‬ Everyday 6/10 2 months

Initial observation:
The client was in his casual clothes but didn’t seem neat and clean. The was anxious
and his shoulders we’re shrugged due to stress.

History of present illness:

The client, Mr. MA started experiencing symptoms in May, 2020 during the time of
quarantine. The client was under the heavy influence of alcohol and was completely out of
his senses. In that state of mind the client read a story online about a brother killing his
brother for property.
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In the beginning it only happened only when the client was under heavy influence
only then he would get such intrusive thought. The client would also experience headaches
after getting sober. After two months of experiencing these intrusive thoughts and severe
headaches the condition of the client got worse to the point that even with less consumption
of alcohol the client would get these disturbing thoughts.
. The client also got strange visuals such as shadows which he called death or
someone coming to get his life. The client would get nightmares and most of the nights the
client wouldn’t sleep. The client started isolating himself and avoided him family especially
his brother. The client also stopped going out and socialising.
But despite everything the client didn’t stop drinking which was making his condition
worse. The client also started experiencing blackouts which was impacting his memory. He’d
forget most of the part of the day. The client came to Benazir Bhutto Hospital in October,
2021 for therapy. The client was put under medication and was recommended to get admitted
in a rehabilitation centre for his drinking problem but the client did not go for it but the
medication helped the client in controlling hallucinations and would keep his mind off
delusions. The client also lessened the amount of alcohol he consumed everyday. This case
was recorded in November 2021.

Background information:
Personal history:
Birth and early childhood:
According to the client, he had a normal birth experience with no complications I
delivery and completed his milestones promptly. The client stated that he has no neurotic
characteristics.
Educational history:
The started school at the age of 4. The client was a bright student and adjusted in
school without any form of trouble. The client got his graduate degree in BBA and
postgraduate degree
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in MBA. Till postgraduation, the client was an extroverted, jolly person with positive vibes
and had a lot of friends.
Sexual history:
The client’s puberty started at the age of 13 and had typical reaction to his sexual
maturity and bodily changes. The client is a heterosexual and is slightly sexually active.
Family history:
The client belongs from a upper-middle class Muslim family and lives ina nuclear
family. The father of the client is a retired brigadier and the mother of the client used to work
in a bank. Father’s pension and older brother are the source of income. The client has a good
relationship with his parents but is closer to his mother.
Drug history:
The client has been involved in alcohol consumption only.
Forensic history:
No court or police case was reported.
Past medical and psychiatric illness:
The client has no past medical or psychiatric illness.
Pre-morbid personality:
Before the occurrence of emotional instability and a psychiatric disorder, the client
described himself as an active, lively, and a social person. The client would handle troubles
smoothly and had no problems in social interaction. The client had a large group of friend
and got along well with his family.
Assessments:
The assessment was done on two levels; formal and informal
Informal assessment:
The informal assessment was conducted on following levels
 Behavioural observation
 Clinical interview
Behavioural observation:
It was done through mental state examination (MSE). The client appeared decent in
his casual clothes but not too neat or clean. The client was anxious and his shoulders were
shrugged
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due to stress. The client was shaking his legs and rubbing his left palm with right thumbs.
The client was stuttering wile the answering the questions. The client couldn’t maintain eye
contact with me while talking to me. The client was feeling a little discomfort and stressed
during formal assessment.
Clinical interview:
An interview was conducted the gain information about clients past and his currant
condition and to find out the factors that predisposed and maintained the client’s illness and
prognosis as well as to formulate a therapeutic management plan. The informant was also
questioned to get accurate information about client.
Formal assessment:
The formal assessment was conducted on following levels:
 Mini mental state examination (MMSE)
 Brief psychiatric rating scale (BPRS)
 Alcohol use disorder identification test (AUDIT)
 Beck anxiety inventory (BAI)
Quantitative analysis of MMSE:
Table 2
Mini Mental State Exam (MMSE) Result

Raw score Cognitive impairment

22 Mild cognitive impairment

Qualitative analysis of MMSE:

The client scored 22 out of 30 on MMSE which showed that the client’s cognitive
functioning is mildly impaired and is not well oriented about his surroundings.
Quantitative analysis of BPRS
Table 3
Brief Psychiatric Rating Scale BPRS) Result

