PSYCHODIAGNOSTIC REPORT

Identifying Information

Name: K.Z

Fathers Name: F.H

Gender: Female

Date of birth: 30-12-1997

Age: 26 years

No. of siblings: 4

Birth order: 1st

Assessment Dates:

Assessment done by: Zuhaa Ali

Referral Source

The client came to the Center for Special Needs and referred to a trainee clinical

psychologist for the purpose of formal and informal psychological assessment and management.

She came with the symptoms of aggression, abusive and stubborn behavior and neglect self-care.

She also has problem in studies.

Presenting Complaints

Presenting complaints and duration are reported by mother

Presenting complaints Duration

Aggressive Since childhood

Stubborn Since childhood

Abusive Since childhood

Neglect self-care Since childhood

Difficulty in learning Since childhood

Clinical Interview

An interview is a conversation which has a purpose or goal (Bingham & Moore, 1924;

Matarazzo, 1965). Clinical Interview is a main tool of gathering information from client, parents,

and other informants (Raynold 2014). A clinical interview is a dialogue between psychologist

and patient that is designed to help the psychologist in diagnosis and development of treatment

plan for the patient (Natalie Boyd). Interviews are flexible, relatively inexpensive, highly portable and

most important capable of providing the clinician with simultaneous samples of client’s verbal and non-

verbal behavior. Clinical interview was conducted with the client’s mother for a detailed history

and psychological assessment and therapy. It was conducted to explore the root causes of the

problem.

Presenting Problems. The presenting complaints mentioned by his mother were

aggressive, abusive and stubborn behavior. She also neglects her self-care. Difficulty in learning

and finding hard to remember things.

History of Present Illness.

Medical History. Client has no severe medical history. There are no issues during

pregnancy. She was born through C-section delivery in hospital with full term. Mother reported

that her neck holding at age of 5-6 months, walking at age of 1-1.5 years and single word at the

age of 1.5 years. All developmental milestones of the client are on time.

Family History. The client lived in a nuclear family system. She has 3 siblings. One

sister is married. One is going to be married soon and one is studying in university. Her father is

61 years old. He is F.A and has shop of printing. Her mother age is 50 years and she is

housewife.
 Family Psychopathology. Client has no other psychiatric illness. Client mother reported

that her father’s first cousin also has the intellectual disability.

School History. The client’s mother reported that at the age of five, she started going to

school. At that time, she was reluctant to go to school. At first, she could not hold the pencil. She

was below average in studies. She has studied till 9th standard because she was weak in studies.

Somatoform.

Test Administration:

Following tests are conducted for assessment:

Bender Gestalt Test BGT

Test of Non-Verbal Intelligence TONI-4

House Tree Person HTP

Vineland Adaptive Behavior Skills VABS

Behavioral Observation:

Her appearance was neat and clean. Her dress was appropriate. Her eye contact was

present. She was comfortably sitting. She was active and responsive during sessions. In the first

session she was little bit shy but later on she was comfortable. Rapport was built easily. She

answered my all questions properly. She behaved obediently during all sessions. She listen my

all instructions carefully and responded in the same way. During assessments she was attentive

and did the tests attentively. Concentration span was good and speech present.

Psychological evaluation:

Table 1

Following scores are showing the results of KOPPITZ-2 applied on client.

Raw Score Visual-Motor Index Percentile Rank Descriptive Rating

23 88 21 Below Average
Conclusion

The clients visual motor integration score, which is in the 21th percentile rank for the

below average category, shows that her brain functioning is not normal. Furthermore, the client

has no emotional indicators; hence her score on emotional indicators is zero.

Table 2

Following scores are showing the results of TONI-4 (Test of Non-Verbal Intelligence).

Raw Score Index Score Percentile Rank Descriptive Term Age Equivalent

26 87 19 Below Average 9-9

Conclusion

Subject’s score falls in the category of below average functioning or reasoning which

means that her non-verbal intelligence is below average according to her age. The below average

score on non-verbal intelligence shows that her thinking, planning and implementation strategies

are below average and not according to her age. It also shows that her ability to organize

belongings and manage time is not average. Poor abstract reasoning, poor judgement and

perceptual abilities was shown by the test.

