1

Subject :

Child Psychiatry

Course Code :

509

Submitted To :

Dr Bushra

Submitted By :

Sehrish Bibi

Roll No : 23016911-012
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CASE 1
Autism Spectrum Disorder DSM-5TR 299.00 (F84. 0)
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CASE SUMMARY

The client was 8.5 years old and a second-born child. The symptoms were observed at the age of 18
months like he was not an active baby and also doesn’t respond to his name. At age of 2.5 years, he was
diagnosed with Autism. The client showed symptoms of recovery related to attention span and speech even he
started to speak some words for at least 1-1.5 years but at the age of 3.5-4 years everything faded. At the age of
6 years, he was bought to the clinic with the symptoms of aggression, sensory concerns, repetitive behavior,
speech issues, lack of eye contact and command following. The client cannot speak on his own now and shows
repetitive behavior like hand flapping and echolalia. He still cannot maintain eye contact for long time but his
command following has improved. He sometime gets very hyper and tries to hit others. For proper diagnosis
and treatment both formal and informal assessment were done. Informal assessment includes clinical interview
from client’s mother, behavioral observation and mental status examination. Further client's condition was
examined through formal assessment by using Child hood Autism rating scale(CARS) and the score was 36
which shows that that client has mildly-moderately autism. Hence, a tentative diagnosis of “Autism Spectrum
Disorder DSM-5TR 299.00 (F84. 0)” is given to the client. The therapeutic recommendations for autism
include Applied Behavior Analysis (ABA therapy), Occupational Therapy and Speech Therapy.
Demographic Information
Name AS
Age 8.5 years
Education No schooling
Gender Male
No of siblings 2
Birth order 2nd Born
Parents Alive
Language Urdu, English, Pashto
Religion Islam
Informant Mother
Source and Reason of Referral:
The best friend of client’s mother told her about this place because her own son comes to this clinic
therapy.
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Presenting Complaints (Verbatim of the mother)

History of Present Illness

The symptoms were observed at the age of 18 months. At first client’s mother thought that the client’s
behavior is normal but his cousin was already diagnosed with Autism, so the client’s aunt told his mother that
client’s behavior is unusual i.e. he is not active, lost in his own thoughts and he also doesn’t respond to his
name. He was given diagnosis of Autism at the age of 2.5 years. The client showed symptoms of recovery
related to attention span and speech even he started to speak some words for at least 1-1.5 years but after
relapse everything faded. The condition relapsed at the age of 3.5 – 4 years. Symptoms of the client are
constant, but sometimes the client shows behavior of obedience and calmness.
Background History
Personal History
Pre-natal history of the client was that the mother conceived when client’s sister was 7 months old.
However, it was normal pregnancy, 9 Months completed. There was a little complication with the mother’s
placenta but it was resolved. Delivery was normal. Post-delivery everything was normal but after 3-4 months he
got Measles, after that he became prone to fever. He doesn’t use to smile and respond like other kids. He was
not an active baby.
The client’s daily routine starts with breakfast after he wakes up, it takes up at least 40 minutes to finish
his breakfast. After that he gets ready, and uses phone for at least 15-20 mints. When he returns from clinic, he
eats his lunch, and then his father involves him in a session in drawing room. After that he goes to sleep. He
goes to bed between 9:30- 10:30 but sometimes it gets late. He doesn’t sleep quickly, sometimes he wakes up
and tries to annoy his siblings. He used to sleep with his sister before but now he sleeps alone and gets
frightened at night and asks someone to sleep with him. The client likes to play with water and is interested in
doing household work. He also loves to ride a bicycle. He loves music and swings. He gets distracted easily
and he is asked repeatedly to do a certain task.
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Developmental Milestones
Table 1
Developmental Milestones of the client
Development Milestone Normal Age Client’s Achieving Age
Neck Holding 3 Months Normal
Sitting 4 Months Normal
Crawling 9 Months Normal
Standing 9-12 Months Normal
Walking 8-18 Months delayed
Feed Self 6 Months Delayed
Using Toilet 18-24 Months – 3Years Delayed
Using Single Words 15-16 Months 2.5 Years
Combining Words 24 Months 3.5 Years
Naming Objects 12-18 Months Delayed
Questioning 2.5 Years -3 Years Delayed
Engaging in Conversations 11-14 Months Delayed

Qualitative Analysis
Few of the developmental milestones of the client were normal. Client showed delayed development in
walking, feeding himself, using toilet, using single words, combining words, naming of objects, questioning and
engaging in conversations. The client cannot feed himself properly. His mother asks him repeatedly to eat or
complete his meal. He also used to rub his private parts repetitively during his course of development and he
also faces problem in washroom tasks like he cannot wash him properly and comes out without cleaning
himself. The client cannot use vocabulary by himself. Every time, verbal prompt is needed for him to engage
him in any task. Whenever, a command is given to him, he repeats every word or sentence.

Family History
The client is living in nuclear family system in the last 7 years. Father is 45 years old; he has done MBA
and he is a government officer. The client’s mother is 37 years old; she has done masters in Pakistan studies
and she is a housewife. Overall, the relationship with mother is good but whenever his mother stops him from
certain things, he starts hitting her. The client is close to his father as his father is very cooperative and
courageous.
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Client has 2 siblings, one sister (9.5 years of age) and one brother (3.5 years of age) and they are school going.
His sister used to tease him at the start and he developed aggressive feelings for her and now he is not friendly
with her at all. His relationship with his brother is relatively good but sometimes, he also fights with him. The
client’s mother reported that her nephew is going through the same problem.
Medical/Psychiatric History
He has never been hospitalized for any serious injury but he was admitted in mental health institutes
where he was given the treatment for the related disorder. The client’s mother reported that he was under
treatment in Peshawar at the age of 2.5 years for few months where he showed improvement. Then she came to
Islamabad and the client was admitted in Umeed-e Noor at the age of 3 years for 1-2 months where he was also
recovering. For some reasons they have to go back to Peshawar and when they came back the client was
admitted in special school at the age of 3.5-4 years for 2 months where his condition relapsed.
Social History
He likes to play with other children in his family or any other surroundings but does not cooperate with
them at all. He becomes aggressive with other children sometimes tries to hit them or snatch things from theme.
During group activities, he doesn’t wait for his turn and interrupts everyone during the play activities.
Assessments
Informal Assessment
The informal assessment includes:
• Clinical interview
• Behavioral observation
• Mental Status Examination
Clinical Interview
The client lives far from the clinic; it was difficult for client’s mother to come to the clinic so the
interview was conducted via the phone. Detailed information about the client was taken from mother like his
identifying data, presenting complaints, history of present illness, personal history, developmental milestones,
family history, medical history and social history. She was very concerned about the client’s condition and was
very hopeful that he would be able to behave like normal kids. During the interview mother was very
cooperative and open. She was giving every little information about the symptoms of the client and was telling
measures she was taking for the management of the client’s symptoms, which helped me in making
management plan. The client’s mother was being psych educated about every aspect of his condition and she
was requested to repeat and practice every strategy or intervention at home that was practiced in the clinic.
From the interview is was seen that client had issues related to verbal and non-verbal communication. His
mother also reported that client is hypersensitive to sound and dark rooms.
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Behavioral Observation
Initially, the client’s behavior was calm during the sessions. He used to come, sit and stare things
around him. Eye contact was very minimal and repetitive behaviors like hand flapping was extreme at that
time. He was not responding when his name was called and was not listening or following any commands. But
after rapport building, improvement was seen in his behavior, like he was following commands, was
responding to his name and started to engage in activities. He became hyperactive during later sessions, like
jumping, leaving his seat and forcing certain objects. He can now maintain focus and eye contact for few
minutes on things of his interest.
Mental Status Examination
The psychiatrist's version of the physical examination is called the mental state examination. Adolf Meyer
created a framework for a systematic technique to assess a patient's "mental status" for psychiatric practice in
1918. During evaluation, it serves as the defining status of the patient's present condition. The broad categories
of appearance, behavior, motor activity, speech, mood, affect, thought process, thought content, perceptual
disturbances, cognition, insight, and judgment comprise the mental status evaluation (Voss & Das, 2022).
Table 2
Mental status examination during sessions Appearance:
Appearance Age: The client is 8.5 years old boy.
Height and Weight: His height and weight is normal
relative to his age.
Grooming: He was always well-dressed and his personal
Hygiene was always maintained
ppy, Gait and posture: sometimes he used to walk on his toes
Happy and sit in an odd posture.
Behavior Eye Contact: Client’s eye contact was not appropriate but
he can maintain eye contact for few seconds. When things are
pointed he look at them
Mannerism: Repetitive behavior like hand flapping,
jumping, lining up objects and moving back and forth
were present.
Altitude: Most of the time the client was calm and
peaceful but there were times when he became
aggressive, angry and hostile.He was good in
command following. He also tried to hit and
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snatch things. He is distracted sometimes.

Facial expressions: Happy, sad, Angry
Psychomotor activity: He felt psychomotor agitation or
arousal during sessions when he was asked to
maintain focus on certain activity or object. He used
to get zone out in the middle of the session. He
used to pace around the room.
Engagement and Rapport: Rapport was easily
established.
Level of arousal: He was not alert and focused. He can get
easily distracted.
Speech: Client cannot speak on his own. Echolalia was
present like he used to repeat every word or He used
to make repetitive sounds as well
Affect: Client was very moody. sometimes he was happy and other
time he was a sad and agitated

Cognition: Client’s attention span was less specially he

Cannot stay focus during an activity, he
starts to stare objects around him. It looks like as
he was lost somewhere. His memory was good
like he positions of puzzles.
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Formal Assessment
• DSM-5-TR Checklist
• Childhood Autism Rating Scale
DSM-5-TR Checklist
In 2022, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, Text Revision
(DSM-5-TR) was released. The DSM-5-TR enumerates the symptoms and indicators of autism spectrum
disorder and specifies the number of symptoms required to make the diagnosis (DSM-5-TR: Autism Spectrum
Disorder Diagnosis, nd).
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Table 3
Autistic symptoms of the client according to DSM5-TR
Symptoms Present
Deficits in social-emotional reciprocity Present
Abnormal social approach Present
Failure of normal back and forth conversation Present
Failure to initiate or respond to social interaction Present
Deficits in non-verbal communication Present
Poorly integrated verbal and non-verbal communication Present
Abnormalities in eye contact and body language Present
Deficits in using and understanding gestures Present
Deficits in developing, maintaining, and understanding relationships Present
Difficulty in adjusting behavior to suit various social context Present
Difficulty in making friends Present
Stereotyped or repetitive motor movements, use of objects, speech Present
Simple motor stereotypies Present
Lining up toys Present
Echolalia Present
Insistence on sameness, inflexible adherence to routines or ritualized
Present
patterns of verbal and non-verbal behavior.
Extreme distress at small changes Present
Eat same food everyday Present
Hyper reactivity to sensory input or unusual Present
Interest in sensory aspects of the environment. Present

Childhood Autism Rating Scale (CARS)

In 1988, Barbara Richen Renner, Robert J. Reacher, and Eric Scholar created CARS. The fifteenth domain of
the CARS rates an overall impression of autism, while the other fourteen domains evaluate behaviors linked to
autism. A scale from 1 to 4 is used to score each domain; higher scores correspond to a higher degree of
impairment. According to Lebowski et al. (2010), total scores can vary from 15 to 60. A score below 30
indicates that the person is not autistic, a score between 30 and 37 indicates mild to moderate autism, and a
score between 37 and 60 indicates severe autism.
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Table 4
Client’s Score on each item
Category Client’s Score
Relating to People 2
Imitation 2
Emotional Response 2
Body Use 3
Object Use 2
Adaptation to Change 3
Visual Response 3
Listening Response 2
Taste, smell and touch response and use 1.5
Fear or Nervousness 1.5
Verbal Communication 3.5
Nonverbal Communication 2.5
Activity Level 2.5
Level and Consistency of Intellectual 3
Response
General Impression 2.5

Table 5
Score, cutoff score and interpretation of client’s CARS test
Score Cut-off Score Interpretation
36 30-37 Mildly-Moderately Autistic

Qualitative Analysis

Client score shows that he has mild to moderate autism. He cannot speak on his own so for this reason
he cannot communicate with others. He shows repetitive behaviors and sounds. He cannot maintain eye contact
for long time. Sensory issues are also present like he becomes hyper when the light is turned off and when there
is noise. He doesn’t like change in his routine, eats same food daily. He loves certain toys such as a bear and a
dog and he doesn’t let his siblings play with his favorite toys.
Tentative Diagnosis:
Autism Spectrum Disorder DSM-5TR 299.00 (F84. 0) Specifier: Requiring substantial support
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Case Formulation

Autism encompasses impairment in multiple domains of functioning. Often called the "triad problems,"
the three main characteristics of autism are behavioral variability (i.e., limited and repetitive behaviors), social
functioning, and impaired verbal and gestural communication. These issues often manifest within the first 36
months of life. Additional issues linked to autism include intellectual incapacity, behavioral issues, and
deficiencies in sensory and perceptual abilities. A concomitant medical issue is present in 10–37% of people
with autism. According to Hixson et al. (2008), autism is regarded as a neurodevelopmental condition that is
biologically mediated.

The client’s case formulation is done using the five p’s model, developed by McNeil et al., 2012, to
better understand all the factors contributing to the client’s illness. This framework provides a conceptualized
way to look at clients and their problems, systematically and holistically taking into consideration the presenting
problems, predisposing factors, precipitating factors, perpetuating factors, and the Protective factors of their
illness.
The presenting complaints of this client were that the 8 ½ years old child had issues with
communication, he made minimal eye contact and had behavioral issues such as aggressive and repetitive
behavior, impulsivity, inattentive behavior and hyperactivity. There were no precipitating factors as client’s
mother reported he doesn’t use to smile and respond like other kids. He was also not an active baby.
The predisposing factors of the child suggest that the gap between conceiving the first and the second
child was only 7 months for the mother and according to research, children born with an interval of 12 -72
months has an increased risk of autism spectrum disorder as compared to children born with a larger gap (Zero
et al., 2015). Another research supports these results as it was found that the later born child had an increased
risk of autism if the pregnancy interval was of less than a year (Gunners et al., 2013). Another Study has also
shown associations between short afterbirth interval and the risk of diseases like childhood autism,
schizophrenia and childhood leukemia (Cardwell et al., 2012).
Another underlying factor could be the presence of the disease in his family as the client’s cousin has
also been diagnosed with autism and research shows that the risk of ASD increases with increasing genetic
relatedness (Sanding et al., 2014). Another research further supports this as it was found that there are certain
genes the increase the risk that a child will develop autism if it has been diagnosed before in their family
(Autism Speaks, 2019).
There may be some other perpetuating factors that can contribute to Autism. In this case, the child has
delayed early milestones which according to research suggests that children with delayed milestones have an
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increased severity of autism with deficits in multiple areas like motor and speech skills (Matson et al., 2010).
Studies indicate that communication deficits are one of the main symptoms of Autism and not reaching early
milestones is an indication that the child may be have the disease. They may be slow at talking or may not learn
to talk at all. This can become a maintaining factor if the child is unable to accomplish the social interactive
goals (Paul, 2007). Developmental delays are often found in children with autism and these are defined as
social, emotional, communication, cognitive and physical milestones which are not reached by the children as
they are expected to. In this case, the client displays delays in reaching communication milestones which
contribute towards maintaining their symptoms of autism (Rudy, 2017).
There is evidence supporting the notion that certain treatments can be very effective in ASD through
proper screening and diagnosis. These early interventions can help improve the conditions and bring
improvement (Myers & Johnson, 2007). However, in this case the client did not receive proper early treatment,
the client’s family tried different treatments but since one specific treatment was not maintained, no
improvement was observed in the client’s condition.
Other perpetuating factor in this case can be the negative experiences the client has had at home, as due
to lack of understanding of his condition, the family were not able to provide him with the support that he
needed. He was often hit as a punishment for his behavior and was reported to be bullied by his sibling which
added additional stress and suffering to his life making therapeutic interventions unsuccessful in improving his
condition. Research indicates that these emotional stressors further contribute to individuals having meltdowns
which do not contribute well to their treatment (Lewis & Stevens, 2023). A study conducted in China indicates
that children with Autism were at an increased risk of child physical maltreatment (CPM) increasing their
symptom severity (Duane et al., 2015). Which shows how important it is to educate the parents as CPM hinders
their progress and makes things harder for the child.
The client has been taking treatment for some time now and his family, especially his father is very
supportive. He makes sure that he attends all his sessions and has made efforts to educate himself and his family
about the client’s condition so that they can be more understanding and supporting and can help him in effective
ways. This is very important as family support is crucial for anyone and incase of children, it is the most
integral part of their treatment. Studies also support this notion as it is found that the parent’s involvement in
treatment greatly helps to reduce their symptoms and aid their treatment journey (Burrell & Borrego, 2012).
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Figure1
Case Formulation

Client: Mr.SA
Male
8.5y/o

Presenting Complaints
Minimal eye contact, communication issues, repetitive and aggressive
behavior, inattention, hyperactivity and impulsivity

Predisposing Factors Perpetuating Factor Protective Factors

Biological: Afterbirth Delayed milestones, Parents unconditional
interval improper treatment support and positive
Genetics: The familial negative life attitude towards his
risk of autism experiences illness

Theoretical Framework
Behaviorism
The data supporting the ideas and environmental origins of autism are examined, along with a discussion of
behavior-analytic theories of autism. There isn't much proof that abnormal parenting styles promote autism.
Nonetheless, functional analyses have demonstrated that the behavior of children with autism can be explained
and treated with the aid of behavior analysis principles, and that changing parenting techniques can result in
improvements in child behavior. Two possibilities are somewhat supported by the research. First, autism is
characterized by a misalignment of the child's neurological system with the environment. Secondly, because
social situations are unexpected, children with autism may have difficulty developing sensory control,
particularly in social situations. (Hixson and others, 2008).

