PSYCHOLOGICAL CASE REPORT
Case Summary
The present case report describes an 8-year-old male child (ABC) referred for psychological
assessment due to concerns regarding persistent inattention, hyperactivity, impulsivity,
delayed speech development, and difficulties in adaptive functioning. The child belongs to a
middle-class family with strong parental involvement. The father is a medical consultant
and the mother is a housewife.
Developmental concerns included early speech delay, excessive motor activity, poor
attention span, and emotional dysregulation. The clinical presentation was consistent with
ADHD, Combined Presentation with associated developmental delays.
Identifying Information
Name: ABC
Age: 8 years
Gender: Male
Religion: Islam
Occupation: Student
Birth Order: First born
Father: Doctor (Consultant)
Mother: Housewife
Socioeconomic Status: Middle class
Presenting Complaints
- Difficulty sustaining attention
- Hyperactivity and restlessness
- Impulsivity
- Speech delay and unclear articulation
- Emotional dysregulation
- Task avoidance
History of Present Illness
Symptoms began in early childhood with speech delay and hyperactivity. The child showed
difficulty sustaining attention, completing tasks, and following instructions. Emotional
outbursts and distractibility were reported across home and school settings.
Personal History
Normal birth history with no complications. Developmental milestones showed delays in
speech and adaptive functioning. Strong attachment with mother reported.
Developmental History
Delayed speech acquisition, poor attention regulation, and delayed self-care skills were
noted.
Mental Status Examination (MSE)
The child was alert, cooperative but highly distractible. Speech was unclear with reduced
articulation. Mood was labile and attention span was significantly reduced.
Childhood Autism Rating Scale (CARS-2)
The CARS-2 is a clinician-rated scale assessing severity of autism symptoms. It was
administered through observation and parental report. The child obtained a total score of
29, indicating mild autism-related features.
CARS Quantitative Analysis
Relating to people: 2.0
Imitation: 2.0
Emotional response: 2.5
Activity level: 3.0
Visual response: 3.0
Total Score: 29
CARS Interpretation
Findings indicated mild autism-related traits with significant hyperactivity and attention
difficulties.
Conners Parent Rating Scale
The scale indicated clinically significant elevations in inattention and hyperactivity,
supporting ADHD Combined Presentation with emotional regulation difficulties.
Bender Gestalt Test (BGT)
The BGT assessed visual-motor integration and perceptual organization. The child showed
mild to moderate distortion, rotation, and spatial errors consistent with ADHD-related
executive functioning deficits.
BGT Interpretation
Results suggest impaired visual-motor integration influenced by inattention and impulsivity
rather than neurological damage.
Therapy Sessions Summary
Week 1: 2 ABA sessions
Week 2: 1 ABA session
Week 3: No show
Week 4: 1 ABA + Speech session
Week 5: 1 ABA + OT session
Week 6 onward: ongoing sessions
Management Plan
Intervention included ABA, Speech Therapy, Occupational Therapy and behavioral
strategies focusing on attention, hyperactivity, communication, and adaptive functioning.
Prognosis
Fair to good due to early intervention and strong parental support, though continued
therapy is required.