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Case No # 1

Intellectual disability
CASE SUMMARY

The child was 8 years old, girl and belonged to a lower socio-economic class Muslim family. The

mother of the child brought her to fountain house for special education with presenting complaints

of Poor understanding, Poor writing, and weak in understanding things. Assessment was carried

out on both formal and informal levels. Informal assessment included clinical interview, subjective

rating according to the mother and therapist, reinforcement survey schedule, DSM-5 criteria and

PGEE. In formal assessment, color progressive Matrices (CPM) were used. The child was

diagnosed as having intellectual disability, Mild according to DSM-5 criteria. The management

was devised on behavior therapy. Structured sessions were conducted three times a week. The

management plan included: Rapport building, psycho-education, positive reinforcement,

prompting, Fading, Modeling, Shaping, Chaining and therapy blue prints. A total number of 12

sessions were conducted with the child. The post assessment showed improvement in the child’s

presenting complaints. Initially the child had poor academic and adaptive skills. With the help of

different techniques, the child is able to learn new skills.


Bio Data

Name M.U

Age 8 Year

Gender girl

Siblings 6

Birth order 2nd

Religion Islam

Socio-economic status: lower class

Informant Mother

Reason for referral

The client was brought by her mother to fountain house with complain of low muscle tone,
stubborn behavior, sensitive with allergy, hitting others, physically weak and also, she feels
down. The child was referred to the trainee clinical psychologist for psychological assessment
and management of his problems.

Presenting complains

Zehan - pechay- h

Chezein- bhol- jti -h

Likhna- ni -ata, dosray- bachon- ki- banisbat- isko- bht- kaam- smj -ata- h

Bohat – zid – krti- h

Bht – dair – sy – bolna – shoro – kiyaa


Initial observation:

Child entered the room at normal pace. She seemed to be 8 years old girl. She had normal
height but physically she looked down. She was dressed in a formal dress. Her clothes looked
neat and clean. She looked a little introvert. She looked a little shy with smiling face. She speaks
in low tune. She had a good eye contact. She had a good behavior. She was cooperative as she
answered all questions very well. There are no behavioral problems was observed during the
sessions.

History of present illness:

The child’s mother reported that the problem got noticed at the age of 3. When they noticed
that the child had problems in understanding things. She was not sharp as other children of her
age and was not good in grab things. Her mother was not well during pregnancy, she was fall
from stairs but unfortunately her was safe at that time. Her mother was very weak during
pregnancy time. Child weight was low. She was kept in hospital for 1 and half month right after
birth. After 6 months of his birth he suffered from pneumonia. She recovered from the disease
after two months with medications. According to the mother her child’s development
milestones were delayed. When the child became 3 years old, she didn’t start to speak, also she
did not understand things even at the age of 4 years. She can’t understand the difference
between animals and birds and other stuff like that. As she was weak in understanding her
patients didn’t send her to school. With the time she started showed different tantrums. She
appeared to be a stubborn child. Her visual perception was ok. She can’t differentiate between
2 things. She started hitting others, also got irritated easily. She often grinds together her teeth.
According to mother of the child, as she was weak in recognizing things and her grip on things
was not good one of her relative told child’s mother about fountain house. The child was
bought by the mother to institute of disadvantaged children. The child was referred by the
senior clinical psychologist to the trainee clinical psychologist with presenting complaints of
stubborn behavior, sensitive with allergy, grinding teeth, hitting others, poor socialization,
physically weak also she feels very low.

Background information

Family History:

The child belongs to a lower-class Muslim family. The child lives in a joint family

system. No other person in the family was reported with any disorder.

Father:

The child’s father age is 50 years old. He studied till middle. He was worked as labor and has
good personality. According to her mother, her father was too concern about her and care
about her. Her father’s always try to fulfill her necessary needs. He never ever yelled at her in
his entire life. He is good in talking. He has not any psychiatry history. He is normal and health
man with hopes.

Mother:

The child’s mother is a 45 years old woman. She is a house wife. She was eight passes, and
know how to wright and read. She is friendly and cooperative by nature. Her general health is
not good. She mostly suffers from low B.P and muscular problems but she has no medical and
psychiatric problem. The child’s parent had 1st cousin marriage. Their marital relationship was
reported to be normal.

Siblings:

M.U has 6 siblings. She came on 2nd number in siblings. The child shared loveable relationship
with their sibling. She has 4 brothers and 2 sisters’ including herself. Her other siblings were
good in mental and physical health. They also good in study and other life material. Low class
but with happy lifestyle. They never quarrel each other and never ever hit each- other.
Home atmosphere:

The home environment is reported to be good and friendly. The child lives in a joint family with
his parents, sibling, grandparent, uncle, aunt and cousin. The attitude of family members
reported good towards her. They eat together and went out for outing. Her family members
never treated her like out sider they always help her with facing problems.

Personal History:

According to her mother she was not well during pregnancy, she was having stomach issues
and was weak throughout the pregnancy period. She was prescribed medication and
supplements by the doctor. The birth was normal but the child was very weak. Her mother
reported that child have low weight that’s why she was kept in hospital for 1.5 months after
birth. Her milestones were delayed. It can also be observed in table showing achieved
milestones of the child.

Table

Development milestones table is as fellows

Milestones Normal range Achieved range


Cry after birth Right after birth Immediate
Neck holding 2-4 months 7 months
Sitting crawling 6-7 months 1 year
Walking 9 months 1.5 year
Babbling 12- 18 months 2.5 year
Speech single word 6 months 1 years
Complete sentence 1 -2 years 2 year
Toilet training 2-3 years 4 years
Dressing without help 5 years 6 years
Taking bath without help 6 years 7 years
Present general state of health of the child is normal but she sometimes showed neurotic traits
such as biting others, bed wetting and aggression. She has average height but weak in health.

Educational History:

She didn’t attended school due to her weak ability of learning.

Psychological assessment:

To get the clear picture of child’s problem and to make effective management plan, a complete
assessment is recommended. Psychological assessment was done in two levels i.e., informal
and formal.

Informal assessment:

Informal assessment was done on the following levels:

1. Clinical interview
2. DSM-5 Checklist for presenting complaints
3. Subjective ratings of presenting complaints
4. Reinforcement identification
5. Portage Guide to early education

Formal Assessment:

1. Color progressive metrics

(i) Clinical interview

Clinical interview in a general form of conversation between a clinician and a

child/ his caregiver aimed at determining diagnosis. History, causes of problem


and possible treatment options. A detailed clinical interview was conducted by the

trainee clinical psychologist, during which she collected presenting complaints,

detailed history of the child’s problems family background and personal history

from the child’s mother. Moreover, formal and informal assessment was carried

out in a well- ventilated and enlightened room.

(ii) DSM-5 checklist for intellectual disability

In order to specify the child’s diagnosis, she was also evaluated on DSM-5 criteria

for intellectual Disability disorder as below

Table 1.2

Showing DSM-5 criteria of intellectual disability disorder

Criteria Yes/No

319 (F70) Intellectual disability

(A) Problems with intellectual activities. Yes

(B) Poor adaptive functioning, failure to meet


developmental

milestones related to independence and


responsibility, and

limited functioning in one or more daily life


activities Yes
(C) Problems developing, maintaining and
understanding relationships.
yes

(iii) Subjective ratings of presenting complaints

Child’s mother and therapist had rated his presenting complaints 0-10 on a scale. A scale which
is used to know about the intensity and severity of the client’s problem. Where “0” mean
average severity of symptoms and “10” mean very severe. The mother was briefed about the
rationale of this rating scale that it will help to identity the changes in the severity level of the
symptoms and efficacy of the treatment.

