Case Report I

Case Summary

Mr. M.H. is 3.4 years old, who belongs to Rawalpindi and was brought by his

parents. He was placed in autism unit. He is the only child of his parents. He

belongs to middle class. His mother had C-section during his birth. The child

experienced huge delay in achieving developmental milestones. His main problem

is impaired speech, lack of eye contact and very extreme lack of social

interaction. There is also hitting in his behavior. Formal assessment was done and

standardized test were used to assess his behavior. CARS was used to assess his

severity of disorder. Another tool Portage Guide to Early Education was used to

assess his Cognitive, Self-help, Language, Socialization, Motor skills. After

administering the tests, it was found that client has Severe Autism Spectrum

Disorder. After complete diagnosis, different sessions were conducted in which

different techniques were used to change the target behavior. Speech therapy was

used to improve his communication skills. Music therapy was used to gain his

attention and improve his attention span. ABA was used to change his target

behavior. Psycho-education was provided to his family.

1
Bio Data

Name M.H

Age 3.4

Gender Male

Religion Islam

No. of Siblings 0

Birth Order 1st

Class None

Family System Joint

Father Alive/Dead Alive

Mother Alive/Dead Alive

Father’s Education Inter

Mother’s Education M.A Islamiyat

Father Occupation Private Job

Mother Occupation House Wife

Socio Economic Status Middle

Referral Source

NIRM

Place of Internship

Sedum Rehabilitation Center and School

2
Informal Assessment

General Source

The client was 3.4 years old child. His appearance was really good and neat. The

client brought by his parents to the center. He had poor eye contact. He could

not speak properly. The client was not paying attention upon calling him. His

social skills were not adequate. His sitting span was very poor. The client

repeatedly lay down on the table. He was not following any kind of commands

by his mother. He was also hitting the walls and shouting. He was hyperactive.

The client was not socialized and did not like to play with others. He did not

like stuffed toys. The client was repeatedly licking everything.

Reported Problem (By Mother)

‫سنتا ہے‬‎ ‫بات نہيں‬

‫وں میں دیکھ کر بات نہيں کرتا ہے‬‎ ‫آنکھ‬

‫کسی بات پہ توجہ نہيں دیتا ہے‬

‫سن کر بہت ڑر جاتا ہے‬‎ ‫اونچی آواز‬

‫دوسرے بچوں کے سات کھيلتا نہيں ہے‬

‫کبھی کبھی بہت غصہ کرتا ہے‬

‫ وہاں ہی ليٹ جاتا ہے‬،‫جہاں بيٹھتا ہے‬

‫دوسرے بچوں کو مارتا ہے‬

3
‫کسی سے ميل جول نہيں رکھتا ہے‬

Personal / Family History

His parents brought him to the center and complained about the problem. The

child belonged to joint family system. The environment of his home was quite

good. His father was doing private job and his mother was house wife. He was

the only child of his parents.

Table No.1

Comparison between Normal Age and Client’s Age of Achieving

Developmental Milestones

Developmental Normal Age Range Client’s Age

Milestones

Neck Holding 3 months 5 months

Sitting 6-8 months 9 months

Crawling 8-10 months 11months

Babbling 4 months 5 months

Walking 1-1.5 years 2 years

Speech 3-4 years 1.5 year

Toilet Training 3-6 years Not Yet

Dressing 4-6 years Not Yet

4
Medical History

According to his mother, she spent good and healthy days while pregnancy. There

was no problem during pregnancy. She had C-section but there was no

complication during delivery and the weight of child was 2.5 kg. He was born

after complete nine months. He also did immediate first cry. The child was

physically healthy and got flu after his birth. There was a minor delay in his

sitting and walking milestone. He achieved his speech milestone at the age of 1.5

but had immediate delay due to loud voice of Azaan.

Educational History

He had never been to the school. This is his first institute where we are working

on his behavior and social skills. He is talking different session in a day.

Formal Assessment Tools

Standardized Assessment Tools

1. Portage Guide to Early Education (PGEE)

2. The Childhood Autistic Rating Scale (C.A.R.S)

5
1. Portage Guide to Early Education (PGEE)

a) Qualitative Interpretation of PGEE

Domains Scoring

Self-help Skills 2-3 years

Motor Skills 0-1 years

Language Skills 0-1 years

Social Skills 0-1 years

Cognitive Skills 0-1 years

b) Qualitative interpretation of PGEE

i. Self-help Skills

The client falls into the mental age range of 2 to 3 years in the domain

of self-help skills. He sometimes can eat without the help of his mother.

The client can hold the bottle and glass. He can remove his cloths easily.

He can eat food with spoon without any help. He can wipe his face and

hands with towel easily without any help. But the client had some

problems in some points like he cannot take off his socks. He cannot open

or close zip without any help. The client cannot wear his shoes without

any help. He cannot protect himself from any harm.

6
ii. Motor Skills

The client falls into the mental age range of 0 to 1 years in the domain

of motor skills. He can sit, jump and walk properly. He has good hand

grip. The client can pick up different things from the floor. But he cannot

imitate different things. He cannot copy different drawings like circle, star,

bird etc. The client cannot do complex motor movements.

iii. Language Skills

The client falls into the mental age range of 0 to 1 years in the domain

of language skills. He understands and follows some commands, but his

speech is very low and has no vocabulary. He uses only one word i-e

mama and tries to avoid conversation with others.

iv. Social Skills

The client falls into the mental age range of 0 to 1 years in the domain

of social skills. The client can dance with music. He shares his things with

others. He can choose things for himself. The client can play alone if

there is no one to play with him. He can make social smile. But the

client cannot make any voice to gain attention of others. He cannot imitate

any gestures i-e bye. He cannot participate in different things.

v. Cognitive Skills

The client falls into the mental age range of 0 to 1 years in the domain

of cognitive skills. The client can make tower of 3-4 blocks. He can make

7
train of blocks. But the client cannot do even simple tasks e.g. find out

pencil. He cannot name his body parts, name of colors. He has no

academic skills. He is unable to perfume simple questions or tasks. The

client cannot arrange things in order.

