Case records
(CHILD & ADOLESCENT PSYCHIATRY)
C.R.F. No.: 1 Dated: 22/4/2023
SOCIO-DEMOGRAPHIC DETAILS
1. Name: M.R. (not real)
2. Gender: Male
3. Age: 11 years
4. Address (Local) – XYZ
5. Telephone No.: 27834***
6.Address (Permanent) - XYZ
5. Marital Status: Single
6. Mother Tongue: Hindi
7. Education: Class 5
8. Occupation: NIL
9. Religion & Caste: Hindu
10. Residence: Urban
11. Family Type: Nuclear
12. Family Size: 3
Adults: 2 Children (below 18 years): 1
13. Socio- economic status: Middle class
14. Income
a) Income Sources: I. Father’s salary II. Mother’s salary)
Family Income: 5-6 lakh/ year
c) Patient’s Income: NIL
SOURCE OF REFERRAL
a friend of M. R’s Mother working in the field of psychology
REASONS FOR REFERRAL
Child was showing deteriorating academic performance and had difficulty in remembering studying material.
PRESENTING COMPLAINTS:
Mother complains “Difficulty in following academic instructions and difficulty remembering studied material since
early childhood, of insidious onset, continuous course and deteriorating progress” and
“Difficult temperament”.
HISTORY OF PRESENT ILLNESS
The client, Mr. M.R, was doing well until he started going to school, he started showing deteriorating academic
performance since early childhood, with insidious onset and continuous course and deteriorating progress. He had
difficulty following academic instructions and difficulty remembering studied material. He has a history of caesarean
delivery, delayed birth cry, birth complications including prolonged labour and promotion in class by request and
consideration (as reported by mother).
Course: continuous
Onset: insidious
Progress: Deteriorating
TREATMENT HISTORY (For Present Illness);
No past history of treatment
FAMILY HISTORY
1. Family Tree
2. Consanguinity: Absent
Father
i. Age- 54
ii. Living
iii. Education- M.A in Fine Arts
iv. Occupation- Artist
v. Relationship with / attitude towards patient- good and friendly (as reported by mother)
3. Family Interaction Pattern
i. Communication- direct
ii. Leadership- Father takes most decisions
iii. Decision Making- mainly by father, least in case of client
iv. Role- active role as a family member, interactive and dependent on each other.
v. Family Rituals-none
vi. Cohesiveness- very cohesive
vii. Family Burden- none
viii. Expressed Emotion: Client has a difficult temperament
4. Family History of Psychiatric Illness/ Mental Retardation/ Substance Dependence/ Epilepsy- none
PERSONAL HISTORY
1. Birth & Developmental History
Father
i. Age- 54
ii. Living
iii. Education-B. A in Psychology
iv. Occupation- Psychologist
vi. Relationship with / attitude towards patient good and friendly (as reported by mother)
Mother
i. Age
ii. Living
25
iii. Education- M.A in Fine Arts
iv. Occupation- Artist
v. Relationship with / attitude towards patient- good and friendly (as reported by mother)
3. Family Interaction Pattern
i. Communication- direct
ii. Leadership- Father takes most decisions
iii. Decision Making- mainly by father, least in case of client
iv. Role- active role as a family member, interactive and dependent on each other.
v. Family Rituals-none
vi. Cohesiveness- very cohesive
vii. Family Burden- none
viii. Expressed Emotion: Client has a difficult temperament
4. Family History of Psychiatric Illness/ Mental Retardation/ Substance Dependence/ Epilepsy- none
PERSONAL HISTORY
1. Birth & Developmental History
a. Type of Birth- full term caesarean delivery
b. Birth Complications- prolonged labour and delayed birth cry
c. Significant Prenatal factors- prolonged labour
d. Significant Perinatal factors- delayed birth cry
e. Milestones- delay and inefficiency in achievement of almost all cognitive Developmental Milestones (from object
permanence and recognizing faces to forming schemas and learning small words)
f. Current Developmental Status- Memory deterioration (reported by mother as “difficulty in remembering”) and
problems in following academic instructions.
2. Childhood Disorders: None
3. Relationship of parents with children- the mother reported that the patient was provided with a warm, congenial
environment with adequate care and love. Although, she reported the client showed difficult temperament.
4. Academic History
a. Age of school admission- 5 years
b. Highest grade completed- 5th
c. Academic performance- below average
d. Reason for Discontinuation: NIL
e. Peer relationships: healthy and close peer relationships, big friend circle
f. Any disciplinary problems: none, the child is very well behaved, has difficult temperament
g. Hobbies & Interests: role playing with puppets, art work
5. Home situation / environment in childhood & adolescence – the relationship of the parents with the client
congenial, the environment provided is warm and friendly.
6. Menstrual history (if applicable)- NA
a. Age of Menarche
b. Date of L.M.P.
c. Duration
d. Associated physical / psychological symptoms
e. Any related symptoms
GENERAL TEMPERAMENT & PERSONALITY ATTRIBUTES:
Mother reports “difficult temperament” by the client. Described as moody, non-adaptable and overreactive.
