Summary of the Case

The client is an 8 years old boy. He was referred with the complaints of Stubbornness, showing
temper tantrums like throwing things on getting disturbed, biting others, non-compliance and
inability to speak and comprehend properly. He was assessed by behavioral observation, clinical
interview, subjective ratings, developmental checklist, and Portage Guide to Early Education. He
was diagnosed with unspecified intellectual disability. His therapeutic techniques include
psychoeducation, rapport building, compliance training reinforcement, token-economy, physical
restraints, prompting, fading, overcorrection, response cost time-out, contingent exercise and
attentional building techniques.
Biodata

Name A.B.
Age 8 years
Gender Male
No. of siblings 4
Birth order 3
Socioeconomic Status Middle
Family System Nuclear
Residence Lahore
Religion Islam
Informant Mother
Reason for Referral

The client was referred with the complaints of Stubbornness, showing temper tantrums

like throwing things on getting disturbed, biting others, non-compliance

and inability to speak and comprehend properly. He was referred to trainee clinical psychologist

for management of his problems.

Presenting Complaints

According to the mother

Duration Problematic Behavior

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History of Present Illness

 According to child’s mother, she remained mentally disturbed for some days while she

was expecting A.B. due to family stressor of having conflicts with her in-laws. The length of

mother’s pregnancy extended from nine months which made the family concerned. Doctors

advised that it child was under-weight so it would be better to wait for natural pains. According

to the mother, she experienced labor pains for 36 hours. At the time of birth, child had less height

and weight. He had blue lines on body due to lack of Oxygen so the doctors kept A.B in

incubator for six hours. Doctor told family that he was not a normal child but a special one i.e.

suffering from Down’s syndrome. Child’s mother got distressed when doctor broke out this news

while his father remained calm and patient. Child’s father consoled mother of child after which

she became relaxed. The family became extremely caring for child. When child was six months

of age in 2007, he suffered from typhoid. He was taken to Children Hospital where he got

treated. He was also gone through complete medical examination i.e. medical tests of whole

body like heart, brain, eyes, ears etc. which revealed no neurological deficit or any other

physiological problem in child. According to the mother, the child had been suffering from

severe chest problem after that typhoid. Doctors suggested keeping him safe from cold as he

might get infection in every changing season as he was extra sensitive to temperature. Mother

reported that child used to catch cold and chest infection in every changing season.

Mother reported that child’s growth was slower as compared to other children of his age

as he didn’t use to make eye-contact, no effort to sit unaided, not responding on being called etc.

Child was under-weight so parents focused a lot on his diet. He was given supplements with

milk. Child left mother feed and started weaning at the age of 8 months. As child appeared weak

and beyond his chronological age so his family took him to physiotherapist at the age of one year

in 2008. Treatment from physiotherapist continued for an year till 2009 who advised exercises
and massage as well as proper diet. Family strictly followed doctor’s advice. Child achieved all

milestones in late age as compared to other children of same age. As family was mentally

prepared by doctors that child would achieve developmental milestones late so they didn’t

become amazed. Child started sleep walking at the age of 6 years in 2013. According to the

mother, his family considered it part of his problem and showed very cooperative and caring

attitude towards child. They used to make him sleep again on catching him walking while asleep

and used to pamper him a lot. Child spoke 1st word at the age of 8 years when her mother

practiced one-word speech with him. Child’s family became very happy when he uttered first

word.

Child started watching Television in 2014 when he was 8 years old and became greatly

interested in watching specific type of cartoon program i.e. Doremon. He gradually became so

greatly fond of that program that if someone changed Tv channel or refrained him from watching

it, he used to show temper outbursts like shouting and throwing things away. He learned the

behavior of hitting and biting others from his elder brothers. He used to show non-compliance

when he was not provided with anything of his choice. He was taken to a speech therapist on

advice of a relative in start of 2015 for two months. Speech therapist gave him exercises to

practice like rolling tongue etc. his parents were advised to speak more words clearly with him

so he could learn language. Mother reported that child A.B has started speaking new words after

practicing it. The child A.B was referred to clinical psychologist of Shahdab Training Institute of

Special Education by speech therapist. He came to clinical psychologist of Shahdab Training

Institute of Special Education with the presenting compliants of stubbornness, non-compliance,

aggression, lack of on-seat behavior, hitting and biting others, showing temper tantrums and
throwing things away. He was referred to trainee clinical psychologist for management of his

problems.

