Case Summary

The child was referred to the trainee clinical psychologist at Dimensions institute for

Autism Special education and psychological services, with the complains of Speech

Delay, Hyperactivity, Stubborn, Stimming (verbal and visual) and easily gets angry.

She was referred for the assessment and management of her symptoms. Psychological

assessment was conducted on informal and formal levels. informal assessment

included clinical interview, behavioural observation and identification of reinforces

while formal assessment included childhood autism rating scale (Cars) and DSM V

checklist. He was diagnosed with 299.00 (F84.0) Autism Spectrum with mild level.

The management plan was based on behavioural therapy. After 15 therapeutic

sessions, post therapy ratings of the therapist presenting complains and problematic

behaviour were taken and there was a significant improvement in almost all the

domains.
Bio Data

Name : M.F

Chronological age: 2.10

Gender: Girl

No of siblings: 2 sisters

Birth order: last

Residence: Lahore

Informant: Parents

Reason and Source for Referral

The child was referred to the trainee clinical psychologist at Dimensions Institute

for special education and psychological services, with the complains of no eye

contact, speech delay, hyperactivity, stubborn behaviour and stimming ( verbal and

visual)..She was referred to the for the assessment and management of her symptoms.

Presenting Complains:

As reported by parents :

Severity Level Presenting Complains

7
‫آنکھ سے آنکھ مال کر بات‬.1

‫نہیں کرتی‬

8
‫بولنے میں تاخیر کرتی ہے‬.2

9
‫غیر معمولی طور پر فعال‬.3
 ‫ہے‬

8
‫بہت زیادہ ضدی ہے‬..4

8
‫جسم اور آواز کی غیر‬.5

‫معمولی حرکت‬

8
‫بہت جلدی غصہ آ جاتا ہے‬.6

History of Present Illness:

According to the parents child had significant autism symptoms from early

age.She always avoided to make eye contact , gets angry easily ,hyperactive all the

time , sleep issues , cries for long time for no reason , speech delay , gets irritated on

small things and sometimes hitting siblings.Her mother stated that she mostly shows

these Behaviour at home mostly , she is quite at relatives houses and other places.She

loves to play with her toys and have a friendly relation with his siblings and

cousins .She is getting special education Dimensions institute for special education

and psychological services for speech and behaviour therapy .

Background Information

Family History:

The child belongs to a upper socioeconomic status and has a nuclear family

system .The total members of his family are 5 including child .Her father is 45 years

old and is educated up to graduation.He is software engineer .He has blood pressure

issues..He is short tempered but friendly by nature, He is very caring toward his
children Her mother is 41 years old.She had done MBA and doing an online

buisness.She also is short tempered but caring in her nature..Her attitude toward child

is always loving .Her parents don’t have a congenital marriage and no family conflict

was reported.

The child had 3 sisters First born sister was 13 years old and was studying in

class 7. Second born sister is 10 years old and was studying in class 4. M.F was third

born . All of her sisters in good heath .They all share a caring and healthy

relationship.

According to child’s parents the overall home environment was very supportive

and loving .

Psychiatric Illness in Family :

There was no psychiatric illness in child’s family.

Personal history

Birth History:

According to the mother she was 38 years old at the time of pregnancy.It was her

third pregnancy. She got caught by COVID.There was a history of one

miscarriage.She gave birth to child via normal delivery.Child gave her first cry

immediate after delivery.There were complication about child position.After birth her

colour was pink and weight was 3.5 kg.

History of Developmental Milestone:

According to mother there was major delays in developmental milestones of the

child .All of them are shown in the following table:

Table 1

Table 1 showing developmental milestones achieved by the child as reported by

mother:

Developmental Child’s age of Appropriate age of

Milestones achievement achieved milestones

Neck holding 3rd month 3 month

Sitting 7 month 6-7 months

Crawling 9 month 7 months

Walking 1 year onward 12-15months

Bowel and Bladder control not yet 2 years

Single word speech 3 year 6 months

Complete sentences Not yet never

Educational History:

Child’s parents reported that child had significant autistic signs from early

age. She had difficulty in speech from early stage .Child is now going to to

Dimensions institute for Autism and special education and psychological services.

