Case 1

Bio data
Name Y
Age 15 years
Gender female
Siblings 1(brother)
Birth order 1st one
Religion Islam
Marital status single

Source of Reference

Presenting problems
Symptoms according to parents: frequent sadness and crying,
increased appetite and overeating, guilt, low self-concept, anxiety,
irritability, insomnia, hopelessness, and difficulty concentrating. In
addition, she presented difficulties in her interpersonal relationships,
persistent negative thoughts about her appearance and scholastic
abilities, as well as guilt regarding her parents' marital problems.
 Background history
Family history
the patient was a 15-year-old y adolescent female living with both her
parents and a younger sibling. Her parents, presented with significant
marital problems, had been separated several times and were discussing
divorce. Her mother reported having a history of psychiatric treatment
for depression and anxiety and indicated that the patient's father suffered
from bipolar disorder and had been receiving psychiatric treatment. He
was hospitalized on multiple occasions during previous years for serious
psychiatric symptoms.

Personal history/ Medical history

The patient's medical history revealed that she suffered from asthma,
used eyeglasses, and was overweight. Her mother reported that she had
been previously diagnosed with MDD 3 years ago and was treated
intermittently for 2 years with supportive psychotherapy and anti-
depressants (fluoxetine and sertraline; no dosage information available).
This first episode was triggered by rejection by a boy for whom she had
romantic feelings. Her most recent episode appeared to be related to her
parents' marital problems and to academic and social difficulties at
school.

Educational history
The patient was failing several classes in school, and her family was in
the process of looking for a new school due to her failing grades and
difficulties getting along with her classmates. She presented the
following symptoms: frequent sadness and crying, increased appetite
and overeating, guilt, low self-concept, anxiety, irritability, insomnia,
hopelessness, and difficulty concentrating. In addition, she presented
difficulties in her interpersonal relationships, persistent negative
thoughts about her appearance and scholastic abilities, as well as guilt
regarding her parents' marital problems.

History of family psychiatry / medical history

Her mother reported having a history of psychiatric treatment for
depression and anxiety and indicated that the patient's father suffered
from bipolar disorder and had been receiving psychiatric treatment. He
was hospitalized on multiple occasions during previous years for serious
psychiatric symptoms.

Psychological assessment
Diagnosis
A diagnosis of MDD was established using the Diagnostic Interview
Schedule for Children (DISC-IV).16 In addition, according to the DISC-
IV, she also met criteria for generalized anxiety disorder, separation
anxiety disorder, and attention deficit disorder. Symptoms of depression
were assessed every 2–4 weeks throughout therapy using the Children's
Depression Inventory—CDI17 . The Children's Depression Rating Scale
—CDRS-R18 was also used to assess depressive symptoms at baseline,
termination, and follow-up. In addition, other variables related to
depression were assessed at pre, mid, post and follow-up treatment using
the Piers Harris Children's Self-concept Scale—PHCSC,19 the
Hopelessness Scale for Children—HSC,20 the Dysfunctional Attitude
Scale—DAS,21 and the Suicide Ideation Questionnaire—SIQ-Jr22 . At
pretreatment evaluation the patient presented depressive symptoms in
the severe range and high suicidal ideation, as well as highly
dysfunctional attitudes and low self-concept.

Case formulation
the patient was a 15-year-old y adolescent female living with both her
parents and a younger sibling. Her parents, presented with significant
marital problems, had been separated several times and were discussing
divorce. Her mother reported having a history of psychiatric treatment
for depression and anxiety and indicated that the patient's father suffered
from bipolar disorder and had been receiving psychiatric treatment. He
was hospitalized on multiple occasions during previous years for serious
psychiatric symptoms.
The patient's medical history revealed that she suffered from asthma,
used eyeglasses, and was overweight. Her mother reported that she had
been previously diagnosed with MDD 3 years ago and was treated
intermittently for 2 years with supportive psychotherapy and anti-
depressants (fluoxetine and sertraline; no dosage information available).
This first episode was triggered by rejection by a boy for whom she had
romantic feelings. Her most recent episode appeared to be related to her
parents' marital problems and to academic and social difficulties at
school.
The patient was failing several classes in school, and her family was in
the process of looking for a new school due to her failing grades and
difficulties getting along with her classmates. She presented the
following symptoms: frequent sadness and crying, increased appetite
and overeating, guilt, low self-concept, anxiety, irritability, insomnia,
hopelessness, and difficulty concentrating. In addition, she presented
difficulties in her interpersonal relationships, persistent negative
thoughts about her appearance and scholastic abilities, as well as guilt
regarding her parents' marital problems.
Her mother reported having a history of psychiatric treatment for
depression and anxiety and indicated that the patient's father suffered
from bipolar disorder and had been receiving psychiatric treatment. He
was hospitalized on multiple occasions during previous years for serious
psychiatric symptoms.

Management plan
Short term goals
Short-term goals for severe depression can focus on immediate steps to
manage symptoms and begin the journey toward recovery. Here are
some potential short-term goals:

 Establish Safety: Ensure the child is in a safe environment. If

there are concerns about self-harm or suicide, it's critical to have
safety measures in place.

 Family Support: Engage the family in understanding and

supporting the child. Educate family members about depression in
children and how they can offer support.
 Regular Therapy Sessions: Begin regular therapy sessions with a
child psychologist or therapist specializing in children's mental
health to help the child express their feelings and learn coping
strategies.

 Consistent Routine: Establish a predictable routine for the child,

including regular sleeping patterns, healthy meals, and structured
activities, which can provide a sense of stability.

 Encourage Expression: Encourage the child to express their

emotions through drawing, writing, or other creative outlets if they
find it difficult to talk about their feelings.

 Limit Stressful Situations: Identify and reduce stressors that

might be affecting the child, such as academic pressure or social
conflicts. Work with the school, if necessary, to create a supportive
environment.

 Monitor and Communicate: Keep a close eye on the child's

mood and behavior and maintain open communication with their
mental health professional and school staff to track progress and
address any concerns.

 Encourage Social Interaction: Encourage the child to engage in

activities they enjoy or connect with friends in a safe and
supportive environment to reduce isolation.

 Celebrate Achievements: Acknowledge and celebrate even small

achievements or positive moments to boost the child's confidence
and motivation.
Long term goals

a. Continuation of short-term goals.

b. Proper follow-up sessions with the client, to revise short term

goal, and to incorporate new skills and techniques to Make
the client proficient. Implementation of therapeutic strategies

Rapport building:
When supporting a child coping with depression, rapport-building serves
as the cornerstone of their recovery journey. Establishing trust and a
strong connection is essential. It starts by creating a safe space where the
child feels understood and accepted without judgment. Listening
attentively to their thoughts and emotions, validating their feelings, and
showing genuine empathy are vital. Engaging in activities the child
enjoys, whether it's playing a game, creating art, or simply spending
quality time together, fosters a sense of comfort and builds a bridge for
open communication. As this rapport strengthens, it becomes a
foundation for the child to gradually express their feelings, concerns,
and challenges. It lays the groundwork for therapeutic interventions and
enables the child to feel supported and understood on their path toward
healing.
Sustained Therapy: It involves establishing a therapeutic relationship
with a mental health professional, aiming for consistency and regularity
in sessions. Over time, therapy might shift focus from immediate
distress to deeper exploration of underlying issues, coping strategies, and
personal growth. Therapeutic modalities could include cognitive-
behavioral therapy (CBT), play therapy (for younger children), or
dialectical behavior therapy (DBT) for adolescents, depending on their
needs and preferences.

