Child Placement Case Report

SAIRA NASIR

ROLL NO. 25

MSCP II

Supervisor

Miss Sadia Mustafa

SESSION: 2021-2023

DEPARTMENT OF PSYCHOLOGY

LAHORE GARRISON UNIVERSITY

LAHORE

i
 Declaration

I, Miss Saira Nasir, Roll No 25 Session 2021-2023 from Department of Psychology,

Lahore Garrison University, do hereby solemnly declare that the work submitted in this
portfolio is my own. This work has been completed at the Shadab institute of special
Education Lahore.

SAIRA NASIR

ii
 Certificate

It is certified that Miss Saira Nasir worked under my supervision. Her internship
project has been approved for submission in its present form, as a requirement for fulfillment
of the MS degree in Clinical Psychology.

Supervisor

Date:

(To be signed after the Viva-Voce Examination)

Approved/Rejected/Sought Revision and Resubmission

External Examiner Head of Department

Date: Date:

iii
 Acknowledgements

First of all I thank God the Almighty for his faithfulness and protection throughout
my project that made it possible for me to encounter this success. I take this great opportunity
to sincerely thank a number of people and institutions who have made it possible for my
project and MS programme to become a reality. she has put great efforts in helping me in
accomplishing this project successfully. Without her this work would not have been what it
looks like now.

My very special thanks go to my supportive family that I can’t find words to explain.
My parents always supported me in every time. I would like to thank to my parents,
grandparents and siblings who have prayed me and made me what I am today.

Last but not least, I am very thankful to my own University professors and Shadab
supervisors and therapists.

SAIRA NASIR

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Contents
Case report 1........................................................................................18
Case Summary.....................................................................................................19

Bio Data...............................................................................................................20

Reason and Source of Referral............................................................................20

Presenting Complaints.........................................................................................21

History of Present illness.....................................................................................21

Background Information.....................................................................................21

Personal history...................................................................................................22

Educational history..............................................................................................23

Psychological Assessment...................................................................................23

Informal Assessment...........................................................................................23
Subjective Ratings of the child Symptoms...........................................................................24

Behavioral Observation........................................................................................................26

Portage Guide to Early Education (PGEE)...........................................................................27

Formal assessment...............................................................................................28

Diagnosis according to DSM-5 checklist............................................................28

Case conceptualization........................................................................................30

Case Formulation................................................................................................31

Management plan................................................................................................33

Structure of Sessions...........................................................................................34

Individualized Educational Plan (IEP)................................................................35

Session #1............................................................................................................39

Session # 2..........................................................................................................40

Session # 3..........................................................................................................41

11
Session #4...........................................................................................................11

Session #5...........................................................................................................11

Session #6...........................................................................................................12

Session # 7..........................................................................................................12

Session # 8..........................................................................................................11

Session #9...........................................................................................................11

Session # 10........................................................................................................12

Session # 11........................................................................................................13

Session # 12........................................................................................................13

Session #13..........................................................................................................14

Session #14..........................................................................................................14

Session #15..........................................................................................................15

Session # 16........................................................................................................16

Session # 17........................................................................................................16

Session # 18........................................................................................................12

APENDICES.......................................................................................................15

Case report 2...........................................................................16

Case Summary....................................................................................................17

Bio Data..............................................................................................................18

Reason and Source of Referral............................................................................18

Presenting Complaints.........................................................................................19

History of Present illness....................................................................................19

Background Information.....................................................................................20

Personal history...................................................................................................20

12
Educational history..............................................................................................21

Medical history....................................................................................................21

Psychological Assessment...................................................................................22

Informal Assessment...........................................................................................22

Formal Assessment..............................................................................................26

Diagnosis according DSM-5 symptoms checklist..............................................26

Case conceptualization........................................................................................28

Case Formulation................................................................................................30

Management plan................................................................................................35

Structure of Sessions...........................................................................................36

Individualize educational plan............................................................................37

Session # 1..........................................................................................................41

Session # 2..........................................................................................................42

Session # 3..........................................................................................................43

Session # 4..........................................................................................................11

Session # 5..........................................................................................................11

Session # 6..........................................................................................................13

Session # 7..........................................................................................................14

Session # 8..........................................................................................................15

Session # 9..........................................................................................................11

Session # 10.........................................................................................................11

Session # 11.........................................................................................................12

Session # 12.........................................................................................................14

Session # 13.........................................................................................................15

13
Session # 14.........................................................................................................16

Session # 15.........................................................................................................17

Session # 16.........................................................................................................17

Session # 17.........................................................................................................19

References...........................................................................................................20

APENDICES.......................................................................................................22

Case report 3............................................................................23

Case Summary.....................................................................................................24

Bio data...............................................................................................................25

Reason for Referral.............................................................................................25

Presenting Complaints.........................................................................................26

Background Information.....................................................................................27

General Home Atmosphere.................................................................................28

Personal history...................................................................................................28

Psychological assessment....................................................................................30

Informal Assessment...........................................................................................30
Subjective Ratings of the child Symptoms.............................................................................31

Formal assessment...............................................................................................34

Diagnosis according to DSM-5 checklist............................................................34

Case conceptualization........................................................................................36

Case Formulation................................................................................................38

Management plan................................................................................................40

Structure of Sessions...........................................................................................41

Individualized Educational Plan (IEP)................................................................43

14
Therapeutic Interventions....................................................................................47

Session # 1..........................................................................................................49

Session #2............................................................................................................50

Session #3............................................................................................................51

Session #4...........................................................................................................11

Session #5...........................................................................................................11

Session # 6..........................................................................................................12

Session # 7..........................................................................................................13

Session # 8..........................................................................................................13

Session # 9............................................................................................................1

Session # 10..........................................................................................................1

Session # 11..........................................................................................................2

Session # 12..........................................................................................................3

Session # 13..........................................................................................................3

Session # 14..........................................................................................................4

Session # 15..........................................................................................................4

Session # 16..........................................................................................................6

References.............................................................................................................7

APENDICES.........................................................................................................9

Case report 4............................................................................10

Case Summary.....................................................................................................11

Bio Data...............................................................................................................12

Reason and Source of Referral............................................................................12

Presenting Complaints.........................................................................................13

15
History of Present illness.....................................................................................13

Background Information.....................................................................................14

General Home Atmosphere.................................................................................14

Personal history...................................................................................................14

Educational history..............................................................................................15

Medical history....................................................................................................16

Psychological Assessment...................................................................................16

Informal Assessment...........................................................................................16

Formal Assessment.............................................................................................12

Diagnosis according to DSM-5...........................................................................12

Case conceptualization........................................................................................15

Case Formulation................................................................................................17

Management plan................................................................................................20

Structure of Sessions...........................................................................................21

Individualized Educational Plan (IEP)................................................................22

Therapeutic Interventions....................................................................................26

Session # 1..........................................................................................................28

Session # 2..........................................................................................................29

Session # 3..........................................................................................................30

Session # 4..........................................................................................................11

Session # 5..........................................................................................................12

Session # 7..........................................................................................................14

Session # 8..........................................................................................................15

Session # 9..........................................................................................................11

16
Session # 10........................................................................................................11

Session # 11........................................................................................................12

Session # 12........................................................................................................12

Session # 13........................................................................................................13

Session # 14........................................................................................................14

Session # 15............................................................................................................................. 14

Session # 16........................................................................................................15

Session # 17........................................................................................................11

References...........................................................................................................12

APENDICES.......................................................................................................15

17
Case report 1

18
 Case Summary

The child Q.A was 11 years old, male belonged to middle class socio economic status. Child
was referred to the trainee clinical psychologist with the complaints of delayed
developmental milestones (e.g. talking in single word, head holding, sitting, walking, toilet
training), difficulty remembering things, difficulty with problem-solving and logical thinking,
low appetite, crying, forgetfulness and studies difficulties. He was referred to present trainee
clinical psychologist for the purpose of psychological assessment. Psychological assessment
was done on formal and informal level. Informal assessment was done by using clinical
interview subjective ratings, Portage Guide to Early Education (PGEE) and behavioral
observation. Formal assessment was done by using DSM-5 criteria checklist of intellectual
disability. After formal and informal assessment, he was diagnosed with borderline
Intellectual disability. A case was formulated to identify the impact of different factors in
contribution of the problematic behaviors. The management plan for the child was based on
Cognitive Behavior Therapy. As therapeutic sessions were conducted with the child and the
he showed progress and improvement.

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Bio Data

Name Q.A

Age 11 years

Gender Boy

No of Siblings 2

Birth Order 1st born

Informant Childs mother

Socioeconomic Status middle class

City Lahore

Reason and Source of Referral

The child was approached to Government Shadab Training Institute of Mentally

Challenged with the presenting complaints of delayed developmental milestones, difficulty
remembering things, difficulty with problem-solving and logical thinking, crying, weak
memory or forgetfulness, studies issues and low appetite. He was referred to present trainee
clinical psychologist for the purpose of psychological assessment.

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Presenting Complaints

The child’s mother reported the following complaints.

Table 1.1

Duration Presenting complaints

1 year ‫چیزیں بھول جاتا ہے‬

2 years ‫کھا نا بہت تھوڑا سا کھاتا ہے‬

6 months ‫کسی ایک چیز کو پکڑ کر بیٹھ جاتا ہے‬

2 years ‫کوئی چیز یاد نیں کر پاتا‬

5 years ‫تھوڑا سا سست ہے ۔‬

1 years ‫کبھی کبھی رونے لگ جاتا ہے۔‬

1 year ‫جب بات نہ مانی جائے تو غصہ کرتا ہے۔‬

History of Present illness

According to the child’s mother he was below in IQ as he is not good studies. The child

parents took him to the Government Shadab Training Institute of Mentally Challenged for the
assessment purpose in 2022. The mother reported that the child was slow from the very start.
His developmental milestones had been delayed. He did not comprehend the school work
simply. The child’s adaptive functioning is low. His self-assist ability and self-care abilities
had been little low.

According to child mother the child’s cognitive skills were below than other same age
children. He has studies issue as he forgets his lesson immediately. His memory was low. His
height and weight is less than other children of same age. He did not do his homework.

Background Information

Family history

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 Father. The child's father M.S was 32 years old and he was uneducated. He was a
labor. His relationship with the target child was loving. His personality traits included
aggression, dominating sometimes non-cooperative. He suffered from high blood pressure.

Mother. The child's mother H.S was 29 years old. She was housewife. Her
qualification was primary. She was loving and cooperative. There are no medical issues with
mother.

Siblings. The target child was 1st born child. He had one younger brother of 6 years
in class kg. The child had a strong bonding with brother. No medical or psychiatric problems
were reported.

Personal history

Birth and Early Development

Child was born through normal delivery. Mother did not complete immunization
during pregnancy. At the time of birth child weight was three pounds. Mother start breast
feeding after 2 to 3 days of birth. Child had delayed developmental milestones.

Table 1.2

Table shows the significantly delayed milestones of the child:

Developmental Normal Age of Achievement Child’s Age of

Milestones (Seigalman & Rider,2010) Achievement

Social Smile 1- 4 months 8 months*

Neck holding 3 months 1 year*

Sits w/o support 5 -10 months 1.5 years*

Crawling 9-11 months 2 year *

Walks without support 10- 15 months 2.5 years*

Talks in single word 6- 12months 3 year*

Complete sentence 3-4 years 6 year*

Dressing without help 6 years 9 Years*

*significantly delayed

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 The child achieved all of his developmental milestones very late (see Table 1.2). He
started neck holding at the age of 1 year. He started sitting without support 18 months late as
compared to the other children. He started crawling at the age of 2 years. He started walking
at the age of 2.5 years as compared to other children who start walking at 1 to 1.5 years of
age. He spoke his first single word at the age of 3 years which was also very late.

And he gets dressed without help at the age of 9 years.

Educational history

Q.A got admission in braining school. But he was weak memory and low in studies.
The teachers said that he was very weak in studies and did not memorized the things easily.
The mother changed his school. The second school took him was Shadad government
institute of special education.

Medical history

The child had no medical history.

Psychological Assessment

Clinical Assessment was done to evaluate the information about the Childs’s family
background, other relationships, the onset of the problem and her present complaints. The
assessment was done on formal and informal level.

Informal Assessment

• Clinical Interview

• Behavioral Observation

• Reinforce checklist

• Subjective Rating Scale

• Portage Guide to Early Education (PGEE)

Formal Assessment

DSM-5 criteria of intellectual disability

Informal Assessment

Clinical Interview

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 Clinical interview facilitated the therapist to comprehend child’s problem and to elicit
precipitating, predisposing and maintaining factors of his illness. It also helped in diagnosis
and devising management plan for the child (Boyd, 2010).

Clinical interview is a tool that helps psychologist to make an accurate diagnosis of a

mental illness by asking questions from a child/child regarding his/her background
information, behavior issues and presenting complaints (Flanagan, 2015).

In the present case, the clinical interview was conducted with the child and his mother to
assess the child’s presenting complaints, history of present illness, child’s background
information including family history, personal history, educational history. The child’s
history of present illness was discussed.

Reinforce

checklist Table 1.3

Types Reinforcer
Edible Candy
Lollipops
Chocolates
Juice
Lays
Biscuits

Material Balloons
Balls
Bubbles

Activity Drawing
Clapping
Cricket

Social Smile
Praise
Recess time or free time

Subjective Ratings of the child Symptoms

Speigler (1998) defined ratings that these are taken to see how frequently problematic
behaviors occurs or how severe they are in which child or his informants rated the symptoms
by using 0-10 scale.

The child was asked to rate presenting complaints on the 10-point scale where

0=no problem

24
5=average

10=severe problem

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Table 1.4

Table showing the subjective rating of the child’s problematic behavior on 10-point scale
reported by the mother.

Symptoms Rating by mother Rating by therapist

Hyperactive 06 07

Hostile 05 05

Study issues 10 09

Laziness 06 05

Irritability 07 06

Poor social skills 05 06

Poor cognitive skills 07 07

Poor self-help skills 05 06

Motor activities 04 05

Crying 06 05

Low Appetite 07 07

Behavioral Observation

Behavioral observation is a structured assessment of child’s behavioral and cognitive

functioning. It includes description of person’s general appearance, speech, thought
perceptions, memory and insight about his or her illness. (Folstein, 1983).

The child was a male with the age of 11 years. Child appeared to be child of small height and
low weight. From his appearance and features it feels that child height is small but age is
greater. He was dressed properly. He was wearing clean and tidy clothes. His hygiene was
good. His speech was good. He maintains eye contact properly throughout the interview.

His orientation about time, place and person was good. He responded every aspect precisely
in little detailed. Child’s attention span was normal. His general knowledge and abstract
thinking was normal.

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Portage Guide to Early Education (PGEE)

The Portage Guide to Early Education (PGEE) program can be conducted in families,
communities, rehabilitation institutions, and early education centers, but the role of the family
and parents needs to be highlighted. The PGEE program has been used widely for early
intervention in children due to its scientific, interesting, coherent, and operable nature. It is an
early intervention method for cognitive training, which can be used as structured teaching
arrangements. However, the core status of game activities, toys, books and stories, and daily
life should be emphasized. (Cameron RJ. 1997)

Quantitative Analysis

Table 1.5

Showing Developmental Area and the Corresponding Age Range of the First Missed and Last
Passed Item

Developmental 1st Missed Item Corresponding Last Passed Corresponding

areas Age range Item Age Range

Socialization 22 0-1 83 5-6

Language 68 3-4 95 5-6

Self help 83 4-5 92 5-6

Cognitive 68 2-3 67 2-3

Motor 98 4-5 108 5-6

Qualitative analysis. The child’s age was mildly below on the areas of adaptive

functioning (socialization, self-help, language and motor skills) as compared to his

chronological age but cognitive functioning is much below then age fellows. The child was 6
years below from his normal chronological age.

Conclusion. The test reveals that child was below from his chronological age. He
had mental age of 5 years.

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Formal assessment

Diagnosis according to DSM-5 checklist

According to DSM 5, Q.A was diagnosed with (319), F(70) Intellectual

Disability.

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Table 1.6

Domains Symptoms Level

Conceptual domain Academic skill ➹

Reading ➹

Writing Χ

➹
Arithmetic
➹
Money recognition
Χ
Time and place orientation

Social domain Communication Χ

Language Χ

➹
Difficulty in accurately perceiving peers
➹
Social judgment
➹
Percieve risk in social situations

Practical domain Support in daily living task ➹

Grocery ➹

Shoping ➹

Transportation ➹

➹
Home and child care organisation
➹
Money management
➹
Hygiene
➹
Eating
Χ
Dressing

Χ= non problematic ➹=problematic

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Case conceptualization

Biological Causes
 Child low weight at the
time of birth

Prenatal Illnesses and Issues

Borderline Maternal illness (hypertension) may lead the

Intellectual patient towards intellectual disability and
disability no immunization of mother

Environmental Factors
Poor home environment, lack of
support, lack of parent-child
Interaction, and
Parental conflicts

Figure 2.1. Figure illustrating the conceptual model of intellectual disability copied

from Vienna, V.A (2015), Langley Residential Support Services.

Overall, the factors gave a comprehensive idea that how this disorder was occurred
and maintained. The predisposing and precipitating factors included the low weight at the
time of his birth and maternal no immunization while the maintaining factors in poor home
environment and parental conflicts were the most obvious features and need to be addressed
in management.

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Case Formulation

Child was referred to the trainee clinical psychologist with the complaints of difficulty
remembering things, difficulty with problem-solving, studies issues and low appetite. Detail
information was taken regarding the personal, family, educational and social areas of
functioning. Informal and formal assessments were carried out. Portage Guide Assessment
Tool administered on the child. Ratings of the problem areas were taken.

Different factors were also studied to understand the problem of child. The child had
extremely low weight at the time of his birth. Low birth weight is known to increase the risk
for major disabilities such as cerebral palsy and mental retardation, but researchers now
suspect that low birth weight may also contribute to minor difficulties in motor skills and in
thinking, learning and memory (cognitive abilities) ( JAMA and Archives Journals. (2006,
October 3). Most children born with extremely low birth weight (ELBW) demonstrate IQ
scores within broadly normal limits. Despite seemingly adequate cognition, these children
frequently experience difficulties in academic achievement, attention, and fine motor
functioning.3 School difficulties appear to be the main sequelae in children with ELBW.
School-aged children with ELBW, when compared with their peers with normal birth weight,
have significantly higher rates of educational assistance, grade failure, and placement in
special classes, and score significantly lower on standardized tests of mathematics, reading,
and spelling, with arithmetic standing out as a common problem area. Even neurologically
intact children with ELBW who have average intelligence demonstrate poorer academic
achievement than their full-term peers with normal birth weight (Saigel et al, 1997).

The maintaining factors for his intellectual disability were the poor and un-
stimulating home environment. A factor that can be better explained by Collin et al. (2017)
who proposed that early childhood is a period of great opportunity for optimum brain growth,
but it is also a period of vulnerability. Development in language, cognition, motor and socio-
emotional domains occur rapidly in these first years. These areas of development do not
operate or develop in isolation, but enable each other and mutually interact as the child learns
to become more independent. If the child receives potentially less stimulation and fewer
learning opportunities through other health service or care routes, then his intellectual
disability starts to go towards the severity level. Early identification of children with
intellectual disabilities, as well as early childhood intervention (ECI), improves children's
opportunities to maximize their developmental potential and functioning as well as their
quality of life and social participation (Johnson & Harman, 2018).

31
According to a research, In ID, higher levels of social support are positively correlated with
higher quality of life and lack of parent child interaction is correlated with the stress which
then leads to poor quality of life in ID childs (Lunsky & Benson, 2001; Meins, 1993; Reiss &
Benson, 1985). So, if the child has social support and adequate parent-child interaction then
his quality of life improves.

Maintaining
Predisposing Factors Protective
Factors Precipitating
Lack of facilities Factors
Poor home
Extremely Low environment Low socio economic Mother and father
weight at birth status support
Conflicts among
parents

Diagnosis
Borderline Intellectual Disability
disorder

Assessment

Informal

• Clinical interview
• Behavioral observation
• Symptom checklist
• Portage Guide to Early
Education (PGEE)

Formal

• DSM-5 criteria checklist

32
Management plan

The management plan of child is conceptualized on eclectic approach using paradigm of

behavior therapy and cognitive behavior therapy; keeping in view idiosyncratic needs of
child. Short Term Goals

• Therapeutic rapport is an essential part of a healthy therapist child relationship and

feeling child so that therapy can be successful

• Psych education will aid in providing insight of disorder, diagnosis and treatment to
the child’s family.

• To cope the family with life stressors in an effective and productive way by teaching
problem solving skills.

• Eating meal tips to improve diet.

• Activity scheduling was done to follow throughout the week and then changed
according to progress.

• Prompting physical and verbal prompts were used to increased desire and decreased
undesirable behaviors.

• Modelling was used to learned the child social and self-care skills like teeth brush,
sharing and greetings etc.

• Chaining was used to learned the child self-care skills like tie the laces and buttoning
or unbuttoning.

• Reinforcement methods were used to increase desirable behavior through clapping,

rewards and praise.

• Individual educational plane (IEP) was made to cover all the areas of portage guide.

• Group therapy was held to increase child interaction with friends and classmate and
to learned social skills.

Long Term Goals

• To continue the short term goals to maintain the change in future.

• To monitor the improvement and effectiveness of management plan by conducting

follow up sessions.

• Continuation of IEP to improve individual functioning of child.

33
 • Maintaining and increasing behaviors (developmental skills) learned during therapy.

• Follow up sessions should be conducted to further reinforce the behaviors learned.

• Instructional planning was done throughout sessions to increase academic and

cognitive skills.

• Parental counseling was done to give awareness about child disorder and needs.

Structure of Sessions

As many as needed sessions were conducted with the child. The management plan
devised, based on establishing and enhancing academic or cognitive, motors and behavioral
skills along with improving child's meal pattern and decreasing anger and irritability. Each
session lasts for about 45-50 minutes, in which 10-15 minutes were given to the mother, in
which homework given to the child was discussed, mother was trained how to follow the
management plan at home and her concerns regarding child's problem were answered. During
30 -35 minutes, therapist mainly focused on all the domains of IEP and muscles retention
exercises.

34
Individualized Educational Plan (IEP)

Student’s Name Q.A

Date of Birth 09-11-2011

Age 11 Years

Gender Male

Strengths of Child

 He has intact visual and hearing ability.

 Has good motor activities and speech
 Respond to immediate reinforcement
 Understand instructions and very obedient

Weaknesses of the Child

 Low level of comprehension.

