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CHILD CLINICAL PLACEMENT REPORT

SUBMITTED TO

Sir Fayyaz

SUBMITTED BY

Sumana Aslam

SAP ID: 54590

SESSION

2023 - 2025

DEPARTMENT OF APPLIED PSYCHOLOGY

RIPHAH INTERNATIONAL UNIVERSITY, ISLAMABAD

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CASE REPORT COMPLETION CERTIFICATE

Certified that these case reports have been carried out and completed by Sumana Aslam,

SAP ID: 54590 under our supervision.

Supervisor Clinical Placement In-Charge

_________________ _________________
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ACKNOWLEDGEMENT
I would like to extend my utmost gratitude and acknowledgment to Allah

Almighty, whose infinite blessings and guidance have enabled me to complete this case

report as a requirement for my MS Clinical Psychology degree.

I am deeply indebted to my esteemed supervisor, Sir Fayyaz, for their invaluable

guidance, expertise, and unwavering support throughout this arduous process. Their

profound knowledge, insightful feedback, and constructive criticism have been

instrumental in shaping and enhancing the quality of this report. Their mentorship has

significantly contributed to my professional and academic growth, and I am sincerely

grateful for their dedication and commitment.

Furthermore, I would like to express my sincere appreciation to Healthy Minds

Clinic. I am grateful for their cooperation and assistance in facilitating the assessment

and treatment process, which has enriched my understanding and practical experience.

Moreover, I would like to express my heartfelt thanks to my colleagues and

fellow students for their valuable input, feedback, and support during discussions and

brainstorming sessions. Their diverse perspectives and contributions have significantly

contributed to the refinement and effectiveness of the ideas presented in this report.

Lastly, I want to acknowledge and express my profound appreciation to my

beloved family and friends for their unwavering support, encouragement, and

understanding throughout my academic journey. Their constant belief in my abilities and

their presence during both challenging and joyous moments have been a source of

strength and inspiration.

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TABLE OF CONTENT

Case 1 9
Global Developmental Delay 9
Case Summary 10
Identifying Information 11
Context of referral 11
Presenting complains (Verbatim) 11
Presenting Complains 12
History of present illness 12
Background History 12
Birth History 12
Developmental History 12
Educational History 13
Family History 13
Social History 14
Medical, Psychiatric and psychological History of client 14
Medical, Psychiatric and psychological History of family 14
Legal History 14
Psychological Assessment 14
Informal Assessment 14
Clinical interview 14
Formal Assessment 15
Portage guide to Early Education 15
DSM-5-TR Checklist for GDD 17
Preliminary diagnosis 18
Case Conceptualization 19
Prognosis 21
Management Plan 21
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Recommendations 28
References 29
Appendices 30
Case 2 75
Intellectual Disability Disorder 75
Case Summary 76
Demographic information 77
Source and reason of referral 77
Presenting complains 77
History of present illness 78
Background History 79
Personal History 79
Background History 79
Personal History 79
Developmental History 79
Educational History 80
Family history 80
Psychological assessment 81
Informal assessment 81
Clinical interview 81
Mental state examination 82
Formal assessment 82
Slosson Intelligence Test 83
Quantitative analysis 83
DSM – 5 TR Checklist 83
Diagnosis 84
Case conceptualization 84
Prognosis 87
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Management Plan 87
Pre and Post Intervention Assessment 93
Recommendations 94
References 94
Appendices 96
Case 3 121
Attention Deficit Hyperactivity Disorder 121
Case summary 122
Identifying Information 123
Reason and source of Referral 123
Presenting Complains (Verbatim) 123
History of present illness 124
Personal History 124
Developmental History 124
Developmental Milestones 125
Family History 125
Family Psychiatric History 125
Social History 126
Academic History 126
Psychological Assessment 126
Clinical Interview 127
Behavioral Observation 127
Portage Guide to Early Education 127
Formal Assessment 128
Conner’s parent rating scale 128
Quantitative scoring 128
DSM-5 Criteria 129
Tentative Diagnosis 130
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Case Conceptualization 130

Management Plan 133
Pre and post intervention assessment 139
Recommendations 140
References 141
Appendices 143
Case 4 191
Autism Spectrum Disorder 191
Case summary 192
Identifying Data 193
Reason and source of Referral 193
History of Present Illness 194
Family Background 194
Family History of Psychiatric Conditions 195
Background Information 195
Medical and Birth History 195
Educational Background 195
Developmental History 195
Psychological Assessment 196
Informal Assessment 196
Clinical interview 196
Behavioral Observations 197
Portage Guide to Early Education Assessment
197
Formal Assessment 198
Childhood Autism Rating Scale 199
DSM 5 Autism Spectrum Disorder (ASD) Checklist 200
Tentative Diagnosis 201
Case Formulation 201
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Management Plan 202

Pre and Post Intervention Rating 207
Recommendations 208
References 209
Appendices 211
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Case 1

Global Developmental Delay

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Case Summary

The client was 4-year-old boy referred for evaluation due to concerns about

developmental delays and behavioral issues first noted by his mother around the age of

2.5 years. These concerns include delayed speech, attention difficulties, high toe walking,

lack of eye contact, and sensory sensitivities. The assessment was done using formal and

informal psychological assessment. He was informally assessed through initial

observation and semi-structured clinical interview, however formal assessment include

Portage Guide for Early Intervention (PGEE) and DSM-5-TR Checklist. Given Y.J's age

and the nature of his symptoms as well as assessment results , a preliminary diagnosis of

Global Developmental Delay (GDD) had made. Management plan was formulated for the

client in order to manage presenting complaints. The initial week of therapy focused on

rapport building through activities tailored to his interests, laying a foundation for further

therapeutic engagement. The prognosis remained optimistic, emphasizing the importance

of continued, specialized support and family involvement in maximizing his

developmental potential.
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Case Report

Identifying Information

Name Y.J

Age 04 years

Gender Male

Education N/A

No of Siblings 4

Birth order Last one

Parental status Both alive

Residence Islamabad

Informants Mother

Place of assessment Healthy minds

Context of referral

His mother (Self- referred) brought the Client to the clinic.

Presenting complains (Verbatim)

According to his mother

‫ سال کی عمر تک بالکل نارمل تھا۔‬2

‫ شروع کی۔‬hand flapping ‫ سال کی عمر میں ہم نے نوٹ کیا جب اس نے‬2

‫ تھا‬less social ‫ میں ہم کوئٹہ گئے وہاں کافی‬2022

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‫ سال کی عمر تک بالکل نارمل تھا۔‬2

Presenting Complains

Client Y.J presented with a cluster of developmental and behavioral challenges

including delayed speech, hand flapping, limited sitting span, high toe walking, jumping

behavior, attention difficulties, excessive screen time usage, aggressive behavior, lack of

eye contact, shadow playing, and sensory sensitivities.

History of present illness

The client Y.J was experiencing a number of developmental and behavioral issues

that became noticeable to his family around the age of 2.5 years. Initially observed were

signs of hand flapping and a marked decrease in social interaction during a family trip to

Quetta, which were early indicators of underlying challenges. Over the past 1.5 years,

these symptoms have not only persisted but intensified, encompassing delayed speech,

limited sitting span, habitual high toe walking, and frequent jumping behavior.

Concurrently, Y.J exhibits significant attention difficulties, engages in aggressive

behaviors, avoids eye contact, participates in shadow playing, and demonstrates sensory

sensitivities. Despite achieving developmental milestones within expected timelines early

in life, the emergence of these symptoms has led to substantial concerns regarding his

overall developmental.

Background History

Birth History

Y.J birth history indicates a normal delivery without any complications. There

were no reported prenatal or postnatal issues affecting clients Y.J health or development.

Developmental History
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According to clients mother all developmental milestones were delayed.

Milestone Client’s data Normal range

Neck holding Age appropriate 0 – 4 months

Sitting Age appropriate 6 – 9 months

Crawling Age appropriate 7 – 9 months

Standing Age appropriate 10 – 14 months

Walking Age appropriate 10 – 18 months

Speech milestones

First cry Immediately after birth At time of birth

Cooing Age appropriate 6 – 8 weeks

Babbling Age appropriate 4 – 6 months

Language milestones

Nonverbal/pointing Delayed 1 year

1st word Delayed 1 – 1.5 years

Phrase level Delayed 2 years

Sentence level Delayed 2 – 2.5 years

Educational History

Client Y.J does not have any documented schooling history because he has not

started his schooling yet.

Family History

Client Y.J resides within a nuclear family structure. His father, aged 50, serves as

the businessperson. His mother, aged 45, fulfills the role of a housewife. Y.J is the
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youngest among his siblings, comprising two sisters and one brother. The family relies

solely on the father's income for financial support. Despite this, Client Y.J shares a

positive and nurturing bond with all family members, indicating a supportive familial

environment. However, clients shares the closet bond with his father and spent more time

with him.

Social History

According to client's mother, client Y.J shows limited socialization with others.

Medical, Psychiatric and psychological History of client

Client Y.J has previously received treatment at Safari Hospital and underwent

assessment by a speech therapist at STL. Additionally, behavior therapy was prescribed

by a neurosurgeon.

Medical, Psychiatric and psychological History of family

There is no documented history of medical, psychiatric, or psychological illness

within client Y.J’s family.

Legal History

Client has no legal history.

Psychological Assessment

Informal Assessment

Clinical interview

During the clinical interview, Y.J's mother, an educated individual with a good

understanding of psychological delays and concepts, provided a detailed account of her

son's developmental history and current challenges. Her attitude throughout the interview

was calm and composed, indicative of a person who is concerned yet hopeful about her
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child's condition and future. She articulated the onset and progression of Y.J's symptoms

with clarity, starting from when they first noticed behavioral changes around the age of

2.5 years, through to the present. Her insights were particularly valuable in understanding

the nuances of Y.J's behavior, such as his hand flapping, reduced social interaction, and

the development of other symptoms like delayed speech, limited sitting span, and sensory

sensitivities. Despite the difficulties described, her proactive approach to seeking help,

including previous assessments and interventions, highlighted a committed and

supportive family environment. This comprehensive input from Y.J's mother was

instrumental for better understanding of client’s behavior.

Formal Assessment

 Portage Guide to Early Education

 DSM-5-TR Checklist

Portage guide to Early Education (Ms. Munavver Fatima)

Portage guide was used to assess the child’s functioning level in accordance with

his developmental age. PGEE was administered to the child with the help of child

caregiver and video recordings to measure his adaptive skills in socialization, language,

self-help, cognitions, and motor area, target behavior.