Healthy Coping Skills: This encompasses a variety of coping

mechanisms tailored to the child's preferences and strengths. For
example, mindfulness exercises could involve guided meditation or
breathing techniques. Journaling might be encouraged as a tool for self-
reflection and emotional expression. Additionally, fostering hobbies or
activities that bring joy can serve as outlets for stress relief and self-
expression.

Education and Awareness: Continual education involves gradually

introducing age-appropriate resources that expand the child's
understanding of mental health. This might start with simple discussions
about emotions and progress to learning about coping strategies, mental
health disorders, and how to seek help without shame or stigma.

Family Involvement: Family therapy sessions or regular check-ins with

a therapist can facilitate healthy communication within the family unit.
Education for family members about depression in children and how
they can support their child's mental health journey is crucial.

Social Support Networks: Encouraging the child to develop and

maintain friendships or participate in support groups builds a network
that provides emotional support outside the family. This helps create a
sense of belonging and reduces isolation.

Academic Support: Collaborating with the school might involve

meetings with teachers to ensure they understand the child's needs.
Developing an Individualized Education Plan (IEP) or 504 Plan that
provides necessary accommodations or modifications supports the
child's academic success while considering their mental health.

Self-Esteem Building: Activities promoting self-esteem could involve

setting achievable goals, acknowledging efforts, and providing positive
reinforcement for accomplishments. It's about emphasizing strengths,
fostering resilience, and teaching self-compassion.

Healthy Lifestyle: This goal emphasizes the importance of regular

exercise, nutritious eating habits, adequate sleep, and mindfulness
practices. Establishing routines that prioritize physical health contributes
significantly to overall well-being and mood regulation.

Resilience and Problem-Solving Skills: Teaching resilience involves

helping the child view challenges as opportunities for growth.
Encouraging problem-solving skills, adaptive thinking, and flexibility in
facing difficulties fosters resilience against stressors.

Monitor and Adjust: Regular assessments of the child's progress by

mental health professionals allow for adjustments in therapeutic
approaches or strategies. Flexibility and adaptability are key as the
child's needs and responses to treatment may change over time.

Session report
SESSIONS 1–4
The first four sessions focused on teaching the patient about the
influence of thoughts on mood and strategies to debate dysfunctional
thought patterns and increase positive thoughts. During the week, the
patient was asked to complete a daily mood thermometer, which was
discussed at the beginning of every session. Homework assignments
such as keeping a daily log of positive and negative thoughts and
identifying and challenging dysfunctional thoughts were some of the
homework assignments that the patient completed between sessions.

The patient's mood fluctuated widely during these first sessions. She
cried several times and verbalized feelings of sadness, guilt, and low
self-concept. The main dysfunctional thoughts identified and challenged
during these sessions were mostly about herself (I'm ugly and stupid;
People look at me because I'm fat), anxiety over not being able to fit in
at a new school (I won't know anyone; I'll be far away from my friends;
It'll be too hard), and guilt about her parents' marital problems (My
parents fight because of me; If I had better grades they wouldn't fight).
By the fourth session, she succeeded in rationally challenging several of
these negative thoughts (I can make new friends; I have a chance to start
over at a new school; I am good at drawing, and I have a good sense of
humor). Nonetheless, many negative thoughts persisted, mostly
surrounding her parents' relationship. By the end of this therapy module,
the patient began to share some of her artistic talents with the therapist
and her self-concept appeared to be improving.

SESSIONS 5–8
The following four sessions worked with increasing pleasant activities,
time management, and goal setting to improve mood. Homework
assignments in this module involved keeping a daily log of pleasant
activities, completing a weekly planner, and establishing specific goals
and steps to complete them.

By the 5th session, the patient's mood improved significantly, most

likely due to having a positive experience at her new school; she had
made new friends, her grades had improved, and she was getting along
well with her teachers. She also reported a decrease in depressive
symptoms. This positive experience at school was used in therapy to
help the patient challenge negative thoughts and expectations by
providing evidence that disqualified them (i.e. she is likeable, she can
cope in a new school). Consequently, the number of negative thoughts
she had decreased markedly, and this reduction was reinforced verbally
by the therapist.

The patient recognized that one of the barriers to enjoying pleasant

activities, particularly social activities, was her negative thoughts (I'll
make a fool of myself; I won't do it right; I'll be rejected by others) and
her parents (obtaining permission for certain activities). The patient kept
track of her pleasant activities and began to organize her time better to
accommodate her homework and chores by using a weekly planner. This
allowed the patient and therapist to evaluate whether she had an
adequate balance of pleasant activities in her schedule that helped
improve her mood and adjust accordingly. Role-playing exercises were
used to help the patient learn to negotiate permission from her parents to
participate in social activities. Her self-concept continued to improve as
evidenced by her verbalizations (Sometimes I feel pretty) and her
physical appearance (increased confidence, better posture, and
grooming). The therapist reflected these observations back to the patient.
She was also handling stressful situations better as evidenced by her
reaction to being teased at school; she simply ignored it instead of
feeling sad and having persistent negative thoughts about herself, which
would have typically been her response. This suggests that the patient
was internalizing skills learned in the first few sessions, such as thought-
stopping techniques to decrease negative rumination.

SESSIONS 9–12
The last four sessions worked on the ways in which interpersonal
relationships affect mood and focused on increasing and maintaining
social support, as well as improving assertive communication skills. The
patient reported having a good social support system, but complained
about one of her close friends who would often put her down; this would
activate negative thoughts about her abilities and attractiveness. This
relationship was examined in the context of adequate expectations for
friendships. The patient presented a passive communication style, which
was contributing to feeling hurt frequently and having her emotional
needs unmet. Thus, the focus of two sessions was to work on developing
assertiveness through role-playing exercises. She reported some
upsetting incidents at school between her new and old friends but
appeared to be handling them well using cognitive strategies learned in
the first module.

However, during the last few sessions of this module the patient was still
experiencing feelings of guilt, anger, and sadness about her parents'
marital problems. Notably, she was disturbed by significant
communication problems between her parents who often spoke
negatively about one another in her presence and used her as a
messenger to communicate with each other. She confided in the therapist
about having witnessed physical and emotional abuse between her
parents, as well as living through several separations over the previous
10 years. The therapist explored the possibility of having a session with
her parents to discuss how their problems affected the patient, and she
agreed. During this session the therapist discussed with the parents how
their behavior was contributing to the patient's depressive symptoms and
recommended marital therapy. The parents admitted to having
significant problems and agreed to seek the couple’s therapy.

ADDITIONAL SESSIONS (13–16)

On completion of the standard 12-session “dose” of CBT, the patient
was still presenting symptoms of depression in the severe range and
continued to meet criteria for MDD; hence, she received additional
sessions of CBT until her symptoms decreased and she no longer met
MDD criteria according to the DISC-IV, as established by the study's
protocol for additional sessions. These four sessions worked mostly with
the patient's feelings and thoughts surrounding the possibility of her
parents' divorce or separation. The focus was on how to manage these
feelings to decrease their impact on her mood and daily functioning.

The patient's main negative thoughts were mostly related to fear that her
father would leave and never contact her, and that he would remarry and
have another family with whom she might not get along. These were
challenged in therapy by asking the patient to find evidence that these
thoughts would come true. The patient realized that most of her friends
whose parents had divorced had good relationships with them and their
new families and acknowledged that although her father had often
threatened to leave, he had also told her that he would always be there
for her. She also realized that it was possible that things would be better
if they separated and that their fights might even decrease. In addition,
role-playing exercises were used to practice talking to her father about
her fears and worries regarding the possibility of his leaving and how it
would affect their relationship.

