CASE REPORT #2

CHILD CASE REPORT

F84.0 Autism Spectrum Disorder, requiring very substantial support for social

communication, and requiring support for restricted, repetitive behaviors with

accompanying language impairment

 Case Summary

M.N, a 9 years old male child, was referred to the trainee clinical psychologist with

complaints of speech delay, severely limited verbal communication and primarily relies on non-

verbal sounds and gestures to express needs and feelings. Complaints also include lack of eye

contact, specific repetitive behaviors, restlessness and hyperactivity. As reported by the

informant, the child had been displaying these signs from early childhood, along with a delay in

milestone achievement following the age of 2 years. He also presented with sleep disturbances,

and more recently with an increase in behavior problems including shouting, crying loudly and

holding mother tightly. The child’s psychological assessment included informal assessment as

well as formal assessment through the use of standardized assessment tools. The informal

assessment consisted of the Clinical Interview and Mental Status Examination. The formal

assessment was carried out using the Child Behavior Checklist (CBCL), Childhood Autism

Rating Scale (CARS), and the Conners Rating Scales (CRS). The results of the psychological

assessment along with the subjective and objective symptoms indicated Autism Spectrum

Disorder, requiring very substantial support for social communication, and requiring support for

restricted, repetitive behaviors with accompanying language impairment.

Client’s Demographics

Name: M.N.

Date of Birth: June, 2014

Age: 9 Years

Gender: Male

Number of Siblings: 5

Birth Order: Third Born

Education: Nil

Family Structure: Joint Family

Informant: Mother

Source and Reasons for Referral

The child was referred to the trainee clinical psychologist for a formal psychological assessment

and evaluation based on the complaints of delayed speech, limited verbal communication, anger

outbursts, lack of eye contact, repetitive behaviors, hyperactivity and sleep disturbances.
Presenting Complaints

Table 2.1

Presenting Complaints according to the informants and their duration

Complaints Duration

Speech Delay 7.5 years

Lack of Eye Contact 6 years

Repetitive Behaviors 4 years

Hyperactivity and Restlessness 4 years

Limited Verbal Communication (2 words per 2 years

sentence)

Behavioral Problems (Crying and Shrieking) 2 years

Sleep Disturbances 2 years

History of Present Illness

 M.N.'s developmental stages initially followed a typical pattern without reported

complications during the prenatal, perinatal, or postnatal phases. Born through, M.N. achieved

developmental milestones within the expected time frames until around 1.5 years of age.

However, following this period, a regression occurred, leading to delays and atypical behaviors.

M.N. exhibited speech delay from infancy, lacking any vocalization. By the age of 2-3,

concerning signs emerged as he displayed a lack of responsiveness to his name and minimal

interaction during playtime. Notably, he avoided eye contact, creating a disconnect in social

interactions. M.N.’s family assumed that maybe he had hearing problems so they sought medical

consultation. Physicians initially diagnosed him with ear problems and prescribed medication.

However, despite the treatment, his speech delay persisted, prompting further investigations

leading to a diagnosis of Autism Spectrum Disorder (ASD).

His parents were recommended a special needs school for him named “Children Special

School” and finally at the age of four, M.N. commenced attending a specialized educational

institution catering to children with special needs. This transition notably affected his behavior,

increasing his overall activity levels. He displayed a marked inclination towards continuous

movement, engaging passionately in football and exhibiting a fascination with playing with

water. His play with water included creating bubbles, transferring water between containers, and

even dousing himself with it. These repetitive behaviors became characteristic of his daily

routine.

M.N. showcased a stringent adherence to specific routines. His keen observational skills

were evident through his efforts to assist his mother with tasks, notably in the kitchen. He would

also make breakfast with his mother. Television, especially channels airing children's rhymes and
poems, became a significant part of his daily routine. Despite this exposure, his verbal

communication remained limited, with an ability to articulate only a few words per sentence.

