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CASE REPORT

Submitted By

Vaniya Junaid Khan

SAP ID.: 40617

B.S Psychology

Sem VII-B

Submitted to

Ms. Urooj Taara

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Table of content

Case No Content Page no

1 Case1: Autism Spectrum Disorder

About the Disorder 3

Reason and source of referral 6

Presenting complaints 6

Assessment 9

Mental State Examination 9

Formal Assessment 11

Tentative diagnosis 13

Prognosis 14

Case Conceptualization 14

Theoretical Orientation 15

Progression of Session 18

Termination 20

References 22
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CASE REPORT

About the Disorder:

Autism Spectrum Disorder (ASD) is a neurodevelopmental condition characterized by

persistent deficits in social communication and interaction, along with restricted, repetitive

patterns of behavior, interests, or activities. Symptoms typically appear in early childhood

and can vary widely in severity.

DSM 5-TR Criteria:

A. Persistent deficits in social communication and social interaction across multiple

contexts, as manifested by all of the following, currently or by history (examples

are illustrative, not exhaustive; see text):

1. Deficits in social-emotional reciprocity, ranging, for example, from abnormal

social approach and failure of normal back-and-forth conversation; to reduced

sharing of interests, emotions, or affect; to failure to initiate or respond to

social interactions.

2. Deficits in nonverbal communicative behaviors used for social interaction,

ranging, for example, from poorly integrated verbal and nonverbal

communication; to abnormalities in eye contact and body language or deficits

in understanding and use of gestures; to a total lack of facial expressions and

nonverbal communication.

3. Deficits in developing, maintaining, and understanding relationships, ranging,

for example, from difficulties adjusting behavior to suit various social contexts;

to difficulties in sharing imaginative play or in making friends; to absence of

interest in peers.
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B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested

by at least two of the following, currently or by history (examples are illustrative,

not exhaustive; see text):

1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g.,

simple motor stereotypies, lining up toys or flipping objects, echolalia,

idiosyncratic phrases).

2. Insistence on sameness, inflexible adherence to routines, or ritualized

patterns of verbal or nonverbal behavior (e.g., extreme distress at small

changes, difficulties with transitions, rigid thinking patterns, greeting rituals,

need to take same route or eat same food every day).

3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g.,

strong attachment to or preoccupation with unusual objects, excessively

circumscribed or perseverative interests).

4. Hyper- or hypo-reactivity to sensory input or unusual interest in sensory

aspects of the environment (e.g., apparent indifference to pain/temperature,

adverse response to specific sounds or textures, excessive smelling or

touching of objects, visual fascination with lights or movement).

C. Symptoms must be present in the early developmental period (but may not

become fully manifest until social demands exceed limited capacities, or may be

masked by learned strategies in later life).

D. Symptoms cause clinically significant impairment in social, occupational, or other

important areas of current functioning.

E. These disturbances are not better explained by intellectual developmental

disorder (intellectual disability) or global developmental delay. Intellectual

developmental disorder and autism spectrum disorder frequently co-occur; to

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make comorbid diagnoses of autism spectrum disorder and intellectual

developmental disorder, social communication should be below that expected for

general developmental level.

Demographics:

Name Abdullah

Gender Male

Age 13

Education Grade 1

Parents’ status Both alive and married.

Birth order 2nd

No. of siblings 2

Occupation None/Student

Marital status Single

Residence Rawalpindi

Accompanied by Pick and Drop driver

Total Number of Sessions: 8

Agency: Oases Child Rehabilitation Centre

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Source of Referral:

The child was brought in for evaluation at the initiative of his mother, who

independently sought professional help after becoming increasingly concerned about his

persistent mimicking behavior and overall developmental differences. Her observations and

growing apprehension regarding his atypical behavior patterns prompted her to pursue

psychological assessment and support.

