Case Report

by
Iqra Saleem
 Patient:
A.H
10 years old
Diagnosis:
Case Report:
Attention-Deficit
Hyperactivity Disorder
  The client has a history of complications starting
from their prenatal and neonatal period. The
mother reported that during her pregnancy, she
experienced significant stress due to her
husband's desire to relocate to Faisalabad to live
History Of with his relatives, which she did not want. The
Present Illness client had his first seizure at 8 months old,
followed by a second seizure 15 days later, and
was admitted to the hospital for observation for 2
days. Later on, when the client was 1 year old, the
family moved back to Lahore and the client was
referred to Jinnah Hospital for further treatment.
  The client has a history of epilepsy and is currently
receiving treatment and medication at Services
Hospital. The client's uncle also has a history of
epilepsy. In 2021, the client fainted due to high
blood sugar and was hospitalized for 8 days. The
History Of client's developmental milestones were mostly
reached at appropriate age, but some were
Present Illeness delayed such as speaking and toileting, and still
requires assistance with dressing.
 Presenting complaints as reported by the client’s
mother.
Problem in learning                           5 years

Presenting Cannot sit at one place                        4 years

Complaints
Lack of on seat behavior                       4 years

Inability to pay attention to any task         4 years

 INFORMAL CLINICAL INTERVIEW BEHAVIOURAL
ASSESSMENT OBSERVATION

Assessment

SUBJECTIVE RATING DSM-V BASED PORTAGE GUIDE TO

OF  PROBLEMATIC CHECKLIST EARLY EDUCATION
SYMPTOMS
Formal Assessment

Corner’s Teacher Rating scale

Revised (L)
The client, a child, was referred to a trainee clinical psychologist
with complaints of poor learning, lack of on-seat behavior,
inattention, and poor social involvement. After an
assessment, the client was diagnosed with Mild Intellectual
Disability with Comorbid Attention Deficit/Hyperactivity
Disorder (ADHD). The client's parents had a cousin marriage
and the mother reported experiencing significant stress and
hypertension during her pregnancy. Studies have suggested
that prenatal stress and hypertension are associated with an
increased risk of developmental delays, behavioral disorders,
and intellectual disability in infants. Additionally, the client
had a history of seizures at the age of 8 months, which could
also be a contributing factor to his diagnosis.

Case
Formulation
 Short Term Goals

Family psychoeducation 

Rapport Building 
Management
Individualized Educational Plan 

Pressure techniques 

Attention techniques 
Positive reinforcement 

Modeling 

Chaining

Short Term Goals

Client will continue
Generalization of the
to exercise short
treatment course of
term goals to
action to other
achieve control and
domains of life as
mastery in learnt
well.
skills.

Long Term Goals
Individualized 1 2
Educational Provide an overview of the
Plan therapy plan: Begin by briefly
introducing the therapy plan
and the different domains of
therapy that will be addressed.
Explain the specific tasks,
objectives, and techniques:
For each domain, describe the
specific tasks that will be
worked on, the objectives of
the therapy, and the
techniques that will be used to
achieve these objectives.
3
Highlight the reinforcement
used: Reinforcement is an
important aspect of therapy,
so be sure to mention the
types of reinforcement used in
each domain, whether it is
social or tangible
reinforcement, to encourage
progress..
1 2 3
Emphasize the importance of the Use visuals: Use visual aids such Conclude with the expected
therapy: Explain how the therapy as images, tables, and charts to outcome: Summarize the
will help the client improve their help illustrate the therapy plan expected outcome of the therapy
cognitive, motor, self-help, and make it more engaging for plan, what improvements and
language and socialization skills the audience. skills are expected, and the time
and how it will benefit them in frame for achieving the goals.
the long run.
Thanks