Summary

The client is a 4 years old good looking and nicely dressed girl child. She has symptoms of
lack of making and maintaining eye contact, aggression by throwing things and hitting others
sometimes and excessive hyperactivity. It is difficult for her to make social connection and
interact with others due to which she has no friends. She shows repetitive movements and
sounds along with it she has speech impairment and cannot speak words. She uses non-verbal
communication but with difficulty to make other people understand. She is sensitive to bright
light and shows temper tantrums. The client also has less attention span and is inattentive.
She is hyper-responsive to sweetness. Her family especially parents are really cooperative
and understanding related to her condition. In-detail interview was taken along with Mental
Status Examination (MSE) for understanding the prevailing condition of the client.
Childhood Autism Rating Scale (CARS) was used on which the child scored 36 which is a
mild-moderate autism score. Childhood Autism Spectrum Test (CAST) is a questionnaire
which was responded by the parents of the client in which the child scored 22. This score
indicates deficits in communication and prevalence of autism. Aberrant Behavior Checklist
(ABC) is a checklist to check the behavioral issues and the client scored 20 on the
hyperactivity/noncompliance subscale of ABC which shows that the child is highly
hyperactive and restless. The interpretation of House Tree Person test (HTP) revealed that the
client is not social, aggressive, hostile, high dependency on others and restlessness. Feelings
of insecurity and use of fantasy was also noted. Hence, a tentative diagnosis of “Autism
Spectrum Disorder (ASD)” is given to the client. The therapeutic recommendations for
autism include Applied Behavior Analysis (ABA), Verbal Behavior Therapy (VBT),
Cognitive Behavioral Therapy (CBT), Developmental and Individual Differences
Relationship (DIR) Therapy, Relationship Development Intervention (RDI) and Group
Therapy.
Demographic Details

Name: X.Y.Z.

Sex: Female

Age: 4years old

Date of Birth: 14th June, 2017

Marital Status: Child

Father: Army officer (Lieutenant colonel)

Mother: Housewife

No. of Siblings: 2 (1 brother of 13 years & 1 sister of 10 years)

Birth order: 3rd (last child)

Socio-economic Status: Upper-middle class

Family Structure: Nuclear

Heritage: Punjabi

Religion: Islam

Language: Urdu & English

Education: Not school going

Source of Referral: Self-referred

Presenting Problems

This is the verbatim of the child’s mother:

‫ سال‬1½ ‫ مگر جب یہ‬-‫ بولے تھے‬late ‫ بولے گی کیونکہ اس کے بہن بھائی بھی‬late ‫شروع میں تو ہمیں لگا کہ شاید‬
‫ سال کی تھی تو ہم نے اسے‬3 ‫ تو جب یہ‬-‫کی ہوئی اور کچھ نہ بولتی تھی باہر جانے پر گھلتی ملتی بھی نہ تھی‬
‫ چیزیں‬-‫ ہے‬hyper ‫ یہ بہت‬-‫ ہوگئی‬hyper ‫ پھر آہستہ آہستہ یہ بہت‬-‫ ہے‬autism ‫ انہوں نے کہا‬-‫ میں دکھایا‬PIMS
‫ اپنی بات کو سہی سے کبھی کبھی سمجھا بھی‬-‫ نہ تو ٹک کر بیٹھتی ہے‬،‫پھینکی ہے اور دوسروں کو مارتی بھی ہے‬
‫ بس دیکھے گی‬-‫ پا رک میں بھی جاۓ گی تو دوسرے بچوں کے ساتھ نہ جھیلے گی‬،‫ کہیں بھی جاۓ گی‬-‫نہیں سکتی‬
 ‫ وہاں‬-‫ میں دکھایا تھا‬occupational therapy department ‫ ہم نے کچھ دنوں پہلے اسے‬-‫ لے گی‬swings ‫اور‬
-‫ دکھاۓ تو رونے اور چیخنے لگی‬colors ‫ اور‬bright light ‫انہوں نے اسے‬