Although he recognized family members and familiar individuals, M.N. rarely initiated

conversations or sought assistance independently, even for basic needs such as using the

restroom. He would often just say two words, for example, “mama washroom” to go to the

washroom and then would wait for his mother to come and clean him up. He showed signs of

irritability, displaying intense emotional reactions, including crying, tantrums, and tightly

grasping his mother when situations did not align with his expectations. Sleep disturbances

became evident, with M.N. experiencing interrupted and shallow sleep patterns, leading to

fragmented rest.

Around a year ago, M.N.'s parents decided to pursue therapy at Amin Maktab. Since

starting therapy, they have observed encouraging progress in his speech development. They

remain optimistic that ongoing therapy will not only improve his speech but also address his

behavioral challenges, such as outbursts, irritability, and hyperactivity, aiming for overall

improvement in his well-being.

Family History

Relationship with Father

M.N’s father is 43 years old and has his own business. He has a very friendly relationship

with his father and often relies on him for help. His father works all day and is only home in the

evenings but makes an effort to understand his needs.

Relationship with Mother

 M.N’s mother is a 33 years old housewife. The child shares a warm and loving

relationship with his mother. Although he is comfortable around his family, he is most closely

attached to her mother. M.N. relies heavily upon his mother for his basic needs throughout the

day. Recently however, his mother reported that M.N. started having a meltdown and would cry

and shout as well as hold his mother tightly. His mother tries to spend quality time with him and

he observes his mother throughout the day however, he does not sit still during some tasks for a

sustained period of time and is constantly running about.

Relationship with Siblings

M.N. has 5 siblings but shares a close relationship with his eldest sister and youngest

brother. Even though he gets along well with all his siblings and shares a comfortable

relationship with them he does not like to share toys with them. When asked to play together, he

often snatches toys from them. He gets upset and starts crying if his siblings try to take his toys

to play with.

General Home Environment

The child lives in a joint family system as there are 5 families living together in one

house and all of them are married and have children. The general home atmosphere is a lively

and comfortable one. He feels comfortable in going to his family members as everyone knows

about M.N’s issue and they all are very supportive especially his grandfather. All the children

play together and also include M.N. in everything.

History of Familial Illness

 According to the informant's knowledge, there is no history of a psychiatric illness in the

child’s family. But there are problems with high blood pressure and heart diseases.

Personal History

Birth and Developmental Milestones

As reported by the mother, M.N. was born through a normal delivery. She reported no

complications experienced during the prenatal and perinatal periods but had a lot of

complications during her postnatal period. Her water bag leaked for a long time and her labor

time was a lot up to 14 hours. Her bp also became low during delivery. But according to my

mother, M.N. was born healthy and his first cry was present as normal. He was breastfed by his

mother as an infant. M.N. achieved her developmental milestones on time up until the age of 1.5

years, following which he began displaying signs of delayed milestone achievement.

He did not start speaking at the age of 2-3 years as normal children do and also was not

toilet trained. Table 2.2 shows his delayed milestones.

Table 4.2

Developmental Milestones and Age of Achievement

Milestones Normal Age of Achieving Child’s Age of Achievement

Cry after birth Immediately after birth Immediately after birth

Neck Holding 2-4 months 2.5 months old

 Sitting 5-7 months 5 months old

Crawling 8-10 months 9.5 months old

Standing 9-10 months 10.5 months old

Walking 13-15 months 14 months old

Monosyllabic speech 9-12 months 7 years old

Talking in complete sentences 3 years Not yet achieved

Toilet Training 2-3 years Not yet achieved

Dressing without help 4 years Not yet achieved

Educational History

M.N. has not been admitted into mainstream educational institutes as of yet. His mother did not

report him being taught anything at home as he is unable to speak and write. Around 3 years of

age, M.N.’s parents consulted a doctor due to concerns about his speech delays. Upon the

doctor’s recommendations, M.N. was admitted to Children Special School where he received

therapy which included speech therapy. M.N. is now currently receiving speech therapy,

occupational therapy, academic assistance, and behavioral therapy for the management of his
symptoms at Amin Maktab. His mother reported that he had no friends as of now and only

played with his siblings.

Medical History

As per the child’s mother, his ears were treated but nothing apart from this.

