CASE REPORT I

Child Psych diagnostic Report

Identifying Information

Name M.N

Father’s Name N.A

Date of birth 19-3-2012

Age 11 years

Gender Female

No. of Siblings 5

Birth Order 2nd

Informant Mother
Referral Source

The child was referred to the trainee clinical psychologist for the purpose of psychological

assessment and management with the presenting complaints hyperactive, hitting other, speech

problem, aggressive behavior, throw things and giggling all the time.

Presenting Complaints

Following complaints are presented by the mother

‫دورانیہ‬ ‫علامات‬
‫تقریبا دو سال سے‬ ‫غصہ بہت کرتی ہے۔‬
‫تقریبا دو سال سے‬ ‫بولنے میں مشکل ہوتی ہے۔‬
‫تقریبا دو سال سے‬ ‫چیزیں پھینکتی ہے۔‬
‫تقریبا دو سال سے‬ ‫دوسروں کو مارتی ہے۔‬
‫تقریبا دو سال سے‬ ‫ہر وقت ہنستی رہتی ہے۔‬

Clinical Interview

The child was brought by her mother to the center of special need with the presenting

complaints of, hyperactivity, hitting others, throw things, aggressive behavior, giggling at the

time, and speech problem.

Clinical interview was conducted with child and with the family of the child. The

child was a 11 years old girl. According to her mother, birth was normal. At the age of 8

month she had fits on and she was with high fever, medication started and now she fits free.

It was also reported that all of her developmental milestones were delay as compared to other

children of her age as she started neck holding at the age of 8 months, sitting at the age of

10 month, crawling at the age of 4 year, walking at 5 year, speech single word at 5 year,
complete word not yet, dressing not yet, taking bath independently not yet, bladder and bowl
control not yet.

The child lives in a nuclear family system. Total number of family members were 5

including the child. She was 2nd born. The father of child is 34 years old and is alive. His
 education was LLB and he worked as a property dealer. He was a busy person but caring

towards child.

There was no physical or psychological issue reported with the child’s father. The mother of

the child was 33 years old. Her education was BA, she was a housewife. She was very

affectionate and humble lady by nature. She spent most of her time with the child and other

children and tried to fulfil their needs and assist them in daily living tasks and learning skills.

The relationship of child with the mother is the most satisfactory. There was no physical and

psychological issue reported with the mother.

Child’s aunt had some psychological issues. The child had satisfactory relationship

with siblings. Her elder brother had learning disability. They played together and also helped

each other in learning different daily tasks. Their relationship with child was good and loving.

General home environment of child’s family was comfortable and peaceful as reported by his

mother.

Test Administration

Following tests were used to evaluate the child psychologically, confirm the

diagnosis, to check the severity of symptoms and to prepare the treatment plan.

• Test of Non-Verbal Intelligence (TONI-4)

• The Childhood Autism Rating Scale (CARS)

• Assessment of Basic Language and Learning Skills (ABLLS)

Behavioral Observation

The child was sitting in classroom with appropriate manners and the child’s personal

hygiene was good. She was wearing neat and clean dress. She has poor eye contact. She has

one word speech. She was of appropriate body weight and height according to her age.

Attention span was 2-3 minutes. Her behavior during test was not satisfactory. It was very
 challenging to gain her attention. She showed less interest in toys and playing with other

children.

Psychological Evaluation

TONI

Child didn’t perform on TONI-4

Childhood Autism Rating Scale (CARS)

Childhood autism rating scale is used to assess the presence and severity of symptoms. it provides a
standardized method for various aspects of behavior associated with Autism.

The test has 15 categories relating to people, imitation, emotional response nonverbal communication
etc., each category has 4 points from mild to severe.

Table 1

Following table showing scores of Childhood Autism Rating Scale (CARS)

4 2 1.5 1.5 2 3 2 2 1 3 4 3 1 3 3 Total

score

I II III IV V VI VII VIII IX X XI XII XIII XIV X 36

V

Table 2

Following table show the severity of symptoms

Raw score Category

36 Moderately Autistic
Table 3

Mild Moderate Severe

II, IX, XII III, IV,VI,VII,X,XII I,XI

The results of the test indicates that the child had moderate autistic level

The child was assessed in all items, in which it was identified that child behavior wasn’t

appropriate to her age. And it was very difficult to get child’s attention and make persistent in doing

some activity. Therapist and trainee clinical psychologist used to give reminders in session and

classroom, but child didn’t use to take initiative. The child showed a number of symptoms or a

moderate degree of autism. In the category of relating to people the child score falls in the category of

