Summary

Client R.B was 10 years old boy. He lived in a nuclear family system. The child was

referred to the trainee clinical psychologist at the Special Learning Institute (SLI) for the

comprehensive assessment and management for several behavioral concerns. These

concerns were hyperactivity, behavior issues, impulsivity and speech delay. In informal

assessment, Clinical interview, Behavioral Observation, Subjective rating of symptoms to

therapist, Identification of reinforcers and DSM-5-TR checklist were used, which provide

valuable insights for the client's behaviors. For formal assessment, Conners' Teacher Rating

Scale and Portage Guide to Early Education (Bluma et al., 1976) were administered. The

child was diagnosed with Attention Deficient Hyperactivity Disorder (ADHD). For the

management, Individualized management plan was devised on the basis of Portage Guide

for early education to teach socialization, self-help skills, language, cognitive and motor

skills. With this management plan, the child's symptoms have been reduced slightly, as

reported by the mother and the child was showing improvement.

Bio Data

Name R.B

Age 10 years

Gender Male

No. of siblings 1

Birth Order 1st

Father’s occupation Analyst

Mother’s occupation House wife

Family system Nuclear

Informant Mother

Reason and source of referral

The child was referred to the trainee clinical psychologist at the Special Learning

Institute for the clinical assessment and management of his symptoms. His presenting

complaints were hyperactivity, behavior issues, impulsivity and speech delay.

Presenting Complaints

Table 1

Table shows presenting complaints and duration as reported by both mother and the

therapist.

‫دورانیہ‬ ‫علامات‬
 2 ‫سال سے‬ ‫ایک جگہ ٹک کر نیں بیٹھ سکتا‬

‫شروع سے ہی‬ ‫مزاج میں تیزی بھت ھے‬

3-2 ‫سال سے‬ ‫ انتظار تو بلکل نیں کرتا۔‬،‫چیزوں پر فورا جھپٹ پڑتا ھے‬

‫کافی سالوں سے‬ ‫کچھ بھی کہا جائے توجہ سے نہیں سنتا‬

‫کافی ٹائم سے‬ ‫ٹھیک سے بول نہیں سکتا۔‬

History of Present illness

The child, was a 10 year old boy with a history of developmental and academic

challenges. While he achieved all developmental milestones at appropriate age, his speech

development was notably delayed. He had poor oral motor skills, which affected his ability

to articulate words clearly, and he struggled significantly with learning basic concepts, such

as the names of the alphabet, colors, fruits, animals, and shapes which indicated difficulties

in language processing and cognitive learning. Despite his speech delay, his hearing and

vision assessments were conducted and found to be normal.

Educationally, the child had never attended formal schooling. He was enrolled in

special education programs, but despite these efforts, he showed no significant

improvement in his academic skills. He continues to exhibit weaknesses in reading,

spelling, and writing, which hinder his learning and overall academic progress. As a result

of these persistent challenges, he was taken to a special learning institute (SLI) for

specialized therapy to address his speech, learning, and communication difficulties.

Family History

The child was came from a nuclear family where both parents were educated and

shared a civil relationship. His father, a 40-year-old man with a Master’s degree in
Education, works as an analyst. He maintains a satisfactory relationship with his children,

providing an acceptable level of engagement and support. The mother, a 30-year-old

educated woman, was a homemaker dedicated to caring for her children.

General Home Environment

The home environment was generally cooperative and supportive. Both parents was

actively contribute to the upbringing of their children.

History of Psychiatric Illness in Family

There was no significant history of psychiatric illness reported in the family.

History of Medical Illness in Family

There was no significant history of medical illness in the family.

Personal History of the children

Birth History

 Prenatal

 Natal

 Post-natal
Prenatal History

The child was conceived through fertility treatment due to the mother’s difficulty

conceiving naturally. At four months of pregnancy, the mother experienced downward

pressure and spotting, which led to the placement of a mcdonald stitch and doctor suggested

her of strict bed rest for the rest of the pregnancy. The mother experienced significant stress

during this period and had occasional episodes of hypertension, which were managed

without any major complications. Despite these challenges, the pregnancy continued to term

and the mother received adequate prenatal care throughout.

Natal History

The child was born through normal vaginal delivery. There were no complications

during delivery. After birth, the twins were kept in the nursery for 3–4 hours for basic

examinations before being handed over to the parents.

Postnatal History

At birth, the twin had low birth weights and weak. Both children developed neonatal

jaundice shortly after birth, which was managed effectively and both were recovered within

two weeks. There were no significant complications or prolonged medical issues after this

period. Despite their initial weakness, the infants were discharged home in stable condition

and the family provided adequate care for the children during this time.

