Case Summary

F.Z was 7 years old girl who had problems in verbal and non-verbal communication, deficits in

social interaction, being stubborn, fixated on certain objects, inadequate eye contact, self-harming

behavior of tapping the chin and self-stimulating behaviors. She also had developmental delays in all

areas, absence of self-help skills, deficits in fine motor functioning as well as in language. For the

purpose of assessment, history of client’s current condition and previously soughed treatment was

obtained from the mother. For further assessment behavioral observation, clinical interviewing,

subjective rating of presenting complaints and Portage Guide For Early Education (PGEE) was

applied. Formal assessment was conducted through Childhood Autism Rating Scale (CARS). In

accordance with the Diagnostic and Statistical Manual of Mental Disorders client was diagnosed

with Autism Spectrum Disorder, requiring very substantial support. For modification of client’s

behavior and to reduce the intensity of symptoms management plan was devised. Management plan

including included Rapport building, Psychoeducation, Compliance Training, short-term and long-

term goals were achieved through different behavior modification techniques such as, reinforcement,

punishment, prompting, fading and chaining. A total number of 22 sessions were conducted with

client. The post subjective rating of symptoms shows that client’s presenting complaints were

lessened.
Identifying Data

Name: F.Z

Age: 7 years

D.O.B 11 july 2014

Gender: female

Birth order: 1st

No. of siblings: Only child

Informant Mother

Reasons and Source of Referral

The client was referred to the trainee clinical psychologist by her mother for the purpose of

assessment and management for her presenting complaints of being stubborn, deficits in verbal and

non-verbal communication, social interaction, inadequate eye contact, self-stimulating and self-

harming behavior of tapping the chin

Presenting Complaints

Table 1

Presenting Complaints of Child as Reported by Her Mother

Duration Complaints

3 years age ‫ضد بہت کرتی ھے‬

By birth ‫کسی سے بات نھی کرتی‬

3 years ‫اپنا خیال نھی رکھ سکتی پانی بھی خود پالنا پڑتا ھے‬

3 years ‫بات نھی مانتی‬

By birth ‫ بالکل نھی ھے‬eye contact

History of Present Illness

Client’s father and mother had a cousin marriage. Client was born after 2 years of marriage

through normal delivery. She suffered from severe fever right after the birth, at the age of 20 days.

She couldn’t hold up her neck and didn’t move her eyes normally till 40 days of age. All other

developmental milestones, babbling, sitting, crawling, walking, were also delayed.

At the age 2 of years, client again suffered from fever and also experienced a seizure after

that she was hospitalized for few days and remained continuously ill for 4 to 5 months. According to

client's mother, she used to harm herself by hitting her chin, didn’t use to speak and play like other

children. Due to these concerns Client’s family took her to a psychiatrist where she was treated for 8

to 9 months. Under the influence of medications prescribed by psychiatrist, she used to remain

drowsy and lethargic. Treatment was discontinued by parents after 9 months.

During all this period her speech was not developed at all, she only used to babble and make

sounds. After having been treated by a psychiatrist client’s family bring her to the institute of

disabled children for 2018 for her behavior modification and speech development.

Background Information

Family History

The client belonged to a joint family of lower middle-class status. There were 10 family

members in their house including her mother father and grandparents.

Client’s parents were related by blood and both were first cousins. As reported by client’s

mother it was a forced marriage as she never wanted to get married so early. Initially, they had a

conflicted married relationship and their interest always clashed with each other. Her in-laws’ family

environment was very chaotic and strict. Client’ was born after 2 years of her parent’s marriage. She
was the only child of her parents. Because of the 1st abnormal child, they decided not to have another

child.

Client’s father was 36-year-old man with good physical health. He has an educational history

of matriculation. He was a paper maker in Urdu bazaar. According to client’s mother her husband

has a serious personality and never really showed warmth towards his child. Client has a distant

relationship with her father. For most time in a day he remain at work and did not get time to spend

with her.

Her mother is a 30 year old housewife with an educational history of graduation. She got

married at the age of 20 years in 2012. Client spend most of his time with mother and is more

attached to her than father.

Client had no siblings. General home environment was reported to be religiously strict and

rigid. The client belongs to a middle class family. The overall home environment was tense and

stressful. The client’s grandfather is the decision maker of the house.

From her father’s side client also had a history of congenital disease in his first-degree

relatives. Her father’s sister had 2 inborn physically disabled children.

Personal History

The client was born on 11th July 2014. According to the client’s mother, she was born through

normal delivery, there were no complications during pregnancy and birth process. Right after the

birth client caught a fever during the initial days of her life. As reported by the mother client’s

milestones were delayed.

She couldn’t hold her head and there was no frequent eye movement till 50 days after birth.

She learned to hold her head at the age of 2 months. She could sit at 11 months and started crawling

after 1 ½ years of age. She just used to babble make sounds till 6 years of age. She achieved her one-

word speech at the age of 6 after frequently visiting the speech therapist. Reaching at the age of 7
years she still can’t hold a spoon or glass. For all the daily activities including eating, drinking using

toilet and changing clothes she needs constant assistance and help of others. She had no

comprehension of self-help and language.

