CASE NO 2

ATTENTION DEFICIT HYPERACTIVITY DISORDER

Case Summary

Client is 7 years old boy. He belongs to middle socio economic status. Client is a secondborn

child and has one elder sister. He is addmited in army special education acadmy . He came

with the complaints of marked behavioral impairments (i.e. difficulty in organizing tasks and

activities, difficulty insustaining attention, Fidgets with the hands ). Client was assessedwith

the help of informal and formal assessment. Informal assessment includes history taking and

interview . Formal assessment included Colored Progressive Matrices (CPM). According to

DSM-5 criteria, results of the psychological tests as well as case history and behavioral

observations seem to indicate that client is having Attention Deficit Hyperactivity

disorder.Therapeutic recommendations include parental training, behavioral treatment,

and,suggestions for parents and teachers and cognitive behavioral therapy.

Demographics

Child’s name I.S

Age 7

Gender Male

Religion Islam

Siblings 1sis and 3 bro

Birth Order 2

Class Not attending School

Family system nuclear family system

Father’s Occupation Government employe

Mother’s Occupation House Wife

Socio Economic Status Middle Class family

Residency Rawalpindi

Reason and Source of Referral

The client was bought by his mother to army special education academy, on account

of his lack of attention and have behavior problems.

Presenting complaints according to mother

‫دشواری میں رکھنے برقرار توجہ‬

‫دشواری میں کرنے منظم کو سرگرمیوں وراموں‬

‫ہلچل ساتھ کے انگلیوں ورہاتھوں‬

History of present illness

As reported by the school Teacher , the client’s behavior was considered problematic

in the class at the age of 4 and a half years, when he was enrolled in school and failed to

follow the instructions given by the teacher and was unable to successfully fulfill the

requirements of school, such as difficulty in understanding . He had difficulty in sustaining

attention, did not seem to listen to when spoken to. Had difficulty in organizing the tasks and

activities . Fidgeting with the hands and feet and squirms in the seat is also present. Easily

distracted especially when doing task .

Family History
Client belongs to middle socioeconomic status. He lives in joint family system with his

parents and grandfather. His mother is a house wife and father is an government employe. He

is second born child of his parents, he is protected and much pampered by his father. Home

environment of the client is least restrictive and so stressful because his grandfather is so

strick and used the critical words for the client but other family members gave more attention

and were more loving to him specially his uncle and his mother.

Personal History

The child was born in a government hospital with normal delivery. His mother

reported that his weight was normal at the time of birth. He was normal till age 2 years.

Developmental Milestones

Developmental milestones Normal age range Child’s achieving age

Crying Birth cry Normal

Neck holding 3 months 3-4 months

Babbling 6-9 months 5-6 months

Sitting 4-7 months 5-6 months

Crawling 6-12 months 8-9 months

Standing 8-10 months 7-8 months

Walking 10-18 months 11 months

Speech (one word) 1-2 years 1 year

Response on name 3-4 years 1 year

Educational History

There was no significant educational history was reported.

Social History

The child has a very poor peer relationship in the school and in neighborhood also. In

the school, as well as playing with the neighborhood children, he created problems and

disruption during playing. He did not wait for his own turn in a group play and often take

others’ turn. He also shows aggression towards his playmates and become irritated easily.

Due to these above mentioned behaviors, his friends dislike him and prefer not to include him

in their games. So, the child faces lot of peer rejection and disapproval. His mother usually

tries to avoid him from such situations and usually does not allow him to play outside home.

She keeps him at home andengages him in activities of his interest like watching cartoons and

playing with ball.

Medical History

He achieved developmental milestone at appropriate age but at the age of 4 he

had suffered from malaria and typhoid after this diseases his performance became low

in school.
Preliminary Assessment

Psychological assessment was done at both formal and informal levels.

Informal Assessment

Informal assessment includes:

Clinical Interview

Behavioral Observation

Clinical Interview

To find important variables that contributed to and sustained the child's illness, a

detailed interview with the child was undertaken. A comprehensive interview was held where

in the mother of the client was questioned about her personal history, family background, and

complaints. Questions about the problem's onset, any underlying medical issues, and its

treatment were raised. The child's relationship with her parents and other family members

was evaluated, and a thorough family history was obtained. The question-and-answer period

then began. Throughout the interview, the child's mother remained composed and provided

succinct responses regarding the client's past.

Behavioral Observation

The client was showing restless behavior. It seemed as if the client was uncomfortable

onthe seat. He was changing his position again and again. I noted the frequency and time of

thechanging of the seats, within 10 minutes he changed his seat thrice. He was moving his
legs back and forth. When I was talking with him, he was staring the other objects in the

room.

Subjective Rating of Presenting Complaints

Subjective rating was taken on the basis of 0-10 point scale which is used to identify

the intensity and severity of the target problem. These ratings are sort at pre post levels to

have an idea about improvements in child’s condition and to assess about the effectiveness of

therapeutic interventions. Showing subjective rating by child therapist of problematic

behaviors on 0-10 point rating scale where:

1 = Very low intensity

10 = High intensity

0 = Absent

Pre-intervention

Poor Eye contact 3

Unable to follow Commands 3

Concentration Issue 2

Inattention Problem 2

Communication Problem 4

Socialization 3

Easily get bored 5

Formal Assessment

Formal assessment includes:

Color Progressive Matrices (CPM)

Colored Progressive Matrices was administered to assess theintellectual capacity of the client.

