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Clinical Case Reports

Submitted by:

M. Hussain Rana (032)

MSCP Clinical Psychology Submitted to:

Mam Ayesha Zafar

Batch: 2023-2025

DEPARTMENT OF CLINICAL PSYCHOLOGY

THE SUPERIOR UNIVERSITY, LAHORE

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Table of Contents

Content Page No.

Case Report 1 1-27

Summary 1

Bio Data 2

Reason and Source of Referral 2

Presenting Complaints 2

History of Present Illness 3

Background Information 4

Family History 4

Personal History 5

Educational History 6

Psychological Assessment 7

Informal assessment 7

Formal assessment 11

Diagnosis 13
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Case Formulation 13

Management Plan 15

Summary of Therapeutic Interventions 16

Structure and Style of Session 22

Post Assessment 23

Outcome of Therapy 24

References 25

Appendices 27

Case Report II 28-52

Summary 28

Bio Data 29

Reason and Source of Referral 29

Presenting Complaints 29

History of Present Illness 30

Background Information 31

Family History 31

History of Medical and Psychiatric Illness 32

Personal History 32

Educational History 34

Psychological Assessment 35

Informal assessment 35

Formal assessment 39

Diagnosis 39

Case Formulation 39

Management Plan 40
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Summary of Therapeutic Interventions 42

Structure and Style of Session 47

Post Assessment 48

Outcome of Therapy 49

References 50

Appendices 52

Case Report III 53-75

Summary 53

Bio Data 54

Reason and Source of Referral 54

Presenting Complaints 54

History of Present Illness 55

Background Information 56

Family History 56

History of Medical and Psychiatric Illness 57

Personal History 57

Educational History 58

Psychological Assessment 58

Informal assessment 58

Formal assessment 62

Summary of Psychological Assessment 63

Diagnosis 63

Case Formulation 63

Management Plan 65

Summary of Therapeutic Interventions 66

Structure and Style of Session 70

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Post Assessment 70

Outcome of Therapy 72

References 73

Appendices 75

Case Report IV 76-99

Summary 76

Bio Data 77

Reason and Source of Referral 77

Presenting Complaints 77

History of Present Illness 78

Background Information 79

Family History 79

History of Medical and Psychiatric Illness 80

Personal History 80

Educational History 81

Psychological Assessment 82

Informal assessment 82

Formal assessment 85

Summary of Psychological Assessment 88

Diagnosis 88

Case Formulation 88

Management Plan 89

Summary of Therapeutic Interventions 91

Structure and Style of Session 94

Post Assessment 96

Outcome of Therapy 96
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Limitations and Suggestions 96

References 97

Appendices 99

CASE Report :1

Client I.F was 05 years old boy who came with complaints of not maintaining eye contact,

not attending to his name, playing in isolation and did not interact with anyone, delayed

speech, psychological assessment was done on two levels. The informal assessment included

a clinical interview, behavioral observations, Portage Guide to Early Education (PGEE), and

reinforcer identification. The formal assessment included the Child Autism Rating Scale. On

the basis of the assessment, the client was diagnosed with 299.00 (F84) autism spectrum

disorder. The behavior therapy was proved effective and there was improvement in the

client’s behavior

Bio data

Name I.F.

Gender Boy

Age 05 years

Date of birth 02-12-2013

No. of siblings 01

Birth order fast born

Informant Client’s mother

Reason for Referral

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The client came to the Autism Resource Center with complaints of not maintaining

eye contact, for the assessment of his behavioral issues and diagnosis. Playing in isolation

and did not interact with anyone, delayed speech. Odd behavior (jumping) stereo type

behavior, and getting excited in isolation gathering and putting had on ears in sound, keeping

doors closed fixed with moving or round object. He was referred to the trainee clinical

psychologist for assessment and management of his problems.

Presenting Complaints

As reported by the client’s mother

 speech delayed,
 lack of social interaction
 Odd behavior (jumping) stereo type behavior, and getting excited in isolation
gathering and putting had on ears in sound, keeping doors closed
 Not maintain eye contact.
History of Present Illness

According to the client’s mother, the client’s mother reported that he was restricted to

home for at least 2.5 years. He was provided with a mobile phone on which he used to spend

almost 5 hours daily. He liked watching Korean videos and songs. His mother reported that

he was just into his phone and did not respond to anyone. He was not even attracted to any

toy and used to put everything in his hand into his mouth. His mother reported that when they

first brought the client to the market along with them, he closed his eyes on seeing other

people. He started crying there and felt uncomfortable being in a crowd.

The client did not maintain eye contact with other people and did not respond to

anyone. He had delayed speech and did not interact with anyone who came to his home. His

mother reported that he seemed to not even care about what others were doing or talking. He

just remained into himself and used to play in isolation.

The client’s mother reported that the client did not speak a single word. He did not

even do babbling. He used to tell his needs by holding his mother’s hand and pointing it to
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the thing he needed. He did not play with other kids and liked to play in isolation. The

developmental milestones of the client i.e., head holding, sitting, crawling, and walking were

age-appropriate, but his speech was delayed. According to the client’s mother, the client was

a pampered child. That’s why, the client’s mother did not notice the client’s behavior as

inappropriate. The client’s parents then took the client to the Autism Center and was referred

to the trainee clinical psychologist for the assessment and management of his problems.

Background History

Family History

The child lives I joint family system. He is first born child among two sibling. He has

a younger brother who is two years old and he has a social personality. His father has private

job. He had heart issue. The client’s mother reported that the client’s father was calm and

friendly toward his children and the client had a congenial relationship with his father.

The client’s mother was 39 years old housewife. She is diabetic. She reported being

calm in nature and used to spend time with the client. She used to play with the client and the

client seemed to have a healthy relationship with her. The client was more attached to his

mother than his father as his father used to stop him from doing certain things. The client’s

mother reported that the client shared a satisfactory relationship with his father and siblings

and a healthy relationship with his mother. The overall home environment was reported to be

healthy.

Family History of Psychiatric Illness

The client’s mother reported that there is no history of any fever, head injury,

dehydration. His paternal family is positive for ASD .he was born through C-section delivery.

His mother was reported diabetes. He had his first cry present. He child mother took feed.

Personal History
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The mother reported that the length of term 9 month. The client was born through c-

section. His prenatal history was normal. His mother was report as diabetic. He had an

immediate cry, and his birth weight was normal. The client’s mother reported that she faced

no pre-natal or post-natal complications. She was not taken medicine in pregnancy. The child

took mother feed. The client achieved his developmental milestones such as head and neck

holding, sitting, crawling, and walking at the appropriate age. But, his speech was not

achieved even at the age of 3 years. He did not even produce sounds.

Table 1

Showing Developmental Milestones, Normal Age of Achievement, and Client’s Achievement

Age

Developmental Milestones Normal Age of Achievement Acquired Age

(Gerber et al., 2010)

Head holding 4-6 months 4 months

Sitting 8-10 months 5-06 months

Crawling 10-12 months 07-08 months

Walking 12-18 months 12 months

Single word speech 8-12 months 4 month

Complete sentence 12-24 months Not Achieved Yet

Bladder control 2-3 years Not Achieved Yet

Bowel control 2-3 years 04 year

Dress without help 4 years Not Achieved Yet

Educational History

The informal education of the client was started at home at the age of 2.5 years. His

mother and father were involved in the teaching process. The client’s mother used to rhyme
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the poems with the client. The client also had a little concept of the “circle” shape. Besides

this, he did not have any concept of colors, alphabets, fruits etc.

Psychological Assessment

The formal and informal assessment was done to assess the client’s problems;

Informal Assessment Formal Assessment

Clinical Interview Child Autism Rating Scale (CARS)

Behavioral Observations

Sensory Checklist

Portage Guide to Early Education (PGEE)

Reinforcer Identification

Informal Assessment

Clinical Interview.

A semi-structured clinical interview was done with his mother in which the personal,

developmental, educational, and familial history was taken. A complete account of the

behavioral issues was taken. Verbal informed consent was taken and confidentiality of

information was ensured. From the interview, predisposing, precipitating, perpetuating, and

prognostic factors were identified which were helpful in determining the diagnosis and the

management of the client’s problems.

Predisposing Factors Precipitating Factors Perpetuating Factors Prognostic Factors

Genetic predisposition Delayed milestones Parent’s pampering Regular follow-up

Male gender Educated parents

Covid-19 restrictions

Excessive screen time

Behavioral Observation. The client was of normal height and weight. He was

dressed neatly in weather-appropriate clothes. During the sessions, it was observed that he
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was responsive toward his name and did not maintain eye contact. The client was fascinated

by the light in the room. He remain in his seat and used to sit on the table to complete his

ABA activity task. Mouthing behavior was also observed in the client as he used to follow

the command to complete his task. He almost attend to any command of the therapist and was

involved in playing and recognized differentiate between small and big same and different

object. His imitation is almost good. He is contract to people.

Rein forcers Identification.

Some of the rein forcers were identified by asking the client’s mother about his

favorite activities and food while others were identified by observing the client during the

session while performing activities. During the session, the free-operant preference

assessment method was used in which the client was provided access to all the available

stimuli and was allowed to freely engage with any presented stimuli. The engagement was

monitored with the duration. It helped in identifying the most preferable reinforcer. Material

reinforcers were the most preferable reinforcers. Following this helped in identifying the

hierarchy of the most to the least preferred reinforcer. The reinforcers were identified to make

it contingent on the individualized educational plan and developmental tasks.

Negative Rein forcer Ruben(pony)

Edible Reinforcer Burger, lays

Social Reinforcer Praise (good job, good boy, wow), clapping

Formal Assessment

Childhood Autism Rating Scale (CARS, Schopler 1980). It is a behavioral rating

scale used for assessing the presence and severity of symptoms of Autism spectrum disorders.

It consists of 15 domains, with each scored on a rating scale from 1 to 4. The total score

ranges from 15 to 60. It has .94 internal consistency and a reliability of .71. It was
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administered by asking the client’s mother and observing the client during the session. The

childhood autism rating scale was administered to assess the current functioning level of the

client. The scores showed that the client had mildly-moderate autism. (Appendix)

Table 4

Raw Scores, Range, and Corresponding Category on Childhood Autism Rating Scale

Raw scores Range Category

36 30-38 Mildly-moderately autistic

The scores on CARS indicated his high scores in the item no. 2, 3, 5, 8, and 11 that

included moderately abnormal imitation, emotional response, object use, listening response,

and verbal communication. The client’s scores fall in the category of mildly to moderately

autistic.

Summary of Psychological Assessment

During the interview, it was revealed that the client had some repetitive behaviors,

had problems interacting and communicating, did not maintain eye contact or attend to his

name, and had sensory issues. These symptoms indicated the client’s autistic behavior.

Sensory checklist was administered that showed the client’s gustatory, olfactory, and auditory

sensory issue. The formal assessment was done using the Childhood Autism Rating Scale.

The scores on CARS indicated his mildly-moderate autism.

Diagnosis:

According to DSM-V criteria and keeping in view the observation and assessment, the client

was diagnosed with 299.00 (F84) autism spectrum disorder, accompanying language

impairment.

Case Formulation
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The client I.F. was 05 years old boy who came with complaints of not maintaining

eye contact, not responding even if called his name 10 times, , playing in isolation and did not

interact with anyone, not doing his self-help tasks, walking on his toes, not speaking a single

word, being lazy, and fascinated with same object. Psychological assessment was done on

two levels. The results on PGEE indicated deficits in language, motor, socialization, self-

help, and cognitive domain. The scores on CARS indicated mildly-moderately autistic in the

client. These results helped in diagnosing the client with an Autism Spectrum Disorder.

The client was not diagnosed with intellectual disability as he had specific repetitive

behaviors that were a feature of Autism. Moreover, he was able to memorize the tasks

learned and was able to perform it in the correct way. He learned his tasks efficiently. He was

not diagnosed with the language and social communication disorder as he had restrictive and

repetitive behavior that were absent in this disorder. The client was not diagnosed with

stereotypic movement disorder as the repetitive behavior was better explained by autism

spectrum disorder. He did not meet the criteria for disorders other than autism spectrum

disorder (DSM, 2013).

The client was born via cesarean delivery. Research has indicated that cesarean

delivery was associated with a 26% increased risk of causing autism in the child either due to

stress or some other possible explanation (Chang, 2011). In addition, the client was a boy

which also increased the incidence of having autism as research has indicated that autism

spectrum disorder was four times more common in males than females (Maenner et al.,

2020).

The client’s history revealed delayed development of milestones. According to Tager-

Flusberg (2016), most children with autism are found to have delays in achieving milestones,

especially the onset of words, phrases, and sentences is delayed. They have problems with

receptive and expressive language due to processing deficits. It has also been found that
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children with autism had difficulties in understanding and responding appropriately to others.

They demonstrate problems with motor control (Cook et al., 2013).

It has been found that the client had sensory issues. These issues were related to

sensory processing. It has been found that over 96% of children with ASD reported hyper and

hypo-sensitivities in multiple domains which ranged from mild to severe ranges (Crane et al.,

2009).

Management Plan

The management plan based on behavior techniques was devised to deal with the

idiosyncratic needs of the client.

Short Term Goals

Table 5

Short Terms Goals with Behavioral Interventions and Activities Used

Short Term Goals Behavioral Interventions Activities

Rapport building

 To engage with the child Floor time technique Playing with the lightning

 To gain the attention and Commonality, toys, Clapping, Smiling

trust of the child reinforcement, while giving a toy

Mirroring

Psych education

 Understanding of Discussion

diagnosis, prognosis, and

treatment

 Understanding of skills

development

Parental training
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 To increase eye contact, on- Discussion of the

seat behavior, attending, management plan and

compliance, and imitation different techniques

 To deal with sensory issues Observation of session

using behavioral techniques while applying techniques

and positive parental

strategies

Sensory issues management

training

 Oral-related (mouthing) Differential Sucking toys

reinforcement of Lollipop

alternate behavior,

Verbal prompts,

modeling

 Auditory Response prevention

Physical restraint

IEP Development

 To work on early Positive and differential

readiness skills, Reinforcement,

developmental skills, Prompting, shaping, and

academic skills modeling

Long Term Goals

 Individualized Educational Plan will be continued for establishing and improving

early readiness, and developmental and academic skills.

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 Speech and language therapy will be continued for the management of his speech-

related issues.

 Behavioral techniques will be continued to be used by his mother to deal with the

problematic behaviors and for strengthening the appropriate behaviors.

Summary of Therapeutic Interventions

Rapport Building. Rapport building was done in the initial sessions to establish an

effective therapeutic relationship with the client. It was done to make the client comfortable

and to develop trust in the therapist. The techniques used were floor time technique,

commonality, mirroring, and reinforcement.

The floor time technique is a relationship-based therapy for children with autism. The

intervention is called Floortime because the therapist gets down on the floor with the child to

play and interact with the child at their level. This was done by sitting on the floor with the

child and playing with his favorite toy. The positive reinforcement was used during playing

with the client.

Commonality is a technique of deliberately finding something in common with a

person in order to build a sense of trust and friendship (Tickle-Degnen & Rosenthall, 1990).

This was accomplished through expressing shared preferences for certain toys and foods. He

was drawn in by using a lightening toy.

Mirroring is a nonverbal method when a person imitates another person’s body

language, vocal characteristics, or attitude. It usually indicates curiosity or perhaps attraction

and is frequently done unconsciously. It is a potent form of nonverbal communication (Pease

& Pease, 2005). When playing with toys, the client’s motions and gestures were replicated.

Psychoeducation. It is a crucial step in the therapeutic process. Psychoeducation (PE)

is defined as an intervention with the systematic, structured, and didactic transfer of

knowledge for an illness and its treatment, integrating emotional and motivational aspects to
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enable patients to cope with the illness and to improve its treatment adherence and efficacy

(Ekhtiari et al., 2017). The client’s diagnosis, its primary symptoms, and the variables

influencing the prognosis rate were explained to the client’s parents in order to provide them

with some psychoeducation about the disorder. Additionally, they were informed about the

management strategies and how they could contribute to the therapeutic activity’s success.

Parental Training. Parental training was done to guide the behavior modification

techniques that would help in the development of skills in the client. The mother was trained

to deal with the behavioral issues of the client. During each session, ten to fifteen minutes

were reserved for the mother in which she was trained to deal with the behavioral issues and

her concerns regarding the application of techniques were catered. The mother was also asked

to observe some of the sessions to have an idea to apply the techniques. She was asked to

conduct a formal session with the client at home. She was shown how to conduct a session at

home, and was informed about the required material such as colored balls, similar objects,

reinforcers, and pegboards. The techniques taught were differential reinforcement of

alternate behavior, positive reinforcement, verbal and physical prompts, joint attention,

modeling, and extinction along with the concept of extinction burst and stimulus control.