Psychological Assessment:

Psychological assessment refers to any type of standardised, mental testing or

behavioral evaluation. Assessment is used to measure intelligence,

development, personality, attitudes and cognitive, social, or emotional functioning and

are also used by clinicians to diagnose disorders. Psychological assessment may

take the form of a questionnaire, an interview, or observational methods

Psychological assessment of the child was carried out in order to gather information

regarding his background, nature of symptoms, their causes and

maintaining factors, in order to diagnose and manage the illness. Two types of

psychological assessment were conducted:

Informal Assessment

Formal Assessment

1.Informal Assessment

 Clinical Interview

 Behavioral Observation

 Identified reinforcer

 Subjective rating of problematic behavior

Clinical Interview:

The clinical interview is foundational to psychological or mental health treatment.

It involves a professional relationship between a mental health provider and a patient

and is used across all major mental health treatment disciplines. Although defined

differently the clinical interview includes an informed consent process and has its

primary goals: initiation of a therapeutic alliance, assessment or diagnosis

data collection,case formulation or implementation of a psychological intervention.

(Zeleke, Hood and Flanagann,2015).

Clinical interview was firstly conducted with the child's teacher to access his current

level of functioning. Secondly,the interview was conducted with the child's parents

in which the trainee psychologists discussed his problems, duration of the problem,
history of present illness, family, personal, educational, and social history.

The confidentiality as also ensured to the child's mother.

Behavioral Observation:

It is a primary assessment approach for verbal and non-verbal children. It

was done to assess the child's current level of functioning. Behavioral observation

focuses on vocalization (crying, whining, groaning), verbalization, facial expression,

guiding body parts, temperamental activity and general appearance (craig 1992).

The child behavioural observation is stated below:

M.F is 2.10 years old with good hygiene .She appeared hyperactive and was

not calm.She was not making any physical contact with the therapist..At the start of

the session she did not make eye with the therapist.During the examination she was

not sitting comfortably , she was moving here and there and was not sitting properly

on her seat.She screamed after some minutes without any reason.She showed verbal

and visual stimming.She was not paying attention to the therapist .It has been

observed that she easily gets angry.After some time she started to cooperate with

therapist with the use of reinforcers (toys and eatable )She showed much interest in

the objects .She didn’t speak with the therapist .No vision and hearing difficulties

were observed.

Identification of reinforcers:

Reinforcement is a term used in operant conditioning that refers to anything that

increases likelihood that a response will occur. Note that reinforcers are defined by
the effect that is has on behaviour. Reinforcement can include anything that strengths

or increases a behaviour, including specific tangible rewards, events, and situations

(B.F Skinner, 2013).

For reinforcer identification, mother and teacher were asked about child's liking,

moreover, the therapist also observed the child's favourite thing on his own.

Following is the list of identified reinforcers:

Table 2

Table 2 shows the list of reinforcers and their types.

Reinforcers Type Identified Reinforcers Priority

Tangible Reinforcers Toys 1st

Eatable Reinforcers Chips, 2nd

Social Reinforcers Clapping 3rd

Subjective Rating of Problematic Behaviour:

The therapist of the child rated the presenting complains on 0to 10 rating scale where

0 shows low severity and 10 shows high severity of symptoms. The ratings were

taken at the pre assessment level to investigate the severity level of complains:

Table 3

Table 3 shows rating of the therapist on presenting complains on a 1 to 10 scale:

Behaviour Therapist Rating

No Eye Contact 7

Speech Delay 9
Hyperactive 7

Stubborn 8

Easily gets angry 8

2 . Formal Assessment:

 DSM V Checklist

 Childhood Autism Rating Scale (CARS)

 Vineland

DSM V Checklist:

A checklist based on the criteria of Diagnostic and Statistical Manual of

Mental Disorders V (APA,2013) was used to diagnose and assess the severity of

symptoms as reported by mother and therapist. It was devised for autism spectrum

disorder and administered on the child results indicated that he met the diagnostic

criteria:

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

contexts as manifested by all the following, currently or by history. (Yes)

1. Deficit in social emotional reciprocity, ranging from, for example from abnormal

social approach and failures of normal back and forth conversation to reduce sharing

of interest, emotions, or affect; to failure to initiate or respond to social

interaction. (Yes)

2. Deficit in nonverbal communication behaviours used for

social interactions, ranging, for example, from poorly integrated verbal and nonverbal
communication to; to abnormalities in eye contact and body language or deficit in

understanding and use of gestures; to a total lack of facial expressions and

nonverbal communication. (Yes)

3. Deficit in developing, maintaining, and understanding

relationships, ranging, for example, from difficulties adjusting behaviour to

suit various social contexts; to difficulties in sharing imaginative play or in

making friends; to absence of interest in peers. (Yes)

B. Restricted, repetitive patterns of behaviours, interests, or activities as manifested

by at least two of the following,currently or by history. (Yes)

C. Symptoms must be present in the early developmental period (but may not become

fully manifest until social demands exceed limited capacities or may be asked by

learned strategies later in life). (Yes)

D. Symptoms cause clinically significant impairment in social, occupational, or other

important areas of current functioning. (Yes)

Childhood Autism Rating Scale (CARS):

The childhood Autism Rating Scale is a fifteen-itembehavioural scale, was developed

by Schopler et al in 1980.The scale was designed to help differentiate children with

autism from those with other developmental delays, such as intellectual disability.

The CARS is a diagnostic assessment method that rates individuals on a scale ranging

from normal to severe and yields a composite score ranging from non-autistic to

mildly autistic, moderately autistic, or severely autistic .The scale is used to observe

and subjectively ratefifteen items. Higher scores are indicative of more severe autism

Children scoring below 30 are considerate non autistic.

Findings are given below:

Table 4

Table 4 showing the therapist rating on CARS :

Categories Raw Score Behavioural Description

1.Relating to People 2 Mildly abnormal

relationship:Child may

avoid looking adults in eye

and become fussy if forced.

2.Imitation 2 Mildly abnormal imitation:

The child imitates simple

behaviour such as clapping .

3.Emotional response 3 Moderately abnormal

 emotional response: Shows

definite signs of

inappropriate degrees of

emotional responses and

sometimes become

rigid even when no apparent

objects or evens present.

4.Body use 2 Mildly abnormal body use:

Some minor peculiarities

may be present

5.Object use 2 Mildly inappropriate

interest in or use of toys

and other objects:

The child may show atypical

interest in a toy or play in

inappropriate way.

6.Adaptation to Change 3 Moderately abnormal

adaptation to change: Child

actively resist changes , tries

to continue old activity and is

difficult to distract.
7.Visual Response 2.5 Mildly to moderately

abnormal visual use:The

child reminded to look at

objects.

8.listening response 2 Mildly abnormal listening

response: The child

sometimes lack of responses

9.Taste, Smell, and touch 1.5 Normal to mildly abnormal

response and use use of, and response

to taste, smell,and

touch: The child sometimes

persist in putting objects in

her mouth , smell or taste

inedible objects.

10.Fear or Nervousness 2.5 Mildly to moderately

abnormal fear of

nervousness: SHe

showed too little fear or

nervousness as compared to

other child of his age.

11.verbal communication 3 Moderately abnormal

 verbal communication:

Speech was absent in certain

situations.

12.Non- 1.5 Normal to mildly abnormal

verbalCommunicaton use of non-verbal

communication: Sometimes

show immature use of

nonverbal communication.

13.Activity Level 3 Moderately abnormal activ

ity level: She was quite

active and difficult

to restrain.