On termination, the patient's depressive symptoms were in the moderate

range, and she no longer met criteria for MDD according to thse DISC-
IV, which was one of the study's criteria for ending therapy. In addition,
her self-concept had improved, and the therapist observed decreased
dysfunctional attitudes and suicidal ideation. These improvements were
maintained at 6 and 12-month follow-up assessments, and her depressive
symptoms decreased to mild by the last three follow-up assessments.

During the last session, the therapist worked on closure with the patient,
reinforced improvements in the patient's mood and coping skills, and
counseled the patient on relapse prevention strategies. Relapse
prevention strategies include monitoring depressive symptoms and
recognizing the need for treatment if they worsen or recur and using
cognitive-behavioral strategies to manage her mood (i.e. debating
dysfunctional thoughts, planning pleasant activities). The therapist also
counseled the patient's mother on how to monitor her daughter's residual
symptoms and the importance of seeking treatment if symptoms
worsened. She also reiterated her previous recommendation that the
parents seek couples counseling, which they had yet to do.

Reference:
CASE 2
Bio Data
Name A
Age 11 year
Gender male
Siblings 1(sister)
Birth order 1st
Religion Islam

Source of reference:
The client was referred by the hospital administration with the
presenting problems of
Presenting problems:
According to parents: An 11-year-old boy, He was socially isolated at
school and in the rural community where he lived. He had behavioral
difficulties at home and difficulties in adhering to the boundaries set by
the parents. His mother labeled him as a “troublemaker”, and he was
oppositional at school with inappropriate behavior. He was frequently
interfering with teaching in the classroom. Although he wanted to
socialize with other children, he was clumsy and aggressive in his
attempts to initiate contact. Teachers and other children’s parents’
complaints objectified the presence of behavioral problems. His
behavior was described as aggressive and violent. His play and his
reactions were often inappropriate and fear-provoking to others—i.e., he
performed animal amputations, made, and collected poisons, destroyed
objects, and set fires.
Background history
Family history
A was born at full term and was described as a quiet baby. In the first
three months of his life, his mother became worried as he was
unresponsive to cuddles and hugs. He also never cried. He has no
friends, and, on occasions, he has been victimized by bullying at school
and in the community. His father is 44 years old and describes having
had a difficult childhood; he is characterized by the family as indifferent
to the children’s problems and verbally violent towards his wife and son,
but less so to his daughters. The mother is 41 years old and describes
herself as having a close relationship with her children and mentioned
that she usually covers up for A’s difficulties and makes excuses for his
violent outbursts.
History of family psychiatry/medical history
His father is 44 years old and describes having had a difficult childhood;
he is characterized by the family as indifferent to the children’s problems
and verbally violent towards his wife and son, but less so to his
daughters. The mother is 41 years old and describes herself as having a
close relationship with her children and mentioned that she usually
covers up for A’s difficulties and makes excuses for his violent outbursts.
Personal history/psychiatry history
An 11-year-old boy, He was socially isolated at school and in the rural
community where he lived. He had behavioral difficulties at home and
difficulties in adhering to the boundaries set by the parents. His mother
labeled him as a “troublemaker”, and he was oppositional at school with
inappropriate behavior. He was frequently interfering with teaching in
the classroom. Although he wanted to socialize with other children, he
was clumsy and aggressive in his attempts to initiate contact. Teachers
and other children’s parents’ complaints objectified the presence of
behavioral problems. His behavior was described as aggressive and
violent. His play and his reactions were often inappropriate and fear-
provoking to others—i.e., he performed animal amputations, made, and
collected poisons, destroyed objects, and set fires.
 psychological assessment
 prognosis
Social Isolation: He experiences social isolation both at school and in
his rural community, likely due to his difficulties in interacting
appropriately with others.
Behavioral Challenges: There's a pattern of oppositional and
inappropriate behavior at school and home. His attempts to socialize are
aggressive and clumsy, resulting in further isolation.
Parental Dynamics: The father is described as indifferent, verbally
violent, particularly toward the mother and son. The mother seems to
cover up his difficulties and makes excuses for his behavior.
Violent Behavior: His actions, such as performing animal amputations,
collecting poisons, destroying objects, and setting fires, are concerning
and fear-provoking to others. These behaviors can indicate a lack of
empathy and serious emotional disturbance.
Early Developmental Red Flags: Lack of responsiveness to cuddles
and hugs as an infant and never crying in early months could suggest
early signs of emotional detachment or potential developmental issues.
Bullying: He has been victimized by bullying, which might exacerbate
his behavioral problems and social isolation.
Teacher and Community Concerns: Complaints from teachers and
other children's parents highlight the severity of his behavior, indicating
it's not just a family issue but something affecting his interactions with
others outside the family circle.
Potential Familial Influence: The difficult childhood experiences of the
father might suggest a pattern of intergenerational issues that could be
contributing to the boy's behavior.

 Diagnosis

1. Conduct Disorder (CD): The boy's pattern of aggressive and violent

behavior, including animal amputations, destruction of objects, and
setting fires, aligns with some symptoms of CD. CD involves persistent
patterns of behavior that violate societal norms and the rights of others.

2. Disruptive Behavior Disorders: His oppositional and defiant

behavior, difficulty adhering to boundaries, and disruptive behavior at
school could align with Oppositional Defiant Disorder (ODD) or other
disruptive behavior disorders.
3. Attachment Issues/Reactive Attachment Disorder (RAD): Early
signs of detachment as an infant, such as unresponsiveness to cuddles
and hugs, could suggest potential attachment issues or Reactive
Attachment Disorder, characterized by difficulties forming emotional
bonds with caregivers.

Isolation Developmental Disorder: The boy's difficulties in social

interactions, inappropriate attempts to initiate contact, and social
isolation might also indicate a broader developmental disorder, such as
autism spectrum disorder (ASD) or Social Communication Disorder.

5.Environmental Factors: Additionally, the family environment, with a

verbally violent father and a mother who covers up the child's
difficulties, might contribute to emotional and behavioral disturbances,
emphasizing the importance of considering the family dynamics in the
diagnostic process.

case formulation
An 11-year-old boy, He was socially isolated at school and in the rural
community where he lived. He had behavioral difficulties at home and
difficulties in adhering to the boundaries set by the parents. His mother
labeled him as a “troublemaker”, and he was oppositional at school with
inappropriate behavior. He was frequently interfering with teaching in
the classroom. Although he wanted to socialize with other children, he
was clumsy and aggressive in his attempts to initiate contact. Teachers
and other children’s parents’ complaints objectified the presence of
behavioral problems. His behavior was described as aggressive and
violent. His play and his reactions were often inappropriate and fear-
provoking to others—i.e., he performed animal amputations, made, and
collected poisons, destroyed objects, and set fires.
A was born at full term and was described as a quiet baby. In the first
three months of his life, his mother became worried as he was
unresponsive to cuddles and hugs. He also never cried. He has no
friends, and, on occasions, he has been victimized by bullying at school
and in the community. His father is 44 years old and describes having
had a difficult childhood; he is characterized by the family as indifferent
to the children’s problems and verbally violent towards his wife and son,
but less so to his daughters. The mother is 41 years old and describes
herself as having a close relationship with her children and mentioned
that she usually covers up for A’s difficulties and makes excuses for his
violent outbursts.
His father is 44 years old and describes having had a difficult childhood;
he is characterized by the family as indifferent to the children’s problems
and verbally violent towards his wife and son, but less so to his
daughters. The mother is 41 years old and describes herself as having a
close relationship with her children and mentioned that she usually
covers up for A’s difficulties and makes excuses for his violent outbursts.
An 11-year-old boy, He was socially isolated at school and in the rural
community where he lived. He had behavioral difficulties at home and
difficulties in adhering to the boundaries set by the parents. His mother
labeled him as a “troublemaker”, and he was oppositional at school with
inappropriate behavior. He was frequently interfering with teaching in
the classroom. Although he wanted to socialize with other children, he
was clumsy and aggressive in his attempts to initiate contact. Teachers
and other children’s parents’ complaints objectified the presence of
behavioral problems. His behavior was described as aggressive and
violent. His play and his reactions were often inappropriate and fear-
provoking to others—i.e., he performed animal amputations, made, and
collected poisons, destroyed objects, and set fires.

