Expressive Language Disorder

CASE SUMMARY
The client was a 4-year-old child who belongs to a middle socioeconomic background and lives

in a nuclear family system. The client was referred as an outdoor patient at Centre for Clinical

Psychology with complaints of delayed speech, particularly in expressive communication. The

child had been psychologically diagnosed with Autism Spectrum Disorder. Speech and

Language assessment was carried out at both informal and formal levels. Informal assessment

included a clinical interview, behavioral observation, pre-linguistic skills evaluation, and oral

motor examination. Formal assessment included Information Carrying Words (ICWs) and Blank

Level of Questioning. After complete assessment and history taking, the client was diagnosed

with Expressive Language Delay. A management plan was devised based on Speech and

Language Therapy.
BIO DATA

Name M.A

Age 4 years

Gender Male

Referred by Family member

Siblings 1 younger brother

Birth Order First born

Family System Nuclear family system

SOURCE AND REASON OF REFERRAL
The client was brought by his mother to Centre for Clinical Psychology on the

recommendation of a relative for speech and language evaluation and intervention due to speech

delay.

PRESENTING COMPLAINTS

HISTORY OF PRESENT ILLNESS

Client's mother reported that the child does not speak and finds it difficult to express his

needs verbally. The child uses gestures or cries when in need of something. All developmental

milestones were delayed. Screen time was 4–5 hours per day. He was formally diagnosed with

Autism Spectrum Disorder by a psychologist.

PERSONAL HISTORY

Pre-Natal History

During the mother’s pregnancy, no major illnesses or infections were reported. However,

she did experience emotional and financial stressors, which may have had some indirect impact

on prenatal development.

Natal History

The child's first cry was delayed at birth, and the birth weight was slightly below average.

No complications during delivery were mentioned.

Post-Natal History

After birth, no post-natal complications were reported. The child appeared to be

medically stable during the early months of life.

FAMILY AND EDUCATIONAL HISTORY

The client is the first-born and the eldest of two siblings. He resides in a nuclear family

setup. The parents are cousins, but no significant family history of speech or language delays

was reported. The child shares a strong emotional bond with his mother and seeks her out for

comfort and support. As of the time of reporting, the child has not been enrolled in any formal

school or tuition, and thus has no educational background.

REINFORCER IDENTIFICATION
 Through observation during therapy, the client was found to respond well to various

forms of reinforcement. Edible reinforcers such as chocolates, biscuits, and candies were highly

motivating. Sensory reinforcers like soft toys and spinning tops helped maintain engagement.

Tangible reinforcers such as balls and blocks were also effective in reinforcing desired

behaviors. Additionally, activity-based reinforcers, especially those involving music and

movement, were observed to be very appealing to the client.

MEDICAL AND PSYCHOLOGICAL HISTORY

Medical History

No major medical illnesses were reported by the mother. The child did not experience

any chronic conditions or significant health concerns requiring medical intervention.

Psychological History

At the age of 3.5 years, the child was diagnosed with Autism Spectrum Disorder (ASD)

by a psychologist. This diagnosis was based on behavioral symptoms and developmental delays

observed over time.

DEVELOPMENTAL AND SPEECH MILESTONES

The client exhibited delays in both developmental and speech milestones. Motor skills,

communication abilities, and social interaction were all noted to be below age expectations. Prior

to the initiation of therapy, the child did not use spontaneous words for communication and

relied heavily on gestures or non-verbal behaviors to express needs and desires.

ASSESSMENT

Formal Assessment

Informal Assessment

Informal ASSESSMENT

The assessment of the client was conducted through both informal and formal methods.

Informal assessment included a clinical interview with the client’s mother, who provided

detailed information regarding the child’s developmental, medical, and psychological history.