14. level and Consistency of 2.5 Mildly to Moderately

intellectual response abnormal intellectual

functioning: The child is not

as smart as other children of

same age.

15.General Impression 2 Mild Autism: She showed a

few symptoms of mild

degree of autism.
Grand Total: 34.5

CAR was completed utilizing information provided by grand total. Based on his

observations and evaluations, grand total score received from an overall rating score

of all categories. His scores on CARS indicated that he falls in the category of Mild

Autistic.

DSM V Diagnosis:

The Child was diagnosed as having 299.00(F84.0), autism spectrum disorder

requiring substantial support for deficit in social communication and requiring

support for restricted,repetitive behaviours.

Table 5

The Table showing the differential diagnosis

Disorder Points in Favor Points in Against

1.Rett Syndrome Speech deficit Rett Syndrome has mostly

loss of motor skills

and speech, there may

be lack of social skills but no

longer a major area of

concern.

2.Selective Mutism Lack of Communication In selective mutism early

development is not typically

disturbed and affected child

usually exhibits appropriate

communication skills but

A.M Had persistent deficit in

communication and social

interaction in every setting

from the developmental

period.

3. Intellectual Development Lack of adaptive skills Autism may be accompanied

al Disorder with intellectual disability

but there must repetitive or

 stereotypic behaviours.

4.Attention Deficit \ Attention and Focus Issues Child had attention issues

Hyperactive Hyperactivity and hyperactivity, which are

common in autism due

to stimulation. However, chil

dpaid attention in herfavourit

e activities and used to do

sequential task iesolving

complex puzzles

5.Language Disorder and Language deficit As language disorder is not

Communication Disorder Communication usually associated with

nonverbal communication

but the child also had

abnormal nonverbal

communication with

restricted interests and

behaviour.

6.Stereotypic Movement Motor Stereotypies Motor stereotypies are the

Disorder among diagnostic

characteristics of autism;but

the child also had

persistent deficit in social

communication and social

interaction across

multiple contexts and this

point differentiates her

diagnosis of autism spectrum

disorder from

stereotypic movementdisorde

r
Prognosis:

The prognosis appeared to not to be bad as he falls in the mild to moderate

category of autism, however taking therapy regularly from very young age can help

her.
 Case conceptualisation: Presenting complains

1.no eye contact

2. Speech delay

3.hyper activity

4. Stubborn

5. Stimming( verbal and visual)

Informal assessment

1.clinical interview Formal assessment

2.behavioural observation Childhood Autism rating scale

3. Identified reinforcers (CARS)

4. Subjective rating of DSM V Checklist

problematic behavior

Diagnosis

299.00(F84.0)

Autism Spectrum Disorder

Case Formulation:
 The child was referred to the trainee clinical psychologist at Dimensions Institute

for Special education and psychological services, with the complains of poor

attention span, behaviour issues, loss of consciousness, easily

distracted, staring spells, restlessness,, changes in mood and hyperactive. He was

referred or the assessment and management of his symptoms.

Aftercomplete assessment, he was diagnosed with autism spectrum disorder. The

problem of child was assessed through behavioural observation, clinical interview,

and Childhood Autism Rating Scale (CARS).According to DSM criteria boys are

about four times more likely to develop autism spectrum disorder than girls

are.The precipitating factors was his symptoms which were maintaining his problem.

Individuals on the autistic spectrum typically experience difficulties with social

communication and interaction and may also exhibit restricted, repetitive patterns

of behaviour,interest or activities, Symptoms are typically recognized between one or

two years of age . The child'ssymptoms were also identified at the age pf

2 years, and itsupports the diagnosis.