Quantitative assessment

Developmental area Functional age Discrepancy

Socialization 0–1 3–4

Language 0–1 3–4

Self help 0–1 3–4

Cognitive 2–3 1–2

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Motor skills 0–1 3–4

Qualitative assessment

While the PGEE scores indicate delays in several developmental areas, the child

also demonstrates some promising strengths. In the social domain, the child enjoys

imitating actions and can interact with small groups of children for a short time. They

seem comfortable with brief separations from their parent. However, larger social settings

might be overwhelming. According to the mother, he reduced social interaction since the

family trip to Quetta at 2.5 years old

Communication skills require further development. The child can make choices

when presented with options but struggles to express their needs verbally. Additionally,

they have difficulty understanding and conveying emotions. Self-help skills are also in

their early stages. The child can manage some tasks like eating with supervision and

using basic hygiene tools with prompting. However, they rely heavily on their mother for

most daily activities. However, Y.J.'s limited sitting tolerance and constant movement

(jumping) suggest potential challenges with focus and independent activity

In contrast, the cognitive area shows encouraging progress, especially since

therapy has begun. The child can solve simple puzzles, recognize colors, and assemble

shapes. However, they may have challenges with identifying objects based on interest or

texture. Additionally, their inability to draw basic lines suggests a need for improvement

in fine motor skills and pre-writing development. Although, Y.J.'s short attention span

and difficulties with sitting still could indicate challenges with focus and concentration.

Motor skills seem to be age-appropriate in general, but there are areas for

improvement. The child might have difficulty with hand-eye coordination or fine motor
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control, as evidenced by turning multiple book pages at once. Additionally, they require

support with balance and coordination while taking steps. He also exhibits unusual motor

behaviors like hand flapping, high toe walking, and frequent jumping

DSM-5-TR Checklist for GDD

Symptoms Present/absent?

Motor Skills

 Difficulty in sitting, crawling, or walking at the expected age Present

 Poor coordination or clumsiness Present

 Trouble manipulating small objects (fine motor skills) Present

Speech and Language

 Limited or no babbling by the age of 12 months Present

 Does not speak single words by 16 months Present

 Does not combine two words by 2 years Present

 Difficulty understanding simple instructions Present

 Poor speech clarity compared to peers Present

Social and Personal Development

 Limited eye contact Present

 Rarely seeks attention or engages in social interactions Present

 Difficulty playing social games (e.g., peek-a-boo) or playing Present

appropriately with toys

 Does not imitate actions or words Present

 Shows little interest in peer interactions Present

Cognitive Skills
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 Delays in achieving milestones related to problem-solving or play Present

 Limited curiosity about the environment Present

 Difficulty focusing or paying attention Present

 Struggles with simple tasks that require cognitive skills (e.g., Present

sorting shapes)

Activities of Daily Living

 Difficulty feeding or dressing self-appropriate to age Present

 Struggles with toilet training beyond the typical age range Present

 Dependence on caregivers for basic needs more than peers Present

Emotional and Behavioral Regulation

 Frequent tantrums or difficulty regulating emotions Present

 Excessive fearfulness or anxiety in social situations Present

 Aggressive behavior towards self or others Present

 Unusual responses to sensory experiences (e.g., textures, sounds) Present

Preliminary diagnosis

The diagnosis of Global Developmental Delay (GDD) 315.8 (F88) has been made

based on careful observation of Y.J's behavior, attitude, thoughts, and physical condition.

His symptoms align closely with the criteria outlined in the Diagnostic and Statistical

Manual of Mental Disorders, Fifth Edition (DSM-5-TR) for GDD.

Case Conceptualization

In the present case, the client was having developmental and behavioral issues.

The Informal and formal assessment indicated the presence of global developmental
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delay. In Pakistan, the etiology of global developmental delay (GDD) is influenced by a

combination of genetic, environmental, and socio-economic factors, highlighting the

complexity of addressing this condition in a developing country context. These findings

suggest the necessity of a holistic approach to early childhood care in Pakistan,

incorporating nutritional support, genetic screening, and environmental health measures

(Wikipedia contributors, 2023). Addressing these underlying causes through public

health initiatives and targeted interventions is crucial for improving developmental

outcomes in Pakistani children.

The "5 P's" model—presenting, predisposing, precipitating, perpetuating, and

protective factors—provides a comprehensive framework for understanding Y.J's

condition, guiding intervention strategies, and informing prognosis.

Presenting Problems

Y.J exhibits a cluster of developmental and behavioral challenges, including

delayed speech, hand flapping, limited sitting span, high toe walking, jumping behavior,

attention difficulties, aggressive behavior, lack of eye contact, shadow playing, and

sensory sensitivities. These symptoms have been persistent daily, with high intensity for

the past 1.5 years. According to the literature, the delayed milestones, tow walking and

odd behaviors like jumping, aggression, lack of eye contact are the common symptoms of

global developmental delay disorder (Nevado et al., 2021)

Predisposing Factors

Predisposing factors are those that increase the vulnerability of an individual to

develop a disorder. Y.J's birth and developmental history do not indicate any known

prenatal, perinatal, or immediate postnatal complications, which suggests that if genetic

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predispositions exist, they might be subtle or undiagnosed. His family history also does

not document any similar conditions, which makes specific genetic predispositions harder

to ascertain without further medical and genetic evaluation. However according to

client’s mother she wasn’t able to give her child proper attention due to the stress and

busy schedule, which can be a contributing factor for clients Y.J’s condition. Early

attachment experiences with caregivers significantly influence a child's ability to manage

emotions, develop trust, and build social relationships. (Thompson, 2016)

Precipitating Factors

Precipitating factors are those that trigger the onset of symptoms or exacerbate the

condition. The mother's observation of Y.J's reduced socialization during a trip to Quetta

and the onset of hand flapping serve as early indicators of underlying developmental

challenges. Moving to a new environment, can expose or exacerbate developmental

delays. New challenges and the need for adaptation may highlight issues that were not

apparent before (Thompson, 2021).

Perpetuating Factors

Perpetuating factors contribute to the continuation or exacerbation of the problem.

For Y.J, the lack of early intervention and possibly limited access to specialized care

tailored to his needs could be seen as perpetuating his developmental delays.

Additionally, excessive screen time and potentially insufficient opportunities for social

interaction and physical activities that stimulate developmental progress could also serve

as perpetuating factors. Literature suggested that the developmental delays and lack of

early interventions results in worsening of symptoms (Sehovic et al., 2020).

Protective Factors
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Protective factors mitigate the risk and promote resilience. Y.J's supportive family

environment, with both parents actively seeking help and intervention for his condition,

acts as a significant protective factor. The initiation of behavior therapy and speech

therapy, even though mentioned as previous treatments, suggests a proactive approach to

his care. The presence of siblings also offers potential for social interaction and modeling

of social behaviors, which can be beneficial if leveraged appropriately in therapeutic

interventions. Researches have proved that the presence of proper intervention plan and

family support can help in managing this developmental disorder (Dunst et al., 2017).

Prognosis

The prognosis for children with GDD varies widely, depending on the underlying

causes, the timeliness, and appropriateness of the intervention. The comprehensive and

multifaceted approach planned for Y.J, focusing on tailored therapeutic interventions and

leveraging protective factors within his family and environment, aligns with

recommended practices for supporting developmental progress and enhancing quality of

life (Case-Smith, J., & Arbesman, M. (2008).

Through early intervention, a supportive family, and tailored therapeutic

strategies. Significant improvements are possible, especially with continued,

multidisciplinary care and regular reevaluation of his needs.

Management Plan

The management plan was devised based on presenting complaints.

Short Term Goals

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 Improve Communication Skills: Enhance Y.J's ability to use non-verbal

gestures (e.g., pointing, nodding) and verbal approximations to communicate

needs and desires, aiming for an increase in consistent use.

 Increase Attention Span: Work on extending Y.J's focused attention span during

structured activities to at least 5 minutes without redirection.

 Develop Social Skills: Facilitate structured playdates with peers to encourage

basic turn-taking and shared play, aiming for successful engagement in at least

two 10-minute sessions per week.

 Enhance Fine Motor Skills: Improve Y.J's ability to perform fine motor tasks

(e.g., holding a crayon, simple puzzles) through occupational therapy, aiming for

him to complete two age-appropriate tasks independently.

 Reduce Sensory Sensitivities: Implement sensory integration strategies to

decrease adverse reactions to sensory stimuli, measured by fewer episodes of

distress in response to sensory triggers.

Long Term goals

 Expand Verbal Communication: Aim for Y.J to use simple 2-3 word phrases

spontaneously to express needs, wants, and interests, with at least a 50% increase

in frequency.

 Improve Gross Motor Skills: Achieve age-appropriate milestones in gross motor

skills, such as jumping with both feet, climbing stairs with alternating feet, and

balancing on one foot for a short time.

 Enhance Social Interaction: Increase Y.J's participation in group activities,

aiming for him to initiate interaction with peers and adults in familiar settings.
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 Develop Adaptive Skills: Support Y.J in achieving greater independence in daily

living activities, such as feeding, dressing, and toileting.

 Promote Academic Readiness: Introduce basic pre-academic skills, such as

recognizing letters, numbers, and following simple instructions, to prepare for a

structured learning environment.

Summary of therapeutic interventions

Research highlights the importance of early detection and intervention in

improving outcomes for children with GDD. Therapeutic approaches such as Applied

Behavior Analysis (ABA), Play Therapy, and Occupational Therapy, as outlined in Y.J's

management plan, are supported by evidence for their effectiveness in addressing similar

clusters of developmental and behavioral challenges (Odom, S. L., Boyd, B. A., Hall, L.

J., & Hume, K. (2010). Evaluation of comprehensive treatment models for individuals

with autism spectrum disorders. Journal of Autism and Developmental Disorders, 40(4),

425-436.).

Rapport building

The first full week of therapeutic engagement was strategically utilized to build

rapport with the client, emphasizing the establishment of a trusting and comfortable

relationship as the foundation for successful intervention. Activities were carefully

chosen to align with the client's interests and comfort zone, fostering a positive and

engaging environment. These included shared lunch times, which provided a relaxed

setting for casual interaction and communication, and engaging in his favorite magnetic

board activity, which not only allowed for collaborative play but also offered insights into

his cognitive and motor skills. The tower building activity and bubble play were
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instrumental in observing and encouraging fine motor skills, problem-solving abilities,

and turn-taking behaviors, all while maintaining an atmosphere of fun and interest.

Calling him by his name during activities served to personalize interactions, reinforcing

his sense of identity and importance in the therapeutic relationship. Through these

thoughtfully selected activities, the week laid a strong foundation for rapport, crucial for

facilitating open communication and effective participation in future therapeutic sessions.

IEP Program: The proposed IEP program consists of daily sessions incorporating

Applied Behavior Analysis (ABA) therapy, Play Therapy, and Occupational Therapy.

Each therapy serves distinct purposes and plays a crucial role in treatment plan.

Table

Individualized Education Program

Area of Shot-term Objectives Long-term Activities

Development Objectives

1. Attention Extend focused attention Participate in group ABA techniques for

Span to 5 minutes during activities with attention, structured

activities. minimal redirection. activity sessions.

2. Social Skills Engage in turn-taking and Initiate interaction Play therapy,

shared play during with peers and adults supervised peer

structured playdates. in familiar settings. interactions.

3. Fine Motor Complete two age- Achieve proficiency Occupational therapy

Skills appropriate fine motor in age-appropriate sessions focusing on

tasks independently. gross and fine motor motor skills.

skills.