severely abnormal relationship. In imitation the child score falls in the category of mildly abnormal

imitation. In the category of emotional response her scores falls in mildly abnormal emotional

response. Her score in the body use falls in the category of mildly abnormal use of body. She had

mildly inappropriate interest in or use of toys and other objects. She had moderately abnormal

adaptation to change. She had mildly abnormal visual response. She also had mildly abnormal

listening response. She had normal use of, and response to taste, smell and touch. She had moderately

abnormal fear or nervousness she showed either quite a bit more or quite a bit less fear then a typical

ever for a younger child in a similar situation. She had severely abnormal verbal communication,

meaningful speech is not used and moderately abnormal use of nonverbal communication. She could

not express needs or desires nonverbally. She had normal activity level .she had moderately abnormal

intellectual functioning.

Assessment of Basic Language and Learning Skill

The assessment of basic language and learning skill was an educational tool used frequently to
measure basic linguistic and functional skills of an individual with developmental delays or
disabilities. It addresses academic, self-help, gross and fine motor skills. It addresses strengths and
weaknesses of an individual in each of the 25 skills set. Each skill set is broken down into multiple
skills, order by typical development or complexity. Individualized education plan was made from
ABLLS.

Tentative Diagnosis

(F84.0) Autism Spectrum Disorder, Moderate

Prognosis

Prognosis of child was poor, although she had good support of family. Her parents

had insight about his problem and they were very much concerned about the treatment.

Conclusion

A.S was an 11 years old girl referred to the trainee clinical psychologist for the

purpose of psychological assessment and management. Child was brought by her mother with

the complaints of hyperactivity, speech problems, hitting others. Throw things aggressive

behavior. Giggling at the time. She was diagnosed with Moderate Autism Spectrum Disorder.

Recommendations

For parents:

1. Parental Psycho Education

2. Increase the participation in family gathering which helps the child in enhance the social
interaction.
3. It is recommended to use clear and concise language to improve his communication.
4. It is recommended to give him reinforcement when he completed his tasks.
5. It is recommended to parents to go for speech therapy to improve his communication.

For Teachers:

1. Teacher must develop individualized education plan according to the child development.
2. Teach the child about daily living skills to become independent in his life.
3. Teach him with the association of two things for his better understanding and recalling.
4. Engage him in social interactions with others in the school and give him social appraisal.
5. Teach him about new things by engaging in playing activities
6. Engage him in playing activities for development of motor skills.
 Case Management Plan

Child’s Name & M.N was a 11 years old girl

Age
Presenting Hyperactive, throw things, aggressive behavior, hitting other, speech problems
Complaints and giggling all time.
 Test Administration Test of Non-Verbal Intelligence (TONI-4)
The Childhood Autism Rating Scale (CARS)
Assessment of Basic Language and Learning Skills (ABLLS)

Tentative Diagnosis 0(F84.0) Autism Spectrum Disorder, Moderate

Goals of Therapy Short Term Goals

Rapport Building
Psycho education of family and teacher.
To maintain eye contact
Engage in group activities
To give him occupational therapy for the betterment of sensory and physical
issues.
Long Term Goals
Continuation of short-term goals.
Continuation of IEPs formation and revision of plan according to individualized
needs of the child.
Speech therapy will be given
Follow up sessions
Main Therapies Behavioral Therapy

No. of Sessions 10 sessions in total and each session 40-45 minutes

Planned

Individualized Education Plan

Name M.N

Age 11years

Gender Female
School CFSN

Birth order 2nd

Strengths

• Carries out simple tasks with prompts

• Greets familiar adults

Weaknesses

• poor eye contact

• Concentration and focus problem

• Poor communication

Task Material Goal Technique

Scale with To improve Physical and
pictures of fruits cognition and verbal prompts
Match identical eye contact
pictures to sample

Alphabets To improve Verbal prompt

Imitate sound on speech
request

Maintain eye Look at me To enhance focus Physical, verbal

contact instructions and gestural
prompt
Follow instruction To improve Physical verbal
to do a simple receptive and gestural
motor action language prompt

Jumping To improve Physical verbal

motor imitation and gestural
prompt
Play with other Toys To improve Physical verbal
children social interaction and gestural
prompt
Touch own body Identification of Molding ,
parts body parts physical and
verbal prompt
Imitation of arm Improvement of Modeling ,verbal
 and leg movement gross motor prompt
functioning
Identification of Emoji’s
emotions (C13)

Label common Picture Improvement of Physical , verbal

objects cognition and gestural
prompt
Use of sentence Voice Improvement of Verbal prompt
communication

