Bio Data

Name S.A
Age 6 years
Sex Male
No of Siblings 2
Birth Order 1st born
Religion Islam
Family System Nuclear
Institute initials S.S.S
Informant Mother
Reason for Referral
The child was brought by his mother to Social Society School of Special
Education with complaints of lagging behind in cognitive skills as compared to his age
fellows, lack of independent functioning, and speech difficulties. He was referred to the
trainee clinical psychologist for the purpose of assessment and management of his
symptoms.
Presenting Complaints
Table 2.1
The child’s mother reported the following presenting complaints.
‫دورانیہ‬ ‫مسائل‬
‫ سال کی عمر سے‬1 ‫تقریبا‬ ‫ذہنی طور پر دوسرے بچوں سے‬
‫کمزور ہے‬
‫ سال کی عمر سے‬3 ‫تقریبا‬ ‫اپنا کام خود سے کرنے میں مشکل پیش‬
‫آتی ہے‬
‫ سال کی عمر سے‬3 ‫تقریبا‬ ‫بولنے میں مشکل پیش آتی ہے‬
History of Present Illness
The mother reported that after the child’s birth, she observed that he had some
unusual features which were not present in other children. He had features of slanting
eyes with folds of skin at the inner corners; short, broad hands; broad feet with short toes;
flat bridge of the nose; short, low-set ears; short neck; small head; and small oral cavity.
After observing that features, he was taken to the Children hospital after 1 month of birth.
 The doctors did complete medical examination of him and informed that he had
Down syndrome. They also reported that he would be different from normal children and
his mental growth would also be slow. Moreover, he would need special assistance for
his development. That information was very stressful for the mother.
Moreover, the mother reported that with the passage of time she observed that the
child was achieving some of the developmental milestones with significant delay. He
started holding his head at the age of 12-14 months, sitting at 1.5-1.75 years, crawling at
2 years, and controlling bladder and bowel movements at 4 years. Furthermore, he didn’t
start to dress and take bath without help and speaking complete sentences till yet.
After observing slow development in child, the mother discussed his case with
one of her relative who was a teacher of special education. She informed her about Social
Society School of Special Education who was dealing with mentally challenged children
who also had Down Syndrome. After getting guidance from that relative, the mother
came to that school for first time with child with the complaints of lagging behind in
cognitive skills as compared to his age fellows, lack of independent functioning, and
speech difficulties. He was than referred to the trainee clinical psychologist for the
purpose of assessment and management of his symptoms.
Background Information
Personal history
Child’s mother had 3 pregnancies of which the child was 1stborn. Child had a
mature birth after complete gestation period of 09 months. There were no illness or
medication intake was experienced by the mother during pregnancy. However, she
experienced stress and had poor diet during her pregnancy. Her vaccination was also
completed on time. Length of labor was about 30 minutes and child was born through
normal delivery. He had immediate first cry after birth. He had reddish complexion and
appropriate weight of about 2 kg at birth.
Breast feeding was initiated immediately after birth and no feeding difficulty was
reported. He didn’t have any breathing problem, jaundice/hepatitis, twitching,
convulsion, fever, and birth injury after birth. He also didn’t have paralysis, measles,
meningitis, typhoid, diarrhea/dysentery, malnutrition/dehydration, failure of thrive, and
marasmus under 1 year after birth.
 Breast feeding was continued till 1 year and after that bottle feeding was initiated
which was continued till 5 years. His vaccination was also completed on time. No history
of any accident or injury was reported by the mother.
The child achieved some of the developmental milestones with significant delay.
He started holding his head at the age of 12-14 months, sitting at 1.5-1.75years, crawling
at 2 years, controlling bladder and bowel movements at 4 years. Furthermore, he didn’t
start to speak complete sentences, dress and take bath without help till yet. The time
period for child to achieve developmental milestones is shown on the table.
Table 2.2
Shows developmental milestones of child corresponding to normal age of achievement

Developmental Normal Age of Child’s Age of

Milestones Achievement Achievement
Head holding 3 months 12-14
months*
Sitting 6 months 1.5-1.75
years*
Crawling 8 months 2years*
Walking 1.5-2 years 2 years
Speech: Single 1-3 years 3 years
word
Speech: 2.5-3 years Not yet*
Complete
sentences
Bladder control 3 years 4 years*
Bowel control 3 years 4 years*
Dressing 5-6 years Not yet*
without help
Taking bath 6-7 years Not yet*
without help

