Case Report

Clinical Placement and Case Studies

Participant’s Name: Mamoona Parvaiz

Registration No: MSCP02203056

Supervisor

Ms. Aleen Fatima

--------

Department of Psychology

Lahore School of Professional Studies, University of Lahore,

Lahore

Fall 2021
 DECLARATION

I am Mamoona Parvaiz Registration No.MSCP02203056, student of MS Clinical

Psychology, Session 2020-2022 hereby declare that the matter presented in this

Report is my own original work.

________________ ______________________________

Date: Signature of the Trainee

 CASE REPORT COMPLETION CERTIFICATE

It is certified that the work contained in this Report has been completed by Mamoona

Parvaiz, Registration No; MSCP02203056 under my supervision.

Date: ____________ Supervisor

__________________

Ms. (Supervisor Name)

Clinical Placement
Supervisor
Department of
Psychology
LSPS, UoL, Lahore.
 Table of Contents

Sr. No Contents Page No.

1 Case Study-1

Appendix

2 Case Study -2

Appendix

3 Case Study -3

Appendix

4 Case Study -4

Appendix

5 Case Study -5

Appendix
 CASE NO 01
Page |1

Case Summary

A 12 years old child with presenting complaints of lack of attention, lack of

concentration, poor academic performance, unable to speak, poor selfcare and

hyperactivity. It was diagnosed with intellectual disability with ADHD, 12 sessions

had been done with her. First rapport was build and after that Vanderbilt ADHD

diagnostic teacher rating scale, and portage guide to early education was used to see

which areas of the child are most affected. For the management purpose reinforces

were identified. Behavioral therapeutic techniques were used to deal with her

complaints by encouraged good behavior with reward immediately.

Identifying information

Name W.Q

Age 12 years

Gender Girl

Birth order 1st

Siblings 3

Religion Islam

No. of sessions 12

Source and reason for referral

The child was referred by her parents for the management of her behavioral

issues, and hyperactivity.

 CASE NO 01
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Presenting complaints

Table 1

Presenting complaints of the child by the teacher.

Duration Presenting Complaints

Last 7 years Hyper active

Last 6 years Lack of concentration

Last 4 years Poor academic performance

Last 6 years Unable to speak.

Last 7 years No sense of danger

Initial Observation

W.Q was a girl of 12 years in special education institute. The child was not

doing her class work with her other class fellows. She came to the trainee on the

request of her class teacher, with shake hand with the trainee but didn’t give any

emotional response. His hygiene was not appropriate, she was not wearing

appropriate uniform and her teeth were not brushed, her nails were also not clean.

Firstly She were not showed any compliance to the trainee, she had no proper

on seat behavior, during whole session she left her seat many time and even seat on

the floor. Eye contact was poor attention span was also low.

After some sessions she maintained her eye contact with the trainee, but it was

very difficult to build rapport with the client. She was too much hyperactive and try to

snitch everything during sessions.

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History of Present Problem

According to client’s mother, client’s birth was c section. Client’s mother

completed nine months of pregnancy. There were no Complications in pregnancy

but during pregnancy client`s mother was in great stress and depressed. Client has

low weight at the time of birth. Client’s first cry was late. Client achieved her

developmental milestones late. When client was 4 year old her mother noticed that

her child is not normal as compare to other children’s. She was unable to sense like

normal children’s and unable to speak and hyperactive. Currently she can speak just

two to three words. She was unable to make full sentence. Client’s academic

performance was also poor.

Background Information

Family history: Client`s father was 33 years old he was graduated. He is the

only source of economy. Client’s father was concerned about her child health but he

does not have too much interaction with her child. Client’s mother was 29 years old

and she was house wife. Client’s parents have first cousin marriage. His mother got

married at young age. Parents has good relationship with each other. Client was

attached with her mother. Parents were conscious about their child’s health. Client has

2 sisters. Client has good interaction with her sisters. Client was living in joint family

and she has low socio economic status. Atmosphere at home was not good according

to her mother due to her grandparents.

Personal history: According to the client’s mother that client’s delivery was C

section. She was in stress during pregnancy. Client has low birth weight. Her

milestones was delayed Child started neck holding at the age 12 months, client’s first

crawl was late. She started to sit 24 months. Client started toilet training at 60 months
 CASE NO 01
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but was not completely trained at present. She starts to speak at 9 months and now she

can speak two to three words. Clint has no interaction with others. Clint has no friends

and his school and class fellows do not make any interaction with her. She go to play

garden and play with the support of sisters. She was physically good and her motor

movements were also good. Client has poor concentration skills. Her attention span

was also low.

Provisional Formulation

On the basis of available information and observation, it seemed that client

had developmental delays that are due to unknown factors. It was provisionally

hypothesized that there was predisposing factor of the client that includes genetic

factors. The precipitating factors of the client was delayed developmental milestones

that made them vulnerable and triggered the disorder of client. The maintaining

factors include poor teaching strategies in the class and over protecting attitude of the

teacher towards the client. The protective factors of the client were the parent’s

affection and encouragement.

 CASE NO 01
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Table 02

Developmental Milestones: normal age of the child and normal age of achievement

Normal Age of

Developmental milestones Age of achievement Achievement

Crawling 9 months 8-12 months

Head holding 6-7 months 3 months

Walking 16 months 12-14 months

Talking(one word speech) 2.5 years 2 years

Toilet training 4-5 years 2 years

Educational History

Clients started to go school in the age of 4 years in normal school. When she

started to go school he was unable to walk properly. Client was unable to speak.

She had poor attention and memory span. She was unable to concentrate things.

She was easily distracted. Her academic performance was low. She had no

interaction with others. She had no peer relationship at school and easily

hyperactive. School referred the child at special school. Her performance in the

school was not good. With these symptoms school diagnosed child with ADHD

disorder.

History of psychiatric/ medical illness

Her mother`s sister was ill with same condition.

 CASE NO 01
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Assessment

Assessment was done by using different assessment techniques:

 Behavior observation

 Reinforcers were identified

 Vanderbilt ADHD diagnostic teacher rating scale

 Portage guide to early education

Informal Assessment

Behavior observation: Behavioral observation is the primary assessment

approach for preverbal and nonverbal children. It focuses on vocalization problems

(e.g. crying, whining and groaning), verbalization (e.g. echolalia, pragmatics), facial

expressions and guarding of body parts, temperament, activity and general

appearance.

In observation we will observe client’s behavior, general appearance of child

and general hygiene of client and his way of communication. By observation observer

will get an idea that what is the current state of client mood and communication skills.

Child has poor concentration, low attention span. Client was unable to remember

things, low memory span. Client was unable to speak, his speech was just limited

from two to three words.

 CASE NO 01
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Formal Assessment

Vanderbilt ADHD diagnostic rating scale: The Vanderbilt ADHD Diagnostic

Rating Scale (VADRS) is a psychological assessment tool for attention deficit

hyperactivity disorder (ADHD) symptoms and their effects on behavior and academic

performance in children ages 6 to12.(Wolraich et al., 2003) This scale also screen for

the following coexisting conditions, oppositional-defiant disorder, conduct disorder,

and anxiety and depression. Total cut off score is 181 and observer administered this

test in class room setting child got 129 score it seems child has inattentive,

hyperactive, and conduct disorder is also present.

Table 03

Obtained Scores and Category of the Client on Vanderbilt ADHD Diagnostic Rating

Scale.

Raw Scores Range Category

181 129 Hyperactive, Inattentive

Severe ADHD
 CASE NO 01
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Informal Assessment

Portage guide to early education

Table 04

Table shows the Functional level of Mental Age

Areas Functional Level of Mental Age

Self-Help motor 3-4 years

Cognitive 4-5 years

Language 3-4 years

Socialization 3-4 years

PGEE assess Functional developmental assessment it is Observational assessment

and it help in Progress monitoring and Record keeping. Management Planning can

be made with the help of PGEE. It can be used in variety of settings (Clinical,

schools, Head start, preschools, infant programs and home settings). There are

different domains those are measured by PGEE, Socialization, Language, Cognition,

Motor, Self – Help, Infant Stimulation. (Sturmey & Crisp, 1986). We will use PGEE

because child has delayed milestones, has difficulty in speech, his motor skills and

language. By using PGEE we can assess these developmental areas. As reported by

his mother child was unable to walk and to play with other children’s and he achieve

his developmental milestones late as compare to normal children’s.

 CASE NO 01
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Case Formulation:

Presenting Complaints:

Hyper active, Lack of attention, unable to

speak

Assessment:
Formel and Informel

Predisposing factor: Perpetuating

factors
Genetics
Peer relations
Diagnosis
iiissues,oSociaFfac
tors ADHD

Precipitating
factors Protective factor

Postnatal factors, Family and teacher

family stressors, support
economic.
 CASE NO 01
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Suspected problem

Client was diagnosed with severe ADHD.

Child`s Prognosis

On the basis of client’s detailed background information and complete

history, assessment and therapist own observation and clinical judgment the child’s

prognosis was said to be favorable. The points that were assumed to be in favor of

client’s prognosis and were currently present includes protective factors such as

support towards the client. The problems that were against child’s prognosis were

delayed milestones and genetic problem.

Management Plan

The management plan which was devised for client was using the behavior

modification techniques so that the client can learn the desired behavior that can be

applied in daily routine using those techniques. The techniques would help the client

in learning basic concepts and functioning of daily lives. It also helps the client to

learn and improve learning readiness skills (attention span, eye contact, non-

compliance and onseat behavior) which were learnt and were taught to client in

different sessions.

 To Build Rapport with the client.

 To enhance attention span of the client.

 To improve the onseat behaviour of the client.

 CASE NO 01
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Implementation of Therapeutic Strategies

All the goals which were set for the client were achieved by using behavior

modification techniques. The detail, procedure and techniques used are given as

following:

To build rapport with the client: Rapport building is the initial step for the

management. Rapport is about the establishment of a relationship in which the people

involved in the interaction understand each other and. have good communication

(Bernieri, 2005). The rapport building process was done with the client through the

technique of reinforcement. The reinforcers were placed on the table and then

reinforcers were identified of the client. The client was engaged in different activities

such as doing conversation with the client, playing with cars. The first thing client had

done was that she had done to play with blocks. Then, she was engaged in other

activities according to her interest.(Gremler & Gwinner, 2008)

Reinforcers identification: The reinforcers identified by the client according to her

interest were as follows:

Table 05

Reinforcers Identification According to Client’s Interest.

Reinforcers Priority

Blocks, stars and making bubbles. Strong priority(Stars)

Blocks, stars and making bubbles. Least priority (Bubbles)

Blocks,stars and making bubbles. Strong priority (Blocks)

Blocks, stars and making bubbles. Strong priority (Blocks,Bubbles)

 CASE NO 01
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To increase onseat behavior of the client: The child cannot sit on her place for more

time. She leaved her place during sessions. She had to forcefully engage on her place.

Modeling: A method used in certain cognitive-behavioral technique

of psycho-therapy whereby the client learns by imitation alone, without any specific

verbal direction by the therapist, and it is also a general process in which persons

serve as models for others, exhibiting the behavior to be imitated by the other.

(Bandura, 1961). Modeling technique was used with the client. The client was

modeled the learning readiness skill such as onseat behavior. The client was taught

how to sit on her place and do activities done in session. Every step was taught to

client and was modeled by the trainee so that the client can understand and learn the

steps of sitting on the chair for some time while doing tasks. The concept was given to

her that chair is a place to sit while doing work. The trainee sat with the client and

engaged her in the work by physical and verbal prompts. When the child was able to

learn the desire behaviors like onseat behavior then, slowly and gradually the prompts

were decreased. (Gemino & Wand, 2003).

Enhance Attention Span: Through Perform different activities and giving

some break tasks into pieces.

Outcome

The total number of sessions with client were twelve and duration of each

session was 30 minutes. The goals of the client were made through detailed clinical

assessment and observation. The main focus of intervention and management was to

enhance her social skills and attention span, non-compliance, onseat behavior and

behavioral issues. The attention span of the client was also enhanced for three minutes
 CASE NO 01
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during the sessions. The improvement was observed in the management of the client

in the performance during session conducted with her.

Pre and Post Management

Table 6

Comparison of the pre and post management ratings of client`s symptoms on scale of

(0-10)

Skill Taught Pre Rating Post Rating

On seat behavior 0 7

Enhancement of Attention Span 2 8

Key: In the scale of (0-10) “0” shows the problematic behavior is absent and “10”

shows the problematic behavior is severe.

Limitations

There were some factors which were affecting the management outcomes:

 Limited time available for sessions

 Client was not regular

 Lack of interest was another limitation of client

Recommendations

 There should be separate room to take sessions and apply therapy on client
 CASE NO 01
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Session Reports

Session no 1-3 25-10-21

Time Duration of each session: 30 Minutes

Session goals:

 To build rapport with client.

 To identify her attention span.

 To identify the reinforcers of the client.

 To develop on seat behavior.

Client was wearing uniform but her hygiene was not appropriate. Her age was

12 years. Suddenly client was showing the tantrum and throwing objects. Client was

showing hyperactive behavior during session. Observer asked about making star on

her hand so she showed calmness. During sessions activity client was very hyper and

did not respond on any activity. Sessions outcome was that the client`s reinforces was

found such as making stars on hand. And other goals will pending for next sessions.

Session no 04-07: 1-11-21

Time duration of each session: 30 Minutes

Client`s hygiene was not appropriate. She was not taking interest in session.

She on seat behavior was so poor but in this session client was sit with calmness for

10 to 12 minutes normally. Client`s speech was nill. Her attention span was low. In

these session client was maintained eye contact when she was called by observer.
 CASE NO 01
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During sessions client respond on “high five” and claping. At the end of the sessions

client intentionally left the room with making star on her hand and she was happy in

mood.

Session no 08-10: 8-11-21

Time duration of each session: 30 Minutes

Session goals:

 To build rapport with client.

 To increase his attention span.

 To develop on seat behavior.

Client`s hygiene was not appropriate. She was not interested in sessions. She

was hyper, and shout during sessions. She was try to throw everything. Therapist

gave task to her which was making bubbles to seeking her attention, So she make

interest on it. During activity therapist noted her attention span which was very

low according to her age. Therapist try to increase her attention span through

giving some task. Client perform making bubbles in class. Little bit of rapport was

build, Sessions outcome were learn about making bubbles and recognization about

nose and eyes.

