CASE NO 1

299.00 (F 84.0) Autism Spectrum Disorder

Case Summary

The client was 9 year old boy who was brought to STL (Step to Learn) by his parents.

The client was brought with the complaints of no conversation, less emotional response, no

eye contact, biting on hands and other stimming behaviors (verbal stimmimg) repetition of

words after hearing (echolalia). Informal assessment was done on the basis of observations

and subjective rating scales. For formal assessment CARS (childhood autism rating scale)

was applied on the child. DSM 5 checklistwas also applied. Client was diagnosed with

Autism Spectrum Disorder Individualized Educational Program (IEP) was devised according

to the symptoms of the client. Client’s socialization skills and behavioral problems were

managed using Behavioral Techniques and Applied Behavioral Analysis.

Demographic data

Name XYZ

Age 9 years

Gender Male

No of siblings 3

Birth order First born

Mothers occupation House wife

Fathers occupation Engineer

Religion Islam

Family system Nuclear

Residence Islamabad

Informant Mother

Sources and reason of referral

The client was brought STL by her mother in 2023 The client came with the
complaints of less to no socialization, no eye contact, no emotional response, stimming
behaviors ( verbalstimming).The client was brought to the trainee psychologist for
assessment and management of problematic behaviors.
Presenting complaint
‫بات چیت نہیں کرتا‬
‫کااظہارصحیح سےنہیں کرسکتا جذبات‬
‫لوگوں میں گھلتا ملتا نہیں ہے‬
‫اپنی مرضی کےعالوہ کچھ اور کرنا پڑے تو چڑ جاتا ہے‬
‫بال ضرورت الفاظ بولتا رہتا ہے‬
‫اگر کام ان کی مرضی کا نہ ہو تو کان پر ہاتھ رکھ لیتا ہے۔‬
History of present illness

The client was a 9 year old boy. He was brought to STL on 2023with the symptoms of

no conversation, no emotional response, stimming behaviors ( verbal stimming),echolalia,

biting on hands, temper tantrums. The client was a normal kid until the age of 1. He started to

show the symptoms after the age of one. He stopped responding on his name first. Then he

started to show the other symptoms. At the age of 3 and half he completely manifest all of the

above described symptoms. He was then taken to the psychiatrist who diagnosed that the

client was suffering from ASD.The client’s mother reported . .

when she got to know that his child is suffering from autism spectrum disorder she started to

do the research. After that she realized that one of the paternal aunt of the client is suffering

from the disorder as she also showed the symptoms. But she was not sure because she was

never taken to the hospital or a psychologist and never been diagnosed.

Background information

Family history

The client belongs to a wealthy family. The client’s father was an engineer while

mother is a house wife. He has 3 siblings. He was the first born. XYZ was very close to

mother and with her younger sister. He used to play more with her sister than other 2 siblings.

Both the siblings have a strong bond. However he also used to enjoy when other siblings are

playing even though he was not playing with them. His siblings always try to get him involve

in their games.

Personal history

Client belongs to a wealthy family and was the first born child. He had 3 siblings. The

client’s birth was normal. There were no complications during the birth. Client was a normal
child. He achieved all his developmental milestones like normal child till the age of 1. After

the age of 1 his mother started to notice the symptoms. Client never suffered with any illness

during this time.

Client achieved almost all of his developmental milestones till the age of 1. The time

period of achieving developmental milestones is shown in the table.

Table no 1

Developmental milestones Normal age Client’s age

Head holding 3 months 3-4 months

Sitting 6 months 6 months

Crawling 8 months 8 months

Walking 1 and half or 2 year 13 months

Speech 1-3 years No speech till 4 year

Toilet training 3 years 4 and half year

Dressing without help 5-6 years Needs assistance

Shower taking 6-7 year Needs assistance

Education History

Despite all of the behavioral symptoms the client had high adaptive functioning. He

started his schooling at the age of 6 in a normal school under the guidance of a shadow

teacher when he and his family was living in Saudi Arabia. He studied in that school from
preschool pkg 1 He was doing great with the help of shadow teacher. They have to move to

Pakistan in 2018. After moving here in Pakistan he was brought here in STL

Preliminary investigation

Both formal and informal assessments were done on client to gain a proper sight of

the behavioral symptoms so that a clear and effective management plan could be made to

manage the behavior.