• B.F. Skinner: Skinner stressed the significance of consequences in shaping behavior. As a

behavioral psychologist, B. F. Skinner, he believed that looking at the causes of an action and its consequences
was the best way to understand behavior, terming this approach, operant conditioning, which looked at the
effects of the behavior. Behavioral theory is grounded on the belief that behavior is learnt. Operant conditioning
works on the premise that behavior can be maintained or altered by reinforcement and punishment, increasing
or decreasing the probability that it is likely to occur in the future. Punishment, by definition, should be
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effective in reducing the target behavior. Nevertheless, qualitative evidence indicates that the ineffective use of
time outs and punishments resulted in the continuation or escalation of challenging conduct in autistic children.
Furthermore, it has been discovered that negative, controlling parent behaviors—such as employing punishment
and/or discipline—have a major role in the behavioral issues that children with ASD face. Additionally, prior
research indicates that these behaviors may also be maintained through an interaction, whereby the child's
problematic behaviors may adversely reinforce the parent's conduct, so perpetuating the behaviors in both the
parent and the child. According to studies, inconsistent responses and the application of punishment and
discipline have been linked to an increase in challenging behavior in children and adolescents with ASD over
time. Differential reinforcement is a new, and more moral, consequence-based behavioral strategy. This entails
rewarding desired behavior while depriving undesirable behavior of reinforcement. According to The Use of
Punishment with Autistic Children Who Use Behavior That Challenges (n.d.), they have been characterized as
offering reinforcement for both engaging in desired behaviors and not engaging in the problematic behavior
(differential reinforcement of other behavior, or DRO).
Skinner's behaviorism greatly influenced a new therapy approach, shifting treatment of psychological disorders
from psychoanalysis and medications to behavior therapy. The underlying assumption for behavior therapy is
the Skinnerian concept that individuals can learn abnormal behavior similarly to learning normal behavior.
Therefore, corrective learning involving removal of reinforces of the adverse behavior and implementing the
reinforcement contingencies strengthening appropriate behavior seems to be the key to effective therapy.
Currently, operant conditioning has a broad application to help individuals affected by autism or other
psychological disorders. Operant conditioning along with positive reinforcement seems to increase desirable
behavior or stimulate learning new behavior in many autistic patients by doing the same simple tasks in a
repetitive way to get a favorable outcome (Jasiurkowski, 2016).
John B. Watson: He was a well-known psychologist in America. Watson preferred to concentrate
immediately on observable behavior and tried to alter it because he thought it was impossible to conduct an
objective investigation of the mind. Therefore, Watson argues that since parents and other caregivers create the
environment in which their children are raised, they are solely accountable for their behavior. Watson came to
the conclusion that by taking control of all stimulus-response linkages, caretakers may influence a child's
behavior and development based on the findings of his "Little Albert" study (Alali, 2023).
Short Term Goals
 Rapport Building
 To maintain eye contact
 Visualization practice
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 To improve command following during activities

 Decrease his repetitive behavior and speech
 Control his aggressive behavior
Long Term Goals
 Achievement of delayed milestones
 Improve speech
 Learning to write
 Improve communication skills
Therapies
• Applied Behavior Analysis (ABA)
• Occupational Therapy
• Speech Therapy
Applied Behavior Analysis (ABA)
Applied Behavior Analysis (ABA) was given by Ivar Loaves. ABA is a therapy based on the science of
learning and behavior. ABA is helpful in increasing language and communication skills. Further it is very useful
in improving attention, focus, social skills, self-help skills, motor skills, memory, and academics. Moreover, its
techniques can be used to reduce problematic behavior (Applied Behavior Analysis (ABA), 2021). ABA is very
effective for children with neurodevelopmental disorders. ABA therapy utilizes behavioral principles to set
goals, reinforce behaviors, and measure outcomes. ABA helps autistic children to look non-autistic by teaching
them behaviors which are appropriate to the specific situation. This is done by breaking goals into smaller steps
and reinforcing the child when a step is achieved. This will increase the probability that behavior will occur in
the future (Rudy, 2006). All the strategies used in the sessions were based on ABA, these strategies were used
to overcome the client's deficiencies.
Occupational Therapy (OT)
Occupational therapy was given by Eleanor Clarke Slagle. It helps a person when he is facing trouble in
doing his daily activities. It teaches basic skills so that a person can live and perform daily activities
independently (WebMD, 2016). OT strategies for autistic child includes play skills, learning strategies and self-
care. It is also effective in minimizing sensory issues in them. Strategies like helping a child to eat on his own or
going to toilet on his own, grooming, independent dressing, improving fine motor skills like writing, coloring,
and cutting with scissors (McGuire & Delano, 2019). During the sessions, I worked on improving the child's
gross motor skills by having him do different activities. These included putting his hands on a big ball and
pressing it, going on slides and swings, jumping, running, and walking. He also played with bubbles, went to
the park, and played games like throwing and catching a ball. To develop his fine motor skills, I asked him to
perform activities like tracing, painting, coloring, and drawing.
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Speech Therapy
Speech therapy was given by Charles Van Riper. It is the treatment for children who have speech,
language and communication problems (Santos-Long hurts, 2019). In dealing an autistic child speech therapy
can be done by using verbal cues, gestures, answering, and asking questions. Strategies of speech therapy can be
an important tool for autistic children to communicate and engage with others (Rudy, 2024). During sessions it
was done by speech therapist.
Techniques
• Rapport building
• Psychoeducation
• Reinforcement
• Prompting
• Fading
• Modeling
Rapport Building
Most important tool during therapy is rapport building. Before starting a therapy, it is very important to
ensure that a good rapport has been established between you and your client. At first client was only observed,
then I exposed him with different activities and items to see things of his interest. He was always welcomed
with a smile. Initially I just played with him the way he wants. He was not given instructions in the beginning of
the sessions but slowly and gradually I started giving him instructions and on following the instructions he was
reinforced like praising and high five.
Psych education
Psychoeducation of parents is very important. Client’s parents already knew about autism and were
doing efforts at home to resolve the issue. The client is the relapse case so I have to tell his mother that we have
to work together patiently as it will take time to minimize the symptoms. His mother was also requested to do
all the activities at home which were done in the clinic for better results. She was also told that hitting him will
make him more aggressive so both parents have to be calm and patient with him.

Reinforcement
Reinforcement is to strengthen a behavior. It improves the probability that behavior will occur in the
future. The client is positively reinforced during the session when he completes certain task or follow certain
commands or instructions. This will make him do that activity or follow that instruction again. Through
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reinforcement many goals can be achieved. During the session client was positively reinforced with high-five,
praise, clapping, and a ball.
Table 6
Clients reinforces and its types
Reinforces Types of reinforces
High-five In-tangible
Praise Intangible
Clapping Intangible
Ball Tangible
Prompting
Instructions, gestures, demonstrations, touches, and other actions we plan or carry out to improve the
probability that kids will give accurate answers are known as prompts. It is actually assistance which is given by
an adult or more knowable person (golden-user, 2022). Prompting helps in improving person’s ability to do a
certain task independently after some time. There are different types of prompts used like gestural prompts, full
physical prompts, partial physical prompts, verbal prompts, visual prompt and positional prompt (Chicago ABA
Therapy, 2017). Verbal prompts were used throughout the sessions to develop his skills where the child was
given different commands to perform activities such as to identify blue color, his organization skills were tested
where he was asked to organize boxes of different sizes, he was asked to Identify body parts and to perform
activities such as to paint, trace, color, jump and run. Full and partial physical prompts were used in almost
every session. Full physical prompts included activities such as folding a mat, touching a ball etc. In Partial
physical prompts, I asked the child to place and touch body parts and to do painting. Gestural prompts were
used by asking the child to touch an object and to perform sequencing activities using different tools. Lastly,
Positional Prompt was also used in matching activity.
Fading
Fading refers to decreasing the level of assistance needed to complete a task or activity. Fading is often
paired with prompting and reinforcement (Cooper et al., 2007). All the verbal and physical prompts used in the
sessions were slowly and gradually removed by the technique of fading. The client became capable of doing
some of his tasks on his own.

Modeling
Modeling is used to demonstrate a desired behavior. Modelling is very important in teaching skills like:
social, communication, self-help and play skills (Association for science in autism treatment, 2016). Client was
modeled to do handshaking with the therapist as well as others in the clinic. During the sessions, the client was
given a demo of how to clean a table and he imitated. Similarly, he was showed to put a ring in a ring tower and
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he was capable to do so. He also learned how to blow a balloon and also learned how to use a paint brush; all of
these tasks were taught by modelling.
Individualized Plan
Table 7
Individualized plan for client
Goals Tasks Achieved Outcomes
For developing focus and eye The outcome was that client
contact following activities was able to maintain focus and
Attention and eye contact
were done: eye contact for few minutes on
certain tasks
 Fish stencil with holes
and cotton buds were
used in this the client
was asked to put
cotton buds in the
stencil
 He was given beans,
spoon and box and was
asked to pour beans in
the box with the help
of spoon
 He was shown sponge
ball with light in order
to develop his focus
 Poppet
 Moving coin in all
directions
 Balloon blowing
 Buttoning
Self-help skills
Identification and labeling of This goal was achieved fully
body parts were done with the
main focus on hair and eye.
He was taught to remove and
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wear shoes. Made him learn

how to fold a mat and dry his
hands

The focus was on blue color The client was able to identify
Color identification everything which was of blue blue color.
color was shown to the client
like triangle, ring, ball, diary,
carryon box, chair, and shirt

Tracing, painting, coloring Client’s fine motor skills were

Fine motor skills and drawing little bit improved Like he
showed improvement in
coloring and tracing

Jumping, sitting, standing, Client’s gross motor skills

Gross motor skills slide taking, running and were also little bit improved
walking like he was able to walk
properly.

Command following During all activities command Client’s command following

were given to the client to was also improved during the
make him follow commands session.

Organizing Small ball, big ball, boxes of The goal was achieved. The
different size, and blocks client was able to organize.

Transportation and farm The goal was achieved. The

Matching animals client was able to organize.
The goal was achieved with
the help of prompts.
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Circle The client was able to identify

Shape identification
circle.

For sensory stimulation yoga The goal was achieved with

Sensory stimulation ball, bubbles, slide, beans and the help of prompts and client
swing were used. used to feel very relaxed in
these activities.

Pre and Post Intervention rating

Table 8
Intervention Rating
Problematic domains Pre rating Post rating
In attention 9 8
Lack of eye contact 9 8
Repetitive behavior and speech 10 9
Aggression 10 8

Pre and post intervention

Figure 2

12

10

0
In attention Lack of eye contact Repetitive behaviour and Aggression
speech
Pre rating Post rating
 23

Prognosis

After assessing the client's history, life circumstances, and surroundings; the client’s
prognosis was unfavorable. Client has a track record of relapse, having experienced it repeatedly.
Limitations
• There were no proper rooms for particular issue or therapy like there were no
sensory rooms.
• Clinic environment was not comfortable.
• There were a lot of distractions in the environment as there were many other
clients present at the same time.
• Limited equipment for the treatment of the client.
• 2 months were not enough for therapy.

Suggestions
• Proper sensory rooms
• To deal client individually in the environment with minimal distractions.
• More group activities to build communication skills.
• There should be enough space to do physical activities.
References
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 24

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Ed.). Cambridge University Press; Cambridge University Press.
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(2014). The Familial Risk of Autism.JAMA, 311(17),1770.ttps://doi.org/10.1001/jama.2014.4144

Santos-Long Hurst, A. (2019, May 9). Speech Therapy: What It Is, How It Works & Why You May
Need Therapy. Health line. https://www.healthline.com/health/speech-therapy#what-to-expect.

The use of punishment with autistic children who use behavior that challenges.
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Interval and Risk of Autism Spectrum Disorders. PEDIATRICS, 136(4), 651–657.
https://doi.org/10.1542/peds.2015-1099 .
 28

CASE 2

Oppositional Defiant Disorder DSM-5TR (F91.3)

 29

Summary
The client was 6.5 years old and a first-born child. At first, the client went to School. He was
a bit slow in learning, but nothing serious. Then, he moved to another School. After that, things
changed. He started hitting people, seeking revenge, and being stubborn. Especially when playing
with other kids, he got very hyper and aggressive. This hitting problem got worse about 5-6 months
ago when his sister was born. His behavior goes up and down. Some days he’s fine, but other times
he shows strange behavior like hitting, throwing things, shouting, and even hurting himself.
Sometimes, he gets extremely hyper and starts breaking things around him. Initially, the symptoms
of the client included inability to maintain focus on a single activity and erratic behavior towards
others by snatching things from others and hitting them. To ensure accurate diagnosis and treatment,
the client underwent both formal and informal assessments. Informal assessment includes clinical
interview from client’s parents, behavioral observation and mental status examination was applied.
Further, client's condition was examined through formal assessment by using Conner’s Parent Rating
Scale, Conner’s Teacher Rating Scale and Vanderbilt Parent Rating Scale. Conner’s Parent Rating
Scale shows that in oppositional domain client’s T- score was 82 which shows that he had severity in
this domain and on Conner’s ADHD index his T-score was 72 which shows that he had severe
problems of inattention and hyperactivity. Conner’s Teacher Rating scale shows that on oppositional
domain client’s T-score was 85 which shows that he had severity in this domain but in Conner’s
ADHD index his T-score was 50 which shows that he had average issue of inattention and
hyperactivity. Vanderbilt Parent Rating Scale shows that the client had Oppositional defiant
disorder, inattention and hyperactivity symptoms. Hence, a tentative diagnosis of “Oppositional
Defiant Disorder DSM-5TR (F91.3) comorbid with Attention-Deficit / Hyperactivity Disorder
DSM-5TR 314.01(F90.2)” was given to the client. The therapies applied on the client included
Applied Behavior Analysis (ABA therapy), Family therapy and Occupational Therapy.
 30

Demographic Information
Name AZ
Age 6.5 years
Education Grade 1
Gender Male
No of siblings 2
Birth order 1st Born
Parents Alive
Place of assessment Clinic
Language Urdu, English
Religion Islam
Informant Parents
Source and Reason of Someone suggested them about this clinic
Referral: The reason for bringing client was his aggressive and inattentive behavior.

Presenting complains (Verbatim of the Parents)

History of Present Illness

Initially the client was admitted in school. The only concern there was that the client was a
slow learner but when he was placed in another branch of the school, he started showing
behavioral shifts, like he started hitting, taking revenge from others and became stubborn. He
further stated that he was very hyper and aggressive towards other kids while playing. Hitting got
impulsive since past 5-6 months when his sister was born. The symptoms of the client wax and
wane i.e. he doesn’t show symptoms on daily basis. Sometimes, he behaves normally for entire
day and there are times when he exhibits unusual behavior like hitting others after getting annoyed,
 31

throwing things, shouting, self-hitting, losing temper and arguing. Parents reported that
occasionally he gets extremely hyper and starts to hit himself and break things in his surroundings.

