Case summary

The client was 9 years old and he was 6th child among 7 siblings. The client was deaf.

He studied in special school for three years. He was referred to the trainee clinical

psychologist by the school administration for psychological assessment and management. He

was referred with the presenting complaints of hitting teachers and students, fits, torn the

books of class fellows. The client was assessed with clinical interviews, subjective rating of

the problematic behaviour, reinforcement identification and House Tree Person Test (HTP).

12 number of sessions were conducted with the client. Management plan was devised based

on behavioural therapy. Management plan included rapport building, psychoeducation, and

differential reinforcement. The outcome of the therapeutic intervention was 10% on the basis

of pre and post-management assessment ratings.

 Identifying Data:

Name Initials: M.R

Age: 9 years

Gender: Male

Birth Order: 6th

No. of Siblings: 7

No. of Sessions: 8

Informant: Mother and teacher

Sources and Reason for Referral:

The child was referred to the trainee clinical psychologist for psychological

assessment and management of problematic behaviour.

Table 1

Presenting Complaints of the Child as Reported by the Mother

Complaints Duration

Table 2

Presenting Complaints of the Child as Reported by the Teacher

 Complaints Duration

Initial Observation:

M.R was of average height and weight. He was wearing neat and tidy clothes. The

clothes were weather appropriate. His hair was combed. His hygiene was proper. He seemed

confused like he did not know what to do. He was sitting comfortably. He was cooperative.

His attention and concentration were appropriate. He was attending the environment and

noticing everything. He was maintaining eye contact during the session. He had fine motor

skills. He knew his name and wrote it down upon request. Reinforcers were identified at that

time. He said Salam when his mom asked him to do that. He also said Salam with a gesture in

response to the trainee’s Salam. He was smiling while leaving the room.

History of Present Illness:

The client was born in 2011. Mother reported that the delivery was normal. His first

cry was delayed. He cried upon the action of the doctor. Mother fed her for 2 days, then she

gave formula milk to the child. Mother of the client reported that he had fever at age of 1

month. His developmental milestones were delayed. They found at the age of 3 that the client

cannot speak and listen. Although, he produces the sounds like baaa. The mother took the

client to the hospital for check-up, but the results were not satisfactory. At the age of 5, the

client was diagnosed with fits. His mother reported that someone hit him at the backside of

the brain and he got faint. Then he fell asleep for 2 to 3 hours. When he woke up, he told her

that someone hit him. According to the mother, the client got faint and then fell asleep for 2
to 3 hours. Upon waking up, he can tell the incident. It happened to the client on and off and

they went to the doctor who gave him medicine for it. Now the client has no complaints of

fits. The client was then admitted to the special school. In the start, everything was going

smooth. Then the class-fellows started teasing him and he hit them in reaction. He started

hitting behaviour in the school. Due to his hitting behaviour, he was expelled from the school.

The client is showing less hitting behaviour since last one year. The client was not going to

school for 1 year.

Background Information:

Personal History:

Client’s mother reported that she had fever during pregnancy, but she did not take any

medicine for it. She gave formula milk to the client for 6 years. The client was born through

normal delivery. There were no complications at the time of birth. Three developmental

milestones of the client were delayed and other three were normal.

Table 3

Developmental Milestones of the Child as Reported by the Mother

Developmental Achieved Age Normal Age Status

Milestones of Milestones of Milestones

Neck Holding 3-4 months 1-4 months Delayed

Sitting Without 6 months 5-9 months Delayed

Help

Walking 1 ½ years 8-12 months Delayed

Bladder Control 4 years 2-4 years Normal

Taking Bath Without 6 years 5-9 years Normal

Help

Dressing Without Help 8 years 7-9 years Normal

Family History:

Client belonged to low socioeconomic status. The family environment was congenial.

The family of the client is understanding and loving. Client belonged to the low

socioeconomic class and was living in a nuclear family.

The client’s father was 38 years old. He was uneducated. He owned a shop. Mother of

the client reported that his father was loving, and kind and he was also concerned about the

client’s health. Client was attached to his father as reported by her mother. Father had

stomach problem.

The client’s mother was 35 years old. She was also uneducated. She was a housewife.