Informal Assessment

1. Clinical interview.

2. Behavioral observation.

3. Subjective ratings for symptoms.

Formal Assessment

1. Childhood Autism Rating Scale (CARS).

2. DSM V checklist.

Clinical interview

The clinical interview was done with the mother of the client. She was interviewed in

a semi structured way. She was asked about the symptoms, present illness, history of the

symptoms family personal and educational history. She was very cooperative and was giving

the required information. Based on the interview many things were known and understand

about the symptoms of client. She was also guided about her concerns towards her child.

Those things helped a lot in understanding the problem deeply and devising a management

plan for those problems.

Behavior Observation
 Client was a 12 year old boy. He had a thin stature and his height was normal. His

hygiene was properly maintained. He was wearing neat clothes. His expressions were blank

during the observatory session. He had no eye contact and was repeating the words after he

listen it. It was looking like he was processing the information. He was also speaking the

words other then he was hearing on the moment. These words were proper words and had

meanings but were irrelevant to the environment and situation. Whenever there was loud

noises in the environment he was placing his hands on his ears and started to make noise as

these noises were irritating him .He used to do so whenever something was not happening

according to his choice or mood.

He was not a social person as he was getting irritated when he was crowded with

people. He was not paying attention to the surroundings as he was lost in his own world. He

just wanted to be in his comfort zone and whenever someone tried to interfere he got irritated

and frustrated.

Subjective ratings of the symptoms

Subjective ratings were given on 1-10 point based on the severity and symptoms of

the problems. Subjective rating was done both by the therapist and the teacher.

Table no 2

Problems Rating by the Teacher Rating by the Therapist

Poor eye contact 8 8

Poor communication 8 9

Poor socialization 9 9

Inattention 8 8
 Hypersensitivity 8 8

No emotional response 9 8

Repetition of words 10 10

Formal assessment

For further confirmation of the observation done on the symptoms of client formal

assessment was done. This also gave the better idea of the problems.Formal assessment was

based on the following:

1. Childhood Autism Rating Scale (CARS).

2. DSM V Checklist.

DSM V Checklist

DSM V checklist was also used to check the criteria to make a proper diagnosis of the

disorder. DSM checklist confirmed the criteria

A. Persistent deficit in social communication.

B. Restricted, repetitive patterns of behaviors, interests or activities.

C. Manifestation until social demands exceeded.

Table no 4

Diagnostic Criteria Symptoms in Client Status of symptoms

 Deficits in social emotional Inable to show emotions

reciprocity according to the situations,


lack in conversation.

Deficit in nonverbal No eye contact or facial

communication expression.


Stereotyped or repetitive Echolalia, use of

motor movements idiosyncratic phrases a lot.



Insistence on sameness, Food item he is fixed to eat

inflexible adherence to and same routines at home.


routines

Hyper or hypo activity to Sensitive for some food

sensory input other than he eats noise or


loud noises.

Childhood Autism Rating Scale

Childhood Autism Rating Scale was applied for the formal assessment of problem.

The child showed the score of 39 out of total 60. It showed that the problems were of severe

level as the cut off score of CARS was 36.

Table no 3

Total score Obtained score

 60 39

Quantitative Analysis

Quantitative analysis was done based on CARS. CARS showed the different score of

the symptoms and the intensity. The scores are given below in the table:

Table no 5

Concerning Behaviors Total score Obtained score

Relating to people 4 4

Imitation 4 1

Emotional response 4 4

Body use 4 1.5

Object use 4 1

Adaptation to change 4 3

Visual response 4 3.5

Listening response 4 3
 Taste, smell, and touch 4 4

response and use

Fear or nervousness 4 1.5

Verbal communication 4 3.5

Nonverbal communication 4 4

Activity level 4 1

Level and consistency of 4 1

intellectual response

General impression 4 3.5

Total score 60 39.5

Qualitative Analysis

Qualitative analysis was done on the bases of observations and interview and also on

the bases of the scores obtained from the formal assessment. It was found that the client was

suffering from autism spectrum disorder and the symptoms were severe.

The main areas that had a problematic scoring meaning that scored high points were

relating to people, emotional response, adaptation to change, visual response, listening

response, taste, smell, and touch response and use, verbal communication and general

impression. The scores were so high ranging from 3.5 to 4 from 4. These areas needed more

work done as comparison to the other areas.

 CARS showed that the scores of other areas like imitation, object use, fear and

nervousness, activity level and level and consistency of intellectual response were 1 to 1.5.

This meant that the functioning in these areas were quite normal.

Tentative Diagnosis

299.00 (F 84.0) Autism Spectrum Disorder with severe symptoms.

Prognosis

The prognosis was good because the client’s parents were concerned and cooperative.

They were very much focused on the betterment of client that they were sending him school

regularly. Moreover the clients physical and social environment was also very good. The

center where client was going (STL) was also good and had been doing best for the client and

his needs.