Table 1.2

Achieved Developmental Milestones as Reported by the Mother

Milestones Age at which milestones were Normal age of achieving

achieved milestones

Head holding 2 months 2-3 months

Sitting 11 months 4-7 months

Crawling 1½ years 6-10 months

Walking 2.3 years 9-12 months

Monosyllabic word 6 years 12-15 months

Toilet training Not achieved 3-4 years

Taking bath without help Not achieved 5-6 years

Getting ready without Not achieved 5-6 years

help

Babbling 2 years 6 months

One-word speech 7 years

1-2 years

Two words (phrases) Not achieved

2-3 years

Complete sentence Still not achieved

13-27 months

Psychological Assessment

Client’s formal and informal assessment were conducted by using different measures, to

assess the level of severity devise a management plan for her problems.
 Informal assessment Formal assessment

Clinical Interview

Reinforcer Identification Childhood Autism Rating Scale (C.A.R.S)

Portage Guide to Early Education (PGEE)

Informal Assessment

Informal assessment included clinical interview, general observation, and identification of

reinforcers and subjective ratings of the presenting complaints.

 Behavioral Observation

 Clinical Interview

 Reinforcer Identification

Clinical Interview

A skillfully conducted clinical interview is the cornerstone of psychological assessment. It is

a dialogue and verbal communication between a clinician and client. This interaction, typically a

face-to-face meeting generates a tremendous amount of data for the clinician via both observation

and direct questioning that is designed to help the psychologist to diagnose and plan treatment

(Maruish, 2008). In case of a child usually, all this information is obtained through clinical

interviewing with mother.

A semi-structured interview was conducted with the mother to get a detailed insight about

client’s presenting complaints, background information which included his family, personal and

educational history, and also about his strengths, interests, and home environment. Client’s mother

showed her full support during the interview. She shared possibly all the details that provided a deep

understanding of client’s problem and helped in diagnosis.

Behavioral Observation

The client was a physically healthy 7 ½-year-old girl. She was attired in neat and clean

clothes with a shirt, trouser, and head covered by staller. She was escorted by her mother forcefully.

She was restless, continuously throwing tantrums and was not ready to sit on chair. Eye

contact was not maintained at all, throughout the session. She was easily bored and had a short

attention span towards therapist and people around her. Client was not attending to the therapist’s

interaction with her.

Rapport was built with the client through poems and coloring. Because of poor fine motor

functioning, she was not able to hold a pencil. Client colored the drawing with the help of therapist.

Client was paying attention and giving response to rhymes and poems.

Reinforcer Identification

Identifying a preferred reinforcer is a process of ‘Preference assessment’ that aims to identify

an individual's favorite things so that they can be used as rewards or potential "reinforcers' of

appropriate behavior. Reinforcement can be any object, condition or activity that when presented

immediately following a behavior, increases the frequency of that behavior and helps in

strengthening child performance and learning of desirable behavior.

Table 1.3

Table for the Identification of Potential Reinforcers for the Client

Types of Reinforcements Reinforcers

Eatable reinforcers None

Activity reinforcers Listening poems and rhymes

Social reinforcers Clapping, stickers, saying good

Portage Guide to Early Education

A behavioral checklist devised by Susan Bluma (1970). A curriculum planning device

intended to assess the child’s Present behavior, target behavior, and suggested techniques to teach

each behavior. PGEE is a international home-based intervention service for children ages birth to 6

years who have special needs, and their families. Using PGEE children are taught new skills and

parents/guardians are shown how to stimulate their child’s overall development. It consists of a

triadic model of service delivery, a set of reading materials, and a method of training parents to teach

their own children.

Portage guide is designed to assess the developmental (functioning) level of young children.

It provides the strategies to teach the unlearned behaviors to them (Curriculum Development Tool).

It is not intended to find out the development age of the child.

Table 1.5
Showing Rating by Mother on Problematic Areas on 0-10 Point Scale at Pre-Assessment Level

Area Developmental Profile Deficits

Socialization 1-2 years Approximately 5 years

Language 1-2 years Approximately 5 years

Self-help 1-2 years Approximately 5 years

Cognitive 0-1 years Approximately 6 years

Motor skills 0-1 years Approximately 6 years

Qualitative analysis

Portage guide for early education was administered on the client with the help of parents and

teacher. According to the analysis of different areas of development, there were significant delays
observed in each area of PGEE and hence, functional age of client was assessed relative to each area.

The chronological age of client was 7 years 6 months.

The client’s functioning in the area of socialization lies in the range of 1-2 years. Her

weaknesses were, she could not initiate and maintain eye contact with others. She was not responsive

even towards her family members. Her speech was not developed except for 1 or 2 words. She did

not respond to being in family circle and to the attention of others. Her interests were fixated on 1 or

2 objects. Her strengths were that she could identify and reaches for the preferred objects. She could

identify her mother and also responds to some of her instructions if asked strictly

Client’s functioning in the area of language lies in the range of 1-2 years. She could hardly

imitate the voice intonation patterns of others. She was not able to vocalize in response to speech of

others and to use single words for labeling objects. Her non-verbal use of language was also not

appropriate for her needs.

