The client is a 10 years old male in year 5 at Carranballac P-9 College. He was referred by his teacher regarding his behavioural issues in the school. The client’s teacher was concerned about the complaints from other teachers and students regarding his behaviour towards other students during lunch time. The teacher was also concerned over his lack of empathetic behaviour towards other students when he hurts or upset them. As per the teacher’s report, he also manifests academic difficulties in reading, sentence building, comprehending new information, understanding written and verbal information, and mathematics.
He also shows extreme concentration issues and fidgeting behaviour in the class. He does not approach for help if he is confused or uncertain about something. His parents reported their concern about his ongoing learning difficulties.
The client’s teacher showed her concern about his performance in all academic subjects. She also finds the client with disruptive behaviour and with lack of empathy towards other students.
His parents believe that the reason behind his behaviour is his lack of attachment with younger sibling who is with developmental delay. They also believe that child was bullied last year and that might have caused the impact on the client’s behaviour.
According to the provided information by the teacher and his parents. The client is 10 years old, living with his parents and two other siblings. The client struggles to maintain social skills and finds difficulty in academics.
He also manifests concentration and comprehension difficulties in his classroom. The parents and his teacher stated about different precipitating factors behind his behaviour.
The client dressed in neat uniform but untied shoe-laces and messy hair. He was found to be struggling to tie his shoe-laces. He showed an indifferent shrug, when encouraged him to tie shoe-laces. He often showed disinterest in conversation and gave minimal responses in one word or short sentences. While playing board games, he kept forgetting about his turn and level of the game. He often squirmed on his chair and got up in between the session and touched other things in the room. When requested to sit, he seemed uneasy. The client’s mood was normal almost in all the sessions. He showed frequent eye contact and appeared to be in good mood. He seemed very polite with clear speech. He showed difficulty in drawing on worksheets and preferred to draw stick figures. He also continued to scribble on a paper whenever asked for any worksheet activities. Though, the client had good insight into empathetic behaviour, but he manifested little understanding about reacting calmly in undesirable situations.
The client’s teacher reported that he is behind his peers in academics including Mathematics, Reading, spelling and Writing. The client also exhibits an impulsive behaviour and often requires constant reminders to stay on a task. The client reported that he engages most of the time in video games at home. He also shows poor self-care skills such as bathing, brushing his teeth, tying up shoelaces and dressing up. He exhibits forgetful and disorganised behaviour. He often forgets his belongings in the school and struggles to tiding up his study table. He does not pay attention to details and often makes careless mistakes. Additionally, as per the teacher’s report, the client finds difficulty in listening and following verbal and written instructions and comprehend sentences. He often struggles in completing his school work, organising tasks, maintaining attention and understanding instructions. He shows fidgety behaviour and does not stay on one task at a time. He blurts out answers and talks incessantly. The client’s teacher described him as showing no empathy towards his peers after hitting or verbally abusing them. He was observed as demonstrating low social skills such as difficulty in making and maintaining friendships and considered as last one to be picked for teams and games.
Family Situation and Developmental History
The client was born in Australia and currently lives with his parents, an older sister and a younger brother. His younger brother has been diagnosed with genetic disorders such as intellectual disability, epilepsy and microcephaly. The client’s family has Turkish background and Turkish is the predominant language at home. The client speaks both Turkish and English languages. The client’s parents described him as a shy and afraid to take independent steps when goes out from home. He would also appear staying close to his parents when goes out to the shopping centre. The client mentioned that he spends most of the time at home on screen playing videogames or watching videos on YouTube. He sleeps late at night and that makes him difficult to wake up early in the morning for school.
The client is currently in Year 5 and relocated to current school in 2017. As for his conduct in the school, he is experiencing many academic difficulties and had many academic difficulties in the past. He reported his interest in Mathematics and his parents also mentioned his performance in Mathematics was good in previous school. The client expressed his concern about his concentration issues, and it takes him longer to grasp the concept. The client had been previously diagnosed with intellectual Disability and was receiving funding under the students with disability program.
The Client’s teacher delineated that he finds difficulty to make and maintain friendship and interrupts his peers in the classroom. The client finds hard to go anywhere independently and seeks assistance from his parents to take him to anywhere outside the home. At shopping mall, he always follows his parents instead of heading himself anywhere. According to his parent’s report, the client was bullied in 2018 in the school and that put a huge impact on his social skills, as he stopped approaching for help and has developed revenge seeking behaviour.
The client was observed in the classroom environment and at playground. He was found to be quiet and inattentive in the classroom, but he was less responsive to the instructions and showed little interest in the classroom activities. At playground, he was enthusiastic and over excited in playing but easily got tired after doing any activity.
In 2017, the client completed a language assessment using the Clinical Evaluation of Language Fundamentals-4th ed (CELF-4). His language performance was reported as severely delayed and he received Programmes for Student Disability Funding. His language skills were assessed again in August 2019 by using the CELF test to seek support through the Program for Student’s with Disability. His performance indicated his core and expressive language skills and memory within the borderline range and his reading comprehension and written expression skills within the moderately delayed range. The Wechsler Intelligence Scale for Children-Fifth Edition (WISC-V) was also administered on him in 2017 to assess his cognitive difficulties. His performance was within the Borderline range and subtests scores were within the Average to Below Average range.
