CASE REPORT

IDENTIFICATION DATA

Name: A.M

Age: 11 years

Sex: Male

Religion: Jain

Education status: Not enrolled in School

Socio economic Status – Upper Middle class

Place of residence: Naraina, Rajasthan

Source of referral- From NGO

Informant: Father

Reliability and Adequacy of Information: Reliable and adequate.

CHIEF COMPLAINTS

 Loss of acquired speech

 Difficulty in expression needs
 Difficulty in following instructions 7 years
 Stubborn Behaviour
 Increased hand movements

HISTORY OF PRESENT ILLNESS

Onset: Congenital

Course: Continuous.

Progress: Deteriorating
Predisposing factor: History of suspected mental illness maternal aunt, and hearing deficits
in brother.

Precipitating factor: Sudden loss of acquired skills.

Perpetuating factor: Negligence by parents due to lack of financial support

The index child is 11 years and 5 months of age, last born and youngest sibling through
Caesarean delivery, with normal birth cry, normal birth weight. Master could speak few
words or two-word phrases by 3 years of age. After which he gradually stopped using speech
and by time of 5 years, Master has lost his speech completely

At 4 years of age, Master had become irritable, and would have difficulty meeting his needs
He would start crying and moving his hands if he needed anything. His parents had difficulty
in understanding what he needed. This led to increased irritability in the child. Further the
caregiver had difficulty in making him follow basic instructions. The child would appear self-
absorbed. He would follow the instructions on repeated demands and with frequent physical
prompts. Master had sought treatment at this time at Government Hospital of Jaipur, with
medications. The doctors suspected an episode of fits, which had led to deterioration of
acquired speech.

Gradually, due to loss of speech and difficulty in expressing and understanding, Master
behaviour concerns had increased. He would get irritated easily, and started crying. Master
would often engage in putting inedible substances like mud, toys in his mouth frequently.

Master had difficulty in understanding presence of danger. He would often go near the edge
of the building and had got hurt multiple times. Due to Covid, the Master could not seek
treatment at this time.

At 7 years of age, Master had sought treatment from a child specialist who had suggested
dietary changes with minimal relief. They had sought psychological treatment in Jaipur, but
the improvement was minimal.

The Master had grown up and was dependent on his parents even for daily needs like feeding
and toileting. Due to persistent financial constraints and conflict between parents, and of his
father and paternal grandparents, there was some negligence in taking care of the child.
Due to the aforementioned complaints, and difficulty in meeting the needs of the child, his
Maternal grandparents brought him to Approach Autism Centre for Full time Residential
Training Program.

Biological Functions

● Sleep: The index child has regular pattern of sleep and wake timings.

● Appetite: The appetite is decreased as the child prefers to have outside food and avoids
eating anything else.

● Bowel Movements: The index child has bowel control and regular pattern of bowel
movements.

NEGATIVE HISTORY

 No significant history of head injury

 No history of nutritional deficiency

Family perception and responses to the problem: Relationship within the family members
is disturbed due to constant conflicts of parents and maternal side. However, they wanted to
support the child in his treatment, which also became difficult due to financial constraint of
his father and lack of adequate sources of treatment in their hometown.

PAST MEDICAL and PSYCHIATRIC TREATMENT HISTORY:

MEDICAL: Master had sought Treatment in Government Hospital of Jaipur since the age of
4 years, with medications. There was not much improvement reported.
FAMILY HISTORY AND GENOGRAM

78Y 70Y 65Y

58 Y 52Y 40 Y 35Y 33Y

55Y 45Y

17Y 14Y 11Y

Family history of illness (psychiatric/medical):

Medical-History of hearing deficits in elder brother.

Psychiatry – History of illness of unknown origin in maternal aunty. The symptoms include
irrelevant talk, irritability, crying spells, lack of interest in daily activities

Living Arrangement -The child is currently staying in a full-time residential program of

Approach Autism Society, which is sponsored by his maternal grandparents. Due to constant
financial constraint and lack of adequate facilities in his hometown.

Description of Family Members: The child’s father is a 55-year-old shop owner, a

Graduate. He is the functional and nominal head of the family. His mother is 44-year-old, a
homemaker. Master has 2 elder brothers. The elder brother is pursuing his 12 th in Private
School in Jaipur. Due to his hearing concerns, he stays this grandparents place, who take care
of his education, finance and medical needs. The younger brother studies in the Local school
of his town.
Home and neighbourhood: Living in a pukka house with 3 rooms and 2 bathrooms in it.
They have a friendly neighbourhood and community in the village.

Family life and relationship: Relationship within the family members is disturbed the
maternal grandparents take major decision of Master and elder brother, which is not liked by
the Masters father. However, he is supportive towards the treatment, due to financial
difficulty and lack of adequate services in his hometown. The father is functional and
nominal head of the family.

Childrearing practices: The child is treated was neglected at home. Due to constant fight
between the parents. The father feels that the person does not take care of the child.