Psychological Assessment

Informal Assessment

● Clinical Interview

● Mental Status Examination

Formal Assessment

● Childhood Autism Rating Scale (CARS)

● Conner’s Rating Scales (CRS)

● Child Behavior Checklist (CBCL)

Informal Assessment

Clinical Interview

A clinical interview was conducted with the child’s mother in order to gain an in-depth

knowledge into the child’s current symptoms and the course of development of his. The

predisposing, precipitating and perpetuating factors of the illness were investigated. It was

ensured to the child's mother that his privacy and confidentiality will be maintained. The clinical
interview further aided in understanding key information about the client that helped formulate

the diagnosis and an effective management plan.

Mental Status Examination

M.N. appeared to be a well-groomed and neatly dressed child, but his hair seemed

uncombed and not freshly showered. No signs of neglect were evident. He did not make eye

contact and did not greet upon arrival. M.N. was holding his mother’s hand upon entering the

room and looked comfortable to go inside the psychologist's office. While his mother was giving

a clinical interview, he was in therapy. He came running to his mother as the session ended and

did not even look at our faces as he kept pulling his mother to stand up. He was lightly shouting

and making weird noises from his mouth while running in circles.

Upon being called by name, he remained aloof and did not respond to his name being

called but looked at his mother as if he knew someone was taking his name. His height and

weight looked below the average level of height and weight a 9 year old should have. He was

able to walk independently and his posture and movements were normal.

According to M.N’s mother, even though he does not speak in full proper sentences but

makes sounds with his mouth and would shriek and shout while crying and during anger. He can

speak two words per sentence and those words are easily understandable and comprehensible.

The child was very quick and active and moved about the room quickly. The child’s attending

behaviors, eye contact, restless behavior and verbal responses were inadequate. His eye-hand

coordination and gross motor movements were observed to be adequate.

He knows where he is and who he is with which means he has good orientation and

according to mother he was able to pay attention to things and did not get distracted so easily.
His memory was better than other children, as he would remember things without skipping any

details and was very observant.

Formal Assessment

Childhood Autism Rating Scale (CARS)

The Childhood Autism Rating Scale (CARS) aids in identifying the signs and symptoms

of Autism in children above the age of 2 years. It also gives a measure of the severity of

symptoms, and distinguishes between mild-to-moderate and severe Autism. CARS also further

aids in distinguishing children with Autism from those with developmental delays or intellectual

disabilities (Schopler et al., 1980)

The Childhood Autism Rating Scale (CARS) was administered on M.N. to assess the

presence of symptoms of Autism and their level of severity. The trainee clinical psychologist

interviewed the informant as well as made observations during the session upon the basis of

which CARS was scored. The following table summarizes the category scores and provides

general data on how M.N. compared to the group norms.

Table 2.3

Summary of Category Scores on CARS

Sr. No. Categories Raw Score Behavior Description

1. Relating to people 2.5 Mild to Moderate Abnormal Relationships:

The child avoids looking into eyes and

 clings to parents.

2. Imitation 2 Normal to Mildly Abnormal Imitation: The

child imitates simple behavior after a great

deal of persistence.

3. Emotional Response 2 Mildly Abnormal Emotional Responses:

Occasionally display inappropriate type or

degree of emotional reactions.

4. Body Use 1.5 Normal to Mildly Abnormal Body Use:

repetitive movements.

5. Object Use 1 Appropriate use and interest in toys and

other objects.

6. Adaptation to Change 3 Moderately abnormal adaptation to change:

The child actively resists changes in

routine, tries to continue the old activity.

7. Visual Response 2 Mildly Abnormal Visual Response:The

child must be reminded occasionally to

look at what he or she is doing (may stare

off into space, avoid looking people in the

 eye).

8. Listening Response 3.5 Moderate to Severely Abnormal Listening

Response: The child’s response to sounds

vary; often ignores a sound the first few

times.

9. Taste, Smell, and Touch 1.5 Normal to mildly abnormal use of, and

Response and Use response to, taste, smell and touch.

10. Fear or Nervousness 2.5 Mild to Moderately Abnormal Fear or

Nervousness: The child shows a little too

less fear.

