Contents

Introduction ..................................................................................................................................... 3

Differential Diagnosis ................................................................................................................. 4

Major and mild neurocognitive disorders ................................................................................... 4

Communication disorders and specific learning disorder ........................................................... 4

Autism spectrum disorder ........................................................................................................... 5

Co morbidity ............................................................................................................................... 5

Intellectual Disability (Intellectual Developmental Disorder) .................................................... 6

Diagnostic Criteria .................................................................................................................. 6

Case 1 .............................................................................................................................................. 8

Referral ....................................................................................................................................... 8

Duration of sessions .................................................................................................................... 8

Identifying data ........................................................................................................................... 8

Presenting complains .................................................................................................................. 9

By client .................................................................................................................................. 9

By informant ........................................................................................................................... 9

Symptoms ................................................................................................................................. 10

Background information ........................................................................................................... 11

Behavioral Observation ............................................................................................................ 13

1
 History of present illness .......................................................................................................... 13

Informal assessment .................................................................................................................. 14

Formal assessment .................................................................................................................... 15

Mental status examination .................................................................................................... 16

Ravens Progressive Matrices ................................................................................................ 21

Parents Report Measures for Children and Adolescents SDQ (P) 04-10 ............................. 23

Systematic behavioral observation ....................................................................................... 26

Case formulation ........................................................................................................................... 28

Tentative Diagnosis .................................................................................................................. 33

Therapeutic Recommendation .................................................................................................. 33

Cognitive behavioral therapy ................................................................................................ 33

Occupational therapy ............................................................................................................ 35

Emotion-Focused Therapy .................................................................................................... 36

TECHNIQUES USED IN EMOTION-FOCUSED THERAPY .......................................... 37

Prognosis ................................................................................................................................... 39

2
 Introduction

Mental retardation is an intellectual disability that results in intellectual capabilities

significantly below average. Mental retardation can interfere with learning, the ability to

care for oneself, and the ability to meet general societal expectations about how to behave.

It is generally defined as an IQ below 70, although people with IQs slightly above this

number may have extreme difficulty functioning while people with IQs slightly below this

number may not have such difficulties. Historically, the diagnosis was given to anyone with

a low IQ, but in contemporary psychology mental retardation has an adjustment component

and below-average intelligence alone is not sufficient to warrant a diagnosis.

To be diagnosed with mental retardation, symptoms must be present in childhood.

Adults who experience a loss in cognitive functioning may be diagnosed with another

illness such as dementia. A number of factors can cause mental retardation, including:

 Down syndrome and fetal alcohol syndrome significantly increase a person‟s risk of

mental retardation, though not all people with these conditions have mental

retardation.

 Improper development during pregnancy can contribute to the development of

symptoms, and exposure to certain drugs in utero—particularly illegal drugs and

alcohol—greatly increases a fetus‟ risk of being born with mental retardation.

 Illness and infection that affect the brain may lead to the condition, and very high

fevers in early childhood can cause mental retardation. Measles and meningitis may

also contribute to the development of mental retardation.

3
Specified

The various levels of severity are defined on the basis of adaptive functioning, and not IQ scores,

because it is adaptive functioning that determines the level of supports required. Moreover, IQ

measures are less valid in the lower end of the IQ range.

Differential Diagnosis

The diagnosis of intellectual disability should be made whenever Criteria A, B, and C are

met. A diagnosis of intellectual disability should not be assumed because of a particular genetic

or medical condition. A genetic syndrome linked to intellectual disability should be noted as a

concurrent diagnosis with the intellectual disability.

Major and mild neurocognitive disorders

Intellectual disability is categorized as a neurodevelopment disorder and is distinct from

the neurocognitive disorders, which are characterized by a loss of cognitive functioning. Major

Neurocognitive disorder may co-occur with intellectual disability (e.g., an individual with Down

syndrome who develops Alzheimer‟s disease, or an individual with intellectual disability who

loses further cognitive capacity following a head injury). In such cases, the diagnoses of

intellectual disability and neurocognitive disorder may both be given.

Communication disorders and specific learning disorder

4
 These neurodevelopment disorders are specific to the communication and learning

domains and do not show deficits in intellectual and adaptive behavior. They may co-occur with

intellectual disability. Both diagnoses are made if full criteria are met for intellectual disability

and a communication disorder or specific learning disorder.

Autism spectrum disorder

Intellectual disability is common among individuals with autism spectrum disorder.

Assessment of intellectual ability may be complicated by social-communication and behavior

deficits inherent to autism spectrum disorder, which may interfere with understanding and

complying with test procedures. Appropriate assessment of intellectual functioning in autism

spectrum disorder is essential, with reassessment across the developmental period, because IQ

scores in autism spectrum disorder may be unstable, particularly in early childhood.

Co morbidity

Co-occurring mental, neurodevelopment, medical, and physical conditions are frequent in

intellectual disability, with rates of some conditions (e.g., mental disorders, cerebral palsy, and

epilepsy) three to four times higher than in the general population. The prognosis and outcome of

co-occurring diagnoses may be influenced by the presence of intellectual disability. Assessment

procedures may require modifications because of associated disorders, including communication

disorders, autism spectrum disorder, and motor, sensory, or other disorders. Knowledgeable

informants are essential for identifying symptoms such as irritability, mood deregulations,

aggression, eating problems, and sleep problems, and for assessing adaptive functioning in

various community settings.

5
 The most common co-occurring mental and neurodevelopment disorders are attention-

deficit/hyperactivity disorder; depressive and bipolar disorders; anxiety disorders; autism

spectrum disorder; stereotypic movement disorder (with or without self-injurious behavior);

impulse-control disorders; and major neurocognitive disorder. Major depressive disorder may

occur throughout the range of severity of intellectual disability. Self-injurious behavior requires

prompt diagnostic attention and may warrant a separate diagnosis of stereotypic movement

disorder. Individuals with intellectual disability, particularly those with more severe intellectual

disability, may also exhibit aggression and disruptive behaviors, including harm of others or

property destruction.