Table 1.3

Subjective ratings of presenting complaints as reported by the client’s mother and therapist.

Subjective rating Subjective rating of


of mother therapist
Problematic Areas

Poor understanding
9 8
Weak in studies
9 8

Poor in memorizing things


9 8

Problem in reading and writing


9 8

(iv) Reinforcement identification

Reinforce refers to anything/stimulus which strengthens or increases the probability of a specific


response. Therapist identified Reinforcers because they are helpful in therapies. In a therapy when the
therapist wants to teach some behaviors or skills to the child, he uses Reinforcers (Miltenberger,

1997). It was observed that the child liked coloring, candies and cartoons. Reinforcement used to design
the sessions. The given reinforcement if he exhibited the desired behavior.

Table 1.4

Types of reinforcement and identified reinforces of the child

Types of reinforces Identified reinforces

Tangible Reinforces Candies

Social Reinforces Praise (Good, Excellent, clapping)

Activity Reinforces Coloring, watching cartoons


(v) Portage guide to early education

The portage guide to early education was developed to serve as an aid to teachers, parents or
others who needs to assess the child’s behavior and plan realistic curriculum goals that lead to
additional skills. There are five goals of PGEE; to enhance a developmental approach to
teaching, to concern itself with several areas of development including cognitive, language,
motor, socialization and self-help skill, to provide a method of recording the existing skills and
recording skills learned in the intervention period, to provide a method of recording the existing
skills and recording skills learned in the intervention period, to provide suggestions on how new
skills could be taught. Discrepancies show between chronological age and current functioning
age in the area give socialization, self, help, cognitive. Discrepancies are positive which shows
that child is developmentally delayed.

Formal assessment:

(i) Color progressive Matrices (CPM)

It was developed by John Carlyle Raven (1949). It is used to assess the degree to which children
and adults can think clearly, or the level to which their intellectual abilities have determined.
This test contains sets A and B from the standard matrices, with further set of 12 items inserted
between the two, as set Ab. Most items are presented on a colored background to make the
test visually stimulating for participants.

Quantitative analysis
Raw score Percentile Grade Discrepancies
6 40 III -6, -2, -1

M.U score on Colored Progressive Matrices is 6 and his percentile is 40 which reflect “low
intellectual capacity” was compared with sub-nominal norms. Her scores fall below 40
percentile which is below average intelligence among sub nominal has been in grade III.

Diagnosis:

According to DSM-5 the child fulfills the criteria of Intellectual Disability, Mild

(intellectual Development Disorder) (319).

Case Formulation:

M.U is 8 years old female brought to fountain house. The client was brought here by her
mother due to her lack of ability, slow understanding, dullness also some other behavioral
issues grinding teeth, hitting others. According to DSM-5, Intellectual disability is a disorder
with onset during developmental period that includes both intellectual and adaptive
functioning deficits in conceptual, social and practical domain. The essential features of
intellectual disability are deficits in general mental abilities and impairment in everyday
adaptive functioning in comparison to an individual’s age gender and socio-cultural matched
peers. In this case the clients have both intellectual and

adaptive functioning deficits. The child’s mother reported that the child had a low birth weight
at the time of his birth due that she was kept in hospital for 1.5 months. The client achieved his
developmental milestones such as sitting, crawling, babbling, walking and utterance of
sentences etc. relatively late. Child has difficulty in understanding things, to differentiate
between things. Assessment was done on both levels, informal and formal. Keeping in view the
assessment it indicated the diagnosis of indicated the diagnosis of Intellectual Disability.
According to DSM-5 Intellectual Disability is as problem of intellectual and adaptive functioning
i.e. reasoning, problem solving, planning, abstract thinking, learning new things, personal
independence and social responsibility. She is issues with learning new things, understanding
person independence and also dullness. The child was weak and low birth weight. According to
Gluck (2015) premature birth, low birth weight can be a cause of intellectual disability.

Prognosis:

Client prognosis looked good

Points in favor of good prognosis

a. She has no other physical or psychiatric illness


b. Cooperative family
c. Social support
d. Language

Points in against of good prognosis

a. Lack of early treatment

Management Plan

Short term goals

 Therapeutic relationship was established with the child through assuring active
listening. Non-judgmental acceptance and by providing empathy. It would build the
basic grounds for the therapy to be affective for the child.
 Structured sessions were conducted three times a week.
 Psycho-education was provided to the child’s parents regarding the child’s illness its
predisposing maintains factors and its treatment.
 Potage guide to early education was used to determine his level on social skills,
language, cognitive, self-help and socialization.
 Positive reinforcement was used. It will help interrupt problems behaviors and reinforce
positive behaviors.
 Daily activity schedule was used to plan a client’s daily activities.

Long term goals

 Follow up session will be conducted which will be helpful to monitored and access
client’s progress and improvement. It will be also helpful to enhance the skills; child will
learn through the therapy.
 Promoting will be used for body parts recognition, sustaining attention and coloring.
 Fading will be used to make the child carry out tasks independently.
 Modeling will be used to teach him the way attainment of new skills.
 Chaining will be used with the child to teach her the difficult tasks that she was unable
to perform

Summary of therapeutic sessions:

Psycho education

It refers to the education offered to individuals with a mental health condition and their
families to help empower them and deal with their condition in an optimal way. Psycho-
education involves all the information that teaches clients and their families about mental
health issues. It helps families to understand what happening “inside the person” with the
mental illness, and to train family members in how to take care of the child. Psycho-education
was given to child’s mother.

Rapport Building

Rapport is defined as the “relation, connection, especially harmonious or sympathetic relation”.


Rapport is based on mutual confidence, respect and acceptance. It is Therapist’s responsibility
to engage the child and bring him to see therapist as a trusting and helping person. Different
techniques of rapport building are given below that were used with the child to build a good
rapport:

Be warm and Friendly

It is important for therapist to be warm and friendly. Therapist’s behavior was very warm and
friendly with the child. It helped a lot to build a rapport with child.

Body language

It means that use mirroring to imitate a child’s body language and posture. Place yourself at or
below the child’s level to diminish your “authoritative image”. The therapist uses posture
mirroring in sitting as she sat on the similar chair as the child’s chair and also made encouraging
gestures.

Active Listening

Focus on the information being relayed to you and reflect the information back to the child for
accuracy. Therapist listened actively and used head nod what the child said and repeat it for
accuracy of the information.

Tone of Voice

In building a rapport, you need to mirror the child’s tone of voice. Being loud, in fact, will not
help establishing a bond with child. In addition, pay attention at the speed of the speech also.
The therapist matched her tone and volume of the speech with child.

Show Empathy

The therapist responses to the emotions of the child by emotional mirroring as reflecting that
she was happy when the child was happy.

Positive reinforcement

Positive reinforcement is very effective to help shape and change behavior.


Positive reinforcement was used during the sessions. Whenever the child

exhibited a desire behavior or he completed the task accurately what was given to him, he was
reinforced. Daily activity schedule Daily activity schedule was used to plan a client’s daily
activities. In activity schedule different activities was discussed with the client’s mother also
these activities were conducted during sessions in which the client engaged himself and learned
new tasks. Different activities were also given to child as homework assignments so that he
could practice these tasks at home also.

