1

Case Summary

R.T was a 9 years old girl living with one elder sibling and her parents. The client was

presented with complaints of lack of communication, lack of socialization, poor eye

contact and no name response. The client came in the institute at the age of 7 and she

was referred to trainee clinical psychology for assessment and for management plan.

The client’s assessment was done informally through behavioral observation,

Subjective Rating of Symptoms and Clinical Interview with his mother. The formal

assessment comprised of administration of Childhood Autism Rating Scale-2 (CARS-

2) and ABLLS-R. The client was diagnosed with 299.0 (F84) Autism Spectrum

Disorder, Moderate. The management plan was developed according to client’s

presenting complaints, rapport building, psychoeducation, different techniques of

behavioral therapy such as prompting, reinforcement, modeling etc. Post intervention

assessment was done and overall therapeutic outcome was 16% which depicted

effectiveness of therapy.

Bio Data

Name R. T

Age 9 years

Gender Female

No. of Siblings 2

2nd

Birth Order (Youngest)

Informants Mother
Reason for Referral
 2

The client was referred to the clinical psychologist at LISCA for psychological

assessment and management with having complaints of lack of socialization skills,

lack verbal communication skills, poor eye contact and no name response.

Presenting Complaints

Table 1.1 showing presenting complaints of client

Lack of verbal communication

Lack of socialization skills

Poor eye contact

No name response

History of Present Illness

The client’s mother reported that she faced no prenatal complications before her

birth. Her delivery was normal as consultation with doctor was done properly. The

client was delivered as a full term [Link] reported no emotional stressors during the
 3

pregnancy. The client’s mother reported no medical or psychiatric illness during

pregnancy or postpartum period.

She achieved her developmental milestones on time except speech and social

emotional [Link] mother reported that the client as a baby and toddler, was

healthy and development was normal until the age of 2 years. The client had an elder

brother with age difference of 1.5years. He was diagnosed with Autism Spectrum

Disorder. Both of the siblings were quite close to each other. The client’s mother

reported that after the age of 2, the client started copying his brother’s behaviors. The

client stopped speaking with little to no verbal communication. The client did not

respond to her name calling and had poor eye contact.

The client’s family moved from Malaysia to Pakistan in 2018. Her parents consulted

a doctor in Pakistan who recommended to consult Psychiatrist and Clinical

Psychologist for her difficulties. The client was diagnosed with Autism Spectrum

Disorder (ASD) in 2018. During the period of COVID-19, the client was exposed to

excessive screen time and she rarely interacted with anyone, so her verbal

communication was not further developed. The client’s parents visited private

institution for her proper assessment and management plan where she was getting

treatment in the form of occupational, speech and play therapies.

Background Information
 4

Personal History

The client’s birth was through normal delivery according to her mother and she

faced no post natal complications. The client achieved developmental milestones on

time except speech and social emotional milestone. Her development was normal

until the age of 2. Then according to her mother she started showing the behaviors

such as no name calling response and poor eye contact.

Developmental Milestones

Table 1.2 showing developmental milestones

Milestone Achieved Age Normal Age

Neck Holding 3 months 2-4 months

Sitting 6 months 5-6 months

Crawling 6 months 6 months

12-14
Walking 2 years
months
Speech Not achieved 2 years
Family History

Father: The client’s father was 35years old who worked in a private company in

Malaysia even before marriage in 2013. He was a caring person and left no stone

unturned in supporting his family. He was an affectionate father who loved his

children equally.
 5

Mother: The client’s mother is 32years old housewife. She had empathetic nature and

loves her family. The client shared a cordial relationship with her parents and

especially with her mother.

Brother: The client’s brother is 11years old who was diagnosed with Autism

Spectrum Disorder (ASD) in 2016. The client shares a strong connection with her

brother. The client’s brother is also quite devoted towards her sister and often

expresses gestures of care through non verbal actions.