In the area of self-help skills, client’s current level of functioning falls into the range of 0-1

years. She could use her body for walking and moving independently. Her weaknesses were she was

not able to hold glass or a spoon without help. She could chew and eat soft food items, but for even

that she needed the help of an adult.

Cognitive skills of client are in the range of 0-1 years. Clients strengths are that she can

identify the preferred objects. She could release and pick up the toys and objects of her liking. She

had the recognition of one body part, like nose but was only able to point through physical

prompting. She had the capacity to remove things that could obscures her vision. Her weaknesses

were she could not perform any action in imitation, had no compliance for verbal, not able to

understand non-verbal commands.

Client’s level of motor functioning was at the age range of 1-0 but her because her gross

motor functioning was intact as she was able to perform many of actions like standing walking,
getting up and sitting independently. She was also able to walk upstairs without any help through

using her hands, could open the door to go outside as well. Her weakness was deficits in fine motor

skills which was not adequate according to her age as she could not hold a pencil, use pincer

grasping to hold objects.

Formal assessment

 Childhood Autism Rating Scale (C.A.R.S)

Childhood Autism Rating Scale (C.A.R.S)

The Childhood Autism Rating Scale (C.A.R.S) is one widely used rating scale published in

1980. It was developed to identify children with autism and to distinguish them from

developmentally handicapped children without autism syndrome. It further distinguishes children

with autism in the mild to moderate range for the detection and diagnosis of autism.

CARS examines 15 categories of behaviors, characteristics, and abilities against the expected

development of typical children to determine whether autistic symptoms are present.

Table 1.6

Table 1.6 showing score range and developmental profile

Score Range Developmental Profile

Below 30 Non-autistic

30-36.5 Mild-moderately autistic

37-60 Severely autistic

Quantitative Analysis
Table 1.7

Table 1.7 showing the areas and corresponding ratings.

Areas Ratings

I. Relating to people 1.5

II. Imitation 3.5
III. Emotional response 3.5
IV. Body use 2.5
V. Object use 1.5
VI. Adaptation to change 1.5
VII. Visual response 3.5
VIII. Listening response 1
IX. Taste, smell, touch response and use 2.5
X. Fear and nervousness 3.5
XI. Verbal communication 3.5
XII. Non verbal communication 1.5
XIII. Activity level 2.5
XIV. Level and consistency of intellectual response 3.5
XV. General impression 3.5

Table 1.8

Table 1.8 showing score range, scores obtained and developmental profile of client

Score Range Client’s score Developmental Profile

7-60 39 Severely autistic

Qualitative Analysis

According to qualitative analysis the score of client F.Z on CARS is 39 which falls into the

category of Severely autistic.

Diagnosis

299.02 (F84.0) Autism Spectrum Disorder, requiring very substantial support.

Case Formulation

The client F.Z was 7 years old girl who came with the presenting complaints of being

stubborn, deficits in verbal and non-verbal communication, impaired social interaction, inadequate

eye contact, self-stimulating and self-harming behavior of tapping the chin. Further problems

reported by the mother include developmental delays in all areas, absence of self-help skills, deficits

in fine motor functioning as well as speech delay. The client belongs to a middle-class family, born

through normal delivery.

Psychological assessment of client was carried out through behavioral observation, clinical

interviewing from mother, subjective ratings of problematic behavior. For formal assessment Portage

Guide for Early Education (PGEE) checklist and Childhood Autism Rating Scale (CARS) were

applied. The client was diagnosed with Autism spectrum Disorder as her scores on CARS were 39

which falls into the range of severely autistic.

The client suffered from severe fever during the initial days of her life which led the client to

the onset of her current problem. According to a research conducted by Andrew, (2017) on the Fever

Effect in autism, suggest that fever appears to be more common in children with significant repetitive

behaviors and other symptoms. In such children, it causes brain differences and behavioral changes

that make them more susceptible to the fever effect. This study examined the data from 2,152

children with autism who participated in the research and Parents of 17 % children, reported that
their sons or daughters had experienced the fever effect. Results of the study showed that such

children had lower nonverbal cognitive skills, less language, and more prominent repetitive

behaviors than children not having fever.

The client’s parents had a cousin marriage, and they have a history of congenital disease in

their 1st degree relative, which predisposed her for the current problem. Consanguinity-marriage

between degree relatives- is a major risk factor in several congenital diseases including autism

spectrum disorder. Consanguinity can increase the risk for autosomal recessive conditions, along

with autism spectrum disorder (ASD). In a cross-sectional research conducted by Autism Spectrum

Disorders at a Centre in Pakistan in 2018, 76 consecutive children with autism spectrum disorder

(ASD) were studied for the clinical and demographic parameters at Autism Resource Centre in

Pakistan. The median age at first consultation was 30 months, 36 months at diagnosis, and 42 months

at referral to a specialized center. There was an average delay of one year between the first

consultation and referral to the specialized center. Consanguinity was observed in 33 (43.4%)

children. Three children had another affected 1st-degree relative. The severity of ASD showed that

13 (17%) children had borderline features, 50 (66%) had mild to moderate ASD, while 13 (17%) had

severe ASD.