Prompting

Prompting is extensively used in behavior shaping and skill acquisition. It provides children with
assistance to increase the probability that a desired behavior will occur. Prompting is a means
to induce an individual with added stimuli (Prompts) to perform a desired behavior. A prompt is
like a cue or support to encourage a desired behavior that otherwise does not occur. Overall,
the goal of using prompts is to help the child independently perform the desired behavior.
Different steps of using prompts are given; (1) Identify the least instructive prompt. Choose a
prompt that is necessary for a correct response to occur (2) Give differential reinforcement.
After a correct response, give appropriate reinforcement that is equivalent to the level of
performance independency. (3) Fade prompt after the child masters a skill, gradually move
prompt away or replace with least intrusive prompt. During sessions response prompts were
used to facilitate the child. Physical prompts were mostly used for learning activities such as the
identification and recognition of different mathematical shapes. These shapes were given to
the child and a board. So, he could place shapes mathematical shapes. These shapes were given
to the child and a board. So, he could place shapes accurately in the board. Prompts were also
used for the recognition of different kinds of animals. Models of animals were shown him. He
also heard the vocal sounds of animals and recognized them. Red, Green and yellow color
identification were also taught to child. The therapist was pointed towards various concrete
objects and verbalized that its red, green and yellow color, the child was provided with pictures
of various objects that are red, green or yellow colored.

Fading
Children are often taught new skills through the use of prompts. However, it is important to
systematically withdraw or fade these prompts so that the individual can perform skills
independently (Alberto & Troutman, 2006). Fading refers to decreasing the level of assistance
needed to complete a task or activity. When teaching a skill, the overall goal is for the child to
eventually engage in the skill independently.

Firstly, prompts were used to teach the child between the differences of vocal sounds of
different kinds of animal, different sounds were presented to child so he could learn the
difference. Later on, the sounds were fading away and asked the child to pronounce the vocal
sound of different animals that were taught to him. In order to know whether the child could
differentiate between animals. The therapist fades away the models of animals and asked him
to distinguish the animal from picture book which she asked from him/her.

Firstly, prompts were given for the identification of red, green and yellow colors. Later on,
these prompts were fading away and asked the child to identify these colors from a set of
colors. The child was asked to point towards various objects of these colors in the surroundings.

Modeling

Modeling, which is also called observational learning or imitation, is a behaviorally based


procedure that involves the use of live or symbolic models to demonstrate a particular
behavior, thought, or attitude that a client may want to acquire or change. Modeling is
sometimes called vicarious learning, because the client need not actually perform the behavior
in order to learn it. Live models were used in which the therapist modeled the child how to do
the task. It was used to teach child the matching of like objects. The therapist modeled
matching like objects and asked the child to do the same. The therapist also provided the child
with concrete objects and asked him to separate the like objects. Chaining It involves task
analysis of the target behavior into as many components. Behavioral chain is series of related
behavior, each of which provides the cue for the next and the last that produces a reinforce
(Miltenberger, 2011). Chaining can be either backward or forward. The therapist reinforced the
successive elements of a behavioral change. It was tailored to the child and it involved as many
steps as based on the need of the child. The therapist used many procedures to teach chains
such as instructions, prompting and fading was provided. In forward chaining the therapist
began with the first element of the chain progressed to the last element. The forward chaining
process was used to teach child about complex behaviors such as making sandwich and
fastening belt etc. Using task analysis, the task was broken down into easy steps and the child
was taught the performance of the tasks through easy steps using reinforcement and
prompting.

Therapy Blueprint

Therapy blueprints were given to the mother of the family of the child as it would be helpful for
her to manage child’s problem. It also provided the outline of treatment carried out in the
therapy which would help in the continuation of further treatment. The blueprint explained
how did the problem develop? What things led to the problem? Why was it a problem at this
time in child’s life? What kept the problem going? What actions, responses or behaviors
prolonged it? What are the most important things that were taught in therapy? What strategies
were used to control the behaviors?

Post Assessment

Subjective Rating of presenting complaints

the subjective ratings were obtained on 10 points rating scale. The scale was used to identify
the severity of the symptoms. The pre and post ratings were taken to assess the improvement
in child’s problem and efficacy of the therapy.

Table 1.6

Subjective ratings of presenting complaints as reported by the client’s therapist.

Problematic Areas Pre therapy rating Post therapy rating

Poor understanding 10 5
Weak in studies 9 4

Poor in memorizing things 11 6

Problem in reading and 10 5


writing

Therapeutic Outcome

The post assessment ratings show much improvement in client’s presenting complaints,
initially, the child was lazy, took so much time in understanding things or academic work. He
wanted to learn new skills. His mother also reported that his understanding, dullness and
laziness were improved.

Session summary

Sessions I-II

 Behavioral observation
 Rapport building
 History taking

Sessions III-IV

 Symptoms prioritizing
 Identify reinforcers
Sessions V-VI

 Portage guide to early education (PGEE)

Sessions VII-VIII

 Color progressive matrices (CPM)

Sessions IX-X

 Psycho educates to mother


 Rapport building
 Positive reinforcement

Sessions XI- X11

 Daily activity schedule


 Homework Assignment
CASE NO # 2
Attention-Deficit/Hyperactivity Disorder (ADHD)
CASE SUMMARY

The child was 10 years old, girl and belonged to an upper-class family. The father of the child

brought her to Fountain House presenting complaints of off seat behavior, poor attention,

stubbornness, disruptive behavior, hitting others, shouting and poor socialization. Assessment was

carried out as informal levels. Informal assessment included clinical interview, subjective ratings

according to the aunt and therapist, reinforcement survey schedule, DSM-5 criteria and PGEE.

According to DSM-5 the child fulfills the criteria of Attention-Deficit/Hyperactivity Disorder

(ADHD). The management was devised on Behavior therapy. Structured sessions were conducted

three times a week. The management plan included: Rapport Building, Psycho-education, Positive

Reinforcement, Attention Training techniques, prompting, fading time out, Positive practice

overcorrection, physical restraints and therapy blue prints. A total number of 15 sessions were

conducted with the child. The post assessment showed improvement in the child’s presenting

complaints. Initially the child was inattentive and disruptive in the class and at home. After

carrying out positive reinforcements the disruptive behaviors of the child were improved as

reported by the father. Moreover, the father of the child reported that with the help of these

different techniques it was easy for her to control the undesirable behaviors of the child.
Bio Data

Name U. Z

Age 10 Year

Gender Girl

Siblings 5

Birth order 3rd

Religion Cristian

Informant father

Status upper class

Reason for referral

The client was brought by his aunt to principle of Institute for disadvantaged of children
with complain of offset behavior, lack of attention, persistent, troublemaking behavior,
beating others, racket and poor socialization. The child was referred to trainee for
assessment and management of his problem.

Presenting complains

Aik- jaga- tik- ky- nahi- beth- sakti

Zayada- dair- tk- kisi- chez- py- gor- nahi- kr- skti- kuch- dair- bd- hi- kisi- or taraf- diyan-
bata- lyti- h
Isko- dar- nahi- lgta- isko- ye- pta- nahi- lgta- k- agr- ma- gir- gi-tu- chot- lgy- gi- mujhe,
gir- b- jaye- tu- roti- nahi- h

Kisi- aik- py- qaim- nahi- rahti- badalti- rahti- h- din-m- kitni- dfa- jotay- badalti- h

Ghuessa- bohat- karti- h, dosron or khud- ko- marti h

Chezon- ko- terteeb- sy- nahi- rakhti-

Zid- bohat- karti- h-, agr – isko- bolo- k – stairs- na – jao- tu mana – ni- hoti-

Initial observation:
Child entered the room in normal mood. He seemed to be a healthy boy. she wore school uniform

which was not tidy. Her shirt out of skirt. She continually jumps from chair to table and then to

cupped. All the time she annoyed others. She can’t sit still for long time even 5 to 8 minutes.