 Management plan
Developing a management plan for the 11-year-old boy involves a
comprehensive approach addressing his behavioral, emotional, social,
and familial challenges. Here's an outline for a management plan:

1. Comprehensive Assessment:
- Conduct thorough psychological, developmental, and behavioral
assessments to identify underlying issues and formulate a precise
diagnosis.
- Involve psychologists, psychiatrists, and other specialists for a
holistic evaluation.

2. Individualized Therapy:
- Cognitive-behavioral therapy (CBT) to address aggressive behavior,
emotional regulation, and social skills.
- Trauma-focused therapy if past traumatic experiences are identified.
- Play therapy or expressive therapies to facilitate emotional
expression and communication.
3. Family Therapy:
- Engage the entire family in therapy to address communication
patterns, parenting strategies, and improve family dynamics.
- Educate parents on effective discipline techniques and support
strategies.
4. School-Based Support:
- Collaborate with the school to implement behavior management
plans and support the boy's social interactions and academic
performance.
- Train teachers on strategies to manage his behavior and promote a
supportive classroom environment.

5. Psychiatric Evaluation and Medication:

- A psychiatric evaluation to assess the need for medication to manage
any underlying psychiatric conditions if identified.
- Monitor medication closely and involve the family in discussions
about its benefits and potential side effects.

6. Social Skills Training:

- Provide specific interventions to improve his social skills, empathy,
and appropriate social interactions.
- Organize peer interaction sessions to practice social skills in a
controlled environment.
7. Community Involvement:
- Connect the family with community resources, support groups, or
mentors to enhance their support network.
- Involve community organizations or clubs to provide structured
activities for social engagement and skill-building.

8. Safety Planning:
- Develop a safety plan to address any dangerous behaviors such as
fire-setting or self-harm.
- Educate the family on crisis management and intervention strategies.

9. Ongoing Monitoring and Support:

- Regular follow-up appointments with mental health professionals to
monitor progress and adjust interventions as needed.
- Continuous communication between all involved parties (therapists,
school personnel, and family) for coordinated care.

10. Psychoeducation:
- Educate the family on the boy's condition, treatment strategies, and
ways to provide ongoing support at home.
1.Objective/Goals of the Session:
 Review progress on managing aggressive behaviors.
 Address social interaction difficulties and bullying experiences.
 Introduce coping strategies for emotional regulation.
2. Client Presentation:
 A presented with heightened anxiety and appeared withdrawn at
the beginning of the session.
 Reported feeling frustrated about recent bullying incidents at
school.
3. Interventions Used:
 Employed CBT techniques to explore coping mechanisms for
handling bullying situations.
 Utilized role-playing exercises to practice appropriate social
interactions and conflict resolution skills.
 Introduced deep breathing and relaxation techniques to help
manage emotional outbursts.
4. Progress Review:
 A showed improved self-awareness regarding his emotional
triggers since the last session.
 Demonstrated better articulation of his feelings during the role-
playing exercise.
 Identified a few situations where he attempted less aggressive
approaches in response to conflict.
5. Challenges/Concerns:
 An expressed difficulty in applying newly learned techniques
during real-life bullying situations.
 Noted continued challenges in initiating positive social interactions
due to fear of rejection.
6. Insights/Revelations:
 A recognized the need for alternative responses to bullying and
expressed motivation to try new strategies.
 Expressed desire to feel more accepted and acknowledged among
peers.
7. Homework/Assignments:
 Assigned journaling exercises to track emotions and responses to
bullying incidents.
 Tasked A with initiating one positive interaction with a peer and
noting the experience.
8. Goals for Next Session:
 Further explore coping strategies and refine their application in
real-life situations.
 Address family dynamics and potential ways to involve the family
in social support.
9. Other Notes/Comments:
 Discussed the importance of practicing relaxation techniques daily
to build resilience.
  Encouraged A to seek assistance from teachers or counselors at
school during bullying incidents.
10. Plan for Follow-Up:
 Schedule the next session for January 25, 2024.
 Consider arranging a family therapy session to involve parents in
coping strategies.
Case 3
Bio data
Name Z
Age 7 years
Gender male
Siblings single
Birth order only child
Religion Islam
Marital status single
History of family psychiatry:
There is an extended family history of Attention Deficit/Hyperactivity
Disorder (ADHD), mental health concerns as well as academic
excellence.
Personal history:
Z is a 7-year-old male Grade 1 student who lives in C.D. with his
parents. He is the only child to two parents, both of whom have
completed post-graduate education.
Z is an intelligent and caring young boy who presents him with
significant potential to excel academically. In his spare time, Jack enjoys
spending time with his friends, and participating in physical activities
such as swimming, running, and skating. He also enjoys participating in
social events and is often invited to date and birthday parties. It is
noteworthy that he did not know his address or home phone number,
could not print his surname, and recognized only a few pre-primer
words. While Z interacts well with peers his own age.
Presenting problems by parents and teachers:
His parents note that he can be easily led and influenced by others. They
also report that Z gets upset when he does not receive recognition or
feels that he has been ignored. His teacher notes that he sometimes acts
'socially immature', and that he often demonstrates attention-seeking
behavior. Jack describes difficulties with focusing and sitting still in
class. He recognizes that he can 'hyper focus' on some activities of
interest, however he often has difficulty sustaining his attention at
school. His parents and teacher indicate that Jack is restless, and often
requires reminders to help him stay on task. He is described as
"constantly running around" and presenting with difficulties listening
and following instructions. Z's teacher indicates that he often blurts out
answers and interrupts other students in the classroom. Jack recognizes
this tendency in himself but says that he 'can't stop' despite his best
intentions. Z has always had challenges falling asleep, and sometimes
finds that he wakes up in the middle of the night. When he wakes up, he
finds that he has a difficult time getting back to sleep - sometimes
staying awake for as long as an hour and a half. His mother reports
difficulties at home with following routines and remembering
instructions. His parents describe emotional reactivity as well as
confrontational behaviors demonstrated both at home and at school. His
teacher notes that Jack is very defiant towards listening to instructions,
but generally interacts well with his peers. He is easily frustrated and
emotionally impulsive – Z has had several incidents of hitting, crying
outbursts, and inappropriate behavior. Behavioral concerns with
aggression, lying, arguments, and disruptive behavior were noted in pre-
school program at age 4.
Family History:
Extended family history of ADHD and mental health concerns suggests
a potential genetic predisposition. Parents have completed post-graduate
education, indicating a higher educational background within the family.
No mention of specific mental health diagnoses or history within the
immediate family, but the emphasis on academic excellence might
suggest high expectations and pressure within the family environment.
Educational History:
Z is a 7-year-old Grade 1 student living with his well-educated parents.
Shows significant potential for academic excellence but struggles with
certain foundational skills such as printing his surname and recognizing
only a few pre-primer words.
Enjoys physical activities and social events, indicating a preference for
active engagement.
Psychological Assessment:
 Attention Difficulties: Z presents symptoms typical of attention
difficulties associated with ADHD. He displays inattention,
hyperactivity, and impulsivity, as observed both at home and in the
classroom.
 Social Immaturity: Exhibits signs of social immaturity, as noted
by his parents and teacher. He seeks recognition, displays
emotional reactivity, and confrontational behaviors when feeling
ignored.
 Sleep Issues: Reports difficulties falling asleep and staying asleep,
which might impact his daytime attention and behavior.
  Emotional Reactivity: Demonstrates emotional impulsivity,
frustration, and confrontational behaviors both at home and at
school.
 Previous Behavioral Concerns: History of behavioral concerns in
a preschool program at age 4, including aggression, lying,
arguments, and disruptive behavior, indicating a prolonged pattern
of behavioral challenges.
Observational report
1. Attention and Focus:
 Z appeared engaged at the beginning of the lesson, sitting
upright and attentive.
 However, after approximately 10 minutes, he started
fidgeting in his seat, frequently tapping his pencil on the
desk, and looking around the room.
 He seemed to struggle to maintain focus on the teacher's
instructions, often glancing at other students' activities.
2. Hyperactivity and Impulsivity:
 Z displayed noticeable restlessness throughout the session,
frequently shifting in his seat and occasionally getting up to
sharpen his pencil or retrieve materials.
 He exhibited impulsive behavior by raising his hand and
blurting out answers without waiting for the teacher's cue,
interrupting the flow of the lesson.
 3. Social Interaction:
 During group activities, Z actively participated but displayed
signs of social immaturity. He occasionally struggled to take
turns and follow group instructions without becoming visibly
frustrated.
 Interacted well with peers during free time, showing
enthusiasm for playing and conversing with classmates.
4. Emotional Reactivity:
 When not called upon to answer a question, Z showed signs
of frustration, sighing audibly, and tapping his feet.
 On receiving praise for correctly answering a question, he
visibly brightened, indicating a strong desire for recognition
and validation.
Analysis and Reflection:
 Z's initial engagement suggests an attempt to focus but displayed
difficulty maintaining attention over time, consistent with reported
attention challenges.
 The observed restlessness and impulsivity align with concerns
raised by parents and teachers regarding hyperactive and impulsive
behavior.
 Social interactions showcased a mix of engagement and challenges
with following group instructions, indicating potential social
immaturity.
 Emotional reactions highlighted a strong need for recognition and
validation, contributing to frustration when attention is not
received.
  Therapeutic Interventions
 Behavioral Therapy:

