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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
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
Name M.U
Age 8 Year
Gender girl
Siblings 6
Religion Islam
Informant Mother
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
Likhna- ni -ata, dosray- bachon- ki- banisbat- isko- bht- kaam- smj -ata- h
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.
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
Educational History:
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:
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:
detailed history of the child’s problems family background and personal history
from the child’s mother. Moreover, formal and informal assessment was carried
In order to specify the child’s diagnosis, she was also evaluated on DSM-5 criteria
Table 1.2
Criteria Yes/No
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.
Poor understanding
9 8
Weak in studies
9 8
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
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:
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
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:
Management Plan
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.
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
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
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
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
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
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
Poor understanding 10 5
Weak in studies 9 4
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
Sessions VII-VIII
Sessions IX-X
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.
(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
Religion Cristian
Informant father
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
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
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
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
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
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
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
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
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.
Table 1.1
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
Informal assessment:
• 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
Psychological health of the child. Moreover, precipitating events of the problem were identified in
In order to specify the child’s diagnosis, he was also evaluated on DSM-5 criteria for Attention-
Criteria Yes/No
activities. Yes
Yes
i. Often forgetful in daily activities.
symptoms. Yes
Yes
b. Often leaves seat in situations when remaining seated is expected.
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.
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
Disruptive behavior 8 8
Make noises 7 6
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
Table 1.4
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
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.
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.
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
ADHD is elevated in the first-degree biological relatives of individuals with ADHD. Visual and
ADHD disorder. In this case the mother of the child was reported to be suffering from psychiatric
ADHD is more frequent in males than females. In U.Z case gender which is girl might also increase
Prognosis
• Regular sessions would also facilitate the treatment and help in bringing
improvement.
• Language of child
• Understanding
Points against of good prognosis
Management plan
• Therapeutic relationship will be established with the client through assuring active
• Structured sessions will be conducted three times a week. These sessions will be
• 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
• Portage guide to early education will be used to determine his level on social skills,
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.
• 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
• 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
• Time out will be given to the child in order to control his undesirable behavior
• Physical restrains will be used to lessen his harming behaviors such as hitting and
kicking others.
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
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:
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
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
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.
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”, “
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
d. Commands were given using specific rather than vague words so that the child knows
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
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
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
independency. (3) Fade prompt after the child masters a skill, gradually move prompt away or
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
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
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
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
Post Assessment
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
Disruptive behavior 5 8
Make noises 7 5
Disruptive behavior 7 3
Make noises 7 4
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
SESSION I
Behavioral observation
Rapport building
SESSION ii
History taking
SESSION III- IV
Symptoms prioritizing
Identity reinforces
SESSION V – VI
SESSION VII
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
Prompting, Fading, Modeling, Shaping, chaining. A total number of 14 sessions were conducted
Name R.H
Age 12 Year
Gender BOY
Siblings 3
Religion Islam
Informant Mother
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
PRESENTING COMPLAINS:
Agr- main- isko- bulao- suntan- nahi- h- iskay- pass- ja- k- isko- mutwaju- krna- prta- h
Sahi- tariqay- sy- chal- nahi- pata- pao- k- aglay- hissay- py- wazan- daal- k chalta- 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
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
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
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
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
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
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
His mother told that the child had completed the course of immunization. Her mother also had
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,
His developmental milestones were delayed. It can also be observed in table showing achieved
Table 1.1
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
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
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:
Clinical interview
Reinforcement identification
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
In order to specify the child’s diagnosis, she was also evaluated on DSM-5 criteria for Autism
Table 1.2
relationships Yes
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.
Inattention 9 8
Restlessness 7 9
Non compliance 7 8
Social communication 5 8
Spit on others 6 4
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
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
socialization, self, help, cognitive. Discrepancies are positive which shows that child is
developmentally delayed.
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
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
Moreover, in autism spectrum disorder child has repetitive pattern of behaviors and activities,
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
Cooperative family
Social support
Language
Management Plan
Psycho-education was provided to the child’s parents regarding the child’s illness its
Potage guide to early education was used to determine his level on social skills,
Positive reinforcement was used. It will help interrupt problems behaviors and
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
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
Individualized education plan will be made. It will help to educate the child according to
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
Session VII-VIII
Rapport building
Session IX-X
Activity schedule
Homework Assignment
Positive reinforcement
Attention training