Fasten buttons Shirt Improvement of Molding ,

fine motor skills physical and
verbal prompt
Colure
identification

Copy numbers Worksheets Visual and

physical prompt

Taking reinforcer Balloons Verbal , gestural

prompt

Task Analysis

Task 1

Taking the reinforcer

Steps

 Arrange the seating in a way that the child is sitting in front of you
 Identify the reinforce i.e. eatables
 Use a reinforcer and place it in front of your face at the eye level
 When the reinforce is placed at the eye level, call upon the child’s name
 Ask the child to point towards the reinforce
 When the child points at the reinforcing item, hand it over to her
Serial No. Task Day Techniques Error/trials Mastery

1. Seat the child 1 Verbal 0/8 100 %

in front of prompt
yourself

2. Place the 2 Verbal 6/8 25 %

reinforce in prompt
front of your
face and
make her
look at you
by calling the
child’s name

3 Verbal 5/8 37.5 %

prompt

4 Verbal 4/8 50 %
prompt and
gestural
prompt

3. Ask the child 5 Verbal an 3/8 62.5 %

to point gestural
towards the prompt
reinforce

4. When the Verbal 0/8 100 %

child points at prompt
the reinforcer,
hand over the
reinforcer to
the child
immediately
Case Formulation Presenting complaints:
Predisposing factors:
Child  Speech problems

M.N  Aggressive
Diagnosis:
ASSESMENTS behavior
Precipitating Factors:
11 years  (F84.0)
Hitting Autism
others
 Clinical interview with Spectrum
Female
mother 
 Behavior observation  Throw Disorder,
things
 Moderate
giggling
 Childhood Autism rating Perpetuating Factor:
scale (CARS)
 Bender Gestalt test 
(KOPPITZ-2)
 Assessment of Basic Protective Factors:
Language and Learning
Skills (ABLLS)
 Supportive parents
 Continuous treatment
 Follow-up sessions
 Management Plan

 Rapport Building
 Psycho-education
 Behavior Modification
 Individualized Education
Plan (IEP)
 Continuation of short-term
goals.
 CASE REPORT II

Identifying Information

Name I.M

Age 17years

Gender Male

No. of Siblings 3

Birth Order 1st

Informant Mother

Referral Source

The child was referred to the trainee clinical psychologist for the purpose of psychological

assessment and management with the presenting complaints of behavioral issues and poor

academic performance.
Presenting Complaints
Duration Complaints

‫تقریباپانچ سال سے‬ ‫ضد بہت کرتا ہے۔‬

‫تقریبا پانچ سال سے‬ ‫غصہ بہت کرتا ہے۔‬

‫تقریبا پانچ سال سے‬ ‫بولنےکا مسلۂ ہے۔‬

‫تقریبا پانچ سال سے‬ ‫متوازن چال نہیں ہے۔‬

‫تقریب ًا پانچ سال سے‬ - ‫پڑھائ ميں اپنی عمر کے بچوں سے پيچھے ہے‬

Clinical Interview

The child was brought by his mother to Center for Special Need (CFSN) with the

presenting complaints of Aggressive behavior, poor academic performance, stubborn

behavior, and un-balance gait and speech problems.

Clinical interview was conducted with child and with the family of the child. The

child was a 17 years old boy. According to his mother, the child’s birth was normal. He

attained all developmental milestones at delay. At the age of 4 year, he was diagnosed with

global developmental delay.

The child was eldest child in his family. The child lived in a nuclear family system

the total number of family members were five excluding the child. His father was 50 years

old man. His education was matric. He was a heart patient. He was canteen contractor. . He

was very friendly with the child. His father was friendly with everybody. He was very

supportive towards the child. The child was more attached to his mother than to his father.

His mother was a housewife. She was uneducated. She was supportive towards the child.

He had satisfactory relationship with his mother. His mother had no psychological illness.
 Child’s parents had satisfactory relationship with each other. Both parents were very

concerned about their child’s problem and protective towards his needs. Child had two

brothers. They were younger to him the child had satisfactory relationship with his siblings.

The child was studying in grade 3rd in special education school. According to his

class teacher, child did not do well in school. His performance was not satisfactory because

he was a slow learner. His relationship with the teacher as well as with his class fellows were

good.

As reported by the child’s mother, they lived in a pleasant home environment. They

lived in a nuclear family system. Overall environment of home is satisfactory.

Test administration

Following tests were used to evaluate the child psychologically, confirm the

diagnosis, to check the severity of symptoms and to prepare the treatment plan.