Sometime she snatched pencil, toys, and copies of another student. She didn’t pay attention on

tasks or activities that were asked to perform. she also sounds out some weird sounds. She

repeatedly asked for drinking juice. She put everything she caught in his mouth i.e., pencil, toy

etc. she fights with other and use force.

History of present illness:

According to her father the child, her problem started during the parental period. Her mother

experienced severe vaginal bleeding. Her mother was taken to the hospital the doctor prescribed

medicines. Her mother doesn’t care about herself because she was job holding women, she can’t

take rest like other women’s. The father reported the mother of child was mentally ill. According

to father her mother was also tensed throughout the pregnancy. The child was suffered from severe

fever after 6 months of his birth. she recovered from it after nearly 1 month with medication. After
1 year of her birth, her father died in an accident and her mother left her. After abandoned by

mother and her aunt adopt her.

According to the aunt the child’s development milestones were delayed. Due to lack of attention

no one noticed and they considered it normal. When became three years old her aunt concerned

about her as she was very stubborn. The aunt of the child took her to the hospital. The doctor told

her that child is weak and advised her that the child needed proper diet. Furthermore, the doctor

asked her to consult a psychiatric but she didn’t consult the psychiatrist.

According to aunt after some time she over come from the weakness but she appeared to be

naughty and stubborn child. The other family members used to scold her for her behavior and

misbehaved with her.

The issue was started when the child sent to a private school. Her problematic behavior became

prominent in the school. Her teacher reported that she seemed to have difficulty in sitting silently

and sustaining attention. she also did not comply teacher’s command and often roam around the

room. she often did not do homework. The teacher complaint again and again, so she was expelled

from the school.

After these academic difficulties of the child her aunt concerned about her, she took the child to

the hospital. The child was referred to the psychiatrist. The psychiatrist diagnosed her with

Attention Deficit Hyperactivity disorder and prescribed medication. He also referred her to clinical

psychologist. The aunt took him to the psychologist. The psychologist diagnosed her with ADHD

with mild intellectual disability. The clinical psychologist referred her to Fountain house.
The client was brought by her aunt to fountain house of children with complain of seat behavior,

poor attention, stubborn, disruptive behavior, hitting others, shouting and poor socialization. The

child was referred to trainee for assessment and management of his problem.

Background information

Family History:

The child belongs to an upper-class, Cristian family. The child lives in a joint family system. His

grandfather and mother were also patient of mental disorder. But when her father died, her mother

abandoned her, and marry again, her aunt adopts her and raise her, because she lived with her after

divorce because she can’t give birth to baby. Her both grandparents were having miner depression.

They are often fine, but in stressful situations they feel depression.

Father:

The child’s father age was30 years. He studied till matric. He died when the child was one year

old. He was a good father. He loved his daughter. He never ever tried to misbehave with her.

Mother:

The child’s mother is a 28 years old woman. She was a nurse. She did job in hospital. After child’s

father death she left the child to his aunt.

Siblings:
She has 5 siblings. her first sibling is brother with 15 years old her second sibling is also brother

with 12 years old. Her number is 3rd. she has 2 more younger sisters but they died after birth. Her

behavior with other is not good, but with father her behavior is much better.

Home atmosphere:

The home environment is reported to be normal. The child lives with her aunt’s. Her aunt can’t

properly take care of her but child’s grandmother does.

Personal History:

U.Z was born on 3rd number but left as last child. She was born at hospital. Her developmental

mile stone was delayed. She controlled her head in one year; first word uttered in 3.5 years and

started walking in 5 years. Birth weight was normal. Unusual behavior pattern also present (e.g.

Like hitting others).

Table 1.1

Developmental milestones chart is as follows:

Milestones Normal Range Achieved Range

Cry after birth Immediate after birth Immediate

Neck holding 2-4 months 1 months

Sitting 6-7 months 11 months

Crawling 9 months 1.5 years


Walking 12-18 months 5 years

Babbling 6 months 8 months


Speech single word 1-2 years 3.5 years

Complete sentences 2-3 years 4.5 years

Toilet training 2-3 years 6 years

Dressing without help 5 years Not yet


Taking bath without help 4 years Not yet

Present general state of health of the child is normal. She has average height and weight according

to her age. No history of jaundice, paralysis was reported. His appetite and sleep were passable.

Educational History:

U.Z was studied in 2nd grade. she has concept of color and money. But she could not identify the

three primary forms. But when she was asking to match or draw them. She didn’t properly identify

each color. she could count up to 30 but could only recognize up to 20. She can draw some shapes

like triangle or circle. she said, his sister helps her doing homework.

Psychological assessment:

To get the clear picture of child’s problem and to make effective management plan, a complete

assessment is recommended. Psychological assessment was done in informal level.

Informal assessment:

Informal assessment was done on the following levels:

• Clinical interview

• DSM-5 Checklist for presenting complaints


• Subjective ratings of presenting complaints

• Identification of the reinforcers

(I) Clinical interview

An interview was conducted to obtain detailed information about the child in order to assess what

types of problems the child is dealing with. It is also helpful to identify significant factors that

predisposed and maintained the child’s illness and also determine the appropriate course of

treatment. During the clinical interview, psychologist will gather information regarding a child’s

family history, previous experience in mental health treatment and other factors that can impact

mental health and well-being. The assessment provides the psychologist a comprehensive picture

of the child’s life, which helps in determine the diagnosis and course of treatment (Gender, Gath,

Cowen, 1996).

Clinical interview was conducted in order to attain detail account of the child’s problem.

Background information was taken in order to identify any significant event that effected

psychological health of the child’s problem. Background information was taken in order to identify

any significant event that effected.

Psychological health of the child. Moreover, precipitating events of the problem were identified in

the history of present illness.

(ii) DSM-5 checklist for Attention-Deficit/Hyperactivity disorder

In order to specify the child’s diagnosis, he was also evaluated on DSM-5 criteria for Attention-

Deficit/Hyperactivity Disorder as below.


Table 1.2

Showing DSM-5criteria Attention-Deficit/Hyperactivity Disorder

Criteria Yes/No

314.01 (F90.2) Attention-Deficit/Hyperactivity Disorder

A. Persistent pattern of Inattention and/or hyperactivity-impulsivity Yes

1. Inattention: Six (or more) of the following symptoms

a. Fails to give close attention to details or makes careless mistakes Yes

in schoolwork and other activities

b. Often has difficulty sustaining attention in tasks or play Yes

activities. Yes

c. Often does not seem to listen when spoken to directly.


Yes

d. Often does not follow through on instructions and fails to finish


Yes
schoolwork, chores.
Yes
e. Often does not follow through on instructions and fails to finish
Yes
schoolwork, chores.

f. Often has difficulty organizing tasks and activities.

g. Often loses things necessary by extraneous stimuli.


h. Often easily distracted by extraneous stimuli. Yes

Yes
i. Often forgetful in daily activities.