4. Sensory Decrease adverse Tolerate a variety of Sensory integration

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Sensitivities reactions to sensory sensory experiences strategies in OT.

stimuli. with minimal

distress.

5. Adaptive Increase independence in Perform daily living OT focusing on self-

Skills daily living activities with activities help skills, ABA for

minimal assistance. independently. routine development.

6. Academic Introduce basic pre- Participate in group Special education

Readiness academic skills (letters, activities with services, educational

numbers). minimal redirection. interventions.

Applied Behavior Analysis

Purpose: ABA therapy aims to improve socially significant behaviors by

systematically applying principles of learning theory. It focuses on increasing desirable

behaviors while decreasing problematic ones through reinforcement and behavior

modification techniques. Applied Behavior Analysis (ABA) therapy has been effective in

improving adaptive behavior and communication skills in children with global

developmental delay (Peters-Scheffer et al., 2011).

Role in Treatment: ABA therapy will target specific behaviors exhibited by Y.J,

such as attention difficulties, aggression, and sensory sensitivities. Structured sessions

will utilize positive reinforcement to encourage desired behaviors and teach functional

skills.

Play Therapy

Purpose: Play therapy provides a safe and therapeutic environment for to express

himself, explore emotions, and develop social skills. Through play, he can communicate
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and process experiences that may be challenging to express verbally. Play therapy offers

an engaging framework that promotes emotional regulation, social skills, and cognitive

development in children with global developmental delay (Ray et al., 2014).

Role in Treatment: Play therapy will facilitate emotional expression, social

interaction, and imaginative play. Guided by a trained therapist, he will engage in various

play activities tailored to his developmental level, fostering creativity, emotional

regulation, and interpersonal connections.

Occupational Therapy

Purpose: Occupational therapy focuses on enhancing functional abilities and

independence in daily activities, including self-care, play, and school-related tasks. It

addresses sensory processing difficulties, motor coordination, and fine motor skills.

Occupational therapy enhances fine motor skills and daily living activities in children

with global developmental delay through personalized interventions (AOTA, 2017).

Role in Treatment: OT sessions will target sensory sensitivities, fine and gross

motor skills, and activities of daily living. Through structured activities and sensory

integration techniques, he will develop sensory regulation, motor planning, and adaptive

strategies to navigate daily challenges.

Table

Pre and Post Intervention Assessment

Symptoms Pre-rating Post rating

Hand flapping 10 6

Toe walking 10 6

Poor attention 10 7
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Poor eye contact 10 7

Hyperactivity 9 4

Sensory issues 9 5

Aggressive behavior 8 4

Pre and Post Intervention Assessment

Pre-rating Post rating

10 10 10 10
9 9
8
7 7
6 6
5
4 4

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io
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tac vi
ty ue vi
ppi alk nt n cti iss a
fla w tte co a be
h
d e ra ye er or
y
an To oo r e yp ns iv
e
H P oo H S e ss
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gg
A

Summary of Sessions

Over the course of 2 months regular sessions, a strong rapport was established

between therapist and client. In the initial sessions, the client displayed confusion and

hesitancy, making it challenging to initiate therapy. To overcome this, the therapist

employed various strategies to build rapport. Playful activities and toys were introduced,

which client enjoyed and actively engaged in. Additionally, activities like ring tower,

picture communication boards and bear game were utilized to create comfortable and

interactive environment.

Recommendations

The followings are the recommendations for this case:

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 After the behavioral management, the main stream school must be started to

polish the academic area of client.

 The client must be allowed to learn the things on a slow pace, this will allow him

to learn more rather than pressurizing him to learn all at once.

 Regular follow up sessions along with proper training to parents must be

schedule.
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References

Dunst, C. J., Raab, M., & Hamby, D. W. (2017). Contrasting approaches to the response-

contingent learning of young children with significant delays and their social–

emotional consequences. Research in Developmental Disabilities, 63, 67-

73. https://doi.org/10.1016/j.ridd.2017.02.009

Freeman, A. (2021). The conceptualization process in cognitive behavioral therapy.

Commentary on chapter “Case formulation in standard cognitive therapy”. CBT

Case Formulation as Therapeutic Process, 35-38. https://doi.org/10.1007/978-3-

030-63587-9_3

Nevado, J., Bel-Fenellós, C., Sandoval-Talamantes, A. K., Hernández, A., Biencinto-

López, C., Martínez-Fernández, M. L., Barrúz, P., Santos-Simarro, F., Mori-

Álvarez, M. Á., Mansilla, E., García-Santiago, F. A., Valcorba, I., Sáenz-

Rico, B., Martínez-Frías, M. L., & Lapunzina, P. (2021). Deep Phenotyping and

genetic characterization of a cohort of 70 individuals with 5p minus

syndrome. Frontiers in Genetics, 12. https://doi.org/10.3389/fgene.2021.645595

Sehovic, E., Spahic, L., Smajlovic-Skenderagic, L., Pistoljevic, N., Dzanko, E., &

Hajdarpasic, A. (2020). Identification of developmental disorders including

autism spectrum disorder using salivary miRNAs in children from Bosnia and

Herzegovina. PLOS ONE, 15(4),

e0232351. https://doi.org/10.1371/journal.pone.0232351
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Appendices
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Case 2

Intellectual Disability Disorder

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Case Summary

The client was a 12 years old boy, he was referred to the clinical psychologist with

presenting complaints of poor hygiene, lack of confidence, aggressive behaviour,

irritability and stubbornness. The assessment was done using formal and informal

psychological assessment. Formal Assessment included DSM 5 TR Checklist, Slosson

Intelligence Test. He was informally assessed through initial observation, clinical

interview and Mental State Examination (MSE). The assessment results revealed that the

client had stubbornness, irritable behaviour and aggressive behaviour. DSM 5 TR was

consulted and formal assessment results demonstrated that the client had 317(F72)

intellectual disability (severe). Management plan was formulated for the client in order to

treat the behaviours like hitting others, lack of confidence, aggressive behaviour,

irritability and stubbornness and manage his presenting complaints.

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Case Report

Demographic information

Name S.A

Age 12 years

Education 1 class

Gender Male

No of siblings 3

Birth order 2st born

Parental status Both alive

Residence Islamabad

Informants Mother

Source and reason of referral

The client was self-referred by mother for the behavioral and IQ assessment, and

for the management of his problematic behavior in different setting including school,

home and playground as well. He was referred with the complaints such as of hitting

others, poor hygiene, crying, lack of confidence, aggressive behavior, irritability and

stubbornness.

Presenting complains
‫لوگوں کے ساتھ گھل مل کر نہیں بیٹھتا‬

‫ضد بہت کرتا ہے‬

‫عام سی چیزیں سمجھ نہیں پاتا‬

‫اس میں خود اعتمادی کی بہت کمی ہے‬

 78

History of present illness

The client’s illness onset started from with behavioural, cognitive and comprehending

issues. He was showing problematic behaviour from the age of development. His

developmental milestones were delayed, specifically sitting, speech and walking. The

mother of the client reported that he is not able to understand the things going around and

also difficulty in comprehending the situations with difficulty. His problem-solving

ability was also poor, according to the mother of the client he is not able to make plan or

decide what to do in emergencies. His judgement was also poor, as he was not able to

name the situations or person in a specific scenario.

His behavior was characterized with aggression both verbal and physical.

According to the mother of the client, he starts shouting and crying suddenly when he is

not able to comprehend anything or things are going differently from what he actually

wants. In addition, he often started throwing things when he is around unfamiliar person.

He started school at the age of 3 years and was performing poorly in the academic

area as he was not able to comprehend the things in the class. He was not able to pay

attention to the academic activities and was also not able to complete the given tasks. His

performance was very low as compared to the age fellows of his class. He was also not

able to form relationship with teacher and the class fellows. His fine motor skills were

also poor as he was not able to pick up the books properly and was also not good at

turning out the pages.

His language skills were also not developed. He is not able to communicate about

what is going through his mind and about his feelings as well. He utters 2 to 3-word
 79

sentences only which is poorly structured. His sleep was good in both quality and

quantity.

Background History

Personal History

During a routine prenatal check-up, the attending physicians expressed concerns

regarding the fetal development. Based on these concerns, they recommended a detailed

ultrasound examination to further assess the situation. The ultrasound results indicated

that the fetus was not developing properly and was diagnosed with microcephaly. Despite

this prenatal diagnosis, the pregnancy proceeded to term without any additional

complications. The mother gave birth to the child through a normal delivery.

Background History

Personal History

During a routine prenatal check-up, the attending physicians expressed concerns

regarding the fetal development. Based on these concerns, they recommended a detailed

ultrasound examination to further assess the situation. The ultrasound results indicated

that the fetus was not developing properly and was diagnosed with microcephaly. Despite

this prenatal diagnosis, the pregnancy proceeded to term without any additional

complications. The mother gave birth to the child through a normal delivery.

Postnatal, the child exhibited the expected characteristics of microcephaly, but

there were no immediate complications associated with the birth process itself.

Developmental History

Milestone Normal range Achieved age

Cry after birth Immediately Immediately

 80

Neck holding 3 months 1-2 months

Crawling 8-9 month 1.5 year

Walking (with 9-12 months 2.5 year and 4 months

support)

Walking (without 12-18 months 2 year 8 months

support)

Speech(babbling) 12 months 3 year

1-2 words 1-2 year 6-7 year

Sentences (3 or 4 2-3 years 10 years

words)

Educational History

The client began schooling at the age of 3 at STL Islamabad Campus. However,

due to the distance, his parents decided to discontinue and opted for home sessions

instead. Subsequently, he was admitted to Sedum Special School. Unfortunately, the

results were unsatisfactory, prompting them to seek additional support. They joined a

clinic for academic and therapeutic sessions while continuing home education and

sessions. Currently, at his age, the client is learning the syllabus of grade one.

Throughout his educational journey, the client has been an intellectually below-

average student with limited satisfactory relationships with his teachers. He was shy,

sensitive, and introverted, showing little interest in participating in extra-curricular

activities. His parents noted that he was not responsive toward educational activities.

Family history
 81

The client’s father is 32 years old. He is educated up till Fsc and working in a

private sector. He is friendly, co-operative and very humble in nature. The client has

friendly relationship with his father. The Child's mother was 29 years old educated up till

bachelor in Science subject. She is house wife. She is kind and caring towards the client.

The client has friendly relationship with his mother. The client's mother has reported that

she often had anger outbursts, and reported her highly emotional state about her child.

The client has one younger brother and sister and one eldest sister . He has friendly

relationship with his brother. Both parents had healthy relations with each other. The

client lives in a joint family system. The general home atmosphere is pleasant and client’s

parents fulfil all the needs of their children. There is also a significant psychiatric history

of family was reported. It includes the intellectual disability in the clients eldest sister and

two first cousins.

Psychological assessment

Informal assessment

 Clinical Interview

 Mental State Examination

Clinical interview

Clinical interview was carried out in a well-illuminated environment with child’s

mother in order to identify the child’s problem. History of present illness and stressors

were also deeply examined to identify the possible causes of the child's current problem.