Session no 11-12: 1-12-21

 PGEE apply

 Increase attention span

Try to increase attention span through perform different activities and giving

some break tasks into pieces. And PGEE test administered in these sessions.

Client showed interest during sessions.

 CASE NO 01
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References

Campbell, J. P. (1990). Modeling the performance prediction problem in industrial

and organizational psychology.

Demchak, M. (1990). Response prompting and fading methods: A review. American

Journal on Mental Retardation.

Eells, T. D. (1997). Psychotherapy case formulation: History and current status.

Gemino, A., & Wand, Y. (2003). Evaluating modeling techniques based on models of

learning. Communications of the ACM, 46(10), 79–84.

Gremler, D. D., & Gwinner, K. P. (2008). Rapport-building behaviors used by retail

employees. Journal of Retailing, 84(3), 308–324.

Laule, G., & Desmond, T. (1998). Positive reinforcement training as an enrichment

strategy. DC: Smithsonian Institution.

Riess, D. (1970). A shaping technique for producing rapid and reliable Sidman bar-

press avoidance. Journal of the Experimental Analysis of Behavior, 13(2), 279.

Sturmey, P., & Crisp, A. G. (1986). Portage guide to early education: A review of

research. Educational Psychology, 6(2), 139–157.

St-Yves, M. (2006). The psychology of rapport: Five basic rules. Investigative

Interviewing, 82–106.

Wolraich, M. L., Lambert, W., Doffing, M. A., Bickman, L., Simmons, T., & Worley,

K. (2003). Psychometric properties of the Vanderbilt ADHD diagnostic parent

rating scale in a referred population. Journal of Pediatric Psychology, 28(8),

559–568.
Appendix-I
Case No 02
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Case Summary

An 11 year old child with presenting complaints of poor attention, getting anxious

about social situations, and hand spinning and unable to speak .It was diagnosed with

autism spectrum disorder, 10 sessions done with him. First rapport was built then

CARS and Base line chart used to see which areas of child are most affected. For the

management purpose reinforces were identified. Behavioral therapeutic techniques

were used to deal with his complaints by encouraging good behavior with reward

immediately.

Identifying Data

Name: U

Age: 11 years

Gender: Male

Birth Order: 1st

No. of siblings: 3

Informant: Mother

Economic status: Middle class

Informants: Parents

No. of sessions: 10
Case No 02
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Source and Reason for Referral

The client was referred by the his mother for the purpose of psychological

assessment and management with the complaint’s visual disability, physically

dependent speech problem, irritability, hand spinning and poor attention span.

Presenting Problems

Table 1

Presenting Complaints and Duration of the Child According to his Teacher.

Presenting Complaints Duration

Deficits in language comprehension Last 7 years

Poor attention Last 3 years

Getting anxious about social situation Last 4 years

Hand spinning Last 4 years

Initial Observation

An observation was done of the client in different settings. Appearance of the

client was that he had neat clothes and her hygiene was proper. His hair was combed

properly. His physical appearance was healthy. The attitude of the client was moody

during the setting. The orientation of client was not developed. He was not aware of

the activities done with him in the sessions.

Reinforces were chosen according to his interest. Different activities were

done with the client to build rapport with him. The child was engaged in different

activities during the session in different settings such as class setting or vocational

setting. The child was observed that he had little appropriate on seat and off seat

behavior. He was sitting on the chair and was leaving her place in between session.

The eye contact of the child was observed during the activities. The child had
Case No 02
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not maintained eye contact and had no establishing eye contact. Attention span of the

child was also observed during the activities.

He was distracting from her work. The child was paying attention and

concentration towards task with the help of physical prompt. The child was imitating

with physical prompt what teacher was saying or the task which was given to him. He

was imitating the verbal commands of the teacher by physical prompt. The hand

movement of the child was poor by holding of the pencil. Her fine and gross motor

skills was not developed appropriately. He cannot hold the things with hands

properly. The learning readiness skills of the client were observed in different

settings.

History of Present Problem

The client’s problem was not reported in the file. When mother was pregnant,

her diet was not proper. At the time of delivery mother was in anxiety. Client was

born with normal delivery. The client had immediate cry after birth. The client had

blue color around her mouth when he was born. It was noticed that client had stomach

problem up to 2 weeks. After 4- 5 days of his birth he had constipation, measles,

vomiting, flue and fever. The reaction of the parents were that they were very tensed

and conscious about their child. They consulted the doctor for the treatment of the

flue and fever of the child. There was no history of keeping in incubator. The client

was given treatment for the constipation, measles, vomiting, flue and fever on time

when problem was suspected.

Case No 02
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Background Information

Personal history.

There was no trauma or serious injury reported of the client at the time of

birth. The milestones which client achieved were that he had normal physical

milestones reported. His speech milestones were delayed. The client’s control of

bowel and bladder was partially reported.

The child was interested in eating mud and shampoo. He was also interested in

songs and poems. He enjoyed the poems and dance on it. He liked to eat rice.

According to her mother, the client had not achieved the puberty as he was 10 years

of age.

Family history: The client had nuclear family system. There were total 5 members of

the family of the client. The client had two sisters and one brother. All his siblings

were normal and were studying in schools.

The client’s father was software developer. His age was 36 years. His

education was Master in software engineering. The father had a friendly personality.

He was a responsible man. The home environment was peaceful and calm and he

cares for his children. The relation of the father with the client’s mother was caring.

The relation of father with the client was that he cared about the client very much.

His mother was housewife. Her age was 34 years. The education of the mother

was Matric. The mother was a sweet and calm lady. She was very caring for her

family. The home environment was good and peaceful. The relation of the mother

with the client’s father was good and caring. The relation of mother with the client

was that she gave extra care and attention to her.

Case No 02
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Educational history: The child started his schooling for the first time at the age of 6

years. He used to spend her time at home by taking objects into her mouth and

listening to poems and rhymes. The child had attended academy. The child was

studying playgroup for one year at academy. The client was then referred in special

school by teachers of not showing compliance towards teachers. According to his

teacher, client was moody. He does work when he was with good mood. His

performance in class was average. He had inappropriate onseat behavior. The client

was irritable child and had poor pincer grip. During class he takes every object into

her mouth. Every task was performed by physical prompt.

History of Psychiatry/ Medical Illness: There was psychiatry or medical illness in the

family (paternal or maternal both sides). There was also genetic family history of the

client that the client’s aunt son was suffering from the disorder.

Provisional Formulation.

On the basis of available information and observation, it seemed that client

had developmental delays that are due to unknown factors. It was provisionally

hypothesized that there was predisposing factor of the client that includes genetic

factors. The precipitating factors of the client was delayed developmental milestones

that made them vulnerable and triggered the disorder of client. The maintaining

factors include poor teaching strategies in the class and over protecting attitude of the

teacher towards the client. The protective factors of the client were the parent’s

affection and encouragement.

Case No 02
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Assessment

The assessment was done to assess child’s adaptive, emotional and behavioral

problems or difficulties. The following assessment modalities were use with the child.

Clinical interview. A clinical interview is a tool that helps

physicians, psychologists and researchers so that they can make an accurate diagnosis

of a variety of mental illnesses. (Reynolds, 2018) The clinical interview was taken of

the client by the teacher. Interview was taken in the classroom that was well

organized. The teacher told about the client without any disturbance or delay. She

discussed about the information of the client in detail. In interview child’s problem

was discussed and small amount of information was told by the teacher. Some

information regarding his academic was also discussed.

Behavioral observation: Behavioral observation includes participant and non-

participant observation of the client. Participant observation is a qualitative research

method in which the researcher not only observes the research participants, but also

actively engages in the activities of the research participants. (Tryon, 1998). The

participant observation was done of the client in the setting of taking session while

doing different activities. Non-participant observation is a research technique whereby

the researcher watches the subjects of his or her study, with their knowledge, but

without taking an active part in the situation under scrutiny. (Tryon, 1998).

The client’s behavioral observation were that the client was irritable, jumping

aimlessly, prefers to be alone, does not want to be cuddled, poor socialization,

mouthing of objects, inappropriate attachment with objects such as bottle, caps,

plastic objects and proper.

Case No 02
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Base line chart: Base-line chart is defined as a line that serves as a basis or reference

point for observing behavior. Because this behavioral performance is stable, it is often

used as a yardstick for assessing how interventions and manipulations would affect

the outcome (Pam,2013). From observation and clinical judgment, the baseline chart

of the client was made of hand spinning.

Table 2
Base Line Chart of Hand spinning During Activities.
Event Behavior Consequences
Teacher went away from Showed excessive hand When teacher hold her hand,
child. spinning. child got happy.

Other children were He spinned her hand less. Child was engaged in other
making noise. activities.

Stranger came into Spinned his hand again. When teacher went from
class. class, child sat on his place.

Portage guide to early education.

Portage guide to early education is a home based early intervention service for

developmentally delayed preschool children. The revised edition of portage guide was

comprised of five developmental areas that are infant stimulation, socialization,

language, cognitive, self-help skills and motor skills. Child had been assessed on

these areas to find out their adaptive functioning level. (Bluma & Shearer, 1976).was

administered on the client. The rationale of administering the portage guide on the

client was to assess the functional age of the child. In portage guide, five areas were

assessed of the client that were Socialization, Cognitive, Self-help skills, and

Language and Motor areas.

Case No 02
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Quantitative interpretation.

Table 3
Functional Age of Child On different Areas of Portage Guide

Areas Functional Age

Cognitive Area 0-1 years
Socialization 0-1 years
Self-Help skills 0-1 years
Motor area 0-1 years
Language Area 0-1 years

Qualitative interpretation.

The child’s functional age was assessed on different areas of PGEE through

different activities. The overall discrepancy between child’s functional age and

chronological age was 9 years.

Socialization. He was functioning according the child of 0-1 years of age. He can

smile and greet adults without being reminded. He follows parental requests, 50% of

the time with verbal prompt. She plays with younger children. He does not take turns

while playing with other children. He cannot say please, thank you or apologize on his

own.

Self- help skills. His functioning level was like a child of 0-1 years of age. The child

can wash her hands and face, use the bathroom and take a bath with physical prompt.

He can eat with physical prompt. He can get water from the water can by physical

prompt. However, she cannot cross the street on her own. He cannot brush his teeth or

comb her hair by her own. He need physical prompt in every task.

Cognitive Area: His functional level was 0-1 years. He can colour in the drawing with

physical prompt. However, he does not recognize any shapes.

Case No 02
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Language: He was functioning at 0-1 years of a child. He can point to three body

parts on self with verbal prompt. He can carry out a series of three directions with

physical prompt. He can find a pair of pictures upon request with physical prompt. He

cannot use the words sister, brother, grandmother, grandfather.

Childhood autism rating scale.

The childhood autism rating scale is a 15-item behavioral rating scale

developed to identify children with autism and to distinguish them from

developmentally handicapped children without the autism syndrome. This scale is

especially effective in discriminating between autistic children and trainable mentally

retarded children. (Morgan, 1988; Teal & Wiebe, 1986).

Quantitative Interpretation: The quantitative interpretation of CARS is as following

on different domains.

Table 4

Obtained Scores and Category of the Client on Childhood Autism Rating Scale.

Raw Scores Range Category

45.5 37- 60 Severely Autistic

Qualitative Interpretation: The overall score of the child was 45.5 which exhibited

that child was severely autistic. The child scored 4 in the category of verbal

communication which showed that child was severely Autistic. This reason seemed

due to her lack of speech problem as she was only producing meaningless sounds.

The child scored 2 in the category of relating to people as he had no eye

contact and he avoids interacting with the strangers. The child scored 4 in the
Case No 02
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category of Emotional response that showed child was unaware of emotional

responses, he didn’t know about when to laugh or cry as it was observed that the child

was smiling and laughing persistently without any reason. The child scored 3 on

imitation category as it indicated that child imitates after delay of some seconds and

he was given physical prompt for the tasks and then she was able to imitate

something. The child scored 2 on body use category. It was observed that child had

repetitive movements such as hand spinning.

The score on object use category was 3.5 as it was observed that child was too

much engaged and attached with the toy. The child became preoccupied with one toy

as he was fixated with that toy. He takes the toy or objects into her mouth. The score

was 4 on Adaptation to change which showed the severe level of autism. It was

observed that if there was change in the environment or client was forced to do some

task. He becomes angry and responds with tantrums. As child was fixated with her

seat, it was difficult to change environment of child during sessions.

The child scored 2 on the categories of taste, smell and touch response and use

which showed the mild level of autism. The child ignores the mild pain when he was

hurt by someone. The score of the child on visual response was 4 that show that child

had no proper use of her vision. He avoids looking at people and stared at the space

for long time. The score on listening response was 2.5 that showed that child’s

response towards human sounds and ignores unusual sounds or may show response

after a delay. The score on the category of fear or nervousness was 2.5 that showed

restlessness and nervousness when strangers talked with her and tries to interact with

her.

The child scored 4 on Nonverbal communication category that showed that

child had immature nonverbal communication as he did not point towards needed
Case No 02
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things, he was unable to aware other person of his needs through gestures or sounds as

if he wanted to go to washroom he stands from his place and goes outside by his self.

The score on the category of Activity level was 2.5 that showed that child was usually

lazy and due to it his performance was affected. He was unable to perform the tasks

during sessions. The score on Level and consistency of intellectual response was 2

that indicated that child had no attention span attention span as he was unable to do

coloring, cutting or solving puzzles with concentration and cannot maintain or

establish the eye contact. Evident features were seen in general impression. Through

observation, the child showed many symptoms of autism as no eye contact, lack of

attention span, avoids people, repetitive behaviors etc.

Case Formulation

The client U was 10 years old boy. The case was formulated on the base of bio

psycho social model. The presenting complaints of the client were speech problem,

irritability; objects take into mouth, hand spinning and shows non-compliance, poor

attention span. The predisposing factor of the client includes genetic factors. There

was genetic history of parents (both maternal and paternal side). Researches showed

evidence that autism comes from many sources, including genetics, twin and family

studies from both maternal and parental side (Eells, 1997).

The precipitating factors of the client was that in pregnancy, mother had taken

depression that caused delayed developmental milestones of the client. Researches

showed that these biological and psychological risk factors are sensitive to contextual

factors such as maternal depression. There is emerging evidence showing that

maternal mental disorders have adverse impacts on the physical and psychological

development of infants that causes the delay in child development such as speech

delay. (Zhang, 2005).