Note. *Significant delays

Present general state of health of child was normal. He had average height and
weight according to his age. His hearing, eye-sight, appetite, sleep, and speech were
normal. His visual motor and gross motor coordination was adequate. His fine motor
coordination was not adequate. No unusual behavioral patterns were reported. Body
rocking, head banging, self-mutilation and autism were not reported. He had interest of
watching doraemon and Tom and Jerry cartoons. He had much interaction with his age
fellows and siblings and he liked to spend time with them. No evidence of emotional
tension, fear, irritation, and lack of confidence was found in him.
Family history
The child’s family belonged to a middle socioeconomic class. The child lived
with his parents and two brothers.
Father. Child’s father M.S. was 42 years old. He had done matriculation and was
salesman. He was friendly and cooperative by nature. He had loving attitude towards the
child as well as other children. His general health was normal. He didn’t have any
physical and psychological illness.
Mother. Child’s mother I.K. was 37 years old. She completed her education till F.A and
was housewife. She was friendly and cooperative by nature. She had loving attitude
towards the child as well as other children. Her general health was normal but sometimes
she had problem of low blood pressure. She didn’t have any psychological illness.
Child’s parents were not relatives. They had congenial relationship between them.
Siblings. Child was 1st born and had two brothers. The first born brother M.A. was 4.5
years old. He had normal general health. He had friendly relationship with child. The
second born brother M.A. was 1.25 year old. He also had normal general health. The
child had loving relationship with his brother.
Home atmosphere
Child belonged to a middle class family. He belonged to a nuclear family system.
His father was authoritative figure in home. The overall environment of the home
remained satisfactory.
 Father Mother

S.A

Brother

Parents
Client
Brothers
Healthy Relationship

Preliminary Investigations
The child was psychologically assessed on the basis of informal and formal level
to get a clear view of his problem and to make effective management plan.
Psychological Assessment
Psychological assessment is a testing method that uses a number of techniques to
find hypotheses about individuals and their behavior, abilities, and
personality (Framingham 2016). Formal and informal assessment was carried out to
assess the presenting complaint.
Informal Assessment
 Clinical Interview
 Behavioral Observation
 Visual Analogue (Subjective Ratings of the Symptoms)
 Identification of Reinforcers
Formal Assessment
 DSM 5 Checklist for Intellectual Disability Disorder
 Portage Guide to Early Education
  Slosson Intelligence Test
Informal Assessment
Clinical Interview. A clinical interview is a face-to-face encounter in which clinicians
ask questions of clients, weigh their responses and reactions, and learn about them and
their psychological problems (Comer, 2013). It was conducted with the child’s mother to
collect detailed information about the child’s identifying data; presenting complaints,
their duration, intensities, and frequencies; lifestyles, relationships, personal, family and
educational history. Moreover, informal and formal assessment was also conducted in an
assessment room.
Behavioral Observation. Behavioral observation is the primary assessment approach for
preverbal and nonverbal children and is an adjunct to assessment for verbal children.
It focuses on vocalizations (e.g., crying, whining, or groaning), verbalizations, facial
expressions, muscle tension and rigidity, ability to be consoled, guarding of body parts,
temperament, activity, and general appearance (Craig, 1992).
The child apparently seemed to be 6years old boy. He was of average height and
weight according to his age. His personal hygiene was properly maintained. He was
wearing weather appropriate clothes. He maintained appropriate eye contact. Rapport
was easily built with him. He seemed to be attentive and was easily responding to the
trainee clinical psychologist. He had proper on seat and compliant behavior. His rate and
tone of speech was low. He didn’t have intact comprehension. His mood was neutral. He
had no idea of money value. He had no orientation about time and place but had intact
orientation about person.
Visual Analogue (Subjective Ratings of the Symptoms). Visual analogue can be used
for subjective ratings of mood, emotion, distress, or other sensations. Clients simply rate
the intensity of the sensation on a scale from 0-10 (McQueen, 2008). Subjective ratings
of the child’s symptoms were rated by the mother and the trainee clinical psychologist by
using 0-10 rating scale. In the ratings, 0 = no problem, 5 = average problem and 10 =
severe problem.
 Table 2.3
Shows rating by mother and trainee clinical psychologist on problematic areas on 0-10
point scale at pre assessment level.
Problems Rating by Ratings by trainee
mother clinical psychologist
Lagging 8 9
behind in
cognitive
skills
Lack of 8 8
independent
functioning
Speech 8 8
difficulties
Identifying Reinforcers. Reinforcement identification was done with the help of two
methods. One was direct observation and other was by asking from the mother (Spiegler
& Guevremont, 2013). It was observed that the child like to watch videos on mobile
phone. The mother also reported that he liked to watch Doraemon and Tom and Jerry
cartoon. Trainee psychologist also identifies that thumbs up and coloring as his
reinforcers. The trainee clinical psychologists always provided the reinforcer to the child
on the completion of the specific task which resulted in strengthening his desirable
behavior.
Table 2.4

