CEP 871 Case

Conceptualization
Sarah Geist
 Client Information
The client is a 15-year-old Caucasian female who has been referred
by her pediatrician for an autism evaluation and treatment plan after
both her mother and school counselor raised concerns about her
struggles to transition from her small middle school to her much
larger high school. The client reports feeling extremely irritable and
overwhelmed by the heightened sensory input at her new school,
which has affected her ability to focus and caused her to be absent
more frequently. Additionally, her teachers have noted a marked
decline in her willingness to participate in class, while her mother
worries that the client is isolating herself from her friends.
 Family History
● The client is an only child. Her parents divorced when she was 6
years old. She currently lives with her mother. The client’s father lives
and works out of state. The client mainly communicates with her
father through phone calls and visits him 1-2 times per year.
● The client’s mother reports being treated for postpartum depression
shortly after the client was born. She has no other history of mental
illness.
● The client’s father has never been diagnosed with or treated for a
mental illness. His sister (the client’s aunt) was diagnosed with
autism spectrum disorder in adulthood.
 Medical History
● The client was carried to term and there were no complications during
the birth. Her mother was 36 years old at the time of her pregnancy.
● During early childhood, the client progressed on time for most verbal
milestones. Her motor development was slightly delayed.
● The client was diagnosed with generalized anxiety disorder at age 11.
She has participated in monthly therapy sessions with a psychologist,
as well as frequent check ins with her school counselors.
● The client and her mother report a history of insomnia, mainly
characterized by difficulty falling and staying asleep. She also has
frequent muscle aches, which her pediatrician has determined to be a
physical manifestation of her anxiety.
 Academic History
● The client is currently in 9th grade. She attended middle school in a
building with around 400 students across 3 grades. Her high school,
which combines students from 3 different intermediate schools,
currently has approximately 1800 students across 4 grades.
● The client has historically performed well in school, receiving A’s and
B’s in her classes. Her recent difficulties with attendance and focus
while in school have led to more Bs and Cs on her report card.
● The client repeated 1st grade due to her teacher’s concerns about
maturity and social skills. Her parents supported that decision.
● The client’s favorite subject is English class, but she reports frustration
with being given less choice in what she reads as she gets older.
● The client dislikes French because she has to talk a lot in class.
 Autism Spectrum Disorder
● Approximately 1 in 36 (2.8%) eight-year-olds have been diagnosed with
autism (ADDM, 2020).
● Over 1/3 of eight-year-olds with autism also have an intellectual disability
(ADDM, 2020).
● Males are around 4 times more likely to be identified as autistic than
females (ADDM, 2020; CDC, 2017).
● An estimated 2.21% of adults in the United States have autism (CDC,
2017).
● 1/4 of autistic children under age eight are undiagnosed, with Black and
Hispanic children being the most under-diagnosed (Verbanas, 2020).
 DSM-5 Diagnostic Criteria
● Autism spectrum disorder (ASD) is classified as a neurodevelopmental
disorder in the DSM-V.
● To be diagnosed with ASD, a person must have:
A. “Persistent deficits in social communication and social interaction
across multiple contexts,” including:
1. “Social-emotional reciprocity” (ex. Turn-taking in conversations)
2. “Nonverbal communicative behaviors used for social interaction”
(ex. Making eye contact)
3. “Deficits in developing, maintaining, and understanding
relationships” (ex. Limited interest in forming friendships)
 DSM-5 Diagnostic Criteria
● To be diagnosed with ASD, a person must have:
B. “Restricted, repetitive patterns of behavior, interests, or activities,”
including at least two of the following:
1. “Stereotyped or repetitive motor movements, use of objects, or
speech”
2. “Insistence on sameness, inflexible adherence to routines, or
ritualized patterns of verbal or nonverbal behavior”
3. “Highly restricted, fixated interests that are abnormal in intensity or
focus”
4. “Hyper- or hyporeactivity to sensory input or unusual interest in
sensory aspects of the environment”
 DSM-5 Diagnostic Criteria
● To be diagnosed with ASD, a person must have:
C. Symptoms “present in the early developmental period,” factoring in
the possibility of masking behaviors
D. Symptoms causing “clinically significant impairment in social,
occupational, or other important areas of current functioning”
E. “Disturbances are not better explained by intellectual developmental
disorder,” noting that ASD and intellectual disabilities frequently co-occur
● People who were previously diagnosed with Asperger’s disorder or
pervasive developmental disorder should receive an ASD diagnosis
 DSM-5 ASD Specifiers
● Levels of severity range from 1-3.