Case Formulation

The client was a 12 year old boy. He was diagnosed with Autism Spectrum Disorder

(severe) according to the DSM V and CARS. Here are the theories that are explaining or try

to explain the cause.

One of the most common and most researched theories of autism is the Theory of

Mind (TM), hypothesis developed by Simon Baron-Cohen.He suggested that it is precisely

this ability that is impaired in children with autism. In essence, this theory suggests that it is

impairment in taking the perspective of others that results in many of the common deficits in

autism, such as intentional communication, pretend play, and inferring others’ emotions and

beliefs (Baron-Cohen, 1999). This deficit is often termed “mind blindness. So may be

sometimes when its feel like he is doing self talk then he is trying to explain something or

processing something.
 A deficit in ToM means that individuals with ASD may struggle in explaining their

behaviors, understanding their emotions, predicting the behaviors or emotional state of

others, understanding the perspectives of others. So in this case the client probably has a

difficulty in understanding the others, their emotions, intentions, communications so it is

making him “mind blind”.

An additional psychological theory of ASD is that individuals on the spectrum have

Weak Central Cohesion (WCC). The WCC theory suggests that individuals on the spectrum

struggle to incorporate information at different levels, and as a result, fail to integrate detail

into global entities (Frith, 1989). Some describe this by saying they are not able “to see the

forest through the trees.”

This theory has been used to describe both assets and deficits in individuals with

ASD. For example, this would explain why individuals with autism quite frequently develop

very strong skills in math or science, but have difficulty grasping the gist of a story. In the

case the client may not be able to process the information properly and as a whole. May be it

is very difficult for him to understand the information at different level so that he can

completely react or act according to it.

This hypothesis, also referred to as the weak central coherence theory, was proposed

by UtaFrith in the late 1980s. A simple explanation of weak central coherence is the inability

to see the big picture. This is not always a bad thing, it may actually be one of the strengths of

the autistic mind. Focusing on, and remembering details, instead of the global form or

meaning (the “big picture”) is a definite advantage in appropriate circumstances.

To accommodate weak central coherence, intervention may be needed; for example

when children learn to read. Kids on the spectrum often have a great voscabulary but many

struggle with reading comprehension. They may focus on details of a story to a degree that
they miss the main idea of the narrative.in the case discussed the child is very intelligent and

it seems like he has a lot of vocabulary and information but could not use it because he is not

able to process the information as a whole. He can remember the detail but how to express it

fully in one go it is not possible for him to explain.

Research into the genetic risk for autism has mainly focused on how mutations that

arise spontaneously in an individual's genome—rather than being inherited from a parent—

disrupt protein-coding regions and lead to the condition. That's because these sporadic

mutations have relatively large effects and studies have shown that such mutations, although

individually rare, together contribute to about 25% to 30% of cases, says Jonathan Sebat, a

geneticist at the University of California, San Diego. But only about 2% of the genome

consists of protein-coding areas. Sebat says the large noncoding portion of our DNA—often

previously referred to as "junk DNA"—has so far been ignored in autism research. In this

case may be the genetic mutation could be the reason for autism spectrum disorder. Although

it is not identified which gene and how but it is a possible reason and may run in families.

Predisposing factors

1. It could be genes.

2. May be gender

Precipitating factors

1. No precipitating factors.

Perpetuating factors

1. If problematic behaviors are not focused always.

2. Irritating behavior if left ignored.

Protecting factors

1. Concerns of the parents and their support.

2. Compliance of the client

3. Regular work done on the management plan

Biopsychosocial model

Psychological
Biological factors factors Social factors
Mutation in genes Impairment in None
(Runs in family) understanding others

Diagnosis

299.00 (F 84.0) Autism Spectrum Disorder (severe)

Management plan

The management plan was devised according to the special need of the client and

keeping the symptoms in mind. Management plan was devised based on Applied Behavioral

Analysis and behavioral therapy.

The main purpose of this plan was to increase the desirable effects of the client and

manage the problematic behavior.

 Identification of reinforcers

 Prompting and fading

  Chaining

 Positive reinforcement

 Social skill practice

 Praise and encouragement

 Removing the stimulus

 Planned ignorance

Identification of reinforcers

First of all the main thing was to identify the reinforcers that were going to be used to

help in rapport building and management plan. These reinforcers were identified with the

help of observations. Some were directly asked from the teacher. His main, primary

reinforcers were swings colors, high five, clapping During the sessions whenever the client

was doing good he was given a reinforcer. Some of the reinforcers like swings and colors

were also used to prepare the client for the activities.