Autism Spectrum Disorder (ASD) are a group of

pervasive neurodevelopmental disorder characterized by impairment in reciprocal

social interaction and communication, as well as restricted, repetitive and stereotyped

patterns of behaviour, interests and activities. The prevalence of ASDs in general

population is estimated to be 1 percent with approximately four times more males

than females being affected by this disorder. It is estimated that between 64% and

91% of risk is due to family history (Tick et al 2016). As of 2018 it appearedthat

74% then 93% of autism spectrum disorder risk is heritable. After an older child is

diagnosed with ASD 7 to 20% off subsequent children are likely to be as well (Blank

et al 2020). If parents have a child with ASD, they have 2 to 8 percent chance of

having second child with ASD. If the child with ASD is an identical twin the other

will be affected 36 to 95 percent of the time. If they are fraternal twins the other will

only be affected up to 1 percent of the time (Centers for Disease Control and

prevention 2015). As of 2018 understanding of genetic risk factors had shifted from a

focus on few alleles to an understanding that genetic involvement in ASD is probably

diffuse, depending on a large number ofvariants, some of which are common and have

a small effect and some of which are rare and have a large effect. The aemost common

gene disputed with large effect rare variants appeared to be CHD8 , but less than 0.5

percent of autistic people have a mutation. Some ASD is associated with clearly

genetic conditions.

Management Plan:

 Rapport Building

 Psychoeducation of parents

 Individualized educational Plan

 Behaviour therapy

 Areas to improve
 1.Attention Span

2.Visual Performance

3.Cooperation and Reinforcer effectiveness

4.Motor imitation

5.Receptive Language

Short Term Goals

Following are the short-term goals:

 Develop rapport with the client for the purpose of informal and formal

assessment.

 Give psycho education to parents about nature of problem.

 Work on daily activities that required focus of attention,concentration and

exhibiting eye contact by using peg board, ring tower, bubble blowing

activities.

 Reduce the intensity of child behaviour such as screaming,tantrums, by using

relaxation technique avoid attendingthe child

screaming behaviour, positive reinforcement,poor compliance.

 Guiding the parents to make their role more effective in intervention.

Long Term Goals

 To Focus the child's cognition and increase the exposure of the child.

 Continuation of short-term goals is also important.

  To continue family counselling to improve the effect of the therapeutic

interventions and to gain support of methods of family as is could have the

reinforcing effect.

 Contino follow ups and parent teacher meetings are also required.

 Home based intervention would be suggested.

Therapeutic Intervention:

Rapport Building

Rapport building was done with the child, so he was able to comply with the

request of the therapist. It was helpful to make her comfortable with therapist during

sessions. As a result, they developed a warm, empathetic supportive relationship.

Rapport building was done to develop a strong therapeutic association between

therapist and client's complaints towards the therapy. The healthy rapport essential to

develop a level of trust and understanding with the client (Fritscher, 2022).

Psychoeducation

Psychoeducation to parents is type of services that aims to provide the

necessary knowledge, tools, guidance and especially support the parents without bias

and judgement. It will be given to parents to educate them more about

their child's problem to use home-based intervention.(Miltenberger,2012).

Reinforcement

Reinforcement is a term used to operant conditioning to refer to anything that

increases the likelihood of a response.

Notethat reinforcement is defined by the effort that it has onbehaviour.It increases or

strengths the behavior.There are many different types of reinforcers that can be used

to increase behaviour, but it is importance to notice that the types of reinforcers used

depend upon the individual's interest and the situation (Miltenberger 2012).

Positive Reinforcement

It involves adding something to increase response such as praising a child

when they complete a designated task. Thiswould motivate the child to get involved

in the task. (Jacob 2021)

Differential Reinforcement

Differential Reinforcement is reinforcing a target behaviour while

withholding reinforcement from an unwanted from an unwanted behaviour's goal is to

keep the unwanted behaviours with desirable behaviors.When a target behaviour is

followed by a reward called reinforcement, it is more likely to report If at the same

time reinforcer is withhold from an unwanted behaviour then this

differential reinforcement arrangement places the unwanted behaviour on extinction

and replaces it by an appropriate one (Li 2022) .