2. The Childhood Autistic Rating Scale (C.A.R.S)

a) Quantitative Scoring

Score Range Category

38 30-60 Severely Autistic

b) Qualitative Analysis

The client has no social interaction. His sense of hearing is very strong and sense

of touch, smell and taste was normal. He has severe fear of loud sounds and

become very scared every time. Verbal communication is very much low. His

speech is absent. His nonverbal communication is not good. The client is unable

to express his needs. His visual response is abnormal. He has no eye contact.

The client has very little interest in objects but his listening response is normal.

He is unable to imitate things frequently. The client has abnormal leg movement.

The general impression was child had severe autism.

Case Formulation

The client falls into the category of Severe Autism Spectrum Disorder as the

primary diagnosis.

8
According to Bio-psycho-social Model, the case can be evaluated in the following

way:

Biological Factors

 Birth through C-section.

 Client experience delay in some developmental milestones.

Psychological Factors

 Low cognitive power can also be considered as psychological factors of the

client’s problem.

Social Factors

 Lack of social interaction

 Impaired social skills

Graphical Representation of Case Formulation

Biological Factors

 Low cognitive power

Psychological Factors Social Factors

 Birth through C-section.  Lack of social

interaction
 Delayed developmental
 Impaired social skills
milestones

2.99.00 (F84.0)
Autism Spectrum
Disorder

9
A review of more than 60 studies and 20 million births has found that caesarean

birth is linked to a higher risk of autism spectrum disorder and attention-deficit

hyperactivity disorder in kids. The international review, which includes Australian

studies, shows kids have 33 per cent higher odds of developing autism spectrum

disorder and 17 per cent higher odds of developing ADHD if they are born by

C-section. Whether the C-section delivery was elective or emergency made almost

no difference to the odds of developing these disorders. The researchers say

understanding why this link might occur will be important given the increase in

C-section rates.

In 1943, the American psychiatrist Leo Kanner used the term “early infantile

autism”‎ to describe children who lacked interest in other people. In 1944, an

Austrian pediatrician, Hans Asperger, independently described another group of

children with similar behaviors, but with milder severity and higher intellectual

abilities. Since then, his name has become attached to a higher functioning form

of autism, Asperger syndrome. It was not until the 1980s that the term pervasive

developmental disorders was first used.

Diagnosis

2.99.00 (F84.0) Autism Spectrum Disorder (Severe)

10
Management Plan

Psycho-Education

The mother of the client was informed about the diagnosis. After that, his mother

was informed about different techniques that can used to modify child’s inattentive

behavior.

Speech Therapy

The child was recommended to the speech sessions. His speech was not

appropriate as his age. Speech sessions may help him to improve his language

skills too.

ABA

Applied behavior analysis has major role in improving behavior in children.

Techniques will help him to improve his behavior. The therapist used different

toys and fruits to engage him in session. The therapist also did bubble blowing

technique to gain his eye contact.

Music Therapy

The music is an effective way to communicate with and reach children with

autism. Music therapy seems to be able to improve social skills, behavior, anxiety

and more. The therapist paired the music with actions of client. His response was

positive to music and was able to get his attention, which made music a potential

therapeutic tool.

11
Behavior Modification

Behavior Modification is a treatment approach, based on the principles of operant

conditioning, which replace undesirable behaviors with desirable behaviors through

positive or negative reinforcement. The therapist targets his hitting behavior. The

client was hyperactive and his hitting behavior was very strong. The therapist

asked the client to sit properly in authoritative voice and note his actions. When

the client was about to hit, the therapist distract his behavior towards another

activity.

Recommendations

The child is already studying in special school, where he is getting all the

important and necessary interventions

 Speech Therapy

Speech therapy helps to improve the person’s‎ communication skills. Some

people are able to learn verbal communication skills. For others, using

gestures or picture boards is more realistic.

 Occupational Therapy

Occupational therapy teaches skills that help the person live as

independently as possible. Skills may include dressing, eating, bathing, and

relating to people.

 ABA

ABA encourages positive behaviors and discourages negative behaviors to

improve a variety of skills. The child’s‎ progress is tracked and measured.

12
 Social Skills Training

Social skills training teaches children the skills they need to interact with

others, including conversation and problem-solving skills.

 Psycho-educate the family.

13
References

Zhang T, Sidorchuk A, Sevilla-Cermeño L, et al. Association of Cesarean Delivery With

Risk of Neurodevelopmental and Psychiatric Disorders in the Offspring: A

Systematic Review and Meta-analysis. JAMA Netw Open. 2019;2(8):e1910236.

Hadeel Faras, Nahed Al Ateeqi, Lee Tidmarsh. Autism spectrum disorders. Ann Saudi

Med. 2010 Jul-Aug; 30(4): 295–300.

14
Appendix A

15
Case Report II

Case Summary

Mr. A.M. is 5 years old child, who belongs to Rawalpindi and was brought by

his parents. He has one younger sister. He belongs to middle class. His mother

had C-section during his birth. The child experienced huge delay in achieving

developmental milestones. His main problem is hyperactivity, excessive speech,

frustration and very extreme lack of social interaction. There is also hitting in his

behavior. Formal assessment was done and standardized test were used to assess

his behavior. Conner’s Teacher Rating Scale was used to assess his severity of

disorder. Another tool Portage Guide to Early Education was used to assess his

Cognitive, Self-help, Language, Socialization, Motor skills. After administering the

tests, it was found that client has Severe Attention Deficit/Hyperactive Disorder.