Development History

Table 2

This table shows developmental milestones, normal age range and the age of

achieved milestones.

Developmental milestone Normal age range Child`s age of achievement

 Neck holding 3 months 3 months

Crawling 7-10 months 7 months

Sitting 6-8 months 7 month

Standing 9-12 months 11 month

Walking 12-15 months 12 months

Babbling 6-8 months 1 year

Single word speech 9-12 months 2.5 years

Sentence completion 2-3 years 3 years

Toilet training 18-24 months 2.5 years

Social History

The mother reported that her child was very hyperactive, impulsive, and sometimes

aggressive, which makes it hard for him to behave appropriately in social situations. She

mentioned that his limited speech adds to the difficulty, as he struggles to express himself

and connect with other children. He finds it challenging to make friends and often ends up

playing alone.

Psychological Assessment

Informal Assessment

 Clinical Interview

 Behavioral Observation

 Identification of reinforces

 DSM-5-TR checklist

 Subjective rating of symptoms

Clinical interviews

A clinical interview is a conversation between clinician and the client typically

intended to develop an understanding of the client's presenting problems and history in

order to explicate the diagnosis and develop a therapeutic plan. It is conversation with a

purpose that can be structured, semi-structured, or unstructured. It involves a series of

questions to be asked by the clinician probably designed by him before the conduction of

interview (Huss, 2009).

Semi-structured questions was asked to the therapist to get the information about the

problematic areas of the child. As the client was taking sessions with his therapist, So

therapist's interview was also taken to know about the most frequent problematic behavior

of the client and to know more about the case history of the client. Therapist's interview was

taken to get baseline about the problematic behavior of the child and therapist's reaction and

understanding of his problem.

The client's therapist provided valuable insights about the client's behaviors and

challenges during the sessions. It was reported by the therapist that the child had limited

interest in participating in various activities besides scribbling, pasting and matching. He

does not wait to the instruction and act in hurry. He had strong observational skills and

sometime, he showed aggressiveness and attack to the therapist. He frequently bite and

attack to the therapist in aggression. Therapist reported that he had attention and

concentration issues due to his hyperactivity and impulsivity.

Behavior Observation

It is informal mode of behavioral assessment used to obtain information in order to

gather specific details about the behavior and document performance. It can be useful for

making judgments by means other than systematic interviews and standardized judgments
(Morrison, 2011). This comprehensive observational analysis aimed to provide valuable

insights for the assessment procedures, there by contributing to the development of an

informed and effective management plan tailored to the client’s specific needs.

The first interaction with the client occurred during his session with the ABA

therapist. The client was 10 years old boy. The client did not display resistance to engaging

with the new therapist. However, it was noticeable that his eye contact was maintained from

the start. He was facing challenges in sustaining focus during tasks. He required full

physical and verbal prompts to complete his activities.

During the session, the child exhibited several behaviors as he was hyperactive,

frequently shifting positions in the chair, fidgeting with objects, and occasionally standing

up or walking around the room without prompting. Impulsivity was evident as the child

often interrupted the therapist before instructions or questions were fully completed and

acting without waiting his turn. The child had significant difficulty staying focused, easily

distracted by any noise and struggled to remain on task which required frequent redirection.

He showed interest at the start of task but often failed to complete the task and moving on to

something else without finishing.

Socially, the child had trouble with turn-taking. Frustration was also visible when

tasks became challenging with the signs of restlessness and agitation when expectations

were not immediately met. While the child displayed aggressive behavior in form of

irritation or impatience, especially when asked to repeat tasks. Overall, the child’s behavior

during the session reflected the key characteristics of ADHD, including hyperactivity,

impulsivity, attention difficulties and emotional regulation challenges.

Identification of reinforcers
 Reinforcers refers to any object that presented immediately after a desired behavior

which increase the frequency of that desired behavior (Nogureas, 1998). Identification of

reinforcers in children is the process of figuring out what rewards or incentives will

motivate a child to repeat positive behaviors. The reinforcers were identified by the help of

therapist and also observed during the clinical observations. The reinforcers were identified

were as mentioned below.

Table 4

Reinforces type Identified reinforce

Tangible reinforcer Car

Social reinforcer High five, Praise

Edible reinforcer chips

Subjective rating of symptoms

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

severe are these behaviors. According to the Scalzi (2013), it is the rating of the target

behavior that an individual assigns based on his or her subjective assessment, response or

impression of that behavior. The child’s mother and her therapist had given him a subjective

rating on a scale of 10 based on the issues he brought up, which the therapist observed.