Behavior Modification Techniques: Implement strategies to reinforce

positive behaviors and manage impulsivity. Use reward systems for
sustained attention and following instructions.
Self-Monitoring and Awareness: Teach Z to recognize his attention
lapses or impulsive behaviors through self-monitoring exercises.

 Social Skills Training:

Social Interaction Practice: Engage in role-playing scenarios to help Z

navigate social situations, take turns, and follow group instructions.
Emotional Regulation Skills: Teach techniques such as deep breathing
or mindfulness to manage frustration and impulsive reactions.

 Parental Education and Support:

Parent Training Programs: Provide parents with strategies to support

Z's behavioral management at home.
Consistent Structure: Encourage consistent routines and clear
expectations at home to support behavior management.
  Classroom Support:

Individualized Education Plan (IEP): Collaborate with the school to

create an IEP tailored to Z's needs, allowing for accommodations and
specialized strategies in the classroom.
Behavioral Supports: Implement a structured environment, preferential
seating, and frequent breaks to aid attention and reduce impulsivity.

 Cognitive-Behavioral Therapy (CBT):

Cognitive Restructuring: Help Z recognize and challenge negative

thoughts or frustrations contributing to impulsive behavior.
Problem-Solving Skills: Teach problem-solving techniques to address
challenges in social interactions or academic tasks.

 Sleep Hygiene Techniques:

Establishing Bedtime Routines: Develop consistent bedtime rituals to

promote better sleep patterns and address nighttime awakenings.

 Mindfulness and Relaxation Techniques:

Mindfulness Exercises: Teach relaxation techniques or guided imagery

to promote relaxation and reduce restlessness.

 Collaboration with School Personnel:

Regular Communication: Maintain open communication between the
therapist, teachers, and other school staff to monitor progress and
implement consistent strategies.

 Supporting Emotional Expression:

Art or Play Therapy: Use creative outlets to help Z express emotions,

providing a safe space for him to explore and communicate feelings.
Medication (if recommended by a professional):

Consider medication in cases where behavioral interventions alone are

insufficient or when recommended by a healthcare professional
specializing in pediatric psychiatry.
Case 4
Bio data
Name N
Age 13 years
Gender Female
Siblings 1 sister
Birth order 1st
Religion Islam
Grade 8th

Symptoms:
ADHD/Learning Differences: Her difficulties with inattentiveness,
disorganization, and reluctance in reading may indicate attention-related
challenges or potential learning differences affecting her academic
performance.
Anxiety and Mood Fluctuations: N experiences anxiety and mood
fluctuations, particularly related to school expectations, public speaking,
socializing, and an overall sense of pressure.
Personal History:
Academic Struggles: N's challenges with schoolwork completion,
inattention, disorganization, and lower reading comprehension suggest
potential difficulties in processing and retaining information, impacting
her academic progress.
Emotional Coping Mechanisms: Engaging in arts, crafts, social media,
drawing, and swimming serve as outlets for relaxation and expression,
indicating her need for activities that alleviate stress or provide comfort.
Family History:
Extended Family Dynamics: The history of alcoholism, marital
instability, and possible ADHD/LD characteristics within the extended
family suggests potential genetic predisposition or environmental
influences.
Sister's Experience: Her sister's academic achievements and struggles
with an eating disorder might reflect family expectations and stressors
impacting the siblings' emotional well-being.

 Case formulation:
N is a 13-year-old Grade 8 student currently living at home in Toronto
with her two parents and older sister. She was referred to Springboard
Clinic for an evaluation to further understand her focusing concerns and
her current learning profile of strengths and concerns. N reports that she
enjoys arts and crafts and participating in social media websites such as
"Tumblr." At times, she experiences mood fluctuations and irritability;
she noted that anger and frustration tend to relate to her sadness.
Drawing, listening to music, and swimming help her to relax. Since first
entering school, N has experienced difficulties with schoolwork
completion, inattentiveness and distractibility, disorganization,
impulsivity, and mood fluctuations. N's teachers describe her as a hard-
working, cooperative student, but they indicate that homework
responsibilities have been an issue. They also note that she is a very
reluctant reader and has consistently scored lower than average on
reading comprehension and vocabulary tests. Psychoeducational testing
indicates average cognitive abilities. N states that she is struggling to
meet expectations at home and at school, complete academic work, and
communicate effectively with others who do not share her interests. N
indicates that she often becomes anxious when she is asked to speak in
public, or to spend time with people she does not know. Her parents note
that N has difficulties making new friends and taking risks - she "longs
to get invited but won't make the first move." She experiences ongoing
sleep difficulties, primarily with settling into routines at night. Her
parents report increased anxiety around school participation this year. N
reports feeling nervous when going to school because of presentations
and homework. She describes hating school and experiencing difficulties
completing her work on time because "she can never focus." Her parents
note concerns with negative body image and self-talk. Her older sister
has been identified as "gifted" and appears to be highly motivated
academically and almost "driven" to excel in all her life domains. (She
later was diagnosed with a serious eating disorder). Both her parents are
university graduates. Her father is a hard-working financier who stays
fit, running marathons. N's mother is currently a full-time homemaker.
There is an extended family history of alcoholism, marital relationship
instability and possible ADHD / LD characteristics.

