CASE RECORD FORMAT

Name: Pranav
Age: 14
Location/ contact: CAN KIDS
Gender: male
Clinical Diagnosis:
A study of Pranav's educational progress, test results, teacher observations,
and reaction to academic assistance were used to diagnose his learning
impairment.
Language spoken: Tamil
Education level/ Type of school (govt/ private etc): special education
Family Income approximately (month)/ SES:
Informant: 20000 approx
● Referred by: chennai volunteer ngo
● Current issue as stated by referral source:
Reading, writing, and/or math difficulties; poor memory; trouble following
instructions; inability to distinguish between or among letters, numbers, and/or
sounds; issues with eye-hand coordination; problems putting things in the
proper order; disorganization; and/or trouble adapting to change.
● Relevant history of present issue:
Mental status Examination:
Presenting complaints (In parent’s own words) in a list (present tense):
1.Difficulty in day to day activities
2. Difficulty in letters and rhyming words
3.disorganised
● Any counselling/ therapy/intervention done so far and current treatment/
medication:
Psychotherapy , speech and language therapy
Check for difficulties and describe and state action taken:
● Health problems (headache, feeling tired, stomach pain) - not any such for a
long period of time
● Emotional difficulties (feeling sa
d, feeling anxious, fear, crying easily, being home sick/ others) - anxiousness ,
can’t adapt to different surroundings or people
● Behavioural difficulties (not paying attention, disturbing others, answering
back, not following rules, problems with school authorities/ others) - difficult to
retain his attention in anything for a long gets diverted and grimly easily
● Difficulties with studies (failing exams, cannot concentrate, cannot
understand, not able to write answers, difficulty with spellings, difficulty with
maths; exam stress; school refusal; adjustment to transition to new school;
difficulty adjusting to pressure to perform/ others) - difficulty in oral language
talking something or replying his interpretation , written language spelling and
written expression gets easily confused between rhyming words ( glass , grass )
● Social difficulties in school (students/teachers) (not getting along with
friends, having no friends, getting bullied, fights with other students, not
getting along with teachers, principal/ class work, cooperative; affectionate with
teachers; seeks approval and belongingness at school; oppositional to
teachers, talks back; participative in class interaction and extra-curricular
activities/quiet and hesitant participative in class interaction and extra-
curricular activities/ indifferent to class activities. - difficulty in self confidence
and increased stress and anxiety when meeting new persons , finding it difficult
to mingle and talk to new friends and difficulty representing anything
● Social difficulties at home/family (not getting along with parents, violence at
home, parents separated, alcoholic father/mother, physical punishment at
home, illness at home, not getting along with brothers/sisters/relatives, losing
somebody they had been close to)
Misinterpret their actions and cues , talks to much or sometimes don’t even
respond
CHILDHOOD DEVELOPMENTAL HISTORY

MILESTONES Expected Subject milestone

milestone
Cognitive Advancement of Individualised
milestone linguistic skills learning and
through abstract instruction ,
thinking, problem reading and math
solving, task and difficulties
responsibility
planning.
behavioural development of Difficulty in
milestone identity, peer coping up
relationships, frustration and
emotional control, anxiety ,
and challenging to
independence foster
positiveanxiety ,
challenging
to foster positive
independence
behaviour in
social
 gatherings
Motor skills more refined Focusing on
development movements in handwriting and
activities like typing while
sports and developing gross
exercise. handle motor skills
tasks requiring through exercises
precision, such as catered to the
playing musical student's ability
instruments or and interests.
crafting. Adaptive tools are
required.

Temperament:
- Activity Level: Highly active, Unable to sit quietly for a while, Under-active/
slow-moving,
-Adequately active - unable to focus or sit for a while is super disturbed to fit in
one set of ambience
- Distractibility: From ongoing behaviour: High / Within normal range/ Low -
distraction is high - Mood: Happy; Irritable; Serious Fluctuates more rapidly
Medical history: Seizures/ head injury: head injury in past ( while he was
approximately 7 years )
Family history of psychiatric or learning problems or difficulties: Alcoholism;
Depression; Anxiety Speech Impairments; Behavioural problems/ others:
There is no prompt family history or genetics involved for the disability of a
child But due to the disability there is a lot of financial issues and repression in
child But due to the disability there is a lot of financial issues and repression in
family

For Pranav’s learning impairment, here’s a tailored approach using the 8 P’s:

1. **Presentation:Pranav struggles with specific learning tasks such as reading,

writing, or mathematical skills. He may experience difficulties in processing
information or following instructions.