Client’s Reinforce with Type and Priority

Reinforcer Type Priority
Praises, Very Social Social 1st
Good,
Thumbs up
Watching Tangible 2nd
Cartoons
Coloring Tangible 3rd
Formal Assessment
DSM 5 Criteria Checklist of Intellectual Disability Disorder
The child was also evaluated on DSM 5 criteria checklist of Intellectual Disability
Disorder to confirm his diagnosis.
Table 2.5
Showing DSM 5 criteria checklist of Intellectual Developmental Disorder
Diagnostic Symptoms Status of
Criteria present in the Symptoms
Child
A. Deficits in He lack planning, 
intellectual decision making,
functions problem solving,
and abstract
thinking.
B. Deficits in He had no 
adaptive understanding of 
functioning numbers, quantity,
time and money.
He is unable to
communicate his
needs clearly to
others. He is
dependent on his
family for daily
living and
appropriate social
functioning.
C. Onset of The symptoms 
intellectual became evident 
and during
adaptive developmental
deficits period.
 during the
developme
ntal period
Portage Guide to Early Education (PGEE)
Test Administration
Portage Guide to Early Education was developed by Bluma, Shearer, Frohman and
Hilliard (1976). Its Urdu version which was translated by Ministry of Education and
Social Welfare, Islamabad, which was administered on the child in an assessment room.
It consists of six areas. Its purpose was to assess the degree to which child’s language,
motor, social, cognitive and self-help skills were developed and his functional age.
Cognitive area was directly administered on the child whereas; questions related to other
areas were asked from mother. Some items related to motor area were also practically
performed by the child. It took almost 30 minutes of 2 sessions to complete the guide
(See Appendix A1).
Results
Quantitative Analysis
Table 2.6
Showing developmental age in years and months
Area Developmental Age
In Months In Years
Self-help 46.68 3.89
Motor 38.4 3.2
Cognitive 57.12 4.76
Language 59.04 4.92
Socialization 37.93 3.16
Qualitative Analysis. The table showed that child’s developmental age is lagging behind
in all areas of Portage Guide to Early Education as compared to his chronological age.
His most little developed areas are cognitive and language. His self-help area is also least
developed. His motor and socialization areas are well developed as compared to other
areas but still lagging behind as compared to his chronological age.
In self-help area, child’s developmental age is 3 years 8 months which is lagging
behind as compared to his chronological age. His first failure on item # 25 (age range 1-
2) that is “zips and unzips large zipper without working catch”. Similarly, his last passed
item # 80 (age range 4-5) that is “go to bathroom in time, undresses, wipes self, flushes
toilet, and dresses unaided” of self-help area.
Furthermore, in motor area, his developmental age is 3 years 2 months which is
also lagging behind as compared to his chronological age. His first failure on item # 48
(age range 1-2) that is “puts rings on peg” and passed the last item # 90 (age range 4-5)
that is “jumps forward 10 times on both foot”. Moreover, in cognitive area, his
developmental age is 4 year 8 which is also lagging behind as compared to his
chronological age. His first failure on item # 25 (age range1-2) that is “completes 3 piece
form board” and passed the last item # 91 (age range 4-5) that is “places objects behind
and next to when asks, and tells where the object is.” Furthermore, in language area, his
developmental age is 4 year and 9 months which is also lagging behind his chronological
age. His first failure on item #26(age range 1-2) that is “ask questions by a rising
intonation at the end of word or phrases” and passed the last item # 60 (age range 3-4)
that is “tell full name when requested”.
Moreover, in socialization area, his developmental age is 3 years 2 month which
is also lagging behind his chronological age. His first failure on item # 33 (age range 1-2)
that is “takes part in activities with another person” and passed the last item # 64(age
range 4-5) that is “engages in socially acceptable behavior in public”.
Solosson Intelligence Test
A brief individual test of verbal intelligence designed for use with individuals
ages 4 and older. It consists of 187 oral questions assessing six cognitive domains:
vocabulary, general information, similarities and differences, comprehension,
quantitative ability, and auditory memory. It provides a screening measure of cognitive
ability for children and adults, including visually impaired or blind individuals (Bradley,
1983)
Slosson Intelligence test was administered on the child to assess his intellectual
functioning.
Quantitative Analysis
Table 2.7
Shows the scoring of child on SIT.
Date of Administration 13-11-2022
Date of birth 12-11-2016
Chronological Age in years 6 years
Chronological age in 72 months
months
Basal age in months 7 months 9 days
Mental age in years 3.2 years
Mental age in months 32.4 months
Ratio IQ 45
Ratio IQ standard Error of 4.3
Measurement
IQ score 44.6
Qualitative Analysis. The child’s mental age came out to be 3years 2months while his
chronological age is 6 years this shows that his mental age is below than his
chronological age. His IQ is 44.6 which is below than average IQ.
Diagnosis
319 (F79) Intellectual Developmental Disorder (Moderately)
Prognosis
The child’s prognosis seemed to be satisfactory as the child’s mother was
concerned about him. She wanted early intervention of child. She was regular in
following instructions given by trainee clinical psychologist but child’s comprehension
was not good.
 Case Conceptualization