Diagnosis:
1. Attention-Deficit/Hyperactivity Disorder (ADHD):
 Symptoms: Inattentiveness, disorganization, impulsivity, and
difficulties completing tasks.
  Potential Diagnosis: ADHD, primarily inattentive type,
considering her struggles with focus, disorganization, and
reading difficulties.
2. Learning Differences:
 Symptoms: Reluctance in reading, lower comprehension, and
persistent academic struggles despite average cognitive
abilities.
 Potential Diagnosis: Learning differences impacting reading
comprehension or processing, possibly dyslexia or specific
learning disorder in reading.
3. Anxiety Disorder:
 Symptoms: Anxiety related to public speaking, social
situations, and school expectations, coupled with mood
fluctuations and irritability.
 Potential Diagnosis: Generalized Anxiety Disorder (GAD) or
Social Anxiety Disorder, given her anxious feelings in
specific situations and mood-related fluctuations.
4. Mood Disorder (Depressive Features):
 Symptoms: Mood fluctuations, sadness, irritability, and
finding solace in activities such as drawing and music.
 Potential Diagnosis: Depressive disorder with persistent
depressive features, especially considering the fluctuations in
mood and feelings of sadness.
Prognosis:
1. Intervention and Support: Early intervention and appropriate
support tailored to her specific challenges can significantly
improve outcomes. Treatment focusing on academic, emotional,
and social aspects can positively impact her well-being.
2. Family Environment: Addressing family dynamics, providing
education and support to parents, and involving the family in
therapeutic interventions can contribute to better outcomes.
3. Individual Resilience: N's coping mechanisms, such as engaging
in creative activities and physical exercise, show adaptive
strategies that, with further support, could aid her resilience.
4. Potential Challenges: Factors like ongoing anxiety, mood
fluctuations, and persistent academic difficulties may present
ongoing challenges that require continual support and
management.
5. Comorbidity Consideration: The presence of multiple potential
diagnoses (ADHD, learning differences, anxiety, mood
fluctuations) suggests a need for a nuanced approach to treatment,
which can impact the prognosis.
 Management plan:
1. Comprehensive Assessment:
 Conduct a thorough evaluation by specialists (psychologists,
psychiatrists, educational psychologists) to confirm
diagnoses and guide tailored interventions.
2. Academic Support:
 Individualized Education Plan (IEP): Collaborate with the
school to develop an IEP providing academic
accommodation like extended time for assignments,
specialized reading support, and organizational aids.
 Specialized Tutoring: Consider targeted support in reading
comprehension or academic areas of struggle.
3. Therapeutic Interventions:
 Behavioral Therapy: Implement strategies for organization,
time management, and coping skills for anxiety and mood
fluctuations.
 Counseling/Therapy: Provide psychotherapy to address
anxiety, mood regulation, self-esteem issues, and social skills
training.
 Family Therapy: Engage the family in therapy to improve
communication and support N's needs effectively.
4. Medication (if deemed necessary):
 Medication Management: Consult with a psychiatrist if
medication is recommended for ADHD symptoms, anxiety,
 or mood regulation. Monitor closely for effectiveness and
side effects.
5. Social Skills and Coping Mechanisms:
 Social Skills Training: Offer sessions to improve social
interactions, assertiveness, and coping with anxiety in social
situations.
 Coping Strategies: Teach relaxation techniques, mindfulness,
or stress management strategies for mood fluctuations and
anxiety.
6. Parental Education and Support:
 Parent Training Programs: Educate parents on ADHD,
learning differences, anxiety, and mood disorders. Provide
strategies for managing N's challenges at home.
 Consistent Support: Maintain open communication between
parents and school regarding N's progress and needs.
7. Healthy Lifestyle Interventions:
 Physical Activities: Encourage participation in activities like
swimming, drawing, and music, which provide relaxation
and a sense of accomplishment.
 Sleep Hygiene: Establish consistent bedtime routines to
address sleep difficulties and enhance overall well-being.
8. Collaboration and Follow-Up:
 Ensure collaboration among healthcare providers, educators,
and therapists for a cohesive approach to N's care.
  Schedule regular follow-ups to monitor progress, adjust
interventions as needed, and provide ongoing suppor

 Short-Term Plan:
1. Immediate Evaluation (within 1 month):
 Schedule initial appointments with specialists for an initial
assessment and start psychoeducational testing.
2. Introduction of Coping Strategies (within 1-2 months):
 Begin teaching immediate coping strategies like relaxation
techniques and stress management to alleviate immediate
symptoms.
3. Initial Academic Support (within 1-3 months):
 Initiate discussions with the school about accommodations
and possible interventions to support N's academic
challenges.
4. Parental Education (within 1-3 months):
 Provide initial education to parents regarding potential
diagnoses and strategies for immediate support at home.
5. Initial Therapy Sessions (within 1-3 months):
 Commence initial therapy or counseling sessions focusing on
immediate concerns such as anxiety management and mood
stabilization.
6. Setting Up Support Systems (within 1-3 months):
  Establish support systems within the school environment to
accommodate immediate needs, like preferential seating or
extended time for assignments.
7. Regular Check-Ins (ongoing):
 Schedule periodic check-ins with various specialists to assess
progress and adjust interventions accordingly.

 Long-Term Plan:
1. Comprehensive Assessment (1-3 months):
 Schedule appointments with specialists for thorough
evaluations to confirm diagnoses and guide treatment plans.
2. Academic Support (3-6 months):
 Collaborate with the school to develop an IEP and implement
academic accommodations.
 Arrange specialized tutoring or interventions to address
reading comprehension challenges.
3. Therapeutic Interventions (6-12 months):
 Initiate behavioral therapy focusing on organization, time
management, and coping skills.
 Begin counseling/therapy sessions to address anxiety, mood
fluctuations, and self-esteem issues.
4. Medication Consideration (if necessary) (6-12 months):
  Consult with a psychiatrist for potential medication
management if deemed beneficial for managing ADHD
symptoms, anxiety, or mood regulation.
5. Social Skills and Coping Strategies (6-12 months):
 Commence social skills training and coping strategy sessions
to improve social interactions and manage anxiety.
6. Parental Education and Support (ongoing):
 Engage parents in training programs and provide ongoing
support for managing N's challenges at home.
7. Healthy Lifestyle Practices (ongoing):
 Encourage consistent participation in activities like
swimming, drawing, and music to support relaxation.
 Implement and monitor consistent sleep hygiene practices for
better sleep routines.
8. Collaboration and Follow-Up (ongoing):
 Maintain regular communication and collaboration among
healthcare providers, educators, and therapists for ongoing
monitoring and adjustments to the treatment plan.
Case 5
Bio data
Name B
Age 19 years
Gender male
Siblings no
Birth order 1st
Religion Islam
Grade university student