She was loving and caring towards the client. She was so concerned about the client. Client

was attached to his mother too. She reported appropriate marital relationship. Mother had B.P

and stomach issues. His mother was so worried about his problem and she was trying her best

to manage his behaviour.

The client had 6 siblings and the client was the 6th born. The client’s elder sister was

18 years old and she was also deaf. She was studying in 3rd class in special school. She had

congenial relationship with the client. Second sibling was 15 years old and she was studying

in 6th class. Third sister was 14 years old and she was studying in 4th class. Fourth brother was

13 years old and he was studying in 4th class. Fifth sister was 9 years old and she was

studying in 3rd class. Sixth child was the client himself. Younger brother was 3 years. Siblings
had a congenial relationship with the client while the client hits his siblings when they

irritated him.

Educational history:

He studied in mainstream school for last three years. He was expelled from the school

due to his aggressive behaviour. According to the client’s teacher, he was a below average

student. He had non-congenial relationship with students and teachers. He used to fight with

the class fellows. He used to hit the class fellows, torn and threw their possessions whenever

the class fellows tried to irritate him.

History of Psychiatric/ Medical illness:

His mother reported that the client’s mother’s brother was with same medical problem

i-e deafness. Client’s eldest sister is also a deaf.

Psychological Assessment:

Psychological assessment was carried out with formal and informal means. These

procedures are as follow

Informal assessment

 Clinical interviews

 Reinforcement identification

 Observation

 Baseline of hitting behaviour

 Subjective rating by the mother and teacher

Formal assessment

 House Tree Person Test (HTP)

 Clinical interview:

Clinical interview was conducted with the mother of the client. The interview

was performed to attain the detailed history of the client and the mother during or

after pregnancy. She reported developmental milestones, postnatal history, medical

history and educational history. She reported each problem the client was facing since

childhood.

Clinical interview was also conducted with the teacher of the client. She

reported the problems of the client regarding the classroom e.g. the classroom

participation, educational performance and hitting behaviour.

Reinforcement identification:

Reinforcers were identified with the help of the mother and the client was also

presented with a list of reinforcers. The reinforcers were noted down by noticing the

client’s response and interest level.

Category Reinforcers

Edible reinforcer paratha, yogurt, chicken, tea

Activity reinforcer playing with ball, drawing

Material reinforcers toys like pistols, cars, and mobile games

___

Observation:

The client was keenly observed during every single session. His behaviours and initial

observations were also noted. Trainee observed the reinforcers, interests, hygiene, obedience,
compliance and nonverbal skills. Mother client and client sibling relationship was also

noticed.

Table 4

Baseline of hitting behaviour:

Baseline of hitting behaviour is given below (see appendices)

Quantitative analysis of baseline:

Category amount

___

Average intensity 7

Average duration 4 min

Average frequency 2 times per week

__

Qualitative analysis of hitting behaviour

Baseline of the Client’s Hitting Behaviour

Antecedent Behaviour Consequence

When someone teases he hits them and threw calm down after few minutes

Him or irritates him their possessions and on his own or when he gets

Or someone takes his Torn them apart his thing back

possession

Subjective ratings:
 Subjective ratings were taken to grasp the intensity of the problematic behaviour.

Subjective ratings were acquired by the mother and the teacher on the scale of 1-10.

Table 5

Subjective Rating for Client’s Presenting Complaints

Complaints Ratings

Hitting behaviour 8

Throwing others’ possessions 8

House Tree Person Test: (HTP)

It is a projective technique. It is used with those who are educationally

deprived, non-verbal, cultural differences, communication problem. It was devised by buck.

HTP was conducted by in a quiet place. Client was given three papers and a pencil.

Client was asked to draw a house, tree and person. Client was showed the pictures of houses,

trees in the environment and pointing to the people in the surrounding. And then the client

was asked to draw these things. Client was reinforced upon the desirable behaviour. He was

given a reinforcer (toy-car) after the completion of the test.

Qualitative scoring:

The drawing of the house indicates that the client had lack of psychological warmth,

and defensiveness. The client is unimaginative or emotionally constricted. The behaviour of

the client is blunt and direct

The drawing of person depicts the following features. Robot figure shows

hiding face and person. More than three figures are drawn that shows anxiety. Client drew

number of different figures that shows depression. Unusual representation of ear shows some
level of psychopathology, physical handicap, inability to social criticism. Unusual

representation of legs shows feeling of insecurity, lack of self-confidence, and inadequacy.