Client: S.A
Assessment Tool
Age: 6Years
Informal Assessment
Clinical Interview
Presenting Complaints Behavioral Observation
Visual Analogue (Subjective Ratings of
‫ذہنی طور پر دوسرے بچوں سے کمزور‬ the Symptoms)
‫ہے‬
Identification of Reinforcers
‫اپنا کام خود سے کرنے میں مشکل پیش آتی‬
‫ہے‬ Formal Assessment
‫بولنے میں مشکل پیش آتی ہے‬ DSM 5 Checklist for Intellectual
Disability Disorder
Portage Guide to Early Education
Solosson Intelligence Test

Maintaining Factors Protective Factors

Predisposing Factors
 Lack of quality care of
mother during pregnancy
 Down Syndrome
 Delayed Milestones
 Child’s comprehension
 Lack of speech
 Mother’s concern
 Regular individual
sessions
 Early Intervention

Precipitating
Factors
Current Symptoms

Management Plan
Diagnosis
 Rapport Building
319 (F79) Intellectual
 Psycho-education
Developmental Disorder Prompting
(Moderately)  Positive
reinforcement
 Applied Behavior
Analysis
Case Formulation
The child S.A was 6 years old boy with the complaints of lagging behind in
cognitive skills as compared to his age fellows, lack of independent functioning, and
speech difficulties. He also had some delayed developmental milestones.
According to DSM-5, intellectual disability is a disorder with onset during
developmental period that includes both intellectual and adaptive functioning deficits in
conceptual, social and practical domain in comparison to an individual’s age, gender, and
socio-culturally matched peers (APA, 2013). It is related with the case of the child
because he was lagging behind in intellectual functioning and had deficits in conceptual,
social and practical domain of adaptive functioning in comparison to his age, gender, and
socio-culturally matched peers. Moreover, its problem started in his developmental
period which was depicted from his history.
Some researchers showed that lack of quality care of mother during pregnancy
can lead to developmental disability (Comer, 2011). This research is also related with the
case of the child because her mother experienced stress during pregnancy due to financial
issues. Therefore, she didn’t take proper care of her health and diet. It might be the cause
of the child’s intellectual disability.
Individuals with Down syndrome have features of poor muscle tone; slanting eyes
with folds of skin at the inner corners (called epicanthi folds); hyper flexibility (excessive
ability to extend the joints); short, broad hands with a single crease across the palm on
one or both hands); broad feet with short toes; flat bridge of the nose; short, low-set ears;
short neck; small head; small oral cavity; and short, high pitched cries in
infancy(National Down Syndrome Society, 1979).This research is related with the case
of the child as he had some observable features of Down syndrome such as slanting eyes
with folds of skin at the inner corners; short, broad hands; broad feet with short toes; flat
bridge of the nose; short, low-set ears; short neck; small head; and small oral cavity.
According to different researches, the most common of the chromosomal
disorders leading to intellectual disability is Down syndrome (APA 2013 &Comer,
2011). These researches are related with the case of the child as he had Down syndrome.
All people with Down syndrome experience cognitive delays. Children with
Down syndrome learn to sit, walk, talk, play, and toilet train and do most other activities
only somewhat later than their peers without Down syndrome (National Down Syndrome
Society, 1979). This research is related with the case of the child as he was also
cognitively delayed and he also had delayed developmental milestones, which was
depicted from his history.
Management Plan
A symptom based management plan was devised which was based on techniques
of Behavior Therapy to improve child’s developmental skills.
Short-term Goals
The short term goals were as follows

