Psychodiagnosis Report
Identifying Information
Name U.H
Date of Birth 1-01-2012
Age 14 years
Gender Male
No of siblings
Birth order 4th
Informant Mother
Reason of Referral
The child was referred to the trainee psychologist for the purpose of psychological
assessment and management with presenting complain of speech issue, stubborn behavior,
memory and focus problems, mood fluctuation and do not follow instruction.
Presenting Complaints of the client as Reported by her mother
Duration Presenting Complaints
5years Speech issue
5 year Stubborn behavior
5 years Poor memory
5years Mood fluctuation
5 year Do not follow instructions
5 year Focus problems
Clinical Interview
Clinical interview was conducted with mother to get history of the child. Mother
reported that child had speech issue, stubborn behavior, poor memory, mood fluctuation, do
not follow instructions, focus problem. Mother remained cooperative and answered all the
questions precisely throughout the interview.
The child was 14 years old boy belonged to middle class family. According to his mother
the birth was through C-section. Mother said that she had normal nausea and vomiting during
pregnancy. The child was born on time, there was no delayed first cry. The child had Down
syndrome features. He achieved other developmental milestones at delay, head holding in 1.5
years, seating 2 years, crawling 3 years, standing 3.5 years, walking 5 years, toilet training 13
years, dressing not yet, speech1, 2 words at the age of 13 years, complete sentence not yet. He
couldn’t did daily living and personal tasks because he was pampered child.
The child lived in a nuclear family system with middle class socio economics status. Total
number of family was 6 including the child. His father M.S was 50 year old alive with good
physical and mental health. His education was M.A and by occupation he was govt-officer. His
relationship with child was satisfactory, he showed much concerned about the child problem.
The mother of the child S.U was 40 years old alive with good physical and mental health. Her
education was F.A and she was house wife. She was caring infect over protective toward child.
Mother reported that they both husband and wife had normal relationship with each other. There
was no any medical and psychological issue was reported with the child parents by his mother.
The child relation with his siblings was satisfactory. They are very cooperative play
together and help the child in daily living tasks. Siblings had good relation with each other.
There was no any physical and psychological issue was reported with the child siblings. There
was no any psychological issue was reported with any first degree relatives of child.
Child performance in school was not good due to his poor memory and focus problems.
His relationship with teacher and peers was not so good due to his stubborn behavior.
The overall home environment was satisfactory and supportive. There was no any conflict
between both parents and siblings. Whole family was concerned about the child problems.
Test Administered
Vineland adaptive Behavior Scale (VABS)
Bender Gestalt Test (KOPPITZ-2)
Test of Non-Verbal Intelligence (TONI – 4)
House Tree Person (HTP)
Behavioral Observation
During the observation period, the child was sitting in classroom with appropriate manners
and the client’s personal hygienic condition was good. He was dressed up in neat and clean school
uniform. During session and assessment his behavior was not good due to his stubborn behavior.
He had poor speech and speak only 2 to 3 words. His eye contact was good but not maintained.
He had intact orientation of place and broken orientation of time and date. Rapport building with
the client was challenging due to his stubborn behavior. He did not showed much interest in
testing. He had some focus problems. He had intact sleep of 7-8 hours per day. He playing with
his peers and after sometime became rude and start to hit them. His speech was not clear. His fine
and gross motor skills were not appropriate according to his age. His weight was not appropriate
according to his age, he was overweight.
Psychological Assessment
Formal and informal assessments were made to gather information about the child’s
current level of functioning in different areas of development. Assessments gave the clear picture
of child’s problems. Informal assessments was include clinical interview and formal assessment
includes psychological tests.
Formal Assessment
Test of Non-Verbal Intelligence (TONI-4)
Table 4:
Following table show clients’ level of intellectual capacity
Raw score Index score SEM %ile Rank Descriptive Test Age Equivalent
23 84 3 14 Below Average 8–0
Form A was conducted from the client. According to the score of Test of Non-Verbal
Intelligence (TONI), the client fell in the below average category which means that the client’s
non- verbal intelligence was below average, which included problem solving skills, abstract
reasoning and ability to classify objects. The client’s performance was not equal to his own age
his mental age equivalent is 8-0.
Vineland Adaptive Behavior Scale 3rd Edition (VABS-3)
Table 2
Sub Domains Age Standard V. Scale Functioning Strength/
Equivalent Score score level weakness
Communication 20 3 Low
Skills
Receptive 2.5 1 Low Strength
Expressive 1.11 1 Low Weakness
Written 3.2 1 Low Strength
Daily living 20 10 Low
Skills
Personal 3.8 2 Low Weakness
Domestic 4.0 7 Low Weakness
Community <3.0 1 Low Weakness
Socialization 60 23 Low
skills
Interpersonal 2.11 7 Low Weakness
relationships
Play and Leisure 10.0 13 Adequate Weakness
Coping Skills <2.0 3 Low Weakness
Motor Skills
Fine Motor -
Skills
Gross Motor -
Skills
Adaptive Behavior Composite ABC Score is 34 which also lies at low functioning level. According to the
child’s score on Vineland Adaptive Behavior Scale she is low behind her expected age group in all domains.