Omission of feet shows lack of independence, helplessness, and possible psychosomatic

conditions. Single line mouth depicts tension, hypercritical or aggressive tendencies,

omission of neck represents immaturity and trouble handling impulse rationally. Open arms

means aggression. No eye pupil indicates communication difficulty.

The drawing of the tree interpreted as follows. Number of different figures shows

depression. No roots means instable personality and sense of insecurity. Leaves shows signs

of success of effort. Braches: constituting separate unit means drawing each and every branch

on every side shows segmentation and concrete thinking, preoccupation with symmetry

(obsessive compulsive personality). No base represents insecure feeling. Absence of colour

depicts low vitality, little zest for life, lack of emotional warmth.

Case conceptualization:

M.R was 8 years old deaf boy with presenting complaints of hitting class fellows and

throwing others, possessions, fits. His birth was normal. There were no natal and post-natal

history. His mother had fever during pregnancy. The child had high grade fever one month

after the birth. He was expelled from the school due to his hitting behaviour. Clinical

interview was conducted with the mother and teacher. Reinforcement identification was

carried out with the mother and the client and subjective ratings were also conducted with the

mother and teacher. HTP was administered to assess the client.

According to the mother, she had cousin marriage. So, there are numerous cases in

their family with same medical problem. His mother’s brother also had same illness. This was

the predisposing factor of this case as this disorder was due to genetic problem (heredity).

Various studies suggest that the cousin marriage can lead to the psychological disorders. A
research investigated that there are high chances of deafness in the children if there is a

history of deafness in their parents’ family. The risk is high if the parents are first cousin

(Wildervanck, 1957)

Environment is the precipitating factor which triggers the behaviour. Client was

studying in special school for 3 years but then he dropped out because of his hitting

behaviour. The environment of the school was not fully structured. Children tend to annoy

and irritate others. If the child will be annoyed, it would eventually result into anger outburst

such as hitting them and throwing the things. Children spend half of the day with their class

fellows. Children learn that they will be teased everywhere so they adopt an angry style in

every situation. The teasing of the class fellows was the precipitating factor. Client showed

hitting behaviour when the class fellows hit him. He used to respond in the same way but in

high intensity. A research indicated that the children show aggressive behaviour because of

being bullied (Roland & Idsoe, 2001)

Ignorance of the hitting behaviour was maintaining the hitting behaviour. The

understanding parents can be a protective factor. Parents were aware of the problem. Parents’

especially his mother tried her best to give him attention and care he needed. Mother is

cooperative and attended every session conducted by the trainee. She was concerned with her

child and was trying her best to decrease his hitting behaviour. Client’s mother was teaching

him what to do in a social situation. The mother was giving more attention to the client than

his siblings.

It is evident from the client’s history that predisposing factor is cousin marriage in this

case which genetically predisposes the client towards deafness and makes him vulnerable as

suggested by different researches. Precipitating factor in this case is the annoying

environment of the school. Ignorance of the hitting behaviour by the parents appeared to be
the maintaining factor. The protective factor in this case is the care and attention given by the

parents especially from the mother. This factor can aid in prognosis. The client’s, other has to

be psych educated on the problematic behaviour and the management strategies required to

deal with this problem. The use of behavioural modification techniques, teaching a way to

communicate anger through non-violating means will help to decrease problematic

behaviour.

Prognosis:

Favour Against

Attend a person hearing impairment

Communication difficulty

By keeping in mind the above factors, the prognosis is guarded.

 Case Conceptualization

Presenting Complaints
Hitting the class fellows and torn
their possessions

Predisposing Factors Maintaining Factors

Cousin marriage, high Ignorance of hitting
grade fever in infancy, behaviour
H/O fits Precipitating Factors
Environment of the school

Protecting factors:
Assessment Tools
Understanding and
Clinical Interview
supportive mother,
Observation
awareness of the problem
Reinforcement Identification
Subjective Rating Scale
baseline chart, House Tree Person
Test

Management Strategies
Rapport Building
Psycho-education
differential reinforcement by using
positive reinforcement
Short term goals:

Intervention Plan

Intervention plan for the child's behavioural and academic problems was based on:

 Short Term Goals.