Personal History

Personal History

The mother reported that she had Blood pressure problem during pregnancy and due to

family stressors, her Blood pressure became high several times during pregnancy. She had no

deficiency of iron and calcium during pregnancy. It was an over-mature pregnancy i.e. of

complete 10 months. His mother had labor pains for almost 36 hours. His height and weight was

less at the time of birth. His first cry was normal. However e was kept in Nursery for 6 hours to

overcome deficiency of Oxygen. No history of jaundice, paralysis, diarrhea, pneumonia,

malnutrition was reported by the mother. Moreover, there was no history of serious brain injury.

However child suffered from typhoid at the age of 6 months after which he developed problem

of chest infection.

Table 1
Table showing Developmental Milestones, Normal Age range, Achieved Age and Developmental

level of child’s Developmental Milestone

Achieved age and Developmental level of

Developmental Milestones Normal age range child’s Achievement Milestone

Social Smile 3 months 8 months Delayed
Neck Holding 3-4 months 2.5 years Delayed
Sitting 7 months 4 years Delayed
Crawling 9 months 3 years Delayed
Walking 12-14 months 5 years Delayed
Single word speech 12-18 months 8 years Delayed
Complete sentence 3 years Not Yet Delayed
Bladder control 2-4 years 7 years Delayed
Taking Bath without Help 4 years 7 years Delayed
Child had great interest in watching Television so he used to watch cartoon Doremon

throughout day. He liked snacks and fruits alot.

Family History

 Father:

M.S was a 48 years old man who was educated up to Bachelors level. He was a

government employee. He was kind, cooperative and sociable by nature. He loved present

child more than other children. He was over protective about child. He didn’t scold him even

on his disruptive behavior. He was concerned about problem of child. He was mentally and

physically healthy.

 Mother:

The client’s mother B.S was 31 years old and educated up till matriculation. She was a

housewife. She was patient, caring and loving by nature. She used to beat his elder child

instead of child A.B because his husband forbade her to scold A.B. She was also concerned

about his problem. She was mentally and physically healthy.

 Siblings:

Brother- Child’s elder brother was 12 years old. He couldn’t perform well in normal

schools so he was brought to Shahdab Training Institute where he was diagnosed with

Attention deficit Hyperactive Disorder. Child used to fight and beat his brother. His

parents used to beat child’s brother instead of scolding child. He was weak in health.

General Home Atmosphere

The child belonged to a middle socioeconomic status. He lived in joint family system

before child’s birth but then they shifted to a new home and were presently living in nuclear

family system. Father was head of the family. Home environment was reported to be congenial.

Preliminary Investigation
 Preliminary investigation of the child was done in order to gather information regarding

is nature of symptoms, Causes and maintaining factors for diagnosing and managing his

problems. It was done on two levels:

Informal Assessment

The following measures were used for this purpose:

 Clinical Interview

 Behavioral Observation

 Subjective rating of Presenting Complaints

 Identification of Reinforcers

 Checklist for Developmental Areas

 Portage Guide to Early Education

Clinical Interview

Clinical interview not only gathers basic background data of any kind but also helps to

give special attention to whatever topics are considered most important (Segal, June, & Marty,

2010). Semi-structured interview was conducted with the mother of child to get information

about the problematic areas of the child. It gave detailed information about identifying data,

presenting complaints, history and prior treatment. This information was used to devise

idiosyncratic case formulation and management plan for the child. It took almost two sessions to

complete the interview.