 Slow learner
 Low mood

Cognitive skills

No. Activity Techniques Trials Reinforcement

C1 Recognition of money Verbal cues 3 Praise

Reinforcement

C2 Table of 2 Worksheet 5 Smile and

Reinforcement praise

08C
3
Eight color names Worksheet 4 Eating (Lays)

Reinforcement

35
69C
4
Addition and subtraction question Worksheet 5 Clapping

Reinforcement

68C
5
Days of week Worksheet 5 Clapping

Reinforcement

Personal take care

No. Activities Techniques Trials Reinforcement

84T
1
Tie the laces Chaining 4 Clapping

Reinforcement

93T
2
Cuts off soft food with knife Modeling 2 Candy

Reinforcement

88T
3
Serves self at table Modelling 2 Praise

Reinforcement

75T
4
Put jam on bread Modelling 2 Praise

Reinforcement

Movements

No. Activities Techniques Trials Reinforcement

98M
1
Cut the circle Modelling 3 Praise and smile

Shaping

99M
2
Draw simple recognizable pictures such as Modelling 2 Juice
house, man, tree

106M
3
Coloring with in line boundaries Reinforcement 2 Allow to play

36
 worksheet game

Language

No. Activities Techniques Trials Reinforcement

84L
1
Home address Verbal cues 3 Clapping

Reinforcement

85L
2
Telephone number Verbal cues 5 Praise

Reinforcement

87L
3
Tells daily experiences Verbal cues 2 Praise and

Reinforcement smile

92L
4
Tells final word in opposite analogies Verbal cues 3 Biscuits

Reinforcement

Social-skills

No. Activities Techniques Trials Reinforcement

67S
1
Take part in different activates with others Modelling 2 Praise and smile

Reinforcement

41S
2
Share lunch and toys with others Modelling 2 Praise and

Verbal cues candy

Reinforcement

37
55S
3
Say thank you Modelling 3 Praise

Verbal cues

Reinforcement

62S
4
Say sorry on mistake Modelling 3 Chocolate

Verbal cues

Reinforcement

65S
5
Take permission before use others things Modelling 3 Clapping

Verbal cues

38
Psychotherapeutic sessions

Session #1

Session goals

 Introduction

 Confidentiality

 Rapport building

Procedure: In first session child was introduced to the therapist. Complete Bio data was
taken from the child’s mother. Starting from the bio data name, age, siblings, birth order, and
education was asked to the child’s mother (informant). Demographic history of child was
obtained from informant which helps to understand how to deal with child according to child
cognitive level and support system. Presenting complaints and history of present illness was
obtained through semi structured interview. Therapist tried to build a rapport with child as
well as with the child to introduce him new behaviors and skills. Rapport means a sense of
having connection with the person. There are a number of techniques that are supposed to be
beneficial in building rapport such as: matching your body language (i.e., posture, gesture,
etc.), indicating attentiveness through maintaining eye contact, be prepared, active listening,
do not judge, don’t give an impression that you are not interesting and there is nothing wrong,
be aware of limitations and listen with empathy. Counseling was provided to child’s mother.
Steps may include establish a safe, trusting environment, help the person put their concern
into words, active listening involve find out the child's agenda, paraphrase, summarize,
reflect, focus on feelings, not events. Childs mother was told about the confidentiality and she
was asked that all of her information will be kept secret and nor his child personal stuff
neither his private information will be revealed to feel comfortable talking about and need of
a safe place to talk about anything they'd like, without fear of that information leaving the
room. The issue of confidentiality was discussed with the mother involved when treating a
child child at the beginning of the therapy. Although it takes a lot of time to done.
Comfortable relationship was made through providing trust and confidence to the child’s. In
the present case, rapport was built by asking the child’s name, how the child is doing, actively
listening to the child mother, showing an attitude of acceptance, and respect, by empathizing
with his problem and distress and ensuring him the confidentiality of information and by
showing motivation to help the child in bringing improvement in his problem. The child’s
mother will be asked by the therapist about how his child’s problem affected his functioning
in different areas of life and what brings
39
his today. As the child, did not have therapy before so the child’s mother will be made
convinced about psychotherapy by building trust and reassurance regarding therapy and
improvement in his condition. Through the building of strong trust and rapport with the
informant the she became very friendly and she was not hesitant to talk and to tell his child
problems and the difficulties he is facing.

Session # 2

Session goals

 Rapport building

 History taking

 Behavioral observation

Procedure: In the second session firstly the child’s mother was asked about the child’s sleep,
appetite and mood. She told the therapist that his sleep is normal. Child mother told that he
forgets things immediately and can’t remember his lesson. His memory is weak. Major focus
was again on rapport building in an attempt to gain detail history of the problem. The purpose
of taken history from the child’s mother was to insure the onset, present problem and factors
regarding the illness. Child’s mother was cooperative and she discussed the detailed history
and answer every single question asked by the therapist the child his self was cooperative.
History was taken from the child’s mother including the history of present illness, birth
history, and educational history. Major findings were brought out from the history and
formulated by the therapist. The precipitating factors, perpetuating factors, predisposing
factors and protective factors were formulated from the history to formularize in the manner.
Informal assessment was also done through the procedure of behavioral observation and
clinical interview which is a structured assessment of child’s behavioral and cognitive
functioning and it includes description of person’s general appearance, speech, thought and
perceptions, level of attentiveness, mood and affect, cognitive abilities and memory.

The child was a male with the age of 11 years. Child appeared to be child of average height
and built. The child’s appearance was tidy, general physical appearance was weak and was
dressed properly. He was wearing clean and tidy clothes. His hygiene was good.

He was very cooperative. He responded every aspect precisely in little detail when asked.
His response was relevant to the question. His motor skills were not good.

40
 Session # 3

Session goals

 Review and feedback of previous session

 History taking

 Psycho education

 Subjective rating of the presenting complaints

Procedure: Overview of previous session was taken from his mother. Overview of previous
session was taken from the child and his mother. As told by the child’s mother she was
satisfied and overwhelmed with the therapist. Child’s mother told the therapist about the
points which she wants to talk more and showed her satisfaction regarding the confidentiality
of his provided information.

Mother was psych educated. Psych education (PE) is defined as an intervention with
systematic, structured, and didactic knowledge transfer for an illness and its treatment to
child and their families and integrating emotional and motivational aspects to enable child’s
to cope with the illness and to improve its treatment adherence and efficacy. It also includes
providing information about mental health conditions to the family of sufferer (Cummings &
Cummings, 2008). Psycho-education was provided to the mother. She was informed about
disorder's symptomatology, peculiar patterns, causes, and etiological factors. She was
explained about the therapy process and the importance of management strategies. She was
provided with emotional support and told that child's problem is manageable, and with her
cooperation and effort child's condition could get better. Importance of homework exercises
and mother's role in the therapy was highlighted. The mother was asked to follow the
instructions. Concerns of the mother regarding diagnosis and management procedure were
addressed. She was motivated to work hard and to give time to their child so that chances of
betterment in child’s condition increases. Psycho education was provided regarding illness,
its risk factors, cause, and prevention, course of treatment and role of child to her mother.

Family history, personal history, social history and developmental history was obtained
through semi structured interview. Subjective rating scales are widely used in almost every
aspect of practice for the assessment of workload, fatigue, usability, annoyance and comfort.
The history of the symptoms tells the therapist about the behavior of the condition in the past

41
and may therefore assist in goal setting and prediction of prognosis. The child was asked to
rate presenting complaints on the 10-point scale where

0=no problem, 5=average, 10=severe problem.

Table 1.7

Subjective Ratings of the child Symptoms (pre assessment) reported by the mother and
therapist as well.

Symptoms Rating by mother Rating by therapist

Hyperactive 06 07

Hostile 05 05

Study issues 10 09

Laziness 06 05

Irritability 07 06

Poor social skills 05 06

Poor cognitive skills 07 07

Poor self-help skills 05 06

Motor activities 04 05

Crying 06 05

Low Appetite 07 07

42
 Session #4

Session goals

 Review of previous session

 Portage Guide to Early Education

 Homework

Procedure: Overview of session was taken from the child and her mother. Child’s mother
told the therapist that child’s mood, sleep and appetite was normal. The PGEE program has
been used widely for early intervention in children due to its scientific, interesting, coherent,
and operable nature. It is an early intervention method for cognitive training, which can be
used as structured teaching arrangements. The results showed delays in developmental
milestones corresponding to the child’s present age. Assessment through Portage Guide to
Early Education revealed that the child was below from his chronological age and 6 years
below from his normal chronological age. He had mental age of 5 years. The Childs’s age
was below on the all the areas of adaptive functioning (socialization, self-help, cognitive,
language and motor skills) as compared to his chronological age.

Session #5

Session goals

 Review of previous session

 Individualized Education Plan (IEP)
 Homework

Procedure: Overview of session was taken from the child and his mother. Child’s behavior at
home and how much he follows the instructions properly was discussed by his mother. The
rationale of the session was to make IEP. Individualized Educational Plan was devised to
meet the idiosyncratic needs of the child (Carmen 2018). IEP based on establishing early
readiness skills (compliance and on seat) along with improving developmental skills like
socialization, motor (eye hand coordination), self-help and cognitive were followed during
therapy. Behavior modification techniques such as shaping, prompting, fading, and positive
reinforcement were

11
used to enhance the desired behavior in the child. The areas covered in IEP are attached at
above.

Homework. Assignments were given to child on the basis of Individualized Educational Plan

(IEP) written at the end of the report. Child’s mother was asked her to practice certain skills
at home.

Session #6

Session goals

 Review of previous session

 Names of colors

 Coloring

 Homework

Procedure: Overview of session was taken from the child and his mother. Child’s behavior at
home and how much he follows the instructions properly was discussed by his mother. The
rationale of session was to teach the child names of colors and worksheet of coloring bird was
completed. Names of color were memorized to child by pointing fingers towards different
colors. Therapist give him color box and call the name of color and asked him to pick the
relevant color from color box. Color recognition will help child to choose the object or dress
of his favorite color. He learned different colors names through repetitions and revisions in
various sessions.

Homework. The child was asked to write and memorize the color names.

Session # 7

Session goals

 Review of previous session

 Table of 2

 Sharing with others

12
  Homework

Procedure: Overview of session was taken. Child’s behavior at home and how much he
follows the instructions properly was discussed by his mother. Child completed is homework
worksheet on which he reinforced by praise and chocolate. The rationale of session was to
teach the child social skill as well as cognitive skill. The social skill was to share toys, lunch
or pencil etc. with classmates and friends. For this purpose, group activity was held. All the
students in class were asked to share their lunch with each other and exchange their pencils
and say thanks to each other’s. furthermore, child was given table of two with starting two
lines, and increased as he starts to memorize and he learned table of two in various sessions.

Homework. Worksheet for table to write and memorize was given to child. And asked his
mother to teach him sharing of toys with his younger brother at home.

13
 Session # 8

Session goals

 Review of previous session

 Tips to take meal

 Tie the laces

 Homework (exercise)

Procedure: Overview of session was taken from the child and his mother. Child will be
asked to check homework. Homework given to the child in the previous session was checked.
Child’s mother told the therapist that child’s appetite was not normal and child not take meal
properly. So to overcome this issue therapist give some tips to child mother and asked to
follow them.

Enjoy eating together as a family

 Don’t force your child to eat when tired or not hungry

 Offer healthy snacks between meal
 Accept some food refusal without worry
 Involve your child in simple meal preparation
 Allow your child some likes and dislike

The second target of the session was teaching child to tie the laces. It takes various sessions to
learned. These skills were learned to child through chaining (big task were divided into
various small task or steps which make the learning of that skill easier and effective) Athen &
G.A (2014), shaping and modelling.

Homework. Child mother was instructed that when and wherever child go, asked him to tie
the laces by self and help the child if needed.

Session #9

Session goals

 Review of previous session

 Parental Training

11
 Draw simple recognizable picture such as house. Person and tree

12
  Homework

Procedure: Overview of session was taken from Childs’s mother. Childs mother was asked
about the child’s appetite, sleep and mood. She told the therapist that meal tips were very
effective and child eat well even the whole day also he remains fresh and irritability was less
from before. Mother training was done as written homework, instructions for tasks done in
the session for practice at home were given daily to the mother. She was also given tips on
how to establish child's socialization and other developmental skills. She was guided to give
reward when child follow instructions and complete worksheets. Furthermore, she was taught
to use reinforcement and contingent it to the relevant behaviors so that they could be
strengthened or reduced accordingly.

The second rational of the session was to teach child that how to draw simple pictures
of house, tree and person. For that peruse child was worksheet and show him pictures and
asked him to draw. Child instructed to use of eraser whenever he made mistakes. Therapist
provide him proper guidance that how to draw. Firstly, therapist draw a line then asked child
to draw similarly.

Homework. Child homework assignment was to draw recognizable house, tree and person.

Session # 10

Session goals

 Review of previous session

 Home address

 Tells daily experiences

 Homework assignment

Procedure: Overview of previous session was taken from the child and his mother. Child’s
mood, her sleep and appetite was normal. The rationale of session was to memorized the
home address to child and asked him about daily life experiences. Therapist asked child about
his daily life experiences that who are his friends either they are helping which one is best
friend. How he spends his aid day or Sunday. It will be helpful in his reasoning and thinking
skills. Child already knows that he lived in Lahore so therapist told the child the area name
where he lived then Mohali name then street number and then house number. And then asked
from child

13
for repetitions. Therapist teach him in chunks and child not learned in one session only he
took a lot of time and various revisions.

Homework. Assignment was given to the child to memorized the home address.

Session # 11

Session goals

 Review of previous session

 Cut off soft food with knife

 Money recognition

 Homework assignment

Procedure: Overview of previous session was taken from the child and his mother. Therapist
asked the child to tell the home address. For child today the goal was money recognition. For
this purpose, therapist kept 10, 20, 50, 100 and 500 rupee notes in front of him and told him
about the value of money. After this child asked him that where are ten rupees or fifty or
twenty etc. therapist also give him work sheet on which pictures of all notes was pasted.
Therapist asked child to match ten rupees with ten similarly twenty rupees with twenty rupee
note and so on. At the end of session child was able to recognize value of money. Second
activity was cutting soft food. Therapist had two knives and apples Therapist gave the knife
and apple to child and asked him to cut the apple through modeling.

Homework. Assignment was given to the child’s mother to fully devote her time to the skills
child lack. And when she went to market let his child to go with her so he will learn that how
to use money well. And practiced him cutting of boiled potato.

Session # 12

Session goals

 Review of previous session

 Serve self at table

 Put jam on bread

 Tell final word in opposite analogies

14
  Homework

Procedure: Overview of session was taken from Childs’s mother. Mother told that he can cut
potatoes well. She was looking very satisfied. The rationale of today session was able child
serve self at table and put jam on bread. Therapist kept jam, bread and spoon in front of child
and asked him to pick up them and put jam on bread. Therapist gave the child verbal
instructions and asked him to follow. Second rational was to learned child analogies. For this
purpose, therapist gave him few words like boy, mother, sister, day, darkness. Therapist told
him analogies of these words and then asked from child.

Homework. Homework assignment was to memorized given words analogies.

Session #13

Session goals

 Review of previous session

 Cut the circle

 Take permission before use of others things

 Homework

Procedure: In this session firstly the child’s mother was asked about the child sleep, appetite
and mood. She told the therapist that his diet is proper now as well as he is following
instructions well. She also said that child take his regular meals to satisfy his appetite and
following the activity schedule properly. Child mood was good as told by the mother and was
also observed during the session. Moreover, therapist asked the child that I will asked you to
bring the colors from zahra (class fellow) so first you take permission from zahra and then
took it. This activity helps him to learn that he has to take permission before tanking others
things. Then therapist teach him that how to cut circle. Therapist give him paper with lines to
follow for cutting circle.

Homework. Assignment was given to the child was to cut different size circle at home.

Session #14

Session goals

15
  Review of previous session

 Days of week

 Say sorry

 Homework

Procedure: Overview of session was taken from child’s mother. Cutting circle was tested in
the therapy session from the child. Verbal and physical prompts were given to the child
during the therapy session. If she responded right, then positive reinforcement were given to
the child in form of clapping and smiling in order to enhance the probability of other
responses. The rationale of this session was to learned child social skill that play a major role
in daily life chores Morin.A (2020) and days of week. For this purpose, therapist regularly
asked child that what day is today. The second goal was to teach child say sorry on mistakes
or did wrong things.

Homework. Assignment given to the child was to memorized days of week.

Session #15

Session goals

 Review of the previous session

 Mobile number

 Homework

Procedure: Overview of all the previous sessions was taken from the child and his mother.
The next goal of therapist was to memorized mobile phone number of his father. For this
purpose, therapist divide number into small chunks as his home address and make practice on
regular basis. In start therapist gave him only code to remember then next digits. Therapist
also told him the importance of memorizing mobile phone number, that it will be helpful in
every thick and thin.

Homework. Homework given to child was memorized phone number.

16
 Session # 16

Session goals

 Review of the previous session

 Addition and subtraction questions

 Homework

Procedure: Overview of all the previous sessions was taken from the child and his mother.
The rationale of the session was to made child able about little and simple subtraction and
addition problems. Which will be helpful in his daily life chores. For this purpose, various
worksheets were completed repetitively. Verbal cues and instructions were given on each
step. Various sessions were conducted on learning of this skill.

Homework. Homework assignment given to child to complete worksheet at home.

Session # 17

Session goals

 Review of all the previous sessions

 Post assessment of subjective rating of symptoms

Procedure: Overview of all the previous sessions was taken from the child and his mother.

Child reported improvement in his all domains like social, cognitive, motor and self-care.

Post assessment

Post assessment was done with the child to assess the improvement in symptoms intensity.

0=no problem, 5=average, 10=severe problem.

17
Table 1.8

Subjective Ratings of the child Symptoms (pre assessment) reported by the mother.

Symptoms Rating by mother Rating by therapist

Pre Post Pre Post

Hyperactive 06 03 07 03

Hostile 05 03 05 03

Study issues 10 03 09 04

Laziness 06 03 05 02

Irritability 07 04 06 03

Poor social skills 05 02 06 02

Poor cognitive skills 07 03 07 03

Poor self-help skills 05 02 06 02

Motor activities 05 02 05 02

Crying 06 03 05 03

Low Appetite 07 03 07 03

18
Graph 1.1

Graphical Representation of the Outcome of the Management

Chart Title
10
9
8
7
6
5
4
3
2
1
0

pre assesment post assesment Column1

11
 Session # 18

Session goals

 Review of all the previous sessions

 Termination session

In the last session child mother was provided hopeful view of managing, and
innovatively improve an accomplishment proposal regarded to diminish mental suffering and
heighten welfare. As the Childs’s progress was favorable and he was working on his
behavior. All the skills and behaviors learned in the session were reviewed. He learned new
skills. So it was decided to terminate the session as child’s mother was feeling motivated to
follow instructions. After taking post rating of the symptoms and giving concluding remarks
therapist terminated the session.

12
References

JAMA and Archives Journals. (2006, October 3). Low Birth Weight Infants May Have
Cognitive and Physical Problems When They Reach Adolescence. Science Daily.
Retrieved September 23, 2022 from
www.sciencedaily.com/releases/2006/10/061002215210.htm

Reiss, S., & Benson, B. A. (1985). Psychosocial correlates of depression in mentally retarded
Adults; Minimal social support and stigmatization. American Journal of Mental
Deficiency, 89(4), 331–337.

Meins, W. (1993). Prevalence and risk factors for depressive disorders in adults with
intellectual disability. Australia and New Zealand Journal of Developmental
Disabilities, 18(3), 147–156.

Lunsky, Y., & Benson, B. A. (2001). Association between perceived social support and
strain, and positive and negative outcomes for adults with mild intellectual disability.
Journal of Intellectual Disability Research, 45(2), 106114.

Fallin, M.D., Riley, A., Landa, R., & Wang, X. (2015). The association of maternal obesity
and diabetes with autism and other developmental disabilities. Journal of pediatrics,

137(2).

Collins, P.Y., Pringle, B., & Alexande, C. (2017). Global services and support for children
with developmental delays and disabilities: bridging research and policy gaps. Journal
of PLoS Medicine, 14(9).

Johnson, L.M., & Harman, J. (2018). Beyond parenting: the responsibility of

multidisciplinary health care providers in early intervention policy guidance.
American Journal of Bioethics, 18(11):58–60.

Carman, B. (2018). Individualized Educational Plan. Retrieved

from http://www.edu.gov.mb.ca/ks4/specedu/iep/index.html

Athens, G.A. (2014). Breaking task into smaller steps, more manageable pieces. Retrieved
from https://news.uga.edu/break-large-tasks-down-into-smaller-more-manageable-

pieces.

McLeod, S. (2018). Operant conditioning. Retrieved from

https://www.simplypsychology.org/operant-conditioning.html.

13
Morin, A. (2020). An overview of Social Skill Training. Retrieved from
https://www.verywellmind.com/social-skills.

Schwartz A. (2018). Therapies for Intellectual Disability. Retrieved from

https://www.mentalhelp.net/intellectual-disabilities/therapies-and-outdated unproven
treatments/.

Brown, J. (1997). Circular questioning: An introductory guide. Australian and New Zealand
Journal of Family Therapy, 18 (2), 109-114.

Saigal, S., Szatmari, P., Rosenbaum, P., Campbell, D., & King, S. (1991). Cognitive abilities
and school performance of extremely low birth weight children and matched term
control children at age 8 years: a regional study. The Journal of pediatrics, 118(5),
751- 760.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental

disorders (5th ed.). Arlington, VA: Author.

14
APENDICES

15
Case report 2

16
 Case Summary

The child A.W was 14 years old, male belonged to middle class status. He studied in
government shadab training institute for mentally challenged. Child was referred to the
trainee clinical psychologist with the complaints of delayed developmental milestones (e.g.
talking in single word, head holding, sitting, walking, toilet training), difficulty remembering
things, difficulty with problem-solving and logical thinking, having trouble with talking, self-
harm, low appetite, crying, unable to maintain eye contact and not interacting with others. He
was referred to present trainee clinical psychologist for the purpose of psychological
assessment. Psychological assessment was done on formal and informal level. Informal
assessment was done by using clinical interview subjective ratings, and behavioral
observation. Formal assessment was done by using Portage Guide to Early Education
(PGEE). After formal and informal assessment, he was diagnosed with Intellectual Disability
with down syndrome. A case was formulated to identify the impact of different factors in
contribution of the problematic behaviors. The management plan for the child was based on
Cognitive Behavior Therapy. A total number of 17 sessions were conducted with the Child
and the Child showed progress and improvement.

17
Bio Data

Name A.W

Age 14 Years

Gender Boy

No Of Siblings 4

Birth Order Last Born

Informant Childs Mother

Socioeconomic Status Middle Class

City Lahore

Reason and Source of Referral

The child was approached to Shadab Government Training Institute Of Mentally

Challenged with the presenting complaints of delayed developmental milestones, difficulty
remembering things, difficulty with problem-solving and logical thinking, having trouble
with talking, can’t maintain eye contact, self-harm. He was referred to present trainee clinical
psychologist for the purpose of psychological assessment.