After complete diagnosis, different sessions were conducted in which different

techniques were used to change the target behavior. Speech therapy was used to

improve his communication skills. Music therapy was used to gain his attention

and improve his attention span. ABA was used to change his target behavior.

Psycho-education was provided to his family. The daily routine was made for the

client that when he will complete certain task.

16
Bio Data

Name: A.M

Age: 5

Gender: Male

Religion: Islam

No. of Siblings: 2

Birth Order: 1st

Family System: Joint

Father Alive/Dead: Alive

Mother Alive/Dead: Alive

Father Education: MBA

Mother Education: MBBS, FCPS

Father Occupation: Manager in Private office

Mother Occupation: Doctor

Socio Economic status: Middle

Referral Source

Family Friend

Place of Internship

Sedum Rehabilitation Center Rawalpindi

17
Informal Assessment

General Observation

He was five year old child. He had no eye contact and he did not to pay

attention towards anything. He had difficulty in maintain attention on the task. He

talked excessively but his speech was disorganized. He had difficulty in

organizing tasks and activities due to hyperactivity. He could not stick to his

place for long time. Child lost his temper and was unable to follow rules and

instructions. He had difficulty while waiting for his turn. His excitement level was

so high. He was shouting and hitting. He had difficulty in learning academic

activities.

Reported Problem (By Mother)

‫شور کرتا ہے‬‎ ‫بہت‬

‫کسی کی بات نہيں ستا ہے‬

‫کسی چيس کے ليے زیادہ انتظار نہيں کر سکتا ہے‬

‫جسبات کو نہيں سمجھتا ہے‬

‫بہت زیادہ بولتا ہے‬

‫ بہت زیادہ ہے‬Excitement level

‫دوسرے بچوں کو مارتا ہے‬

‫کسی کو سالم نہيں کرتا ہے‬

18
‫ہوۓ بہت تنگ کرتا ہے‬
‎ ‫کھانا کھاتے‬

Personal History/Family History

The client was living in joint family system. His father was manager at private

office and mother was a doctor. The client belonged to middle class family. He

had one younger sister and he was elder one. The client was born after nine

months with C-section. He was born in Hospital. He had not achieved his

milestone at proper time. According to his mother, there was no physical or head

injury as well as no seizures or fits being experienced by child.

Table No.1

Comparison between Normal Age and Client’s Age of Achieving

Developmental Milestones

Developmental Normal Age Range Client’s Age

Milestones

Neck Holding 3 months 6 months

Sitting 6-8 months 1 year

Crawling 8-10 months 1.4 year

Babbling 4 months 6 month

Walking 1-1.5 years 3.5 year

Speech 3-4 years Not Yet

Toilet Training 3-6 years Not Yet

Dressing 4-6 years Not Yet

19
Medical History

According to his mother, she spent healthy days during her pregnancy. The

duration of her pregnancy was healthy. She used the folic acid and some

multivitamins for her and fetus health. She had C-section due to some medical

reasons but there was no complication in her delivery. According to mother, the

weight of the child was 2.3 kg at birth. At birth the child was normal and

physical fit but after the child was about 20 days old, he got pneumonia.

Educational History

The child was attending special education school since 2 months. He did not sit

in the class and used to hit things. He had difficulty in learning and academic

skills. In this school, the child took one to one session with speech therapist.

This was his first school.

Formal Assessment

Standardized Assessment Tools

1. Portage Guide to Early Education (PGEE)

2. Conner’s Teacher Rating Scale (CTRS)

20
1. Portage Guide to Early Education (PGEE)

a) Quantitative Interpretations of Portage Guide

Domains Scoring

Self-Help Skills 2-3years

Motor Skills 1-2years

Language skills 1-2years

Social Skills 0-1years

Cognitive Skills 0-1years

b) Qualitative interpretation of Portage Guide

i. Self-Help Skills

The client falls into the mental age range of 2 to 3 years in the domain

of self-help skills. The client can eat and hold the bottle. He can hold the

cup and glass. But the client can change his clothes with the help of his

mother. He can easily remove pent when his mother opened buttons of his

pent. He can clean his hands with the towel. He can unable to travel

outside with his own.

ii. Motor Skills

The client falls into the mental age range of 1 to 2 years in the domain

of motor skills. He can sit, jump and walk properly. He can approach the

things or objects if needed. He can easily change his position while

21
sleeping. He can easily climb stairs. He has good hand grip. He can hold

ball easily with his hands. He can easily ride tricycle.

iii. Language Skills

The client falls into the mental age range of 1 to 2 years in the domain

of language skills. He can try to speak. His babbling was normal. He can

recognize the objects but he has problems in some points. He can speak

four to five words. His speech is disorganized. He cannot recognize the

body part till age of 5. He is unable to answer the question properly.

iv. Social Skills

The client falls into the mental age range of 0 to 1 years in the domain

of social skills. He plays with toys when he was alone. He can move the

toys and can hear the sound of toy. He has problems in some points like

he was unable to pay attention properly. He usually plays with his sister

and friends.

v. Cognitive Skills

The client falls into the mental age range of 0 to 1 years in the domain

of cognitive skills. He can differentiate the things. He can tell 3 objects or

body parts. He can make tower of the blocks. He can turns pages of book

2-3 at a time to find named picture. He can point to named pictures.