1. Level 1 (requiring support): Some difficulty or lack of interest in social interactions;
may be considered odd or unusual by others; inflexible behavior interferes with
functioning in one or more contexts
2. Level 2: (requiring substantial support): Social difficulties apparent even with
supports; restrictive/repetitive behaviors obvious to a casual observer; inflexible
behavior interferes with functioning in multiple contexts
3. Level 3: (requiring very substantial support): Participates in very limited social
interactions; extreme inflexible behavior strongly interferes with functioning in all
contexts
● Other symptoms associated with autism include linguistic impairments,
difficulties with perspective taking, executive function deficits, self-injury, motor
deficits, and catatonic-like behavior.
 Client Diagnosis
● Because the client exhibits both significant difficulties in social interaction and
restricted/repetitive patterns, a diagnosis of Level 1 ASD is appropriate.
A. “Persistent deficits in social communication and social interaction”
1. “Social-emotional reciprocity”: The client experiences discomfort in situations
that require her to engage in conversation with peers, for example, French
class.
2. “Nonverbal communicative behaviors”: The client made inconsistent eye
contact during interviews. She explains that it is often difficult for her to
determine how other people feel based on their face and body language.
3. Deficits in relationships: The client has struggled to make friends most of her
life, leading to her being held back in 1st grade. She has recently withdrawn
further from her few friendships and feels overwhelmed by the number of
people at her new school.
 Client Diagnosis
● Because the client exhibits both significant difficulties in social interaction and
restricted/repetitive patterns, a diagnosis of Level 1 ASD is appropriate.
B. “Restricted, repetitive patterns of behavior, interests, or activities”
2. “Insistence on sameness, inflexible adherence to routines, or ritualized patterns
of verbal or nonverbal behavior”: The client has experienced significant distress
due to a change in the environment at school. She and her mother both
describe her feeling a need to do daily tasks in the same order every day.
4. “Hyperreactivity to sensory input: The client describes feeling tense and
overwhelmed at school due to the bright lights, loud noises, and constant
motion. Her mother describes the client as an unusually picky eater.
C. The client has exhibited many symptoms since childhood (notably 1st grade). Her
recent increase in distress is likely due to the demands exceeding her capacities
since transitioning to a much larger high school.
 Client Diagnosis
● Because the client exhibits both significant difficulties in social interaction and
restricted/repetitive patterns, a diagnosis of Level 1 ASD is appropriate.
● While the client exhibits symptoms in multiple contexts, they mainly interfere
with functioning in a single environment, at school. Thus, the severity of her
ASD is Level 1, support needed.
● ASD and generalized anxiety disorder are frequently comorbid. Some of the
clients symptoms of anxiety may be due to sensory overload and attempts at
masking. However, the client also experiences heightened anxiety due to
factors not related to autism, particularly significant worries about making
mistakes and failing to succeed at tasks. Thus, her previous diagnosis of
generalized anxiety disorder should remain.
 ICF Body Functions
■ In children ages 6-16, ASD can include impairment in orientation functions,
intellectual functions, global psychosocial functions, dispositions and
intra-personal functions, temperament and personality functions, energy
and drive functions, sleep functions, attention functions, memory
functions, psychomotor functions, emotional functions, perceptual
functions, thought functions, higher-level cognitive functions, mental
functions of language, fluency and rhythm of speech functions, control of
voluntary movement functions, and involuntary movement functions.
 ICF Activities and Participation
■ In children ages 6-16, ASD can include difficulty in watching, listening,
copying, acquiring information and concepts, learning to read and write,
acquiring skills, focusing and directing attention, thinking, solving
problems, making decisions, undertaking a single task and multiple tasks,
carrying out daily routines, handling stress and other psychological
demands, managing one’s own behavior, receiving spoken and nonverbal
messages, speaking, conversation, using transportation, washing oneself,
toileting, dressing, looking after one’s health and safety, basic and complex
interpersonal interactions, relating with strangers, informal social
relationships, family relationships, school education, engagement in play,
and recreation and leisure.