Individualized Educational Plan. An individualized educational plan is a written

plan for parents, teachers, and school administration to work together to design instructions,

accommodations, and services for children with special needs (Kamens, 2004). They all work

together to meet the needs of the individual requiring a range of support. The goals based on

the child’s current needs and skills are developed (Dotson, 2016). It was formed to meet the

idiosyncratic needs of the client. It was made to develop and strengthen early readiness skills,

and developmental skills which included cognitive skills, language skills, socialization skills,

self-help skills, motor skills. The work on the individualized educational plan was continued

throughout the sessions and his mother was asked to work on it at home as well. The early
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readiness skills that were worked on included increasing on-seat behavior and eye contact,

increasing the response to his name, imitation and attending. The tasks focused on providing

things to the client by maintaining eye contact with him, pointing to one body part, imitating

high-five, hand shaking, and bye-bye, attending to his name, following the commands of start

and stop, give me, and take it.

The eye contact and response to name was increased using reinforcers, verbal and

gestural prompts and differential reinforcement of alternate behaviors. Prompting is a method

of providing a clue to the person about the next step to be done. Prompting can be verbal,

gestural or physical. Verbal prompting usually consists of giving a directive command about

the next step. Most-to-least intrusive prompting is usually followed, which means that the

teacher starts with maximal support and ends with minimal prompting (Miltenberger &

Perkins, 2020). To get the attention of the client, his favorite activities were used which were

playing with the lighting toys. He was given reinforcement for sustaining attention and

completing the tasks. The side gaze of the client was managed by using tunnel vision. The

side of the eyes was blocked either by placing hands on the side of his eyes or using objects

on the sides so that the client could look straight in front of him and at the tasks in front of

him. The attending to his name was increased using these activities and snacks. He would

attend the therapist mostly on the account of getting the lightning toy or lays. This positive

reinforcement technique proved to be helpful.

The on-seat behavior was increased using physical restraints and differential

reinforcement of alternate behavior. The client was made to sit on the seat in the corner of the

room and he was blocked using the table. He was unable to get out of the seat and even if he

tried, he was verbally asked and physically forced to sit back on the seat.

The compliant behavior was achieved using physical and verbal prompts, modeling,

and differential reinforcement of alternate behavior. The task was modeled and then the client
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was asked to do the same. One-word and two-word commands were used such as stop, start,

give me, put there, and not now. Social and edible reinforcers were provided for the

complaint behavior. The client was asked to place the toys in a toy box and place the rings in

the stacker. This was done while keeping the edible reinforcer in the therapist’s hands. He

was not given until he completed the tasks. After the completion of each activity, the client

was given some of the snacks

The sensory issues were dealt with by educating the mother about the alternatives.

Differential reinforcement of alternate behavior, physical restraints, and verbal prompts were

used for this purpose and the appropriate response was positively reinforced. During the

session, verbal prompting and differential reinforcement for alternative behavior were

employed to address these sensory difficulties. It is a procedure that entails reinforcing a

behavior that serves as a viable alternative for the problem behavior but is not necessarily

incompatible with the problem behavior (Speigler & Guevremont, 2015). The client was

provided with the sucking toys and lollipop for the management of his mouthing behavior

and physical restraints and response prevention was used for the management of his behavior

of putting fingers into his ears on hearing loud noise.

Structure and Style of Sessions

Forty structured sessions were conducted with the client. Each session had been of

half an hour to 45 minutes. The initial 15 sessions were of one hour. The sessions included

history taking, observations, assessment, and management of problematic behaviors. The last

ten to fifteen minutes of each session was reserved to discuss the concerns of the mother and

to train her to deal with the problematic behaviors. The sessions were conducted in a

collaborative manner involving the mother along with the trainee in dealing with the client’s

problems.

Post Assessment
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The post-assessment of the behavioral problems was done to gain an understanding of

the progress made by the client.

Post-Assessment of Individualized Education Plan

Table 6

Skills, Pre-Assessment, and Post-Assessment Mastery Level on IEP Tasks

Skills Mastery Level

Pre- Post Assessment

Assessment

Early readiness skills

Eye-contact

Looking into eyes and responding when called by 0% 40%

name

On-seat

To remain seated for 10 minutes 20% 80%

To remain seated for 15 minutes 10% 70%

To remain seated calmly for 30 minutes 0% 70%

Attending

Looking at the therapist when asked “look at me” 0% 40%

Responding to his name 0% 50%

Giving commands to focus on a task (look here, 0% 60%

complete this, finish it)

Using gestures and pointing at the task to complete 0% 40%

it

Imitation

Imitate handshake 0% 70%

Imitate clapping 0% 70%

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Compliance

Following one word command 0% 60%

Following two word command 0% 50%

Developmental Skills

Socialization

Smiles and vocalizes to mirror image 0% 60%

Seeks eye contact often when attended for 2-3 min 0% 50%

Claps hands in imitation to adults 0% 70%

Waves bye-bye in imitation of adult 0% 70%

Self-help

Holds bottle without help while drinking 10% 60%

Takes spoon filled with food to mouth without help 10% 80%

Cognitive

Performs simple gestures on request 0% 70%

Points to one body part 0% 80%

Points to self when asked ‘where’s (name)? 0% 20%

Motor

Turns door knobs, handles etc. 20% 80%

Sensory Issues Management

Avoiding mouthing of inedible objects 0% 40%

Stop putting his fingers into his ears on hearing 10% 50%

loud noise

Outcome of Therapy
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The therapy proved to be helpful in improving early readiness skills of the client. The

individualized educational plan was designed for the client. The on seat behavior and

compliance of the client was improved and eye contact was also maintained a bit. Some of

the tasks were achieved by practicing during the sessions and at home. The client was able to

show a little compliance towards the commands, started cooperating with the requests, and

pointed some objects. He started responding to his name a little buy, imitating simple

gestures of an adult, and doing handshaking and bye-bye in imitation. The client showed

progress during the sessions. The client’s mother also reported his better behavior at home.

The therapy proved to be effective in dealing with the problems of the client.

References

Crane, L., Goddard, L., & Pring, L. (2009). Sensory processing in adults with autism

spectrum disorders. Autism, 13(3), 215–228.

https://doi.org/10.1177/1362361309103794

Cook, J., Hull, L., Crane, L., & Mandy, W. (2021). Camouflaging in autism: A systematic

review. Clinical Psychology Review, 89. https://doi.org/10.1016/j.cpr.2021.102080

Dotson, R. (2016). Goal setting to increase student academic performance. Journal of School

Administration Research and Development, 1(1), 45–46.

https://doi.org/10.32674/jsard.v1i1.1908

Ekhtiari, H., Rezapour, T., Aupperle, R. L., & Paulus, M. P. (2017). Neuroscience-informed

psychoeducation for addiction medicine: A neurocognitive perspective. Progress in

Brain Research, 239–264. https://doi.org/10.1016/bs.pbr.2017.08.013

Kamens, M. W. (2004). Learning to write IEPS. Intervention in School and Clinic, 40(2), 76–

80. https://doi.org/10.1177/10534512040400020201
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Maenner, M. J., Shaw, K. A., Baio, J., Washington, A., Patrick, M., DiRienzo, M.,

Christensen, D. L., Wiggins, L. D., Pettygrove, S., Andrews, J. G., Lopez, M., Hudson,

A., Baroud, T., Schwenk, Y., White, T., Rosenberg, C. R., Lee, L.-C., Harrington, R.

A., Huston, M., … Dietz, P. M. (2020). Prevalence of autism spectrum disorder among

children aged 8 years — autism and Developmental Disabilities Monitoring Network,

11 sites, United States, 2016. MMWR. Surveillance Summaries, 69(4), 1–12.

https://doi.org/10.15585/mmwr.ss6904a1

Miltenberger, R. (2015). Behavior modification: Principles and practices (6th ed.). Academic

Internet Publishers.

Case Report: 2

Client W.A was 5 years and 5 months old boy who came with complaints of delayed speech,

avoid maintaining eye contact, not attending after calling his name, not play or interact with

other children, unusual hand movements, eating inedible objects, and hit other children.

Psychological assessment was done on two levels. The informal assessment included a

clinical interview, behavioral observations, Portage Guide to Early Education (PGEE),

curriculum-based assessment, and reinforce identification. The formal assessment included

the Child Autism rating scale. On the basis of the assessment, the client was diagnosed with

299.00 (F84.0) autism spectrum disorder (Level I) requiring support. The management of the

client’s problems was focused on using behavioral therapy techniques to modify the client’s

behavior. A total of 11 sessions were conducted with the client. The therapy was proved

effective and the improvement was observed in the client’s behavior.

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Bio data

Name W.A

Gender Male

Age 5 years 5 months

Date of birth 16-01-2017

No. of siblings 3

Birth order 2nd

Informant Client’s mother

Reason for Referral

The client came to the autism center Lahore with complaints of delayed speech, avoid

maintaining eye contact, not attending after calling his name, not play or interact with other

children, unusual hand movements, eating inedible objects, and hit other children. He was

referred to the trainee clinical psychologist for assessment and management of his problems.

Presenting Complaints

As reported by the client’s mother

Poor compliance

Speech delay

Aggression
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Self-hitting

Drooling

Self-biting

‫دورانیہ‬ ‫شکایات‬

‫تین سال سے‬ ‫اس کی سپیچ کم ہے۔ایک دو لفظ سے زیادہ نہیں بولتا۔‬

‫دو سال سے‬ ‫اسے چیزیں جلدی یاد نہیں ہوتی۔ بہت وقت لگاتا ہے۔‬

‫تین سال سے‬ ‫آنکھوں میں نہیں دیکھتا۔‬

‫تین سال سے‬ ‫چار پانچ بار آوازدو تو اس کے بعد بات سنتا ہے۔‬

‫تین سال سے‬ ‫ اکیلا ہی کھیلتا رہتا ہے۔‬،‫کسی کے ساتھ گھلتا ملتا نہیں ہے‬

‫تین سال سے‬ ‫چیزوں کو لاین میں رکھتا ہے۔‬

‫چار سال سے‬ ‫ہر چیز کو منہ میں ڈال لیتا ہے اور چوستا رہتا ہے۔‬

Background History

Family History of Psychiatric Illness

The client’s mother reported that one of the client’s paternal uncles was having

diagnosis of intellectual disability.

Personal History

The client was born through cesarean section after prolonged labor. He was a twin

brother. He had an immediate cry, and his birth weight was normal i.e. 6 pounds. The client’s

mother reported that she faced no pre-natal or post-natal complications. The client was

breastfed for 2-3 days. After that, his mother started bottle feeding along with breastfeeding.

When the client was one month of age, he suffered from a severe chest infection for which

the doctors prescribed him medicines at that time.

The client’s mother reported that the client did not do burping. Because of this, he

used to vomit milk. When the client was of 2 months, he suffered from severe diarrhea but
 26

got recovered after proper treatment and care. The client’s developmental milestones of head

and neck holding, sitting, crawling, walking, and bladder and bowel control were achieved

appropriately for his age, but he was significantly delayed in speech. The client started

babbling at the age of 9 months, but his speech was regressed after two months. His mother

reported that his screen-time was increased up to 6-7 hours. He stopped saying mama, baba.

After therapy, he started speaking one-word at the age of 21 months.

Birth and medical history

Condition during pregnancy Depression, tuberculosis

Taken medicine in pregnancy Myrin p,estezene

Type of delivery Normal

Birth Full term

Birth crying Immediate

Birth condition of the child Normal

History of fits No

Table 1

Showing Developmental Milestones, Normal Age of Achievement, and Client’s Achievement

Age

Developmental Milestones Normal Age of Achievement Acquired Age

(Gerber et al., 2010)

Head holding 2-4 months 3months

Sitting 8-10 months 8months

Crawling 10-12 months 10 months

Walking 12-18 months 3 years

Single word speech 8-12 months 21 months

Complete sentence 12-24 months Not achieved yet

 27

Bladder control 2-3 years 4 years

Bowel control 2-3 years Not yet

Dress without help 4 years Not achieved yet

Taking bath without help 4 years Not achieved yet

Educational History

His mother and father were involved in the teaching process. As the client’s speech

was delayed, his parents consulted a speech therapist at RCL, where he was diagnosed with

autism spectrum disorder and delay speech disorder was referred to the clinical psychologist.

He took the therapy based on early readiness skills and developmental skills for almost 6

months. His teachers used to complain about his behaviors as he used to hit his class fellows

and did not sit calmly on the chair. He avoids maintaining eye contact and did not respond to

his name. Where session of 30 minutes was taken based on developmental activities and

academics.

The client had not the concept of shapes, recognition and naming of English alphabets

(A-Z) and Urdu alphabets (‫)ا تا خ‬, could write English alphabets (A & B), and Urdu alphabets

(‫ آ‬, ‫)ا‬. He only speck two words AAA, BAAAA He had not recognition of numbers (1-10),

and could not write numbers (1-2), match numbers by counting objects (1-4), and matching

of letters to letters and letters to objects (A-J).

Psychological Assessment

The formal and informal assessment was done to assess the client’s problems;

Informal Assessment Formal Assessment

Clinical Interview Child Autism Rating Scale (CARS)

Behavioral Observations
 28

Portage Guide to Early Education (PGEE)

Reinforcer Identification

Informal Assessment

Clinical Interview. A semi-structured clinical interview was done with his mother in

which the personal, developmental, educational, and familial history was taken. A complete

account of the behavioral issues was taken. Verbal informed consent was taken and

confidentiality of information was ensured. From the interview, predisposing, precipitating,

perpetuating, and prognostic factors were identified which were helpful in determining the

diagnosis and the management of the client’s problems.

Predisposing Factors Precipitating Factors Perpetuating Factors Prognostic Factors

Birth through C- Delayed speech Parent’s pampering Regular follow-up

section Educated parents

Male gender Practicing therapy

Severe chest infection work at home as

under one month of guided by the

birth therapist

Behavioral Observation.

The client was of normal height and weight. He was dressed neatly in weather-

appropriate clothes. During the sessions, it was observed that he was not much responsive

toward his name and did not maintain eye contact. The client was easily distracted by the

activities around him such as the child playing with pegboards or taking therapeutic sessions.

In the first session, it was bit difficult to build rapport with him. He want to continue

activities of his own choice. He seemed calm. He was not fellow simple commands. His

activity level was lower than any other child of his age.
 29

The client had poor on-seat as he roams around in the session room. He avoids

maintaining eye contact. He continuously went towards switches to switch on and off the

button. Mouthing behavior was also observed as he used to put pencil or eraser in his mouth.

Table 2

Showing Rating of Behavioral Problems on a scale of 0-10

Behavior Rating (0-10)

Eye-contact 2

Imitation 3

Respond to name 2

Onset 4

Compliance 3

Mouthing 8

Lining up objects 5

Side gaze 3

Fixation (switches) 6

Lying on the floor 8

Repetitive movement of hands while holding objects 7

Teeth grinding 7

The rating of the problematic behaviors of the client was done by asking the client’s

mother and observing the client during the session. The client was observed in the initial

sessions to get the ratings

Portage Guide to Early Education (Sturmey & Crisp, 1986). It was administered

on the client to assess his current functioning level in five domains. (Appendix)

Table 3

Developmental Areas, First Crossed Item with Age Range, Last Correct Item with Age Range

and Functional Level in Portage Guide to Early Education

 30

Developmental Areas First Missed Item Last Correct Item

Item No. Age Range Item No. Age Range

Language 41 2-3 years 62 3-4 years

Socialization 27 1-2 years 51 2-3 years

Self-Help 24 1-2 years 55 3-4 years

Cognitive 31 1-2 years 75 4-5 years

Motor 79 2-3 years 107 4-5 years

The results showed that the client lacked behind his chronological age in language,

cognition, socialization, and self-help. The client was taking therapy sessions for the last 2

years, and many of his PGEE items were achieved. The socialization of the client was not

age-appropriate as it was evident from the history and observation that he did not attend to

other individuals immediately and respond to them after calling him 4-5 times, and did not

wait for his turn The scores on the self-help domain revealed his lack of skills in dressing up

himself, tying and untying laces, and buttoning and unbuttoning his jacket. The result of the

motor domain revealed his normal development in fine motor and gross motor skills.

Rein forcers Identification.

Some of the rein forcers were identified by asking the client’s mother about his favorite

activities and food while others were identified by observing the client during the session

while performing activities. The engagement was monitored with the duration. It helped in

identifying the most preferable reinforce. The reinforces were identified to make it contingent

on the individualized educational plan and developmental tasks.

Material Rein forcer Pegboard, bubbles

Edible rein forcer Lunch (Tiffin), cake chocolate,

 31

Social rein forcer Praise(hi ten low ten , good boy, wow)

Formal Assessment

Childhood Autism Rating Scale (CARS) (Schopler, 1980).

