Assignment: Prepare a Management Plan for the following case as a

Rehabilitation Psychologist

Socio Demographic Details:

Name: K.S
Age: 7 years 2 months
Date of birth: 14 October 2014
Sex: Male
Education: Enrolled in play school
Socio economic status: low SES
Family type: Joint family structure
Domicile: Urban
Religion: Hinduism
Informant: Father and Mother
Information: Adequate and Reliable
Source of referral: AFCME

Chief Complaints:

According to the informant (Parents):

‘’Do shabadon mein baat karta hai sirf’’……since birth
‘’ Baat nahi suntan’’…… since birth
‘’ Apne mein khoya khoya rehta hai’’…..since birth
‘’ kabhi hasne lagta hai kabhi rone lagta hai” ….. since birth
‘’Routine mein kuch bhi idhar udhar ho toh rone lagta hai’’……since birth
History of Presenting Illness:
The child was born to a non consanguineous parents after a full term pregnancy
through a normal vaginal delivery at hospital. No pre natal complications were
reported in the pregnancy and the mother’s age at the time of conception was 20
years . The father reported that the birth cry was immediate and the birth weight
was 2kg 50 grams. The child has never sustained a traumatic brain injury and all
immunizations were administered to the child at appropriate ages. The
developmental milestones of the child were delayed. Gross motor milestones
were achieved on time as the child learnt to support his neck at the age of 3
months, started sitting without support after 6 months, rolling from back to
stomach at after 6 months, crawling after 10 months, walking without support
after 1 year 3 months and running after 1 year 6 months. The fine motor skills
however were nit achieved on time he could not follow the moving objects like
moving pencil with eyes and hold pencil with thumb and finger till 7 years of
age. There was a delay in the attainment of speech milestones as the babbling
appeared when the child was approximately I year and began to say mumma
and dadda by the age of 1 year 5 months, still cannot make full sentences and
uses telegraphic speech.
The father reported that when the child was 9 month old he had a seizure during
which the child use to cry and take deep breaths followed by body turning blue
and the stiffness in hands and legs and in response the parents use to turn the
child upside down as suggested by the local doctor that it helps the oxygen
reach the brain followed by which the child use to sleep. Whenever the child use
to cry and had a seizure episode the parents use to turn the child upside down.
These episodes continued for three years. At the age of 3 years the child was
taken to AIIMS hospital where tests were administered for hearing, seizure, a
syrup following which no seizure like episode was reported.
After 3 years the child was sent to a play school near his place where the teacher
reported that the child does not respond when called, keeps talking to himself
and even after clapping hands in front of him he does not maintain eye contact
and pays attention. The teacher advised the parents to put the child in special
school as that might help him. The child was again taken to AIIMS hospital
where he was diagnosed with autism by Dr. Nitika in the year 2018. The parents
also reported that the child has higher threshold for pain as they narrated an
incident when the child was 4 years old he fell down with the bicycle and got
injured in the head with blood coming out of the wound and he neither did cry
or react to it at all at. He has extreme tolerance for pain and did not even realize
that he has sustained an injury.
The parents reported that since the child was a toddler they have always felt
something different about the child’s response pattern to stimuli as he would
never make an eye contact with anyone, social smile never appeared, was
always within himself and he would ignore instructions and would not respond
when parents tried to interact with him and would not seek attention from his
parents neither would be affected when parents left the toddler alone for
extended periods of time. At 3 years of age the child also use to flap his hands
and this hand flapping continued for 2 years till the age of 5 years. At the age of
2 years the child also use to slap himself and cry. Since the child has learnt
walking the he also spent a lot of time walking around the house which was
quite unusual for the parents and also had an unusual sleep pattern as when the
child was 2 years old he use to sleep at 2 am in the night and get up around 7 in
the morning and did not sleep during the day. Toilet control was also not present
till 2 years and 6 months even though the parents tried to toilet train the child.
Since childhood the child has shown preference to indulge in isolated activities
of play and does not feel comfortable around other individuals except his
parents such as he leaves the room and tries to hide himself whenever the guest
is around. From 5 years of age he also watches the same movie everyday and
spends at least one hour daily listening to the set up box advertisement. From 3
years of age he has extreme attachment to old car keys and always keep it in his
hand and even sleeps with the car keys and gets annoyed if someone even tries
to touch it. Whenever chips, biscuits and lays are brought to the child he reacts
to it by smelling it since four years of age and smell every biscuit before eating
it. At 3 years of age the child also started displaying echolalic speech that is in
school he use to repeat everything the teacher said such as ‘’book nikalo’’. The
parents also reported that he is good in remembering directions as when he was
3 years old once he could come back from the play school on his own and can
also accurately tell which room we were sitting in the NIMH.
Since the age of 5 to 6 years, the child has been experiencing extreme difficulty
with sitting in his chair as he frequently gets up from his place and keeps
walking through out the room despite being reprimanded by his parents and was
also walking in the room throughout the clinical interview. He is very fidgety,
restless and unable to sit still and since 6 years of age the parents have also
complained of the temper tantrums and aggressive behavior as he often push
back his parents when they do not do anything that he desires or when there is a
minor change in his routine. Since the 6 years of age the child has been on
speech therapy and occupational therapy for 45 minutes session per day but the
parents have not reported any progress or improvement. Presently the parents
also complained that his emotions are also inappropriate as ‘’kabhi bhi hasne
lagta hai kabhi bhi rone lagta hai ‘’ and this was also evident during the
behavioral observation as he was crying without reason. At five years of age the
parents also reported that the child talks a lot to himself and uses one words that
have no meaning. Currently the child cannot read, hold pencil, can just scribble.
The child was again referred to AIIMS hospital three months back where a
senior resident doctor prescribed him Rhesperidone and Valprax and his
behavior and sleeping pattern has improved since then and the parents
approached NIMH for certification purpose. He has to be currently assisted with
activities of daily living such as brushing his teeth, combing his hair, eating and
bathing.