GENERAL TEMPERAMENT & PERSONALITY ATTRIBUTES:
Mother reports “difficult temperament” by the client. Described as moody, non-adaptable and overreactive.
PAST HISTORY (Symptoms, Diagnosis, Treatment, Outcome)
1. Medical- the child had birth complications including prolonged labor and delayed birth cry.
2. Psychiatric- NIL (Symptoms, Diagnosis, Treatment, Outcome)
1. Medical- the child had birth complications including prolonged labor and delayed birth cry.
2. Psychiatric- NIL
MENTAL STATUS EXAMINATION
Initial Observation- Well kempt and tidy appearance
Body built age appropriately
Eye contact and touch with surroundings present
Attention & Concentration
Attention and concentration could be aroused and sustained
Activity Level & Motor Behaviour
Good gross and fine motor skills
Speech & Language Ability
The child was Communicable and had no speech defects.
General Intelligence & Other Cognitive Functions
Intact recent and remote memory and below average cognitive functioning
Mood & Affect
Rapport was established easily, child showed a cooperative attitude towards the clinician with cheerful affect, stable
and of adequate range and communicable.
Thought Process
Normal thought form and stream
Perception
Normal perceptual process
Child’s version of the problem
Child reports not being able to solve problems, remember, learn, and make decisions and defects in reasoning all
parts of cognition. The child denied showing any difficult temperament at home, he reported that he was very
cooperative and cheerful even at home.
3-wish test & Animal Test
Any other observation or comments, such as playroom observations
Case study 2.
Index client, S.A (initials of an imaginary name), aged 9 years, Hindu, female, hailing from middle-socio economic
status, urban background, Hindi-speaking nuclear family currently studying in class 4 was brought by the mother with
complaints of difficulty in recognising numericals and symbols .The patient has difficulty understanding basic
arithmetical concepts , and identifying mathematical operations. Since, early childhood, of insidious onset,
continuous course and deteriorating progress, with personal history of full term normal delivery, normal birth cry,
birth complications including prolonged labour, with deteriorating academic performance and promotion in class by
request and consideration, congenial home environment, with difficult temperament, behavioural observation
indicating well kempt and tidy appearance, with age appropriate body built, eye contact and touch with surroundings
present, rapport established easily, cooperative attitude towards the clinician, attention and concentration could be
aroused and sustained, intact recent and remote memory and below average cognitive functioning with cheerful
affect, stable and of adequate range and communicable, normal thought form and stream and normal perceptual
process .Normal in reading writing and other academic work.
Case records
(CHILD & ADOLESCENT PSYCHIATRY)
C.R.F. No.: 0928 Dated:22/04/23
SOCIO-DEMOGRAPHIC DETAILS
1. Name : Mr. M.K
2. Gender :male
3. Age :11years
4. Address (Local) – 24, Sri Lakshmi Nagar, Ganapathy,Mumbai.
Telephone No.963888****
Address (Permanent) – 25, Sri Lakshmi Nagar, Ganapathi Mumbai.
5. Marital Status: single
6. Mother Tongue: Hindi
7. Education :class 5
8. Occupation: student
9. Religion & Caste: Hindu
10. Residence Rural Urban✓ Suburban
11. Family Type: Nuclear ✓ Joint
Extended
12. Family Size: 3 Adults:2
Children (below 18 years):1
13. Income
a) Income Sources
I. Father II. Mother
b) Family Income:50,000/-
c) Patient’s Income :nil
SOURCE OF REFERRAL – self reasons for referral Deteriorating academic performance.
PRESENTING COMPLAINTS:
The mother reports difficulty in following academic instructions and difficulty in following instructions , poor
academic performance.
Onset : Insidious
Course: Continuous
Progress: Deteriorating
HISTORY OF PRESENT ILLNESS:
Mr. M.R was doing well till his the last month when his poor academic performance started causing trouble for him in
school. Despite being a student with below average performance all his life, the client was always able to make it
through to the next class by just passing his final exams. This term, however, the problems became worse when his
score in the final exams were not sufficient to get him to grade 5. As the client’s father was an employee in the
client’s school, the child was promoted to the next class Due to special requests and consideration done on part of
the management. The client has two friends in school and reports being teased and bullied rarely. He liked to go to
school And enjoyed playing sports but does not like tests and exams. Recently, the client is facing increasing difficulty
in remembering and recalling the teacher’s instructions And faces difficulty staying in the same level as the rest of his
class. He finds it difficult to follow the lessons and forgets formulas and concepts easily, even after taking a lot of time
to learn it from his mother. After advice from the class tutor, the mother decided to bring the client to meet with a
psychologist.
TREATMENT HISTORY (For Present Illness):
No preceding history of treatment.
FAMILY HISTORY
Consanguinity: Present/ Absent
Absent
3. Father
i. Age:45
ii. Living / Deceased: living
iii. Cause of death-nil
iv. Education-graduate from Delhi University.
v. Occupation : bank manager
vi. Relationship with / Attitude towards patient: Very kind , takes care of his son ,Cordial with his son.