Raw score Level of psychosis

89 Severely ill

Qualitative analysis of BPRS:

The client scored 89 out of 126 on BPRS which showed the presence of severe
psychotic symptoms.
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Quantitative analysis of AUDIT:

Table 4
Alcohol Use Disorder Identification Test (AUDIT) Result

Raw score Alcohol severity

22 Severe alcohol dependency

Qualitative analysis of AUDIT:

The client scored 22 out of 40 on AUDIT which indicates the presence of alcohol
dependences and abuse of alcohol.
Quantitative analysis of BAI:
Table 5
Beck Anxiety Inventory (BAI) Result

Raw score Level of anxiety

33 Severe anxiety

Qualitative analysis of BAI:

The client scored 33 out of 63 on BAI which indicated the severity of anxiety.

Case formulation:
The client was a 26 year old male who was referred to a training psychologist in
Benazir Bhutto hospital (BBH) by a friend with presenting complaints of false belief that his
brothers might kill him and auditory hallucinations such as gun shots and visual
hallucinations such as weird shadows. The client also faces discomfort in social setting and
find t difficult to interact with people. The client is an alcohol addict and highly depends on
it. After administration psychological assessments and conducting an interview keeping in
mind the criteria of DSM- 5-TR it was established that the client has Substance Induced
Psychotic disorder (F10. 259).
The anxiety, low mood and insomnia experienced by the client could be explained
using following research in which it has been stated that insomnia, anxiety, and depression
(including suicidality) are symptomatic of alcohol-use disorders (Schuckit 2009). Similar
symptoms were documented in early descriptions of AIPD (Bleuler 1916; Glass 1989a).
Compared with alcohol dependence, more patients with AIPD had histories of depression
(Tsuang et al. 1994), and anxiety symptoms may be a risk factor for suicidality in AIPD
(Jordaan et al. 2009).
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Biopsychosocial and spiritual model

Substance-Induced Psychotic disorder

(F10. 256)

Biological factors Psychological factors Social factors Spiritual factors

No genetic Hallucinations andImpaired
delusions.social and occupational life.
Weak faith on
disposition God.

Diagnosis:
According to DSM-5-TR the client fulfils the criteria hallucination and delusions of
Substance induced psychotic disorder, (F10.259).
Prognosis:
The prognosis for the client is low since the client is still consuming alcohol which
could make the psychosis worse and could also develop dependency for medication
prescribed by the psychiatrist.
Management plan:
 Depending on the severity medications such as antipsychotics could be prescribed.
 Cognitive behaviour therapy (CBT)
 Eye movement desensitization and reprocessing (EMDR)
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 Inpatient rehabilitation for drug and/or alcohol use

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References
Aliyev ZN, Aliyev NA (2008) Valproate treatment of acute alcohol hallucinosis: a double-
blind placebo-controlled study. Alcohol Alcohol 43(4):456–459
Borg S, Kvande H, Valverius P (1986) Clinical conditions and central dopamine metabolism
in alcoholics during acute withdrawal under treatment with different pharmacological
agents. Psychopharmacology 86:12–17
Gross MM, Rosenblatt SM, Lewis E (1972a) Acute alcoholic psychoses and related
syndromes: psychological and clinical characteristics and their implications. Br J Addict
6:15–31
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Appendices
Appendice A
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Appendice B
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Appendice C
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Appendice D
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CASE NO 2

AUTISM SPECTRUM DISORDER

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Case Summary

The client S.A is a 5 years old boy enrolled in Sedum school for special children. A psychologist

referred the client to this institution for the management of his behavioral and communication problems.

The client severely lacked in verbal and non-verbal communication.

The client also had behavioral issues such as having minimal to no eye contact, stubbornness, aggression

and refusal to follow instructions to name a few. Portage Guide Early Education (PGEE) and Childhood

Autism Rating scale (CARS) was used to evaluate functional and behavioral areas of the client.

Demographic Information

Name: S.A

Age: 5

Gender: Male

Father: Alive

Mother: Alive

Birth order: First born child

Religion: Islam

Siblings: Nil

Education: NIL

Languages: Urdu

Informant: Parents
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Reason and Source of Referral

The client was brought by his parents on the recommendation of a psychologist. He was given admission

on basis of his delayed speech as well as cognitive and behavioral issues. The client came with issues

such as sensitivity, noncompliance,

no eye contact.