Intellectual Disability (Intellectual Developmental Disorder)

Diagnostic Criteria

Intellectual disability (intellectual developmental disorder) is a disorder with onset during the

developmental period that includes both intellectual and adaptive functioning deficits in

conceptual, social, and practical domains. The following three criteria must be met:

A. Deficits in intellectual functions, such as reasoning, problem solving, planning, abstract

Thinking, judgment, academic learning, and learning from experience, confirmed by both

clinical assessment and individualized, standardized intelligence testing.

B. Deficits in adaptive functioning that result in failure to meet developmental and sociocultural

standards for personal independence and social responsibility. Without ongoing support, the

adaptive deficits limit functioning in one or more activities of daily life, such as communication,

social participation, and independent living, across multiple environments, such as home, school,

work, and community.

6
C. Onset of intellectual and adaptive deficits during the developmental period.

Note: The diagnostic term intellectual disability is the equivalent term for the ICD-11 diagnosis

of intellectual developmental disorders. Although the term intellectual disability is used

throughout this manual, both terms are used in the title to clarify relationships with other

classification systems. Moreover, a federal statute in the United States (Public Law 111-256,

Rosa‟s Law) replaces the term mental retardation with intellectual disability, and Research

journals use the term intellectual disability. Thus, intellectual disability is the term in common

use by medical, educational, and other professions and by the lay public and advocacy groups.

Specify current severity (see Table 1):

317 (F70) Mild

318.0 (F71) Moderate

318.1 (F72) Severe

318.2 (F73) Profound

7
 Case 1

Referral

Client reported that he started to have treatment from a spiritual scholar in mosque, after

the effective result were not gain then on suggestion of my uncle I visit a doctor in Benazir

Bhutto Shaheed hospital where he recommend me a special education so I join garden school

where I faced so many problem so changed my school and join chambeli institute for special

education.

Duration of sessions

The session was conducted from 24 October, 2022 to 2ndNovember, 2022. Each session

was of approximately 1 hour.

Identifying data

Age: 7 years

Gender: male

Education: grade 2

Father: alive

Mother: alive

Father„s education: masters

Mother‟s education: F.A

8
‫‪Father occupation:‬‬ ‫‪government job‬‬

‫‪Mothers‟ education:‬‬ ‫‪house wife‬‬

‫;‪No of siblings‬‬ ‫‪2‬‬

‫‪Brothers:‬‬ ‫‪1‬‬

‫‪Sisters:‬‬ ‫‪1‬‬

‫‪Family system:‬‬ ‫‪nuclear‬‬

‫‪Presenting complains‬‬

‫‪By client‬‬

‫جت ہن ظت کھیلتے ہیں تو هیں ظت ظے شیبدٍ تیص زفتبز هیں ثبگتب ہوں۔‬

‫هیں گھس واپط اکیلے ثھی جبظکتب ہوں۔‬

‫هجھے ظبزے زاظتوں کب پتہ ہے ۔‬

‫هجھے ڈاًط کس ًب ثھی آتب ہے ۔‬

‫هجھے گب ًب ثھی آتب ہے ۔‬

‫هیں ظت ظے شیبدٍ پیبزا ہوں۔‬

‫هیسی اهی ثھی خوثصوزت ہے ۔‬

‫‪By informant‬‬

‫یہ کالض هیں هیسی کوئی ثھی ثبت ًہیں ظٌتب ۔‬

‫‪9‬‬
‫ثہت ثبتوًی ہے ۔‬

‫اظکو کوئی ثبت کسوں تو ایعے اًجبى ثي جبتب جیعے کچھ ظٌب ہی ًہیں ۔‬

‫زیبضی هیں ثہت کن ًوجس آتے ہیں ۔‬

‫یہ ایک جگہ ٹک کے ًہیں ثیٹھ ظکتب ۔‬

‫اظکو ثبزثبز ثولٌب پڑتب کہ اپٌب کبم کسوں‬

‫یہ جت ثبت کستب ہے هٌہ ظےتھوک ًکلتی ہے اظکو ظوجھ ہی ًہیں آتی کہ هٌہ صبف کسًب ہے ۔‬

‫یہ اگس کجھی واشسوم جبئےتو ثیلٹ ثٌد کسًب ثھول جبتب ہے۔یہ صفبئی کب خیبل ًہیٌکستب۔‬

‫ہس وقت ہٌعتب زہتب ہے ثہت شیبدٍ ثولتب ہے ۔جھوٹ ثھی ثولتب ہے ۔‬

‫شسوع شسوع هیں تو ثہت شیبدٍ تٌگ کستب تھب اة پھس تھوڑا ثہتس ہے۔‬

‫‪Symptoms‬‬

‫‪‬‬ ‫‪Problem in memorizing previous events.‬‬

‫‪‬‬ ‫‪Difficulty in learning‬‬

‫‪‬‬ ‫‪Reading problems‬‬

‫‪‬‬ ‫‪Writing problem‬‬

‫‪‬‬ ‫‪Unable to focus‬‬

‫‪‬‬ ‫‪Difficulty in mathematics and reasoning‬‬

‫‪‬‬ ‫‪Unable to understand logics‬‬

‫‪‬‬ ‫‪Forgetting‬‬

‫‪‬‬ ‫‪Pronunciation problem‬‬

‫‪10‬‬
Background information

Personal history

The client was born with normal pregnancy in Rawalpindi and his mother didn‟t face any

difficulty during delivery. He had normal life events. He had problem in speech. Sometimes it‟s

difficult to understand client speech. He faces difficulty in conveying his point. He had a good

motor skill. He had great interest in cricket and running. He was very talkative and of jolly

nature. He has great memory issues and difficulty in recalling previous events. He has problems

in learning especially in mathematics. He did not take care of his hygiene. According to his

mother he did not brush his teeth did not comb his hairs did not take bath properly. He had no

behavioral problems he was very helpful caring and command following. He gets nervous when

he met strangers he is very shy at first. He is more close to his mother. He spent most for his time

with his mother h has no emotions. He did his work independently with out anyone‟s help.