22
2. Conner’s Teacher Rating Scale-Revised(S)

a) Quantitative Interpretation

Domains Raw T. Percentiles Guidelines

scores scores

Oppositional 13 89 98%+ Markedly

Atypical

Inattention 15 90 98%+ Markedly

Atypical

Hyperactivity 19 76 98%+ Markedly

Atypical

Conner’s 23 66 95-98% Moderately

ADHD Atypical

Index

b) Qualitative Interpretation

According to this test, client failed to pay attention on the details. Client

had difficulty in maintaining attention on the tasks. Child had squirms

while sitting and leaves the seat when sitting was expected from him.

Client did not seem to listen when spoken to directly. Client had difficulty

in organizing tasks and activity due to hyperactivity. Client was unable to

speak. Client could not wait and had difficulty while waiting for the turns.

Child lost his temper and was unable to follow the rules or instructions

23
and easily become annoyed by others. Client had difficulty in learning new

things. Child scores high in oppositional, inattention and hyperactivity.

Client had trouble of concentration in class. Child was so aggressive. His

behavior was so repetitive.

Case Formulation

The client falls into the category of Severe Attention Deficit Hyperactive Disorder

as the primary diagnosis.

According to Bio-psycho-social Model, the case can be evaluated in the following

way:

Biological Factors

 Birth through C-section.

 Client experience huge delay in developmental milestones.

 No family or genetic history of mental disorder has been detected.

Psychological Factors

 Aggressive tendencies

 Hyperactivity and inattention

Social Factors

 Lack of social Interaction.

 Poor social skills.

24
Graphical Representation of Case Formulation

Biological Factors

 Birth through C-section.

 Huge delay in
developmental milestones.
 No family or genetic
history of mental disorder

Psychological Factors Social Factors

 Aggressive tendencies  Lack of social Interaction.

 Hyperactivity and  Poor social skills.
inattention

314.01 (F90.2)
Attention-
Deficit/Hyperactivity
Disorder with
combined
presentation

A review of more than 60 studies and 20 million births has found that caesarean

birth is linked to a higher risk of autism spectrum disorder and attention-deficit

hyperactivity disorder in kids. The international review, which includes Australian

studies , shows kids have 33 per cent higher odds of developing autism spectrum

disorder and 17 per cent higher odds of developing ADHD if they are born by c-

section. Whether the c-section delivery was elective or emergency made almost no

difference to the odds of developing these disorders. The researchers say

25
understanding why this link might occur will be important given the increase in

C-section rates.

Children with ADHD are more likely to have poor academic outcomes including

lower academic performance, grade retention, and higher dropout rates. Those with

persistent (current) symptoms experience greater challenges in school performance

compared with those with no persistent symptoms and children without ADHD.

Severity of ADHD symptoms has been found to predict lower academic

performance in reading, writing, and mathematics in children and overall academic

performance in adolescents. While specific learning disorders are common

comorbid conditions with ADHD, learning disorders do not completely account for

the lower academic performance.

Diagnoses

314.01 (F90.2) Attention-Deficit/Hyperactivity Disorder with combined

presentation (Severe)

Management Plan

Considering the problem of the client, following management plan was provided

to him

Psycho-education

The family of the client especially his mother was informed about the diagnosis.

After that, mother was guided about different techniques that can help and modify

the child’s inattentive and hyperactive behavior.

26
Speech Therapy

Speech therapy was used to improve his communication skills. The client used to

talk excessively and his speech was much disorganized. When the client was

talking repeatedly, the therapist involved him in other activity.

ABA

Applied behavior analysis has major role in improving behavior in children.

Techniques will help him to improve his behavior. The therapist used different

toys and fruits to engage him in session. The therapist used rotating toys to

improve his attention span.

Music Therapy

Music therapy is a form of expressive therapy. Music can work wonders on the

ADHD brain, improving everything from language development to impulse control.

The music therapist involved the client in different poem and rhythms to gain his

attention. The therapist paired the music with actions of client. The client

response was very positive towards music.

Play Therapy

Play therapy provides a way for children to communicate their experiences and

feelings through play. The therapist used different games i.e. puzzles, block

building, tower making, and color matching. The therapist asked him to build

block and match the color of block with given color. The therapist also made

him wait for the next game that he will learn how to wait for the next things.

27
Establish Routine

The therapist and teacher made daily schedule for him. The child knows at which

time he has to do work, lunch and do extra-circular activities.

Recommendations

Following techniques were recommended to the parents so that they can easily

help their child to cope with the disorder

 Occupational Therapy

Occupational therapy teaches skills that help the person live as

independently as possible. Skills may include dressing, eating, bathing, and

relating to people

 Parenting training in behavior management

When parents become trained in behavior therapy, they learn skills and

strategies to help their child with ADHD succeed at school, at home, and

in relationships. Learning and practicing behavior therapy requires time and

effort, but it has lasting benefits for the child and the family.

 Give praise immediately

The sooner that approval is given regarding appropriate behavior, the more

likely the client will repeat it.

 Speech Therapy

Speech therapy helps to improve the person’s‎ communication skills. Some

people are able to learn verbal communication skills. For others, using

gestures or picture boards is more realistic.

28
 ABA

ABA encourages positive behaviors and discourages negative behaviors to

improve a variety of skills. The child’s‎ progress is tracked and measured.

 Social Skills Training

Social skills training teaches children the skills they need to interact with

others, including conversation and problem-solving skills.

29
References

Zhang T, Sidorchuk A, Sevilla-Cermeño L, et al. Association of Cesarean Delivery With

Risk of Neurodevelopmental and Psychiatric Disorders in the Offspring: A

Systematic Review and Meta-analysis. JAMA Netw Open. 2019;2(8):e1910236.

