SUMMARY

The client was 9-year-old, come from a middle-class family and has two sisters. The
mother refer child due to concerns about the child's learning difficulties, which had been
previously addressed in another school. A comprehensive assessment strategy was
employed, encompassing both informal and formal approaches. During the informal
assessment phase, interviews were conducted with both the mother and the child's
teacher. They provided valuable insights into the child's learning behaviors, attitudes, and
challenges. Formal assessment includes Color Progressive Matrices (CPM), Bangor
Dyslexia Test (BDT) test were used for the psychological assessment. Color Progressive
matrices results showed that clients had average IQ. Bangor Dyslexia Test results show
that client had learning problems in different domains. Based on the result, the child had
marked problem in learning.
DEMOGRAPHIC DETAIL

Name A. B

Age 9

Siblings 2 sisters

Birth order 3

Mother Occupation Housewife

Father Occupation Business

Religion Islam

Family system joint

Residence Islamabad

Informant Mother

REASONS AND SOURCE OF REFERRAL

The client was referred by his mother after noticing that their child was having trouble
learning new things and remembering what they learned. She observed that their child
faced challenges in picking up new information and recalling things they had already
learned. According to her, he is not wise according to his age. He is not like normal
children. His basic education is not age appropriate. He can't sit in one place permanently
for a few hours. He cannot express himself well. There is a problem in his speech; his
words are often unrelated. He talks more but understands less. He has to be explained
things repeatedly

PRESENTING COMPLAINTS BY PARENTS

‫وہ اپنی بات بہتر طریقے سے سمجھا‬

‫نہیں سکتا‬

‫اسکو بولنے میں پرابلم ہے‬

‫اسکی بات میں اکثر بے ربطگی ہوتی ہے‬

 ‫وہ بولتے زیادہ ہے سمجھتا کم ہے‬

‫اسے بار بار بات کو سمجھانا پڑتا ہے‬

GENERAL OBSERVATION

The 9-year-old child was dressed neatly and maintained a respectful posture while seated
in the chair. I greeted him warmly, fostering a positive connection. He exhibited
disciplined behavior by adhering to instructions and ensuring a structured environment.
He actively participated in his classwork during our initial engagement but easily
distracted by outer environment. The child displayed proficient listening skills and
promptly responded to the therapist's instructions, consistently making eye contact
throughout our conversation.

BACKGROUND INFORMATION

Personal History

He was born through a cesarean section, and his mother experienced health challenges
during pregnancy, and there were complications during birth. Mother has high blood
pressure during pregnancy, also challenged rubella infection during first trimester of
pregnancy. The child experience delay in developmental milestones. His developmental
journey lacked distinctive characteristics. Instead of achieving normal developmental
milestones, he displayed weak motor skills and was uncooperative and unresponsive to
commands. However, challenges emerged in his cognitive development. Understanding
new concepts posed significant difficulties for him, leading to nervousness when
encountering unfamiliar information. Learning became a struggle, marked by prolonged
periods to grasp new concepts and subsequent forgetfulness after initial learning.
Although talkative and socially active, he also manifests behavioral issues like stealing
lunch box of classmates, impulsivity, interrupting Others and difficulty waiting. Spending
more time with his mother, he demonstrated a preference for her company. Despite his
independence in completing tasks, hygiene maintenance, including teeth brushing and
proper bathing, presented challenges. These aspects, when viewed against typical
developmental milestones, underscore the unique characteristics and challenges in the
child's developmental journey.
Developmental milestones Normal Age Achievement of milestones

Developmental milestones Normal Age Achievement of milestones

First Cry After Birth Immediately

Sitting 6 months 5-6 months

Crawling 8 months 7-8 months

Walking 1 and half or 2 year 14 months

Speech 1.5 years

Toilet training 5 years

Family History

He belonged to a middle-class family. The client’s father was employee in private sector,
and his mother was a housewife. His family environment was very cooperative,
especially his mother was very cooperative with him and had given more attention to
him. He had 2 sisters, and his birth order was last. He had a good relation with family.

Medical History

According to his mother he had gastrointestinal infection by birth. Hernia and pyloric
surgeries were performed when he was just one month old. He had problem to metabolize
the food. Often he had vomiting and diarrhea. He also had influenza sleep issues. His
mother regularly visits the doctor. She reports that all medicine is quit now. And he can
sleep naturally. His immunity was not developed still.