Illness Specifiers:
Onset: Since Birth
Course: Continuous
Progress: Static
Duration: Since birth (7 years 2 months)

Negative History:

No history suggestive of:

• Traumatic brain Injury
• Use, abuse or dependence on alcohol or any other substance
• Hearing voices, or seeing or feeling things in awake state which are not
present
• Presence of fixed false beliefs held with conviction
• Preoccupation with having or acquiring serious illness
• Infections
• Locomotor, visual and speech impairment
• Recurrent attacks of severe anxiety not restricted to any situation
• Fear of objects or places from which escape might be difficult or
social situations in which the individual is exposed to possible
scrutiny by others.
Past History:

Past Medical History: History of seizures at nine months of age for

three years which stopped after 3 years following the medications.
Past Psychiatric History ; No significant psychiatric history reported.

Treatment History:

The child is currently seeking pharmacotherapy, occupational therapy and

speech therapy.
Pharmacotherapy: The child has been prescribed tablet Rhesperidone, Valprax
and since past three months. The parents have reported significant improvement
in his temper tantrums after beginning with the medication.
Speech therapy: Speech therapy started at 6 years of age at Faridabad Speech
and Hearing Centre and the child visits the centre for 45 minutes five days in a
week and the informant reported no significant improvement as he still uses
telegraphic speech.
Occupational Therapy: The child visits the centre for occupational therapy
once a week and the informant reported slight benefits in sitting tolerance, even
though he does not participate in activities enthusiastically.

Family History
Family history of Psychiatric illness:
No significant history of psychiatric illnesses was reported in the family.
Although there is a history of substance use by the father.
Home environment:
The child currently lives in joint family structure along with his parents and
grandparents. His father is into property business and mother is a home maker.
The child has been reported to be unresponsive and unattached to both his
parents and mostly is occupied with himself, as if he is lost in his own world.
The informant reported that the child seems aloof and distant and is also unable
to warm up with his brother and grandparents. Parents reported to share a
cordial and amicable relationship amongst themselves. They have prioritized the
child’s needs and education and always intend to provide him with best care and
treatment.
Relationship with parents:
The child spends most of his time with both the parents and they have also tried
to provide him training from the beginning for better socio adaptive functioning
such as toilet training and language but the child has not been able to benefit
from the same. The parents often do not give into child’s demands and as the
child is growing up they have changed their parenting style to be slightly firm to
bring his aggressive behaviour and temper tantrums under control. Although,
the style of punishment is not punitive or overly harsh.