Case No 02
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The maintaining factors include overprotective attitude of the teacher towards

the client. Number of researches showed that in theory of personality styles

overprotective attitude of parents and teachers will frequently encourage a child to be

dependent on others. The child was not taught the coping strategies to deal with fear

and child cannot face the hurdles of life. That’s why the children were physically

dependent on others. The overprotection of parents and teachers towards the child

leads them to be dependent on parents and teachers and disorder will be maintained.

(Elmore, 2017).

The protective factors of the client were the parent’s affection and

encouragement. They care and had concern for their child. They encourage their child

on little things to increase her motivation level. The child’s temperament can be

understood to cope with the problems. A research was conducted according to Social

learning theory, people learn by watching what others do, people model the behavior

of learning and imitate it. Parent’s through watching other parents learn that children

should be given treatment. They get motivation through modeling and imitate it by

sending their children for the treatment. This theory gave motivation to parents and

children.
 Case No 02
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Case Formulation

Symptoms

 visual disability
 speech problem
 objects take into mouth
 non-compliance
 irritability
 Head spinning

Assessment

 Initial interview
 Behavioral
observation
A
 Portage guide (P.G)
 CARS

Predisposing factors Precipitating Factors Maintaining factors

 Genetic  Developmental  Overprotective

factors delays style of teacher

Protective Factors

 Parent’s affection
and
encouragement
 Motivation level
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Child’s prognosis

On the basis of client’s detailed background information and complete

history, assessment and therapist own observation and clinical judgment the child’s

prognosis was said to be favorable. The points that were assumed to be in favor of

client’s prognosis and were currently present includes protective factors such as

support and overprotective attitude of teachers towards the client. The problems that

were against child’s prognosis were delayed milestones and genetic problem.

Intervention Plan

The management plan which was devised for client was using the behavior

modification techniques so that the client can learn the desired behavior that can be

applied in daily routine using those techniques. The techniques would help the client

in learning basic concepts and functioning of daily lives. It also helps the client to

learn and improve learning readiness skills (attention span, eye contact, non-

compliance and onseat behavior) which were learnt and were taught to client in

different sessions.

 Build Rapport with the client.

 To enhance attention span of the client.

 To improve the onseat behaviour of the client.

 To improve non-compliant behaviour of the client.

 To minimize the head spinning of the client.

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Implementation of Therapeutic Strategies

All the goals which were set for the client were achieved by using behavior

modification techniques. The detail, procedure and techniques used are given as

following:

To build rapport with the client: Rapport building is the initial step for the

management. Rapport is about the establishment of a relationship in which the people

involved in the interaction understand each other and. have good communication (St-

Yves, 2006). The rapport building process was done with the client through the

technique of reinforcement. The reinforcers were placed on the table and then

reinforcers were identified of the client. The client was engaged in different activities

such as doing conversation with the client, doing coloring activities with her, playing

with blocks. The first thing client had done was that she had done colours in the

drawing sheet. Then, he was engaged in other activities according to her interest.

Reinforce identification: The reinforces identified by the client according to his

interest were as follows:

Table 5

Reinforces Identification According to Client’s Interest.

Reinforces Priority

Coloring book, stars and ring tower. Strong priority(Stars)

Coloring book, stars and ring tower. Least priority (coloring)

Coloring book, stars and ring tower. Strong priority (Stars)

Coloring book, stars and ring tower. Strong priority (ring tower)
Case No 02
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Enhance attention span of the client.

There was lack of attention span during activities or tasks given to her. She

was distracted so much while doing work. Her attention span was very little on the

tasks during the session.

Positive reinforcement’s: Positive reinforcement involves the addition of a

reinforcing stimulus following a behavior that makes it more likely that the behavior

will occur again in the future. When a favorable outcome, event, or reward occurs

after an action, that particular response or behavior will be strengthened. (Laule &

Desmond, 1998). This technique was used with the client to enhance his attention

span. He was given different activities such as coloring in the drawing sheet, he had to

color on it through physical prompt. While coloring, if the client was distracted from

surroundings, he was asked to pay attention. He was further asked if she paid proper

attention to her task then he’ll get reward for strengthening the behavior of child, he

was reinforced with the stars. It was noticed that after some sessions, he was little

distracted and he also paid more attention to the task as compared to earlier sessions.

Another activity, ring tower building was done to increase attention span of the client.

Client was given ring tower and was asked to put the rings on the tower with physical

prompt. The client stacked blocks and made tower from it. In this way, there was little

distraction during activity and client was engaged in session. The attention span of the

client was increased for two minutes during the session.

Case No 02
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To increase onseat behavior of the client.

The child cannot sit on her place for more time. He leaved her place during sessions.

He had to forcefully engage on his place.

Modeling: A method used in certain cognitive-behavioral technique of psycho-

therapy whereby the client learns by imitation alone, without any specific verbal

direction by the therapist, and it is also a general process in which persons serve as

models for others, exhibiting the behavior to be imitated by the other (Campbell,

1990). Modeling technique was used with the client. The client was modeled the

learning readiness skill such as onset behavior. The client was taught how to sit on his

place and do activities done in session. Every step was taught to client and was

modeled by the trainee so that the client can understand and learn the steps of sitting

on the chair for some time while doing tasks. The concept was given to her that chair

is a place to sit while doing work. The trainee sat with the client and engaged her in

the work by physical and verbal prompts. When the child was able to learn the desire

behaviors like onset behavior then, slowly and gradually the prompts were decreased

(faded out). The client was able to learn the mouth wipe with tissue without any

prompt.

To improve non-compliant behavior.

The client was not showing compliance towards the instructions given to her.

He was not listening to the teacher. He had no interest during activities done in

session.

Prompting and fading: Prompts are used to increase the likelihood that a child will

provide a desired response. Fading is gradually reducing the prompting (Demchak,

1990). The prompts which was used with the client was verbal prompt, physical
Case No 02
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prompts and it was constantly used in the management session to achieve the goals

like learning readiness skills such as non-compliance behavior of the client. When the

child was able to learn the desire behaviors like showing compliance towards the

teacher, listening to the instructions given by trainee or teacher, slowly and gradually

the prompts were decreased (faded out). The client was able to show little

compliances towards the instructions and commands given to her.

Minimize hand spinning of the client.

The client had the behavioral problem such as hand spinning. He was

constantly engaged in behavior and does it multiple times.

Prompting and fading. Prompts are used to increase the likelihood that a child will

provide a desired response. Fading is gradually reducing the prompt. (Alberto &

Troutman, 2003). The prompts which was used with the client was verbal prompt,

physical prompts and it was constantly used in the management session to achieve the

goals like behavioral issues such as hand spinning of the client. When the client

spinned hand constantly, he was given physical prompt so that he can stop this

behavior. When the child was able to learn the desire behaviors like minimizing hand

spinning, slowly and gradually the prompts were little decreased. The client stopped

hand spinning when he was given physical and verbal prompt.

Outcome

The total number of sessions with client were twelve and duration of each

session was 30 minutes. The goals of the client were made through detailed clinical

assessment and observation. The main focus of intervention and management was to

enhance her learning readiness skills such as attention span, non-compliance, onseat
Case No 02
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behavior and behavioral issues. The attention span of the client was also enhanced for

three minutes during the sessions. The improvement was observed in the management

of the client in the performance during session conducted with her.

Sessions:

Session no 01-03: 25-10-21

Time Duration of each session: 30 Minutes

Session goals:

 To build rapport with client.

 Try to respond on name.

 Try to learn sitting in appropriate way.

 To identify the reinforced of client.

Client was wearing pant and T-shirt his hygiene was appropriate. Client was

inattentive and do not sitting well during session. Client show poor eye contact and do

not gave respond on his name. Client was mute during session. In the end of the

session observer try to learn him good bye but in this session client did not respond on

it.

Client was not following the instructions like clapping and tap the table that was given

to him during session.

The outcome of these sessions was that, the reinforces of client was not identify.
Case No 02
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Session No 04-07: 1-11-21

Session Goals:

 To identify the reinforce of client

 Try to maintain on seat behavior

Client`s appearance was appropriate. In this session client was attentive partly and

sitting well rather than previous session. Client was show poor eye contact still. Client

was respond on name in these sessions. Client was mute during sessions.

Client`s on seat behavior was noted its duration was 2 to 3 minutes. After that time

client was not follow the any instruction.

The outcome of these sessions was his onset behavior was maintained in these

sessions and rapport was build.

Session no 08-10: 22-11-21

Session Goals:

 To identify the reinforce of client

 To build response on greeting

Client`s hygienic stat was appropriate. His facial expressions was anxious

sometimes. His greeting were inappropriate. Client`s eye contact were avoidant

during session. But when observer touch his hands for tapping the table so he respond

on it. client`s personality is kinesthetic he feels good and respond on it when observer

touch him.
Case No 02
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Client were started interacting with observer and showing little interest upon calling

his name when observer touch his hands. Client`s reinforce were identified during

sessions.
Case No 02
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References

Campbell, J. P. (1990). Modeling the performance prediction problem in industrial

and organizational psychology.

Demchak, M. (1990). Response prompting and fading methods: A review. American

Journal on Mental Retardation.

Eells, T. D. (1997). Psychotherapy case formulation: History and current status.

Gemino, A., & Wand, Y. (2003). Evaluating modeling techniques based on models of

learning. Communications of the ACM, 46(10), 79–84.

Gremler, D. D., & Gwinner, K. P. (2008). Rapport-building behaviors used by retail

employees. Journal of Retailing, 84(3), 308–324.

Laule, G., & Desmond, T. (1998). Positive reinforcement training as an enrichment

strategy. DC: Smithsonian Institution.

Riess, D. (1970). A shaping technique for producing rapid and reliable Sidman bar-

press avoidance. Journal of the Experimental Analysis of Behavior, 13(2), 279.

Sturmey, P., & Crisp, A. G. (1986). Portage guide to early education: A review of

research. Educational Psychology, 6(2), 139–157.

St-Yves, M. (2006). The psychology of rapport: Five basic rules. Investigative

Interviewing, 82–106.

Wolraich, M. L., Lambert, W., Doffing, M. A., Bickman, L., Simmons, T., & Worley,

K. (2003). Psychometric properties of the Vanderbilt ADHD diagnostic parent

rating scale in a referred population. Journal of Pediatric Psychology, 28(8),

559–568.
Appendix-II
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Case Summary

A.A 11-year old female client referred to the trainee clinical psychologist by her

family member withthe complaints of recurrent and persistent thoughts, repetitive

behaviors (e.g., hand washing, and damaging her toys), restlessness, irritability,

which is due to her disintegrated thoughts and her inability to control the overflow of

them. Detail history was taken from the client’s mother. The clientbelonged to low

socio economic class family clients father is labor and client mother is also house

wife. History of present illness, clinical interview, and mental state examination were

used for the purpose of informal assessment. For formal assessment, the Beck

Anxiety Inventory (BAI), and Children`s Yale-Brown Obsessive Compulsive Scale

(CY-BOCS) was used. Obsessions and compulsions are being reported equal, if ten-

time thought came in his mind about the untidy or dirty hands, she washes themup to

ten times. Cognitive Behavior Therapy based treatment was used like Rapport

building, psycho-education of patient, deep breathing, muscle relaxation, sleep

hygiene, coping statements, and baseline chart. 10 sessions were conducted with her,

which resulted in improvement in her symptomsafter the implementation of

therapeutic intervention.
 CASE NO 03
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Bio data

Name A.A

Age 11 years

Sex Female

Education 5th class

No. of siblings 0

Birth Order 1st

Occupation student

Marital status single

Source of Referral Mother

Reason of referral

The patient was admitted to the psychiatric ward of Jinnah Hospital with

complaints of Recurrent and persistent thoughts, Repetitive behaviors (e.g., hand

washing and taking a long bath),Restlessness. The patient was referred to the Trainee

Clinical Psychologist for the psychological assessment and management.

 CASE NO 03
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Presenting Complaints

As reported by mother

Complaints Duration

Expressed worries about dirt Since four years

Repetitive behaviors like hand washing, Since three years

Recurrent and persistent thoughts, urges

Since four years
Irritability and restlessness.

Damaging her toys and equipment’s Since childhood

History of Present Illness

The client problem started 2 months ago. After her father death, her mother

looks after heruntil adulthood and educates her in order to support her family because

she is the only child of herparents. After her father death she expressed worries about

dirt damage her toys, These appeared uncontrollable as she could not forget about

them enough to have fun in other activates. She manifested the criteria of

psychological symptoms with irritability and restlessness.

She started to spend three or four hours in a washroom and takes the shower

three to four timesa day. She properly washes her hand after touching her toys. Her

family realized that the child is not well because of the repetitive behavior of

cleaning, overspending times in a washroom, and talking about the same things.

According to her mother the client's sleep was very disturbed.

The client was very much disturbed and also complained that her body also

pain. Her muscleswere stressed because she was not taking proper sleep. Some of her

friends left her due to the client'srepetitive behaviors.

 CASE NO 03
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Background History

Family History

A. A belongs to a low-class family. She lives in a nuclear family setup. The

general homeatmosphere was good. Her father's name was H.A. Her father was

physically healthy but died due to a sudden heart attack. Her father was uneducated.

He was also a mason. Her relation with her father is good. She said that her father's

relations with her mother was good.

Her mother was 36 years old. She was not educated. She was a housewife.

She was physicallyfit & her personality was also very good and nice. Her relations

with all family members were good enough. The client's behavior with her mother

was appropriate. She never faced any psychiatric problems. She is very religious. She

is a strong woman who raised her child by working hard. The client’s had no siblings.

She was the only child of her parents.

 CASE NO 03
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Personal History

Birth and early childhood

Client birth was normal. Her early development was good and proper and

achieved all his milestones like crawling, walking, talking, and toilet training at an

appropriate age. Physically she wasa healthy person. The relationship of the client

with peers was friendly. Her father died during the childhood of the client and he

looks after by her mother.

Milestone Normal range Achieved age

Cry after birth Immediate after birth Approximately after a

minute

Neck holding 2 months- 4 months 3 months

Sitting 6 -7months 6 months

Crawling 8-9 months 8 and half months

Standing 9-10 months 9 and a half months

Walking with support 10 -12 months 11 months

Walking without support 12-18 months 12 months

Babbling 6 months 5 months

One word 1-2 years 1 years

Two words(small 1-2 years/2-3 years 2 years

sentences)

Toilet training 2 – 3 years 3 years

 CASE NO 03
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Educational History.