Presenting Complaints:

Mother’s Verbatim:

‫میرا بچہ عمر کے لهاذ سے چھوٹے بچوں والی حرکتیں کرتا ہے۔ اسکو رشتے سمجھنے میں مسلہ ہوتا ہے۔ اسکو‬

‫باتیں سمجھنے میں وقت لگتا ہے۔ وہ باقی بچوں کی طرح بات نہیں کر سکتا۔ اور بار بار ایک ہی چیز بار بار دہراتا‬

‫ہے ۔ اور اسے لکھنے میں مسلہ ہوتا ہے۔‬

Target Symptoms:

The client appears to be developmentally behind his peers in both social and cognitive

domains. He demonstrates a limited understanding of social norms and interpersonal

relationships, which is evident in his inability to appropriately interpret or respond to social

cues. His communication is marked by frequent echolalia and inappropriate mimicry, often

repeating words or actions without grasping their contextual meaning. Additionally, he

exhibits significant difficulty in learning new tasks or following multi-step instructions,

indicating challenges in processing and comprehension. Overall, he lacks age-appropriate

levels of independence and functional communication skills, further highlighting

developmental delays that impact his daily functioning.

History of Present Illness:

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The parents first began to observe developmental delays in their child—specifically in

areas such as speech and motor milestones like walking—around the age of 4. Despite these

concerns, they did not pursue a professional evaluation or intervention at that time. Instead,

their approach centered on enrolling the child in mainstream educational settings, with an

emphasis on academic learning, rather than addressing the underlying developmental

challenges.

It wasn’t until the child reached 12 years of age that the parents sought professional

help for the first time. At that point, they approached this organization/child rehabilitation

center for support. Since then, the child has been receiving structured therapeutic intervention

and treatment as part of a multidisciplinary rehabilitation program.

Past Psychiatric and Medical History:

The child has no documented history of prior psychiatric or medical interventions.

According to the parents, they have not pursued any form of psychological or

pharmacological treatment in the past. Additionally, there is no history of alternative or

spiritual healing practices being sought for the child's condition.

Family History:

The child resides within a joint family system characterized by a warm, nurturing,

and relaxed home environment. Family interactions are generally positive, with healthy

relationships observed among household members. While the child demonstrates overall

positive connections with both parents and siblings, there is a noticeably stronger emotional
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attachment to the mother compared to the father. Additionally, the child tends to form closer

bonds with female family members, which may reflect a preference for or comfort in female

companionship. Furthermore, there is no known family history of Autism Spectrum Disorder

(ASD) or related neurodevelopmental conditions among immediate or extended relatives.

Past Personal History:

The child's prenatal and perinatal history is largely unremarkable in terms of

complications. The pregnancy was full-term and progressed without any reported medical

issues. The child was delivered via cesarean section. Both the mother and the infant remained

physically healthy during and following the pregnancy, with no notable illnesses or medical

concerns in the immediate postnatal period.

However, significant developmental delays were observed early on. The child failed

to achieve age-appropriate developmental milestones within expected timeframes. For

instance, crawling did not begin until approximately 2 years of age — a marked delay.

Similarly, other major milestones such as independent walking, expressive speech, and toilet

training were all significantly postponed. These developmental lags were among the first

indicators prompting concern.

It is also worth noting that the mother was over 45 years old at the time of conception,

which may be considered a potential contributing factor to the developmental challenges, as

advanced maternal age is sometimes associated with increased risk for neurodevelopmental

disorders.
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Psychological Assessment:

Informal assessment:

Communication: The client exhibits significant challenges in the area of

communication. His verbal output is notably limited, and when speech is produced, it often

lacks meaningful content or functional use. Although spontaneous initiation of interaction

does occur on occasion, it remains infrequent. The client generally responds appropriately to

verbal prompts, though there are instances where repetition and simplification of language

are required to ensure comprehension and compliance. His receptive language abilities appear

to be moderately intact, but expressive language remains a primary area of concern.

