Content

Case report:1

Summary

Bio data

Reason and source of Referrals

Presenting complains

History of present illness

Background information

Family history

Personal history

Educational history

Psychological assessment

Informal assessment

Formal assessment

Diagnosis

Case formulation

Management plan

Summary of therapeutic intervention

Outcome of therapy

References

Appendices

CASE REPORT:2

Summary

Bio data
Reason and source of Referrals

Presenting complaints

History of present illness

Background information

Family history

Personal history

Education history

Psychological assessment

Informal assessment

Formal assessment

Diagnosis

Case formulation

Management plan

Summary of therapeutic intervention

Post assessment

Outcome of therapy

References

Appendices

CASE REPORT 3

Same as it above mention content

CASE REPORT 4

Same content as it is above mention

CASE Report
Client I.F was 11 years old boy who came with complaints of not maintaining eye contact, not

attending to his name, not sitting on a chair, playing in isolation and did not interact with anyone,

delayed speech, walking on his toes, being lazy, and fascinated with lights. Psychological

assessment was done on two levels. The informal assessment included a clinical interview,

behavioral observations, Portage Guide to Early Education (PGEE), and reinforcer identification.

The formal assessment included the Child Autism Rating Scale. On the basis of the assessment,

the client was diagnosed with 299.00 (F84) Autism Spectrum Disorder, (level II), requiring

substantial support, accompanying language impairment. The management of the client’s

problems was focused on using behavioral techniques to modify behavior. A total of 40 sessions

were conducted with the client. The behavior therapy was proved effective and there was

improvement in the client’s behavior.

Bio data

Name I.F.

Gender Boy

Age 11years

Date of birth 02-12-2013

No. of siblings 2

Birth order Last born

Informant Client’s mother

Reason for Referral

The client came to the Autism Resource Center with complaints of not maintaining eye

contact, for the assessment of his behavioral issues and diagnosis. playing in isolation and did

not interact with anyone, delayed speech. He was referred to the trainee clinical psychologist for

assessment and management of his problems.

Presenting Complaints

As reported by the client’s mother speech delayed, lack of social interaction odd behavior

(jumping) stereo type behavior, toe walking, fixed routine, not maintain eye contact.

History of Present Illness

According to the client’s mother, the client’s mother reported that he was restricted to

home for at least 2.5 years. He was provided with a mobile phone on which he used to spend

almost 5 hours daily. He liked watching Korean videos and songs. His mother reported that he

was just into his phone and did not respond to anyone. He was not even attracted to any toy and

used to put everything in his hand into his mouth. His mother reported that when they first

brought the client to the market along with them, he closed his eyes on seeing other people. He

started crying there and felt uncomfortable being in a crowd.

 The client did not maintain eye contact with other people and did not respond to anyone.

He had delayed speech and did not interact with anyone who came to his home. His mother

reported that he seemed to not even care about what others were doing or talking. He just

remained into himself and used to play in isolation.

The client’s mother reported that the client did not speak a single word. He did not even

do babbling. He used to tell his needs by holding his mother’s hand and pointing it to the thing

he needed. According to the client’ mother, the client was very lazy and he used to lie down on

the floor and saw lights. He did not play with other kids and liked to play in isolation. The

developmental milestones of the client i.e., head holding, sitting, crawling, and walking were

age-appropriate, but his speech was delayed. According to the client’s mother, the client was a

pampered child as he was born after 10 years gap of his elder brother. That’s why, the client’s

mother did not notice the client’s behavior as inappropriate. The client’s mother reported that a

relative of them observed the client and told them that his behaviors were not normal. He

recommended them to the center for clinical psychology. The client’s parents then took the client

to the Autism Center and was referred to the trainee clinical psychologist for the assessment and

management of his problems.

Background History

Family History

The client’s father F.A. was 43 years old, did Ph.D. in microbiology, and worked as an

Associate Professor. The client’s mother reported that the client’s father was calm and friendly

toward his children and the client had a congenial relationship with his father.

The client’s mother was 39 years old housewife. She did masters in chemistry. She

reported being calm in nature and used to spend time with the client. She used to play with the
client and the client seemed to have a healthy relationship with her. The client was more attached

to his mother than his father as his father used to stop him from doing certain things.

The client’s parents had an arranged marriage outside of their family. They shared a

congenial relationship.

The client had 2 siblings, one sister, and one brother. His elder sister was 17 years old,

studying in intermediate. The client’s mother reported that the client shared a satisfactory

relationship with his sister. The second-born brother was 14 years old, studying in matriculation.

The client’s mother reported that the client shared a satisfactory relationship with him. The client

did not play with his siblings and only liked to play with his mother.

The client lived in a nuclear family along with his parent and siblings. He belonged to an

upper-middle-class family. The client’s mother reported that the client shared a satisfactory

relationship with his father and siblings and a healthy relationship with his mother. The overall

home environment was reported to be healthy.

Family History of Psychiatric Illness

The client’s mother reported that there is no history of any fever, head injury,

dehydration. His paternal family is positive for ASD. There is history of depression psychiatric

illness and Down syndrome in maternal family.

Personal History

The mother reported that the length of term 9 month. The client was born through c-

section. His prenatal history was normal. His mother was report as diabetic. He had an

immediate cry, and his birth weight was normal. The client’s mother reported that she faced no

pre-natal or post-natal complications. She was not taken medicine in pregnancy. The child took

mother feed.The client achieved his developmental milestones such as head and neck holding,
sitting, crawling, and walking at the appropriate age. But, his speech was not achieved even at

the age of 3 years. He did not even produce sounds.

Table 1

Showing Developmental Milestones, Normal Age of Achievement, and Client’s Achievement Age

Developmental Milestones Normal Age of Achievement Acquired Age

(Gerber et al., 2010)

Head holding 4-6 months 6 months

Sitting 8-10 months 5-10 months

Crawling 10-12 months 10 months

Walking 12-18 months 18 months

Single word speech 8-12 months 4 year

Complete sentence 12-24 months Not Achieved Yet

Bladder control 2-3 years Not Achieved Yet

Bowel control 2-3 years 5 year

Dress without help 4 years Not Achieved Yet

Taking bath without help 4 years Not Achieved Yet

Educational History

The informal education of the client was started at home at the age of 2.5 years. His

mother and father were involved in the teaching process. The client’s mother used to rhyme the

poems with the client. The client also had a little concept of the “circle” shape. Besides this, he

did not have any concept of colors, alphabets, fruits etc.

