63

Summary

The client A was 7 years old girl. She belonged to a middle class family. She was born full
term following a normal pregnancy and delivery but her mother suffered from mild anxiety as she
had already two miscarriages. Her newborn screen and neonatal hearing test indicate that she had
low birth weight. She had delayed in walking, talking, sitting and other developmental activities.
She changed two schools because of her behavioral problem. Her previous school teachers
recommended that she don’t follows the direction. Her mother addressed that she was a good child
but she also shares that her tantrums prolonged when she denied to do some work. During these
tantrums she bang her head and sometimes bite her hand. Most of the time she didn’t likes to play
with her age fellow cousins. These symptoms and their period shows that she had suffering from
Autism Spectrum Disorder. For the assessment different psychological tools had applied which
includes Brief mental status examination (MSE), Autism Spectrum Screening Questionnaire
(ASSQ) form and Mini mental state examination (MMSE). Moreover, other assessment techniques
have also been employed such as clinical observation and clinical interview. The level of her
disorder was moderate. Psychological interventions including play therapy, Occupational therapy,
social skills and Applied behavioral Analysis (ABA) have been provided for management of
Austin spectrum disorder. Total 5 sessions were conducted with the client. After treatment
implementation some improvement in his symptoms were observed.
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Demographic Information

Name A.B
Age 7
Gender Female
Education 1 class
Family System Joint
Parents Both alive
Siblings 3
Birth order Middle born
Religion Islam
Residence Sargodha
Past psychiatry history of family None

Past psychiatry history of client Problems from developmental period

Source of Referral

The client was referred by his mother for assessment and management of her Presenting
complaints.
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Presenting Complaints

Table 1

Presenting complaints of client as reported by her are given below:

Duration Symptoms Presenting Complaints

5 years Inflexible interest ‫کام کو ایک ہی طریقے سے کرتی ہے‬

6 years Repetitive motor activities ‫بار بار ہاتھوں کو اوپر نیچھے ہالتی ہے‬

5 years Poor eye contact ‫نظر مال کر بات نہیں کرتی‬

5 years Sameness in routine ‫ہر روز ایک ہی طرح سے کام کرتی ہے‬

5 years Speech problem ‫زیادہ الفاظ بول نہیں پاتی‬

5 years Limited social interaction ‫زیادہ لوگوں سے بات نہیں کرتی‬

6 years Fail to respond on sensory stimuli ‫نام لینے کے باوجود جواب نہیں دیتی‬

5 years Repeat words ‫کچھ الفاظ بار بار دہراتی ہے‬

5 years Fixation on an object ‫ایک ہی کھلونے سے کھیلنا پسند ہے‬

5 years Specific food preferences ‫ہمیشہ جام اورڈبل روٹی کھانا چاہتی ہے‬
 66

Initial Observation

The client A.B was 7 years old girl. Her hygienic condition was good and she was
maintaining relaxing posture. Her hair was properly combed. She was wearing a clean dress. She
did not maintain proper eye contact during interview. He is continuously looking at surrounding
and also flapping her hands. Her behavior was not too much cooperative and talking style was
polite. She was bit resistant. She had no insight about his problems and also not willing to manage
it. Her orientation about time, people and place was intact.

Past Personal History

Her developmental milestones were not normal. She had delayed in sitting, speaking,
walking and other developmental activities. She had low birth weight but pregnancy and delivery
was normal. Her mother was suffering from mild anxiety because before A. she had two
miscarriages. Most probably it was one the reason.

History of Present Illness

She was suffering from autism spectrum disorder from last 5 to 6 years.

Educational History

6 months ago she attending specialized school and it was her third school.

Medical History

Due to delay in developmental milestone she had weak immune system.

Developmental History

Her developmental milestones were not normal. She had delayed in sitting, speaking,
walking and other developmental activities. Her birth was normal. Her mother faced anxiety issues
during pregnancy.

Drug History

There was no drug history of her.

 67

Family psychiatric history

There was no family psychiatric history present.

General Home Atmosphere

Her home atmosphere was good and all the family members were very cooperative.

Presenting Complaints Diagram

Inflexible
interest
Specific food Speech
preferences problem

Fixation on Sameness in
an object routine

Autism Spectrum Disorder

Repetitive
Repeat motor
words activities

Fail to
respond on Poor eye
sensory contact
stimuli Limited social
interaction
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Family History

Ms. A.B belongs to a middle-class family. She had 1 younger brother. Among siblings she
was lst born. She had strong relationships with her parents, brother and grandparents who were
supportive and caring to her. Her family members were very cooperative.

