Biodata

Name: UF

Age: 5 years

Religion: Islam

Gender: Female

Education: MCC

Siblings: Nill

Birth Order: Only child

Father Occupation: Waiter

Father’s Education: 5th grade

Mother Occupation: Housewife

Mother’s Education: 5th grade

Socio-economic Status: Lower Class

Presenting Complaints
The client has a below average understanding which is not consistent with developmental age.

The client has severe difficulties with her speech, she doesn’t utter any word, phrase or sentence

other than one word ‘mama’ denoting towards her mother. She does understand simple sentences

and commands such as if asked ‘did your mother help you get ready today?’ she would nod in a

‘yes’. Other than basic simple sentences, she doesn’t understand complex sentences even one as

‘if you run towards the class you’ll fall down’. She only communicates through pointing at

things she wants or by nodding yes/no. The client has not been enrolled in any school before

hence her understanding of basic academic material lack severely. Recognition of basic shapes,

colors and objects is not present. The child has impulsivity and depicts aggressive behaviour

when poked by other classmates. She shows impulsivity during tasks.

History of the problem

The problem was initially observed by parents at birth because the client was feverish and

severely weak. At the age of 6 months, the mother noticed the client’s declining health even

more. The parents became concerned due to her delayed speech and language development.

Prenatal History

The mother of the client reported having a full term pregnancy but the delivery was a C-

section.
Milestones/Developmental History:

Milestones, Normal Age and Child’s Age of Achievement.

Milestones Age of Achievement

1st Cry Immediate
Head Holding 5 Months
Sat alone 8 Months
Crawling 1 years
Standing 2.5 years
Walking 3 years
Fed self 5 years
Toilet Training Not yet
One-word Speech 4 years

Medical History

The client had fever at the time of birth. At the age of 4 years, the client was admitted to the

hospital due to high fever and was given medications to recover.

Family History

The client’s family relationship history involves close relation with parents. The client is

a single child hence usually hangs out alone at home. As reported by the mother, the client has

good relationship with her grandparents and close cousins. No serious medical illness or

psychiatric/psychological disorder is observed in the family.

Educational History

The client has never been enrolled in a school before. When the client’s parents observed

developmental difficulties in her, they enrolled her in her present special school.

Social History

The client has positive interactions with family members. She likes to spend time with

her classmates but occasionally indulges in aggressive behavior when provoked by her fellows.

Apart from that normally the client has positive interactions with others and she is cooperative

with her classroom teacher as well.

General Characteristics

The client has a friendly nature. She is eager to attend sessions and has a pleasant mood.

Level of Functioning:

Personal

The client has speech and language difficulties hence she only communicates through

hand gestures such as pointing towards things she wants. She has one word speech and usually

nods in a yes/no depending on whatever asked. The client is friendly but when provoked by

fellows, she displays aggressive behavior.

Cognitive

The client shows difficulties in the ability to recognize basic objects, shapes, colors.

Attention is inconsistent, requiring focused, engaging activities to sustain his interest. She

requires learning of basic objects such as body parts, everyday essentials and simple tasks.
Social

The client demonstrates good social interactions with family but can display impulsive and

aggressive behavior when mistreated. She requires a supportive and engaging environment to

grow in academic as well as social domain.

Psychological Assessment

 Mental Status Examination

The mental status examination of the client will indicate important details relating to his

appearance, mood, and perception, several cognitive functions such as orientation,

attention and memory. MSE also includes the evaluation of client’s abstract reasoning

and whether or not he has insight of the problem.

 Child Behaviour Rating Scale (CBRS)

CBRS is a rating scale to examine child’s well being and behavior with other

children, adults and material in classroom or virtual classroom setting.

 School Function Assessment (SFA)

The School Function Assessment (SFA) form serves as a crucial tool, developed

by Pearson Education, Inc., to evaluate students' performance, participation, and

support needs in academic and non-academic activities within the school

environment. By providing a comprehensive record for individual case studies, it

helps educators and support staff identify areas where students may require

additional assistance to thrive. .

 Slosson Intelligence Test (SIT)

 Slosson Intelligence Test is used here to determine the intelligence quotient of the

client as well to evaluate the level of intellectual functioning.

1. Mental Status Examination (MSE)

The client’s appearance was neat. Her clothes were clean and ironed. Her hair were brushed

and tied in a ponytail. Her mood was pleasant. She has issues with attention and

concentration as well as speech. The client lacked insight about her issues.