 Structured individual sessions were conducted in an assessment room. 2 sessions

were conducted per week. In initial sessions, informal assessment was done. In
further sessions, main focus was maintained on improving development skills of
the child and for that purpose different behavior modification techniques were
applied.
 Rapport was built with the child and his mother to build a trusting relationship
with them in order to made therapy effective.
 Psycho-education was given to the child’s mother for her better understanding of
the child’s problem and to effectively play her role in therapeutic intervention.
 Positive reinforcement was used with the child to increase his desirable behavior
to improve his problem.
 Prompting was used to engage the child in the correct behavior at the correct
time.
 Fading was used to gradually elimination of the prompts given to the child.
 Chaining was used to teach difficult tasks to the child.
 Individualized Education/Training Plan was devised to teach the child
developmental skills.
Long-term Goals
The long term goals were as follows:
 Short term goals will be continue to keep improvement in child.
 Individualized Education/Training Plan will be continue to teach further
developmental skills to child according to his need.
 Follow up sessions will be conducted to make sure and increase improvement in
child.
Summary of Therapeutic Intervention
Rapport Building
Rapport building defined as “the ability to connect with others in a way that
creates a climate of trust and understanding” (Zakaria & Musta'amal, 2014).
Rapport was built with the child and his mother to engage them in therapy. It was
built with the mother by actively and empathetically listening and showing genuine
concern and giving unconditional positive regard to her (Resident Assistance Program
Newsletter, 2009). It was easily built with the child by just making compliments and
talking about his interests. As a result of this technique, the child and his mother showed
cooperation with the trainee clinical psychologist.
Psycho-education
The term “psycho-education” was first employed by (Anderson et al,
1950s) .Psycho-education is the education of a person in subject areas that serve the goals
of treatment and rehabilitation. It involves teaching people about their problem, how to
treat it, and how to recognize signs of relapse so that they can get necessary treatment
before their difficulty worsens or occurs again. Family psycho-education includes
teaching coping strategies and problem solving skills to families, friends, and/or
caregivers to help them deal more effectively with the individual. When behavioral or
psychological difficulties arise, people need specific information about what is
happening: the diagnosis of specific symptoms, what is known about the causes, effects,
and implications of the problem in question. The more family and friend know, the less
they will blame the person who is experiencing it or themselves for thinking they had
somehow caused it (Psycho-Educational Counseling Services, 2002).
In the present case, the child’s mother was psycho-educated about child’s
problem. It consisted of information on meaning of intellectual disability, its nature and
causes, treatment etc. Its rational was to reduced distress, confusion, and anxiety of
mother, which might in turn help the child to improve life style.
Mother was told about the child’s diagnosis. She was psychoeducated that
Intellectual disability is a disability characterized by significant limitations both
in intellectual functioning (reasoning, learning, problem solving) and in adaptive
behavior, which covers a range of everyday social and practical skills. This disability
originates before the age of 18.Down syndrome is major cause of it. It also consists of
delayed developmental milestones in child. Through behavior modification techniques,
child can acquire social and practical skills. Results of PGEE were discussed with
mother. She was consoled to reduce her distress. Significant of homework assignments
were told to mother to improve child’s problem.
She was told about procedure of giving reinforcement. As she had received some
information from doctor about child’s problem, so she faced no difficulty in
understanding further information. At the end, she told that now she had clear view of
child’s problem and it also helped her to reduce her distress (See Appendix A3).
Positive Reinforcement
Reinforcement is the process in which a behavior is strengthened by the
immediate consequence that reliably follows its occurrence. When a behavior is
sstrengthened, it is more likely to occur again in the future. There are two types of
reinforcement: positive reinforcement and negative reinforcement. Positive
reinforcement is defined as the occurrence of a behavior is followed by the addition of a
stimulus (a reinforcer) or an increase in the intensity of a stimulus, which results in the
strengthening of the behavior (Miltenberger, 2012).Positive reinforcement was given to
the child and for this purpose continuous reinforcement schedule was applied for the
acquisition and learning the desirable behavior of the child. It is a schedule in which each
occurrence of a response is reinforced (Miltenberger, 2012). Afterwards an intermittent
reinforcement schedule (fixed ratio) was applied so that the child continued to engage
in the desirable behavior. It is a schedule in which each occurrence of the response is not
reinforced (Miltenberger, 2012). Whenever the child gave correct response, he was being
reinforced with watching videos of Doraemon or Tom and Jerry cartoons. It resulted in
increase his number of correct responses that was desirable behavior.
Prompting and Fading
Prompts. Prompting are used to increase the likelihood that a person will engage
in the correct behavior at the correct time. They are used during discrimination training to
help the person engage in the correct behavior in the presence of the discriminative
stimulus (SD). These are stimuli given before or during the performance of a behavior.
They help behavior occur so that the child can provide with reinforcement. Various types
of prompts are used in behavior modification; the two major categories are response
prompts and stimulus prompts. A response prompt is the behavior of another person
that evokes the desired response in the presence of the SD. Verbal prompts, gestural
prompts, modeling prompts, and physical prompts are all response prompts. Verbal
prompts are when the verbal behavior of another person results in the correct response in
presence of the SD. It is a verbal prompt when we say something that helps the person
engage in the correct behavior. Verbal prompts may include instructions, rules, hints,
reminders, questions, or any other verbal assistance. Physical prompts include
physically guiding or touching the child to help him use the target behavior or skill. They
are used when the child does not respond to less restrictive prompts (e.g., modeling,
verbal, visual). They are useful when teaching motor behaviors (Miltenberger, 2012).
Both verbal and physical prompts were used with child to teach him
developmental skills. For example, while doing a cognitive task in which the child drew
a vertical line, the trainee clinical psychologist assisted him verbally as well as
physically. She held hand of him and also verbally instructed that “now draw a straight
line.”
Fading. Fading is the gradual elimination of the prompt as the behavior continues
to occur in the presence of the SD. Fading is one way to transfer stimulus control from the
prompts to the SD (Miltenberger, 2012). For example, the trainee clinical psychologist
started to provide less and less verbal and physical guidance when the child started to
drew a correct vertical line. It resulted in maintenance of his behavior.
Chaining
A complex behavior consisting of many component behaviors that occur together
in a sequence is called a behavioral chain. Each behavioral chain consists of a number of
individual stimulus-response components that occur together in a sequence. For this
reason, a behavioral chain is often called a stimulus-response chain. Each behavior or
response in the chain produces stimulus change that acts as an SD for the next response in
the chain. The first response produces an SD for the second response in the sequence. The
second response produces an SD for the third response in the sequence, and so on, until
allthe responses in the chain occur in order. Of course, the whole stimulus-responsechain
is under stimulus control, so the first response in the chain occurs when a particular SD is
presented. There are three types of chaining: forward chaining, backward chaining, and
total task presentation.
Forward chaining. Forward chaining was used with the child. It is a type of
chaining in which one component of the chain at a time is teach and then chain the
components together, and prompting and fading is used to teach the behavior associated
with the SD at each step in the chain. We move from the front of the chain to the end. The
 process of analyzing a behavioral chain by breaking it down into its individual stimulus-
response components is called a task analysis (Miltenberger, 2012).
An example of forward chaining applied with the child is as follows:
 SD1 (need of washing face and hand)-R1 (adults regulates water)
 SD2(availability of water)-R2 (wash face and hand with water)
 SD3 (face and hand washed with water)-R3 (pick up soap)
 SD4 (soap in hand)-R4 (wash face and hand with soap)
 SD5 (face and hand washed with soap)-R5 (wash face and hand with water)
 SD6 (face and hand washed with water)-R6 (cleaned face and hand)
Individualized Education/Training Plan
An Individualized Education/Training Program (IEP) is a written statement of the
educational program designed to meet a child’s individual needs. Every child who
receives special education services must have an IEP. That’s why the process of
developing this vital document is of great interest and importance to educators and
families alike (The Short-and-Sweet IEP Overview, 2017).
An IEP was established for the child which was based on the areas of PGEE to
meet the distinctive needs of him. It consisted of targets and the techniques such as
reinforcement, prompting, chaining, and fading to achieve those targets(See Appendix
A3).
Post Assessment. Post- assessment of the child was done on the basis of visual analogue
(subjective ratings of symptoms)after applying therapeutic intervention. A clear
difference can be seen between pre-assessment and post-assessment of the child.
Visual Analogue (Subjective Ratings of the Symptoms)
Subjective ratings of the child’s symptoms were taken by the mother and the
trainee clinical psychologist by using 0-10 rating scale in order to see improvement after
applying therapeutic intervention.
Table 2.8
Shows rating by mother and trainee clinical psychologists on problematic areas on 0-10
point scale at pre and post assessment level.
Problems Rating by mother Ratings by trainee
clinical psychologist
Pre Post Pre Post
Lagging behind 8 5 9 6
in cognitive
skills
Lack of 8 5 8 5
independent
functioning
Speech 8 5 8 5
difficulties
Graph 1.1 Showing pre and post assessment rating by mother of G.M. on 0-10 point
scale