It is a behavioral rating scale used for assessing the presence and severity of symptoms of

autism spectrum disorders. It consisted of 15 domains, with each scored on a rating scale

from 1 to 4. The total score ranges from 15 to 60. It has .94 internal consistency and a

reliability of .71. It was administered by asking the client’s mother and observing the client

during the session. The childhood autism rating scale was administered to assess the current

functioning level of the client. The scores showed that the client had mildly to moderate

range of autism. (Appendix)

Areas Row score Areas ROW score

Relating to people 2 Listening response 2

imitation 3 Test, smell, touch 2

Emotional response 2.5 Fear 2

Body use 3 verbal 3

Object use 2

Adaptation to change 1.5

Visual response 2

Table 5

Raw Scores, Range, and Corresponding Category on Childhood Autism Rating Scale

Raw scores Range Category

24 30-38 Mildly-moderately autistic

Diagnosis
 32

According to DSM-V criteria and keeping in view the observation and assessment,

the client was diagnosed with on the basis of history, test result and clinical observation W.A

is diagnosed as having “moderate symptoms autism spectrum disorder along with

developmental delay”

Management Plan

A management plan based on behavior techniques was devised to deal with the

idiosyncratic needs of the client. The management plan included;

1. Rapport building

2. Psycho-education

3. Parental Training

4. Behavior therapy

5. Individualized Education Plan

Short Term Goals

 Rapport building was done with the client to make him at ease with the therapist

during the sessions.

 Psycho-education was done with the client’s mother to give him the understanding of

diagnosis, prognosis, and management of the problem. She was informed about her

role in the management of the client’s behavioral problems. This helped in motivating

the client’s mother towards therapy sessions.

 Positive parental training was given to the client’s mother. She was trained to deal

with the client’s eye-contact, attending, compliance, and on-seat.

 Individualized education plan was developed to work on the client’s early readiness

skills, developmental skills, and academic skills.

 33

 Behavioral modification techniques were used to teach the client the tasks of IEP.

These techniques included reinforcement, prompting, modeling, differential

reinforcement of alternative behavior, shaping, and response cost.

1. Reinforcement was used to increase the likelihood that a behavior will occur

again in the future.

2. Physical and verbal prompts were used to assist the client in performing a

specific task. These prompts were given before and during the tasks to help the

client complete the specific task.

3. Modeling was used to show the client about a particular task so she would

engage in imitation of that particular task after observing it that encourage

learning.

4. Differential reinforcement of alternative behavior was used to reduce problem

behaviors. This technique helps in decreasing challenging behaviors, such as

mis-consuming household things, and increase positive behavior, such as

asking for a permission before using anything.

5. Shaping was used to teach the client particular tasks by reinforcing successive

approximation to the target behavior.

Long Term Goals

 The continuation of short-term goals to enhance the client’s developmental, and

academic skills.

 Speech and language therapy will be continued for the management of his speech-

related issues.

 Behavioral techniques will be continued to be used by her mother to deal with the

problematic behaviors and for strengthening the appropriate behaviors.

Summary of Therapeutic Interventions

 34

Rapport Building. Rapport building was built to establish an effective therapeutic

relationship with the client. It was done to make the client comfortable and to develop trust in

the therapist. The techniques used were commonality and mirroring.

The commonality is a technique of deliberately finding something in common with a

person in order to build a sense of trust and friendship (Tickle-Degnen & Rosenthall, 1990).

This was accomplished through expressing shared preferences for certain toys and foods. He

was drawn in by using ring stackers and pegboards.

Mirroring is a nonverbal method when a person imitates another person’s body

language, vocal characteristics, or attitude. It usually indicates curiosity or perhaps attraction

and is frequently done unconsciously. It is a potent form of nonverbal communication (Pease

& Pease, 2005).

Psychoeducation. It is a crucial step in the therapeutic process. Psychoeducation (PE)

is defined as an intervention with the systematic, structured, and didactic transfer of

knowledge for an illness and its treatment, integrating emotional and motivational aspects to

enable patients to cope with the illness and to improve its treatment adherence and efficacy

(Ekhtiari et al., 2017). The client’s diagnosis, its primary symptoms, and the variables

influencing the prognosis rate were explained to the client’s parents in order to provide them

with some psychoeducation about the disorder. Additionally, they were informed about the

management strategies and how they could contribute to the therapeutic activity’s success.

Parental Training. Parental training was done to guide the behavior modification

techniques that would help in the development of skills in the client. The mother was trained

to deal with the behavioral issues of the client. During each session, ten to fifteen minutes

were reserved for the mother in which her concerns regarding the application of techniques

were catered. The mother was also asked to observe some of the sessions to have an idea to

apply the techniques. She was asked to conduct a formal session with the client at home. She
 35

was shown how to conduct a session at home, and was informed about the required material

such as colored balls, similar objects, reinforcers, and pegboards.

The client's mother was instructed to do the exercises at home to maintain the client’s

eye-contact and improve his attending to his name. She was also taught the techniques,

including verbal, physical, and gestural prompting strategies, positive reinforcement, joint

attention, modeling, and differential reinforcement of alternate behaviors. These techniques

were also used in the academic tasks.

Individualized Educational Plan. An individualized educational plan is a written

plan for parents, teachers, and school administration to work together to design instructions,

accommodation and services to children with special needs (Kamens, 2004). They all work

together to meet the needs of the individual requiring a range of support. The goals based on

the child’s current needs and skills are developed (Dotson, 2016). It was formed to meet the

idiosyncratic needs of the client. It was made to develop and strengthen early readiness skills,

and developmental skills which included cognitive skills, language skills, socialization skills,

self-help skills, motor skills, and academic skills. The work on the individualized educational

plan was continued throughout the sessions and his mother was asked to work on it at home

as well.

Early Readiness Skills. The early readiness skills that were worked on included

maintaining eye-contact, increasing on-seat behavior, attending to his name, imitation and

compliance. The eye contact and response to name was increased using reinforcers, verbal

and gestural prompts and joint attention. To get the attention of the client, his favourite

activities were used that were ring stackers and peg boards. He was given reinforcement for

sustaining attention and completing the tasks. The side gaze of the client was managed by

using tunnel vision. The side of the eyes were blocked either by placing hands on the side of
 36

his eyes or using objects on the sides so that the client could look straight in front of him and

on the tasks in front of him.

The on-seat behavior was increased using physical restraints and differential

reinforcement of alternate behavior. The client was made to sit on the seat in the corner of the

room and he was blocked using the table. He was verbally and physically prompted to sit on

the chair and finish the task. The attending to name was increased using academic activities

and snacks. The technique used for increasing the client’s attending was positive

reinforcement, joint attention, and verbal prompts. He would attend the therapist mostly on

the account of getting snacks. The positive reinforcement technique was proved to be helpful.

The compliant behavior was achieved using verbal prompts, modeling, and

differential reinforcement of alternate behavior. The task was modeled and then the client

was asked to do the same. One-word and two-word commands were used such as stop, start,

give me, put there, and not now. Social and edible reinforcers were provided for the

complaint behavior. The client was asked to place the pegs in peg boards, rings in the stacker,

match the letters with pictures, and do academic tasks. This was done while keeping the

edible reinforcer in therapist’s hands. He was not given the reimforcer until he completed the

tasks. After the completion of each activity, client was given some of the biscuits or his

lunch.

Sensory Issues. The sensory issues were dealt by educating the mother about the

alternatives. Differential reinforcement of alternate behavior techniques was used for this

purpose and the appropriate response was positively reinforced. During the session, verbal

prompting and differential reinforcement for alternative behavior were used to address the

sensory issues of the client.

Developmental skills. For socialization skills, the client was taught the tasks including

sharing pencil or eraser with peers, taking permission from other people before using their
 37

things, and saying please and thank you. The techniques used for these tasks were

Reinforcement, verbal prompts, and modeling. The client was trained to share his pencil and

eraser with his peers. The behavior was first modeled by the therapist. Then the therapist

asked the client to share his eraser to his peer. The client was verbally prompted to share his

things with his Peers.

Asking permission to use objects was taught to the client through modeling and

prompting. The therapist modeled this task by asking for permission to the client for using his

material like pencil, book, and eraser. After that, verbal prompts were used and the client was

only given desirable objects when he sought permission for them to use. The client was

trained to say please and thank you. For this, the therapist modeled the behavior in front of

the client by saying please and thank you herself while using ring stacker with the client. The

client was then verbally prompted on it. He was given a reinforcement when he said please

and thank you on taking something from anyone.

The cognitive skills taught to the client included differentiating heavy and light and

identifying shapes. For the purpose of categorization, identification and naming of shapes

(triangle, circle, square, and rectangle) were used. Verbal and gestural prompts and

reinforcements were used and later the client would categorize it himself on the command.

The client was given the concept of heavy and light objects by using verbal and gestural

prompts, and reinforcement. The client was provided with the heavy and light objects on both

hands and verbally prompted to differentiate between these objects.

Academic Skills. The client was taught the academic skills including English, Urdu,

and Mathematics. These tasks included writing English alphabets A-E, counting numbers 1-

20, writing numbers 1-5, matching Urdu alphabets with objects, and pointing from early

learners English and Urdu alphabets book. The techniques used for these tasks were physical

and verbal prompts, shaping, and reinforcement. He was taught these tasks in chunks.
 38

Behavior Modification Techniques

Positive Reinforcement

Positive reinforcement is the addition of a reinforcing stimulus following a behavior

that makes it more likely that the behavior will occur again in the future (Premack, 1959).

Positive reinforcement was used to develop new desirable behaviors and strengthen the

previously learned behaviors in the client. Social and material reinforcers were used with the

client. Social reinforcers included praise, clapping, and smile, whereas material reinforcers

included lays and juice.

Prompting

Prompting is a method of providing a clue to the person about the next step to be

done. Prompting can be verbal or physical. Verbal prompting usually consists of giving a

directive command about the next step. Most-to-least intrusive prompting is usually followed,

which means that the teacher starts with maximal support and ends with minimal prompting

(Miltenberger & Perkins, 2020).

Fading

Fading is a process of gradually removing prompts until the behavior starts occurring

in the presence of the discrimination stimulus without any supplemental stimuli

(Miltenberger, 2015). The various types of prompts including physical prompts, verbal

prompts, gestural prompts, visual prompts and model prompts were gradually faded so that

the client could perform the tasks independently

Chaining

The process of analyzing a behavioral chain by breaking it down into its individual

stimulus–response components is called chaining (Miltenberger, 2015). It was used to teach

the child self-help skill i.e. Laces shoes, and academic skills i.e., writing English and Urdu

alphabets and numbers.

 39

Modeling

Modelling occurs when a behavior is deliberately displayed by a role model to a

learner or observer who then may learn that behavior and carry it on (Sam, 2013). This

technique was used to teach the client socialization, self-help, and cognitive tasks by first

showing the client how the task would be done, and after that the client was asked to imitate

it.

Structure and Style of Sessions

Eleven structured sessions were conducted with the client. Each session was of 1 to

1½ hour. The sessions included history taking, behavioral observations, assessment, and

management of the problematic behaviors. In the last ten to fifteen minutes of each session,

the client’s mother was guided and trained to deal with the client’s problematic behaviors.

The mother was involved in the therapy by giving homework assignments in dealing with the

client’s problems.

Post Assessment

The post-assessment subjective ratings of the problematic symptoms of the client

were obtained on a 10-point rating scale. The therapist and the mother of the client rated the

presenting complaints 0 to 10 severity rating scale, “0” means “not present”, and “10” means

“severe”. The subjective ratings of the symptoms of the client rated by his mother were;

Table 6

Pre and post assessment rating by the client’s mother on problematic symptoms on 0-10

rating scale

Behavior Pre-assessment Post-assessment

Eye-contact 2 4

Imitation 3 6

Respond to name 2 5
 40

Onset 4 6

Compliance 3 5

Mouthing 8 5

Lining up objects 5 4

Side gaze 3 2

Fixation (switches) 6 4

Lying on the floor 8 6

Repetitive movement of hands while holding 7 5

objects

Teeth grinding 7 5

Table 7

PGEE Items Pre and Post Assessment showing Missed and Achieved Items

Developmental Missed Items Achieved Items

Areas

Socialization 27, 31, 33, 35, 37, 40, 41, 42, 46, 49, 37, 42, 47

52, 53, 54, 55, 56, 57, …

Cognitive 31, 35, 41, 44, 50, 60, 66, 68, 69, 71, 44, 71

72, 73, 74, 76, 77, 78, 79, …

Outcome of Therapy

The behavior therapy was found to be effective in addressing the client's problematic

behaviors. The post-assessment showed improvement in the client’s behavior. The client’s

eye-contact, om-seat, attending, and compliance was improved. His mother reported that the

client’s socialization and cognitive skills were also improved as he started asking for

permission before using anyone’s things, saying thank you, and please, and also got the

concept of long and short, colors and shapes recognition. His academic skills were also
 41

improved. He started writing English alphabets A-E, numbers 1-4, and Urdu alphabets ( ‫)ا تا پ‬

with verbal prompts and started matching letters to objects. He started counting numbers

from 1-15 and pointing Urdu alphabets from the mathematics and Urdu book for early

learners. The client was referred to another clinical psychologist to continue his

individualized education plan and work on his early readiness, developmental, and academic

skills.

References

Ben-Sasson, A., Soto, T. W., Martínez-Pedraza, F., & Carter, A. S. (2013). Early sensory

over-responsivity in toddlers with autism spectrum disorders as a predictor of family

impairment and parenting stress. Journal of Child Psychology and Psychiatry, 54(8),

846–853. https://doi.org/10.1111/jcpp.12035

Cook, J., Hull, L., Crane, L., & Mandy, W. (2021). Camouflaging in autism: A systematic

review. Clinical Psychology Review, 89. https://doi.org/10.1016/j.cpr.2021.102080

Dotson, R. (2016). Goal setting to increase student academic performance. Journal of School

Administration Research and Development, 1(1), 45–46.

https://doi.org/10.32674/jsard.v1i1.1908

Ekhtiari, H., Rezapour, T., Aupperle, R. L., & Paulus, M. P. (2017). Neuroscience-informed

psychoeducation for addiction medicine: A neurocognitive perspective. Progress in

Brain Research, 239–264. https://doi.org/10.1016/bs.pbr.2017.08.013

Kamens, M. W. (2004). Learning to write IEPS. Intervention in School and Clinic,

 42

Case Summary

Client A. A was 5 years and 6 months old girl who came to the outpatient department of

children hospital with complaints of being aggressive, not doing classwork or homework

while sitting on the chair, excessive talk, difficulty paying attention, lack of concentration,

restless, having difficulty waiting for her turn, breaking and mis-consuming household things,

not listening to anyone’s commands, and stubborn. Psychological assessment was done on

two levels. The informal assessment included a clinical interview, behavioral observations,

Portage Guide to Early Education (PGEE), and reinforcer identification. The formal

assessment included Slosson Intelligence Test (SIT) and Conner’s rating scales. On the basis

of the assessment, the client was diagnosed with 314.01 (F90.2) Attention

Deficit/Hyperactivity Disorder with Combined Presentation, Severity Level Moderate. The

management of the client’s problems was focused on using behavioral therapy techniques to

modify the client’s behavior. A total of 11 sessions were conducted with the client. The

therapy was proved effective and the client’s behaviors were improved.
 43

Biodata

Name A .A

Gender Female

Age 5 years 6 months

Date of birth 10-03-2017

No. of siblings 3

Birth order 2nd

Informant Client’s mother

Reason and Source of Referral

The client came to the Iffat Anwar medical Hospital, Lahore with complaints of being

aggressive, not doing classwork or homework while sitting on the chair, excessive talk,

difficulty paying attention, lack of concentration, restless, having difficulty waiting for her

turn, breaking and mis-consuming household things, not listening to anyone’s commands,

and stubborn. She was referred to the trainee clinical psychologist for assessment and

management of her problems.

Presenting Complaints
 44

As reported by the client’s mother

‫دورانیہ‬ ‫شکایات‬

‫تین چار سال سے‬ ‫دوسرے بچوں کو مارتی ہے۔‬

‫تین سال سے‬ ‫ایک جگہ ٹک کر نہیں بیٹھتی۔‬

‫تین سال سے‬ ‫بات نہیں مانتی۔‬

‫تین سال سے‬ ‫ٹک کر کام نہیں کرتی۔‬

‫تین سال سے‬ ‫پڑھائی میں دھیان نہیں دیتی۔‬

‫تین سال سے‬ ‫ خراب کر دیتی ہے یا ضائع‬،‫چیزوں کو چھڑتی ہے‬

‫کر دیتی ہے۔‬

‫تین سال سے‬ ‫بہت زیادہ باتیں کرتی ہے۔‬

History of Present Illness

The client’s mother reported that when she was pregnant, the fetus was not growing

properly. So, the doctors prescribed her injections. The dosage of these injections was 2

injections/month during the first trimester and 1 injection/month during the second and third

trimesters. The client’s mother faced complications during the client’s birth. She was born

through C-section. She had an immediate cry after birth but her weight was low. One month

after birth, the client suffered from jaundice. The client achieved all her developmental

milestones at the appropriate age. Her mother reported that after one year of age, when the

client started crawling, she used to pick the household things and mis-consume them. When

the client was 3 years of age, her screen time was increased up to 5 hours a day. Her mother

reported that whenever she took the mobile from the client, she behaved stubbornly. She used

to lay on the floor or hit the elders if her need was not met. When the client was 3.5 years old,

her mother started teaching her at home. At this time, the client’s mother noticed that the

client did not pay attention to studies, got easily distracted, and was restless.
 45

The client’s mother took the client to the children hospital in Aug, 2022. The client was

referred to trainee clinical psychologist for assessment and management of her problems.