Speech. The client demonstrates a clear absence of conversational reciprocity, with

limited ability to engage in back-and-forth verbal exchanges. His understanding of spoken

language appears inconsistent; while he is generally able to comprehend and follow basic

instructions, he often struggles with more complex or multi-step directives, requiring

additional time or simplified language to process them effectively. In unstructured or idle

moments, the client is observed to engage in self-stimulatory vocalizations, such as abnormal

humming, repetition of nonsensical syllables, and episodes of inappropriate or contextually

unrelated laughter. These behaviors may serve as self-soothing mechanisms or indicate

sensory-seeking tendencies commonly associated with Autism Spectrum Disorder.

Physical Activity. The client exhibits repetitive behaviors, including frequent

fidgeting and lining up toys in a rigid manner. He typically prefers solitary play but is

occasionally able to participate in group play when appropriately motivated. Some of his
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physical movements appear purposeless and are likely influenced by internal stimuli rather

than external goals.

Mood. The client's emotional responses are moderately inconsistent and dysregulated.

Sudden shifts in affect—such as abrupt transitions from laughter to distress—are frequently

observed, particularly during periods of inactivity, but not as often when occupied. He may

display mild irritability or disinterest when familiar routines are disrupted; however, with

sufficient motivation or redirection, he is generally able to adapt over time.

Sensory Observations. The client displays mild sensory sensitivities. While not

overly reactive, he occasionally appears disturbed by specific auditory stimuli and certain

tactile experiences, such as rough surfaces. His response to auditory cues, such as his name

being called, is generally appropriate. However, during tasks that demand sustained attention

or when his interest begins to wane, repeated prompts may be necessary to regain his focus

and redirect his attention effectively.

Psychomotor Behavior. Abdullah exhibits motor instability, characterized by

moderately uncoordinated walking and difficulty maintaining balance. He also shows mild

challenges with fine motor skills, such as holding and manipulating basic tools (e.g., crayons,

pencils), which may impact his ability to engage in tasks requiring precise hand-eye

coordination.

Posture and Motor Activity. The client demonstrates a reasonably good attention

span during sessions. When engaged in activities, he exhibits relatively low levels of

restlessness, and his ability to remain seated for extended periods is generally adequate.
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Appearance. The client consistently presents to sessions well-groomed and

appropriately dressed, indicating adequate attention to personal hygiene and caregiving. His

overall appearance reflects a supportive and attentive home environment.

Eye Contact. The client maintains a moderate level of eye contact during

interactions, typically holding it for about 5-7 seconds when conversing..

Object Manipulation. The client frequently engages in repetitive behaviors, such as

sequencing and aligning objects (e.g., toys) in a specific and rigid manner, without clear

functional purpose or flexibility. He shows significant resistance to changes in his patterns or

arrangements and becomes visibly distressed if these behaviors are interrupted or altered.

Formal Assessment:

Symptom Specific Assessment. The Child Autism Rating Scale, Second Edition –

Standardized Tool (CARS2-ST) was utilized for symptom-specific assessment. The

evaluation took place in a clinical setting and lasted approximately 15-20 minutes, conducted

in the presence of the clinician. The client achieved a raw score of 29.15, which corresponds

to a T-score of 42 and places him in the 21st percentile. According to the CARS2 manual, this

score falls within the Level 2 category, indicating mild-to-moderate symptoms of Autism

Spectrum Disorder (ASD).

Cognitive Assessment. The Colored Progressive Matrices (CPM) – Standardized

Tool was administered in a clinical setting, with the assessment lasting approximately 10–15

minutes. The client obtained a total score of 33, placing him in the 90th percentile for his age

group. As per the CPM manual, this score falls within Grade II, indicating a cognitive level

that is definitely above average in intellectual capacity.

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Personality Assessment. The House-Tree-Person (HTP) projective technique was

employed to gain insight into the client's emotional and psychological functioning. The

drawings suggest several indicators consistent with underlying emotional tension, social

withdrawal, and cognitive rigidity often observed in individuals with Autism Spectrum

Disorder.