18
Presenting Complaints

Table 1.1

The Child’s mother reported the following complaints.

Duration Presenting complaints

3 months ‫غےص م ںی خود کو چپ ں ڑییں مارتا ےہ اور بال کھینچتا ےہ‬

‫ی‬ ‫ے‬
6 months ‫کھا نا کھال ن م ںی مشکل ہو ت ےہ بہت مشکل ےس کھانا کھاتا ےہ‬

11 years ‫بولتا نہ ںی ےہ‬

‫ی‬ ‫ی‬
4 years ‫ا ِس کو سمجھ نہ ںی آ ت پڑھا ت یک‬

5 years ‫سست بہت ےہ۔‬

5 years ‫پیسوں کا پتہ نہ ںی چلتا‬

‫ی‬ ‫ے‬
1 year ‫جب بات نہ ما ت جا ن تو غصہ کرتا ےہ۔‬

History of Present illness

According to the child’s mother, she noticed significant problem when he was 6
months and showed developmental milestone delay and he was intellectually low and
recommended by doctors to take him admission to a special school. As doctors reported that
child is suffering from down syndrome.

So due to this reason his parents took him to the to Shadab Government Training
Institute Of Mentally Challenged for the assessment purpose in 2022. The mother reported
that the Child was slow from the very start. His developmental milestones had been delayed.
He did not comprehend the school work simply. The Childs adaptive functioning changed
into additionally very low and insufficient. His self-assist ability and self-care abilities had
been underneath than average. He was not able to brush his teeth, to tie the laces of his shoes,
to shut the zip of his jacket, to shut the buttons of his shirt etc. He did not recognize the way
to make friends and the way to behave with different people. He remained quite in the front
of different people.

19
 According to childs mother the Child’s cognitive, and language skills were very
below than other same age children. He did not do his homework. He did not understand the
nonverbal cues. He even did not recognize the money correctly. He did not follow the
instructions properly. He was aggressive and beat himself whenever in anger. He was very
lazy. Do not talk till now in clear words. He had fixed patterns of eating and throw away the
food if did not like the food items. It’s very difficult to eat him food.

According to childs mother his speech and communication skills were also very weak. The
Child did not perform the motor functions effectively. He lacked some motor skills. He was
always requiring some support and help.

Due to his odd behavior, the parents brought him to the special school for evaluation.

Background Information

Family history

Father. The child's father W.H was 62 years old and his qualification was matric. He
is a labor. His relationship with the Child was sometime harsh and sometime loving. He
suffered from diabetes and high blood pressure.

Mother. The child's mother F.W was 55 years old. She was housewife. Her
qualification was middle. She was living a very busy routine with his family. There are no
medical or psychiatry issues with mother. She suffered from bones and body pain.

Siblings. The child was last born child. He had two elder sisters and one brother. The
first born sister was 27 years old and married. Second born brother was 22-year-old who was
in 3rd year. And, the third born sister was 22 years’ old who was in 3 rd year. The Child had a
strong bonding with siblings. He did not used to play with him because they are elder and
busy in their studies. No medical or psychiatric problems are reported.

Personal history

Birth and Early Development

She suffers from complication at time of delivery. Child was born through
complicated delivery. Mother did not complete immunization during pregnancy. At the time
of birth child was suffering from hepatitis C. Mother start breast feeding after 5 to 6 days of
birth. Child had delayed developmental milestones.

20
Table 1.2

Table shows the significantly delayed milestones of the child:

Developmental Normal Age of Achievement Child’s Age of

Milestones (Seigalman & Rider,2010) Achievement

Social Smile 1- 4 months 1 year*

Neck holding 3 months 1.5 year*

Sits w/o support 5 -10 months 1.5 years*

Stands w/o support 9-11 months 1.9 year *

Walks without support 10- 15 months 2 years*

Talks in single word 6- 12months 3 to 4 year*

Complete sentence 3-4 years Not yet achieved*

Eating without help 3 years 5 Years*

*significantly delayed

The Child achieved all of his developmental milestones very late (see Table 1.2). He
started neck holding at the age of 1.5 year. He started sitting without support 18 months late
as compared to the other children. He started crawling at the age of 20 months. He started
walking at the age of 2 years as compared to other children who start walking at 1 to 1.5
years of age. He spoke his first single word at the age of 3 years which was also very late.

And he was toilet trained at the age of 6 years.

Educational history

A.W was very lazy and low in studies. The teachers said that he was very weak in
studies and did not understand the things easily. In one class, he got fail. The mother changed
his school. The second school took him to special education school. A.W did not like to go
school and study.

Medical history

The child had medical history as reported by his parents that he suffered from
double pneumonia at the age of 6 months.

21
Psychological Assessment

Clinical Assessment was done to evaluate the information about the child’s family
background, other relationships, the onset of the problem and her present complaints. The
assessment was done on formal and informal level.

Informal Assessment

• Clinical Interview

• Behavioral Observation

• Subjective Rating Scale

• Reinforcer checklist

• Portage Guide To Early Education (PGEE)

Formal Assessment

• DSM-5 symptoms checklist

Informal

Assessment Clinical

Interview

Clinical interview facilitated the therapist to comprehend Child’s problem and to

elicit precipitating, predisposing and maintaining factors of his illness. It also helped in
diagnosis and devising management plan for the Child (Boyd, 2010).

Clinical interview is a tool that helps psychologist to make an accurate diagnosis of a mental
illness by asking questions from a child/child regarding his/her background information,
behavior issues and presenting complaints (Flanagan, 2015).

In the present case, the clinical interview was conducted with the Child and his mother to
assess the child’s presenting complaints, history of present illness, Child’s background
information including family history, personal history, educational history. The Child’s
history of present illness was discussed.

Subjective Ratings of the child Symptoms

Speigler (1998) defined ratings that these are taken to see how frequently problematic
behaviors occurs or how severe they are in which Child or his informants rated the symptoms
by using 0-10 scale.

22
The child was asked to rate presenting complaints on the 10-point scale where

23
0=no problem

5=average

10=severe problem

Table 1.3

Table showing the subjective rating of the Child’s problematic behavior on 10-point scale
reported by the mother.

Symptoms Rating by mother Rating by therapist

Hyperactive 07 07

Speech 10 10

Study issues 10 09

Self-harm 07 07

Laziness 08 08

Irritability 07 06

Poor social skills 07 08

Poor cognitive skills 09 08

Un recognition of money 08 08

Eye contact 07 08

Motor activities 08 08

Behavioral Observation

Behavioral observation is a structured assessment of Child’s behavioral and cognitive

functioning. It includes description of person’s general appearance, speech, thought
perceptions, memory and insight about his or her illness. (Folstein, 1983).

The child was a male with the age of 14 years. Child appeared to be child of average height
and built. The Child’s appearance was tidy, general physical appearance was not good as his
features were related to down syndrome with round eyes and thick lips and irregular walking
style. He was dressed properly. He was wearing clean and tidy clothes. His hygiene was

24
good.

25
His speech was slow and voice tone was low however speech was coherent and devoid of
bizarre content i.e. derailment, and circumstantiality etc. Rate and volume of the child’s
speech was low. Child was not defensive and he can’t openly tell about his problematic
issues and circumstances. He did not maintain eye contact properly throughout the interview.

His orientation about time, place and person was not good. He responded every aspect
precisely in just yes and no. Childs thought process was not intellectual. Depersonalization
and decreolization was not present observed through his answers and behavior. Child’s
attention span was normal. His general knowledge and abstract thinking was inadequate. The
child reported no obsessions. The child reported no delusions, hallucinations, phobia and
suicidal ideation. Child’s judgment was inadequate. He had no suicidal and homicidal
ideations. His short term and long term memory was moderate.

Reinforce

checklist Table 1.4

Types Reinforcer
Edible Candy
Lollipops
Juice

Material Balloons
Bubbles

Activity Play with blocks

Social Smile
Praise
Recess time

Portage Guide to Early Education (PGEE)

The Portage Guide to Early Education (PGEE) program can be conducted in families,
communities, rehabilitation institutions, and early education centers, but the role of the family
and parents needs to be highlighted. The PGEE program has been used widely for early
intervention in children due to its scientific, interesting, coherent, and operable nature. It is an
early intervention method for cognitive training, which can be used as structured teaching
arrangements. However, the core status of game activities, toys, books and stories, and daily
life should be emphasized. (Cameron RJ. 1997)

Quantitative Analysis

26
27
Table 1.5

Showing Developmental Area and the Corresponding Age Range of the First Missed and Last
Passed Item

Developmental 1st Missed Item Corresponding Last Passed Corresponding

areas Age range Item Age Range

Socialization 17 0-1 47 4-5

Language 1 0-1 3 0-1

Self help 32 3-2 93 5-6

Cognitive 12 0-1 34 2-1

Motor 49 1-2 89 4-5

Qualitative analysis. The Child’s age was below on the all the areas of adaptive

functioning (socialization, self-help, cognitive, language and motor skills) as compared to his
chronological age. The Child was 10 years below from his normal chronological age.
Conclusion. The test reveals that Child was below from his chronological age. He had mental
age of 4 years.

Formal Assessment

Diagnosis according DSM-5 symptoms checklist

According to DSM 5, R.A was diagnosed with 319 (F72) Intellectual

Disability with down syndrome.

28
 Table 1.6

Domains Symptoms Level

Conceptual Academic skill ➹

domain Reading ➹

Writing ➹

Arithmetic ➹

➹
Money recognition
➹
Time and place orientation

Social domain Communication ➹

Language ➹

Difficulty in accurately perceiving peers ➹

➹
Social judgment
➹
Percieve risk in social situations

Practical domain Support in daily living task ➹

Grocery ➹

Shoping ➹

➹
Transportation
➹
Home and child care organisation
➹
Money management
➹
Hygiene
➹
Eating
➹
Dressing

29
Case conceptualization

Biological Causes
 Child hepatitis C at the
time of birth
 Double pneumonia

Prenatal Illnesses and Issues

Intellectual Maternal illness (hypertension) may lead the

disability patient towards intellectual disability and
With down down syndrome and no
syndrome immunization of mother

Environmental Factors
Poor home environment, lack of
support, lack of parent-child
interaction.

Figure 2.1. Figure illustrating the conceptual model of intellectual disability copied

from Vienna, V.A (2015), Langley Residential Support Services.

Overall, the factors gave a comprehensive idea that how this disability was occurred
and maintained. The predisposing and precipitating factors included the hepatitis C at the
time of his birth and maternal no immunization while the maintaining factors in which lack of
parent-child interaction, poor home environment and lack of support were the most obvious
features and need to be addressed in management.

30
31
Case Formulation

Child was referred to the trainee clinical psychologist with the complaints of
difficulty remembering things, difficulty with problem-solving and logical thinking, having
trouble with talking, unable to understand instructions poor eye contact, self-harm and low
appetite. Detail information was taken regarding the personal, family, educational and social
areas of functioning. Informal and formal assessments were carried out. Portage Guide
Assessment Tool administered on the Child. Ratings of the problem areas were taken.

The child was diagnosed case of Intellectual Disability with Down syndrome. Based
on collective information about the child’s history, interview with mother and teacher,
behavior observation, and PGEE.

According to the biological approach children with birth deficits such as blue babies
or medical problems (Down syndrome, Cerebral palsy or microcephaly, etc.) are at risk of
developing Intellectual disability than other children. Research shows that children who are
born with birth deficits are 27 times more likely to have Intellectual disabilities.

The child was diagnosed with Down syndrome and intellectual disability. Research
showed that 66.7% of the case had an intellectual disability as an associated problem
diagnosed with Down syndrome. This medical condition might serve as a contributing factor
for his cognitive and adaptive problems.

Down syndrome is a set of physical and mental traits caused by a gene problem that
happens before birth. Children who have Down syndrome tend to have certain features, such
as a flat face and a short neck. They also have some degree of intellectual disability. This
varies from person to person. But in most cases, it is mild to moderate.

Down syndrome is a lifelong condition. It is caused by a problem with the baby’s

chromosomes. Normally, a person has 46 chromosomes, but, most people with Down
syndrome have 47 chromosomes. In rare cases, other chromosome problems cause Down
syndrome. Having extra or abnormal chromosomes changes the way the brain and body
develop. Experts don’t know the cause, but some things increase the chance that you’ll have a
baby with Down syndrome is higher if: You are older when you get pregnant. Many doctors
believe that the risk increase for women age 35 and older. In this case, the mother was
pregnant at the age of 40 years.

Most children with Down syndrome have distinctive facial features such as small
ears, flat faces, short neck, short arms and legs, slanting eyes, and a small mouth. Low
muscle tone
32
and loose joints. Below average intelligence. Many children with Down syndrome are also
born with heart, intestine, ear, or breathing problems. These health conditions often lead to
other problems, such as airways (respiratory) infections, or hearing loss. But most of these
problems can be treated. In the current case, the child has below average intelligence, round
and small eyes, small nose and thick lips.

Sometimes a baby is diagnosed after birth. A doctor may have a good idea that a baby
has Down syndrome based on the way the baby looks and the result of physical examination.
To make sure, the baby’s blood will be tested. It may take 2 to 3 weeks to get the test results.

The child’s head circumference was smaller as compared to the other children of his
age and has problems in learning. Researches show that children with smaller head size were
more likely to exhibit cognitive delays.

The child also faced delayed language development. Research showed that most
children with Down syndrome experience difficulties when learning to talk (Buckley, S.
1993).

Different factors were also studied to understand the problem of Child. The Child had
hepatitis C at the time of his birth and after 6 months suffered from double pneumonia.

The maintaining factors for his intellectual disability were the poor and un-
stimulating home environment. A factor that can be better explained by Collin et al. (2017)
who proposed that early childhood is a period of great opportunity for optimum brain growth,
but it is also a period of vulnerability. Development in language, cognition, motor and socio-
emotional domains occur rapidly in these first years. These areas of development do not
operate or develop in isolation, but enable each other and mutually interact as the child learns
to become more independent. If the Child receives potentially less stimulation and fewer
learning opportunities through other health service or care routes, then his intellectual
disability starts to go towards the severity level. Early identification of children with
intellectual disabilities, as well as early childhood intervention (ECI), improves children's
opportunities to maximize their developmental potential and functioning as well as their
quality of life and social participation (Johnson & Harman, 2018).

According to a research, In ID, higher levels of social support are positively correlated with
higher quality of life and lack of parent child interaction is correlated with the stress which
then leads to poor quality of life in ID Childs (Lunsky & Benson, 2001; Meins, 1993; Reiss
& Benson, 1985). So, if the Child has social support and adequate parent-child interaction
then his quality of life improves. In the present case, predisposing factors were the child’s
33
family

34
history with special needs, child’s slurred speech, Down syndrome, and delayed
developmental milestones were the precipitating factor, contributing to the child’s current
problems. Protective factors and an effective management plan can help a child deal with their
problems.

35
 Maintaining
Predisposing Factors Protective
Precipitating
Factors Severity of problem Factors
Poor parent child
Hepatitis C and
interaction Mother support
Pneumonia Lack of facilities
poor home
Low weight at birth Environment Low socio economic
poor academic status
Down syndrome performance

Diagnosis
Intellectual Disa bility Disorder

Therapeutic Recommendations
Progressive muscle
relaxation technique
Activity Scheduling
Instillation of Hope
Positive Reinforcement
Behavior interventions

36
 Assessment

 Clinical interview
 Behavioral observation
 Symptom checklist
 Portage Guide to Early
 Education (PGEE)
 Dsm-5 symptoms checklist

37
Management plan

The management plan of child is conceptualized on eclectic approach using paradigm of

behavior therapy and cognitive behavior therapy; keeping in view idiosyncratic needs of
child. Short Term Goals

• Therapeutic rapport is an essential part of a healthy therapist child relationship and

feeling child so that therapy can be successful

• Psych education will aid in providing insight of disorder, diagnosis and treatment to
the child’s family.

• To cope the family with life stressors in an effective and productive way by teaching
problem solving skills.

• Eating meal tips to improve diet.

• Activity scheduling was done to follow throughout the week and then changed
according to progress.

• Prompting physical and verbal prompts were used to increased desire and decreased
undesirable behaviors.

• Modelling was used to learned the child social and self-care skills like teeth brush,
sharing and greetings etc.

• Chaining was used to learned the child self-care skills like tie the laces and buttoning
or unbuttoning.

• Reinforcement methods were used to increase desirable behavior through clapping,

rewards and praise.

• Individual educational plane (IEP) was made to cover all the areas of portage guide.

• Group therapy was held to increase child interaction with friends and classmate and
to learned social skills.

Long Term Goals

• To continue the short term goals to maintain the change in future.

• To monitor the improvement and effectiveness of management plan by conducting

follow up sessions.

• Continuation of IEP to improve individual functioning of child.

38
 • Maintaining and increasing behaviors (developmental skills) learned during therapy.

• Follow up sessions should be conducted to further reinforce the behaviors learned.

• Muscles retention techniques done throughout sessions to increase motor skills.

• Parental counseling was done to give awareness about child disorder and needs.

Structure of Sessions

A total number of 17 sessions were conducted with the child. The management plan
devised, based on establishing and enhancing cognitive, motors and behavioral skills along
with improving child's meal pattern and decreasing its self-harm, anger and irritability. Each
session lasts for about 45-50 minutes, in which 10-15 minutes were given to the mother, in
which homework given to the child was discussed, mother was trained how to follow the
management plan at home and her concerns regarding child's problem were answered. During
30 -35 minutes, therapist mainly focused on all the domains of IEP and muscles retention
exercises

39
 Individualize educational plan

Student’s Name A. W

Date of Birth 18.11.2008

Age 14 Years

Gender Male

Strengths of Child

 He has intact visual and hearing ability.

 On seat behavior
 Understand instructions

Weaknesses of the Child

 Low level of comprehension.

 Poor social communication and speech
 Poor motor skills
 Poor eye contact

Cognitive skills

No. Activity Techniques Trials Reinforceme

nt

C1 Recognition of money Verbal cues 5 Praise

Reinforcement

40
38C
2
Match the similar things Worksheet 3 Smile and

Reinforcement praise

83C
3
Counting from 1 to 10 Worksheet 5 Eating

Reinforcement (lollipop)

33C
4
Recognition The three colors Verbal cues 4 Clapping

Reinforcement

63C
5
Recognition of circle, triangle and square Worksheet 4 Praise and

Reinforcement smile

51C
6
Worksheet of english and urdu alphabets Worksheet 2 Clapping

Reinforcement

Personal takecare

No. Activities Techniques Trials Reinforcement

84T
1
Tie the laces Chaining 8 Clapping

Reinforcement

36T
2
Brush the teeth Modeling 3 Candy

Reinforcement

70T
3
After eating meal clean the table Reinforcement 2 Praise

Movements

No. Activities Techniques Trials Reinforcement

98M
1
Cut the circle Modelling 5 Praise and smile

Shaping

41
102M
2
Roop jumping Modelling 5 Juice

M3 Muscle relaxation exercises Modeling 4 Clapping

Reinforcement

104M
4
Copy small and capital letters worksheet 3 Praise

Reinforcement

106M
5
Coloring with in line boundries Reinforcement 2 Alow to play

worksheet game

58M
6
Four pearl in thread with in two minutes Modelling 2 Praise and
clapping

Language

No. Activities Techniques Trials Reinforcement

11L
1
Speak five different words Prompting 3 Clapping

Reinforcement

22L
2
Five family members name Prompting 4 Praise and smile

Reinforcement

27L
3
Tells the name of part of body Prompting 4 Candy

Reinforcement

Social-skills

42
No. Activities Techniques Trials Reinforcement

67S
1
Take part in different activites with others Modelling 2 Praise and smile

Reinforcement

41S
2
Share lunch and toys with others Modelling 2 Praise and

Verbal cues candy

Reinforcement

55S
3
Thank you Modelling 5 Praise

Verbal cues

Reinforcement

62S
4
Sorry on mistake Modelling 3 Candy

Verbal cues

Reinforcement

65S
5
Take permission before use others things Modelling 3 Clapping

Verbal cues

43
Psychotherapeutic sessions

Session # 1

Session goals

 Introduction

 Confidentiality

 Rapport building

Procedure: In first session child was introduced to the therapist. Complete Bio data was
taken from the child’s mother. Starting from the bio data name, age, siblings, birth order, and
education was asked to the child’s mother (informant). Demographic history of child was
obtained from informant which helps to understand how to deal with child according to child
cognitive level and support system. Presenting complaints and history of present illness was
obtained through semi structured interview. Therapist tried to build a rapport with Child as
well as with the child to introduce him new behaviors and skills. Rapport means a sense of
having connection with the person. There are a number of techniques that are supposed to be
beneficial in building rapport such as: matching your body language (i.e., posture, gesture,
etc.), indicating attentiveness through maintaining eye contact, be prepared, active listening,
do not judge, don’t give an impression that you are not interesting and there is nothing wrong,
be aware of limitations and listen with empathy. Counseling was provided to child’s mother.
Steps may include establish a safe, trusting environment, help the person put their concern
into words, active listening involve find out the child's agenda, paraphrase, summarize,
reflect, focus on feelings, not events. Childs mother was told about the confidentiality and she
was asked that all of her information will be kept secret and nor his child personal stuff
neither his private information will be revealed to feel comfortable talking about and need of
a safe place to talk about anything they'd like, without fear of that information leaving the
room. The issue of confidentiality was discussed with the mother involved when treating a
child child at the beginning of the therapy. Although it takes a lot of time to done.
Comfortable relationship was made through providing trust and confidence to the childs. In
the present case, rapport was built by asking the Child’s name, how the Child is doing,
actively listening to the child mother, showing an attitude of acceptance, and respect, by
empathizing with his problem and distress and ensuring him the confidentiality of
information and by showing motivation to help the Child in bringing improvement in his
problem. The Child’s mother will be asked by the therapist about how his child’s problem
affected his functioning in different areas of life and
44
what brings his today. As the Child, did not have therapy before so the child’s mother will be
made convinced about psychotherapy by building trust and reassurance regarding therapy and
improvement in his condition.

Outcome. Through the building of strong trust and rapport with the informant the she became
very friendly and she was not hesitant to talk and to tell his child problems and the difficulties
he is facing.