History of Present Illness

According to the Mother of the client, she had been suffering from high stress throughout her

pregnancy. The child was delivered through cesarean (CSection), the delivery was not normal; they had

to induce labor. After the age of one he started displaying problems such as not responding to his name,

not saying anything besides “mama”, he would smell things over and over again like toys, utensils, and

soap. However, he would refuse to use utensils and soap for their intended purpose.

General Information:

The client's physical appearance was normal. His clothing was clean. During the session, he was mostly

quiet. His speech was not comprehensible; all he did was call for his mother and babble. He used much

of his time avoiding eye contact and looked shy. He continuously looked around the room sideways,

flapped his hands on his chest and made loud sounds.

Background History

Family History

The client is a first-born child and is the only child. The client is close to his family, especially his

mother. Most of his socialization is with his family; the client is close with them but likes to stay distant

and spends time by himself. The client has no history of any psychological illnesses in the family.

Social History: The client refuses to interact verbally and nonverbally with others. The only socialization

client has is with his family. The client does not maintain eye contact.
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History of Psychiatric Illness: According to the client’s parents, they both have no diagnosis of any

psychiatric illnesses and nor have they been made aware of any history of psychiatric illnesses on either

side of the family.

Informal Assessment Clinical Interview

The client’s parents gave the interview, and an informal assessment of client was done through

observation. According to the mother of the client, the client was delivered through cesarean (C-Section)

and had developmental delays but his symptoms and behavioral issues started showing after the age of

one. According to the father, he likes sticking to a routine and gets aggressive towards change. He also

refuses to listen to his parents or anyone if he is not given what he wants. He avoids socializing with his

cousins and becomes 7 rowdy to the point of pushing them away. The client sometimes makes eye

contact but it does not last for more than a second or two. According to the mother, during bath time,

eating time his stimming behavior increases significantly to the point where the mothers needs another

person’s assistance to calm him down and complete the task. He does not do the tasks himself like

eating, bathing, wiping his faeces and putting on clothing items. However, he tries to keep himself clean

by attempting to wash his hands, brush his teeth, and wipe his nose. He has started to respond to his

name and is able to ask for his mother. For the most part he understands nonverbal commands when

doing tasks. At first the parents thought he may be hard of hearing so they got a medical checkup where

he was referred to a neurologist and later to a psychologist. He does not always respond to incentives

especially when a new task is involved.

Behavioral Observation The client being a five years old boy looked his age. The client was well dressed

and his hair was combed and nails were cut. He was not answering the questions properly in coherent

speech and he did not acknowledge any nods or smiles by the psychologist. Throughout the first session,
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he did not make any eye contact with the psychologist. During the activity he stared at the walls, the

ceiling and kept turning his head to look behind him.

Quantitative Analysis Table 2 shows that the client functional age in motor area is 6months, in self-help

it is 8 months, and in language it is 3 months. The client has 1 year and 3 month in social skills and in

cognitive development it is 6 months. The result shows that there is a deficit in all five domains through

which it can be deduced that there is an enormous gap between his mental age and chronological age. In

Motor area, child can do a few tasks only for example he can imitate folding arms, bends at waist t to

pick up objects etc. Whereas, his peers can do a lot of motor activities like holding the pencil, going up

and down the slide and kick a ball in certain direction but the client was not able to do any of those. In

social domain, he can do things like high five, hug familiar person and shows response to his own name.

He is able concentrate only for 2-3 minutes after that he wants to stop. In language area he is only able to

call for his mother. In self-help domain, he is able to drink from a cup and he can distinguish edible

items from nonedible items. In cognitive domain, he can distinguish between big and small items. The

client can search for hidden objects.

Formal Assessment Childhood Autism Rating Scale (CARS)

Quantitative Analysis The symptoms of the client seemed to meet the DSM V criterion of autism. Hence,

in order to confirm C.A.R.S was applied.

Table no 1

Behavioral Items Scores

Relating to people 2.5

Imitation 3

Emotional response 2.5

Body use 3
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Table no 2

Test Score Sum Range Severity Range

44 42 – 45 Severely Autistic

Qualitative Analysis

Behavioral items such as visual response and listening response show a score of 3.

