Case Study "Anna" Essay

2224 Words Oct 24th, 2014 9 Pages
Case Study: “Anna”
Internship in Clinical Community Counseling Johns Hopkins University Fall 2008

2 Identifying Information Anna1 is a seven year old Caucasian female of low socioeconomic status. She lives in Pasadena with her paternal aunt and her aunt’s husband, who are Anna’s legal guardians. Also living with them are Anna’s five year old brother, their seven year old female cousin, and Anna’s paternal grandparents. Nature of Referral Anna was brought to counseling by her aunt, who was recommended to bring Anna to therapy by her pediatrician. Anna and her brother were removed from their biological parents’ home in 2004 due to severe neglect. Anna’s aunt also suspects that Anna was a victim of physical abuse by her biological
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Her mother denied using substances during the pregnancy. Anna reached all developmental milestones on time. Anna is below average in social, language, and emotional development and average in physical and intellectual development. Academic. Anna is in second grade, has never been held back, and has a 504 plan. She enjoys school and is a good student. Social. Anna gets along well with other children and has at least one close friend. She is somewhat shy and reserved in large groups and with people she doesn’t know well. Medical. Anna is relatively healthy but does suffer from hearing impairment that requires the use of hearing aids. Past medical procedures include having tubes in her ears and her tonsils and adenoids removed. Anna also suffers from asthma and seasonal allergies. Mental Status Exam Anna is a casually dressed and cooperative seven year old who appears her stated age. She is alert and oriented to person, place, and time and makes good eye contact. Anna’s memory is intact and her attention and concentration are good. Her speech is normal in rate, rhythm, volume, and tone and her stream of thought is linear and logical. Anna reports her mood as happy and affect is congruent. She denies any current suicidal ideation or homicidal ideation and displays no evidence of delusions, hallucinations, obsessions, compulsions, or phobias. Anna’s insight and judgment are fair for her age and she seems to have control over her impulses. Anna

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