Table 4

Symptoms Therapist’s ratings

Hyperactive 8

Impulsive 8

Poor attention 9

Tantrum 8
Bond with brother 9

Non-verbal communication 8

DSM-5-TR checklist

Checklist of Attention Deficit Hyperactive Disorder

Diagnostic criteria Child’s symptoms

Impulsivity

1. Often blurts out answers before questions have been completed. No

2. Often interrupts. Yes

3. Often has difficulty taking turns Yes

Hyperactivity

1. Often talks excessively. No

2. Often squirms or fidgets feet or hands when seated. Yes

3. Often has difficulty playing quietly. No

4. Often will leave situations or classrooms when supposed to stay Yes

seated? No

5. Often runs or climbs excessively. Yes

6. Often seems to be “on the go.”

Inattention
1. Often fails to pay attention to details or makes careless mistakes. Yes

2. Often has difficulty in focusing on one task or completing it. Yes

3. Often is forgetful in daily activities. Yes

4. Often is easily distracted. Yes

5. Often does not seem to listen. Yes

6. Often has difficulty organizing. Yes

7. Often avoids or dislikes tasks requiring long mental focus. Yes

8. Often misplaces or loses items. No

9. Often does not follow through with instructions. Yes

Have the checked symptoms/behaviors been present for six or more Yes

months?

Do these symptoms/behaviors cause difficulty or are they Yes

disruptive?

Are the symptoms/behaviors present in more than one setting? Yes

Were these symptoms present before the age of seven? Yes

Formal Assessment

1- Conners’ Teacher Rating Scale-Revised

The Conners' Teacher Rating Scale-Revised (CTRS-R) was developed by Dr. C.

Keith Conners as part of a series of rating scales designed to assess behavioral, emotional

and academic problems in children. This scale focuses on gathering input from teachers,

who are in a position to observe children's behavior in structured, social and academic

settings. The revised version (2001) improved upon earlier versions to enhance reliability,

validity and applicability across diverse populations.

.

Rationale

The Conners' Teacher Rating Scale-Revised (CTRS-R) is designed to help

understand and measure a child’s behavior based on how teachers see them in the

classroom. Teachers spend a lot of time with children in a structured environment, so they

can provide valuable insights into behaviors like attention problems, hyperactivity,

emotional challenges, or issues with peers.

Quantitative Interpretation

Table 5

This table shows the raw score, T-score and categories of Conner’s scale

Categories Raw Score T-score Category

Oppositional 8 73 Markedly Atypical

Cognitive problems/ 15 77 Markedly Atypical

Inattention

Hyperactivity 8 58 Typical

ADHD index 19 57 Typical

Qualitative Interpretation
 The qualitative interpretation of the scores indicates significant behavioral and

cognitive concerns. The Oppositional subscale has a raw score of 8 and a T-score of 73 that

indicate the markedly atypical range, which suggests severe oppositional behaviors. The

Cognitive Problems/Inattention subscale, with a raw score of 15 and a T-score of 77 also

falls in the markedly atypical range, indicating severe difficulties with focus, attention and

cognitive processing that effects the child's ability to perform tasks effectively.

The Hyperactivity subscale has a raw score of 8 and a T-score of 58, that is less

severe and showing issues with excessive activity or impulsivity. In the last, the ADHD

Index with a raw score of 19 and a T-score of 57, suggests typical patterns of behavior

consistent with ADHD. Overall, the scores highlight significant concerns, particularly with

inattention and oppositional behaviors, demanding targeted interventions and support.

2-Portage Guide to Early Education (Bluma et al., 1976)

The Portage Guide to Early education is one of the developmental assessment used

to establish a child’s social, language, self-help, cognitive and motor skills upto the age 6

years. Portage guide was used to assess the child’s functional age and the difference

between child’s mental age and his chronological age in the areas which is mentioned

above. The guide provides an overall framework for the children’s development which

pointing out the strengths and weakness and gives guidelines for setting up individual

educational programs (Bluma et al., 1976).

Quantitative interpretation

Table 6

Sr. No Developmental Area Functional Age

1- Cognitive 2 year, 4 months

2- Socialization 3 year, 4 months

 3- Motor Skills 7 years 5 months

4- Language 2 year, 1 month

5- Self Help 5 year, 3 months

Qualitative Interpretation

The Portage Guide to Early Education assessed children across five domains

cognitive, motor, socialization, language and self-help skills by determining their functional

age relative to their chronological age. In this 10-year-old boy with ADHD, his

developmental profile reflected a combination of strengths and significant delays across

various areas. His cognitive and language skills were notably behind his chronological age,

suggested that he faced considerable challenges in communication. Socialization difficulties

were another area of concern, as his ability to interact with peers is delayed due to

impulsivity and difficulty understanding social cues. While his motor skills and self-help

abilities were relatively more developed.