The client experienced developmental delays in all major domains of functioning.

Developmental delay is a term that refers to a child who isn’t meeting multiple milestones as quickly

as expected compared to others of the same age. Delays may occur in the areas of motor function,

speech and language, cognitive, play, and social skills. A delay means kids are continually behind in

gaining the skills expected by a certain age. Sometimes we may observe signs in infancy, such as

rolling over, sitting, crawling, walking, and talking, but in other cases they may not be noticeable

until your child reaches school age that include slow learning, Difficulty communicating or

socializing with others, Difficulties talking or talking late, Inability to connect actions with
consequences Inability to do everyday tasks like getting dressed or using the restroom without help

(Curran & Zimmerman, 2017).

Another major factor that contributed in client’s current problem is that at the age of 2 year,

2016, she suffered from a seizure after which affected her health badly and her condition continues

to decline after that. According to Pellock (2013) seizures are the most common neurologic

complication and there can be a profound effect on the development of a child with ASD. Even

children with milder forms of epilepsy, such as absence seizures, experience problems with attention

or processing information and it can also impact their ability to learn. Medical researchers have also

proposed that some of the brain abnormalities associated with ASD may also contribute to seizures.

According to some research, electrical activity in the brains of children with autism show epileptic

discharges more often than in people without ASD. Further, children with epilepsy are more likely to

develop autistic traits.

Summary of Case Formulation
Figure 1: pictorial summary of case formulation

Presenting complaints

 deficits in social interaction

 being stubborn
 fixated on certain objects
 Poor fine motor control
 No speech

Predisposing factors
Assessment
 Cousin marriage
 Clinical Interview
 Family history of congenital
 Reinforcer
disease
Identification
 Childhood Autism Client
Rating Scale
(C.A.R.S)
 Subjective rating of Maintaining factors
presenting
complaints  Developmental delays
 Portage Guide To  No speech
Early Education  Seizure
(PGEE)  Health related
Protective factors problems

 Mother’s support and

cooperation
 Frequent therapeutic
sessions

Management plan
 Psychoeducation
 Behavior modification techniques
 Individualized educational plan
 Play therapy
Management plan

The following strategies will be used as short term and long-term goals with the client as

intervention plan and will be implemented on her to resolve his symptoms.

Short Term Goals

Table 1.7

Short Term Goals and Therapeutic Interventions

Short Term Goals Therapeutic Interventions

To engage client in the therapy and to develop Rapport Building

trust and understanding between client and

therapist

To make client’s mother aware of nature, Psychoeducation

complication and severity level of the client’s

problem, mode of treatment and prognosis.

To improve cognitive, social and motor skills of IEP was devised according to the needs of the

the client client and to improve early readiness skills (Eye

contact, attention, compliance, imitation and

understanding of verbal commands) and

developmental skills (Cognitive, motor and

socialization skills). It was established on the

basis of Behavior modification techniques i.e.

prompting, shaping and reinforcement

In order to increase her compliance. Compliance Training was done using one step

command following.

In order to work on her attending behavior. Attending Behavior Techniques (i.e, shape
 fixing, light balls, block building etc.)

To manage client’s problem at home Parental Training

Long Term Goals

 Continuation of short term goals

 Implementation of goals of individualized educational plan

 Follow up sessions

Summary of Therapeutic Interventions

Rapport Building

Rapport was built with the client to promote a comfortable environment and a friendly bond

which is necessary to actively encourage clients to take part in the therapeutic process. Different

ways can be used to build rapport which starts from the very first meeting with client. The trainee

clinical psychologist greeted the client warmly, with a smile, and started a brief introduction by

telling her name. As the client’s social interaction and non-verbal communication were not fully

developed, she showed resistance toward the psychologist. Therefore rapport-building process

continued for a number of sessions. Client’s speech was not developed because of that

communicating with her was difficult. The trainee psychologist identified the reinforcers for the

client with the help of her mother and by presenting her different things such as, stickers, colors,

chocolate, poems and music. Client was very responsive towards the music, therefore trainee clinical

psychologist build rapport her by making her listen to different poems and rhymes. The techniques

used for rapport building were; reciprocity and commonality.

Floor time technique. The Floor Time technique focuses on developing relationships and

affect in autistic children. Although affective engagement such as showing pleasure, sharing
emotions, and reciprocating interactions is secondary to the primary symptoms of autism (e.g.,

cognitive deficits), affect and relationships are more amenable to intervention and play an important

role in initial relationship sharing and building (Greenspan & Weider, 2005). It was used to build

rapport with client as she seemed disinterested in the sessions. She would not respond to any of the

therapists actions or requests and not make any eye contact. The therapist worked with the client for

one hour in each session on the floor.

Reciprocity. It is defined as giving gifts or doing favors without directly asking for something

in return. Reciprocity is an effective technique for building rapport with children. The therapist gave

reinforcers such as watching favorite poems and playing games to the client without directly asking

something in return.