The test was introduced to the client and the instructions weregiven how to respond. He did

not give all responses he left the test after 4 minutes because hewas so impulsive. He stood

many times and changing his place

Quantitative Analysis

Sets Obtained Scores

A 10

Ab 7

B 6

Total 23

Discrepancy

Obtained score Discrepancy

10 -1

7 -1

6 0
Total Score: 23

Percentile: 50th

Grade: III (Intellectually Average)

Qualitative Analysis

The child total score was 23 in set A, set Ab and set B which lies in 50 th percentile

that shows that the child is intellectually average.

Diagnosis

Attention deficit hyperactivity

Specifiers

314.01(F90.2) with hyperactivity

Case Formulation:

Psychological factor

A retrospective study conducted by( Megan S et al) to assess the behavior

problems in children aged 1-6½ years that had survived cerebral malaria with severe

neurological sequelae who had suffered cerebral malaria at the ages of 5 months-4 years

found them to have behavior problems that included inattention and impulsivity, aggression

Management Plan

Pre and Post Intervention

 Pre Intervention Post Intervention

Poor Eye Contact 3 2

Unable to follow Commands 2 1

Concentration issue 4 2

Inattention problem 4 2

Communication problem 4 3

Socialization 3 1

Easily get bored 5 3

Summary of Sessions

Got familiar with client, an appropriate place for the relationship building process

with the client was initially selected observations were made and preliminary data was

conducted Color Progressive Matrices was conducted as psychological assessment to the

client and data on the intellectual abilities of client was collected. Based on the child’s

vulnerability, short and long term target is set for the client. Child has limited motor skills so

it is recommended and also enforced to improve the motor capacity. Some strategies have

been developed to enhance the effectiveness of client.

Recommendations

Behavioral treatment is very effective in treating ADHD and mostly given in

combination with other treatments. So I recommended a behavioral treatment for this

child.
 An individual psychologist has been recommended to the client.

Psycho education is necessary to modify child’s behavior and helped him engaged in

many activities, increasing social interaction.

Limitations

There were many problems faced while assessing and taking Sessions with child.

Some of the history of child was not properly reported by either parents or teachers

present there.
 References

Appendix-C

Individualized Education Plan

Main Areas Goals

1. Inattention Attention Span enhance through using:

Practice reasoning, logic, and problem-solving skills

through games and other cognitive processing

activities.

Eye Contact (for 2-3minutes)

2. Behavior Two command following:

Sit on the seat for 3 minutes

Put the hands on the table.

Have a walk for 5 to 1 minutes In the ground

Socialization

Greeting with teacher , clapping for others.

3. Time management Assignment/task

Given a task or homework to complete in a

 specific time.

4. Self-help and daily Independent Eating

living skills
Washing hands

Session Report

1st Session

Got familiar with the client, an appropriate place for the relationship building process

with the client was initially selected. Observations were made and preliminary data was

conducted.

2nd Session

CPM has been conducted as psychological assessment to the client and data on the

intellectual abilities of client was collected. Moreover, the client was moved to other groups

in order to make her familiar to gathering.

3rd Session

For ten to fifteen minutes, the client walked slowly, and at that time, the child was taught the

notion of left and right to improve his cognitive function and help him distinguish between

his right and left hands.He was instructed to spend one minute sitting in the word chair.

4th Session

A few tactics have been created to increase the client's efficacy. The same management

approach has been used to address problems. To ameliorate their inattention, some actions

were conducted. .

5th Session

These kinds of strategies were suggested, such as motivation, reinforcement, behavior

patterns shaping, so that their problem could be solved. In another class, children were

brought to work with peers to make a bonds with them

6th Session

The child was taught, inspired, and given practice at the duties. Excellent reinforcement

of the lesson, the child completed a five-minute coloring assignment.

7th Session

To train social skills, group activities were organized. (soccer) matches were held. This

helps the youngster become more adept at using their motor skills, reduce shyness, and

enhance their socializing. The youngster picked up basic self-care techniques.

8th Session

He engaged in another socialization exercise when he made an introduction to the group.

9th Session

A school therapist attends this session and reports to the psychologist and school

administration on all activities. and participate in a group therapy session aimed at improving

the client's social skills

Reference

1.Ssemata AS, Nakitende JA, Kizito S, Whipple EC, Bangirana P, Nakasujja N, John CC,

McHenry MS. Associations of childhood exposure to malaria with cognition and behavior

outcomes: a systematic review protocol. Syst Rev. 2020 Aug 9;9(1):174. doi:

10.1186/s13643-020-01434-2. PMID: 32772929; PMCID: PMC7416398.

2.Macarayan E, Papanicolas I, Jha A. The quality of malaria care in 25 low-income

and middle-income countries. BMJ global health. 2020;5(2)