Psychological Assessment

The formal and informal assessment was done to assess the client’s problems;
 Informal Assessment Formal Assessment

Clinical Interview Child Autism Rating Scale (CARS)

Behavioral Observations

Sensory Checklist

Portage Guide to Early Education (PGEE)

Reinforcer Identification

Informal Assessment

Clinical Interview. A semi-structured clinical interview was done with his mother in

which the personal, developmental, educational, and familial history was taken. A complete

account of the behavioral issues was taken. Verbal informed consent was taken and

confidentiality of information was ensured. From the interview, predisposing, precipitating,

perpetuating, and prognostic factors were identified which were helpful in determining the

diagnosis and the management of the client’s problems.

Predisposing Factors Precipitating Factors Perpetuating Factors Prognostic Factors

Genetic predisposition Delayed milestones Parent’s pampering Regular follow-up

Male gender Educated parents

Covid-19 restrictions

Excessive screen time

Behavioral Observation. The client was of normal height and weight. He was dressed

neatly in weather-appropriate clothes. During the sessions, it was observed that he was

responsive toward his name and did not maintain eye contact. The client was fascinated by the

light in the room. He remain in his seat and used to sit on the table to complete his ABA activity

task. Mouthing behavior was also observed in the client as he used to follow the command to

complete his task. He almost attend to any command of the therapist and was involved in playing
and recognized differentiate between small and big same and different object. His imitation is

almost good. He is contract to people.

Sensory Checklist. The sensory checklist was administered to the client to assess the

sensory issues he was having. There were seven sensory issues domains catered in the

assessment i.e., Tactile (touch), Gustatory (taste), Olfactory (smell), Visual (sight), Auditory

(hearing), Proprioceptive (body awareness), and Vestibular (movement/balance).

Reinforcers Identification. Some of the reinforcers were identified by asking the client’s

mother about his favorite activities and food while others were identified by observing the client

during the session while performing activities. During the session, the free-operant preference

assessment method was used in which the client was provided access to all the available stimuli

and was allowed to freely engage with any presented stimuli. The engagement was monitored

with the duration. It helped in identifying the most preferable reinforcer. Material reinforcers

were the most preferable reinforcers. Following this helped in identifying the hierarchy of the

most to the least preferred reinforcer. The reinforcers were identified to make it contingent on the

individualized educational plan and developmental tasks.

Negative Rein forcer Ruben(pony)

Edible Reinforcer Burger, lays

Social Reinforcer Praise (good job, good boy, wow), clapping

Formal Assessment

Childhood Autism Rating Scale (CARS, Schopler 1980). It is a behavioral rating scale

used for assessing the presence and severity of symptoms of Autism spectrum disorders. It

consists of 15 domains, with each scored on a rating scale from 1 to 4. The total score ranges

from 15 to 60. It has .94 internal consistency and a reliability of .71. It was administered by
asking the client’s mother and observing the client during the session. The childhood autism

rating scale was administered to assess the current functioning level of the client. The scores

showed that the client had mildly-moderate autism. (Appendix)

Table 4

Raw Scores, Range, and Corresponding Category on Childhood Autism Rating Scale

Raw scores Range Category

36 30-38 Mildly-moderately autistic

The scores on CARS indicated his high scores in the item no. 2, 3, 5, 8, and 11 that

included moderately abnormal imitation, emotional response, object use, listening response, and

verbal communication. The client’s scores fall in the category of mildly to moderately autistic.

Summary of Psychological Assessment

During the interview, it was revealed that the client had some repetitive behaviors, had

problems interacting and communicating, did not maintain eye contact or attend to his name, and

had sensory issues. These symptoms indicated the client’s autistic behavior. Sensory checklist

was administered that showed the client’s gustatory, olfactory, and auditory sensory issue. The

formal assessment was done using the Childhood Autism Rating Scale. The scores on CARS

indicated his mildly-moderate autism.

Diagnosis

According to DSM-V criteria and keeping in view the observation and assessment, the

client was diagnosed with 299.00 (F84) autism spectrum disorder, (level II), requiring substantial

support, accompanying language impairment.

Case Formulation
 The client I.F. was 11years old boy who came with complaints of not maintaining eye

contact, not responding even if called his name 10 times, , playing in isolation and did not

interact with anyone, not doing his self-help tasks, walking on his toes, not speaking a single

word, being lazy, and fascinated with same object. Psychological assessment was done on two

levels. The results on PGEE indicated deficits in language, motor, socialization, self-help, and

cognitive domain. The scores on CARS indicated mildly-moderately autistic in the client. These

results helped in diagnosing the client with an Autism Spectrum Disorder.

The client was not diagnosed with intellectual disability as he had specific repetitive

behaviors that were a feature of Autism. Moreover he was able to memorize the tasks learned

and was able to perform it in the correct way. He learned his tasks efficiently. He was not

diagnosed with the language and social communication disorder as he had restrictive and

repetitive behavior that were absent in this disorder. The client was not diagnosed with

stereotypic movement disorder as the repetitive behavior was better explained by autism

spectrum disorder. He did not meet the criteria for disorders other than Autism Spectrum

Disorder (DSM, 2013).

The client was born via cesarean delivery. Research has indicated that cesarean delivery

was associated with a 26% increased risk of causing autism in the child either due to stress or

some other possible explanation (Chang, 2011). In addition, the client was a boy which also

increased the incidence of having autism as research has indicated that autism spectrum disorder

was four times more common in males than females (Maenner et al., 2020).

The client’s history revealed delayed development of milestones. According to Tager-

Flusberg (2016), most children with autism are found to have delays in achieving milestones,

especially the onset of words, phrases, and sentences is delayed. They have problems with
receptive and expressive language due to processing deficits. It has also been found that children

with autism had difficulties in understanding and responding appropriately to others. They

demonstrate problems with motor control (Cook et al., 2013).

It has been found that the client had sensory issues. These issues were related to sensory

processing. It has been found that over 96% of children with ASD reported hyper and hypo-

sensitivities in multiple domains which ranged from mild to severe ranges (Crane et al., 2009).

Management Plan

The management plan based on behavior techniques was devised to deal with the

idiosyncratic needs of the client.