Background History

Family History

The client’s father A.M was 38 years old, educated up to MBA, and worked in a bank.

He reported being calm and friendly toward his children and the client had a healthy

relationship with her father.

The client’s mother was 34 years old, housewife and educated up to bachelors. She

reported being calm in nature but sometimes got irritated by the client’s behavior and beat

her. The client seemed to have a healthy relationship with her mother.

The client’s parents were first cousins. Their relationship was reported to be

satisfactory, but the client’s mother also reported that her husband physically abused her

when they had a fight on any issue. This also had an impact on the client’s behavior as after

seeing her father beating her mother, she thought that beating someone is an acceptable

behavior and she used to beat her cousins and fellow kids when they did not listen to her.

The client had 2 siblings, one brother, and a sister. Her elder sister was 8 years old,

studying in 2nd class. The client’s mother reported that the client shared a healthy relationship

with her sister. The client’s younger brother was 3 years old. The client shared a healthy

relationship with him and used to take care of him.

The client lived in a joint family with her grandparents. The overall home

environment was reported to be satisfactory.

Personal History

The client was born through cesarean section after prolonged labor. She had an

immediate cry, but her birth weight was low. The client’s mother faced pre-natal and post-

natal complications. She reported that when she was pregnant, the fetus growth was not
 46

normal so the doctors prescribed her injections. During childbirth, the mother faced intestinal

malrotation. Within one month of the client’s birth, she suffered from jaundice and fever.

The client achieved her developmental milestones i.e., head holding, sitting, crawling,

walking, speech, bowel and bladder control, dressing, and taking bath without help at the

appropriate age.

Table 1

Showing Developmental Milestones, Normal Age of Achievement, and Client’s Acquired Age

Developmental Milestones Normal Age of Achievement Acquired Age

(Gerber et al., 2010)

Head holding 4-6 months 6 months

Sitting 8-10 months 6-7 months

Walking 12-18 months 13 months

Single word speech 8-12 months 9 months

Complete sentence 12-24 months 15 months

Bladder control 2-3 years 4 years

Bowel control 2-3 years 4 years

Dress without help 4 years 4 years

Taking bath without help 4 years 4 years

Educational History

The informal education of the client was started at home by her mother at the age of

4.5 years. The client’s mother reported that the client used to get easily distracted while

studying and was involved in playing. She had difficulty paying attention and completing the

tasks. She did not sit on her seat. The client did know some of the body parts and animals’

names, but couldn’t recognize colors, numbers, and alphabets.

 47

The client did not receive any formal education. Her parents were deciding to start her

formal education once some of her behavioral issues will be reduced.

Psychological Assessment

The formal and informal assessment was done to assess the client’s problems;

Informal Assessment Formal Assessment

Clinical Interview Conners Rating Scale

Behavioral Observations

Portage Guide to Early Education (PGEE)

Reinforcer Identification

Behavior Rating Scale

Informal Assessment

Clinical Interview.

A semi-structured clinical interview was done with her mother in which the personal,

developmental, educational, and familial history was taken. A complete account of the

behavioral issues was taken

Predisposing Factors Precipitating Factors Perpetuating Factors Prognostic Factors

Prolonged labor and Deficiency of protein Parent’s pampering Mother was

complications during Methylmalonic Parent’s delayed supportive, kept

delivery acidosis acceptance of the seeking help for the

Slow pre-birth growth behavioral issues client, and brought

Jaundice, diarrhea, her regularly for the

and dehydration under sessions.

 48

1 year after birth

Lactose intolerance

Behavioral Observation. The client was of normal height and weight. She was

dressed neatly in weather-appropriate clothes. She was very active during the whole session.

She explored the things and roam here and there in the session room. During the sessions, the

client was easily distracted by the activities around her such as the child playing with

pegboards or bubbles. After being asked three to four times, she used to focus on the task but

still was distracted after sometime. The client had poor on-seat during the session. The client

was excessively talking during the session. She was talking about her family members, her

favorite activities, and toys.

Behavior Rating Scale. The client’s on-seat behavior and not waiting for her turn

was subjectively rated through behavioral observation of the client.

Table 2

Subjective rating for wait and on-seat behavior of the client

Behavior Rating

Waiting behavior 1 min

On-seat behavior 2 min

Portage Guide to Early Education (Sturmey & Crisp, 1986). It was administered

on the client to assess her current functioning level in five domains. (Appendix)

Table 3

Developmental Areas, First Crossed Item with Age Range, Last Correct Item with Age Range

and Functional Level in Portage Guide to Early Education

Developmental Areas First Missed Item Last Correct Item

 49

Item No. Age Range Item No. Age Range

Socialization 39 1-2 years 64 4-5 years

Self-Help 48 2-3 years 74 4-5 years

Cognitive 18 1-2 years 80 4-5 years

Motor 79 2-3 years 129 5-6 years

The results showed that the client lacked behind her chronological age in majorly

three domains of PGEE. The socialization of the client was not age-appropriate as it was

evident from the history and observation that she had a stubborn attitude and did not

cooperate with the parental requests. She used to engage in inappropriate social behaviors.

She immediately wants the object of her choice if she has seen it somewhere. She rarely

listens to the commands of elders, wait for her turn, or request an object. The scores on the

cognitive domain revealed her lack of skills in naming colors, categorization, differentiating

heavy and light, identifying the missing part, and academic tasks (alphabets, counting). She

had a problem with cutting straight lines and shapes and pasting, printing letters, standing on

one foot, and copying complex shapes.

Reinforcers Identification. Some of the reinforcers were identified by asking the

client’s mother about her favorite activities and food while others were identified by

observing the client during the session while performing activities

Material Reinforcer Colored rings, pegboard, bubbles

Edible Reinforcer Juice, lays

Social Reinforcer Praise (good job, wow), smiling at her, high-five

Formal Assessment

Conners Rating Scale (Conners, 1997). The Conners Behavior Rating Scale was

used to better understand certain behavioral, social, and academic issues. It was used to help

diagnose the client. The parent’s rating and teacher’s ratings were obtained. The observations
 50

were also taken into account when the parent’s version was administered with the help of her

mother. The teacher’s version was filled by the client’s school teacher. (Appendix)

Table 5

Raw scores and t Scores on Parent’s Rating of Oppositional, Inattention, Hyperactivity and

ADHD Index along with the Relevant Category

Parent’s Rating
Subscale
Raw scores t score Category

Oppositional 7 61 Mildly atypical

Cognitive problems/Inattention 9 71 Moderately atypical

Hyperactivity 11 78 Markedly atypical

ADHD index 18 68 Moderately atypical

Total 41

The scores of the parent’s ratings indicated that the client obtained mildly atypical

scores on oppositional, moderately atypical scores on cognitive problems, inattention and

markedly atypical scores on hyperactivity making the client moderately atypical on ADHD

index. It provided a strong indication towards diagnosing the client and indicated that

behavioral and emotional problems were severe.

Table 6

Raw scores and t Scores on Teacher’s Rating of Oppositional, Inattention, Hyperactivity and

ADHD Index along with the Relevant Category

Teacher’s Rating
Subscales
Raw scores t scores Category

Oppositional 4 70 Moderately atypical

Cognitive problems/Inattention 3 52 Not significant

 51

Hyperactivity 12 80 Markedly atypical

ADHD 19 72 Moderately atypical

Total 38

The scores on the teacher’s rating were in accordance with the scores on parent’s

rating. It indicated the client’s moderately atypical scores on oppositional showing the

client’s vulnerability towards developing oppositional defiant disorder. High t scores on

hyperactivity and ADHD provided evidence of Attention Deficit/Hyperactivity Disorder in

the client.

Diagnosis

According to DSM-V, the diagnosis of the client was 314.01 (F90.2) Attention Deficit

Hyperactivity Disorder Combined Presentation, Severity Level Moderate.

Case Formulation

The client was 5 years and 6 months old and came with the presenting complaints of

being aggressive, not doing classwork or homework while sitting on the chair, excessive talk,

difficulty paying attention, lack of concentration, being easily distracted, restless, having

difficulty waiting for her turn, breaking and mis-consuming household things, not listening to

anyone’s commands, and stubborn. The client was diagnosed with Attention-Deficit/

Hyperactivity Disorder with the specifier of combined presentation.

Management Plan

A management plan based on behavior techniques was devised to deal with the

idiosyncratic needs of the client. The management plan included;

1. Rapport building

2. Psycho-education

3. Parental Training
 52

4. Behavior therapy

5. Individualized Education Plan

Short Term Goals

 Rapport building was done with the client to make her at ease with the therapist

during the sessions.

 Psycho-education was done with the client’s mother to give her the understanding of

diagnosis, prognosis, and management of the problem. She was informed about her

role in the management of the client’s behavioral problems. This helped in motivating

the client’s mother towards therapy sessions.

 Positive parental training was given to the client’s mother. She was trained to deal

with the client’s hyperactivity and inattention, stubborn behavior, her excessive talks,

and her behavior of breaking and mis-consuming household things.

 Individualized education plan was developed to work on the client’s early readiness

skills, developmental skills, and academic skills.

 Behavioral modification techniques were used to teach the client the tasks of IEP.

These techniques included reinforcement, prompting, modeling, differential

reinforcement of alternative behavior, shaping, and response cost.

 Long Term Goals

 The continuation of short-term goals to enhance the client’s developmental, and

academic skills.

 Behavioral techniques will be continued to be used by her mother to deal with the

problematic behaviors and for strengthening the appropriate behaviors.

Summary of Therapeutic Interventions

Rapport Building. Rapport-building was built with the client to create a successful

therapeutic relationship with the client. It was done to help the client feel at ease and gain
 53

confidence in the therapist. The methods employed were mutual attentiveness and

commonality. The mutual attentiveness established a focused and harmonious relationship. It

is believed that nonverbal conduct is a potent form of successful communication (Segal et al.,

2022). The client was given thorough attention, her narratives were carefully listened to, and

she was questioned about her favorite meals, cartoons, and plays.

The commonality technique was used to establish trust and a friendly relationship with the

client.

Psychoeducation. Psychoeducation is an evidence-based treatment technique for

patients and their families that gives knowledge and assistance to help them understand and

manage their condition (Sarkhel, Singh, & Arora, 2020).

After the evaluation and client diagnosis was complete, the client’s mother was

psycho-educated by providing her with a complete understanding of the diagnosis, causes,

signs and symptoms, and management of attention deficit hyperactivity disorder. The client’s

diagnosis, its primary symptoms, and the variables influencing the prognosis rate were

explained to the client’s mother in order to provide her with some psychoeducation about the

disorder. Additionally, she was informed about the management strategies and how she could

contribute to the therapeutic activity’s success. She was psycho-educated about the benefits

of early management of her problems. In order to deal with these symptoms, behavioral

techniques were introduced. Moreover, the client’s mother was told about adherence to

behavioral techniques in order to manage the behavior.

Parental Training. Parental training was done to guide the behavior modification

techniques that would help in the development of skills in the client. The mother was trained

to deal with the behavioral issues of the client. During each session, ten to fifteen minutes

were reserved for the mother in which her concerns regarding the application of techniques

were catered. The mother was also asked to observe some of the sessions to have an idea to
 54

apply the techniques. She was asked to conduct a formal session with the client at home. She

was shown how to conduct a session at home, and was informed about the required material

such as colored balls, similar objects, reinforcers, and pegboards.

Handling of Behavioral Problems.

Planned ignorance and differential reinforcement of alternate behavior were used to

control the stubbornness of the client during the sessions. Either the client was ignored or

encouraged to perform the assigned duty to obtain the desired item.

Verbal prompts, modeling, and differential reinforcement of alternate behavior were

used to encourage the compliant behavior. The client was requested to complete the work

once it had been modeled for them. The laying down on the floor of the client was managed

using differential reinforcement of alternate behavior and physical and verbal prompts. She

was distracted from and asked to come sit on the seat in order to play the game, perform the

activity or to get the snacks.

Individualized Education Plan. An individualized education plan (IEP) is a written

document that outlines how parents, educators, and the school administration will collaborate

to create guidelines, accommodations, and services for kids with special needs (O’Shea,

2022). They all collaborate to address the requirements of the person needing a variety of

assistance. Goals are formed based on a student's current requirements and abilities (Dotson,

2016). It was created to satisfy the idiosyncratic needs of the client. It was designed to build

and enhance developmental abilities, including cognition, socialization, self-help, motor, and

academic skills. Throughout the sessions, the work on the individualized education plan was

continued, and her mother was requested to continue it at home.

Developmental skills. For socialization skills, the client was taught the tasks including

asking permission before taking things from other people, turn-taking, saying please and

thank you, and saying sorry on reminder after doing mistake. The techniques used for these
 55

tasks were Reinforcement, verbal prompts, and modeling. The client was trained to say please

and thank you. For this, the therapist modeled the behavior in front of the client by saying

please and thank you herself while using ring stacker with the client. The client was then

verbally prompted on it. She was given a reinforcement when she said please and thank you

on taking something from anyone. Asking permission to use objects was taught through

modeling and prompting.

For self-help tasks, the client was taught about using dustbin and tying and untying

shoe laces. The client was asked to use dustbin to throw the waste. The techniques used were

modeling, verbal prompts, and reinforcement.

Academic Skills. The client was taught the academic skills including English, Urdu,

and Mathematics. These tasks included recognizing and writing English alphabets A-C,

counting and writing numbers 1-5, matching Urdu alphabets, and pointing letters with objects

from early learners Urdu alphabets book. The techniques used for these tasks were physical

and verbal prompts, shaping, and reinforcement. She was taught these tasks in chunks.

Behavior Modification Techniques

Positive Reinforcement

Positive reinforcement is the addition of a reinforcing stimulus following a behavior

that makes it more likely that the behavior will occur again in the future (Premack, 1959).

Positive reinforcement was used to develop new desirable behaviors and strengthen the

previously learned behaviors in the client. Social and material reinforcers were used with the

client. Social reinforcers included praise, clapping, and smile, whereas material reinforcers

included lays and juice.

Prompting
 56

Prompting is a method of providing a clue to the person about the next step to be

done. Prompting can be verbal or physical. Verbal prompting usually consists of giving a

directive command about the next step. Most-to-least intrusive prompting is usually followed,

which means that the teacher starts with maximal support and ends with minimal prompting

(Miltenberger & Perkins, 2020).

Fading

Fading is a process of gradually removing prompts until the behavior starts occurring

in the presence of the discrimination stimulus without any supplemental stimuli

(Miltenberger, 2015). The various types of prompts including physical prompts, verbal

prompts, gestural prompts, visual prompts and model prompts were gradually faded so that

the client could perform the tasks independently.

Chaining

The process of analyzing a behavioral chain by breaking it down into its individual

stimulus–response components is called chaining (Miltenberger, 2015). It was used to teach

the child self-help skill i.e., Laces shoes, and academic skills i.e., writing English and Urdu

alphabets and numbers.

Modeling

Modelling occurs when a behavior is deliberately displayed by a role model to a

learner or observer who then may learn that behavior and carry it on (Sam, 2013). This

technique was used to teach the client self-help, and cognitive tasks by first showing the

client how the task would be done, and after that the client was asked to imitate it.

Structure and Style of Sessions

Eleven structured sessions were conducted with the client. Each session was of 1 to

1½ hour. The sessions included history taking, behavioral observations, assessment, and

management of the problematic behaviors. In the last ten to fifteen minutes of each session,
 57

the client’s mother was guided and trained to deal with the client’s problematic behaviors.

The mother was involved in the therapy by giving homework assignments in dealing with the

client’s problems.

