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Challenges of psychological evaluation

Case Study #2

Christian is a 4-year, 3-month-old, African-American male seen for a psychological evaluation after his mother brought him in seeking guidance with behaviors that she felt were of concern, including: impaired concentration, aggression in the home with siblings, difficulty making friends, and the presence of “imaginary friends that he talks to about planets and science,” which leads him to withdraw from classroom peers. In addition, he reportedly has considerable difficulty identifying letters and numbers. According to his mother, these behaviors became more pronounced since he began Preschool in August.

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Christian was the result of a full-term uncomplicated pregnancy and delivery. However, postnatal complications included kidney reflux (grade 3) and obstructed tear ducts, however he was placed on antibiotics and discharged from the hospital within 24 hours. Developmentally, motor milestones were met on time although his mother perceived them to be delayed. However she reported that he has always demonstrated difficulty coordinating both hands while carrying out activities such as playing with a toy, buttoning his shirt, or tying his shoes; typically he carries out these tasks with either his right or left hand but rarely simultaneously. Language milestones developed early. Specifically, Christian’s mother reported during the administration of the ADI-R that by 6 to 7 months, he was saying “mom” and “dad”, and using single words like: binky (pacifier), granny (grandmother), granpy (grandfather), and Tuti (his name for his aunt). By 8-9 months, he was reportedly saying phrases like: “yellow house,” “I love you” and “I miss you” and between 12 and 18 months, he was reportedly using additional short phrases meaningfully like: “let’s go home,” “I’m tired,” “nap time,” and “I want my binky.” Christian resides with his parents and 4 four siblings; he is the 2nd of 4 children. Christian demonstrates albino traits that predispose him to a sun allergy and an episode of Steven-Johnson Syndrome when he was 13 months old before his parents were aware of this allergy. In addition, he is also allergic to Ibuprofen, honey and cinnamon. Christian’s mother also reported that her son presents with emerging difficulties with vision and has noticed that he tends to look at things from close up. He is currently not taking any prescription medication.

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