Session # 2

Session goals

 Rapport building

 History taking

 Behavioral observation

Procedure: In the second session firstly the child’s mother was asked about the childs sleep,
appetite and mood. She told the therapist that his sleep is normal. He did not take his regular
meals instead of it he takes a few bites of bread or any junk food. Child mother told that he
cried and pulled his hair and beat to self. Childs mood was low as told by the mother and also
was observed during the session. Major focus was again on rapport building in an attempt to
gain detail history of the problem. The purpose of taken history from the child’s mother was
to insure the onset, present problem and factors regarding the illness. Child’s mother was
cooperative and she discussed the detailed history and answer every single question asked by
the therapist the child his self was cooperative. History was taken from the child’s mother
including the history of present illness, birth history, and educational history. Major findings
were brought out from the history and formulated by the therapist. The precipitating factors,
perpetuating factors, predisposing factors and protective factors were formulated from the
history to formularize in the manner. Informal assessment was also done through the
procedure of behavioral observation which is a structured assessment of Child’s behavioral
and cognitive functioning and it includes description of person’s general appearance, speech,
thought and perceptions, level of consciousness and attentiveness, mood and affect, cognitive
abilities, memory and insight about his illness.

The child was a male with the age of 14 years. Child appeared to be child of average
height and built. The Child’s appearance was tidy, general physical appearance was weak
and was

45
 dressed properly. He was wearing clean and tidy clothes. His hygiene was good. He was
comfortably sitting on the chair. His speech was zero. Rate and volume of the child’s
speech was low. Child was not defensive and he openly tells about his problematic issues
and circumstances He did not maintained eye contact properly throughout the interview.

The Child’s subjective objective mood was dysphoric. His orientation about time, place and
person was not good. He was very cooperative. He responded every aspect precisely in just
yes and no. His response was relevant to the question. Childs thought process was not
intellectual. His short term and long term memory was low. The child had no insight about
his illness. His motor skills were not good. Child had symptoms of down syndrom As his
walking style was not appropriate and his body was loose even he can’t hold massive or
heavy objects in hands. His eyes were round shape. And child lower lip was thick.

Outcome. At the end of session therapist completed almost half of the history of child and
observed the child behavior.

Session # 3

Session goals

 Review and feedback of previous session

 History taking

 Subjective rating of the presenting complaints

Procedure: Overview of previous session was taken from his mother. Overview of previous
session was taken from the child and his mother. As told by the child’s mother she was
satisfied and overwhelmed with the therapist. Child’s mother told the therapist about the
points which she wants to talk more and showed her satisfaction regarding the confidentiality
of his provided information. As told by the mother childs mood was normal, he had poor
appetite. Family history, personal history, social history and developmental history was
obtained through semi structured interview. Subjective rating scales are widely used in
almost every aspect of practice for the assessment of workload, fatigue, usability, annoyance
and comfort. The history of the symptoms tells the therapist about the behavior of the
condition in the past and may therefore assist in goal setting and prediction of prognosis. The
child was asked to rate presenting complaints on the 10-point scale where

0=no problem, 5=average, 10=severe problem.

Table 1.7

46
Subjective Ratings of the child Symptoms (pre assessment) reported by the mother.

Symptoms Rating by mother Rating by therapist

Hyperactive 07 07

Speech 10 10

Study issues 10 09

Self-harm 07 07

Laziness 08 08

Irritability 07 06

Poor social skills 07 08

Poor cognitive skills 09 08

Un recognition of money 08 08

Eye contact 07 08

Motor activities 08 08

47
 Session # 4

 Review of previous session

 Psycho education

Procedure: Overview of previous session was taken from her mother.

Mother was psych educated. Psych education (PE) is defined as an intervention with
systematic, structured, and didactic knowledge transfer for an illness and its treatment to
Child and their families and integrating emotional and motivational aspects to enable Childs
to cope with the illness and to improve its treatment adherence and efficacy. It also includes
providing information about mental health conditions to the family of sufferer (Cummings &
Cummings, 2008). Psycho-education was provided to the mother. She was informed about
disorder's symptomatology, peculiar patterns, causes, and etiological factors. She was
explained about the therapy process and the importance of management strategies. She was
provided with emotional support and told that child's problem is manageable, and with her
cooperation and effort child's condition could get better. Importance of homework exercises
and mother's role in the therapy was highlighted. The mother was asked to follow the
instructions. Concerns of the mother regarding diagnosis and management procedure were
addressed. She was motivated to work hard and to give time to their child so that chances of
betterment in child’s condition increases. Psycho education was provided regarding illness,
its risk factors, cause, and prevention, course of treatment and role of child to her mother.

Outcome. At the end mother had much knowledge and awareness regarding illness of child
and agree to support the child.

Session # 5

Session goals

 Review of previous session

 Formal assessment

 Portage Guide to Early Education

 Activity chart

 Homework (activity chart)

11
Procedure: Overview of session was taken from the child and her mother. She told her
experience of solving a questionnaire. Child’s mother told the therapist that Child’s mood,
sleep and appetite was normal. The PGEE program has been used widely for early
intervention in children due to its scientific, interesting, coherent, and operable nature. It is an
early intervention method for cognitive training, which can be used as structured teaching
arrangements. The results showed delays in developmental milestones corresponding to the
child’s present age. Assessment through Portage Guide to Early Education revealed that the
Child was below from his chronological age and 11 years below from his normal
chronological age. He had mental age of 2 years. The Child’s age was below on the all the
areas of adaptive functioning (socialization, self-help, cognitive, language and motor skills)
as compared to his chronological age.

Activity chart was established in order to manage time at home with the child.
Levisohn defined activity scheduling as a process of restoring the level, quality and range of
activities and interactions by carefully scheduling those activities which demonstrate
reinforcement potential for the Child. It is an effective tool to engage the person in the
activities which were part of her routine. It works as a timetable for the Childs. Its present
goal is to engage Child in the activities which were pleasurable for him before illness to
combat his irritability and laziness (Grohol, 2010).

Activity scheduling is a process of restoring the level, quality and range of activities
and interactions by carefully scheduling those activities which demonstrate reinforcement
potential for the Child. It is an effective tool to engage the Child in the activities which were
part of his routine. It works as a timetable for the Childs. Its present goal is to engage Child in
the activities which were pleasurable for him before illness to combat his irritability and
laziness. Activity chart was made by firstly explaining the purpose of daily routine chart that
why a therapist formularized it for the Child. The activity chart was based on the need of
child physical well-being, education, hobbies, social relations, emotional health, meaningful
daytime activity, and spirituality. Secondly certain steps were made in order to simplify it
which includes the following steps:

• The rationale of activity scheduling will be explained to Child and Child’s mother.

 The actual routine of child can be specific, but it should last around 20 minutes and
consist of three to four quiet, soothing activities such as brushing teeth, a warm bath,
and reading. Bedtime routines provide children with a sense of familiarity and
comfort.
12
  Go to bed at the same time each night and get up at the same time each morning,
including on the weekends. Bedtimes are most useful when they’re consistent, so try
to keep the same bedtime on weekends as on school nights.

 Make sure your bedroom is quiet, dark, relaxing, and at a comfortable

temperature.

 Remove electronic devices, such as TVs, computers, and smart phones, from
the bedroom

 Avoid large meals and tea before bedtime

 Get some exercise. Being physically active during the day can help child fall
asleep more easily at night. These often consist of simple breathing
techniques, body awareness, or guided imagery.

• An activity chart for whole week will be made on a blank paper by focusing on the Child’s
problematic behavior.

• This chart will be provided to informant and explained thoroughly.

• After one week, therapist will take this chart to see the results and make changes according
to progress.

Homework. Child was asked by the therapist to follow the activity chart for one week but
beside the formation of activity chart the therapist made compulsory for the mother to make
sure to the child to practiced regularly task at home.

Session # 6

 Review of previous session

 Individualized Education Plan (IEP)
 Homework

Procedure: Overview of session was taken from the child and his mother. Child’s behavior at
home and how much he follows the instructions properly was discussed by his mother. The
rationale of the session was to make IEP. Individualized Educational Plan was devised to
meet the idiosyncratic needs of the child (Carmen 2018). IEP based on establishing early
readiness skills (compliance and on seat) along with improving developmental skills like
socialization,

13
motor (eye hand coordination), self-help and cognitive were followed during therapy.
Behavior modification techniques such as shaping, prompting, fading, and positive
reinforcement were used to enhance the desired behavior in the child. The areas covered in
IEP are attached at the end of report.

Homework. Assignments were given to child on the basis of Individualized Educational Plan

(IEP) written at the end of the report. Child’s mother was asked her to practice certain skills
at home.

Session # 7

Review of previous session

 Activities to increase eye contact

 Activities for Eye hand coordination

 Homework

Procedure: Overview of session was taken from the child and his mother. Child’s behavior at
home and how much he follows the instructions properly was discussed by his mother. The
rationale of today session was to increase eye contact and perform muscle relaxation
techniques. It was used to build rapport with child as he did not interact with the therapist, not
making eye contact and remained indulged in his own play in initial sessions. Therapist
copied all the child's actions by doing the same, what he was doing with the blocks. Therapist
also copied his actions of putting everything back and running around in session room from
one place to other. Initially, the child didn’t pay attention but the therapist continued to
parodist his action. After some time, the child started to make eye contact with the therapist
by giving him a smile whenever he copied therapist’s actions. Later in the session's child got
comfortable with therapist, gave eye contact. Child also started to recognize therapist as she
entered the session room he went straight to the place where he was sitting.

After making eye contact therapist work on child’s eye-hand coordination. For this
purpose, therapist conduct different activities. Therapist spread bubbles in the whole room
and asked child to catch them. Therapist also play with child catch the ball and threw back
toward

14
therapist. These activities were very helpful in his muscles activation and eye-hand
coordination.

Outcome. To some extent Child was able to make eye hand coordination and give eye conctact

Homework. The Child was asked to model this behavior and to practice catch bubbles and
ball at home. Chart for whole week was made on a blank paper by directing on the Child’s
needs that when he had to do these trainings.

Session # 8

Review of previous session

 Progressive Muscle Relaxation training

 Counselling and motivation to the mother

 Homework (PMR chart)

Procedure: Overview of session was taken from the child and his mother. Child’s behavior at
home and how much he follows the instructions properly was discussed by his mother.
Child’s mood was up to the mark; his sleep was proper but his appetite was still disturbed.
Progressive Muscle Relaxation training was provided to the child. It is an effective technique
to release the tension of body due to psychological disorder. It contains 16 different muscles
of body. These muscles were tense and then relax slowly. Its goal is to enhance the bodily
movement and release tension. It was taught to the child on steps and the steps of the
Progressive muscle relaxation are as following. Firstly, the therapist will explain the purpose
of PMR to the Child. Secondly the therapist will explain each and every single step of PMR
to Child and ask the Child to model this behavior. In the first step the child was asked to get
comfortable by just sitting up in a chair in calm state of mind. It was make sure that child and
therapist was in a place that's free of distraction. Child was asked to close his eyes if that feels
best for him. Then the child was asked to breathe and Inhale deeply through his nose, feeling
his abdomen rise as it fill his diaphragm with air. Then slowly exhale from the mouth,
drawing navel toward the spine and repeat three to five times. In the third step the child was
asked to tighten and release his muscles, starting with his feet and then clench toes and
pressing his heels toward the ground. Squeeze tightly for a few breaths and then release. Now
flex the feet in, pointing toes up towards the head. Hold for a few seconds and then release.
Child was asked to continue to work

15
his way up to his body, tightening and releasing each muscle group. Work his way up in this
order: legs, gluteus, abdomen, back, hands, arms, shoulders, neck, and face. Try to tighten
each muscle group for a few breaths and then slowly release. Repeat any areas that feel
especially stiff. After modeling, Child will start PMR independently with only instructions of
therapist. Then the Child will be asked about his experience after doing exercise and post
rating of problem will be noted as well. Mother was counseled that from tending to the daily
needs of the child, parents are also responsible for helping their children develop social skills,
life skills and appropriate behavior. Continuous counselling of the parents is crucial as they
learn to cope with their personal inadequacies and their feelings of guilt and stress. He was
motivated to work hard and to give time to their child so that chances of betterment in child’s
condition increases. Therapist provide counseling the mother how to treat a child at home. It
is important to ask the mother about the child’s problems and listen to what she is already
doing for the child, this will include praising her for the things that she is doing well and
advising her on things she can do to improve the care of his child at home. Mother was told
that there are three basic teaching steps she should take when teaching her child at home.
These are: give information, show an example and let him practice. Letting a mother practice
is the most important part of teaching a task because the mother is more likely to remember
something that he has practiced than something that he has heard.

Homework. Importance of homework exercises was told to his mother. The mother was
asked to follow the instructions and counselling was provided to her. Regarding the
homework schedule. Each and every single step of PMR to Child was taught to the Child.
The Child was asked to model this behavior and to practice PMR at home throughout the
sessions. Chart for whole week was made on a blank paper by directing on the Child’s needs
that when he had to do the Progressive Muscle Relaxation training.

16
 Session # 9

Session goals

 Review of previous session

 Tips to take meal

 Alphabet ABC practice

 Homework (exercise)

Procedure: Overview of session was taken from the child and his mother. Child will be
asked about his experience after doing exercise and post rating of problem will be noted as
well.

Homework given to the child in the previous session was checked. Child’s mother told the
therapist that Child’s appetite was not normal and child not take meal properly. So to
overcome this issue therapist give some tips to child mother and asked to follow them.

 Enjoy eating together as a family

 Don’t force your child to eat when tired or not hungry
 Offer healthy snacks between meal
 Accept some food refusal without worry
 Involve your child in simple meal preparation
 Allow your child some likes and dislike

The second target of the session was to complete worksheet of alphabet ABC. Therapist give
him worksheet with doted words and asked child to practice it and give him worksheet for
home assignment.

Outcome. Child was able to practice dotted alphabets.

Homework. Child was asked by the therapist to complete his worksheet. Child was told to
exercise regularly. Exercise is a natural stress buster and anxiety reliever. Childs mother was
asked by the therapist to make sure that the mother follow the meal tips for proper diet.

Session # 10

Session goals

 Review of previous session

11
  Parental Training

 Colors recognition

 Homework

Procedure: Overview of session was taken from Child’s mother. Childs mother was asked
about the child’s appetite, sleep and mood. She told the therapist that meal tips were very
effective and child eat well even the whole day also he remains fresh and irritability was less
from before. Mother training was done as written homework, instructions for tasks done in
the session for practice at home were given daily to the mother. He was also given tips on
how to establish child's socialization and other developmental skills. He was guided to give
reward when child follow instructions and complete worksheets. Furthermore, she was taught
to use reinforcement and contingent it to the relevant behaviors so that they could be
strengthened or reduced accordingly.

The second rational of the session was to give child color recognition as include in
IEP. So the wall of classroom was decorated with multiple colors so the therapist pointed
toward each color and told the names of color then after various repetition therapist asked
from child until he completely learned the colors differences.

Outcome. Child was able to recognize different colors.

Homework. Therapist give him worksheet on which blocks of different colors were made
and asked child to revised at home.

Session # 11

Session goals

 Review of previous session

 Coloring

 Behavioral interventions

1) Prompting

2) Positive reinforcement

 Homework assignment

Procedure: Overview of previous session was taken from the child and his mother. Child’s
mood, her sleep and appetite was normal. The rationale of session was to made practice of

12
coloring. Therapist gave the worksheet with drawing of bird and asked child to color in it.
Therapist give him color box and call the name of color and asked him to pick the relevant
color from color box. Color recognition will help child to choose the object or dress of his
favorite color. Behavioral interventions should be one of the first interventions applied to
reduce disruptive behaviors like aggression, temper tantrums and self-injurious behaviors,
and to promote skills that support normal development. Behavioral approaches for teaching
daily life skills like toilet training, feeding, taking bath, brushing teeth are important aspects
of day to day living which are important in improving quality of life (Lovas, 1976).
Prompting is a revenue to encourage a child with added stimuli (prompts) to achieve a
wanted performance.

A prompt is like a reminder or provision to reassure a chosen behavior that else does not
occur. In other words, a prompt is an antecedent that is provided when an ordinary antecedent
is ineffective. It is used to increase the likelihood that a person will engage in the correct
behavior at the correct time. This is used during discrimination training to help the person
engage in the correct behavior in the presence of the discriminative stimuli so the behavior
can be reinforced (Walker, 2008). The response prompts that were used to facilitate the child
during therapy included verbal, modeling, physical and visual prompts. Verbal prompts can
be defined as the verbal behavior of another person which results in the correct response in
presence of the discriminative stimuli (Miltenberger, 2006). Verbal prompts may include
instructions, rules, hints, reminders, questions, or any other verbal assistance. These were
used during command training (Sit down, hands quiet and give me), while establishing on
seat, socialization skills (playing with peers, turn taking), categorizing objects, while teaching
counting (1-10) and tying laces. A physical prompt often involves hand-over-hand guidance,
in which the trainer guides the person’s hands through the behavior. Positive reinforcement is
the exhibition of a prize directly following a wanted behavior planned to style that
performance more probable to happen in the future (Mcleod 2018). Constant positive
reinforcement was used during the initial sessions when the child was getting the patterns and
developing skills (socialization, self-help, motor etc.). Each time the child displayed the
target behavior, he was reinforced.

However, later the therapist encouraged on to irregular reinforcement to uphold the behavior.
Therapist used eatable (lays), candies, social (good, smile) and possession (blocks) as
reinforces throughout therapy.

Outcome. To some extent Child was able to coloring.

13
Homework. Assignment was given to the mother. She was told to give her proper time of
half an hour at home to learn new skills on daily basis. And assignment given to child was to
color the bird.

Session # 12

Session goals

 Review of previous session

 Instillation of hope

 Money recognition

 Homework assignment

Procedure: Overview of previous session was taken from the child and his mother. Mother
reported that he attempted the homework at home complete she also follows the instructions.
Firstly, the rationale of instillation of hope was told to the child that if it increases in therapy
then it predicts resilience and restoration from tension. It is a critical mechanism for therapists
to repair in sufferers to transport them forward closer to recovery. The instillation of hope
creates a sense of optimism. Child mother was told by the therapist that lack of desire
mentioned that people without wish have a long way poorer health consequences than people
who do so she should focus on child as well as her mental health to overcome stress and
anxiety in the child. Instillation of hope motivate the child to move them ahead towards
healing. Yalom (2005) asserts that a high expectation of assist earlier than the start of therapy
is drastically correlated with an advantageous therapy outcome. Faith inside the remedy mode
itself is therapeutically powerful. It takes almost 20 minutes to tell his mother that to work
with motivation with the child and to have stronger belief of betterment would lead towards
the betterment of child’s life and his anxiety issues would reduce. Therapist provide mother
instillation of hope in certain steps. She was told that: -

1. Stay away from impression that nothing is wrong

2. Consolation outfitted that it's genuine and there had been no regular explanation three.
Give models

4. Clarify roughly what oblivious mean for direct.

14
5. Consolation was typically provided by expressing shared regret for the loss of child’s
mental health and studies and highlighting the hope for positive events in the future.

6. Verbal support was given that provide signs and indications of improvement.

7. Give time to Child and yourself. Effects, circumstances and happenings need time to
change and to be restored and recovered.

8. Hopeful view of managing, and innovatively improve an accomplishment proposal geared

to reduce mental suffering and heighten welfare.

For child today the goal was money recognition. For this purpose, therapist kept 10, 20, 50,
100 rupee notes in front of him and told him about the value of money. After this child asked
him that where are ten rupees or fifty or twenty etc. therapist also give him work sheet on
which pictures of all notes was pasted. Therapist asked child to match ten rupees with ten
similarly twenty rupees with twenty rupee note and so on. At the end of session child was
able to recognize value of money.

Outcome. To some extent Child was able to recognize money.

Homework. Assignment was given to the child’s mother to fully devote her time to the skills
child lack. And when she went to mark let his child to go with her so he will learn that how to
use money well.

Session # 13

Session goals

 Review of previous session

 Counting 1 to 10

 Homework

Procedure: In this session firstly the child’s mother was asked about the childs sleep,
appetite and mood. She told the therapist that his diet is proper now as well as he is focusing
on doing muscles relaxations techniques well. She also said that child take his regular meals
to satisfy his appetite and following the activity schedule properly. Childs mood was good as
told by the mother and was also observed during the session.

15
 Therapist give the child work sheet of counting from 1 to 10 with doted words and
asked him to make practice and gave him 1 worksheet for homework.

Outcome. At the end of session child was able to practice doted number from 1-10.

Homework. Assignment was given to the children to complete worksheet of counting.

Session # 14

Session goals

 Review of previous session

 Social Skills Training

 Greetings
 Sharing with others
 Take permission before use others things

 Homework

Procedure: Overview of session was taken from child’s mother. Color recognition and
money recognitions were both tested in the therapy session from the child. Verbal and
physical prompts were given to the child during the therapy session. If she responded right,
then positive reinforcement were given to the child in form of clapping and smiling in order
to enhance the probability of other responses. The rationale of this session was to learned
child social skills that play a major role in daily life chores Morin.A (2020)

Group practice. Working with friends is a helpful manner to practice social abilities thru
role- playing greetings or ordinary scenarios. Child asked to meet with friends in class room
give hugs and made handshake. Furthermore, all the students in class were asked to share
their lunch with each other and exchange their pencils and say thanks to each other’s.

Moreover, therapist asked the child that I will asked you to bring the eraser of ali (class
fellow) so first you take permission from ali and then took it. This activity helps him to learn
that he has to take permission before tanking others things.

Outcome. Child was able to play with friends, share lunch and ask permission before use
others things.

16
Homework. Assignment turned into given to the child’s that when he went to home he will
have met to family members. And share his toys with little cozens.

Session # 15

Session goals

 Review of the previous session

 Self-care skills

 Button unbutton
 Tie laces
 Teeth brush

Procedure: Overview of all the previous sessions was taken from the child and his mother.
The rationale of the session was to made child able about self-care including tie laces,
buttoning and unbuttoning and teeth brush. Various sessions were conducted on learning of
self-care skills. These skills were learned to child through chaining (big task were divided
into various small task or steps which make the learning of that skill easier and effective)
Athen & G.A (2014), shaping and modelling. \

Outcome. After many trials and session child was able to thies self care skills.

Homework. Homework assignment given to child that practice these skills at home.

Session # 16

Session goals

 Review of all the previous sessions

 Post assessment of subjective rating of symptoms

Procedure: Overview of all the previous sessions was taken from the child and his mother.