Rigoni M, Blevins LZ, Rettew DC, Kasehagen L. Symptom Level Associations Between

Attention-Deficit Hyperactivity Disorder and School Performance. Clinical

Pediatrics. 2020;59(9-10):874-884.

30
Appendix B

31
Case Report III

Case Summary

Mr. A.A is 11 years old boy, who belongs to Rawalpindi and was brought by his

parents. He has 4 siblings and he is 2nd in order. He belongs to middle class. His

mother had normal delivery and she had no complications during his birth but the

very second day after his birth, he had typhoid with very high degree fever.

Flagyl Injection were used as the treatment but had side effect on the brain

which caused the brain to have slow processing speed. The child experienced

huge delay in achieving developmental milestones. His main problem is impaired

speech, lack of learning skills, lack of self-help skills, shouting behavior and very

extreme lack of social interaction. There is also frustration in his behavior. Formal

assessment was done and standardized test were used to assess his behavior. CPM

was used to assess his severity of disorder. Another tool Portage Guide to Early

Education was used to assess his Cognitive, Self-help, Language, Socialization,

Motor skills. After administering the tests, it was found that client has Severe

Intellectual Developmental Disorder. After complete diagnosis, different sessions

were conducted in which different techniques were used to change the target

behavior. Speech therapy was used to improve his communication skills. Different

behavior techniques were used to change his target behavior. Shaping techniques

was used to change his negative behavior. Psycho-education was provided to his

family. Specific schedule was made by therapist and guided his mother to follow

the schedule.

32
Bio Data

Name: A.A

Age: 11 years

Gender: Male

Religion: Islam

No. of Siblings: 4

Birth Order: 2nd

Family System: Joint

Father Alive/Dead: Alive

Mother Alive/Dead: Alive

Father Education: MBA

Mother Education: Intermediate

Father Occupation: Private Job

Mother Occupation: Housewife

Socio Economic status: Middle

Referral Source

Mother’s‎‎Friend

Place of Internship

Sedum Rehabilitation Center Rawalpindi

33
Informal Assessment

General Observation

He was eleven years old boy. He had good eye contact. He had difficulty in

maintain attention on the task. He was talking excessively but his speech was

disorganized. He had difficulty in organizing tasks and activities due to

hyperactivity. He could not stick to his place for long time. He had difficulty in

learning academic activities. His social skills were not adequate. He was unable to

take care of his personal hygiene.

Reported Problem (By Mother)

‫شروع کر دیتا ہے‬‎ ‫بات کاٹ کر دوسری بات‬

‫بہن بھائ کو بہت تنگ کرتا ہے‬

‫پانی ميں چال جاتا ہے‬

‫اپنے ہاتھ خود نہيں دھو سکتا ہے‬

‫بہت زیادہ بولتا ہے‬

‫کبھی کبھی بہت غصہ کرتا ہے‬

‫پنسل نہيں پکڑ سکتا ہے‬

‫شور کرتا ہے اور مارتا ہے‬

‫ نہيں کر سکتا ہے‬Sharing

34
Personal History/Family History

All the information was obtained from his mother. He had three siblings and he

was 2nd in order. His parents brought him to the center and complained about the

problem. The child belonged to joint family system. The environment of his home

was quite good. His father was doing private job and his mother was house wife.

Due to puberty, his aggressive tendency was enhancing. His relationship with his

parents and siblings were very good. His social skills were not good. He was

emotionally attached with his mother.

Table No.1

Comparison between Normal Age and Client’s Age of Achieving

Developmental Milestones

Developmental Normal Age Range Client’s Age

Milestones

Neck Holding 3 months 1 year

Sitting 6-8 months 1.5 year

Crawling 8-10 months 1.2 year

Babbling 4 months 8 months

Walking 1-1.5 years 4 year

Speech 3-4 years 7 year

Toilet Training 3-6 years Not Yet

Dressing 4-6 years Not Yet

35
Medical History

Mother had not healthy pregnancy. In a routine blood test, anemia is reported as

low hemoglobin. During pregnancy, she got many injections due to weakness. The

child was born after complete 9 months. The mother had normal delivery and

there was no complication during delivery.

There was a significant medical history. The very second day after his birth, he

had typhoid with very high degree fever. Flagyl Injection (Metronidazole Injection)

were used as the treatment but had side effect on the brain which caused the

brain to have slow processing speed.

Educational History

The client was studying in Bahira Foundation School. The school worked on his

behavior. He left the school after spending a year because there was not enough

improvement.

The client jointed this institute one month ago. Here his individual sessions were

taken from speech therapist and psycho therapist. Although his speech was much

disorganized but speech therapist was working on him. The psycho therapist

worked on his behavior problems like command following, responding to his

name and others. And through occupation therapy, he tried to learn self-help skills

and gross motor skills.

36
Formal Assessment

Standardized Assessment Tools

1. Portage Guide to Early Education (PGEE)

2. Colored Progressive Matrixes (CPM)

a) Portage Guide to Early Education (PGEE)

a) Quantitative Interpretations of Portage Guide

Domains Scoring

Self-Help Skills 0-1years

Motor Skills 0-1years

Language skills 1-2years

Social Skills 1-2years

Cognitive Skills 0-1years

b) Qualitative interpretation of Portage Guide

PGEE scoring shows that the client’s intellectual and social domain is somehow

impaired.

i. Self-Help Skills

The client falls into the mental age range of 0 to 1 years in the domain

of self-help skills. The child can eat properly but if given instructions. The

client can change his clothes but with the help of his mother. The client
37
can clean his hands with the towel. He can comb his hair himself. He is

unable to travel outside with his own.

ii. Motor Skills

The client falls into the mental age range of 0 to 1 years in the domain of

motor skills. He can sit, jump and walk properly. He can approach the

things or objects if needed. He can easily change his position while

sleeping. The client can easily climb stairs. He can hold ball easily with

his both hands because he has not good hand grip. He can pick up

different things from the floor. He cannot do complex motor movements

and unable to draw many things like tree, pen etc.

iii. Language Skills

The client falls into the mental age range of 1 to 2 years in the domain of

language skills. The client tries to speak but his speech was disorganized.