9
8
7
6
5
Pre
4
Post
3
2
1
0
Lagging behind in Lack of independent Speech difficulties
cognitive skills functioning

Graph 2.2 Showing pre and post assessment rating by trainee clinical psychologist on 0-
10 point scale.

10
9
8
7
6
5 Pre
4
Post
3
2
1
0
Lagging behind in Lack of independent Speech difficulties
cognitive skills functioning
 Qualitative analysis
The above graphical representation shows a significant improvement in
developmental skills of child after post assessment which proved the therapy to be
effective.
Outcome of the therapy
The child had 20 sessions with trainee clinical psychologist (2 sessions/ week).
Post assessment showed overall 30% improvement in his developmental skills according
to the mother and the trainee clinical psychologist.
Limitations
 There was no availability of a separate session room which might be a hindrance in more
improvement of child.
 No test was administered on the child to measure verbal IQ of the child due to his speech
difficulties.
Structure of session
The therapeutic process was continued for 12 sessions. Each session was of 45
minutes. The initial 60 minutes were given to the client to work on his cognitive and
adaptive skills. The last 10 minutes were provided to the client`s mother to give his
understanding of the client’s condition and mental level, homework assignments,
techniques to manage undesirable behaviors, procedures to develop his self-help skills
(wash hands mouth with soap, comb hair) and listen to his concerns regarding the client.

Session Record Form

Session No. 1

Time duration
45 minutes

Behavioral observation
Client showed alliance with trainee psychologist.

Session goals
 Rapport building
 Observation of client

Session structure and outcomes

During the 1st rapport was building with client. Different activities performed,
such as coloring and drawing, given a sheet for coloring, and also draw vertical and
horizontal lines, all these activities was for rapport building so it would be helpful for
future sessions with the client. Rapport with the client was built gradually. Identification
of reinforcer was done, checked client gross and fine motor movements, and also
checkedclient’s onset behavior, and compliance. Through 1st session, it was checked that
his gross and fine motor movement was appropriate and also shown compliance and has
onset behavior.
Session No. 2
Time duration
45 minutes

Behavioral observation
Client was in smile face but on-seat behavior of client was short time of duration
and does not maintain eye contact.