Child reported improvement in his all domains like social, cognitive, muscles working and
self- care

Post assessment

17
Post assessment was done with the child to assess the improvement in symptoms intensity.

Table 1.8

Subjective Ratings of the child Symptoms (Post assessment)

Symptoms Rating by mother Rating by therapist

Pre Post Pre Post

Hyperactive 07 03 07 02

Speech 10 09 10 09

Study issues 10 06 09 05

Self-harm 07 02 07 01

Laziness 08 03 08 03

Irritability 07 03 06 02

Poor social skills 07 02 08 02

Poor cognitive skills 09 05 08 04

Un recognition of money 08 03 08 02

Eye contact 07 02 08 02

Motor activities 08 03 08 03

18
Graph 1.1

Graphical Representation of the Outcome of the Management

Chart Title
12

10

pre assessment post assessment Column1

Session # 17

Session goals

 Review of all the previous sessions

 Termination session

In the last session childs mother was provided hopeful view of managing, and innovatively
improve an accomplishment proposal regarded to diminish mental suffering and heighten
welfare. As the child’s progress was favorable and he was working on his behavior. All the
skills and behaviors learned in the session were reviewed. His symptoms were getting better.
He learned new skills. So it was decided to terminate the session as child’s mother was
feeling motivated to follow therapy techniques. After taking post rating of the symptoms and
giving concluding remarks therapist terminated the session.

19
References

Antonarakis et al., (2004). Chromosome 21 and down syndrome: from genomics to

pathophysiology. Nature reviews genetics, 5(10), 725-738.

Gardiner, K. J. (2010). Molecular basis of pharmacotherapies for cognition in Down

syndrome. Trends in pharmacological sciences, 31(2), 66-73.

Chapman , R.S. & Hesketh, L.J. (2000). Behavioral phenotype of individuals with Down
syndrome. Mental Retardation and Developmental Disability Research Review,
6(2), 84-95.

Dykens et al., (2002). Maladaptive behavior in children and adolescents with Down's
syndrome. Journal of Intellectual Disability Research, 46(Pt 6), 484-92.

Evans , D.W. & Gray, F.L. (2000). Compulsive-like behavior in individuals with Down
syndrome: its relation to mental age level, adaptive and maladaptive behavior. Child
Development, 71(2), 288-300.

Reiss, S., & Benson, B. A. (1985). Psychosocial correlates of depression in mentally retarded
Adults; Minimal social support and stigmatization. American Journal of Mental
Deficiency, 89(4), 331–337.

Meins, W. (1993). Prevalence and risk factors for depressive disorders in adults with
intellectual disability. Australia and New Zealand Journal of Developmental
Disabilities, 18(3), 147–156.

Lunsky, Y., & Benson, B. A. (2001). Association between perceived social support and
strain, and positive and negative outcomes for adults with mild intellectual
disability. Journal of Intellectual Disability Research, 45(2), 106114.

Fallin, et al., (2015). The association of maternal obesity and diabetes with autism and other
developmental disabilities. Journal of pediatrics,

137(2).

Collins, P.Y., Pringle, B., & Alexande, C. (2017). Global services and support for children
with developmental delays and disabilities: bridging research and policy gaps. Journal
of PLoS Medicine, 14(9).

Johnson, L.M., & Harman, J. (2018). Beyond parenting: the responsibility of multi
disciplinary health care providers in early intervention policy guidance. American
Journal of Bioethics, 18(11):58–60.

20
Carman, B. (2018). Individualized Educational Plan. Retrieved from
http://www.edu.gov.mb.ca/ks4/specedu/iep/index.html

Athens, G.A. (2014). Breaking task into smaller steps, more manageable pieces. Retrieved
from https://news.uga.edu/break-large-tasks-down-into-smaller-more-manageable-

pieces.

McLeod, S. (2018). Operant conditioning. Retrieved from

https://www.simplypsychology.org/operant-conditioning.html.

Morin, A. (2020). An overview of Social Skill Training. Retrieved from

https://www.verywellmind.com/social-skills.

Schwartz, A.(2018). Therapies for Intellectual Disability. Retrieved from

https://www.mentalhelp.net/intellectual-disabilities/therapies-and-outdated unproven
treatments/.

Brown, J. (1997). Circular questioning: An introductory guide. Australian and New Zealand
Journal of Family Therapy, 18 (2), 109-114.

21
APENDICES

22
Case report 3

23
 Case Summary

The child A.W was 15 years old, male belonged to low socio economic status. Child was
referred to the trainee clinical psychologist with the complaints of delayed developmental
milestones (e.g. talking in single word, head holding, sitting, walking, toilet training), speech
impairment, aggressive behavior, verbal and physical harm to mother, difficulty with
problem- solving and logical thinking and studies difficulties. He was referred to present
trainee clinical psychologist for the purpose of psychological assessment. Psychological
assessment was done on formal and informal level. Informal assessment was done by using
clinical interview subjective ratings, Portage Guide to Early Education (PGEE) and
behavioral observation. Formal assessment was done by using DSM-5 criteria checklist of
intellectual disability. After formal and informal assessment, he was diagnosed with mild
Intellectual disability. A case was formulated to identify the impact of different factors in
contribution of the problematic behaviors. The management plan for the child was based on
Cognitive Behavior Therapy and follow IEP. As therapeutic sessions were conducted with
the child and he showed progress and improvement.

24
Bio data

Name A.W

Age 15 years

Gender Male

No of Siblings 2

Birth Order 1st born

Religion Islam

Family System Joint

Residence Lahore

Informant Mother

Number of session 19

Reason for Referral

The child was brought by his mother to Government Shadaab Training Institute of Special
Education with complaints of lagging behind in cognitive skills, lack of independent
functioning, stubbornness, speech difficulties and aggressive behavior specifically towards
mother. He was referred to the trainee clinical psychologist for the purpose of assessment and
management of his symptoms.

25
Presenting Complaints

The child’s mother reported the following presenting complaints.

Table 1.1

Duration Presenting complaints

12 year ‫ٹھیک سے بولتا نیں ہے‬

2 years ‫ضد بہت کرتا ہے‬

4 years ‫اپنے کام خود نہیں کرتا دوسروں پر انحصار کرتا ہے‬

3 years ‫کوئی چیز یاد نیں کر پاتا‬

6 months ‫ماں کو مارتا ہے‬

4 years ‫پڑھتا نہیں ہے‬

1.5 year ‫غصہ بہت کرتا ہے‬

History of Present Illness

From the period of 12 years the child has been suffering through the above mentioned
presenting complains. He presented with the complains of lagging behind in cognitive skills
as compared to his age fellows, lack of independent functioning and speech difficulties.
Moreover it was reported by the mother that child has started showing aggressive behavior
towards mother both physically and verbally. The history of present illness started when the
child was of 1 years of age and suffered from seizures.

Mother reported that her pre-natal history was not complicated and she did not
suffered from any illness during pregnancy. As she used to live in a joint family system so
she had to go through some minor stressors or negative comments of mother-in-law and
sister-in-law. One of the major stressor was the financial stress, moreover no emotional
trauma or stressor was there.

26
 The mother reported that the child didn’t have his first cry and after the child’s birth.
Also he couldn’t breathe properly and remained in incubator for 6 days and recovered later
on. At the age of one year he never took the proper sleep, and used to have fever and diarrhea
on and off. Moreover at the age of 2 years child had seizures twice in a week but was not
observed later on till now.

The mother reported that with the passage of time she observed that the child was
achieving some of the developmental milestones with significantly delay. He started holding
his head at the age of 8 months, sitting at 1-1.5 years, crawling at 1 year, and controlling
bladder and bowel movements at 7 years. Furthermore, he didn’t start to dress and take bath
without help and was unable to speak complete sentences still at present.

After observing slow development in the child, the mother discussed it with her sister-
in-law and then both decided to consult any specialist. So when the child was 5 years of age
his mother took him to children hospital and there she was informed that his child had
inability in intellectual functioning, and requires some extra attention and care as compare to
other children of his age. After that she tried to get him admission in the government school
near to her house but could not have access there. Then his mother got to know about
Government Shadaab Training Institute of Special Education. The mother came to the school
for first time with child with the complaints of lagging behind in cognitive skills, lack of
independent functioning, stubbornness, speech difficulties and aggressive behavior
specifically towards mother. He also had some developmentally delayed milestones. He was
than referred to the trainee clinical psychologist for the purpose of assessment and
management of his symptoms.

Background Information

Family History
The child’s family belonged to a lower socio-economic class. The child lived in a
joint family system with his parents, sister, grandmother, cousins, paternal uncle and aunts.

The father of the child was 37 years old, with no education and ran his own small
setup of work in Township. He was stubborn and aggressive by nature. Moreover he had
dominating and non-cooperative attitude towards all his family members. It was further
reported that he had harsh and careless attitude towards the child. He had no other
psychological and physical problem except for high blood pressure.
27
The mother of the child was 35 years old, she never went to school is a house wife and works
as a maid in houses. It was reported that she has calm and cooperative attitude towards the
child. She was reported to have a calm temperament. She used to spend time and play with
the child. Moreover she was very over concerned regarding the child’s health, education and
overall progress. The child had two siblings. The first born was the child himself, the 2nd born
was a 13 years old sister who is dumb and deaf. Third born was his 6 years old brother who is
also dumb and deaf. The child had satisfactory relationship with both his siblings. The child
had satisfactory relationship with both the siblings, but he sometimes had slight fights with
them.

General Home Atmosphere

The child lived in a joint family system and belonged to a lower class family. The
parents of the child had conflicting relationship. It was an arranged marriage and both of
them were cousins. They had spent their 15 years of marriage. The household decisions were
usually taken by the father while the mother of the child was responsible for arranging
financial resources for the family. Mother tried to keep herself calm and realized that her son
was different and he should be treated differently than other children, with care and patience.
But the father showed negligence towards the child and his special needs, moreover he was
least concerned regarding the financial need of child and the whole family. His father did
second marriage after the birth of his sister 13 years ago. The reason of second marriage was
that he used to blame his wife for the birth of special children and he had fear of having any
special child in the future.

Personal history

The child’s mother reported that she faced some stressful situations during her
pregnancy with the child. However, the child had a mature birth after a complete 09 months
gestation period. There was no illness or medication intake by the mother during pregnancy.
However, she experienced stress and had poor diet during her pregnancy. Her vaccination
was not completed

on time. Length of labor was about 30 minutes and child was born through normal delivery.
He didn’t have immediate first cry after birth. He had white complexion and appropriate
weight of about 2 kg at birth. Breast feeding was initiated immediately after birth and no
feeding difficulty was reported. He didn’t have any illness at the time of birth. No history of
any accident or injury was reported by the mother. The child achieved some of the
developmental milestones with significant delay. He started holding his head at the age of 8

28
months, sitting at

29
1.5 years, crawling at 1.75 years, walking at 2 years, controlling bladder and bowel
movements at 7 years. Furthermore, he didn’t start to speak complete sentences, dress and
take bath without help till yet.

The time period for child to achieve developmental milestones is shown on the table.

Table 1.2

Shows developmental milestones of child corresponding to normal age of achievement

Developmental Milestones Normal Age of Achievement Child’s Age of Achievement

Head holding 3 months 8 months*

Sitting 6 months 1.5 years*

Crawling 8 months 1.75 years*

Walking 1.5-2 years 2 years

Speech: Single word 1-3 years 3 years

Speech: Complete sentences 2.5-4 years Not yet*

Bladder control 3 years 7 years*

Bowel control 3 years 7 years*

Dressing without help 5-6 years Not yet*

Taking bath without help 6-7 years Not yet*

Note. *Significant delays

Present general state of health of child was normal. He had average height and weight
according to his age. His hearing, eye-sight, appetite and sleep were normal. His speech was
not normal and had just one or two word speech. His visual motor, fine motor and gross
motor coordination was adequate. It was reported that he does thumb sucking till now and
shows aggressive temper tantrums. Body rocking, head banging, self-mutilation and autism
were not reported. He had interest of watching doraemon and Tom and Jerry cartoons. He
had much interaction with his age fellows, cousins, siblings and he liked to spend time with
them. The child also likes to eat chips, biscuits and candies.

30
Psychological assessment

The child was psychologically assessed on the basis of informal and formal level to get a
clear view of his problem and to make effective management plan.

Informal Assessment

 Clinical Interview
 Behavioral Observation
 Subjective Ratings of the Symptoms
 Identification of Reinforcer
 Portage Guide to Early Education
Formal Assessment
 DSM 5 Checklist for Intellectual Disability Disorder

Informal Assessment

Clinical Interview

A clinical interview is a face-to-face encounter in which clinicians ask questions of

childs, weigh their responses and reactions, and learn about them and their psychological
problems (Comer, 2013). It was conducted with the child’s mother to collect detailed
information about the child’s identifying data; presenting complaints, their duration,
intensities, and frequencies; lifestyles, relationships, personal, family and educational history.
Moreover, informal and formal assessment was also conducted in an assessment room.

Behavioral Observation

Behavioral observation is the primary assessment approach for preverbal and nonverbal
children and is an adjunct to assessment for verbal children. It focuses on vocalizations (e.g.,
crying, whining, or groaning), verbalizations, facial expressions, muscle tension and rigidity,
ability to be consoled, guarding of body parts, temperament, activity, and general appearance
(Craig, 1992).

He was of average height and weight according to his age. His personal hygiene was not
much maintained and his shalwar kameez was not properly ironed. He was wearing weather
appropriate clothes. He did not maintain appropriate eye contact and rapport was not built with
him. He was not much attentive and was not responding to the trainee clinical psychologist. He had
proper on seat and compliant behavior. His rate and tone of speech was not average, had just one or
two word speech with very low tone. He didn’t have intact comprehension and his mood was
normal.

31
He had no idea of money value. He had no orientation about time and place but had intact orientation
about person.

Reinforce checklist

Table 1.4

Types Reinforcer
Edible Candy
Lollipops
Chocolates
Juice
Lays

Material Balloons

Activity Drawing

Social Smile
Praise
Recess time

Subjective Ratings of the child Symptoms

Visual analogue can be used for subjective ratings of mood, emotion, distress, or other
sensations. Speigler (1998) defined ratings that these are taken to see how frequently
problematic behaviors occurs or how severe they are in which child or his informants rated
the symptoms by using 0-10 scale.

The child was asked to rate presenting complaints on the 10-point scale where

0=no problem

5=average

10=severe problem

32
Table 1.4

Table showing the subjective rating of the child’s problematic behavior on 10-point scale
reported by the mother.

Symptoms Rating by mother Rating by therapist

Non compliance 07 07

Anger 07 06

Study issues 09 10

Eye contact 05 06

Irritability 07 06

Poor social skills 06 07

Poor cognitive skills 07 08

Poor self help skills 05 06

Motor activities 04 05

Speech issues 08 09

Harm mother 07 07

Behavioral Observation

Behavioral observation is a structured assessment of child’s behavioral and cognitive

functioning. It includes description of person’s general appearance, speech, thought
perceptions, memory and insight about his or her illness. (Folstein, 1983).

The child was a male with the age of 11 years. Child appeared to be child of small height and
low weight. From his appearance and features it feels that child height is small but age is
greater. He was dressed properly. He was wearing clean and tidy clothes. His hygiene was
good. His speech was good. He maintain eye contact properly throughout the interview.

His orientation about time, place and person was good. He responded every aspect precisely
in little detailed. Child’s attention span was normal. His general knowledge and abstract
thinking was normall.

33
Portage Guide to Early Education (PGEE)

The Portage Guide to Early Education (PGEE) program can be conducted in families,
communities, rehabilitation institutions, and early education centers, but the role of the family
and parents needs to be highlighted. The PGEE program has been used widely for early
intervention in children due to its scientific, interesting, coherent, and operable nature. It is an
early intervention method for cognitive training, which can be used as structured teaching
arrangements. However, the core status of game activities, toys, books and stories, and daily
life should be emphasized. (Cameron RJ. 1997)

34
Quantitative Analysis

Table 1.5

Showing Developmental Area and the Corresponding Age Range of the First Missed and Last
Passed Item

Developmental 1st Missed Item Corresponding Last Passed Corresponding

areas Age range Item Age Range

Socialization 22 0-1 83 5-6

Language 68 3-4 95 5-6

Self help 83 4-5 92 5-6

Cognitive 68 2-3 67 2-3

Motor 98 4-5 108 5-6

Qualitative analysis. The child’s age was mildly below on the areas of adaptive

functioning (socialization, self-help, language and motor skills) as compared to his

chronological age but cognitive functioning is much below then age fellows. The child was 6
years below from his normal chronological age.

Conclusion. The test reveals that child was below from his chronological age. He had mental
age of 5 years.

Formal assessment

Diagnosis according to DSM-5 checklist

According to DSM 5, Q.A was diagnosed with 319 (F71) Intellectual

Disability.

35
Table 1.6

Domains Symptoms Level

Conceptual domain Academic skill ➹

Reading ➹

Writing ➹

Arithmetic ➹

➹
Money recognition
χ
Time and place orientation

Social domain Communication ➹

Language ➹

Difficulty in accurately perceiving peers ➹

➹
Social judgment
➹
Percieve risk in social situations

Practical domain Support in daily living task ➹

Grocery ➹

Shoping ➹

➹
Transportation
➹
Home and child care organisation
➹
Money management
➹
Hygiene
Χ
Eating
Χ
Dressing

Χ= non problematic ➹=problematic

36
Case conceptualization

Biological Causes
 Child low weight at the
time of birth

Prenatal Illnesses and Issues

Borderline Maternal illness (hypertension) may lead the

Intellectual patient towards intellectual disability and
disability no immunization of mother

Environmental Factors
Poor home environment, lack of
support, lack of parent-child
Interaction, and
Parental conflicts

Figure 2.1. Figure illustrating the conceptual model of intellectual disability copied

from Vienna, V.A (2015), Langley Residential Support Services.

Overall, the factors gave a comprehensive idea that how this disorder was occurred and
maintained. The predisposing and precipitating factors included the low weight at the time of
his birth and maternal no immunization while the maintaining factors in poor home
environment and parental conflicts were the most obvious features and need to be addressed
in management.

37
38
Case Formulation

Child was referred to the trainee clinical psychologist with the complaints of
difficulty remembering things, difficulty with problem-solving, studies issues and low
appetite. Detail information was taken regarding the personal, family, educational and social
areas of functioning. Informal and formal assessments were carried out. Portage Guide
Assessment Tool administered on the child. Ratings of the problem areas were taken.

The maintaining factors for his intellectual disability were the poor and un-stimulating
home environment. A factor that can be better explained by Collin et al. (2017) who proposed
that early childhood is a period of great opportunity for optimum brain growth, but it is also a
period of vulnerability. Development in language, cognition, motor and socio-emotional
domains occur rapidly in these first years. These areas of development do not operate or
develop in isolation, but enable each other and mutually interact as the child learns to become
more independent. If the child receives potentially less stimulation and fewer learning
opportunities through other health service or care routes, then his intellectual disability starts
to go towards the severity level. Early identification of children with intellectual disabilities,
as well as early childhood intervention (ECI), improves children's opportunities to maximize
their developmental potential and functioning as well as their quality of life and social
participation (Johnson & Harman, 2018).

According to a research, In ID, higher levels of social support are positively correlated
with higher quality of life and lack of parent child interaction is correlated with the stress
which then leads to poor quality of life in ID childs (Lunsky & Benson, 2001; Meins, 1993;
Reiss & Benson, 1985). So, if the child has social support and adequate parent-child
interaction then his quality of life improves.

39
 Maintaining
Predisposing Protective
Precipitating Factors
Factors Lack of facilities Factors
Poor home
Extremely Low environment Low socio economic Mother and fathe r
weight at birth status support
Conflicts among
parents

Diagnosis
Moderate Intellectual Disability
disorder

Assessment

Informal

• Clinical interview
• Behavioral observation
• Symptom checklist
• Portage Guide to Early
Education (PGEE)

Formal

• DSM-5 criteria checklist

40
Management plan

The management plan of child is conceptualized on eclectic approach using paradigm of

behavior therapy and cognitive behavior therapy; keeping in view idiosyncratic needs of
child. Short Term Goals

• Therapeutic rapport is an essential part of a healthy therapist child

relationship and feeling child so that therapy can be successful

• Psych education will aid in providing insight of disorder, diagnosis and

treatment to the child’s family.

• To cope the family with life stressors in an effective and productive way by
teaching problem solving skills.

• Eating meal tips to improve diet.

• Activity scheduling was done to follow throughout the week and then
changed according to progress.

• Prompting physical and verbal prompts were used to increased desire and
decreased undesirable behaviors.

• Modelling was used to learned the child social and self-care skills like teeth
brush, sharing and greetings etc.

• Chaining was used to learned the child self-care skills like tie the laces and
buttoning or unbuttoning.

• Reinforcement methods were used to increase desirable behavior through

clapping, rewards and praise.

• Individual educational plane (IEP) was made to cover all the areas of
portage guide.

• Group therapy was held to increase child interaction with friends and
classmate and to learned social skills.

Long Term Goals

• The child would be taught to engage in socially acceptable behavior.

• To continue the short term goals to maintain the change in future.
• To monitor the improvement and effectiveness of management plan by conducting
follow up sessions.

41
 • Continuation of IEP to improve individual functioning of child.
• Maintaining and increasing behaviors (developmental skills) learned during therapy.
• Follow up sessions should be conducted to further reinforce the behaviors learned.
• Instructional planning was done throughout sessions to increase academic and
cognitive skills.
• Parental counseling was done to give awareness about child disorder and needs.

Structure of Sessions

As many as needed sessions were conducted with the clhild. The management plan
devised, based on establishing and enhancing academic or cognitive, motors and behavioral
skills along with improving child's meal pattern and decreasing anger and irritability. Each
session lasts for about 45-50 minutes, in which 10-15 minutes were given to the mother, in
which homework given to the child was discussed, mother was trained how to follow the
management plan at home and her concerns regarding child's problem were answered. During
30 -35 minutes, therapist mainly focused on all the domains of IEP and muscles retention
exercises

42
43
Individualized Educational Plan (IEP)

Student’s Name A.W

Date of Birth 18-09-2007

Age 15 Years

Gender Male

Strengths of Child

 He had good visual and hearing ability.

 Respond to immediate reinforcement
 Understand instructions

Weaknesses of the Child

 Low level of comprehension.