Short Term Goals

Table 5

Short Terms Goals with Behavioral Interventions and Activities Used

Short Term Goals Behavioral Interventions Activities

Rapport building

 To engage with the child Floor time technique Playing with the lightning

 To gain the attention and trust Commonality, toys, Clapping, Smiling

of the child reinforcement, while giving a toy

Mirroring

Psychoeducation

 Understanding of diagnosis, Discussion

prognosis, and treatment

 Understanding of skills

development

Parental training
  To increase eye contact, on- Discussion of the

seat behavior, attending, management plan and

compliance, and imitation different techniques

 To deal with sensory issues Observation of session

using behavioral techniques while applying techniques

and positive parental

strategies

Sensory issues management

training

 Oral-related (mouthing) Differential Sucking toys

reinforcement of Lollipop

alternate behavior,

Verbal prompts,

modeling

 Auditory Response prevention

Physical restraint

IEP Development

 To work on early readiness Positive and differential

skills, developmental skills, Reinforcement, Prompting,

academic skills shaping, and modeling

Long Term Goals

  Individualized Educational Plan will be continued for establishing and improving early

readiness, and developmental and academic skills.

 Speech and language therapy will be continued for the management of his speech-related

issues.

 Behavioral techniques will be continued to be used by his mother to deal with the

problematic behaviors and for strengthening the appropriate behaviors.

Summary of Therapeutic Interventions

Rapport Building. Rapport building was done in the initial sessions to establish an

effective therapeutic relationship with the client. It was done to make the client comfortable and

to develop trust in the therapist. The techniques used were floor time technique, commonality,

mirroring, and reinforcement.

The floor time technique is a relationship-based therapy for children with autism. The

intervention is called Floortime because the therapist gets down on the floor with the child to

play and interact with the child at their level. This was done by sitting on the floor with the child

and playing with his favorite toy. The positive reinforcement was used during playing with the

client.

Commonality is a technique of deliberately finding something in common with a person

in order to build a sense of trust and friendship (Tickle-Degnen & Rosenthall, 1990). This was

accomplished through expressing shared preferences for certain toys and foods. He was drawn in

by using a lightening toy.

Mirroring is a nonverbal method when a person imitates another person’s body language,

vocal characteristics, or attitude. It usually indicates curiosity or perhaps attraction and is

frequently done unconsciously. It is a potent form of nonverbal communication (Pease & Pease,

2005). When playing with toys, the client’s motions and gestures were replicated.

Psychoeducation. It is a crucial step in the therapeutic process. Psychoeducation (PE) is

defined as an intervention with the systematic, structured, and didactic transfer of knowledge for

an illness and its treatment, integrating emotional and motivational aspects to enable patients to

cope with the illness and to improve its treatment adherence and efficacy (Ekhtiari et al., 2017).

The client’s diagnosis, its primary symptoms, and the variables influencing the prognosis rate

were explained to the client’s parents in order to provide them with some psychoeducation about

the disorder. Additionally, they were informed about the management strategies and how they

could contribute to the therapeutic activity’s success.

Parental Training. Parental training was done to guide the behavior modification

techniques that would help in the development of skills in the client. The mother was trained to

deal with the behavioral issues of the client. During each session, ten to fifteen minutes were

reserved for the mother in which she was trained to deal with the behavioral issues and her

concerns regarding the application of techniques were catered. The mother was also asked to

observe some of the sessions to have an idea to apply the techniques. She was asked to conduct a

formal session with the client at home. She was shown how to conduct a session at home, and

was informed about the required material such as colored balls, similar objects, reinforcers, and

pegboards. The techniques taught were differential reinforcement of alternate behavior, positive

reinforcement, verbal and physical prompts, joint attention, modeling, and extinction along with

the concept of extinction burst and stimulus control.

Individualized Educational Plan. An individualized educational plan is a written plan

for parents, teachers, and school administration to work together to design instructions,
accommodations, and services for children with special needs (Kamens, 2004). They all work

together to meet the needs of the individual requiring a range of support. The goals based on the

child’s current needs and skills are developed (Dotson, 2016). It was formed to meet the

idiosyncratic needs of the client. It was made to develop and strengthen early readiness skills,

and developmental skills which included cognitive skills, language skills, socialization skills,

self-help skills, motor skills. The work on the individualized educational plan was continued

throughout the sessions and his mother was asked to work on it at home as well. The early

readiness skills that were worked on included increasing on-seat behavior and eye contact,

increasing the response to his name, imitation and attending. The tasks focused on providing

things to the client by maintaining eye contact with him, pointing to one body part, imitating

high-five, hand shaking, and bye-bye, attending to his name, following the commands of start

and stop, give me, and take it.

The eye contact and response to name was increased using reinforcers, verbal and

gestural prompts and differential reinforcement of alternate behaviors. Prompting is a method of

providing a clue to the person about the next step to be done. Prompting can be verbal, gestural

or physical. Verbal prompting usually consists of giving a directive command about the next

step. Most-to-least intrusive prompting is usually followed, which means that the teacher starts

with maximal support and ends with minimal prompting (Miltenberger & Perkins, 2020). To get

the attention of the client, his favorite activities were used which were playing with the lighting

toys. He was given reinforcement for sustaining attention and completing the tasks. The side

gaze of the client was managed by using tunnel vision. The side of the eyes was blocked either

by placing hands on the side of his eyes or using objects on the sides so that the client could look

straight in front of him and at the tasks in front of him. The attending to his name was increased
using these activities and snacks. He would attend the therapist mostly on the account of getting

the lightning toy or lays. This positive reinforcement technique proved to be helpful.

The on-seat behavior was increased using physical restraints and differential

reinforcement of alternate behavior. The client was made to sit on the seat in the corner of the

room and he was blocked using the table. He was unable to get out of the seat and even if he

tried, he was verbally asked and physically forced to sit back on the seat.

The compliant behavior was achieved using physical and verbal prompts, modeling, and

differential reinforcement of alternate behavior. The task was modeled and then the client was

asked to do the same. One-word and two-word commands were used such as stop, start, give me,

put there, and not now. Social and edible reinforcers were provided for the complaint behavior.

The client was asked to place the toys in a toy box and place the rings in the stacker. This was

done while keeping the edible reinforcer in the therapist’s hands. He was not given until he

completed the tasks. After the completion of each activity, the client was given some of the

snacks

The sensory issues were dealt with by educating the mother about the alternatives.

Differential reinforcement of alternate behavior, physical restraints, and verbal prompts were

used for this purpose and the appropriate response was positively reinforced. During the session,

verbal prompting and differential reinforcement for alternative behavior were employed to

address these sensory difficulties. It is a procedure that entails reinforcing a behavior that serves

as a viable alternative for the problem behavior but is not necessarily incompatible with the

problem behavior (Speigler & Guevremont, 2015). The client was provided with the sucking

toys and lollipop for the management of his mouthing behavior and physical restraints and
response prevention was used for the management of his behavior of putting fingers into his ears

on hearing loud noise.