Behavioral Observation
 Behavioral Observation helps to assess the child’s present level of functioning.

Behavioral observations focus on vocalizations (e.g. crying, whining or groaning),

verbalizations, facial expressions, guarding of body parts, temperament, activity and general

appearance (Craig, 1992).

The child seemed to be seven years old with age inappropriate height and weight. He was

neatly dressed in trousers and shirt. His hair were combed. His facial expressions were not

appropriate. He didn’t maintain eye-contact. He was not speaking but giving gestures. His mood

was irritable and behavior was bizarre. He had no on-seat. He showed greatly disruptive behavior

like hitting things, running away, throwing saliva, biting therapist and shouting. He didn’t follow

instructions in his initial sessions but later he showed compliance and his on-seat behavior was

greatly improved.

Table 2
Table showing areas observed during Behavioral Observation
Covered Areas Observation
Height and Weight Inappropriate
Facial Expressions Not appropriate
Speech One word
Hygiene Appropriate
Posture Not appropriate
Motor Agitation Present
Eye contact Not maintained
On seat Behavior Not present
Compliance Non-compliant
Comprehension Poor
Mood Irritable
Inappropriate and Disruptive Behavior Showing tantrums
Activity Level Very Active
Social Not very Social
Self-help Dependent
Qualitative Analysis

Behavior observation of child correlated well with presenting complaints of the child and

DSM-5 diagnosis of Autism Spectrum Disorder and Intellectual Disability.

Subjective Rating of Symptoms

Subjective Ratings are taken to see how frequently problem behaviors occur and how

severe these behaviors are (Spiegler & Guevrement, 1998). Likert Scale of 0 to 10 points can be

used to note severity and intensity of target problem (Cournoyer, 2000). Ratings were taken from

the mother which showed intensity on 0-10; whereas 0 indicated no problem, 5 meant average

level of problem and 10 reflected that the problem was severe.

His symptoms were rated on zero to 1 point scale to get an estimate of intensity of the

problems at pretreatment stage. She was told that rating on zero means no problem, rating on one

means minimum problem and ratings at ten means problem at maximum level. These ratings

were taken so that they can be compared with ratings on post-treatment level to evaluate

effectiveness of therapy.

Table 3
Table showing Problematic Areas and Pre-Treatment Rating by Mother of the Child (0-10)

Problematic Areas Pre-Treatment Rating (0-10)

On-seat 10
Hitting others 10
Temper Tantrums 09
Poor Adaptive Skills 09
Throwing saliva 09
Poor Comprehension 08
Poor Socialization 08
Lack of Compliance 08
Biting Others 09

Identification of Reinforcers

Potential reinforcers were identified through direct questioning, selecting from

generalized reinforcers and observing the routine of the child. Potential reinforcers were first

identified and tested to see if they accelerate target behavior (Spiegeler & Guevrement, 1998). In
present case, reinforcers were identified by direct questioning and observing routine of child.

Following were the identified reinforcers:

Table 1.5
Table showing Different Types of Renforcers of child
Types of Reinforcers Identified Reinforcers
Tangible Reinforcers Snacks, Biscuits, Juice
Social Reinforcers Praise, Clapping, Patting, Smile
Activity Reinforcers Playing with the blocks, swings

Checklist for Developmental Areas

Checklist for Developmental Areas developed by Government Shahdab Training Institute

of Special Education was administered for assessing various areas of adaptive functioning of the

child such as Fine motor, Gross motor, Pre-writing, Writing, Language development, Speech,

Mathematics, Social and Practical skills, Art and Craft and General Knowledge.