Family’s Attitude towards the Child:

The parents know that the child has been diagnosed with the autism but they do
not appear to be psychoeducated regarding the condition and it’s etiology. They
have not expressed a critical, hostile or judgemental attitude towards the child
and are supportive of his condition. They have suffered financial stress due to
seeking different therapies and treatment modalities for the child. Overall, they
have been cooperative and adherent with the recommendations made by regular
occupational and speech therapists.

Personal History:

Birth History: The child was born through a full term normal vaginal delivery
in hospital with immediate birth cry, mother’s age at the time of conception was
20 years and the father reported stress during her pregnancy and frequent
vomiting after third month of her pregnancy, the child suffered seizures when he
was nine month old and his birth weight was 2kg 750g. No significant
infections were reported during his childhood and all immunizations were
administered to the child on time.
Developmental History:

Motor development Socio emotional Language and

development speech
development
 Neck holding:4 months Social smile Absent Cooing 2 years
Rolling Over: 6 months Recognizes mother after 1. Babbling 2.5 years
5
years
Sitting: after 6 months Responds to name 2 years First words 2 years
Crawling; after 10 Making eye contact absent Two words2.6 years
months
Standing without Peer relationships No Simple sentences uses
support; interaction with peers telegraphic speech
after 10 months
Walking without Solitary play frequent, Colour naming not
support; after 1 cannot engage in achieved yet
year cooperative play with
other children
Impression:insignificant Impression: Delay in Impression significant
delayin achievement of achievement of socio delay in achievement
motor milestones emotional milestones of speech and
language milestones

Academic History: The child was enrolled in a play school at three years
of age after the seizures stopped and the teacher reported that he spends
a lot of time alone, does not interact with the peers and does not even pay
attention to anything even when pointed out and advised the parents to
get him admitted to a special school after which the child was diagnosed
with autistic features and was not admitted to any school after that.
Currently the child can just scribble and cannot read, write and draw.
Relationship with peers: The child is unable to initiate conversation with
either peers or parents. He mostly stays aloof and shows no interest in
activities that others are performing. When others approach him for play,
he does not respond and remains indifferent.
Activities of daily living: The child needs assistance with activities like
bathing, brushing teeth, combing his hair, dressing. He is toilet trained
and achieved bladder control at 3 years of age. He is unable to perform
minor household chores or follow instructions.
Temperament

The following is the detailed description of the child’s temperament on 9

dimensions:
 Dimensions Description Impression
Activity level Level of motor activity High (the
demonstrated by the child child
was
physically
active)
Rhythmicity Regularity of bodily Regular
functions: eating, sleeping pattern etc.

Distractibility Influence of distractions in the Distractible

environment on child’s
behaviour

Approach/ Initial response to a new Negative

withdrawal stimuli in the environment
Adaptability Getting accustomed to Not adaptive
prolonged changes in the environment (eg.
School)

Attention span Sustaining attention while Short

and performing a task
persistence
Intensity of Energy level of response Intense
reaction when an error is made (eg temper tantrums)

Threshold of Stimulus intensity required for eliciting a Low

responsiveness response from
the child

Quality of mood Overall mood state Indifferent

Overall impression: Difficult child

Behavioural observation:

The child appeared to be well kempt and groomed. His interaction with
the examiner was very limited and he only once made the eye contact
with the examiner when he was asked repeatedly by the informant. His
gait and posture were normal.
Reaction time was delayed as he did not follow the instructions of the
examiner. Eye contact was not maintained. Psychomotor agitation was
observed as the child kept frequently getting up from the chair and was
walking in the room throughout the clinical interview. He was very
fidgety and restless. His affective behaviour was inappropriate as he was
found to be crying and smiling after some time for no apparent reason.
He was only found to be verbal when he was vocalizing meaning less
words throughout the interview. Attention was aroused with difficulty
towards the examiner but was not sustained and the child was found to
touch his genital area frequently. Rapport could not be established and
the child’s comprehension of instructions was inadequate.

