Presented by: Ghazal Zaidi(45604)

child placement
Supervisor: Ms. Rahmeena Iqbal
 CASE SUMMARY
• The child S.A was a 5-year-old boy and was brought to the institute by his parents
with complaints of not maintain eye contact, did not respond to his name, did not
uttering even a single word and did not respond to nonverbal cues either. He also
showed stubborn behavior and used to place toys in an order. He was referred to a
trainee clinical psychologist for the purpose of assessment and management. Formal
and Informal assessment were both carried out to make an appropriate diagnosis and
management plan. For informal assessment, clinical observation, behavioral
observation and subjective rating of symptoms was done. For formal assessment,
DSM 5 checklist, Portage Guide for Early Education, CARS (Childhood Autism
Rating Scale) were used.
• The reinforcers were identified with the help of his parents and clinical observation.
According to behavioural observation, psychological assessment and DSM-V criteria
and symptoms it is conclude that the child meets the criteria of “Autism Spectrum
Disorder 299.00 (F84.0)”. requiring substantial support for deficit in social
interaction, delayed speech and restricted repetitive behaviours. The management
plan was devised based on Behavior Therapy. It included Rapport building, Psycho-
education of parents, attention training, use of reinforcements, extinction, Prompts,
fading, shaping, chaining and generalization. The post assessment showed some
improvement in the child’s problem areas. Individualized Educational Plan (IEP) was
developed for target behaviors of client. The overall therapeutic outcome was 10%
approximaitly.
 Bio data
• Name: S.A
• Age: 5 years
• Gender: Male
• Date of Birth: 17-03-2018
• No.of Siblings: 1
• Birth Order: 2nd born
• Religion: Islam
• Informant: client’s parents
‫‪Presenting compaints‬‬
‫‪•Duration‬‬ ‫‪complaints‬‬

‫‪3 years‬‬
‫• بات کروں تو نظریں نہ یں مالتا۔‬
‫‪•3 years‬‬
‫• نام لے کر بالنے پر بھی کوئی جواب نہیں دیتا۔‬
‫‪•3 years‬‬
‫• کسی کے ساتھ گھلتا ملتا نہیں ہے۔‬
‫‪•3 years‬‬
‫• بالکل بات نہ یں مانتا۔‬
‫‪•3 years‬‬
‫•باتیں نہ یں کرتا بلکہ بیٹھے بیٹھے ہنسنا شروع‬
‫•کر د یتا ہے۔‬
‫• گاڑیوں کی الئن بناکر کھلتاہے‬
History of Present Illness
• Mother was Stressed during pregnancy
• C-section but no complications
• Achieved early milestones on time
• Everything was normal till 1 year
• Problem started when he was 1.5 year old
• When his phopoo got married and screen time was
increased almost 8 to 10 hrs.
• Mother and father both are working
• History of bipolar in family
Back Ground History
• Family history

• Personal history

• Past medical or psychiatric history

 Developmemtal Milestones and Achieved Age
Developmental Milestones Average Age of achieved Achieved Age of milestones
milestones

First cry At birth Immediately

Neck holding 4 months
5 months
Sits without support 7-8 months 8 months

Babbling 6-9 months 8 months

Walks without support 11-13 months 1.1 year

Speech one word 10-18 months Not yet

syllable
PSYCHOLOGICAL ASSESSMENT

Informal assessment Formal assessment

• Clinical interview
• Behavioral • DSM 5TR checklist
observation • Portage guide to early
• Identification of
education
reinforcers
• Autism rating scale
• Subjective ratings of
symptoms by mother
Reinforcement check list

Type of reinforces identified reinforces

Eatables Chips, cup cake
Activity Playing with his toy
dinosaur
Social Well done. Clapping
Subjective Ratings of the Client’s Problem ( pre assessment)
Problem Rating
No Eye contact 0 1 2 3 4 5 6 7 8 9 10
Response on name 0 1 2 3 4 5 6 7 8 9 10
No Self-care 0 1 2 3 4 5 6 7 8 9 10
Self-help skills 0 1 2 3 4 5 6 7 8 9 10
Repetitive behaviour 0 1 2 3 4 5 6 7 8 9 10
Tantrum 0 1 2 3 4 5 6 7 8 9 10
Onset behaviour 0 1 2 3 4 5 6 7 8 9 10
Attention spam 0 1 2 3 4 5 6 7 8 9 10
 Results of formal assessment

PGEE Childhood
Developmental Areas Functional Age
Autism
Rating scale
Socialization 1 years 2 months
Rawscore Severity level
Language 10 months

34.5 Mildly to
Self-help 1 year 10 months
Moderately Autistic
Cognative 2 years 9 months

Motor
2 years 8 months
DSM V-TR Criteria PRESENTING COMPLAINTS

Persistent deficits in social communication and social Client had serious deficits in social communication
interaction across multiple contexts, as manifested by the across multiple contexts.
following, currently or by history.

