Psychological Case Report

Abstract
Ahmed, a 13-year-old 7th-grade student, was referred for assessment due to excessive social media use, declining academic performance, and withdrawal from family activities. He spends over 6–7 hours daily on social media platforms, mainly late at night, leading to poor sleep, irritability, and reduced concentration in school. Psychological assessments (BDI-II Child version, TIPI, Social Adjustment Scale, and SPM) revealed mild depressive symptoms, high impulsivity, low conscientiousness, and difficulties in peer adjustment. Cognitive functioning was within the average range. The findings suggest problematic social media use affecting emotional regulation, academic focus, and interpersonal relationships. Early intervention through CBT, parental guidance, and structured digital use is recommended.

Identifying Information

Client ID: 2025-007
Name: Ahmed K.
Age: 13 years
Gender: Male
Class: 7th grade
Date of Assessment: June 2025
Assessor: Psychology Student Intern
Institution: Middle School Counseling Unit

I. Presenting Problem

CategoryPresenting Complaints
EmotionalIrritability, restlessness, boredom without phone.
CognitiveDistractibility, constant preoccupation with online notifications.
BehavioralExcessive late-night screen time, refusal to complete homework, neglect of hobbies.
PhysiologicalSleep disturbance, morning fatigue.
SocialReduced interaction with family, superficial peer connections.

II. Referral Information

Referred by parents after teachers reported declining grades, inattention during classes, and excessive talk about social media trends.

III. Background Information

Family History: Lives with both parents and one elder sister. Supportive family, no psychiatric history.
History of Present Illness: Began using social media at age 11; gradually increased to compulsive daily use. Reports irritability when restricted. Parents observed changes in sleep, appetite, and academic focus over the past year.
Academic History: Previously an above-average student; recent decline in math and science grades. Teachers report daydreaming in class.
Social History: Previously active in sports; now avoids outdoor play, spends free time online.
Medical History: Physically healthy, no medical illnesses.

IV. Behavioral Observations

  • Appeared restless, constantly checking his phone during breaks.

  • Speech rapid when discussing online games and social media.

  • Eye contact inconsistent; more engaged when talking about technology than school.

  • Mood mildly irritable; affect restricted.

  • Insight limited, judgment immature for age.

V. Psychological Testing

Table 1. Beck Depression Inventory for Children (BDI-C)

ScoreSeverityInterpretation
18Mild DepressionLow mood, irritability, feelings of boredom.

Table 2. Ten-Item Personality Inventory (TIPI)

TraitScore / TrendInterpretation
ExtraversionHighEnergetic online but socially avoidant in person.
AgreeablenessAverageCooperative with peers but moody at home.
ConscientiousnessLowPoor discipline, procrastination with studies.
NeuroticismHighEmotional instability, irritability.
OpennessHighCurious, enjoys new trends online.

Table 3. Social Adjustment Scale (Adolescent Form)

Total ScoreInterpretation
38 / 75Moderate Social Maladjustment

Table 4. Raven’s Standard Progressive Matrices (SPM)

ScorePercentileInterpretation
41 / 6055th PercentileAverage Cognitive Functioning

VI. Diagnostic Impression

DSM-5 / ICD-11:

  • F63.8 – Problematic Internet/Social Media Use

  • Z55.8 – Academic Problems Related to Behavioral Difficulties

  • F32.0 – Mild Depressive Episode (secondary to lifestyle disruption)

VII. Treatment Plan

Goals:

  • Reduce daily screen time and regulate sleep.

  • Improve focus and academic engagement.

  • Strengthen offline peer and family interactions.

  • Build self-regulation and coping strategies.

Interventions:

  • Cognitive Behavioral Therapy (CBT): Restructure thoughts about online validation, promote balance.

  • Parental Guidance: Set digital boundaries (screen time schedules, phone-free hours).

  • Behavioral Modification: Reward system for offline activities (sports, hobbies).

  • Psychoeducation: Educate child and parents on risks of excessive screen use.

  • Skill Training: Time management and mindfulness techniques for focus.

VIII. Conclusion and Recommendations

Ahmed, a 13-year-old, shows average intelligence but significant emotional and behavioral issues linked to excessive social media use. His academic and social functioning are declining due to digital overuse. Early interventions focusing on structured routines, CBT, and family support are essential to prevent long-term psychosocial difficulties.

Recommendations:

  • Continue weekly CBT sessions.

  • Enforce consistent sleep schedule and limited screen time.

  • Encourage outdoor play, group activities, and family interaction.

  • Teacher collaboration to monitor school performance.

IX. Counseling Sessions

Session 1 – Rapport Building & Psychoeducation
Created a supportive environment to make Ahmed comfortable sharing his online habits and feelings about school. Explained in simple terms how excessive social media use affects mood, sleep, and concentration. Established trust and set collaborative goals for therapy.

Session 2 – Behavioral Assessment & Goal Setting
Assessed daily screen time, sleep patterns, and homework habits. Helped Ahmed set realistic goals, such as limiting social media to 1–2 hours after homework and introducing phone-free periods before bedtime. Introduced self-monitoring through a daily log.

Session 3 – Cognitive Restructuring (CBT)
Explored Ahmed’s beliefs about online popularity and validation (“I need likes to feel important”). Challenged these thoughts and encouraged alternative thinking, e.g., “I can enjoy online games but still succeed in school.” Taught positive self-talk strategies.

Session 4 – Time Management & Skill Building
Taught practical strategies to balance school, offline hobbies, and online activities. Introduced a structured daily schedule with breaks for homework, reading, and physical activity. Practiced mindfulness and grounding exercises to reduce compulsive phone-checking.

Session 5 – Social Skills & Family Engagement
Encouraged Ahmed to reconnect with offline peers and participate in family activities. Role-played scenarios to improve communication and assertiveness at home. Guided parents on reinforcing positive behaviors and maintaining consistent rules regarding screen use.

Session 6 – Stress Management & Future Planning
Taught relaxation techniques such as deep breathing, progressive muscle relaxation, and guided imagery to reduce irritability. Collaboratively developed a long-term plan for balancing online and offline life, including monitoring, reward systems, and weekend social activities.

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