Social Reinforcement

All reinforcing events that affected human behaviour or social

events involving the nearness, praise. The assumption is that the human beings
learn to value other human beings since they are constantly paired

with material, unlearned reinforcers individual engaged in

inappropriate behaviour (hand flapping and

drooping things to floor and refusing to get up arecommon) because it is shortly follo

wed by social contact.Behaviours that occur for the reason are called attention-

maintained behaviours. (Miltenberger).

Prompting

It is used to increase the likelihood that a person will engage in the correct

behaviour at the correct time.They are used during discrimination training to help the

person engage in the correct behaviour in the presence of the discriminative stimulus

(SD). Prompts are stimulus given before or during the performance of a

behaviour.They help behaviours occur so that the teacher can provide reinforcement

(Cooper, Heron and Heward 1987, p,120).

Fading

It is the most used method of transferring stimuli control. With a

prompt fading, a response id gradually removed across learning trials until the prompt

is no longer provided.

Modelling

It is the process in which one or more individuals or other entities serve as

examples (models) that a child will emulate. Models are often parents, other adults or

other children, nut they may also be symbolise.

Post Assessment:

The subjective rating was obtained on 10 points rating scale. The scale as used to

identify the severity of the symptoms. The ratings are taken at pre and post

assessment of levels to assess the improvement in child's problematic behaviours and

efficacy of the therapy.

Table 6

Table 6 shows rating of child's therapist on problematic symptoms on 0-to-10-

point rating scale.

Behaviour Pre rating Post rating

No Eye Contact 7 6

Speech Delay 8 7

Hyperactive 9 7

Stubborn 8 6

Easily gets angry 8 7

Session Reports

1st Session :

In first session Clinical interview was conducted with the child’s parents in which

the complete history of the child and presenting complaints were identified.The

therapist observed the child when other therapist was taking the session in a separate

room and giving her the commands.Behaviour observation was also done.

2nd Session:
 The session was a rapport building session.In this session Rapport was

built .Child mood was not good through this session.She was showing tantrums and

was not sitting comfortably on her hair.She was trying to move from her place .This

condition of child was managed by holding his hands .Reinforcer in form of her

favourite toys were given without any condition..No other task or command were

given to her in this session.Session ended by saying her a good bye.

3rd Session:

Session started by greeting her to which she responded.She was in a good

mood.She was not paying much attention to commands given to her.She was not

making eye contact with the therapist.But when her favourite tangible reinforcer

( toys) were given she started to play with it .After that she started to pay attention to

therapist.After playing with her toy she became a like more relaxed with the therapist.
4th Session

In this session she was not in good mood so again he was observed properly to

help to build rapport with her.Through this session , the personal appearance , physics

features, social interact of child, language and play skills were observed..In this

session the child was very hyperactive .He seemed to be in a good mood .He was

responding a little bit to the commands.She was observed in this session.

5th Session

The session started by greeting the child .He was in good mood .Formal

Assessment was done as Childhood Autism Rating Scale was administered to identify

the symptoms clearly.His score on CARS showed that the child is in Severely Autistic

Category.In this session he was given reinforcer to sit at his place .As compared to

last sessions he was at least sitting at his place and was holding the therapist hand .He

was looking toward the therapist with a big smile on his face.The session was ended

with a good bye.

6th Session:

The session started by greeting her.She was in a good mood.She showed

stimming behavior both verbal and visual .The goal of this session was to start follow

one step instructions which included instructions like sit down, stand up,come

here ,clap your hands etc.She was not able to imitate these instructions at one go.The

therapist instruct her and show her by modelling so that she can see and follow when

given command.She was paying attention to the modelling of the therapist.

7th Session:

The session started by saying hello to the child.The therapist asked the child how

are you? On which she responded “ I am fine”.The child was in a good mood .Then

the therapist started the work by saying let’s do work to the child.In this session the

goals was to repeat follow one step instructions.The therapist instructed the child to

follow instructions like stand up,sit down,clap hand,come here etc.The child

responded in a good way and follow instructions by performing one step

instructions.She was given reinforcers ( chips) after each step.At last the session was

ended by saying good bye to the child.