Quantitative Analysis
Table 4
Table showing Quantitative Analysis of Developmental Checklist
Categories Total Score Obtained Score
Fine Motor 25 6
Gross Motor 24 13
Pre-Writing 20 0
Writing 25 0
Language 22 4
Speech 28 8
Mathematics 33 1
Social and Practical 41 10
Art and Craft 11 1
General Knowledge 24 0

Portage Guide to Early Education (PGEE)

 Urdu version of Portage Guide to Early Education (PGEE) translated by Ministry of

Education and Social Welfare, Islamabad was administered on the child with the assistance of

mother to assess the current functioning level of child. Its rationale is to assess the functioning in

five domains i.e. Cognitive, Socialization, Self-Help, Motor and language (Bluma, Shearer,

Frohman & Hilard, 1979).

Administration

It was administered in distraction-free room. Cognitive area was administered on the

child. Questions of other areas such as Socialization, Self-help, Motor and Language were asked

from the mother of the child. Administration of Portage Guide to Early Education (PGEE) took

two sessions.

Analyses of Portage Guide to Early Education (PGEE)

Analysis of PGEE was done on following two levels:

Qualitative Analysis

Functioning in different domains of PGEE

Table 5

S. No Subscales/ Areas of Current Discrepancy

Functioning Functioning Age between CFA and
(CFA) in months chronological age
in months
1 Language 16 80
 
2 Self Help 46 50
3 Socialization 37 59
4 Motor 37 59
5 Cognitive 12 84

Quantitative Analysis
 From the above mentioned quantitative analysis, it can be concluded that child is lacking skills

in all areas. His cognition and language areas are least developed, socialization and motor skills are

better than cognition but yet far behind according to his chronological age. His self-help area is

better than all other areas.

The child’s chronological age is 8 years but accordingly his developmental age in self-help

area is equivalent to child of 3 years 10 months. Hence, his self-help area is better than other areas but

still improvement is required. His first failure was on item # 35 (of age range 2-3) “can wear shoes”.

This item was failed as it was reported by mother of client that he was unable to wear shoes or clothes

by himself. Similarly, the child had passed last item # 71 (4-5) “uses right utensils for eating” of self-

help area. His self-help skills were better as he was able to dress up himself, wipe his nose on need and

use washroom on own.

In motor area, the child’s developmental age is 3 years 1 month and hence is lacking behind his

chronological age. He failed first item # 58 (2-3) “putting 4 beads in strings in 2 minutes” and passed

the last item # 86 (4-5) “picks up things by bending himself”. His deficits in motor domain indicate

that he was capable to perform simple motor movements but is still unable to perform complex motor

tasks like bouncing ball, using scissors, jumping on feet 10 times etc.

Moreover, on cognitive area, his developmental age was 1 year indicating severe

developmental delay in this area. His first failed item was no. 25 (1-2) “able to put 3 basic shapes in

appropriate places” and passed the item # 50 (1-2) “sorts things by their types”. Severe deficits in

Cognitive domain were found as the child was unable to identify colors, shapes, sort objects by size,

use pencil to draw straight lines, draw anything etc.

In Language area, the developmental age of child was 1 year and 4 months. He failed first item

#28(1-2) “asks questions in interrogative tone” and passed the last item # 31 (4-5) “tells the need to go
to washroom”. There were severe deficits in language area as the child was unable to tell his home

address, telephone number and explain simple incidences of daily happening.

Likewise, in Socialization area, his developmental age was 3 years 1 month. He first failed the

30 item (1-2) “plays with other children in a game” and passed last item# 61 (4-5) “can sing and

dance on demand”. In socialization domain, there were some deficits.

Table 6

Table showing criteria of DSM 5 of intellectual Disability

DSM 5 Criteria Yes/ No

Deficits in intellectual functions such as Yes
academic performance
Deficits in adaptive function Yes
Symptoms must be present in Yes
developmental period
Symptoms cause clinically significant Yes
impairment in important areas of
functioning