He can recognize the objects but he has problems in some points. He can

speak four to five words in a row but he cannot use words properly. The

client is unable to answer the question completely.

iv. Social Skills

The client falls into the mental age range of 1 to 2 years in the domain

of social skills. The client is very close to his siblings and play with

them. He waits for his turn during play time. He can move the toys and

can hear the sound of toy. He can shake hand to different people. But the

client has problems in some areas like he is unable to pay attention

38
properly. He cannot tell about his emotion and also he cannot choose his

friends.

v. Cognitive Skills

The client falls into the mental age range of 0 to 1 years in the domain of

cognitive skills. The client can differentiate the things. He can tell 3

objects or body parts. He can make tower of the blocks. He can turns

pages of book 2-3 at a time to find named picture. He can point to

different colors or named pictures.

b) Colored Progressive Matrixes

a) Quantitative Analysis

Total Score: 9

Percentile: 5th

Grade: V

Guideline: Intellectually Detective.

b) Qualitative Analysis

The intellectual functioning of the client is not good. His IQ level shows that

the client is not good in academic, occupational, social skills and other

activities. The client scored 9 in the test, which falls in 5 percentile. This

shows that the client is intellectually detective.

39
Case Formulation

The client falls into the category of Intellectual Disability Disorder as the primary

diagnosis.

According to Bio-psycho-social Model, the case can be evaluated in the following

way:

Biological Factors

 After birth, Client had typhoid with very high degree fever.

 Client experience huge delay in developmental milestones.

 No family or genetic history of mental disorder has been detected.

Psychological Factors

 Aggressive tendencies

 Inattention

 Poor self-esteem and low cognitive power

Social Factors

 Poor social skills.

 Difficulties learning academic skills

 Immaturity in social interaction.

40
Graphical Representation of Case

Biological Factors

 Typhoid with very high

degree fever.
 Huge delay in
developmental milestones.
 No family or genetic history
of mental disorder has been
detected. Social Factors
Psychological Factors

 Aggressive tendencies  Poor social skills.

 Inattention  Difficulties in
 Poor self-esteem and learning academic skills
low cognitive power  Immaturity in
social interaction.

318.1 (F72) Intellectual

Developmental
Disorders (Severe)

Evidence from the United Kingdom and the United States has indicated significant

improvements in the life expectancy of persons with ID and for milder forms of

disability, life expectancies are now almost comparable to those in the general

population.

People with IDD experience a wide range of health disparities including decreased

life expectancy and greater rates of co-occurring conditions (Scepters et al., 2005).

Such persons are more likely to experience increased rates of sensory impairment,

41
epilepsy, psychiatric disorders, limited mobility, and gastrointestinal disorders than

those without IDD (Traci, Seekins, Szalda-Petrie, & Ravesloot, 2002)

Diagnosis

318.1 (F72) Intellectual Developmental Disorders (Severe)

Management Plan

Psycho-Education

The mother of the client was informed about the diagnosis. After that, his mother

was informed about different techniques that can used to modify child’s inattentive

behavior.

Speech Therapy

The child was recommended to the speech sessions. His speech was not

appropriate as his age. Speech sessions improve his language skills and

communication skills. When the client was talking excessively, the therapist

engaged him in different actively i.e. coloring the drawing to overcome his

excessive talking behavior.

Physical Therapy

Physical therapy was done in the presence of professional physio therapist to

improve his motor movements. In the physical sessions, the therapist practiced

different exercises to relax his hand muscles and to improve his hand grip.

42
Behavioral Modification Therapy

The techniques of behavioral modification were used to enhance the adaptive

behavior i.e.

 Positive Reinforcement

Positive reinforcement may occur in the form of behavior specific praise or

individualized reward systems. The mother was asked to praise or reward the

child whenever he showed the desirable behavior. The family would motivate him

to learn new things and would encourage him to do more. This would build

confidence in him.

 Shaping

Shaping is also important technique of behavioral therapy. This technique could

use to normalize his negative behaviors. The first step is done by teacher or

parents. Teacher of the client gave him verbal prompt. Teacher and therapist gave

some instructions to direct the client to complete the task i.e. coloring the fruits

drawings.

 Time Management

Teacher must give him homework in chunks, in order to put fewer burden on

him. Time management is important so that he feels easy while going his works.

43
Play Therapy

Play therapy has been suggested as an intervention to help the client strengthen

adaptive behaviors and develop stronger social relationships. The therapist asked

the client to build rainbow tower. He also solved the puzzled but took some time.

The client also made the tower of blocks. The play therapy also helped the client

to maintain his attention.

Occupational Therapy

This therapy can help him to learn more adaptive and social skills. The therapist

provided training to the client to improve his personal and physical needs. The

client was given adaption to improve his routine daily living skills. The therapist

provided specific schedule to improve his hygienic skills. The mother of the client

was strictly instructed to follow the schedule.

Recommendations

The client is already studying in special school, where he is getting all the

important and necessary interventions

Various therapeutic services can improve a person's adaptive behavioral skills.

