Case Report

Fozia bibi

Roll No. 33(M)

BS .VII

Session 2020-2024

Submitted to

Ms. Hidna Iqbal

CENTRE FOR CLINICAL PSYCHOLOGY

UNIVERSITY OF THE PUNJAB

LAHORE
Case Summary

The client was 13 years old male and was dressed neat and clean and came with the

complaints of not taking interest in studies, restless and required more practice was needed to

learn things. both formal and informal testing was done. Color Progressive Matrices, Slosson

Intelligence Test and CABS was administered. The results of the SIT indicated that the client has

low IQ. The results of the CABS indicated that the adaptive functioning of the client is at 8 years

of age. the client was diagnosed with moderate intellectual disability, with down syndrome. A

management plan was proposed.

Identifying Information

Name M.T

Age 13years

Gender Male

Siblings 10

Birth order last born

Religion Islam

Informant Teacher and School File Record

Reason and Sources of Referral

The client was referred to a trainee clinical psychologist for assessment and management plan as

it was an academic requirement. He was referred to Amin Rising sun institute with complaints of

behavior problems, speech problem and problmes in understanding things.

Presenting Complaints

‫پڑھائ میں دلچسپی نہیں لیتا۔‬

‫چی زیں یاد رکھوانے کے لیے با ر با ر پ ریکٹس کروانی پڑتی ہے۔‬

‫کبھی کبھا ر بے چین ہو جاتا ہے ۔‬

History of Present Illness

The client was delivered normally at home by midwife. His color was reddish and his weight

was below normal. His mother reported that he looked different from other children. After some
days of birth, the client sweats excessively and sleeps more. He was taken to hospital for

checkup with complaint of chest infection. The client’s mother reported that the doctor told them

that their child had down syndrome and a small hole in his heart, which needed to be treated

immediately. The client was operated at the age of 7 months at Children hospital. The operation

was good but there was chest infection even after the surgery. The client got fever and was

hospitalized for the treatment. Client remained on breast feeding for 1 year. Powder milk was

given to the child at 3 months of age till 2 years. He had received physical as well as psychiatric

treatment.

Developmental milestones were significantly delayed. The client mother reported that he did not

speak till the age of 8. He did not attend any mainstream school and was admitted in Rising sun

institute at the age of 9 years with one word speech, problems in understanding common things

and behavior problems like beating other children when became angry. The client’s teacher

reported that he is a bit shy, his behavior has improved and can communicate with others too.

The client was referred to trainee clinical psychologist with complaints of

Background Information

Family History

The client’s father is 63 years old. He has done matric and is a shopkeeper. He has loving

attitude towards the children.

The client’s mother is 53 years old and is not educated. She is a housewife and has a caring and

loving attitude towards the children.

Amongst 5 children, first born is client’s brother who is 29 years old. He is a civil judge and is

happily married. He has loving attitude towards the client and shares a good relationship with

client.

Second born is 31 years old client’s sister who has done PhD in microbiology. Client shares

good relationship with her. Third born is 28 years old sister. She is currently a student of PhD.

She also has a loving attitude towards the client.

25 years old is fourth born sister of the client. She is happily married and has 2 children.

She shares a good relationship with the client. The client’s brother who is 22 years old is fifth

born. He is studying in university. He loves the client and shares a good relationship with him.

Sixth born is client’s brother who is 21 years old and is studying in a university. Client shares a

good relationship with him. Seventh born is client’s brother who is who is 19 years old. He has a

caring attitude towards the client.

Eight born is client’s 17 years old sister. She is studying in intermediate part-1. She shares a

good relationship with the client. Ninth born is client’s sister who is 15 years old and is in 10 th

grade. She shares a loving relationship with the client.

Parents of the client shared good marital relationship. Their marriage was arranged marriage and

they were not relatives. The client’s family belong to lower class and family system is nuclear.

Decisions are made with the mutual understanding of both parents. Father and two brothers are

the earners in the family and deal with the financial issues. Parents have loving attitude toward

the children. Client’s mother reported in the record file that all siblings of the client have loving

attitude towards the client. Client also shares a loving relationship with all of his siblings.
History of Psychological and Physical Illness in Family

Client’s father was a sugar patient. He was taking medication for it. Mother of the client had

high Blood Pressure problems. She also had weak bones and it is difficult for her to walk long

distances. The client’s mother reported in the record file that no psychological illness runs in the

family.

Personal History

The client was born through normal delivery at home by a midwife. Her mother did not

remember about his first cry. The client’s color was reddish and he has low birth weight. He

sweats a lot after few days of birth and excessive sleep was there. He had downs syndrome. He

had a hole in his heart, for which a surgery was performed on him when he was 7 months old.

Educational History

He did not attend any regular school. He got admission in Rising sun at the age of 9 years. The

client’s teacher reported that he is responsive and attends well. He takes more interest in sports

than in class work. He is interested in basketball, bat ball and tennis ball.