Diagnosis

319 (F79) Unspecified Intellectual Disability

Case Formulation

According to DSM 5, Intellectual Disability is a disorder with onset during the

developmental period that includes both intellectual and adaptive functioning deficits in

conceptual, social, and practical domains. Deficits in intellectual functions, includes problems in

reasoning, problem solving, planning, abstract thinking, judgment, academic learning, and

learning from experience whereas deficits in adaptive functioning includes problems that result

in failure to meet developmental and sociocultural standards for personal independence and

social responsibility. The various levels of severity such as mild, moderate, sever and profound

are defined on the basis of adaptive functioning, and not IQ scores (American Psychological

Association, 2013). Child had deficits in intellectual and adaptive functioning as he was unable

to solve problems, to think reason or judge according to environment or situation. He also had

problem in adaptive functioning characterized by his inability to fulfill any social responsibility.

Similar results are revealed through scores of Portage Guide to Early Education (PGEE). The

individual’s conceptual skills, social and communicative skills and care for personal need lack

far behind his chronological age and peers of his age group. Moreover these symptoms had onset

in early developmental period as child’s mother indicated that his problems started in early

developmental period. Child was over 5 years of age. Formal assessment and testing could not be
administered on him because he had no educational basis and had speech problem too. So a

diagnosis of Unspecified Intellectual Disability was given to him.

According to research evidence, the diagnosis of Intellectually Disable is heterogeneous

in matter of physical appearance and behavioral features of child. Some intellectually disable

children are quiet, polite and confident while others are aggressive, anxious, impulsive and

hostile. The features of aggressive, anxious, impulsive and hostile are related to increased risk of

behavioral problems in intellectually disabled children (Kronenberger & Meyers, 1996). In

present case, child M.A. was stubborn, restless and showed anger outburst when his demands

were not met. He lacked compliance towards others and was used to hit others.

Evidence indicates that primary cause of Intellectual disability is biological, although

people who function at this level are greatly affected by their family and social environments

(Comer, 2010). M.A parents had cousin marriage.

The environment of a child also plays an important role in the child’s frequency of

temper tantrums. A caregiver’s extra response or lack of response to inappropriate behaviors

determines the future course for both the misbehavior and the child (Zirpoli, 2010). Mother told

that child’s father had over-protective attitude towards child. Neither he neither forbid child on

his disruptive behavior nor he allowed others to say scold child A.B. Due to this, he learnt to

show temper tantrums, his behavior was reinforced by his father’s over-protective attitude.

It was evidenced that all people with Down's syndrome will have some degree of

intellectual disability. Children with Down's syndrome do learn to walk, talk and be toilet trained

but in general will meet these developmental milestones later than their non-disabled peers.

There is a wide variation in ability in people with Down's syndrome just as there is in the rest of

the population. It was also suggested that early intervention programmes which help in all areas
of child development are widespread. These programmes can include speech and physical

therapy as well as home teaching programmes for the child and the family (Bittles & Glasson,

2004). Child had down’s syndrome and Unspecified Intellectual Disability. His developmental

milestones were delayed as told by his mother. Child took speech therapy sessions too.

According to a research, signs of intellectual disability in children include slowness in

learning to sit, crawl or walk, delay in learning to talk or ongoing trouble with talking, poor

attention capacity, limited planning or problem solving abilities, difficulty with understanding

rules and instructions, behavioral and social problems, trouble with self-care tasks such as

getting dressed, toileting and feeding themselves (Blacher & McIntyre, 2005). All of these

problems were observed and reported by child’s mother.

The majority of intellectual disability results from genetic disorders such as Down

syndrome. The main cause of intellectual disability is unknown. The most common causes

include genetic conditions such as Down syndrome and fragile X syndrome, problems during

pregnancy such as infections or exposure to drugs and over-mature pregnancy (i.e. pregnancy

exceeding 9 months) (Arvio & Sillanpaa, 2003).

