Case 1
Title of your case
Case Summary
Bio Data
Name:
Gender:
Age:
Birth order:
Number of siblings:
Reason of Referral
The client was referred by special education institute to a trainee clinical psychologist for
diagnostic assessment and management of problematic behavior.
Presenting complaints
Duration Presenting Complaints
Background Information
Family History
Table 2
Birth order, age, gender, education and relation of sibling with index child
Birth order Gender Age Schooling Relation with client
1 Male 13 years Index child -
2 Female - Normal Sister
3 Female - Normal Sister
4 Male - Autistic Brother
General Home Environment
History of Medical/Psychiatric Illness in Family
Personal History
Birth History
Table 3
Developmental milestones of the client in comparison to the normal range of the milestones
achievement
Developmental milestones Normal age of achievement Client’s age of achievement
(Gerber, Wilks & Lalena 2010)
First cry after birth Immediate
Social smile 1 month
Neck holding 3-4 months
Sitting 6-7 months
Crawling 9 months
Standing 10-11 months
Speech 9 months
Walking 12-13 months
Bladder bowl control 28 months
Medical History
Educational History
Psychological Assessment
Psychological assessment is the process of gathering and integrating psychology-related
data for a psychological evaluation accomplished through tools. i.e., interviews, tests, behavioral
observations, case studies and specially designed measurement procedures and apparatuses
(Cohen & Swerdilk, 2009).
Informal Assessment
Clinical interviews
Behavioral observation
Identification of reinforces
Subjective rating of symptoms
Clinical Interview
A clinical interview is a goal-oriented professional conversation between the clinician and the
client. The difference between it and a casual conversation is the interviewer’s attention to how
the respondent answers questions or does not answer those (Kring et al. 2012).
Behavioral Observation
Behavioral observation is an assessment approach focusing on interactions between
situations and behaviors to effect behavioral change. In this method, the clinician observes and
records the frequency of the behavior in question, including any other relevant situational
variables (Davison et al. 2004).
Identification of Reinforces
Reinforcement is a process in which the consequences of a behavior increase the likelihood that
a behavior will be performed again (Sharf, 2010).
Table 4
Reinforces of the client according to the priority level
Reinforce Type Priority level
Coloring (crayons, color pencils) Tangible 1st
Verbal praise ( good boy, well done) Social 2nd
Playing with ball Activity 3rd
Subjective Rating of Symptoms
The rating on the problems was taken to get information about the severity level of the
problematic behavior perceived by teachers and parents. Ratings were taken through a 0-10
scale, where “0 = no problem at all”, “5 = average” and “10 = severe problem”.
Table 5
Pre-Subjective Rating of the Client’s Symptoms from 0-10 Scale
Symptoms Subjective Rating Scale (0-10)
Inattention and lack of concentration 5
Symptoms Subjective Rating Scale (0-10)
Inattention and lack of concentration 5
Symptoms Subjective Rating Scale (0-10)
Inattention and lack of concentration 5
Formal Assessment
1. The Childhood Autism Rating Scale (CARS)
2. The Assessment of Basic Language and Learning Skills-Revised (ABLLS-R)
3. DSM 5-TR symptoms checklist
The Childhood Autism Rating Scale (CARS)
Quantitative Analysis
4. Table 6
5. Scores of Childhood Autism Rating Scale
Raw score Ranges Category
31.5 30-36 Mild-moderate Autistic
Qualitative Analysis
The Assessment of Basic Language and Learning Skills-Revised (ABLLS-R)
DSM 5-TR symptoms checklist
Diagnosis Formation
The client came up with the symptoms of hand flapping, stimming. Moreover Vocalizing,
echolalia, lack of eye contact and difficulty to socialize. According to DSM 5-TR and
comprehensive psychological assessment, the client was diagnosed with Autism Spectrum
Disorder.
Table 7
Code Diagnosis Specifier
299.00 Autism Spectrum Disorder Level 1: Requiring support
Prognosis
Case Formulation
Case Conceptualization
The following figure summarizes the client’s presenting problems the biopsychosocial
factors contributing to the problems and the proposed management.
Presenting Complaints Assessment
Informal Formal
Management plan Predisposing factors
Management plan
Short-term goals
Long term goals
Summary of Therapeutic Interventions
Pre and post Subjective Rating of Symptoms
The rating on the problems was taken to get information about the severity level of the
problematic behavior perceived by teachers and parents. . Ratings were taken through a 0-10
scale, where “0 = no problem at all”, “5 = average” and “10 = severe problem”.
Table 9
Pre- and post-Subjective Rating of the Client’s Symptoms from 0-10 Scale
Symptoms Pre Subjective Rating Post subjective
Scale (0-10) Rating Scale (0-10)
Deficit in social 7 7
communication
Lack of eye contact 6 5
Restlessness/short sitting span 5 4
Hyperactivity 7 6
Hypersensitivity to loud noises 7 6
Speech issues (only sound 8 8
making)
Unusual pattern of 8 8
behavior/activities (repetitive
head banging, and hand
wiggling, lining up thigs,
throwing things, spitting,
pinching, laughing and
shouting without purpose, tip-
toe walking)
Inattention and lack of 5 4
concentration
Absent of interest in peers 6 5
Stubborn attitude 6 5
Total 65 58
Outcome
Session Details
Session 1 to 5
Recommendations
Appendix A