 Long Term Goals.

Short Term Goals

 Rapport building: Rapport building will be done with the client to make him feel

comfortable.

 Psychoeducation: Psychoeducation of the teacher and mother will be done to

conduct activity to teach sign language

 Differential reinforcement: it will be used to increase desirable behaviour of using

signs and to decrease undesirable behaviour that is hitting behaviour.

Long term goals:

Teaching alphabets and other signs

Implementation of therapeutic intervention:

Rapport building:

Rapport building was established in two to three sessions. Client was made

comfortable and was also asked to do what he liked to do. The interaction was made possible

by allowing him to write, draw things. Because these were opening the channel between the

trainee and the client. Trainee was praising the client after making something or writing

something e.g his name (Leach, 2005)

Psychoeducation:
 Psychoeducation is the teaching and guidance of the people surrounding the client

especially the mother (primary caretaker) and the teacher. The purpose of the

psychoeducation is to guide people how to treat the client, how to deal with problematic

behaviour and how to reduce it. It also aims to tell them about the diagnosis, causes and

effects of the behaviour. It will help to decrease the causes to improve the behaviour or to

make behaviour adaptable. It also includes telling them how to cope with the environment

and teaching them problem solving skills. It also communicates how to maintain healthy

behaviour. (Donker, Griffiths, Cuijpers & Christensen, 2009)

Psychoeducation was done with the mother to reduce her tension and worry and to

make her realize that her child will improve. Hope was established, and few instructions were

given to improve the behaviour. She was also encouraged to learn signs so that she could

communicate properly with the client. Psychoeducation of the mother was also done. Because

the protecting factors were the care and attention given by the parents. Mother was educated

not to attend the problematic (hitting) behaviour gradually. She was also taught not to ignore

the hitting behaviour rather give her but to give him slight punishment e.g response cost. If he

shows hitting behaviour, take his pistol for 3 to 4 minutes and return it on the client’s non-

hitting behaviour. Mother was asked to control every reinforcer. Trainee was able to control

few reinforcers in the formal setting.

Positive reinforcement:

Reinforcement strengthen a behaviour. Reinforcement involves following the

occurrence of a behaviour with an immediate consequence. It strengthens a behaviour and the

behaviour is more likely to occur in the future. Reinforcers explored during the session were

used as positive reinforcement whenever client showed favourable behaviour (Miltenberger,

2008).
Differential reinforcement:

It is used to increase the desirable behaviour and to decrease the undesirable

behaviour (Petscher, Rey, & Bailey, 2009).Sign language was also taught. Mother was

encouraged to learn few signs too. During the session, 2 signs were taught to the mother and

the client. Client was taught not to hit the person when the person hit him but to use eyes to

communicate anger. It will communicate a sense that the person needs to stop himself. He

was reinforced for this eye behaviour.

Teach him to do Salam when someone comes to talk through the modelling prompts.

Trainee models the process with the client’s mother and other trainees. Then the client was

asked to copy it first with the trainee then with the mother and then with the 2 other people

approaching him. Imitation to teach how to learn from others. Imitation was applied so that

the child can learn from peoples’ actions.

Pre-management and Post-management Assessment:

Pre-management and post-management ratings are described below

Table 6

Pre-Management and Post-Management Ratings

Presenting complaint pre-management rating post-management rating

Hitting behaviour 8 7

Throwing other’s possessions 8 7

Graphical representation of pre-management and post-management ratings

 Chart Title
8.2

7.8

7.6

7.4

7.2

6.8

6.6

6.4
hitting behaviour throwing other's possessions

pre-management rating post management rating

Figure 1. Graphical representation of pre-management assessment and post-management

assessment.

Outcome:

11 number of sessions were conducted with the client. Client acquired the skills and

learnt the behaviour to some extent. 10% outcome is observed.

Limitations:

Client had hearing impairment so the communication was so difficult

The winter vacations created a gap

Client remained absent due to the cold weather

Client was not attending the school on regular basis

Recommendations:
 Client must taught the sign language properly because here is a huge communication

gap. He cannot communicate his feelings and needs that’s why the problem is increasing day

by day.