Structure and Style of Sessions

Forty structured sessions were conducted with the client. Each session had been of half

an hour to 45 minutes. The initial 15 sessions were of one hour. The sessions included history

taking, observations, assessment, and management of problematic behaviors. The last ten to

fifteen minutes of each session was reserved to discuss the concerns of the mother and to train

her to deal with the problematic behaviors. The sessions were conducted in a collaborative

manner involving the mother along with the trainee in dealing with the client’s problems.

Post Assessment

The post-assessment of the behavioral problems was done to gain an understanding of the

progress made by the client.

Post-Assessment of Individualized Education Plan

Table 6

Skills, Pre-Assessment, and Post-Assessment Mastery Level on IEP Tasks

Skills Mastery Level

Pre- Post Assessment

Assessment

Early readiness skills

Eye-contact

Looking into eyes and responding when called by 0% 40%

name

On-seat

To remain seated for 10 minutes 20% 80%

To remain seated for 15 minutes 10% 70%

To remain seated calmly for 30 minutes 0% 70%

Attending

Looking at the therapist when asked “look at me” 0% 40%

Responding to his name 0% 50%

Giving commands to focus on a task (look here, 0% 60%

complete this, finish it)

Using gestures and pointing at the task to complete it 0% 40%

Imitation

Imitate handshake 0% 70%

Imitate clapping 0% 70%

Compliance

Following one word command 0% 60%

Following two word command 0% 50%

Developmental Skills

Socialization

Smiles and vocalizes to mirror image 0% 60%

Seeks eye contact often when attended for 2-3 min 0% 50%

Claps hands in imitation to adults 0% 70%

Waves bye-bye in imitation of adult 0% 70%

Self-help

Holds bottle without help while drinking 10% 60%

Takes spoon filled with food to mouth without help 10% 80%
 Cognitive

Performs simple gestures on request 0% 70%

Points to one body part 0% 80%

Points to self when asked ‘where’s (name)? 0% 20%

Motor

Turns door knobs, handles etc. 20% 80%

Sensory Issues Management

Avoiding mouthing of inedible objects 0% 40%

Stop putting his fingers into his ears on hearing loud 10% 50%

noise

Outcome of Therapy

The therapy proved to be helpful in improving early readiness skills of the client. The

individualized educational plan was designed for the client. The on seat behavior and compliance

of the client was improved and eye contact was also maintained a bit. Some of the tasks were

achieved by practicing during the sessions and at home. The client was able to show a little

compliance towards the commands, started cooperating with the requests, and pointed some

objects. He started responding to his name a little buy, imitating simple gestures of an adult, and

doing handshaking and bye-bye in imitation. The client showed progress during the sessions.

The client’s mother also reported his better behavior at home. The therapy proved to be effective

in dealing with the problems of the client.

 References

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Case Summary
Client J.A was 4 years and 8 months old boy who came with complaints of delayed speech,

avoid maintaining eye contact, not attending after calling his name, not play or interact with

other children, unusual hand movements, eating inedible objects, and hit other children.

Psychological assessment was done on two levels. The informal assessment included a clinical

interview, behavioral observations, Portage Guide to Early Education (PGEE), curriculum-based

assessment, and reinforce identification. The formal assessment included the Child Autism rating

scale. On the basis of the assessment, the client was diagnosed with 299.00 (F84.0) Autism

Spectrum Disorder (Level I) requiring support. The management of the client’s problems was

focused on using behavioral therapy techniques to modify the client’s behavior. A total of 11

sessions were conducted with the client. The therapy was proved effective and the improvement

was observed in the client’s behavior.

Biodata

Name M.A

Gender Male

Age 4 years 8 months

Date of birth 22-01-2018

No. of siblings 3

Birth order 2nd

Informant Client’s mother

Reason for Referral

The client came to the Children Hospital, Lahore with complaints of delayed speech,

avoid maintaining eye contact, not attending after calling his name, not play or interact with

other children, unusual hand movements, eating inedible objects, and hit other children. He was

referred to the trainee clinical psychologist for assessment and management of his problems.

Presenting Complaints

As reported by the client’s mother

‫دورانیہ‬ ‫شکایات‬

‫تین سال سے‬ ‫اس کی سپیچ کم ہے۔ایک دو لفظ سے زیادہ نہیں بولتا۔‬

‫دو سال سے‬ ‫اسے چیزیں جلدی یاد نہیں ہوتی۔ بہت وقت لگاتا ہے۔‬

‫دو سال سے‬ ‫ اور ان کے ساتھ کھیلتا نہیں ہے۔‬،‫دوسرے بچوں کو مارتا ہے‬

‫تین سال سے‬ ‫آنکھوں میں نہیں دیکھتا۔‬

‫تین سال سے‬ ‫چار پانچ بار آوازدو تو اس کے بعد بات سنتا ہے۔‬

‫تین سال سے‬ ‫ اکیلا ہی کھیلتا رہتا ہے۔‬،‫کسی کے ساتھ گھلتا ملتا نہیں ہے‬

‫تین سال سے‬ ‫چیزوں کو لاین میں رکھتا ہے۔‬

 ‫چار سال سے‬ ‫ہر چیز کو منہ میں ڈال لیتا ہے اور چوستا رہتا ہے۔‬

History of Present Illness

The client’s mother reported that the client was a twin to his brother and was born

through C-section. There were no pre-natal complications reported. When the client was one

month old, he suffered from a chest infection, and was successfully treated. He also did not do

burping, therefore vomit the milk. At 2 months of age, the client had severe diarrhea and was

treated successfully through medicines.

The client’s mother reported that the client achieved one-word speech at the age of 9

months. But, when his younger brother was born, the client’s mother provided the client with

mobile phone. His screen time was 6-7 hours in a day. His speech regressed after it. He became

mute and did not speak a single word. His mother noticed him and took him to the hospital. They

recommended the client for speech sessions. After taking sessions, his one-word speech was

achieved at the age of 21 months. When he started crawling, his mother reported that he would

not attend to or respond to anyone’s voice. After consulting a doctor, the problem identified was

wax in his ears. He was 18 months of age at that time. The doctors prescribed ear drops to him.

The client’s attending to other people did not improved after using those ear drops, after which

the doctor suggested the parents to consult a psychologist.

According to the client’s mother, when the client was of 2.5-3 years of age, he did not

play with anyone and preferred playing alone. He also used to place toys in a line. He did not

maintain eye contact with other people and did not respond to anyone. He just remained into

himself and used to play in isolation.