She is going to school and studying in class six. The client was not an

intelligent student. She had not good experiences of school life. She is done her

initial primary education with low marks.

Physical and Medical history

No history of any illness or injury was reported.

Socio-Economic history

She belonged to the Low-class family. Her father is the only person to earn for

her family. They face many financial issues.

History of Psychiatric illness in Family.

No psychiatric illness was found in the family.

 CASE NO 03
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Psychological Assessment

1. Informal Assessment

2. Formal assessment

Informal Assessment

 Clinical Interview

MSE

In different settings. By this we know about the frequency and Informal

assessment is conducted to obtain the detailed information regarding the client’s

problem. By obtaining this detailed information we can assess the level of

problematic behavior. This can be done to assess the behavior of child intensity

of problematic behavior. Through this we should know about the client condition

that gives an overview that client’s orientation regarding time, place and person.

We know about the clothing, voice tone, memory through mental status

examination

Clinical Interview

It is a common feature in attempting to appropriately diagnose many learning

disabilities and mental disorders through specific interviews. A structured clinical

interview is a tool that helps to make an accurate diagnosis of a verity of mental

illnesses (Kelley, 2009).

A clinical interview is a type of psychological assessment. It is a way for a

mental health professionalto ask client questions, engage in dialogue to learn more

about the client, and form initial opinions about a client’s psychological state. A

clinical interview is otherwise known as an intake interview, anadmission interview,

 CASE NO 03
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a mental state exam, or a diagnostic interview. The clinical interview was conducted

to get information from the client to reveal his problem. The interview was

conducted to obtain detailed information i.e., history of present illness, family

history, personal history, educational history, and pre-morbid personality of the

client.

The interview starts with rapport building to make sure that the client feels

comfortable and notfeel hesitation in communicating. She has been given assurance

that the information given to the psychologist will be kept confidential.

Mental Status Examination

B.A was a tall and young female of 11 years old. She was having anxious

expressions on her face when entered the therapy room. She was impatiently waiting

for her turn for a checkup, showing too much concerned about her treatment and

sessions. She was wearing casual neat and clean cloths. Good eye contact maintain

during session. Her rate of speech was too fast at the beginning gradually became

moderate then the speech was easily hearable. Speech content was relevant and

responded to questions correctly. There was no stuttering in her speech. She was a

manner, able person. Her mood was sad. No Suicidal thoughts were reported by

patients at the time of evaluation and there was no signof depersonalization, de

realization, and delusions. Her perception of life was becoming negative and lack of

interest. Not any hallucination experienced was demonstrated. Her orientation was

good; she was well oriented in time and space and she was not having a concentration

problem she was completely in her senses. She answered general knowledge question

accurately. Her short and long term memory both were intact. Her abstract thinking

was satisfactory; judgment was also accurate and appropriate. She was confused

about her mental illness. She does not have insight about her illness
 CASE NO 03
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Formal Assessment

 Beck Anxiety Inventory

 Children`s Yale-Brown Obsessive-Compulsive Scale (YBOCS)

Rationale

Formal assessment is a standardized tool that helps in diagnosis and in getting

valid and reliable information according to the information obtained from the clinical

interview; yalebrown obsessive compulsive scale rates the severity separately for

both obsessions and compulsions of OCD according to the time occupied, degree of

interference, subjective distress,internal resistance, and degree of control and BAI

anxiety scale measuring the intensity of cognitive, affective, and somatic anxious

symptoms experienced during the last seven days.

 CASE NO 03
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Beck Anxiety Inventory (BAI)Quantitative interpretation.

Table No 1

Table Showing Ratings of Statements

Statement No. Statements Rating (0-3)

1 Numbness or tingling 1

2 Feeling hot 0

3 Wobbliness in legs 1

4 Unable to relax 1

5 Fear of worst happening 2

6 Dizzy or lightheaded 0

7 Heart pounding and racing 1

8 Unsteady 0

9 Terrified 0

10 Nervous 1

11 Feeling of choking 1

12 Hands trembling 1

13 Shaky 0
14 Fear of losing control 2
15 Difficulty breathing 1
16 Fear of dying 0
17 Scared 1
18 Indigestion in abdomen 1
19 Faint 0
20 Face flushed 1
21 Sweating (not due to 0
heat)
 CASE NO 03
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Table No 2

Table Showing Raw Scores

Obtained Range Severity level

0-7 Minimal Anxiety

8-15 Mild Anxiety

18 16-25 Moderate Anxiety

25-63 Severe Anxiety

Qualitative Analysis:

The client reported that he was feeling restless and anxious about his thoughts.

The client raw scorewas 18. This score suggests a moderate level of anxiety, but could

also result from the ability of the subject to masking their anxious symptoms or if the

subject is in denial of such symptoms. Heconstantly worries all day.

Children`s Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). Yale-Brown

Obsessive Compulsive Scale wasused to assess the severity of the obsessions and

compulsions.
 CASE NO 03
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Table No 3

Table Showing Categories of CY-BOCS Scores

Score Range
0- 7 Subclinical

8- 15 Mild

16-23 Moderate

24-31 Severe

32- 40 Extreme
 CASE NO 03
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Quantitative Interpretation

Table 4

Table Showing Ratings of Statements

Statement No. Statements Ratings (0- 4)

1 Time spent on an obsession 2

2 Interference from obsession 1

3 Distress from obsession 4

4 Resistance to obsession 1

5 Control over obsession 2

6 Time spent on compulsion 2

7 Interference from 2
compulsion
8 Distress from compulsion 4

9 Resistance to compulsion 1

10 Control over compulsion 2

Sum= 21

Table 3

Table Showing Raw Scores

Total items Obtained Score Result

10 21 Moderate

Qualitative Interpretation.

Obsession and compulsions was being reported equal, if ten-time thought

came in her mind about the untidy or dirty hand, she washes them up to many times.

She almost stops touching things due to the fear of germs. Takes long showers to get
 CASE NO 03
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rid of untidiness or thoughts of untidiness and dirt.She spends much of her time

ordering things like when she wore clothes, she used to wear it, again and again, to set

them in a right place.

Case Formulation

A.A. was 11 years old female and obtained education up to 5th class. The

client lives in a nuclearfamily setup and belongs to low socioeconomic status. She

comes to the jinnah Hospital with complaints including recurrent and persistent

thoughts, restlessness, repetitive behaviors (e.g. hand washing, and taking long baths).

According to the DSM-5 criteria, OCD is due to the presence of obsessions,

compulsions, or both. Obsessions are recurrent and persistent thoughts, urges, or

mental images that are experienced and in most individuals, it causes anxiety or

distress. Compulsions are repetitive behaviors or mental acts thatthe individuals feel

driven to perform in response to an obsession.

According to the psychoanalysis school of thought, unconscious conflicts can interfere

with all areas ofa person’s life, including work, school, and relationships. Problem-

solving and higher thinking are greatly diminished.

This can leave a person feeling helpless and worthless. For the treatment of

OCD, it is necessary to uncovering hidden motivations and gaining insight. According

to the (Adams, 2004) life events that may be linked to the onset of OCD are a specific

and distressing event. This may include the loss of a pet, a divorce in the family, death

of someone close, a change in schools, or unhappiness at school Research has

suggested that either by itself or as a combination with pharmacotherapy or cognitive-

behavioral therapy, the use of exposure and response prevention (ERP) would be an

effective treatment for OCD (Bram & Bjorgvinsson, 2004).This can be correlated with
 CASE NO 03
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the client's present case that she feels anxious after her father death and face

obsessions. According to the behaviorist perspective, the individual associates an

event or a situation withfear and anxiety and so they create a response or behavior

which reduces their fear. This suggests that

The ritualistic nature of behaviors is conditioned response to reduce anxiety (Essays

UK, November 2018). The client reported that after her father death she feels anxious

and suffering from theobsessions of dirty and turns washing and cleaning everything

for removing her obsessions.

As concerned with predisposing factors the client was very sensitive about

sanity. She alwaysarranges in a tidy way.

The precipitating factors include when her father death, aggressive nature.The

perpetuating factors include her depressive thought about her illness.

The protective factor includes his family support, coping strategies, and

had an insight abouther illness.

Diagnosis

According to the Diagnostic and Statistical Manual 5, the client was diagnosed with

Obsessive Compulsive Disorder300.3 (F42)

Prognosis

The prognosis of a patient depends upon the following factors i.e, treatment,

family support, cooperative behavior, etc. In the present case, the client was suffering

from an obsessive-compulsive disorder. She had an insight and wants to be recovered.

She had motivation for her treatment and she was fully cooperating to follow the

giventherapeutic plan. The Prognosis of the client’s problem seemed to be good due

to the presence of many supportive factors for the treatment.

 CASE NO 03
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Treatment and Management Plan

Rapport building. Rapport has been described as ―the relative harmony smoothness

of relations between people. Rapport is established at the first meeting between the

client and psychologist and is developed throughout the therapeutic relationship. It is

the process of responsiveness at the unconscious level. Rapport is a state of

harmonious understanding with another individual or group that enables greater and

easier communication. The goal of developing a good rapport is to improve your

chances for a successful outcome, along with developing mutual trust and respect.

The rational of the emotional ventilation therapy was to given the opportunity

to the client to express her feelings in front of the psychologist and to build rapport

with the client and provide a wayfor catharsis. At first, the client faced some

difficulty but when she assured that her information will not disclose to anyone she

started to tell about her problems.

The client becomes confident when the rapport was built she comfortably

shared her problem. Rapport was built by asking questions related to the client's likes,

dislikes, interests, hobbies, and dailyroutine questions. Trainee psychologist also

clarifies his role to the client and makes him assure thatconfidentiality was made

about the whole information. When the therapeutic relationship ends, the

psychologist should assist the client to assess progress and plan the next stage of

recovery.

Psycho-Education. Psycho-education, as the name suggests, is education about a

certain situation or condition thatcauses psychological stress. It does not exclusively

deal with psychological or mental illness‟ but rather any condition you are

experiencing during a psychological interview the client was psycho- educated about
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his symptoms, their severity, and also the management plan. The client was also

educated about her aggressive behavior, anger control tips in the 4th session.

Deep Breathing. Deep breathing was also introduced and taught to the client during

the first and secondsessions. It is a simple yet powerful relaxation technique. It’s easy

to learn, can be practiced almost anywhere, and provides a quick way to get your

stress levels in check. Deep breathing is the cornerstone of many other relaxation

practices.

Depression is often accompanied by shallow breathing, deep breathing exercises

can also behelpful. Try the following form of yoga breathing:

 Lie on your back in a comfortable place.

 Breathe in slowly through your nose, using your diaphragm to suck air into your lungs

while allow-ing your abdomen to expand. (Put your hand on your abdomen just

below the navel to make sure the abdomen is being pushed up and out by the

diaphragm.) After the abdomen is expanded, con- tinue to inhale as deeply as

possible.

 When you breathe out, reverse the process: Contract the abdomen while exhaling

slowly and com-pletely.

 Repeat several times.(Joseph Goldberg, MD. 2017)

Coping Statements.

Generating coping statements can be helpful in getting clients through

the critical period when hopelessness and sadness are on a peak, they seem to lose the

ability to reason objectively. The usefulness of coping statements can be enhanced by

asking patients to write these statements on flashcards, e.g., index cards (Wright et

al., 1993)
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Coping statements are a tool that can be used with many clients who feel

anxious or overwhelmed. These positive statements can help the patient to cultivate

attitudes of accepting andallowing the needed time to pass during the anxiety.

The client was asked that once she feels anxious or a depressive sensation coming on,

he should simply pull out the small piece of paper or repeat a single statement over

and over in his mind. Deep breathing also helps.

Perhaps some of these coping statements will help the client and provided to the

client in the 9thsession:

 This feeling isn’t comfortable or pleasant, but I can accept it.

 I can be anxious and still deal with this situation.

 I can handle these symptoms or sensations.

 This isn’t an emergence. It is okay to think slowly about what I need to do.

 I am going to go with this and wait for me to learn, to cope with my depression.

 There is no need to push me.

I have applied and provided all these statements to my client to control the

situations which triggerthe stress and tension.

Generating coping statements can be helpful in getting patients through the

critical period when obsessions and compulsions are strong; they seem to lose the

ability to reason objectively. These statements encourage the A.A to think positively

and get enough courage to make decisions again.

The copying statements were written with the collaborative discussion between

the patient and thetherapist.

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Progressive Muscle Relaxation

Progressive muscle relaxation is a two-step process in which the client systematically

tenses and relaxes different muscle groups in the body. With regular practice, it gives

him an intimate familiaritywith what tension—as well as complete relaxation—feels

like in different parts of the body. This can help her to react to the first signs of the

muscular tension that accompanies stress. And as her bodyrelaxes, so her mind will

also remain relaxed. Progressive muscle relaxation can be combined withdeep

breathing for additional stress relief. Following instructions were given to the client:

 Start at your feet and work your way up to your face, trying to only tense those

muscles in-tended.

 Loosen clothing, take off your shoes, and get comfortable.

 Take a few minutes to breathe in and out in slow, deep breaths.

 When you’re ready, shift your attention to your right foot. Take a moment to

focus on the wayit feels.

 Slowly tense the muscles in your right foot, squeezing as tightly as you can. Hold

for a count of10.

 Relax your foot. Focus on the tension flowing away and how your foot feels as it

becomes limpand loose.

 Stay in this relaxed state for a moment, deeply and slowly.

 Shift your attention to your left foot. Follow the same sequence of muscle tension
and release.

 Move slowly up through your body, contracting and relaxing the different muscle
groups.

 It may take some practice at first, but try not to tense muscles other than those
intended.

Progressive muscle relaxation was taught to the client. The client has
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explained the whole procedure in which she was told how to stretch her major muscle

groups and then relax them systematically, then she did the exercise according to the

instructions. It provided a way of identifyingparticular groups and distractions

between sensations of tensions and deep relaxation. It was taught tothe client to

distract herself from stress, negative thoughts, and muscle tension.

Medication Adherence.

Medication adherence was provided to the client in the 6th session and she was

educated about medication reduces the risk of relapse and hospitalization. The

benefits of medicine were told to the client that taking medicines reduces the

symptoms of illness. The principle of medication management was also explained to

the client. The client was asked to follow the prescribed medicine only. If the client

noticed any side effects, then she should inform the doctor before taking any step.