11. Verbal Communication 4 Severely abnormal verbal communication:

Meaningful speech is not used.

12. Nonverbal 3.5 Moderate to Severely Abnormal Use of

Communication Nonverbal Communication: The child is

generally unable to express needs or desires

non-verbally.

13. Activity Level 3.5 Moderate to Severely Abnormal Activity

Level: The child may be quite active and

 difficult to Restrain.

14. Level and Consistency 2 Mildly abnormal intellectual functioning:

of Intellectual Response the child is not as smart as typical children

of the same age.

15. General Impressions 3 Moderate Autism: The child shows a

number of symptoms or a moderate degree

of autism.

Qualitative Analysis of the ratings on CARS. M.N. obtained a total raw score of 37.5

on CARS, which falls in the Severely Autistic range. This score is indicative of the presence of

various peculiarities in the child’s behavior and suggests that the child requires immediate

clinical attention for her symptoms.

M.N. scored normal to mild abnormalities in body use and taste, smell and touch

response as well as mild abnormalities in imitation, emotional response,visual response and level

of intellectual response. The child also showed mild to moderate abnormalities relating to people

and fear or [Link] made little to no eye contact, and sustained it for 2-3 seconds only.

He also feared things very less. M.N. also showed moderate abnormality in adaptation to change

as it was observed that M.N. showed a resistance to change when transitioning from one task to

another. He got visibly upset and frustrated in the process and began to scream and cry.
 M.N. scored moderate to severely abnormal in her listening response, nonverbal

communication and activity level. He does not use meaningful speech to communicate verbally.

Lastly she was severely abnormal in verbal communication. It was observed that he had no

verbal response with the exception of shrieking and saying 1-2 words.

Conner’s Rating Scales

The Conner’s Rating Scales (CRS) are used for an assessment of Attention Deficit

Hyperactivity Disorder (ADHD). The scales contain various subscales for assessment of conduct

problems, cognitive problems, family problems, emotional problems, anger management

problems, and anxiety problems. CRS is widely used as a screening tool, a treatment monitoring

device, a research instrument, as well as a direct diagnostic aid (Conners, 2003). Conner’s Parent

Rating Scale (CPRS) was administered on M.N. to assess the presence of hyperactive and

inattentive symptoms as well as to determine the severity of these symptoms. The trainee clinical

psychologist interviewed the informant upon which the basis of which CRS was scored. The

following tables summarize the subscale scores on the Parent rating scales, and provides general

data on how M.N. is functioning relative to the group norms.

Table 2.4

Summary of Subscale Scores on Conner’s Parent Rating Scale

Subscale Raw Score T-Score Guideline Common characteristics of high

scorers

Oppositional 8 53 Average: Should not Breaks rules, problems with

 raise concern authority figures, easily annoyed

and angered

Cognitive 10 52 Average: Should not Inattentive, academic difficulties,

Problems/Inattention raise concern organizational problems,

difficulty completing tasks,

concentration problems

Hyperactivity 17 78 Markedly Atypical: Difficulty sitting still for long,

Significant Problem restless, impulsive

Anxious-Shy 12 74 Markedly Atypical: Fearful, emotional, sensitive to

Significant Problem criticism, anxious in unfamiliar

situations, shy and withdrawn

Perfectionism 13 77 Markedly Atypical: Set high goals for themselves,

Significant Problem fastidious, obsessive about their

work

Social Problems 2 53 Average: Should not Few friends, low self-esteem and

raise concern self-confidence, feel socially

detached from peers

Psychosomatic 3 58 Slightly Atypical: More physical symptoms (aches

Borderline concern and pains) than most children

 their age

Conner’s ADHD Index 19 62 Mildly Atypical: Children at risk for ADHD

Possible Significant

Problem

CGI Restless-Impulsive 10 62 Mildly Atypical: Restless and impulsive

Possible Significant

Problem

CGI Emotional Lability 7 78 Markedly Atypical: Prone to more emotional

Significant Problem responses (crying, anger etc.)