2. Hyperactivity and impulsivity: Six (or more) of the following Yes

symptoms. Yes

a. Often fidgets with or taps hands or feet or squirms in seat. Yes

Yes
b. Often leaves seat in situations when remaining seated is expected.
Yes

c. Often runs about or climbs in situations where it is inappropriate. Yes

Yes
d. Often unable to play or engage in leisure activities quietly.
Yes

Yes
e. Often “on the go” acting as if driven by a motor.
Yes
f. Often talks excessively. Yes

Yes
g. Often blurts out an answer before a question has been completed.

h. Difficulty waiting his turn. Yes

i. Often interrupts or intrudes on others.

B. Symptoms were present prior to age 12 years.

C. Symptoms are present in two or more settings.

D. Symptoms interfere with, or reduce the quality of social,

academic functioning.
(iii) Subjective Ratings of the Problematic Symptoms

The subjective ratings were obtained on a 0-10 points rating scale. The scale was used to identify

the intensity and severity of the symptoms. The therapist and the aunt were asked to rate the

presenting complaints on a scale where “0” mean average severity of symptoms and “10” mean

very severe. The aunt was briefed about the rationale of this rating scale that it will help to identify

the changes in the severity level of the symptoms and efficacy of the content.

Table1.3

Subjective ratings of presenting complaints as reported by the client’s aunt and therapist

Problematic Areas Subjective Rating by Subjective Rating by


aunt
therapist

Disruptive behavior 8 8

Off seat behavior 7 10

Does not pay attention 5 8

Does not comply 6 7

Make noises 7 6

Does not wait for turn 9 9

(iv) Reinforcement identification

Reinforce refers to anything/stimulus which strengthens or increases the probability of a specific

response. Therapist identified Reinforcers because they are helpful in therapies. In a therapy when
the therapist wants to teach some behaviors or skills to the child, he uses Reinforces (Miltenberger,

1997).

U.Z aunt reported about the favorite food items and games of the child. She reported that the child

liked snacks and junk food. At home he likes to play in kitchen. Later it was also observed that the

child liked candies, colors, stickers. Identified reinforces used to design the sessions. The child

was given reinforces if he exhibited the desired behavior.

Table 1.4

Types of reinforces, and identified reinforces of the child

Types of Reinforces Identified Reinforces

Tangible Reinforces Candies, Stickers

Social Reinforces Praise (good/excellent), Clapping

Actively Reinforces Playing in ground, coloring activities

Formal assessment:

The portage guide to early education was developed to serve as an aid to teachers, parents or others

who needs to assess the child’s behavior and plan realistic curriculum goals that lead to additional

skills. There are five goals of PGEE; to enhance a developmental approach to teaching, to concern

itself with several areas of development including cognitive, language, motor, socialization and

self-help skill, to provide a method of recording the existing skills and recording skills learned in

the intervention period, to provide a method of recording the existing skills and recording skills

learned in the intervention period, to provide suggestions on how new skills could be taught.
Discrepancies show between chronological age and current functioning age in the area give

socialization, self, help, cognitive. Discrepancies are positive which shows that child is

developmentally delay.

Diagnosis

According to DSM-5 the child fulfills the criteria of Attention-

Deficit/Hyperactivity Disorder (ADHD) combined presentation (314.01)

Case Formulation

U.Z was 10 years old girl. The child was referred with presenting complaints of seat behavior, poor

attention, stubborn, disruptive behavior, hitting others, shouting and poor socialization.

The essential feature of Attention-Deficit/hyperactivity disorder (ADHD) is a persistent pattern of

inattention and/or hyperactivity-impulsivity that interferes with functioning or development.

Inattention manifests behaviorally in ADHD as wandering off tasks, lacking persistence, having

difficulty sustaining focus, and being disorganized and is not due to defiance or lack of

comprehension. In the present case the child had off seat behavior, the child had off seat behavior,

the child also seemed to have difficulty in sustaining attention as he often seemed to be distracted.

she had an attention span of 3 seconds.

Hyperactivity refers to excessive motor activity such as a child running about when it is not

appropriate, or excessive fidgeting, taking, talkativeness, the child seemed to be restlessness. She

had off seat behaviors and often seen wandering in the school.

Impulsivity may reflect a desire for immediate rewards or an inability to delay gratification.

Impulsive behaviors may manifest at social intrusiveness (e.g., Interrupting others excessively)
and/or as making important decisions without consideration of long-term consequences. In this

case the child often snatches food and toys from other children. she seemed to have difficulty in

waiting for his turn.

ADHD is elevated in the first-degree biological relatives of individuals with ADHD. Visual and

hearing impairment, metabolic abnormalities should be considered as possible influences on

ADHD disorder. In this case the mother of the child was reported to be suffering from psychiatric

disorder. This genetic factor might also contribute in his problem.

ADHD is more frequent in males than females. In U.Z case gender which is girl might also increase

the risk of ADHD.

Prognosis

The prognosis of the child seemed to be good.

Points in favor of good prognosis

• Institution provide healthy environment for learning

• Regular sessions would also facilitate the treatment and help in bringing

improvement.

• Cooperative behavior of child’s aunt

• Language of child

• Understanding
Points against of good prognosis

• Ill of client’s mother

• Minimal attention and rejection from parents

Management plan

Short term goals

• Therapeutic relationship will be established with the client through assuring active

listening, non-judgmental acceptance by providing empathy. It would build the basic

grounds of the therapy to be affective for the client.

• Structured sessions will be conducted three times a week. These sessions will be

conducted in distraction free room.

• Rapport building will be carried out through colorful writing and fun activities with

the child. Rapport building is essential so that the sessions could be carried out in a

comfortable environment.

• Psycho-education will be carried out with the aunt in order to brief her about the

nature of child’s illness, his strengths and weakness, the maintain factors of his undesired

behavior and therapy protocol which would be followed as a treatment mode.

• Portage guide to early education will be used to determine his level on social skills,

language, cognitive, self-help and socialization.

• Positive reinforcement techniques will be used to improve child’s

attention.
• Eight rules for effective commands to build compliance were used with the child

to improve his compliance level and hence take a step towards easy flow of therapy.

Long term goals

• Follow up sessions will be conducted which will be helpful to monitored and access

client’s progress and improvement. It will be also helpful to enhance the skills; child

will learn through the therapy.

• Promoting will be used for body parts recognition, sustaining attention and

coloring.

• Fading will be used to make the child carry out in order to deal with his disruptive

behavior such throwing toys on the floor and making noises.

• Time out will be given to the child in order to control his undesirable behavior

during the class and with class fellows.

• Physical restrains will be used to lessen his harming behaviors such as hitting and

kicking others.

Summary of therapeutic sessions

Psycho education

It refers to the education offered to individuals with a mental health condition and their families to

help empower them and deal with their condition in an optimal way. Psycho-education involved
all the information that teaches clients and their families about mental health issues. It helps

families to understand what is happening “inside the person” with the mental illness, and to train

family members in how to take care of the child. Psychoeducation was given to child’s aunt.

Rapport Building

Rapport is defined as the “relation, connection, especially harmonious or sympathetic relation”.

Rapport is based on mutual confidence, respect and acceptance. It is Therapist’s responsibility to

engage the child and bring him to see therapist as a trusting and helping person. Different

techniques of rapport building are given below that were used with the child to build a good

rapport:

Be warm and Friendly

It is important for therapist to be warm and friendly. Therapist’s behavior was very warm and

friendly with the child. It helped a lot to build a rapport with child.

Body language

It means that use mirroring to imitate a child’s body language and posture. Place yourself at or

below the child’s level to diminish your “authoritative image”. The therapist use posture mirroring

in sitting as she sat on the similar chair as the child’s chair and also made encouraging gestures.