Limitations:

It was difficult to control every reinforcer

Sometimes the environment was unstructured for the session

The weather was so cold, so the client remained absent

Recommendations:

Every reinforcer needs to be controlled

Follow ups are necessary

 Session Report:

Session 1

Goal: goal of the session is

Introduction

Rapport building

Observation

Outcome: In this session, rapport building was done. The child was engaged in the session

from the beginning. Rapport building was done by engaging the child in writing alphabets

because the client liked to do that. Initial observation was done by keenly observing the

client’s behaviour during the whole session.

Session 2

Goal: The goal of the session is

Rapport building

Observation

Reinforcement identification

Outcome: Eye contact was observed keenly. Reinforcers were identified by showing

different stimuli for example list of toys, edibles, stickers. His excitement level for the

reinforcers was noticed. These reinforcers were used to increase desirable behaviour i-e

Salam and reducing undesirable behaviour i-e hitting behaviour. All the reinforcers were

noted.
Session 3:

Goal: The goal of the session is

Clinical interview by the mother

outcome: Half of the history was taken in this session through clinical interview. Questions

regarding the prenatal, natal, post-natal history were asked. Client’s complete history was

also taken which include birth history, infantile history, history of medical and psychiatric

illness, developmental milestones, education history, presenting complaints and the present

behaviour.

Session 4:

Goal: The goals of this session is

Clinical interview by the mother

Clinical interview by the teacher

Outcome: Remaining history was taken from the mother. Clinical interview was also

conducted with the teacher who reported that the client had shown excessive hitting

behaviour in the school. Information about the client, client’s family, and classroom

participation was gathered completely by covering all aspects.

Session 5:

Goal: The goals of this session is

Teach the child how to say Salam to a person other than family member

Teach imitation

Technique: Modelling prompt with the use of positive reinforcement

Outcome: Client was asked to perform Salam following the reinforcer. The client was

interested in writing during the session. So, the client could write after showing desirable

behaviour. Trainee showed how to do Salam and then asked the client to do so. Intermittent

reinforcement was used.

Session 6:

Goal: The goal of this session is

To check the previous learning (imitation and Salam)

Subjective ratings from the teacher

Administration of HTP

Outcome: Client was imitating early this time. The client learned the behaviour (imitation) to

some extent. And the client drew house. The house was interpreted later. Client was shown

different pictures of the house and then he was asked to draw house. Teacher was asked to

rate client’s hitting behaviour.

Session 7:

Goal: The goal of this session is

Complete administration of HTP

Technique: positive reinforcement, chaining

Outcome: The client drew pictures of tree and person by noticing the trees around and the

acknowledgement of the trainee. Client was shown trees in the surrounding and then he was

asked to draw tree. Trainee pointed to different people in the surrounding and asked the client

to draw that too. Client was reinforced (praise and playing with a ball) after drawing half tree

so that he would make the whole tree.

Session 8:

Goal: The goal of this session is

Baseline of hitting behaviour

Psychoeducation of the mother

Outcome: Baseline of the hitting was obtained by asking the mother about antecedent,

behaviour and consequences (ABC) of hitting behaviour. Mother reported that she pays

attention to the client when the child hits his siblings. Mother was educated not to attend the

behaviour (extinction). Mother also reported that the client gets irritated when she does not

get what he is trying to say. The mother was educated to learn signs so that she can

understand what the client is trying to say. Mother was also asked to control all the

reinforcers.

Session 9 to 11

Goal: the goal of this session is

To use differential reinforcement to communicate his anger non aggressively.

Outcome: the outcome of these sessions was achieved to some extent.

References:

Donker, T., Griffiths, K. M., Cuijpers, P., & Christensen, H. (2009). Psychoeducation for

depression,

anxiety and psychological distress: a meta-analysis. BMC medicine, 7(1), 79.

Wildervanck, L. S. (1957). Audiometric Examination of Parents of Children Deaf from Birth:

The Influence of Consanguineous Marriage. AMA archives of otolaryngology, 65(3),

280-295.

Roland, E., & Idsøe, T. (2001). Aggression and bullying. Aggressive Behavior: Official

Journal of the International Society for Research on Aggression, 27(6), 446-462.

Appendix