Personal History:
 Academic Challenges: B has experienced disappointment and
perceived underachievement academically, resulting in being
placed on academic probation, which significantly impacted his
motivation.
 Work Experience: Successful summers as a camp counselor
where he was well-liked, indicating social competence and positive
peer relationships.
 Relationship Challenges: Experiences anger outbursts with his
girlfriend, leading to arguments and lashing out when feeling
frustrated.
 Behavioral Changes: Escalating behavioral challenges since
Grade 9, including verbal defensiveness, irritability, and a
tendency to shut down when stressed.
  Substance Use: Daily dependence on marijuana to alleviate
perceived restlessness and stress, along with increased alcohol and
cigarette consumption, raising concerns.
Symptoms:
 Academic Underperformance: Struggles with concentration,
time management, and shutting down under stress have contributed
to academic challenges and led to academic probation.
 Emotional Instability: Demonstrates anger outbursts, verbal
defensiveness, irritability, and arguments, particularly with his
girlfriend.
 Substance Use Dependency: Daily marijuana uses to manage
restlessness, increasing alcohol consumption, and cigarette
dependency.
Family History:
 Concerned Parents: B's parents express worry about his declining
academic performance and escalating behavioral challenges,
particularly since his successful secondary school years.
 No Detailed Family History Provided: The information provided
does not explicitly detail B's family history beyond his parents'
concerns and their reference to his previous success in secondary
school.
Case formulation
B is a bright and articulate 19-year-old student who is currently in his
second year of university. He is living in an apartment with two other
young men of a similar age, with whom he is good friends. He was
referred to the clinic by his parents, who seek to better understand his
attention profile and learning challenges. BS has spent the last two
summers working as a camp counsellor where he describes being well-
liked by both his peers and campers. He notes that he has recently been
experiencing anger outbursts with his girlfriend, who he has been seeing
for the past year. While they have many common interests, he finds that
he sometimes lashes out at her when feeling frustrated. He is challenged
by low motivation and is struggling with perceived academic
underachievement. B is creative and intelligent but has been
disappointed by his academic performance in the last year. Last semester
he was placed on academic probation - this was a large motivator for
him coming into the clinic. B reports a tendency to "shut down" when he
becomes overwhelmed by stress. He attributes this tendency as the
reason he performed poorly on his last set of exams, and why he was
placed on academic probation. There is evidence of escalating
behavioral challenges since Grade 9. B also reports that he struggles
with feelings of internal restlessness, an inconsistent ability to
concentrate, and difficulty with time management. He indicates that he
has always had a difficult time concentrating in class, and that his mind
tends to wander. He states that at times his immediate reaction to anger,
and frustration is to become verbally defensive and irritable. He
sometimes breaks things if he is angry or gets into arguments with his
girlfriend. B admits to having a daily dependence on marijuana. He
states that this smoking helps to "calm" his mind and to decrease the
perceived "non-stop" restlessness of his thoughts. While he has been
trying to cut back on his marijuana usage, he smokes half a pack of
cigarettes per day, and reports some concern that he has begun replacing
marijuana with alcohol use. "Binge" drinking with friends is increasing.
His parents are concerned, especially when he had previously been
successful academically and socially in secondary school when he was
living at home.

prognosis
Positive Factors:
1. Youthfulness and Motivation: At 19, B's young age and
motivation to seek help due to academic probation suggest a
potential for change and improvement.
2. Social Skills: B's ability to form positive relationships, evident
from his successful summer camp counselor experiences, might
indicate a capacity for building strong support networks.
3. Treatment Access: Seeking help and being open about his
struggles indicate a potential willingness to engage in therapy or
interventions.
Challenges and Concerns:
1. Substance Dependence: Daily marijuana use and increasing
alcohol and cigarette consumption raise concerns about potential
addiction and their impact on his mental and physical health.
 2. Emotional Instability: B's difficulty managing anger, frustration,
and arguments with his girlfriend might indicate underlying
emotional struggles that need to be addressed.
3. Academic Underperformance: Previous academic probation and
struggles with concentration, time management, and stress
management significantly impact B's academic success and overall
well-being.
4. Behavioral Challenges: Escalating behavioral issues, including
shutting down under stress, verbal defensiveness, and irritability,
pose challenges in managing emotions and relationships.

Diagnosis
1. Attention-Deficit/Hyperactivity Disorder (ADHD):
 Symptoms: Difficulty concentrating, mind wandering,
restlessness, impulsivity, time management challenges, and
academic underachievement.
2. Intermittent Explosive Disorder (IED):
 Symptoms: Anger outbursts, verbal defensiveness, irritability,
and arguments, particularly with his girlfriend, leading to
aggressive behaviors.
3. Substance Use Disorder:
 Symptoms: Daily dependence on marijuana, increased
alcohol consumption, and half-pack daily cigarette usage
leading to concerns about potential substance abuse or
dependency.
 4. Adjustment Disorder with Disturbance of Conduct:
 Symptoms: Escalating behavioral challenges since Grade 9,
shutting down under stress, difficulty managing emotions,
and disruptive behavior in response to stressors.
5. Potential Co-occurring Disorders:
 Anxiety Disorder: Restlessness, shutting down under stress,
and difficulties with time management and concentration
might indicate underlying anxiety.
 sDepressive Disorder: Academic underachievement, low
motivation, disappointment, and perceived underperformance
contributing to his emotional state.
Short-Term Goals (3-6 months):
1. Substance Use Reduction:
 Short-Term Goal: Decrease daily marijuana use and limit
alcohol intake.
 Strategies: Engage in substance abuse counseling or support
groups, set achievable reduction targets, and establish
healthier coping mechanisms.
2. Anger Management and Emotional Regulation:
 Short-Term Goal: Develop coping strategies to manage anger
outbursts and verbal defensiveness.
 Strategies: Engage in cognitive-behavioral therapy (CBT) or
anger management sessions to learn techniques for emotional
regulation and conflict resolution.
3. Academic Support and Improvement:
  Short-Term Goal: Develop strategies to improve academic
performance and address academic probation.
 Strategies: Work with an academic advisor or counselor to
create a structured study plan, improve time management,
and seek tutoring or academic support.
4. Behavioral and Relationship Improvement:
 Short-Term Goal: Reduce arguments and improve
communication in relationships, especially with his
girlfriend.
 Strategies: Couples counseling or relationship therapy to
address conflict resolution, communication skills, and anger
management within the relationship context.
Long-Term Goals (6-12 months and beyond):
1. Sustained Substance Use Reduction and Healthy Coping:
 Long-Term Goal: Achieve and maintain a significant
reduction in marijuana, alcohol, and cigarette use.
 Strategies: Continued engagement in substance abuse
counseling, development of healthier coping mechanisms,
and ongoing support networks.
2. Emotional Regulation and Stress Management:
 Long-Term Goal: Master effective emotional regulation
techniques and stress management.
 Strategies: Continue CBT or therapy to reinforce coping
skills, mindfulness, and stress reduction techniques for long-
term emotional stability.
3. Academic and Career Progression:
 Long-Term Goal: Improve academic performance, stay off
academic probation, and set career-oriented goals.
 Strategies: Consistent adherence to study plans, continued
academic support, and exploring career counseling or
vocational training for future aspirations.
4. Healthy Relationships and Behavioral Stability:
 Long-Term Goal: Foster healthier relationships and maintain
behavioral stability.
 Strategies: Continued relationship therapy, conflict resolution
training, and ongoing support to manage interpersonal
conflicts and emotional reactions.
Case 6
Bio data
Name S
Age 36 years
Gender Female
Siblings 1 sister
sBirth order 1st
Religion Islam
Grade 8th