The client wastaught that every medication has some side effects, she should not stop

the medication abruptly withoutconsulting the doctor.

Anger Control Tips.

Some anger control tips were given to the client in the 8th session. Anger

management is a termused to describe the skills you need to recognize that you, or

someone else, are becoming angry and take appropriate action to deal with the

situation in a positive way.

I gave her some tips to control her anger:

 Recognize your anger early

 Remain silent

 Delay your reaction

 Change position

 Think of the consequences

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 Breathe deeply and slowly

 Focus on the issue, not the person or past

 Stick to ―I statements

 Once you are calm, express your anger

 Get some exercise

 Identify some solution

 Take a timeout

 Do counting

Sleep Hygiene Tips.

The following are the sleep hygiene tips given to the client in the 5thand 6th

sessions to balance hersleep and to have normal sleep.

 Go to bed only when sleepy

 Develop sleep rituals to let your body know to prepare for bed

 Don’t take your worries and responsibilities to bed

 Have a light snack before bed

 Take a hot bath 1-2 hours before bed

 Stay away from caffeine, nicotine, and alcohol at least 4-6 hours before bed

 If you cannot fall asleep to the point of becoming frustrated, get up and do

something relax-ing or boring until you feel sleepy

 Maintain your bedroom temperature

 Keep daytime naps below 20 minutes

 Keep your bedroom pitch black at night

 Regular exercise is a good idea to help with good sleep.

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Self-Control and will Power.

A baseline chart was given to her to maintain a record of her daily routine,

how many times sheused to spend her time and thinking. It was demonstrated to

patients how to fill the chart during the session and it was ensured that the patient was

clear what was require. The patient was teaching to takecontrol of her distorted

thinking and behavior. She became able to control a little bit of behavior and thinking

with his will power.

Activity plan.

The activity plan was designed for her according to her circumstances.

Activity charts cover her daily life activities including her meals, avoiding using

the washroomagain and again for hand washing and shower. Going back to the shop

etc which was difficult for her to follow in the start but later she starts following,

including exercise.

CBT.

 Executing tips

 Exposure graded

Limitation:

 limited amount of information was available due to hypothetical case

 Detail interview and assessment tools was not possible

 As no therapeutic intervention was applied in reality so efficacy of

the outcome of theseinterventions could not be assessed in the

particular case scenario.

Recommendations:

 Self-Help tool is to learn good coping strategies for dealing with stress like

getting enough sleep,eating well, exercising, meditation, and sticking with the
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treatment plan.

 Medication can be helpful for managing compulsive behaviors or related

mental healthchallenges.

 Many people who struggle with compulsive behavior find support groups to be

beneficial.

 Spend quality time with family and peers in social manner.

 Engaged child in active play.

Sessions Reports

Sessions-1 12-05-21

 Rapport building

 History of present illness from the client and the informant

 Mental state examination

In this session rapport was building and taking the history of present illness from

client and informant and try to examine the mental state examination.

Rapport was building during session.

Session-2 13-05-21

 Mental state examination (Completed)

 Background information from patient and informant

 Beck Anxiety Inventory was administered

In this session observer complete the mental status examination. Background

information from patient was taken. And beck anxiety inventory test was

administered.
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Session-3 17-05-21

 Sleep hygiene tips

 Medical Adherence

 Psycho education of the informant

Session-4 20-05-21

 Sleep Hygiene tips were given

 CY-BOCS was administered

In this session observer gave the tips of sleep hygiene due to lack of her sleep and

children Y-bocs test was administered.

Session-5 24-05-21

 Homework was revised

 Planned Activity Schedule

 Coping Statements were suggested

In this session observer giving the tasks to client and observer check the homework

which was planned of her activity schedule of her hand washing in which observer

check the how many times client washed her hands and coping statements were

suggested.

Session-6 1-06-21

 Homework was revised

 Relaxation Exercise was done

Session-7-8 3-06-21

 Homework was revised

 Self-control training was done

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Session-9-10 10-06-21

 Homework was revised

 Anger control tips

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References

 Kalanthroff E., Marsh R., Hassin R.R., Simpson H.B.Evidence for trial-by-

trial dynamic adjustment of task control in unmedicated adults with OCD

Behaviour Research and Therapy, Volume 126, 2020

 M S.J., Lee S.-A., Ryu H.U., Han S.-H., Lee G.-H., Jo K.-D., Kim J.B.

Factors associated with obses-sive–compulsive symptoms in people with

epilepsy Epilepsy and Behavior, Volume 102, 2020

 Hollander, E., & Wong, C. M. (1995). Obsessive-compulsive spectrum

disorders. The Journal of Clini-cal Psychiatry, 56(Suppl 4), 3–6.

 Rasmussen, S. A., & Eisen, J. L. (1990). Epidemiology of obsessive

compulsive disorder. The Journalof Clinical Psychiatry, 51(2, Suppl),

10–13.

 Weissman MM, Bland RC, Canino GJ, et al. The cross national epidemiology

of obsessive compulsivedisorder. J Clin Psychiatry 1994; 55 (suppl): 5–10.

 Murray CJL, Lopez AD. Global burden of disease: a comprehensive

assessment of mortality and mor-bidity from diseases, injuries and risk

factors in 1990 and projected to 2020. vol I. Harvard: WHO,

 https://www.psychiatry.org/patients-families/ocd/what-is-obsessive-compulsive-

disorder.
Appendix-III
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Case Summary

The client was 7 years old boy. His parents brought him to Noor Zainab Rehablitation

School with complains of stubborn behavior, speech problem, difficulty in reading

and writing, poor concentration, moody. There were total 13 sessions were conducted

with him. For the Informal assessment behavioral observation, clinical interview, and

the formal assessment Portage Guide to Early Education (Bluma, Shearer, Froham &

Hilliard, 1976) were administered. He was given the diagnosis of Cerebral Palsy

along with mild Intellectual Disability. In the management plan of the client Rapport

was built with the client and then the items of IEP were managed with the help of

behavioral modification techniques like through physical, visual and verbal prompting

with reinforcement, fading, shaping, chaining etc.

Bio Data

Name A.A

Gender Male

Age 7 years

No of Siblings 04

Birth Order 4th

Informant Mother
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Reason of Referral

The client is a student at Noor Zainab rehabilitation center. He was referred to the

trainee clinical psychologist for the assessment and management of complaints such

as of speech, excessive repetition of words, short attention span, poor on-seat

behavior, poor social interaction lack of socialization, and stubborn behavior to the

trainee clinical psychologist. Child was referred by the clinical psychologist for the

purpose of psychological assessment and management of his behavioral, learning and

academic problems

Presenting Complaints

Table 1

Presenting Complaints by the teacher

Presenting Complaints Duration

Attention Seeking By birth

Crying By birth

Aggressiveness By birth

Don`t Share things By birth

Family History

The child belongs to nuclear family system. They have total 5 members in

house which included his parents and his younger sister and brother. The client was

elder. The entire family members were cooperative and loving with each other.

The child’s father was about 45 years old at the time of his birth. He was not

educated. He was a street seller, he sell balloons. The relationship of child with his

father was loving as he was the only son in his family and he received attention from

everyone.
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The child’s mother was a housewife and she was 40 years old at the time of

client’s birth. She was not educated. The relationship of mother and client was loving.

The child was very attached with his mother as she was caring towards him and

fulfills his all needs.

The client was elder among siblings his birth order was 1st he had one

younger sister and one brother. Both of his sibling were going to mainstream school.

He had a good relationship with his siblings.

History of Present Illness

As per teacher report client has difficulty in reading and writing since he got

admission in this school. He did not recognize the alphabets. He had ability to trace

the dots.He also has limited verbal skills. Client has speech problem from birth as he

cannot speak properly. He answered in one word but the listener cannot understand he

is saying. Because of this he never participate in other conversation.

Client is not very social. He used to sit alone in his class. He did not

participate in class activities. As he observed in playground where he did not play

with other students and sit alone.He did not have social interaction as he does want to

talk with anyone. He does have any friend and sit alone in corner.

He is having problem in making friends as he does not want to share his

personal stuff with others. He is slow in every task and has difficulty in concentrate.

Personal History

The Client's mother conceived him when she was 28 years old. There was

some difficulty a mother had felt during pregnancy i.e she had high blood pressure

issue and toke medicine. According to mother he had pre-mature birth (8 months).

Client birth was normal at Jinnah hospital, the mother said the client cried after the
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birth there was no delay in his cry but she reported that the client was so much tiny

and underweighted she reported that the size of her client was equal to her hand, he

was that tiny at the time of birth, his birth weight was 5 pounds (approximately) the

client was shifted to incubator for few days and after birth.

At the age of 10 months, the mother noticed that he had developmental delays

i.e he did not hold his neck, he started crawling at the age of 1 year. He started sitting

with support at the age of 2 years.

The client was 6 years old and he is the elder among siblings, after coming

back from school the client’s daily routine was reported by his mother , she told about

his interest and activities she said the child after coming back to school came to home

didn’t change his clothes , he found her sister and started playing with her after that he

took lunch and then turned on TV and started watching cartoons with her sister after

finishing his lunch he changed clothes and got fresh and then he started playing

cricket , his favorite hobby reported by his mother was cricket and watching TV with

sister. But he did not talk or give attention to others. Most of time he played alone and

did not showed any social behavior.

Educational History

The client started his education from 4 years old. The child’s mother reported

that he was physically weak from the birth as he was born after 8 months. His

millstones were delayed, so he did not went to any school before because he had a

language deficit. His doctor told his parents about NSES and then his parents admitted

him in this school. He did not read and write properly, even he did not write A

without tracing. He was not social in class room setting. He sit alone in class and only

did not participate in some vocational activities. The client improved a lot after
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management, he did not talk but he performed his daily life activities well. The

academic performance was improved as compared to before coming in this school

Table 2

History of Developmental Milestones

Milestones Achieved Age Normally Achieved

Neck Holding 3 months 3 months
Social smile 3 months 2 months
Sitting 1 year 6 months
Crawling 1 year 2 months 6-9 months
Standing 1 ½ year 10-12 months
Walking 3 ½ year 9-18 months
Speech Not yet 13-18 months
Bladder & Bowl Control Not yet 2.5-3 years

Informal Assessment

Informal assessment involves observing the learners as they learn and

evaluating them from the data gathered. It can be compared to formal assessment,

which involves evaluating a learner's level of language in a formal way, such as

through an exam or structured continuous assessment.

Clinical Interview Clinical interview was carried out in a well-illuminated

environment with child’s teacher. Interview was conducted to identify child’s

problem, history of present illness and stressors to identify the possible causes of the

child's current problem. Child’s background history, personal history and educational

history was also explored to get a complete picture of anticipatory and maintaining

factors. His academic and classroom performance was also explored during the

interview. Child’s teacher was cooperative and compliant during the interview. She
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shared all the details that could possibly help in diagnosis and proposing an effective

management plan for the child.

Behavioral Observation The child was of average height and weight. He was wearing

neat and tidy warm clothes which were appropriate to the weather. The child was

walking on his toe as observed while he was entering in the class room. He was

continuously wiggling his fingers while sitting in the chair. He seemed to be a

compliant child as he followed instructions of his teacher but with a little delayed

response of 2 to 3 seconds. It was also observed that he was avoiding eye contact. He

was trying to hide his face with both of his hands for about 2-3 times in every 5

minutes. He used to smile in an inappropriate manner for 3-4 seconds in every 10

minutes and stopped laughing on the instruction of his teacher. He could hardly speak

a single word whenever he needed anything. He could imitate a few words uttered by

his teacher like name of colors i.e., red, blue, green, yellow. He told his name when

asked by his teacher.

Formal Assessment

Portage Guide to Early Intervention Portage Guide to Early Education is a home‐

based early intervention service for developmentally delayed preschool children. It

consists of the triadic model of service delivery, a set of reading materials and a

method of training parents to teach their own children. Each of these components is

critically evaluated and recommendation made for the future development of portage.

Outcome studies are reviewed and evidence is found of developmental acceleration

for mildly delayed child. (Sturney& Crisp, 2006)The potage guide was devised by

Susan Bluma in 1969. It is a behavioral checklist or curriculum planning device

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intended to assess the child’s present behavior, target behavior. The mental age range

of portage guide is 0-6 years.

The purpose of portage guide was that it was administered to child because the

child didn’t perform the complex task and because of the child functional level was

minimum so the portage guide was used to assess current functioning of child.

Different aspects of client’s development were assessed with the help of portage guide

to early education. Client’s mother was asked some questions while other items were

administered on the client by the therapist herself.

Quantitative Interpretation

Table 3

Area Functional Level

Socialization 2 years 2 months
Self Help Skill 1 year 5 months
Language 1 year 2 months
Cognition 2 years 3 months
Motor 11 months

Qualitative Interpretation

The client’s functional level is 2 years 3 months which is behind her chronological

age that is 7 years. His functional level in motor, language, socialization, and self-help

areas is also behind his chronological age.

List of Reinforcers

Rein forcers were identified for the child in order to be used for strengthening child’s

performance and learning. The rein forcers were identified by using Rein forcer

identification checklist from the teacher and also from child’s mother. The reinforcers

identified for him were chips, Games on Tab, Coloring, and Drawing.
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Diagnosis

The child is diagnosed with Cerebral Palsy Along with Mild Intellectual Disability.

Case Formulation

The Client is7 year’s old boy. The presenting complaints reported by his teacher were

his shy behavior, speech problem, difficulty in reading and writing, poor socialization.

The child was observed in different settings in which his early readiness skills were

observed and identified the child early readiness skills were developed except his

speech as he was not able to talk. To assess the child’s problem Portage Guide to

Early Education, along with behavioral observation and clinical interview were

conducted.

The case was formulated according to bio psychosocial model. According to

biological predisposing factor it was reported that the child was so tiny and weak and

have a very low birth weight at the time of birth. According to WHO a birth weight

below 2,500 grams is the leading cause of infant and child mortality and contributes

to several poor health outcomes(WHO,2004) .previous studies reported that It is

associated with poor neurological and cognitive development, childhood morbidity,

growth impairment, a range of poor health outcomes, and chronic diseases later in

life. It is a cause of both short-term and long-term consequences leading to adverse

social and economic impacts (Magnesia, 2017).