Table 3

Following interpretation is showing the results of House Tre Person.

Table 4
Following scores are showing the results of Vineland Adaptive Behavior Scale applied on client.

Domains/Sub- V-scale Standard Age Functioning Strengths/

Domains Score Score equivalent level Weakness

Communication 48 7.5 years Low Range Low Range

Receptive 8 4:0 Low Range Weakness

Moderately
Expressive 12 11:9 Strength
Low Range

Written 5 6:11 Low Range Weakness

Daily living
61 13.6 years Low Range Low Range
skills

Personal 9 11:6 Low Range Weakness

Domestic 13 16:9 Adequate Strength

Community 8 12:9 Low Range Weakness

Socialization
67 11.11 years Low Range Low Range
skills

Interpersonal
13 10:0 Adequate Weakness
relationship

Play and leisure 11 14:9 Moderately Strength

Coping skills 9 8:7 Low Range Weakness

Motor skills 8:8

Gross motor 8:10+

Fine motor 8:10

Conclusion

The Vineland Adaptive Behavior Scale (VABS) evaluates the client's adaptive

functioning and results indicate that a child presents with strengths and areas for improvement

across different adaptive behavior domains. In all three domains she has low range. And the

comprehensive overview of the sub-domains is as follows;

In the communication domain, the low receptive skills suggest that the child does not

understand what is happening in the show or presentation properly which is her weakness. The

moderately low range in expressive skills suggests that the client somehow expresses oneself

verbally but not expresses ideas or opinions according to her age. Low range in written skills

indicates that the client has difficulty in reading a material and understanding it and faces

difficulties in communication through writing like mail, letters etc.

In Daily living domain, the client's low range in personal skills shows difficulty with self-

care because she can't rinse her hair on her own. She has unhealthy eating choices and can't take

her medicine on her own. In domestic skills, adequate range shows that she can do daily routine

activities easily like basic household chores, food preparation, cleaning after meals and home
safety. In community skills, her low range indicates that she lacked basic money skills, safety

understanding outside the house and in traveling.

In the Socialization domain, she has adequate range in interpersonal skills but not

according to her age and areas of improvement are participation in conversations and responds to

indirect cues. In play and leisure activities, she has moderately low range which shows that she

has challenges in planning activities. In coping skills, she has challenges in making decisions and

apologizing to others. She has difficulty in controlling anger and emotional regulation which

indicates her weakness in this area.

Conclusion

K.Z is a 26 years old girl. The assessment of the patient was done both informally and

formally. Informal assessment was done through clinical interview, mental status

examination and behavioral observation and for formal assessment, tests like Bender Gestalt

(BGT), Test of Non-Verbal Intelligence (TONI-4), House tree Person (HTP) and Vineland

Adaptive Behavior Scales (VABS). According to the formal assessment it was diagnosed that

client has intellectual disability mild level. Interventions can improve adaptive functioning

throughout her life. With ongoing support and interventions, children with intellectual disability

can learn to do many things.

Tentative diagnosis

(F70) Intellectual disability mild level

Prognosis

Recommendations

Patient name and age K.Z 26 years

care, difficulty in learning,, finding it hard to

remember things.

Test administered  Bender Gestalt (BGT)

 Test of Non-Verbal Intelligence

(TONI-4)

 House Tree Person (HTP)

 Vineland adaptive Behavior scale

(VABS)

Tentative diagnosis (F70) Intellectual disability mild level

Treatment plan Short term goals

 Build Rapport with the client

 Psychoeducation about problem

 Parents counselling about Special

Education

 Target areas of improvement are

identified

 Taught how to perform ablution.

 Taught tashhud and how to perform

prayer.