Cognitive

The child's cognitive development was considerably delayed and his functioning at a

level of a typical 2-year-old. This delay indicated that the child had difficulty with tasks

requiring reasoning, problem-solving and abstract thinking, which are important aspects of

cognitive development. For this child, tasks that require sustained attention, memory recall

and the ability to plan or organize information were likely overwhelming. This cognitive

delays reflected in difficulties in sessions, particularly in those activities that require

sustained focus such as Dot to dot matching, matching, tracing and following multi-step

instructions.

Motor
 The child’s motor development functioning was at a 7-year-old’s level, suggesting

that his gross motor (large muscle movements such as running, jumping) and fine motor

(smaller muscle movements such as writing or manipulating objects) skills are developing

at a more typical pace compared to other areas. Although this is still somewhat delayed

compared to his chronological age, it indicates that motor skills were relatively stronger

compared to his cognitive, social and language development. However, ADHD can still

affect motor skills in specific ways, particularly when impulsivity or inattention impacts the

child’s coordination and focus on tasks that require fine motor skills, such as handwriting

and drawing.

Socialization

In terms of socialization, the child’s functional age was at the level of a 3-year-old,

which indicated that his ability to interact with peers and understand social norms were

significantly delayed. Children with adhd often struggle with impulsivity, which can lead to

interrupting others, dominating conversations and engaging in inappropriate behavior that

affects the social interactions. Additionally, children with ADHD have difficulty

understanding and responding to social cues which makes forming and maintaining

friendships a challenging task. This social delay can lead to frustration as the child struggle

to regulate his emotions and impulses in social settings.

Self Help

The child’s self-help skills were functioning at a 5-year-old’s level, suggesting that

he was capable of completing basic tasks independently, such as dressing, feeding himself

and attending to personal hygiene (brushing teeth, using the toilet). While his self-help

abilities were more advanced compared to his cognitive, social and language skills, ADHD-
related issues, such as distractibility and impulsivity might still impact his ability to

consistently complete these tasks.

Language

The child’s language skills were significantly delayed, functioning at the level of a

2-year-old. This delay suggested that the child had difficulty with both receptive and

expressive communication. He were struggling to understand simple instructions and social

cues and his vocabulary were limited to basic words and short phrases which making it

difficult for him to engage in conversations or express his needs clearly. His communication

were relayed mostly on gestures and his ability to form complete sentences or articulate

thoughts was impaired.

Case formulation

Clinical case formulation is a personalized combination of many judgments about

the client’s issue and goals, the creative factors which mostly significantly affects them and

other characteristics that can influence the attention, techniques, and outcomes of

intervention with the client (Eells, 2007). The client was 10 years old boy. He was referred

to the trainee clinical psychologist at Sen Learning Institute with the presented complaints

were hyperactivity, behavior issues, impulsivity, no waiting and speech delay. His case

formulation had been done through 4 Ps.

The child’s developmental challenges appear to be influenced by both biological and

environmental factors. In predisposing factors, the child was exposed to stress, including

maternal hypertension which had impacted brain development. Research suggests that

maternal stress during pregnancy can increase the risk of developmental delays and

neurodevelopmental disorders in children (Kinsella & Monk, 2009). The child’s delayed

speech development and cognitive difficulties in processing basic concepts like colors,

shapes and the alphabet point to potential language processing and learning difficulties.

Theories of language development, such as Vygotsky’s Sociocultural Theory, highlight that

environmental interactions and social support are critical for language acquisition,

suggesting that delays in early language input could hinder normal development (Vygotsky,

1978).

The child’s continued academic struggles, including difficulty with reading, writing,

and spelling, despite attending special education programs, suggest that these issues are

persistent and require ongoing intervention. Cognitive-behavioral theory (Beck, 1967)

posits that children with learning and developmental delays developed maladaptive
cognitive patterns, such as low self-esteem and learned helplessness which perpetuate his

academic and social difficulties. In this case, the child's limited progress despite

intervention could be a sign of feelings of inadequacy and frustration which further

hindered his ability to engage with academic tasks. Additionally, the child’s behavioral

difficulties marked by hyperactivity and impulsivity continued to delay his social

functioning.

The poor relationship with his twin brother, who also had psychological challenges,

contributed to a negative family dynamic that worsen the emotional and behavioral

struggles. Research indicates that sibling relationships can play a significant role in the

emotional development of children, and conflict in these relationships may perpetuate

behavioral problems (McHale et al., 2012). In this case, the sibling relationship marked by

difficulty in maintaining positive interactions, could contribute to the child’s social

difficulties and behavioral problems.