House. In the House drawing, the higher placement of the image on the page suggests

underlying frustration or a sense of disconnection from the environment. The large size of the

house may reflect internal tension or a desire for control. Minimal detailing and the absence

of pathways indicate maladaptive social functioning and limited desire for interpersonal

engagement. The red coloring reflects a certain degree of vitality, yet the lack of detail in the

roof suggests avoidance of authority or overwhelming external control. A horizontal

emphasis in the structure may reflect social ambivalence or hesitation in forming

interpersonal bonds.

Tree. The Tree drawing was notably small and fantasy-like, suggesting limited

developmental skill and possible distortion in perception or unrealistic thinking patterns. The

absence of branches points toward self-withdrawal, while the small trunk and lack of roots

reflect limited ego strength and an unstable or insecure sense of self. The flatness of the

drawing may indicate pressure from the external environment. Central placement on the page

suggests rigidity in thought and behavior. Color choices such as green and brown may reflect

a calm temperament with signs of timidity and fixation.

Person. In the Person drawing, the figure appears younger than the client’s actual age,

indicating possible emotional fixation or developmental delay. The depiction of a same-sex

figure may hint at hysteric traits or identification with the self. Extended arms reflect

outwardly directed aggression, whereas their weak form and the omission of fingers suggest a
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dependent and helpless stance. The omission of certain body parts (e.g., abdomen) points to

conflict or discomfort related to those areas. The firm lines and centered placement, along

with straight and rigid strokes, may denote underlying aggression, strong internal drives, and

inflexible patterns of behavior.

Overall Interpretation. The HTP drawings portray a personality marked by emotional

distress, low frustration tolerance, dependency, and social withdrawal, with indications of

internal conflict and externalized aggression — all of which align with the broader

presentation of mild-to-moderate ASD.

Tentative Diagnosis:

Based on clinical observations, behavioral symptoms, and informal assessment, the

client appears to meet the criteria for:

Autism Spectrum Disorder (ASD) – Level 2 (requiring substantial support)​

The client displays significant deficits in social-emotional reciprocity, limited verbal

communication, minimal eye contact, and repetitive behaviors (e.g., lining up toys, flapping

hands, resistance to change in routine). Sensory sensitivities (e.g., discomfort to textures and

sounds) and delayed speech are also evident, supporting a diagnosis within the autism

spectrum.

Possible Comorbidities:

Language Disorder (Expressive and Receptive Impairments). The client exhibits

difficulty in both the acquisition and use of language, including limited vocabulary, reduced
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sentence formation, and impaired comprehension, which interferes with social and functional

communication.

Prognosis:

The prognosis is fair. With early intervention, structured support, and consistency in

therapeutic input (speech therapy, occupational therapy, behavior therapy), improvement in

communication, self-regulation, and adaptive functioning is possible. However, due to the

current severity of symptoms and sensory sensitivities, progress may be gradual and require

long-term support. The presence of strong parental involvement and therapeutic consistency

will be key prognostic factors.

Case Conceptualization:

Abdullah is a 13-year-old boy diagnosed with Autism Spectrum Disorder (ASD),

Level 2, characterized by mild-to-moderate symptoms that require substantial support,

particularly in the areas of social communication and adaptive behavior. Developmental

concerns were observed as early as age 4, including delays in speech and motor milestones;

however, formal intervention was not sought until age 12, resulting in a significant gap in

early support.

Currently, Abdullah displays prominent deficits in social communication, including

limited expressive language, echolalia, and context-inappropriate mimicking, all of which

indicate impairments in pragmatic language use. He struggles with reciprocal interaction,

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often failing to initiate or respond appropriately in social situations. His nonverbal

communication, such as eye contact and gestures, is also limited.

Cognitively, Abdullah shows above-average non-verbal reasoning (90th percentile on

Raven’s CPM), suggesting strengths in pattern recognition and visual-spatial processing.

However, these abilities are offset by significant challenges in language and social cognition.

His presentation is consistent with ASD Level 2, necessitating a structured support plan

focused on communication, social skills, and behavioral strategies, along with ongoing

parental guidance.