Genogram

M F

A.B

G.M G.F
B
 69

Keys Description

M Mother

F Father

B Brother

G.F Grand Father

G.M Grand Mother

Female

Male

Strong Relationship

Normal Relationship
 70

Assessment

Following psychometric tests were used to test his functioning.

• Brief Mental Status Examination (MSE)

• Clinical Interview
• Clinical Observation
• Autism Spectrum Screening Questionnaire (ASSQ)
• Mini Mental State Examination (MMSE)

Mental Status Examination (MSE)

The mental status examination (MSE) is a useful diagnostic tool in psychiatric practice.
MSE is a semi-structured method for describing a patient's mental state and behavior at a given
moment. Appearance, behavior, mood, emotion, speech, thinking process and content, perceptual
disturbances, memory, and insight and judgement are the major components of an MSE. An MSE
is conducted by a therapist who observes and asks specific questions about the behavior of the
person being interviewed. Diagnostic and therapeutic decisions are based on the findings of MSE.

Appearance

Ms. A.B, was wearing neat and beautiful dress and her hair were properly combed. She
had good hygienic condition.

Attitude

Her attitude was not too much cooperative and she shows a little bit resistance. She did not
maintain eye contact. She is always watching at the surroundings.

Behavior

She was constantly showing unusual movements.

Speech

Her speech was normal. Her tone was low.

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Affect

Her affect was labile.

Mood

She was having normal mood throughout the interview.

Thought Processes

Her thought processes were not too logical. She was not interested in any conversation
that’s why she had not answer most of the questions.

Thought Content

There were no signs of suicidal and homicidal ideation.

Perception

No hallucinations and delusions were present during the interview.

Orientation

She had fair orientation about time, people, place and about herself.

Memory/Concentration

Her short-term memory has some problems. There were distractions present with her
memory. She was not listening and responding attentively.

Insight/Judgment

She had poor insight about him and his surroundings.

Clinical interview

Clinical interview is a flexible research method that uses open ended questions to obtain a
lot of information from the clients. The purpose of conducting this interview was to know the cause
of his problems by getting the history of client from his early life to present state of life. Through
the interview his psychiatric, medical, developmental, educational, personal and family history
was taken. Her and her complaints and problems were explored through the interview. The client
was very uncooperative. We conduct interview from his mother. She willfully discussed his
 72

problems. Along with taking history from his past life events, his current life issues were also
explored through the unstructured interview.

Autism Spectrum Screening Questionnaire (ASSQ)

The ASSQ is a screening questionnaire for autism designed by Ehlers and Gillberg in
1999. The ASSQ is a 27 question assessment filled in by parents or teachers of children or
adolescents (6 to 17 years of age). It is designed to be an initial screen for Autism Spectrum
Disorder (ASD). The questionnaire is scored using a likert scale, with the following alternatives
for each item: “not true” (0 points), “somewhat true” (1 point) and “certainly true” (2 points). All
points are tallied up to produce a total score (maximum of 54 points).

Results consist of a total score between 0 and 54, where higher scores indicate that
many characteristics of ASD were reported. A score of 13 and above indicates ASD is probable.
 73

Table 2
Severity levels for autism spectrum disorder
Severity level Social communication Restricted, repetitive behaviors
Level 3 • Severe deficits in verbal and nonverbal • Inflexibility of behavior
“Requiring very substantial support” social communication skills. • Extreme difficulty coping with
• Very limited initiation of social change.
interactions. • Great distress/difficulty changing
• Minimal response to social overtures from focus or action.
others.
Level 2 • Marked deficits in verbal and nonverbal • Inflexibility of behavior.
“Requiring substantial support” social communication skills. • Difficulty coping with change.
• Limited initiation of social interactions. • Distress and/or difficulty changing
• Reduced or abnormal responses to social focus or action.
overtures from others.
Level 1 • Deficits in social communication cause • Inflexibility of behavior causes
“Requiring support” noticeable impairments. significant interference.
• Difficulty initiating social interactions, and • Difficulty switching between
clear. Appear to have decreased interest in activities.
social interactions. • Problems of organization and
planning hamper independence.
 74

Qualitative Interpretation

The client’s severity level of autism spectrum disorder is at level 2. She was facing some
kind of difficulties with language, learning and communication. She was not fully independent to
doing some tasks like motor skills.

