Case Summary
This case involved a 10-year-old female client named Z.B who was brought to H.H Rehabilitation
Center by her mother with noncompliance with forgetfulness, difficulty in focusing, delayed speech,
and lack of attention. The client's developmental milestones were delayed.The client came
from a nuclear family with middle-class socioeconomic status.The formal and informal assessment
included a clinical interview ,behavioral observation and Color Progressive Matrices (CPM) test. The
results of the CPM test indicated that the client had a score corresponding to moderate intellectual
disability. The prognosis for the client was considered good, given the family's concern
and the client's regular follow-up sessions.The case formulation indicated that the delayed milestones
and other environmental factors led to ID. Play therapy, art therapy, positive reinforcement, shaping,
activities of daily living (ADLs), differential reinforcement, prompting, fading, chaining, modeling
and response were used. While the goals focused on prerequisite skills and daily living tasks.Overall,
therapeutic intervention promoted independence in activities of daily
living.
Identifying Data
Name
Z.B
Age
10 years
Gender
Female
Education
K.G
No. of sibling
5
No of birth Order
4th
Father
Alive
Mother
Alive
Socioeconomic Status Middle class
Family Origin
Nuclear system
ParentingStyle
Authoritarian style
Religion
Islam
Reason and Source of Referral
The client was brought by his mother to H.H Rehabilitation Center with the noncompliance of anger,
stubbornness, restlessness, poor concentration and delayed response.
Presenting Complaints
‫بھول جاتی ہے ۔‬
‫پڑھنےکا شوق ہے اور کتابوں سے لگاو بھی ۔‬
‫ڈاکٹر نے بتایا تھا ۔‬، ‫دماغ کا حصہ کام نہیں کرتا‬
‫دیر سے بولتی ہے ۔‬
‫توجہ نہیں دیتی ہے۔اود بات سمجھنے میں دیر لگاتی ہے‬
‫ایکٹو نہیں ہے ۔‬
History of Present Illness
The mother reported that her pregnancy was under stress due to lower socio-economic
growth.So,The client had encountered maternal malnutrition .But Client had a full term baby along
with normal birth and normal cry but her weight was low.The mother reported that the doctor
explained that the baby's condition was congenital and not acquired later in life.
Her mother reported that her developmental milestones were delayed. After that client was given
homeopathy medicine for three months and multivitamin for five months to reduce stubborness and
for a weak mind.
Client’s personal History
At the age of 6, Miss Z.B enrolled in a nearby regular school alongside her younger brother.
However, the client struggled to understand basic concepts until she reached the age of 10.She had
difficulties with reading and writing, even struggling to write complete alphabets or read simple onesyllable words.
Additionally, she faced challenges in counting money and was unable to progress to the next
class. By the age of 10, she was still in nursery class. Unfortunately, she experienced bullying from
other students, leading to her refusal to attend school. As a result, she eventually dropped out. She
engaged in solitary play as pretending to be a teacher while using a doll and playing with cut pieces
of paper.
Client’s family History
The individual came from a family of seven, including three brothers, two sisters, and their
parents. The client's father worked as a teacher while the mother was a housewife . It's worth noting
that there was no history of cousin marriage within the family. Although the client 's siblings were
typically developing, their grandfather (dada) had a disability.The atmosphere in her house was
consistently unpleasant due to the constant arguments between her parents.She depended on mother
for daily functioning as well as her elder sister.She had limited interaction with anyone.
Genogram
M
2
Key
_________________________________________________________________
Male
Female
F
Father
M
Mother
B
Brothers
S
Sister
_________________________________________________________
Assessment
Informal Assessment
● Clinical Interview
● Behavioral Observation
● Portage Guide to Early Education (PGEE)
● Subjective Rating of Symptoms
Formal Assessment
● Color Progressive Matrices (CPM)
Informal Assessment
Clinical Interview
Through the interview, gathered detailed information about the client. Her mother reported
that the client faced challenges in fulfilling personal and social responsibilities, as well as
difficulties in learning from experiences. Additionally, she exhibited difficulties in storing,
recalling and retaining information. which impacted her problem-solving skills and contributed to a
poor academic record.
During the clinical interview, the mother reported that the client experienced emotional and
behavioral challenges, including instances of stubbornness and anger.The good point was that the
client had multiple hobbies and activities. Client support system was good .