Additionally, the child’s enrollment in a special learning institute (SLI) and his

participation in speech and educational therapies offer valuable opportunities for

improvement. Research shows that early and specialized intervention, particularly in speech

and language therapy, significantly improves outcomes for children with developmental

delays (Law et al., 2000). The combination of formal therapy and a supportive family

provides a foundation for future progress.

Furthermore, the absence of significant medical or psychiatric illnesses in the family

reduces the likelihood of inherited conditions that could compound the child’s

developmental challenges, allowing for a more targeted focus on intervention. This family

history suggests that the child's issues may be more closely related to environmental factors

and early life experiences rather than genetic predispositions.

Case Formulation with 4 Ps

4 Ps

Predisposing factors  The child was conceived through fertility treatment, with some

prenatal complications (stress and hypertension) that had

contributed to developmental challenges.

 Delayed speech development and difficulties with cognitive

learning reflected a biological predisposition, particularly

considering the challenging prenatal and early life environment.

Precipitating factors  Initial lack of formal schooling, as parents believed the child’s

issues would resolve naturally, delayed his intervention.

 Hyperactivity and behavioral difficulties in early childhood

(impulsivity and aggression) further complicate social

interactions and educational progress. Difficulty in forming

friendships, which worsens the child’s social isolation.

Perpetuating factors  Ongoing difficulties with speech, motor skills and learning which

persist despite enrolling in special education programs and

receiving therapy.

 Behavioral issues (hyperactivity, impulsivity and aggression)

continued to hinder social interactions and relationships with

peers including with his twin brother.

Protective factors  Supportive and cooperative family environment with both parents

who were actively involved in the child's care and education.

 Enrolled in special education programs and attended a special

 learning institute (SLI) to address speech, learning, and social

challenges.

 Positive family dynamics, with stable relationships between

parents and their children, offering emotional support despite the

challenges.

 No significant medical or psychiatric history in the family as well

as he had not any medical issues.

Case Conceptualization
 Presenting Complaints
Hyperactivity, behavior issues,
impulsivity, no waiting and speech delay.

Assessment
Informal assessment: Clinical interview, Behavioral observation, Subjective
rating of symptoms, Baseline chart & DSM-5-TR checklist
Formal Assessment: Conner’s rating scale and Portage guide to early
education,

Predisposing Precipitating Perpetuating

Factors Factors Factors Protective
Factors
Prenatal Delayed speech Ongoing
complications milestone & difficulties with Supportive family
(stress & delayed speech, motor environment & no
hypertension) intervention skills and medical illness
learning reported in child.

Diagnosis
(90.0) Attention Deficit Hyperactive
Disorder

Management
Rapport Building, Psychoeducation, IEP Plan according
to portage guide and techniques of behavior therapy were
used like positive reinforcement, promptings etc.

TDiagnosis
 The diagnosis was (F90.0) Attention Deficient Hyperactivity Disorder (ADHD) with

combined presentation.

Prognosis

The child’s strengths, a supportive family environment and access to specialized

education and therapies, provide a solid foundation for progress. With consistent

intervention and emotional support, he had the potential to improve his communication,

academic skills, and social functioning over time.

Differential Diagnosis

Disorder Similarities with ADHD Difference with ADHD

Autism Spectrum Disorder Hyperactivity, impulsivity, Includes restricted interests,

social challenges repetitive behaviors,

significant communication

and social deficits.

Intellectual Disability Developmental delays in Global cognitive and

cognitive and adaptive delays but in

communication skills ADHD involves typical

intellectual abilities but

impaired attention.

Oppositional Defiant Defiance, impulsivity and Focuses more on

Disorder trouble following rules oppositional behavior, anger

and irritability but with

fewer attention problems.

Conduct Disorder Impulsivity, disruptive More severe antisocial

behaviors behaviors like aggression,

 theft, and rule-breaking but

not primarily inattention or

hyperactivity.

Management Plans

The management plan for the child R.B, was devised based on his unique and

specific needs.

Individualized Educational Plan (IEP)

The individualized educational program (IEP) is a personalized education plan

tailored for a child that described the special education and related services that the child

would receive depending upon his specific educational needs (National council for special

education, 2006).

Goal Objective

Waiting without This task help the child develop self-regulation and impulse control

touching stimuli by practicing patience and refraining from engaging with a stimulus

until permitted.

Distant command Improve command following which leads to accomplish the daily

following with task with therapist like (Stop, come here, Close the door, get an item

therapist & give it to others).