General House Environment: The client belonged to a middle class family with

nuclear family system. The general home atmosphere is warm and friendly as

reported by client’s mother. The client’s parents look after towards the client and her

brother nicely.
 6

Genogram

M F

Symbols Description

Male (M) Father

Female (F) Mother

 7

Sibling (s) Client (c)

Satisfactory Relationship

Strong Relationship

Educational History

The client was admitted at the age of 7years in private institute. She learned a few

tasks related to academics of writing numbers and letters through tracing and coloring.

Her behavior in the class was solitary and she only interacted with her brother through

non verbal gestures.

History of Psychiatric or Medical Illness

The client’s brother had Autism Spectrum Disorder (ASD). The client’s mother

reported no other medical or psychiatric illness in family.

 8

Psychological Assessment

Psychological assessment was done at two levels.

1. Informal Assessment

2. Formal Assessment

Informal Assessment

Clinical Interview

Behavioral Observation

Rating of presenting complaints

Reinforcer Identification
Behavioral Observation

Behavioral observation is the systematic recording of behavior by an external

observer. The systematic nature of behavioral observation is characterized by

carefully detailed procedures that are designed to collect reliable and valid data on

client behavior and the factors that control it (Barrios, 1993; Tryon, 1998).
 9

The client’s behavior was observed in the classroom. She had height and weight

appropriate to her age. She was wearing clean clothes suitable according to weather

conditions. Rapport building was done by sitting close to her. The client did not

respond to her name calling and did not make eye contact with the trainee clinical

psychologist. Her sitting behavior was normal while on the other hand she was easily

distracted by her peers doing other activities. She was able to make a few sounds and

could point towards objects but her verbal communication was not fully developed.

She was playing with a toy in her hand. The client was interested in pasting and

coloring activities so in order to build rapport with her, she was involved in paper

pasting activity. She had good fine motor and gross motor activities which became

obvious by her pasting activities.

Clinical Interview

The clinical interview is a fundamental part of psychological treatment. The clinical

interview is a dialogue between the therapist and the client which help to initiate

therapeutic alliance, assessment of the problem of the client and implementing the

intervention for these problems. Informed consent is an important element of the

clinical interview (Flanagan, Zeleke, & Hood, 2015).

A detailed clinical interview was conducted from the client’s mother regarding her

pre natal history, complications, the client’s developmental milestones, history of

present illness and background information. Her mother reported about delayed

milestones, lack of verbal communication and no socialization.

Identification of Reinforcers
 10

A reinforce is a stimulus that increase the likelihood that a specific behavior or

response will occur. So, in order to build rapport with child and engaging her in this

session her preferred reinforcers were identified by observing his interest during

observation, in clinical interview with her mother and her therapist.

List of reinforcers

Table 1.3 showing list of reinforcers for client

Types Reinforcers Priority

Tangible Colors 1st

Edible Candy 2nd

Social High five, praise 3rd

Subjective Rating of Symptoms

Speigler (2019) defined subjective ratings of symptoms that these are taken to see

how frequently problematic behaviors occur or how severe they are in which client or

his informants rated the symptoms by using 0-10 scale.

0= no problem

1-5 Average

6-10 Severe
 11

Table 1.4 showing subjective rating of client’s symptoms

Presenting complaints Subjective rating

Lack of verbal communication 9/10

No name response 8/10

Poor eye contact 7/10

Lack of socialization skills 7/10

Formal Assessment

Childhood Autism Rating Scale (CARS-2)

Childhood Autism Rating Scale (CARS-2) includes three forms. Childhood Autism

Rating Scale- Standard Version (CARS2-ST), the Childhood Autism Rating

ScaleHigh Functioning (CARS2-HF) and the Questionnaire. Each of the two rating

forms asks about 15 areas of behavior defined by unique rating system developed to

assist in identifying individuals with Autism Spectrum Disorders (ASDs). CARS2-ST

was used in this assessment was administered in order to assess presence of autism in

him.

The test was rated on the basis of self-observation of child’s behavior.