The precipitating factor was the child’s delayed milestones such as his language

problem. Early studies reported Delays in speech and language acquisition are an

early indicator of developmental deficits that can affect academic performance for

children in school. Rodriguez and Higgins (2005) indicate that young children who
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learn to master basic interpersonal communication skills, cognitive and language

skills will be successful in academic and social settings.

The mother of the child reported that he was the most lovable kid among in his family

and his all wishes were fulfilled by his family and he spoke at home whatever he

needs, but in school it was observed that he remained silent as he was under the

pressure of teachers and he had to follow rules which might be his maintaining or

perpetuating factors. Overprotective parenting in low-risk environments may have

negative consequences for the psychosocial development of children and youth.

Though not well studied, a number of different bodies of literature can be used to

speculate on the reasons for overprotective parenting and the impact it has on

children.(Gagnon 2019). The protective factors were the support of client’s parents as

they were loving and caring towards him.

Management Plan

The management plan of the client is based on behavioral modifications.

Short Term Goals

 Rapport building with the client.

 Psycho-education was done with the client’s parents about the causes and

current severity of client’s problem.

 Positive reinforcement will be given when the client performs well on

homework.

 Modeling, verbal, gestural and physical prompts were used for improving fine

motor skills such as coloring and drawing.

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 Forward chaining and backward chaining were used to teach client to follow

rules in game as identified by portage guide to early education.

 Overcorrection will be used for minimizing the shouting and aggressive

behavior in client.

Long Term Goals

 Continuation of long term goal.

 Follow up session.

Summary of Therapeutic Intervention

Psycho-education Psycho-education is an educative method aimed to provide

necessary information and training to families with psychiatrically ill persons to work

together with mental health professionals as part of an overall clinical treatment plan

for their ill family members. In the present case psycho-education will be given to

client’s parents.

Positive Reinforcement. When a pleasant stimulus is presented as a consequence of a

person’s performing a behavior, it is known as positive reinforcement, and the

consequence is positive reinforce (Speigler & Guevremont, 2010). In the present case,

rein forcers will be identified and then they will be given to the client on performing

well in homework like drawing, coloring, pasting and grafting. When clients will give

full attention on her task then therapist give positive (Tangible reinforces)

reinforcement toys, CDs and cards. And client work with therapist and follow

command then therapist give social reinforcement like good, excellence and yes you

going good continue. Therapist smile and say ‘good or superb’ every time when client
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perform good. Primary reinforces like candy used as a reward at the end of task

completion.

Shaping. With shaping, the components of a target behavior are reinforced rather

than the complete target behavior. Successively closer approximations of the total

behavior are reinforced so that finally the complete behavior is reinforced (Riess,

1970). For example rule of games will be taught with the help of shaping.

Chaining. Chaining involves hand over hand prompting to learn the behavior

sequence. In forward chaining, behaviors are developed in the order in which they are

supposed to occur in skill sequence (Matson, 2009).To teach the complex task like

eating, tooth brush, wearing shoes, wearing shirt, the technique of chaining was used.

The complex task was then analyzed into small components and each step is

prompted and the achievement of task itself served as reinforce. The mother was told

to help the client with physical and verbal prompts in the beginning and as he starts to

gain independence, the mother was taught to fade the prompts, reinforce taking off the

shirt and move on to the other step once the mastery has been achieved in the step

taught. Through a series of steps, by moving this way from one step to the other, the

client’s mother was asked to teach him the required skills. For example, teach her

eating meal training. When therapist learn the eating behavior. Therapist to make a

task and divide into steps. Therapist used backward chaining for learn eating

behavior. 1. Open your mouth and eat the rice. 2. Spoon bring to the mouth. 3. Put

Rice on the spoon. 4. Put the spoon into the plate.5. Hold the spoon into the hand.
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Outcome

The therapy outcome did not reveal much of the difference in her condition

overall. Taking permission before using objects and basic social skills were improved

are little but other skills involving IEP, there was hardly some improvement observed.

Pre and Post Rating of the Goals of the Child

The post assessment of client on IEP revealed that she was better able to group

the things related to socialization as she was a social child and liked to interact with

people. It was also found out that the client was not able to understand the cognitive

tasks and she was not able to learn them.

Limitations

Sessions with the client were conducted mostly on consecutive days, which

may have resulted in tiredness on the part of the client in term of mental effort. Also,

it provided to the rather hectic for the counselor as daily visits to the hospital were

required. This may have affected the counseling relationship and the process of

session.

Suggestions

 The client and her family should accept the fact that the client’s physical condition

has a chronic and gradually progressive nature and is not completely treatable.

Therefore, it needs to be managed in the best way possible with the least degree of

disability.

 The client and her family need to realize that they have to work together in order

for the treatment of work.

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 The client and her family should be prepared that it may be slow and long process

for the client to learn to adjust to her current state.

Sessions Report

Session No: 1 25-10-21

 To build rapport with client

 To find out the problematic area of client

In the first session the child was observed in classroom settings in which he was

observed during different periods like classroom, lunch break, he was also observed in

playground setting. The outcome of the session was that a number of information

about the child behavior and his Early Readiness Skills in different setting was

obtained and a brief session of rapport building was done. And Assessment was

started of two domains on the first session.

Session No: 2 2-11-21

 Identification of Re-enforcers

 To administered the PGEE

In this session the assessment of Portage Guide to Early Education was completed

and two domains were covered during this session. The child was cooperative and

assessment was completed in this session.

Session No: 3 13-11-21

 To administered the PGEE

In this session the next two domains of Portage Guide to Early Education was

covered. For rapport Building his favorite coloring activity was done.
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Session No: 4 22-11-21

 To administered the PGEE

 To administered sllosoon Intelligence Test

In this session the last domain of Portage Guide to Early Education was completed.

Trainee clinical psychologist tried to apply Sllosoon Intelligence Test but the client

had language deficit that's why we could not administered the test.

Session No: 5 23-11-21

 Try to develop self-help care tips

In this session management was done on the items of portage Guide including

language, socialization and cognitive, self-help etc.

Session No: 6 1-12-21

In this session the management was started from socialization. Because he is

very shy. Clinical psychologist practice greetings (say thank you and welcome and

please) by involving Co therapist.

Session No: 7 2-12-21

In this session client learned sharing through group activities (passing Ball,

colors and pencils). The client seems very happy during this activity.

Session No: 8 6-12-21

In this session color identification was started. Client learned two name of colors and

identify them. Client seems happy by achieving this goal.

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Session No: 9 7-12-21

In this session clinical psychologist take review of the last session. Revise the

last session activities and then client learned one new color name and identify it.

Client start taking interest in the session.

Session No: 10 8-12-21

In this session the clinical psychologist take review last session activity but the

forget the name of colors which he learned in last session. It may be because of less

practice. Trainee clinical psychologist again repeat this activity but this time client

easily learned the name of colors.

Session No: 11 13-12-21

This day client seems down because he was not looking well. He did not show any

interest towards the activities.

Session No: 12 15-12-21

In this session the client seemed euthymic. Trainee clinical psychologist revise

last session activity. Client shows positive result about it. Client learned one more

color name in this session.

Session No: 13 16-12-21

In these sessions the management was done on the items of portage Guide including

language, socialization and cognitive, self-help and motor domain. The child faced

difficulty in language and socialization domain as his speech was not developed. The

child was cooperative during the management sessions different items were repeated

from the first management session as well.

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References:

Campbell, J. P. (1990). Modeling the performance prediction problem in industrial

and organizational psychology.

Cox, J. A., & Boren, L. M. (1965). A study of backward chaining. Journal of

Educational Psychology, 56(5), 270.

Demchak, M. (1990). Response prompting and fading methods: A review. American

Journal on Mental Retardation.

Sturmey, P., & Crisp, A. G. (1986). Portage guide to early education: A review of

research. Educational Psychology, 6(2), 139–157.

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Appendix-IV
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Case Summary

S.A. was 10 years old in special education institute, 10 sessions had been done with

him. His teacher reported that he had physical weakness, inability to speak and

inactivity. According to the PGEE the overall discrepancy between his chronological

and functional age was 6-7 years, first rapport was build and after that coloring was

done which was not within the boundaries. For the management purpose ITPs were

developed, reinforcers were identified. Behavioral therapeutic techniques were used

to deal with his complaints. Chaining was used to make him able to hold the pencil in

appropriate manner by providing physical and verbal prompts, afterward work was

done on his prewriting skills. He had identification of colors but concept of

boundaries was not present. Physical, visual and verbal prompts were given to him to

give him concept of boundaries. The child would be referred to the speech therapist so

that he would be able to speak more than one word.

Identifying information

Name S.A

Age 10 years

Gender Boy

Class Green group

No. of sessions 10

Date seen 12-10-21

Last date seen 20-12-21

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Source and reason for referral

The child was referred by his teacher for the assessment and management of

his speech problem, problems of physical weakness and inactivity.

Presenting complaints by the teacher

Table 1

Presenting complaints of the child by the teacher

Duration Presenting Complaints

Last 2 years Speech problem.
Last 3 years He is physically weak
Last 4 years He can’t do his work properly.

Initial Observation

S.A was a boy of 10 years in special education. The child was doing his class

work with his other fellows in a group activity; the client was doing his drawing paper

with the aid of his class teacher. He came to the trainee on the request of his class

teacher, on saying salaam he shakes hand with the trainee but didn’t give any

emotional response. His hygiene was good, he was wearing appropriate uniform but

his teeth were not brushed, his nails were not trimmed.

He showed 95% compliance to the trainee, he had proper on seat behavior,

during whole session he left his seat to use washroom by the permission of trainee.

His self-help skills were developed enough so that he could help himself in public as

he was toilet trained, he could button and unbutton his shirt and can also zip his pent

etc.
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He establish and then maintained eye contact with the trainee, it was easy to

build rapport with the client according to his interests. He was physically weak, his

muscles were not working appropriately, and his lower limbs were stiff which was

causing difficulty for him to walk properly. His inflexible muscle tone was also

affecting his hands due to which he was not able to hold the pencil appropriately and

was not able to imitate any written thing.

History of Present Problem

The problem of the child started from his birth, as his father and mother were

in contingency relation their genetic make match like this that dominate the recessive

genes which cause this medical condition to their child, also effecting his

psychological functioning. The child achieved his milestones at the late age because

of his muscles weakness, his hands and feet were bended inwardly that make it

difficult for him to walk balance and hold pencil in his hand strongly.

He jerks forward while walking, his walk was no balanced due to which he

fall many times, as it was also told by his mother that he start walking again but when

he walk he walks in a very fast speed due to which he fell down most of the time. He

fall again and again because his walk was not balanced and he got severely injured

most of the time, also effecting his physical health. Due to his muscle weakness and

speech problem his parents took him to a physiotherapist in Mayo hospital at the age

of 6 years who gave him some medication and recommend him some exercise with

the tongue, to help him able to speak. His exercise plan was no followed properly

which doesn’t produce any fruit full results, he also gave some physiotherapy session

for 3 months but due to the negligence of the parents those sessions were no

continued.
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He had one word speech, and was not able to produce any other sound other

than this word was due to his small jaw bone, air didn’t filled in his mouth enough to

produce pressure to make sounds or words. In home he was in constant supervision of

his mother and he was attached to her more than any one.

He father was no willing to send him school because when his mother wake

him up for school he start crying, to avoid his behavior of crying and discomfort his

father always was reluctant to send him school. He got admission in school when he

was in 10 years, before that he was in his home getting training by his mother. He got

admission in Cerebral Palsy unit, there he got slapped by his teacher, and due to his

behavior he left school and showed reluctance for the school. Now he came back

school after a year not in the same section but in the special group class of Mental

Retardation section, where he was not getting proper training according to his needs.

He had poor pencil grip, can snip but was not able to cut the paper.

Background Information

Personal history. The client was born normally, at the time of birth his
structure was short, he was physically weak, and his weight was less than normal.

Table 2

Developmental Milestones: normal age of the child and normal age of achievement

Developmental milestones Age of achievement Normal Age of

Achievement
First cry Late Immediate after birth
Head holding 2 ½ years 4-6months
Walking 07 years 12-14 months
Talking(one word speech) 07 years 3 years
Toilet training 8-9 years 2.5-3 years
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His developmental milestones were not developed normally; he took more

time than normal to achieve his major milestones. The child got early in the morning

with the physical and verbal instructions of the mother, he always don’t want to come

to school, and when he came to school he kept on asking when will be the school off.

He take part in every activity of the class, he was very active and curious.

After going back to the school he got fresh by his own and changes cloth by

the help of his mother and sister, he took his lunch by his own but with the verbal

instructions of his mother. He set his food on dinning by his own and clean mess after

taking by his own too.

He was very active in the home too, he tried to take part in every chore with

his mother, he tried to clean utensils with her, want to wash clothes with his mother

etc. According to his mother he had his own cupboard and drawer like his other

siblings and he love to manage his belongings in his drawer. He loved his father so

much, he wait for his father till late night to meet him and to show him his things and

share his routine with his father. His father was not warm welcoming person as he

came late from his tuff job, he was not able to provide such emotional warmth to his

child, and for this his child feel rejected for some times.

He was not aggressive, abusive, destructive and antisocial, but he showed

some possessiveness and withdrawn symptoms. He loved, friendly, cheerful,

cooperative and playful that’s why it was easy to build rapport with him. He liked

colors, playing with blocks. His first reinforcer was verbal appraisal and stickers of

stars.

Educational history. He started his education from his home, as he lived in a joint

family system so he got more social support from his home. He was been there at
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special education school from last two years, first he was in cerebral palsy unit. At CP

unit his teacher hit him, as a result he starts showing behavioral problems, and he

refused to sit in class, due to his this behavior he was shifted to the Mental

Retardation section. At first he showed some adjustment and onseat behavioral

problems but with the teacher’s concern he adjusted in class, start interacting with

fellows. No history of informal education was available.

Family history. According to the information given by the teacher, the client belongs

to joint family system of middle socio economic status. His parents were cousins and

then they got married. In his family he had father, mother and 4 siblings (2 brothers, 2

sisters).

At the time of marriage his father’s age was 27 years, he was in police.

According to his teacher his father was a strict person, who doesn’t want anyone to

know about his child’s disability. He wanted his child to be at home, and doesn’t want

him to get education of any formal type; he was also against of his schooling. He also

didn’t show affection and concern about his child’s condition; rather he took him as

punishment from God.