These therapies are helpful for many people with intellectual disabilities (ID,

formerly mental retardation)

a) Occupational Therapy

 Meaningful and purposeful activities

 Self-care (e.g., grooming, dressing, feeding, bathing)

44
 Employment activities and skills

 Leisure activities (e.g., knitting, playing games)

 Domestic activities (e.g., cooking, cleaning, laundry).

b) Speech Therapy

 Improves communication skills

 Improves receptive and expressive languages skills

 Improves speech articulation

 Improves vocabulary

c) Physical Therapy

 Enhances quality of life by maximizing mobility and self-locomotion

 Provides adaptive solutions to mobility problems

 Increases sensory integration

45
References

A.H. Bittles, B.A. Petterson, S.G. Sullivan, R. Hussain, E.J. Glasson, P.D. Montgomery,

The Influence of Intellectual Disability on Life Expectancy, The Journals of

Gerontology: Series A, Volume 57, Issue 7, 1 July 2002, Pages M470–M472,

Scepters M, Keer M, O'Hara D, Bainbridge D, Cooper S-A, Davis R, Wehmeyer M.

Reducing health disparity in people with intellectual disabilities: A report from

the health issues special interest research group of the International Association of

Intellectual Disability. Journal of Policy and Practice in Intellectual Disabilities.

2005;2(3–4):249–255.

Traci MA, Seekins T, Szalda-Petree A, Ravesloot C. Assessing secondary conditions

among adults with developmental disabilities: a preliminary study. Ment Retard.

2002 Apr; 40(2):119-31

46
Appendix C

47
Case Report IV

Case Summary

Mr. H.A. is 11 years old boy, who belongs to Rawalpindi and was brought by

his parents. He has 4 siblings and he is 4th in order. He belongs to middle class.

His mother had normal delivery but she had so many complications during her

pregnancy. The child experienced huge delay in achieving developmental

milestones. At the age of 9, the client fell from stairs and his skull bone was

broken which badly affected his learning and academic functioning. His main

problem is lack of learning skills, lack of understanding different concepts and

difficulty in reading/writing. There is also frustration in his behavior. Formal

assessment was done and standardized test were used to assess his behavior. CPM

was used to assess his severity of disorder. Another tool BGT was used. After

administering the tests, it was found that client has Specific Learning Disorder

with impairment in reading and writing impression. After complete diagnosis,

different sessions were conducted in which different techniques were used to

change the target behavior. Psycho-education was provided to his family. Specific

schedule was made by therapist and guided his mother to follow the schedule. A

predictable classroom and intensive teaching techniques were used to make

learning better.

48
Bio Data

Name: H.A

Age: 11

Gender: Male

Religion: Islam

No. of Siblings: 4

Birth Order: 4th

Family System: Nuclear

Father Alive/Dead: Alive

Mother Alive/Dead: Alive

Father Education: Uneducated

Mother Education: Middle

Father Occupation: Tailor

Mother Occupation: Housewife

Socio Economic status: Middle

Referral Source

Parents

Placement of Internship

Sedum School for Special Children

49
Informal Assessment

General Observation

The client was seventeen years old boy. He had good eye contact. He had

difficulty in recognizing difficult words. The client had problems in reading and

writing. He was talking properly but his speech was little disorganized. The client

had problems in understanding words and different concepts. He had difficulty in

learning academic activities. The client had difficulty in learning new words

(vocabulary), either while reading or hearing. His social skills were adequate.

Reported Problem (By Mother)

‫پيدائش سے پہلے بہت مسلے تھے‬

‫زیادہ دیر پڑھ نہيں سکتا یے‬

‫ بھول جاتا ہے‬،‫جو بھی یاد کرتا ہے‬

‫کبھی کبھی بہت غصہ کرتا ہے‬

‫زیادہ دیر توجہ نہيں دے سکتا یے‬

‫پڑھائ ميں بہت پيچھے ہے‬

Personal History/Family History

The child was living in nuclear family system. His father was tailor and his

mother was housewife. He belonged to middle class family. He had three elder

sisters and he was younger one. He was born after seven months and three weeks

50
with normal delivery. He was born in hospital. He had not achieved his milestone

at proper time.

Table No.1

Comparison between Normal Age and Client’s Age of Achieving

Developmental Milestones

Developmental Normal Age Range Client’s Age

Milestones

Neck Holding 3 months 8 months

Sitting 6-8 months 2.5 year

Crawling 8-10 months 2 year

Babbling 4 months 9 month

Walking 1-1.5 years 6 year

Speech 3-4 years 4years

Toilet Training 3-6 years 8 years

Dressing 4-6 years 9 years

Medical History

According to his mother, she had so many complications during her pregnancy.

She had too much amniotic fluid in the womb due to marital diabetes. During

pregnancy, the doctor suggested the mother to abort the fetus due to immaturity

but she refused. She used the regular folic acid and some multivitamins for her

and fetus health. She had normal delivery but child is immature. The client was

51
born after seven months. According to mother, the weight of the child was 3

pounds at birth. The client had huge delay in major developmental milestones.

At the age of 9, the client fell from stairs and his skull bone was broken which

badly affected his learning and academic functioning.

Educational History

The client was studying in ZLS. The school worked on his behavior. He left the

school after spending 2-3 years because there was not enough improvement.

The client jointed this institute five years ago. Here the client was learning proper

skills to improve his academics. According to his mother, the client was very

fond of computer.