The client roam around in house and had excessive running. He also used to bang his

head or do body rocking when his needs were not met. The client’s parents ignored his behaviors

as the client started speaking one-word on his own will by too much effort of his mother. When
the client was 4 years and 4 months old, his parents admitted him to school. The teachers

complained about his behaviors as he used to hit other kids, roam around in class, did not sit

calmly on a chair, and not responding to class activities.

In 2020, when the client’s mother observed that the client did not speak two-words

phrases and did not maintain eye contact, avoid playing with other kids, having unusual hand

movements, she consulted a psychiatrist in Mayo Hospital. After a thorough assessment, the

client was diagnosed with Autism Spectrum Disorder (mild). He took speech and behavior

therapy sessions there. His mother reported significant improvement in his behaviors, but when

his therapist was changed, he regressed.

In June 2021 the client’s parents took him to the Children Hospital, Lahore where he was

diagnosed with Autism Spectrum Disorder by developmental pediatrician and clinical

psychologist and referred for therapy. The client was taking sessions based on early readiness

skills and developmental activities. After a follow-up of 1 year, the client was referred to the

learning center for developmental and academic skills, where he was taking sessions for the last

two months.

Background History

Family History

The client’s father H.F. was 35 years old, did BS(Hons) in computer science, and worked

in WAPDA. The client’s mother reported that the client’s father was calm and friendly toward

his children and the client had a healthy relationship with his father. The client’s father used to

take the client to the park and play with him. He also helped the client’s mother in completing

their children’s homework.

 The client’s mother was 33 years old housewife. She did BS(Hons) in computer science

and B.Ed. She reported being calm in nature and used to spend her time with client and other

children. She used to help her children in completing their school homework daily. The client

seemed to have a healthy relationship with his mother.

The client’s parents were first cousins of each other. They had congenial relationship.

Her husband was caring and he helped her in managing children and doing household tasks.

The client had 3 siblings, one sister, and two brothers. His elder sister was 6 years old,

studying in 1st class. The client’s mother reported that the client had congenial relationship with

his sister. His sister cared for him. The second-born brother was a client’s twin brother. He was

studying in kindergarten. The client’s mother reported that the client did not play with his

brothers. His younger brother was 2 years old. The client used to hit him whenever he touched

his toys.

The client lived in a joint family with his grandparents and the families of six paternal

uncles. He belonged to a middle-class family. The client’s mother reported that the client had

congenial relationship with his uncles, but used to beat his cousins or stopped them from entering

his room. The overall home environment was reported to be satisfactory.

Family History of Psychiatric Illness

The client’s mother reported that one of the client’s paternal uncles was having diagnosis

of intellectual disability.

Personal History

The client was born through cesarean section after prolonged labor. He was a twin

brother. He had an immediate cry, and his birth weight was normal i.e. 6 pounds. The client’s

mother reported that she faced no pre-natal or post-natal complications. The client was breastfed
for 2-3 days. After that, his mother started bottle feeding along with breastfeeding. When the

client was one month of age, he suffered from a severe chest infection for which the doctors

prescribed him medicines at that time.

The client’s mother reported that the client did not do burping. Because of this, he used to

vomit milk. When the client was of 2 months, he suffered from severe diarrhea but got recovered

after proper treatment and care. The client’s developmental milestones of head and neck holding,

sitting, crawling, walking, and bladder and bowel control were achieved appropriately for his

age, but he was significantly delayed in speech. The client started babbling at the age of 9

months, but his speech was regressed after two months. His mother reported that his screen-time

was increased up to 6-7 hours. He stopped saying mama, baba. After therapy, he started

speaking one-word at the age of 21 months.

When the client was of 2 years, he suffered from jaundice, that was treated with

medications and proper care. The client’s mother reported that when the client was of 2.5-3 years

of age, he did not play with anyone and preferred playing alone. He also used to place toys in a

line. He did not maintain eye contact with other people and did not respond to anyone. He just

remained into himself and used to play in isolation.

Table 1

Showing Developmental Milestones, Normal Age of Achievement, and Client’s Achievement Age

Developmental Milestones Normal Age of Achievement Acquired Age

(Gerber et al., 2010)

Head holding 4-6 months 5 months

Sitting 8-10 months 7 months

Crawling 10-12 months 12 months

Walking 12-18 months 14 months

 Single word speech 8-12 months 21 months

Complete sentence 12-24 months Not achieved yet

Bladder control 2-3 years 4 years

Bowel control 2-3 years 4 years

Dress without help 4 years Not achieved yet

Taking bath without help 4 years Not achieved yet

Educational History

The informal education of the client was started at home at the age of 3.5 years. His

mother and father were involved in the teaching process. As the client’s speech was delayed, his

parents consulted a speech therapist at Mayo hospital where he was diagnosed with autism

spectrum disorder and was referred to the clinical psychologist. He took the therapy based on

early readiness skills and developmental skills for almost 4 months. Then he discontinued as the

client’s parents reported that his therapist was changed so they discontinued taking sessions at

Mayo hospital. After that, he was referred to the Children hospital for speech and behavior

therapy sessions. He continued therapy from the children hospital. At the age of 4 years and 4

months, the client started formal schooling in the school nearby his home. His teachers used to

complain about his behaviors as he used to hit his class fellows and did not sit calmly on the

chair. He avoids maintaining eye contact and did not respond to his name. The client was taking

behavior therapy session from children hospital along with his formal schooling. At the age of 4

years and 6 months, the client was enrolled in the learning center of children hospital, where

session of 2 hours was taken based on developmental activities and academics.

 The client had the concept of shapes, recognition and naming of English alphabets (A-Z)

and Urdu alphabets (‫)ا تا خ‬, could write English alphabets (A & B), and Urdu alphabets(‫ آ‬, ‫)ا‬. He

had recognition of numbers (1-10), and could write numbers (1-2), match numbers by counting

objects (1-4), and matching of letters to letters and letters to objects (A-J).

Psychological Assessment

The formal and informal assessment was done to assess the client’s problems;

Informal Assessment Formal Assessment

Clinical Interview Child Autism Rating Scale (CARS)

Behavioral Observations

Portage Guide to Early Education (PGEE)

Reinforcer Identification

Informal Assessment

Clinical Interview. A semi-structured clinical interview was done with his mother in

which the personal, developmental, educational, and familial history was taken. A complete

account of the behavioral issues was taken. Verbal informed consent was taken and

confidentiality of information was ensured. From the interview, predisposing, precipitating,

perpetuating, and prognostic factors were identified which were helpful in determining the

diagnosis and the management of the client’s problems.