Commonality. It refers to deliberately finding something in common with a person in order to

build rapport. The therapist actively participated in playing games with him on the mobile in order to

give the client notion that the therapist also likes these activities. Moreover, while identification of

reinforcement, the therapist told that she also liked chips and playing games and watching videos.

Psychoeducation

Psychoeducation is a specialized form of education aimed at helping client’s family to learn

and create awareness about the range of emotional and behavioral difficulties, their effects and

strategies to deal with them. Psychoeducation began as a family-focused intervention in the treatment

of mental disorders with the intent of reassuring family members that they are not the cause of the

disorder while helping them to understand how patterns of interaction in the family may influence

the course of the illness. As a part of overall treatment plan trainee clinical psychologist

psychoeducate the parents about the client’s nature of illness, their specific needs and how they as

family could play a more beneficial role for child, in cooperation with mental health professionals.

Individualized training program (ITP: Miltenberger, 2012)

 An individualized training program was designed based on the strengths and weaknesses of

child. The tasks were taught in different steps using different behavior modification techniques. The

targeted behaviors were defined on the basis of a detailed assessment through which client learned

new tasks with help and support of therapist.

Early readiness skills

Eye Contact

Eye contact is a type of body language that is extremely important during

communication and conversation, a form of nonverbal communication and can have a large influence

on social behavior. For an effective therapeutic process to occur eye contact is the foremost

component. Client had no eye contact. She was avoiding to initiate eye contact completely.

Hanging light ball Technique. The trainee clinical psychologist used light ball techniques. A

fidget ball with lighting was used to gain client’s eye contact by moving that ball in front of eyes

from right to left. Client was fascinated by light thus she responded to the changing direction of ball.

For few sessions this technique was repeated.

Paraphernalia. A technique of using different weird eye glasses, making funny faces or use

silly getups such as clown noses, glasses with funny noses attached, or stick-on moustaches for

making the child to attend and give eye contact to other person. Different types of paraphernalia on

eyes head and face were used to gain child’s attention. After every few seconds therapist used to call

client’s name and sing poems to the client while wearing those glasses and stickers on the face.

Wearing paraphernalia during sessions and performing activities helped therapist to receive child’s

eye contact.

Visual and auditory stimulation. Client was very responsive towards sounds of poems and

rhymes. Therapist used videos of poems with sounds while moving it in front client’s eyes keeping it
 close to therapist’s eyes. Constant movement and stimulation through sound were useful in obtaining

eye contact from child.

Peek-a-boo. in which therapist used to hide her face with a small piece of cloth and slowly

bring it down while calling for client’s attention. The purpose of this activity was to increase

interaction and to increase eye contact.

Compliance training

Compliance refers to the act of responding favorably to an explicit or implicit request

offered by others. It means a change in behavior that is requested by another person or group, the

individual acted in some way because others asked him or her to do so, but it was possible to refuse

or decline (Breckler & Olson, 2006). The request may be explicit, such as a direct request for

donations, or implicit, such as an advertisement promoting its products without directly asking for

purchase.

Compliance training is a process of teaching the client to develop the willingness to follow

through with the directive instructions to initiate or complete tasks on the given by of adults. There

are four types of noncompliance (Walker, 2004)

Passive noncompliance: child does not to perform requested behavior but is not

overtly noncompliant (simply ignores directive – not angry or hostile).

Simple refusal: child acknowledge the direction but indicates via words or gestures that

he/she does not intend to comply – not angry unless command persists or there are adult

attempts to force the issues.

Direct defiance: child displays hostility, anger, overt resistance and attempts to

intimidate.

Negotiation: child attempts to bargain, compromise; proposes alternative solutions.

 Client displayed passive non compliance during the sessions. For the purpose of building

compliance therapist used the following strategies:

Strategies for building compliance

i. Obtaining attention and eye contact

ii. Delivering one directive or command at a time – for tasks with multiple steps, separate

command for each step

iii. Giving as many commands as needed (decreased compliance occurs with increases in the

number of commands given)

iv. Using more “initiating: (or “start”) commands versus “terminating (or “stop”) commands

v. clear, concise, and specific language (“alpha” commands)

vi. Allowing time to comply

vii. Only give the command two times – if not followed after second time, provide consequence for

noncompliance

viii. Give direction from a distance of three feet.

ix. Use a matter-of-fact and non-emotional tone of voice (do not yell, plead or threaten)

x. Reinforcing compliance

Compliance training was applied and observed throughout all the sessions. Whenever

therapist used to give the commands to the client during activities and she complied with the

commands, she was immediately reinforced.

Hold and drop. Through physical prompts the activity of hold and drop was performed.

Multiple colored balls and a container were used to carry out the activity. Initially the therapist

placed the container on a table in front of the client, gave the ball to the client and gave the command

of “hold” while giving it. Physical prompts were used by grasping her hand and then dropping the

ball in the container with the command of “drop”. This activity was performed three times in a

session. The achieved mastery level of the activity was 60% at the end.
 Throw the ball. Through physical prompts the activity of throwing a ball was performed.