Post Assessment

The post-assessment subjective ratings of the problematic symptoms of the client

were obtained on a 10-point rating scale. The therapist and the mother of the client rated the

presenting complaints 0 to 10 severity rating scale, “0” means “not present”, and “10” means

“severe”. The subjective ratings of the symptoms of the client rated by her mother were;

Table 8

Pre and post assessment rating by the client’s mother on problematic symptoms on 0-10

rating scale

Problematic behavior Pre-assessment ratings Post-assessment rating

Stubbornness 9 7

Hitting elders 8 6

Mis-consuming household things 9 6

Inattentiveness 9 7

Table 9

Pre and Post Assessment of Baseline for Wait Training and On-seat Behavior

Behavior Pre-Assessment Post Assessment

Wait 1 minutes 8 minutes

On-seat Behavior 2 minutes 10 minutes

Table 10

PGEE Items Pre and Post Assessment showing Missed and Achieved Items

Developmental Missed Items Achieved Items

Areas

Socialization 39, 40, 44, 53, 55, 56, 59, 60, 61, 63, 65, 66, 67, 40, 44, 56, 57,
 58

68, 69, 70, 72 59, 61

Self Help 48, 50, 51, 52, 54, 58, 59, 62, 63, 64, 65, 66, 67, 55, 68, 70

68, 69, 70, 71, 72, 73, 75, 76

Cognitive 18, 22, 31, 32, 33, 34, 39, 41, 42, 43, 44, 46, 47, 18, 22, 32, 33,

49, 50, 53, 54, 58, 59, 60, 62, 63, 64, 65, 66, 67, 34, 39, 41, 44,

68, 71, 73, 74, 76, 78, 81, 82, 83, 84, 85, 86 49, 63, 64

Motor 79, 88, 90, 92, 95, 96, 98, 101, 104, 108, 109, 110 -

111, 112, 113, 114, 115, 119, 122, 124, 126, 127,

128

Outcome of Therapy

The behavior therapy was found to be effective in addressing the client's problematic

behaviors. The post-assessment showed improvement in the client’s behavior. The client’s

attention was improved and she sat on the chair for 10 minutes without moving back and

forth. Her mother reported that her hitting behavior and stubbornness was reduced and her

attention was improved. Her mother also reported that the client’s socialization and cognitive

skills were also improved as she started asking for permission before using anyone’s things,

saying sorry, thank you, and please, and also got the concept of long and short, colors and

shapes recognition. Her academic skills were also improved. She started matching letters to

letters and letters to objects. The client was referred to another clinical psychologist to

continue her individualized education plan and work on her academic and developmental

skills.
 59

References

Amor, L. B., Grizenko, N., Schwartz, G., Lageix, P., Baron, C., Ter-Stepanian, M.,

Zappitelli, M., Mbekou, V., & Joober, R. (2005). Perinatal complications in children

with attention-deficit hyperactivity disorder and their unaffected siblings. Journal of

Psychiatry & Neuroscience, 30(2), 120–126.

Cherry, K. (2022, October 24). Positive reinforcement can help favorable behaviors.

Verywell Mind. Retrieved January 1, 2023, from https://www.verywellmind.com/

what-is-positive-reinforcement-2795412

Conners, C. K. (1999). Conners Rating Scales-Revised. In M. E. Maruish (Ed.), The use of

psychological testing for treatment planning and outcomes assessment (pp. 467–

495). Lawrence Erlbaum Associates Publishers.

Curran, E. A., Khashan, A. S., Dalman, C., Kenny, L. C., Cryan, J. F., Dinan, T. G., &

Kearney, P. M. (2016). Obstetric mode of delivery and attention-deficit/hyperactivity

disorder: a sibling-matched study. International Journal of Epidemiology, 45(2),

532–542. https://doi.org/10.1093/ije/dyw001

Dotson, R. (2016). Goal setting to increase student academic performance. Journal of School

Administration Research and Development, 1(1), 45–46. https://doi.org/10.32674/

jsard.v1i1.1908

Garner, A. A., O'Connor, B. C., Narad, M. E., Tamm, L., Simon, J., & Epstein, J. N. (2013).

The relationship between ADHD symptom dimensions, clinical correlates, and

Appendices
 60

Individualized Education Plan

Compliance

 Following two and three word command

On-seat

 To remain seated for 5 minutes

 To remain seated for 8 minutes without sliding back and forth

 To remain seated calmly for 10 minutes

 To remain seated calmly for 15 minutes

Developmental Skills

Socialization

 Asking permission before taking things from other people

 Turn-taking

 Saying please and thankyou

 Saying ‘sorry’ if did something wrong (with reminders)

Self-help

 Laces shoes

 Using dustbin for throwing waste

Cognitive

 Recognizing and naming colors (red, blue, green, yellow, pink)

 Practicing pre-writing skills (+, V)

 Identifying long and short

 Differentiating heavy and light objects

 Identifying shapes (circle, triangle, square, rectangle)

 61

 Matching shapes with shapes

 Matching colors with colors

 Matching letters with letters

 Matching letters with objects

Academics

English

 Recognizing and writing alphabets (A-C)

Mathematics

 Writing numbers (1-5)

 Recognizing numbers (1-5)

Urdu

 Matching urdu alphabet with objects

 Pointing urdu alphabet from urdu book for early learners

Maenner, M. J., Shaw, K. A., Baio, J., Washington, A., Patrick, M., DiRienzo, M., Christensen,

D. L., Wiggins, L. D., Pettygrove, S., Andrews, J. G., Lopez, M., Hudson, A., Baroud, T.,

Schwenk, Y., White, T., Rosenberg, C. R., Lee, L.-C., Harrington, R. A., Huston, M., …

Dietz, P. M. (2020). Prevalence of autism spectrum disorder among children aged 8 years

— autism and Developmental Disabilities Monitoring Network, 11 sites, United States,

2016. MMWR. Surveillance Summaries, 69(4), 1–12.

https://doi.org/10.15585/mmwr.ss6904a1
 62

Case Report: 3

Client j. A was 5 years and 6 months old boy who came to the ARCL with complaints of being

aggressive, not doing classwork or homework while sitting on the chair, excessive talk, difficulty

paying attention, lack of concentration, restless, having difficulty waiting for her turn, breaking

and miss-consuming household things, not listening to anyone’s commands, and stubborn.

Psychological assessment was done on two levels. The informal assessment included a clinical

interview, behavioral observations, Portage Guide to Early Education (PGEE), and reinforcer

identification. The formal assessment included Slosson Intelligence Test (SIT) and Conner’s

rating scales. On the basis of the assessment, the client was diagnosed with 314.01 (F90.2)

Attention Deficit/Hyperactivity Disorder with Combined Presentation, Severity Level Moderate.

The management of the client’s problems was focused on using behavioral therapy techniques to

modify the client’s behavior.

Bio data:

Name j.A

Gender Male

Age 5 years 6 months

Date of birth 26-07-2018

No. of siblings 1

Informant Client’s mother

Reason and Source of Referral

 63

The client came to the autism center, ARCL Lahore with complaints of being aggressive,

for the assessment and management of behavioral issue and diagnosis Not doing classwork or

homework while sitting on the chair, excessive talk, difficulty paying attention, lack of

concentration, restless, having difficulty waiting for her turn, not listening to anyone’s

commands, and stubborn. She was referred to the trainee clinical psychologist for assessment

and management of her problems.

Presenting Complaints

As reported by the client’s mother

Speech delay

Self-stimulatory behavior

Lack of social interaction

Birth and medical history:

Condition during pregnancy Stressful

Taken medicine in pregnancy None

Type of delivery C-section

Birth crying Not sure

Birth condition of the child Normal

History of fits No

Birth Full term

History of fever NO

Developmental milestones (as report by mother)

 64

Developmental Achieved age of Normal age of Remark

milestone milestone archived

Neck holding 6 months 2-4 month Delay

Sitting without 8 months 5-10 month Normal

support

Crawling 10 months 8-12 month Normal

Walking 18 months 12-20 month Normal

Speech 4 years 8-12 month Delayed

Bladder and bowel 5 years 2.5 to 3 years Delayed

Family history:

He was born to non-carmangtaineous parent and only born child. His mother is a housewife. His

primary language is Urdu. His family history was positive for psychological dysfunction.

Clinical observation:

At first visit, it was observed that he was young child with average height. According to his age.

He was wearing eat and press cloth. When he enter the room he seemed lost, and did not explore

his environment .he did not interact with people around him.it was difficult to build report him as

he is lost in his self-stimulatory behavior. He was involved in jumping and trampoline. He was

not willing to fellow simple commands.

Assessment tool Applied:

 Portage guide early education program

 Child autism rating scale
 Assessment of basic language and learning skill
 65

Portage guide early education programe

Development profile was done and result are as follows

Areas Chronological age, 5, 4 developmental age

level

Cognitive 1year

Socialization 11 months

Quantitative analysis

Development Areas Cut off score

communication Autism 04

Autism spectrum 02

Reciprocal social interaction Autism 07

Communication+ reciprocal+ Autism12 18

social interaction Autism spectrum 7

Play 04

Stereotyped behavior 06

Qualitative Analysis:

The score classification of Autism diagnosis observation schedule model 1include that the child

fails under the category of autism spectrum disorder.

Communication:

The obtain score of the child indicated that he has single word speech through words. He is

speech limited to imitation of sound. He uses adult body as a way to communicate.

 66

Reciprocal social interaction:

He maintains eye contact during activity, physical interaction and when he needs nothing. He

responds to initial greeting but does not initiate a social interaction. Social interaction is

restricted and he has no peer play. He has interest in different sensory toys like musical and

lightening toys. He also took interest in peg boards but unable to use it properly as he put

everything in mouth. He is more interested in object like lip gloss and nail polish.

Stereotyped behavior and restricted interest:

His stereotype behavior is spinning, finger wiggling, hand clapping and shouting.

Management Plan

A management plan based on behavior techniques was devised to deal with the

idiosyncratic needs of the client. The management plan included;

6. Rapport building

7. Psycho-education

8. Parental Training

9. Behavior therapy

10. Individualized Education Plan

Short Term Goals

 Rapport building was done with the client to make him at ease with the therapist during

the sessions.

 Psycho-education was done with the client’s mother to give him the understanding of

diagnosis, prognosis, and management of the problem. She was informed about her role
 67

in the management of the client’s behavioral problems. This helped in motivating the

client’s mother towards therapy sessions.

 Positive parental training was given to the client’s mother. She was trained to deal with

the client’s eye-contact, attending, compliance, and on-seat.

 Individualized education plan was developed to work on the client’s early readiness

skills, developmental skills, and academic skills.

 Behavioral modification techniques were used to teach the client the tasks of IEP. These

techniques included reinforcement, prompting, modeling, differential reinforcement of

alternative behavior, shaping, and response cost.

6. Reinforcement was used to increase the likelihood that a behavior will occur

again in the future.

7. Physical and verbal prompts were used to assist the client in performing a specific

task. These prompts were given before and during the tasks to help the client

complete the specific task.

8. Modeling was used to show the client about a particular task so she would engage

in imitation of that particular task after observing it that encourage learning.

9. Differential reinforcement of alternative behavior was used to reduce problem

behaviors. This technique helps in decreasing challenging behaviors, such as mis-

consuming household things, and increase positive behavior, such as asking for a

permission before using anything.

10. Shaping was used to teach the client particular tasks by reinforcing successive

approximation to the target behavior.

Long Term Goals

 68

 The continuation of short-term goals to enhance the client’s developmental, and academic

skills.

 Speech and language therapy will be continued for the management of his speech-related

issues.

 Behavioral techniques will be continued to be used by her mother to deal with the

problematic behaviors and for strengthening the appropriate behaviors.

Summary of Therapeutic Interventions

Rapport Building. Rapport building was built to establish an effective therapeutic

relationship with the client. It was done to make the client comfortable and to develop trust in the

therapist. The techniques used were commonality and mirroring.

The commonality is a technique of deliberately finding something in common with a

person in order to build a sense of trust and friendship (Tickle-Degnen & Rosenthall, 1990). This

was accomplished through expressing shared preferences for certain toys and foods. He was

drawn in by using ring stackers and pegboards.

Mirroring is a nonverbal method when a person imitates another person’s body language,

vocal characteristics, or attitude. It usually indicates curiosity or perhaps attraction and is

frequently done unconsciously. It is a potent form of nonverbal communication (Pease & Pease,

2005).

Psychoeducation. It is a crucial step in the therapeutic process. Psychoeducation (PE) is

defined as an intervention with the systematic, structured, and didactic transfer of knowledge for

an illness and its treatment, integrating emotional and motivational aspects to enable patients to

cope with the illness and to improve its treatment adherence and efficacy (Ekhtiari et al., 2017).

The client’s diagnosis, its primary symptoms, and the variables influencing the prognosis rate
 69

were explained to the client’s parents in order to provide them with some psychoeducation about

the disorder. Additionally, they were informed about the management strategies and how they

could contribute to the therapeutic activity’s success.

Parental Training. Parental training was done to guide the behavior modification

techniques that would help in the development of skills in the client. The mother was trained to

deal with the behavioral issues of the client. During each session, ten to fifteen minutes were

reserved for the mother in which her concerns regarding the application of techniques were

catered. The mother was also asked to observe some of the sessions to have an idea to apply the

techniques. She was asked to conduct a formal session with the client at home. She was shown

how to conduct a session at home, and was informed about the required material such as colored

balls, similar objects, reinforcers, and pegboards.

The client's mother was instructed to do the exercises at home to maintain the client’s

eye-contact and improve his attending to his name. She was also taught the techniques, including

verbal, physical, and gestural prompting strategies, positive reinforcement, joint attention,

modeling, and differential reinforcement of alternate behaviors. These techniques were also used

in the academic tasks.

Individualized Educational Plan. An individualized educational plan is a written plan

for parents, teachers, and school administration to work together to design instructions,

accommodation and services to children with special needs (Kamens, 2004). They all work

together to meet the needs of the individual requiring a range of support. The goals based on the

child’s current needs and skills are developed (Dotson, 2016). It was formed to meet the

idiosyncratic needs of the client. It was made to develop and strengthen early readiness skills,

and developmental skills which included cognitive skills, language skills, socialization skills,
 70

self-help skills, motor skills, and academic skills. The work on the individualized educational

plan was continued throughout the sessions and his mother was asked to work on it at home as

well.

Early Readiness Skills. The early readiness skills that were worked on included

maintaining eye-contact, increasing on-seat behavior, attending to his name, imitation and

compliance. The eye contact and response to name was increased using reinforcers, verbal and

gestural prompts and joint attention. To get the attention of the client, his favourite activities

were used that were ring stackers and peg boards. He was given reinforcement for sustaining

attention and completing the tasks. The side gaze of the client was managed by using tunnel

vision. The side of the eyes were blocked either by placing hands on the side of his eyes or using

objects on the sides so that the client could look straight in front of him and on the tasks in front

of him.

The on-seat behavior was increased using physical restraints and differential

reinforcement of alternate behavior. The client was made to sit on the seat in the corner of the

room and he was blocked using the table. He was verbally and physically prompted to sit on the

chair and finish the task. The attending to name was increased using academic activities and

snacks. The technique used for increasing the client’s attending was positive reinforcement, joint

attention, and verbal prompts. He would attend the therapist mostly on the account of getting

snacks. The positive reinforcement technique was proved to be helpful.

The compliant behavior was achieved using verbal prompts, modeling, and differential

reinforcement of alternate behavior. The task was modeled and then the client was asked to do

the same. One-word and two-word commands were used such as stop, start, give me, put there,

and not now. Social and edible reinforcers were provided for the complaint behavior. The client
 71

was asked to place the pegs in peg boards, rings in the stacker, match the letters with pictures,

and do academic tasks. This was done while keeping the edible reinforcer in therapist’s hands.

He was not given the reimforcer until he completed the tasks. After the completion of each

activity, client was given some of the biscuits or his lunch.

Sensory Issues. The sensory issues were dealt by educating the mother about the

alternatives. Differential reinforcement of alternate behavior techniques was used for this

purpose and the appropriate response was positively reinforced. During the session, verbal

prompting and differential reinforcement for alternative behavior were used to address the

sensory issues of the client.

Developmental skills. For socialization skills, the client was taught the tasks including

sharing pencil or eraser with peers, taking permission from other people before using their

things, and saying please and thank you. The techniques used for these tasks were

Reinforcement, verbal prompts, and modeling. The client was trained to share his pencil and

eraser with his peers. The behavior was first modeled by the therapist. Then the therapist asked

the client to share his eraser to his peer. The client was verbally prompted to share his things

with his Peers.

Asking permission to use objects was taught to the client through modeling and

prompting. The therapist modeled this task by asking for permission to the client for using his

material like pencil, book, and eraser. After that, verbal prompts were used and the client was

only given desirable objects when he sought permission for them to use. The client was trained

to say please and thank you. For this, the therapist modeled the behavior in front of the client by

saying please and thank you herself while using ring stacker with the client. The client was then
 72

verbally prompted on it. He was given a reinforcement when he said please and thank you on

taking something from anyone.