He loved his father so much, he wait for his father till late night to meet him and to

show him his things and share his routine with his father. His father was not warm

welcoming person as he came late from his tuff job, he was not able to provide such

emotional warmth to his child, and for this his child feel rejected for some times.

The child was more attached to his mother, she was a house wife. At the time of

marriage her age was 25 years, and the time of H.I.’s birth she was of 30 years. She

was motivated and was concerned about the condition of her son, she wanted him to

be that much independent so that he could survive in his life and could show
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appropriate public behavior. He got his basic training from his mother; she taught him

basic self-help skills and toilet training.

He had 4 siblings, 2 elder sisters than him and 2 brothers younger than him.

He was attached to his siblings. He was more attached to his elder sister who was very

loving, caring and sharing with him, she also help him in his studies. He was not

attached to his elder brother, his elder brother didn’t liked him due to his physical

disabilities. He was also attached to his younger sister as he used to play with her, she

also shared her toys and things with him in return he also gave her, his own gifts. He

got into fight with his younger brother who didn’t gave his things to him to play with

them.

History of psychiatric/ medical illness. Family history of the problem was founds, he

two first cousins one from maternal family and one from parental family was also

suffering from the same problem.

Provisional Formulation

According to the clinical observation and assessment:

 His physical weakness might be due to his medical condition, as his muscles

were stretch, stiff and weak.

 He can’t speak proper words might be this problem was due to his same

muscle weakness that caused stretched jaws problem or might be his jaw bone

is small than normal causing sound production problems. This might also be

due to ignorance of the parents, may be no one taught him how to sound

different words.
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 His writing problem may be caused by his muscle tension and not proper

development of the muscles, as he was motivated to write but with physical

assistant, this can be the possibility that no one give him the exposure to write

by his own.

 As he can’t color within the boundaries and can’t imitate, there might be some

brain organicity resulting in poor eye hand coordination of the client.

 Due to the cousin marriages trend in his family, the recessive gene having

traits of the disorder become dominant and become cause of his problems.

Assessment

Assessment was done by using different assessment techniques:

 Behavior observation

 Reinforcers were identified

 Clinical interview

 Drawing

 Portage Guide to Early Education (PGEE) (Bluma, Shearer, Frohman

and Hilliard 1976)

Behavior Observation: Behavior observation was done to check the behavior of the

child in different settings, to see his interaction level with other fellow students, his

participation in the class, his level of understanding and comprehension. Behavior

observation was done in different settings:

Classroom observation. In class child’s LRS were observed, he had attention span of

60 seconds, he had proper on seat behavior, he maintained eye contact with his

teacher, and his comprehension toward his teacher was also good. He was following

her instructions to complete his paper this shows that he had the ability to
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comprehend. He was doing his paper with the help of his teacher; she was giving him

both physical and verbal aid. He was not holding his pencil properly; his grip on

pencil was very weak.

His hygiene was good; he was wearing appropriate, neat and clean uniform.

He was an active child in the class was taking part in every class activity. His

behavior with other fellows was indicating his socialization. He came to the trainee by

the request of his teacher, he shakes hand for salaam but didn’t show any emotional

response.

Playground observation: The child was also observed during his break time. First he

collects his all belongings, put them in his bag and take out his lunch on the request of

his teacher. He started his lunch with the permission of her teacher; he also shared his

lunch with his fellows without the request. In the play time he participated in the play

whole heartedly, he took his turn; he was talking to his fellows nonverbally. She

didn’t go out from his class, as it was instructed by his teacher, during all the time he

was sitting on his seat and didn’t left it once.

Session observation. The client was an active and curious participant of the session,

child take interest in every activity given to him. It was easy to build rapport with the

child as he was a social child, he showed 95% compliance to the trainee in first

session, he maintained eye contact, and she didn’t left his seat during the whole

session, he goes for the toilet 2 times by asking permission of the trainee. His gross

and fine motor skills were not well developed as he was not able to do his work

without any physical aid. His self-help skills were partially developed as he was able

to button and button his shirt but wasn’t able to wear his shoes.
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Reinforce Identification: Reinforce identification was done to immediately reinforce

the child in a positive way to strength and to increase the frequency of desired

behavior and to diminish the occurrence of undesirable behaviors causing problems

and affecting the performance of the child. To identify top prior reinforces child was

given different things of his likeness and after list was prepared. Reinforces were

provided right after showing the desired behavior instead of the undesirable behavior.

Reinforces were selected according to the likes and dislikes of the child so he actively

participate in the learning.

Table 3

Reinforcer of the child according to the priority level

Priority level Type of Reinforces Reinforce

01 Activity reinforced Coloring
02 Drawing
03 Cutting
04 Tangible reinforced Cards
05 Star’s stickers
06 Social reinforce Verbal appraisal

Clinical Interview: Clinical Interview was conducted to assess the level of the

problematic behavior of the child through his teacher’s and mother’s perspective.

Interview was constructed having qualities of both structured and unstructured type of

interview, it helps in getting right to the point of the problematic behavior and it key.

Clinical interview with the teacher: As the child was referred by his teacher, so

teacher’s interview was also taken to know about the most frequent problematic
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behavior of the child and to know more about the case history of the child. Teacher’s

interview was also taken to get baseline about the problematic behavior of the child

and teacher’s reaction and understanding of his problem. The teacher told the trainee

about the most frequent problematic behavior of the child for which he was referred

for the assessment and management. The teacher’s perspective on the setting of the

goals was also taken.

Clinical interview with the mother: Clinical interview with the mother had been

conducted to assess the level of problematic behaviors in the home settings.

According to his mother there were two of his cousins, one of his paternal aunt’s

daughter and one of his maternal uncle’s daughter was also suffering from the same

problem. She told that there was no problems during the pregnancy, the child birth

was also normal, but his first cry was delayed, his structure was normal but his weight

was not normal, he was physically weak. She told that he was been in home for eight

years and get trained by his mother, they also saw a doctor to know about the problem

of their child but they didn’t continue his treatment due to their own negligence. She

told that he was a very active and hyper kid, who want to take part in every activity

and was very possessive about his things.

Drawing: Drawing and coloring was done to assess the imaginative power of the

child, and to assess his fine motor skills, his eye hand coordination, and his

recognition of colors and concept of boundaries. The client was very fond of coloring;

he didn’t have concept of boundaries. He had orientation of almost 7-8 colors. His

pencil grip was not strong as he was not able to hold pencil properly. He was not able

to hold pencil proper with strength due to his weak muscles. He also didn’t write

without the physical assistance of others. If he tries to hold pencil with strength he
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exert so much force and pressure on the pencil and make lines very dark and strong,

leading to misinterpretation of aggression.

Portage Guide to Early Education: Portage Guide to Early Education (Bluma,

Shearer, Frohman and Hilliard 1976) was administered to the child to assess the

child’s present behavior on the areas of socialization, self-help, cognitive, language

and mot The overall discrepancy between child’s chronological and mental age was

found to be 6-7 years or.

Table 4

The functional age of the child on five areas of PGEE

Areas Functional Level

Self help 4-5 years

Socialization 4-5 years

Cognitive 4-5 years

Motor 3-4 years

Language 1-2 years

Qualitative Interpretation: The child was boy of 8 years, the overall age discrepancy

between child’s chronological and functional age was found to be 6-7 years. The self-

help skills of the child were partially developed. He knows how to dress himself,

buttoning, and wearing his shoes. He knows how to eat in proper way. He was toilet

trained and he asked the trainee to go for the toilet, knows to wash hand after using

toilet, can also wash his face and brushes his teeth’s. He can button his shirt but he

can’t unbutton it, he can’t comb his hair. He can’t find front of clothes too. He can
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wear his shoes but can’t tie and lace them. He knew about the correct utensils used for

food like glass for drinking water and spoon for bringing food into mouth. He avoided

common hazards as he knew knife and broken glass is dangerous for him.

The child was social as he was sharing his colors with his other fellows; he

showed full compliance to his trainee. He took part in group class task and play with

his fellows. He also greet adults by shaking hand and pull the psychologist to show

his work, but with all these abilities he was not able to speak he had one word speech

which sometimes make it difficult to communicate with him, and for him it becomes

difficult to convey his message properly. He asked permission only from the teacher

and therapist but did not ask permission to use things of the class fellows. He showed

feelings of love, laugh and sad but did not understand and verbalizing it as he didn’t

have language.

The age discrepancy between children’s chronological and mental age on the

area of cognition was 3-4 years. His strengths in this area where he can recognize

different colors i.e. red, blue and green etc. He knew about her identity as ask her “H.I

kahan hy?” he pointed himself and said “Mai”. He can also differentiate between

different shapes of the objects, he know alphabets and counting. He understood the

meaning of in, on and under as he asked to put note book on the table, in the bag and

under the table. He can also point toward the body parts like eyes, nose, lips etc, can

also points to the short and long object, can also differentiate width and height, but he

can’t imitate the figure of any kind like square or circle drawn in front of him. He

can’t draw v strokes, he can’t print his first name, also could not color with in

boundaries.
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On the area of motor the age discrepancy between the chronological and

mental age of the child was found to be 4-5 years. His strengths in this area where he

could walk independently, he could hold his pencil, can handle his bag and books. He

can also walks up stairs with alternating feet, he can kick large ball, he can also build

tower by using blocks but there were some problems too due to his physical weakness

he couldn’t walk properly he walks on his toes, he can’t jump but he take steps too

fast to maintain his balance.

Language skills of the child were not developed properly, the age discrepancy

between the chronological and mental age was 6-7 years. He had one word speech but

he tried to produce sounds by imitating others. He used gestures to make others

understand what he trying to say, he could also answer the simple questions with

nonverbal language (how may siblings they are? & how he comes to school?). He

could points towards other objects when asked or named (pencil, colors, shoes, table

etc), but he can’t produce any sound rather than the single word (Mama), except this

all he tried to speak sound same. He know about objects, can recognize them and

point to them but can’t name them because he didn’t have speech.

The child’s overall performance on the area of self-help skills and

socialization was good than other areas of cognition, motor and language. His motor

skills were very poor as he can’t grip the pencil, he can’t turn thin page of book. His

muscles were so stiff that he can’t walk properly. His language skills were very poor

because of his muscular problem, his jaw bone was very stiff and he was unable to

produce different sounds. May be due to the ignorance of the family he didn’t tried to

speak any other word.

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Case Formulation

The client was activate and attentive child. His hygiene was good; he was

wearing appropriate, neat and clean uniform. He was an active child in the class was

taking part in every class activity. His behavior with other fellows was indicating his

socialization. He came to the trainee by the request of his teacher, he shakes hand for

salaam but didn’t show any emotional response.

He can’t hold pencil properly, his grip on pencil was very strong, he can’t

write properly but he can draw lines. His lines were not straight, they were wavy and

lines showed his pressure on the pencil which he exert to draw. He also can’t walk

properly, he walk in jerking movements and on his toes but still with this difficulty he

did managed his balance and can walk by his own without any aid.

He was eight years of age but by his appearance he looked like a six to seven

years boys, he was physically weak. His learning readiness skills were also affected

due to his physical problem. He had one word speech (Mama), all other sounds he

produce make same sound, may be his this problem was due to the muscle tension

caused by his physical weakness.

The reason of his physical weakness was genetical as his parents were having

cousin marriage and there are chances that might anyone of them was carrying

defective gene which became dominant in their child resulting in his disabilities, as it

is reported that about 2% of all cerebral palsy cases are believed to be due to a genetic

cause. Cerebral palsy is caused by damage to the motor control centers of the

developing brain and can occur during pregnancy, during childbirth, or after birth up

to about age three (topic overview, 2008) He was having these problems from his
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birth, due to his this problem he always drool and cleaned it up by his sleeves this

factor work as predisposing factor for his problem.

He first cry was delayed, after 15 minutes of his birth, delay cry can cause

damage to the brain cells due to the deprivation of the oxygen to the brain cells. Due

to the deprivation of the oxygen brain cells started dying and effect major parts of the

brain as studies reported, first of all, the baby's first cry that is, its first breath causes

the lungs to expand, secondly, fetal circulation is transformed into the circulation of

the newborn, and thirdly blood and oxygen circulation to the brain cells started

(Carreiro, 2003 & Goerke, 2002).

He had developmental delays as he started walking and speaking late, with his

muscle tone problem he is physically weak to which work as precipitating factor for

his problem. His physical weakness also had movement problem, difficulties with

thinking, learning, feeling, communication. Different researches concluded that

children with CP, 28% have epilepsy, 58% have difficulties with communication, at

least 42% have problems with their vision, and 23–56% has learning disabilities

(Kent, Ruth 2013).

He had one word speech, he can’t produce different sounds, Overall associated

with problems of intellectual disability, hearing impairment, and learned helplessness

in him as he didn’t left his seat during whole break, and he didn’t interact with much

with his fellows. It is also reported in researches that children with cerebral palsy are

at risk of learned helplessness and becoming passive communicators, initiating little

communication (Beukelman, David, Mirenda, Pat, 1999)

Speech and language disorders are common in people with cerebral palsy. The

incidence of dysarthria is estimated to range from 31% to 88%.

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His low socioeconomic status was maintaining factor of his condition as his

mother was not well educated, she didn’t know how to best handle him but still she

was motivated enough to do something which can make life of his son more

independent. His economic crises were not allowing his parents to give him best to

fulfill his special needs. The attitude of his father was not warm enough that can help

him to cope with his physical challenges. The client was motivated to learn, he had

developed LRS and self-help skills, his gave full attention to the activities and had

good learning ability all these work as protective factor for his condition.
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Summary of Case Formulation

Precipitating factors
Predisposing Factors
Delayed Milestones
Genetial disposition
Absentees from school

Presenting Complaints

i. Speech problem.
ii. He is physically
weak
iii. He can’t do his
work properly.

Maintaing Factors Protective Factors

(i) Neglegence of parents (i) Motivated
(ii) Low socio economic (ii) Comprehension
status (iii) (iii) Curiosty
Speech problem (iv) Social Support

Assessment

i. Clinical
Observation
ii. General
Drawing
iii. PGEE

Management

i. Prompting
ii. Modeling
iii. Shaping
iv. Chaining
v. Fading
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Diagnosis

319 (F71) Intellectual disability (intellectual developmental disorder),

moderate, with Cerebral Palsy.