Symptoms

• A little eye contact and cannot maintain eye contact

• Inadequate imitation
• Lack of obeying commands
• Speech impaired
• Produces high pitch sounds without any reason
• Sensitive to bright light
• Use of non-verbal communication with difficulty
• Rocking behavior
• Hand flapping
• Stubborn
• Inattentive
• Highly hyperactive
• Less attention span
• Less sitting span
• Shows temper tantrums
• Throwing things
• Sometimes aggressive behavior towards others

History of Problems

The client was 1 ½ years old when her parents noted delayed speech, her lack of
communication and her increasing temper tantrums. Initially when she was an infant, no such
signs were observed but as she grew the symptoms started to appear mainly in the form of
delayed speech and lack of social contact even in public gatherings or social events. Over the
period of time, the intensity of the symptoms mentioned above is increasing along with
significant hyperactivity.

Prior Treatment

When she was 3 years old, her parents took her to Pakistan Institute of Medical Sciences
(PIMS) for the presenting problems. She was diagnosed with Autism Spectrum Disorder
(ASD) in PIMS by a psychiatrist. Currently her mother came to the hospital for confirming
the diagnosis and seeking adequate treatment for her condition.

Medical History

She is not on any medications and has not taken any medication in the past related to her
problem.

Personal History

Pre-natal history

Her mother had a full-term pregnancy. There were no complications during the pregnancy.

Peri-natal history

She had a normal delivery and there were no complications during the delivery. When the
client was born, she had a weight of 7 pounds.

Post-natal history

All the developmental milestones such as grasping, cooing, crawling and walking were
achieved timely. But there is delay in her speech and toilet training. She can make sounds but
cannot speak words or communicate verbally.

Family History

The marriage of child’s mother and father was not cousin marriage, it was out of family.
There is no serious disease or disorder reported by the family of the client. The client and her
family lived in Mangla but due to posting a few months ago, they are currently living in
Rawalpindi. She has a good relationship with her parents as well as siblings. She frequently
plays with her sister and brother. She shares her toys with her siblings but does not share food
with them. She is close to her mother and communicates with her more as compared to
others. She comes to the hospital with her mother too.

History of Friendship

The client does not go to school and does not have any friends. She does not make any
friends. Even when she goes to a park, she observes other children but do not play with them
or engage in any activity.
Behavioral Observation

The client is a neat and tidy girl child. Her hair had light brown color. She had an
evident speech issues and she makes a sound “eeeeeeeeeeeeee” or “yeayeyeaye….” when she
is excited, angry or feels any emotion. She made high pitch sounds which could be heard
from another room. She cried when she came to the hospital for the first time and started
hand flapping. She gave a little eye contact and did not maintain it. She threw the number
chips and blocks during the session. She was not able to say mama or papa. She understood
what her mother was saying such as “do you want to drink water?” In next sessions, it was
observed that she is hyperactive and did not imitate behavior and follow command. But it was
observed that she imitated behavior and obeyed command such as giving ‘high five’ when
she was reinforced. She followed command more often when she was shown reinforcement
in the form of confectioneries or jellies.

During her session on Tobii Dynavox Indi, a device which is an ideal for children
with communication issues was used to evaluate her sitting span which was 3-4 minutes and
attention span was 1-2 minutes. At first she was not sitting without her mother but later on
her attention was being diverted by toys and a person coming in the room.