The cognitive skills taught to the client included differentiating heavy and light and

identifying shapes. For the purpose of categorization, identification and naming of shapes

(triangle, circle, square, and rectangle) were used. Verbal and gestural prompts and

reinforcements were used and later the client would categorize it himself on the command. The

client was given the concept of heavy and light objects by using verbal and gestural prompts, and

reinforcement. The client was provided with the heavy and light objects on both hands and

verbally prompted to differentiate between these objects.

Academic Skills. The client was taught the academic skills including English, Urdu, and

Mathematics. These tasks included writing English alphabets A-E, counting numbers 1-20,

writing numbers 1-5, matching Urdu alphabets with objects, and pointing from early learners

English and Urdu alphabets book. The techniques used for these tasks were physical and verbal

prompts, shaping, and reinforcement. He was taught these tasks in chunks.

Behavior Modification Techniques

Positive Reinforcement

Positive reinforcement is the addition of a reinforcing stimulus following a behavior that

makes it more likely that the behavior will occur again in the future (Premack, 1959). Positive

reinforcement was used to develop new desirable behaviors and strengthen the previously

learned behaviors in the client. Social and material reinforcers were used with the client. Social

reinforcers included praise, clapping, and smile, whereas material reinforcers included lays and

juice.

Prompting
 73

Prompting is a method of providing a clue to the person about the next step to be done.

Prompting can be verbal or physical. Verbal prompting usually consists of giving a directive

command about the next step. Most-to-least intrusive prompting is usually followed, which

means that the teacher starts with maximal support and ends with minimal prompting

(Miltenberger & Perkins, 2020).

Fading

Fading is a process of gradually removing prompts until the behavior starts occurring in

the presence of the discrimination stimulus without any supplemental stimuli (Miltenberger,

2015). The various types of prompts including physical prompts, verbal prompts, gestural

prompts, visual prompts and model prompts were gradually faded so that the client could

perform the tasks independently

Chaining

The process of analyzing a behavioral chain by breaking it down into its individual

stimulus–response components is called chaining (Miltenberger, 2015). It was used to teach the

child self-help skill i.e. Laces shoes, and academic skills i.e., writing English and Urdu alphabets

and numbers.

Modeling

Modelling occurs when a behavior is deliberately displayed by a role model to a learner

or observer who then may learn that behaviors and carry it on (Sam, 2013). This technique was

used to teach the client socialization, self-help, and cognitive tasks by first showing the client

how the task would be done, and after that the client was asked to imitate it.

Structure and Style of Sessions

 74

Eleven structured sessions were conducted with the client. Each session was of 1 to 1½

hour. The sessions included history taking, behavioral observations, assessment, and

management of the problematic behaviors. In the last ten to fifteen minutes of each session, the

client’s mother was guided and trained to deal with the client’s problematic behaviors. The

mother was involved in the therapy by giving homework assignments in dealing with the client’s

problems.

Post Assessment

The post-assessment subjective ratings of the problematic symptoms of the client were

obtained on a 10-point rating scale. The therapist and the mother of the client rated the

presenting complaints 0 to 10 severity rating scale, “0” means “not present”, and “10” means

“severe”. The subjective ratings of the symptoms of the client rated by his mother were;

Table 6

Pre and post assessment rating by the client’s mother on problematic symptoms on 0-10 rating

scale

Behavior Pre-assessment Post-assessment

Eye-contact 2 4

Imitation 3 6

Respond to name 2 5

Onseat 4 6

Compliance 3 5

Mouthing 8 5

Lining up objects 5 4

Side gaze 3 2

Fixation (switches) 6 4
 75

Lying on the floor 8 6

Repetitive movement of hands while holding 7 5

objects

Teeth grinding 7 5

Table 7

PGEE Items Pre and Post Assessment showing Missed and Achieved Items

Developmental Missed Items Achieved Items

Areas

Socialization 27, 31, 33, 35, 37, 40, 41, 42, 46, 49, 37, 42, 47

52, 53, 54, 55, 56, 57, …

Cognitive 31, 35, 41, 44, 50, 60, 66, 68, 69, 71, 44, 71

72, 73, 74, 76, 77, 78, 79, …

Outcome of Therapy

The behavior therapy was found to be effective in addressing the client's problematic

behaviors. The post-assessment showed improvement in the client’s behavior. The client’s eye-

contact, om-seat, attending, and compliance was improved. His mother reported that the client’s

socialization and cognitive skills were also improved as he started asking for permission before

using anyone’s things, saying thank you, and please, and also got the concept of long and short,

colors and shapes recognition. His academic skills were also improved. He started writing

English alphabets A-E, numbers 1-4, and Urdu alphabets (‫ )ا تا پ‬with verbal prompts and started

matching letters to objects. He started counting numbers from 1-15 and pointing Urdu alphabets

from the mathematics and Urdu book for early learners. The client was referred to another
 76

clinical psychologist to continue his individualized education plan and work on his early

readiness, developmental, and academic skills.

References

Ben-Sasson, A., Soto, T. W., Martínez-Pedraza, F., & Carter, A. S. (2013). Early sensory over-

responsivity in toddlers with autism spectrum disorders as a predictor of family impairment

and parenting stress. Journal of Child Psychology and Psychiatry, 54(8), 846–853.

https://doi.org/10.1111/jcpp.12035

Cook, J., Hull, L., Crane, L., & Mandy, W. (2021). Camouflaging in autism: A systematic

review. Clinical Psychology Review, 89. https://doi.org/10.1016/j.cpr.2021.102080

Dotson, R. (2016). Goal setting to increase student academic performance. Journal of School

Administration Research and Development, 1(1), 45–46.

Portfolio

Case Summary
 77

Client M.A was 5 years and 1 month old boy who came to the ARCL with complaints of having

difficulties in learning anything, speech delay not interacting with other individuals and not

understanding how to behave in a certain situation, psychological assessment was done on two

levels. The informal assessment included a clinical interview, behavioral observations, Portage

Guide to Early Education (PGEE), and reinforcer identification. The formal assessment included

the Colored Progressive Matrices, Slosson Intelligence Test, and Child Adaptive Behavior Scale.

On the basis of the assessment, the client was diagnosed with 319 (F71) Intellectual Disability

Disorder, Moderate. The management of the client’s problems was focused on using behavioral

techniques to modify behavior. The techniques used included positive reinforcement, physical

and verbal prompts, shaping, task analysis, and modeling. A total of 20 sessions were conducted

with the client. The therapy was proved to be effective and the client behavior was improved.

Biodata

Name M.A.

Gender Male

Age 10 years 1 months

Date of birth 25-08-2012

No. of siblings 2
 78

Birth order Last born

Informant Client’s mother, sister, and teacher

Reason for Referral

The client came to the OPD of Center for Clinical Psychology with complaints of having

difficulties in learning anything, not interacting with other individuals and being shy, not

understanding how to behave in a certain situation, forgetting learned material even after

learning it for one month, his parents have to assist him in his daily life functioning, not have the

concept of practical things in daily life such as colors differentiation, the concept of money, and

fruits categorization, and delayed speech. He was referred to the trainee clinical psychologist for

assessment and management of his problems.

Presenting Complaints

As reported by the client’s mother

‫دورانیہ‬ ‫شکایات‬

‫پانچ سال سے‬ ‫اسے بار بار یاد کروانے پر بھی کوئی چیز یاد نہیں ہوتی۔‬

‫پانچ سال سے‬ ‫ اور ایک دن کا گیپ دو تو یہ بھول جاتا ہے۔‬، ‫پورا مہینہ اسے کوئی ایک چیز یاد کراؤ‬

‫چھ سال سے‬ ‫اس نے بولنا بہت لیٹ شروع کیا اور ابھی بھی پورے جملے نہیں بولتا۔‬

‫چار سال سے‬ ‫اسے سمجھ نہیں آتی کہ کون سے موقع پر کیسا رویہ رکھنا ہے۔‬

‫چار سال سے‬ ‫ کئی بار بیٹھے بیٹھے ہنسنے لگ جاتا ہے۔‬،‫عجیب سا رویہ ہے اس کا‬

‫پانچ سال سے‬ ‫ ہر کام میں اسے کسی کی مدد کی ضرورت ہوتی ہے۔‬،‫اپنے کام خود نہیں کر پاتا‬

‫چار سال سے‬ ‫ نہ اسے رنگوں کی پہچان ہے اور نہ‬،‫اسے روزمرہ کی زندگی کی معمولی چیزوں کا بھی نہیں پتا‬

‫ہی پیسوں کی‬

‫پانچ سال سے‬ ‫ لوگوں کی آنکھوں میں نہیں دیکھتا۔‬،‫بہت شرمیلا ہے‬

History of Present Illness

 79

According to the client’s mother, when the client was one month of age, he suffered from

severe diarrhea, but it was treated by taking medicines. The developmental milestones of the

client were not age-appropriate.

He did not have any concept of colors, fruits, counting, alphabets, and other practical things.

Background History

Family History

The client’s father A.A. was 45 years old, educated up to F.A., and worked as an

shopkeeper. The client shared a healthy relationship with his father. He liked spending time with

his father and considered him as his friend.

The client’s mother was 42 years old housewife. She was educated up to matriculation.

She reported being calm in nature and used to spend her time with her children. The client shared

a healthy relationship with his mother, but was more attached with his father.

The client had 2 siblings, i.e., two sister. His elder sister was 18 years old, studying in

BS(Hons.). The client’s mother reported that the client shared an unhealthy relationship with his

sister. He used to be feared of her as she had a strict nature. The second-born sister was 15 years

old, and did take any formal education. The client lived in a nuclear family along with his parent

and siblings. He belonged to a middle-class family. The overall home environment was healthy

and the client was treated well at home.

Family History of Psychiatric Illness

The client’s mother reported that the client’s elder sister also had the same problem. She

was delayed in speech and her developmental milestones. She was not taken to any clinical

psychologist, but when the client came for therapeutic sessions, his parents also took his sister

for therapeutic sessions.

 80

Personal History

The client was born through cesarean delivery after prolonged labor. He had an

immediate cry, and his birth weight was normal. The client’s mother reported that she faced no

pre-natal or post-natal complications. The client was breastfed for 6 months. After that, his

mother started him bottle feeding along with breastfeeding. When the client was one month of

age, he suffered from severe diarrhea for which the doctors prescribed him medicines at that

time.

The client’s developmental milestones were significantly delayed. He achieved neck and

head holding at the age of 8 months. He started sitting at the age of 14 months and walking at the

age of 3 years. His one-word speech was achieved at the age of 4.5 years.

Table 1

Showing Developmental Milestones, Normal Age of Achievement, and Client’s Achievement Age

Developmental Milestones Normal Age of Achievement Acquired Age

(Gerber et al., 2010)

Head holding 4-6 months 8 months

Sitting 8-10 months 14 months

Walking 12-18 months 3 years

Single word speech 8-12 months 4.5 years

Two-word speech 12-24 months 5 years

Complete sentence 2 years Not achieved yet

Bladder control 2-3 years 4 years

Bowel control 2-3 years 4 years

Dress without help 4 years 8 years

Taking bath without help 4 years 7 years

 81

Educational History

The informal education of the client was started at home at the age of 4 years. His mother

and elder sister were involved in the teaching process, but the client did not learn many things.

At the age of five, he started his formal schooling. He continued his formal schooling for one

year only. After that, his parents withdrew him from school as the teachers complained to them

about his learning problem. The client had difficulty in learning academic tasks and his speech

was also not appropriate of his age. His parents then sent him to the tuition center near their

home. The client was going to his tuition teacher at the time of starting therapy. He did not have

any concept of color identification, categorization of fruits, counting, alphabets, and shapes. His

teacher reported that even if she taught the client one color name for one month and a gap of

only one day was taken, the client would forget that. She had to start it from the beginning.

Psychological Assessment

The formal and informal assessment was done to assess the client’s problems;

Informal Assessment Formal Assessment

Clinical Interview Colored Progressive Matrices

Behavioral Observations Slosson Intelligence Test

Portage Guide to Early Education (PGEE) Childhood Adaptive Behavior Scale

Reinforcer Identification

Informal Assessment
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Clinical Interview. A semi-structured clinical interview was done with his mother, sister,

and tuition teacher in which the personal, developmental, educational, and familial history was

taken. A complete account of the behavioral issues was taken. Verbal informed consent was

taken and confidentiality of information was ensured. From the interview, predisposing,

precipitating, perpetuating, and prognostic factors were identified which were helpful in

determining the diagnosis and the management of the client’s problems.

Predisposing Factors Precipitating Factors Perpetuating Factors Prognostic Factors

Male gender Delayed milestones Difficulties in learning Educated sister

Not consulting any Concerned parents

consultant and tuition teacher

Behavioral Observation. The client was of normal height and weight. He was dressed

neatly in weather-appropriate clothes. During the sessions, it was observed that he did not

understand instructions at one-time. He was shy and did not maintain eye contact without asking.

He used to smile at the therapist when she asked him anything. When he was given two

commands at a time (i.e., to touch the table and close the door), he did not perform even one

command. He asked again and again and still did not get them. He was not much interested in

doing session work and wanted the therapist to finish the session earlier. His speech was also not

appropriate of his age. He could not speak complete sentences and skipped some words.

Portage Guide to Early Education (Sturmey & Crisp, 1986). It was administered to

the client to assess his current functioning level in five domains. Some of the items were asked

by his mother while for other items, the client was asked to perform the given task. (Appendix)

Table 2
 83

Developmental Areas, First Crossed Item with Age Range, Last Correct Item with Age Range

and Functional Level in Portage Guide to Early Education

Developmental Areas First Missed Item Last Correct Item

Item No. Age Range Item No. Age Range

Language 41 2-3 years 62 3-4 years

Socialization 30 1-2 years 73 5-6 years

Self-Help 24 1-2 years 99 5-6 years

Cognitive 15 1-2 years 60 3-4 years

Motor 79 2-3 years 140 5-6 years

The results showed that the client lacked behind his chronological age in all the domains

i.e., language, socialization, self-help, cognitive, and motor. The socialization of the client was

not age-appropriate as it was evident from the history and observation that he did not know how

to behave appropriate to the situation, not playing with other children, not greeting familiar

adults without reminder, and was shy. The scores on the language domain indicated his lack of

speaking complete sentences, not using past present tenses, ing in the sentences, and usually

skipped some words from the sentences as evident from the history. The scores on the cognitive

domain revealed his lack of skills in identifying colors, shapes, categorizing fruits and

vegetables, pre-writing skills, counting, and differentiating objects. The scores on the self-help

domain revealed his lack of skills in dressing himself independently, zip unzips jackets, tying

shoe laces, buttoning and unbuttoning his shirt, and cleaning his table. The result of the motor

domain also revealed his delay in fine motor and gross motor skills.

Reinforces Identification. Some of the rein forcers were identified by asking the client’s

parents and his sister about his favorite activities and food while others were identified by
 84

observing the client during the session while performing activities. It helped in identifying the

most preferable reinforcer. Following this helped in identifying the hierarchy of the most to the

least preferred reinforcer.

Material Rein forcer Walking on the treadmill, cycling

Edible rein forcer biscuit, lays

Social rein forcer Praise (good job, good boy, wow)

Formal Assessment

Colored Progressive Matrices (Raven et al., 1990). It is a non-verbal intelligence test

that has been developed for evaluating mental development and intellectual maturity. CPM was

administered to the client to assess his intellectual maturity. (Appendix)

Table 4

Raw Scores, Percentiles, and Category on CPM

Raw Scores Percentile Subnormal IQ Category

11 5th 50 Intellectually impaired

The scores of the client indicated that the client falls in the category of intellectually

impaired. His subnormal IQ was 50, which indicated the client has an intellectual disability. The

scores were to be affected by inattention as the client was not paying much attention and was

answering rapidly without thinking.

Slosson Intelligence Test (Slosson, 1963). It is a test of verbal intelligence consisting of

oral questions assessing six cognitive domains that are, vocabulary, general information,

similarities and differences, comprehension, quantitative ability, and auditory memory. It was
 85

administered to the client to assess the verbal intelligence and intelligence quotient and to assess

the risks for the development of the cognitive disorder.

Table 5

Shows Chronological Age, Basal Age, Mental Age, IQ Ratio, and Category

Date of administration 17-09-2022

Date of birth 25-08-2012

Chronological age (years) 10 years 1 month

Chronological age (months) 121 months

Basal age (years) 2 years

Basal age (months) 24 months

Credit months 33 months

Mental age (years) 4.9 years

Mental age (months) 57 months

Ratio IQ 47

IQ range Below 70

Category Intellectually deficit

The client’s chronological age was 10 years and 1 month whereas his mental age as

calculated was 4 years and 9 months which indicated his delayed development. The IQ of the

client as calculated through the Slosson intelligence test was 47 which indicated his deficit in

intellectual functioning.