PERSONAL HISTORY:

Significant Pre Natal-Factors

The index child was the last born among his siblings. His mother was 31 years of age when
he was born. It was reported that the child’s mother had weakness, low haemoglobin. The
pregnancy of the child was unplanned. The Mother had also planned for an abortion, but
could not proceed with it, due to complications.

Significant Peri – Natal Factors

Master was born out of full-term gestational period C- section delivery at a private clinic in
Jaipur, The birth cry was immediate and birth weight was normal.

Health Status During Pregnancy

The index child mother had excessive weakness and low haemoglobin during the pregnancy.

Post Natal Development

The child had developed age-appropriate milestones around 3 years of age. After which he
gradually lost his speech. There is suspected history of fever and episode of seizures.

DEVELOPMENTAL HISTORY:

The index child had started crawling at the age of 10 months and had started walking at 1.5
year with support, at 24 months he was able to walk independently.
He spoke the first work at age of 10 months and could speak in two words by 30 months.

Impression: There are no significant delays in development of speech and motor skills.

● Scholastic History: As reported by the informant, the index child, has not received any
formal education due to speech and behavioural concerns.

CHILD BEHAVIOUR

Adaptive Behaviour in following areas

Self-help skills (Bathing, eating, dressing, toilet etc.): The index child is able to

brush, bathe or go to the toilet with assistance. He can eat food on his own with some
difficulty. He cooperates while dressing. He is toilet trained but needs assistance in
completion of the activities.

b. Sleeping: Regular pattern of sleep

c. Communication skills:

1. Receptive language: The child has not developed age-appropriate receptive skills.

2. Expressive language: The child has not developed age-appropriate expressive

skills

d. Awareness about neighbourhood/immediate environment: The child can recognize his

home, but requires supervision in the environment.

e. Participation in routine household work: The child does not cooperate in household
work.

f. Money concept clarity: The child has yet not attained clarity of the concept of money.

TEMPERAMENT

• Activity level: Master is a very active child. He has difficulty staying at one place,
like to roam around in garden or free spaces.
 • Rhythmicity: The child has regular and predictable pattern of sleep, bowel and
bladder movements.

• Distractibility: The child is easily distracted by changes in the environment.

• Approach/withdrawal: The child approaches on insistent by the caregiver.

• Adaptability: Master has difficulty adapting to new environment and situations.

• Attention span and persistence: The child has a short attention span and frequently
shifts from one activity of another.

• Intensity of reaction- Master has a high intensity of reaction. He reacts intensively if

his demands are not met.

• Sensitivity: High Sensitivity and is easily bothered by noises and other stimulus.

• Quality of mood: Master gets easily irritable and angry.

Impression: Slow-warmup

BEHAVIORAL OBSERVATION

 General appearance and behaviour

The child was kempt and untidy. He was dressed appropriate to age and surroundings. The
child was restless and took time to settle down. He greeted the examiner on few verbal
prompts. He had fleeting eye contact. Rapport was built.

 Attitude towards examiner:

The child was distracted and would respond after few verbal prompts. The attitude
towards examiner was distracted. He appeared to be self-absorbed and engaged in
self-smiling.
 Motor Behaviour:
The child is hyperactive. The child explored various things kept in the room. He
engaged in the sorting activity and was settled.

 Speech:
 The child would carry out instructions like Bring the ball, on few verbal prompts.

 Attention and Concentration

The index child had difficulty in sustaining attention.

CASE SUMMARY

Index Child AM,11yr, male, Hindu, hailing from upper middle socio-economic status of
Naraina, Rajasthan came with chief complaints of Loss of acquired speech, Difficulty in
expression needs, Difficulty in following instructions, Stubborn Behaviour and Increased
hand movements. Onset: Congenital, Course: Continuous, Progress: Deteriorating. The
Predisposing factor: History of suspected mental illness maternal aunt, and hearing deficits in
brother. Precipitating factor: Sudden loss of acquired speech skills and Perpetuating factor
being Negligence by parents due to lack of financial support. The total duration of illness is 7
years

The Family History reveals that child is youngest born and persistent conflicts among parents
and paternal grandparents due to financial constraints. There is History of hearing deficits in
elder brother and psychiatric illness of unknown origin in maternal aunt.

The Personal History reveals deteriorating health of mother due to low hemoglobin. There
was difficulty in enrolling to school due to developmental delays and behavioral concerns.
There skills of speech are not age appropriate.

The temperament was indicated to be Slow-warmup. Behavioral observation revealed

fleeting eye contact, easily distracted, increased motor activity and difficulty in following
instructions.

DIAGNOSTIC FORMULATION:

Index child AM 11 years, male, Hindu, Hailing from Upper Middle socio economic status,
of Naraina Rajasthan, with history of health issues of mother and hearing deficits in elder
brother, with congenital onset, continuous course and deteriorating progress, with complaints
of Loss of acquired speech, Difficulty in expression needs, Difficulty in following
instructions, Stubborn Behaviour and Increased hand movements .Behavioural observation
revealed fleeting eye contact, easily distracted, increased motor activity and difficulty in
following instructions.