• Test of Non-Verbal Intelligence (TONI-4)

• Vineland Adaptive Behavior Scale (VABS)

• Bender Gestalt Test(BGT/ KOPPITZ- 2)

Behavioral Observation

Child was 17 years old boy with neat and clean uniform and hygiene was also

appropriate. He was observed having appropriate built and height. He maintained eye contact

during session. He was an active child but showed mood swings and became aggressive

easily. His dressing was according to weather. Child had improper gait. Child’s facial

expressions were calm and relaxed. He was very cooperative, rapport building with him was

not challenging. He could follow 1 to 2 commands at a time.

 It was observed that child had some issues in learning. Child short compliance in all

sessions and her attitude towards testing and assessment, activities was also very cooperative.

. He followed commands very well. His sleep and appetite were adequate. The child motor

skills were not good. He had delayed developmental milestones. He had a lot of interest in

extracurricular activities like watching cartoon, movies and plying. He was food lover.

Psychological Evaluation

Test of none verbal intelligence (TONI)

Test of Non-verbal intelligence offers an assessment of abstract reasoning, aptitude and problem
solving.
Table 1

Child’s result on Test of Non-Verbal Intelligence (TONI-4)

Raw Score Index Score SEM %ile Rank Descriptive Term Age Equivalent
14 71 3 3 Poor 6-0

The child scores fall in the 3rd percentile in the category of poor which indicates the child’s

non-verbal intelligence is poor. Child’s performance was less than people of her age. Non-

verbal intelligence includes abstract reasoning, problem solving and classifying objects based

on common features and how the childs form link between these objects based on abstract

reasoning. The environmental conditions under which the child was normal and didn’t

interfere the performance

Bender Gestalt Test (KOPPITZ-2)

Bender gestalt test is used to assess the visual motor functioning and provide a more comprehensive

assessment. It helps to identify specific visual motor deficits.

Table 2

Following table shows child level of visual-motor coordination

Raw score Visual motor Percentile Rank Descriptive Age equivalent

index rating

6 44 <1 Significantly

impaired

The results of the test show that the subject had raw score of 6 with 44 visual motor index

and <1 percentile rank so she falls in significantly impaired category. The child shows poor planning

and inability to organize the material. He may reflect emotional instability, poor motor control, lack

of interest and attention.

Qualitative Interpretation of Drew A Person Test (DAP)

Figure of a person has a large head which shows inflated ego.

Vineland Adaptive Behavior Scale (VABS)

Vineland Adaptive Behavior Scale (VABS) is a tool used to assess an individual’s

adaptive functioning. It measures their skills in various domains such as communication,

daily living, socialization and motor skills. It’s commonly used in clinical and educational

settings to understand an individual’s strengths and areas for support. It’s a valuable tool for

understanding and supporting individuals with developmental disabilities.

Table 1

Sub domain Age Standard V. Scale Functioning Strength/

 Equivalent Score Score Level Weakness
(AE)

Communication 50 20

Receptive 4:8 10 Moderately Strength

low

Expressive 5:10 9 Low Strength

Written 5:10 1 Low Strength

Daily living 48 19
skills

Personal 5:3 6 Low Weakness

Domestic 12:0 12 Moderately Strength

Low

Community 4:7 1 Low Weakness

Socialization 71 31

Interpersonal 7:4 12 Low Weakness

relationship

Play and Leisure 7:7 9 Low Weakness

Coping Skills 7:7 10 Moderately Weakness

Low

Motor skills 18

Gross Motor

Fine motor

ABC 58

Qualitative analysis
 Adaptive behavior composite ABC score is 58 which also lie at low functioning level.
According to the child score on Vineland adaptive behavior scale he is significantly behind his
expected age group in all domains. All domains fall in the low category. According to the finding of
the assessment, the adaptive level of the child is generally low. The child’s adaptive functioning fall
in the low category in communication, daily living skills, socialization skills and motor skills that
was also observable during the session and in his behavioral observation. The child requires a long-
term treatment plan and assistance in almost all the domains of his adaptive functioning.

Tentative Diagnosis

(F71) Intellectual disability. Moderate (Down syndrome)

Prognosis

Prognosis of the child is fair as the family and home environment was very supportive.

Parents have insight about the child’s problem and they were very much concerned for the

treatment.

Conclusion

I.M was a 17 years old boy referred to the trainee clinical psychologist for the purpose of

psychological assessment and management. Child was brought by his mother with the complaints of

speech problems, stubborn behavior, aggressive behavior, improper gait, poor academic

performance. Psychological assessment of child indicated the tendency of neurodevelopmental

disorders. He was diagnosed with intellectual disability.