Background History
Personal History
The client mother reported that her pregnancy was smooth, 9 months were completed and she had a
normal delivery without any complications. After one month, the client suffered from hernia for which
he was admitted at the hospital where he was treated with drips and steroids.
The client’s daily routine involves waking up at 9’o’ clock for his tuition class, after that he comes to
the clinic and stays for at least 4-5 hours at the clinic. During this time period, he also attends his
Quran class at the clinic via mobile phone. Around 4’o’ clock, he leaves for home and then he
indulges himself in physical activities like gardening, riding scooty and playing outside. He does his
homework with the help of his mother after Maghreb prayers. He goes to bed at 10. Sometimes, he
gets scared during sleep and wakes up.
Client’s parents reported that client’s favorite activity is gardening. His screen time only
involves television in which he loves to watch cartoons that include fighting, racing and speeding up.
The client reported that his favorite subject is math and his favorite games include car games,
punching games and snowball game. The client reported that his favorite TV show is Sonic and he
likes it because the characters in the show used to fight a lot and they kill and beat people around
them. His parents reported that he wants everything for which they denied or refused. He argues for
that particular thing and don’t get distracted by any other thing. Whenever he is opposed for his
demands, he loses temper and shows aggressive behavior including shouting, hitting and throwing
things. He often blames others for his mistakes or misbehavior. The client is very moody. He only
shoes interest in activities in which he is interested. During any work-related tasks or activities like
reading books, he maintains his focus for some time but can get easily distracted.
 32

Developmental Milestones

Developmental Milestones of the client

Developmental Milestone Normal Age Client’s age of achieving

Neck Holding 3 Months Normal

Sitting 4 Months Normal

Crawling 9 Months Normal

Standing 9-12 Months Normal

Walking 8-18 Months Normal

Feed Self 6 Months Normal

Using Toilet 18-24 Months – 3Years Delayed

Using Single Words 15-16 Months 3 Years

Combining Words 24 Months 3 Years

Naming Objects 12-18 Months 4 years

Questioning 2.5 Years -3 Years 4 years

Engaging in Conversations 11-14 Months 4 years

Qualitative analysis
Most of the developmental milestones were normal and appropriate with age except using
toilet and language milestones. The language milestones were not developed age appropriately but
 33

currently they are normal. The client can use toilet on his own, but most of the times he refuses to
go the washroom and pees in his pants.
Family History
Client was born in Kenya. When he was 4 months old he came to Pakistan currently he is
living in a joint family system with his parents, siblings, grandmother and his uncle. Client’s father
is 35 years old and is chartered accountant. His mother is 30 years old and she is a housewife.
Client has 2 sisters, one sister is 4 years of age and the other one is of 2 years. According to his
father, client is very close and friendly with him and his younger sister but he doesn’t give respect

to other members of the family. The client himself reported that his father works for whole
day but he is very close to his father and his younger sister and he loves them a lot. The client also
reported many times that he used to hit and snatch things from his elder sister, and also used to
annoy his grandmother and uncle. Further, he also reported that he shows tantrums and throw
things away whenever his mother refuses or denies his request. When he was asked about the
reason of doing so, he reported that my sister annoys me and in result my mother gets angry, shouts
on me and hit me very hard. The client’s mother reported that there is history of ADHD and Autism
in their family.
Educational history
The client was school going. He used to go to school where he was given special care and
attention as his parents requested. He was an average student; he loved art projects and his parents
were satisfied. When his school was changed, he showed major behavioral shifts because he was
not given proper attention. His parents reported that the teachers were not responsible enough to
accommodate him with special care or attention. There was a boy in his class who was very
authoritative and abusive due to which every student there was afraid of him. The client shifted his
behavior at that time and he wanted to become dominant like him as he always wanted that others
should always listen to him. Currently, he is not admitted in any educational institute and only
home tuition is being provided to him. Parents reported that he annoys his teacher too.
Medical/psychiatric History
After one month of birth, client suffered from hernia for which he was admitted at the
hospital where he was treated with drips and steroids. When he was 3-4 years old, he got tonsillitis
and asthma as well. Since last 1 year, he gets fever easily for which he is treated with antibiotics.
There was no psychiatric history like he has never been to any other clinic or center for his
 34

behavioral issues. However, 3 months back he was admitted in this clinic for his inattentive and
aggressive behavior. There was a family history of autism and ADHD.

Social History
The client is usually social as he loves to play and spend time with his family members.
Whenever guests appear, he shows welcoming behavior and is willing to get involved with them.
During his play time in park or outside home, he likes to play with others but he doesn’t want to
share his things with them. He was friendly with his classmates at school but occasionally he
became frustrated with them. At clinic, sometimes he shows friendly behavior and takes care of
other kids and there are times when he hits and snatches things from other kids.

Informal Assessment
The informal assessment includes:
• Clinical Interview
• Behavioral Observation
• Mental Status Examination
Clinical interview
The clinical interview with parents was conducted in person at the clinic. Parents were
very concerned about the symptoms and the interventions related to the symptoms of their child.
The parents were very cooperative as they were indulged in giving every little information about
the child’s history and this was very helpful in planning the related interventions. The client’s
mother reported that due to the child’s defiant behavior she gets frustrated and hits him. At the
start of every session, open ended questioning was being done with the client related to everyday
events and his behavior. Whenever he used to hit or show tantrums, he reported every single
thing with reasons in detail.
Behavioral observation
Client was cooperative as he performed every task or activity given. Sometimes, he used
to take more time to complete the given task because he easily used to get distracted during
activities and he was not able to maintain focus on single activity. During the sessions, client
never showed tantrums or aggressive behavior towards the therapist. Initially, he used to snatch
and hit the other children in the clinic but this behavior declined as now he became very friendly,
responsible sand helping. He takes care of other children there and helps them a lot. Whenever
client was asked about the reasons about his aggressive behavior or hitting others, he used to zone
 35

out and show behaviors like eye rolling and unnecessary movements. Once, rapport building was
done, he was able to justify his behaviors openly in detail.
Mental Status Examination
The mental status examination is a clinical assessment of the individual which reflects
both the individual’s subjective report and experience, and the clinician’s observations and
impressions at the time of the interview. Assessment of mental status is a vital component of
clinical care (Rachel & Joe, n.d.).

Table2

Mental status examination during sessions

Age: The client is 6.5 years old boy.
Height and Weight: His height and weight is
normal relative to his age.
Appearance
Grooming: He was always well-dressed and his
personal hygiene was always maintained.
Clothing: He used to wear weather
Appropriate clothes.
Gait and Posture: Appropriate gait and posture but
sometime he had slouched posture.
Behavior Facial Expression: Expressive, relaxed,
Smiling, happy, sometimes sad and tired
Psychomotor activity: Rapid talking
Mannerism: Eye rolling and unnecessary movements
Attitude: Client was cooperative, open and friendly
with the therapist. Sometimes he gets aggressive with
other peer’s other times he is helping and caring
Gestures: Appropriate
Gesture: Appropriate
Body Language: Open and engaged
Engagement and Rapport: Rapport was good and
 36

was easy to establish.

Level of arousal: He was not alert and focused. He
can get easily distracted specially in tasks related to
academics
Rate and Flow: Normal
Quantity: Talkative and spontaneous
Speech
Prosody and Tone: Normal prosody
Fluency and Rhythm: Clear but sometimes hesitant.
Mood is constant. When asked about his feelings he
Mood
sometimes used to say that he is angry and sad.

Intensity: Normal
Quality: Happy and sometimes sad.
Affect Fluctuations: Normal
Range: Normal
Congruence: Congou
Orientation: Fully oriented
Clouding of consciousness: inattention, lethargic and
Cognition
vigilant
Memory: Good memory
The client had insight about his issue and symptoms
Insight and he was ready to work with the therapist to
overcome such issues.

Formal Assessment
• DSM-5TR Checklist for ADHD
• DSM-5TR checklist for oppositional defiant disorder
• Conner’s Parent and Teacher rating scale
• Vanderbilt Parent rating scale
 37

DSM-5TR Checklist for Oppositional Defiant Disorder

Table 3
Oppositional symptoms of the client according to DSM5-TR
Diagnostic Criteria Symptoms
Angry irritable mood
1. Often loses temper Present

2. Is often touchy or easily annoyed Present

3. Is often angry and resentful Present

Argumentative and defiant behavior

4. Often argues with authority figures or Present

for children and adolescents, with

adults.
5. Often actively defies or refuses to Present

comply with requests from authority

figures or with rules.
6. Often deliberately annoys others Present

7. Often blames other for his mistakes or Present

misbehavior
Vindictiveness
Has been spiteful or vindictive at least Present

twice for past 6 months.

 38

DSM-5TR Checklist for ADHD

Table 4
ADHD symptoms of the client according to DSM5-TR
Diagnostic Criteria Symptoms

Inattention
Often fails to give close attention to details or Present
makes careless mistake in school work, at
work or during other activities.
Often has difficulty sustaining attention in tasks or Present
play activities.
Often does not seems to listen when spoken to directly. Present
Often does not follow instructions and fails to finish Present
schoolwork and chores.
Often has difficulty organizing tasks and activities. Absent
Often avoids, reluctant to engage in tasks that require Present
sustained mental effort.
Often loses things necessary for task or activities. Absent
Often distracted by extraneous stimulus. Present
Often forgetful in daily activities. Absent
Hyperactivity
Fidgeting and tapping hands or feet Absent
Leaving their seat when expected to remain seated Absent
(e.g., during a meeting or lecture)
Often runs about or climbs in situations where it Absent
is inappropriate
Often unable to play or engage in leisure activities Present
quietly
Often on the go and unable to sit still Present
Talking excessively Present
Blurting out answers and completing other Present
people’s sentences
Trouble waiting their turn Present
Interrupting other people or intruding on their Present
activities
 39

Conner’s Rating Scale for ADHD

The Conner’s Comprehensive Behavior Rating Scale was given by C. Keith Conner’s in
1990s. It is a questionnaire that focuses on behavioral, social, and academic issues in children
aged 6–18 years old. It can help diagnose attention deficit hyperactivity disorder (ADHD). There
are also 2 different forms within each version of the Connors’s assessment. One is designed for
parents to fill out and another for teachers (Johnson, 2018). Conner’s parent rating scale consists
of 27 items and teacher rating scale consists of 28 items both are rated on 0-3 scale. Score of 30-
55 means average typical, 55-60 means slight borderline, 61-65 means mind atypical, 66-70
means moderate atypical and 70 above means severe atypical.
Conner’s Parent Rating Scale
Table 5
Conner’s Parent Rating Scale Score

Index Score T-score Severity

Oppositional 15 82 Severe atypical
Inattention 15 75 Severe atypical
Hyperactivity 13 77 Severe atypical
Conner’s ADHD Index 27 72 Severe atypical

Qualitative Analysis of Parent Rating Scale

Conner’s parent rating scale shows that on oppositional domain client score is 15 and
score is 82 which shows that there is a severe problem in this domain. Their rating shows that the
client is defiant and angry. On inattention domain the client score is 15 and t-score is 75 which
also shows that client has severe problem of in-attention and distraction. On domain of
hyperactivity his score is 13 and t-score is 77 which also indicates severe problem of
hyperactivity and restlessness. Overall, on Conner’s ADHD index the score is 27 and the t-score
is 72 which means he have severe inattention and hyperactivity issues.
Conner’s Teacher Rating Scale
Table 6
Conner’s Teacher Rating Scale Score
Index Score T-score Severity
Oppositional 10 85 Severe atypical
Inattention 04 51 Average
Hyperactivity 07 55 Average
 40

Conner’s ADHD 10 50 Average

Index

Qualitative Analysis of Conner’s Teacher Rating Scale

Conner’s teacher rating scale shows that on oppositional domain client score is 10 and
score is 85 which shows that there is a severe problem in this domain. Her rating shows that the
client is defiant and angry. On inattention domain the client score is 04 and t-score is 51 which
shows that client has average problem of in-attention and distraction. On domain of hyperactivity
his score is 07 and t-score is 55 which also indicates average problem of hyperactivity and
restlessness. Overall, on Conner’s ADHD index the score is 10 and the t-score is 50 this shows
that client only have few symptoms of ADHD but not a proper disorder.
Vanderbilt Rating Scale
The Vanderbilt rating scale is a screening and information gathering tool which can assist
with making and ADHD diagnosis and with monitoring treatment effects over time (Anderson et
al., 2022).

Vanderbilt Parent Rating Scale

Table 7
Vanderbilt Parent’s Rating Scale Score
Number of Questions Counted Behaviors Type
1-9 9 Inattentive
10-18 7 Hyperactive
1-18 39 Combined
19-26 6 Oppositional-defiant disorder
27-40 3 Conduct disorder
41-47 0 Anxiety or depression

Qualitative Analysis of Vanderbilt Parent Rating Scale

Vanderbilt parent rating scale shows that on 1-9 item client score is 9 which means he
have problem of inattention. On item 10-18 his score is 7 which shows hyperactivity. On 1-18
items client total score is 39 which shows that client have problem related to both inattention and
 41

hyperactivity. Client score is 6 on 19-26 which shows that client have oppositional
defiant- disorder. Lastly on 27-40 his score is 3 which shows in future there are chances that he
will develop conduct disorder.

.
Tentative Diagnosis
Oppositional Defiant Disorder DSM-5TR (F91.3) comorbid with Attention-Deficit /
Hyperactivity Disorder DSM-5TR 314.01(F90.2)
Specifier: Moderate
Case Formulation
A kid with oppositional defiant disorder (ODD) exhibits a pattern of irascible or irritable moods,
combative or defiant behavior, and vindictiveness toward those in positions of authority. The
child's behavior frequently interferes with their everyday schedule, which includes family and
school-related activities (Aggarwal et al., 2022).
The client’s case formulation is done using the five p’s model, developed by McNeil et
al., 2012, to better understand all the factors contributing to the client’s illness. This framework
provides a conceptualized way to look at clients and their problems, systematically and
holistically taking into consideration the presenting problems, predisposing factors, precipitating
factors, perpetuating factors, and the Protective factors of their illness.
The presenting complaints of this child are that he is very aggressive and his anger issues
result in physical aggression as well as verbal aggression as he engages in behaviors such as
shouting, hitting others, throwing things, losing his temper and being stubborn. He also has issues
with attention and shows hyper active behaviors.
Precipitating factor in this case is teacher’s negligence and authoritative boy. As a student,
the client was often not given the attention that he needed and was not provided with the right
resources at school which contributed to him developing more behavioral issues. The client also
has ADHD which is defined as a disorder that leads to children acting aggressively and
impulsively. Negligence from adults at home or school can further contribute to such behaviors.
There are numerous studies highlighting the interplay between student and teacher relationship
and how the environment created at school shapes a child’s behavior. A study by Demonte and
Van Boutte conducted in 2012 shows that in cases where the teachers had low expectations for
students, the students felt less supported and had higher rates of misconduct at schools. Another
research shows that interactions between students and teachers follow patterns of mutual
 42

influence, as observed by Ly and Zhou (2016). Consequently, these exchanges are likely
to have a substantial impact on molding the school atmosphere (Ronda & Komen, 2020).
The client also experienced a change of environment when he moved to a new school.
This change in his environment turned out to have a negative impact on him. Behaviors such as
aggressive behavior can be learned through modelling and when children are exposed to a toxic
and negative environment, they absorb these traits into their own behavior. The client is
diagnosed with Oppositional defiant disorder (ODD) and children when presented with negative
behavior modeling, by an authoritative figure, will adapt the same behavior as this is what
happened in the client’s case. Another study also shows that deviant peer groups contribute to the
development of ODD (News-Medical, 2017 and Cleveland Clinic, 2022).
The predisposing factors in this case include the client’s health problems. After one month
of birth, client suffered from hernia for which he was admitted at the hospital where he got
treated with drips and steroids. When he was 3-4 years old, he got tonsillitis and asthma as well.
Since the past one year, he is more prone to getting a fever for which he is treated with
antibiotics. Being on medications at a young age and experiencing these illnesses are likely to
change your brain neurochemistry and behavior. A study conducted in 2017 found that ODD has
been associated with specific neurotransmitters, or brain chemicals, that may function
abnormally. When these chemicals do not operate as they should, messages within the brain may
be disrupted, potentially resulting in symptoms characteristic of ODD (Leclerc et al., 2017). The
gender of the client also plays a role in making him more susceptible to ODD, with boys being
more prone to developing the disorder as compared to girls (Holland, 2019).
It was also seen that there is a family history of ADHD and autism and this increases the
risk of developing ODD. Following studies shows that Mood disorders, anxiety disorders,
neurodevelopmental disorders, and personality disorders are among the mental problems that
many kids and teenagers with ODD have close relatives with. This implies that there may be a
genetic component to the likelihood of developing this illness. According to another study,
people who have a positive family history of conduct disorder, ODD, mood disorders like
depression and bipolar disorder, attention-deficit/hyperactivity disorder (ADHD), drinking, or
substance abuse are more likely to be susceptible to ODD (News-Medical, 2017).
Another predisposing factor is the teacher negligence, change of school and authoritative
boy (News-Medical, 2017 and Cleveland Clinic, 2022). Lastly, the client’s behavioral problems
could be a seen as way to cope with their emotions as research suggests that children with mood
or anxiety
 43

disorders may develop behavioral patterns seen in Oppositional Defiant Disorder (ODD)
as a coping mechanism. These children often have temperament issues, struggle to regulate their
emotions, and are highly sensitive, reacting strongly to situations that typically wouldn't provoke
such responses.
Impairments in brain areas responsible for judgment, reasoning, and impulse control, along with
chemical imbalances, exposure to toxins, and malnutrition, are also associated with increased
susceptibility to ODD (News-Medical, 2017 and Aggarwal & Maratha, 2023).
The perpetuating factors in the client’s case is the violence based television shows that the
client watches. He has reported to watch shows with a lot of fighting and he plays aggressive and
violent games. Research suggests that screen time and the content that the children are exposed to
has an impact on their ADHD symptoms making them worse. It also causes other problems like
sleep issues, behavior outbursts and lack of interest in other academic activities. Other researches
have also shows that higher screen time has an association with violence in children and them
breaking more rules. It was also found that the hours spent on social media were associated with
the prevalence of conduct disorder and time spent playing videogames and watching television
were associated with higher prevalence of oppositional defiant disorder. Increased screen time
can also affect the attention span of children leading to ADHD symptoms. This negative use of
screen time can be a maintaining factor and could also contribute to worsening the condition and
symptoms of ADHD and ODD. Research supports the notion that exposure to violent content can
decrease empathy and cause increased aggressive thoughts, anger, and aggressive behavior. It
was found that engaging with violent games was also related to aggressive behavior patterns
(McQueen, 2022; Nagata et al., 2022 and Americas, 2023).
Another perpetuating factor in the client’s case is the birth of his sibling as the hitting
became impulsive since the past 5-6 months when his sister was born. Aggression towards
siblings can be sign of atypical behavior and when it happens repeatedly, it indicates significant
behavioral or emotional dysfunction that can escalate with time (Dolling, 2017). Another
important factor is the mother’s attitude. The client’s mother was strict and would scold the child
and hit him for misbehaving which can affect the child negatively. Parent’s aggressive behavior
and parenting styles that are harsh with frequent punishments can contribute to more behavior
problems in children and in adolescents and can lead to disorders like ODD. A model by
Patterson (1982) about how parental behavior may exacerbate a child’s negative behavior. His
work shows that parents often apply their rules inconsistently when the child shows disruptive
 44

behavior so the harsh parental responses escalate the child’s oppositional behavior and
reinforces it when the parents give in (Naeimavi et al., 2015; Trepat et al., 2014 and Quy, n.d.)
Despite all the factors contributing towards the child’s worsening condition, now he has
his parent’s support to trying to help decrease his symptoms and contribute towards his
wellbeing. Research shows that family lays an important role in the prevention of serious
symptoms of disorders in the future through correct ways of parenting and by taking the right
training. Especially positive training plans for mothers can bring about a change in children with
ODD and improve their behavioral problems. An integral part of this support is consistency and
unconditional love and accepting children for who they are even during difficult situations, the
support should always be there. It’s important for parents to stay patient and to continue the
support for their children (Mayo Clinic, 2023 and Naeimavi et al., 2015). Another protective
factor is child’s insight into his own condition which is crucial as it helps him understand his
behavior and problems that he face as this reduces his confusion and frustration. Children can
only self-regulate when they understand their condition and in this case the client has good
insight about his condition and understand what he needs to change and why, which is helpful for
his treatment. This self-awareness can also enhance his communication with parents, teachers,
and clinicians, leading to more effective support. It can overall promote their wellbeing.
 45

