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Transcript

identifying info

Diagnostic impressions

Presenting issue

background info

Gianni , 3 yr 11 m

Assesments

Attention

observations

Theoretical orientation

Case formulation

Multicultral

Treatment

Prognosis

Good: Bright, Parent Sipport, Teacher Support

Clinician

  • Client-centered play therapy
    • allow her to take lead/ be child
  • Uncondional positive regard
  • CONSITENCY
  • Allow herself to make mistakes
  • Modeling Sharing behaviors/ providing support in classroom

Client-Centered/ Systems

Teacher:

  • Positve Reinforcemtn
      • I love how you stayed with your art project and glued everything so carefully!” or “You waited so patiently for your turn—great job staying calm!”
  • Sensory Breaks: Allow her short breaks to engage in sensory play, which may improve attention in other tasks
  • Sensory Integration Techniques: Use tactile materials in learning tasks to maintain her engagement.
  • Teachers should respond promptly when Gianni seeks validation (e.g., “Ms. Marshall, look!”), so she feels seen and valued. Even a quick response—“I see that you’re working so carefully!
  • Understadning of tactile learning style

Home: .

  • Model Vulnerability
  • Teach parents importance of play
  • What will happen i she doesnt do chores?
  • Growht mindset priase the effort
  • Peer Groups
  • Postiive reinforcemnt

Attentional Regulation

Difficulting Attening when:

Attends Well When:

Dynamic Attential Span

Highly Energetic need for Kinesthetic engagement for self expression, emotional release, effective learning

- Unstructured Playtime - No Instructions where to go - Finishes a task quickly - Not receiving feedback - If task is not engaging/stimulating/ of interest - Waiting her turn - Transition times

- Structured Activity - Interactive activities with others - When task is interactive/ provides feedback - in Public Spaces - In Preferred activities

Ethical/Legal Concerns

APA Standard 4.02: Maintaining client confidentiality Standard 2.01 – Boundaries of Competence:Standard 3.04 – Avoiding Harm

Family Dynamics

  • Mom (23), Dad (39)
  • "Everyithing is good" "full of love"
  • Outdoors actiivies
  • Dad works full time
  • Parents started chores with her
  • Mental Health/ Susbtance hustory
  • None

Background

Living ArrangemntIt’s

  • Lives with mom and dad in studo apt
SES
  • Low SES neighborhood in south LA
  • Dad- self employed sales
Medical Hx
  • Induced delivery, full term,
  • Last medical exam about a yr ago
  • Sleep challenges
Develeopmental Hx
  • Babbling: 4M, 1st word: 4-6M, 2 word statements: 12M, Sentences: 1.5yr, Pull up/Crawling: 6M, Walking 1yr,
  • "Mini Adult"
School Hx
  • August 2023- TCCI King San Pedro M-Fri 8-2pm
Specizlied Services
  • None
Social
  • Close to moms friend daughter
  • Religious
  • Mom- No family here

Difficulting Attening when:

An Dynamic Attential Sp an title

Nurturing/Adult activity in play

Rescue Activity

Absense of "Father"

Play Observations

No postive reinforcement

No Clear instructions

Classroom Observations

No validation/ modeling

- Unstructured Playtime - No Instructions where to go - Finishes a task quickly - Not receieving feeeedback - If task is not engaging/stimulating/ of interest - Waiting her turn - Transitina time - Doesnt recieve feedback

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Assesments

Parent Report CBCL

Teacher Report CBCL

ASQ

Case Formulation

Gianni regularly seeks immediate feedback and validation from adults, often becoming restless or disengaged if not given validationLikely that she doesnt feel seen, or only valued for achivements/ doing things right (perfect) Possible Feelings of Inadequacy or Loneliness:Environmental Family: Early Pressure to Meet Adult Expectations:Envirornmental Influence: Teachers- often putting her down and point out what she did "bad"

Referred by head teacher at TCCI- King San Presenting Concerns:

Presenting Concerns:

high activity levels

difficulties sharing

Difficulty with 2-step directions

"Gianni constantly moves from one activity to the next ""She cant stay for longer then a minute on one thing! " "Shes always moving around!""Good luck with her! "

Diagnostic Impressions

Possible Depression/Anxiery

Multicultural Considerations

Spanish speaking mother Generational Differences in Mental Health Views- "Always Good"Low SESIntergenerational Expectations of Responsibility

Strengths

Warm/Friendly Energetic Personality Strong creative thinking/imaginary play Problem solve abilitiesStrong expressive and receptive langugae akills Self- Help skillsGreat MemoryCapacity to have deep friendships/social connections

Person- Centered

Person-Centered Play Therapy (PCPT) is an approach to therapy for children grounded in the principles of Carl Rogers' person-centered theory, which values empathy, unconditional positive regard, and genuineness."Play is their langugae, Toys are their words" Therapist’s role is to foster a trusting relationship, allowing the child to lead sessions without direct interventions or instructions. This autonomy lets childrenallows them to express their inner worlds. The therapist carefully observes and reflects on the child's expressions and actions, which helps the child feel validated and understood.

Systems

A systemic approach is a perspective that focuses on understanding individuals in the context of their relationships and broader environments, such as family, community, and society. Rather than viewing an individual's issues in isolation, this approach considers how different elements in their life interact to influence their behavior, thoughts, and emotions

  • 3 yr 11M
  • Hispanic
  • Female
  • English /Spanish

Gianni