Mini Mental Status Examination (MMSE)

The mini mental status examination is a brief screening tool that provides a quantitative
assessment of cognitive impairment and to record changes over time. The MMSE consists of 11
simple questions or tasks grouped into 7 cognitive domains; orientation to time, orientation to
place, registration of three words, attention and calculation, recall of three words, language and
visual construction.

Table 3
Quantitative Interpretation of MMSE
Questions Client’s score Maximum scores
Orientation to time 5 5
Orientation to place 5 5
Registration of three words 1 3
Calculation 3 5
Recall of three words 1 3
Language 1 2
Speaking 0 1
Motor activity 1 3
Visual construction 0 1
Learning 0 1
Drawing 1 1
Total 18 30
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Table 4

Qualitative interpretation of MMSE

Interpretations Scores

No cognitive impairment 24-30

Mild cognitive impairment 18-23

Severe cognitive impairment 0-17

Qualitative Interpretation

The client’s obtained score on MMSE was 18 which was under the category of “Mild
cognitive impairment”
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Table 5
Quantitative Interpretation of ASSQ
Statements No Somewhat Yes
is old-fashioned or precocious 0 1 2
is regarded as an "eccentric professor" by the other children 0 1 2
lives somewhat in a world of his/her own with restricted idiosyncratic 0 1 2
intellectual interests
accumulates facts on certain subjects (good rote memory) but does not really 0 1 2
understand the meaning

has a literal understanding of ambiguous and metaphorical language 0 1 2

has a deviant style of communication with a formal, fussy, old-fashioned or 0 1 2
"robot like" language
invents idiosyncratic words and expressions 0 1 2
has a different voice or speech 0 1 2
expresses sounds involuntarily; clears throat, grunts, smacks, cries or 0 1 2
screams
is surprisingly good at some things and surprisingly poor at others 0 1 2
uses language freely but fails to make adjustment to fit social contexts or the 0 1 2
needs of different listeners
lacks empathy 0 1 2
makes naive and embarrassing remarks 0 1 2
has a deviant style of gaze 0 1 2
wishes to be sociable but fails to make relationships with peers 0 1 2
can be with other children but only on his/her terms 0 1 2
lacks best friend 0 1 2
lacks common sense 0 1 2
is poor at games: no idea of cooperating in a team, scores "own goals" 0 1 2
has clumsy, ill coordinated, ungainly, awkward movements or gestures 0 1 2
has involuntary face or body movements 0 1 2
has difficulties in completing simple daily activities because of compulsory 0 1 2
repetition of certain actions or thoughts
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has special routines: insists on no change 0 1 2

shows idiosyncratic attachment to objects 0 1 2
is bullied by other children 0 1 2
has markedly unusual facial expression 0 1 2
has markedly unusual posture 0 1 2
Total score on the scale= 34

Qualitative Interpretation

Results consist of a total score was 34, which indicate that Ms. A. had ASD.
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Autism Spectrum Disorder 299.00 (F84.0)

Diagnostic Criteria

A. Persistent deficits in social communication and social interaction across multiple contexts, as
manifested by the following, currently or by history (examples are illustrative, not exhaustive; see
text):

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

approach and failure of normal back-and-forth conversation; to reduced sharing of
interests, emotions, or affect; to failure to initiate or respond to social interactions.
2. Deficits in nonverbal communicative behaviors used for social interaction, ranging, for
example, from poorly integrated verbal and nonverbal communication; to abnormalities in
eye contact and body language or deficits in understanding and use of gestures; to a total
lack of facial expressions and nonverbal communication.
3. Deficits in developing, maintaining, and understanding relationships, ranging, for example,
from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing
imaginative play or in making friends; to absence of interest in peers.

Specify current severity:

Severity is based on social communication impairments and restricted, repetitive patterns of

behavior (see Table 2).

B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two

of the following, currently or by history (examples are illustrative, not exhaustive; see text):

1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor
stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases).
2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or
nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions,
rigid thinking patterns, greeting rituals, need to take same route or eat same food every
day).
 79

3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong
attachment to or preoccupation with unusual objects, excessively circumscribed or
perseverative interests).
4. Hyper or hyporeactivity to sensory input or unusual interest in sensory aspects of the
environment (e.g., apparent indifference to pain/temperature, adverse response to specific
sounds or textures, excessive smelling or touching of objects, visual fascination with lights
or movement).

Specify current severity:

Severity is based on social communication impairments and restricted, repetitive patterns of

behavior (see Table 2).

C. Symptoms must be present in the early developmental period (but may not become fully
manifest until social demands exceed limited capacities, or may be masked by learned strategies
in later life).