Diagnostic formulation:
K.T., 7 year old male, living in a joint family, with history of seizures at 9
months and delays in the attainment of motor and speech milestones was
accompanied by his parents with the complaints of telegraphic speech,
aloofness, solitary play, inappropriate emotions, absent eye contact, intolerance
to changes in routine, low intensity to pain, increased hyperactivity and
restlessness, inattention, difficulty in joint attention, temper tantrums, echolalic
speech, restricted range of interests and deficits in reciprocal social
communication with an onset since birth, continuous course and static progress
that is varying across symptomology. Behavioural observation revealed absent
eye contact, poor attention, echolalic speech, use of meaningless words,
psychomotor agitation and inappropriateness of emotions.

Provisional diagnosis
F84.0 Childhood Autism Points in favour:
• Significant delays or deficits in the language and cognitive development
which are present in child.
• The child has moderate deficits in socio adaptive functioning
• Abnormal development manifested before 3 years of age
• Abnormality in reciprocal social interaction
• Restricted, stereotyped and repetitive repertoire of interests, activities and
behaviours
 • Presence of aggression, temper tantrums and sleeping disturbances
• Presence of echolalic speech and episodes of self injury (slapping
oneself)

Differential diagnosis:
F.90 Hyperkinetic Disorder:
Points against:
The diagnosis of pervasive developmental disorders take precedence when
features of hyperkinetic disorders, example inattention and hyperactivity are
present in a child with features of autism.
F.84.5 Asperger’s syndrome Points Against:
Significant delay in language and cognitive development

Psychological testing:
Tests administered and rationale for testing

Tests administered Rationale for testing

Vineland social maturity scale To assess the child’s level of socio
(VSMS) adaptive
functioning.
Developmental Screening Tool To assess the child’s development
Quotient
INCLEN Diagnostic Tool To confirm the diagnosis of Childhood
for Autism Spectrum autism and rule out other
disorder pervasive
developmental disorders
Indian Scale for assessment of To assess domain wise features of autism
Autism for
the certification of disability
Gessell’s Drawing Test of To screen for the intellectual functioning
Intelligence of
the client.
Tests results:

Vineland Social Maturity Scale

Domains of Social Age for Social Quotient Interpretation

VSMS Each for
domain Each domain
Self help General 52 months 41 Moderate deficit
Self Help eating 112 months 88 Dull normal
functioning
Self Help Dressing 88 months 69 Mild deficit
Self Direction 128 months 101 Average
functioning
Occupation 104 months 82 Dull normal
functioning
Communication 56 months 41 Moderate deficit
Locomotion 76 months 60 Mild deficit
Socialization 64 months 50 Moderate deficit

Impression on VISMS, the child obtained a social age of 2 years and 9

months. His social quotient was computed to be 39, which suggests that
he has moderate deficits in his social adaptive areas.

Development Screening test (DST):

On developmental Screening test, his developmental age was found to be
2 years 6 months and developmental quotient was 35 indicating moderate
deficits in developmental functioning.

Gessell’s Drawing Test of Intelligence:

On GDT, the child’s IQ was computed to be 60 which indicates mild
deficits in intellectual functioning.

On INCLEN Diagnostic Tool for Autism Spectrum Disorder (INDT

– ASD)
Through INDT – ASD, the other Pervasive developmental disorders were
ruled out and the child was diagnosed with childhood Autism

Indian Scale for assessment of autism (ISAA)

Following is the tabular presentation of the child’s performance on ISAA

Domains of ISAA Score

Social Relationship and reciprocity 33
Emotional Responsiveness 14
Language and communication 19
Behaviour patterns 16
Sensory Aspects 9
Cognitive Component 9

Impression:
On ISAA, the child obtained a total score of 100 which suggests that he has
mild autism (70 %) disability.