 Poor speech
 Poor social communication

Cognitive skills

No. Activity Techniques Trials Reinforcement

C1 Recognition of money Verbal cues 3 Praise

Reinforcement

73C
2
Counting 11-20 Worksheet 2 Smile and praise

Reinforcement

65C
3
Match the pictures with alphabets Worksheet 2 Eating

Reinforcement (chocolate)

63C
4
Recognition of triangle, square, circle Worksheet 3 Clapping

44
 Reinforcement

08C
5
Recognition of colors Worksheet 3 Praise and smile

Reinforcement

Personal takecare

No. Activities Techniques Trials Reinforcement

36T
1
Brush the teeth Prompting 2 Clapping

Reinforcement

93T
2
Cuts off soft food with knife Modeling 2 Candy

Reinforcement

88T
3
Serves self at table Modelling 1 Praise

Reinforcement

86T
4
Recognition of summer and winter stuff Verbal cues 3 Praise

Reinforcement

Movements

No. Activities Techniques Trials Reinforcement

95M
1
Cut the different lines and circle Modelling 3 Praise and smile

Shaping

105M
2
Hits nail with hammer Modelling 1 Juice

86M
3
Picks up objects from ground while Modelling 2 Praise
running Reinforcement

106M
4
Coloring with in line boundries Reinforcement 2 Alow to play
game

45
 worksheet

Language

No. Activities Techniques Trials Reinforcement

48L
1
Names five colors Verbal cues 3 Clapping

Reinforcement

08L
2
Repeats sounds made by others Verbal cues 3 Praise

Reinforcement

54L
3
Ask some common food item by name Verbal cues 3 Praise and smile

Reinforcement

44L
4
Point to 12 familiar objects when name Verbal cues 2 lollipop

Reinforcement

Social-skills

No. Activities Techniques Trials Reinforcement

67S
1
Take part in different activites with others Modelling 2 Praise and smile

Reinforcement

41S
2
Share lunch and toys with others Modelling 2 Praise and candy

Verbal cues

Reinforcement

46
55S
3
Say thank you Modelling 3 Praise

Verbal cues

Reinforcement

62S
4
Say sorry on mistake Modelling 3 Chocolate

Verbal cues

Reinforcement

65S
5
Take permission before use others things Modelling 3 Clapping

Verbal cues

47
Therapeutic Interventions

Rapport Building

Rapport is a close and harmonious relationship in which the people or groups

concerned understand each other’s feelings or ideas and communicate well. Report building
with the child helps a professional in the smooth conduction of therapy.

Reciprocity

It is defined as giving gifts or doing favors without asking for anything in return.
Reciprocity is an effective technique for building reports with children. In return, the
therapist gave reinforces and gifts to the child without asking directly.

Reinforcement

One of the teacher’s most valued behavior management tools is reinforcement.

Reinforcement can be used to teach new skills, teach a replacement behavior for an
interfering behavior, increase appropriate behaviors, or increase on-task behavior (Afirm
Team, 2015).

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 45
favorable outcome, event, or reward occurs after an action, that particular response or
behavior will be strengthened. (Afirm Team, 2015).

Overall in achieving every goal reinforcement was used and suggested. For write and
memorize counting and alphabets. Different types of reinforcement techniques were used.
When the child completed his work successfully he was awarded his favorite reinforcement
to a maintained desired behavior.

Prompts and Fading

Prompting is a means to induce an individual with added stimuli (prompts) to

perform the desired behavior. Prompting is provided when an ordinary antecedent is
ineffective and is extensively used in behavior shaping and skill acquisition. (Burke).
Prompts were provided and suggested to the child to aid him to achieve the goal easily. After
this, the child started learning the targeted behavior prompts were started fading to remove
hid discrepancy or trainee clinical psychologist. Physical and verbal prompts were used with
the child. A verbal prompt was used for coloring and pasting, memorizing, and writing
counting whenever the child started doing his work on a task physical and verbal prompt was
given to him then started fading prompt.
48
Modeling

In social learning theory, Albert Bandura (1977) states that behavior is learned from
the environment through the process of observational learning. Modeling, which is also
called observational learning or imitation, is a behaviorally-based procedure that involves the
use of live or symbolic models to demonstrate a particular behavior, thought, or attitude that a
child may want to acquire or change. Modeling is sometimes called vicarious learning
because the child needs to perform the behavior to learn it. Modeling was used to reduce the
inappropriate behaviors of the child. Stories such as storytelling were used to inculcate the
moral values in the child. The stories were about the 46 awareness of appropriate social
behaviors and the consequences of immoral acts. The child was interested in listening to
stories.

Chaining

Chaining is an instructional procedure used in behavioral psychology. It involves

reinforcing individual responses occurring in a sequence to form a complex behavior. It is
frequently used for training behavioral sequences that are beyond the current repertoire of the
learner. The technique of chaining was used to teach the child how to tie the shoelaces? First
make a cross, in the second step take the top lace under the cross and through the hole, in the
third step make a lope in one lace, in the fourth step wrap the other lace around the loop and
push some lace through the hole that is made at the bottom to make a second loop ad then
pull both loops tight. It was rehearsed by the child two times a day. (Cooper et, al. 2014).

Shaping

Shaping is a way of adding behaviors to a person’s repertoire. Shaping is defined as

the differential reinforcement of successive approximation of a target behavior until the
person exhibited the target behavior. Shaping is used to develop a target behavior that a
person does not currently exhibit. The Shaping was used for cutting circles with the scissors
and pasting them. The completion of this goal task would be divided into small steps after
completing each step the child was positively reinforced. (Skinner, B. F,1938).

Social skills training

Social skills training aims to increase the ability to perform key social behaviors that
are important in achieving success in social situations . Social skills training would be
suggested for the child for establishing and maintaining social relations. Social skill training
taught the child to smile when greeting people and shake hands when meeting someone.
Gresham, et, al2006).
49
Psychotherapeutic sessions

Session # 1

Session goals

 Introduction

 Confidentiality

 Rapport building

Procedure: In first session child was introduced to the therapist. Complete Bio data was
taken from the child’s mother. Starting from the bio data name, age, siblings, birth order, and
education was asked to the child’s mother (informant). Demographic history of child was
obtained from informant which helps to understand how to deal with child according to child
cognitive level and support system. Presenting complaints and history of present illness was
obtained through semi structured interview. Therapist tried to build a rapport with child as
well as with the child to introduce him new behaviors and skills. Rapport means a sense of
having connection with the person. There are a number of techniques that are supposed to be
beneficial in building rapport such as: matching your body language (i.e., posture, gesture,
etc.), indicating attentiveness through maintaining eye contact, be prepared, active listening,
do not judge, don’t give an impression that you are not interesting and there is nothing
wrong, be aware of limitations and listen with empathy. Counseling was provided to child’s
mother. Steps may include establish a safe, trusting environment, help the person put their
concern into words, active listening involve find out the child's agenda, paraphrase,
summarize, reflect, focus on feelings, not events. Childs mother was told about the
confidentiality and she was asked that all of her information will be kept secret and nor his
child personal stuff neither his private information will be revealed to feel comfortable
talking about and need of a safe place to talk about anything they'd like, without fear of that
information leaving the room. The issue of confidentiality was discussed with the mother
involved when treating a child child at the beginning of the therapy. Although it takes a lot of
time to done. Comfortable relationship was made through providing trust and confidence to
the childs. In the present case, rapport was built by asking the child’s name, how the child is
doing, actively listening to the child mother, showing an attitude of acceptance, and respect,
by empathizing with his problem and distress and ensuring him the confidentiality of
information and by showing motivation to help the child in bringing improvement in his
problem. The child’s mother will be asked by the therapist about how his child’s problem
affected his functioning in different areas of life and what brings
50
his today. As the child, did not have therapy before so the child’s mother will be made
convinced about psychotherapy by building trust and reassurance regarding therapy and
improvement in his condition. Through the building of strong trust and rapport with the
informant the she became very friendly and she was not hesitant to talk and to tell his child
problems and the difficulties he is facing.

Session #2

Session goals

 Rapport building

 History taking

 Behavioral observation

Procedure: In the second session firstly the child’s mother was asked about the childs sleep,
appetite and mood. She told the therapist that his sleep is normal. Child mother told that he
forgets things immediately and can’t remember his lesson. His memory is weak. Major focus
was again on rapport building in an attempt to gain detail history of the problem. The purpose
of taken history from the child’s mother was to insure the onset, present problem and factors
regarding the illness. Child’s mother was cooperative and she discussed the detailed history
and answer every single question asked by the therapist the child his self was cooperative.
History was taken from the childs mother including the history of present illness, birth
history, and educational history. Major findings were brought out from the history and
formulated by the therapist. The precipitating factors, perpetuating factors, predisposing
factors and protective factors were formulated from the history to formularize in the manner.
Informal assessment was also done through the procedure of behavioral observation and
clinical interview which is a structured assessment of child’s behavioral and cognitive
functioning and it includes description of person’s general appearance, speech, thought and
perceptions, level of attentiveness, mood and affect, cognitive abilities and memory.

The child was a male with the age of 15 years. Child appeared to be child of average height
and built. The child’s appearance was tidy, general physical appearance was weak and was
dressed properly. He was wearing clean and tidy clothes. His hygiene was good.

He was very cooperative. He responded every aspect precisely in little detail when asked.
His response was relevant to the question. His motor skills were not good.

51
 Session #3

Session goals

 Review and feedback of previous session

 History taking

 Psycho education

 Subjective rating of the presenting complaints

Procedure: Overview of previous session was taken from his mother. Overview of previous
session was taken from the child and his mother. As told by the child’s mother she was
satisfied and overwhelmed with the therapist. Child’s mother told the therapist about the
points which she wants to talk more and showed her satisfaction regarding the confidentiality
of his provided information.

Mother was psych educated. Psych education (PE) is defined as an intervention with
systematic, structured, and didactic knowledge transfer for an illness and its treatment to
child and their families and integrating emotional and motivational aspects to enable childs to
cope with the illness and to improve its treatment adherence and efficacy. It also includes
providing information about mental health conditions to the family of sufferer (Cummings &
Cummings, 2008). Psycho-education was provided to the mother. She was informed about
disorder's symptomatology, peculiar patterns, causes, and etiological factors. She was
explained about the therapy process and the importance of management strategies. She was
provided with emotional support and told that child's problem is manageable, and with her
cooperation and effort child's condition could get better. Importance of homework exercises
and mother's role in the therapy was highlighted. The mother was asked to follow the
instructions. Concerns of the mother regarding diagnosis and management procedure were
addressed. She was motivated to work hard and to give time to their child so that chances of
betterment in child’s condition increases. Psycho education was provided regarding illness,
its risk factors, cause, and prevention, course of treatment and role of child to her mother.

Family history, personal history, social history and developmental history was
obtained through semi structured interview. Subjective rating scales are widely used in
almost every aspect of practice for the assessment of workload, fatigue, usability, annoyance
and comfort. The history of the symptoms tells the therapist about the behavior of the
condition in the past
52
and may therefore assist in goal setting and prediction of prognosis. The child was asked to
rate presenting complaints on the 10-point scale where

0=no problem, 5=average, 10=severe problem.

Table 1.7

Subjective Ratings of the child Symptoms (pre assessment) reported by the mother and
therapist as well.

Symptoms Rating by mother Rating by therapist

Non compliance 07 07

Anger 07 06

Study issues 09 10

Eye contact 05 06

Irritability 07 06

Poor social skills 06 07

Poor cognitive skills 07 08

Poor self help skills 05 06

Motor activities 04 05

Speech issues 08 09

Harm mother 07 07

53
 Session #4

 Review of previous session

 Portage Guide to Early Education

 Homework

Procedure: Overview of session was taken from the child and her mother. The PGEE
program has been used widely for early intervention in children due to its scientific,
interesting, coherent, and operable nature. It is an early intervention method for cognitive
training, which can be used as structured teaching arrangements. The results showed delays
in developmental milestones corresponding to the child’s present age. Assessment through
Portage Guide to Early Education revealed that the child was below from his chronological
age and 6 years below from his normal chronological age. He had mental age of 5 years. The
childs’s age was below on the all the areas of adaptive functioning (socialization, self-help,
cognitive, language and motor skills) as compared to his chronological age.

Session #5

Session goals

 Review of previous session

 Individualized Education Plan (IEP)
 Homework
Procedure: Overview of session was taken from the child and his mother. Child’s behavior
at home and how much he follows the instructions properly was discussed by his mother. The
rationale of the session was to make IEP. Individualized Educational Plan was devised to
meet the idiosyncratic needs of the child (Carmen 2018). IEP based on establishing early
readiness skills (compliance and on seat) along with improving developmental skills like
socialization, motor (eye hand coordination), self-help and cognitive were followed during
therapy. Behavior modification techniques such as shaping, prompting, fading, and positive
reinforcement were used to enhance the desired behavior in the child. The areas covered in
IEP are attached at above.

11
Homework. Assignments were given to child on the basis of Individualized Educational Plan
(IEP) written at the end of the report. Child’s mother was asked her to practice certain skills
at home.

Session # 6

Session goals

 Review of previous session

 Techniques to minimize Aggressive behavior

• A-B-C (antecedent, behavior and consequences)

• Teach the child if then strategies

 Homework

Procedure: Review of the previous session was taken from child and mother. As mother
reported that child show anger and beat her so to minimize this behavior therapist provide
counsling to both mother and child and asked mother to monitor the triggers which cause
tentrums and try to minimize them.

Determine the conditions or settings where most of the aggressive behavior occurs.
therapist talked about doing an A-B-C recording where you write down the antecedents-
behaviors-and consequences for the aggressive behaviors you observe. It usually only takes a
little bit of time to figure out some patterns of when your child acts out. For example you
may find that your child shows more aggression during taking meal, before or after sleep,
when he needs somethinglike money, attention or meal etc. therapist also monitor the child
during unstructured times at school such as recess or waiting for classes to begin. It may be a
situation where these times need to be more controlled or structured for child. In this instance
child could be paired with a buddy during these times, a peer who gets along with child and
can assist him or her with the schedule. Therapist engaged him in fun activities during those
times when there is less formal structure. Therapist told the mother that there are many
possibilities for keeping child busy and occupied so that they don't have time to get into
trouble.

Teach your child if-then strategies. Furthermore therapist asked mother to teach child if then
strategies. Therapist told that the A-B-C data you will collect may also tell you something
about your child's triggers for aggressive behavior. For example, your child may be more

12
prone to

13
act out when they feel frustrated that something is not working as they expect. You could
teach your child that if something is broken or malfunctioning then this is a time to ask for
help. Perhaps your child becomes aggressive when they feel criticized in some way. You
could role play such a situation and brainstorm ways your child could respond without
aggression. The key here is to list all your child's known triggers for aggressive behavior and
teach alternate ways to handle the situation

Session # 7

Session goals

 Review of previous session

 Names of five colors

 Coloring

 Homework

Procedure: Overview of session was taken from the child and his mother. Child’s behavior at
home and how much he follows the instructions properly was discussed by his mother. The
rationale of session was to teach the child names of colors and worksheet of coloring bird was
completed. Names of color were memorized to child by pointing fingers towards different
colors. Therapist give him color box and call the name of color and asked him to pick the
relevant color from color box. Color recognition will help child to choose the object or dress
of his favorite color. He learned different colors names through repetitions and revisions in
various sessions.

Outcome. At the session through many trials child was to recognize color and coloring
within boundary.

Homework. The child was asked to write and memorize the color names.

Session # 8

Session goals

 Review of previous session

 Social Skills Training

14
 • Greetings
• Sharing with others
• Take permission before use others things
• Take part in different activities

 Homework

Procedure: Overview of session was taken from child’s mother. Color recognition was tested
in the therapy session from the child. Verbal and physical prompts were given to the child
during the therapy session. If he responded right, then positive reinforcement were given to
the child in form of clapping and smiling in order to enhance the probability of other
responses. The rationale of this session was to learned child social skills that play a major
role in daily life chores Morin.A (2020)

Group practice. Working with friends is a helpful manner to practice social abilities thru
role- playing greetings or ordinary scenarios. Child asked to meet with friends in class room
give hugs and made handshake. Furthermore, all the students in class were asked to share
their lunch with each other and exchange their pencils and say thanks to each other’s.

Moreover, therapist asked the child that I will asked you to bring the eraser of ali (class
fellow) so first you take permission from ali and then took it. This activity helps him to learn
that he has to take permission before tanking others things.

Outcome. At the end of many trials child was able to socialization to some extent.

Homework. Assignment turned into given to the child’s that when he went to home he will
give hugs to siblings. And share his toys with siblings.

15
 Session # 9

Session goals

 Review of previous session

 Self care skills

 Cut off soft food with knife

 Teeth brush
 Serve self on table

 Homework assignment

Procedure: Overview of previous session was taken from the child and his mother. Therapist asked
the child to tell the home address. . The rationale of today session was able child serve self at table
and cut soft foods. Therapist kept apple and banana with knife in front of child and asked him to pick
up them cut into pieces. Therapist had two knives and apples Therapist gave the knife and apple to
child and asked him to cut the apple through modeling. For learning that how to serve self therapist
go the mess hall of childrens during lunch time and instruct the child to serve self. Therapist instruct
him through verbal cues and modelling. Before going to take lunch therapist provide toothpaste and
brush to child and go to washroom to brush the teeth before lunch. Therapist moved with him and
give him verbal instructions as well as modelling. And the fruits which child cut was asked to share
with friends and classmates to learn sharing skills.

Outcomes. At the end of session child was able in these self care skills.

Homework. Assignment was given to the child’s mother to fully devote her time to the skills child
lack. And practiced him cutting of boiled potato.

Session # 10

Session goals

 Review of previous session

 Money recognition
 Homework

1
Procedure: Overview of session was taken from childs’s mother. Mother told that he can cut
potatoes well. . For child today the goal was money recognition. For this purpose, therapist kept 10,
20, 50, 100 and 500 rupee notes in front of him and told him about the value of money. After this
child asked him that where are ten rupees or fifty or twenty etc. therapist also give him work sheet on
which pictures of all notes was pasted. Therapist asked child to match ten rupees with ten similarly
twenty rupees with twenty rupee note and so on. At the end of session child was able to recognize
value of money.

Outcome. At the end of session child was able to recognize money well.

Homework. And when she went to market let his child to go with her so he will learn that how to
use money well.

Session # 11

Session goals

 Review of previous session

 Cut the circle

 Cut the different lines

 Homework

Procedure: In this session firstly the child’s mother was asked about the child sleep, appetite and
mood. She told the therapist that his diet is proper now as well as he is following instructions well.
She also said that child take his regular meals to satisfy his appetite and following the activity
schedule properly. Child mood was good as told by the mother and was also observed during the
session. Moreover, therapist asked the child that I will asked you to bring the colors from zahra
(class fellow) so first you take permission from zahra and then took it. This activity helps him to
learn that he has to take permission before tanking others things. Then therapist teach him that how
to cut circle. Therapist give him paper with lines to follow for cutting circle.

Outcome. At the end of session child wqas able to cut different lines and circle.

Homework. Assignment was given to the child was to cut different size circle at home

2
 Session # 12

Session goals

 Review of all the previous sessions

 Counting 11-20

 Home work

Procedure: Overview of all the previous sessions was taken from the child and his mother.

Mother reported improvement in his all domains like social, cognitive and self-care skills. So
rationale of today session was learned the child counting from 11-20 as he already memorized the
counting from 1-10. For this purpose therapist completed worksheets. In start therapist gave
worksheet with doted numbers and asked to trace them. Therapist also provide verbal cues on each
number that its eleven or twelve etc. then therapist give him paper on which there was different
objects with counting numbers 11-20 and asked the child to count number of ducks, balls and
mangoes made on paper. Child not learned in one session only it took various time and sessions.

Outcomes. At the end of session child memoroized counting among 11-20.

Homework. Worksheet given to child to trace the counting and complete it.

Session # 13

Session goals

 Review of all the previous sessions

 Recognition of triangle square and circle

 Match the pictures with alphabets

 Home work

Procedure: Overview of all the previous sessions was taken from the child and his mother.

Child reported improvement in his all domains like social, cognitive and self-care. The rationale of
session was to learned differenc between circle, triangle and square. Childs were told about
difference between circle triangle and square through pictures pasted on worksheet. Therapist also
showed him the objects of these shapes and asked child which one is circle shaped, square or
triangle. Therapist provide worksheet to child and asked him to match circle with circle, square
shape with square and
3
triangle with triangle. Second goal was to match the shapes of different objects with relevant alphabets.
Therapist completed worksheet to meet this goal.

Outcomes. After many trials child was able to recognize and differentiate between circle, triangle and
square. Child was also able to match the alphabets with pictures.

Homework. Homework assigmenyt given to child was to complete both worksheets.

Session # 14

Session goals

 Review of all the previous sessions

 Pick up objects while running

 Put nail with hammer

 Homework

Procedure: Overview of all the previous sessions was taken from the child and his mother.

Mother reported improvement in his all domains like social, cognitive, motor and self-care. Rationale
of today session was to enhace his motor skills through activity held in playground. therapist had
hammer and five nail. Therapist mark number on wall and kept hammer their. Therapist took few
nail kept them in line with equal distance. Then therapist instruct the child that he will pickup every
nail while running and came toward wall where therapist mark numbers. When he reached near wall
he will pickup hammer. And wait for two minutes to relax then put the each nail with hammer in
wall on marked numbers one by one.

Outcomes. After this activity child was able to put nail in wall successfully.

Homework. Homework assignment was to pick up any convinent object from ground while running.

Session # 15

Session goals

 Review of all the previous sessions

 Post assessment of subjective rating of symptoms

Procedure: Overview of all the previous sessions was taken from the child and his mother.

4
Child reported improvement in his all domains like social, cognitive, motor and self-care

Post assessment

Post assessment was done with the child to assess the improvement in symptoms intensity.

0=no problem, 5=average, 10=severe problem.

Table 1.8

Subjective Ratings of the child Symptoms (pre assessment) reported by the mother.

Symptoms Rating by mother Rating by therapist

Non compliance 07 04 07 03

Anger 07 04 06 03

Study issues 09 04 10 05

Eye contact 05 02 06 03

Irritability 07 03 06 02

Poor social skills 06 03 07 03

Poor cognitive skills 07 04 08 04

Poor self help skills 05 03 06 03

Motor activities 04 02 05 02

Speech issues 09 07 09 07

Harm mother 07 03 07 03

5
Graph 1.1

Graphical Representation of the Outcome of the Management

Chart Title
12

10

preassessment post assessment Column1

Session # 16

Session goals

 Review of all the previous sessions

 Termination session
In the last session child mother was provided hopeful view of managing, and innovatively
improve an accomplishment proposal regarded to diminish mental suffering and heighten welfare.
As the childs’s progress was favorable and he was working on his behavior. All the skills and
behaviors learned in the session were reviewed. He learned new skills. So it was decided to terminate
the session as child’s mother was feeling motivated to follow instructions. After taking post rating of
the symptoms and giving concluding remarks therapist terminated the session.

6
References

Archives Journals. (2006, October 3). Low Birth Weight Infants May Have Cognitive And Physical
Problems When They Reach Adolescence. ScienceDaily. Retrieved September 23, 2022 from
www.sciencedaily.com/releases/2006/10/061002215210.htm

Reiss, S., & Benson, B. A. (1985). Psychosocial correlates of depression in mentally retarded Adults;
Minimal social support and stigmatization. American Journal of Mental Deficiency, 89(4), 331–
337.

Meins, W. (1993). Prevalence and risk factors for depressive disorders in adults with intellectual
disability. Australia and New Zealand Journal of Developmental Disabilities, 18(3), 147–156.