Childhood Adaptive Behavior Scale (Kicklighter & Richmond, 1983). The Childhood

Adaptive Behavior Scale (CABS) was used to assess the adaptive functioning of the client.

Table 6
 86

Table showing scores on five domain of Child Adaptive Behavior Scale

Domains Raw Score Age Equivalence Age Equivalence

(EMR) (Regular)

Language Development 7 -6 years -5 years

Independent Functioning 13 -7 years -5 years

Family Role Performance 9 6 years -5 years

Economic Vocational Activity 7 -6 years -5 years

Socialization 9 -6 years -5 years

The scores on the five domains of the Childhood Adaptive Behavior Scale indicated

significant delay in the client’s adaptive functioning. His language was significantly delayed as

the functional age of the client in language development was -6 years. The minus sign indicated

that the client’s scores were below 6 years in language development. His independent

functioning, family role performance, economic vocational activity, and socialization scores also

indicated significant delays in these areas.

Summary of Psychological Assessment

Portage Guide for Early Education was administered to assess the current functioning

level of the client which revealed delays in the cognitive, socialization, self-help, language, and

motor domains. Colored progressive matrices and Slosson Intelligence Test were administered to

assess the intellectual functioning of the client. The subnormal IQ on CPM was 50, and scores on

SIT indicated IQ of 47. The scores on these assessment tests indicated that the client’s IQ was
 87

below borderline. This indicated his deficit in intellectual functioning. The Childhood Adaptive

Behavior Scale was administered to assess the adaptive functioning of the client. The scores on

the five domains indicated a significant deficit in the client’s adaptive functioning. The client’s

scores on these assessment tests indicated the diagnosis of Intellectual Disability Disorder

(Moderate).

Diagnosis

According to DSM-V, the diagnosis of the client was 319 (F71) Intellectual Disability

Disorder, Moderate.

Case Formulation

The client was 10 years and one month old who came with complaints of having

difficulties in learning anything, not interacting with other individuals and being shy, smiling on

seeing people and not maintaining eye contact without asking, not understanding how to behave

in a certain situation, forgetting learned material even after learning it for one month, his parents

have to assist him in his daily life functioning, not have the concept of practical things in daily

life such as colors differentiation, the concept of money, and fruits categorization, and not have

complete sentences speech. The psychological assessment done included informal and formal

assessment. The scores on Portage Guide to Early Education indicated his developmental delays

in language, cognitive, self-help, socialization, and motor domain. The scores on CPM and SIT
 88

indicated deficit in intellectual functioning. The scores on CABS revealed deficit in the adaptive

functioning. After thorough assessment, the client was diagnosed with 319 (F71) Intellectual

Disability Disorder, Moderate.

The client was not given the diagnosis of Autism Spectrum Disorder as non-verbal

communication behaviors such as eye contact, facial expressions, and attending were present in

the client. His problem in communicating and interacting with others was due to his deficit in

adaptive functioning. This was the characteristic of Intellectual Disability Disorder. The client

was not given the diagnosis of Attention Deficit/Hyperactive Disorder. The lack of concentration

in the client was not due attention deficit as in ADHD. This is because he was not properly

understanding the instructions. This factor made him inattentive of what he was not

understanding. This was due to his deficit of Intellectual Functioning. Considering these factors,

the client was given the diagnosis of Intellectual Disability Disorder.

As evident from the history, the client was born through C-section. Research findings

revealed that those children born through C-section have 10-30% increased risk of being

diagnosed with neurodevelopmental disorders (Zhang et al., 2021). The child’s gender also

predicts the probability of the development of neurodevelopmental disorders. According to

DSM-5, males are more likely than females to be diagnosed with intellectual disability. This can

also be a predisposing factor of the client diagnosing with Intellectual Disability Disorder.
 89

Portfolio

Client I.F was 05 years old boy who came with complaints of not maintaining eye contact, not

attending to his name, playing in isolation and did not interact with anyone, delayed speech,

psychological assessment was done on two levels. The informal assessment included a clinical

interview, behavioral observations, Portage Guide to Early Education (PGEE), and reinforcer

identification. The formal assessment included the Child Autism Rating Scale. On the basis of

the assessment, the client was diagnosed with 299.00 (F84) Autism Spectrum Disorder. The

behavior therapy was proved effective and there was improvement in the client’s behavior

Bio data

Name I.F.

Gender Boy
 90

Age 05 years

Date of birth 02-12-2013

No. of siblings 01

Birth order fast born

Informant Client’s mother

Reason for Referral

The client came to the Autism Resource Center with complaints of not maintaining eye

contact, for the assessment of his behavioral issues and diagnosis. Playing in isolation and did

not interact with anyone, delayed speech. Odd behavior (jumping) stereo type behavior, and

getting excited in isolation gathering and putting had on ears in sound, keeping doors closed

fixed with moving or round object. He was referred to the trainee clinical psychologist for

assessment and management of his problems.

Presenting Complaints

As reported by the client’s mother

 speech delayed,
 lack of social interaction
 Odd behavior (jumping) stereo type behavior, and getting excited in isolation gathering
and putting had on ears in sound, keeping doors closed
 Not maintain eye contact.
History of Present Illness

According to the client’s mother, the client’s mother reported that he was restricted to

home for at least 2.5 years. He was provided with a mobile phone on which he used to spend

almost 5 hours daily. He liked watching Korean videos and songs. His mother reported that he

was just into his phone and did not respond to anyone. He was not even attracted to any toy and

used to put everything in his hand into his mouth. His mother reported that when they first
 91

brought the client to the market along with them, he closed his eyes on seeing other people. He

started crying there and felt uncomfortable being in a crowd.

The client did not maintain eye contact with other people and did not respond to anyone.

He had delayed speech and did not interact with anyone who came to his home. His mother

reported that he seemed to not even care about what others were doing or talking. He just

remained into himself and used to play in isolation.

The client’s mother reported that the client did not speak a single word. He did not even

do babbling. He used to tell his needs by holding his mother’s hand and pointing it to the thing

he needed. He did not play with other kids and liked to play in isolation. The developmental

milestones of the client i.e., head holding, sitting, crawling, and walking were age-appropriate,

but his speech was delayed. According to the client’s mother, the client was a pampered child.

That’s why, the client’s mother did not notice the client’s behavior as inappropriate. The client’s

parents then took the client to the Autism Center and was referred to the trainee clinical

psychologist for the assessment and management of his problems.

Background History

Family History

The child lives I joint family system. He is first born child among two sibling. He has a

younger brother who is two years old and he has a social personality. His father has private job.

He had heart issue. The client’s mother reported that the client’s father was calm and friendly

toward his children and the client had a congenial relationship with his father.

The client’s mother was 39 years old housewife. She is diabetic. She reported being calm

in nature and used to spend time with the client. She used to play with the client and the client

seemed to have a healthy relationship with her. The client was more attached to his mother than
 92

his father as his father used to stop him from doing certain things. The client’s mother reported

that the client shared a satisfactory relationship with his father and siblings and a healthy

relationship with his mother. The overall home environment was reported to be healthy.

Family History of Psychiatric Illness

The client’s mother reported that there is no history of any fever, head injury,

dehydration. His paternal family is positive for ASD .he was born through C-section delivery.

His mother was reported diabetes. He had his first cry present. He child mother took feed.

Personal History

The mother reported that the length of term 9 month. The client was born through c-

section. His prenatal history was normal. His mother was report as diabetic. He had an

immediate cry, and his birth weight was normal. The client’s mother reported that she faced no

pre-natal or post-natal complications. She was not taken medicine in pregnancy. The child took

mother feed. The client achieved his developmental milestones such as head and neck holding,

sitting, crawling, and walking at the appropriate age. But, his speech was not achieved even at

the age of 3 years. He did not even produce sounds.

Table 1

Showing Developmental Milestones, Normal Age of Achievement, and Client’s Achievement Age

Developmental Milestones Normal Age of Achievement Acquired Age

(Gerber et al., 2010)

Head holding 4-6 months 4 months

Sitting 8-10 months 5-06 months

Crawling 10-12 months 07-08 months

Walking 12-18 months 12 months

Single word speech 8-12 months 4 month

 93

Complete sentence 12-24 months Not Achieved Yet

Bladder control 2-3 years Not Achieved Yet

Bowel control 2-3 years 04 year

Dress without help 4 years Not Achieved Yet

Educational History

The informal education of the client was started at home at the age of 2.5 years. His

mother and father were involved in the teaching process. The client’s mother used to rhyme the

poems with the client. The client also had a little concept of the “circle” shape. Besides this, he

did not have any concept of colors, alphabets, fruits etc.

Psychological Assessment

The formal and informal assessment was done to assess the client’s problems;

Informal Assessment Formal Assessment

Clinical Interview Child Autism Rating Scale (CARS)

Behavioral Observations

Sensory Checklist

Portage Guide to Early Education (PGEE)

Reinforcer Identification

Informal Assessment

Clinical Interview.

A semi-structured clinical interview was done with his mother in which the personal,

developmental, educational, and familial history was taken. A complete account of the

behavioral issues was taken. Verbal informed consent was taken and confidentiality of
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information was ensured. From the interview, predisposing, precipitating, perpetuating, and

prognostic factors were identified which were helpful in determining the diagnosis and the

management of the client’s problems.

Predisposing Factors Precipitating Factors Perpetuating Factors Prognostic Factors

Genetic predisposition Delayed milestones Parent’s pampering Regular follow-up

Male gender Educated parents

Covid-19 restrictions

Excessive screen time

Behavioral Observation. The client was of normal height and weight. He was dressed

neatly in weather-appropriate clothes. During the sessions, it was observed that he was

responsive toward his name and did not maintain eye contact. The client was fascinated by the

light in the room. He remain in his seat and used to sit on the table to complete his ABA activity

task. Mouthing behavior was also observed in the client as he used to follow the command to

complete his task. He almost attend to any command of the therapist and was involved in playing

and recognized differentiate between small and big same and different object. His imitation is

almost good. He is contract to people.

Rein forcers Identification.

Some of the rein forcers were identified by asking the client’s mother about his

favorite activities and food while others were identified by observing the client during the

session while performing activities. During the session, the free-operant preference assessment

method was used in which the client was provided access to all the available stimuli and was

allowed to freely engage with any presented stimuli. The engagement was monitored with the

duration. It helped in identifying the most preferable reinforcer. Material reinforcers were the

most preferable reinforcers. Following this helped in identifying the hierarchy of the most to the
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least preferred reinforcer. The reinforcers were identified to make it contingent on the

individualized educational plan and developmental tasks.

Negative Rein forcer Ruben(pony)

Edible Reinforcer Burger, lays

Social Reinforcer Praise (good job, good boy, wow), clapping

Formal Assessment

Childhood Autism Rating Scale (CARS, Schopler 1980). It is a behavioral rating scale

used for assessing the presence and severity of symptoms of Autism spectrum disorders. It

consists of 15 domains, with each scored on a rating scale from 1 to 4. The total score ranges

from 15 to 60. It has .94 internal consistency and a reliability of .71. It was administered by

asking the client’s mother and observing the client during the session. The childhood autism

rating scale was administered to assess the current functioning level of the client. The scores

showed that the client had mildly-moderate autism. (Appendix)

Table 4

Raw Scores, Range, and Corresponding Category on Childhood Autism Rating Scale

Raw scores Range Category

36 30-38 Mildly-moderately autistic

The scores on CARS indicated his high scores in the item no. 2, 3, 5, 8, and 11 that

included moderately abnormal imitation, emotional response, object use, listening response, and

verbal communication. The client’s scores fall in the category of mildly to moderately autistic.

Summary of Psychological Assessment

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During the interview, it was revealed that the client had some repetitive behaviors, had

problems interacting and communicating, did not maintain eye contact or attend to his name, and

had sensory issues. These symptoms indicated the client’s autistic behavior. Sensory checklist

was administered that showed the client’s gustatory, olfactory, and auditory sensory issue. The

formal assessment was done using the Childhood Autism Rating Scale. The scores on CARS

indicated his mildly-moderate autism.

Diagnosis

According to DSM-V criteria and keeping in view the observation and assessment, the

client was diagnosed with 299.00 (F84) Autism Spectrum Disorder, accompanying language

impairment.

Case Formulation

The client I.F. was 05 years old boy who came with complaints of not maintaining eye

contact, not responding even if called his name 10 times, , playing in isolation and did not

interact with anyone, not doing his self-help tasks, walking on his toes, not speaking a single

word, being lazy, and fascinated with same object. Psychological assessment was done on two

levels. The results on PGEE indicated deficits in language, motor, socialization, self-help, and

cognitive domain. The scores on CARS indicated mildly-moderately autistic in the client. These

results helped in diagnosing the client with an Autism Spectrum Disorder.

The client was not diagnosed with intellectual disability as he had specific repetitive

behaviors that were a feature of Autism. Moreover he was able to memorize the tasks learned

and was able to perform it in the correct way. He learned his tasks efficiently. He was not

diagnosed with the language and social communication disorder as he had restrictive and

repetitive behavior that were absent in this disorder. The client was not diagnosed with
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stereotypic movement disorder as the repetitive behavior was better explained by autism

spectrum disorder. He did not meet the criteria for disorders other than Autism Spectrum

Disorder (DSM, 2013).

The client was born via cesarean delivery. Research has indicated that cesarean delivery

was associated with a 26% increased risk of causing autism in the child either due to stress or

some other possible explanation (Chang, 2011). In addition, the client was a boy which also

increased the incidence of having autism as research has indicated that autism spectrum disorder

was four times more common in males than females (Maenner et al., 2020).

The client’s history revealed delayed development of milestones. According to Tager-

Flusberg (2016), most children with autism are found to have delays in achieving milestones,

especially the onset of words, phrases, and sentences is delayed. They have problems with

receptive and expressive language due to processing deficits. It has also been found that children

with autism had difficulties in understanding and responding appropriately to others. They

demonstrate problems with motor control (Cook et al., 2013).

It has been found that the client had sensory issues. These issues were related to sensory

processing. It has been found that over 96% of children with ASD reported hyper and hypo-

sensitivities in multiple domains which ranged from mild to severe ranges (Crane et al., 2009).
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Portfolio

Case Summary

Client j. A was 5 years and 6 months old boy who came to the ARCL with complaints of being

aggressive, not doing classwork or homework while sitting on the chair, excessive talk, difficulty

paying attention, lack of concentration, restless, having difficulty waiting for her turn, breaking

and miss-consuming household things, not listening to anyone’s commands, and stubborn.

Psychological assessment was done on two levels. The informal assessment included a clinical

interview, behavioral observations, Portage Guide to Early Education (PGEE), and reinforcer

identification. The formal assessment included Slosson Intelligence Test (SIT) and Conner’s

rating scales. On the basis of the assessment, the client was diagnosed with 314.01 (F90.2)

Attention Deficit/Hyperactivity Disorder with Combined Presentation, Severity Level Moderate.

The management of the client’s problems was focused on using behavioral therapy techniques to

modify the client’s behavior.

Bio data:

Name j.A

Gender Male

Age 5 years 6 months

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Date of birth 26-07-2018

No. of siblings 1

Informant Client’s mother

Reason and Source of Referral:

The client came to the autism center, ARCL Lahore with complaints of being

aggressive, for the assessment and management of behavioral issue and diagnosis Not doing

classwork or homework while sitting on the chair, excessive talk, difficulty paying attention, lack

of concentration, restless, having difficulty waiting for her turn, not listening to anyone’s

commands, and stubborn. She was referred to the trainee clinical psychologist for assessment

and management of her problems.

Presenting Complaints

As reported by the client’s mother

Speech delay

Self-stimulatory behavior

Lack of social interaction

Birth and medical history:

Condition during pregnancy Stressful

Taken medicine in pregnancy None

Type of delivery C-section

Birth crying Not sure

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Birth condition of the child Normal

History of fits No

Birth Full term

History of fever NO

Developmental milestones (as report by mother)

Developmental Achieved age of Normal age of Remark

milestone milestone archived

Neck holding 6 months 2-4 month Delay

Sitting without 8 months 5-10 month Normal

support

Crawling 10 months 8-12 month Normal

Walking 18 months 12-20 month Normal

Speech 4 years 8-12 month Delayed

Bladder and bowel 5 years 2.5 to 3 years Delayed

Family history:

He was born to non-carmangtaineous parent and only born child. His mother is a housewife. His

primary language is Urdu. His family history was positive for psychological dysfunction.

Clinical observation:
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At first visit, it was observed that he was young child with average height. According to his age.

He was wearing eat and press cloth. When he enters the room, he seemed lost, and did not

explore his environment. he did not interact with people around him.it was difficult to build

report him as he is lost in his self-stimulatory behavior. He was involved in jumping and

trampoline. He was not willing to fellow simple commands.

