CHILD CASE REPORTS
Submitted to
MS Abida Kareem
Submitted by
Roll No. ( )
Registration number
Course Title
Clinical Training and Placement-I (PSY-705)
MS Clinical Psychology 1st Semester
DEPARTMENT OF APPLIED PSYCHOLOGY
GOVERNMENT COLLEGE UNIVERSITY FAISALABAD
2
DECLARATION
I, _________ , Roll No. , student of MS Clinical Psychology,
Session hereby declare that the matter presented in this case report is
my original work.
Dated: _____________ Signature of Deponent
3
CASE REPORTS COMPLETION CERTIFICATE
It is certified that the work contained in these Case Reports has been completed
by Mr./Ms. , Roll No. under my supervision.
Dated: _________________ Supervisor
MS Abida Kareem
Lecturer,
Department of Applied Psychology
Govt. College University, Faisalabad
Summary of Cases
S. No Client Age Gender Total Presenting Assessment Diagnosis Management Outcome
Initials Sessio Complaint
1. Test name
Code only
2.
3.
4.
4
5
Summary of the Case No. 1
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Identifying Data
Name: initial
Father’s Name:
Age:
Gender:
Siblings:
Birth Order:
School:
No. of Sessions:
Date First Attended:
Date Last Attended:
Source and Reason of Referral
The child was approached for academic purposes.
Presenting Problems
Table no. 1
Presenting complaints and their duration according to mother as reported by teacher
Duration Presenting Complaints
ہ
Table no. 2
Presenting complaints and their duration as reported by the class teacher
Duration Presenting Complaints
Initial Observations
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Table 3
Showing details of Learning Readiness Skills
Learning Readiness Skill Level of development
1. On-seat duration
2. Eye contact
3. Attention Span
4. Interest
5. Compliance
History of Present problem
Background Information
Personal History
Table 4
Showing Developmental Milestones, age achieved and normal age ranges
Developmental Milestones Age of Achievement Normal Achievement Age
First cry Immediate after birth
Neck Holding 4-6 months
Sitting without aid 6 months
Standing without aid 10-12 months
Walking 12-14 months
Speech 13-18 months
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Family History
Educational History
History of Psychiatric/Medical Illness
Assessment
Behavioral Observation
After the detailed case history interview, and initial behavior observations, and
reinforcement identification, formal assessment of child was carried out by using a test
battery, consisting of
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Psychological Testing
a. Neuropsychological Screening Test – Slosson Drawing Coordination Test (SDCT)
b. Intelligence Test – Slosson Intelligence Test (SIT)
c. Adaptive Functioning Test – Portage Guide to Early Education (PGEE)
d.
e.
Clinical interview
Reinforcer identification
Interpretation of Psychological Tests
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Case Formulation
According to 4p’s
Presenting Initial
Complaints Observation
Summary of Case Formulation
Figure 1 shows presenting complaints and initial behavior observations
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Figure 2 shows details of assessment
Initial
Assesm
ent
Formal
Assess
ment
Figure 3 shows details of assessment
predisposing precipitating maintaining protective
factors factors factors factors
Figure 4 shows different contributing factors in illness
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Biological Psychological Social
Factors Factors Factors
Figure 5 shows Biopsychoscial Model of Illness
Figure 6 shows Management Techniques
Diagnosis
Child was diagnosed according to DSM-5 with
Child’s Prognosis
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Intervention Plan
Based on child’s nature of illness, and immediate management necessity in different
areas of adaptive functioning as noted from behavior observation, case history interview and
formal assessment, intervention plan was devised for the child. The short and long term goals
of this intervention plan were,
Short Term Goals
Long Term Goals
Implementation of Therapeutic Strategies
Individualized Training Program was devised for child based on his current level of
adaptive functioning according to Portage Guide to Early Education.
Due to limited duration of internship at the special education school, following five
important goals were selected from the Individualized Training Program, which were to be
taught during a short time period of ----sessions.
Techniques used for achieving goals:
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Post Management Assessment
Termination
.
Outcome
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Table 7
Showing comparison of pre and post assessment in terms of success level
Goals Pre assessment Post assessment Success
Level
1.1
2
3
4
5
Limitations
Recommendations
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Session Reports
Session 1 to 3 date
Session 4 to 6 date
Session 7 to 8 date
Session 9 to 11 date
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APPENDIX
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REFERENCES