CGI Total 17 68 Moderately Atypical: General problematic behavior

Significant Problem

DSM-IV Inattentive 12 58 Slightly Atypical: Correspondence with DSM-IV

Borderline concern diagnostic criteria for inattentive

type

DSM-IV Hyperactive- 15 72 Markedly Atypical: Correspondence with DSM-IV

Impulsive Significant Problem diagnostic criteria for

hyperactive impulsive type

DSM-IV Total 27 65 Mildly Atypical: Correspondence with DSM-IV

 Possible Significant diagnostic criteria for combined

Problem inattentive and hyperactive

impulsive type.

Analysis of the Index Scores. The results show elevated scores on the Hyperactivity,

Anxious-Shy, Perfectionism, CGI Emotional Lability as well as DSM-IV Hyperactive-Impulsive

subscales. The child showed moderately atypical behavior in CGI total subscale. Moreover, the

child also showed borderline to mildly atypical scores on the Psychosomatic, Conner’s ADHD

Index, CGI Restless-Impulsive, DSM-IV Inattentive subscales. These elevated scores indicate

the presence of some hyperactive and inattentive features in the child’s profile. However, the

child has scored not clinically significant scores on the DSM-IV Symptoms Subscales (that

suggest possible DSM-IV diagnosis), on both the inattentive and hyperactive-impulsive

subscales across the parent ratings. These subscales suggest possible DSM-IV diagnosis and a

score of 3 on the hyperactive-impulsive scale and score of 1 on inattention scale indicates that

the child does not meet the DSM-IV criteria for diagnosis of ADHD, despite the presence of

inattentive and hyperactive features. The child is functioning normally in the Oppositional,

Cognitive Problems/Inattention, Social Problems, and these scores indicate no point of concern.

Child Behavior Checklist

 The Child Behaviors Checklist (CBCL) is a questionnaire that aids in assessing

behavioral and emotional problems in children. It provides a general profile of the variety and

degree of behavioral problems manifested in the child’s behavior. The profile is obtained based

on observations of the parents or primary caregivers and offers a comprehensive approach to

assessing adaptive and maladaptive functioning (Achenbach, 1999). The Child Behaviors

Checklist (CBCL) was administered on M.N. in order to assess the behavioral problems

observed in the child. The subscale scores are summarized in the following table.

Table 2.5

Summary of subscale scores on CBCL

Sr. No Subscale Raw Score T- Score Score Interpretative Guidelines

Percentile

1. Somatic Complaints 0 55 <69 Scores are in normal range.

2. Depressed 6 61 85 Scores are in normal range.

3. Schizoid/Anxious 5 72 >98 Scores are in clinical range.

4. Social Withdrawal 4 64 93 Scores are in normal range.

5. Obsessive 15 79 >98 Scores are in clinical range.

Compulsive

6. Aggressive 13 61 85 Scores are in normal range.

 7. Delinquent 0 55 <69 Scores are in normal range.

8. Hyperactive 8 67 93 Scores are in normal range.

9. Uncommunicative 6 73 >98 Scores are in clinical range.

Table 2.6

Summary of scores on social competence subscales

Sr No. Subscale Raw Score T-Score Percentile Guideline

1. Activities 3 28 >2 Scores are in

clinical range

2. Social 0 10 >2 Scores are in

Participation clinical range

3. School 0 0 >2 Scores are in

Performance clinical range

 Analysis of CBCL Subscale Scores. The analysis of the scores obtained by M.N. on the

CBCL indicate the presence of behavioral maladjustment in the child, as the scores are falling in

the clinical range in at least three domains. The high scores on the anxious, uncommunicative

and obsessive-compulsive subscales are consistent with the behavioral observations of the child

of not being responsive, being restless and repetitive behavior. Furthermore, the child’s scores

are in the clinical range in all social competence scales.

