Child Psychpodiagnostic Report

Identifying information:
Client’s Name: M.Z
Father’s Name: M.Z
Gender: Female
Age: 5 years
Assessment Dates: (30 Sep,1,2,3,4 Oct, 2024)
Examiner: Hafza Pervaiz

Referral Source:
Child was referred to trainee clinical psychologist by the psychologist at Step Ahead
school with the presenting complaints of lack of eye contact, toe walking, animal voices and
lack of attention for psychological assessment and management plan.
Presenting Complaints:
Complaints Duration

Lack of eye contact ‫انکھيں ملا کے بات کرنے ميں دشواری ہے‬
Animal noises ‫جانوروں کی آوازيں نکالتی ہے۔‬
Toes walking ‫ايڑھياں اٹھا کے چلتی ہے۔‬
Lack of attention ‫توجہ نہيں دی پاتی۔‬

Clinical Interview:
A Clinical Interview was arranged with the client along with her mother. The
age of client was 5 years. She was referred by his mother with the presenting complaints of
lack of attention, animal voices, lack of attention and toe walking. When the child was two-
year-old, her mother noticed that she did not respond at all. The mother of client is a doctor.
She reported that she often gave him mobile phone to keep her busy in lockdown during the
days of covid-19.

At the age of two years the problems in client’s life were started when her mother
noticed that she was not responding like children of her age. She had developmental delays.
The mother of the client enrolled her to Step Ahead School, Jubilee town Lahore. She is
hopeful now that at this school her daughter will learn the basic skills that are necessary for
life.

Recently, she is not using any type of medications. She had no any other medical
issue at early childhood. She resists on eating food along with average sleeping pattern. She
cannot eat sweet dishes. She likes rice and chicken and is taking dietary supplements. She
had not any disability at the time of birth.

The family of the client had an upper-class socioeconomic status. The family system
of client was nuclear that was based on single family unit. The total members in the family
are 3. The father client is M. Z with an age of 37 years. He is an educated men and PhD
degree in the field of Mathematics. Currently, he is assistant professor in a university. The
relationship between the parents of client is good. The father of client was attached with her
and takes care of her. Client’s father had not any medical and psychological issues.

The age of client’s mother is 33 years. She is very concerned for the betterment of her
daughter. The mother of client loves her very much and she was graduated. Client’s mother
spends most of her time with client and always tries to improve her behaviors. Client’s
mother had no serious complications during the pregnancy and she had no medical and
psychological issues. The mother reported that she had C-section during birth with no any
major complications. The first cry of client was on time and she had a normal body weight of
2.5 kg. The developmental delays of the client include delayed speech, no response, no toilet
training and she walks on toes.

Clients has no siblings. The mother was the client reported that there was no any
physical and psychological history or illness in the family.

Test administration

 Vineland Adaptive Behavior Scale (VABS)

 The Childhood Autism Rating Scale(CARS)
Behavioral observation:
Client was looking normal from appearance. She was wearing salwar kameez and was
in good hygiene. The on- sit behavior of the client was not appropriate and she started to run
after 5 minutes. She was not making eye contact any time. She had lack of attention in all
activities. She was making animal noises. She pinched others in aggression. She sits on
ground if her desires when not fulfilled. She has difficulties with non-verbal cues such as
gestures, facial expressions, or body language. She had no speech. Furthermore, the she
4appeared to be dependent on parents for self-help tasks, indicating potential delays in
developing independence and autonomy. She was not cooperating during the performance of
test. She became rigid at all activities. She faced difficulty in both verbal and written
activities.
Psychological Evaluation
Table 1
 ABC & Domains (Sub-domains) Scores

SS VSS AE S&W AL
Domains &
Subdomains
Communication -
Receptive 1 0:4 W Low
Expressive 1 0:5 W Low
Written - <3:0 W Low
Daily life skills 47

Personal 1 1:2 W Low

Domestic 6 <3:0 W Low
Community 4 <3:0 W Low
Socialization 36
Interpersonal 1 0:0 W Low
Relationship
Coping Skills 7 0:0 W Low
Play & leisure 2 <2:0 W Low
Motor Domain
Gross motor 7 1:7 S Low
Fine motor 6 1:3 W Low
Adaptive 28
behavior
Composite