Active Listening

Focus on the information being relayed to you and reflect the information back to the child for

accuracy. Therapist listened actively and used head nod what the child said and repeat it for

accuracy of the information.


Tone of Voice

In building a rapport, you need to mirror the child’s tone of voice. Being loud, in fact, will not help

establishing a bond with child. In addition, pay attention at the speed of the speech also. The

therapist matched her tone and volume of the speech with child.

Show Empathy

The therapist responses to the emotions of the child by emotional mirroring as reflecting that she

was happy when the child was happy.

Attention training techniques

Attention and concentration is very important skills to perform a task. Attention building exercise

was carried out with the child. Coloring activities were carried was given different coloring

materials such as pencil colors, crayons. The child reinforced as he performed the drawing

activities.

Eight Rules of Effecting commands to build compliance

a. The commands were direct, precise and small so that no question is left that the child was

being told to do something. Moreover, the command did not imply a choice or confused

the child. e.g. the child was asked in direct and precise manner that “ sit on the chair”, “

take out the blocks”.

b. The commands were positively stated and the focus was on “what to do” rather than “what

not to do”. Instead of saying the child to not to shout, he was encouraged to do a positive

task such as “keep quiet”.


c. Commands were given one at a time so that a child easily understands and follows it.

d. Commands were given using specific rather than vague words so that the child knows

exactly what he was supposed to do.

e. The commands given to the child were age appropriate. the child was not given such tasks

which was beyond his mental age to comprehend it and perform it.

f. Commands were given in a polite and respectful manner e.g. when the child threw all

activity things on floor, he was asked “please pick up these blocks and put them back”.

g. The commands were explained before they were given. If the commands were difficult, it

was modeled for child to explained in easy terms e.g. pass the ball like this (modeling).

h. Commands were used when necessary. When the child was running

around here and there was asked “please sit in chair”.

The therapist initially took start of compliance building in play activities. Later on the appliance

building work also started during sessions. However, was made sure that the id’s favorite items

were made a part of sessions to maintain his interest and attention level.

Positive reinforcement

Positive reinforcement is very effective to help shape and change behavior. Positive reinforcement

was used during the sessions. Whenever the child exhibited a desire behavior such as taking part

in drawing activities, sat quietly he was reinforced.

Prompting

Prompting is extensively used in behavior shaping and skill acquisition. It provides children with

assistance to increase the probability that a desired behavior will occur. Prompting is a means to
induce an individual with added stimuli (Prompts) to perform a desired behavior. A prompt is like

a cue or support to encourage a desired behavior that otherwise does not occur. Overall, the goal

of using prompts is to help the child independently perform the desired behavior. Different steps

of using prompts are given; (1) Identify the least instructive prompt. Choose a prompt that is

necessary for a correct response to occur (2) Give differential reinforcement. After a correct

response, give appropriate reinforcement that is equivalent to the level of performance

independency. (3) Fade prompt after the child masters a skill, gradually move prompt away or

replace with least intrusive prompt.

During sessions response prompts were used to facilitate the child. Physical prompts were mostly

used for learning activities such as body parts recognition. The therapist pointed held the hand of

the child and pointed towards his organ in order to teach him body parts recognition. Physical

prompts were also used to teach a child draw a straight line. The therapist used different worksheets

with dotted pattern for tracing. The therapist also used verbal prompts in carrying out activities

such as coloring, building blocks etc.

Fading

Children are often taught new skills through the use of prompts. However, it is important to

systematically withdraw or fade these prompts so that the individual can perform skills

independently (Alberto & Troutman, 2006). Fading refers to decreasing the level of assistance

needed to complete a task or activity. When teaching a skill, the overall goal is for the child to

eventually engage in the skill independently. Fading was used in body parts recognition. Initially,

the therapist held the child’s hand and pointed towards his organ later the therapist started to hold

the hand just half the way and gradually she faded the prompt and finally the child was not provided
the prompt and he was required to point towards the body organs by himself. Fading is also used

in drawing lines. Initially, the child was given worksheets with dotted patterns on tracing. Later

on, the therapist faded away the prompt which is patterned worksheet and asked the child to draw

the lines accordingly.

Positive practice overcorrection

It is the application of a negative event or the removal of a negative event. It has been used to

reduce disruptive, annoying, and self-injurious behaviors. It used where the person practices an

activity with the appropriate behavior. It was carried out during the sessions with his disruptive

behavior such as throwing wrappers of his lunch on the floor. Whenever the child thrown the

wrappers, papers or something on the floor the therapist asked him to pick up the material (over

correction) and he was also made to pick up other wrappers from the floor in the room.

Time out

Time out is a behavior change technique used to decrease the frequency of a target behavior. Time

out is a discipline technique that involves placing children in a very boring place for several

minutes following unacceptable behaviors. Time-out really means time out from any attention.

There are two types of timeout: time-out really means time out from any attention. There are two

types of time out: “exclusionary” and “non-exclusionary”.

A non-exclusionary time-out was used. Anon-exclusionary time-out is in place when the person is

allowed to remain within the reinforcing environment but is not permitted to engage in any

reinforcing activities for a pre-specified period of time; this form of time-out removes reinforcers
from the individual. During sessions whenever the child showed undesirable behavior such as not

listening to therapist, leaving his seat he was given non-exclusionary time-out for 2 minutes.

Therapy Blueprint

Therapy blueprints were given to the aunt of the child as it would be helpful for her to manage

child’s problem. It also provided the outline of treatment carried out in the therapy which would

help in the continuation of further treatment. The blueprint explained how did the problem

develop? What things led to the problem? Why was it a problem at this time in child’s life? what

actions, responses or behaviors prolonged it? What are the most important things that were taught

in therapy? What strategies were used to control the behaviors?

Post Assessment

Subjective Ratings of Presenting complaints

The subjective ratings were obtained on 10 points rating scale. The scale was used to identify the

severity of the symptoms. The pre and post ratings were taken to assess the improvement in child’s

problem and efficacy of the therapy.


Table 1.5

Subjective ratings of presenting complaints as reported by the client’s aunt

Problematic Areas Pre-Therapy Rating Post therapy Rating

Disruptive behavior 5 8

Off seat behavior 7 9

Does not pay attention 7 5

Snatches other children’s things 8 6

Does not comply 6 5

Make noises 7 5

Does not wait for his turn 8 4


Tables 1.6

Subjective ratings of presenting complaints as reported by the therapist

Problematic Areas Pre-Therapy Rating Post therapy Rating

Disruptive behavior 7 3

Off seat behavior 10 7

Does not pay attention 8 5

Snatches other children’s things 9 7

Does not comply 8 5

Make noises 7 4

Does not wait for his turn 9 5

Therapeutic Outcome

The post assessment ratings show much improvement in client’s presenting complaints. Finally,

the child was inattentive and disruptive in the class. The child’s aunt and class teacher reported
that child’s behavior was improved. With the help of techniques, it was easy for her to control the

undesirable behaviors of the child.


Session summary

SESSION I

Behavioral observation

Rapport building

SESSION ii

History taking

SESSION III- IV

Symptoms prioritizing

Identity reinforces

SESSION V – VI

Portage guide to early education (PGEE)

SESSION VII

Psycho- education to mother

SESSION VIII

Positive reinforcement

SESSION IX
Daily activity schedule

SESSION X

Homework assignments

SESSION XI

Observe improvement

SESSION XII

Session termination
CASE NO # 3

Autism
Summary of case
The child was 12 years old, boy and belonged to a middle socio-economic class Muslim family.