Summary of Assessment. The profile of M.N. on the CBCL indicates that the child is

displaying significant maladaptive behaviors in the three domains of schizoid/anxious,

uncommunicative and obsessive compulsive behaviors. Although these behaviors can be

explained by the simultaneous presence of significant autistic features in the child, however, the

elevated scores on the schizoid/anxious subscale warrant clinical attention. Furthermore, the

child’s scores on the social competence scales also fall in the clinical range. This can be

explained by the child’s speech delay and lack of friends as well as the additional autistic

features that are evident in the child’s profile. It can be concluded that the child is functioning

normally in all areas of functioning, except the communication, obsessive compulsive behaviors

as well as schizoid and anxious domains where clinical attention is needed.

Case Formulation

M.N. is a 9 years old male child presenting with evident symptoms that align with the

diagnostic criteria for Autism Spectrum Disorder (ASD). He demonstrates a lack of eye contact,

repetitive movements, irritability, and behavioral problems such as crying, shouting and

throwing objects. In addition to these symptoms, there are indications of hyperactivity in his

behavior.
 M.N. was born through a normal delivery, with his mother reporting complications

during birth. According to her, her labor time was a lot during the child's birth and her blood

pressure also got low during birth. There were no complications after birth. The immediate

presence of his first cry upon birth is noted. This mode of delivery is recognized as a potential

predisposing factor as investigated by Rodgers (2020) continuous electronic fetal monitoring

during longer labor times can cause autism spectrum disorder in children.

Even though the child's mother had low blood pressure during her delivery, she came

from a family which had a problem of high blood pressure. This caused her to have high blood

pressure most of the time. Zeliadt and Spectrum (2018) did research on the relationship between

high blood pressure and autism and concluded that children born to women who had diabetes or

high blood pressure while pregnant are at an increased risk of autism.

While a child's initial developmental milestones progressed typically until approximately

1.5 years of age, a subsequent regression occurred, manifesting delays and atypical behaviors

such as there was speech delay, repetitive movements and lack of eye contact.

Given the shared etiological factors and similar neurobiological substrates implicated in

both ASD and ADHD, it's possible that M.N. displays features of both conditions but M.N.

mostly shows symptoms of hyperactivity and not inattention. Research has highlighted the

overlapping symptoms and underlying mechanisms between ASD and ADHD, indicating that

30-50% of individuals with autism concurrently exhibit ADHD symptoms. (Davis & Kollins,

2012) One of the most common and classic autism diagnostic features M.N. had was lack of eye

contact. Senju (2011) relates this impairment to the theory of mind to difficulties in forming

social connections, exhibited through a lack of eye contact, a common feature in autism.
 Moreover, M.N.'s exposure to electronic screens from an early age, as reported in his

history, may contribute to the development of symptoms associated with both disorders. Studies

indicate that excessive screen time negatively influences language development, attention span,

and may contribute to hyperactivity, all commonly seen in autism and ADHD. (Hermawati et al.,

2018)

In addition to classic symptoms, M.N. also exhibits behavioral problems like hitting,

throwing objects, and crying. Mazefsky (2015) reports that these behavioral manifestations are

often observed in individuals with autism, attributed to deficits in theory of mind, which impacts

perspective-taking and emotional regulation.

While M.N.'s parents are supportive and actively seek treatment, it's important to note

that providing a stimulating environment is crucial for optimal developmental health in children

with ASD. The lack of enriched stimulation can also affect M.N.'s developmental progress.

(Bölte et al., 2018)

Diagnosis

F84.0 Autism Spectrum Disorder, requiring very substantial support for social communication,

and requiring support for restricted, repetitive behaviors with accompanying language

impairment.

Prognosis

The child’s prognosis is guarded.

The prognosis is favorable because the child has:

1. Adequate parental support

2. Received timely intervention for the management of her symptoms

3. A stable and well-resourced socio-economic family background

4. No reported history of psychiatric illness in the family

The prognosis seems to be unfavorable because the child has:

1. Lack of a stimulating environment and effective management at home

2. A condition that is neurodevelopmental in nature.

Management

Short Term Goals

1. A strong therapeutic rapport will be established between the therapist and the child in

order to ensure that the therapeutic process is most effective and beneficial for the child.
2. The child’s parents will be psychoeducated regarding the child’s problem, diagnosis, and

the effective management of her symptoms at home.