Deficits in social emotional reciprocity, ranging from he is unable to reciprocate his emotions or carry any
abnormal social approach and failure of normal back and conversation forward , appropriate for a 5-year-old. His
forth conversation, to reduced sharing of interests, non verbal behavior is also not age appropriate with
emotions, or affect, to failure to initiate or respond to inability to communicate verbally according to his age.
social interactions. His facial expressions remain flat unless there’s a
Deficits in nonverbal communicative behaviors used for tantrum.
social interaction, ranging for example, from poorly The client was also in adaptive in various social contexts
integrated verbal and nonverbal communication, to and also apathic.
abnormalities in eye contact and body language or
deficits in understanding and use of gestures, to a total
lack of facial expressions and non-verbal communication.
Deficits in developing, maintaining and understanding
relationships, ranging for example, from difficulties
adjusting behavior to suit various social contexts, to
difficulties in sharing imaginative play or in making
friends, to absence of interest in peers.
DSM V-TR Criteria PRESENTING COMPLAINTS

Restricted, repetitive patterns of behavior, interests or

activities as manifested by at least two of the following, Echolalia, repetitive movements, screaming and hitting
currently or by history and scratching at small changes was also present.
Stereotyped or repetitive motor movements, use of Client also had sensory issues.
objects, or speech (e.g., simple motor stereotypies, lining
up toys or flipping objects, echolalia idiosyncratic
phrases).
Insistence on sameness, inflexible adherence to routines
or ritualized patterns of verbal or nonverbal behavior (eg
extreme distress at small changes, difficulties with
transitions, rigid thinking patterns, greeting rituals, need to
take same route or eat same food everyday).
Highly restricted, fixated interests that are abnormal in
intensity or focus (e.g. strong attachment to or
preoccupation with unusual
objects, excessively circumscribed or perseverative
interests).
Hyper- or hyperactivity to sensory input or unusual interest
in sensory aspect of the environment (eg apparent
indifference to pain/temperature, adverse response to
specific sounds or textures, excessive smelling or
touching of objects, visual fascination with lights or
movement..
DSM V-TR Criteria PRESENTING COMPLAINTS

Symptoms must be present in the early developmental

period (but may not become fully manifest until social Symptoms were present in the early developmental
demands exceed limited capacities, or may be masked by period. 1.5 year
learned strategies in later life).

Symptoms cause clinically significant impairment in Symptoms caused significant impairment in all domains.
social, occupational or other areas of current functioning.
 DIAGNOSIS

Tentative Diagnosis
• According to behavioral observation, psychological
assessment and DSM-V criteria and symptoms it is
conclude that the child meets the criteria of “Autism
Spectrum Disorder 299.00 (F84.0)”.
 DIFFERENTIAL DIAGNOSIS
AUTISM ADHD

Detailed oriented Cant focus and easily distracted

Rigid with rules and routines Do not follow rules
Hyper focus Restlessness
Follow order and pattern Forgetful
Repetitive behavior Age 3-6 years
Lack of eye contact 2 year exposure to school setting
12-24 age
Delayed speech and language
 DIFFERENTIAL DIAGNOSIS
AUTISM Social communication
disorder

Detailed oriented No issue in non verbal behavior

Rigid with rules and routines No restricted and repitative behavior
Hyper focus No rigidity in activities and interests
Follow order and pattern
Repetitive behavior
Lack of eye contact
12-24 age
Delayed speech and language
Abnormal non verbal communication
 DIFFERENTIAL DIAGNOSIS
AUTISM IDD

Detailed oriented All functions are not according to age

Rigid with rules and routines Social communication and other skills are
Hyper focus equally disturb
Follow order and pattern
Repetitive behavior
Lack of eye contact
12-24 age
Delayed speech and language
Case conceptualization
Management plan
Short Term Goals
 Short term goals……..
Individualized Educational Plan Physical and Verbal Prompts Working on developing the early reading skills,
adaptive behaviors using reinforcers and instructions
PGEE Positive reinforcement

ERS Shaping

Chaining

Symptom based management for restricted repetitive Differential reinforcement of other behavior Squeezing a rubber ball, and rubber toys having
behaviors whistle in it

Managing the temper tantrums Extinction Planned ignorance

Relapse prevention Giving therapy blueprint for the for done during the
therapy sessions
Individualized Educational Program (IEP)
Goals

ERS

Eye-contact On calling his name, Using soap bubbles, While performing some tasks

Imitation For clapping, Kicking the large rubber ball

Attention To attend the ongoing activity by giving eye-contact and giving attention to the tasks

Compliance (single step command) Give-me, Pick-up, Put-in, Open, close the door, Sit-down
Individualized Educational Program (IEP)…….
Goals

PGEE

Socialization Clapping , Waving bye-bye when leaving ,Attention on his name , Sharing food

and toys

Cognitive 3 blocks tower, Pick-out items one-by one. Pointing to at least 3 parts of body,

Pairing of same objects, Making lines

Motor Building a ring tower, Peg-board for geometrical shapes, Stairs climbing and

coming down

Self-help Dressing/undressing with help, Zip/unzip without help, Washing hands by himself

Language Refer to speech therapist

Long term Goals
• Continuation of short-term goals will be preferred, and it
will be done for the maintenance of desirable behaviours.

• Follow up sessions. Follow-up sessions will be conducted

to ensure maintenance of skills learned in therapy.