The mother of the child brought him to Institute of disadvantaged children for special education

with presenting complaints of repetitive behaviors and words, restlessness, stubbornness, spit on

others, noncompliance behavior and inattention. He also had some fixated interests that he used to

on and off switches, shut and open the doors and spin the cooking utensils. Assessment was carried

out on both formal and informal levels. Informal assessment included clinical interview, subjective

ratings according to the mother and therapist, reinforcement survey schedule, DSM-5 criteria and

PGEE. According to DSM-5 the child fulfills the criteria of Autism Spectrum Disorder. The

management plan included: Rapport building, Psychoeducation, Positive reinforcement,

Prompting, Fading, Modeling, Shaping, chaining. A total number of 14 sessions were conducted

with the child.


Bio Data

Name R.H

Age 12 Year

Gender BOY

Siblings 3

Birth order 1st

Religion Islam

Socio-economic status: middle class

Informant Mother

REASON FOR REFRALL:

The client was brought by her mother to fountain house with complain of hyper activity, self-

harm, head banging, repetitive behavior, restlessness, poor socialization, poor speech and

inattention. The child was referred to the trainee clinical psychologist for psychological

assessment and management of his problems.

PRESENTING COMPLAINS:

Agr- main- isko- bulao- suntan- nahi- h- iskay- pass- ja- k- isko- mutwaju- krna- prta- h

Ye- 6- or- 9- mein- faraq- nahi- kr- pta- h

Isko- pata- ni- lgta- alfaz- ksy- bolnay- or – ada- krnay- h


Bohat- behain- rahta- h

Iskay- expressions- tabdeel- nahi- hoty- chahy- koi- b -moka- ho

Sahi- tariqay- sy- chal- nahi- pata- pao- k- aglay- hissay- py- wazan- daal- k chalta- h

Guessa- aye-tu- hud-ko- or- dosron- ko- marti- h

Initial observation:

Child entered the room at normal pace. He seemed to be 12 years old boy. His height and weight

appeared to be normal according to his age and his hygiene was not enough good. He was not

bothering who else was in the room or who was talking to his mother. Instead he kept on playing

with toys and pulling the doors of cupboard. He was not maintaining eye contact. His onset

behavior and attention were very poor. He had poor speech. He didn’t engage in back and forth

conversation with therapist. He hit others even yourself. His walking style is unique he walk on

foot fingers. He sounds too awkward.

History of present illness:

Background information

The child’s mother reported that when I am pregnant, I used to be sick often, and I have too much

burden because we lived separated so my child milestones were delayed other than normal

children’s he sits after much time, speak too lait and walk too lait. Even talking or babbling also

not on time. His mother reported that my child birth was normal he cried immediate after birth and

having growth normally but at the age of 5 years he was sick too much. His health not so good
after recovering. According to his mother her child at the age of 1 year shows vital signs of ADHD

he never sits silently, he never listens and even hit me when he feels anger.

. According to R.H mother even at the age of 4 years his speech was very poor. He did not utter

any word. They were much worried about their child. They consulted general physician at children

hospital but they did not give satisfied answer. Then they took him to the psychologist. The

psychologist conducted some psychological test and diagnosed him autism spectrum disorder. The

psychologist also referred him to the speech therapist. Child’s parents took him to the speech

therapist for few months and during his period he spoke some words at the age of 5 years.

Child’s mother reported that due to getting regular session from psychologist and speech therapist

his condition became improved. They continued the sessions because they wanted to cure their

child. In that period of time the child got so much improvement.

R.H mother reported they got him admission in a nearby school when the child was 6 years old.

The child got admission in prep class because his mother was also a teacher at there and she taught

the child at home. His speech was also improved at that time. The child passed his prep class but

he was stuck in class one he did not continue his studies.

According to child’s mother she got pregnant when the child was 7 years old, so, she did not

concentrate on him properly as before. The child was in one class but his mother did not give

proper time to him due to her health. She reported that due to this his condition became poor,

behavior became problematic. He did not focus on his studies. He became hyperactive. He got

angry easily. He did not sit quietly. In the class his behavior was also changed. He did not listen

to his teacher and pulled her arm in anger. He repeated words and different behaviors. That’s why

he left the school.


His mother stated that the child remained at home for few months and his mother did not give him

proper attention due to her health. Due to this child’s condition became worse. Then someone told

child’s parents and they took him to the institute of disadvantaged children for the management of

his problem.

Background information

Family History:

The child belongs to a middle socioeconomic class Muslim family. The child lives in a separate

family system. Child parents have anxiety history. Because of job work husband often feel anxiety

and due to household duties mother also feel anxiety more often.

Father:

The child’s father is 45 years old. His education is B.A He works in a printing press job and lived

in Kuwait. General health of child’s father is good. He has no medical problem but having

psychiatric illness as reported. His attitude in the house is loveable.

Mother:

The child’s mother is 40 years old. Her education is F.A. She is a housewife. She is friendly and

cooperative by nature. Her general health is also good. Her attitude in home is loveable. According

to her she has no medical but psychiatric problem reported.

The child’s parent had out of family marriage. Their marital relationship is normal.

Siblings

RH has 3 siblings. He came on 1st number in siblings. he has 2 more brothers. His brothers don’t

have any psychiatry problem nor medical. The child shared normal relationship with her sisters.
Home atmosphere:

The home environment is reported to be good. The child lives in a separate family with his parents,

siblings. The attitude of family members reported good towards him. They are lovely and taking

too much care about him. They never treated him as psycho child. They love him as dearly like

son or brother.

Personal History:

The mother of the child had a total 3 pregnancies. According to his mother she had a normal

delivery and the child was matured at birth. He had first cry immediately and complexion was

normal. He had a normal birth weight.

His mother told that the child had completed the course of immunization. Her mother also had

completed the entire immunity course during pregnancy.

After birth at the age of 5-month-old he suffered from tones at the age of 4. He became so much

ill but recovered soon after few days of treatment. There was no evidence of paralysis, meningitis,

measles, and typhoid under 1 year of age.

His developmental milestones were delayed. It can also be observed in table showing achieved

milestones of the child.

Table 1.1

Developmental milestones chart is as follows:


Milestones Normal Range Achieved Range

Cry after birth Immediate after birth Immediate

Neck holding 2-4 months 6 months

Sitting 6-7 months 10 months

Crawling 9 months 2 years

Walking 12-18 months 12 months

Babbling 6 months N/A

Speech single word 1-2 years 4 years

Complete sentences 2-3 years 5 years

Toilet training 2-3 years 6 years

Dressing without help 5 years Not yet

Taking bath without help 4 years Not yet

Present general state of health of the child is normal. He has normal height and weight according

to his age. His appetite and sleep are not good enough. He sometimes showed neurotic traits such

as biting others, aggression, tantrum.

Educational History:

R.H got admission in a nearby school when he was 6 years old. He got admission in 1 class because

his mother was also a teacher there and she taught the child at home. He did not adjust in the

school. He had no interest in studies and friends. He passed his 1 class but he was stuck in class.

His behavior became more problematic. His relationship with his teachers and peers was
unsatisfactory. He used to pull his teacher’s arm in anger. The teachers of the school tried to

involve him by engaging him with other children but he did not interact with his peers. He was

noticed to talk to himself and did not engage in any interaction with others. Due to these adjustment

issues, the teacher advised to parents to get him admitted to some special school. Afterwards, the

mother had brought him to institute of disadvantaged children.

