Submit your diagnosis for the client in the case. Follow the guidelines below.

• The diagnosis should appear on one line in the following order. Note: Do not include the plus sign in your diagnosis. Instead, write the indicated items next to each other.

Code + Name + Specifier (appears on its own first line) Z code (appears on its own line next with its name written next to the code)

Then, in one to two pages, respond to the following:

• Explain how you support the diagnosis by specifically identifying the criteria from the case study.
  • Describe in detail how the client's symptoms match up with the specific diagnostic criteria for all the disorder that you finally selected for the client. Note: You do not need to repeat the diagnostic code in the discussion.
• Identify the differential diagnosis you considered.
• Explain why you excluded this diagnosis/diagnoses.
• Explain the specific factors of culture that are or may be relevant to the case and the diagnosis, which may include the cultural concepts of distress.
• Explain why you chose the Z codes you have for this client. Remember: When using Z codes, stay focused on the psychosocial and environmental impact on the client within the last 12 months.

IDENTIFYING/DEMOGRAPHIC DATA: Aiyana is a 9-year-old, Native American female in the fourth grade from the Lakota Sioux. She lives with her parents, grandmother, and twin brother, Anakin, on the Pine Ridge Reservation in South Dakota. Aiyana's dad is an attorney, and her mom works in the community center. Aiyana is bilingual speaking English with exposure to Lakota at home. She attends a local public elementary school on the reservation. CHIEF COMPLAINT/PRESENTING PROBLEM: Aiyana was referred by her classroom teacher for observation due to increasing difficulty participating in class discussions, hesitations and unusual speech patterns during verbal tasks, and noticeable struggles with peer communication and group work. There are concerns about her limited verbal participation, visible frustration when speaking, and increasing emotional withdrawal during academic and social activities. When Aiyana attempts to speak sometimes no sound comes out, with some sound and syllable repetitions. These disruptions are especially noticeable during unstructured conversation, reading aloud, or when she is called on without warning. When having trouble, Aiyana often exhibits secondary behaviors such as eye blinking, jaw tension, or looking away, indicating physical and emotional strain. Her teacher reports that Aiyana often seems unsure how to join conversations, responds in ways that don't quite fit the context, and appears socially isolated during structured and unstructured activities. HISTORY OF PRESENT ILLNESS: Aiyana's difficulties with classroom communication have gradually become more noticeable over the past 12 to 18 months. According to her fourth-grade teacher, Aiyana was more verbally engaged during the previous school year, occasionally participating in group discussions and answering questions aloud with some hesitation. However, over the past year, her classroom participation has declined significantly. She now appears visibly tense when called on to speak and often pauses before answering. On multiple occasions, she has repeated the beginning of a word several times or elongated sounds, followed by silence or a rushed completion of her thought. Despite any challenges, Aiyana continues to complete her schoolwork. Aiyana frequently misunderstands the "flow" of conversations. She may interrupt at odd times, shift topics abruptly, or fail to respond appropriately to verbal and nonverbal cues from peers. During cooperative assignments, she rarely initiates dialogue and often seems confused about what to say or when to speak. Despite having strong reading comprehension and written expression skills, she

avoids verbal tasks and has difficulty navigating peer interactions, especially when subtle social expectations are involved. Aiyana has challenges with social attachments, as evinced by her difficulty with peer relationships. PAST PSYCHIATRIC HISTORY: There is no formal psychiatric diagnosis on record. Aiyana has not previously received counseling or mental health services. No prior evaluations have been conducted for behavior, speech, or learning concerns until this school year. Her teachers in earlier grades noted that she was quiet and preferred solitary activities but did not express concerns at the time. SUBSTANCE USE HISTORY: Aiyana denies any use of drugs or alcohol. PAST MEDICAL HISTORY: Aiyana was a full-term birth with no complications. She met early milestones within normal ranges. There are no known hearing or vision issues or any diagnosed medical conditions. Aiyana has never been evaluated for speech or language services. FAMILY MEDICAL AND PSYCHIATRIC HISTORY: This is a Native American family which adheres to the behaviors and parenting of their culture. Aiyana's maternal uncle was diagnosed with a learning disability in childhood. No known family history of speech-language diagnoses, although her mother recalls being "a quiet, late talker" herself. Her grandmother has a history of depression, reportedly following the loss of her spouse. No known family history of severe mental illness, substance dependence, or neurological disorders. Any medical conditions were treated with herbal remedies or medicinal foods. CURRENT FAMILY ISSUES AND DYNAMICS: Aiyana's family actively participates in community traditions, and her grandmother often teaches her Lakota stories and songs. Aiyana's mother works at the local community center and is deeply involved in ensuring her children stay connected to their heritage. Aiyana is described by family as creative, kind, and quiet. She enjoys art, music, and listening to stories but has become more withdrawn over the past year, especially in group settings. At home, Aiyana's mother notes that her daughter tends to speak more freely but occasionally shows similar patterns of hesitancy, especially when excited or under time pressure. Aiyana has begun to alter the words she uses or avoid speaking in certain situationslike answering the phone or speaking to guests. Aiyana's mother is highly involved in community work and values education but reports some difficulty accessing specialized services on the reservation. There are no current reports of conflict or instability in the home. Aiyana is described as respectful, helpful, and emotionally sensitive. Her mother has