Case Presentation Template 2

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Liberty University *

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831

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Psychology

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Nov 24, 2024

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PSYC 645 C ASE P RESENTATION T EMPLATE I. Key Clinical Issues A. Client Demographics Our client is 9 year old Dustin, who has been referred by his pediatrician to speak with a psychologist due to his history of low academic acheivement. Dustin’s pediatrician is concern that Dustin’s low academic acheivement may be due to a learning disability. Dustin lives with mom, dad, and younger brother who is 7years of age. Dustin’s mother is a 3 rd grade elementary school teacher and Dustin’s father is an architect. B. Presenting Problem Dustin’s parents have indicated that his history of low academic achievement, difficulty listening, and lack of attentiveness has started as early as 2 nd grade. In addition, the client’s parents have also indicated that Dustin’s lack of attentiveness and difficulty listening are issues at home just as they are within his school environment. Both Dustin’s parents and teachers have identified Dustin continuous daydreaming and doodling when he is to be completing other tasks such as homework and/or chores. Due to Dustin’s lack of attentiveness, Dustin’s finds himself missing out on key instructions that would enable him to adequately complete assignments within class. At home, Dustin’s parents are learning that it is taking Dustin an hour to complete a 15min assignment or task. Dustin has been reprimanded by both his parents and teachers regarding his lack of attentiveness. Despite being reprimanded, neither the parents or teacher are seeing any change in Dustin’s behavior. Having Page 1 of 6

PSYC 645 being continuously reprimanded, Dustin has become uncomfortable with asking for help or requesting additional time to complete his work within school. Dustin parents and teacher convey that Dustin is a very bright student; however, he cannot sit still for longer than 10 minutes without having to get up or wonder off into his own world. This behavior was also observed by a referred psychologist during Dustin’s psychological evaluation. During the psychological evaluation there were multiple tests completed on Dustin such as an IQ test, academic achievement test, and several executive functioning test. II. Diagnosis A. Diagnostic Impressions 1. Autism Spectrum Disorder: To meet diagnostic criteria for ASD according to DSM-5, a child must have persistent deficits in each of three areas of social communication and interaction, and at least two of four types of restricted repetitive behaviors (F84.0) (American Psychiatric Association, 2013) . 2. Attention Deficit/Hyperactivity Disorder: To be diagnosed with ADHD, a person needs to fulfill the following criteria- A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by (1) and/or (2) (American Psychiatric Association, 2013):  Inattention: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities (F90.0). Page 2 of 6

PSYC 645  Hyperactivity and impulsivity: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities (F90.1). 3. Specific Learning Disorder: DSM-V criteria has characterized Specific Learning Disorder by identifying persistent impairment in at least one of three major areas: reading, written expression, and/or math and has for at least 6 months despite targeted help (F81.0/F81.81) (American Psychiatric Association, 2013). B. Differential Diagnosis: 1. The client is most likely not experiencing ASD, as there has been no mention or signs of deficits in communication or interaction. Also the clients does not meet the criteria, as there is been no mention or displaying of restricted repetitive behavior. 2. The client is most likely not experiencing Specific Learning Disorder, as his IQ test shows that his overall intellectual functioning is within the high range. There is no indication of persistent impairment within reading, mathematics, or writing skills/comprehension for at least 6 months. C. Full DSM Diagnosis 1. The most likely diagnosis for Dustin is Attention Deficit/Hyperactivity Disorder, with Inattention ( DSM-5, 2013 ). Page 3 of 6

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PSYC 645 a) The clients displays continuous daydreaming and doodling that impacts his academic achievements, as well as impact in home responsibilies (i.e., chores, daily hygiene, misplacing of items, etc.). b) The client continuously ask for parents and teacher to repeat instructions or request, as client does not pay attention when instructions or guidance is conveyed to him. c) The clients has now become uncomfortable with asking for help due to being reprimanded for not paying attention, which the lack of seeking assistance is having a major impact on his academic achievements d) The client has become disorganized and forgetful of belongings, as well as completing routine daily tasks and new tasks presented. e) The client take extended time to complete short tasks due to daydreaming and/or doodling. III. Etiology of the Problem/Disorder A. Biological Theory: With Attention Deficit/Hyperactive being identified as a neurodevelopmental disorder, the client must exhibit six or more deficits in communication and social interaction, as well as restricted repetitive behavior for over the course of 6 months. Dustin has exhibited over six of the qualifying criteria for ADHD (e.g. lack of attentiveness, trouble holding attention, disorganized, misplacing of items, easily distracted, and forgetting of daily activities). “There are also data suggesting that there is overlap in the genetic influences on learning disorders and ADHD (Pennington, 2006)” (Parritz & Troy, 2018). Despite the success Page 4 of 6

PSYC 645 of the parents, obtaining more information on the parents childhood journey can provide a clearer picture of Dustin path. Identifying any similarities in behavior. B. Psychosocial Theory: Dustin has indicated that he is aware of his inability to concentrate while at school. In addition, because of his lack of attentiveness and being reprimanded for it, this has position Dustin in a mindset where is feels that he is unable to succeed. In such an environment and what feels to be a lack of support from his teacher can create a continuous stressful situation for Dustin that may offset other cognitive disorders. “Gene-by-environment research has identified several promising interactions. For example, genetic variants that have an effect on the regulation of dopamine and serotonin interact with psychosocial factors to influence the severity of ADHD symptoms (Nigg, 2013; Nigg, Nikolas, & Burt, 2010)” (Parritz & Troy, 2018). IV. Treatment Recommendations: A. Biological Intervention: With Dustin finding it difficult to maintain organization and completing tasks, the parents and teacher can work together to impliment a nonpharmological approach such as behavior modification. Behavior modification enables both the parents and teacher to set clear goals and limits for Dustin that will assist him on maintaining a schedule and being rewarded when that schedule is maintained. However, there will be consequences enforced if the schedule is not maintained as well (i.e., loss of video games, riding bicycle, etc.). Dustin’s parents can discuss various rules/guidelines that they had as children and found to be affective. Test those rules/guidelines on Dustin Page 5 of 6

PSYC 645 see if they work well with him; especially if either parent conveyed that they had similar behavior as Dustin when they were children. B. Psychosocial Intervention: Dustin’s IQ tests, academic achievement tests, and overall intellectual functioning is within the high average range. With that stated, Dustin’s parents may consider seeking out a school that may be more challenging for Dustin and that offers interactive teaching styles that may motivate Dustin to become more engaged. Interactive teaching styles present the opportunity for children to be more mobile and hands-on. Page 6 of 6

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