Figure 1
Case Formulation Ps
Presenting Predisposing Factors Perpetuating Protective
Complaints Precipitating Biological: Health Factors Factors
Hitting Factors problems and being a Screen time Parent's
behavior Teacher's boy.
Violence based Support
Anger issues Negligence Genetic: Family history
television Client's
Arguing Change of of autism and ADHD.
shows insight
Shouting school and Environmental: Change
authoritative
Birth of a
Stubborn of school and
boy sibling
Losing temper authoritative boy
Throwing Temperamental factors
Mother's

things attitude
Inattention
Hyperactive

Theoretical Framework
Learning theory
Learning theory plays a crucial role in understanding the maintenance and persistence of
Oppositional Defiant Disorder (ODD) by emphasizing the interaction between behavior and the
environment. This theory suggests that the negative symptoms of ODD are learned attitudes.
They mirror the effects of negative reinforcement methods used by parents and others in power.
The use of negative reinforcement increases the child’s ODD behaviors. That’s because these
behaviors allow the child to get what they want: attention and reaction from parents or others
(Oppositional Defiant Disorder (ODD) in Children - Health Encyclopedia - University of
Rochester Medical Center, n.d.).
Social Learning Theory
Social learning theory states that behavior patterns come from observing and imitating
other people, typically significant others. Bandura also stated that children need 4 things in order
to learn and repeat aggressive behavior (Cassata, 2016).
• Attention- They must lay attention to the aggressive behavior.
• Retention- They must remember what they have seen so they can then repeat it later.
• Reproduction- They must be physically able to reproduce it.
• Motivation- They must be motivated to do that behavior e.g. Expect a reward
 46

Attachment Theory
According to this hypothesis, children develop ideas about themselves and other people to help
them manage their unpleasant emotions. It is believed that unstable attachments are the result of
bad parenting practices. Youngsters do not learn how to cope with negative emotions; instead,
they learn to expect them in intimate relationships. These unfavorable expectations give kids a
model that keeps them doing badly. In addition, parents have their own expectations, which can
help them respond to behavioral issues in a positive or negative way (McKinney & Renk, 2007).
Adlerian theory
The Adlerian birth order theory states that firstborn children gain by receiving more care prior to
the birth of their younger siblings. However, the birth of the following child takes away your
position of authority. As the oldest sibling, they are held to a high standard because they are
supposed to lead by example. It goes on to say that firstborn children are more likely to be
authoritarian and believe they have a right to authority. As adults, they end up in leadership roles
(Marais, 2022).
Oppositional Defiant Disorder comorbid with ADHD
Different researches have shown that ADHD can co-occur with ODD. A research was
conducted on community samples and it found out that children with ODD are 4 times more
likely to be diagnosed with ADHD. (McKinney & Renk, 2007b). In the context of oppositional
defiant disorder and comorbidity with other disorders, researchers often conclude that ODD co-
occurs with an attention deficit hyperactivity disorder (ADHD), anxiety disorders, emotional
disorders as well as mood disorders but higher connection with ADHD in relation to ODD can be
seen. For instance, children or adolescents who have ODD with coexisting ADHD will usually be
more aggressive and have more of the negative behavioral symptoms of ODD, which can inhibit
them from having a successful academic life. This will be reflected in their academic path as
students (Wikipedia Contributors, 2019a). Another study was conducted in which there were 199
children to see whether ODD and ADHD are comorbid. The results show that angry, irritable
mood, argumentative and defiant behavior all correlates with ADHD (Harvey et al., 2016).
According to Kim et al. (2010), children and adolescents with disruptive behavior disorders often
show high aggression and delinquency and display other psychiatric disorders, including both
attention deficit/hyperactivity disorder (ADHD).
 47

Short Term Goals

• Reduce Defiant behavior
• Reduce aggressive behavior
• Improving social skills
• Improve attention span
• Follow commands and instructions
Long Term Goals
• Academic growth
• Relationship with family and significant others
Therapies
Applied Behavior Analysis (ABA)
Applied Behavior Analysis (ABA) is a therapy based on the science of learning and
behavior. ABA is helpful in increasing language and communication skills. Further it is very
useful in improving attention, focus, social skills, self-help skills, motor skills, memory, and
academics. Moreover, its techniques can be used to reduce problematic behavior (Applied
Behavior Analysis (ABA), 2021). ABA is very effective for children with neurodevelopmental
disorders. ABA therapy utilizes behavioral principles to set goals, reinforce behaviors, and
measure outcomes. All the strategies used in the sessions were based on ABA, these strategies
were used to overcome the client's deficiencies.
Family Therapy
A child therapist uses family therapy to make communication, getting along, and solving
problems better for everyone in the family. This can help the child do well and behave better.
Parents learn better ways to tell their child what to do and how to be a good parent, so they can
always make rules and make sure their child follows them. This gives the child the rules and
steady life they need. In meetings with the parents, we talked about how they deal with their
child's tantrums, when to encourage certain behaviors, and when to discourage them. We also
suggested doing the same activities at home that they practiced in the clinic, and we gave them
tasks to do at home, written down in a diary. If the child hit someone and the parents hit back, we
explained that this could make the hitting behavior worse. We talked about finding different ways
to respond in those situations (Oppositional Defiant Disorder (ODD) Counselling Online |
TalktoAngel, n.d.).
 48

Occupational Therapy
A subspecialty of medicine called occupational therapy (OT) treats patients of all ages
who have cognitive, sensory, or physical issues. They can restore their freedom in every aspect
of their lives with the aid of OT. By practicing their anger and frustration management
techniques, they can acquire positive behaviors and social skills. To manage his surplus energy,
the client engaged in a variety of physical activities (Finlan, 2014).
Techniques
• Rapport building
• Reinforcement
• Token economy
• Case conceptualization
• Breathing techniques
• Counselling and psychoeducation
• Prompting and fading
• Selective attention
• Social skills training
Rapport Building
Most important tool during therapy is rapport building. Before starting the therapy, it is
very important to ensure that a good rapport has been established between therapist and the
client. It was not difficult and time taking to establish rapport with the client as he was
cooperative during the sessions. Initially, open ended questioning was being done about his
family, his daily routine and his interests and the client was very friendly as he was willing to
answer every question asked.
Reinforcement
Reinforcement is to strengthen a behavior. It improves the probability that behavior will
occur in the future. The client is positively reinforced during the session when he completes
certain task or follow certain commands or instructions. This will make him do that activity or
follow that instruction again. Through reinforcement many goals can be achieved. During the
session technique of differential reinforcement was used differential reinforcement is a behavior
modification which involves selectively reinforcing desired behaviors while withholding
reinforcement for undesired behaviors.
 49

Table 8
Client’s reinforces and its types
Reinforces Types of reinforces
Praise (Good, very good, clap for yourself, asking Intangible
therapist and parents to appreciate)
Stars Tangible
Chocolate Tangible
Ball Tangible

Token economy
A token economy is a method of behavior modification aimed at boosting positive
behavior and curbing negative behavior using tokens. Individuals earn tokens promptly upon
displaying desired behavior, which are then exchanged for meaningful rewards or privileges at a
later time (Token Economy System | Encyclopedia.com, 2020). The client was given a white sheet
with "seven days" written on it. He was told that if he collected three stars initially, he will get a
big star. If he behaved well throughout the week, he will get a star every day, and at the end of the
week, he well gets a gift as a reward. The client asked for a chocolate as his reward at the end of
the week, which he received
Case conceptualization
Case conceptualization uses positive language to describe issues and assists clients in
understanding how problems persist. It encourages clients to participate in therapy by sparking
curiosity and interest. Additionally, it guides clients in understanding the routes to achieving their
objectives and overcoming challenges. Moreover, it simplifies complex issues by recognizing
client strengths and proposing strategies to enhance their resilience (Kunken & Pesky, 2009).
During the sessions, if client said he hit someone, I used to ask why he did it. Then, he was given
other ways to handle his anger. Different activity sheets were used where he was shown how to
recognize what he was thinking when he felt angry and how he could control his thoughts and
emotions.

Breathing Techniques
 50

According to research, deep breathing causes the body to go into a relaxation mode, which can
help when you're upset. You can relax and reset your brain to stop the fight-or-flight reaction by
taking deep, steady, and prolonged breaths (LCSW-S, 2023). During the sessions different
activities related to breathing technique were done. Further he was also asked to do breathing
techniques every time he feels agitated or angry.
Counselling and Psychoeducation
It is a process where an individual, couple or family meet with a trained professional
counsellor to talk about issues and problems that they are facing in their lives. Counselling of both
parents and client were done. The parents were educated about their child's problems, discussing
what's causing them and how to fix them. They were told that with their full support, their child
can get better, and they need to be there for him. Both the parents and the client were psych
educated, where the anger issues and thoughts of the client were discussed. The client was
educated about how the anger was stopping him from going to school, and it's important for him
to control his anger so he can go to school and have a better life. The client was told not to hit
anyone and to be nice to his parents. He was told to do things to distract himself when he got
angry, like playing with a poppet or drinking water.
Prompting and fading
Prompts are instructions, gestures, demonstrations, touches, or other things that we
arrange or do to increase the likelihood that children will make correct responses. It is actually an
assistance which is given by an adult or more knowable person (golden-user, 2022). Prompting
helps in improving person’s ability to do a certain task independently after some time. There are
different types of prompt used like gestural prompts, full physical prompts, partial physical
prompts, verbal prompts, visual prompt and positional prompt (Chicago ABA Therapy, 2017).
Fading refers to decreasing the level of assistance needed to complete a task or activity. Fading is
often paired with prompting and reinforcement (Cooper et al., 2007). In all activities of focus and
attention verbal prompt was used to bring his focus back on the task and as soon as I realized now
he can do on his own prompts were removed.
 51

Selective attention
Selective attention is crucial because it enables people to ignore irrelevant or unimportant
information and concentrate on what is going on around them. People can more easily digest
information, encode memories, and perform better on a variety of cognitive tasks because to this
selective attention. Selective attention refers to the processes that allow people to dismiss
distracting or irrelevant information while simultaneously choosing and focusing on particular
data for deeper processing. Such competing information may arise externally, such as extraneous
auditory or visual stimuli in the surroundings, or internally, like distracting thoughts or habitual
responses hindering the execution of the current task (Stevens & Bavelier, 2012). When the client
was reading, there were often many noises around, so the technique used was to have him read
amidst the noise to help him practice selective focus. This included completing activity sheets,
and he was reminded to focus on the task at hand. He would also get distracted by the pictures in
the book, so he was instructed to read first and then look at the pictures. During clinic hours, he
would attend his Quran class even with background noise. He was encouraged to ignore the noise
and concentrate on his class.
Social skills training
Social skills training entails instructing children in suitable social behaviors, including
communication, problem-solving, and conflict resolution. Such training aids children in
enhancing their relationships with both peers and adults. Moreover, it can assist children with
ODD in refining their interpersonal abilities to foster better interactions with others. The training
encompasses skills such as active listening, turn-taking, collaboration, and the management of
anger and conflicts. Role-playing and practical exercises are commonly employed in this process.
During the session, client was given a Conflicting situation using activity sheets in which he was
asked to select the right option. Further, he was asked to help his peers. And if you need anything
from someone, he was asked to request for that if denied, he was asked to understand that it was
not for him. He was also instructed to listen to his parents, cooperate with them and respect them
always. He was asked to report an issue whenever he came across one and not to deal with it
himself for example by using force and report it to his elders that this is wrong. Through role-
playing, a therapist can instruct a client in a behavior, see them practice it, and have them perform
it while being surrounded by stimuli that are likely to occur in everyday life. In another in group
session client was asked to sit with me and observer how I am reacting to a child who is hitting
me. Similarly, if another client in that session was doing something good, he would be shown
how well he is behaving and acting. This helped the client learn to replace those thoughts with a
more balanced perspective (Donohue & Perry, 2023).
 52

Individualized Plan
Table 9
Individualized plan for client
Goals Task Achieved Outcomes
For improving attention span following This goal was 60% achieved.
activities were used. Client was able to maintain
• Fishes were with numbers and the focus on certain tasks for
client was asked to put circles certain time of period.
according to that numbers.
• In many sessions he was asked to
do reading.
• He was asked to write and say one
word 10 times.
• Storytelling and in the end
Attention
questions were asked.
• Puzzle was also used.
• Activity sheet…
• Mandala coloring
• He was asked to sharp pencils.
• Essay writing
• Write A-Z on white board and with
acrylic alphabets.
• To separate the rice on the basis of
colors
 In this he was asked to share things with This goal was also achieved client has
53
others. Activity sheet was used to teach become very friendly and
Social Skills Training
him about how to be a good listener and cooperative.
how to help others.
Encouraging problem Storytelling
solving skills
To control his aggression, following
Pre and Post Intervention Client’s aggressive behavior
activities were done: Table 10 was reduced.
Intervention Ratings
• Slide taking
Physical activities
Problematic Domain Pre-Rating Post Rating
• Foot ball
Inattention • Sit and stand-up game 8 6

Communication and •social

Counting
skills while jumping 9 6
Mountain breathing, star breathing, to Client himself reported that using
Aggressive
Breathing Behavior
techniques show a gesture how you will8 smell a these breathing5 exercises were

Defiant Behaviorflower and blow a candle. 8 beneficial for him.

5
Patience maze was used. He was asked Client became peaceful and patient.
to write his memory or experience
Teach emotion
related to certain emotions. An activity
regulation and coping
sheet of different zones was also used so
skills
that he can differentiate between
different moods
Modify negative Activity sheets and counselling. Client was able to think
thinking positively.
patterns
Parents were also involved like they were
Involve parents asked to do all activities at home. Helped in client’s
Homework was written on diary. Recovery.
Throughout the sessions he was told you Helped in reducing
Self-awareness
are a good boy and counselling was done. symptoms of the client.
Addition and subtraction with blocks and The goal was 40% achieved.
sticks were used. He was asked to learn
Academics
some words and later on dictation was
taken.
In this the client was provided conflicting Client was able to think what to do in
scenarios and was asked what he will do conflicting scenarios.
Conflict Resolution
in such situations. at home. Homework
was written on diary.
Throughout the sessions he was told you Helped in reducing symptoms of the
 54

Figure 2
Pre and Post Rating

10
9
8
7
6
5
4
3
2
1
0
Defiant behavior Aggressive behavior Inattention Deficits in social and
communication skills
Pre Rating Post Rating
 55

Prognosis
Prognosis was favorable, as evidenced by a decrease in the client's symptoms and
improvement in his behavior.