Personal History:
 Academic Challenges: S has a history of poor attention and
required special accommodations in school. She struggled with
focusing and time management, using earplugs for studying.
 Career and Family: After a break from work to raise her children,
she resumed her career as a dietitian, facing challenges balancing
work and family responsibilities.
 Mental Health History: S has been on antidepressants for eight
years due to symptoms of anxiety, depression, guilt, and low self-
esteem. She experiences stress-induced paralysis and withdrawal
when overwhelmed.
 Recent Stresses: Dealing with severe illnesses in her family
(stepfather and cat) has added to her stress.
Symptoms:
 Attention and Focus Issues: Difficulty staying focused, managing
time, and organizing tasks, affecting her performance at work and
her ability to balance responsibilities.
 Emotional Challenges: Symptoms of anxiety, depression, guilt,
and low self-esteem due to perceived underachievement and
inefficiency at work and in managing family responsibilities.
 Avoidance and Withdrawal: Tendency to retreat into herself
rather than seeking help or support when overwhelmed by stress or
feeling confused.
Challenges:
 Work Performance: Recent disappointment in her work
performance due to increased demands at home impacting her
ability to focus on work-related duties.
 Parenting Challenges: Concerns about neglecting her children
while managing work responsibilities, feeling overwhelmed by
parenting demands.
Family history
1. Current Family Situation: S lives with her husband and two
young children. Her challenges in balancing work, family, and her
emotional struggles could be impacting her immediate family
dynamics.
2. Illness in the Family: S is dealing with severe illnesses affecting
both her stepfather and her cat, which could be causing significant
stress and emotional strain within her family unit.
 3. Support System: While specific family history details aren't
provided, S’s tendency to retreat into herself instead of seeking
help might indicate potential dynamics within her immediate
family, such as limited support or challenges in openly discussing
and managing stressors.

Case formulation
S is a 36-year-old female, currently living at home with her husband of
11 years and two young children, ages 2 and 4, in Toronto. She recently
resumed working after taking four years off after the birth of her first
child. S is experiencing increased levels of stress as she tries to balance
the challenges of parenting with the academic demands of her career as a
dietician. S reports a longstanding history with poor attention. She was
identified in grade school as requiring special accommodation and
support from her teachers but was never diagnosed with a confirmed
learning disability. She used ear plugs when studying in school. Her
difficulties with focusing and time management have continued into
adulthood, affecting her ability to effectively manage her finances and to
balance her work/family time relationship. She has been able to cope by
creating “pressure” to engage her focus, but this has resulted in
symptoms of anxiety, depression, feelings of guilt, and loss of self-
esteem. S worries that by focusing her energies on managing her work
responsibilities, she is neglecting other areas of her life, particularly her
children. S is concerned with perceived underachievement and
inefficiency at her place of employment. She struggles with
procrastination and has difficulty with organization. Due to the increased
demands and responsibilities, she now faces in the home, S finds that
she is not able to focus on work-related duties the way she used to. As a
result, she has been disappointed by her recent performance at her place
of work. S is an intelligent and engaging communicator, but she feels
overwhelmed by her current responsibilities and worries that she is not
performing to her real potential. She sometimes feels paralyzed by stress
and reacts by retreating into herself rather than by asking for help. She
says that she needs a life "GPS" to function - "I feel confused." Recent
stresses include her stepfather, and her cat are both severely ill with
cancer. She has been on an anti-depressant for 8 years from her
psychiatrist. She demonstrates no hyperactivity but is challenged to stay
focused even to read a book.

Diagnosis
1. Attention-Deficit/Hyperactivity Disorder (ADHD -
Predominantly Inattentive Presentation):
 Symptoms: Longstanding history of poor attention, difficulty
focusing, time management challenges, and struggles with
organization.
2. Anxiety Disorders (Generalized Anxiety Disorder or
adjustment disorder):
 Symptoms: Stress-induced paralysis, symptoms of anxiety,
including feelings of overwhelm, confusion, and avoidance
behavior in response to stressors.
3. Depressive Disorder (Major Depressive Disorder or Persistent
Depressive Disorder):
 Symptoms: Chronic feelings of guilt, low self-esteem,
symptoms of depression, and disappointment over perceived
 underachievement, along with being on antidepressants for
eight years.
4. Stress-Related Disorder (adjustment disorder):
 Symptoms: Overwhelm and withdrawal in response to stress,
particularly due to recent family health issues and balancing
work with family responsibilities.
5. Potential Impact of Medication:
 Considering S's use of antidepressants for an extended
period, understanding the influence and potential effects of
long-term medication use on her mental health and
functioning is crucial.

Prognosis
Positive Factors:
1. Seeking Help: S recognizes her challenges and has sought
professional help, indicating a willingness to address her issues.
2. Treatment History: Being on antidepressants for eight years
suggests some management of her symptoms, although it's
important to reassess their effectiveness.
3. Awareness and Insight: S is aware of her difficulties and
acknowledges the need for a "life GPS," indicating self-awareness
about her struggles and a potential readiness for change.
Challenges and Concerns:
1. Longstanding Issues: S's history of attention challenges since
childhood, coupled with ongoing emotional struggles and stress-
 induced paralysis, suggests persistent difficulties that may require
comprehensive intervention.
2. Current Stressors: Recent family health issues (stepfather and
cat's illness), increased work demands, and parenting
responsibilities add to her stress and emotional strain.
3. Avoidance Behavior: S tends to retreat when overwhelmed, which
might hinder progress in therapy or seeking support when needed.

Management plan
Short-Term Goals (3-6 months):
1. Therapy and Support:
 Goal: Initiate regular therapy sessions (weekly/bi-weekly) to
address anxiety, depression, and stress management.
 Strategies: Cognitive-behavioral therapy (CBT) to tackle
negative thinking patterns, stress management techniques,
and mindfulness practices.
2. Medication Review:
 Goal: Reevaluate the effectiveness of current antidepressant
medication and discuss potential adjustments with her
psychiatrist.
 Strategies: Monitor medication response, side effects, and
explore alternative medications or adjustments as necessary.
 3. Time Management and Organization:
 Goal: Enhance time management skills to balance work and
family responsibilities effectively.
 Strategies: Implement daily schedules, prioritize tasks, and
use tools like planners or apps for organization.
4. Parenting Support:
 Goal: Develop strategies to manage parenting stress and
balance work-life demands.
 Strategies: Parenting workshops, support groups, or
counseling focusing on effective parenting, stress reduction,
and self-care techniques.
Long-Term Goals (6-12 months and beyond):
1. Coping Skills Development:
 Goal: Establish effective coping mechanisms to manage
overwhelm and avoid withdrawal.
 Strategies: Continued therapy to reinforce coping skills,
relaxation techniques, and assertiveness training.
2. Improved Work Performance:
 Goal: Enhance work performance by addressing attention
difficulties and procrastination.
 Strategies: Work with a career counselor or coach for
strategies on time management, concentration, and
addressing work-related stress.
3. Family Therapy or Support:
  Goal: Strengthen family dynamics and support network to
manage stressors effectively.
 Strategies: Family therapy sessions to improve
communication, stress reduction strategies, and shared
responsibilities.
4. Self-Advocacy and Communication:
 Goal: Encourage open communication and seeking support
when overwhelmed.
 Strategies: Develop assertiveness skills and communicate
needs effectively in both personal and professional settings.
5. Holistic Well-being:
 Goal: Focus on overall well-being by incorporating healthy
lifestyle changes.
 Strategies: Regular exercise, healthy eating habits, sufficient
sleep, and engaging in activities for relaxation and stress
reduction.
6. Continued Follow-Up:
 Goal: Maintain regular check-ins with mental health
professionals to monitor progress and make necessary
adjustments.
 Strategies: Scheduled follow-ups to assess treatment
effectiveness and make modifications as needed.