 Occupational therapy
  Behavior therapy for behavior

modification

 Individualized Educational Program

(IEP)

Long term goals

 Continuation of short terms goals

 Follow up sessions

 Offering prayer

 Special education school

No of sessions planned 14

Initial session (1-3)

 Rapport building

 Clinical Interview with mother, History

taking

 Psychological Assessment

Middle session (4-10)

 Psychological Assessment

 Psychological Assessment

 Memorize the ablution, memorize

Tashhud

 Memorize the Tashhud, memorize the

prayer

 Counselling about personal hygiene

 Parents psychoeducation about problem

Ending sessions (11-14)

 Counselling to modify her abusive

behavior

 Counselling about parents respect

 Revision of all tasks

 Continuation of IEP

Individualized educational program

Strength

 She is good in command following.

 She can follow basic instructions.

 She is cooperative.

 She tries to perform the given task.

Weakness

 She did not do the work given at home.

 She can’t understands the written text.


 Management plan

Domain Sub- Target Rationale Techniques Reinforcement

domains behavior

Communication Receptive Understanding To Verbal Social reinforcer

sarcasm understands prompts

the indirect

cues and

hints in

conversation

Written Understands Be able to Verbal Social reinforcer i.e

material of understands prompts written

second-grade the basics of appreciation cards

level or higher reading and and tangible

writing reinforcer i.e

stationary items

Daily living skills Personal Washes her Be able to do Physical Tangible reinforcer

hairs on her her personal prompts i.e bags

own chore on her (physical

own guidance) by

mother and

visual prompt

Learn how to Be able to do Visual

take her care prompt

Domestic Basic laundry Be able to Physical and Social reinforcer

wash her verbal

personal prompts

clothes on

her own

Communit Money Be able to Visual and Social reinforcer

y concept and buy basic verbal

how to do things when prompt

grocery needed

Socialization Coping Anger Be able to Modelling Tangible reinforcer

skills management improve prompt and i.e new books,

wellbeing verbal stationary items

and have prompt

good

relations and

sound health

Accept helpful Be able to Physical and Social reinforcer

suggestion, solve verbal

problems prompts
 Apologize and Be able to Verbal and Social reinforcer

respect others understands gestural

the feelings prompts

of others

Case conceptualizations

The client came with the presenting complaints of intellectual disability. Client’s paternal

cousin has also intellectual disability. Its means the client has genetic neurodevelopmental

disorder intellectual disability.

Genetics theory of neurodevelopmental disorder suggests that Intellectual disability (ID)

is a complex condition with a wide range of causes, including genetic and environmental factors.

Genetic factors play a significant role in the development of ID, and there are many different

genes that have been linked to the condition. There are a number of different genetic factors that

can cause ID. These disorders are caused by a mutation in a single gene. Examples of single-

gene disorders that can cause ID include Down syndrome, fragile X syndrome, and

phenylketonuria (PKU). Chromosomal abnormalities occur when there is an extra or missing

chromosome. Examples of chromosomal abnormalities that can cause ID include Down

syndrome and trisomy 13. Polygenic disorders are caused by a combination of multiple genes.

The specific genes involved in polygenic disorders are often not known, but they are thought to

interact with each other and with environmental factors to cause ID. (Sturmey & Didden, 2014;

Fletcher, 2011).
 Inheritance of intellectual disability the way in which ID is inherited depends on the

specific genetic cause. For single-gene disorders, the inheritance pattern is usually autosomal

dominant, autosomal recessive, or X-linked. Autosomal dominant means that only one copy of

the mutated gene is needed to cause ID. People with one copy of the mutated gene will have the

condition, and they can pass the mutated gene on to their children. (Lamar et al., 2011; Selkoe,

1991). Autosomal recessive means that two copies of the mutated gene are needed to cause ID.

People with one copy of the mutated gene will not have the condition, but they can carry the

mutated gene and pass it on to their children. If a child inherits two copies of the mutated gene

from their parents, they will have the condition. This means that the mutated gene is located on

the X chromosome. Males have only one X chromosome, so they are more likely to be affected

by X-linked disorders than females. Females have two X chromosomes, so they are usually not

affected by X-linked disorders unless they inherit two copies of the mutated gene, one from each

parent. (Hazlett et al., 2011).