Identifying data

Abenezer Yaye 4-year-old male patient who is the first child for the family. He lives with his
mother, sibling and father. He didn’t start attending kindergarten. This is his 1st visit to
psychiatric outpatient clinic thru self referal.

Source and reliability

The interview was taken from mother .The data from the interview is reliable.

Chief complaint

“delayed speaking.” Of 3 years duration

HPI
This is a 4 year-old female child who is the first child for the family. The family had concerns of
delayed speech which he only started to say few words this year by age of 4 years . His first
words are delayed in onset; he said single words which are limited in number which he started
recently. By now he is able to say single words that are intelligible like mama, baba. He
understands the orders given. He can bring what he told but unable to express it. He expresses
his hunger by bringing his food plates, cupes and by making a gesture whenever he wants to
pee. He is unable to make sentence and that are grammatical organized. He has the drive to
explore environments and ability to play and initiate interaction with other children

He was able to crawl by2 months. He started to stand without support, 1year and 3 months. He
was able to use toilet popo by of age of 3year. By 3years old, he could drink from a cup, eat
with a spoon, and help during dressing. His athletic abilities emerge at age 2 year started, with
running, kicking, throwing, jumping, and climbing. .He doesn’t have self-care skills like dressing
by himself but he assists while dressing, He didn’t start school. He always going here and there
he engages in interaction with his peers and family. He has doesn’t have much opportunity to
interact socially and get along with other people, including having friends because doesn’t go out
from home. He is not verbally social with strangers .He also loves it when he became consoled
whenever crying. He laughs whenever appropriate and maintains eye contact. He is able to
maintain plays that take longer time &He is able to play and obey rules in games. He can wear
his slippers shoes. His mother helps him with her personal care including eating, dressing,
bathing, grooming, and hygiene.

Otherwise he doesn’t have history of experiencing traumatic event associated with flash aback
and night mares
He has no repetitive mannerisms such as head banging, flapping of hands
No social deficit
No hyperactivity and impulsivity
Has no hx of seizure on treatment
No history of sexual traits
Past Psychiatric History
first visit to psychiatric clinic

Medical History.
He doesn’t have any history of seizures, allergy. He had trauma by fall down accident history
when he was 1 year old. He went to health center to clean the trauma site; there was no loss of
consciousness and seizure afterwards. There is no reported history of allergies to medications.

Family History
There is no reported history of Presence of psychiatric illness in family members or psychiatric
treatment, suicidal attempt. He lives with both parents. His mother is a house wife. His father
earns his living working as office .They are financially secure and able to take care of their
childrens. He has close relation towards his mother when compared tofather. He has one sibling
1sister; the child is 4 months that is has started talking. He was having jealousy when little girl is
being breast fed and tried to take it away at first few days after her delivery. The mother seems
concerned his delayed speaking when compare it with other kids she also claims that him not
getting the opportunity to interact with children iand people more has impacted on speaking
abilities. She is aware that he might require special support I.e. special schooling and the support
he needs. Shee is willing and enthusiastic to do what’s necessary.
Developmental history
The mother had routine follow up in ghandi hospital during pregnancy. The pregnancy was
eventful. She was diagnosed with GDM during pregnancy and her follow up was transferred to
BLH. The delivery was via CS for NRFHR by 9months of gestation. The baby has cried right
away. The outcome was a 3.8kg baby and was discharged after few days . he didn’t require any
NICU admission. He has been breast fed till 3 years old and complementary feeding was started
by 6 months of age. There is no use of drugs, alcohol during pregnancy. Other development
milestone is described in HPI

Mental Status Examination

General description
He looked younger than stated age. He was able to stay still at one place and maintains eye
contact and did respond to engagement forwarded. During interview he was engagable and
obeyed whatever was instructed. When we call her by his name he had good response to it. he
was wearing clean clothes.. His attitude was familiar, obeying and calm.
Behavior and psychomotor activity; There is no agitation, no mannerism, no tics and no tremors

Speech and language

No verbal response

Mood
D/A for age

Affect
D/A for age

Thought process
D/A for age

Thought content
D/A for age
Thought perception D/A
Sensorium and cognition
He is alert.
Attention &concentration
He sustained his attention and concentration to activities ordered

Overall intelligence and fund of knowledge:

he can copy a line but not circle
Abstract reasoning D/A
Insight D/A

Judgment D/A

Physical examination NAD

Summary
Abenezer Yaye 4-year-old male who presented with delayed speaking. He also had deficit in
expressive communication skills.

Biopsychosocial formulation

Biological Psychological Social

Predisposing factor - maternal - Limited number

intrapartum social encounter in
complication early age

- NRFHR

- cs delivery

- GDM

- early trauma left

frontotemporal
Precipitating factor

Perpetuating factor - Limited number

social encounter in
early age

Protective factor -Absence of co- -Good social support

morbid medical
- adequate SES
illness

DX Language disorder ; expressive

 Age = developmental age

 Reduced vocabulary (word knowledge and use).
 Limited sentence structure (ability to put words and word endings together to form
sentences based on the rules of grammar and morphology).
 Impairments in discourse (ability to use vocabulary and connect sentences to explain or
describe a topic or series of events or have a conversation)
 Absence of other developmental delay

DDX
 Normal variations in language
 Acquired language problems may result from a variety of neurological insults
 Global Developmental Delay
 selective mutism
Case formulation
- Abenezer Yaye 4-year-old male child with diagnosis Language disorder. The factors that
seem to have predisposed him to diagnosis include having maternal intrapartum
complication like NRFHR ,cs delivery , dx of GDM, early trauma left
frontotemporal ,and the presence of limited number social encounter in early age .The
current problem is maintained by Limited number social encounter in early age .
However, his protective and positive factors include Absence of co-morbid medical
illness treatment, ,good social support and adequate SES

Management
Immediate management
-psycho-education

 To give the parents all the basic and current medical information regarding causes,
treatment, and other pertinent areas (e.g., special training and the correction of sensory
defects)

Short-term
 Speech therapy
 Educational settings for children with language disorders should include a comprehensive
program that addresses academics and training in communication