CASE REPORT

Submitted To
MAM HAFSA RAIZ

Submitted By
ZUNAIRA MEHMOOD

Roll No.48

(MSC APPLIED PSYCHOLOGY, 1st Semester)

 (Intellectual disability)

Bio Data

Name A.M

Father Name M.A

Age 13 Years

Gender Male

Siblings 5

Birth Order 4th

Education KG2 (MCC)

Father Alive/ Dead Alive

Mother Alive/ Dead Alive

Mother’s Education illiterate

Mother’s Occupation House Wife

Identifying Information

Client wa s a boy of 13 years. He was belonging to a lower family. He was a Muslim and his
education was KG2. He had 2 sisters and 3 brothers. Client birth order was fourth in siblings. His
father was alive. His mother was also alive. His mother was a housewife. He lived in Faisalabad.

Source of referral

The client had taken for the assessment and management of the psychological complaints. Client
was referring by her mother and teacher.

Presenting Complaints

The client was mentally disabled since his birth. At the time of his birth, he had respiratory
problem due to lack of oxygen. He could not speak clearly and precisely.
Symptoms of illness

Lack of self-confidence since birth

Delayed milestones

Sit up, crawl, or walk

Learn to talk later, or have trouble speaking.

Hard to remember things

Have trouble solving problems.

Psychological Assessment

Patient was assessing through:

 Clinical Interview

 Mental State Examination

 Behavioral Observation

 Psychological tests

Clinical Interview

Client was 13 years old and he was a boy. He had 5 siblings and he was at 4th order in his
siblings. His family status was low. His education was KG2. His mother was illiterate. His
relationship with his siblings and other members of the family was quite good. He attached with
his mother more than anyone else. His father was alive. He was very cooperative. Patient had
been mentally retarded since his birth. His milestones were 4 delayed. He was abnormal. He did
not accept any change in daily routine. Mostly, he played with his mother, sister and brother. He
was mentally retarded.

Mental State Examination

General appearance of the client was good. He was mentally weak. His behavior was normal.
The pitch of the voice of patient was very low and he answered me in low voice. He use to
shuttered while talking. Client perception was less then average. He knew his name.

Insight

He had no insight about his illness.

Behavioral Observation

The client was a boy. Physically he was a fit boy. He speaks slowly and sometimes stuttering. He
was cooperative but he was distress by seeing. His behavior was normal. His mood was good and
paid attention on work. His behavior during assessment was shy and nervous. He was not a
talkative person. He took time for rapport building. After two to three sessions his shyness
decreased and he was cooperative during testing.

Psychological Tests

 Colored Progressive Matrices (CPM)

 Soloson Drawing Coordination Test (SDCT)

 Human Figure Drawing (HFD)

Child Progressive Matrices (CPM)

Quantitative analysis

Age 13 years

Score 20

Percentile 5th

Grade V

Time taken

Intellectual level
20 minutes

Intellectually defective

Qualitative analysis

The client has 5th percentile on CPM and the result of CPM shows that the client was
intellectually defective.

Soloson Drawing Coordination Test (SDCT)

Quantitative analysis

Age 13

Errors 17

Accuracy scores 53

Cut off score 85%

Qualitative Analysis

Patient obtained 53 scores on SDCT which indicates that patient’s eye hand coordination was not
intact.

Human Figure Drawing (HFD)

Qualitative analysis

The result of HFD (emotional indicator) indicated that instability, regression due to emotional
disturbance, impulsiveness, confusion, shy, insecurity, immaturity and poor inner control.

Tentative Diagnosis

Client seemed to be intellectual disable with language disorder.

Prognosis
Client prognosis was good. He could be partially recover if his parents, caregivers and teachers
paid proper attention on it.

Case Formulation

Client was 13 years old boy who was belong to a lower class family. He was in KG2. He was
very innocent. His family was consisting of 7 members 3 brothers, 2 sisters, mother and father.
His father was a laborer and his mother was a housewife. He was referring by her teacher due to
intellectual deficits. She reported that he had been mentally retarded since birth. . Five sessions
were conduct with the client and psychological assessment had done. The three psychological
tests that were administered on client were SDCT, CPM and HFD. I assessed his eye hand
coordination through SDCT for the purpose of diagnosis and the result of SDCT revealed that he
seemed not to be intact. I also assessed his intellectual ability through CPM. The results on CPM
showed that the client was intellectually defective. I also assessed his personality through HFD
which result showed that he was immature and had a sense of insecurity. The client had given
some suggestions during his sessions which he followed properly due to which an improvement
had observed in his behavior during the sessions. At the end of the session he was giving some
recommendations that would be helpful for him in the future.

Conclusion

Clinical interview, mental state examination, behavioral observation and results of different
psychological tests revealed that the client was mentally retarded and had language problems.

Recommended Psychotherapeutic Techniques

 Speech Therapy

 Family Therapy