I.

Case History

1. Background of Information
Name:
Agent X
Age: 3 years old
Gender: Male
Fathers Name: Rex
Mothers Name: Charlene
Siblings Name: Stephanie, Isabella
Familys Medical History: His father blood line has diabetes and asthma.
2. Description of Presenting Problem
Agent X is a 3 year old boy who has a hard time to cope with the normal
developmental milestones of his age. He is the middle child of the 3 siblings yet
on his current age he has a hard time verbalizing how he feels or create 2-4 word
phrases. He sometimes inflicts pain on his head by banging it to a wall or plastic
bottle. Agent X also has no proper eye contact upon conversing with other people.
Agent X likes to stay on corners and does not want to socialize with other people
if necessary but when he is at home he loves to run around and hes very active.
3. Diagnosis
According to the DSM-5, Agent X fits in 299.00(F84.0)Autism Spectrum
Disorder based on the following criterion; A, B, C, D, E(Refer to the DSM-5
posted at the back). The severity of the condition is on level 3, which means that
his social communication has a deficit in verbal and nonverbal social
communication skill that causes impairments in functioning, very limited
initiation of social interactions, and minimal response to social overtures from
others.Agent X said his first words on age 2. What word?when?where?how?
He also now has a hard time expressing his wants and his needs when he
asks for something and he seeks attention like touching his mothers hand when
he wants to eat, drink watch, and he also has no eye contact during conversation
with other people and has a hard time uttering words(A). In the restricted,

repetitive behaviors inflexibility of behavior, difficulty coping with, or other

restricted/repetitive behaviors appear frequently enough to be obvious to the
casual observer and interfere with functioning in a variety of context (B) aha si
gerx dani? A, b, c lang? si gerx dapat idiscuss dili and WORDS SA CRITERIA
SA DSM. Distress and/or be specific difficulty changing focus or action. He
usually like to play with his I-pad and loves to stay on corners he also tends to
bang his head on walls or plastic bottles he has a hard time at finishing the task
which is given to him (C).

II.

Intervention and Treatment Plan

Agent X has been supported by his family since then, his receiving an
Occupational Therapy session from a known hospital for him to enhance his
condition. Agent X was also enrolled in an institution for children that helps attain
appropriate developmental milestone for his age. The institution has its own strategies
and techniques on how to address the agent X condition. The institution has a 3 times
a week session in which they teach agent X the basic forms learning like, mouth
imitation, fine motor skill and gross motor skill. This type of strategy will help agent
x to somehow enhance his ability to be as normal as other children. The institution
also provided the parents or guardians home based task for the children which will
enable the child to have his improvement at home. Discuss the goals not the number
of hours, what is for Agent x from OT and from BMT?

Childs Individual Treatment Plan

A.

B.

Cooperation and reinforcer effectiveness

Waits appropriately for up to 10 counts if reinforcement delivery is
delayed.
Receptive language
Will be able to select an item that is the same or different form an
array of two items when shown a third item.

C.

Mouth Imitation
Will spontaneously imitate 4 sounds per session.

D.

Play and Massage

Massage to stimulate muscle movements.
Gives 5 verbal responses when playing with toys and talking to peers.
Dressing
Can untie shoe lace in one shoe.

E.

F.
G.

Grooming
Can brush his teeth independently.
Gross motor
Jump over and matching cards activity.

Please focus on the FIVE AREAS of the intervention and discuss your 2-3 goals for Agent X
instead
III.

Current Status
As seen and observed in the actual presentation, the client shows a healthy
living, the clients follow all the scheduled therapy and session. In a matter of
time, agent X will have an improvement in the current condition if the family and
agent x will continue to manifest the urgency for development. Even the progress
runs slow but still it is useful because great things starts at simple things. Be
specific and concise According to the institution, agent X has his great
improvement since the day he first started his therapy. The concluding words
must COME FROM YOU since you are the ones who do the study and not the
institution

IV.

Recommendation
The author would like to recommend a program that helps Agent X in the
speech department. First off the author would like for Agent X to indulge in
articulation pronunciation enhancement programs because he could not murmur
simple words this would help him become fluent to hopefully ask for his needs
more clearly. After the pronunciation enhancement author would like to
recommend expression based enhancement programs to help him gather up his
thoughts to speak clearly. After these specific communication programs the author
would like to recommend improving Agent X socialization skills, by using
modelling techniques such as the covert modelling which indulges the Agent X to
let him imagine his self in a scenario where he is talking to a stranger or new
person which could help him in future situations when new people try to converse
him and live modeling where 2 teachers may show how people normally converse
and act in a conversation so Agent X would know how to act when the given
situation comes along. Also giving relaxation techniques like breathing exercise
or counting while closing his eyes could help Agent X in stressful situations
where he could feel relaxed in an anxious state. These programs may help Agent
X when he goes to the regular school which is the goal of this intervention.
Revise or rephrase and PLEASE read DSM5 for reference