In above table SS=Standard Score, VSS=V Scale Score, AE=Age Equivalent, S &W=
strengths and weakness and AL=Adaptive Level.
Qualitative Interpretation:
The age equivalent in the sub domain of receptive is 4 months that indicated
low functioning level. Client communication skills are overall weak. In the sub domain of
expressive the age equivalent is 5 months and which indicated low functioning level. In the
subdomain of written communication, the clients age equivalent is less than 3 years which
indicates moderately low functioning level.
The clients’ daily life skills are overall weak. The age equivalent in the sub domain of
personal is 1 years and 2 months indicated low functioning level. The age equivalent in the
sub domain of domestic is less than 3 years that indicated low functioning level. The age
equivalent in the sub domain of community is less than 3 years that indicated low functioning
level. The subdomains of daily life skills are the weakness of child.
The socialization skills are overall very weak. The age equivalent in the sub domain
interpersonal relationship is 0 which indicated low functioning level. The age equivalent in
the sub domain coping skills is less than 2 years indicated low functioning level. The age
equivalent in the sub domain play and leisure is 0 which indicated low functioning level. The
client had poor social skills. All the subdomains of socialization are the weakness of client.
The motor domain of the client was overall low. The age equivalent in the sub domain
of gross motor is 1 year and 7 months. The age equivalent in the sub domain of fine motor is
1 year and 3 months. The gross motor skills are the strength of client and fine motor skills is
the weakness of client.
Table 2
The quantitative scoring of CARS is as follows;

Severity level at each item

Item Mild Moderate Severe

Relating to people ✔
Imitation ✔
Emotional Reponses ✔
Body Use ✔
Object use ✔
Adaptation to change ✔
Visual Response ✔
Listening Response ✔
Taste, Smell, Touch Response and Use ✔
Fear or Nervousness ✔
Verbal Communication ✔
Non Verbal Communication ✔
Activity Level ✔
Level and Consistency of Intellectual Response ✔
General Impression ✔

Qualitative Analysis:

The above table indicates the severity level at each of the different areas from
moderate to severe level. The total raw score is 50 indicating that the child is severe autistic.
She always avoids eye contact and forceful attempts are required for getting attention.
Emotional responses of the child are not appropriate to the situation. The body use of the
child involves toe walking. The child shows little interest in toys and was only fascinated by
the light reflecting the object. When the activity is changed the tries to do the same activity.
Listing response occasionally is delayed, child easily gets distracted by the sounds and
occasionally ignores the sounds or commands made. There are no verbal communications as
no meaningful speech is observed and only the voices of animals are observed. There is no
non-verbal communication as child only uses bizarre gesture with no apparent meaning. The
activity level of the child is moderately abnormal. The intellectual response is somewhat
lower to the children of the similar age.

Raw score Range

50 Severely Autistic

Tentative diagnosis
F84.0 Autism Spectrum Disorder Requiring Very Substantial Support, Severe
Prognosis:
The support from client’s family was the main factor for prognosis. Her parents have
insight about his problem and they are very much concerned about the treatment. Although,
client was unaware of her problems.

Conclusion:
M.Z is 5 years old with the presenting complaints of lack of eye contact, toe walking,
animal voices and lack of attention. She was diagnosed with F84.0 Autism Spectrum
Disorder Requiring Very Substantial Support.

Limitations
 The client was unable to perform Toni-4 as she had not any recognition of shapes.
 The client was unable to perform BGT as she had not pencil holding skills.
Recommendations
 The time period for sessions should be increased.
 The number of sessions should be increased.
 Assessment should gathered in separate room that will be free of distortions.

_______________ ____________________ ____________________

(Hafza Pervaiz) (Sadia Atif) (Dr.Khawer Bilal)
 MS Internee Internship Supervisor Head of department

Management Plan:

Name and age M.Z, 5 years

Presenting Complaints Lack of eye contact ,toe walking, Animal
noises ,Inattention
Test Administered ● CARS
● VABS

Tentative Diagnosis F84.0 Autism Spectrum Disorder

Requiring Very Substantial
Support ,Severe
Goals of therapy Short -term goals
 Rapport building with
the client.
 Psychoeducation of
family of client.
 Formation of IEP from
ABLLS
 Identifying the
strengths and weakness
of client
 Identify the
reinforcement of client.