Prompting and fading

Prompting was used for effective therapy and guide the client in IEP as there was

need to guide the child in every step. While also doing academic activities prompts were used

visual and verbal prompts. Then just to make the client independent fading was also used.

After some time, prompts were given at some intervals not on every step just to fade out the

help he is getting.

Chaining

Using chaining therapy client was taught how to do normal daily routine things like

how to button up his shirt, how to eat slowly and appropriately, how to comb his hair and

using scissors. Overall the main purpose was to improve fine motor skills and daily life skills.
.

Positive Reinforcement

Whenever client was showing a positive response to a command or was sowing a

positive behavior he was given positive reinforcement. For example, if he did his classwork

without getting lost and with attention, he could use the swing or go to the playground. Small

reinforcements like high five, were also given on daily bases and on small tasks and in

between the bigger tasks.

Social Skills Practice

The client was made to do some of the social skills daily in order to improve his

communication. Whenever he was entering the class he has to say slam to everyone. He had

to play with others and often a visit to other classroom. He was also taught to share his lunch

with a fellow or friend whoever he was sitting with just to make him social. He was also

participating in the morning assembly along with other. He was also visiting other classroom

in order to take or give different things. This was also helping him improving his social skills.

Removing the Stimulus

In order to improve his attention al other stimulus except the necessary one were

removed. This was done to increase his attention span. In order to gain his attention, he was

engaged in tasks like drawing, asking questions continuously.

Planned Ignorance

Some of the irritated behaviors of the client were ignored if the sole purpose was

gaining the attention. It was noted that some of the time while doing some activities client
started to show irritated behaviors like laughing and making sounds. There was no other

technique working at that time so as it was only an irritating behavior. So here irritating

behavior was just ignored. After some time, client was again in the normal position and

started to do what he was doing before the behavior.

Individualized Education Program (IEP)

IEP was based on the individual need of the client. As the client was good in studies

so the plan was kept according to the special needs of child. The main points in the program

was work on the attention of child during the class, work completion, learning of new skills.

Client’s attention span had to be increased during the tasks and activities specially

during class work. This was done based on the positive reinforcers. There was also an

educational plan based on the child’s level of understanding. How to make a proper sentence

and how to use it in situations. Different types of information according to the situation were

given so that the child could relate it to his real life

In social perspective the objective was to develop appropriate play skills with other

mates so that he could be more socialized with others and can have proper knowledge about

the sport or game.

Sessions

Session 1

Main objective in session one was to build the rapport with the client. This was

achieved

with the help of some techniques. Some of the reinforcers like toys, swing, and drawings

were identified so that it could help in rapport building. Client liked to play with tennis ball.
So it was a best play to build rapport with him. In this session no activity was done make a

proper bond with the client. In this session very little to no commands were made with the

client for the better compliance.

Session 2

Rapport building was still the part of the session. This was still the part of session

because it was necessary to make a good pair for effective planning and management for the

problematic behaviors. In this session client was started given commands and instructions so

that proper compliance could be develop with the client. Assessment was also done on the 2 nd

session. CARS was applied to see the intensity of the problematic behaviors.

Session 3

From the third session proper management plan was applied to the client. First work

was done on the attention of the client. For that purpose, specific things were included in the

environment that client thought was interesting. To gain his attention drawing was a best

option as he was more interested in drawings. Another technique was used in this session to

gain the attention from client that was the removing of undesired able stimulus. The stimulus

that was gaining more interest of client was removed e.g., a stimulus like noise that was not

allowing the client to have a proper concentration like noise.

Some work was also done on socialization of the client like he was taken to the

different classes. There he had to say greetings to the teachers and the fellow member. He

was also taken to the ground to play with his other mates to improve his socialization.

Session no 4

Client’s basic needs were the first priority. In this session many of the problems were

kept in mind. There was work done on the echolalia of client or the idiosyncratic words of the
client. It was noticed that client was involved in a lot of self-talk. For example, if he has

heard some poem somewhere he will repeat it again and again during the session. So first of

all it was noticed that why he was doing this. The reason was he used to do this when he was

not paying attention to the environment or what is happening around. So whenever he was

doing so he would be stop and tried to get his attention in other work or asked him some

questions like how is the weather. These type of questions were forcing the client to be

present in the moment and be focused.

Client was also let played different types of activities with other members so that his

socialization could be improved. His repetition of words was also tried to managed with the

techniques like stopping and repeating a little bit of the answer’s first part. Some curricular

activities were also done like class work. That gave more idea about the intellectual abilities

of the client.