The child was having the Cerebral Palsy, which is a non-progressive medical

condition causing inability of the muscles to work appropriately. He had muscle

stiffness in his lower limbs which was also affecting the function of his upper limbs to

some extent, he can’t produce speech, can’t hold pencil properly, can’t cut and color

within the boundaries all this indicate that he had Severe Spastic Hemiplegi. In

associated symptoms he had learning disabilities, speech problem, and small jaws.

Child’s Prognosis

As child was motivated, had good ability of comprehension, his compliance

was also very good, he had proper on seat behavior all these strengths could work as

his protective factors can make him able to live a more independent life. The child’s

teacher was very cooperative, helping and warmth toward the child. She was giving

her best and helping the child to deal with his problems, although she was not

specialized in dealing with the children having Cerebral Palsy still she was getting

advise from her colleagues and give special attention to him.

The child’s family was educated and aware about the conditions and needs of the

child, her mother and elder sister was playing important role in the training of the

child, he was also an active member of the family, taking part in every work and

playing with his siblings. He had the sense of his belongings and manage them too in

his own cupboard and drawer.

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He lived in a joint family system where he get more social support which gave him

confidence and boost his self-esteem which can also work as his strength factor.

The support of his mother and siblings, concern of his teacher could also play their

role in the betterment of the child. The child himself was very active, energetic and

curious about things, he had commendable comprehension and memory, but the only

factor effecting his learning was his physical disability which was also effecting his

speech.

Overall keeping in view the whole picture of the client’s situation his prognosis was

guarded, because he had motivation, courage and above all ability of comprehension,

he also had support from his teacher rand family who gave him sense of self -worth

and independency which will help him in future as a guard against the hardships of

the life.

Implementation of the therapeutic Strategies

Different therapeutic techniques were used to manageable the problematic

behavior of the child. First of all reinforcers were identified so to reinforce the client

immediately after displaying desired behavior and to avoid undesirable behavior.

Positive reinforcement technique was used to teach the child desirable behaviors.

Reinforcers were identified by giving him different options like stickers of different

things, handmade card, and verbal appraisal; cutting sheets, clay etc. The top 5

reinforcers were selected by the priority of the child, and were used to reinforce him

on desired behavior.
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ITP. Individualized training program (ITP) is a written document required for each

child who is eligible to receive special education services. ITP is provided to the

client who has some disability. ITP not only provides information on children’s

current levels of performance but also directs special services and supports that are

provided to client. After the completion of assessment ITP was developed covering

strengths and weaknesses of client on all areas.

Behavioral therapeutic techniques were used to achieve his desired behavior and to

restrict his undesirable behaviors.

Reinforcement. Reinforcement is defined as the consequence that strengthens a

particular behavior (Miltenberger, 2008). This technique was used with the client in

order to appreciate the client whenever he learn something new so that particular

behavior would be strengthened in the client. Reinforcement was used to make him

able to write independently, holding pencil independently, drawing straight lines etc.

Soon after the manifestation of the desirable able behavior to increase and strengthen

the frequency of this behavior, reinforcement was also withheld on the manifestation

of the undesirable behavior and also to decrease the frequency of the undesired

behavior.

Modeling. The technique of the modeling was used to teach him saying salaam

nonverbally by shaking hands with the others. As he didn’t say salaam to anyone, first

he was told about the concept of the salaam, and he was also told that Allah love those

people and kids who say salaam to others before starting the conversation. After

giving him background of the salaam therapist modeled before him how to say

salaam, than he had to repeat it, he was also physically and verbally aided throughout

this process. To make him able to take initiate in salaam he was told that session will
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be started when he would shake hand with the therapist. Prompts were given as a

reminder first physically and then verbally. When child started learning this behavior

prompts were faded.

Shaping. Shaping or successive approximation is a form of operant conditioning that

is used in behavioral learning techniques that refers to the teaching of new skills or

behaviors by reinforcing learners for approaching the desired final behavior

(Miltenberger, 2008). Shaping was used to make the client able to hold the pencil

properly for this purpose the client was physically guided by the therapist. First of all

child was given thick marker so he could be able to hold it properly and easily, in the

second step tap was rolled over the pencil to make it thick enough so child could hold

pencil properly at right angle. The thickness of the tape was lessen day by day and at

the last day child was able to hold the pencil in the proper way at the right angle.

Shaping was also used to make polish his pre writing skills, this was done along with

the pencil holding task. Child was provided with sheets of tracing on basic pre writing

figures. Physical and verbal prompts were also provided along with the training.

Prompting. Prompting means providing some aid or help to client while teaching

something new to him. The client was facilitated with different type of prompts (like

physical, gestural, verbal or modeling) to learn new skills. Prompting was provided

starting from most intrusive type like physical prompting and gradually the physical

aid will be faded. The technique of prompting was used to make him able to write

independently without the physical assistance.

First he was provided with full physical assistance that was faded by giving less and

less assistance every time afterward and come to the level of verbal prompts.
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The client had no concept of boundaries, to give him concept of boundaries the child

was provided with the visual prompts. First boundaries of the figures were make thick

so he could not colors out of the boundaries and he can learn the meaning of the

boundary. Slowly when client started coloring within the thick boundary the thickness

of the boundary was lessen to the extent that he could understand the concept of

boundary of the figure.

As the client was on the basic pre writing skill, he was not able to draw single straight

line, to make him able to draw a straight line he was provided with the worksheets

where straight line was drawn with thick boundaries and child had to draw line within

the boundaries. The prompt was faded gradually when child started showing desirable

behavior.

Physical restriction. The technique of physical restriction was used to hold the head

of the client while writing to a normal distance from the page. As the child totally lean

his head to the paper while doing some work he was told to keep his head distant from

the paper. First full physical assistance was given but when child started

understanding the concept of physical restriction it was started fading because child

also started keeping his head distant from the paper. At the end child was on the

verbal instructions to keep his head up right from the paper.

Cutting. The child’s muscles were not strong he was not able to use scissor, but he

can snip through scissor. To make able to cut with the scissor physical prompting was

used child was taught how to cut paper in random form. First full physical assistance

was provided to the child and was gradually faded with the learning of the child. This

thing also taught to him to make full use of his muscles with his own control and to
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make his muscles more mobile and toned. This activity could also help him in his

vocational training.

Buttoning. The client was able to unbutton his shirt but he was not able to button it.

To him learn this behavior forward chaining technique was used, in which the point of

instruction and reward begins with the first unmastered step and progresses to the last

unmastered step. For this purpose total task analysis of the behavior was done in

which all steps in the chain are taught simultaneously, as compared to one step at a

time to criterion in forward and backward chaining.

1. Hold the button in one hand

2. Hold the button hole in the other hand

3. Bring both button and hole near to each other

4. Try to insert the button partially in the hole

5. Bring button hole more near to the button

6. Insert whole button into the button hole

7. Now catch button by the other side of the whole

8. Settled down the button on the button whole

The client was reinforced socially and tangibly on the achievement or approximation

on the each step.

Wiping drooling. Due to weak muscle tone and small jaw bone of the client, he was

not able to control the muscles of his face and he continuous used to drool, he didn’t

use anything to wipe out his mouth. The child was taught this behavior to make him

able to look more presentable and sophisticated. The child was taught to wipe his

mouth chaining was used with the help of the total task analysis.
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1. Bring your hand near to the pocket.

2. Put your hand in the pocket

3. Bring out handkerchief out

4. Bring handkerchief near to the mouth

5. Place it on your lips

6. Softly slide handkerchief over and under your lips

7. Do it again by the other side of the lips

8. Take handkerchief away from mouth

9. Took it to the pocket

10. Take your hand in the pocket

11. Place handkerchief in pocket

12. Take your hand out of the pocket

The techniques of both forward and backward chaining were used simultaneously.

The child was reinforced after every successive approximation on each step.

Outcome

Outcomes of the identified goals as pre writing skills, writing independently,

pencil holding etc. is given as followed:
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Pre and Post Management

Table 5

Comparison of the pre and post management ratings of client’s symptoms on scale of
(0-10)

Skill Taught Pre Rating Post Rating

Saying salaam 0 7
Pencil holding 2 8
Prewriting skills 1 6
Drawing straight line 1 5
Writing independently 1 6
Head holding while writing 1 7
Coloring within boundaries 2 7
Buttoning 1 9
Cutting 1 7
Drool wiping 2 8

Key: In the scale of (0-10), “0” shows that the problematic behavior is absent and

“10” shows the problematic behavior is very severe

Difference between the pre and post rating of the management done with the client,

the results showed that management plan help the client to achieve new skills and

polish already existing skills.

Limitations

There were some factors which were affecting the management outcomes:

 Distractions in the environment was distracting the child due to which he gave

more attention to the environment.

 Limited time available for sessions, due to which everything was happening in

fast pace.
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 Client was not regular due to which limited sessions were conducted.

 Lack of speech by client was another limitation, sometimes it become difficult to

understand what child tried to say.

 Client was not getting the proper guidance from the teacher as she was not

specialized in CP due to which child was getting double messages and it was

becoming difficult for him to cope with.

Recommendations

There were some factors which could be change to get better outcome of the

management:

 Proper physical therapy should be given to the child to him more active and

workable in his life, so he could live his life not independently but semi

dependently.

 Environment should be adequate enough to get the full attention of client.

 Individual attention should be given to the child, as he had ability of

comprehension was commendable, and he had curiosity to learn new things.

 There should be separate room to take session and apply therapy on client.

 Proper speech therapy should be provided to the child to make him able to learn

more words, and make him able to speak.

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Session Reports

Session No. 1 25-10-21

In the first session class room observation of the child had been done. Functional

Checklist was administered to assess the level of learning readiness skills of the child

along with the level of socialization, self-help skills, language, motor and area of

cognition. The child’s LRS were well developed, he was social and cooperative.

Rapport with the child was built by giving him his favorite activities.

Session No. 2 26-10-21

In the second session to rule out the hypothesis of the age difference in chronological

and mental age of the child PGEE was administered to the half section of the self-help

area. Child was told to say salaam when meeting to someone with shaking hand, it

was taught to him by modeling, physical and verbal prompts.

Session No.3 07-11-21

In the 3rd session PGEE was administered to the child, two areas of PGEE was

administered Socialization and self-help skills, both areas showed no discrepancy

between his mental and functional age. Saying salaam was taught with the pencil

holding, child was given work sheets of pre writing to trace with board marker.

Session No. 4 16-11-21

In the 4th session remaining part of the PGEE was administered, the areas of language,

cognition and motor was assessed. There was discrepancy of 0ne year in motor area

due to the lack of exposure. The activity of saying salam was continued and child was
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taught to write with thick pencil on prewriting skills, his head holding was also started

by physical restriction.

Session No. 5 21-11-21

In the 5th session history of the child was taken from the child by clinical interview,

family history was taken. Child compliance was good, he was an active and co-

operative. Child was asked to shake hand by his own, pre writing skills were carried

out with head holding.

Session No. 6 22-11-21

In the 6th session history of the child was taken from the teacher through the clinical

interview. Child’s class participation, socialization and academic performance of the

child was discussed and subjective rating of the teacher was also taken according to

the problematic behaviors of the child. Management relating to the drooling behavior

of the child was started, and coloring with in boundaries was told to the child.

Session No. 7 23-11-21

In the 7th session child was asked to say salam by his own. Pre writing was started by

the pencil rapped tape on it, and work sheet for drawing straight line was given and

his head was hold to keep it distant from the paper. Child was taught to wipe his

drooling time by time and to put handkerchief back in his pocket.

Session No. 8 28-11-21

The child was asked to say salam, pre writing skills were carried out with the physical

help, child was also given work sheet to draw straight line within the boundaries, head

holding was also done throughout the session with verbal prompts to. First step of

buttoning was told to the child with the physical aid.

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Session No.9 06-12-21

In this session child was not willing to do any work, he was showing obstinate

behavior and was asking for reinforcement again and again. Child was taught how to

cut with scissor as it was his favorite activity to do. After that next step of buttoning

as taught to him.

Session No. 10 07-12-21

In the 10th session child was able to say salam without any reminder. He learned to

write partially without physical aid, work sheet for straight line was given to him with

a pencil with little tape rolled on it. Child was told to wipe out his drooling time by

time. Child also stated to keep his head to a distance from the paper.

Session No. 11 12-12-21

Child was taught to color within thick boundaries, work sheet for drawing straight line

was given by tracing, and he was able to write independently. Next step of buttoning

was taught to him inserting button into the hole. Cutting was also done to make his

hand movements more workable and toned. Drool wiping was also carried out.

Session No. 12 20-12-21

In this session child was able to draw straight lines within the boundaries and was

able to hold pencil in proper way and in right angle. He was also able to hold his head

to a distance from the paper. Buttoning was taught to him at the last steps, he was told

to settle down the button on the shirt after pulling it from the button hole. Child was

also told about the termination of the therapeutic sessions.

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Session No. 13 21-12-21

In this session child was given work sheet to color with in boundaries, cutting was

taught to him and he was able to cut the paper. He was also able to trace over the

straight line without any physical or verbal aid. Child was also able to wipe his face

without any verbal instructions. He was given a card as a token of appreciation.

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References

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Burden in Individuals with Cerebral Palsy. Journal of Rehabilitation Research

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American Psychiatric Association. (2000). Diagnostic and statistical manual of

mental disorders (4th ed., Text Revision). Washington, DC: American

Psychiatric Association.

Beukelman, David R., Mirenda, and Pat (1999). Augmentative and Alternative

Communication: Management of severe communication disorders in children and

adults. Baltimore: Paul H Brookes Publishing Co. pp. 246–249

Bluma, S., Shearer, M., Froman, A., & Hilliard, J. (1976).The portage guide to early

education manual (Rev. Ed.). Portage, WI: cooperative Educational Services

agency.

Cerebral Palsy – Topic Overview" (2008). WebMD Medical Reference from

Healthwise.

Kent, Ruth (2013). "Cerebral Palsy". Handbook of Clinical Neurology. In Barnes MP, Good

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Miltenberger, R. G. (1997). Behavior modification: principles and procedures. USA:

Brooks / Cole Publishing Company

Spiegler, M.D., Guevremont, D.C. (2003). Contemporary behavior therapy 5th Ed.

USA: Wadsworth Cengage Learning.

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Causal Pathways. London, United Kingdom: MacKeith Press

Appendix-V