 ICF Environmental Factors
■ In children ages 6-16 with ASD, their functioning can be help or hindered by
products for personal consumption, technology for daily living, products
and technology for communication, products and technology for
education, sound, immediate and extended family, friends, acquaintances,
peers, and community members, people in positions of authority, personal
care providers, health and other professionals, individual attitudes of the
people around them, societal attitudes, social norms, practices, and
ideologies, and services, systems, and policies around communication,
the law, social security, health, social support, education and training, and
labor and employment.
 Client Functioning
● In the category of body functions, the client experiences impairment in global
psychosocial functions (2), temperament and personality functions (2), sleep
functions (1), attention functions (1), emotional functions (2), perceptual
functions (2), and thought functions (2).
● In the category of activities and participation, the client experiences difficulty
with , focusing attention (1), solving problems (2), making decisions (2), handling
stress (2), communicating with nonverbal messages (2), conversation (2),
relating with strangers (2), informal social relationships (2), and education (2).
● In the category of environmental factors, the client’s functioning is most
influenced by products and technology for education (+1), sound (3), friends (+1),
acquaintances and peers (1), authority figures (+1), individual attitudes of
immediate family members (+1), social norms (2), and education systems (1).
 Primary Goals - Short Term
● Attend school every day for a week.
○ The client has been missing a lot of school due to sensory
overload and anxiety. This has negatively affected the client’s
grades and friendships, which causes her increased stress.
Reducing absences will likely reduce this stress, as well as help
the client acclimate to her new educational environment and
routine.
○ The rehabilitation counselor will help the client set up a
self-administered reward system to support her achievement of
this goal.
 Primary Goals - Short Term
● Hang out with 1 or more friends after school for at least an hour.
○ Both the client and her mother recognize that the client has been
withdrawing from her friends. The client wants to maintain these
friendships, but she is unsure how. Rather than attempting to form
a new friendship, which could be very overwhelming to the client
given her current functioning, it would be more effective to focus
on strengthening an existing relationship.
○ The rehabilitation counselor will help the client identify which
friend(s) she would like to hang out with, as well as a few options
for date and time. If desired, the counselor can also help the client
write a text to said friend.
 Primary Goals - Long Term
● Receive all B’s or higher on next report card.
○ The client’s grades have dropped since transitioning to high
school, most likely due to the increased stress of her new
environment. The client cares about school and is unhappy with
her lower grades. Getting all B’s or higher is an attainable goal for
the client that can increase her self-efficacy.
○ The rehabilitation counselor will help the client identify 1-2 classes
that are the most challenging and create a plan to help her be
more successful in those classes. The rehabilitation counselor
may also help the client and her mother communicate this goal
with the school counselor.
 Primary Goals - Long Term
● Make 1 new friend OR 5 new acquaintances.
○ The client has been struggling with transitioning from a smaller
middle school where she knew everyone to a larger high school
filled with strangers. Getting to know her classmates better will
help her feel more comfortable in her environment. Having a
choice between 1 close friend and a few acquaintances will help
reduce the client’s anxiety about achieving this goal.
○ The rehabilitation counselor will help the client identify
places/situations that could foster connection between her and
her peers. The counselor will also check in regularly with the client
to help navigate obstacles and solutions.
 Secondary Goals - Short Term
● Ask a teacher for help.
○ The client struggles to initiate social interactions. Additionally, she
is struggling in a few of her classes. Asking a teacher for help is a
more structured, less stressful introduction to this skill.
Additionally, it will contribute to her primary goal of better grades.
○ The rehabilitation counselor will help the client identify which
teacher the client will approach, as well as a few methods/times of
attempting this interaction. The counselor may also assist the
client in brainstorming things to say to the teacher and potential
teacher responses.
 Secondary Goals - Short Term
● Establish a before bed routine.
○ The client has been struggling with falling and staying asleep, with
negatively affects her energy and ability to cope with stress.
Creating an effective and regular before bed routine will bring the
client some comfort in embracing sameness and support her
getting longer and deeper sleep.