Session goals
 Observation of client
 History of client’s problem from class teacher

Session structure and outcomes

During the 2nd session information about client’s problem was asked from his
class teacher. Conduct information about client’s attitude during class. The client drew
lines on the paper given by therapist. Client likes to play with colors. Reinforcement was
used in the session when the client showed desired behavior.

Session No. 3
Time duration
45 minutes

Behavioral observation
The client has one some activities related o fine and gross motor skills.

Session goals
 Identification of reinforcers
 Check Motor Skills

Session structure and outcomes

The target of the session was administration of the reinforce identification
checklist. Prompting and positive reinforcement were used for showing compliant
behavior and reinforce identification checklist was also administer to identify the further
reinforcer. The reinforcer of the client was identified because it would be helpful for
modifying the maladaptive behavior of the client and teaching him new things. The
therapist identified that the client likes drawing and coloring, thumbs up. Revision of the
last activities of color identification and cutting of shapes was done. Trainee Clinical
Psychologist done some activities related to gross and fine motor skills.

Session No. 4
Time duration
45 minutes

Behavioral observation
The client was showing interest in activities and cooperative with Trainee Psychoogist
during the whole 4th session.

Session goals
The goal of the session was to conduct test.
 PGEE
 Revision of previous task

Session structure and outcomes

During 4th session used the client’s reinforcer and checked clients self help skills
hoe to close buttons, how to wear socks, how to clean nose and hands. Through that
session, PGEE was administered, some items were missed that were asked from client’s
mother when she visited school and find out the client’s function age of all the areas of
PGEE. Attention increasing activities was also done. Revision of last activity of color
identification was done which client has achieved partially.

Session No. 5
Time duration
45 minutes

Behavioral observation
The client was in a pleasant mood. He was wanted to play out-door.
Session goals
The goal of the session was to conduct test.
 PGEE
 Colors identification and Tracing

Session structure and outcomes

During 5th session used the client’s reinforcer and checked clients motor areas
such as jumping, kick the ball, and also fine motor skills such as pick the pencil, snip
with scissor. PGEE was administered, some items were missed that were asked from
client’s mother when she visited school and find out the client’s function age of all the
areas of PGEE. Color identification was taught to the child through using different color
pencils. Trainee Clinical Psychologist taught him tracing with physical prompts.

Session No. 6
Time duration
45 minutes

Behavioral observation
His mood was not so good. He was not showing compliance properly. He had a
little fever.

Session goals
 Administration of Sollosson Intelligence Test (SIT)
 Revise previous Task

Session structure and outcomes

In this session colored progressive matrices that measure the learning
difficulties and issues of cognitive processes who may think clear was administrated.
Different body parts names were asked by showing cards. Revision of last activities of
color identification and Tracing was done which client has achieved partially.
Session No. 7
Time duration
45 minutes

Behavioral observation
The client was lethargic He responded to allquestion and performed activates
according to the instructions but he was taking some time to respond.

Session goals
 Self help skills
 Greetings
 IEP

Session structure and outcomes

In this session, due to the client’s condition and mood trainee psychologist
revised previous task. Tracing of alphabet was done with physical and verbal prompts.

Session No. 8
Time duration
45 minutes

Behavioral observation
The client was in a pleasant mood. Feedback of previous session was recorded.

Session goals
 To review the all previous sessions
 Worked on child previously managed behavior
 Work to strengthening them and some proposed management
 Self help skills

Session structure and outcomes

Self help skills were taught how to tie shoes laces. Exercises were done and
interventions were used for strengthening the desired behavior of child. Review all the
sessions and improvement in child’s behavior.
Session No. 9
Time duration
45 minutes

Behavioral observation
Client was interested to do different activities. He was cooperative during the
whole sessions.

Session goals
The goal of the session was to teach him following
 Revision of previous skills
 Socialization

Session structure and outcomes

In this session, previous skills were revised after that Trainee clinical
psychologist performed a group activity in which the Trainee clinical psychologist played
with toys and make a circle round game with the client and children to allow the client to
play with others. All the previous skills were revised. IEP was learnt to client how to ask
for permission when wanted to use other person’s belongings. How to greet first, when to
say thank you and please etc. Self helpskills were also taught how to communicate and
team work with class fellows.

Session No. 10
Time duration
45 minutes

Behavioral observation
The client was in a pleasant mood.

Session goals
The goal of the session was to teach him following
 Revision of previous skills
 Learning, Tracing and coloring

Session outcomes
 In the 10 session different activities were arranged side by side and client was
involved and show compliance. The client did not do proper coloring inside of the shape
so the Trainee clinical psychologist asked the client to color inside of the shape (verbal
prompt) and whenever the client tried to color outside of the shape Trainee clinical
psychologist kept one hand outside of the shape. All previous sessions activities were
revised.

Session No. 11
Time duration
45 minutes

Behavioral observation
The client was in a pleasant mood. He responded properly on previous task
revision.