Educational History

He started his schooling from normal school because of the learning problem and his
behavior issues he was expelled from the school. Then they admitted him in step to learn
in which he is in nursery class. He was very weak in studies when his mother complained
during the interview that they did not focus on him properly. He had a learning problem.
He did not do his work properly. He did not understand the things. He had a lot of
 problems in study. His onset behavior was not good. He had change schools because of
his problem

Behavioral Observation

Interview was taken from the mother and child teacher and informal assessment was done
through observation. The client was thoroughly observed and assessed during his
sessions. made a rapport with him easily because he was very good at compliance and
command following. welcomed him and made a compatibility with him. He was very
order following. He was listening. The client was 9-year-old. He was properly dressed
and sat in his chair with a proper poster. He was to maintain eye contact. During the first
communication, he was doing his class work. He was attentively listening and was
commanded following and responding to a therapist’s commands. During observation
likewise conversed with his instructor and took a lot of data about youngster. She had
given me a lot of data. I got some information about his conduct just as his performance
in the class she disclosed to me that he is poor in class work he didn't comprehend the
new things. He cannot get familiar with the new things. He got apprehensive at whatever
point he attempted to become familiar with the new things. He was poor in perusing and
became familiar with the things. She revealed to me that at whatever point she gave him a
test or any school work he didn't do it. What’s more, extremely delayed in work
additionally saw him when I was sitting with him. His instructor had given him a one
simple question and posed to him to learn it and compose it after he had done. He has
trouble telling the sequence of events. He set aside a lot of effort to become familiar with
the inquiry after that when he composed that question, he made a lot of mistakes and
spelling botches. He got nervous. During math’s work he was doing addition and
subtraction addresses his instructor revealed to me that she had given a lot of time to gain
proficiency with the basic expansion questions yet following day he overlooked and even
he couldn't comprehend the straightforward questions only he could do through lines. In
one session I worked with his concepts of math’s and gave him consideration and teach
him how to solve the questions of math’s basically without lines he did it well overall yet
required some investment to comprehend what I need to state however he did it. I like
wise dealt with his phonetics in which I teach him how to deliver the sound of various
 words in which I utilized an alphabetic book through that I asked him how to create the
sound at whatever point he confronted trouble in perusing. I took 2 sessions to teach him
the hints of letters in order and words identified with that. I asked him at whatever point
he was doing perusing simply recollect the sound of words.

Mother Interview

I had taken a meeting with his mother. She revealed to me that he didn't deal with his
cleanliness and in some cases he didn't comply. She was stating that his family
relationship was generally good but sometime he argues. He cannot take care of himself.
He could not share his things, and his social abilities were also weak. She disclosed to me
that there was family history epilepsy. His family members were inattentive and ignorant
towards the client Mother couldn't have cared more about him when he was consuming
because of family issues she was simply concentrating on those issues. She conceded him
in various schools, he faced difficulty in understanding new information. He has slow
cognitive processing time. Yet he couldn't have done like an ordinary youngster that is
the reason he began his tutoring in this school. She additionally disclosed to me that his
mentor likewise came in house to train him, and his guide gave him a lot of time.
According to her mother, she cannot give enough time to him, as her health was not good
and she also take care of other family members.

COLOURED PROGRESSIVE MATRICES (CPM)

Colored progressive matrices (CPM)

The CPM is a test of observation skills and clear thinking ability. It is suitable for the
general population – individual with average intellectual ability.

Set A AB B
Total 8 6 5
Grand total 21
Discrepancies -1 1 0
 Percentile 10th
Grade IV Definitely below average

QUALITATIVE ANALYSIS

The client total score is 6 which indicates that his IQ level is below average.

DSM-5-TR check list for intellectual disability disorder

The client was assessed through formal and informal tools, and through the assessment
reports it was suggested that most of the symptoms of intellectual disability disorder were
present. The final diagnosis was made after checking the symptoms checklist from DSM-5-TR.
For intellectual disability.