His parents are very co-operative and they help him in doing his homework and tasks which

were assigned to him like pressing clothes, to make his bed and to fry an egg.

Psychological Assessment

The client was assessed by two ways i.e., formal and informal

Informal Assessment Clinical

Interview

The clinical interview was conducted with the teacher of the client to gather information.
Detailed information was gathered from client’s record file. Through information which was

gathered, it was determined that the predisposing factor was mother age and the perpetuating

factor were financial stressors and down syndrome.

Behavioral Observation

The client was a boy of average weight and height. He was wearing neat school uniform, gloves,

cap and mask. He was observed in class room settings as well as while performing tests. He was

cooperative with the trainee clinical psychologist. He was attending every request and was

making an eye contact with the trainee clinical psychologist. Rapport was built with the client.

He was answering every question, though it was difficult to understand his answer because of his

speech problem. He was using his fingers to answer questions like how old are you? How many

siblings are you?

Slosson Intelligence test was administered at the client. He was answering questions. When he

did not know the answer, he simply said no or take some time and became irritated. Water break

was given to the client while performing SIT. While performing CPM, the client was first

interested in it. Colors were fascinating for him. While doing last items he became distracted and

was answering the questions hurriedly. The test was performed in a class room where others were

also present. He started to see other children at the end. Reinforcement was given to the client

after completion of the test. He became happy and immediately started to eat it. After this, Child

Adaptive Behavior Scale was administered. While answering some questions, he was taking time

and became irritated. He became distracted thrice while performing this test. When

reinforcement was given, he started to pay attention to the test. While performing the test, water

break was given to the client. Another break of 05 minute was given to the client.
 Reinforcement was identified by asking the client and teacher. Reinforcements that were

identified was cocomo, chocolate, clapping, playing bat ball.

Informal Academic Assessment

For informal academic assessment, checklist of intellectual disability was used to determine the

severity level. He likes to color shapes and was coloring fruit shapes with interest.

He was naming animals too with interest.

Formal Assessment

Slosson Intelligence Test (SIT)

Slosson Intelligence Test (SIT) was administered on the client to assess the IQ of client.

Table 02

Result of Slosson Intelligence Test

Date of Administer 18.01.2022

Date of Birth 05.07.2005

Chronological Age (Years) 16 years 06 months

Chronological Age (Months) 198 months

Basal Age (Years) 7 years 06 months

Basal Age (Months) 90 months

Credit Months 14 months

Mental Age (Years) 08 years 06 months

Mental Age (Months) 104 months

Ratio IQ 52.25

Standard Error of Measurement 4.3

 IQ Range 47.95-56.55

Scores of Slosson Intelligence Test revealed that he performed low on test with an IQ range that

falls in extremely low category (Weschler, 1997).

Color Progressive Matrices (CPM)

CPM was administered to evaluate the logical reasoning, reason by analogy and

intellectual capacity.

Table 03

Showing Raw Score, Percentile, Grade, Category

Raw Score Percentile Grade Category Time

14 Below 5th V Intellectually 20 minutes

impaired

Child Adaptive Behavior Scale (CABS)

CABS was administered to assess adaptive functioning of the client

Table 04

Shows Language developmental, independent functioning, Family role performance, Economic

vocational activity, socialization areas and age equivalent.
Areas Score (Raw) Age Equivalent

Language development 26 8-

Independent Functioning 21 8+

Family role performance 24 8

Economic vocational activity 28 9
Socialization 19 7-
Total Score 118 8

The chronological age of the client is 16 years. The results of CABS showed that his adaptive

functioning age is 08 years which lags from his chronological age by 08 years.

Summary of Psychological Assessment

Formal and informal assessment was done on the client. Slosson Intelligence Test (SIT), Color

Progressive Matrices (CPM) and Child Adaptive Behavior Scale (CABS) were used for the

formal assessment of the child. The results of SIT and CPM demonstrated that the client has low

IQ. Result of CABS showed that the client’s adaptive functioning is also low from his

chronological age, this shows that the client has Intellectual Disability (ID), which was also

confirmed by informal assessment.

Summary of Psychological Assessment

Formal and informal assessment was done on the client. Slosson Intelligence Test (SIT), Color

Progressive Matrices (CPM) and Child Adaptive Behavior Scale (CABS) were used for the

formal assessment of the child. The results of SIT and CPM demonstrated that the client has low

IQ. Result of CABS showed that the client’s adaptive functioning is also low from his

chronological age, this shows that the client has Intellectual Disability (ID), which was also

confirmed by informal assessment.

Diagnosis

According to DSM-V

319.0 (F71) Intellectual Disability with Down’s Syndrome, moderate.

Case Formulation

According to DSM-V, 319.0 (F71), individual with intellectual disability with moderate

severity level shows slow progress in reading, writing, mathematics and understanding of time.

The progress is markedly limited compared to that of peers. Their language is less complex as

compare to their peer group, which was observed by formal and informal assessment of the

client. Individual can take care of personal needs like dressing, eating and elimination but require

an extended period of teaching. The client was trained to take care of his personal needs in

individual therapy by school therapist.