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Nagata, J. M., Chu, J., Gadson, K. T., Murray, S. B., Iyer, P., Gabriel, K. P., Garber, A. K.,
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Oppositional Defiant Disorder (ODD) in Children - Health

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CASE III
Attention-Deficit / Hyperactivity Disorder DSM-5TR 314.01(F90.2)
 61

CASE SUMMARY
The client was 5 years 5 months old boy and he is the only born child. The client’s
mother reported that he didn't start talking until he was 3 years old. She thinks this was because
he was given everything, he needed without having to ask. At 1-year-old, he could only say
"Mama" and "Baba." He started school at 3.5 years old, but his teachers noticed he couldn't
speak well and preferred to run and play rather than sit still. He went to a therapy clinic for 3
months, and started to speak a little. When he turned 4, his family decided to wait for him to ask
for things verbally before giving them to him. He went to another center for 3 months at age 4,
where he began learning some words and sentences but also started humming. Again, he started
attending the current clinic for issues with speech, inattention, and hyperactivity but the main
focus at that time was speech therapy. Now, he is receiving treatment for hyperactivity and
inattention, and his speech concerns have been resolved. During sessions, the client displayed
hyperactive behavior, including hand stimming, fidgeting, and being easily distracted. Despite
reminders to focus and occasional periods of sitting, he struggled to remain still and engaged,
often interrupting others during group activities. To ensure accurate diagnosis and treatment, the
client underwent both formal and informal assessments. Informal assessment includes clinical
interview from client’s mother, behavioral observation and mental status examination. Further,
client's condition was examined through formal assessment by using Portage Guide, Conner’s
Parent Rating Scale and Vanderbilt Parent Rating Scale. Conner’s Parent Rating Scale showed
that the client had moderate issue of inattention and hyperactivity. Vanderbilt Parent Rating
Scale also showed that client had symptoms of inattention and hyperactivity. Hence, a tentative
diagnosis of Attention-Deficit / Hyperactivity Disorder DSM-5TR 314.01(F90.2) was given to
the client. The therapeutic recommendation for client includes Applied Behavior Analysis
(ABA therapy), Occupational Therapy, Group Therapy and Art Therapy.
 62

Demographic Information
Name B
Age 5.5 years
Education Nursery
Gender Male
Birth order Only child
Parents Alive
Place of assessment Clinic
Language Urdu and English
Religion Islam
Informant Mother

Source and reason of Referral:

The client’s mother found out about this center through her neighbor to express concerns about their child’s
development.

Presenting Complaints (Verbatim of the mother)

 63

History of Present Illness

The client’s mother reported client didn’t talk until he was 3 years old. The client’s
mother observed that he started speaking at a late age, possibly because he was given
everything he needed before he even had to ask for it. At the age of 1, he only said "Mama"
and "Baba." He started school at 3.5 years, but his teachers noticed that he couldn't speak
well and preferred to run and play instead of sitting still. At the same time, he began going
to a therapy clinic for 3 months, where he started to speak a little. When he turned 4, they
decided to wait for him to ask for things verbally before giving them to him. He went to
another center for 3 months at age 4, where he began learning some words and sentences
but also started humming. Now again he started attending the current clinic off and on for
issues related to speech, inattention and hyperactivity but the main focus was on speech
therapy. However, he is presently undergoing treatment for hyperactivity and inattention,
and his speech-related concerns have been already addressed and resolved.

Background History
Personal History
Pre-natal history of the client was that it was stressful pregnancy. Delivery was
through C-section and it was a smooth procedure. Post-delivery everything was normal
and the client was a healthy and responsive child. Client achieved his milestones on time,
except for the communication related milestones which were achieved late.
The client’s mother reported that he goes to bed early at night, around 8:30 pm,
and wakes up at 7:30 am to go to school. He returns from school at 12:30 pm, has lunch,
plays, then visits the clinic. After returning from the clinic, he plays again until bedtime.
She mentioned that his sleep is sound; he sleeps with her but has no issues sleeping alone
if needed. His hobbies include running and playing, and he is fascinated by wires and
switches, showing an interest in making circuits. He is mischievous and enjoys teasing
others. Around the age of 3.5 to 4 years, his screen time increased as he started watching
 64

cartoons like Tom and Jerry, and he currently spends about 3-5 hours in front of a screen.
The client’s mother also reported that he lacks the capacity to stay focused and cannot sit
in one place for long. The maximum he can sit still is about 20 minutes, but only if he is
engaged in something he finds interesting. He even has difficulty sitting still for food and
is in the habit of running around continuously.
Educational History
He is in Nursery class. His teachers are concerned because he is constantly running
around and cannot sit still for long. He has trouble focusing and gets easily distracted.
Academically, he is not a quick learner and does not grasp things easily. But his mother
reported that he is good in mathematics.

Developmental Milestones
Table 1

Developmental Milestones of the client

Developmental Milestone Normal Age Client’s Achieving Age

Neck Holding 3 Months Normal

Sitting 4 Months Normal
Crawling 9 Months Normal
Standing 9-12 Months Normal
Walking 8-18 Months Normal
Feed Self 6 Months Normal
Using Toilet 18-24 Months – 3Years 3.5 years
Using Single Words 15-16 Months 3.5-4 years
Combining Words 24 Months After 4 years
Naming Objects 12-18 Months 4 years
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Questioning 2.5 Years -3 Years 4.5 years

Engaging in Conversations 11-14 Months 5 years

Qualitative Analysis
Most of the developmental milestones of the client were normal and age
appropriate. It was seen that all of the client’s communication milestones were achieved
but they were not age appropriate like they were achieved mostly after 3.5- 4 years.
Family History
The client lives in a nuclear family. His father, a 36-year-old pilot, is often away
due to work. His mother, a 29-year-old with a master’s degree, is a housewife. The client’s
mother reported that he has a healthy and loving relationship with both parents and is very
attached to them. When his father is home, the client spends most of his time with him. The
mother mentioned that the client is spoiled and over-pampered, receiving everything he
asks for. When other family members visit, the client is busy running and playing but
misses them when they leave and often asks them to come back. There are psychiatric
issues and ADHD on the client’s paternal side.

Medical/Psychiatric History
The client has no serious medical issues. He began going to a therapy clinic for 3
months, where he started to speak a little. He went to another center for 3 months at age 4,
where he began learning some words and sentences but also started humming. In 2023, he
started attending the current clinic, for speech and behavioral therapy, off and on. Now, the
main concern of therapy in this clinic is to deal with his inattention and hyperactive
symptoms.
Social History
The client’s mother mentioned that he plays with other children but often becomes
hyperactive during play. He doesn’t wait for his turn, snatches things from others, and
cannot play while sitting in one place. As a result, he doesn't have friends. When she takes
him to the park or the street to play with other kids, he doesn't interact with them and
instead runs around on his own, hurriedly using the slides and swings.
Assessments
Informal Assessment
• Clinical Interview
• Behavioral Observation
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• Mental Status Examination

Clinical Interview
The clinical interview with the client’s mother took place at the clinic.
Comprehensive information about the client was gathered to understand his life
circumstances and environment, helping to identify areas for intervention. During the
interview, the mother mentioned that mostly the previous therapies had focused on speech
and hadn't addressed the client's issues with inattention and hyperactivity. She expressed
her and client’s teacher’s concern about the client's difficulty remaining seated for extended
periods, indicating attention and hyperactivity issues. Additionally, the mother expressed
concern about the client's hand stimming. It was also noted that the client is overly
pampered, with his parents fulfilling all his wishes.
 67

Behavioral Observation
During the sessions, it was noticed that the client was hyperactive. He had hand
stimming issue, would often move back and forth, tap his toes, move his legs excessively
and mess with things nearby. He also got distracted easily. To gain his attention and focus,
he was asked to ‘look here’, ‘look down’ multiple times. While he could sit for a bit, he
would eventually get up and walk around before sitting back down. During individual
activities, he would get distracted when someone entered the room, smiling at them. In
group activities, he tended to interrupt others and didn't wait for his turn.

Mental Status Examination The psychiatrist's version of the physical examination is

called the mental state examination. Adolf Meyer created a framework for a systematic
technique to assess a patient's "mental status" for psychiatric practice in 1918. During
evaluation, it serves as the defining status of the patient's present condition. The broad
categories of appearance, behavior, motor activity, speech, mood, affect, thought process,
thought content, perceptual disturbances, cognition, insight, and judgment can be used to
categorize this mental status test (Voss & Das, 2022).
 68

Table2
Mental status examination during sessions

Age: The client is 5.5 years old boy.

Height and Weight: His weight is normal to his age
but he looks tall as compared to his age. Grooming:
Appearance
He was always well-dressed and his personal
hygiene was always maintained.
Clothing: He used to wear weather
appropriate clothes.
Gait and Posture: Appropriate gait and posture but
sometime he had slouched posture.
Behavior Facial Expression: Expressive, relaxed,
smiling, happy and sometimes sad
Psychomotor activity: Pacing around the room
and foot tapping. Sitting span was also not
appropriate
Mannerism: Unnecessary movements like hand
stimming, back and forth movements, fidgeting and
tapping hands or feet. Attitude: Cooperative and
distracted
Gestures: Appropriate other than hand stimming
Body language: Open and engaged
Engagement and Rapport: Rapport was good
and was easy to establish
Level of arousal: He was not alert and focused.
He can easily get distracted
Rate and Flow: Normal
Speech
Quantity: Spontaneous
Prosody and Tone: Normal prosody
Fluency and Rhythm: Clear
 69

Mood Mood is constant.

Intensity: Normal
Quality: Happy and sometimes sad.
Affect Fluctuations: Normal
Range: Normal
Congruence: Congruent
Clouding of consciousness: Inattention and
Cognition
lethargic
Memory Good Memory

Formal Assessment
• Portage Guide
• DSM5-TR checklist of Attention deficit/ hyperactivity disorder
• Conner’s Rating Scale for ADHD
• Vanderbilt Rating Scale for ADHD
Portage Guide
Table 3
Domains and Functional Age of the Client
Domains Functional Age Discrepancy
Self-Help Skills 0-1 Years 3 Years
Motor Skills 1-2 Years 2-3 Years
Language Development 0-1 Years 3 Years
Social Development 1-2 Years 2-3 Years
Cognitive Development 0-1 Years 3 Years

Qualitative Analysis
Portage guide results shows that client is facing delays in the all domains. Client’s age is
4 years 7 months but his functional age is 1-2 years in the domains of motor skills and social
development. In self- help skills, language and cognitive development his functional age is 0-1
years. So, discrepancy is seen between his chronological and functional age.
 70

DSM5-TR
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision
(DSM-5-TR) was published in 2022(DSM-5-TR: Autism Spectrum Disorder Diagnosis, n.d.).
DSM5-TR checklist of Attention deficit/ hyperactivity disorder
Table 4
DSM-5TR Checklist for ADHD
Diagnostic Criteria Inattention Symptoms
Often has difficulty sustaining attention in tasks or play activities. Present

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

Often does not follow instructions and fails to finish schoolwork and chores. Present
Often has difficulty organizing tasks and activities. Present
Often avoids, reluctant to engage in tasks that require sustained mental effort. Present
Often loses things necessary for task or activities. Absent
Often distracted by extraneous stimulus. Present

Often forgetful in daily activities. Absent

Hyperactivity
Fidgeting and tapping hands or feet Present
Leaving their seat when expected to remain seated (e.g., during a meeting Present
or lecture)
Often runs about or climbs in situations where it is inappropriate Present
Often unable to play or engage in leisure activities quietly Present

Often on the go and unable to sit still Present

Talking excessively Absent

Blurting out answers and completing other people’s sentences Absent

Trouble waiting their turn Present

Interrupting other people or intruding on their activities Present

 71

Conner’s Rating Scale for ADHD

The Conner’s Comprehensive Behavior Rating Scale was given by C. Keith Conners in
1990s. It is a questionnaire that focuses on behavioral, social, and academic issues in children
aged 6–18 years old. It can help diagnose attention deficit hyperactivity disorder (ADHD). There
are also 2 different forms within each version of the Conners’s assessment. One is designed for
parents to fill out and another for teachers (Johnson, 2018). Conner’s parent rating scale consists
of 27 items and teacher rating scale consists of 28 items both are rated on 0-3 scale. Score of 30-
55 means average typical, 55-60 means slight borderline, 61-65 means mind atypical, 66-70
means moderate atypical and 70 above means severe atypical.
Conner’s Parent Rating Scale
Table 5
Conner’s Parent Rating Scale Score
Index Score T-score Severity
Oppositional 01 42 Average typical
Inattention 11 66 Moderate atypical
Hyperactivity 10 68 Moderate atypical
Conner’s ADHD Index 22 66 Moderate atypical

Qualitative Analysis of Parent Rating Scale

Conner’s parent rating scale shows that on oppositional domain client score is 01 and
score is 42 which shows that there is no problem in this domain. On inattention domain the client
score is 11 and t-score is 66 which also shows that client has moderate problem of in-attention
and distraction. On domain of hyperactivity his score is 10 and t-score is 68 which also indicates
moderate problem of hyperactivity and restlessness. Overall, on Conner’s ADHD index the
score is 22 and the t-score is 66 which means he has moderate inattention and hyperactivity
issues.
Vanderbilt Rating Scale
The Vanderbilt rating scale is a screening and information gathering tool which can assist
with making and ADHD diagnosis and with monitoring treatment effects over time (Anderson et
al., 2022).
 72

Vanderbilt Parent Rating Scale

Table 6
Vanderbilt Parent Rating Scale Score
Number of Questions Counted Behaviors Type
1-9 6 Inattentive
10-18 7 Hyperactive
1-18 13 Combined
19-26 0 Oppositional-defiant
disorder
27-40 0 Conduct disorder
41-47 0 Anxiety or depression
Qualitative Analysis of Vanderbilt Parent Rating Scale
Vanderbilt parent rating scale shows that on 1-9 item client score is 7 which means he have
problem of inattention. On item 10-18 his score is 7 which shows hyperactivity. On 1-18 items
client total score is 13 which shows that client have problem related to both inattention and
hyperactivity. On item 19-47 client’s score is 0 which shows that client don’t have any issue
related to oppositional –defiant disorder, conduct disorder and anxiety or depression.
Tentative Diagnosis
Attention-Deficit / Hyperactivity Disorder DSM-5TR 314.01(F90.2)
Specifier: Moderate
Case Conceptualization
The case formulation was done by using Biopsychosocial model. It was given by George
Engel 1977. It suggests that there are factors other than biological to fully understand an
individual’s condition and these are the social and psychological factors. Biological factors include
their physiological pathology. Psychological factors include thoughts and emotions and social
factors include socio-economic factors, cultural factors and family circumstances etc. (Lowe,
2023).
Biological factor of the client was that he was delivered through C-section. Cesarean
section is a potential factor that may be associated with different mental health problems in kids. A
study found that children born with cesarean section had higher rate of ADHD symptoms as
 73

compared to vaginal delivery. Evidence shows that these children have different hormonal,
physical, bacterial, and medical exposures, and this can alter their neonatal physiology and may

even cause behavioral problems. Another study supports this as the results indicate that C
section children had higher risk of ASD, ADHD and other intellectual disabilities (Xu et al., 2023
and Lin et al., 2023).
One of the psychological factors in this case could be stressful pregnancy for the mother as
indicated by the client’s history and this high level of stress experienced during pregnancy can lead
to neurobehavioral development problems. A number of studies have shown that prenatal maternal
stress (PNMS) increases risk of behavior and emotional problems, language delay and cognitive
problems. Which can lead to children developing symptoms of ADHD later in life. Studies have
shown a clear link between maternal stress severity of ADHD symptoms. It has been found that
activation of the sympathetic nervous system, which occurs during stress, causes an increase in
uterine artery resistance that subsequently reduces blood flow to the fetus. This decrease in blood
flow may impair the development of organs, including the brain. (Ronald et al., 2011 and
Grizenko et al., 2008).
Another psychological factor is the language delay. The client was very late to achieve the
communication milestones as he only started speaking at the age of 3. One of the early symptoms
of ADHD is language delay. This language delay affects a child's cognitive development,
emotional regulation, and social interaction. It can hinder problem-solving, cause frustration due to
difficulty expressing emotions. These language difficulties are associated with symptoms of
ADHD and learning problems as well (Bruce et al., 2006).
A first client was only given speech therapy and no proper treatment for ADHD symptoms
was given so delayed treatment is another factor that can exacerbate symptoms, as early
intervention is crucial for effective management of ADHD. Without timely treatment, children
may struggle longer with attention, hyperactivity, and impulse control issues, which can negatively
affect their academic performance, self-esteem, and social relationships. Additionally, prolonged
untreated symptoms can lead to increased frustration and anxiety, further complicating the
psychological well-being of the individual. Children have to face problems at home and school as
it becomes hard for children to pay attention in class (Hammed et al., 2015).
One of the factors in the social domain of the model is screen time that the child gets and
the clients screen time per day exceeds 3 hours. Research shows that excessive screen time can
affect brain development and cognitive functioning. It also affects memory and attention span and
this in turn affects the individual’s social relationships. The results of the research show a link
 74

between excessive screen time and symptoms of ADHD and increasing this screen time also
increases the intensity of these symptoms. Another Study also show that attention related problems

can arise due to excessive use of screens and with this frequent usage of screens, the
arousal level of the child reduces leading to ADHD-related behaviors (Wallace et al., 2023 and
Zhou et al., 2023).
Parenting style is also an important factor that influences the onset of ADHD which can
then lead to behavioral problems. In this case the client was very pampered and a very permissive
style of parenting was used. Research shows a significant relationship between permissive
parenting and the risk of ADHD in children. The results of this research revealed parents of
children with ADHD used permissive parenting style. This makes the children less responsible and
grow more impulsive. This style often leads to parents rejecting the symptoms of ADHD in their
children which then leads to inattention and behavior problems. Another study shows that
permissive parenting style also lacks structure and discipline leading to lack of impulse control,
hyperactive behavior, low self-esteem and self-control, both of which can play a major role in the
development of ADHD (Setyanisa et al., 2022 and Rogers, 2023).