Child’s background, personal and educational history were also explored to get a

complete picture of anticipatory and maintaining factors. His academic and classroom

performance were also investigated during the interview. Child’s mother was cooperative
 82

and compliant during the interview. She shared all the details that could possibly help in

diagnosis and proposing an effective management plan for the child. A detail interview

was conducted with the client’s mother.

Mental state examination

The client was of an average height and weight. He was wearing season

appropriate neat clothes and hairs were combed properly. Eye contact was made for a

couple of seconds and then become distracted. He was sitting on a chair in a relaxed

position. The child showed compliance when asked to put the pencil on table. When his

name was called, he attended the therapist.

When the therapist touched his nose, eyes and mouth the client imitated this along

with the therapist. He was not good in self-help as he opened his bag by himself which

was not appropriate and drinks water with the help of mother. Receptive skills were good

as he understood and followed the commands given by the therapist. His gross motor

skills were not much good as he could not hold the pencil properly. Both the volume and

tone of his speech were low. He had a good orientation of the place and person but was a

bit confused about the time. It was very clear that he was having trouble communicating.

The client was examined, and it was determined that they did not have any perceptual

abnormalities. He received a score of 1 out of 5 for retention and recall. Memory for the

short term was not affected, but long-term memory was not intact. And there was no

evidence of a formal disorder of thought. The ability to think abstractly was lacking, and

judgment was not strong. Rapport was established with the client.

Formal assessment

 Slosson Intelligence Test (SIT)

 83

 DSM 5 TR Checklist

Slosson Intelligence Test

Quantitative analysis

Date of administration 10 - 03 – 2024

Date of birth 12 – 06 – 2012

Chronological age(in years) 12 years,

Chronological age (in months) 144 months

Basal age (in years) 4 year

Basal age (in months) 48 months

Credit months 6 months

Mental age (in years) 4.5 years

Mental age (in months) 48+6=54 months

Ratio IQ (54 / 144) x 100 = 37.5

Ratio IQ (estimation standard) 37.5 + 3.8 = 41.3

37.5 - 3.8 = 33.7

IQ Range 37.5-41.3

Qualitative analysis

Slosson Intelligence test was administered on the patient and the results showed that the

child is having an IQ ratio of 64.86, which indicates that the child is having mild level of

IQ deficits and this limits the functioning in more than 2 areas of the client’s life.

DSM – 5 TR Checklist
 84

Symptoms Present or
not?
Onset during the developmental period ✓

Both intellectual and adaptive deficit ✓

Deficits in intellectual functioning ✓

Poor functioning, reasoning, abstract thinking and decision-making ✓

abilities
Poor academic learning and deficit in learning from experience ✓

Deficit in adaptive functioning ✓

Deficiency in personal independence and social responsibility ✓

Deficit limited functioning in one or more activities of daily life ✓

Poor communication, social participation and independent living ✓

Poor performance multiple areas, in school, home, work or community. ✓

Spoken language is limited in terms of vocabulary and grammar ✓

Conceptual skills poor for quantity, time and money ✓

Caretakers provided extreme support throughout the life ✓

Needed support for all activities including daily living, meals, dressing, ✓
bathing and elimination
Maladaptive behavior i.e. self-injury ✓
Diagnosis

317(F72) Intellectual Developmental Disorder Specifier: Severe

Case conceptualization

In the present case, the client was having intellectually average in adaptive

functioning i.e. conceptual, social and practical domains as revealed by tests and by
 85

clinical judgment of therapist which is based on formal and informal assessment. Onset

of these intellectually average occurred in developmental period. The test applied on

client does not have diagnostic ability but clinical judgment of the therapist indicated the

presence of Unspecified Intellectual Disability with behavioral issues.

Biopsychosocial Model

Biological Factors

Prenatal Diagnosis of Microcephaly

Microcephaly is associated with intellectual disabilities due to abnormal brain

development. The client’s delayed milestones, such as sitting, walking, and speech, align

with this condition. According to Von der Hagen et al. (2014), microcephaly often results

from genetic mutations that impair brain development, leading to intellectual disabilities

and developmental delays. This study supports the case by highlighting the direct impact

of microcephaly on cognitive and motor skills, explaining the client’s developmental

challenges.

Genetic Factors

A family history of intellectual disability in the client’s first cousins suggests a

genetic predisposition to developmental disorders. Curry et al. (2018) emphasize the

importance of genetic factors in intellectual disabilities, noting that a detailed family

history can provide crucial insights into potential genetic causes. This research supports

the case by underlining the genetic influence on the client’s intellectual and

developmental issues, indicating a hereditary component to his condition.

Psychological Factors

Behavioral Issues
 86

The client exhibits aggression, irritability, and repetitive behaviors. Matson &

Shoemaker (2009) found that such behaviors are common in children with intellectual

disabilities and developmental disorders, often due to their frustration with

communication barriers and environmental understanding. This research supports the

case by explaining the psychological basis of the client’s behavioral issues, linking them

to his intellectual disability

Cognitive Deficits

Poor problem-solving skills, comprehension, and judgment are evident in the

client. Gilmore et al. (2005) explored cognitive impairments in children with intellectual

disabilities, highlighting deficits in problem-solving, comprehension, and decision-

making. This study supports the case by providing a framework for understanding the

client’s cognitive challenges, which are typical in children with microcephaly and

intellectual disabilities.

Educational Challenges

The client’s poor academic performance, limited attention, and inability to form

relationships with peers and teachers indicate significant cognitive and social deficits.

According to Gilmore et al. (2005), these educational challenges are common in children

with intellectual disabilities, affecting their academic and social development. This

research supports the case by detailing the typical academic struggles faced by children

with similar conditions, emphasizing the need for tailored educational interventions.

Social Factors

Family Dynamics
 87

The supportive family environment and the mother’s proactive approach in

seeking help indicate a positive social support system. However, the mother’s emotional

state and occasional anger outbursts, and busy schedule of his father might contribute to

the child’s stress. Guralnick (2017) discussed the impact of family dynamics on children

with developmental disabilities, highlighting the importance of a supportive environment

and the potential negative effects of parental stress. This research supports the case by

illustrating how family dynamics influence the client’s behavior and emotional well-

being.

Social Interaction

The client’s inability to form relationships with peers and teachers and his

aggressive behavior in unfamiliar settings highlight social deficits, influencing his overall

social development.

Prognosis

The client prognosis was unfavorable.

Management Plan

The management plan was devised on the basis of presenting complaints.

Short term goals

 To establish rapport with the child

 Psychoeducation

 To use strategies for effective commands to build compliance

with the non-compliant behavior of the client

 Work on the level of confidence

 To use attention building techniques in order to improve attention level.

 88

 To use positive reinforcement with client to increase his desirable

behavior to improve his problem.

 To use prompting to engage client in correct behavior at correct time.

 To use fading, to gradually elimination of prompts given to client.

 To use modeling, to demonstrate correct behavior for client.

 To use chaining to teach difficult task to the client.

 To practice pre-academic activities in order to prepare them for the mainstream

 Play therapy techniques

Long term goals

 Continuation of short-term goals

 Work on relapse prevention

 To plan follow up sessions to make sure and increase improvement in client.

Summary of therapeutic intervention

Rapport building

Rapport building is one of the most initial steps of a therapy procedure to be

started, and it also enhance the effectiveness of the whole procedure (Nor, 2020). Client

was confused and was hesitating in talking to the therapist at the start, and was also

showing. rapport was established with the client in the 1 st week sessions. Different toys

were given to the client and he was engaged in different playful activities, including

animal and color matching, which he enjoyed a lot. Then different type of cars was given

to the patient and he was asked to ride them, in order to build the rapport with the client.

Jumping and Ring tower activities were also used by therapist for the purpose of

developing rapport. And in the 5th session, rapport as strongly build with the patient.
 89

Psychoeducation

Psychoeducation in a therapy refers to the process of providing education and

information to those seeking or receiving mental health services and it enhances the

effect of a therapy (Beresford, et al., 2016). In the 1 st and 2nd session, history was taken

from the client’s mother and teacher. And it has been observed that the client’s mother

was so distress because of the condition of her child. Then, the detailed psychoeducation

was given to the client’s mother including the underlying causes of the disorder (which

were explored through the history taken from her. The detailed management plan

including the all the techniques of the therapy were discussed with the client’s mother.

And the goal of the sessions was successfully achieved after receiving the positive

feedback from the client’s mother.

Behavior Therapy

Prompting: As the client was having issues of low confidence, attention deficiency and

unable to understand the basic concepts of academic area and also to improve the fine

motor and gross motor skills of the client; So, prompting was used for the initial startups

in the session but later on child become independent of doing things. The following are

the activities which were started with prompting but gradually fade it.

Pealing and pasting activities: Client was given A4 size white plain paper, and some

square shape glitter sheets. This helped in improving the fine motor skills by following

the command to paste the sheet pieces in a specific shape and on specified dots.

Pealing and pasting activities: Client was given A4 size white plain paper, and some

square shape glitter sheets. This helped in improving the fine motor skills by following

the command to paste the sheet pieces in a specific shape and on specified dots.
 90

Raising hand: In group activities raising hand was taught to the client in order to

increase the level of confidence in him. This was started with prompt and then after 4 th

session prompt was fade.

Engaging in group activities: Different playful activities including sharing of lunch,

greetings with the classmates, hello and good-bye gestures were practiced with the client

Pre-academic activities

In order to prepare them for mainstream, the following activities were practiced with

the client:

 Pointing and identification.

 Pencil holding.

 Coloring with boundaries.

 Coloring without boundaries.

 Joining dots and tracing.

 Paper and chart cutting.

Fading

Fading is used to make client independent to complete task without any prompting. It is

used to avoid prompt and dependence are withdrawn gradually after a certain time period.

Positive Reinforcement

Client often respond to positive and negative reinforcements. Reinforcement

identification is the premier part that needs to be done before conducting behavior

therapy. This was done with the help of two methods. One was direct observation and the

other was by asking client’s mother. After the identification of the reinforcer, continuous

schedule was utilized by aa as excitement in a proper and even totally practical way (such
 91

as constructive, exploratory games requiring creativity). Playing is a natural way for

children to express themselves, and it will provide them with an opportunity to gradually

release suppressed emotions and tensions, disappointments, feeling of insecurity,

aggression, and fear of confusion and most importantly, in constructive interaction with

other children. This will help the client to have friends and interact with other children.

Play Therapy

Play therapy technique were used to increase the compliance and response rate of

the client. Outdoor play activities were used to increase the compliance of the child. The

child was taken to outdoors area for play. Play therapy also encourages the use of

language or improve fine and gross motor skills. The child started uttering some basic

words and sounds after the 6th session. The child was taken to swings and was taught to

wait for his turn while the other child gets off the swing. This therapy helps out the child

to develop the following behavior and skills:

 taking more responsibility for certain behaviors

 empathy and respect for others

 alleviation of anxiety

 stronger social skills

Puppets, Stuffed Animals, and Masks techniques were used in the outdoor activities,

in which they were asked to help the animals in walking and going home, this helped the

child to develop the concept of how different animals walks and how they go to home.

