Psychodiagnostic Report/ Child

Identifying Information

Name J.A

Father name J.K

Age 05 years, 09 months

Date of birth 21-07-2018

Gender Male

Assessment Date 24 April 2024

30 April 2024
07 April 2024

Assessment by Zeeshan Manzoor

Informant Parents

Reason and Source of Referral

The client was referred to a trainee clinical psychologist for psychological assessment
and management plan by the Fountain House, Lahore.

Presenting Complaints

Presenting complaints presented by the parents

‫ مہینے کی عمر سے‬03 ‫آنکھوں میں د یکھ کر بات نہیں‬

‫کرتا‬

‫ سال کی عمر سے‬03 ‫اپنی عمر کے بچوں کے ساتھ نہیں‬

‫گھلتا ملتا‬

‫ سال کی عمر سے‬03 ‫ایک ہی کام کو بار بار کرتا ہے‬

‫سال کی عمر سے‬03 ‫چیختا چیالتا ہے بہت‬

‫سال کی عمر سے‬03 ‫بات چیت کرنے میں مسلہ ہوتا ہے‬
Clinical Interview

The boy's illness was progressive. His mother noticed that his initially poor eye contact
gradually diminished until there was none at all. His laughter seemed improper and atypical. He
displayed repetitive behaviors and often appeared lost in his surroundings, showing limited
engagement with people and the environment. Recognizing these unusual behaviors and
developmental regression, the boy's mother sought help from a behavior therapist. However, the
therapy did not significantly improve his behavior or overall functioning.

The client, who was delivered through a C-section and is the second child in a joint
family, did not face any health issues at birth. However, developmental history reveals delays in
achieving motor milestones and a decline in speech abilities. Due to insufficient attention from
their mother, the client spent considerable time on screens, either provided with a mobile device
or engaged in watching cartoons. The client exhibited distinct features in social and emotional
development, including poor eye contact, unusual laughter, and repetitive behaviors. Despite
these challenges, the family, particularly the elder sister, provided a supportive and caring
environment, which played a pivotal role in the client's well-being.

The 4-year-old boy had a history of developmental delays and regression in milestones.
Initially, he achieved some developmental milestones at the expected age, but there were delays
in sitting, crawling, and walking. He started sitting, crawling, and walking later than expected.
However, the most concerning aspect was the loss of previously acquired skills. Around one year
of age, the boy could speak three to four words, demonstrating typical language development.
However, after six months, his speech suddenly regressed, and he became completely mute,
causing significant concern for his parents.

The child's mother mentioned that since the symptoms began to manifest at an early age,
they chose not to enroll him in mainstream education. Instead, they took the child to a
rehabilitation center to address and manage his behaviors.

The client belonged to a middle-class socio-economic status and resided in a joint family.
The family structure consisted of the client's parents, grandparents, and an elder sister. The
client's father was employed in a private company, while the mother fulfilled the role of a
housewife. The marriage of the parents was arranged against their will. At the beginning of their
marital life, they faced complications, leading to parental negligence in the client's early
childhood. Consequently, the client did not receive warmth and acceptance, especially from the
mother. She also had conflicts with her in-laws, making it challenging for her to handle the
situation with her special child. After the manifestation of symptoms in the child, efforts were
made to manage the home environment. Currently, both parents are described as caring,
supportive, and actively involved in the client's upbringing. They provide the client with full
attention, care, and support.

In addition to the parents, the client's grandparents also lived with them, contributing to a
supportive family environment. The presence of the grandparents provided additional guidance,
wisdom, and emotional support for the client and the family as a whole.

The client had a positive and nurturing relationship with their elder sister. The sister
assumed a caring role and took care of the client's needs, demonstrating a strong bond between
them. This sibling relationship provided an additional layer of support and companionship for the
client.

No significant history of psychiatric illness is present in client family as reported by

client’s mother.

Test Administered

The following test list is used to evaluate the client’s severity of symptoms, to confirm
the diagnosis and prepare treatment plans.

 Childhood Autism Rating Scale (CARS)

 Vineland Adaptive Behavior Scale (VABS)

Behavioral Observation

The client was of average height but had a lower weight compared to peers of the same
age. He exhibited delayed speech and language development, with limited spontaneous speech
and difficulty in effective communication. He seemed inactive and unresponsive, needing
prompts to initiate tasks. Eye contact was poor. While he showed some ability to complete tasks,
his behaviors were repetitive. These observations suggest potential developmental concerns and
indicate the need for further evaluation and intervention to address communication and social
interaction difficulties. He was not oriented to time, place, and person. Rapport was established
with the client.

Psychological Evaluation

Table 1:

Client’s sore on Childhood Autism Rating Scale (CARS)

Obtained Score Cut Off Score Interpretation

44 37-60 Severe autistic symptoms

In the Childhood Autism Rating Scale (CARS), the obtained score for the client is 44,
falling within the range of 37-60. According to the established cut-off scores, this places the
 client in the category of severe autistic symptoms. A score of 38 suggests a significant presence
of behaviors associated with autism spectrum disorder, indicating a high level of impairment in
social interaction, communication, and restrictive or repetitive patterns of behavior.