Figure 1

Biological Factors Psychological Factors Social Factors

Stress during
pregnancy Screen Time
Late achievemnet of
C-section communication
milestone
Over-pampering
Late treatment

The Executive Dysfunction Theory of ADHD

Executive dysfunction refers to difficulties in higher-order cognitive processes, such as
planning, sequencing, reasoning, maintaining attention, working memory, and inhibiting
inappropriate behaviors while selecting appropriate ones. These executive functions manage and
control lower-level cognitive tasks, like language, perception, explicit memory, learning, and
actions. Executive functioning relies on neural circuits that connect the frontal cortices with the
basal ganglia, thalamus, and parietal cortices. Research has shown structural differences and
 75

altered activation in the prefrontal cortex, fronto-parietal, and fronto-striatal circuits in children
with ADHD. Additionally, dysfunction in dopaminergic and noradrenergic neurotransmitters,

which are crucial for the fronto-striatal and fronto-parietal circuits, is also implicated in
ADHD (Johnson et al., 2009).
Biological Theories
Brain development is slower in people with ADHD because neural pathways
do not connect or mature at the same rate, partly due to low levels of neurotransmitters like
noradrenaline and dopamine. This makes it harder for them to pay attention and focus, impairing
executive functions that manage organization and routine tasks. Dopamine is crucial for mood
regulation and is associated with motivation, memory, and learning. Noradrenaline significantly
affects concentration by enhancing attention span and focus, and it also plays a role in mood
regulation. The low levels of these neurotransmitters explain many symptoms observed in
individuals with ADHD. Several brain regions, including the frontal cortex, limbic system, basal
ganglia, and reticular activating system, have decreased blood flow and impaired function in
people with ADHD. Reduced neurotransmission between the prefrontal cortex and basal ganglia
leads to a decreased attention span, short-term memory issues, and difficulty in prioritizing tasks.
The prefrontal cortex is responsible for judgment, helping to categorize tasks by importance and
maintain focus on one task at a time. The basal ganglia, responsible for impulsiveness, contribute
to the difficulty individuals with ADHD have in focusing on a single task (Vora, 2022).
The State Regulation Theory
Three levels of cognitive processes impacted by ADHD are identified by Sergeant's 2000 State
Regulation theory of ADHD: a) Lower-level cognitive functions that are dispersed throughout the
brainstem and cerebellum, including response organization, central processing, and encoding. b)
Mid-tier processes, including arousal, activation, and effort, centered around the ventral tegmental
region of the midbrain. c) Higher-order cortical executive functions, centered on the anterior
cingulate gyrus. This theory suggests that the deficits observed in ADHD are caused by
inefficiency at each of these cognitive levels, especially at the mid-tier level of arousal and
activation.
The State Regulation theory suggests that ADHD symptoms can vary based on the child's
state. For example, symptoms of inattention may occur during slow or boring tasks, while
impulsivity and hyperactivity may arise as attempts to increase stimulation. Conversely, when a
task is stimulating or rewarding, it can sufficiently arouse the individual, enabling them to focus
 76

appropriately. This theory explains why individuals with ADHD can maintain attention for
extended periods during highly stimulating activities, such as playing video games or watching
television, but struggle with less engaging tasks (Ory, 2017)

Short Term Goals

• Increase his sitting Span
• Decrease his hyperactivity
• Improve attention span
• Improve social and communication skills
• Reduce hand stimming
Long Term Goals
• Achievement of short term goals
• Improve Academics
Therapies
• Applied Behavior Analysis
• Group Therapy
• Occupational Therapy
• Art Therapy
Applied Behavior Analysis (ABA)
All client sessions were based on Applied Behavior Analysis (ABA), a structured and
evidence-based approach designed to enhance socially significant behaviors by systematically
examining and adjusting the factors that influence them. This method involves breaking down
skills into smaller, manageable steps and employing positive reinforcement to increase desired
behaviors while reducing unwanted ones. Numerous studies have demonstrated that ABA therapy
is effective in treating ADHD in children. Implementing ABA therapy has shown substantial
improvements in social and adaptive skills, as well as notable reductions in problem behaviors
such as hyperactivity, inattention, and aggression (Moller, 2024).

Group Therapy
This often entails group psychotherapy where multiple individuals participate together.
Those with ADHD might find value in learning from others who share the condition and gaining
peer support (Kandola, 2023). The therapy emphasizes the development of skills related to forming
 77

friendships, collaborating effectively with others, coping with frustration, and enhancing emotional
intelligence within an enjoyable and supportive setting. During certain sessions, the client
participated in group activities alongside peers of similar age. This was aimed at developing
patience, as well as enhancing social and communication skills.

Occupational Therapy
Occupational therapy helps individuals overcome barriers to important activities,
increasing their independence and life satisfaction. It enables full participation in social situations
and, for children with ADHD, can improve school performance, work ethic, and reduce excessive
physical energy (Sherrell, 2021). In the sessions, occupational therapy was utilized to diminish the
client's hyperactive and stimming behaviors.
Art Therapy
Art therapy aids children and adults with ADHD and other neuropsychological disorders by
allowing them to express their thoughts more effectively through visual images and art-making,
rather than through written or spoken words. This form of therapy is particularly beneficial for
active, busy children with ADHD, as it engages their hands and fosters a level of mental and
emotional focus that talk therapy often does not achieve. Art therapy offers a means for children to
address and improve issues related to attention and hyperactivity (NeuroHealth Associates, 2020).
During certain sessions, art therapy was incorporated, involving activities such as painting,
coloring, and tracing letters and shapes.
Techniques
• Rapport Building
• Psychoeducation
• Reinforcement
• Social skills training
• Shaping
• Prompting and Fading
• Modeling
• Selective attention
Rapport Building
Building rapport fosters emotional connection, providing pathways into our children's lives.
It enables us to immerse ourselves in their world, comprehend their worries, and celebrate their
achievements. Initially, no instructions or commands were given to the client; instead, I engaged in
play activities that he enjoyed. During this time, I identified reinforces that improved his focus and
 78

attention, as well as the activities he enjoyed most. Concurrently, I asked open-ended questions to
build rapport. After 2-3 days, I gradually began giving instructions and conducting activity-based
sessions.

Psychoeducation
During the first interview session, client’s mother was psych educated. She mentioned that
the client was an over pampered child. I explained that fulfilling all his wants would not improve
his condition and that only his acceptable wants should be met. I also informed her that, unlike
previous therapy which focused primarily on speech, our main focus would now be on addressing
his inattention and hyperactivity. It was emphasized that the activities performed at the center
should also be practiced at home. In subsequent sessions, when the client's mother came to pick
him up, I inquired about the activities performed at home and provided guidance on activities to
continue there. If she reported any behavior related to the client's inattention or hyperactivity, I
used to educate her on techniques to manage and control such behavior at home.
Reinforcement
Reinforcement is to strengthen a behavior. It improves the probability that behavior will
occur in the future. The client is positively reinforced during the session when he completes certain
task or follow certain commands or instructions. This will make him do that activity or follow that
instruction again. Through reinforcement many goals can be achieved (Cherry, 2023). During the
session technique of differential reinforcement was also used it is a behavior modification which
involves selectively reinforcing desired behaviors while withholding reinforcement for undesired
behaviors (tprestianni, 2023). For example, during the sessions, the client was asked to perform a
task with focus. If he successfully completed the task, he was rewarded with a star. However, if he
did not complete the task, he did not star. This taught him that he would not be reinforced if he did
not exhibit the desired behavior.

Table 7
Clients reinforces and its types
Reinforces Types of reinforces
Praise (Good, very good, excellent, good Intangible
boy, and clapping)
Stars Tangible
Smiley stickers Tangible
 79

Play time Tangible

Car Tangible
Laptop Tangible

Social skills training

Social skills training aims to enhance peer relationships and teach interpersonal interaction
skills that promote success in the classroom or at home. Unlike individual or group therapy, these
classes focus primarily on improving interpersonal interactions rather than managing emotions or
personal change. Group settings are most common, as they offer immediate opportunities to
practice newly acquired skills with other children in the class (ADHD Group Approaches, n.d.). In
group activities, 3-4 children of the same age as the client participated. Activities included playing
with a racket and ball, finding a specific object on his turn, and placing rings of a particular color on
a tower during his turn. He was taught to wait for his turn during games, not to interrupt his peers
while they performed activities, to request or ask for things politely if he needed anything, to be
patient and communicate effectively while playing with others.
Shaping
Shaping involves reinforcing successive approximations toward a desired goal or skill. This
process begins by identifying the ultimate target behavior and then providing reinforcement for
behaviors that increasingly resemble that goal, starting from the learner's current level (Gilmore,
2020). During the session shaping technique was used while helping him write letters properly and
the client was also taught weekdays, with a primary focus on writing "Monday." If he correctly
wrote the first letter, 'M,' he was reinforced.

Prompting and Fading

Prompts are instructions, gestures, demonstrations, touches, or other things that we arrange
or do to increase the likelihood that children will make correct responses. It is actually assistance
which is given by an adult or more knowable person (golden-user, 2022). Prompting helps in
improving person’s ability to do a certain task independently after some time. There are different
types of prompts used like gestural prompts, full physical prompts, partial physical prompts, verbal
prompts, visual prompt and positional prompt (Chicago ABA Therapy, 2017). Fading refers to
decreasing the level of assistance needed to complete a task or activity. Fading is often paired with
 80

prompting and reinforcement (Cooper et al., 2007). Verbal prompts were used consistently
throughout the sessions, repeatedly instructing him to "look down," "focus," and "don't get
distracted." Gestural, partial and full physical prompt were used during matching and tracing
activities.

Modeling
Modeling is used to demonstrate a desired behavior. Modelling is very important in teaching
skills like: social, communication, self-help and play skills (Association for science in autism
treatment, 2016). Modeling was used during the sessions by demonstrating to the client how to
move beads through a maze, shifting them one by one from one side to the other. Additionally,
modeling was employed to show him how to trace. Furthermore, in an activity where he had to
place the correct number of coins on a number written on paper, the client was first shown how to
do it through modeling and then successfully completed the task.
Selective attention
Selective attention is important because it allows people to focus on what’s happening
around them and ignore things that are not relevant or important. This selective attention makes it
easier for people to process information, encode memories, and enhance performance in various
cognitive tasks. Selective attention involves the mechanisms enabling individuals to choose and
concentrate on specific input for deeper processing while concurrently suppressing irrelevant or
distracting information. Such competing information may arise externally, such as extraneous
auditory or visual stimuli in the surroundings, or internally, like distracting thoughts or habitual
responses hindering the execution of the current task (Stevens & Bavelier, 2012). Some sessions
with the client were conducted in the presence of other clients to help him selectively focus and
avoid distraction from surrounding noises. During these sessions, he was tasked with activities such
as counting, identification, matching, tracing, and coloring.

Individualized Plan
Table 8
Individualized plan for client
Goals Tasks Achieved Outcome
To improve sitting and attention Client was able to sit
span following activities were and focus on certain
 81

done. tasks for long time.

• Coins and numbers were
used like he was asked to
put coins according to the
number placed.
• Maze with beads was used
in which he was asked to
take beads one by one.
• Sticks and numbers were
used.
• Counting number of items in
Improve Attention and Sitting the book.
• Recognition device for
identification.
• Finger counting.
• The alphabets book was
used and he was asked to
place the object starting with
that particular letter.
Scrabble was used.
He was asked to find
letters and make
words.Mandala
coloring
 Colorful balls were used a
nd he was asked to find that
color and put it in the
basket
 Puzzle of body parts
 Following physical activities Client now sometime
were done to reduce his waits for his turn.
hyperactivity and stimming
behavior.
 He was asked to clean up all
the coins slowly and one by
 82

one.
 Monkey bar
 Racket and ball were used to
make him stand still and to
reduce his excessive
movements.
 Yoga Ball
 Poppet
 Painting
Span Reduce Social Skills  Group activities were done
like in which he was taught
how to wait for his turn.
Following activities were
done:
 To play with racket and
ball on his turn.
 To find the asked object on
his turn.
 Ring tower was used in
this activity the client was
Training Hyperactivity asked to put that particular
color on his turn
Pre and Post Intervention Rating
Table 9
Intervention Ratings
Problematic Domain Pre-Rating Post Rating
Inattention 8 6
Hyperactivity 8 6
Hand stimming 8 5
Deficits in social and communication skills 8 7
 83

Figure 2
Pre and post rating

0
Inattention Hyperactivity Hand stimming Deficits in social and
communication skills

Pre Rating Post Rating

Prognosis
The client’s prognosis is favorable, as there has been a noticeable reduction in his symptoms. With proper
treatment, it is likely that his symptoms would reduce and he will be able to exhibit appropriate behavior.
 84

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Association for science in autism treatment. (2016, May 21). Modeling. Association for Science in Autism
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Bruce, B., Thernlund, G., & Nettelbladt, U. (2006). ADHD and language impairment. European
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Cherry, K. (2023, April 4). Positive and Negative Reinforcement in Operant Conditioning.
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Cooper, J. O., Heron, T. E., & Heard, W. L. (2007). Fading | Nebraska Autism Spectrum Disorders Network
| Nebraska. Www.unl.edu.
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DSM-5-TR: autism spectrum disorder diagnosis. (n.d.). Raising Children Network. Retrieved April 29,
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Gilmore, H. (2020, February 20). Shaping, Chaining, & Task Analysis with an Example from Everyday Life.
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 85

example-from-everyday-life golden-user. (2022, December 1) Prompts: An ABA Technique. Golden

Care.
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Grizenko, N., Shaman, Y. R., Polotskaia, A., Ter-Stepanian, M., & Joober, R. (2008). Relation of maternal
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CASE IV
INTELLECTUAL DISABILITY
 89

CASE SUMMARY
Client was a 7-year-old girl who was brought to the Institute by her mother. she came. with presenting
complaints of anger outburst, hitting others, stubbornness, poor. academic skill and difficulty in
comprehending concepts. she was referred to the clinical psychologist for the assessment and management of
her symptoms. Client’s formal and informal assessments were done. In informal assessment, her behavior
was. observed and an unstructured clinical interview was conducted with her mother. Informal assessment,
Colored Progressive Matrices (CPM) was applied along with DSM-VTR checklist for intellectual disability.
The client was diagnosed with intellectual disability. A management plan was devised for the client focusing
on her academic skills as well as social/communication skills. Behavioral techniques were used with the
client.
Identifying Information
Name: M.D
Gender: Female
Age: 7 years
Number of siblings: 2
Birth order: 1st
Father’s occupation: Private job
Mother’s occupation: Housewife
Informant: Mother
Reason and source of Referral
Client was referred to institute with the complaints of language issue, poor memory, lack of
concentration, hitting behavior. She was referred to clinical psychologist for the assessment and management
of her symptoms.
Presenting Complaints
‫ٹک اٹک کر بولتی ہے۔‬

‫بات بات پر غصہ کرتی ہے ۔‬

‫چھوتی بہن کو غصے میں مار بھی دیتی ہے۔‬

‫سیدھی بات سمجھانے میں بھی مشکل ہو تی ہے۔‬

‫خود اپنا کام نہیں کرتی زیادہ لاڈ پیار سے بگڑ گئی ہے۔‬
 90

History of present illness

According to the mother, she had a prolonged labor and she started noticing some problems after the
birth. Client was diagnosed with CP due to absence of birth cry at the age of one month. The child had
delayed milestones like neck holding, sitting, crawling, walking and speaking. According to the mother, the
child cannot speak till at the age of 5 and has a lot of behavioral issues.
 91

Developmental Milestone
Table 1
Comparison between normal age and child age of achieving developmental milestone
Developmental Milestone Normal age range Child achieving age

Crying Birth Delayed

Neck holding 3 months 7 months
Sitting 6-8 months 1 year
Crawling 8-10 months 1.5 years
walking 1-1.5 years 3.5 years
Speech (one word) 1.5-2 years 5 years
Speech (sentences) 3-4 years Not achieved
Bowl control 3 years Not achieved
Bladder control 3 years Not achieved

Family History
The client was first born. She lived in a joint family system and the parents of the client were first
cousins. Her father is an IT engineer and mother of the client used to teach at a school but resigned a few years
back. Client had two younger siblings.
Client lived with his parents, paternal grandparents and paternal uncle. Since the client was first born,
she was loved by everyone in the family, as reported by the mother. Her mother described her as a spoiled
child. She was always given extra attention and her relationship was good with everyone except her younger
sister. She often got irritated by her younger sister.
Medical History
According to the client mother’s child birth was pre-mature. After 2 years of birth, she faced Aspiration
Pneumonia. According to her mother, developmental milestones of child were delayed. Such as holding up her
hands, sitting, standing, crawling on time. The speech development of the client is also delayed. She has
normal vision and hearing. Eye and hand coordination was also good. She received speech and language
therapy from the age of 4 years.
 92