Quantitative Interpretation

Table 1.5
 12

Sr no. Categories Score

1 Relating to people 2

2 Imitation 3

3 Emotional response 2

4 Body use 2.5

5 Object use 2

6 Adaptation to change 3

7 Visual response 3

8 Listening response 2

9 Taste, smell, touch response 2.5

and use

10 Fear or nervousness 2

11 Verbal Communication 3.5

 13

12 Nonverbal Communication 2.5

13 Activity level 2

14 Level and consistency of 1

intellectual response

15 General impression 3

Table 1.6 Showing raw total score of client on CARS-2

Total Score range T score Percentile

Age 2-12
Raw
Age 2-12
Score

35 MildModerately 46 35

Autistic

Qualitative Interpretation
 14

The total raw score of the client was 35 overall in all categories of CARS-2 total

scale, above the cutoff score of 30, which showed that she was in category of

moderate symptoms of Autism Spectrum Disorder. T score for Age 2-12 is 47. This T

score indicates Average level of autism related symptoms according to autism

diagnosis as provided in the manual. On the other hand, the percentile rank of the

client according to age 2-12 is 35.

Some of categories showed high impairment such as in verbal communication with

a score of 3.5 because her verbal communication was very less. She couldn’t speak

properly. The client also showed high score in adaptation to change where she scored

3 . The child was generally unable to express needs or desires clearly through

nonverbal communication. The client score 2.5 in body use and 3 on visual response

where she was reminded to focus on the tasks she was doing and her eye contact was

inconsistent.
Assessment Of Basic Language and Skills (ABLLS-R)

The assessment of basic language and learning skills-revised (ABLLS-R) is a

criterion referenced assessment tool, curriculum planning guide, and tracking system

of requisite skills needed for basic language and communication development, as well

as skills needed to support learning in important academic, adaptive, and motor areas.

The primary aim of the ABBLS-R is to assess and identify skills in language or

communication and critical academic learning, self help, and motor areas in order to

optimize communication, social interaction, and ongoing learning in everyday

situations. A secondary purpose is to assist in determining and prioritization

educational objectives for individual child. The ABLLS-R assessment can identify
 15

skills currently in the child’s repertoire, the level of skill attainment, and allow for the

ongoing.

Qualitative Interpretation

The assessment (The assessment of basic language and learning skills) was used to

identify child’s skills in different domains of the assessment.

Cooperation and Reinforcer effectiveness A domain. Reinforcement can be used

to teach new skills, teach a replacement behavior for an interfering behavior, increase

appropriate behaviors, or increase on-task behavior. Positive reinforcement is most

effective when it occurs immediately after the behavior. Reinforcement should be

presented enthusiastically. Deliver reinforcement quickly. ABLLS was used to

determine client’s skills of cooperation and reinforce effectiveness. The client could

wait for 10sec without touching the stimuli and she could scan upto 2 task related

items so work was done further on A8 ad A10.

B Visual performance: Visual performance is the ability to perceive and identify

objects or small details and visual tasks. The client had no response on baseline at B8

and she could connect 2 puzzles with 5 pieces. So in order to work further B8 and

B10 were added in tasks.

 16

C. Receptive language. Receptive language is the “input” of language, the ability to

understand and comprehend spoken language that you hear or read. The client

couldn’t comply with instructions provided, properly.

D. Motor imitation: Motor imitation refers to the ability or task of mimicking and

reproducing the movements of another person. The client could imitate only 2 actions

with full physical and verbal prompting.

E. Vocal imitation: The refers to the imitation of sounds by the child. The client was

unable to vocally imitation upon request when provided with verbal prompts. So no

response at baseline on E1.

F. Request: This domain helps to identify the point where client respond by

indicating. Client was unable to request with word. There was no response at baseline

on E1.

G. Labelling: Labelling or using a label is describing someone or something in a

word or short phrase. Client was unable to label common object when provided with

physical prompt.