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

areas of current functioning.

E. These disturbances are not better explained by intellectual disability (intellectual developmental
disorder) or global developmental delay. Intellectual disability and autism spectrum disorder
frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual
disability, social communication should be below that expected for general developmental level.
 80

Case Formulation

The client A was 7 years old girl. She belonged to a middle class family. She changed two
schools because of her behavioral problem. Her previous school teachers told that she doesn’t
follows the direction. Her mother addressed that she was a good child but she also shares that her
tantrums prolonged when she denied to do some work. During these tantrums she bang her head
and sometimes bite her hand. Most of the time she didn’t likes to play with her age fellow cousins.

She was born full term following a normal pregnancy and delivery but her mother suffered
from mild anxiety as she had already two miscarriages. Her newborn screen and neonatal hearing
test indicate that she had low birth weight. She had delayed in walking, talking, sitting and other
developmental activities. Her symptoms at the present time met the criteria for Autism Spectrum
Disorder 299.00 (F84.0) according to the DSM-5. The level of her disorder was moderate.

Factors that were the cause, maintaining the disorder and played role for her as protection from
getting disorder more severe were as follows:

Predisposing factors

There was developmental factor involved in his presenting problems. Her growth and
development were not normal.

Precipitating factors

Her mother anxiety and low birth weight contributed in her problem.

Protective factors

The support, positive climate and care of his family was acting as protective factor for her.

Maintaining factor

She was not having much social support from his friends and fellows. She has been
criticized by others for her shy personality and low mental age. Her sensitive nature was acting as
a maintaining factor for his disorder.
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Prognosis

She had poor insight about his problems and also not willing to solve these problems. The
major problem is that his disorder was a developmental disorder and mental age was low which
cannot fully recover but can overcome it. The chances of overcome the disorder is more because
it was not severe it was on moderate level which we can control by developing some degree of
self-care, acquire adequate communication and academic skills.
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Case Conceptualization

Presenting Complaints
Inflexible interest
Repetitive motor activities
Poor eye contact
Sameness in routine
Speech problem
Limited social interaction
Fail to respond on sensory stimuli
Repeat words
Fixation on an object
Specific food preferences

Maintaining Precipitating
factors Predisposing Protective
factors factors
factors
Lack of social Mother anxiety
support, criticized Developmental Family care and
delay and Low birth
by others support
weight

AUTISM SPECTUM DISORDER

Evaluation techniques
Outcomes
Management
• Mental status examination
techniques • Better mental and
(MSE)
physical health
• Clinical interview • Occupational
• Developed interest
• Clinical observation therapy
in social activities
• Early development and • Play therapy
• Improve Attention
home background form • Applied behavior
• Improve motor
• Mini Mental state analysis (ABA)
skills
examination (MMSE)
• Improve language
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Treatment

Treatment depends on the severity level of autism spectrum disorder and how much these
disorders affect’s the person’s ability to daily life functioning. The most common treatment for
autism spectrum disorder includes special education, occupational therapy and applied behavior
analysis.

Play Therapy

The child gains confidence and control over feelings and thoughts in the setting of the
playroom. The process takes place over time and allows the child to gain a better sense of self and
self-worth, which can replace challenging behaviors. Play therapy continues to be an effective
means to facilitate the counseling relationship and promote positive change for children. Given the
flexible conditions of play therapy and its uses, it can also be used to meet the needs of children
with disabilities. Play is one of the media through which the child can easily give expression to his
general and common tendencies. The importance of play in promoting healthy child development
and maintains strong parent bonds. An unstructured play is healthy and, in fact essential for helping
children reach important social, emotional, and cognitive developmental milestones as well was
helping them manage stress and become resilient.

Occupational Therapy

Occupational therapists (OTs) work with children in special schools to help them develop
functional skills for everyday life in the areas of self-care, life skills, school work and play.
Occupational Therapy focuses on the life skills each individual needs for their life, across the
environments where they spend time. Barriers to accessing typical experiences are overcome by
modifying the task or environment, or teaching new skills, step by step. When working with people
with intellectual disabilities or cognitive impairment, the OT brings knowledge of activity analysis
to break down tasks into component parts, and to identify what underlying skills and/or adaptations
are needed for greater independence and inclusion.