Multiple colored balls were given to the client and then she was commanded to throw the ball.

Initially, she didn’t comply with the command but when she did through the ball the therapist would

immediately pair the command with the action and praise her. Upon repeatedly doing this the client

started to through the ball upon the command of the therapist 70% of the time.

Give me. The command of “give me” was given to the client 5 times in a session. The

therapist gave different things i.e. pencil, crayon, ball and toys to the client and gave command of

“give me”. The client was able to perform this activity 50% of time at the end of session with verbal

prompts.

Imitation

‘Arms up’ ‘Arms down’

To improve motor imitation and body awareness client was made to imitate simple

arm movements without assistance. Therapist moved the client’s arms above, hold them for a minute

and said ‘Arms up’, then while putting the arms down therapist said ‘arms down’ and lastly putting

her arm straight out for her sides said ‘arms out’. This exercise was repeated multiple times un till

client become more skilled at the task and occasionally started moving her arms on verbal commands.

Noise makers

Using different noise makers therapist used to make the appropriate motion with the

noise maker (i.e squeezing or shaking) with one hand, and by bthe help of other hand help the client

to make the same motion

Attending behavior

Attending behaviors are verbal and non-verbal behaviors displayed by the listener which

communicate that the listener is paying attention to and is interested in the speaker’s message.
For examples:

o Refer to the speaker by name

o Use encouraging statements, i.e. “Uh huh,” “Go on,” “I’m listening”

o Posture toward the speaker

o Maintain appropriate eye contact

o Display facial expressions that express interest and concern

o Nod head to convey affirmation

o Avoid distractions

Attending behavior was built in the client by using the following techniques.

Single piece puzzles

To improve client’s attention span single piece puzzle peg boards were used, which helped

the therapist to obtain client’s concentration towards sessions. Client completed the activities by

verbal and physical prompting.

Block building

To get client involved and playing with others, through block-building activities were

used. Client was teach the concept of counting through arranging blocks through physical prompting.

Client was very responsive towards sound that is why using rhymes for counting helped a lot in

increasing client’s attending behavior.

Blowing bubbles

The therapist used to blow bubbles in front of the client and gave the command of “look at

the bubbles.” By this activity, she maintained eye contact for 5 seconds. The activity was done four

times in a session for 2 minutes and after every successful trial, she was reinforced.

Positive reinforcement
 Positive reinforcement refers to the introduction of a desirable or pleasant stimulus after a

behavior which make it more likely that the behavior will reoccur. Reinforcing behavior through

desirable and pleasant consequences is a greatly effective way of producing a long term change in

behavior as Thorndike’s “law of effect” states that a behavior that is followed by pleasant or

desirable consequences is likely to be repeated, while behavior that is followed by undesirable

consequences is less likely to be repeated (McLeod, 2018).

after the completion of targeted behavior successfully to establish the desired behavior and

increase its likelihood to occur again in future.

While working on the behavior deficits of client she was given her reinforcement which

include listening to poems and rhymes, stickers, clapping, swings in every session while conducting

the activities of eye contact, compliance, turn taking, greeting adults and holding a glass.

Reinforcement schedule was designed including client’s favorite objects, as a part of reinforcing the

occurrence of appropriate behaviors each time it occurred. It helped therapist in producing the

desirable results of behavior modification.

Stimulus Generalization

Stimulus generalization was used to develop stimulus control for a particular behavior for

which the child was provided reinforcement to strengthen the occurrence of behavior. Child’s learned

behaviors were generalized to different situations to enable her to give appropriate response on

similar situations such as reaching for the other objects instead of mobile phone. Then the child was

taught to reach and hold different objects like ball, stuff toy, glass and spoon.

Prompting

Prompts are supplemental stimuli that control the target response, work as an antecedent that

induces a person to perform a behavior that otherwise does not occur (Touchette & Howard, 1984).
Prompts are given before or during the performance of a behavior, they help behavior occur so that

can be reinforced. Different level and types of prompts were used to including verbal to full physical

prompts.

Step 1. Identifying the Target Skill/Behavior, in terms that are observable and measurable.

Client’s targeted behaviors were i. pointing towards body parts ii. Picking the balls from jar

Step 2. Identifying the Target Stimulus levels of prompting. The target stimulus is the event

or thing that cues the learner to engage in the target behavior after instruction or prompt has stopped.

Completing an instructional activity is the target stimulus, ‘pointing towards eye when asked for’

Target stimulus for reaching the jar is ‘putting the jar with its lid open in front of client’ was an

external signal to reach the objects in it.

Step 3. Providing task directions. A verbal or physical cue which basically tells the learner

that it is time to use the target skill.

Step 4. Selecting Reinforcers, selecting reinforcers that are appropriate. Client’s reinforcer

was listening to poems on mobile phone.

Step 7. Selecting the types of prompts to be used at each level of the prompting hierarchy.

These prompts may be from the same or different types:

Verbal: a step by step instruction is given. (e.g., clues, hints, commands, questions, rule statements)

Full physical: hand over hand manipulation to control or direct motor movements.