2. Predisposition:early developmental issues could have contributed to his

learning impairment. For instance, injury in brain can be a reason

3. Precipitants:Recent stressors like changes in his educational environment,

social challenges, or increased academic demands could have exacerbated his
learning difficulties.

4. Protective Factors:Supportive family members, access to special education

services, and personal strengths like determination or interests in specific areas
could help mitigate the impact of his learning impairment.

5. Pattern:The learning difficulties might have been consistent over time or

could have worsened with increased academic pressures. Understanding
whether the impairment has been stable or progressive can guide interventions.

6. Perpetuates:Ongoing factors such as lack of appropriate accommodations in

school, low self-esteem, or continued exposure to stress might be maintaining
or worsening Pranav’s learning challenges.

7. Plan:The intervention plan may include personalized learning strategies,

7. Plan:The intervention plan may include personalized learning strategies,
additional educational support, tutoring, psychological counseling, or
specialized therapy to address Pranav’s specific needs.

8. Prognosis:With appropriate interventions and support, Pranav’s prognosis

can be positive. He may improve his academic skills and coping strategies,
although ongoing support might be necessary to manage his learning
impairment effectively.

This approach helps in creating a holistic support plan tailored to Pranav’s

unique situation.

GENOGRAM
1)Type of family: Joint/Nuclear - nuclear
2)Type of marriage: Consanguineous / Non-consanguineous - non
consanguineous 3)Father/ Mother/ Siblings: Education, Occupation - father is
going job , no siblings
4)Who all live at home/ extended family/ caregivers (specify) - shifted here for
treatment ( mom has accompanied the child )
5)Parents’ Expectations: take studies seriously/ co-operate at home/ others
Progress , clear communication , realistic academic achievement and growth
Academic performance of client: Below average
6)Home environment: affectionate/ spends time/ independent/ Sibling rivalry/
relationship difficulties and fearful/ others (elaborate)
Love , Affection and acceptance

These are techniques adopted by tutor , students who come to guide him

-Consistent Routine: Establish a consistent daily routine that includes

designated times for learning, breaks, and other activities. Routines provide
designated times for learning, breaks, and other activities. Routines provide
structure and predictability, which can be comforting for many learning-
disabled children.

-Visual Schedules: Use visual schedules, charts, or calendars to help your child
understand and anticipate daily activities and tasks. Visual aids can enhance
their comprehension and organization skills.

-Multisensory Learning: Incorporate multisensory learning techniques that

engage multiple senses. For example, use hands-on activities, visual aids, and
auditory resources to reinforce learning concepts.
-Hobbies/ interest in client:
Activities that help him to draw , play and learn are his interest

INTERVENTION PLANS
- Goals (based on issues given by client):
● Short term goals: proper communication, prompt day to day activities ,
independence in personal works
● Long term goals:
Academic achievement , speech and written achievement and growth
- *Types of interventions planned (specific psychometric testing; art, play
therapy, counselling , Psychotherapy , speech and learning based techniques ,
art therapy)

CONCLUSION ( should be self reflective minimum 5 points . )

They have unique way of perceiving and understanding things
Empathy and compassion from society , care takers and family members can
help them a lot in the process of requery
Determination - learning disabled students frequently exhibit determination and
hard work
They learn to communicate and seek support for their accommodations and
need when needed this made me realise the importance of communicating the
need we as general individual face instead of being shameful to ask on help
Their innovative style to learn on things
● My reflections as a student
- What did I learn in the process;
How have I changed; What was challenging /Could have been done differently
I understood the importance of empathy and the role guidance and help can
play to a individual who is not doing well , I learned the importance of patience
while being with people who are disabled, the role support system can play in
Individuals well being .

Things I could have done better :

I could have been more patient and could have structured the interview more
better with open ended questions
It was challenging to meet on to the emotions that was occurring with the
parents while interviewing and talking about it from the start . It was challenging
to cover all the things as time given was less because the client had his therapy
sessions after that .
I could have got printouts and could have planned activities to test clients
developmental milestones instead of just analysing it with the help of the
conversation I had .