Predisposing Factors Precipitating Factors Perpetuating Factors Prognostic Factors

Birth through C- Delayed speech Parent’s pampering Regular follow-up

section Educated parents

Male gender Practicing therapy

Severe chest infection work at home as

under one month of guided by the

 birth therapist

Behavioral Observation. The client was of normal height and weight. He was dressed

neatly in weather-appropriate clothes. During the sessions, it was observed that he was not much

responsive toward his name and did not maintain eye contact. The client was easily distracted by

the activities around him such as the child playing with pegboards or taking therapeutic sessions.

In the first session, he tried to snatch a toy from the kid in a session room while history was

being taken from his mother.

The client had poor on-seat as he roams around in the session room. He avoids

maintaining eye contact. He continuously went towards switches to switched on and off the

button. Mouthing behavior was also observed as he used to put pencil or eraser in his mouth.

When toys were given to him, he lined them up and had unusual hand movements while holding

toys in his hands.

Table 2

Showing Rating of Behavioral Problems on a scale of 0-10

Behavior Rating (0-10)

Eye-contact 2

Imitation 3

Respond to name 2

Onset 4

Compliance 3

Mouthing 8

Lining up objects 5

Side gaze 3
 Fixation (switches) 6

Lying on the floor 8

Repetitive movement of hands while holding objects 7

Teeth grinding 7

The rating of the problematic behaviors of the client was done by asking the client’s

mother and observing the client during the session. The client was observed in the initial sessions

to get the ratings

Portage Guide to Early Education (Sturmey & Crisp, 1986). It was administered on

the client to assess his current functioning level in five domains. (Appendix)

Table 3

Developmental Areas, First Crossed Item with Age Range, Last Correct Item with Age Range

and Functional Level in Portage Guide to Early Education

Developmental Areas First Missed Item Last Correct Item

Item No. Age Range Item No. Age Range

Language 41 2-3 years 62 3-4 years

Socialization 27 1-2 years 51 2-3 years

Self-Help 24 1-2 years 55 3-4 years

Cognitive 31 1-2 years 75 4-5 years

Motor 79 2-3 years 107 4-5 years

The results showed that the client lacked behind his chronological age in language,

cognition, socialization, and self-help. The client was taking therapy sessions for the last 2 years,

and many of his PGEE items were achieved. The socialization of the client was not age-
appropriate as it was evident from the history and observation that he did not attend to other

individuals immediately and respond to them after calling him 4-5 times, and did not wait for his

turn. He used to hit other kids and did not play with them. The scores on the cognitive domain

revealed his lack of skills in matching textures, placing objects in, on, and under upon request,

differentiating heavy and light, and long and short objects, and academic tasks (alphabets). The

scores on the self-help domain revealed his lack of skills in dressing up himself, tying and

untying laces, and buttoning and unbuttoning his jacket. The result of the motor domain revealed

his normal development in fine motor and gross motor skills.

Table 4

Developmental Areas and Missed Items of Portage Guide to Early Education

Developmental Missed Items

Areas

Language 41, 44, 46, 54, 55, 57, 60, 63, 64, 65, 66, 67, 68, 69, …

Socialization 27, 31, 33, 35, 37, 40, 41, 42, 46, 49, 52, 53, 54, 55, 56, 57, …

Self Help 24, 30, 31, 33, 35, 37, 42, 43, 47, 48, 50, 51, 52, 54, 56, 57, 58, 59,…

Cognitive 31, 35, 41, 44, 50, 60, 66, 68, 69, 71, 72, 73, 74, 76, 77, 78, 79, …

Motor 79, 82, 88, 90, 92, 95, 96, 98, 101, 103, 106, 108, 109, 110, 111, 112, …

Reinforcers Identification. Some of the reinforcers were identified by asking the client’s

mother about his favorite activities and food while others were identified by observing the client

during the session while performing activities. During the session, the free-operant preference

assessment method was used in which the client was provided access to all the available stimuli

and was allowed to freely engage with any presented stimuli. The engagement was monitored

with the duration. It helped in identifying the most preferable reinforcer. The response restriction
method involved free access to all stimuli but with the removal of highly preferred stimuli.

Following this helped in identifying the hierarchy of the most to the least preferred reinforcer.

Edible reinforcers were the most preferable reinforcers. The reinforcers were identified to make

it contingent on the individualized educational plan and developmental tasks.

Material Reinforcer Pegboard, bubbles

Edible Reinforcer Lunch (Tiffin), biscuit

Social Reinforcer Praise (good job, good boy, wow), smiling at him

Formal Assessment

Childhood Autism Rating Scale (CARS) (Schopler, 1980). It is a behavioral rating

scale used for assessing the presence and severity of symptoms of autism spectrum disorders. It

consisted of 15 domains, with each scored on a rating scale from 1 to 4. The total score ranges

from 15 to 60. It has .94 internal consistency and a reliability of .71. It was administered by

asking the client’s mother and observing the client during the session. The childhood autism

rating scale was administered to assess the current functioning level of the client. The scores

showed that the client had mildly to moderate range of autism. (Appendix)

Table 5

Raw Scores, Range, and Corresponding Category on Childhood Autism Rating Scale

Raw scores Range Category

30 30-38 Mildly-moderately autistic

Diagnosis

According to DSM-V criteria and keeping in view the observation and assessment, the

client was diagnosed with 299.00 (F84.0) autism spectrum disorder (Level I) requiring support.

Case Formulation
 The client was born via c- section. Researches have indicated that cesarean section was

associated with a 26% increased risk of causing autism in child either due to stress or some other

possible explanation (Zhang, 2019). In addition, the client was a boy that also increased the

incidence of having autism as researches have indicated that autism spectrum disorder was four

times more common in males than females (Maenner et al., 2020).

The client’s history revealed delayed milestone of speech. According to Tager-Flusberg

(2016), most children with autism are found to have delays in achieving milestones, especially

the onset of words, phrases and sentences are delayed. They have problems with receptive and

expressive language due to processing deficits. It has also been found that children with autism

had difficulties in understanding and responding appropriately to others (Cook et al., 2021).

It has been found that the client had sensory issues. He liked lying on the floor, usually

involve in teeth grinding, and had mouthing. These issues were related to sensory processing. It

has been found that over 96% of children with ASD reported hyper and hypo-sensitivities in

multiple domains which ranged from mild to severe ranges (Marco et al., 2012). It has also been

found that these sensory issues can cause distress that can result in aggressive behavior as it was

evident that the client would scream or resist when his needs were not met (Ben-Sasson et al.,

2009).