According to the findings of the assessment, the adaptive level of the child is low. The child’s low adaptive
functioning was also observable during the session and her behavioral observation.
Tentative Diagnosis
(F71) Intellectual Disability, Moderate
Conclusion
The child U.H was 14 years old boy who came with presenting complains of speech
problems, stubborn behavior, poor memory, and mood fluctuation, do not follow instruction, focus
problems and poor academics. He was referred to the trainee psychologist for the purpose of
psychological assessment and management. Psychological assessment of the child indicated
tendency of neurodevelopmental disorder. The assessment of the child was done both formally
and informally, informal assessment was done through clinical interview, mental status
examination and behavioral observation and for formal assessment tests like TONI, BGT, VABS
and HTP. The child was diagnosed with moderate Intellectual disability.
Recommendations
Group activities will be introduced for enhancing social interaction activities
Speech therapy to improve his speech problems
Parents should spend quality time with child
Training should be given to parents for supporting their child and learning strategies to
manage challenging behavior
Parents should prefer healthy food over fast-food to keep him physically fit and healthy
Give him reinforcement and positive regard when he play with other children without
being rude
Teacher must develop individualized education plan according to the child development
Give small academic tasks
Andleeb MS Internee Ms. Khawer Dr. Khawer Bilal Head of
Department
Treatment Plan
Client Name U.H was 14 years old boy
Present Complaints speech problems, stubborn behavior, poor memory, mood fluctuation, do not
follow instruction, focus problems and poor academics
Test Administration
• Bender Gestalt Test (KOPPITZ-2)
• Test of Non-Verbal Intelligence (TONI – 4)
• House Tree Person (HTP)
• Vineland Adaptive Behavior Scale (VABS)
Tentative Diagnosis (F71) Intellectual disability, Moderate
Goals of Therapy Short Term Goals
• Rapport building to build a therapeutic relationship with the client
• Psycho educate the parents to help understand the client
• Improve socialization skills to involve in group activities
• Improve social communication like what to say, how to say and
when to say
• Using role playing activities and social stories to teach social
behavior.
• Provide training to child for dressing skills by breaking down the
task in small and, manageable tasks and giving positive reinforcement
• Provide training and support to siblings to make positive
interaction with child
• Arrange activities to increase his attention span such as give
attention to a story without being interrupted.
Long term goals
• Continuation of short-term goals
• Continuation of IEP plan according to individualized needs of the
child and modify with progress in child
• Speech therapy will be given
Major Therapies Applied Behavior Therapy
Behavior Modification
No of Sessions 12
Initial sessions
Rapport building
History taking
Psychological assessment
Psychoeducation
Middle sessions
Behavior Modification
Final
Termination
Follow up session
Individualized Educational Plan
Name U.H
Age 14 years
Gender Male
Institutions CFSN
Birth Order 4th
Strengths
Follow instructions
Good eye contact
Weakness
Focus problem
Mood fluctuations
Task Material Goal Technique
Pay attention to a task for at Instructions only Enhance receptive skills
Prompting
least 15 minute (R26)
Identify left and right side To Improve receptive Prompting
of body (R31) skills
Say first and last name Verbalize only To improve expressive Prompting
when asked (E33)
skills
Tells about every day Verbalize only To improve expressive Prompting
skills
routine (E44)
Says complete home Notebook , pencil To Improve expressive Prompting
address correctly (E48) skills
Identifies at least 10 Alphabet cards To improve written skills Prompting
alphabet letters
( W5)
Reads at least 10 words Worksheet with animal To Improve Prompting
name and pictures
Fastens snaps(P31) Shirt Improve personal skills Modelling, Prompts
Cuts food with knife (P44) Banana , knife To Improve personal Modelling, Prompting
and fine motor skills
Sit appropriately in large Reinforcer Follow instructions and Reinforcement
Group Participation
Use of clock to tell time Clock To improve community Prompting
(C6) skills
Keep personal belonging To improve community
instructions
secure(C32) skills
Cuts out shapes Cards, paper, scissors Prompting
To improve fine motor
skills
Task Analysis
Baseline
The child plays with his peers
Target Behavior
The child interacts with his peers in a classroom setting without disturbing others
Steps
The child will interact with his peers without being rude to them
The child will play with his peers with toys, while waiting for his turn
The child will share his toys with others
The child will interchange toys with his peers and play with them without disturbing others
The child will complete his playtime without disturbing others
Serial No. Baseline Target Steps Procedure Material
Behavior Used
1. The child The child The child will The child will
plays with his interacts with interact with interact with
