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Community

Individual Case Report

Submitted to:

Ms. Madawa Maryam

Submitted by:

Khadija Nadeem (Psy-19010)

BS-Psychology (2019-2023)

GOVERNMENT COLLEGE WOMEN UNIVERSITY,

SIALKOT.
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Bio Data

Name A.H

Gender Female

Age 12 year

Date of birth 13-12-2010

Religion Islam

Education 6th class

No. of siblings: 1(1 sister)

Birth order. 1 (Elder)

Socioeconomic status Middle class

Informant Client (herself)

Source for Referral

The client was taken by the trainee psychologist from Community as a part of her
course work requirement.

Presenting Complaints

As reported by the client,

Sr.No Complaints
1
2
3
4
5

History of present Illness

As reported by client herself, she felt low or down at times and she face the above
mention presenting complain from past two years (from the last of 2019). She told
that they lived happily when her father was in Pakistan.In the start of 2019 her father
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got a job offer from Saudi -Arabia ,he tried to took his family along with him but
didn’t able to afford family expenditure there, that’s why he left his family and gone
to Saudi-Arabia alone in sake of her children better future. As time passes everything
is going to be smooth. Client has a hope that after few months her father settled and
sponsored her family. But this could not be happened and she began to feel
hopelessness all the time. From here the history of presenting complaints begun.

As reported by client mother, the client began to feel sad and unhappy all the time.
There is a visible change in her pattern of sleep and appetite. She started to loss
interest in her nearby people and in activities she normally enjoyed.

As reported by client, she began to spend her free time in her room and became
stubborn when someone asked her to do something especially her grandparents. She
had faced difficulties in carrying out daily activities, and due to this reason she was
scolded by her mother.

This triggers aggression in clients and she tried to release her aggression towards
her younger sister, that’s why she had no attachment with her sister and had
adjustment issues with her. She also reported that she felt that her family members
love her sister more than herself.

During the period of COVID-19 her father lost her job and her family faces many
Financial crises .during this time period sadness became persistent in client and she
reported a lot of Irritability in her daily mood that affects her different domains of her
daily life.
General home environment
As reported by client she lived in a joint family system. Her father's lived abroad
and she lived with her grandparents, her uncle aunt and with her mother and younger
sister .The descion taking authority of her house is her Grandmother.The client
doesn't have smooth relationship with her grandparents, because they feel that her
grandparents always dictate her and client feel uncomfortable.

Family history
As reported by the client's mother, she was 33years old, a housewife and has
intermediate level of education. Her temperament was a bit high. Her bond towards
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her offspring are quite protective and caring ,but she stated that she easily lost her
temper when her children didn't obey or understand her instructions .As reported by
clients mother although her temperament was high but the client somehow shares her
problems with her mother and she always took advice about important matters from
his mother.
Her father was 35 years old, who stays in Saudi Arabia, and was a safety officer
He was also caring and protective towards the client and his siblings .Client had a
congenial relationship with her father and her father's possessed a humble
temperament . Due to distance between both the client is not so much expressive
towards her father, but she love her father very much.
As reported by the client, she had 1 sisters. First born was client herself who was
12 years old, studying in 6th grade. The client stated the second born was a sister,
who was 8 years old, studying in 2nd grade. As reported by client she didn't have
good relationship with her younger sister .She had obsessive thoughts about physical
harm towards her younger sister. Client shows aggression towards her younger sister.
Personal history
The birth history of the client could took from her mother as she did not remember
any. As reported by the client's mother during his infancy and childhood period she
did not diagnose with any serious medical or psychiatrist illness. She completed her
developmental milestones on normal age as all normal kids have completed .As
reported by her mother, the client was a difficult child .She performed attention
seeking activities in order to attract her mother towards herself.
The client mother stated that client became independent in clothing and bathing
very early and always choose her clothes by herself. She had a great interest towards
art and drawing. Her mother stated that she shows an abrupt outburst of anger, cry and
negative emotions from past few years.
Her mother stated that she did like going to the school but only had trouble
waking up in the morning just as all normal kids have.