Attention Complete the puzzle, pasting and matching, tracing, dot to dot

concentration matching.

activities Off table ( Shapes & ball sorting)

Interconnecting Different complex inter-connecting puzzles will be practiced to boost

Puzzles brainstorming of the child (Varied puzzles) 4-6 pieces.

Follow daily routine Help to work functionally in routine like bag pack, set the table &

chair.

Socialization with To improve good bond between them.

brother Sit independently, socialize and practice social skills like turn taking,

sharing with brother, respond to instructions

Management Plan

1. Psychoeducation of Parents

Psychoeducation is a critical component of managing autism in children. Parents are

educated about ADHD, its symptoms and how it manifests in the child. The goal is to help

parents understand the nature of their child's condition, set realistic expectations and equip

them with strategies to support the child’s development. Topics were included the

importance of structured routines, effective communication techniques and managing

behavior issues. This helped to reduce parental stress and enhances their ability to provide

consistent care at home.

2. Rapport Building

Building rapport with the child was foundational for effective intervention. The initial

phase involves engaging the child in preferred activities and creating a safe, predictable

environment to gain their trust. This phase allows the therapist to observe the child's

strengths, interests and challenges, which was essential for tailoring interventions. For the
child, rapport building reduces anxiety, fosters a positive association with therapy and

encourages active participation in sessions.

3. Individualized Educational Program (IEP)

The Individualized Education Plan (IEP) serves as a personalized roadmap for the

child’s developmental and educational goals. The purpose was to address specific skill

deficits and build on strengths across areas such as communication, socialization, motor

skills, and adaptive behaviors. Objectives were measurable and time-bound, such as

increasing expressive communication, enhancing peer interaction skills and improving fine

motor abilities. The IEP provided a structured framework for tracking progress and

adjusting strategies as needed.

4. Positive Reinforcement

Positive reinforcement involves providing a reward or favorable things immediately

after a desired behavior to increase the likelihood of behavior being repeated. For example,

if a child completes a task correctly, they will receive verbal praise, a sticker and access to

a favorite toy. This technique is foundational in applied behavior analysis (ABA) and helps

motivate children to learn new skills.

5. Shaping

Shaping involves reinforcing successive approximations of a target behavior. The child

is rewarded for steps toward the desired behavior, even if they are not perfect initially. This

method helps in teaching complex skills by breaking them into manageable parts.

6. Prompting
 Prompting is the use of cues to encourage a child to perform a specific behavior.

Prompts can be physical (guiding a child’s hand), verbal (saying “What’s next?”), visual

(showing a picture card) and gestural (pointing to an object).

7. Modeling

Modeling involves demonstrating a desired behavior for the child to imitate. It is an

effective method for teaching social skills, appropriate play and communication. Children

observe the behavior and then replicate it in their own way. For example, A therapist claps

hands and encourages the child to do the same.

8. Fading

Fading is the gradual removal of prompts and assistance to encourage independence. It

ensures that the child will continues to perform a task or behavior without relying on

external help. This technique is essential for teaching new skills while preventing

dependence on cues. For example, initially guiding a child’s hand to complete a puzzle,

then reducing physical assistance over time until the child does it independently.

9. Build Compliance

Building compliance focuses on encouraging a child to follow instructions and

complete tasks, even if they initially resist. This is achieved by starting with simple, easily

achievable tasks and using reinforcement to create a pattern of following directions.

Gradually, more challenging instructions can be introduced. For example: Asking a child to

perform a simple action like clap your hands and praising them when they comply. Over

time, this progresses to more complex tasks.

Short term goals (To Manage Behavior)

 To reduce hyperactivity of the child

 To reduce his problematic behavior of the child

 To improve compliance with commands and instruction

 To improve his understanding with his brother

Long Term Goals

 Continuation of short term goals

 Follow up sessions

 Reassessment of goals

 Parental involvement

 Long term maintenance planning

Pre and Post rating of symptoms

Table 7

Symptoms Pre- ratings Post-ratings

Hyperactive 8 7

Impulsive 8 7

Poor attention 9 7

Tantrum 8 7

Good bond with brother 9 7

Non-verbal communication 8 7

Graphical representation of pre and post rating

 10
9
8
7
6
5
4
3
2
1
0
Hyperactive Impulsive Poor attention Tantrum Good bond with Non-verbal
brother communication

Pre- ratings Post-ratings

Therapy Outcome

Sessions were conducted with the client and there was observed improvement with the

following intervention.

Limitation

Persistent hyperactivity and aggression remain barriers to positive peer and sibling

relationships, affecting his emotional and social development.

Suggestions

 Counseling and training for parents to ensure consistent support and effective

management of the child’s needs at home.