Session goals
 Revision of previous skills
 Termination

Session structure and outcomes

In the 11 session different activities were arranged side by side and client was
involved and show compliance. The end of therapy was positive experience with a long
lasting impact on both the client and therapist. Successful termination was done and the
goals were achieved. Specified time for working was ended.

Session No. 12

Time duration
45 minutes

Behavioral observation
The client was in a pleasant mood. He was enjoying the revision of tasks.

Session goals
 Revision of previous skills
  Termination

Session structure and outcomes

In the 12 session different activities were arranged side by side and client was
involved and show compliance. The end of therapy was positive experience with a long
lasting impact on both the client and therapist. Successful termination was done and the
goals were achieved. Specified time for working was ended.
References
Ahmed, M. Impact of Psycho-Education and Support Program for Parents of Children with
Intellectual Disability. Retrieved from:
https://www.google.com.pk/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&cad=rja
&uact=8&ved=0ahUKEwjF1dDpmsXYAhVIFuwKHSCaAxUQFggzMAE&url=http
%3A%2F%2Facid.afid73.org%2Fkaidd_abs%2Fpds%2F20110600330_16th_A_26.p
df&usg=AOvVaw1AUIlVMvkpEKN6M2leU4CQ
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental
Disorders.(5th Ed.). Washington, DC: Author
Bluma, S. D. M., Shearer, M. S., Froahman, A. H., &Williard, J. M. (1976).Manual for
PortageGuide to Early Education. (Revised Ed.) U.S: Cooperative Educational
Service Agency.
Comer, J. R. (2013). Abnormal Psychology. (8th Ed.). USA: Catherine Woods.
Craig, K.D. (1992). The facial expression of pain: better than a thousand words? APS
Journal, 1(3):153-62.
McQueen, P. (2008). VAS Scale. Retrieved from: https://psychologytools.com/vas-
scale.html
Miltenberger, R. G. (2012). Behavior Modification: Principles and Procedures. (5th Ed.).
USA, Wadsworth: Cengage Learning.
National Down Syndrome Society. Down Syndrome. Retrieved from: www.ndss.org
Spiegler, M. D., &Guevremont, D.C. (2010). Contemporary Behavior Therapy.(5th Ed.).
USA, Wadsworth: Cengage Learning.
Individual Training Plan
Name: S.A Gender: Male DOB:11-10-2016 Age: 6 years
Diagnosis: Intellectual developmental disorder ( Moderate)
Area Target Current technique Material Strategies Achiev
Objective Functio ed
ning
Socialization To say sorry He physical Flashcards Started from sorry 25%
immediately cannot prompts , candies with physical
after doing apologiz reinforcement prompts
something e when ,
wrong wrong
Self-Help To spread He can’t Shaping Bread child will be 40%
Skills butter on bread spread slice, provided a
slice butter on spreader, spreader in hand
the bread butter, and butter pack
plate

Language To remember He could Shaping Starts from the 35%

home address recall the area name, then
regardin the street name
H# 3, St# 14,
g area and then the house
Mughalpura
name name
Lahore
Cognitive To remember He can Shaping Notebook, Start from A, ‫ا‬ 40%
and write urdu recall pencil.
and english and write
alphabets in ‫ا‬. He can
sequence from recall.
(‫ )ا تا ث‬and (A He could
to E) recogniz
e A, B
but
couldn’t
write.

Motor To cut paper He can Chaining Paper, Starts from the 45%
with scissors only hold scissors simple 1” page and
the then to 2” page
scissors
 APPENDIX –II Developmental Ages in various Areas of PGEE

AREA Age Level Total Failures Passes Age Months

(T) (F) (P) (P/T*12)

Socialization 0-1 28 0 28 12

1-2 15 4 11 8.8

2-3 8 6 2 3

3-4 12 10 2 2

4-5 9 7 2 2.6

5-6 11 11 0 0

Developmental Age 37.8 M 3Y

Language 0-1 10 0 10 12

1-2 18 0 18 12

2-3 30 5 25 10

3-4 12 6 6 6

4-5 15 5 10 8

5-6 14 11 4 4

Developmental Age 52 M 4.3 Y

Cognition 0-1 14 0 14 12

1-2 10 0 10 12

2-3 16 3 13 9.75

3-4 24 8 16 8

4-5 22 15 7 3.8

5-6 22 22 0 0
 Developmental Age 45.55 M 3.7 Y

Motor 0-1 45 0 45 12

1-2 18 4 14 9.3

2-3 17 8 9 5.64

3-4 15 9 6 4.8

4-5 16 11 6 4.5

5-6 29 29 0 0

Developmental Age 36.2M 3.02 Y

Self Help 0-1 13 0 13 12

1-2 12 0 12 12

2-3 27 17 10 4.4

3-4 15 9 6 4.8

4-5 23 17 6 6

5-6 15 10 5 4

Developmental Age 43.2 M 3.6 Y

33