H. Intraverbal. This domain is helpful in improving verbal as well as non-verbal

communication. The client showed no response at baseline. H1 Filling up words was

added in client’s tasks.

 17

L. Socialization. Socialization helps to interact with the people around without any

hindrance. This domain covers the tasks helpful in improving socialization. For client

tasks were, L13: Sharing items with others and L21: Initiates the greetings with

others.

Q. Reading skills: Reading is the process by which a reader extracts visual

information from a piece of written text and makes sense of it. Client was unable

to read upper letter.

[Link] skills: This refers to ability to write where the client writes alphabets or

letters. The client was able to write a few alphabets with physical prompts. S4 trace

letters and numbers.

Diagnosis formulation

According to the DSM V client met the criteria of “Autism Spectrum Disorder”. The

client was having deficits she did not interact with other child, she did not response on

her name, and also she had poor eye contact. These symptoms of client were present

from early childhood and limited her everyday activities.

Table 1.7 showing diagnosis according to DSM-5

Code DSM-5 Diagnosis Specifier

 18

299.00 (F84.0) Autism Spectrum Moderate

Disorder (ASD)

Prognosis

The term prognosis refers to making an educated guess about the expected outcomes

of any kind of health treatment, including mental health, in essence making a

prediction of the process an individual may have to go through in order to heal and the

extent of healing was expected to take place.

Prognosis in favor of better prognosis

The client’s interest in activities was favorable for good prognosis. Teacher’s

guidance and family support were also crucial factors in good prognosis of client’s

treatment.

Prognosis against the better prognosis

The client had poor verbal communication skills which were good good prognosis.
Case Conceptualization Case Formulation

ClienCtlient
Predisposing Factor
R .T R .T
G eneti cs
9 y ea9rsy ears

Presenting Complaints Precipitating Factor

- L ack of v erbal D el ay ed D ev el opmental
communi cati on M i l estones
-L ack of soci al i z ati on
-N o name response
- P oor ey e contact
 19

R. T was a 9 years old girl living with one elder sibling and her parents. The client was

presented with complaints of lack of communication, lack of socialization, poor eye

contact and no name response. The client came in the institute at the age of 7 and she

was referred to trainee clinical psychology for assessment and for management plan.

The client’s assessment was done informally through behavioral observation,

subjective rating of symptoms and clinical interview with his mother. The formal

assessment comprised of administration of Childhood Autism Rating Scale-2 (CARS-

2) and ABLLS-R. The client was diagnosed with 299.0 Autism Spectrum Disorder,

(F84) Moderate.

Autism Spectrum Disorder has tendency to run in genetics. This was a contributing

factor in the client’s case. According to various researches done, links between

Autism Spectrum Disorder and genetics have been identified. ASD is now understood

to be a disease of complex interaction between genetics and the environment, with

heritability estimates ranging from 40 to 80% (Chaste and Leboyer, 2012). Extensive

genetic studies have revealed hundreds of genes linked to autism. This shows that

there might be genetic links of Autism which is passed down to the client through

hereditary.

The client’s only sibling, elder brother was also diagnosed with Autism Spectrum

Disorder. As proven through many researches, there have been increased of Autism

occurrence in a child with Autistic sibling. According to research of Muhle R.

(2004),the recurrence risk of pervasive developmental disorder in siblings of children

with autism is 2% to 8%;4 and it rises to 12% to 20% if one takes into account the
 20

siblings showing impairment in one or two of the three domains impaired in autism

respectively ( Bolton,[Link], 1994). Moreover, several twin studies have suggested that

this aggregation within families is best explained by shared genes as opposed to shared

environment (Baiely A, 1995). It is evident from these researches that familial links

increase prevalence of ASD.

S. Delayed developmental milestones are always associated with developmental

disorders. Where the client achieves milestones at a later age than other age fellows.

The client had delayed milestone of speech and social emotional communication.