A research by Eisenhower, Baker and Blache (2005) reveals that Down syndrome also

causes intellectual disability. Most people with Down syndrome have a level of intellectual

functioning (IQ) that is in the mild to moderate range of intellectual disabilities. They may also

be slow in developing language skills and learning to control their movements. So children with

Down syndrome can often be helped by Speech therapy, Physical therapy to help them learn to

control their movements, Occupational therapy to help them learn activities of daily living and

Special education
 The mental health, adaptive behavior and intellectual abilities of people with

Down syndrome (n=129) were evaluated in a population-based survey of social and

health care records. Females had better cognitive abilities and speech production

compared with males. Males had more behavioral problems than females (Maatta, Tervo-

Maatta, Taanila & Kaski, 2006). Child was male which can be a contributing factor to his

poor cognitive abilities, behavioral problems and speech problem.

Management plan

It was based on behavior therapy keeping in view idiosyncratic need of the child. Problems of

the child were managed through:

 Psychoeducation

 Behavior Therapy

Short Term Goals

Psychoeducation: Mother was psychoeducated regarding the problem of the child. The therapist

guided mother regarding the problems of child and the ways through which they can be

managed.

Rapport Building: It was carried out to make child open and engaged in therapy sessions.

Compliance Training: It was carried out to build compliance of child towards therapy.

Behavior Therapy: It was used in order to manage disruptive behaviors of child and to replace

unwanted problematic behaviors with desired and appropriate behaviors. Following techniques

of Behavior therapy were used:

Reinforcement: It was used to increase frequency and probability of desirable behavior to occur

again in the future. It was used to increase child’s on-seat behavior and to reduction in non-

compliance and hitting behavior.

Token-Economy- It was used to increase on-seat behavior of child.

Physical Restraints: These were used to improve on seat behavior as well as to reduce temper

tantrums of child.

Prompting: Child was provided aids in the form of verbal and physical prompts to help him

complete the target behavior and to make him learn that behavior.

Fading: It was used to enable child to carry out the learnt behaviors independently.

Overcorrection: It was used to lessen his disruptive behavior of showing tantrums, throwing

things away, hitting other and spitting on therapist.

Response cost: It was used to reduce child’s disruptive behavior of hitting and shouting at

others.

Time-out- Time-out was given to child to decrease his behavior of stubbornness and non-

compliance.

Contingent Exercise: the purpose was to reduce child’s disruptive behavior of hitting others,

shouting, misbehaving and showing non-compliance.

Attentional Building Techniques- were used as techniques to build his attention.

Long Term Goals:

These will include:

o Continuation of Short Term Goals

o Follow up sessions
References

Arvio, M., & Sillanpaa, M. (2003). Prevalence, aetiology and comorbidity of severe and

profound intellectual disability in Finland. Journal of Intellectual Disability Research,

47(2), 108-112. doi: 10.1046/j.1365-2788.2003.00447.x

Bittles, A. H., & Glasson, E. J. (2004). Clinical, social, and ethical implications of changing life

expectancy in Down syndrome. Developmental Medicine & Child Neurology, 46(4),

282-286. doi: 10.1111/j.1469-8749.2004.tb00483.x

Blacher, J., McIntyre, L. L. (2005). Syndrome specificity and behavioural disorders in young

adults with intellectual disability: cultural differences in family impact. Journal of

Intellectual Disability Research, 50 (3), 184-198. doi: 10.1111/j.1365-2788.2005.00768.x

Eisenhower, A. S., Baker, B. L., & Blache, J. (2005). Preschool children with intellectual

disability: syndrome specificity, behaviour problems, and maternal well-being. Journal

of Intellectual Disability Research, 49 (9), 657–671. doi: 10.1111/j.1365-

2788.2005.00699.x

Hall, T. M., Kaduson, H. G., & Schaefe, C. E. (2002). Fifteen Effective Play Therapy

Techniques. Professional Psychology: Research and Practice, 33(6), 15–522. doi:

10.1037//0735-7028.33.6.515
Maatta, T., Tervo-Maatta, T., Taanila, A., & Kaski, M. (2006). Mental health, behaviour and

intellectual abilities of people with Down syndrome. Down Syndrome Research and

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