peers his peers in a his peers his peers
The child classroom without being without being
plays with his setting rude to them rude to them
peers without when given
disturbing verbal
others prompts 1/8
trials
The child will
interact with
his peers
without being
rude to them
when given
verbal
prompts 2/8
trials
The child will
interact with
his peers
without being
rude to them
when given
verbal
prompts 3/8
trials
The child will
interact with
his peers
without being
rude to them
when given
verbal
prompts 4/8
trials
The child will
interact with
his peers
without being
rude to them
when given
verbal
prompts 5/8
trials
The child will
interact with
his peers
without being
rude to them
when given
verbal
prompts 6/8
trials
The child will
interact with
his peers
without being
rude to them
when given
verbal
prompts 7/8
trials
The child will
interact with
his peers
without being
rude to them
when given
verbal
prompts 8/8
trials
2. The child will The child will Building
play with his play with his Balloons
peers with peers with
toys, while toys, while
waiting for waiting for
his turn his turn when
given verbal
prompts 1/8
trials
The child will
play with his
peers with
toys, while
waiting for
his turn when
given verbal
prompts 2/8
trials
The child will
play with his
peers with
toys, while
waiting for
his turn when
given verbal
prompts 3/8
trials
The child will
play with his
peers with
toys, while
waiting for
his turn when
given verbal
prompts 4/8
trials
The child will
play with his
peers with
toys, while
waiting for
his turn when
given verbal
prompts 5/8
trials
The child will
chose
between two
tasks when
given verbal
prompts 6/8
trials
The child will
play with his
peers with
toys, while
waiting for
his turn when
given verbal
prompts 7/8
trials
The child will
play with his
peers with
toys, while
waiting for
his turn when
given verbal
prompts 8/8
trials
3. The child will The child will Building
share his toys share his toys blocks
with others with others
when given
verbal
prompts 1/8
trials
The child will
share his toys
with others
when given
verbal
prompts 2/8
trials
The child will
share his toys
with others
when given
verbal
prompts 3/8
trials
The child will
share his toys
with others
when given
verbal
prompts 4/8
trials
The child will
share his toys
with others
when given
verbal
prompts 5/8
trials
The child will
share his toys
with others
when given
verbal
prompts 6/8
trials
The child will
share his toys
with others
when given
verbal
prompts 7/8
trials
The child will
share his toys
with others
when given
verbal
prompts 8/8
trials
4. The child will The child will Building
interchange interchange blocks & play
toys with his toys with his dough
peers and peers and
play with play with
them without them without
disturbing disturbing
others others
when given
verbal
prompts 1/8
trials
The child will
interchange
toys with his
peers and
play with
them without
disturbing
others
when given
verbal
prompts 2/8
trials
The child will
interchange
toys with his
peers and
play with
them without
disturbing
others
when given
verbal
prompts 3/8
trials
The child will
interchange
toys with his
peers and
play with
them without
disturbing
others
when given
verbal
prompts 4/8
trials
The child will
interchange
toys with his
peers and
play with
them without
disturbing
others
when given
verbal
prompts 5/8
trials
The child will 2 minute
interchange
toys with his
peers and
play with
them without
disturbing
others
when given
verbal
prompts 6/8
trials
The child will
interchange
toys with his
peers and
play with
them without
disturbing
others
when given
verbal
prompts 7/8
trials
The child will
interchange
toys with his
peers and
play with
them without
disturbing
others
when given
verbal
prompts 8/8
trials
5. The child will The child will
complete his complete his
playtime playtime
without without
disturbing disturbing
others others
when given
verbal
prompts 1/8
trials
The child will
complete his
playtime
without
disturbing
others
when given
verbal
prompts 2/8
trials
The child will
complete his
playtime
without
disturbing
others
when given
verbal
prompts 3/8
trials
The child will
complete his
playtime
without
disturbing
others
when given
verbal
prompts 4/8
trials
The child will
complete his
playtime
without
disturbing
others
when given
verbal
prompts 5/8
trials
The child will
complete his
playtime
without
disturbing
others
when given
verbal
prompts 6/8
trials
The child will
complete his
playtime
without
disturbing
others
when given
verbal
prompts 7/8
trials
The child will
complete his
playtime
without
disturbing
others
when given
verbal
prompts 8/8
trials
Case Formulation
Presenting Complains
Speech problems, stubborn behavior, poor
memory, and mood fluctuation, do not follow
instruction, focus problems and poor
academics
Assessment
Behavioral observation, Clinical Interview
BGT, TONI,VABS and HTP
DSM 5-TR diagnostic Criteria (F71)
intellectual disability, moderate
Precipitating Perpetuating Factors, Protecting Factors
Predisposing Factor Factors Overprotective behavior Good relation with
Genetic factor of mother and sister parents and
Delayed milestones
toward child siblings, supportive
home environment
and teachers
Suspected Problem
(F71) Intellectual disability
moderate