During the period of Covid-19, the client was exposed to increased screen time and

she used to watch videos all day long. After such period of exposure the client’s

verbal communication developmental was negatively effected. This is supported by

various research studies. According to a study, screen time can negatively affect

language acquisition, early language development (Byeon & Hong, 2015).

The protective factors in client’s case were her parents’ support. The management

plan was developed according to client’s presenting complaints, rapport building,

psychoeducation, different techniques of behavioral therapy such as prompting,

reinforcement, modeling etc.

Management Plan

Management plan is a mental health treatment plan, also known as mental health care

plan for the people who have mental health issues. This management plan identifies
 21

which what type of health care and behavioral therapies a client needs to get free from

the problem. Management plan was designed to manage her issues.

Short Term Goals

To improve the verbal communication of client by the tasks such as making a

request.

To improve the socialization of client through interaction with others using

techniques of reinforcement. Such as by greeting others while entering a room or

sharing toys with other kids.

To improve the eye contact of the client with therapist and with others.

Reinforcement techniques were used to strengthen the desirable behavior. Such as

using a tunnel technique for making eye contact and then behavior was reinforced

by providing candies.

To improve the eye contact of client by providing reinforcement every time she

responded to her name in front of the trainee.

To improve the client’s motor activities such as jumping and clapping through

modeling.

Long Term Goals

 22

Continuation of short- term goals to learn each behavior efficiently and gain

mastery over them.

Family counselling for more insight in the child’s problem and to the role of

family in its management.

Summary of Therapeutic Techniques

Rapport Building

Rapport building is necessary for building strong child-therapist relationship. In

order to build therapeutic bond rapport built with the child. For this purpose, her

interests were identified during her behavioral observation and to get her involve in

her favorite activities. The client liked to color and play with toys so she was provided

opportunity to do that. The child started responding after 2-3 sessions. In rapport

building the child engaged different activities of her interest like coloring and

scribbling.

Psycho Education

A fully guided explanation was given regarding what was being done (diagnosis) for

consideration during the therapeutic process (treatment plan) and the rationale for the

way they were being done to enhance the motivation and reduce the confusion of the

client and family in treatment The client’s parents were psycho educated regarding the

client condition after assessment they were told about the common symptoms and its
 23

main causes and treatment plan the client’s parents were educated about the prognosis

of the illness and treatment procedure. The client’s parents were also psychoeducated

regarding symptoms and their management in home environment.

Reinforcement

Reinforcement was the process in which a behavior is strengthened by the immediate

consequence that reliably follow its occurrence. When behavior is strengthened, it is

more likely to occur again in the future.

Trainee clinical psychologist used reinforcement in different tasks to strength the

behavior of client. Client was given reinforcement in the form of candies; colors were

her reinforcers. In beads activity when client put the bead in the string, she was

reinforced by saying ‘very good’. The number of beads increased when she gained

mastery in beads activity. Then client’s activity level was increased to aligning 2

different sets of beads in string. In puzzle solving activity when client put the correct

piece of puzzle the client was reinforced by verbal appreciation. To improve her

socialization skills the client was asked to greet her peers by waving after entering the

room. And soon after that she was provided with candy for performing the desired

behavior. Tunnel technique was used through reinforcement to improve the client’s

eye contact. Naming response was strengthened every time she responded to the her

name.

Prompting
 24

Miltenberger described that prompting was technique used to increase the likelihood

that an individual will engage in correct behavior at the correct time. They were

stimuli given before and during the performance of a behavior. The function of

prompts was to produce an instance of a correct behavior so that it can be reinforced.

Physical and verbal prompt were used to make the client able to learn new skills.

Physical prompt was given in coloring line, pasting, beads in string and puzzles

solving.

Modeling

Modelling helped the child to learn new skills and to help her understand how she

could the task by observing therapist indulging in the same task. Modelling was used

to treat the client motor activities like jumping and clapping. Firstly, the client was

given instructions about the task and told her that she had to do “what I would do”,

she had to follow “what I was doing”, after that trainee clinical psychologist

performed the action and asked the child to watch carefully. Then the child was

requested to do what she saw. After many rehearsals child was able to do the task.