Individualized educational plan

Area of Short-term goals Long-term goals Therapies and activities

development
Cognitive Cognitive Achieve age- -Pre-academic activities
development appropriate cognitive (pointing and identification,
 92

Area of Short-term goals Long-term goals Therapies and activities

development
development functioning for daily pencil holding, coloring
Improve attention tasks within and without
span to 10 minutes Master foundational boundaries
during tasks academic skills Cognitive games and puzzle
Enhance equivalent to grade Regular assessments and
understanding of basic one tailored educational plans
academic concepts
(e.g., shapes, colors)
Fine and Gross Improve fine motor Achieve fine motor - Peeling and pasting
motor skills skills to handle control suitable for activities
objects like pencils basic academic and Joining dots and tracing
and scissors daily tasks Paper and chart cutting
Enhance gross motor Develop gross motor Outdoor play therapy
coordination through skills sufficient for involving swings, running,
guided play independent outdoor and balance exercises
play
Social Skills - Participate in group - Form meaningful - Group activities (sharing
activities with relationships with lunch, greeting classmates,
minimal prompting peers hello and good-bye gestures)
Engage in basic social Demonstrate empathy Play therapy using puppets,
interactions (e.g., and respect for others stuffed animals, and masks to
greetings, sharing) in various social teach social concepts
settings Role-playing scenarios
Communication - Utter basic words - Communicate - Speech therapy sessions
Skills and sounds during effectively with peers Play therapy to encourage
sessions and adults using verbal interactions
Use simple sentences complete sentences Activities focused on
(2-3 words) to express Understand and follow language development (e.g.,
needs and emotions multi-step instructions storytelling, singing)
Behavioral - Reduce incidents of - Develop self- - Behavioral therapy with a
Management aggression and regulation skills focus on positive
irritability Maintain positive reinforcement
Improve compliance behavior in school, Implementation of fading
with instructions and home, and community techniques to reduce
tasks settings dependency
Regular monitoring and
 93

Area of Short-term goals Long-term goals Therapies and activities

development
adjustment of behavioral
plans

Pre and Post Intervention Assessment

Symptoms Pre-rating Post rating

Aggression 9 4

Less social interaction 10 6

Stubbornness 10 7

Low Confidence 10 7

Inability to learn 10 6

Pre and Post Intervention

12

10

Aggression Less social Stubborness Low Confidence Inability to learn

interaction
Pre rating Post rating

Summary of sessions

Over the course of 3 months sessions, a strong rapport was established between

the therapist and the client. In the initial sessions, the client displayed confusion and

hesitancy, making it challenging to initiate therapy. To overcome this, the therapist

 94

employed various strategies to build rapport. Playful activities and toys were introduced,

including animal and color matching, which the client enjoyed and actively engaged in.

Additionally, the client was given different types of cars to ride, further enhancing the

rapport-building process. Activities such as jumping and Ring tower were utilized to

create a comfortable and interactive environment.

Recommendations

 The client must be allowed to learn the things on a slow pace; this will allow

him to learn more rather than pressurizing him to learn all at once.

 Regular follow up- sessions along with proper training to parents must be

scheduled.

References

Beresford, B., Stuttard, L., Clarke, S., & Maddison, J. (2016). Parents’ experiences of

psychoeducational sleep management interventions: A qualitative study of parents

of children with neurodevelopmental disabilities. Clinical Practice in Pediatric

Psychology, 4(2), 164.

Chambers & Pinnock, (2011). Psycho-educational interventions. Retrieved from:

https://www.ons.org/intervention/psychoeducationpsychoeducational-interventions

Cooper, A., Butto, T., Hammer, N., Jagannath, S., Fend-Guella, D. L., Akhtar, J., ... &

Schweiger, S. (2020). Inhibition of histone deacetylation rescues phenotype in a

mouse model of Birk-Barel intellectual disability syndrome. Nature

Communications, 11(1), 480.

 95

Hou, T., Jiang, S., Wang, Y., Xie, Y., Zhang, H., Feng, Y., ... & Hu, C. (2020). Alpha

thalassemia/intellectual disability X-linked deficiency sensitizes non-small cell lung

cancer to immune checkpoint inhibitors. Frontiers in Oncology, 10, 608300.

McMahon, M., Hatton, C., Hardy, C., & Preston, N. J. (2022). The relationship between

subjective socioeconomic status and health in adults with and without intellectual

disability. Journal of Applied Research in Intellectual Disabilities, 35(6), 1390-

1402.

Nor, M. Z. M. (2020). Counselling: What and how. In Counseling and Therapy.

Saint-Georges, C., Pagnier, M., Ghattassi, Z., Hubert-Barthelemy, A., Tanet, A.,

Clément, M. N., ... & Cohen, D. (2020). A developmental and sequenced one-to-one

educational intervention (DS1-EI) for autism spectrum disorder and intellectual

disability: A three-year randomized, single-blind controlled trial.

EClinicalMedicine, 26.

Wison, K. and Ryan, V. (2019). Play therapy: a non-directive approach for Children and

adolescents, (ed. 2nd). London: Elsevier Science

 96

Appendices
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
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118
119
120
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Case 3

Attention Deficit Hyperactivity Disorder

 122

Case summary

M.I., a five-year-old boy, was brought to clinic by his parents due to concerns about his

poor concentration, irritability, teasing others, restlessness, and aggression. He has one

older sister and one younger brother and comes from a middle socioeconomic

background. His behavioral issues began at the age of two. Living in a supportive and

loving nuclear family, M.I's problems were assessed through both formal and informal

methods. Informal assessments included a clinical interview and behavioral observations,

while formal assessments utilized the Conner’s Parent Rating Scale, the Portage Guide to

Early Education, and the DSM-5 TR ADHD Checklist. Based on these assessments, M.I

was diagnosed with Attention Deficit/Hyperactivity Disorder (ADHD) with the specifier

"combined presentation" according to DSM-5 TR criteria. A behavioral management plan

was implemented, resulting in noticeable improvements in his behavior. The structured

assessment and intervention effectively addressed M.I's symptoms, leading to significant

behavioral improvements.
 123

Identifying Information

Name M.I

Age 5 years

Gender Male

Birth order 2nd

Siblings 2 (1 Brother and 1 sister)

Socio-economic status Middle

Mother’s occupation Housewife

Father’s occupation Government job

language Urdu

Religion Islam

Reason and source of Referral

Client has been brought to clinic by his parents having complaints of inattention,

irritability and aggressive behavior, difficulty staying still and sitting

Presenting Complains (Verbatim)

‫ہر وقت دوڑتا رہتا ہے‬

‫دوسروں کو مارتا ہے‬

‫نہ سمجھ پاوں تو چیخیں مارتا ہے‬

‫آرام سے نہیں بیٹھتا‬

‫بہت تنگ کرتا ہے‬

 124

History of present illness

M.I.'s issues began at the age of two when he started crying more than usual and

did not respond when called by name. His parents initially suspected a hearing problem

and consulted an ENT specialist, but the reports showed no hearing issues. By the age of

three, M.I began hitting his older sister and younger brother. He struggled with

remembering what he was taught without consistent repetition due to inattention. He was

taken to a child specialist at CMH, Rawalpindi, who referred him to AFIMH,

Rawalpindi. There, a comprehensive psychological assessment revealed that M.I. had

Attention Deficit/Hyperactivity Disorder (ADHD).

Currently, M.I. has been experiencing a severe episode for the past eight months,

characterized by extreme hyperactivity and an inability to focus on tasks. His parents are

particularly concerned about his anger outbursts and teasing behavior. His sleep patterns

were also disturbed, as he sleeps only about five hours each day. M.I. throws temper

tantrums when his desires are not met and is unable to speak proper words and sentences

without assistance. His parents for further support have now brought him to clinic.

Personal History

The client mother reported that he had a normal birth without complications.

Although he was very weak at birth, he gained the required weight by the time he was

nine months old. He achieved developmental milestones later than usual. His siblings and

cousins frequently complain about his aggressive behavior. He becomes easily offended

and does not play with other children.

Developmental History
 125

The client’s mother did not recall any issues with his birth or prenatal history,

stating that no unusual events occurred during that time. She reported no head injuries or

trauma and no family history of neurological problems. The client achieved his

developmental milestones late, starting to walk at the age of three and still struggling to

speak properly.

Developmental Milestones

Developmental milestones Normal age Achievement of milestones

Crying After birth Immediate

Crawling 6-9 months Normal

Sitting 6 months 7 months

Walking 9-18 months 3 years

Cooing 3 months Delayed

Babbling 6-9 months Delayed

First word 10-15 months 2.5 years

Combine words 15-32 months Not yet

Phrase level 3 years Not yet

Family History

The client belongs to a middle-class family and lives in a nuclear family setup,

including his parents, a seven-year-old sister, and a two-year-old brother. He maintains a

good relationship with both parents. He does not enjoy the company of his siblings and

often beats them, never playing or sharing his toys with them. According to his mother,

the relationship between his parents is also good.

Family Psychiatric History

 126

The client’s first cousin was diagnosed with ADHD.

Social History

The client does not play with his siblings, other children, or cousins. He has no

friends and prefers to play alone with his toys. Although he enjoys watching other

children play, he never joins them and does not share his toys or belongings. His father

reported that he shows physical aggression towards guests and neighbor children.

Academic History

The client has no previous academic history, as he has never been admitted to

school.

Psychological Assessment

The psychological assessment consisted of:

PRELIMINARY
INVESTIGATIO

Formal Informal
Assessment Assessmen
t

Conner’s DSM 5 Clinical Behavioral Portage Guide

Parent Check Intervie Observatio to Early
Rating Scale
List

Informal Assessment
 127

Clinical Interview

An unstructured clinical interview was conducted with the client's mother to

gather detailed information about the child's history of present illness and presenting

complaints. They were asked about the child's developmental details and reported that he

exhibits irritability and inattention, unable to concentrate on a single activity for more

than five minutes. He also shows aggressive behavior at home, teasing his siblings and

other children. The client had a normal birth, and his mother's condition was normal at

the time of birth. The mother mentioned being under stress due to an unplanned

pregnancy before his birth, but she was very excited when he was born.

Behavioral Observation

The client's behavior was informally observed during sessions and interviews.

The client was dressed very neatly and tidily. He exhibited repetitive meaningless sounds

and words, found it difficult to sit still on the chair, and kept roaming around the room.

Psychomotor agitation was easily observed. He cried loudly during the first few sessions

and was easily distracted by other stimuli in the room. Throughout session, he kept

moving or shaking his legs and hands. He spat on toys, didn't like and threw them away.

Portage Guide to Early Education

The Portage Guide was administered to assess the child's language, motor, social,

cognitive, and self-help skills, as well as his developmental deficits. The cognitive area

was directly assessed with the child, while the mother provided information on items

related to other areas. The assessment took almost an hour to complete.