Partial physical: moves the body in the direction client’s need to go towards the targeted object.

Model gesture: pokes or makes an action to indicate the next step of the task.

Visual: just pointing without any other guidance. (e.g., pictures, objects)

Model: (full, partial—can be verbal or motoric), modeled behavior by the person performing the

prompting.
 Step 8. Sequencing prompts from least-to-most assistance. The least-to-most prompting

procedure is used with discrete (single behaviors or relatively short duration) and chained skills, a

series of behaviors sequenced together to form a complex skill. (Neitzel & Wolery, 2009).

Holding glass. Using forward chaining to teach the child to hold the glass. 1st step was

putting the spoon in field of child’s vision and get her attention. 2nd step helping her to wrap her

fingers around the glass and hold it. 3rd step was reinforcing her grasp to prevent her from dropping.

4th step gradually increasing the amount of time she holds the glass. 5th decreasing the pressure of

hand as her hand exerting more control. Finally withdrawing hand entirely and observe her grasping

without providing any assistance.

Grasping a spoon

Feel box. To improve client’s ability to grasp objects without seeing them cardboard box was

used. Client had to pull three objects out of a closed box through a hole in the box. She was prompt

to reach into the whole and pull out one of the objects. on pulling out any object therapist act surprise

to the client and reinforced her immediately. Activity was repeated until she reach her hand alone

without assistance to withdraw an object.

Hand strength.

Modelling

Observational learning (Modelling), Individual learn through observing others and then

imitating, or modelling, the same behavior. The individuals performing the imitated behavior are

called models. For modeling to be most effective the correct behavior is demonstrated for the learner

and the learner must be able to pay attention and perform the behavior that the model just

demonstrated. Research suggests that this imitative learning involves a specific type of neuron, called

a mirror neuron (Hickock, 2010).

 Play dough activity was used in this technique. The child was given a piece of dough and

through modelling the action of tearing off small bits of play dough and putting them in a can was

demonstrated. then through prompting client was encouraged to imitate the therapist. Usage of

appropriate reinforcer helped in the performance of activity and in achieving the goal of developing a

good pincer grasping and improve fine motor control.

Blowing bubbles. Blowing bubbles with children promotes eye contact, joint attention,

requesting and turn-taking. Therapist sat face-to-face and start blowing bubbles to gain the client’s

attention. Then encourages the client to imitate the same lip motion and blow.

It also help in developing oral motor skills, abdominal muscle and breath support for

sustained speech when child blow long consistent streams of bubbles. Blowing exercises are great

for developing lip rounding positions which are needed for speech sounds such as ‘oo’, ‘w’, ‘oh’ and

‘sh’.

Socialization skills

Turn taking. Group was conducted to get client involved and playing with others, through

structured block-building activities. This technique was intended to improve client’s social

interaction like sharing with others and taking turns. With 3 to 4 more children client was sat in the

group and they were given the commands of rotating ball while giving it to each other on the sound

of music. As the music stopped the child holding the ball was reinforced and was given the time to

listen his or her favorite poem. the amount of guidance provided by the therapist in the form of

verbal commands of giving ball to each other was gradually decrease to the point where the children

can start and finish the turn taking of ball on their own. Client showed interest in the activity and her

social interaction also get better.

Pointing to body parts

 Greeting others

Parental Training

Parent training (PT) is well understood as an evidence-based treatment for typically

developing children with problematic behavior. Behavioral Parent Training is a way that helps

parents learn ways to help their child behave better. Parental training is done with mental health

professional. It is important for parents to provide training to the parents that fits the needs of their

family, which help change behavior problems, also wide range of interventions including care

coordination, psychoeducation, treatments for language or social development, as well as dealing

with maladaptive behaviors.

Throughout all the sessions a brief amount of time was given to the mother of the client,

explaining what goals were being targeted, the homework given, future plans and how she can

collaborate with the therapist for a more consistent change in behaviors. For example, therapist gave

the instructions and elaborated how the process of playing with the child can be modified to increase

her attention span and her response to verbal commands. Mother was asked not to give child glass

or spoons and let her reach those objects herself. The mother was also helped in how to use

extinction for decreasing the child’s behavior of only following the instructions because of

reinforcing consequence of receiving mobile phone.

Post Assessment

Table 1.10

Table 1.10 showing Skills and their Pre and Post Mastery Level

Skills Mastery Level

Pre Post

Eye contact and Attending

Magic star wand 05% 40%

 05%

10% 60%/

10% 60%

Compliance

Response to verbal commands 20% 50%

Throw the ball 10% 50%

Give me 10% 60%

Hold and drop 10% 70%

Cognitive skills

Ponting to 5 body parts 10% 80%

Response to counting 10% 70%

Motor skills

Holding stuff toy 40% 80%

Pincer grasping 40% 60%

Hand strength 40% 60%

Socialization

Shaking hands with teachers and fellows 10% 50%

Following directions 10% 60%

Turn taking 10% 60%

Eye-hand integration 10% 20%

Self help

Holding a glass 05% 70%

 Grasping and using spoon 05% 50%

Outcome of the Therapy

The client was a 7 ½ years old girl and she was diagnosed with autism spectrum disorder.