Developmental milestones Normal age Achievement of milestone

First cry After birth Normal

walking 9-18 months normal

sitting 6 months normal

crawling 6-9 months normal

cooing 3 months normal

bubbling 6-9months normal

communication 6-11months normal

Family history

11
His father is government employee and belongs to a middle class family. His mother is house

wife. He is very attached to his mother and possessive about her but shows no feelings for other

family members. He had 2 siblings. Have one sister and brother and his birth order were last. He

has no feelings or emotions for anyone. His family environment was pleasant and healthy.

According to his mother he spent most his time playing in street. And he try his best to maintains

good relations with everyone.

Medical history

According to his mother he was so healthy and active in first 2 year after birth. But gradually

when he started talking he was having speech problem but no one taken him serious. Then at the

age of 4 he get admission in school the teachers usually do complains about his speech problem

and learning issues so on suggestion of his one teacher we consult a doctor so here they came to

know that this school is not suitable for their child. Their child needs special education.

Educational history

He started his schooling from garden school because of learning problem he was admitted in

another institute that was chambeli institute of disable children. Then they admitted him in step

to learn in which he is in grade 1he was very week in study his mother complained during

interview that they did not focused on him properly. His tutor had also come in weekend she

given more attention to him and on his study. He had a learning problem. He did not do his work

properly. He did not understand the thing. His hand writing is unreadable .he has zero reading

skills. He had already changed school for this problem.

12
Behavioral Observation

1stsession: In the first session the client was not comfortable. He was very shy at the start of

session. He keeps smiling during whole session. He shows hesitation in answering my question.

He was moving his chair throughout his session he was having some speech problem I was

unable to understand his point. He was turning his fingers and rubbing the hands from start till

the end of the session. He was not taking any interest in my questions discussion. He was unable

to understand my questioning and unable to answer properly.

2ndsession: The client showed relatively open attitude and was comfortable as compared to

previous session. He was smiling but not shies in this session. And having same behaviors as in

previous session such as moving of chair, rubbing of hands and turning of finger etc. and he was

taking interest in my questions. And he was also trying to ask me question such as can u sing or

dance?

3rdand 4rth session: in the 3rd and 4rth session client got so frank. He shares quite personal

things such as his bitter experiences as his father beat him last night and his mother save him

from father. He shows emotions for his mother and having no emotions for other family member

neither good nor bad.

History of present illness

The client has intellectual disability and accused of misbehavior since from one year. He was so

normal in short after birth but at age 2 or 3 their parents come to realize that they have so many

abnormalities. At the age of five he was admitted in a slow learner school where he also attends

therapies. No hallucinations are reported of any category. Nor the delusions experience of any

13
category. Client reported an injury he got in an accident which causes fractured in right arm at

the age of five.

1. Premorbid personality: the client had several disabilities since after some time of birth.

He lived with family members who are also suffering from similar disabilities. He has

very good relation with family especially with mother. He used to be very sensitive about

his disability and when someone point out his disability he shows frenzies behavior.

Client sometimes reported that he is absolutely fine and there is no abnormality in him.

2. Onset of the illness: the client become to note that he has some disability after he gets

admission in special education. There family realize at the age 3 that their child need

special education when they noticed that their child have speech problem and memory

issues. Therapist also recommends special education for their child.

Informal assessment

An informal assessment is spontaneous. It is a method of evaluation where the instructor

tests participants‟ knowledge using no standard criteria or rubric. This means that there is no

spelled-out evaluation guide. Rather, the instructor simply asks open-ended questions and

observes students‟ performances to determine how much they know.

If informal assessments are not concerned with grading students, then what are they

about? It‟s simple—feedback. Data from these evaluations help the instructor make ongoing

adjustments to create better learning experiences for participants.

The client was observed during the session he seems to be very happy and cheerful life

but little depressed about his physical condition client showing continuous movement such as

14
crossing of legs, moving of chair and rubbing of hands which shows his restlessness. He was

curiously looking rapidly here and there and keenly observing my activities. During his sessions

through several answers of client I came to know that he is materialistic and selfish. According

to client he can sing a song and can dance. And I observed that the client was having pure

feelings for friends and mother.

The history of client and the informant was observed in which he has been reported with

several aspect of antisocial act such as fighting, disgusting attitude, abusing and unethical

behavior in society. The client behavior was observed to be too much defensive during session.

When asked for questions regarding to area of his conflicts, so it can be assumed that he is

defensive in nature because of his past experiences. But in last sessions client get so frank and

start discussing his experiences that was the happiest and most pride able event for him in life

such as he got full marks in quiz.

Formal assessment

Formal assessment consist primarily of standardized test a or performance reviews that

have been validated and tested using samples of the intended test groups. they have specific test

administration and scoring procedures, as well as credential or training requirements for test

administrators test scores may be criterion based(based on knowledge and ability in a specific

academic or vocational area) or norm-referenced ( based on a comparison to the sample of the

test takers peers).

The following tests are used to asses client‟s problems, their intensity and personality through

standards.

15
  Ravens progressive matrices

 Parents Performa

 Mental status examination

 Systematic behavioral observation

Mental status examination

The mental status examination is a structured assessment of the patient's behavioral and

cognitive functioning. It includes descriptions of the patient's appearance and general behavior,

level of consciousness and attentiveness, motor and speech activity, mood and affect, thought

and perception, attitude and insight, the reaction evoked in the examiner, and, finally, higher

cognitive abilities. The specific cognitive functions of alertness, language, memory,

constructional ability, and abstract reasoning are the most clinically relevant.