Observations during the Sessions

• The client gives a little eye contact and cannot maintain eye contact. When she gives
eye contact, it is usually for 1-2 seconds.
• Her imitation abilities are not good enough but she can imitate sometimes. She
imitates according to her mood as well as interest. For instance, she responded to
“peek-a-boo” and imitated it but she did not imitate clapping of hands or raising hands
in the air.
• There is a lack of obeying commands. She does not follow commands of her parents,
siblings or anyone else.
• She only follows command when she is shown a sweet or a sugary item in the form of
reinforcement. It was noted that she responded quickly when she was given a
confectionary rather than a packet of chips. This means that she is hyper-responsive to
sweetness and it is a power sensory input for her. She has a hyper-responsiveness to
toffees and bubble gums made up of mint.
 • Her language is impaired and expression through language is limited to vocalization.
She produces continuous high pitch sound while engaging in an activity. She
communicates through non-verbal cues such as hand gestures, pointing towards things
and facial expressions. She has sometimes difficulty in using non-verbal
communication.
• Rocking behavior is reported by her mother. Hand flapping and repetitive behavior
such as back and forth rocking and running continuously was observed.
• She is stubborn and inattentive. She is hyperactive with a sitting span of 3-4 minutes
even while playing with toys. Her attention span is also less and her attention is easily
diverted by another stimulus such as opening of door. She gives selective attention
towards the things that attract her.
• She shows temper tantrums and throws things such as throwing number chips during
sessions on the floor on purpose.
• She shows hostile behavior and shows aggression by throwing things towards others.
During a session, she threw alphabets on a psychologist.
• She has a good intellectual ability and problem solving skills. She solved puzzles on
Tobii several times and she can also use blocks to make towers. She was also able to
do the “big pegs task” in DOTCA-CH battery test which is an intervention for
children with cognitive difficulties and is also used to identify the areas of potential
cognitive strengths in children which can benefit them.
• She has a fair memory as she was able to make a tower of the same shape from blocks
which she made in the previous session.

Psychological Assessment

Mental Status Examination

Mental status examination (MSE) was used as a tool to describe appearance, behavior,
cognition, speech and mood of a patient. MSE indicated that the child was well-groomed and
well-dressed girl with suitable weight according to her age. Impairment in the some areas
were noted which were; behavior, speech, mood, orientation, attention and concentration.
 • Behavior
Repetitive behaviors, which included using gestures (finger pointing) with mother
only and stereotypical behavior (hand flapping and body rocking) were displayed.
Over activity in the form of hyperactivity was observed.
• Speech
Her speech was limited to making sounds only which were loud and high pitched.
Echolalia was noted when her sister randomly said “Peek-a-boo” and she started
repeating it as “pee, pee,….” as she cannot say the whole word due to impaired
speech.
• Mood and affect
Agitated mood and irritability was detected during examination. The client also threw
things on others.
• Concentration
The client was easily distracted by any stimulus and by the presence of others but did
not directly see another as well as did not gave eye contact.
• Attention
The child gave selective attention to activities in which she was interested. She did
not respond to a colorful abacus and a toy with sound rather she paid attention to the
colorful blocks in the Box and Block Test (BBT).

No delusions and hallucination were present or reported by the parents. Her memory was
sound. She seemed to be intellectually normal. Her overall behavior was in accordance with
her symptoms and problems.

Childhood Autism Rating Scale (CARS)

CARS is a diagnostic assessment tool to diagnose autism which was used for the client. The
child is rated on a scale ranging from normal to severe, and the scores range from non-autistic
to mildly autistic, moderately autistic, or severely autistic. The scale consists of 15 items on
which the child is rated subjectively and through observation on a 4-point Likert scale.
Hence, the clinician rates the child on the scale. The cut-off of CARS is 30. The minimum
score is 15 and maximum score is 60 (Schopler et al., 2010).
 Category Range
Non-autistic Below 30
Mild-moderate 30-36.5
Severe 37-60
Interpretation of CARS scores

The client scored 36 on the Childhood Autism Rating Scale (CARS). This score falls in the
mild-moderate (30-36.5) range of scores. It indicates that the client has mild-moderate
autism.

Childhood Autism Spectrum Test (CAST)

CAST is a screening tool for autism spectrum disorder (ASD) which can be
completed by the parents of the client. The parents of children between the ages of 4 to 11
years can fill this questionnaire. It is a 39-item scale and is actually a parental self-completion
questionnaire. The questions are about the child's social behaviors and social communication
tendencies. The measure consists of 2 items under a separate special needs section which are
not scored and these items are about the presence or absence of a comorbid disorders in the
child. It is a dichotomous scale with Yes/No options. The cut-off score of CAST is 15. CAST
does not give a confirm diagnosis but it is helpful in evaluating the child’s condition (Scott et
al., 2002).

6 items are control questions on the CAST questionnaire and these items are not
scored. These control items are item number 3, 4, 12, 22, 26 and 33. Thus, the maximum
score is 31. The items are scored corresponding to the key which contains the correct answers
according to which responses on CAST are scored.