Quantitative score
Domains Functional Age Range
 128

Self-help skills 0-1

Motor skills 2-3

Language skills 0-1

Social skills 0-1

Cognitive skills 0-1

Description: The client’s age was 5 years and there is a marked difference between chronological age and

functional age of the child on five developmental area

Qualitative Analysis

The table indicates that the client’s developmental age lags behind in most areas

assessed by the Portage Guide to Early Education compared to his chronological age. His

least developed areas are language, cognitive, self-help, and social skills. The results

show delayed milestones in all five domains. In the motor area, the child's functional age

is equivalent to that of a 1-2 year old. In the cognitive, social, practical/self-help, and

language domains, his functional age is equivalent to that of a 0-1 year old. These

interpretations highlight the client's delayed developmental milestones.

Formal Assessment

Conner’s parent rating scale

Conner’s parent Rating Scale was completed utilizing information provided by

client’s mother and observation. The symptoms, behavior and score in Conner’s scale

showed that client was an ADHD child.

Quantitative scoring

Factors Raw sore T score Percentile Guideline

Oppositional 11 75 98% Markedly atypical (indicate

significant problem)
 129

Cognitive 14 84 98% Markedly atypical (indicate

Problem/inattention significant problem)

Hyperactivity 8 90 98% Markedly atypical (indicate

significant problem)

Conner’s ADHD index 12 77 98% Markedly atypical (indicate

significant problem)

Qualitative Analysis

The client's scores indicate that he often fails to pay close attention to details and

makes careless mistakes in his work. He struggles to sustain attention in tasks or play

activities and has difficulty organizing tasks and activities. His concentration level and

attention capability are inadequate, and he has some memory-related issues. While he

does not experience perceptual issues such as illusions or hallucinations, his thought

process is not optimal. The client has significant problems with maintaining attention,

making it challenging for him to focus on school activities, homework, and tasks. This

often results in underperformance at school and conflicts with other children over not

following rules during play. He is excessively talkative and unable to complete tasks. The

client becomes easily frustrated with effort. His scores are as follows: oppositional = 11,

cognitive = 14, hyperactivity = 8, and Conner ADHD index = 21. According to T scores

and percentiles, he falls into the category of markedly atypical, indicating a significant

problem.

DSM-5 Criteria

After conducting both formal and informal assessments, the diagnostic criteria

from the DSM-5 TR were checked. The assessments indicated symptoms of Attention
 130

Deficit Hyperactivity Disorder (ADHD), and the symptoms were confirmed to meet the

DSM-5 TR criteria for ADHD.

Diagnostic criteria Symptoms present in client Status of

symptoms
Often fails to give close Mistakes in grammar and ✓
attention to details or makes spelling in copies
careless mistakes in
schoolwork.
Trouble holding attention on Trouble concentration. ✓
tasks or
play activities.
Does not follow through on Unwillingness to follow ✓
instructions. instructions.
Often leaves seat in situations Roams about in class, doesn’t ✓
when remaining seated is sit at one place and stands on
expected. the benches.
Often talks excessively. Can’t stay quite. ✓

Tentative Diagnosis

“314.01 (F90.2) Attention-Deficit/ hyperactivity disorder, Severe, with combined

presentation.

Case Conceptualization

The client is a six-year-old boy from a middle-class background who has

exhibited symptoms of ADHD for four years, starting when he was two. He achieved his

developmental milestones later than usual. Living in a nuclear family. His behavior

became highly disruptive and problematic after the age of three. There is a family history

of ADHD, as a cousin also has the disorder.

 131

According to the biopsychosocial model, both biological and environmental

factors contribute to the development of a disorder. Molecular genetics suggest that

genetics and heredity play crucial roles in determining who develops ADHD. Studies

support the hypothesis that genes significantly contribute to ADHD, although specific

genes associated with the disorder are not identified. Research has focused on specific

genes, particularly dopamine genes, such as DAT1 and DRD4, which have been

associated with ADHD by numerous scientists. While genetics are believed to be a

primary cause of ADHD, cultural and environmental factors also play a role, though the

emphasis is on genetic makeup.

In this case, both genetic and environmental factors likely contributed. As the first

baby boy in the family, the client was very dear to them and allowed to do anything he

wanted, potentially aggravating his symptoms. Research by McLean and Donald (2010)

indicates that ADHD behavior in children can be reinforced when they receive extra

attention from parents and family. These factors likely played a significant role for this

client.

ADHD is diagnosed and treated more frequently in males than in females.

Research on gender differences suggests that girls may be consistently under-identified

and under-diagnosed due to differences in how the disorder is expressed in boys and girls

(Eric et al., 2013). Evidence also suggests that maternal stress during the prenatal stage

can cause ADHD symptoms in children, resulting in delayed developmental milestones,

difficulties in self-management, and cognitive problems (Alina & Gunilla, 2005).

 132

Bio Psycho Social Model

Biological Psychological
Factors:
Factors:
learning
Genetic
Vulnerabilit
y, First

Social Factors:
Over protective
parenting style

Short-Term Goals

The systematic strategies of child-behavior therapy include:

 Setting specific behavioral goals using the Individualized Educational Plan (IEP)

protocol.

 Implementing therapeutic procedures based primarily on behavioral and learning

principles.

 Initiating the treatment program at the child’s current level of performance

(baseline) and continuously monitoring progress.

 Providing psychoeducation to the child’s parents.

 Identifying the most effective reinforcer for the child, from least to most effective.
 133

 Minimizing the core features of ADHD, with a primary focus on improving

attention span and controlling hyperactivity, while eliminating unhelpful or

disruptive behaviors.

 Assisting the child in daily living activities to promote independence.

Long-term goals

 Continuation and maintenance of short-term goals to help the client effectively

retain and reproduce learned functional, academic, language, and motor skills.

 Generalizing the learned skills in a classroom setting (one-on-one) to help the

client function in neutral environments.

 Improving the client’s socialization and academic skills to enable him to function

independently in daily activities and attend mainstream school.

Management Plan

Psychoeducation

Psychoeducation involves providing education to individuals living with

psychological disturbances. The client’s mother received psychoeducation about her

child's condition and how to manage his learning and behavior at home. This

collaboration between the psychologist and the parent aimed to establish and maintain a

consistent routine for the child (DuPaul & Stoner, 2014). DuPaul and Stoner (2014)

highlight the importance of psychoeducation in managing ADHD, emphasizing the need

for structured routines and parental involvement.

Reinforcement techniques

Reinforcement techniques are critical in behavior therapy, as they help the client

respond to positive and negative reinforcements. Identifying effective reinforcers was

 134

essential and was done through direct observation and consultation with the client’s

mother. After identifying the reinforcers, a continuous reinforcement schedule was

implemented, providing reinforcement each time the child exhibited the desired behavior

(Barkley, 2015). Barkley (2015) discusses the effectiveness of reinforcement strategies in

modifying ADHD behaviors, particularly in children.

Daily routine Schedule

A structured daily schedule was established to help the client understand and meet

expectations. This schedule included predictable rituals for meals, homework, play, and

bedtime, aiding the client in focusing on and completing his activities on time (Evans,

Owens, & Bunford, 2014). According to Evans et al. (2014), structured routines

significantly improve the management of ADHD symptoms by providing consistency and

predictability.

Learn to focus

The client practiced performing activities slowly and deliberately, such as

walking slowly to sessions and doing tasks in a focused manner. He was encouraged to

place items quietly on the table to enhance attention and mindfulness during activities

(Rabiner & Murray, 2016). Rabiner and Murray (2016) emphasize the importance of

mindfulness and deliberate practice in improving attention and reducing hyperactivity in

children with ADHD.

Recreational therapy

Recreational therapy, which uses activity-based interventions to address assessed

needs, was conducted every Friday (activity day). Activities included pasting stars and

shapes on paper, sorting objects, and matching colored balls. These activities aimed to
 135

improve cognitive and motor skills while making learning enjoyable (Sibley et al., 2014).

Sibley et al. (2014) highlight how recreational activities can support cognitive and motor

development in children with ADHD.

Chaining (for activities of daily living)

The client was taught daily life tasks using the "forward chaining" procedure.

Tasks were broken down into small steps, and each step was taught using modeling and

assistance as needed. This approach helped the client learn and perform daily tasks

sequentially (Matson, 2009). Matson (2009) discusses the efficacy of chaining procedures

in teaching children with developmental delays to complete complex tasks.

Positive reinforcement

Positive reinforcement was emphasized. The client received praise and rewards

for completing parts of tasks, such as a "good job" or a high-five, which helped build his

confidence and motivation. This approach is more effective for children with ADHD than

focusing on incomplete tasks (Hoza et al., 2006). Hoza et al. (2006) found that positive

reinforcement significantly improves task completion and reduces negative behaviors in

children with ADHD.

Reward chart

A reward chart was used at home and school. Whenever the client exhibited

desired behavior, a star was placed on the chart by his name, and others clapped for him.

This method motivated the client and reduced distraction, encouraging him to acquire

new skills (Chronis-Tuscano et al., 2010). Chronis-Tuscano et al. (2010) demonstrated

the effectiveness of reward systems in enhancing motivation and reducing distractibility

in children with ADHD.

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Applied Behavior Analysis

ABA techniques were used to develop a variety of skills, including

communication, social skills, self-control, and self-monitoring. These techniques were

applied in both one-on-one sessions and everyday home settings, with parental

involvement. ABA helps generalize these skills to different situations (Smith & Iadarola,

2015). Smith and Iadarola (2015) highlight how ABA can be used effectively to teach

and generalize essential skills in children with ADHD.

Social Skills Training

The client was introduced to his schoolmates and teachers and taught how to greet

them. This training helped him socialize with peers, share things, apologize when

necessary, and express gratitude, enhancing his social interaction skills (Gresham et al.,

2010). Gresham et al. (2010) discuss the importance of social skills training in improving

peer interactions and social competence in children with ADHD.

Play therapy

Play therapy engaged the client using different colored blocks, plastic fruits, and

vegetables for color recognition, counting, and naming objects. Books and flashcards

were also used. The focus was on time management, helping the client understand time

limits while learning through play (Knell & Dasari, 2016). Knell and Dasari (2016)

emphasize the role of play therapy in enhancing cognitive and social skills in children

with ADHD.