○ The rehabilitation counselor will review positive and negative
sleep habits with the client and her mother, and help them identify
and sequence a few strategies to try. The counselor will also
check in with the client after a week to evaluate and make any
necessary changes to the routine.
 Secondary Goals - Long Term
● Identify sensory triggers and effective self-soothing strategies.
○ The client experiences frequent sensory overload at school.
Identifying which sounds, movements, etc. are the most
overwhelming will help the client feel more in control of her
surroundings and allow her to take measures to avoid those
triggers and/or offer options for coping.
○ The rehabilitation counselor will assist the client with reflecting on
sensory experiences (either through discussion or a journal) and
identifying trends or patterns. The counselor may also educate the
client on coping strategies such as stimming.
 Secondary Goals - Long Term
● Share information about ASD diagnosis with close friends.
○ Autism is not only a mental disorder, but it is also an identity for
many. The client has been very open with her friends about her
struggles with anxiety and wishes to do the same with her new
diagnosis. This may strengthen her relationships as well as give
her friends more knowledge on how to support her.
○ The rehabilitation counselor will help the client identify situations
and language to use when talking about autism with friends. They
will set boundaries between what the client wants her friends to
know/do and what she does not want.
 Treatment Plan
● Begin taking SSRI to treat anxiety
● Continue therapy and meetings with school
counselor
● Occupational therapy
● Family and individual psychoeducation
● Educational accommodations
 Pharmaceutical Treatment
● Until this point, the client has not taken any medication to
help cope with her anxiety. There is no specific
pharmaceutical treatment for autism. Thus, the goal of any
medication should be to treat the client’s anxiety and stress.
Due to the client’s family history of depression, an SSRI
(selective serotonin reuptake inhibitor) is a good starting
point, as it is used to treat both anxiety and depression.
 Pharmaceutical Treatment
● Common side effects of SSRIs include nausea, headache,
drowsiness, insomnia, nervousness, dizziness, sexual
problems, and an impact on appetite. The side effects most of
concern to the client include insomnia and nervousness.
● The client and her mother should speak to her pediatrician
and/or psychiatrist to begin this treatment.
 Continued Therapy
● The client and her mother believe that she has benefitted
from regular therapy sessions and check ins with the school
counselor. As effective treatments, they should be continued.
Additionally, having a strong relationship with an adult at
school can help the client identify stressors and feel more
comfortable in her new environment.
● The rehabilitation counselor will communicate the client’s
goals with her therapist and school counselor.
 Occupational Therapy
● Occupational therapy has been shown to help people with
autism with sensory processing and increasing cognitive
flexibility, two areas that the client struggles with. Improving her
coping skills in these areas will help the client feel more
comfortable at school.
● The rehabilitation counselor will assist the client and her mother
in seeking these services. The counselor may also support the
client as she builds trust with a new provider.
 Family Psychoeducation
● The client’s aunt was also recently diagnosed with ASD.
Connecting with her may support the client as she begins to
understand her new diagnosis. Educating the client’s parents
about ASD will also provide them with the knowledge to best
support her.
● The rehabilitation counselor will provide resources with
information about ASD, as well as identify local support
groups for both the client and her family.
 Individual Psychoeducation
● As the client incorporates autism into her identity, she may
find it helpful to learn more about her diagnosis. Because she
loves to read, books are an excellent tool for this education.
● The rehabilitation counselor will provide book
recommendations for the client. Potential options include
The Awesome Autistic Go-To Guide by Purkis and
Mastermann and The Spectrum Girl’s Survival Guide by
Castellon.
 Educational Accommodations
● Because school is such a stressful place for the client, she
may benefit from accommodations that will allow her to
access the content and feel safer in her educational
environment. The client’s parents should request a 504 plan
or an IEP (Individualized Education Plan) to support her
needs.
● The process of getting a 504 or IEP can be quite complex.
The rehabilitation counselor will help the client’s parents
navigate this system and provide recommendations for
accommodations.
 Educational Accommodations
● Recommended accommodations include:
○ Access to noise reducing/noise canceling ear plugs
○ Use of a fidget
○ Prioritized scheduling in smaller classes
○ New locker in a less crowded part of the building
○ Frequent checks for understanding
○ Extended time on tests and assignments
○ Alternative testing location
○ Ability to take sensory breaks as needed
Questions?