The purpose of the MSE is to obtain a comprehensive cross-sectional description of the

patient‟s mental state, which when combined with the biographical and historical information of

the psychiatric history, allows the clinician to make an accurate diagnosis and formulation.

Below is a framework that demonstrates the type of information that the mental state

examination hopes to gather.

a. Appearance ,aptitude and activity

Appearance

 Outlook of patient: outlook of patient was satisfactory he was in proper school uniform.

 Level of consciousness: client was active and attentive and is fully conscious and

observing everything.

16
  Position /posture: Session 1: client was seated in a comfortable chair but he was showing

restlessness but continuous movements.

Session 2: client was trying to sit but unconsciously he was moving

chair, changing position, rubbing hands and crossing the legs etc .he was not able to sit

properly.

Session 3: client was properly seated little comfortable and relax

compare to previous sessions.

 Attire/grooming: client overall appearance was fine he was in proper uniform and have

proper hairstyle which is according to client made by her mother.

 Abnormal physical traits: physically he was normal but has some problem in walk and

hand movements.

 Eye contact: Session 1: Clients was so shy and maintain no eye contact in 1st session.

Session 2: rare eye contact.

Session 3: the client maintained approximately proper eye contact.

Attitude (degree and type of cooperative and resistance)

Session 1: client have friendly attitude and he get frank as time passes but at the start of

session he was shy, smiling on my question and didn't answer me properly.

Session 2: client was open and cooperative but still on my questions and tasks, client

showed self laughing regressive and rationalizing and defensive responses with

comparatively less intensity.

Session 3: client was open and showing no resistance in this session.

Activity (physical movement): voluntary localized movement by client was shown. The

client was showing movements like crossing of legs and rubbing of hands.

17
 Involuntary movements: Nils

Tics (vocal/motor): nil

Compulsions: nil

b. mood and effect's :

Mood (person‟s predominant mood) The mood of client was normal happy mood and

stable. The client also seems in confused mood.

Affect (external manifestation of emotion and feelings.

 Types of Affects: (happy, sad, apprehensive and confused): the client showed normal

mood but on discussion related to her mother he gets really emotional.

 Intensity degree: the client shows noticeable moderate degree of effects.

 Reactivity: the client shows positive responses and reaction several times during his

sessions. Happiness was shown in areas related to games fun, music, dances and food.

 Range of effects: client shows noticeable moderate degree of reactivity.

 Appropriateness: the activity and effects shown by client were not appropriate for

example he was laughing while on serious questions and showing misbehavior in very

serious time.

 Mobility (change of effect/mood shift for reaction): the client shows no mood shift he

was laughing during whole session even on my strict behavior. He has no mood shift

overall.

c. speech and language:

 Fluency: the speech of client was not fluent and improper. He was having speech

problem really difficult to understand client speech.

 Comprehension: the client showed understanding of direction he was given.

18
  Repetition: the client repeated certain words in description such as „roti,dost‟ in

conversation he not really repeated many words.

 Naming: nil

 Writing: the writing of client was very poor. I asked him to write counting and he wrote

„5‟for more than 20 times.

 Reading: the client was in grade 2 so he was unable to read.

 Prosody (intonation, speech, rate of conversation): speech was really disturbed,

intonations were normal accept on question related to his family members but on his

mother. overall speech rate was low.

 Quality of speech (pitch, volume and articulation): his pitch was normal, volume was

very low even difficult to hear client voice and articulation problem was also present in

client.

d. thought processes, thought content and perception:

Thought process

 Connectedness: client shows uncertain shifts in the topic or he discussed mostly about his

mother and friend. Client was having strong bond with mother.

 Peculiar thought process (neologism [naming], preservation [repetition], clanging [logical

association], and blocking [resistance]): thought blocking was observed in his

conversation regarding to his mother specially and thought preservation was not observed

in client.

Thought content

 Delusions: nil

19
  Overvalued ideas: ideas related to his negative environment, parents importance and

games were overvalued in whole conversation.

 Obsession: nil

 Ruminations (repeated thoughts related to ideas): ideas related to games, fun, feelings for

her mother and friends were ruminated in his whole conversation.

 Preoccupation (pre entangled thoughts): client was pre occupied with the negative feeling

for siblings.

 Suicidal ideation: nil

 Violent ideas: the client in his discussion and test presented theme of irresponsible

attitude and carelessness.

 Phobias: nil

e. perceptual abnormalities

 hallucinations: nil

 Other perceptual abnormalities mental processing and function Collin the clients

neurocognitive functioning was damage and was strongly evident in raven progressive

test.

f. cognition

 Orientation: it was not severely distorted but was present to an extent causing

significant impairment.

g. attention and concentration

20
  Registration (capacity to immediately repeat live info): client was behaviorally

attentive but preoccupied in several thoughts at the time and could not fully respond

to stimuli accurately.

 Memory (long term/short term): the client was not having a good memory neither

short term memory nor log term memory I asked him about his early childhood

experiences he was unable to answer about them. Then in the 3rd session I asked him

the about the 1st session but he was unable to memorize anything.

 Visual constructional ability : nil

 Executive functioning: poor, the client has distorted concept of ending up problem.

h. insight and judgment

 Insight: inside is distorted as the client tends to perceive him as a very good and a

faultless person. According to client he is prettiest of all and he is perfectionist and

able to do everything.

 Judgment: the client overall cyclical condition is under great potential concern as he

has very distorted self concept recording to himself. The bad events effected the client

psyche to a very deep extent

Ravens Progressive Matrices

Introduction

The tests were originally developed by John C. Raven in 1936. In each test item, the

subject is asked to identify the missing element that completes a pattern. Many patterns are

presented in the form of a 6×6, 4×4, 3×3, or 2×2 matrix, giving the test its name.