Individualized education program

Area of Short-Term Long-Term Therapies/Interventions

Development Goals Goals
Attention/Focus Attention/Focus Sustain attention Therapies/Interventions
 137

Improve attention on tasks for 20 Positive reinforcement,

span to maintain minutes or more, daily routine schedule,
focus on a single reducing psychoeducation for
activity for at least inattention during parents, applied behavior
10 minutes. school activities analysis (ABA)
and homework.
Behavior Reduce instances Eliminate Behavioral therapy,
Management of aggressive disruptive reinforcement
behavior towards behaviors and techniques,
siblings and peers. improve self- psychoeducation for
control, enabling parents, positive
A.A. to interact reinforcement
positively with
others.
social skills Participate in Develop Social skills training,
social skills &generalize social play therapy, recreational
groups and skills to function therapy
practice sharing independently in
and polite group settings,
interactions with forming
peers. meaningful peer
relationships.
Academic Skills Complete assigned Improve academic Applied behavior
tasks and activities performance to analysis (ABA), positive
with minimal meet grade-level reinforcement, reward
reminders and expectations, chart
assistance. independently
completing
schoolwork and
homework.
Communication Improve ability to Develop age- Play therapy, social skills
 138

form simple appropriate training, chaining for

sentences and communication daily living activities
express needs skills, including
effectively. forming complex
sentences and
engaging in
conversations.
Motor skills Enhance fine and Achieve age- Recreational therapy,
gross motor skills appropriate motor play therapy, chaining
through structured skills, for daily living activities
play activities and participating in
physical tasks. physical activities
and sports with
peers.
Self-Help Skills Learn to complete Become Chaining (for daily living
basic daily living independent in activities),
tasks (e.g., performing daily psychoeducation for
dressing, eating) living activities, parents, daily routine
with minimal demonstrating schedule
assistance. self-management
and responsibility.
Attention/Focus Attention/Focus Sustain attention Therapies/Interventions
Improve attention on tasks for 20 Positive reinforcement,
span to maintain minutes or more, daily routine schedule,
focus on a single reducing psychoeducation for
activity for at least inattention during parents, applied behavior
10 minutes. school activities analysis (ABA)
and homework.
Pre and post intervention assessment

Before
Intervention
10

9
 139

Recommendations

 Transition M.I. to a mainstream school after significant behavioral improvements

to develop his academic skills and social interactions.

 Allow M.I. to learn at a gradual pace to help him retain information more

effectively and reduce stress.

 Schedule regular follow-up sessions to monitor progress and adjust the

management plan as needed.

 Provide ongoing training and support for parents to implement effective behavior

management strategies at home.

 Maintain a structured daily routine to provide predictability, stability, and

improve focus and task completion.

 Continue using positive reinforcement techniques, such as reward charts and

praise, to encourage desired behaviors and achievements.

 140

References

ADHD. ADHD Attention Deficit and Hyperactivity Disorders, 11, 241-253.

Brown, M. B., Swigart, M., Bolen, L. M., Webster, R., & Hall, C. (1998). Doctoral

and Non Doctoral practicing school psychologists: Are there differences?

Psychology in the Schools, 35, 347-354.

Gökel, Ö., & Dağlı, G. (2017). Effects of social skill training program on social skills of

young people. Eurasia Journal of Mathematics, Science and Technology Education,

13(11), 7365-7373.

Huang, X., Zhang, Q., Chen, X., Gu, X., Wang, M., & Wu, J. (2019). A functional

variant in

Jaffe, A. (2011). Failure to thrive: current clinical concepts. Pediatr Rev 32:100.

Luo, N., Luo, X., Zheng, S., Yao, D., Zhao, M., Cui, Y., ... & Sui, J. (2022). Aberrant

brain dynamics and spectral power in children with ADHD and its subtypes.

European Child & Adolescent Psychiatry, 1-12.

Morrow, A. S., Campos Vega, A. D., Zhao, X., & Liriano, M. M. (2020). Leveraging

machine learning to identify predictors of receiving psychosocial treatment for

Attention Deficit/Hyperactivity Disorder. Administration and Policy in Mental

Health and Mental Health Services Research, 47, 680-692.

Norris, C. M., Danis, P., & Garner, T. (1999). Cause and effects of epilepsy in

newborn, young infant. American family physician, 59(10), 2761. Neuwirth,

S. (1993). Learning disabilities (No. 93). DIANE Publishing

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Sedgwick, J. A., Merwood, A., & Asherson, P. (2019). The positive aspects of attention

deficit hyperactivity disorder: a qualitative investigation of successful adults with

SLC1A3 influences ADHD risk by disrupting a hsa‐miR‐3171 binding site: A two stage

association study. Genes, Brain and Behavior, 18(5), e12574.

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Appendices
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Case 4

Autism Spectrum Disorder

 192

Case summary

The patient, Z.B., a nine-year-old boy, was brought to the clinic by his parents due to an

impairment in social and communication abilities, alongside various behavioral issues.

These issues include self-harm, spitting, yelling, excessive crying, biting, challenges in

command following, physical aggression, repetitive speech of words, restrictive interests,

and lack of attention. Z.B.'s mother reported that he experienced pneumonia and received

treatment four days post-birth. Developmental delays were noticed from 10 months of

age, as he began to avoid eye contact, did not respond to his name, and avoid interactions.

He exhibited a pronounced interest in screens (e.g., cell phones, tablets, and television),

frequently viewed objects from unusual angles, and showed a particular fascination with

lights, especially of the red spectrum, and musical toys. Assessment procedures included

informal methods such as behavioral observations, clinical interviews, and the Portage

Guide to Early Education, as well as formal methods comprising the Childhood Autism

Rating Scale (C.A.R.S) and the DSM-5 TR checklist for Autism Spectrum Disorder.

Based on these assessments, Z.B. was diagnosed with Autism Spectrum Disorder

requiring substantial support. A behavioral management plan was implemented through

Applied Behavior Analysis (ABA) sessions and accompanied by speech therapy, which

resulted in noticeable improvements in his behavioral symptoms.

 193

Identifying Data

Name Z.B

Age 9 years

Gender Male

Birth order 3rd

Siblings 3 (2sisters, 1 brother)

Socio-economic status Middle class

Mother’s occupation Housewife

Father’s occupation Businessman

Dominant language Urdu, Punjabi

Religion Islam

Reason and source of Referral

The client was bought to clinic by his parents for psychological evaluation of

issues including behavioral issues such as self-hitting, spitting, yelling, excessive crying,

biting, command following issue, physical aggression, repetition of meaningless words,

restrictive and repetitive interests, inattentiveness and speech issues.

Presenting complaints

‫کسی بات پر دھیان نہیں دیتا‬

‫مرضی کا کام نہ ہو تو غصہ کرتا ہے‬

‫بہت تنگ کرتا ہے‬

‫بولنے کا مسئلہ ہے‬

 194

‫ میں کسی سے بات نہیں کرتا‬Gathering

‫خود کو الگ رکھتا ہے‬

History of Present Illness

The client Z.B got pneumonia after 4 days of birth, necessitating medical

intervention were provided through injections. By the age of 10 months, the child's

mother began to notice developmental delays similar to those of his elder sister,

particularly in achieving milestones.

It was at this age that a regression in social and emotional development became

apparent, marked by a decreased tendency to make eye contact and diminished

responsiveness to his name. His decreased interest in social interactions, leading to

increased isolation and engagement with gadgets, such as cell phones. The patient

displayed a particular fascination with lights—especially the color red—and was

responsive to musical sounds. At 2.5 years, abrupt episodes of laughter and crying were

observed, alongside the repetitive use of basic words like "Mama" and "Papa," without

progression to more complex speech patterns. Following these observations, the child's

mother consulted a pediatrician who referred them to a neurologist, the same specialist

treating the patient's sister. Subsequently, the neurologist recommended evaluation by a

psychologist, resulting in a diagnosis of autism spectrum disorder. Following the

diagnosis, the patient was enrolled at clinic to address his developmental challenges.

Family Background

The client lives in nuclear family, which includes his parents and three siblings.

He shares a satisfactory relationship with his siblings and a good relationship with his

father. However, he has struggled to form an ideal relationship with his mother, she has
 195

stated that due to the stress of raising child with Autism Spectrum Disorder and an

unplanned pregnancy, she was unable to provide him with significant attention and love.

Despite these challenges, the overall family environment remains healthy.

Family History of Psychiatric Conditions

The client's eldest sister has been diagnosed with Autism Spectrum Disorder.

Additionally, a first cousin on the client’s side has Intellectual Disability. His mother has

also experienced postpartum depression and had significant stress during her pregnancy

with the client.

Background Information

Medical and Birth History

The client was born via normal delivery following a full-term pregnancy, with no

reported postnatal complications. However, there were reports of prenatal high blood

pressure and significant maternal stress during the pregnancy.

Educational Background

The client has no educational background.

Developmental History

Developmental Normal age Achievement of

milestones milestones

Crying After birth Immediate

Crawling 6-9 months After a year

Sitting 6 months 10 months

Walking 9-18 months 2 years

Cooing 3 months Delayed

Babbling 6-9 months Delayed

 196

First word 10-15 months 2.5 year

Combine words 15-32 months Not yet

Phrase level 3 years Not yet

Psychological Assessment

The psychological assessment consisted of:

PRELIMINARY
INVESTIGATIO
N

Formal Informal
Assessmen
Assessment t

Childhood DSM 5 Clinical Behavioral Portage Guide

Autism Rating Intervie Observatio to Early
Scale Check List w n Education
(C.A.R.S)

Informal Assessment

Clinical interview

An unstructured interview was conducted with the client's mother to gather in-

depth information about the child's current health issues and initial symptoms. During the

interview, the mother described instances where Z.B would suddenly start laughing and
 197

then begin crying. He also frequently repeats words such as "Mama" and "Papa." The

mother highlighted her own past neglect of the child, noting that Z.B did not receive

much maternal affection in his early years. Additionally, she mentioned that Z.B enjoys

playing with toys such as cars, musical toys like toy pianos, and sensory balls. She

observed that he is less sensitive to the sounds from musical toys and often taps objects to

create noise. Z.B also shows a keen interest in puzzles, boards, and using cell phones, and

he prefers watching cartoons at a high volume.

Behavioral Observations

During observational sessions, it was noted, Z.B chose a red chair to sit in and

displayed aggression when it was occupied by others. He often avoided eye contact,

looking downward or into space, and did not respond when his name was called. His

attention span and ability to remain seated were limited, and he struggled with command

following. His speech was not functional, and he frequently placed any red-colored object

into his mouth. He was particularly drawn to a red umbrella hanging from the ceiling,

becoming distraught when he could not reach it, leading to loud yelling and crying. Z.B

tends not to interact with other children and requires full prompting to engage in tasks.

Additional behaviors included making noises, discarding unwanted toys, and seeking

approval for his actions. He showed strong attachment to his eldest sister, and separation

from her would provoke aggressive reactions. If a favorite item was taken away, he

would exhibit tantrums, self-harm, and screaming. It was also observed that Z.B could

imitate single words.

Portage Guide to Early Education Assessment

The Portage Guide to Early Education was used to evaluate Z.B's development in
 198

language, motor skills, social interactions, cognitive abilities, and self-help skills. The

cognitive section was directly assessed with the child, while information for the other

areas was provided by the mother. The assessment took approximately one hour to

complete.

Quantitative scoring
Chronological Age: 5 years
Domains Functional Age Range

Self-help skills 3-4

Motor skills 2-3

Language skills 0-1

Social skills 0-1

Cognitive skills 0-1

Description: The client’s age was 9 years old and there is a marked difference between

chronological age and functional age of the child on five developmental areas.