The WISC-V was administered on client in August 2019 and his performance was within the Average range and subtests scores were Average to Below Average range. His Overall intellectual functioning can be measured by the Full-Scale Intelligent Quotient. His FSIQ scores fell within the average range (FSIQ=92), which suggests his cognitive functioning is not impaired.
Additionally, the three Connors tests (Parent. Teacher & self-report) were completed to assess his emotional, behavioural and academic concerns. His teacher’s and self-report yield a very elevated score on inattention, hyperactivity, learning problems, executive functioning, aggression, peer related and conduct disorders subscales. These scores suggest his difficulties in all three domains such as emotional, behavioural and academics. The test suggests that he has 87-98% probability of presence of Attention Deficit and Hyperactive symptoms.
The client spends most of the time at home in playing video games or using electronic devices to watch videos. He comes to the school with poor sleep because of his late gaming routine. According to the parents, the client was bullied last year and that might have also affected his behaviour. His forgetful behaviour might be one of the factors that contributes to impact on his behaviour and social skills. His lack of friendship and less involvement in the classroom activities might be a cause of his behavioural issues.
The client often displays forgetful behaviour and concentration issues. The client shows impulsive behaviour in various school settings such as in classrooms and playing with his peers at playground. The client struggles in decision making and comprehend things. He gets agitated and reacts physically or verbally in response, when other children tease him or hit him.
The client has been having different perceptions to respond in situations where the others annoy or make fun of him. He believes that the only way to punish others is to equally hit back or verbally abuse them. He finds difficulty to be quick at playground with his peers which distresses him. The client’s daily routine might have contributed to his lack of concentration in the classroom. His mother cannot spend much time with him as she has to take care of the client’s younger brother. He has low self-care skills and has difficulty in making and maintaining friendships.
The client has good physical health. The support from parents, teachers and sister can be considered as his strength. Client’s cooperation and polite mannerism might be good protective factors. The client also demonstrates a good insight about his behaviour towards others. He is also very acceptive to the different coping strategies such as using grounding techniques to calm himself in situations.
314.01 (F90.2) Attention Deficit Hyperactive Disorder (ADHD) with Combined presentations (American Psychiatric Association, 2013).
The client shows difficulty in academic work, such as in using and learning academic skills. However, he displays inattentive behaviour in academic work, at home and other social situations. The comorbidity of SLD with ADHD may be confirmed via administering the Wechsler Individual Achievement Test- Fourth Edition (WIAT-IV) on the client.
The ODD may be considered as differential as client manifests some symptoms of this disorder. However, It may be ruled out because the client does not often show angry or irritable mood and vindictive behaviour.
The client does not display intolerance to change and does not show tantrums during any transitioning. There is no extreme social dysfunction in the client. Thus, the Autism Spectrum Disorder may be ruled out.
Discussion related to Evidenced Based Theories
Related evidenced-based theories for diagnosis
The client presented with ADHD displays learning problems at some extent and the client with learning disorders also shows attention problems as both disorders overlap each other (Mayes, Calhoun, & Crowell, 2000).
Related evidenced based theories for formulation
The ADHD related behaviour links with low baseline arousal level (Beauchaine, Katkin, Strassberg, & Snarr, 2001; Lazzaro et al., 1999).Children with ADHD related behaviour display a likelihood to use arousing activities such as video games or watching videos on media that settle down their low baseline arousal level (Beauchaine, et al., 1999). Thus, media use instigates ADHD- related behaviour or symptoms. Barini, & Hage, (2015) proposed that the children with attention deficit hyperactive disorder manifests limited vocabulary and low verbal comprehension skills. The children with impulsive behaviour, attention issues and hyperactivity struggle to maintain their concentration in academic work, they struggle especially in learning new vocabulary and with building receptive and expressive language skills.
· Psychoeducation to the client and establish a therapeutic alliance with him by using play therapy.
· Speech therapy- The client struggles in receptive and expressive language skills. The speech and language therapy may benefit the client to learn strategies which develop reasoning skills.
· Classroom adjustment strategies which include providing simple and short instructions, assistance in different academic tasks, encouragement to raise hands often and participation in class discussions.
· Behavioural Management- This includes to encourage the client towards his behavioural modification and reinforces his positive behaviour by providing verbal praises or rewards. The psychoeducation of behavioural management can be provided to the client’s parents to use reward strategies at home as to encourage the client to learn different skills such as self-care skills and social skills.
· Modification of daily routine- Suggest the parents to modify the client’s daily routine by cutting down his screen time and encourage him more on physical activities.
· Provide impulse control strategies to the client along with different calming techniques.
· Implementation of motivation strategies such as interest and ability for the client to motivate him towards learning different academic tasks. The presentation methods for motivation can be simple and attention seeking which includes role-play, visual learning etc. It is also imperative to modify the tasks according to his ability and expectations.
· His participation in enjoyable activities that build up his confidence. To develop skills in many areas of functioning, it is important to encourage him to join extracurricular activities.
· Further assessment related to ADHD is needed to make a formal diagnosis. Additionally, WIAT needs to be administered to assess Specific Learning Disability in the client.
Working with this client was a good learning experience. While using Connors test on the parents, they both seemed like not agreed with each other’s responses. During the assessment, they had arguments over what is the correct response that relates to the client’s ability. Further, the school principal provided positive feedback about the client’s social functioning. The principal reported that the school staff noticed tremendous change in the client since the therapy has commenced, as he has started been showing impulse control behaviour at various situations.
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