Lunsky, Y., & Benson, B. A. (2001). Association between perceived social support and strain, and
positive and negative outcomes for adults with mild intellectual disability. Journal of Intellectual
Disability Research, 45(2), 106114.

Fallin, M.D., Riley, A., Landa, R., & Wang, X. (2015). The association of maternal obesity and
diabetes with autism and other developmental disabilities. Journal of pediatrics,

137(2).

Collins, P.Y., Pringle, B., & Alexande, C. (2017). Global services and support for children with
developmental delays and disabilities: bridging research and policy gaps. Journal of PLoS
Medicine, 14(9).

Johnson, L.M., & Harman, J. (2018). Beyond parenting: the responsibility of multidisciplinary health
care providers in early intervention policy guidance. American Journal of Bioethics, 18(11):58–
60.

Carman, B. (2018). Individualized Educational Plan. Retrieved from

http://www.edu.gov.mb.ca/ks4/specedu/iep/index.html

Athens, G.A. (2014). Breaking task into smaller steps, more manageable pieces. Retrieved from
https://news.uga.edu breaklarge tasks down into smaller more manageable pieces.

Morin, A. (2020). An overview of Social Skill Training. Retrieved from

https://www.verywellmind.com/social-skills.

7
Schwartz, A. (2018). Therapies for Intellectual Disability. Retrieved from
https://www.mentalhelp.net/intellectual-disabilities/therapies-and-outdated unproven treatments/.

Brown, J. (1997). Circular questioning: An introductory guide. Australian and New

Zealand Journal of Family Therapy, 18 (2), 109-114.

Saigal, S et al., (1991). Cognitive abilities and school performance of extremely low birth weight
children and matched term control children at age 8 years: a regional study. The Journal of
pediatrics, 118(5), 751-760.

8
APENDICES

9
Case report 4

10
 Case Summary

The child M.F was 5.6 years old, male belonged to lower socio-economic status. He studied in
playgroup. Child was referred to the trainee clinical psychologist with the complaints of delayed
developmental milestones (e.g. talking in complete sentence, talking single word), difficulty with
problem-solving and logical thinking, having trouble with talking, unable to understand instructions
and commands, stubbornness, aggressive behavior, beat/hit others, poor on seat behavior, low
speech. He was referred to present trainee clinical psychologist for the purpose of psychological
assessment. Psychological assessment was done on formal and informal level. Informal assessment
was done by using clinical interview subjective ratings, reinforce checklist, Portage Guide to Early
Education (PGEE) and behavioral observation. Formal assessment was done by using DSM-5
symptoms checklist After formal and informal assessment, he was diagnosed with speech
impairment and mild Intellectual Disability Disorder. A case was formulated to identify the impact
of different factors in contribution of the problematic behaviors. The management plan for the child
was based on Cognitive Behavior Therapy. A total number of 8 sessions were conducted with the
child and the child showed progress and improvement.

11
Bio Data

Name M.F

Age 5 years

Gender Boy

No of Siblings 3

Birth Order last born

Informant Childs mother

Socioeconomic Status Middle class

City Lahore

Reason and Source of Referral

The child was approached to Shadab training institute of mentally challenged children 2022
unaccompanied with the presenting complaints of delayed developmental milestones, difficulty with
problem-solving and logical thinking, having trouble with talking, stubbornness, aggressive
behavior, hit others, low speech, poor on seat behavior and disobedience. He was referred to present
trainee clinical psychologist for the purpose of psychological assessment.

12
Presenting Complaints

The child’s mother reported the following complaints.

Table 1.1

Duration Complaints

6 months ‫پڑھائی میں بلکل زیرو ہے۔‬

3 years ‫ایک جگہ بیٹھتا نیں‬

1.5 years ‫غصے میں بہن بھائیوں کو مارتا ہے۔‬

‫جب بات نہ مانی جائے تو غصہ کرتا ہے۔‬

2 years
‫بچوں کو مارتا ہے۔‬
1.5 years
‫بات کچھ کہو کرتا کچھ ہے۔‬
1 years
‫صاف لفظوں میں با ت نیں کرتا۔‬
4.5 years
‫بت کم بولتا ہے۔‬
2 years
‫ انگلی منہ میں ڈالتا ہے۔‬/‫کپڑے‬/‫بٹن‬
5 years
‫ضد بہت کرتا ہے۔‬
6 months

2 years

History of Present illness

According to the child’s mother child was below in various domains as discussed below‫ ۔‬His
mother said that they admissioned him in private school but he can't study well and due to his
aggressive behavior and low speech the headmaster of that school recommended them to take him
admission to special school named Shadab training institute of mentally challenged children.

The mother reported that the child had low speech from the very start. His developmental
milestones had been delayed. He starts to speak single word after one year and completes sentence
few months ago. He was not able to tie the laces of his shoes, to shut the buttons of his shirt etc. He
remained quite in the front of different people.

According to childs mother the child’s cognitive, and language skills were also below than
other same age children. He did not do his homework. He did not follow the instructions properly.
He was very aggressive and beat his siblings whenever in anger. He was very slow. Do not talk till

13
now

14
in clear words. According to childs mother his speech and communication skills were very weak.
Due to his odd behavior, the parents brought him to the special school.

Background Information

Family history

Father. The child's father M.1 was 40 years old and his qualification is under matric. He is a
court belt. The father had not too bad temperament and his relationship with his family was normal.
He spent most of his time outside the home. His relationship with the child was sympathetic. He was
cooperative, caring and friendly. Sometimes beat the children’s when they disobey or did mistakes.
He did not have any physical or medical illness. He used to take cigarette.

Mother. The child's mother S.I was 33 years old. She was housewife. She was living a very
busy routine with his family. Her attitude toward target child is loving and caring.

There are no psychiatry issues with mother. She had the medical issue if low blood pressure.

Siblings. The child was 3rd born youngest child. He had two elder sisters. The first born
sister was 10 years’ old who was studying in the 5th grade. Second born was 7 year old girl who was
in K.G. The child had a strong bonding with her. No medical or psychiatric problems are reported.

General Home Atmosphere

The child belongs to a middle class family. He lived in a nuclear family system. Parents had
cousin marriage. The child had been loved by his parents even though he was the last born and
usually parents show affectionate behavior towards him. All the decisions are being taken by father
and there was little involvement of a mother or any outsider. The home environment was livelyvery.

Past history of medical and psychiatric illness

As reported by the parents of the child’s no one in their family suffered from medical illness
however there was no psychotic illness reported in his family.

Personal history

Birth and Early Development

Child was born through full-term normal delivery. Mother's age at the time of
conception was 28 years. Mother and child immunisation were given properly. Her delivery
was normal and there was no complications during pregnancy. The weight of child was
normal and he was healthy. Mother start breast feedi g immediately after birth. The child
suffered from pneumonia under the age of one year. 1.5 years ago he slipped and brick cause

15
his head injurry.

16
 His fine, motor and gross coordination were normally working. His present general health,
height, weight, appetites, sleep were normal.

Table 1.2

Table shows the significantly delayed milestones of the child in speech:

Developmental Milestones Normal Age of Achievement Child’s Age of

(Seigalman & Rider,2010) Achievement

Social Smile 1- 4 months 4 months

Neck holding 3 months 3 months

Sits w/o support 5 -10 months 5-10 months

Stands w/o support 9-11 months 1 year

Walks without support 10- 15 months 10-15 months

Talks in single word 6- 12months After 1 year*

Complete sentence 3-4 years 5 years*

Eating without help 3 years 3Years

Toilet Training 3-4 3-4 years

years

*significantly delayed

The child achieved all of his developmental milestones according to other childrens (see
Table 1.2). He started neck holding at the age of 3 months. He started sitting without support at the
age of 1 year as otrher childrens. He started crawling at the age of 8 months. He started walking at
the age of
1.5 years as other children who start walking at 1 to 1.5 years of age. He spoke his first single word
after the age of 1 years which was also very late. And start to speak complete sentence at the age of 5
years as compared to other childrens who start at the age of 3 to 4 years. And he was toilet trained at
the age of 3-4 years.

Educational history

17
 M.F started school at the age of five years. His parents admitted him in private school but
due to his speech impairment and aggressive behavior the principle of that school kick out from
school

18
after a month and then he got admission in government Shadab training institute of mentally
challenged children. At the age of 4.5 years he go to the Hamza foundation for speech therapy. And
his speech get improved. But there was convince issue for parents so they left him out from that
institute.

Medical history

The child had medical history as reported by his parents that he suffered from pneumonia at
the age of 6 months and get treatment for that and recover his health. According to his parents at the
age of 4 years he slipped and get injured because his head hit on brick. His parents reported that all
thr MRI and CT scan are analysed and his reports were normal.

Psychological Assessment

Clinical Assessment was done to evaluate the information about the child’s family
background, other relationships, the onset of the problem and her present complaints. The assessment
was done on formal level.

Informal Assessment

• Clinical Interview

• Behavioral Observation

• Subjective Rating Scale

• Reinforcer checklist

• Portage Guide to Early Education (PGEE)

Formal assessment

 DSM-5 symptoms checklist

Informal

Assessment Clinical

Interview

Clinical interview facilitated the therapist to comprehend child’s problem and to elicit
precipitating, predisposing and maintaining factors of his illness. It also helped in diagnosis and
devising management plan for the child (Boyd, 2010).

Clinical interview is a tool that helps psychologist to make an accurate diagnosis of a mental
illness by asking questions from a child/child regarding his/her background information, behavior

19
issues and presenting complaints (Flanagan, 2015).

20
 In the present case, the clinical interview was conducted with the child and his parents to
assess the child’s presenting complaints, history of present illness, child’s background information
including family history, personal history, educational history and personality. The child’s history of
present illness was discussed.

Reinforce checklist

Table 1.3

Types Reinforcer
Edible Candy
Biscuits
Lays
Juice

Material Balloons
Balls
Blocks

Activity Clapping
Watching Cartoons

Social Smile
Praise
Recess time

Subjective Ratings of the child Symptoms

Speigler (1998) defined ratings that these are taken to see how frequently problematic behaviors
occurs or how severe they are in which child or his informants rated the symptoms by using 0-10 scale.

The child was asked to rate presenting complaints on the 10-point scale where

0=no problem

5=average

10=severe problem

21
Table 1.4

Table showing the subjective rating of the child’s problematic behavior on 10 point scale reported by
the mother.

Symptoms Rating

Hyperactive 08

Unclear speech 10

Study issues 09

Do not understand instructions 07

Inattention 08

Self-hygiene 02

Poor social skills 07

Beat others 09

Poor cognitive skills 08

On seat behavior 08

Stubborn 09

22
Behavioral Observation

Behavioral observation is a structured assessment of child’s behavioral and cognitive

functioning. It includes description of person’s general appearance, speech, thought
perceptions, memory and insight about his or her illness. (Folstein, 1983).

The child was a male with the age of 5.6 years. Child appeared to be child of average
height and built. The child’s appearance was tidy, general physical appearance was good and
was dressed properly. He was wearing clean and tidy clothes. His hygiene was good. He was
not bit comfortably sitting on the chair. The child was hyperactive and not sitting in the same
posture. His speech was slow and voice tone was low however speech was coherent and
devoid of bizarre content i.e. derailment, and circumstantiality etc. Rate and volume of the
child’s speech was low. Child was not defensive and he can't penly tells about his
problematic issues and circumstances. Child was little anxious and depressed.

His orientation about time, place and person was good. Child has recognition of
money. He was cooperative. He responded every aspect precisely in just yes and no. His
response was relevant to the question. The child mood was normal. Childs thought process
was not much intellectual.

Portage Guide to Early Education (PGEE)

The Portage Guide to Early Education (PGEE) program can be conducted in families,
communities, rehabilitation institutions, and early education centers, but the role of the family
and parents needs to be highlighted. The PGEE program has been used widely for early
intervention in children due to its scientific, interesting, coherent, and operable nature. It is an
early intervention method for cognitive training, which can be used as structured teaching
arrangements. However, the core status of game activities, toys, books and stories, and daily
life should be emphasized. (Cameron RJ. 1997)

Quantitative Analysis

11
Table 1.5

Showing Developmental Area and the Corresponding Age Range of the First Missed and Last
Passed Item

Developmental 1st Missed Item Corresponding Last Corresponding

areas Age range correct Age Range

Item

Socialization 22 0-1 65 4-5

Language 1 0-1 21 1-2

Self help 83 4-5 93 5-6

Cognitive 12 0-1 62 2-1

Motor 49 1-2 108 5-6

Qualitative analysis. The child’s age was below on the all the areas of adaptive

functioning (socialization, self-help, cognitive, language and motor skills) as compared to his
chronological age. The child was 2 years below from his normal chronological age.
Conclusion. The test reveals that child was below from his chronological age. He had mental
age of 3 years.

Formal Assessment

Diagnosis according to DSM-5

According to DSM 5, R.A was diagnosed with 319 (F71) Intellectual

Disability Disorder

12
 Table 1.6

Domains Symptoms Level

Conceptual domain Academic skill ➹

Reading ➹

Writing ➹

Arithmetic ➹

➹
Money recognition
➹
Time and place orientation

Social domain Communication ➹

Language ➹

Difficulty in accurately perceiving peers ➹

➹
Social judgment
➹
Percieve risk in social situations

Practical domain Support in daily living task ➹

Grocery ➹

Shoping ➹

➹
Transportation
➹
Home and child care organisation
➹
Money management
➹
Hygiene
Χ
Eating
Χ
Dressing

13
Note Χ= non problematic ➹=problematic

14
Case conceptualization

Biological Causes
Child s head injury after his
Birth and pneumonia
Low Speech

Prenatal Illnesses and Issues

No parentall illness but their busy routine
Intellectual and harsh behavior may lead towards
intellectual disability.
Disability

Environmental Factors
lack of support and not join school
at the perfect age

Figure 2.1. Figure illustrating the conceptual model of intellectual disability copied

from Vienna, V.A (2015), Langley Residential Support Services.

Overall, the factors gave a comprehensive idea that how this disability was occurred
and maintained. The predisposing and precipitating factors included the traumatic head injury
at the age of 4 years, pneumonia at the age of 6 months and parental behavior while the
maintaining factors in which lack of parent-child interaction, lack of support were the most
obvious features and need to be addressed in management.

15
16
Case Formulation

Child was referred to the trainee clinical psychologist with the complaints of difficulty
remembering things, difficulty with problem-solving and logical thinking, having trouble
with talking, unable to understand instructions and commands, stubbornness, aggressive
behavior, hitting siblings and other children and put button, finger and clothes in mouth.
Detail information was taken regarding the personal, family, educational and social areas of
functioning. Informal and formal assessments were carried out. Portage Guide Assessment
Tool was administered on the child. Ratings of the problem areas were taken.

Different factors were also studied to understand the problem of child. Child suffered
from pneumonia at the age of 6 months it may lead him toward low speech. Child at the age
of 4 years slipped and fell on brick which caused head injury. It might be possible that head
injury or abnormality of brain occurred at that time and predispose him to low intellectual
functioning. As Evans (2006) did a research which reveals that several types of brain damage
can lead to an intellectual disability. These include traumatic brain injury, congenital brain
damage (present before birth), and progressive brain damage. Traumatic Brain Injuries (TBI)
was the injuries to the brain that occur after birth (but before age 18). These injuries may be
caused by an auto accident, a blow to the head, or a fall. Brain injury also occurs when infants
are shaken or dropped (Durkin et al., 2000).

The child’s mother reported that she was normal during pregnancy there was no hypertension
or trauma etc. All mother and child immunization were completed properly.

The maintaining factors for his intellectual disability may the home environment
because his mother reported that her sister in law died and she was looking after two families.
Due to busy routine she cant give much time to target child A factor that can be better
explained by Collin et al. (2017) who proposed that early childhood is a period of great
opportunity for optimum brain growth, but it is also a period of vulnerability. Development in
language, cognition, motor and socio-emotional domains occur rapidly in these first years.
These areas of development do not operate or develop in isolation, but enable each other and
mutually interact as the child learns to become more independent. If the child receives
potentially less stimulation and fewer learning opportunities through other health service or
care routes, then his intellectual disability starts to go towards the severity level. Early
identification of children with intellectual disabilities, as well as early childhood intervention
(ECI), improves children's opportunities to maximize their developmental potential and
functioning as well as their quality of life and social participation (Johnson & Harman, 2018).

17
 According to a research, In ID, higher levels of social support are positively correlated
with higher quality of life and lack of parent child interaction is correlated with the stress
which then leads to poor quality of life in ID childs (Lunsky & Benson, 2001; Meins, 1993;
Reiss & Benson, 1985). So, if the child has social support and adequate parent-child
interaction then his quality of life improves. In the present mother or father not given him
proper time. Amd when child show stubbornness or aggressive behavior his father beaten
him. Therefore, the child remain little fearful and anxious. (Sturmey & Didden, 2014).

18
 Predisposing
Precipitating Factors Protective
Perpetuating
Factors Factors
Factors Lack of parent -
Pneumonia and Poor home child interaction Mother support
head injury environment Father punished

Diagnosis
Intellectual Disa bility Disorder

Therapeutic Recommendations
Relaxation Exercise
Activity Scheduling
Instillation of Hope
Positive Reinforcement
Mazes

19
Management plan

The management plan of child is conceptualized on eclectic approach using paradigm of

behavior therapy and cognitive behavior therapy; keeping in view idiosyncratic needs of
child. Short Term Goals

 Therapeutic rapport is an essential part of a healthy therapist child relationship and

feeling child so that therapy can be successful
 Psych education will aid in providing insight of disorder, diagnosis and treatment to
the childs family.
 To cope the family with life stressors in an effective and productive way by teaching
problem solving skills.
 Hygiene condition was improved
 Activity scheduling was done.
 Modelling was used to learned the child social and self-care skills like teeth brush,
sharing and greetings etc.
 Chaining was used to learned the child self-care skills like tie the laces and buttoning
or unbuttoning.
 Reinforcement methods were used to increase desirable behavior through clapping,
rewards and praise.
 Individual educational plane (IEP) was made to cover all the areas of portage guide.
 Group therapy was held to increase child interaction with friends and classmate and
to learned social skills.

Long Term Goals

• To continue the short term goals to maintain the change in future.

• To monitor the improvement and effectiveness of management plan by conducting

follow up sessions.

• Continuation of IEP to improve individual functioning of child.

• Maintaining and increasing behaviors (developmental skills) learned during therapy.

• Follow up sessions should be conducted to further reinforce the behaviors learned

Speech therapy should be done.

20
Structure of Sessions

A total number of 16 sessions were conducted with the child. The management plan
devised, based on establishing and enhancing cognitive and behavioral skills along with
improving child's sleep pattern and decreasing its self-harm, anger and irritability. Each
session lasts for about 45-50 minutes, in which 10-15 minutes were given to the mother, in
which homework given to the child was discussed, mother was trained how to follow the
management plan at home and her concerns regarding child's problem were answered. During
30 -35 minutes, therapist mainly focused on all the domains of IEP and attention building
exercises.

21
Individualized Educational Plan (IEP)

Student’s Name M.F

Date of Birth 29.02.2017

Age 5.6 Years

Gender Male

Strengths of Child

 He has intact gross motor, visual and hearing ability.

 Respond to immediate reinforcement

Weaknesses of the Child

 Low level of comprehension.

 Easily distracted by others
 Poor speech, language and social communication
 Stubborn, beat children, poor on seat behavior

Cognitive skills

No. Activity Techniques Trials Reinforcement

47C
1
Recognition of long and short Worksheet 3 Smile and praise

Reinforcement

19C
2
Pre writing skills Worksheet 3 Eating (Lays)

Reinforcement

22
33C
3
Recognition The three colors Verbal cues 3 Clapping

Reinforcement

63C
4
Recognition of circle, triangle and square Worksheet 3 Praise and smile

Reinforcement

Personal takecare

No. Activities Techniques Trials Reinforcement

84T
1
Tie the laces Chaining 6 Clapping

Reinforcement

33T
2
Brush the teeth Modeling 2 Candy

Reinforcement

70T
3
After eating meal clean the table Reinforcement 1 Praise

Movements

No. Activities Techniques Trials Reinforcement

98M
1
Cut the circle Modelling 3 Praise and smile

Shaping

102M
2
Roop jumping Modelling 2 Juice

95M
3
Cut all type of lines with scissor Modeling 3 Clapping

Reinforcement

104M
4
Copy small and capital letters worksheet 3 Praise

Reinforcement

23
106M
5
Coloring with in line boundries Reinforcement 2 Alow to play

worksheet game

Language

No. Activities Techniques Trials Reinforcement

11L
1
Speak five different words Prompting 4 Clapping

Reinforcement

31L
2
Name the pictures in book Prompting 3 Praise

Reinforcement

22L
3
Five family members name Prompting 3 Praise and smile

Reinforcement

27L
4
Tells the name of part of body Prompting 2 Biscuits

Reinforcement

Social-skills

No. Activities Techniques Trials Reinforcement

42S
1
Say Assalam o alaikum Modelling 3 Praise and smile

Verbal cues

Reinforcement

41S
2
Share lunch and toys with others Modelling 2 Praise and candy

Verbal cues

24
 Reinforcement

55S
3
Say thank you Modelling 3 Praise

Verbal cues

Reinforcement

62S
4
Say sorry on mistake Modelling 3 Candy

Verbal cues

Reinforcement

65S
5
Take permission before use others things Modelling 3 Clapping

Verbal cues

25
Therapeutic Interventions

Rapport Building

Rapport is a close and harmonious relationship in which the people or groups

concerned understand each other’s feelings or ideas and communicate well. Report building
with the child helps a professional in the smooth conduction of therapy.

Reciprocity

It is defined as giving gifts or doing favors without asking for anything in return.
Reciprocity is an effective technique for building reports with children. In return, the
therapist gave reinforces and gifts to the child without asking directly.

Reinforcement

One of the teacher’s most valued behavior management tools is reinforcement.

Reinforcement can be used to teach new skills, teach a replacement behavior for an
interfering behavior, increase appropriate behaviors, or increase on-task behavior (AFIRM
Team, 2015).

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 45
favorable outcome, event, or reward occurs after an action, that particular response or
behavior will be strengthened. (AFIRM Team, 2015).

Overall in achieving every goal reinforcement was used and suggested. For write and
memorize counting and alphabets. Different types of reinforcement techniques were used.
When the child completed his work successfully he was awarded his favorite reinforcement
to a maintained desired behavior.