 Establish a consistent and structured daily routine.

Implementation of Therapeutic Strategies

Psychoeducation to parents

The term psychoeducation was first employed by Anderson et al 22 and was used to

describe a behavioral therapeutic concept consisting of 4 elements, Briefing the parents

about the child illness, problem solving training, communication training and self-

assertiveness training (Anderson, 2001).

Rationale

The rationale for providing psychoeducation to parents of children with Attention

Deficit Hyperactive Disorder (ADHD) is to empower them with the knowledge and skills

needed to effectively support their child’s development and well-being. Parenting a child

with ADHD can be challenging due to the unique communication, social and behavioral

characteristics associated with the condition. Psychoeducation helps parents understand the

nature of adhd, its impact on their child’s daily life and the strategies they can use to address

specific challenges. By equipping parents with practical tools, such as behavior

management techniques and communication strategies. Psychoeducation reduces the

feelings of helplessness and stress while fostering confidence and resilience.

Procedure

The psychoeducation of the parents was done with the help of biopsychosocial factors.

2- Rapport building

Defined as the ability to connect with others in a way that creates a climate of trust

and understanding, establishing client rapport is the therapist’s first objective (Leach, 2005).

Rationale

The rationale for rapport building with a child lies in establishing a foundation of trust,

safety and mutual respect, which is essential for effective communication and interaction.

Building rapport helps the child feel understood, valued, comfortable and fostering a

positive emotional connection. This is particularly important when working with children in

therapeutic, educational and caregiving settings as it creates an environment where they are
more likely to engage, express themselves openly and respond to guidance. Rapport

building also allows adults to gain insight into the child’s interests, preferences, and unique

needs, enabling tailored and effective interventions. By prioritizing rapport, adults can

reduce the child’s anxiety, build confidence and encourage cooperation which ultimately

support the social, emotional and cognitive development.

Procedure

In a session, I start by observing the child’s behaviors, interests and non-verbal cues to

understand what he enjoy or feel comfortable with. I make sure to approach him calmly and

at his level using open body language and a friendly behavior to make him feel safe. I often

introduce activities or objects I think he might like, such as toys, sensory materials or his

favorite car to capture his interest and encourage his engagement. I use gestures, facial

expressions and visual aids to communicate, ensuring my actions are clear and inviting. I

remain patient, giving him time to respond or adjust to my presence and I appreciates small

act of his interaction with positive reinforcement, like a smile or a clap. By staying attuned

to his needs and reactions, I aim to create a trusting and positive connection that helps him

feel understood and valued.

3-Individualized Educational

The Individualized Education or managment plan is a personalized education plan tailored

for a child that describes the special education and related services that the child would

receive depending upon his specific educational needs (National Council for Special

Education, 2006). IEP tells about the client’s current level and what other tasks are required

devised to improve cognitive and academic skills of the child.

Rationale
 To meet the child’s need based on the child’s development rather than on

predetermined expectations based on grade level.

Procedure

The portage guide to early education was used to develop the child’s IEP.

5-Prompting

A prompt can be anything that ABA practitioners find effective and that the client

responds to. Prompts are always an antecedent, which means they are given before the

behavior starts (Eshelman, 1988).Prompts are instructions, gestures, demonstrations,

touches and other things that we arrange or to do to increase the likelihood that children will

make correct responses. It is essentially a particular type to support which is provided by an

adult before or as the learner attempts to use a skill. Prompting procedures are systematic

ways of presenting and withdrawing the prompts so that the learner starts to perform skills

on their own. Therefore, these procedures rely a great deal on the reinforcement of correct

promoted and unprompted responses.

Types of Prompts

 Gestural Prompt

 Full physical Prompt

 Partial physical Prompt

 Verbal Prompt

Rationale

To give the child cues that will help him to perform given tasks and eventually enable him

to engage in target behavior independently.

Procedure

Different prompts were provided to help the child perform the desirable tasks and perform

various specific skills.

Sessions Report Summary

This session plan begins with rapport building, behavior observation and a thorough assessment

(informal and formal) to understand the child’s current skill levels, strengths and challenges.

Individualized Educational Plan (IEP) were planned from portage guide and techniques of behavior

therapy were used to achieve the goals to encourage learning, improve hyperactivity, inattention, and

foster independence in daily activities.

Session 1: Rapport Building

Initial session aim was to create a trusting and positive relationship between the

therapist and the child. Activities like sorting toys, stacking blocks and playing with a

favorite car are used to engage the child in a comfortable and non-threatening manner.

Positive reinforcement, such as praise, high five was given to encourage the participation.

Outcome
By the end of the session, the child feels safe and begins to associate with me.