3. Functional Behavioral Analysis will be conducted in order to identify the possible

antecedents and reinforcing consequences that are maintaining the child’s problematic

behaviors.

4. Compliance training and command following will be encouraged in the child through the

use of direct, clear and concise commands which are easy for the child to understand and

follow. This will ensure that the long-term therapeutic process is smooth and effective.

5. Applied Behavior Analysis technique will be used to address the child’s problem

behaviors and encourage the acquisition of healthy, prosocial behaviors.

6. Behavior modification techniques, such as prompting and fading, shaping and

reinforcement techniques will be implemented throughout the therapy in order to reduce

the frequency of problem behaviors as well as to address the child’s skill deficits and

teach her new skills.

7. Positive reinforcement will be used to strengthen the performance of desired behaviors,

such as eye contact, sharing objects, waiting for turn, remaining on-seat, and following

commands.

8. Differential reinforcement will be used to increase the occurrence of desired behaviors

and decrease the expression of undesired behaviors such as throwing objects and hitting.
 9. Positive behaviors will be encouraged through the use of response prompts, such as

physical, visual, gestural and verbal prompts, as well as through the use of stimulus

prompts.

10. Discrete Trial Training will be used to address attentional deficits using a series of trials

to teach each step of a desired behavior to the child.

11. Pivotal Response Training will be used to increase the child’s motivation to learn,

monitor their own behavior and initiate meaningful communication.

12. Eye contact and attention building exercises to increase sustained eye contact and

enhance attention during activities.

13. The child will be engaged in socialization activities with other children, through circle

time and group activities, to encourage healthy socialization with other children.

14. An Individualized Education Program (IEP) will be developed to cater to the child’s

unique learning needs in the various domains of socialization, attending skills, functional

skills, cognitive skills, motor skills and self-help skills.

Long Term Goals

1. Effective implementation of the short-term goals.

2. Providing an adequate level of psycho-education to the child’s parents in regards to her

symptoms, diagnosis and management techniques. Furthermore, the parents will be

encouraged to reduce his screen time and develop a stimulating learning environment for

the child at home.

 3. As the individual grows, plan for transitions from childhood to adolescence and

adulthood, ensuring appropriate support systems are in place.

4. Periodic evaluations and assessments help track progress and adjust intervention

strategies according to the evolving needs of the individual.

Proposed Therapeutic Interventions

Psychoeducation

Psychoeducation refers to the process by which the therapist provides adequate

information to the child’s parents or primary caretakers regarding the child’s symptoms and

diagnosis in order to enhance their understanding of the condition. The specific symptoms,

etiological factors, child’s prognosis, and the course of management is explained in depth. With

an adequate insight into the child’s problem, the parents can take greater responsibility and

assume an active role of participation in the process of management at home.

Rapport Building

Rapport building is an essential core condition in ensuring that the therapeutic process is

effective and beneficial for the child. Good rapport between the therapist and child is integral in

ensuring that the child feels comfortable and at ease in the therapist’s presence, and is open

towards learning.

Functional Behavioral Analysis

Functional Behavioral Analysis (FBA) is a process that helps in identifying the factors

that are maintaining problem behaviors by studying the antecedents and reinforcing

consequences surrounding that behavior. Identifying the antecedents and consequences that are
reinforcing and maintaining the problem behaviors can then aid in developing interventions to

help eliminate the problem behavior.

Shaping

Shaping is defined as the differential reinforcement of any successive approximations of

a target behavior, until the child learns to exhibit the target behavior. To effectively implement

shaping technique, it is important to first clearly define the target behavior to be worked on, and

then identify the starting behavior. Once a target behavior has been determined, every moderate

behavior change towards the target behavior is reinforced. It is essential to ensure the shaping

steps are not too large or too small, and that the behavior is reinforced at an appropriate pace.