Behavioral Observation
Miss Z.B came with her mother.Her general appearance and hygiene reported to be good,
with appropriate clothing and well-combed hair.She showed a repetitive blinking eye, which
could indicate possible nervousness or discomfort.She was extremely shy and did not engage
in typical greeting gestures when interacting with others. Her eye contact was not present. She
had a restless sitting span and easily distracted by extraneous stimuli.
Her attention span and concentration level was poor.She had compromised speech,
characterized by delayed responses along with consistently low pitch.The efficacy of Miss
Z.B's command following was dependent upon her comprehension of the instructions
provided.She had difficulty with orientation, which included recognizing, recalling, and
copying skills related to color, shapes, and distance.
Her understanding and comprehension of the assigned tasks was limited. The client
found it difficult to understand and memorize simple tasks and concepts such as shapes,
monetary value, and alphabets. Her knowledge seems limited to the understanding that edible
items are acquired through money. She struggles with reading and writing tasks that lead to
poor academic skills or possible learning difficulties.
Portage Guide to Early Education (PGEE)
Quantitative analysis
Table: 1
________________________________________________________________________________
Domains
Functional Age
Discrepancy
________________________________________________________________________________
help
5-6
7-8
Motor
5-6
7-8
Cognitive
5-6
7-8
Language
5-6
8-9
Socialization
4-5
8-9
________________________________________________________________________
______ Quantitative Analysis
It revealed significant delays in various areas according to her chronological age. Her
cognitive, motor, and self-help skills were notably underdeveloped. Additionally, she faced
challenges in her language development. While her socialization skills showed some progress, she
still fell behind her chronological age.
Subjective Rating of Symptoms %
Table: 2
_____________________________________________________________________________
Target Behaviour
Pre Rating %
_____________________________________________________________________________
Restlessness
40%
Stubbornness
30%
Poor Confidence
50%
Poor Sitting span
30%
poor eye contact
90%
Inattention
80%
Poor understanding
80%
Poor orientation
80%
Poor Command following
40%
Poor Imitation
60%
_____________________________________________________________________________
Formal Assessment
Color Progressive Matrices (CPM)
The total score obtained on Colour Progressive Matrices was 17.The corresponding grade
for this obtained score was V whereas for this raw score percentile was 5. Both the grade and 1Q
scores gave the indication that the client was intellectually defective.
Tentative Diagnosis
319 (F71) Moderate Intellectual Disability
Case Formulation
There is a high level of under‐ or malnutrition in persons with profound or serious ID
(Kolset SO, 2020).
The diagnosis of GDD is limited to children younger than 5 years old, but these children
often evolve to meet diagnostic criteria for ID (Stacey A Belanger, Joannie Caron discovered in
2018).
The current view is that intellectual disability has multiple causal factors, including genetic
predisposition, environmental insults, developmental vulnerability, heredity and environment
(Harris, 2006).
Four Ps
Predisposing Factors
● Maternal Stress during pregnancy.
● Maternal malnutrition
● Lower socio economic growth
Precipitating Factors
● Lower socio economic growth
● Malnutrition
Maintaining Factors
● Delayed treatment
● Delayed milestone
● Education in General public school
● Bullying by peers
● Authoritarian Parenting Style
Protective Factors
● Family’s concern
● Positive Socializing
● Followup sessions
Short term Goals
1. To built rapport with client and family.
2.To Psychoeducated the mother regarding the client's problem.
3.He did supportive work with his mother.
4. To reduced extraneous stimuli.
5. To improved sitting span.
6. To minimized the level of restlessness and stubbornness.
7. To developed eye contact
8. To incresed self confidence
8. To increased attention span.
9. To increased understanding
10. To maximized Command following
11. To improved verbal and nonverbal imitation.
Long term goals
1. To learnt prerequisite skills.
2. To developed appropriate behavior.
3. To developed self help skills
4. To followed up sessions for improvement.
5.To
overcame his hindrances faced in continuation of assigned tasks.
Long term goals
1. To Continue short term goals
2. To have follow up sessions with both client and other to assess the improvement.
3. To overcome her hindrances faced in continuation of assigned tasks.Alternative
sentence for
Summary of therapeutic intervention
Play Therapy
Rapport building took the first four sessions in which the client was taken to the playing areas
with contingent reinforcement.
Art therapy
In which , she drew her own hand by tracing or drawing the outline of her hand and then
used colors to fill it in.