Assessment tool Applied:

 Portage guide early education program

 Child autism rating scale
 Assessment of basic language and learning skill

Portage guide early education program

Development profile was done and result are as follows

Areas Chronological age, 5, 4 developmental age

level

Cognitive 1year

Socialization 11 months

Quantitative analysis

Development Areas Cut off score

communication Autism 04

Autism spectrum 02

Reciprocal social interaction Autism 07

Communication+ reciprocal+ Autism12 18

social interaction Autism spectrum 7

Play 04
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Stereotyped behavior 06

Qualitative Analysis:

The score classification of Autism diagnosis observation schedule model 1include that the child

fails under the category of autism spectrum disorder.

Communication:

The obtain score of the child indicated that he has single word speech through words. He is

speech limited to imitation of sound. He uses adult body as a way to communicate.

Reciprocal social interaction:

He maintains eye contact during activity, physical interaction and when he needs nothing. He

responds to initial greeting but does not initiate a social interaction. Social interaction is

restricted and he has no peer play. He has interest in different sensory toys like musical and

lightening toys. He also took interest in peg boards but unable to use it properly as he put

everything in mouth. He is more interested in object like lip gloss and nail polish.

Stereotyped behavior and restricted interest:

His stereotype behavior is spinning, finger wiggling, hand clapping and shouting.

Diagnosis:

Portfolio

Case summary

M. shayyan tariq came to the iffat hiospital visin for the special need children for children with

presenting complaints of hyperactivity, inability to speak age appropriately and lack of

communication skills and repetation of words.

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He was born at full term by c-section on mothers will with the birth weight of 3 kg. immediate

cry was present. There was no history of jaundice and fits. History of pneumonia was present at

the age of 4.5 months. Appendectomy was done at the age of 8 year. His vaccination was up to

date. His eating was age appropriate but he gulped food in hurry.

He archived all his developmental millstones at the following age level.

Neck holding = 3-4 month

Sitting = 5-6 months

Crawling = 6-7 months

Walking = before 1 year

Vocalization = 3-4 month

Babbling = 1-5 year

1 word = 3 year

2 words = 3 years

Small sentence = 4-5 years

Current status:

could speak the small sentences but repeat the words

Family and personal history:

x.y.z was born to consanguineous parents and was younger than two brothers. There was history

of developmental delay in the family. There was history of schizophrenia in grandmother of

child. He took speech therapy at the age of 2.5 years. He took consultation at 2.5 years from

mayo hospital and was diagnosis as autism spectrum disorder (ASD) and took therapy for some

month. After that she move to iffat anwar hospital Lahore at the age of 3 year and took therapy

for 5-6 month. The child basically belongs to Chakwal so went there in vacation and
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discontinued therapy. He starts schooling at the age of 6 year in play group and promote to next

class after 1 year 5 months. At came to the iffat hospital for therapy and academic skill.

Clinical observation and examination:

During consultation x.y.z have good response to name and eye contact. He was hyperactive, he

covered ears on hearing loud sounds. Hand flapping was observed wich was present in

excitement and aggression. Hair cutting and nail cutting were not problematic. History of toe

walking was present but settled at present. He followed the given instruction. Head banging was

present in presenting. interactive play was started from last 3-4 years. He took big bits and then

gulped them in hurry. He used to watch TV, mobile and tab for 2 to 2.5 hours per day at the age

of 5 year till 8 years and it got 3-4 hours per date from 8 years of age till 10 years

Assessment:

For assessment purpose (clinical psy) has done the given test

1 : developmental profile
2 Childhood autism rating scale (CARS)
3 Behavior rating scale

Informal assessment:
During assessment x.y.z was given eye contact and response to name. He could follow
two step instruction, imitation and pointing was present. Pretend play was present. Hand
flapping was present during excitement. He could communication his feeling with other.
He sometimes threw tantrums if his desire did not be fulfilled. He followed and behavior
like his brother. Attention seeking behavior was present. He got excite in gathering. He
took food too much. He was interested in cooking. He used to arrange his room properly
and put things at their proper place. He was fixed his routine.

1: developmental profile:
CA = 11-year 4 month
Areas Developmental age level
socialization 4-year 5 month
Self help 4-year 6 month
cognition 4-year 8 month
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motor 6 years

2: childhood autism rating scale (CARS)

Areas Score

Relating to people 2.5

Imitation 1

Emotional response 2

Body use 2.5

Object use 2.5

Adaptation to change 2.5

Visual response 2

Listening response 2

Taste, smell, touch response and use 2.5

Verbal communication 2

Non-verbal 1.5

Activity level 2.5

Level and consistency of intellectual response 2.5

General impression 2.5

Total 33

Category Mild moderate autism

Assessment & results:

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Areas Functional level

Functional language 3.8

Expressive language 4.5

Receptive language 3.5

 Feeding: independent
 Dressing:
Independent
Couldn’t tie his shoes laces

Conclusion Behavior rating scale:

behavior Parent’s rating Psy, rating

on seat behavior 40 to 45 minutes 40 mints
Eye contact 8 8
Response to name 8 8
imitation 9 9
compliance 7 6
hand flapping 6 6
pointing 7 7

Diagnosis:
According to DSM 5TR on the basis of above history, clinical observation, & test result
x. y. z was diagnosed as having autism spectrum disorder (ASD)
Recommendation:

1. Continue structure session applied behavior analysis (ABA)

2. Self-help skill and behavior modification therapy
3. Continue speech therapy
4. Continue occupation therapy
5. Parental counseling.
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Case Summary

Client A. A was 5 years and 6 months old girl who came to the outpatient department of children

hospital with complaints of being aggressive, not doing classwork or homework while sitting on

the chair, excessive talk, difficulty paying attention, lack of concentration, restless, having

difficulty waiting for her turn, breaking and mis-consuming household things, not listening to

anyone’s commands, and stubborn. Psychological assessment was done on two levels. The

informal assessment included a clinical interview, behavioral observations, Portage Guide to

Early Education (PGEE), and reinforcer identification. The formal assessment included Slosson

Intelligence Test (SIT) and Conner’s rating scales. On the basis of the assessment, the client was

diagnosed with 314.01 (F90.2) Attention Deficit/Hyperactivity Disorder with Combined

Presentation, Severity Level Moderate. The management of the client’s problems was focused on

using behavioral therapy techniques to modify the client’s behavior. A total of 11 sessions were

conducted with the client. The therapy was proved effective and the client’s behaviors were

improved.
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Biodata

Name A .A

Gender Female

Age 5 years 6 months

Date of birth 10-03-2017

No. of siblings 3

Birth order 2nd

Informant Client’s mother

Reason and Source of Referral

The client came to the Iffat Anwar medical Hospital, Lahore with complaints of being

aggressive, not doing classwork or homework while sitting on the chair, excessive talk, difficulty

paying attention, lack of concentration, restless, having difficulty waiting for her turn, breaking

and mis-consuming household things, not listening to anyone’s commands, and stubborn. She

was referred to the trainee clinical psychologist for assessment and management of her problems.

Presenting Complaints

As reported by the client’s mother

‫دورانیہ‬ ‫شکایات‬

‫تین چار سال سے‬ ‫دوسرے بچوں کو مارتی ہے۔‬

‫تین سال سے‬ ‫ایک جگہ ٹک کر نہیں بیٹھتی۔‬

‫تین سال سے‬ ‫بات نہیں مانتی۔‬

‫تین سال سے‬ ‫ٹک کر کام نہیں کرتی۔‬

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‫تین سال سے‬ ‫پڑھائی میں دھیان نہیں دیتی۔‬

‫تین سال سے‬ ‫ خراب کر دیتی ہے یا ضائع کر‬،‫چیزوں کو چھڑتی ہے‬

‫دیتی ہے۔‬

‫تین سال سے‬ ‫بہت زیادہ باتیں کرتی ہے۔‬

History of Present Illness

The client’s mother reported that when she was pregnant, the fetus was not growing

properly. So, the doctors prescribed her injections. The dosage of these injections was 2

injections/month during the first trimester and 1 injection/month during the second and third

trimesters. The client’s mother faced complications during the client’s birth. She was born

through C-section. She had an immediate cry after birth but her weight was low. One month after

birth, the client suffered from jaundice. The client achieved all her developmental milestones at

the appropriate age. Her mother reported that after one year of age, when the client started

crawling, she used to pick the household things and mis-consume them. When the client was 3

years of age, her screen time was increased up to 5 hours a day. Her mother reported that

whenever she took the mobile from the client, she behaved stubbornly. She used to lay on the

floor or hit the elders if her need was not met. When the client was 3.5 years old, her mother

started teaching her at home. At this time, the client’s mother noticed that the client did not pay

attention to studies, got easily distracted, and was restless.

The client’s mother took the client to the children hospital in Aug, 2022. The client was referred

to trainee clinical psychologist for assessment and management of her problems.

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Family History

The client’s father A.M was 38 years old, educated up to MBA, and worked in a bank.

He reported being calm and friendly toward his children and the client had a healthy relationship

with her father.

The client’s mother was 34 years old, housewife and educated up to bachelors. She

reported being calm in nature but sometimes got irritated by the client’s behavior and beat her.

The client seemed to have a healthy relationship with her mother.

The client’s parents were first cousins. Their relationship was reported to be satisfactory,

but the client’s mother also reported that her husband physically abused her when they had a

fight on any issue. This also had an impact on the client’s behavior as after seeing her father

beating her mother, she thought that beating someone is an acceptable behavior and she used to

beat her cousins and fellow kids when they did not listen to her.

The client had 2 siblings, one brother, and a sister. Her elder sister was 8 years old,

studying in 2nd class. The client’s mother reported that the client shared a healthy relationship

with her sister. The client’s younger brother was 3 years old. The client shared a healthy

relationship with him and used to take care of him.

The client lived in a joint family with her grandparents. The overall home environment

was reported to be satisfactory.

Personal History

The client was born through cesarean section after prolonged labor. She had an

immediate cry, but her birth weight was low. The client’s mother faced pre-natal and post-natal

complications. She reported that when she was pregnant, the fetus growth was not normal so the
 111

doctors prescribed her injections. During childbirth, the mother faced intestinal malrotation.

Within one month of the client’s birth, she suffered from jaundice and fever.

The client achieved her developmental milestones i.e., head holding, sitting, crawling, walking,

speech, bowel and bladder control, dressing, and taking bath without help at the appropriate age.

Table 1

Showing Developmental Milestones, Normal Age of Achievement, and Client’s Acquired Age

Developmental Milestones Normal Age of Achievement Acquired Age

(Gerber et al., 2010)

Head holding 4-6 months 6 months

Sitting 8-10 months 6-7 months

Walking 12-18 months 13 months

Single word speech 8-12 months 9 months

Complete sentence 12-24 months 15 months

Bladder control 2-3 years 4 years

Bowel control 2-3 years 4 years

Dress without help 4 years 4 years

Taking bath without help 4 years 4 years

Educational History

The informal education of the client was started at home by her mother at the age of 4.5

years. The client’s mother reported that the client used to get easily distracted while studying and

was involved in playing. She had difficulty paying attention and completing the tasks. She did

not sit on her seat. The client did know some of the body parts and animals’ names, but couldn’t

recognize colors, numbers, and alphabets.

 112

The client did not receive any formal education. Her parents were deciding to start her

formal education once some of her behavioral issues will be reduced.

Psychological Assessment

The formal and informal assessment was done to assess the client’s problems;

Informal Assessment Formal Assessment

Clinical Interview Conners Rating Scale

Behavioral Observations

Portage Guide to Early Education (PGEE)

Reinforcer Identification

Behavior Rating Scale

Informal Assessment

Clinical Interview.

A semi-structured clinical interview was done with her mother in which the personal,

developmental, educational, and familial history was taken. A complete account of the

behavioral issues was taken

Predisposing Factors Precipitating Factors Perpetuating Factors Prognostic Factors

Prolonged labor and Deficiency of protein Parent’s pampering Mother was

complications during Methylmalonic Parent’s delayed supportive, kept

delivery acidosis acceptance of the seeking help for the

Slow pre-birth growth behavioral issues client, and brought

her regularly for the

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Jaundice, diarrhea, sessions.

and dehydration under

1 year after birth

Lactose intolerance

Behavioral Observation. The client was of normal height and weight. She was dressed

neatly in weather-appropriate clothes. She was very active during the whole session. She

explored the things and roam here and there in the session room. During the sessions, the client

was easily distracted by the activities around her such as the child playing with pegboards or

bubbles. After being asked three to four times, she used to focus on the task but still was

distracted after sometime. The client had poor on-seat during the session. The client was

excessively talking during the session. She was talking about her family members, her favorite

activities, and toys.

Behavior Rating Scale. The client’s on-seat behavior and not waiting for her turn was

subjectively rated through behavioral observation of the client.

Table 2

Subjective rating for wait and on-seat behavior of the client

Behavior Rating

Waiting behavior 1 min

On-seat behavior 2 min

Portage Guide to Early Education (Sturmey & Crisp, 1986). It was administered on

the client to assess her current functioning level in five domains. (Appendix)

Table 3
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Developmental Areas, First Crossed Item with Age Range, Last Correct Item with Age Range

and Functional Level in Portage Guide to Early Education

Developmental Areas First Missed Item Last Correct Item

Item No. Age Range Item No. Age Range

Socialization 39 1-2 years 64 4-5 years

Self-Help 48 2-3 years 74 4-5 years

Cognitive 18 1-2 years 80 4-5 years

Motor 79 2-3 years 129 5-6 years

The results showed that the client lacked behind her chronological age in majorly three

domains of PGEE. The socialization of the client was not age-appropriate as it was evident from

the history and observation that she had a stubborn attitude and did not cooperate with the

parental requests. She used to engage in inappropriate social behaviors. She immediately wants

the object of her choice if she has seen it somewhere. She rarely listens to the commands of

elders, wait for her turn, or request an object. The scores on the cognitive domain revealed her

lack of skills in naming colors, categorization, differentiating heavy and light, identifying the

missing part, and academic tasks (alphabets, counting). She had a problem with cutting straight

lines and shapes and pasting, printing letters, standing on one foot, and copying complex shapes.

Reinforcers Identification. Some of the reinforcers were identified by asking the client’s

mother about her favorite activities and food while others were identified by observing the client

during the session while performing activities

Material Reinforcer Colored rings, pegboard, bubbles

Edible Reinforcer Juice, lays

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Social Reinforcer Praise (good job, wow), smiling at her, high-five

Formal Assessment

Conners Rating Scale (Conners, 1997). The Conners Behavior Rating Scale was used

to better understand certain behavioral, social, and academic issues. It was used to help diagnose

the client. The parent’s rating and teacher’s ratings were obtained. The observations were also

taken into account when the parent’s version was administered with the help of her mother. The

teacher’s version was filled by the client’s school teacher. (Appendix)

Table 5

Raw scores and t Scores on Parent’s Rating of Oppositional, Inattention, Hyperactivity and

ADHD Index along with the Relevant Category

Parent’s Rating
Subscale
Raw scores t score Category

Oppositional 7 61 Mildly atypical

Cognitive problems/Inattention 9 71 Moderately atypical

Hyperactivity 11 78 Markedly atypical

ADHD index 18 68 Moderately atypical

Total 41

The scores of the parent’s ratings indicated that the client obtained mildly atypical scores

on oppositional, moderately atypical scores on cognitive problems, inattention and markedly

atypical scores on hyperactivity making the client moderately atypical on ADHD index. It

provided a strong indication towards diagnosing the client and indicated that behavioral and

emotional problems were severe.

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Table 6

Raw scores and t Scores on Teacher’s Rating of Oppositional, Inattention, Hyperactivity and

ADHD Index along with the Relevant Category

Teacher’s Rating
Subscales
Raw scores t scores Category

Oppositional 4 70 Moderately atypical

Cognitive problems/Inattention 3 52 Not significant

Hyperactivity 12 80 Markedly atypical

ADHD 19 72 Moderately atypical

Total 38

The scores on the teacher’s rating were in accordance with the scores on parent’s rating.

It indicated the client’s moderately atypical scores on oppositional showing the client’s

vulnerability towards developing oppositional defiant disorder. High t scores on hyperactivity

and ADHD provided evidence of Attention Deficit/Hyperactivity Disorder in the client.

Diagnosis

According to DSM-V, the diagnosis of the client was 314.01 (F90.2) Attention Deficit

Hyperactivity Disorder Combined Presentation, Severity Level Moderate.

Case Formulation

The client was 5 years and 6 months old and came with the presenting complaints of

being aggressive, not doing classwork or homework while sitting on the chair, excessive talk,

difficulty paying attention, lack of concentration, being easily distracted, restless, having

difficulty waiting for her turn, breaking and mis-consuming household things, not listening to

anyone’s commands, and stubborn. The client was diagnosed with Attention-Deficit/

Hyperactivity Disorder with the specifier of combined presentation.

117