21
 Raven's Progressive Matrices (often referred to simply as Raven's Matrices) or RPM is a

non-verbal test typically used to measure general human intelligence and abstract reasoning and

is regarded as a non-verbal estimate of fluid intelligence. It is one of the most common tests

administered to both groups and individuals ranging from 5-year-olds to the elderly. It comprises

60 multiple choice questions, listed in order of increasing difficulty. This format is designed to

measure the test taker's reasoning ability, the adductive ("meaning-making") component

of Spearman's g (g is often referred to as general intelligence).

Current Administration

Subject information

Gender Male

Age 8 years

Education Grade 2

Behavioral Observation

The test was administered in a casual setting. The respondent doesn‟t ask any question.

He has listened to the instructions carefully and started performing test. He has completed the

whole raven‟s progressive matrices in 20 minutes.

Scoring and Interpretation

The total score is 9/60.she scored percentile 5.This score interpret that subject has

extremely poor intelligence.

Conclusion

22
 The test has revealed that subject has poor abstract intelligence. He was doing the test

with great pace he took less time for selection of each picture. In set A the client had given 5

correct answers out of 12, but when the difficulty level increases the client responded least

correct answer. In set B, the client only had given 2 correct responses out of 12 while in other

sets C the client respond only 1 correct answer and in set,D and E the client was not able to give

any correct answer.

Parents Report Measures for Children and Adolescents SDQ (P) 04-10

SDQ correlates highly with Rutter scales (longstanding measure of parent informant of

child symptomatology) (.78-.88-parent) (.87-.92 teacher). The SDQ is able to discriminate

between clinical and community sample with self-report. It demonstrates reasonable cross

informant correlations and good internal consistency. In comparison to the Child Behavior

Checklist (CBCL), the CBCL was developed empirically from USA case files, while the SDQ

was developed empirically based on nosology (DSM4 and ICD9). The SDQ is brief 25 vs. 118

items of the CBCL. The SDQ correlates higher with clinical interview than the CBCL.

On hyperactivity/inattention, SDQ correlation of .43 compares to the CBCL of .15 with

clinical interview, with some suggestion that CBCL overestimates hyperactivity. In a community

sample, mothers preferred SDQ to CBCL (Goodman and Scott, 1999).

The emotional problem scale consists of item number 3, 8, 13, 16 and 24 i.e.

Often complains of headaches, stomach-aches or other diseases. ‫ پیٹ هیں دزد یب ثیوبزی‬،‫اکثس ظس دزد‬

‫۔‬ ‫کی شکبیت ہوتی ہے‬

Many worries or often seems worried. ‫ثہت ظی پسیشبًیبں یب اکثس پسیشبى ًظس‬

‫۔‬ ‫آتے ہیں‬

23
Often unhappy, depressed or tearful. . ‫ افعسدٍ یب آًعو ثھسے ہوتے‬،‫اکثس ًبخوغ‬

‫ہیں‬

Nervous or clingy in new situations, easily loses confidence. ‫ آظبًی‬،‫ًئے حبالت هیں گھجساًب یب چپچپب زہٌب‬

‫۔‬ ‫ظے اعتوبد کھو دیتب ہے‬

Many fears easily scared .‫ثہت ظے خوف آظبًی ظے ڈز جبتے ہیں۔‬

And the clients score on this scale is 5 which shows their client is abnormal on emotional

problem scale. The conduct problem scale consists of item number 5, 7, 12, 18 and 22 i.e.

Often loses temper. ‫اکثس غصہ کھو دیتب ہے۔‬

Generally well behaved, usually do what adults request. ‫ عبم طوز پس‬،‫عبم طوز پس اچھب ظلوک کستے ہیں‬

‫وہی کستے ہیں جو ثبلغوں کی دزخواظت ہے‬

Often fights with other children or bullies them. ‫کثس دوظسے ثچوں کے ظبتھ لڑتے ہیں یب اى کو تٌگ کستے‬

‫۔‬ ‫ہیں‬

Often lies or cheats. . ‫اکثس جھوٹ یب دھوکہ دہی‬

‫۔‬

Steals from home, school or elsewhere. .‫ اظکول یب کعی اوز جگہ ظے چوزی کستب ہے‬،‫گھس‬

And the score of this subject is also 2 which show that client is normal on the conduct problem

scale. The hyperactivity scale consists of item number 2, 10, 15, 21 and 25 i.e.

Restless, overactive, cannot stay still for long .‫ شیبدٍ دیس تک خبهوغ ًہیں زٍ ظکتب۔‬،‫ شیبدٍ هتحسک‬،‫ثے چیي‬

Constantly fidgeting or squirming. .‫هعلعل ہلچل هچبًب یب ہڑثڑاًب۔‬

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Easily distracted, concentration wanders. .‫ ازتکبش ثھٹک جبتب ہے‬،‫آظبًی ظے هشغول‬

Thinks things out before acting. ‫اداکبزی کسًے ظے پہلے چیصوں کو ظوچتب ہے‬

Good attention span sees chores or homework through to the end. ‫اچھی توجہ کب دوزاًیہ کبم یب ہوم وزک‬

‫۔‬ ‫کو آخس تک دیکھتب ہے‬

And score of this subject is 6 which show that client is on borderline of hyperactivity scale.

Peers problems care consist of item number 6,11,14,19 and 23 i.e.

Rather solitary, prefers to play alone. . ‫ اکیلے کھیلٌے کو تسجیح دیتے‬،‫ثلکہ تٌہب‬

‫۔‬Has at least one good friend. .‫کن اش کن ایک اچھب دوظت ہے‬

Generally liked by other children. ‫عبم طوز پس دوظسے ثچوں کو پعٌد کستے ہیں‬

Picked on or bullied by other children .‫دوظسے ثچوں کی طسف ظے اٹھبیب گیب یب اى کے ذزیعے تٌگ کیب گیب‬

Gets along better with adults than with other children. ‫ثڑوں کے ظبتھ دوظسے ثچوں کے هقبثلے هیں ثہتس‬

‫ہوتب ہے‬

And the score of this subject is 4 which show that the subject is abnormal on peers problem

scale.