Individualized Education Plan (IEP) was established and applied with the help of Behavior

modification Techniques i.e. positive reinforcement, prompting, and fading were used to establish

new behaviors and increase his independent functioning. The overall duration of the IEP was three

months. Client’s showed improvement in all the developmental areas and understood and

comprehended concepts efficiently.

Termination of Therapy

The therapy was terminated and therapy blue print was given to the mother. In order to

achieve the required mastery level practice of cognitive and adaptive skills was continued by the

mother.

Limitations

 Limited time duration and a gap of closed schools during sessions due to winter vacations.

 Busy schedule of mother which didn’t allow her to continue the activities on her child at home.

 Less exposure of child to adult interaction at home and other social situations.

 Severity of client’s repetitive and fixated behavior and interests.


 Individualized Educational Plan (IEPs)

Student’s Name F.Z Date of Birth 11.07.2014

Age 7 ½ Years Gender Female

Diagnosis Autism Spectrum Disorder

 She has intact gross motor functioning

 She responds to sounds and music
Strengths of Client
 Can indicate needs through non-verbal behavior
 Have a partial understanding of verbal command

 Developmental delays
 Low level of comprehension.
 Resistance to eye contact
Weaknesses of the
 Poor fine motor functioning
Client
 No compliance
 Short attention span
 Low level of eye-hand coordination
Goals/Target Socialization

Improving interaction of physical contact

Increasing eye contact

Performing simple gestures on request i.e bye-bye,

shaking hands,
Sharing toys with other children

Following directions

Turn taking

Playing in group

Cognitive skills

Putting and removing objects from container on

verbal command

Recognition of body parts

Placing things and specific objects through

pegboard and feel box

Motor skills

Fine motor skills

Improve pincer grasping

Holding spoon and glass

Holding pencil

Improving hand strength

Finger tracing

Putting and pulling out things into box

Self-Help Skills

Grasping and holding spoon independently

Holding glass without help while drinking

Wiping hands, mouth

 Session report

Initial phase

Goals

 Rapport building

 Psychoeducation

 Clinical interview

 Subjective rating of symptom

 CARS

 Portage guide for early education

 Identification of reinforcer

 Eye-contact exercise

Activities

Rapport was build with the client using floor time technique, reciprocity, and commonality.

Strongly built rapport helped the therapist in continuing a smooth process of behavior modification

and it also helped the client to be comfortable around psychologist. Mother of client was

psychoeducated about the client’s nature of illness, their specific needs and how they as family could

play a more beneficial role for child. They were also briefly inform about the management plan.

Subjective rating or symptoms was taken from the mother. Portage guide for early education and
childhood autism rating scale was administered on client for a assessment purpose. Reinforcers were

identified, and techniques for initiating and developing eye contact i.e hanging ball, peek-a-boo,

paraphernalia, stickers along with techniques for increasing attention span i.e blocks, blowing

bubbles, were used with the client.

Outcome

Rapport was built with the client gradually throughout the course of some initial sessions. It

took the therapist to put an extra effort into rapport building as client had stubbornness and resistance

to human interaction. Presenting complaints and their severity as well as functional age of client was

identified. Client was able to follow some of verbal commands and her eye contact also increased for

about 6 to 7 seconds.

Middle phase

Goals

 Attention training

 Imitation activities

 Identification of body parts

 Compliance training

 Fine motor skills

Activities

Different behavior modification techniques such as reinforcement, prompting, generalization

and were used to enhance client’s attention, developing the understanding of verbal commands, and

improving her fine motor skills i.e pulling out objects and pincer grasping as well as to teach

cognitive skills i.e identification of body parts, reaching for the objects. Physical restraints were used
to reduce client’s disruptive and self-harming behaviors. Compliance training was also done with the

client.

Outcome

Client’s attention span and on seat behavior was increased. She showed improvement in

recognition of body parts through pointing. Her understanding of verbal commands while got

improved through the use of imitation activities. Client also showed improvement in compliant

behavior. Through fine motor exercises her hand strength and pincer grasping got better. Client’ self

harming behavior of chin tapping was reduced.

Final phase

Goals

 Socialization skills

 Holding a glass

 Grasping a spoon

 Parental training

Activities

Client’s social interaction was improved through using group play. Other socialization skills

i.e greeting others, bye bye with hand gesture, were practiced during the sessions so that client can

exhibit then in other social settings. To improve client’s independent functioning basic self-help

skills such as holding a glass and spoon were practiced. For the purpose of parental training mother

of the client was given a detailed brief on goals being targeted, the homework activities, future plans

and how she can collaborate with the therapist for a more consistent change in behaviors.

Outcome
 Techniques used for social skills helped in the improvement of client’s interaction with

others. Improvement in fine motor skills also assisted in learning of holding glass and spoon. This

goal was achieved 50% during the sessions. Parental training gave the direction to the mother in how

the activities can continue further at home.

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