However, relating to people is 2.5 which depicts that the client has social deficits

and has poor social communication/interactions with people outside of his family.

The score on adaptation to change shows that the client has repetitive patterns. He

likes sticking to a consistent routine. The total score of the items indicate severe

level of autism as the score 44 lies between ranges of 44-45. Behavioral items of

fear/nervousness and level of consistency of emotional response is 2.5 indicating

the client needs supervision and would require full physical and verbal prompts to

complete the tasks.

DSM V checklist

The checklist consists of the symptom criteria of Autism Spectrum Disorder according

to diagnostic and statistical manual (DSM V). The client meets the criteria A-C.
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Tentative diagnosis

“299.00(F84.0) Autism Spectrum Disorder with requiring very substantial support”

Case formulation

The client was a 5-year-old boy with language impairment, lack of self-help skills, inability to

concentrate, poor eye contact, fixation with certain things, forgetfulness and poor social skills. Client met

all the criteria’s mention in DSM V and was diagnosed with Autism spectrum disorder (DSM-5, 2013).

Parental role is very important in the psychological and emotional development. Due to the negligence of

love and warmth from the parents, child becomes addict to their surroundings rather than their parents. A

research suggested that children with neurodevelopmental disabilities are at a higher risk of facing

parental negligence. This negligence was associated with aggression and temper tantrums for children

with ASD (MacDonnell, 2019).

Rapport Building

Rapport building was crucial to forming a friendly yet authoritative relationship with him. It was built

by letting the client choose his favorite activity and toys and then engaging with him while he does the

activity or plays with his toys, his reinforcers were also identified to build a better rapport with him.

Operant Conditioning

Positive reinforcement technique from operant conditioning was used to modify the client’s behaviors

such as; making eye contact, increasing compliance, reducing flapping of hands, slamming items and

pacing behavior. It was also used throughout the client’s sessions so he can work better to complete his

ttasks and for reducing his maladaptive behaviors.

Modeling
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It was used to teach the child how to greet others, use of courtesy words and wait for their turn and not to

touch other things without their permission.

Picture Exchange Communication System (PECS)

PECS was used to teach communication in which pictures were displayed on the wall with different

actions like drinking, playing, sleeping and using toilet. The child was taught to point out the action he

wanted to do like at the time of washroom he point the picture.

Occupational Therapy

Occupational therapy teaches abilities that assist the person to live as independently as possible.

Dressing, feeding, bathing, toilet training, and relating to individuals may be skills. Buttoning was

included to target the client’s fine motor skills and to teach him a basic life skill – i.e., buttoning was

used to target the client’s grooming in terms of dressing and to give the client independence in terms of

his dressing and grooming. Psychologist ask client’s mother to start working to his toilet and bath

training so that he can learn how to bath under supervision of his mother.

Summary of Sessions

Following is the brief summary of sessions that were conducted with the client. All sessions had

different time period depending on the condition of the child and maximum time of each session was at

least 40 minutes. Total twelve sessions were conducted and at least two to three sessions were taken in a

week. In these sessions, consent form was taken from the client’s mother and relevant information

regarding the client’s personal history and his present illness probblems were discussed.

Limitations 
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Shortage of time. 

Unavailability of a separate room affected the client’s performance.

Disruption from others made it difficult for both client and the psychologist to concentrate on tasks.

Recommendations

Applied behavioral analysis is recommended to manage his maladaptive behaviors.  Occupational

therapy plan is suggested to improve his cognitive problems and abilityto perform day to day task
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1 Socialization Paying attention to own name, giving object on

request, turn taking, waiting, tolerance.

2 General Recognition and drawing of shapes

Recognition of body parts (eyes, nose, lips,

mouth)

Recognition of colors (red, blue, green, yellow)

Recognition of fruits (orange, apple, banana,

mango)

Recognition of animals( cat, dog)

3 Daily life skills Pouring water, washing hands after meal, eating

independently and taking small bites, can wear

shoes, wipes nose by himself

4 Activities Puzzle fixation, matching fruits and vegetables,

stacking puzzles, blowing activity,

5 Main aspects to be focused Attention span, pre-learning skills, pre-speech

skills, randomization, generalization, compliance,

Behavior modification.
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ACTIVITIES