CASE PRESENTATION 2
I. Key Clinical Issues
A. Client Demographics
Ms. S. is a 17 year old female currently employed as a fast food restaurant worker for
the past six months. Ms. S. reports she was brought up in a middle-class, southern
neighborhood with a brother two years younger. Ms. S. is the child of a teacher aide
and a master carpenter. Ms. S. dropped out of high school in the junior year, but
reports new goals of obtaining a driver’s license and finding a new career.
B. Presenting Problem
The client reports persistent difficulties with reading and writing dating back to early
school years. The client reports having to complete extra work outside of normal
assignments to barely pass the courses. Client states workload became overwhelming.
Due to these persistent difficulties, the client dropped out of high school in the junior
year. The client was evaluated by a neuropsychologist and the findings suggested that
the client’s current language skills were on the level equivalent to that of a six year
old.
II. Diagnosis
A. Diagnostic Impressions:
1. Dyslexia: Client reports persistent difficulties reading and writing. Client reports
being a slow reader as well as struggling to spell common words. Client reports
having failed multiple writing assignments. These symptoms coincide with the
DSM-5 criteria for dyslexia which are difficulty reading fluenty, spelling, and
written expression (American Psychological Association, 2013).
CASE PRESENTATION 3
2. Dysgraphia: Client reports difficulties or spelling and successfully completing
writing assignments. These symptoms coincide with the DSM-5 criteria of
dysgraphia which include difficulty putting one’s thoughts onto paper (American
Psychological Association, 2013).
3. Intellectual Developmental Disorder: Client’s language skills are equivalent to
that of a six year old while other skills are age appropriate. These symptoms align
with the DSM-5 criteria for Intellectual Developmental Disorder by impairment
of IQ scores (American Psychological Association, 2013).
B. Differential Diagnosis:
1. Intellectual Developmental Disorder: Client’s symptoms do not align in total
with the DSM-5 criteria for this diagnosis. The DSM-5 criteria includes social and
practical impairments. Social impairments include difficulty expressing empathy
and building and maintaining friendships (American Psychological Association,
2013). The client does not report experiencing these symptoms. Therefore,
Intellectual Developmental Disorder is not an accurate diagnosis.
2. Dysgraphia: Client does not report difficulties with handwriting. According to
the DSM-5, individuals with dysgraphia struggle to form letters and write legibly
(American Psychological Association, 2013).
C. Full DSM Diagnosis: The most likely diagnosis for Ms. S. is Dyslexia.
1. Client must have experienced difficulty with reading, understanding what is
read, difficulty spelling, and written expression for atleast six months (American
Psychological Association, 2013). Ms. S. reports having struggled with reading
CASE PRESENTATION 4
and writing since elementary school. Ms. S. reports reading slowly, stumbling
over words, and struggling to spell common words correctly. Ms. S. reports
having failed the writing portion of the driver’s license test multiple times.
These persistent struggles support the DSM-5 Diagnosis.
2. Client must have academic skills that are substantially lower than expected for
an individual of their age that affect their school, work, and social lives
(American Psychological Association, 2013). Ms. S. reports only being able to
pass the tenth grade by comipleting extra credit assignments due to scores on
basic assignments being too low. Ms. S. reports having to drop out of school due
to unmanageable workload and extreme difficulty of assignments. Ms. S. was
evaluated by a neuropsychologist and was found that her full scale IQ was in the
low average range with her verbal fluency, spelling, and reading scores were
equivalent to that of a six year old.
3. Client must experience difficulty with written expression (American
Psychological Association, 2013). Ms. S. reports not learning to spell common
words correctly until much later after her peers. Ms. S. reports having failed the
written portion of the driver’s license test multiple times.
III. Etiology of the Problem/Disorder
A. Biological Theory: According to Thapar et al. (2012) learning disorders and learning
deficits are often linked to genetic factors. The authors argued that genetic variants
contribute to the possibility of a child acquiring a specific learning disorder (Thapar
CASE PRESENTATION 5
et al., 2012). Ms. S. has been experiencing learning, reading and writing difficulties
since her early school years.
B. Psychosocial Theory: According to Bonifacci et al. (2015) there are outside
influencing factors that contribute to the presence of learning difficulties and deficits.
Ms. S may have been conditioned by early experiences in the school system to fear
school since the expectation of student learning has little room for student differences
and struggles. Through failure in early school years, Ms. S may have become used the
the negative feelings and fears associated with school performance and expectations.
IV. Treatment Recommendations
A. Biological Intervention: The first step in biological intervention for Ms. S. is to see a
psychiatrist in order to receive a specific diagnosis. Ms. S may be prescribed
medication such as methylphenidate that may address and treat the symptoms
associated with her diagnosis (Tino, 2017). Treating with a pharmacological approach
may lead to a decrease in symptoms associated with any underlying biological factors
contributing to her learning deficits.
B. Psychosocial Intervention: The first step in psychosocial intervention is to seek
work with a mental health professional such as a counselor or Board Certified
Behavior Analyst to create a specialized and unique plan for the learning needs of the
client. An individualized education plan (IEP) is created with the purpose of assisting
an individual with educational tasks with the help of necessary supports (Parrtiz &
Troy, 2018). An IEP may be helpful for Ms. S. as it is a tailored plan for learning that
takes into account the individual’s unique needs.
CASE PRESENTATION 6
Resources
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition. (DSM-5) American Psychiatric Association Publishing. 2013.
Bonifacci, P., Storti, M., Tobia, V., Suardi, A. (2015). Specific Learning Disorders: ALook Inside
Children's and Parents' Psychological Well-Being and Relationships.Journal of Learning
Disabilities, 49(5).
Parritz, R. A. & Troy, M. F. (2018). Disorders of Childhood: Development
andPsychopathology(3ed.). Wadsworth.
Thapar, A., Cooper, M., Jefferies, R., Stergiakouli, E. (2012). What causes attentiondeficit
hyperactivity disorder?Achieves of Disease in Childhood, 97(3).
Tiño, P. (2017). Personalized Medication Response Prediction for Attention-DeficitHyperactivity
Disorder: Learning in the Model Space vs. Learning in the DataSpace.Frontiers in
Physiology.,8, 199-199.
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