Table 2:

Client’s sore on Vineland Adaptive Behavior Scale (VABS)

Domains- Age equivalent Functioning level

Sub Domains

Communication Skills 3:0

Receptive 1:8 Low

Expressive 2:2 Low

Written 5:2 Adequately-Low

Daily Living Skills 3:0

Personal 3:0 Low

Domestic <3:0 Low

Community <3:0 Low

Socialization Skills 2.1

Interpersonal Relationship 1:0 Low

Play and Leisure 2:3 Low

Coping Skills 3:2 Moderately-Low

Motor Skills 2.9

Fine motor 1:8 Low

Gross Motor 4:1 Moderately-Low

ABC: 69

Overall age 2:7

Client overall adaptive behavior functioning is equivalent to a child of 2:7 years which falls within

the “mild functioning” functioning range. The adaptive functioning shows how much a child utilizes
his intellectual potentials in various domains of everyday life. This adaptive behavior functioning is

comprised of communication skills, Daily living skills and socialization skills. Further analysis

revealed that:

• Within Communication skill domain J.A was unable to respond appropriately according to the

gesture, cannot understand at least 10 words, to comprehend body right-left orientation, comprehend

and report informational general knowledge videos etc. similarly, unable to express report, using

verb, noun, conjunctions, adjectives, past present orientation and usage of actions. Moreover, in

reading and writing, he was unable to hold a pencil, he don’t know about any alphabets, he doesn’t

even recognize his name in printed form. These are within “low” functioning range. He can speak 2-3

words of speech and this limited vocabulary and comprehension seems to be hindrance in learning

and he has lower reading and writing skills.

• Within the Daily living skills, he cannot feed himself with fork, wipes his or her nose using tissue,

and cover his mouth and nose when sneezing. He was unable to wipes his own spill. In terms of

community skills, he cannot stay near his parents and wander around. He doesn’t have the concept of

personal and other’s privacy etc. Many of the skills may not be learned due to limited exposure from

the environment. He was little bit able to do self-care

• Within Socialization skills Domain, his overall lower functioning seems mainly due to hyperactive

behavior. He is unable to control his impulses. So, He was not able of maintaining good relationships

due to his hyperactive and impulsive behavior. His mother also fulfill his demanding behavior. His

overall adaptive functioning lies within low range.

Tentative Diagnosis

 299.00(F84.0) Autism Spectrum Disorder, Severe

Prognosis

The prognosis for the presented case of ASD depended on factors such as early
identification, access to appropriate interventions, family support, and the client's response to
treatment. With early intervention and a supportive environment, individuals with ASD could
make significant improvements in communication, social interaction, and adaptive behaviors,
enhancing their overall quality of life. No significant points were found against the prognosis.

Conclusion

I.R., a 5-year-old boy was brought to the Mayo Hospital by his parents due to noticeable
difficulties in communication, limited eye contact, social withdrawal, and delays in development.
Although he initially achieved some developmental milestones, there were delays in sitting,
crawling, and walking. The most concerning issue was the sudden regression in his speech
development, leading to complete silence. His mother observed a gradual decline in eye contact,
unusual laughter, repetitive behaviors, and limited interaction with people and the surroundings.
The child's background history revealed a supportive family environment, though there were
early complications in the parental relationship. The family sought assistance to address the
child's behaviors, and a psychological assessment indicated significant developmental delays and
severe autistic symptoms. A management plan was developed to address the presenting
complaints.
Recommendations

 Encourage the client to join support groups or peer support networks so he can get in
touch with people who have gone through similar things. This can give him a sense of
community, validation, and access to common coping mechanisms.
 Stress the value of leading a healthy lifestyle, which includes getting regular exercise,
getting enough sleep, and eating a balanced diet. These elements may support symptom
management and general health.
 Establish regular follow-up sessions with the client to keep track of his development,
evaluate the efficacy of the treatment, and address any new problems or worries.
Maintaining stability and modifying the treatment plan as necessary might be facilitated
by continual support and monitoring.

(Assessor Name) (Supervisor Name) (Head of

Department) MS Internee Internship Supervisor

 Management Plan

Patient's Name and Age I.R, 05Y

Test Administration  Childhood Autism Rating Scale (CARS)

 Vineland Adaptive Behavior Scale (VABS)

Tentative diagnosis 299.00(F84.0) Autism Spectrum Disorder, Severe

Goals Therapeutic Intervention

Short-Term Goals

 Establish rapport through active listening, empathy, and

unconditional positive regard

 Psycho-education to develop insight

 Family counselling and training to enhance

understanding, and support within the family system

 Training to maintain an eye contact

 Teach him the fundamentals, such as how to address and

feed himself

Long-Term Goals

 Continuation of short-term goals

 Encourage the helping and supportive environment

  Positive Parenting

 Follow up sessions

Main Therapies Applied Behavior Analysis

No of Planned Session 10-12

Case Conceptualization

Biopsychosocial Approach

The client's developmental delays and autistic symptoms have a genetic component,
contributing to the manifestation of Autism Spectrum Disorder (ASD). Being delivered through
a C-section and experiencing no health issues at birth are notable factors. However, potential
prenatal and perinatal factors have played a role in the developmental delays. Insufficient
attention and warmth during early childhood, compounded by conflicts in the mother's
relationships, could have impacted the child's emotional and social development the client's
delays in achieving motor milestones and the sudden regression in speech development are
crucial developmental factors indicating ASD. Excessive screen time during early development
might have contributed to delayed social and language skills. . The initial parental negligence
due to complications in the parents' relationship might have influenced the child's attachment and
overall psychological well-being. The joint family structure, though supportive, might have
introduced complexities and challenges, especially with conflicts between the mother and in-
laws. Belonging to a middle-class background, the family may face challenges in accessing
specialized interventions and resources for the child.