Table 1.6 intellectual disability checklist

Diagnostic criteria Symptoms present Status of symptom
Intellectual disability deficits in intellectual Present
functions, such as reasoning,
problem solving, planning,
abstract thinking, academic
learning. Confirmed by both
clinical assessment and
individualized, standardized
intelligence testing.
Deficits in adaptive function Present
that result in failure to meet
developmental sociocultural
 standards.
On set during the Present
developmental period
(includes intellectual and
adaptive functioning)

Table 1.7 Checklist of DSM-5-TR for the level of severity of intellectual disability

SEVERITY CONCEPTUAL SOCIAL PRACTICA STATUS

LEVEL DOMAIN DOMAIN L
DOMAIN

MODERATE conceptual skills shows can care for Present

lag markedly markedly personal needs
behind those of difference from involving
peers peers in social eating,
and dressing,
communicative elimination.
behavior across
development
language and Spoken hygiene as an Present
pre academic language is adult but
skills develop much less reminder may
slowly. complex than be needed.
that of peers

For school age social can do present

Markedly limited judgement and household
Progress in decision- tasks under
reading, Writing, making abilities strict
 mathematics are limited supervision
and
understanding of
Money value.

Tentative Diagnosis

318.1 (F72) Severe Intellectual Developmental Disorder

CASE FORMULATION
The client’s age was 9 years old and was referred to by his mother. He belonged to a
middle class family. She had 2 sisters, and his birth order was last. Assessment was done
through CPM and intellectual disability checklist.

Currently the client is suffering from impulsivity and can’t remember things for long
period. He can’t speak properly and the client had trouble forming social relationships,
communicating and interacting with others. The client was slow learner as compared to
other fellows.

Intellectual disability can be caused by any condition that impairs development of the
brain before birth, in this case the predisposing factor for client’s ID was known. because
the client’s mother report infection during pregnancy that could lead to intellectual
disability in child. This also served as biological factor.

The precipitating factors were, it has further been known that mild intellectual disability
is linked to sociocultural causes such as poor and un-stimulating environments during a
child’s early years and inadequate parent child interactions which was seen in the case of
the client. The client’s parents didn’t notice anything abnormal related to their child till
six months and didn’t gave her any treatment which serve as precipitating factor for the
child’s intellectual disability.

The home environment for child with ID was not suitable, parents and siblings were
inattentive and ignorant towards the client which serves as maintaining factor as well as
 maintaining factor. Later the client’s parents show support towards their child and give
her proper treatment like physiotherapy which served as protective factor.

SUMMARY OF CASE FORMULATION

Predisposing Precipitating factors

factors
Health issues
genetics

Perpetuating Protecting
factors
factors

parents

support.
MANAGEMENT PLAN

Considering the problems of the child following management plans were put into
action. The management plan was devised according to the special need of the client and
keeping the symptoms in mind. Management plan was devised based on Applied
Behavioral Analysis and behavioral therapy.
  Identification of reinforces

 Prompting and fading

 Chaining
 Positive reinforcement
 Social skill practice

Identification of reinforces
First of all, the main thing was to identify the reinforcer that were going to be used to

help in rapport building and management plan. These reinforcers were identified with the help of

observations. Also I directly asked from him and his teacher. His main, primary reinforces were

puzzle, coloring and football. During the sessions whenever the client was doing good he was

given a reinforcer.

Prompting and fading

Prompting was used for effective therapy for the client as there was need to guide the

child in every step. While also doing academics work during reading and writing prompts were

used. To imitate shape, like circle, use prompting and fading techniques. Verbal prompts include

clear instructions, simple language, and breaking down tasks into smaller steps. Visual prompts

include showing the child the shape and using gestures. Physical prompts involve guiding the

child's hands into the shape. As the child gains confidence, gradually reduce prompts to

encourage independent imitation. Then just to make the client independent fading was also

used. After some time, prompts were given at some intervals not on every step just to fade out

the help he is getting.

Chaining
Chaining therapy is like building a chain, one link at a time. For reading problems, I help

him learn to read in small, easy steps. For example, firstly I show a flash card of cat and ask
about it, once he identify it next, I introduce sight words. For this I use flashcards with words

like "the," "and," and "is.". I teach the child how to sound out words. We start with simple words

like "cat" and help the child sound out each letter. After that, we put words together to make

sentences. The child reads sentences like "The cat is black". Finally, I focus on understanding.