Psychological assessment:

To get the clear picture of child’s problem and to make effective management plan, a complete

assessment is recommended. Psychological assessment was done in two levels i.e., informal and

formal

Informal assessment:

Informal assessment was done on the following levels:

 Clinical interview

 DSM-5 Checklist for presenting complaints

 Subjective ratings of problematic symptoms

 Reinforcement identification

(i) Clinical interview

Clinical interview in a general form of conversation between a clinician and a child/ his caregiver

aimed at determining diagnosis, history, causes of problem and possible treatment options. A

detailed clinical interview was conducted by the trainee clinical psychologist, during which she
collected presenting complaints, detailed history of the child’s problems, family background and

personal history from the child’s mother. Moreover, formal and informal assessment was carried

out in a well- ventilated and enlightened room.

(ii) DSM-5 checklist for intellectual disability

In order to specify the child’s diagnosis, she was also evaluated on DSM-5 criteria for Autism

Spectrum Disorder as given:

Table 1.2

Showing DSM-5 criteria of Autism Spectrum Disorder


Criteria Yes/No

299.0 (F84.0) Autism Spectrum Disorder

D. Deficits in social communication and social interaction Yes

(1) Deficits in social emotional reciprocity Yes

(2) Deficits in nonverbal communicative behavior Yes

(3) Deficits in developing, maintaining and understanding Yes

relationships Yes

E. Restricted, repetitive patterns of behavior, interest and activities Yes

(1) Repetitive motor movements, use of object or speech Yes

(2) insistence on sameness, inflexible adherence to routine No

(3) highly restricted or fixated interests Yes

(4) Hyper/hypo-reactivity to sensory input Yes

F. Onset during the developmental period Yes


(iii) Subjective ratings of problematic symptoms

The subjective ratings were obtained on a 0-10 points rating scale. The scale was used to

identify the intensity and severity of the symptoms. The therapist and the mother was asked to

rate the presenting complaints on a scale where “0” mean average severity of symptoms and

“10” mean very severe. The mother was briefed about the rationale of this rating scale that it

will help to identify the changes in the severity level of the symptoms and efficacy of the

treatment.

Table 1.3

Subjective ratings of presenting complaints as reported by the client’s mother and therapist.

Problematic Areas Subjective rating of Subjective rating


mother of therapist
Stubbornness 9 8

Inattention 9 8

Restlessness 7 9

Fixated interests, behaviors 6 7

Non compliance 7 8

Social communication 5 8

Spit on others 6 4

(iv) Reinforcement identification

Reinforce refers to anything/stimulus which strengthens or increases the probability of a

specific response. Therapist identified Reinforcers because they are helpful in therapies. In a
therapy when the therapist wants to teach some behaviors or skills to the child, he uses

Reinforcers (Miltenberger, 1997).

It was observed that the child liked coloring, candies and cartoons. Reinforcement used to

design the sessions. The given reinforcement if he exhibited the desired behavior

Table 1.4

Types of reinforcement and identified reinforces of the child

Types of Reinforces Identified reinforces

Tangible Reinforcers Candies

Social Reinforcers Praise (good/excellent, clapping)

Activity Reinforcers Toys

socialization, self, help, cognitive. Discrepancies are positive which shows that child is

developmentally delayed.

Formal Assessment:

Portage guide to early education

The portage guide to early education was developed to serve as an aid to teachers, parents or others

who needs to assess the child’s behavior and plan realistic curriculum goals that lead to additional

skills. There are five goals of PGEE; to enhance a developmental approach to teaching, to concern

itself with several areas of development including cognitive, language, motor, socialization and

self-help skill, to provide a method of recording the existing skills and recording skills learned in
the intervention period, to provide a method of recording the existing skills and recording skills

learned in the intervention period, to provide suggestions on how new skills could be taught.

Discrepancies show between chronological age and current functioning age in the area give

Diagnosis:

According to DSM-5 the child fulfills the criteria of Autism Spectrum Disorder, 299.0 (F84.0).

Case Formulation:

.R.H is a 12 years old boy. He was referred with presenting complaints of restlessness,

stubbornness, spit on others, repetitive behavior and words, no compliance, inattention and lack of

social communication.

According to DSM-5 criteria Autism Spectrum Disorder is deficits in social communication and

social interaction. They have poorly integrated verbal and nonverbal communication, abnormal

eye contact, deficits in using and understanding gestures and a lack of facial expressions. This

relates with the child A.H as he has prominent deficits in appropriate use of both verbal and

nonverbal communication, deficits in social communication, difficulty in social interaction. He

has no interest in peers.

Moreover, in autism spectrum disorder child has repetitive pattern of behaviors and activities,

repetitive use of objects or speech, hyper/hypo-reactivity to sensory input or unusual interest in

sensory aspects of the environment. This is also relating with R.H as he has repetitive activities

like on and off switches, push and pull the doors. He has repetitive speech as he has echolalia and

he like different sounds as he taps the pencil near his ear and enjoy its sound.
These deficits must be present in the early developmental period. It was evident from the history

collected from child’s mother shows that the child A.H achieved his developmental milestones

delayed.

Halladay et.al (2015) showed in a study that males are at high risk of autism spectrum disorder

then females. So, gender might be a cause of this disorder in R.H case.

An article “inattention, over activity and impulse vanes in Autism Spectrum Disorder|” (2016)

shows that autistic child displays abnormal behaviors such as poor attention, restlessness, span and

over activity. It relates with A.H that he has inattention and restlessness.

Prognosis

The client prognosis seemed to be good

Points in favor of good prognosis

 He has no other physical illness

 Cooperative family

 Social support

 Language

Points in against of good prognosis

 Lack of early treatment

Management Plan

Short term goals


 Therapeutic relationship was established with the child through assuring active

listening. Non-judgmental acceptance and by providing empathy. It would build the

basic grounds for the therapy to be affective for the child.

 Structured sessions were conducted three times a week.

 Psycho-education was provided to the child’s parents regarding the child’s illness its

predisposing maintains factors and its treatment.

 Potage guide to early education was used to determine his level on social skills,

language, cognitive, self-help and socialization.

 Positive reinforcement was used. It will help interrupt problems behaviors and

reinforce positive behaviors.

 Eight rules for effective commands to build compliance were used with the child to

improve his compliance level and hence take a step towards easy flow of therapy.

 Physical restrains were used to improve his onset behavior and reduce his problematic

behavior like pulling arm of therapist.

 Daily activity schedule was used to plan a client’s daily activities.

Long term goals

 Follow up session will be conducted which will be helpful to monitored and access client’s

progress and improvement. It will be also helpful to enhance the skills; child will learn

through the therapy.

 Individualized education plan will be made. It will help to educate the child according to

his strengths and needs.

 Promoting will be used for body parts recognition, sustaining attention and coloring.
 Fading will be used to make the child carry out tasks independently.

 Modeling will be used to teach him the way attainment of new skills.

 “Do this” imitation tasks were used to improve limitation skills and enhance compliance.

 Chaining will be used with the child to teach her the difficult tasks that she was unable to

perform.
Session summary

Sessions I-II

 Behavioral observation

 Rapport building

 History taking

Session III-IV

 Determination of Milestones

 Symptoms prioritizing

 Identify reinforces

Session V-VI

 Portage guide to early education (PGEE)

Session VII-VIII

 Psycho educates to the family

 Rapport building

Session IX-X

 Activity schedule

 Homework Assignment

Session XI- X11

 Positive reinforcement
 Attention training

Session XIII- X1V

 Review of homework Assignments

 Daily activity schedule


Appendix