The pro social skill consists of item number 1, 4,9,17 and 20 i.e.

Considerate of other people‟s feelings ‫دوظسے لوگوں کے جرثبت کب خیبل زکھی۔۔‬

Shares readily with other children, for example toys, treats, pencils. ‫دوظسے ثچوں کے ظبتھ آظبًی ظے‬

‫ پٌعل‬،‫ عالج‬،‫ هثبل کے طوز پس کھلوًے‬،‫شیئس کستب ہے‬

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Helpful if someone is hurt, upset or feeling ill. ‫ پسیشبى ہو یب ثیوبز هحعوض ہو تو‬،‫اگس کعی کو تکلیف ہو‬

‫هددگبز‬

Kind to younger children ‫چھوٹے ثچوں کے ظبتھ هہسثبى۔‬

Often volunteers to help others (parents, teachers, other children). ‫اکثس زضبکبزاًہ طوز پس دوظسوں کی‬

‫۔‬ )‫ دوظسے ثچے‬،ٍ‫ اظبتر‬،‫هدد کستے ہیں (والدیي‬

The subject score on this scale is 10 which show that client is normal on pro social scale.

The total difficult score of the client is 27 which show the abnormality in client.

Systematic behavioral observation

Systematic observation typically involves specification of the exact actions, attributes, or

other variables that are to be recorded and precisely how they are to be recorded. The intent is to

ensure that, under the same or similar circumstances, all observers will obtain the same results.

Behavioral observation is a commonplace practice in our daily lives. As social creatures and

"informal scientists," we rely upon observations of behavior to understand current social

experiences and predict future social events. In fact, direct observation of behavior is one of the

most important strategies we use to process our social world. Thus, it is not surprising that the

field of psychology also is drawn to behavioral observation as a research method for

understanding human behavior. The current chapter will focus upon behavioral observation as a

formal research tool. In this context, behavioral observation involves the systematic observation

of specific domains of behavior such that the resulting descriptions of behavior are replicable. In

order to accomplish this task, the ongoing stream of behavior must be coded or broken down into

recordable units and the criteria for the assignment of labels or for making evaluations must be

objectified. These practices of specifying units of behavior and objectifying coding criteria are

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the key steps in translating informal behavioral observations into formal, scientific observations.

As will be seen below, the challenge of employing behavioral observation in research settings

involves the myriad of decisions that an investigator must make in this translation process from

informal to formal observation.

behavior 10:00_10:05 10:10_10:15 10:20_10:25 10:30-10:35 10:40_10:45

Nail biting 1 nil nil nil 1

Moving chair 1 nil nil 1 1

Rubbing of nil 2 nil nil nil

hands

smiling nil 1 nil nil 1

Opening nil nil 2 11 nil

notebook

Different behaviors of client have been recorded in systematic observation in different

time slots of 5 minutes and 5 different behaviors were observed in these time slots such as nail

biting, moving chair, rubbing of hands, smiling and opening notebook. In the first time slot I

observed nail biting, moving chair and opening notebook. In second slot I observed rubbing of

hand and smiling. In the 3rd time slot he just open notebook twice . in the 4rth time slot I

observed moving chair and opening notebook and in the last time slot I observed nail biting,

moving chair and smiling.

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Case formulation

The client was a male of 8 year old who belong s to Gujranwala. Client has intellectual

disability and accused of misbehavior since from one year at his age of 3 his family member

came to know that he is suffering from several disabilities. At the age of five he was admitted in

a slow learner school where he attends sessions as well.

According to presenting complaints, he has learning disability and accused of

misbehavior since from one year. At this age of 3 his family member s came to know that he is

suffering from several disabillities.at the age of five he was admitted in a slow learner school and

also in therapy center. no hallucinations are reported of any category. Nor the delusion

experience of any category. Client reported an injury he got in an accident which causes

fractured in right arm at the age of 5.the predisposing factor was his mother. She had been spent

a very tough time when he was born she didn‟t take care of him because of many family issues.

She had spent a lot of time in family issues.

The Social Cognitive Theory

Social Cognitive Theory (SCT) started as the Social intellectual Theory (SLT) in the 1960s by

Albert Bandura. It developed into the SCT in 1986 and posits that learning occurs in a social

context with a dynamic and reciprocal interaction of the person, environment, and behavior. The

unique feature of SCT is the emphasis on social influence and its emphasis on external and

internal social reinforcement. SCT considers the unique way in which individuals acquire and

maintain behavior, while also considering the social environment in which individuals perform

the behavior. The theory takes into account a person's past experiences, which factor into

whether behavioral action will occur. These past experiences influences reinforcements,

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expectations, and expectancies, all of which shape whether a person will engage in a specific

behavior and the reasons why a person engages in that behavior.

Many theories of behavior used in health promotion do not consider maintenance of behavior,

but rather focus on initiating behavior. This is unfortunate as maintenance of behavior, and not

just initiation of behavior, is the true goal in public health. The goal of SCT is to explain how

people regulate their behavior through control and reinforcement to achieve goal-directed

behavior that can be maintained over time. The first five constructs were developed as part of the

SLT; the construct of self-efficacy was added when the theory evolved into SCT.

1. Reciprocal Determinism - This is the central concept of SCT. This refers to the dynamic

and reciprocal interaction of person (individual with a set of learned experiences),

environment (external social context), and behavior (responses to stimuli to achieve

goals).

2. Behavioral Capability - This refers to a person's actual ability to perform a behavior

through essential knowledge and skills. In order to successfully perform a behavior, a

person must know what to do and how to do it. People learn from the consequences of

their behavior, which also affects the environment in which they live.