To ask questions about them. Like what is color of cat? Chaining therapy is a slow process, but it

helps kids learn to read in a way that makes sense to them.

Positive Reinforcement
Whenever client was showing a positive response to a command he was given positive

reinforcement. For example, if he did activity with attention, he could play with blocks or do

coloring.

Social Skills Practice

The client was made to do some of the social skills daily like practice engaging in

greetings, following rules, taking turns, sharing and cooperating with others. Social rules and

etiquette like saying please and thank you.

Token Economy

Token economy is an extremely effective contingency system. this technique helps to

change undesirable behavior to desirable behavior. for example, in this case client not learn

lesson. psychologist says if you write this work I give one star.

Short Term Goals

 Demonstrate understanding of basic math concepts through currency notes
 Self-help skills like shoe laces, teeth brush
 Strengthen social interactions by practicing interacting with others
 Communication skill by making a story from visual cards
Long Term Goals
 Master basic math operations like addition, subtraction

 Read and write the 3 letter words (Cat, bat, hat)

 Develop the ability to read smoothly and at an appropriate pace

 Develop self-regulation skills to manage emotions effectively

 Develop effective communication skills to interact with peers and adults in various social

settings

SUMMARY OF THERAPEUTIC INTERVENTION

An individualized education program (IEP) was created, incorporating tasks like
letter recognition, picture identification, and word tracing to cater to the child's specific
learning needs. The intervention sessions focused on building upon the child's strengths,
encouraging them to pursue interests that boosted their confidence. Coping strategies
were developed to help the child manage challenges, including lowering expectations,
engaging in problem-solving, and maintaining supportive relationships. ABA therapy
was implemented to address behavioral issues, teaching the child to wait their turn,
maintain focus, and complete puzzles. Additionally, word recognition, sound recognition,
writing practice, currency notes identification, time identification was incorporated to
enhance literacy skills. Various strategies were implemented to enhance the effectiveness
of the intervention, such as building rapport, focusing on strengths, developing coping
skills, and promoting socialization. Additionally, the child was trained to seek permission
before entering the classroom or taking anything, and color blocks were used as a visual
aid to enhance cognitive understanding. Reinforcement was provided to encourage
desirable behaviors, and behavior therapy techniques were employed to teach turn-taking
skills

SUMMARY OF SESSIONS
 A strong rapport was established with the child in first and second session, fostering a
sense of trust and comfort that facilitated engagement and cooperation. The child's compliant
nature and willingness to follow instructions contributed to building a positive relationship.

The child struggled with maintaining cleanliness and following instructions, two sessions were
dedicated to addressing these issues. The child was guided on proper hygiene practices,
including brushing teeth, wiping nose and maintaining personal cleanliness.

In a fifth and sixth session dedicated to math, the child was provided with individualized
instruction and additional time to grasp basic arithmetic concepts. Give a concept of money
through currency notes of 10,20,50 and 100. Also taught him basic addition through currency
notes. The child eventually demonstrated proficiency with consistent practice and support.

To enhance phonological awareness, seventh and eighth sessions focused on teaching the child to
identify and pronounce the sounds of various words. An alphabet book was utilized to introduce
letter sounds and provide visual cues. The child was encouraged to recall the sounds of words to
improve reading fluency.

From ninth to eleventh session, the child received instruction on reading time on a watch.
Through repeated practice, the child gradually gained the ability to tell time only the hour i.e.
first start from digital watch then on analogue watch effectively. However, still lots of practice
needed in this area.

Also worked on the social skills on twelve and thirteen sessions, like greetings sharing, turn
taking during activity, maintaining eye contact, standing tall with good posture, following rules
and cooperating with others. Social rules and etiquette like saying please and thank you.

To channelize his energy and improve his attention, teach him deep breathing, short walks and
jumping.

Recognizing the importance of repetition for memory improvement, the child was asked to recap
the previous session's activities at the beginning of each new session. This practice helped
solidify understanding and enhance retention of newly acquired knowledge.
LIMITATIONS
 It was very difficult for me to take a separate session because of lack of space in
the school.
 During the session constant disruption creates difficulty for me to catch the
attention of the child. He disturbed me again and again.