Interpretation of CAST scores

The child scored 22 on the Childhood Autism Spectrum Test (CAST). As the cut-off score is
15, so this indicates that the child has social-communication difficulties and autism spectrum
disorder (ASD).

Aberrant Behavior Checklist (ABC)

The Aberrant Behavior Checklist (ABC) is a checklist which was filled by the response from
the child’s parents. ABC by Aman et al., (1987) is used to measure behavioral disturbances
across 5 domains. These domains are irritability, social withdrawal, stereotypic behavior;
hyperactivity/noncompliance and inappropriate speech. It is a widely used for the assessment
of principle symptoms as well as comorbid emotional and behavioral issues for individuals
with autism. ABC checklist questions can be rated on a range of 0-3 by a caregiver. It is a
rating scale with 58 items and higher scores indicate more severe symptoms in the child

Interpretation of score of ABC

The child’s score was highest in “hyperactivity/noncompliance” i.e. 20. This shows that the
client is very hyper and restless. The scores on other subscales were within the range and not
in much severity.

House Tree Person (HTP) Test

HTP is a projective test used to measure personality in which the test taker provides abstract
or ambiguous stimuli in the form of drawings. HTP was developed by Buck (1948) and later
modified by Hammer (1969). In the HTP, the test taker is asked to draw a house, tree, and a
person. These illustrations provide a degree of attitudes and perceptions of the client. It has
flexibility as it is subjective to interpret. It can be given to children over the age of 3. As the
clients age was above 4 and the client has interest in drawing and makes figures of the things
she is interested in as told by her mother so HTP was used.

Interpretation of House

The interpretation of house reveals that the child has guarded personality and is not social.
Hostile behavior is present along with poor relations with others. The client also fantasizes
excessively. Psychotic and psychological issues are evident as the house is not structured
properly and at the verge of collapse.

Interpretation of Tree

The interpretation of tree shows that the client has a sense of insecurity and a confused
personality. It also signifies that the client is not very social and there are withdrawal
tendencies.

Interpretation of Person

The interpretation of person indicates restlessness, impulsivity and aggression in the client’s
personality. Need of security and rigidity is depicted through the drawing. The drawing
significantly shows a high dependency of the client on close relations. It also indicated that
the client has anti-social tendencies.

Prognosis

The prognosis in the client seems to be fair as her symptoms are not of severe intensity. The
symptoms are frequent but with mild to moderate intensity which can be managed with time.
Her family is very cooperative, are well-aware of her condition and understand to some
extend that how to manage her symptoms.

Tentative Diagnosis

“Autism Spectrum Disorder 299.00 (F84.0)”

The following criteria of Autism Spectrum Disorder are fulfilled according to the client’s
symptoms from DSM-5 (American Psychological Association, 2013):

A. Persistent deficits in social communication and social interaction across various

contexts
1. Deficits in social-emotional reciprocity
2. Deficits in nonverbal communicative behaviors used for social interaction
3. Deficits in developing and understanding relationships
B. Restricted, repetitive patterns of behavior, interests, or activities (at least two)
1. Stereotyped or repetitive motor movements and speech
2. Restricted and fixated interests
3. Hyper-reactivity to sensory input
C. Symptoms present in the early developmental period
D. Symptoms cause clinically significant impairment in social functioning
E. These disturbances are not better explained by intellectual disability or global
developmental delay.

Therapeutic Recommendation

1. Applied Behavior Analysis (ABA)

In ABA, reward or reinforcement is used to reinforce positive behaviors and train

children with to learn new skills. The aim is to understand and change behavior of the child.
Parents are also trained to give feedback to the autistic child related to skills. Objectives of
the treatment may comprise of social skills, communication and personal care. It can also
help in dealing with aggressive behavior and inattentiveness. As a behavior is influenced by
the stimuli in the surrounding and that behavior is followed by positive consequences due to
which the behavior is more likely to occur again.