The purpose of this activity was for her to express herself and shared something unique about
herself through his art. Explained that she could choose the colors that she felt represent her
emotions or personal preferences.
Positive reinforcement
Positive reinforcement was used when the client was able to acquire the cognitive skills
that were taught by the therapist. Whenever the client properly wrote the alphabetical letters she
was reinforced with clapping and praise and attention on some occasion .She was also reinforced
by consumable reinforcements ie.. Chocolate, Pops,Stickers, Stars.This technique encourages the
client to learn the skills early and effectively, Initially the client was reinforced after every letter
continuous reinforcement . Later on she was reinforced after writing a specific number of letters.
Intermittent was also used when counting was taught but the client was only able to
learn the counting till 8. This technique contributed to 70-75 percent of learning of the client.
Subjective Rating of Symptoms %
Table: 2
_____________________________________________________________________________
Target Behaviour
Pre Rating %
Post Rating %
_____________________________________________________________________________
Restlessness
40%
20%
Stubbornness
30%
20%
Poor Confidence
50%
30%
Poor Sitting span
30%
15%
poor eye contact
90%
65%
Inattention
80%
70%
Poor understanding
80%
75%
Poor orientation
80%
70%
Poor Command following
40%
25%
Poor Imitation
60%
40%
_____________________________________________________________________________
Graphical Representation Of Pre & Post Rating %
Session
Session 1
Conducted a clinical interview with the client's mother to explore the client's history
,particularly his emotional and behavioral difficulties etc .
Session 2
Closely observed the client's verbal and nonverbal behavior challenges while maintaining a
strong rapport over the course of four sessions to ensure the reliability and validity of their symptoms.
Session 3
Employed the Portage guide as a framework to facilitate the continuation of goal achievement
and ensuring accurate assessment developmental milestones.
Session 4
Applied the Color Progressive Matrix (CPM) to formally assess the client's diagnosis and
determine the level of severity.
Session 5
Engaged with a client and followed his interests. How did he want to play? This approach
promoted engagement and helped build rapport.
Initially, Sessions started with a shorter sitting duration and gradually increased over time.
Provided reinforcement immediately followed with consistency.
Session 6
When the client wanted attention or escape or avoid .The client was engaged in diverse
learning aids like the rainbow tower ,ring tower , alphabetically train , wooden puzzles and
geometrical shapes.
Session 7
Used positive reinforcement techniques such as verbal praise (good and excellent ) , a preferred
item or activity( painting ,geometrical shapes and used crayons colours ) or a tangible rewarded
(claps ,high chain and low chain and high fives ).That helped establish a strong connection between
the behavior and the reward.
Session 8
For self Help, Skill Z brushed her teeth. Wore shoes appropriately .Combed hair properly.
Session 9
For motor Skills ,Z copied the capital letters and wrote independently. She
also colored
remaining within lines.
Session 10
For cognitive Skills , Z recognized five primary colors and solved the geometrical
puzzles.She also learnt geometric shapes. Used of an abacus, face Painting and eye hand
coordination, she was encouraged to play and interact. When the client engaged in undesirable
behaviors that interfered with attention. Then gently interrupting the behavior and redirecting
attention towards the desired task or activity.
Art therapy was also used for multiple times.
Session 11
Adjusting the environment to reduce distractions (minimizing noise, removing irrelevant
items) and optimize attention. Provided verbal prompts or cues to practice greetings ( Assalam o
alaikum with hand shake ) and farewells (bye with wave) along with making eye contact.
Session 12
Generalized his greeting skills by encouraging greetings with a wider range of people, including
other psychologists ,peers and family members .But started with familiar people.
For language Skills, Z learnt 10 non-living objects and also learnt difference between singular and
plural.
Session 13
For social Skills Z w maintained eye contact through stickers on the therapist's face and
face painting. She learnt greeting gestures as well as learnt to say thank you. She learnt social
interaction with friends and cousins
Over time, gradually faded the prompts to promote independent command following.
Used multiple leaning aids in all aboved sessions multiple times.
Reference
Kolset SO, (2020 Oct 7) Intellectual disability and nutrition-related health.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7539213/
Stacey A Bélanger , Joannie Caron, ( 2018, September) Evaluation of the child with global
developmental delay and intellectual disability
https://doi.org/10.1093/pch/pxy093
Harris, 2006