Session 2: Introducing Waiting without Touching Stimuli

The child was introduced to the concept of waiting by using a preferred toy or snack.

The therapist asked the child to wait for 3-5 seconds before accessing the item and provides

immediate reinforcement for successful waiting and with time, increased the waiting from 5

to 20.

Outcome

The child started understanding of the concept of waiting and demonstrated the initial self-

regulation and impulse control skills.

Session 3: Following Short Commands

This session focuses on improving the child’s ability to follow simple commands,

such as "Sit," "Stop," or "Come here." The therapist uses verbal prompts and rewards

compliance with praise or tangible reinforcer like chips.

Outcome

The child shows improvement in understanding and responding to single-step

instructions and it somehow reduced his impulsivity and fostered better listening skills.

Session 4: Enhancing Attention and Concentration

The child engaged in tasks that require sustained focus, such as dot-to-dot matching,

tracing patterns and pasting shapes. The therapist provides guidance and prompts as needed

while encouraging task completion.

Outcome
 The child showed increase ability to maintain attention for short periods and

completes simple tasks which shows gradual improvement in focus.

Session 5: Practicing Turn-Taking

In this session, the goal was to learned the child with turn-taking oractice, such as

rolling a ball or sharing toys were introduced to encourage the patience and cooperation.

The therapist models the behavior and guides the child through interactions with a peer and

with his brother.

Outcome

The child begins to wait for their turn during activities, displaying better social skills

and reduced impulsivity in group settings.

Session 6: Improve socialization with brother

Structured activities, such as building a tower or playing simple games were

conducted with the child and with his twin brother. The therapist reinforces positive

behaviors like sharing and turn-taking, when he was in any aggressive behavior.

Outcome

The child started building a stronger bond with his brother which showed improved

interaction and reduced conflicts.

Session 7: Following Distant Commands

The therapist introduces commands involving movement, such as Close the door and

bring the toy. Initially, therapist used prompts but gradually faded as the child begins to

follow commands independently.

Outcome
 The child demonstrates improved understanding and execution of functional tasks

which enhanced the auditory processing and compliance.

Session 8: Following Daily Routines

The therapist worked with the child on tasks like packing a bag, setting the table and

arranging the toys. Step-by-step instructions are provided and successful completion was

reinforced with praise or tangible rewards.

Outcome

The child learn to follow daily routines with increasing independence and showed

improved adaptive skills.

Session 9: Increasing Waiting Duration

On earlier waiting tasks, the therapist gradually extends waiting times to 5-20

seconds while introducing mild distractions. Successful attempts were reinforced positively.

Outcome

The child showed greater patience and impulse control and did longer waiting

without frustration.

Session 10: Enhancing Fine Motor Skills

Activities like interconnecting puzzles or sorting shapes were used to strengthen the fine

motor skills.

Outcome

The child shows improved hand-eye coordination and fine motor abilities,

completing tasks with reduced assistance.

Session 11: Generalization and Review

In the final session, the child practices learned skills in varied settings, such as the

institute and in home. The therapist reviews progress and provided strategies to the parents

for continued reinforcement and improvement.

Outcome

The child showed consistent improvement in his behaviors, including waiting,

following commands and social interaction, across different environments which indicated

his further independence.

References

Beck, A. T. (1967). Depression: Clinical, experimental, and theoretical aspects. Harper

& Row.

Bronfenbrenner, U. (1979). The ecology of human development: Experiments by nature

and design. Harvard University Press.

Kinsella, M. T., & Monk, C. (2009). Impact of maternal stress, depression, and anxiety

on fetal development. The Clinical Journal of the American Society of Nephrology,

4(5), 859-865.

Law, J., Boyle, J., Harris, F., Harkness, A., & Nye, C. (2000). Communication disorders

in children: A review of the literature. The Nuffield Foundation.

McHale, S. M., Updegraff, K. A., & Whiteman, S. D. (2012). Sibling relationships and

influences in childhood and adolescence. In M. E. Lamb & C. D. H. (Eds.), The role

of the family in the development of children. John Wiley & Sons.

Pine, D. S., Cohen, P., & Brook, J. S. (2001). Adolescent depressive symptoms as

predictors of adult depression: Moodiness or mood disorder? American Journal of

Psychiatry, 158(4), 529-535.

Vygotsky, L. S. (1978). Mind in society: The development of higher psychological

processes. Harvard University Press.

Zwicker, J. G., Harris, S. R., & Klassen, A. F. (2012). The impact of motor difficulties

on academic performance in children with developmental coordination disorder.

Developmental Medicine & Child Neurology, 54(3), 305-310.