Management Plan

A management plan based on behavior techniques was devised to deal with the

idiosyncratic needs of the client. The management plan included;

1. Rapport building

2. Psycho-education

3. Parental Training
 4. Behavior therapy

5. Individualized Education Plan

Short Term Goals

 Rapport building was done with the client to make him at ease with the therapist during

the sessions.

 Psycho-education was done with the client’s mother to give him the understanding of

diagnosis, prognosis, and management of the problem. She was informed about her role

in the management of the client’s behavioral problems. This helped in motivating the

client’s mother towards therapy sessions.

 Positive parental training was given to the client’s mother. She was trained to deal with

the client’s eye-contact, attending, compliance, and on-seat.

 Individualized education plan was developed to work on the client’s early readiness

skills, developmental skills, and academic skills.

 Behavioral modification techniques were used to teach the client the tasks of IEP. These

techniques included reinforcement, prompting, modeling, differential reinforcement of

alternative behavior, shaping, and response cost.

1. Reinforcement was used to increase the likelihood that a behavior will occur

again in the future.

2. Physical and verbal prompts were used to assist the client in performing a specific

task. These prompts were given before and during the tasks to help the client

complete the specific task.

 3. Modeling was used to show the client about a particular task so she would engage

in imitation of that particular task after observing it that encourage learning.

4. Differential reinforcement of alternative behavior was used to reduce problem

behaviors. This technique helps in decreasing challenging behaviors, such as mis-

consuming household things, and increase positive behavior, such as asking for a

permission before using anything.

5. Shaping was used to teach the client particular tasks by reinforcing successive

approximation to the target behavior.

Long Term Goals

 The continuation of short-term goals to enhance the client’s developmental, and academic

skills.

 Speech and language therapy will be continued for the management of his speech-related

issues.

 Behavioral techniques will be continued to be used by her mother to deal with the

problematic behaviors and for strengthening the appropriate behaviors.

Summary of Therapeutic Interventions

Rapport Building. Rapport building was built to establish an effective therapeutic

relationship with the client. It was done to make the client comfortable and to develop trust in the

therapist. The techniques used were commonality and mirroring.

The commonality is a technique of deliberately finding something in common with a

person in order to build a sense of trust and friendship (Tickle-Degnen & Rosenthall, 1990). This

was accomplished through expressing shared preferences for certain toys and foods. He was

drawn in by using ring stackers and pegboards.

 Mirroring is a nonverbal method when a person imitates another person’s body language,

vocal characteristics, or attitude. It usually indicates curiosity or perhaps attraction and is

frequently done unconsciously. It is a potent form of nonverbal communication (Pease & Pease,

2005).

Psychoeducation. It is a crucial step in the therapeutic process. Psychoeducation (PE) is

defined as an intervention with the systematic, structured, and didactic transfer of knowledge for

an illness and its treatment, integrating emotional and motivational aspects to enable patients to

cope with the illness and to improve its treatment adherence and efficacy (Ekhtiari et al., 2017).

The client’s diagnosis, its primary symptoms, and the variables influencing the prognosis rate

were explained to the client’s parents in order to provide them with some psychoeducation about

the disorder. Additionally, they were informed about the management strategies and how they

could contribute to the therapeutic activity’s success.

Parental Training. Parental training was done to guide the behavior modification

techniques that would help in the development of skills in the client. The mother was trained to

deal with the behavioral issues of the client. During each session, ten to fifteen minutes were

reserved for the mother in which her concerns regarding the application of techniques were

catered. The mother was also asked to observe some of the sessions to have an idea to apply the

techniques. She was asked to conduct a formal session with the client at home. She was shown

how to conduct a session at home, and was informed about the required material such as colored

balls, similar objects, reinforcers, and pegboards.

The client's mother was instructed to do the exercises at home to maintain the client’s

eye-contact and improve his attending to his name. She was also taught the techniques, including

verbal, physical, and gestural prompting strategies, positive reinforcement, joint attention,
modeling, and differential reinforcement of alternate behaviors. These techniques were also used

in the academic tasks.

Individualized Educational Plan. An individualized educational plan is a written plan

for parents, teachers, and school administration to work together to design instructions,

accommodation and services to children with special needs (Kamens, 2004). They all work

together to meet the needs of the individual requiring a range of support. The goals based on the

child’s current needs and skills are developed (Dotson, 2016). It was formed to meet the

idiosyncratic needs of the client. It was made to develop and strengthen early readiness skills,

and developmental skills which included cognitive skills, language skills, socialization skills,

self-help skills, motor skills, and academic skills. The work on the individualized educational

plan was continued throughout the sessions and his mother was asked to work on it at home as

well.

Early Readiness Skills. The early readiness skills that were worked on included

maintaining eye-contact, increasing on-seat behavior, attending to his name, imitation and

compliance. The eye contact and response to name was increased using reinforcers, verbal and

gestural prompts and joint attention. To get the attention of the client, his favourite activities

were used that were ring stackers and peg boards. He was given reinforcement for sustaining

attention and completing the tasks. The side gaze of the client was managed by using tunnel

vision. The side of the eyes were blocked either by placing hands on the side of his eyes or using

objects on the sides so that the client could look straight in front of him and on the tasks in front

of him.

The on-seat behavior was increased using physical restraints and differential

reinforcement of alternate behavior. The client was made to sit on the seat in the corner of the
room and he was blocked using the table. He was verbally and physically prompted to sit on the

chair and finish the task. The attending to name was increased using academic activities and

snacks. The technique used for increasing the client’s attending was positive reinforcement, joint

attention, and verbal prompts. He would attend the therapist mostly on the account of getting

snacks. The positive reinforcement technique was proved to be helpful.

The compliant behavior was achieved using verbal prompts, modeling, and differential

reinforcement of alternate behavior. The task was modeled and then the client was asked to do

the same. One-word and two-word commands were used such as stop, start, give me, put there,

and not now. Social and edible reinforcers were provided for the complaint behavior. The client

was asked to place the pegs in peg boards, rings in the stacker, match the letters with pictures,

and do academic tasks. This was done while keeping the edible reinforcer in therapist’s hands.

He was not given the reimforcer until he completed the tasks. After the completion of each

activity, client was given some of the biscuits or his lunch.

Sensory Issues. The sensory issues were dealt by educating the mother about the

alternatives. Differential reinforcement of alternate behavior techniques was used for this

purpose and the appropriate response was positively reinforced. During the session, verbal

prompting and differential reinforcement for alternative behavior were used to address the

sensory issues of the client.