Qualitative Analysis

The analysis of the Portage Guide to Early Education reveals that the client's

developmental age lags behind his chronological age across all assessed areas. His least

developed areas are language and social skills. Although he has developed some

language abilities, they are not functional and remain largely incomprehensible. In terms

of social skills, he interacts primarily with family members and appears indifferent to the

presence of others, often avoiding eye contact. While the client's motor and self-help

skills are relatively more advanced compared to other areas, they still fall short of

expectations for his chronological age.

Formal Assessment
 199

Childhood Autism Rating Scale

Childhood Autism Rating Scale (CARS) was administered to rate the individual’s

symptoms on a scale ranging from normal to severe.

Quantitative Scoring
# Categories Rating

1. Relating to people 3.5

2. Imitation 3

3. Emotional response 2

4. Body use 1.5

5. Object use 3

6. Adaptation to change 1.5

7. Visual response 3

8. Listening response 3

9. Taste, smell and touch response and use 1

 200

10. Fear or nervousness 2

11. Verbal communication 4

12. Non-verbal communication 3

13. Activity level 2.5

14. Level and consistency of intellectual response 2

15. General impressions 3

Total Score 38
Qualitative Analysis

The client's total score on the Childhood Autism Rating Scale is 38, indicating

severe autism. He received notably high scores, specifically 3.5 and 4, in the areas of

verbal communication and relating to people. Additionally, the client scored high in

categories such as object use, imitation, adaptation to change, listening responses, non-

verbal communication, and overall impression, reflecting a significant difficulty in

socializing with others. His use of body movements, however, was comparatively more

appropriate. The assessment also highlighted substantial challenges in his responses to

visual, taste, smell, and tactile stimuli. Furthermore, the client occasionally shows a

preference for touching soft objects and toys, often placing them in his mouth.
 201

DSM 5 Autism Spectrum Disorder (ASD) Checklist

The checklist consists of the symptom criteria of autism spectrum

disorder according to diagnostic and statistical manual (DSM-5 TR). The client

meets the criteria A-E for ASD.

Showing diagnostic criteria of ASD Symptoms present in client and status of symptoms

Diagnostic criteria Status of symptoms

Deficits in social emotional reciprocity Present

Deficits in non-verbal communicative behavior used for social Present

interaction

Deficits in developing, maintaining and understanding Present

relationships

Insistence on sameness, inflexible adherence to routine, or Present

ritualized

patterns of verbal and non-verbal behavior

Tentative Diagnosis

“299.00 (F84.0) Autism Spectrum Disorder with language impairment”.

Case Formulation

Predisposing Factors: Z.B is a 9-year-old boy diagnosed with Autism Spectrum

Disorder (ASD), meeting the diagnostic criteria outlined in the "Diagnostic and Statistical

Manual of Mental Disorders DSM-5 TR" (American Psychiatric Association, 2013).

Research suggests that prenatal stress and maternal health issues, such as the high blood

pressure and significant stress experienced by Z.B's mother, can contribute to

developmental risks for conditions like ASD (Beversdorf et al., 2018). Additionally,
 202

genetic predispositions are indicated by the presence of ASD in a sibling, contributing to

Z.B.'s risk factors.

Precipitating Factors: The familial environment during Z.B.'s early development

featured significant maternal distress and familial conflicts, which may have precipitated

or exacerbated his condition. The mother’s emotional state during pregnancy and ongoing

family stresses could have influenced Z.B.’s early neurodevelopmental environment,

aligning with findings that maternal emotional states can impact developmental outcomes

in children (Jones et al., 2019).

Perpetuating Factors: Z.B.'s behavioral issues, including aggression and repetitive

behaviors, may be perpetuated by the family's handling of these behaviors. Specifically,

the family's reinforcement of negative behaviors (e.g., giving attention or comforting him

when he exhibits undesirable behaviors) can maintain and strengthen these actions. This

dynamic is supported by behavioral studies indicating that certain responses from

caregivers can reinforce the behaviors they aim to diminish (McLean et al., 2010).

Protective Factors: Though not explicitly described, potential protective factors for Z.B

could include structured behavioral interventions, consistent and appropriate parental

training on handling ASD behaviors, and social support systems including therapy and

special education resources. These can help mitigate the impacts of ASD and support

better developmental outcomes.

Management Plan

Short-term goals
 203

Reduce Frequency of Negative Behaviors: Aim to decrease incidents of self-harm,

aggression, and excessive crying within three months through consistent behavioral

interventions.

Improve communication skills: Facilitate the use of functional words and simple

phrases in appropriate contexts over the next six months using speech therapy.

Enhance Social Interaction: Encourage basic social interactions, such as making eye

contact and responding to his name, through structured play sessions within a controlled

environment.

Long-term goals

Social Skills Development: Enable Z.B. to participate in group activities and improve

his ability to form friendships by the end of the year.

Educational Advancement: Tailor educational approaches to Z.B.'s learning style to

support his cognitive and language development, aiming for integration into a specialized

educational setting that caters to his needs.

Independence in Daily Activities: Gradually increase Z.B.'s self-help skills, such as

dressing and feeding himself, with the goal of independent performance of these

activities within two years.

Therapeutic Interventions

Recreational Therapy: Recreational therapy involves activity-based interventions

tailored to meet the client's needs. These activities, conducted every Friday, include

pasting stars and shapes on white paper or charts, sorting objects, matching balls of

different colors, and other engaging tasks designed to enhance cognitive and motor skills.
 204

Applied Behavior Analysis (ABA):Applied behavioral techniques focus on skills that

enhance independence and long-term success. This approach employs a structured

methodology to foster functional skills and reduce problematic behaviors.

Identification of Reinforcers To effectively implement behavior therapy, identifying the

most impactful reinforcers is crucial. This process involved direct observation and

consultations with the client’s mother, revealing that the most effective reinforcers are:

 Possession Reinforcer: Rainbow activities, stars on hand or chart

 Activity Reinforcer: High fives, clapping from others, and opening doors

Continuous Reinforcement Schedule (CFR): Following reinforcer identification, a

continuous reinforcement schedule was applied, providing rewards after each correct

response to encourage behavior modification.

Discrete Trial Training (DTT): DTT is a structured intervention based on ABA

principles, often combined with other therapeutic approaches to teach various skills (Leaf

et al., 2016). Skills focused on included:

 Academics (Pencil Gripping): The client was encouraged to scribble on paper

using a primitive grasp, with the goal of developing a dynamic tripod grasp.

 Receptive Language Tasks (Command Following): Initially using full physical

prompts, the client was taught to follow commands, gradually reducing prompts

as proficiency increased.

 Labeling (Body Parts): Through reinforcement, the client successfully labeled

seven body parts within 12 sessions.

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Functional Communication Training: The client, who typically showed irritation when

needing something, was taught to communicate needs functionally by pointing to objects,

thereby reducing frustration and improving interaction.

Chaining (For Daily Living Activities): Using the forward chaining technique, daily

living tasks were broken down into manageable steps. Each step was taught sequentially

with modeling and assistance as needed to ensure skill acquisition.

Managing Behavioral Issues: Specific behaviors were targeted for intervention:

 Head Banging: To address attention-seeking head banging, the behavior was

ignored, leading to its reduction after several instances.

 Hitting/Pinching/Shouting: These behaviors, often used as escape mechanisms,

were managed through planned ignorance and redirection, effectively reducing

their occurrence.

 Mouthing: Negative reinforcement was applied by removing the client’s sister

from the room when mouthing occurred, which gradually decreased this behavior.

Reward Chart: A reward chart was used both at home and school to encourage and

recognize desired behaviors. Stars were placed on the chart and clapping was employed

to motivate the client and acknowledge progress.

This report provides a comprehensive overview of the therapeutic interventions employed

to address various developmental challenges faced by the client with Autism Spectrum

Disorder. Each intervention is aimed at improving specific functional areas, with progress

closely monitored through structured activities and reinforcement strategies

Individualized Education Program (IEP)

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Area of Short-term Long-term Activities

Development objectives objectives
Behavioral skills Reduce frequency Enhance ability to Implement ABA
of negative regulate emotions techniques; Use a reward
behaviors (self- and reactions in chart for positive
harm, aggression, various settings by behavior reinforcement.
excessive crying) end of the year.
by 50% within
three months.
Communication Increase use of Develop ability to Daily speech therapy
Skills functional words use complex sessions; Use of PECS
and simple phrases sentences and and sign language basics.
to 20 different engage in back-
words/phrases and-forth
over six months. conversation
within one year.
Social interaction Encourage basic Enable M.H. to Organize supervised
social interactions, participate in playdates and structured
such as making group activities play sessions; Enroll in
eye contact and and form social skills group
responding to friendships by sessions.
name during participating in
structured play meaningful
sessions, interactions during
achieving this in group settings by
80% of the end of the
opportunities year.
within six months.
Educational Skills Introduce basic Tailor educational Use of visual aids and
pre-academic approaches to tactile learning materials;
skills (letters, M.H.'s learning Special education
 207

numbers) and style for cognitive services focusing on

achieve mastery in and language adapted curriculum.
simple academic development,
tasks within six aiming for
months. integration into a
specialized
educational setting
within one year.
Daily living skills Assist in daily Perform daily Occupational therapy
living activities living activities focusing on self-help
with prompts, such as dressing skills; Use chaining
aiming to increase and feeding methods for complex
independence with independently tasks.
minimal assistance within two years.
within six months.

Before Intervention
Intervention
9

5 Frequency (0-
10)
4
3

0
Comman Mouthin Hitting Behavior Excessive
d g Crying

Pre and Post Intervention Rating

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Recommendations

After Intervention
IIntervention
8

5
Frequency (0-
4 10)
3 Intensity (0-10)
2

0
Command Mouthing Hitting Behavior Excessive
Crying
Following

The followings are the recommendations for this case:

 After the behavioral management, the main stream school must be started to

polish the academic area of client.

 The client must be allowed to learn the things on a slow pace, this will allow him

to learn more rather than pressurizing him to learn all at once.

 Regular follow up sessions along with proper training to parents must be

schedule.
 209

References

Cohen, L., Manion, L., Morrison, K., (2018). Research methods in education.

(6th ed). London: Routledge

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A. D. (2019). Identification of common genetic risk variants for autism spectrum

disorder. Nature genetics, 51(3), 431-444.

Hodges, H., Fealko, C., & Soares, N. (2020). Autism spectrum disorder: definition,

epidemiology, causes, and clinical evaluation. Translational pediatrics, 9(Suppl 1),

S55.

J. Med. 366, 733–743 (2019).

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Manning, J., Billian, J., Matson, J., Allen, C., & Soares, N. (2021). Perceptions of

families of individuals with autism spectrum disorder during the COVID-19 crisis.

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Sikich, L., Kolevzon, A., King, B. H., McDougle, C. J., Sanders, K. B., Kim, S. J., ... &

Veenstra-VanderWeele, J. (2021). Intranasal oxytocin in children and adolescents

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Siracusano, M., Riccioni, A., Gialloreti, E., Carloni, E., Baratta, A., Ferrara, M&

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Neurodevelopmental Disorders in Offspring: Preliminary Results from the

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Smith, D., (2020). Introduction to Special Education.London: Allyn and Bacon

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