Session no 5

Client had also a habit of biting his hand whenever he was not liking something, or he

does not want to do something. In that case it was tried to associate his habit with something

that was also a reinforcer for him for example writing something on his hand with a pen or a

marker. This thing was also gaining his attention. After that he was focused on what he is

doing. His biting behavior was also managed by engaging him another activities

Session no 6

In this session the focus was still on his main symptoms no socialization,

communication, sensory issues, irritability. For the improvement of social skills another

technique was applied like sharing. He was taught to share things with others and lunch too.
Then he was taught to say thanks and welcome on return. Through this technique he was a bit

used to the custom that to have to share things with others and interact with others.

For his hyper sensitivity some of the work was done. He was not eating some of the

the food due to their taste or because of the reason it feels like. So he was asked to eat the

food. After a bit of chewing and feeling it he somewhat accepted that this is also to eat.

Activities like playing catch and throw and drawing and football were also the part of the

session with other fellows in order to learn socialization.

Session no 7

This session was the continuation of the previous sessions. Work done on his most

prominent symptoms. For the better conversation some of the techniques were applied like

he was not talking unless he is forced by other and then upon forcing he used to say just one

words or the sentences he heard. For that purpose, random talk was done with him. At first,

he was not responsive then he started to take part and given the answers even though the

answers were not accurate. He was also taught to say proper sentences. It was started with the

simple and short sentences like “how is the weather today’ or “what is the date” This type of

conversation was also according to his interest as he used to respond and hear it clearly.

Session no 8

In session 8 discrete trial training was the part of therapy. Here the information was

divided into smaller steps so that the client can process it. For example, if the child has to go

to some other room he was asked like “get up and go to ma’am and ask her to give a sheet”.

But this was started as 1 step command then like 2 step command and 3 step command step

by step. The information was divided into chunks.

 In this session client was also taught some of the self-help techniques like how to cut

the nails or combing with the help of planned teaching and instructions and modeling also.

Session 9

If the client was involving in activities that were irritated then he was asked to do so

like laughing. This paradoxical homework did affect him and after sometimes he stopped

laughing. In this session to increase the intensity of the desired behaviors like command

following or paying attention or greetings whenever he was entering the class he was given a

positive reinforcement like clap or a praising word.

Moreover, he also learned in this session some of the common social skills like how

to wait for his turn and how to wait for others just with the help of compliance. School work

was the part of the session because during academics some of the problems were completely

manifested. So that time was the best time to manage his behaviors. He was get irritated when

he was working so this was managed with the help of attention diversion. Verbal and physical

prompting were also used during this session while doing homework. If he was paying

attention and doing well token economy was used. Stickers were used as the token economy.

Session no 10

Last 2 sessions were the sessions that were the summary of the previous two

symptoms.in this session it was seen whether the client had learned something his behaviors

were managed or not with the help of previous techniques used for various symptoms.

Positive reinforcement was used for the desirable outcome. Social skill trainings were used

for better socialization. To remove his undesirable behaviors like stubbornness sometimes

planned ignorance was used. Removing stimulus was used if there was something unpleasant

in the environment that was triggering the symptoms. Occupational therapy was also used
here for better skill trainings. Using occupational therapy his fine or gross motor skills were

also improved like using a scissor to cut the paper, or catching throwing or playing.

Outcomes of Therapy

There were at least 3 months during this case and the sessions. At first observation

and assessment was done and after that proper management plan and IEP were devised for

the management of the behaviors. Over the period of time the management plan was followed

properly and timely. Each and every session was taken according to the plan. So at the end of

the sessions there were improvements very visible in the behavior of the client.

Client’s social skills were very much better than previous conditions. He was more

willing to participate in the activities and was not showing any irritating behaviors during the

activities. His academics were also improved. He was following the instructions and was in

full compliance. His stimming behaviors were also improved although still need to be work

done on those. He was also able to understand the emotions like he was more responsive

whenever he was shown anger.

Limitations

As all of the sessions were good and the main effort was to take a proper session but there

were also some limitations which are following

 Sometimes during the sessions, the environment was not quiet and peaceful as it

should be. There was some time distractions and noise.

 Moreover, time was also less as the symptoms of client needed more and prolonged

time to be managed.

Suggestions
There were several suggestions regarding the case

 Environment should be peaceful suitable for the sessions and time should be more and

properly managed.

 Along with that the management plan that was made for the client should be followed

properly so that the behavioral symptoms of the client could be managed accordingly

and effectively.

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https://doi.org/10.3390/healthcare9020150.

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