Developmental skills. For socialization skills, the client was taught the tasks including

sharing pencil or eraser with peers, taking permission from other people before using their

things, and saying please and thank you. The techniques used for these tasks were

Reinforcement, verbal prompts, and modeling. The client was trained to share his pencil and

eraser with his peers. The behavior was first modeled by the therapist. Then the therapist asked
the client to share his eraser to his peer. The client was verbally prompted to share his things

with his Peers.

Asking permission to use objects was taught to the client through modeling and

prompting. The therapist modeled this task by asking for permission to the client for using his

material like pencil, book, and eraser. After that, verbal prompts were used and the client was

only given desirable objects when he sought permission for them to use. The client was trained

to say please and thank you. For this, the therapist modeled the behavior in front of the client by

saying please and thank you herself while using ring stacker with the client. The client was then

verbally prompted on it. He was given a reinforcement when he said please and thank you on

taking something from anyone.

The cognitive skills taught to the client included differentiating heavy and light and

identifying shapes. For the purpose of categorization, identification and naming of shapes

(triangle, circle, square, and rectangle) were used. Verbal and gestural prompts and

reinforcements were used and later the client would categorize it himself on the command. The

client was given the concept of heavy and light objects by using verbal and gestural prompts, and

reinforcement. The client was provided with the heavy and light objects on both hands and

verbally prompted to differentiate between these objects.

Academic Skills. The client was taught the academic skills including English, Urdu, and

Mathematics. These tasks included writing English alphabets A-E, counting numbers 1-20,

writing numbers 1-5, matching Urdu alphabets with objects, and pointing from early learners

English and Urdu alphabets book. The techniques used for these tasks were physical and verbal

prompts, shaping, and reinforcement. He was taught these tasks in chunks.

Behavior Modification Techniques

Positive Reinforcement

Positive reinforcement is the addition of a reinforcing stimulus following a behavior that

makes it more likely that the behavior will occur again in the future (Premack, 1959). Positive

reinforcement was used to develop new desirable behaviors and strengthen the previously

learned behaviors in the client. Social and material reinforcers were used with the client. Social

reinforcers included praise, clapping, and smile, whereas material reinforcers included lays and

juice.

Prompting

Prompting is a method of providing a clue to the person about the next step to be done.

Prompting can be verbal or physical. Verbal prompting usually consists of giving a directive

command about the next step. Most-to-least intrusive prompting is usually followed, which

means that the teacher starts with maximal support and ends with minimal prompting

(Miltenberger & Perkins, 2020).

Fading

Fading is a process of gradually removing prompts until the behavior starts occurring in

the presence of the discrimination stimulus without any supplemental stimuli (Miltenberger,

2015). The various types of prompts including physical prompts, verbal prompts, gestural

prompts, visual prompts and model prompts were gradually faded so that the client could

perform the tasks independently

Chaining

The process of analyzing a behavioral chain by breaking it down into its individual

stimulus–response components is called chaining (Miltenberger, 2015). It was used to teach the
child self-help skill i.e., Laces shoes, and academic skills i.e., writing English and Urdu

alphabets and numbers.

Modeling

Modelling occurs when a behavior is deliberately displayed by a role model to a learner

or observer who then may learn that behavior and carry it on (Sam, 2013). This technique was

used to teach the client socialization, self-help, and cognitive tasks by first showing the client

how the task would be done, and after that the client was asked to imitate it.

Structure and Style of Sessions

Eleven structured sessions were conducted with the client. Each session was of 1 to 1½

hour. The sessions included history taking, behavioral observations, assessment, and

management of the problematic behaviors. In the last ten to fifteen minutes of each session, the

client’s mother was guided and trained to deal with the client’s problematic behaviors. The

mother was involved in the therapy by giving homework assignments in dealing with the client’s

problems.

Post Assessment

The post-assessment subjective ratings of the problematic symptoms of the client were

obtained on a 10-point rating scale. The therapist and the mother of the client rated the

presenting complaints 0 to 10 severity rating scale, “0” means “not present”, and “10” means

“severe”. The subjective ratings of the symptoms of the client rated by his mother were;

Table 6

Pre and post assessment rating by the client’s mother on problematic symptoms on 0-10 rating

scale

Behavior Pre-assessment Post-assessment

 Eye-contact 2 4

Imitation 3 6

Respond to name 2 5

Onseat 4 6

Compliance 3 5

Mouthing 8 5

Lining up objects 5 4

Side gaze 3 2

Fixation (switches) 6 4

Lying on the floor 8 6

Repetitive movement of hands while holding 7 5

objects

Teeth grinding 7 5

Table 7

PGEE Items Pre and Post Assessment showing Missed and Achieved Items

Developmental Missed Items Achieved Items

Areas

Socialization 27, 31, 33, 35, 37, 40, 41, 42, 46, 49, 37, 42, 47

52, 53, 54, 55, 56, 57, …

Cognitive 31, 35, 41, 44, 50, 60, 66, 68, 69, 71, 44, 71

72, 73, 74, 76, 77, 78, 79, …

Outcome of Therapy
 The behavior therapy was found to be effective in addressing the client's problematic

behaviors. The post-assessment showed improvement in the client’s behavior. The client’s eye-

contact, om-seat, attending, and compliance was improved. His mother reported that the client’s

socialization and cognitive skills were also improved as he started asking for permission before

using anyone’s things, saying thank you, and please, and also got the concept of long and short,

colors and shapes recognition. His academic skills were also improved. He started writing

English alphabets A-E, numbers 1-4, and Urdu alphabets (‫ )ا تا پ‬with verbal prompts and started

matching letters to objects. He started counting numbers from 1-15 and pointing Urdu alphabets

from the mathematics and Urdu book for early learners. The client was referred to another

clinical psychologist to continue his individualized education plan and work on his early

readiness, developmental, and academic skills.

References

Ben-Sassoon, A., Soto, T. W., Martínez-Pedraza, F., & Carter, A. S. (2013). Early sensory over-

responsivity in toddlers with autism spectrum disorders as a predictor of family impairment

and parenting stress. Journal of Child Psychology and Psychiatry, 54(8), 846–853.

https://doi.org/10.1111/jcpp.12035

Cook, J., Hull, L., Crane, L., & Mandy, W. (2021). Camouflaging in autism: A systematic

review. Clinical Psychology Review, 89. https://doi.org/10.1016/j.cpr.2021.102080

Dotson, R. (2016). Goal setting to increase student academic performance. Journal of School

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