Theoretical Orientation:

Theory of Mind Deficit (Baron-Cohen):

‎It refers to a cognitive and developmental theory that highlights the difficulty some

individuals experience in understanding that other people have separate and distinct thoughts,

beliefs, intentions, desires, and emotions. This ability—commonly developed during early

childhood—is crucial for engaging in meaningful and reciprocal social interactions, empathy,

perspective-taking, and understanding implicit social cues. A deficit in Theory of Mind is

most commonly associated with Autism Spectrum Disorder (ASD), and is believed to

contribute significantly to the social and communicative difficulties seen in such individuals.

Those with ToM deficits often struggle to infer or predict the thoughts and feelings of others,

leading to inappropriate or awkward social behavior, misunderstandings, and limited capacity

for imaginative or symbolic play.

In Abdullah’s case, several behavioral patterns point toward a marked Theory of Mind

deficit. He demonstrates a limited understanding of interpersonal relationships and social

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roles, which is evident in his difficulties maintaining reciprocal conversation. Instead of

engaging meaningfully with others, Abdullah often resorts to echolalia (repeating others'

words) and mimicking behavior, typically without grasping the underlying social or

emotional context of the interaction. Furthermore, his challenges in initiating or responding

appropriately to social cues, combined with a noticeable absence of imaginative play, suggest

an impaired capacity to attribute mental states—such as intentions or feelings—to others.

These behaviors collectively reflect the core features of a ToM impairment, aligning with the

theory’s assertion that such individuals have difficulty comprehending that others may think

or feel differently from themselves.‎

‎Weak Central Coherence (Frith & Happé)

Weak Central Coherence (WCC) is a cognitive theory often used to explain certain

patterns of information processing observed in individuals with Autism Spectrum Disorder

(ASD). The theory suggests that such individuals tend to focus excessively on local or

detailed aspects of information, rather than integrating these details into a coherent and

meaningful whole. While this detailed-oriented processing style can sometimes lead to

strengths in tasks requiring precision or attention to fine detail, it often comes at the expense

of understanding broader context, narrative flow, or social subtleties. Weak Central

Coherence has been proposed to account for various behaviors in autism, including repetitive

routines, literal interpretation of language, and difficulty interpreting nonverbal cues or

abstract concepts.

In Abdullah’s case, several behaviors are consistent with a Weak Central Coherence

processing style. He exhibits rigid and repetitive behavior patterns, such as lining up toys and

becoming visibly distressed when these patterns are disrupted. This need for structure and
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sameness reflects a focus on specific details rather than a flexible understanding of the

situation as a whole. His speech also includes repetitive or contextually inappropriate

language, which may indicate fragmented processing and difficulty grasping the broader

meaning of conversations. Furthermore, Abdullah struggles to follow complex or multi-step

instructions unless they are broken down into simpler components—another clear sign of a

detail-focused cognitive style. These characteristics collectively suggest that Abdullah may

have difficulty integrating information into a cohesive framework, which aligns with the core

principles of Weak Central Coherence theory.

‎Hyper-Systemizing Theory (Baron-Cohen):

Hyper-Systemizing Theory is a neurocognitive framework that suggests individuals

with Autism Spectrum Disorder (ASD) have a heightened ability to understand and engage

with systems—defined as rule-based patterns that are predictable and follow logical

structures. Proposed by Simon Baron-Cohen, this theory posits that while individuals on the

autism spectrum may show strengths in identifying patterns, classifying information, and

analyzing how systems work, they often experience corresponding difficulties in

empathizing, which involves recognizing and responding to the thoughts and emotions of

others. Hyper-systemizing can manifest as a deep interest in specific topics, strict adherence

to routines, and a preference for predictable environments. Although this tendency can lead to

strengths in certain cognitive domains, such as mathematics, engineering, or pattern

recognition, it may also contribute to the social and behavioral rigidity commonly observed in

autism.

In Abdullah’s case, several behaviors align closely with the principles of

Hyper-Systemizing Theory. He demonstrates rigid routines and ritualistic behavior, such as

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the meticulous alignment of objects and a strong insistence on sameness in his environment.