3. Observational Learning - This asserts that people can witness and observe a behavior

conducted by others, and then reproduce those actions. This is often exhibited through

"modeling" of behaviors. If individuals see successful demonstration of a behavior, they

can also complete the behavior successfully.

4. Reinforcements - This refers to the internal or external responses to a person's behavior

that affect the likelihood of continuing or discontinuing the behavior. Reinforcements can

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 be self-initiated or in the environment, and reinforcements can be positive or negative.

This is the construct of SCT that most closely ties to the reciprocal relationship between

behavior and environment.

5. Expectations - This refers to the anticipated consequences of a person's behavior.

Outcome expectations can be health-related or not health-related. People anticipate the

consequences of their actions before engaging in the behavior, and these anticipated

consequences can influence successful completion of the behavior. Expectations derive

largely from previous experience. While expectancies also derive from previous

experience, expectancies focus on the value that is placed on the outcome and are

subjective to the individual.

6. Self-efficacy - This refers to the level of a person's confidence in his or her ability to

successfully perform a behavior. Self-efficacy is unique to SCT although other theories

have added this construct at later dates, such as the Theory of Planned Behavior. Self-

efficacy is influenced by a person's specific capabilities and other individual factors, as

well as by environmental factors (barriers and facilitators).

Theory of Mind

Theory of Mind is the branch of cognitive science that investigates how we ascribe

mental states to other persons and how we use the states to explain and predict the actions of

those other persons. More accurately, it is the branch that investigates mindreading or metalizing

or mentalist abilities. These skills are shared by almost all human beings beyond early childhood.

They are used to treat other agents as the bearers of unobservable psychological states and

processes, and to anticipate and explain the agents‟ behavior in terms of such states and

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processes. These mentalist abilities are also called “folk psychology” by philosophers, and

“naïve psychology” and “intuitive psychology” by cognitive scientists.

It is important to note that Theory of Mind is not an appropriate term to characterize this

research area (and neither to denote our mentalist abilities) since it seems to assume right from

the start the validity of a specific account of the nature and development of mindreading, that is,

the view that it depends on the deployment of a theory of the mental realm, analogous to the

theories of the physical world (“naïve physics”). But this view—known as theory-theory—is

only one of the accounts offered to explain our mentalist abilities. In contrast, theorists of mental

simulation have suggested that what lies at the root of mindreading is not any sort of folk-

psychological conceptual scheme, but rather a kind of mental modeling in which the simulator

uses her own mind as an analog model of the mind of the simulated agent.

Both theory-theory and simulation-theory are actually families of theories. Some theory-

theorists maintain that our naïve theory of mind is the product of the scientific-like exercise of a

domain-general theorizing capacity. Other theory-theorists defend a quite different hypothesis,

according to which mindreading rests on the maturation of a mental organ dedicated to the

domain of psychology. Simulation-theory also shows different facets. According to the

“moderate” version of simulations, mental concepts are not completely excluded from

simulation. Simulation can be seen as a process through which we first generate and self-

attribute pretend mental states that are intended to correspond to those of the simulated agent,

and then project them onto the target. By contrast, the “radical” version of simulations rejects the

primacy of first-person mindreading and contends that we imaginatively transform ourselves into

the simulated agent, interpreting the target‟s behavior without using any kind of mental concept,

not even ones referring to ourselves.

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 Finally, the claim common to both theorists of theory and theorists of simulation that

mindreading plays a primary role in human social understanding was challenged in the early 21st

century, mainly by phenomenology-oriented philosophers and cognitive scientists.

Jean Piaget theory of cognitive development

7 to 11 years: Concrete operational stage (Logical thought)

At this stage, children start to show logical thinking about concrete events.

They start to grasp the concept of conservation. They understand that, even if things change in

appearance but some properties still remain the same.

Children at this stage can reverse things mentally. They start to think about other people's

feelings and thinking and they also become less egocentric. This stage is also known as concrete

as children begin to think logically. According to Piaget, this stage is a significant turning point

of a child's cognitive development because it marks the starting point of operational or logical

thinking. At this stage, a child is capable of internally working things out in their head (rather

than trying things out in reality).

Children at this stage may become overwhelmed or they may make mistakes when they are

asked to reason about hypothetical or abstract problems. Conservation means that the child

understands that even if some things change in appearance but their properties may remain the

same. At age 6 children are able to conserve number, at age 7 they can conserve mass and at age

9 they can conserve weight. But logical thinking is only used if children ask to reason about

physically present materials.

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 Tentative Diagnosis

Multiaxial system assessment A Multiaxial system involves an assessment of several axes, each

of which refers to different domain of information that may help the clinician plan treatment and

predict outcomes (APA,1994).

ICD-9-CM

Therapeutic Recommendation

Cognitive behavioral therapy

Cognitive behavioral therapy (CBT) is a form of psychological treatment that has been

demonstrated to be effective for a range of problems including depression, anxiety disorders,

alcohol and drug use problems, marital problems, eating disorders, and severe mental illness.

Numerous research studies suggest that CBT leads to significant improvement in functioning and

quality of life. In many studies, CBT has been demonstrated to be as effective as, or more

effective than, other forms of psychological therapy or psychiatric medications.

It is important to emphasize that advances in CBT have been made on the basis of both

research and clinical practice. Indeed, CBT is an approach for which there is ample scientific

evidence that the methods that have been developed actually produce change. In this manner,

CBT differs from many other forms of psychological treatment.

CBT is based on several core principles, including:

1. Psychological problems are based, in part, on faulty or unhelpful ways of thinking.

2. Psychological problems are based, in part, on learned patterns of unhelpful behavior.

33
 3. People suffering from psychological problems can learn better ways of coping with them,

thereby relieving their symptoms and becoming more effective in their lives.

CBT treatment usually involves efforts to change thinking patterns. These strategies might

include:

 Learning to recognize one‟s distortions in thinking that are creating problems, and then to

reevaluate them in light of reality.