The father exhibits critical comments when the client’s academic performance is discussed and owing to its
complications to his job and relationship with colleagues at the school. Otherwise, affectionate and supportive.
4. Family Interaction Pattern
i. Communication: Affectionate and direct .
ii. Leadership : Paternal Authoritative leadership.
iii. Decision Making: Paternal influenced by parents.
iv. Role : All member can voice out opinions
v. Family Rituals: weekend movies nights and family dinners.
vi. Cohesiveness: cohesive, tightly bound family
vii. Family Burden: nil
viii. Expressed Emotion:
a. Warmth✓ b. Hostility c. Critical Comments
d. Emotional Over Involvement e. Reinforcement
5. Family History of Psychiatric Illness/ Mental Retardation/
Substance Dependence/ Epilepsy: Nil
PERSONAL HISTORY
1. Birth & Developmental History
a. Type of Birth : Full term caesarean delivery.
b. Birth Complications: prolonged labour , delayed birth cry.
c. Significant Prenatal factors:
d. Significant Perinatal factors
e. Milestones
f. Current Developmental Status
2. Childhood Disorders
Had thumb sucking problem and bed wetting until the age of 9 years.
3. Relationship of parents with children:
The parents are supportive and affectionate with the children. The father is generally busy and makes time for the
children during the weekends. They play board games and sports together. Mother acts as the primary aregiver as
she works from home and is more easily available.
4. Academic History
a. Age of school admission: 4years
b. Highest grade completed:4th grade
c. Academic performance: below average, deteriorating
d. Reason for Discontinuation: No discontinuation recorded.
e. Peer relationships
f. Any disciplinary problems
g. Hobbies & Interests
5. Home situation / environment in childhood & adolescence (Congenial / Broken / Dysfunctional)
The patient has a pleasant house hold , very comfortable and safe . Though his parents had a love married their
relationship with their parents was cordial . They haven’t argued or fought in front of the child.
GENERAL TEMPERAMENT & PERSONALITY ATTRIBUTES:
(emotionality, attention/concentration, activity, motivation, sociability, aggression, trustworthiness, moral standards,
rhythm city, regularity of habits, adaptability) The client has a difficult temperament. He is easily provoked and is
slow to adapt to new situations. Attention and concentration could be aroused and sustained. Normal activity levels
and motivation. The client is slow to warm up, has decent social skill and exhibits cooperative interactions with the
clinician. The client mirrors his parents’ conservative moral standards. No abnormality is rhythmicity is seen.
PAST HISTORY (Symptoms, Diagnosis, Treatment, Outcome)
1. Medical: The client was diagnosed with asthma at 7 years of age. He uses Albuterol inhalers whenever he
experiences mild symptoms. The asthma is likely to be chronic.
2. Psychiatric: No Psychiatric diagnoses was undertaken so far.
MENTAL STATUS EXAMINATION
Initial Observation: Well kempt and tidy appearance with age-appropriate body build. The client maintains eye
adequate eye contact and is in touch with the surroundings. He is dressed neatly and is well-groomed. Rapport was
easily established easily and the client has a cooperative attitude towards the clinician.
Attention & Concentration:
Attention and concentration could be aroused and sustained.
Activity Level & Motor Behaviour:
He has normal activity levels and does not exhibit any abnormal motor activity. Adequate eye contact is present.
Speech & Language Ability:
The client showcased relevant, coherent and goal-directed speech.
General Intelligence & Other Cognitive Functions:
The client has intact recent and remote memory. He has below average cognitive functioning.
Mood & Affect:
He has a cheerful affect that is appropriate. The emotional range is stable and mood-congruent. The client reports “ I
am feeling good. I was very scared at first because I thought you will be rude but I am happy to see that you are
kind.” His anxiety in the beginning eased as conversation progressed and he became more relaxed and open after ice
breaking.
Thought Process:
The thought process of the client is logical and rational , there are no defects. The client does not exhibit any
delusional or psychotic patterns of thinking.
Perception:
No hallucinations were found. He is in touch with reality.
Child’s version of the problem:
The child believes that he is bought to improve his academic performance and he is aware of the fact he has difficulty
in academics.
3-wish test & Animal Test
Any other observation or comments, such as playroom observation:
He is very playful , gets distracted easily by different games.
My experience:
By far my experience of this internship was quite good. It helped me in enhancing my knowledge about the intricate
subject matter of child psychology. As a whole, this internship helped me in many ways, as it developed my skills and
techniques for working with children and adolescents. It enhanced my communication skills as well. It also helped me
to understand the challenges faced by a practicing child psychologist.
Conclusion:
I learned a variety of skills during the course of this internship including case history taking and assessment and
diagnosis of major childhood disorders. I learned core principles of some therapeutic techniques. I wish to utilize this
knowledge in my career ahead. As a psychology student I was very interested in the therapy sessions. But we didn't
get a chance to attend the actual session, but they explained as much as they could in the virtual class, so that we
can get an idea about the therapies.