Preliminary Investigation
The client was assessed on both informal and formal levels to get a better understanding of his
behavioral problems.
Informal Assessment
Unstructured Clinical Interview. An unstructured clinical interview was conducted with the client’s
mother in order to collect detailed information regarding the presenting complaints of the client, his personal
history, family history and history of present illness. She was cooperative in this regard. She was concerned
and understood the condition of the client.
Behavioral Observation. The client was a 7-year-old girl. She was in good hygiene and properly
dressed. She was in an irritable mood but was attentive. She gave proper eye contact to the therapist. Speech of
the client was stuttered. She had difficulty in comprehending tasks.
Formal Assessment
. CPM was used to get an estimate about the client’s cognitive processes, analytical reasoning and
observational capacity. CPM helps in providing an estimate about the intellectual level of a child. This test was
applied with the client in a separate room.
Quantitative Analysis.
Clients age 7
Total 6
score
Per 2
ce 5
ntil
e
Discrepancy 2
G 2
ra
d
e
Level of 4
intelligence

A, Ab and B respectively. Total score of the client was 16. The corresponding grade for her obtained
score was IV which indicated that the client is below average in intellectual capacity. The client’s cognitive
ability is not according to her normal age range. Since her score falls below average, her non-verbal
intelligence is not age appropriate.
 93

Diagnosis
319 (F71) Intellectual Disability, Moderate
Case Formulation
The client’s parents were first cousins. There are various studies on relationship of consanguinity and
mental disorders. A study by Sad et al. (2014) indicated that intellectual and developmental disabilities in
addition to other genetic disorders are most likely to occur among inbred offspring and the risk is significantly
higher than in non-consanguineous families. Another study examined the effects of premature and low
birthweight on mental health outcomes among US children aged 2–17 years. It was found that prevalence of
mental disorders was 22.9% among children born prematurely, 28.7% among very-low-birth-weight children,
and 18.9% among moderately low-birth-weight children, compared with 15.5% in the general child population.
It was concluded that low birth weight and premature birth are significant factors for mental health problems
among children.
The client also exhibited behavioral problems such as tantrums and hitting other children. A study was
conducted to assess and compare the prevalence of a wide range of emotional and behavioral problems in
children with and without intellectual disability (ID). Almost 50% of children with ID had a Total Problem
score in the deviant range as compared to about 18% in children without ID. Compared to children without ID,
the most prominent problem behaviors of ID children were
Social Problems, Attention Problems, and Aggressive Behavior
Biopsychosocial Model
Biological Factors Psychological factors Social Factors
Premature birth Poor cognitive skills Problematic behaviors ignored
by family
Delayed first cry
Delayed developmental
milestones

Management Plan
Management plan was based on client’s diagnosis and symptoms and their
severity.
Rapport Building
To build rapport with the client she was seated comfortably on the seat. Client was given full attention.
She was engaged in simple activities e.g. playing with ball, doll etc. simple instructions were given and positive
reinforcement was provided on compliance with commands.
 94

Reinforcement
Reinforcement was used throughout the sessions to help the client perform different activities and
strengthen desired behaviors. Positive reinforcement i.e. favorite toy, verbal and positive gestures like good,
high five, thumbs up was used to teach client tracing. Negative reinforcement was provided to reduce hitting

behavior of the client. Whenever she hit a student, she was asked to sit for some time at the back of
class while not allowing her to play with his favorite toy for some time.
Chaining
Chaining was used to teach client different self-help skills such as teaching shoe-lacing. Whole task was
divided into simple steps like hold the strings, make a cross, fold one string on the other, make a knot, take one
string, make a loop, fold other string on the looped string, pull and make a bow. All these steps were taught one
by one followed by reinforcement.
Prompting
Prompting was used to teach the client alphabetical letters, matching the geometrical shapes, and
writing numbers; both verbal and physical prompts were provided. The hand of client was held by the therapist,
and she was guided how to trace on lines and match the columns. The use of prompts made teaching of tasks
more effective. After the client completed the tasks, she was provided with reinforces.
Fading
Gradually physical prompts were reduced and when the client was able to distinguish between shapes
and was able to draw on paper, only verbal prompts were given. Verbal prompts were also removed completely
when the client was able to write letters, numbers and draw shapes.
Modelling
To teach money value to the client, she was taken to the photocopier shop of the school. There, the
therapist modelled shopping for pencils and erasers by paying with coins’/currency notes. The amount was
counted with the client before giving to the shopkeeper. This was then gradually taught to the client for her to
imitate.
Summary of Sessions
In initial sessions, the rapport was built with the client. Her behavior was observed as well as her
reinforces were identified. In 3rd session, a session with mother was arranged to take information regarding
history of client. The client was assessed using Colored Progressive Matrices and DSM-VTR checklist for
Intellectual Disability. Different activities and were carried out to teach concepts to client including money
value. Behavioral techniques were used to improve desired behavior and reduce undesired behavior of hitting.
 95

Only 10 sessions could be continued, after that the client was handed over to her therapist for continuation of
sessions.

Session 1
In the first session, the focus is on building rapport with the client and conducting an initial assessment.
I greet the client warmly and engages in casual conversation to create a comfortable environment. Initial
observations are made regarding the client's behavior, speech, and social interaction.
Session 2
This session involves closely observing the client's behavior in a naturalistic setting. She was engaged
in activities they enjoy and it will help to know about her speech difficulties, social interaction, cognitive and
emotional state.
Session 3
In third session, interview is conducted with her mother to gain detailed information about her birth,
developmental and illness history. After conducting interview, I did formal assessment using CPM. Then
mother was also psycho educated about the child disorder, causes and treatment.
Session 4
Based on the assessment results, an Individualized Education Plan (IEP) was formulated. The IEP
outlined specific goals and objectives to address the client’s educational and developmental needs. The plan
included interventions aimed at improving academic skills, social interactions, and daily living skills.
Collaboration with the client's family and educators was emphasized to ensure consistency and support across
settings.
Session 5
The skill-building activities tailored according to the client's developmental level. Activities focused on
enhancing basic academic skills, such as reading, writing, and arithmetic, using engaging and interactive
methods. The senior therapist provided structured tasks and positive reinforcement to encourage participation
and learning.
Session 6
In this session work on Social skills training to improve the client's ability to interact with peers and
adults. I used role-playing, modeling, and social stories to teach appropriate social behaviors, such as taking
turns, sharing, and initiating conversations. Feedback and praise were provided to reinforce positive social
interactions.
 96

Session 7
In this session, worked on developing the client's daily living skills. Activities included self-care tasks
such as dressing, grooming, and hygiene routines. I used visual schedules and step-by-step instructions to help
the client learn and practice these skills, promoting independence and self-sufficiency.
Session 8
The session was terminated and handover to her senior psychologist.
Limitations
 Non-compliance at home i.e. the client’s problematic behaviors (such as hitting) were not addressed at
home.
 Limited number of session
 97

References
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th Edition:
DSM-5 (5th ed.). American Psychiatric Publishing

Dekker, M. C., Koot, H. M., Ended, J. V. D., & Verhulst, F. C. (2002). Emotional and behavioral problems in
children and adolescents with and without intellectual disability. Journal of Child Psychology and Psychiatry,
43(8), 1087–1098.
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 98

Raven, J. C. (1965). Guide to Using the Coloured Progressive Matrices. H.K. Lewis.

Saad, H. A., Elbedour, S., Hallaq, E., Merrick, J., & Tenenbaum, A. (2014). Consanguineous Marriage and
Intellectual and Developmental Disabilities among Arab Bedouins Children of the\Negev Region in Southern
Israel: A PilotStudy. Frontiers in Public Health, 2, 3. https://doi.org/10.3389/fpubh.2014.00003

Singh, G. K., Kenney, M. K., Ghandour, R. M., Kogan, M. D., & Lu, M. C. (2013). Mental Health Outcomes in
US Children and Adolescents Born Prematurely or with Low Birthweight. Depression Research and Treatment,
2013, 1–13.https://doi.org/10.1155/2013/570743
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Case – 5
LEARNING DISABILITY
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CASE SUMMARY

The client was an 8-year-old boy who was brought to the clinic by his parents. He was referred to the
clinical psychologist with complaints of poor memory and poor academic performance. Informal assessment
was done through an unstructured clinical interview with the client’s mother and through behavioral
observation. Formal assessment consisted of Child Progressive Matrices and Dyslexia Teacher Observation
Checklist. He was diagnosed with learning disability disorder. A management plan was devised for the client
focusing on his academic skills as well as social/communication skills. Behavioral techniques were used with
the client.
Identifying Information
Name A. R
Gender Male
Age 8 years
Siblings 2
Birth order 2nd
Father’s Education M.Com
Father’s Occupation Government Employee
Mother’s Education Matric
Family System Nuclear
Informant Mother
Reason and Source of Referral
The client was brought to the hospital by his parents, with complaints of poor memory and poor
academic performance. He was referred to trainee clinical psychologist for the assessment and management of
his symptoms.
Presenting Complaints
‫جو بھی سکھاو بھول جاتا ہےسکول کا کام نہیں ہوتا اس سے۔حساب بہت کمزور ہے۔‬
‫صحیح طرح لکھتا نہیں ہے۔‬
Family History
The client lived in a nuclear family system with his parents and siblings. He was 2nd born to his
parents. The father of the client was a 45-year-old man; he was a government employee. The client’s mother
reported strict behavior of father towards the client. He often scolded him while helping him with his
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homework. But he was concerned about the client’s progress. The mother of the client was a 39-year-
old woman; she was a homemaker. The client was closer to his mother than his father. Client had an elder sister
aged 15 years and a younger brother aged 6 years. His relationship with both his siblings was good. There was
no psychiatric history reported in the family.
Personal History
The client was born a full-term baby i.e. after 9 months of gestation. He was born through C-section.
His developmental milestones were met at appropriate time. He started walking at the age of 1 year, he was
toilet trained by the age of 3 years. however, he started speaking at the age of 3 years.
History of Present Illness
The client started school at the age of 4 years. He performed well initially as it did not involve much
reading or writing. But he faced problems in copying letters and alphabets. He had difficulty telling left from
right. The teachers always gave reports emphasizing on improvements. The client had to change schools due
his condition. Client changes three schools.
Preliminary Investigation
Informal Assessment
Unstructured Clinical Interview. The client’s mother was asked about the details regarding family
history of client, his personal history and history of his present illness. She reported about the presenting
complaints of the client. The mother was quite cooperative and extremely concerned about the client.
Behavioral Observation. The client was properly dressed and in good hygiene. He had sound
speech. The client was emotionally sensitive. He was continuously crying because he was hit by a football in
the school’s play area. He repeatedly said the same sentence over and over to the therapist i.e. he was hit by a
football. He was distracted by an activity. Then he was told to write alphabets. It was noticed that the client had
difficulty in writing and copying letters.
Formal Assessment
Raven’s Colored Progressive Matrices. CPM was administered on the client to assess his
cognitive ability and non-verbal intelligence.
Quantities Analysis
Client’s age 8 years
Total score 19
Percentile 50
Discrepancy 1+(-1)+0
Grade 3
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Level of intelligence Greater than the medium

Qualitative Analysis.
The client scored 7, 6 and 5 on sets A, Ab and B respectively. Total score of the client was 19. The
corresponding grade for his obtained score was III which indicated that the client scored greater than the
median and he was average in intellectual capacity. This analysis shows that client’s nonverbal intelligence and
cognitive abilities are appropriate for the child’s age.
Dyslexia Teacher Observation Checklist.
The client showed problems in all domains of the dyslexia checklist. In early literacy challenges, the
client had difficulty in writing words by recognizing their sounds. In reading challenges, the client had
significant problems in comprehending text and maintaining fluency while reading. In writing challenges, he
had difficulty in copying, spelling, and staying within the margins.
Tentative Diagnosis
315.2(F81.81) Specific Learning Disorder with impairment in written expression.
Case Formulation
Compared to children who do averagely, children with specific reading and/or math learning disabilities
are more likely to experience general working memory capacity limitations. Constraints in working memory
capacity for children with learning disability are localized to components of the phonological systems which
include difficulties in the sequential recall of letters, numbers, real words, and pseudo words (Swanson, 2015).
The client’s score of CPM indicated that he is intellectually average. Children with dyslexia do not typically test
low on standard IQ tests, except when the test requires reading (Das, et al. 1994).
Another study was carried out to compare interpersonal sensitivity and emotional balance in students
with and without specific learning disability. Results showed that there was significant difference between the
two groups of students in Interpersonal Sensitivity and Emotional Balance. The findings of this study indicated
that learning disabled students face difficulties in the context of Interpersonal communication skills and
shortcomings in emotions (Norimaki et al. 2015).
Biopsychosocial Model
Biological factors Psychological factors Social factors

No significant present Poor in academic skills Father strict behavior

Emotional sensitivity

Management Plan
Management plan was based on client’s diagnosis and symptoms, and their severity.
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Rapport Building
Rapport was built with the client in the initial session. He was asked simple questions about his name,
age, favorite toy etc. He was provided with full attention and was praised by the senior psychologist.
Reinforcement
Client was given positive reinforcement to strengthen desired behaviors such as answering questions
correctly during class activities. Cartoon stickers were stacked on his hand as a positive reinforcement. This
enhanced his self-confidence and significantly increased in participation in classroom activities.
Chunking
Chunking method was used to help the client in memorizing information. He was taught spellings of
shapes, numbers, his telephone number using chunking. This enabled him to remember these for longer periods
of time.
Communication Skills
To enhance communication skills of client, he was taught different tasks such as asking the teacher
before entering the classroom, call another student from the next classroom, ask the teacher to pass him objects
in complete sentence. He was taught to say please before requesting and thankyou upon receiving something.
Behavior Modification
The client had crying behavior and was emotionally sensitive. He started crying when another student
sneezed near him or touched him. He was distracted by involving him in another activity. He was also
instructed to look down when he exhibited crying behavior, this resulted in reduced crying.
Academic Skills
Writing Skills. He was taught to color within edges of shapes.
Mathematics. He was instructed to write counting from 1 to 10. Prompts were used at first, but they
were gradually faded.
English. Client was taught capital and small letters separately. He was taught spelling of different
words e.g. cat, dog. This also included reading of simple sentences (such as; how are you?)

Urdu. He was taught simple hereof e Taraji, and with verbal prompts he was aided in reading.
Summary of Sessions
Rapport was built with the client in initial sessions. His behavior was observed, and he was reinforced
for exhibiting desired behaviors. 3rd session was conducted with the client’s 90 mother over the phone, in
which history of client and his presenting complaints were noted. CPM was applied to assess his intellectual
capacity and the client’s score indicated average intellectual performance. Upon observation of client’s reading
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and writing performance, dyslexia teacher observation checklist was used to assess for dyslexic symptoms in
client. Management plan focused on his academic skills; reading, writing and mathematics skills. The client left
after 5 sessions with the clinical psychologist. Due to which it was not possible to continue further.
Limitations
Number of sessions were limited therefore it was not possible to complete prognosis.

References
 105

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders,
5th Edition: DSM-5(5thed.). American Psychiatric Publishing.

Das, J. P., Mishra, R. K., & Kirby, J. R. (1994). Cognitive Patterns of Children with Dyslexia. Journal of
Learning Disabilities, 27(4), 235–242.
https://doi.org/10.1177/002221949402700405

Norimaki, M., Parlor, P., Bashar pour, S. (2015). Comparison of interpersonal senility and emotional balance in
students with and without specific learning disorder. Journal of Learning Disabilities, 5(1), 125-141.

Raven, J. C. (1965). Guide to Using the Colored Progressive Matrices. H.K. Lewis.

Swanson, H. L. (2015). Intelligence, Working Memory, and Learning Disabilities.