Positive Reinforcement

Positive reinforcement is used to strengthen desirable behaviors by rewarding their

occurrence with reinforcing consequences or reinforcers. These reinforcers are administered

contingent upon the occurrence of the positive behaviors. (Miltenberger, 2012)

Differential Reinforcement

Differential Reinforcement technique involves the use of both reinforcement and

extinction to increase the occurrence of desirable target behaviors while at the same time

decreasing the occurrence of undesirable behaviors. This is achieved by reinforcing the desirable

behaviors each time they occur to increase their likelihood of being repeated in the future.

Simultaneously, the undesirable behaviors are not reinforced and are instead ignored, resulting in

a decrease in their likelihood of recurring.

Prompting
 Prompting is a technique that uses prompts to increase the likelihood of occurrence of a

desired target behavior, by acting as an antecedent stimulus or event that evokes the appropriate

behavior. Prompts are used to increase the likelihood that the child will engage in a certain

behavior at the appropriate times and situations. The types of prompts frequently used are

stimulus prompts and response prompts (Miltenberger, 2016).

Fading

Fading is the gradual elimination of the use of prompts to evoke a behavior, in order to

ensure that the behavior then occurs independently in the absence of any prompts. To complete

the teaching process, the use of all prompts is eventually completely faded. However, this

process is done gradually over time, through prompt fading and prompt delay.

Eye contact building exercises

As children with Autism Spectrum Disorder have deficits in maintaining eye contact and

attending to other people in social interactions, eye contact building exercises serve as an integral

part of their management. Eye contact is enhanced through the use of various techniques. When

the child attempts to grab the objects, the therapist can ask the child the look into their eyes

first.

Individualized Education Plan

An Individualized Education Plan (IEP) is a management tool that is used to address a

child’s unique learning needs. An IEP plan is a written document outlining a plan catering to the

child’s learning needs in various domains including socialization, cognitive skills, motor skills,

self-help skills and functional skills. The goals are set individualized to the child’s unique needs
and learning capability. The IEP can be used to ensure that the child receives the support and

resources needed for academic and functional success.

 References

Achenbach, T. M. A. (1999). Child Behaviour Checklist. APA Psychnet.

[Link]

Bölte, S., Girdler, S., & Marschik, P. B. (2018). The contribution of environmental

exposure to the etiology of autism spectrum disorder. Cellular and Molecular Life

Sciences, 76(7), 1275–1297. [Link]

Conners, C. K. (2003). Conners’ Rating Scales-revised CRS-R ; Technical Manual,

Parent Rating Scale, Teacher Rating Scale, Wells’adolescent Self-report.

Davis, N., & Kollins, S. H. (2012). Treatment for Co-Occurring Attention

Deficit/Hyperactivity Disorder and autism spectrum disorder. Neurotherapeutics, 9(3),

518–530. [Link]

Hermawati, D., Rahmadi, F. A., Sumekar, T. A., & Winarni, T. I. (2018). Early electronic

screen exposure and autistic-like symptoms. Intractable & Rare Diseases Research, 7(1),

69–71. [Link]

Mazefsky, C. (2015). Emotion Regulation and Emotional Distress in Autism Spectrum

Disorder: Foundations and considerations for Future research. Journal of Autism and

Developmental Disorders, 45(11), 3405–3408. [Link]

Miltenberger, R. G. (2012). Behavior modification: Principles and Procedures.

Rodgers, C. (2020). Continuous electronic fetal monitoring during prolonged labor may

be a risk factor for having a child diagnosed with autism spectrum disorder. Medical

Hypotheses, 145, 110339. [Link]

Schopler, E., Reichler, R. J., DeVellis, R. F., & Daly, K. (1980). Toward objective

classification of childhood autism: Childhood Autism Rating Scale (CARS). Journal of

Autism and Developmental Disorders, 10(1), 91–103.

[Link]

Senju, A. (2011). Spontaneous theory of mind and its absence in autism spectrum

disorders. The Neuroscientist, 18(2), 108–113.

[Link]

Zeliadt, N., & Spectrum. (2018, July 19). Study ties autism to maternal high blood

pressure, diabetes. Scientific American.

[Link]

pressure-diabetes/#:~:text=They%20pooled%20the%20results%20from,an%20increase

%20in%20autism%20risk.
Appendices