PROVISIONAL DIAGNOSIS

F84.3 Other Childhood Disintegrative Disorder

TEST ADMINISTERED

Test Taken Test Rationale

1. Developmental Screening Test To assess the developmental progress of

the child.

2. Vineland Social Maturity Scale To assess the socio adaptive functioning of

the child.

3. Indian Scale for Assessment of To assess the severity of symptoms of

Autism Autism Spectrum Disorder.

TEST FINDINGS

1. Developmental Screening Test – The test findings revealed that the child had
attained developmental age of 32.2 months. The development quotient was indicative
of severe intellectual deficits.
 2. Vineland Social Maturity Scale –

The findings indicate social age to be 42 months and Social quotient of 24 indicative of
Severe intellectual deficits.

The findings on various domains of social adaptive functioning were:

Self Help General: The Child age in domain was found out to be 32 months. This shows he
is capable of performing general activities like going to toilet and avoiding obstacles on the
way.

Self-help eating: This caters with child ability to handle his eating patterns and take care of
his nutritional needs. The Child age was found to be 36 months. He could perform activities
like eating his food with minimal assistance and helping himself during meals.

Self Help Dressing: This category indicates child ability to cleanse himself as well as
dressing himself. Child age was found to be 56 months which indicates that child is average
in independence of in terms of dressing. Child can dress and undress himself. He has
difficulty in buttoning and tying of laces.

Occupation: Child age was found to be 60 months, which indicates his skills in carrying out
his general house hold activities is below average. Child takes part in simple activities like
paper folding or art, but has not been given exposure of complex activities like managing
money.

Locomotion: Locomotion involves social movements including going in neighbourhood and

other social places. Child age obtained was 16 months which shows that child is highly
dependent in locomotion and requires assistance in this area.

Communication: Communication deals with social use and application of language and
other communicative skills including writing and spoken. Child social age was found out to
be 16 months which indicates that although child requires communicative tools in daily life.

Self-Direction: Child social age obtained was 10 months, which shows that child requires
exposure in taking up responsibility and is dependent completely on the authority. He
requires exposure of basic understanding of math.

Socialization: Child age obtained was 19 months. This indicates that child has severe deficits
socialization skills and requires more interaction in group.
 +
3. Indian Scale for Assessment of Autism

The total scores on the Scale are 108, indicate of moderate level of autism.

The areas of deficits in Subscales are:

1. Social Relationships & Reciprocity

The child scored 33 in this domain. He remains socially unresponsive, aloof and has
difficulty in understanding another person's feelings, such as pain or sorrow. The have
significant problems in nonverbal communication, such as eye contact, facial expressions,
and gestures and establishing friendships with children of the same age.

2. Emotional Responsiveness

The child scores on this domain are 14. The child engages in excitement that is
inappropriate and lacks reason and has lack fear of danger.

3. Speech & Language

The scores on this domain are 25. Masters finds it difficult to express their needs verbally
and nonverbally and has difficulty in understanding the non-verbal language of others.

4. Behavioural Patterns

The child scores on this domain are 14. The child insists on following routine of walking
every day in open areas. He gets extremely irritated when intervened. He engages in self-
hitting if his demands are not me.

5. Sensory Aspects
 The scores in the domain are 18. The child engages in frequent staring of space for long
period of time. He explores his environment by smelling, touching, or tasting objects

6. Cognitive Component

The score in this domain is 10. Master has difficulty in sustaining his attention. He does not
respond to instructions promptly or respond after a considerable delay.

Management Plan

Areas

1. Psychoeducation
2. Management of Maladpative behavior
3. Skills Training – Adaptive and Speech

Goals

Short Term Long Term

To enhance attention span To enhance nonverbal skills
To improve reception language skills Improve peer and social interaction
To focus on adaptive skills

Initial Phase

 Psychoeducation
 Structuring or making a routine for various task to enhance skills
 To improve attention span by activities like sorting

Middle Phase
 Use of behavioural techniques of shaping and chaining to teach adaptive skills like
feeding and toileting.
 Behavioural techniques of differential reinforcement for management of temper
tantrums.
 Use of picture exchange communication to improve communication
 Engage in Group therapy of activities of dance or art to enhance social skills

Terminal Phase
 Vocational Training
 Psychosocial Rehabiltation

CASE CONCEPTUALIZATION

Biological Factors
Genetic Predisposition –
History of hearing
deficits in brother
Pre Natal Factors – Low
haemoglobin of Mother

Social Factors

Psychological Neglect

Temperament Financial constraints

Parental conflicts
 (Engel,1977)

CLINICIAN IMPRESSION

The child had sudden loss of acquire skills had complicated the clinical picture. The lack of
adequate training and exposure affect the severity of the symptoms. The residential program
may provide benefits in provision of adequate skills training and management of behavioural
concerns, herby improving Masters social interaction. In future I would like explore further
models and plans of management.