Case Study
Patient Demographic: Name: Luna Clinical Issues: Developmental processes/tasks/issues Diagnostic Category: Neurodevelopmental Disorders Provisional Diagnosis: F81.0 Specific Learning Disorder, with Impairment in Reading Age: 13 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Hispanic Marital Status: Not Applicable Modality: Individual Therapy Location of Therapy : School  
Mental Status Exam: The client is an average-built individual who is alert. The client is casually dressed and adequately groomed. Speech volume is quiet, and speech flow is slow. She has difficulty maintaining eye contact for extended periods and often looks down at her feet. She demonstrates irritability at times during the interview and sighs several times. Her thought process is logical. Her estimated level of intelligence is in the low average range, with limited abstract thinking. Concentration is intact. The client shows no problems with memory impairment.
Presenting Problem: First session As the mental health therapist working in a school setting, you welcomed your new client and her parents into your office. They explained their daughter's struggle with reading and how it caused her to freeze when faced with a spelling or math test. After listening to them closely, you asked the client why she did not enjoy reading. She said that words confused her and made no sense, so she found it difficult to remember what she read.    You consider possible solutions for your client, who was having difficulty with schooling due to a lack of literacy skills. You proposed an idea: "Let's try incorporating creative activities as part of our therapy sessions." Doing so, we can develop strategies for improving written language comprehension and expression while making learning fun for your daughter."    The parents were hesitant but agreed to try it after seeing their daughter's enthusiasm about trying something different than traditional methods like instruction books or worksheets, as those have not been effective in the past. During the session, you brainstormed ideas around stories, role-playing games, and drawing activities focusing on using everyday experiences as inspiration for creating unique narratives within each session – not only reinforcing literacy skills but also providing an opportunity for emotional growth through storytelling exercises.
Other Contexts:  The client says she is only poor at reading and "good at everything else." She says that she feels stressed when she has to read. The client's IQ is 89. A reading specialist assessed her, and her reading skills are abnormally low. Throughout elementary school, teachers noted the client has difficulty reading and that, in turn, it has adversely affected the client's academic achievement. As a result, special needs are implemented in the client's school setting. The client has an active Individualized Education Plan (IEP). Pre-existing Conditions: The client has also been diagnosed with epilepsy and is on medication for seizures. The client had frequent seizures for many years until a medication that lessened the occurrence of her symptoms was prescribed. The client fell when she was eight, hit her head, and fractured her skull. She was not diagnosed with any traumatic brain injury, but she did need stitches. Additional Characteristics: The client portrays positive interactions with both staff and peers at school. The client does state she feels she is "stupid" when it comes to reading and wishes she could get better. The client's family is supportive and values education. They are hands-on in supporting the client in any way they can. 

Question: Besides a learning disability, what would you identify as an area of clinical concern?
(A): Mathematical capabilities
(B): Sleep patterns
(C): Medical history
(D): Lack of parental involvement

Correct Answer: Medical history
Explanation: The client's medical history would be indicated as an area of clinical concern due to her seizures. If the client has a seizure in session, it is important to discuss with the parents what should be done to ensure her safety. Therefore, the correct answer is (C)
Competency: intake, assessment, and diagnosis