After every trial child was praised by the trainee. After trials the child understood the

concept.

Therapeutic Outcome

The assessment and management of IEP goals were done with the client. Client’s eye

contact, socialization skills, name response were a bit improved than before. Her
 25

verbal communication skills were still underdeveloped according to the therapeutic

outcome and post intervention assessment. The client’s mother reported progress in

their child problematic symptoms after following the therapy. The overall outcome of

therapy was 17%.

Limitations

There was a long time required to see changes. More session should be held to

apply various techniques to overcome the child’s problem.

Because the session was held in a classroom setting, the child’s concentration

was easily distracted.

Suggestions

Parents should practice activity at home according to individualized educational plan.

More session should be conducted for applying different techniques to overcome

client’s problems.
 26

Post Assessment

Table 1.9 Showing rating of presenting complaints

Presenting complaints Subjective rating Subjective rating

Pre intervention assessment Post intervention assessment

Lack of verbal communication 9/10 8/10

No name response 8/10 6/10

Poor eye contact 7/10 5/10

Lack of socialization skills 7/10 5/10

Graphical Representation
27
 28

Individualized Training Program

Bio data
Name: R.T
Age:

Gender: Female
Birth order:
Number of siblings:

Resource Person
Mam Mariam Khalil

Tools:
Behavioral Observation
ABLLS

Strengths:
She can hold pencil without prompting
She follows instructions for different tasks performance
She can trace well on alphabets and urdu letters
She can make eye contact for a few seconds

Weaknesses:
Not good with written expression
Cannot draw lines and shapes
No non verbal or verbal communication
Cannot maintain proper eye contact

Mont Domain and Therapist’s Task Startin Endin Task

 29

h codes notes g date g date completion

June A=Corporatio
2023 n and

Reinforce
Effectiveness
A8 Wait She waits for 20-30 80%
without 10 seconds seconds
without
touching with verbal
verbal
the prompting or
physical
stimuli (like
prompt
backward
counting)

done at
baseline
A10 Scans She can scan Upto 5 70%
items in array upto 2 task items
before
related items task
responding
within 3 related
seconds
in 3
at
seconds
baseline

B= Visual
Performance
B8 sort non- No response atGive 6 50%
identical baseline items (2 each
objects of

items)
can at
least
 30

sort 4
items
B10 Puzzles She can Connect 60%
with multiple connect 4
puzzles
connecting 2
with at
pieces in an puzzles with least 5
pieces
insert-type 5 pieces
frame
C=Receptive
Language
C7 Follow She complies At least 70%
instructions in with 3
routine
instructions activitie
situations
of 3 or more
s
activities with
partial with
physical only
verbal
prompt or
at pointing
baseline prompti
ng
D= Motor
Imitation
D1 Motor 2 actions at At least 80%
Imitation using baseline with 5
objects physical actions
prompting with
verbal
prompti
ng

E=Verbal
Behavior
E1 ImitatesNo response atAt least 30%
 31

sounds on baseline 2 sounds

with
request verbal
prompti
ng

F= Requests
F1 Requests by No response atRequest 40%
Indicating baseline of at
least 1 item
or one
activity per
day
G= Labeling
G1 Label No response atAt least 30%
reinforcers baseline labeling

of 2
items
with
partial
verbal
prompti
ng

H=
Intraverbal
 32

H1 fills in the No response at Up to 2 50%

song the words

baseline in a
song
partial
verbal
prompti
ng

L= Appropriate
Socialization near siblings

L13: Sharing With 40%

partial
items with
physical
others L21: or
verbal
prompti
Initiates the

greetings with
others. ng

S= Writing 60%
Skills
 33

S4 Trace lettersCan trace

and numbers numbers and
letters with
physical Trace
prompting numbers
and

letters
without
physical
prompti
ng and
not just
straight
lines
34