Long-term goals
 Play therapy to help client learn
to interact with people in a way
that they understand about
playing
 Music therapy enable to assist
client in relating to her own and
others' emotions.
  Sensory integration to control
sensory input and help them better
manage sensory overload.
Number of sessions 6 sessions

Initial sessions
 Observation of client’s behaviors,
skills and interactions with others.
 Rapport building with the client.
 History was taken from parents
regarding developmental
milestones, medical history, family
history and history of problems.
 Psychological assessment to assess
the client’s severity level.
 Psychoeducation of family was
done for the better management
plan.

Middle Sessions

 Behavioral therapy was given to

client.
 Activities of daily living (ADL)
were introduced to client.
 Speech therapy was given to client.

Ending Sessions

 Present limitations and future

recommendations were given.
 Follow up sessions.
Individualized Educational Program (IEP)
Cooperation and reinforcer effectiveness
Task Objective Material
 She will wait without touching stimuli. we will use her rein forcers such as
 When the instructor gives instructions, hard object, Gym ball, squeezing
she will be able to respond quickly. ball, strings
 Looks to instructor for instruction Will work on eye contact, waiting
skills and turn taking

Visual performance
Task Objective Material
 When given an item the student does Use different pictures and objects.
match the object to one of three
pictures.
 She will match the picture to objects.

Receptive language
Task Objective Material
 She will follow the instructions for Reinforces list, hard object, Gym ball,
reinforcers. squeezing ball
 She will follow the instruction to
perform an action
 She will touch on body parts.

Motor Imitation

Task Objective Material

 She will imitate arm and hand Work on motor imitation (holding
movements. utensil, zipper board, pushing a
 She will imitate mouth and tongue car/toy)
movements. Clapping hands, stomping feet,
raising a hand.

Play and leisure skills/Social interaction

 Task Objective Material
 She will take interest in toys and also Use different colorful toys to develop
not in outdoor leisure activities. her interest in play. Daily practice of
 She will allow touch/manipulate her greetings. Practice with role playing.
things.

Writing skills/ Class room routine

Task Objective Material
 She will follow daily class room 1. practice of bag hanging open & close
routine. bottle lid
 She must sit and wait appropriately in 2. Use pincer gripper for pencil gripping.
class room routine. 3. Beading for fine motor skills
 She will trace the alphabets A till D
and numbers 1 till 5.

Gross Motor skills

Task Objective Material

 She will walk appropriately and also Use a walking track for appropriate
run smoothly. gait and also daily practice of
 She will jump forward. jumping. Climbing.
 She will catch and throw the ball.
 She will climb a ladder.
Fine motor skills
Task Objective Material
 She will transfer the objects into opposite Daily practice of fine motor skills.
hand. Coloring activities, Beading
 She will remove lids of jars.
 She will remove wrappers.

Task Analysis
Domain: Visual performance
Task: Maintenance of eye contact during interaction
 Sr No Procedure Days Success Prompts Mastery
5/5

1 Brief eye contact (1-2 sec) by 1 1 Physical+ verbal 20 %

pointing favorite toy.

Brief eye contact (1-2 sec) by 1 3 Verbal 30%

pointing favorite toy.

2 Increase frequency/duration 2 2 Physical +verbal 10 %

of eye contact (3-5 sec)

Increase frequency/duration 2 3 Verbal 20%

of eye contact (3-5 sec)

3 Practice during activities 3 1 Physical +verbal 20 %

Practice during activities 3 2 Verbal 40%

4 Increase duration (5-10 sec) 4 1 Physical +verbal 20%

Increase duration (5-10 sec) 4 3 Verbal 40%

5 Independent eye contact 5 2 Reinforcement 30%

without prompt
Independent eye contact 5 3 Reinforcement 50%
without prompt

Task Analysis 2
Domain: Class room routines
Task: She will follow daily class room routine.

Sr No Procedure Days Success Prompts Mastery

5/5

1 Walk to classroom door 1 1 Physical+ verbal 20 %

independently.
 Walk to classroom door 1 3 Verbal 30%
independently.

2 Hang the bag on the wall. 2 2 Physical +verbal 10 %

Hang the bag on the wall. 2 3 Verbal 20%

3 Open and close the zip of 3 1 Physical +verbal 30 %

bag.

Open and close zip of bag. 3 2 Verbal 40%

4 Identify assigned seat and sit 4 1 Physical +verbal 20%

down
Identify assigned seat and sit 4 3 Verbal 40%
down
5 Identification of book and 5 2 Physical +verbal 0%
pencil.
Identification of book and 5 3 Verbal 10%
pencil.