These behaviors suggest an internal drive to organize and control his surroundings based on

predictable patterns and structures. His pronounced preference for repetition and the

significant distress he experiences when these routines are interrupted further reflect a

heightened tendency to systemize. Notably, Abdullah’s performance on the Raven's Colored

Progressive Matrices (CPM), where he scored in the 90th percentile, indicates above-average

fluid intelligence. This cognitive strength is often associated with enhanced pattern

recognition and logical reasoning, which supports the idea that Abdullah possesses an

exceptional capacity for systemizing. However, this strength appears to coexist with marked

challenges in social cognition and emotional reciprocity, further validating the relevance of

Hyper-Systemizing Theory in understanding his behavioral and cognitive profile.

Progression of Sessions:

Session 1:

It was focused on establishing rapport through interactive play and casual dialogue, helping

the client feel comfortable and secure in the therapeutic environment.

Session 2:

In Session 2, a detailed history-taking process was initiated under supervision, gathering

essential information regarding the client's developmental milestones, medical history, and

psychological background.

Session 3:
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Session 3 involved informal assessment through structured behavioral observations,

incorporating input from multiple informants to gain a broader perspective on the client’s

functioning across contexts.

Session 4:

In Session 4, formal evaluation began with the administration of the Childhood

Autism Rating Scale, Second Edition - Standard Version (CARS2-ST) to assess the presence

and severity of core autism-related symptoms.

Session 5:

This was followed by Session 5, during which the Raven's Colored Progressive

Matrices (CPM) were administered to evaluate the client’s non-verbal cognitive abilities.

Session 6:

Session 6 completed the assessment process with the House-Tree-Person (HTP)

projective test, aimed at exploring the client’s personality characteristics and underlying

emotional dynamics.

Session 7:

In Session 7, findings from the assessments were reviewed and treatment planning

discussions were held with the supervising clinician to identify appropriate therapeutic

interventions.

Session 8:

Finally, Session 8 was dedicated to consolidating and reviewing all collected data,

concluding the assessment phase and setting the stage for further therapeutic planning.
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Termination:

A termination meeting was conducted with the client’s parents to review the overall

progress and provide guidance for continued support at home. During the session, the parents

were asked to rate their perception of their child's improvement on a scale from 1 to 10. They

rated the improvement as 7, indicating noticeable progress and a positive response to the

interventions implemented during the assessment and observation period.

As part of the termination process, several evidence-based strategies were introduced

to the parents to support their child’s ongoing development. These included:

Interactive Storytelling:

Parents were encouraged to use stories that require active participation, such as asking

the child to answer questions or predict outcomes during the narrative. This technique is

designed to enhance comprehension, conversational turn-taking, and engagement.​

Token Economy Systems:

A behavior modification strategy was suggested, where tokens or small rewards are

given to reinforce and encourage desired behaviors. This approach promotes consistency,

motivation, and structure in behavioral management.​

Music and Movement Activities:

The use of music combined with physical actions (e.g., clapping, marching, dancing)

was recommended to improve the child’s coordination, focus, and self-regulation. These
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activities are engaging and enjoyable, offering a playful yet structured way to support

attentional and motor development.

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References

Polónyiová, K., Kruyt, J. & Ostatníková, D. To the Roots of Theory of Mind Deficits in

Autism Spectrum Disorder: A Narrative Review. Rev J Autism Dev Disord (2024).

https://doi.org/10.1007/s40489-024-00457-y

Anonymous. (2025, February 27). Weak central coherence theory. Scottish

Autism.https://www.scottishautism.org/about-autism/about-autism/thinking-styles/we

akcentral-coherence-theory

Baron-Cohen, S. (2006). The hyper-systemizing, assortative mating theory of autism.

Progress in Neuro-Psychopharmacology and Biological Psychiatry, 30(5), 865–872.

https://doi.org/10.1016/j.pnpbp.2006.01.010