Down Syndrome is also one of the leading causes of the intellectual disability (Asim et al.,

2015). The client was born with down’s syndrome; therefore, it was a contributing factor, which

helps in his diagnosis of intellectual disability. Maternal age is a risk factor for down syndrome

(Sotonica, 2016). As the mother ages increases, the chances of down syndrome in individual also

increases. The client’s mother was 42 years old when she conceived him. It can also be a reason

because of which client has down syndrome which in turn leads to intellectual disability.

Low birth weight is also linked with neurological problems like mental retardation and

cerebral palsy (Collier & Houge, 2007). It was reported that client was born with low birth

weight which also helps in the diagnosis of the intellectual disability.

Proposed Management Plan

For management plan of the client, there will be short-term and long-term goals.

Short Term Goals

Rapport Building

Rapport building will be done with the client. In rapport building, a relationship of trust is

developed between therapist and client which helps in further treatment. It is extremely important

in therapeutic process. The reinforcers will be identified first and a list will be made. The trainee

should also identify the activities that client like the most.

Psychoeducation

It is an important step in treatment of the client. In this, we will educate the parents and family

about the illness, symptoms and nature of the problem, how they can help, what things are to be

done on their part. Teachers will also be psycho-educated about developmental delays and

symptoms of the client.

Behavior Modification Techniques

The techniques used are concerned with the analysis and modification of the human behavior.

These techniques can be used to develop a new behavior, to strengthen a behavior and to stop an

inappropriate behavior.

Positive Reinforcement

The occurrence of a behavior is followed by the addition of a stimulus or an increase in

the intensity of a stimulus which results in the strengthening of the behavior (Miltenberger,

2008). This technique will be used to increase his attention during work. Positive reinforcement

can be used to help him identify the age-appropriate jobs like in which age we cast vote.
Shaping

Shaping is defined as the development of a new behavior by the successive reinforcement

of closer approximations and extinguishing of preceding approximations of the behavior

(Miltenberger, 2008). Shaping will be used with the client to help him in reading three letter

word like bag, dog, see etc.

Modeling

Modeling is one way in which behavior is learned. In this process the client learns the

behavior by observing the other person and then imitates that behavior, also known as

observational learning or social learning. there is no direct instruction in this process. This

technique will be used to teach the client how to cut a shapes e.g circle, square by the trainee

clinical psychologist. It can also be used to help client in learning story.

Verbal Prompting

A verbal prompt involves telling the learner the answer, giving a verbal cue, such as, the

beginning sound of the answer, and/or giving the direction more than once. Verbal prompting

will be used by the client for storytelling.

Individualized Education Plan

It is an inevitable part of education for children with special needs. IEP is an illustration of the

students’ conditions (strengths, weaknesses and learning needs), the learning plan, along with the

accommodation requires by the student, monitoring and means of communicating, and

documenting student’s progress. IEP was proposed for improvement in his adaptive functioning

according to CABS.
Long Term Goals

• Continuation of the short-term plans

• Follow up sessions

Limitations and Suggestions

• Interview was not conducted with parents

• Limited sessions were conducted with child i.e., 2 sessions

• A detailed interview with clients parents should have conducted

• More sessions should be there so that the rapport was build easily
 Appendix

Individualized Educational Plan

Strengths

• Eye Contact

• Follows instructions

• Coloring

• Counting 1-40

Weaknesses

• Distraction

• Anger

• Speech problems
Behavior Technique

Three letter word Shaping

Cutting Shapes Modeling

Age-appropriate jobs Positive reinforcement

Story learning and telling Verbal prompting, modeling

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
 (5th ed.). American Psychiatric Pub.

Asim, A., Kumar, A., Muthuswamy, S., Jain, S., & Agarwal, S. (2015). Down syndrome: an

insight of the disease. Journal of biomedical science, 22(1), 1-9.

https://doi.org/10.1186/s12929-

015-0138-y

Collier, S. A., & Hogue, C. J. (2007). Modifiable risk factors for low birth weight and their effect

on cerebral palsy and mental retardation. Maternal and Child Health Journal, 11(1), 65-

71. https://doi.org/10.1007/s10995-006-0085-z

Kicklighter, R. H., & Richmond, B. O. (1980). Children’s Adaptive Behavior scale. Stoelting
CO.

Miltenberger, R. G. (2008). Behavior modification: Principles and procedures. Belmont, CA.

Thomas Wadsmorth.

Raven, J. C., Court, J. H., & Ravens, J. (1984). Colored Progressive Matrices & vocabulary

scales. J. C. Raven Ltd.

Sotonica, M., Mackic-Djurovic, M., Hasic, S., Kiseljakovic, E., Jadric, R., & Ibrulj, S. (2016).

Association of parental age and the type of down syndrome on the territory of Bosnia and

Herzegovina. Medical archives, 70(2), 88.

https://dx.doi.org/10.5455%2Fmedarh.2016.70.88-91