Cognition, Intelligence, and Achievement, 175–196.
https://doi.org/10.1016/b978-0-12-410388- 7.00010-5
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CASE 6
SPECIFIC LEARNING DISORDER
315.2(F81.81) WITH IMPAIRMENT IN
WRITTEN EXPRESSION
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CASE SUMMARY
The client G. K is 14 years old boy; she is 2rd born having 3 siblings. She was brought to CMH by her
mother for slow in learning as compare to other children of her class. Mother reported that she was unable to
read properly when she read, she read with abuses and also take more time to memorize. Client’s mother
reported that she uses abusive language with everyone when someone tries to make her understand or advise her,
she gets abusive and uses bad words for that person Client uses to quarrel with everyone at home and got
aggressive and irritable towards her family. Client mother further reported she play with younger children and
enjoy their company. Client feels shy and speak less when interact with people. According to her mother her
birth was normal and she cries immediately after birth but 3 months after birth suddenly she suffered from skin
problem Fever and weakness in muscles. She said that her developmental milestones were delay. The informal
assessment includes the behavioral observation, unstructured clinical interview, Mental State Examination
(MSE) and Portage guide to early education. Formal assessment includes Olsson Intelligence Test (SIT) and
DSM-5 TR checklist for Disorder on basis of history and interpretation of results.
Identifying Data
Name: G.K
Gender: Female
Age: 14 years
No. Of siblings: 3
Birth order: 2nd
Father: Teacher
Mother: Housewife
Family structure: Joint
Education: 4th Grade
Religion: Islam
Residence: Abbottabad
Referral:
The client was brought to the CMH by her mother for,
hyperactivity, inattention, sustaining attention for long, easily distracted by extraneous stimuli,
impulsiveness and aggression and also with speech problems.
Presenting Complaints
Clients Mother’s Verbatim:
‫ا س کو پڑھنے لکھنے کا بلکل شوق نہیں ہے‬
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‫ریڈ کریں بھی تو بہت ٹائم‬ ‫ہم بہت بھی کوشش کرے تو لکھ نہیں پاتی‬
‫لگاتی ہے روک کے پڑتی ہے اور ٹیچر ٹیچر کو بھی بہت تنگ کرتی ہے اسکول‬
‫میں بھی نہیں پھڑتی گھر میں بھی مشکل سے بیٹھی ہے اپنے بہن بھائیوں سے‬
‫لڑتی ہے غصہ بہت کرتی ہے مگر دوسروں کے سامنے بات بھی نہیں کرتی اپنے‬
‫سب دوستوں سے اور بہن بھائیوں سے پیچھے رہ گئی ہے‬
History of Presenting Illness
According to client’s mother client problem started when she was admitted in school, she was slow in
learning as compare to other children of her class. Client mother reported she was unable to read properly when
she read she read with pauses and also take more time to memorize. Client’s mother reported she uses abusive
language with everyone when someone tries to make her understand or advise her, she gets abusive and uses bad
words for that person client uses to quarrel with everyone at home and got aggressive and irritable towards her
family. Client mother further reported she play with younger children and enjoy their company. Client feels shy
and speak less when interact with people. According to her mother her birth was normal and she cries
immediately after birth but 3 months after birth suddenly she suffered from skin problem Fever and weakness in
muscles. She said that her developmental milestones were delay.
Previous treatment
No any treatment was given before coming to CMH.
Family History
The client belongs to lower socio-economic status Pashto speaking Muslim family with nuclear
setup residing at Peshawar. Her mother is a housewife while her father is a school teacher.
Their marital relationship was normal. According to client’s mother they are very friendly and
cooperative. And there was no psychological and physiological problem in family. As far as her
family is concerned she has unhealthy relationship with her family except her mother she is
much attached with her mother. She uses to quarrel with her siblings and got aggressive towards
them.

History of psychiatry/medical illness in family

No major or minor psychiatry or medical history was being reported by the parents.
Personal History
According to mother, she was under stress during pregnancy because of her household and financial
problems, she did not face any serious illness or difficulty and the baby was delivered through normal
 109

delivery, after birth the child had a mild head injury due to miss management of nurse, she was normal
healthy baby and cried after birth. Her weight was normal. But the developmental milestone wasn’t achieved
at age appropriate.
Childhood history
Developmental milestones
According to mother, milestones were not achieved at appropriately age.
Table 1
Developmental milestone
Normal Age
Achievement
Crying After birth After birth
Neck holding 5-6 months 5 month
Sitting 6-9 months 12 month
Crawling 9-18 months 16 month
Walking 6-9 months 2 years
Babbling 10-15 months 1 and half years
One Word 15-16 months 1 year

Educational History
As far as her educational history is concerned, she started her education at the age of five years. Due to
slow in learning she is failed in class 2 nd and class 3rd. Now she is in class 4th and her ages 14 years. Client has
good relation with her teachers and class fellows, but couldn’t read or write like her other class fellows, she has
difficulties in maintaining attention, she couldn’t read simple words and having much more difficulties in
writing in a straight line, she has difficulties with holding and controlling a writing tool. Having trouble
knowing when to use lower- or upper-case letters.
Social history
Client was very social. She was having many friends at school and have good relation with her siblings.
When someone tries to make her understand or advise her she gets abusive and uses ad words for that person
Client uses to quarrel with everyone at home and got aggressive and irritable towards her teachers and class
fallows. Client mother further reported she play with younger children and enjoy their company. Client feel shy
and speak less when interact with people.
Medical history
Client had a past history of medical illness. Her mother reported that they visited for a child
 110

specialist for his fever and chest tonsils and delayed milestones.
Psychiatric history
The client had no past psychiatry history.
Psychological Assessment
Informal Assessment
 Mental State Examination (MSE)
 Portage Guide to Early Education (PGEE)69
 Behavioral assessment
Formal (Standardize Assessment Tools)
 Sollosson Intelligence Test (SIT)
 DSM 5 TR checklist

1. Mental Status Examination (MSE)

MSE showed that the client behavior during the session wasn’t friendly. She was friendly and
cooperative but some time she looks stubborn. Her clothes were neat and cleaned client look restless but her
conversation was not proper. Client mood was sad and was looking very sap pointed. Her general health was
satisfactory her hearing sleep and appetite was normal her general behavior was good. She wanted to avoid all
the paper pencil activities she wanted to play with dolls and she just talk about. Her speech was not normal and
voice pitch is very low. Her posture was restless. Her eye contact was also not good. Client’s thought was in
sequence and normal. Her perception was not really good. She was well oriented in time and place and has no
awareness of problem.
Identification reinforces
Reinforcement identification was done by direct observation in natural setting and by asking from
mother. Following is the categorization of the clients reinforces. These reinforces were provided to the client on
the completion of the specific task or whenever he showed desirable behavior which resulted in strengthening
his desirable behavior.
Showing kinds of reinforce and identified reinforce of child
Type of Reinforce
Identified Reinforce
2. Portage Guide to Early Education
Portage guide was administered on the client to assess the degree to his language skill, motor skills,
social skills, cognitive skills and self-help skills. It almost took an hour to complete it.
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Interpretation
Quantitative scoring
Table 2
DOMAINS Functional Age
Discrepancy
Social skills 4 year 2-3
Language skills 3 year 1 months 3-4
Self-help 3 year 6 months 3-2
Cognitive skills 4 year 9 months 3-4
Motor skills 3 year 5 months 2-3

Qualitative Analysis
PGEE was administered to get her developmental profile of the child of motor area is seemed to be very
poor. Her developmental profile of socialization poor and seems to be unable to welcome strangers. Her is
unable to develop the peer relationship. Her developmental profile depicts that he is very slow from her age
group her was not able to solve three-piece picture her Consumable reinforce Chocolates and chips Possession
reinforce Dolls Activity reinforce Stuff toys 71 developmental profile of self-help shows that the client doesn’t
know how to eat thing. Her developmental profile of speech showed that her does not speak proper line he just
says two words of line.
Formal assessment
Interpretation of Early Assessment Tools
3.Slosson Intelligence Test (SIT)
Quantitative analysis:
Test administration date 2024-11-7
Date of birth 2010-1-2
Chronological age 14 years -10months
Chronological age in months 171
Basal age 3years 11months
Basal age months 47
Credit months 20.5
Mental age 5years 6 months
Mental age in years 67
Ratio IQ 39.1
Chronological age (C.A)
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Mental age (M.A)

Intelligence (I.Q)
Quotient 14year-10month
5year-6month 39.1%
Qualitative analysis:
The client exhibited severe intellectual disability. Slosson Intellectual Test results showed deficits in
client’s vocabulary, general information, similarities and differences, comprehension, quantitative ability and
auditory memory.
4. DSM 5 TR
Disorder Checklist
The checklist contains of the symptoms criteria of disorder according to the diagnostic and
statistical manual (DSM-5 TR). The client meets the criteria for
i.e. criteria A-E are met.
DIAGNOSTIC CRITERIA STATUS
1. Inaccurate or slow and effortful word reading present
2. Difficulty understanding the meaning of what is read Present
3. Difficulties with written expression Present
4. Difficulty with spelling Present
5. Difficulties mastering number sense, number facts, or calculation Present
6. Difficulties with mathematical reasoning Present
7. The affected academic skills are substantially and quantifiably below
those expected for individual’s chronological age, and cause significant
interference with academic performance. Present

Tentative Diagnosis
Specific Learning Disorder
315.2 (F81.81) With Impairment in written
expression
Prognosis:
The prognosis of the child is good in the adaptive functioning and also in intellectually
functioning. Her condition can be improved with proper treatment, guidance, assistance, and her
parents and teacher struggle.
 113

Case Formulation:
Child is a 14 years old girl. She belongs to a Muslim Urdu speaking middle class family.
The presenting complaints as reported by her mother include The Child was thoroughly accessed
by formal and informal assessment method includes, Interviewing information, Behavior
observation, Portage Guide to Early Interventions (PGEE), Olsson Intelligence Test (SIT) These
test scores reveal that the child has below I.Q and poor adaptive functioning as compare to her
fellows. The child diagnosis was Specific Learning Disorder 315.2 (F81.81) With Impairment in
written expression After formal informal assessment behavior therapy techniques is used to
management plan rapport building positive reinforcement relaxation training to manage the child
problem.
4 P’s
4P’s Description
Predisposing Factors Delayed developmental milestone, weakness in muscles and skin problem
shortly after birth.
Precipitating Factors Difficulty memorizing and the inability to keep up with classmates.
Perpetuating Factors Difficulty in reading and memorization, which might reduce self-esteem
and contribute to frustration.
Protective Factors Family support, positive social interaction

Theoretical Framework
To create a theoretical framework for the case of this 14-year-old girl diagnosed with Specific Learning
Disorder (F81.81) and Impairment in Written Expression, the following theoretical perspectives are
essential to understanding the child's challenges and guiding effective interventions. The framework integrates
cognitive, behavioral, developmental, and sociocultural theories.

Cognitive-Behavioral Theory (CBT)

Cognitive-Behavioral Theory, developed by Aaron T. Beck and Albert Ellis, focuses on the interrelation of
thoughts, feelings, and behaviors. The key principle is that maladaptive thoughts lead to negative emotions and
behaviors, which can be reshaped through therapeutic intervention.
 114

Application to the Case:

 Cognitive Component: The child may hold negative beliefs such as "I’m not good enough," which
might stem from repeated failures in academic tasks (e.g., written expression). These thoughts can lead
to low self-esteem, frustration, and anger.
 Behavioral Component: The child’s aggressive behaviors and use of abusive language in response to
academic challenges are maladaptive responses that need to be addressed through reinforcement
techniques and cognitive restructuring.
 Interventions: The therapeutic approach can include identifying and challenging these negative thought
patterns and replacing them with more positive, realistic beliefs, such as improving her self-concept and
belief in her abilities. ( Beck, A. T). (1976).

Developmental Theory (Piaget and Erikson)

Developmental theories, particularly those by Jean Piaget and Erik Erikson, offer insight into the
child’s cognitive and psychosocial development. Piaget’s theory of cognitive development and Erikson’s
psychosocial stages highlight the developmental milestones and challenges at different stages of life.

 Piaget’s Theory: At age 14, children should be entering the formal operational stage, where abstract
thinking, logical reasoning, and hypothetical thinking become more pronounced. However, delays in
cognitive processing due to Specific Learning Disorder might limit her ability to meet these milestones.
 Erikson’s Psychosocial Stage: At this age, the child is navigating the Identity vs. Role Confusion
stage. Academic struggles and social difficulties can hinder the development of a positive self-concept,
leading to frustration, irritability, and possible behavior problems like aggression. (Piaget, J.) (1952)

Application to the Case:

The formal operational stage may be delayed due to the child’s Specific Learning Disorder, and thus
interventions need to support cognitive development through tailored strategies, such as cognitive
remediation and written expression exercises.

The identity crisis (Erikson) could be worsened by the child's academic struggles, leading to insecurity
and aggression in social and family interactions.
 115

Neurodevelopmental Theory (Specific Learning Disorder)

Specific Learning Disorders are neurodevelopmental conditions that affect how individuals process and use
information. The child’s difficulties in written expression, along with below-average IQ and poor adaptive
functioning, suggest that neurodevelopmental factors are at play. ( Pennington, B. F. (2009).

Application to the Case:

 The child’s cognitive difficulties are likely related to specific processing deficits in areas such as
working memory, attention, and language processing, all of which can affect written expression.
 Early intervention and support to develop compensatory strategies are essential for managing the
learning disorder and improving academic performance.

Management Plan:
Short term goals.
 To make child able to understand the sentences
 To make the child able to write 1-3 words.
 To make the child able to read simple words.
 To reduce shyness and anger.
 To boost up her confidence.
 To make child able to follow the commands. 74
Long term goals
 To make child able to manage herself
 To make child improve her memory.
 To make the child able to respond appropriately
 To make child able to improve motor skills
 To make child able to improve her social functioning.
 To make child able to improve her cognitive abilities.
Therapeutic Intervention and Recommendations
Encouragement
Child is encouraging and reinforce to improving his good behavior and reduce punishment on reducing
his teasing and stealing behavior that is helpful to improve his self-concept and reduce anxiety. To increase
attention span and reduce hyperactivity during class work different colors and shape worksheets added in the
child’s activities. Child encourages writing 1-5 learnt to go to his teacher and check his copy.
 116

Feeling word game

Learning to identify, label, and share feelings is an important ingredient of healthy personal,
social, and family functioning. The Feeling Word Game provides a lively, creative context for
these tasks.
Board Book play therapy
The board book play therapy was conducted on the child the child Sit in a group and display the board
books in front of child Ask child what he see and what he can find in the pictures in the books. Ask child to
point to some of the pictures. If the children cannot show you, try to find the pictures together. Ask the child to
tell a story about the pictures, or to say what he think about them. Ask the child to find and name objects in
their environment that look like the pictures. Child was communicating with therapist Child had fun and enjoy

talking about what he sees in the book or flash cards. The therapy helped child to sit for long and pay attention
and was reinforced for every correct response.
Token economy
One of the most important technologies of behavior modifiers and applied behavior analysts
over the last 40 years has been the token economy. These procedures are useful in that they help
provide a structured therapeutic environment, and mimic other naturally occurring reinforcement systems such as the
use of money. ( K.M. Chung et al.2017)
Self-instructional training
To improve the cognitive ability concept of left and right, concept of shapes and concept of
color was given to the child.
Social skill training (SSK)
To work with child teasing child was learnt to help other and say sorry in the case of mistake. And also
instructed to hand shake with other class fellows Child was learnt, motivated and encouraged to perform that
behavior. And punish when he teases other or snatch the copy or Pencil of other students.
Puppets Stories
The therapist conducted the therapy in school free period have a few children use the hand
puppets to help you tell a familiar story. Put a puppet on your hand, and give each child a puppet to hold. Tell
each child who his/her puppet will be in the story. Have the children listen carefully so that they will know when
to make their puppets talk. Begin telling the story. When the time comes for a child’s puppet to say something,
give help if needed. • Children may use the puppets to play out events that have occurred, both happy and sad,
and may want to discuss such events with the caregiver.
• Children interact together and share stories, developing their imagination and expressing
their feelings.
 117

• Children can talk to their puppets and learn how to take care of them.
• Children express their happiness in movement and sound
Motor skill training
To control the child hyper activity and increase attention span different color bus given to
the child and said him to arrange. With these buses color recognition also learnt to the child. Child has poor
motor skill so to enhance the motor ability building block, grip of pencil and write on copy 1 and walk slowly 10
to 15 min are suggested and also implemented.

Stringing Beads
The play therapy was conducted with the child under the supervision of therapist necklaces are used
during play. Child have to put a set of colorful beads freely the child was encouraged to put beads on the string
by colors and/or shape. The child has to count with the therapist, how many beads he had strung. The therapist
congratulates the child for the necklace or bracelet that he has created. Child learned about different colors.
Child increase his control in handling objects and develop dexterity
Shaping of behavior
Shaping is the use of reinforcement of successive approximations of a desired behavior.
Specifically, when using a shaping technique, each approximate desired behavior that is demonstrated is
reinforced, while behaviors that are not approximations of the desired behavior
are not reinforced.
Pre and post intervention
6

3 pre
post
2

0
reading writing aggression attention memory
 118

Limitations
Limitations of the process was that the parents were not managing client’s therapy time
and were not accepting their child’s problem. The father shows mostly aggressive behaviors.

References
Billings, D. C., & Lasik, B. H. (1985). Self‐instructional training with preschoolers: An attempt to replicate.
Journal of Applied Behavior Analysis, 18(1), 61-67.

Bryant, L.E. and Budd, K.S., 1982. Self‐instructional training to increase independent work performance in
preschoolers. Journal of applied behavior analysis, 15(2), pp.259-271.

K.M. Chung et al. Research in Developmental Disabilities (20017).

Beck, A. T. (1976). Cognitive Therapy and the Emotional Disorders. International Universities Press.

Ellis, A. (1962). Reason and Emotion in Psychotherapy. Lyle Stuart.

Piaget, J. (1952). The Origins of Intelligence in Children. International Universities Press.

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