8th Session:

In this session the therapist started his work by greeting the child.The child was in

a good mood.The session started with one step instructions.The child follow these

instruction with one go.The therapist reinforced the child with her favourite toy to

play withShe played with the toy for some minutes.After this the therapist asked the

child to give back the toy and she handed the toy to the therapist.The goal of this

session was to start to imitates actions with objects .She was given instructions while

modelling was also given by the therapist.The instructions included ring bell, push the

car,hit drum, place block in bucket etc.The objects were presented to child according

to the instructions The child was asked to imitate them.She imitates some of them on

which she was given reinforcer on each step.After this the session was ended by

saying good bye to the child.

9th session.

This session started by greeting the child.The child was not in good mood.She

was screaming without any reason.The therapist ignored this behaviour for some

minutes.After some time the child stop screaming.After this the therapist give her ,

her favourite toy on thigh she start playing with the child.The therapist asked the child

to give back the toy on which she resisted.She was not in a mood to work.The

therapist tries to make her calm down on which she was showing tantrums .After

some time the session was ended by saying good bye to the child.

10th Session:

The session started by greeting the child .She was in a good mood.The child

smiled at the therapist.Then the therapist started his work.In this session the goal was

to work on imitating action with objects.The therapist have done this with the child in

last session.The therapist started the session by repeating one step instructions.The

child follow these instructions on one go.Then the therapist repeat instructions for

imitating actions with objects.The therapist give 5 trials to the child on which she

completed 3 trials.She was given reinforcer on imitating instructions on each

trial.After thus the session was ended .

11th Session:

The session started by greeting the child .The child was in a good mood and was

smiling toward the therapist.He often remain hyperactive in her sessions.The session

stated by repeating action with objects which were to be imitates by the child.The

child was given 5 trials on which the child completed 4 trials.After this the child was
given two step instructions like touch the nose and tap the table,touch head and touch

nose, give me high five and then clap your hands.The therapist instruct the child by

showing them by modelling.The therapist give 5 trials but two step instructions seems

to ne very difficult for her.She mixes the instructions.After some trials the session was

ended.

12th Session:

The session started by greeting the child.The child was in a good mood.The

therapist started his work by repeating previous instructions After this therapist again

started two step instructions . The therapist repeat them by showing to the child how

to follow them.The therapist give 5-6 trials to the child on which she complete 4-5 of

them .Reinforcer were used on each step to motivate her for the next step.After thus

the therapist introduced imitation of action paired sounds like push the car and say

zoom, bang gamer and say bang bang etc.It was introduced to which child show no

interest so the session was ended after sone time.

13th Session:

The session started by greeting the child.The child was in a good mood.After

greeting the therapist started his work with the child.The therapist started motor

imitation goals.

The therapist give 5-6 trails to the child to which 2-3 were fulfilled.Each time she

was given a reinforcer .After waiting for sone minutes he again give same trials to the

child to which 3 were fulfilled.At end the therapist hold the hands of child on table
and asks him to make eye contact to which he responded for only 2-3 seconds.After

this the session was ended by the therapist.

14th Session:

The session started with the child by greeting the child.He was in a good

mood.The therapist started his work by repeating old instructions.She was given trials

of each instructions to which she performed very well.She was paying attention to the

In instructions.Besides there were many activities like puzzle solving , block making .

Identified colour and vegetable books etc.These activities were introduced in each

session and till14 session the child was good at attempting themThe therapist repeat

some of them and then the session was ended.

15th Session:

The session started by greeting the child .He was in a good mood.The therapist

asked the child’s lets start out work by calling his name.The therapist practice all

previous activities so that child learn these readiness skills in his life.Initially the

therapist use full physical, gestural and verbal prompt on previous different

activities.But after sone trials the therapist start using partial physical, gestural and

verbal prompts with the child .The fading was also used in this session .After this the

session was ended by saying goodbye to the child.