Name : Syeda Sheral Zainab
Class : ADCP1
Roll no : 12
Submitted to Dr Mohsin Atta
Patient Information:
Name: Esha Anwar
Age: 12 years
Gender: Female
Referral Source: School Counsellor
Presenting Problem:
A 12-year-old girl was referred to the psychological clinic by her school counsellor due to
concerns about mood changes, withdrawal from social activities, and declining academic
performance. The school counsellor reported that the child has been frequently absent from
school, has shown a marked disinterest in extracurricular activities, and has difficulty
concentrating during lessons. Teachers noted that she has become increasingly disengaged,
rarely participating in class discussions, and has started isolating herself during breaks.
Parents reported similar concerns at home, mentioning that the child seems "tired all the
time" and has difficulty getting out of bed in the mornings.
History of Present Illness:
The patient’s parents described her as an initially cheerful and socially engaged child, but
over the past 6-8 months, they began noticing changes in her mood and behaviour. She has
become more withdrawn, irritable, and tearful at times. She often expresses feelings of
hopelessness and worthlessness, especially when discussing school or her relationships with
friends. The girl has also reported feeling "empty" and "useless," and has occasionally
mentioned that she “doesn’t see the point of trying.”
At home, the girl has become increasingly withdrawn, preferring to stay in her room rather
than participate in family activities. She has stopped participating in activities she once
enjoyed, such as dance and playing with friends. Her parents are concerned about her lack
of energy and sleep disturbances, as she often sleeps longer than usual or experiences
trouble falling asleep.
Despite reassurances from her parents, the girl’s distress has persisted. She does not seem
to have experienced any significant life events or trauma in the past year that might explain
the changes, though there was a recent change in her friendship group at school that she
seemed to struggle with.
Developmental and Medical History:
Prenatal and Birth History:
The pregnancy and birth were uncomplicated. She was born full-term and met
developmental milestones on time (e.g., walking at 12 months, speaking in full sentences by
age 2).
Medical History:
The child has a history of mild asthma, for which she takes a rescue inhaler as needed. There
is no history of chronic medical conditions or significant health issues.
Psychiatric History:
There is no prior history of psychiatric diagnoses or treatment. No known substance use or
self-harm behaviours.
Family History:
Father: History of depression (diagnosed in his 20s, treated with medication).
Mother: No psychiatric history.
Siblings: An older brother (15 years old) with no psychiatric concerns.
Psychiatric Evaluation:
Mental Status Examination:
Appearance: Well-groomed, appropriately dressed for age.
Behaviour: Quiet and cooperative during the interview but appeared visibly sad, often
looking down and avoiding eye contact.
Speech: Normal rate and tone, though soft and hesitant at times.
Mood and Affect: Described mood as "sad" and "tired all the time." Affect was congruent
with the mood, showing signs of sadness and withdrawal.
Thought Process: Coherent and logical, though dominated by negative thinking (e.g., "I’m
not good enough," "Nothing will get better").
Thought Content: Focused on feelings of hopelessness, worthlessness, and self-criticism. No
delusions or psychosis observed.
Cognition: Alert and oriented to time, place, and person. No significant cognitive
impairments noted.
Insight and Judgment: Limited insight into her emotional state; difficulty recognising the
impact of her feelings on daily life. Judgment appears age-appropriate.
Diagnostic Assessment:
LEVEL 2 : Depression: Child age : 11-17
“PROMISE emotional distress: Depression: Parent item bank”
The score was elevated , intimating moderate to severe depressive
symptoms, particularly in the areas of self criticism, feeling sad and lost of
interest in activities.
LEVEL 2 : Depression: Parent guardian of child age : 6-17
PROMISE emotional distress: Depression: Parent item bank”
Although the focus is on depression there were some elevated scores on
anxiety sub scales particularly social anxiety indicating that anxiety
symptoms may also be contributing to her emotional distress.
Diagnosis:
1. Primary Diagnosis:
Major Depressive Disorder (MDD), Moderate
2. Secondary Diagnosis:
Anxiety Disorder, Not Otherwise Specified (NOS) (due to symptoms of social anxiety and
excessive worry)
Treatment Plan:
1. Psychotherapy:
The child was referred for Cognitive Behavioural Therapy (CBT) to address depressive
symptoms, negative thought patterns, and feelings of worthlessness. CBT will also focus on
increasing social engagement and reintroducing activities she previously enjoyed.
A focus will be placed on emotion regulation and self-compassion to help the child manage
feelings of sadness and frustration.
2. Parental Involvement:
Parents will be educated on the importance of maintaining a supportive environment while
also encouraging the child to gradually re-engage in social and extracurricular activities.
Parents will be trained in behavioural strategies to help improve communication with their
daughter and to ensure they are reinforcing positive behaviours and providing emotional
support.
3. School Support:
A meeting will be scheduled with the school counsellor and teachers to discuss
accommodations that may be needed, such as a quieter space for completing assignments,
extra time for tests, and a reduction in school-related pressures.
The school counsellor will also be involved in providing emotional support during the school
day.
4. Follow-up and Monitoring:
Weekly therapy sessions will be scheduled for the first 6 weeks, followed by bi-weekly
sessions based on progress.
Regular follow-ups with parents to assess improvement and identify any changes in
symptoms.
5. Medication Consideration:
Given the moderate severity of her depressive symptoms, medication (e.g., SSRIs, such as
fluoxetine) may be considered if there is insufficient improvement with therapy alone after
6-8 weeks of treatment.
Prognosis:
With appropriate treatment, including therapy and family support, the prognosis for this
child is generally positive. However, due to the moderate severity of her depressive
symptoms, it is important to monitor progress closely and adjust interventions as needed.
Early intervention and addressing both the emotional and behavioural aspects of her
condition are key to improving her mood, social engagement, and academic performance.