Prompts and Fading

Prompting is a means to induce an individual with added stimuli (prompts) to

perform the desired behavior. Prompting is provided when an ordinary antecedent is
ineffective and is extensively used in behavior shaping and skill acquisition. (Burke).
Prompts were provided and suggested to the child to aid him to achieve the goal easily. After
this, the child started learning the targeted behavior prompts were started fading to remove
hid discrepancy or trainee clinical psychologist. Physical and verbal prompts were used with
the child. A verbal prompt was used for coloring and pasting, memorizing, and writing
counting whenever the child started doing his work on a task physical and verbal prompt was
given to him then started fading prompt.
26
Modeling

In social learning theory, Albert Bandura (1977) states that behavior is learned from
the environment through the process of observational learning. Modeling, which is also
called observational learning or imitation, is a behaviorally-based procedure that involves the
use of live or symbolic models to demonstrate a particular behavior, thought, or attitude that a
child may want to acquire or change. Modeling is sometimes called vicarious learning
because the child needs to perform the behavior to learn it. Modeling was used to reduce the
inappropriate behaviors of the child. Stories such as storytelling were used to inculcate the
moral values in the child. The stories were about the 46 awareness of appropriate social
behaviors and the consequences of immoral acts. The child was interested in listening to
stories.

Chaining

Chaining is an instructional procedure used in behavioral psychology. It involves

reinforcing individual responses occurring in a sequence to form a complex behavior. It is
frequently used for training behavioral sequences that are beyond the current repertoire of the
learner. The technique of chaining was used to teach the child how to tie the shoelaces? First
make a cross, in the second step take the top lace under the cross and through the hole, in the
third step make a lope in one lace, in the fourth step wrap the other lace around the loop and
push some lace through the hole that is made at the bottom to make a second loop ad then
pull both loops tight. It was rehearsed by the child two times a day. (Cooper, J. O., Heron, T.
E., & Heward, W. L. 2014).

Shaping

Shaping is a way of adding behaviors to a person’s repertoire. Shaping is defined as

the differential reinforcement of successive approximation of a target behavior until the
person exhibited the target behavior. Shaping is used to develop a target behavior that a
person does not currently exhibit. The Shaping was used for cutting circles with the scissors
and pasting them. The completion of this goal task would be divided into small steps after
completing each step the child was positively reinforced. (Skinner, B. F,1938).

Social skills training

Social skills training aims to increase the ability to perform key social behaviors that
are important in achieving success in social situations (2009). Social skills training would be
suggested for the child for establishing and maintaining social relations. Social skill training

27
taught the child to smile when greeting people and shake hands when meeting someone.
Gresham, F., Mai Bao, V., & Cook, C. 2006).

Session # 1

Session goals

⮚ Introduction

⮚ Confidentiality

⮚ Rapport building

Procedure: In first session child was introduced to the therapist. Complete Bio data was
taken from the child’s mother. Starting from the bio data name, age, siblings, birth order, and
education was asked to the child’s mother (informant). Demographic history of child was
obtained from informant which helps to understand how to deal with child according to child
cognitive level and support system. Presenting complaints and history of present illness was
obtained through semi structured interview. Therapist tried to build a rapport with child as
well as with the child to introduce him new behaviors and skills. Rapport means a sense of
having connection with the person. There are a number of techniques that are supposed to be
beneficial in building rapport such as: matching your body language (i.e., posture, gesture,
etc.), indicating attentiveness through maintaining eye contact, be prepared, active listening,
do not judge, don’t give an impression that you are not interesting and there is nothing wrong,
be aware of limitations and listen with empathy. Counseling was provided to child’s mother.
Steps may include establish a safe, trusting environment, help the person put their concern
into words, active listening involve find out the child's agenda, paraphrase, summarize,
reflect, focus on feelings, not events. Childs mother was told about the confidentiality and she
was asked that all of her information will be kept secret and nor his child personal stuff
neither his private information will be revealed to feel comfortable talking about and need of
a safe place to talk about anything they'd like, without fear of that information leaving the
room. The issue of confidentiality was discussed with the mother involved when treating a
child child at the beginning of the therapy. Although it takes a lot of time to done.
Comfortable relationship was made through providing trust and confidence to the childs. In
the present case, rapport was built by asking the child’s name, how the child is doing, actively
listening to the child mother, showing an attitude of acceptance, and respect, by empathizing
with his problem and distress and ensuring him the confidentiality of information and by
showing motivation to help the
28
child in bringing improvement in his problem. The child’s mother will be asked by the
therapist about how his child’s problem affected his functioning in different areas of life and
what brings his today. As the child, did not have therapy before so the child’s mother will be
made convinced about psychotherapy by building trust and reassurance regarding therapy and
improvement in his condition. Through the building of strong trust and rapport with the
informant the she became very friendly and she was not hesitant to talk and to tell his child
problems and the difficulties he is facing.

Session # 2

Session goals

⮚ Rapport building

⮚ History taking

⮚ Mental Status examination

Procedure: In the second session firstly the child’s mother was asked about the childs sleep,
appetite and mood. She told the therapist that his sleep is well and not disturbed. He took his
regular meals. Childs was in good mood and active also was observed during the session.
Major focus was again on rapport building in an attempt to gain detail history of the problem.
The purpose of taken history from the child’s mother was to insure the onset, present problem
and factors regarding the illness. Child’s mother was cooperative and she discussed the
detailed history and answer every single question asked by the therapist. History was taken
from the child’s mother including the history of present illness, birth history, and educational
history. Major findings were brought out from the history and formulated by the therapist.
The precipitating factors, perpetuating factors, predisposing factors and protective factors
were formulated from the history to formularize in the manner. Informal assessment was also
done through the procedure of Mental State Examination which is a structured assessment of
child’s behavioral and cognitive functioning and it includes description of person’s general
appearance, speech, thought and perceptions, level of consciousness and attentiveness, mood
and affect, cognitive abilities, memory and insight about his or her illness.

The child was a male with the age of 5.6 years. Child appeared to be child of average height
and weight according to age. The child’s appearance was tidy, general physical appearance
was good and was dressed properly. He was wearing clean and tidy clothes. His hygiene was
good. He was not bit comfortably sitting on the chair. The child was hyperactive and not
sitting in
29
the same posture. His body posture showed that he was restless and anxious as he was not
sitting on chair properly. His speech was slow and voice tone was low however speech was
coherent and devoid of bizarre content i.e. derailment, and circumstantiality etc. Rate and
volume of the child’s speech was low. Child was not defensive and he openly tells about his
problematic issues and circumstances He maintained eye contact properly. His orientation
about time, place and person was good. He was very cooperative. He responded every aspect
precisely in just yes and no. His response was relevant to the question. Childs thought process
was not intellectual. His mother reported that he has aggressive and stubborn behavior. He hit
his siblings and other children. Depersonalization and DE realization was not present
observed through his answers and behavior. Child’s attention span was normal. His general
knowledge and abstract thinking was inadequate. The child reported no obsessions. The child
reported no delusions, hallucinations, phobia and suicidal ideation. Child’s judgment was
inadequate. He had no suicidal and homicidal ideations. His short term and long term
memory was moderate.

Session # 3

Session goals

⮚ Review and feedback of previous session

⮚ History taking

⮚ Subjective rating of the presenting complaints

Procedure: Overview of previous session was taken from his mother. Overview of previous
session was taken from the child and his mother. As told by the child’s mother she was
satisfied and overwhelmed with the therapist. Child’s mother told the therapist about the
points which she wants to talk more and showed her satisfaction regarding the confidentiality
of his provided information. Family history, personal history, social history and
developmental history was obtained through semi structured interview. To check the
understanding of child’s problems and severity visual analogue scale was used. As Visual
analogue scales (VAS) is psychometric measuring instrument designed to document the
characteristics of disease-related symptom severity in individual childs. Subjective rating
scales are widely used in almost every aspect of practice for the assessment of workload,
fatigue, usability, annoyance and comfort. The history of the symptoms tells the therapist
about the behavior of the condition in the past and may therefore assist in goal setting and
prediction of prognosis. The child was asked to rate presenting complaints on the 10-point
30
scale where

31
0=no problem, 5=average, 10=severe problem.

Table 1.7

Subjective Ratings of the child Symptoms (pre assessment) reported by the mother.

Symptoms Rating

Hyperactive 08

Unclear speech 10

Study issues 09

Do not understand instructions 07

Inattention 08

Self-hygiene 05

Poor social skills 07

Beat others 09

Poor cognitive skills 08

On seat behavior 08

Stubborn 09

32
 Session # 4

Session goals

⮚ Review of previous session

⮚ Psycho education

⮚ Increase on seat behavior

⮚ Speech therapy

Procedure: Overview of previous session was taken from her mother. Mother was psych
educated. Psych education (PE) is defined as an intervention with systematic, structured, and
didactic knowledge transfer for an illness and its treatment to child and their families and
integrating emotional and motivational aspects to enable childs to cope with the illness and to
improve its treatment adherence and efficacy. It also includes providing information about
mental health conditions to the family of sufferer (Cummings & Cummings, 2008). Psycho-
education was provided to the mother. She was informed about disorder's symptomatology,
peculiar patterns, causes, and etiological factors. She was explained about the therapy process
and the importance of management strategies. Importance of homework exercises and
mother's role in the therapy was highlighted. The mother was asked to follow the instructions.
Concerns of the mother regarding diagnosis and management procedure were addressed. She
was motivated to work hard and to give time to their child so that chances of betterment in
child’s condition increases. Mother training was done as written homework, instructions for
tasks done in the session for practice at home were given daily to the mother. Furthermore,
she was asked to make daily schedule for child's activities, and daily took him to that portion
for doing various activities according to her schedule, so she could have got familiar with his
activity corner. He was also given tips on how to establish child's socialization and other
developmental skills, improved her on seat behaviors and attention span. He was guided to
use positive, clear directions like "Sit down", "Give me" instead of telling the child what not
to do. She was asked to teach child through interesting activities and also use educational toys
as prompts in learning process. Furthermore, she was taught to use reinforcement and
contingent it to the relevant behaviors so that they could be strengthened or reduced
accordingly. Psycho education was
11
provided regarding illness, its risk factors, cause, and prevention, course of treatment and role
of child to her mother. Therapist also work on increase of his on seat behavior. Child asked
him to sit on seat for five minutes then he will be given biscuit as biscuit was his reinforce. So
daily basis therapist worked with his on seat behavior with increased on seat time. Further
speech therapy also provided to child which include movement of tongue and pronunciation
of different sounds. It helps child to improve speech. Bubble gum given to child and asked
him to chew for five minutes.

Outcomes. Ate end of session mother was learned all instructions and able to did practice of
given activities to child at home and how to deal with child at certain behaviors.

Homework. For home assignment his mother instructed that repeat this practice at home and
also used honey. Honey putt on the palate and asked child to eat with help of tongue. And on
positive response give him reinforce

Session # 5

 Review of previous session

 Portage Guide to Early Education

 Activity chart

 Individualized Education Plan (IEP)

 Homework (activity chart)

Procedure: Overview of session was taken from the child and her mother. She told her
experience of solving a questionnaire. Child’s mother told the therapist that child’s speech
therapy shows little improvement. The PGEE program has been used widely for early
intervention in children due to its scientific, interesting, coherent, and operable nature. It is an
early intervention method for cognitive training, which can be used as structured teaching
arrangements. The results showed delays in developmental milestones corresponding to the
child’s present age. Assessment through Portage Guide to Early Education revealed that the
child was below from his chronological age. He had mental age of 3 years. The child’s age
was below on the areas of adaptive functioning (cognitive, language and socialization) as
compared to his chronological age. Activity chart was established in order to manage time at
home with

12
the child. Levisohn defined activity scheduling as a process of restoring the level, quality and
range of activities and interactions by carefully scheduling those activities which demonstrate
reinforcement potential for the child. It is an effective tool to engage the person in the
activities which were part of her routine. It works as a timetable for the childs. Its present
goal is to engage child in the activities which were pleasurable for him before illness to
combat his irritability and laziness (Grohol, 2010).

It includes the following steps:

• The rationale of activity scheduling will be explained to child’s mother.

• An activity chart for whole week will be made on a blank paper by focusing on the child’s
problematic behavior.

• This chart will be provided to informant and explained thoroughly.

• After one week, therapist will take this chart to see the results and make changes according
to progress.

Individualized Education Plan (IEP) was made which include goals and targets that how to
work throughout the sessions. In which areas therapist has to work to improve child social,
cognitive, language, motor and personal take care skills. Behavior modification techniques
such as shaping, prompting, fading, and positive reinforcement were used to enhance the
desired behavior in the child. The areas covered in IEP are attached at the end of report.

Homework. Child was asked by the therapist to follow the activity chart for one week but
beside the formation of activity chart the therapist made compulsory for the mother to make
sure to the child to practiced regularly task at home.

Session # 6

Session goals

⮚ Review of previous session

⮚ Attention Building exercises

1) Discrete trial training.

13
 2) Response training.

Procedure: In this session firstly the child’s mother was asked about the childs sleep,
appetite and mood. She told the therapist that his sleep is proper now as well as he is focusing
and following sleep hygiene tips to sleep well. She also said that child take his regular meals
to satisfy his appetite and following the activity schedule properly. Childs mood was good as
told by the mother and was also observed during the session.

Discrete trial training. DTT method helps the child master complex tasks by first
mastering the small subcomponents of the task. Positive reinforcement and incentives were
used to reward correct answers and behaviors of the child. The desired behavior or skill is
taught and repeated until the child learns.

Response training. RT focuses on four pivotal areas of a child’s development:

motivation, self-management, self-initiation and responsiveness to multiple cues. It is a child

directed intervention because the therapist often uses an activity or an item that interests the
child to teach and help the child reach a goal.

Homework. Assignment was given to the child’s mother to fully devote his time to the skills
child lack.

Session # 7

Goals

 Review of previous session

 Say slam
 Pencil holding

 Pre writing skills

 Distinguish between long and short

 Homework (practice on worksheet)

Procedure:. Overview of session was taken from the child and his mother. Child’s behavior
at home and how much he follows the instructions properly was discussed by his mother.
Child’s properly follow activity chart. Child asked to say slam to classmates, friend’s mother.
Therapist

14
teach him to say slam or greetings to everyone he met anywhere. To learn pre writing skills
firstly therapist teach him pencil holding and then therapist given worksheet to the child with
dotted zigzags lines and asked him to make practice. Further therapist told him the difference
between long and short objects through different pictures.

Outcomes. At the end of session child was able to hold pencil and make practice on
worksheets. He was also able to distinguish short and long objects.

Homework. The child was asked to practice on worksheets at home.

Session # 8

Goals

 Review of previous session

 Tie the laces

 Brush the teeth

 Counseling of mother

 Homework (practice)

Procedure: Overview of session was taken from the child and his mother. Child’s behavior at
home and how much he follows the instructions properly was discussed by his mother.
Therapist told the child that how to tie the laces and made him practice for a number of time
through chaining and prompting. Child also practiced how to brush the teeth’s. various
sessions were conducted then child become able to tie the laces. Mother was counseled that
from tending to the daily needs of the child, parents are also responsible for helping their
children develop social skills, life skills and appropriate behavior. Continuous counselling of
the parents is crucial as they learn to cope with their personal inadequacies and their feelings
of guilt and stress. He was motivated to work hard and to give time to their child so that
chances of betterment in child’s condition increases. Therapist provide counseling the mother
how to treat a child at home. It is important to ask the mother about the child’s problems and
listen to what she is already doing for the child, this will include praising her for the things
that she is doing well and advising her on things she can do to improve the care of his child
at home. Mother
15
was told that there are three basic teaching steps she should take when teaching her child at
home. These are: give information, show an example and let him practice. Letting a mother
practice is the most important part of teaching a task because the mother is more likely to
remember something that he has practiced than something that he has heard.

Outcomes. After various sessions and trials child was able to tie the laces and learned how to
brush the teeth.

Homework. Homework given to child was to practice of tie the laces and brush the teeth
and asked mother to follow instructions.

16
 Session # 9

Session goals

⮚ Review of previous session

⮚ Take permission before use of others things

⮚ Recognition of circle, triangle, square

⮚ Homework

Procedure: Overview of session was taken from the child and his mother. Homework given
to the child in the previous session was checked. Child’s mother told the therapist that child’s
follow instruction and work properly. Child was teaching that he must take permission
whenever he used or take others toys or things. For practice therapist asked the child to
borrow pencil from classmate. Reinforcer was also given to him when he took permission to
others before use things or toys.

Outcomes. At the end of session child learned to before use of others things and toys he had
to take permission, moreover he learned the difference of triangle, circle and square.

Homework. For homework child mother was asked to make him practice of take permission.

Session # 10

Session goals

 Review of previous session

 Cut the different straight lines
 Cut the circle
 Homework

Procedure: Overview of session was taken from the child and his mother. Homework given
to the child in the previous session was checked. Child’s mother told the therapist that child’s
follow instruction and work properly. Rationale of session was to learned child how to cut
circles and different lines. Therapist told him how to use scissor for cutting purpose. He
practiced through cutting circle and straight lines with paper. Therapist marked line and
instruct child to cut them by follow these line.

11
Homework. homework assignment was to practice the cutting lines and circle at home.

Session # 11

Session goals

⮚ Review of previous session

⮚ Share lunch and toys with others

⮚ Five family members name

⮚ Rope jumping

⮚ Homework

Procedure: Overview of session was taken from child’s mother. Childs mother was asked
about the child take of permission behavior and cutting circles and lines. She told the
therapist that child followed the instruction and work well. In this session child asked to share
his lunch and toys with friends and classmates. Therapist held the activity of sharing lunch of
all students of class to make practice of child. On sharing toys and lunch he was rewarded by
reinforce as his reinforce was biscuits. Due to his low speech he was not able to call his
family members name properly so he asked to recall the five family members name including
father, mother, two sisters and uncle. Third goal of session was to improve his motor
movement for that purpose child was performed the activity of rope jumping. Therapist
conduct this activity for whole class so that child also learned to enjoy and interact with
others.

Outcomes. At the end of session child was able to rope jumping and adapt behavior of
sharing toys and lunch with others.

Homework.

Child’s mother was asked him to practice certain skills at home. Asked child to practiced call
family members name.

Session # 12

Session goals

⮚ Review of previous session

12
 ⮚ Counselling and motivation to the mother

⮚ Name of three colors

⮚ Coloring within the boundary

⮚ Clean the table after lunch

⮚ Homework assignment

Procedure: Overview of previous session was taken from the child and his mother.
Counseling is a therapeutic intervention meant for behavioral change in a desired path.
Generally, this shift or exchange is in tremendous route aimed toward bringing development
in child's bodily and mental fitness. Although there may be a few variations at some point of
a consultation, there may be a primary structure. That shape turned into defined with the aid
of Cormier and Hackney (1987) as a 5-level procedure: relationship building, evaluation, aim
putting, interventions, and termination and observe-up. Steps may additionally include
establish a secure, trusting environment, help the individual put their problem into phrases,
energetic listening contain discover the customer's schedule, paraphrase, summarize,
replicate, recognition on emotions, not activities. Further child was learned the recognition of
three colors by pointing toward colors on wall which include red, Green and yellow. When he
memorized the colors names then he asked to color in apple and instruction given to him that
coloring should must be within the boundary. At the end of session therapist practiced to
child that after lunch clean his table which help him in socialization.

Outcomes. At the end of session child was able to memorized the color names and coloring
within boundary.

Homework. worksheet was given to the child for coloring and to memorized the name of
colors.

Session # 13

Session goals

⮚ Review of previous session

⮚ Name the pictures in book

⮚ Say thank you

⮚ Homework assignment

13
Procedure: Overview of previous session was taken from the child and his mother. Child
completed his homework assignment of coloring. Mother reported that he attempted the
homework at home complete and follow the activity chart. The rationale of this session was
to recall the names of the picture in story book. Therapist read the story and then asked him
to tell that where are these characters in book and tell their names also. The second goal of
the session was to teach him to say thank you when friends or classmate share their toys,
pencil or lunch with him. Therapist gave him candy on daily basis and asked him to say thank
you until child not learned and say thank you without clue or prompt.

Outcomes. At the end of session, he was able to speak the name of pictures in story book and
to say thank you.

Homework. Assignment was given to the child to practice the names of picture in book.

Session # 14

Session goals

⮚ Review of previous session

⮚ Speech and language

⮚ Speak complete sentence

⮚ Homework

Procedure: Overview of previous session was taken from the child and his mother. The
rationale of today session was to work on child speech and language. Therapist work on his
speech in different areas like playtime, meal time and going places. For going places therapist
took him toward the school playground and ask where we are going? Child only said
playground, then therapist ask him to say we go to playground and repeat again and again.
Similarly, for mealtime therapist ask what are you eating, child replied bread. Therapist ask
him to say I am eating bread and make practice by repeating again and again.

Outcome. At the end of session child was able to speak few but complete sentences.

Homework. His homework assignment was to made practice speaking of complete sentence.

Session # 15

Session goals

14
 ⮚ Review of all the previous sessions

⮚ Early math’s and Counting

⮚ Home assignment

Procedure: Overview of all the previous sessions was taken from the child and his mother.
The rationale of this session was to learnt child early math’s. Therapist give him one candy
and asked the child that how many are these? Child told its one. Similarly, therapist give two,
three, four and five respectively, and asked how many are these.

Outcome. At the end of session child was able to count candies, pencils, classmates etc.

Homework. His mother asked to make counting practice of different objects at home.

Session # 16

Session goals

⮚ Review of all the previous sessions

⮚ Post assessment of subjective rating of symptoms

Procedure: Overview of all the previous sessions was taken from the child and his mother.

Child was quite better in many domains of behavior. Child reported improvement in his
symptoms.

Post assessment

Post assessment was done with the child to assess the improvement in symptoms intensity.

15
Table 1.8

Subjective Ratings of the child Symptoms (post assessment) reported by the mother.

Symptoms Rating Mother By therapist

by Rating
Post Post
Pre Pre

Hyperactive 08 05 08 04

Unclear speech 10 07 10 07

Study issues 09 04 08 04

Do not understand instructions 08 04 07 03

Inattention 08 03 07 03

Self-hygiene 05 01 05 01

Poor social skills 07 03 08 04

Beat others 09 05 08 04

Poor cognitive skills 08 05 09 05

On seat behavior 08 03 08 03

Stubborn 09 05 08 04

16
Graph 1.1

Graphical Representation of the Outcome of the Management

Chart Title
12

10

pre assesment post assesment Column1

Session # 17

Session goals

 Session termination

Termination session

In the last session childs mother was provided hopeful view of managing, and
innovatively improve an accomplishment proposal regarded to diminish mental suffering and
heighten welfare. As the child’s progress was favorable and he was working on his behavior.
All the skills and behaviors learned in the session were reviewed. His symptoms were getting
better. He learned new skills. So it was decided to terminate the session as child’s mother was
feeling motivated to follow therapy techniques. After taking post rating of the symptoms and
giving concluding remarks therapist terminated the session.

11
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APENDICES