The client was observed during therapy sessions, where he presented with on-seat behavior,

showed interest in play materials, and demonstrated limited social interaction. He responded to

auditory stimuli but was shy around unfamiliar individuals. Pre-linguistic skills such as eye

contact, turn-taking, and gesture use were partially developed. Joint attention was inconsistent,

and imitation skills were emerging. Oral motor examination revealed no structural abnormalities;

lips were closed at rest, and there was no drooling. Facial symmetry and oral structures (jaw,

tongue, lips, and palate) appeared within normal limits.

FORMAL ASSESSMENT

ICW’s (Information Carrying Words)

Level Task Accuracy Comments

Responded correctly in 8 out
Identify one object
Level 0 80% of 10 trials using familiar
with no distraction
toys.
Identify object with No accurate responses. Did
Level 1 two key words or 0% not differentiate between
descriptors cues.

Follow simple
Will include tasks like “Give
Level 2 instructions with 2+ To be assessed
me the big red ball.”
elements

Understand abstract Will assess understanding of

Level 3 concepts and follow To be assessed reasoning and sequencing
complex commands concepts.

Blank Level of Questioning

Level Type of Question Response Remarks

Naming, pointing, 3 verbal prompts given. No

Level 1 answering “what,” No response verbal output noted.
“who,” etc. Expressive delay present.

Describe attributes,
Planned for upcoming
Level 2 actions (“What is he To be assessed
sessions.
doing?”)
 Respond to “Why,”
Higher-level comprehension
“How,” and
Level 3 To be assessed tasks will be introduced in
reasoning-based
future sessions.
questions
DIAGNOSIS

Speech & Language Diagnosis Expressive Language Delay

Psychological Diagnosis Autism Spectrum Disorder (ASD)

 CASE FORMULATION

Predisposing Factors

The client presented with several predisposing factors that may have contributed to his

current communication difficulties. These include a delayed first cry at birth and slightly low

birth weight, both of which can be early indicators of neurological or developmental

vulnerabilities. Additionally, a family history involving consanguineous marriage (parents are

cousins) may carry genetic risks that can influence developmental outcomes.

Precipitating Factors

The psychological diagnosis of Autism Spectrum Disorder (ASD) at the age of 3.5 years

serves as a primary precipitating factor. The client also had limited exposure to interactive social

environments, particularly due to high screen time (4–5 hours daily), which reduced

opportunities for natural language learning and peer interaction. Behavioral concerns such as

hyperactivity and tantrums further interfered with early language acquisition and structured

learning experiences.

Perpetuating Factors

The child’s expressive language delay appears to be maintained by a combination of

factors, including a lack of functional verbal communication, dependency on non-verbal

behaviors (e.g., crying or pointing), and limited reinforcement of verbal attempts at home.

Inconsistent joint attention and poor imitation skills may also contribute to the continuation of

language deficits.
Protective Factors

Despite the challenges, several protective factors are present. The client has a supportive

family system, particularly a strong emotional bond with his mother, who is actively involved in

therapy. Early identification of the disorder and the initiation of speech and language therapy

provide a critical window for intervention. The child shows responsiveness to reinforcers and has

begun to engage with therapeutic activities, indicating a good prognosis with continued support.

Reference

Adapted from the 4Ps Case Formulation Model (Predisposing, Precipitating,

Perpetuating, Protective), widely used in clinical psychology and speech-language pathology for

understanding contributing factors in developmental and behavioral disorders (Carr, A. (1999).

The handbook of child and adolescent clinical psychology).

SHORT TERM GOALS

 Rapport building and therapeutic relationship

 Develop eye contact and imitation

 Increase use of functional words

 Reduce non-verbal tantrum behavior using alternative communication

 Parent training and psychoeducation

LONG TERM GOALS

 Enable the client to use two-word and three-word phrases to express needs with 60–70%

accuracy.

SESSION DETAILS

Total Sessions Conducted: 9

 Sessions 1–3 Rapport building, sensory play, imitation of sounds

 Sessions 4–6 Increased use of gestures, attempts at single words

 Sessions 7–9 Initiated verbal requests, used 1–2 word combinations with prompts