 Gaining a better understanding of the behavior and motivation of others.

 Using problem-solving skills to cope with difficult situations.

 Learning to develop a greater sense of confidence in one‟s own abilities.

CBT treatment also usually involves efforts to change behavioral patterns. These strategies might

include:

 Facing one‟s fears instead of avoiding them.

 Using role playing to prepare for potentially problematic interactions with others.

 Learning to calm one‟s mind and relax one‟s body.

Not all CBT will use all of these strategies. Rather, the psychologist and patient/client work

together, in a collaborative fashion, to develop an understanding of the problem and to develop a

treatment strategy.

CBT places an emphasis on helping individuals learn to be their own therapists. Through

exercises in the session as well as “homework” exercises outside of sessions, patients/clients are

helped to develop coping skills, whereby they can learn to change their own thinking,

problematic emotions, and behavior.

34
CBT therapists emphasize what is going on in the person‟s current life, rather than what has led

up to their difficulties. A certain amount of information about one‟s history is needed, but the

focus is primarily on moving forward in time to develop more effective ways of coping with life.

Occupational therapy

Advocating for patient health

Occupational therapy (OT) is a global healthcare profession. It involves the use of

assessment and intervention to develop, recover, or maintain the meaningful activities,

or occupations, of individuals, groups, or communities. The field of OT consists of health care

practitioners trained and educated to improve mental and physical performance. Occupational

therapists specialize in teaching, educating, and supporting participation in any activity that

occupies an individual's time. It is an independent health profession sometimes categorized as

an allied health profession and consists of occupational therapists (OTs) and occupational

therapy assistants (OTAs). While OTs and OTAs have different roles, they both work with

people who want to improve their mental and or physical health, disabilities, injuries, or

impairments.

The American Occupational Therapy Association defines an occupational therapist as

someone who "helps people across their lifespan participate in the things they want and/or need

to do through the therapeutic use of everyday activities (occupations)". Definitions by

professional occupational therapy organizations outside North America are similar in content.

Common interventions include:

35
 Helping children with disabilities to participate in school and social situations (independent

mobility is often a central concern)

 Training in assistive device technology, meaningful and purposeful activities, and life skills.

 Physical injury rehabilitation

 Mental dysfunction rehabilitation

 Support of individuals across the age spectrum experiencing physical and cognitive changes

 Assessing economics and assistive seating options to maximize independent function, while

alleviating the risk of pressure injury

 Education in the disease and rehabilitation process

Emotion-Focused Therapy

Emotion-focused therapy (EFT) is a therapeutic approach based on the premise that

emotions are key to identity. According to EFT, emotions are also a guide for individual

choice and decision making. This type of therapy assumes that lacking emotional awareness

or avoiding unpleasant emotions can cause harm. It may render us unable to use the

important information emotions provide. Therapists qualified in EFT can help

people seeking assistance with a range of concerns. These therapists may help people learn

to become more aware of their emotions. EFT also allows people to become better at using

information provided by adaptive emotions. People may be better able to cope with and

decrease negative effects of maladaptive emotions.

36
 In this approach to treatment, the therapist and the person in therapy collaborate in

an active process. Both are viewed as equal contributors. The person in treatment, not the

therapist, is seen as the person most capable of interpreting their emotional experience.

EFT is founded in the idea that emotions should be used to guide healthy, meaningful

lives. Its theory is based on a scientific inquiry into the human emotional experience.

Scientific study of human emotion has provided information about:

 How emotions are produced

 The importance of emotions to human functioning

 How emotions are related to thought and behavior

Emotion schemes are the core concept of EFT. It was developed largely from these theories

of human emotion. Emotion schemes are models that outline how emotion can:

 Be experienced physically

 Cause physiologic changes

 Influence thinking

 Guide future action

EFT helps people both accept and change their personal emotion schemes.

Techniques used in emotion focused therapy

EFT sessions typically center on the development of two key skills. These are:

1. Arriving at one's emotions through increased awareness and acceptance.

2. Learning to transform emotions and better use the information they provide to avoid

negative or harmful behaviors or other effects of certain emotions.

37
Therapists practicing this method take a compassionate, non-judgmental, and reflective

approach to listening and questioning. This allows the person in therapy come to a better

understanding of their emotions. Then, various therapeutic techniques known as emotion

coaching are utilized. These help people learn new ways to use healthy emotions to guide

their actions. Emotion coaching may further help people transform and move on from

challenging emotions.

Initial sessions of therapy focus on helping people arrive at emotions. One or more of the

following goals are often included in each session:

 Become more aware of emotions

 Learn to welcome, allow, and regulate emotions

 Learn to describe emotions clearly and in detail

 Increase awareness of the multiple layers of emotional experiences and learn to

identify the most direct reaction

The next phase of treatment focuses on leaving. It may include the following goals:

 Evaluate whether emotions are helpful or unhelpful in various situations

 Learn to use helpful emotions to guide action

 Identify the source of unhelpful emotions

 Learn to change unhelpful emotions

 Develop alternative, healthy ways of coping with situations that often elicit

maladaptive emotions

38
  Form personal scripts that help challenge the destructive thoughts that may be

associated with unhelpful or maladaptive emotions

EFT is generally thought to have been successful when the person in treatment has an

increased awareness of their emotional experience. They may also have an improved ability

to regulate emotions and be better able to transform unhelpful emotions.

Prognosis

The client is a careless and impatient, the therapeutic methodology and care may be

potential source of treating his issues but as a client he have to accept his abnormality

because there are not much chances of his recovery, the symptoms that I observed in the

session is speech problem, writing and reading problem and memory issues. Moreover

intellectual disability is identified and should be treated earlier there are much chances of

his recovery because her teacher inform that in starting it was so difficult to understand his

speech. The client can learn to develop his personal strength and become a very productive

and successful adult if he accepts his disability and continue his learning process in a

special school.

39
40