Educational history
As reported by the client, she started school at the age of 3 years .She stated
about her first day school experience that was a mixture of excitement and sadness.
She always scored good grades in her class. She was not so friendly and only have
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limited no of friends and unable to socialize with hers class fellows and also had
congenial relationship with her teachers.
From the beginning of her school life she took part in co-curricular activities but
with the passage of time from last 2 years she felt hesitation and feel low confidence
in front of others and tried to avoid them. The client stated that she changed her
school twice because of her father's employment .The client stated that she has a bit
problem in understanding sums of math and always wish that no one asked him to
write her school lessons.
Sexual history
As reported by the client, she reached at the stage of puberty at the age of 11.
She got the first hand information about puberty by her mother .She stated that when
she reached at the stage of puberty, she was just quite nervous and began to cry
because that was her first time but gradually she became used to it, but every month
when periods came she take first day off from school due to fear of stain and pain.
Social History:
As reported by the client form the beginning she was very shy in front of others
and need a lot of time in adjustment with guest and relatives .She has a very limited
social circle and felt comfortable between them .She also stated that she was not
socially very active.
Pre-Morbid Personality
Before having these psychological problem client stated that her daily activities
included taking part in household activities, spent time in playing with her little sister,
mother and spend quality time with other family members. She performed her little
chores by herself like cleaned her room, arranged her wardrobe and shoe rack and
ate meals on time.
But know she doesn't care about the mess she created she doesn't care about the
meals she skipped, she doesn't care about what was going around herself and only she
involve in her mother's mobile phone. Her mother stated that she spent a lot of time
on mobile phone and now only mobile is her life.
Behavior during Session
As total no of session conducted with client was 3.Durring First session trainee
psychologist work on Repo building between client and herself. Overall client shows
normal behavior her sitting posture was fine. Her voice tone is quite friendly but pitch
was slow.
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Her personality was a bit introvert and didn’t open up during her first session.
Although as the series of session started the client felt more comfort and ease in
sharing her background information .Some of her information was took from her
mother in order to well understand about the causes and effects of presenting
complaints reported by the client herself .
Preliminary Investigation
Pretreatment assessment of the client was done at two levels.
Informal Assessment
Informal assessments are assessment procedures that are used in informal
situations. These settings include settings that are not structured in nature. Informal
assessments are therefore procedures that are developed at home or homegrown
which are aimed at assessing certain aspects of a situation (Neukrug & Fawcett,
2010). Though they are subjective, these assessment procedures are usually set up to
meet certain standards (Neukrug & Fawcett, 2010)
It has three main parts:
o MMSE
o Behavioral observation
o Subjective ratings from client

Mini-Mental State Examination

A Mini-Mental State Examination (MMSE) commonly use to check for
cognitive impairment (problems with thinking,communication and understanding).

Table 1.1

Mini-Mental State Examination

Total score Obtained score MMSE Generalized Scoring Range

30 29 24-30: No cognitive Impairment

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Quantitative Observation

29/30 (Normal)

Qualitative Observation

The maximum score for the MMSE is 30.A score of 24 or higher is classed as
normal with no cognitive impairment. If the score is below 24, the result is usually
considered to be abnormal, indicating possible cognitive impairment.

Behavioral Observation

The client was cooperative. Her dressing was weather and situation appropriate .Her
hair was neatly tied. Eye contact was maintained. Her mood was cheerful. Her attitude
was cooperative and she actively participated in the tasks given to her. At some
questions she started smiling without any cause and suddenly stopped when someone
entered in the room.
Subjective Rating of Presenting Complaints

The subjective rating of presenting complaints were taken from the client to
estimate the severity of her presenting complaints on a scale of 1-10 where 1 being
the least problematic and 10 being the most problematic.

Table 1.2

Subjective Rating of Presenting Complaint of the Client

Complaints Ratings by client

Irritability 7
Restlessness 6
Aggression 8
Loss of Appetite 4
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Low confidence 2
Sadness 6
Self harming 4
Feeling of worthlessness 7

Prognosis

The client prognosis was better because she has episodes of depressive disorder
that appears totally spontaneously, in these situations the prognosis is usually better.
On the other hand, when it is associated with some precipitating event or with
personality traits of the patient, it usually has a tendency towards becoming chronic.

Conclusion

Depression can be show up in children and adolescents as prolonged periods of

unhappiness or irritability. It is quite common among older children and teenagers,
but often goes unrecognized. Just because a child seems sad, it doesn't necessarily
mean they have depression. But if the sadness becomes persistent or interferes with
normal social activities, interests, schoolwork or family life, it may mean they need
support from a mental health professional.

Remember, only a doctor or a mental health professional can diagnose depression,

so don’t hesitate to ask your health-care provider for advice if you are worried about
your child.