Research proves that children who are provided with ABA at an early stage can have a
long lasting effect. For instance, if the autistic child is asked to say ‘hello’ then a chocolate
can be given as reinforcement so that the behavior is learned.

• Discrete Trial Training (DTT): The desired behavior is broken into the simplest
steps in DTT.
• Early Intensive Behavioral Intervention (EIBI): It promotes skill development,
learning, and changing behavior of a child. It is designed for young children, usually
under age five.
• Pivotal Response Treatment (PRT): PRT emphasizes on child’s development, self-
management and handling social situations.
2. Verbal Behavior Therapy (VBT)

VBT is a form of applied behavior therapy and can be used to teach non-vocal children how
to communicate according to the situation. It can assist the child in learning how to use words
to get response from others. VBT helps the child to vocalize their request rather than labeling
objects. In VBT, children are stimulated through repetition so that they understand that
communication leads to positive consequences if they use language. For instance, if a
therapist presents chocolate as a stimulus which is the child’s favorite food then it will attract
the child to vocalize.

3. Cognitive Behavioral Therapy (CBT)

CBT is recommended for children with milder symptoms of autism and its goal is to describe
the causes or triggers of particular behaviors. In this way, the child starts to identify those
events or triggers. Through practice, the child learns to respond to a situation such as
listening to the music when the individual is overburdened. Additionally, it helps to deal with
issues faced by autistics such as anxious state. It facilitates the development of skills a child
has and helps in improving in a better way.
 4. Developmental and Individual Differences Relationship (DIR) Therapy

DIR therapy which is also known as Floortime, involves the therapist and parents in such a
way that they engage with the child through activities in which the child has interest. It
depends on a child according to the motivation they have to engage and interact with others.
The therapist leads the child in working on a particular skill.

5. Relationship Development Intervention (RDI)

RDI is a family-centered behavior-oriented used to treat autism by emphasizing on the main

areas which are social and emotional skills. The goal of RDI is to facilitate autistic children in
building meaningful relationships. It involves building skills to form social binds and share
experiences with others. Through this therapy, the therapist works on the ability of the child
to build social relations. This aids in developing interpersonal skills and empathy. RDI
consultants train the parents or caregivers.

6. Group therapy

Social difficulties and deficits are evident in children. Hence, group therapy is a beneficial
way of improving the social difficulties among children with autism. The size of the group
defines the type of therapy which would be chosen and which children are good candidates
for group therapy. Autistic children with same age and same level of difficulty can be
selected for similar treatment. Group therapy provides an opportunity for these kids to
socialize and interact with others. Children with ASD can apply what they have learned in
individual therapy on group therapy. It also provides a friendly environment which can aid in
boosting an individual’s self-esteem.

Other Recommendations
Some other suggestions include decreasing the amount of sugar intake by the child as
excessive sugar intake may contribute to hyperactivity and restlessness. Screen time of the
child needs to be reduced which 10-12 hours is approximately according to child’s parents.
Reducing screen time and involving child in other activates such as playing various sports
might include social communication and interaction.
References
Aman, M. G., Richmond, G., Stewart, A. W., Bell, J. C., & Kissel, R. C. (1987). The aberrant
behavior checklist: factor structure and the effect of subject variables in American and
New Zealand facilities. American Journal of Mental Deficiency.
American Psychological Association. (2013). Diagnostic and statistical manual of mental
disorders (DSM-5®). American Psychiatric Pub.
Buck, J. N. (1948). The HTP technique; a qualitative and quantitative scoring manual.
Journal of Clinical Psychology.
Hammer, E. (1969). The use of the House-Tree-Person in a clinical court: Predicting acting
out. J., Buck, E. Hammer,(Eds.), Advances in the House-Tree-Person Technique:
Variations and Applications, 267–293.
Schopler, E., Reichler, R. J., & Renner, B. R. (2010). The childhood autism rating scale
(CARS). WPS Los Angeles, CA, USA:
Scott, F. J., Baron-Cohen, S., Bolton, P., & Brayne, C. (2002). The CAST (Childhood
Asperger Syndrome Test) Preliminary development of a UK screen for mainstream
primary-school-age children. Autism, 6(1), 9–31.
Appendix