Recommendations for Parents:

 • Parental psychoeducation

• Gain knowledge about disorder to better support your child.

• Partnership with your child’s school to develop and implement an effective educational plan.

• Seek specialized therapies that address your child's specific learning challenges.

• Create a positive and structured space for learning and homework at home.

• Teach your child to understand and articulate their needs.

For Teachers:

• Teacher must develop individualized education plan according to the child development.

• Give small academic tasks.

Case Treatment Plan

Child’s Name I.M was a 17 years old boy.
& Age
Presenting Speech problems, stubborn behavior, aggressive behavior, improper gait and
Complaints learning deficiencies.
Test Administration Test of Non-Verbal Intelligence (TONI-4)
Vineland Adaptive Behavior Scale (VABS)
Bender Gestalt Test (BGT)

Tentative Diagnosis 0 (F71) Intellectual disability moderate (down syndrome)

Goals of Therapy Short Term Goals

Rapport Building
Psycho education of family and teacher.
To maintain eye contact through look at me instructions.
Improve academic skills
Long Term Goals
Continuation of short-term goals.
Continuation of IEPs formation and revision of plan according to individualized
needs of the child.
Follow up sessions
Main Therapies Behavioral Therapy
 No. of Sessions 10 sessions in total and each session 40-45 minutes
Planned

Individualized Education Plan

Name I.M

Age 17 years

Gender Male

School CFSN

Birth order 1st

Strengths

• Good communication

• Fair eye contact

Weaknesses

• Concentration and focus problem

• Difficulty in understanding new concepts

Task Material Goal Technique

Watch To improve Modeling and
Tell time using academic skills prompting
clock or watch
 stories To improve Physical and
Summaries at academic skills verbal prompts,
least 3 sentences modelling
long
Use of Thermometer To improve Physical verbal
thermometer academic skills and gestural
prompt
Tell time using Watch To improve Physical verbal
clock or watch academic skills and gestural
prompt
Use of knife to cut Knife. Apple Improvement of Modeling and
fruits motor skills verbal prompt

Talk with other Improve behavior Verbal prompt

without being
rude

Task Analysis

Task 1

Cut fruit with knife

Steps

 Introduced the child with all the material required to cut the fruits

 Firstly use the plastic props that imitate the cutting of fruits

 After the child becomes familiar with the artificial props, introduce the real fruit and cutlery

 Start with simpler fruit such as apple and guide the child to peel the apple

 Place the apple on the plate and guide through physical and verbal prompts to slice the apple

 Reinforce every step the child takes in the direction of learning how to cut the apple
Serial no. Task Day Technique Error/ Trial Mastery

1. Look at the 1 Visual 0/8 100 %

fruit props Prompt

and identify

them

2. Take the fruit 2 Visual and 5/8 37.5 %

and use the verbal

prop knife to prompts

split the fruit

into half

3 Verbal and 4/8 50 %

physical

prompt

4 Verbal 2/8 75 %

prompts

3. Introduce the 5 Verbal and 3/8 42.5 %

real fruit i.e. visual prompt

apple and

knife and

guide the
 child to peel

the apple

6 Verbal 1/8 87.5 %

prompt

4. Place the 7 Modeling and 8/8 100 %

apple on plate visual prompt

and slice it,

and instruct

the child what

you are doing

5. Now guide 8 Verbal and 6/8 25 %

the child to physical

cut the apple prompt

using the

knife

9 Visual and 6/8 25 %

physical

prompts

10 Verbal and 5/8 37.5 %

physical
 prompts

11 Visual 3/8 62.5 %

prompts and

physical

prompts

Case Formulation Presenting complaints:

Predisposing factors:
Child  Stubborn
behavior
I.M
 Diagnosis:
Aggressive
ASSESMENTS
behavior Precipitating Factors:
17 years
(F71) Intellectual
 Clinical
Maleinterview with  Speechdisability
problem
mother 
Moderate
 Behavior observation  Un-balance gait Perpetuating Factor:
 TONI  Poor acadamics
 Bender Gestalt test
(KOPPITZ-2) 
 Assessment of Basic
Protective Factors:
Language and Learning
Skills (ABLLS)
 Supportive parents
 Continuous treatment
 Follow-up sessions
 Management Plan

 Rapport Building
 Psycho-education
 Behavior Modification
 Individualized Education
Plan (IEP)
 Continuation of short-term
goals.