Occupational therapy services include fine motor skill development for hand function,
sensory processing support for a range of environments, and motor skills learning for leisure and
occupational tasks. The emphasis is often on life skills for greater independence: manipulation and
orientation skills for independent dressing (buttons, snaps, tying laces), money management skills
 84

including coin differentiation and value, food preparation skills such as using a knife to cut or
spread or using appliances safely, recognition of traffic signs and rules for navigating streets safely,
use of public transportation, and other independence skills for living at home and in the
community. Occupational therapy session could include sensory based play using swings, monkey
bars and obstacle courses, fine motor activities through board games and adaptive aides like the
iPad to enhance time management and visual attention. Sensory processing is the ability of the
brain to receive information from sense organs Such as the eyes, ears, joints, and skin, process it,
and help the body give an appropriate response.

There are some activities that child can perform during sessions:

• To develop fine motor skills (by brushing teeth, opening and closing zippers, putting a plug
into a socket, turning doorknobs, keys and locks, tying shoelaces).
• To develop gross motor skills (by running, jumping, throwing a ball, climbing stairs.
Caching a ball).
• To develop visual spatial skills (word searches, puzzles).
• To develop attention to task (by providing soft cushions, again and again pronounce his
name).

Applied Behavior Analysis (ABA)

Applied behavior analysis (ABA) approach utilizes two, well-researched learning theories. These
are: 1) Classical conditioning and 2) Operant conditioning. Applied behavior analysis (ABA) is a
form of therapy to treat issues with communication, motor skills, and behavioral disorders. The
American Psychological Association classifies ABA as an evidence-based practice, meaning it’s
been supported by the peer-reviewed literature as a form of treatment. Reduces frustration by
building skills gradually and using prompting and reinforcement to support learning. It is effective
way to teach many new skills.

Skills are systematically introduced in small steps. As one small skill is mastered, the next step
is introduced. Students learn by making simple associations between cause and effect. If they
respond correctly for that step, they are immediately rewarded. If they respond incorrectly.
Nothing happens. Following activities were Performed by using reinforcement technique:

• Play appropriately with toys

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• Respond to social-play initiations from parent/sibling/friend

• Assert self appropriately if sibling/friend tries to take something
• Take turns and share toys
• Follow basic rules of activities
• Clean up when requested by adult
• Stay with adult when going for community trips
• Put on shoes, socks and outer garments when going for outdoor activities

Limitations

There were following limitations in the present case study:

✓ There was not separate room for interview.

✓ The time was limited therefore only 7 sessions were managed.
✓ The home environment was not suitable for conducting interview.
✓ There was noise and interruption of other family members.

Suggestions

It was suggested to the client’s mother that she can try some of these techniques on daily
routine functioning that are likely to trigger symptoms:

✓ Practice gross and fine motor skill on daily routine.

✓ Get physical exercise or be physical activities on a regular basis.
✓ Eat a healthy, well-balanced diet.
✓ Participate in social situations by reaching out to people with whom you feel comfortable.
Develop positive attitude.
✓ Don’t sit him alone.
 86

Session Report

1st Session goals

The foremost and necessary step is to build good rapport and trusting therapeutic
relationship with the client. First session should base on 40 to 45 minutes which started from
interacting with the client. To reach the problem of a person it is important to assure that the
information client is sharing will be kept confidential.

Activity / Techniques

Providing safe environment, assuring confidentiality, Genuineness, acceptance and

empathy help to develop the trusty therapeutic relationship.

Performance

At first client was hesitant to talk and don’t pay attention. but with time she feels better and
start take part in conversation.

2nd Session goals

The assessment measures and tools were applied in second session to know more about clients.
Case history and presenting complaints were also inquired.

Activity / Techniques

In 2nd session Psychological tests were applied which are following

• MSE
• Clinical interview
• ASSQ
• MMSE

Performance

Her performance was good. She was cooperative and gave proper responses on measures.

3rd Session Goals

• Provide psychoeducation
 87

• Develop attention
• Improve self-esteem
• Improve confidence

Activity / Techniques

• Psychoeducation
• Reinforcement therapy

Performance

• Able to perform activities interestingly

• Self-worth feeling develop
• Attention develops

4th Session Goals

• Develop adaptive functioning

• Practicing fine and gross motor skills
• Practicing previous goals

Activity / Techniques

• Play therapy
• Occupational therapy
• Applied behavior therapy

Performance

• Communication skills develops

• Small motor skills develop
• Language skills develop

5th Session Goals

• Develop problem solving skills

• Practicing all previous skills
• Terminate session
 88

Activity / Techniques

• Play therapy
• Occupational therapy
• Applied behavior therapy

Performance

• Problem solving skills develop

• Other skills practice was strong