Formal Assessment

Standardized Assessment Tools

1. Colored Progressive Matrices (CPM)

2. Bender-Gestalt Test (BGT)

1. Colored Progressive Matrixes

a) Quantitative Analysis

Total Score: 19

Percentile: 10th

Grade: V

52
Guideline: Definitely below average in intellectual capacity

b) Qualitative Analysis

The client completed CPM in 32 minutes. The intellectual functioning of

the client is not good. His IQ level shows that the client is not good in

learning new things and academics but his occupational and social skills

are much better. The client scored 19 in the test, which falls in 10

percentile. This shows that the client is definitely below in intellectual

capacity.

2. Bender Gestalt Test (BGT)

a) Quantitative Analysis

Score Range Area

12 9-12 Strong evidence of

Brain Impairment

b) Qualitative Analysis

The test administered on client and he took 23 minutes to complete the

test. He scored 11 in the final results which show that he falls in the area

of strong evidence of brain impairment. During the test, the client faced

difficulty to draw few figures from the test. The rotation of the figure

indicates the lack of attention and capacity to learn new things. The

overlapping of the figures indicates insecurity, compulsive self-doubt and

53
potential for aggressive acting out. Perseveration indicates the poor ego

control, difficulty in planning and poor concentration. Increased size

indicates poor frustration tolerance. Dashes substituted for dots indicate the

lack of interest and aggressiveness. Wavy lines indicate lack of stability in

motor coordination.

Case Formulation

The client falls into the category of Specific Learning Disorder as the primary

diagnosis.

According to Bio-psycho-social Model, the case can be evaluated in the following

way

Biological Factors

 Immature fetus

 Client experience huge delay in developmental milestones

 Skull injury

 No family or genetic history of mental disorder has been detected

Psychological Factors

 Low cognitive power

 Difficulty in academics

 Low self esteem

54
Social Factors

 Good social Interaction.

 Good communication skills.

Graphical Representation of Case Formulation

Biological Factors

 Immature fetus
 Huge delay in developmental
milestones
 Skull injury
 No family or genetic history of
mental disorder has been
Psychological Factors
detected Social Factors
 Low cognitive power
 Good social Interaction.
 Difficulty in academics
 Good communication
 Low self esteem
skills.

315.00 (F81.0) Specific

Learning Disorder with
impairment in reading.

315.2 (F81.81) Specific

Learning Disorder with
impairment in writing
expression.

One of the most common co-morbid conditions in childhood is that of reading

disabilities and attention deficit hyperactivity disorder (ADHD). Children with

55
specific learning disabilities (SpLDs) show an increased risk of hyperactivity.

There is a strong relationship between inattentiveness and reading disabilities.

Children with‎‎“learning‎ difficulties”‎‎underachieve‎academically‎‎for‎‎a‎‎wide‎‎range‎‎of‎‎

reasons, including factors such as behavioral, psychological, and emotional issues;

English being their second language and not their mother tongue; ineffective

instruction; high absenteeism; or inadequate curricula. These children have the

potential to achieve age-appropriate levels once they are provided support and

evidence-based instruction. Students with below average cognitive abilities whom we

cannot‎ term‎ as‎ disabled‎ are‎ called‎ “slow‎ learners.”‎ The‎ ‎ slow‎ ‎ learning‎ ‎ child‎ ‎ is‎ ‎ not‎‎

considered mentally retarded because he is capable of achieving a moderate degree of

academic success even though at a slower rate than the average child.

Diagnosis

315.00 (F81.0) Specific Learning Disorder with impairment in reading.

Management Plan

Learning disabilities have no cure, but early intervention can lessen their effects.

Following are the ways to cope with the disability. i.e.

Psycho-Education

The mother of the client was informed about the diagnosis. After that, his mother

was informed about different techniques that can used to modify child’s learning

behavior.

56
Intensive Teaching Techniques

These can include specific, step-by-step, and very methodical approaches to

teaching reading with the goal of improving both spoken language and written

language skills. Teacher was giving extra time to finish tasks to improve his

learning.

Patterns of Strengths and Weaknesses

A pattern of strengths and weaknesses (PSW) is one approach for determining

specific learning disabilities. Teacher and therapist appreciated the client for his

strengths and worked more on his weaknesses.

Maintain a Predictable Classroom

Teacher maintained the similar schedule every day and made sure to announce

when things are in different way. Teacher explained the reasons for the change

i.e. Friday was only the activity day.

Engagement in Different Activities

Teacher and therapist engaged the client in different fun activities i.e. coloring the

color book, painting, different games, solving different puzzles.

Homework Assignments

Teacher and therapist gave the client different homework assignments to maintain

his attention and better learning.

57
Recommendations

The client is already studying in special school, where he is getting all the

important and necessary interventions

 Psych educate the family

 Special Teaching Techniques

These can include helping a child learn through multisensory experiences

and by providing immediate feedback to strengthen a child's ability to

recognize words.

 Classroom Modifications

Teachers can give students that need it, extra time to finish tasks and

provide recorded tests that allow the child to hear the questions instead of

reading them.

 Use of Technology

Children with impairment in reading may benefit from listening to books

on tape or using word-processing programs with spell-check features.

 Other ways of reducing the need for writing

Teachers can provide notes, outlines, and preprinted study sheets.

 Make and display plan

 Keep lessons simple and short

 Occupational Therapy

Occupational therapy teaches skills that help the person live as

independently as possible. Skills may include dressing, eating, bathing, and

relating to people.
58
 Have basic resources at home

 Avoid constant multitasking

 Facilitate a Small Group Discussion

59
References

Kohli, Adarsh & Sharma, Samita & Padhy, SusantaK. (2018). Specific Learning

Disabilities: Issues that Remain Unanswered. Indian Journal of Psychological

Medicine. 40. 10.4103/IJPSYM.IJPSYM_86_18.

60
Appendix D

61