2. Child Behavior Rating Scale (CBRS)

Quantitative Analysis:

Age Classroom self-regulation score Social Skills Score Total Score

05 40 10 50

Qualitative Analysis:

The CBRS data indicates a significant challenge in both classroom self-regulation and

social skills for this client. With a Classroom Self-Regulation score of 40, the client may struggle

to stay focused, follow directions consistently, and complete tasks without substantial support.

The Social Skills score of 10 indicates difficulty with peer interactions, likely involving

challenges with taking turns, sharing, and cooperating. The Total Score of 50 reflects the need

for targeted interventions that focus on enhancing social-emotional skills, self-regulation, and

developing strategies to improve academic engagement and peer relationships.

3. School Function Assessment (SFA)

Quantitative Analysis
 Participation Task Supports Activity Performance

1 2 1

The client demonstrates moderate challenges across various areas, In participation and activity
performance, the client requires substantial support to engage in activities and remain focused.
Physical task skills and motor coordination are also limited, though progress is possible with
practice. The client has basic self-care skills but still requires assistance with more complex
tasks. Significant difficulty is noted in social behavior, where the client struggles with peer
interactions, indicating a need for social skills development.

4. Slosson Intelligence Test (SIT) (Richard L. Slosson 1963)

Quantitative Analysis

Basal Age Mental Age Chronological Age I.Q

120 100 60 50

Qualitative Analysis:

The individual assessed with the Slosson Intelligence Test demonstrates cognitive abilities

consistent with moderate intellectual disability. With an IQ of 50, this client experiences

significant delays in acquiring basic literacy, numeracy, and adaptive skills compared to their

peers.

Diagnosis

Intellectual Disability (Intellectual Developmental Disorder with Moderate level) 317 (F71).

Management Plan

 Improve  Use pictures of objects and shapes.

 recognition of  Sensory Activity with play dough to shape
Academic skills objects, shapes, objects and colors.
development and colors.  Use interactive matching games and
Enhance attention puzzles with basic objects.
span.

 Enhance social  Scratch wooden pencil diaries

interaction, for calming tactile activities
Social and Emotional manage  Reinforce positive behavior
Skills emotions, and through reward and
improve impulse diminishing maladaptive
control behavior.
 Practice self-feeding skills
using utensils.
 Improve basic
Adaptive Behavior self-help and  Engage in fine motor skill
Development daily living skills. activities with play dough for
hand-eye coordination.
 Engage in gross motor skills
activities with
throwing/passing ball games.

Session Reports
Session 1

The initial session was focused primarily on observation and gathering information, using the

SFA (School Function Assessment) test with the support of the teacher. The session was

designed to assess the client’s functioning in a school setting, and I observed her behavior and

responses. The client displayed limited communication, primarily through gestures, and showed

some impulsivity when interacting with peers. She was able to follow simple instructions, such
as nodding in agreement or pointing to express her needs. The session was used to gather

baseline data on the client’s abilities, and I aimed to build rapport by engaging her with crayon

paper and pencil coloring activities. These activities were chosen to establish trust and encourage

the client to feel comfortable with me.

Session 2

During the second session, I administered the SIT Intelligence Test, which aimed to assess the

client's cognitive abilities. The test involved tasks that measured problem-solving, pattern

recognition, and attention span. The client had some difficulty staying focused during longer

tasks but showed some responsiveness to simpler items. Throughout the session, I used crayon

paper and pencil to maintain the client’s interest and make the environment more engaging. This

rapport-building activity helped the client remain calm and cooperative. While the results of the

test highlighted certain cognitive challenges, it was evident that with ongoing support, the client

has the potential to make progress.

Session 3

In session 3, I administered the CBRS (Child Behavior Rating Scale) to assess the client’s

behavioral tendencies, including aggression, attention, and emotional regulation. This process

was done with the teacher’s support, ensuring that accurate observations were made in both the

classroom and home settings. During the session, I focused on rapport-building by engaging the

client in coloring activities using crayon paper and pencils. These activities helped reduce any

initial discomfort and encouraged the client to participate. The client displayed some impulsivity

and frustration during the session, but she was able to calm down when redirected. The data from
the CBRS provided important insights into the client’s behavioral patterns, particularly regarding

aggression and social interactions.

Session 4

In session 4, I focused on academic skills development, specifically working on body parts

recognition. The client already had some knowledge of her body parts, so we expanded on this

foundation by engaging in activities such as pointing to or naming different parts of the body.

The client was able to identify several body parts, and with further practice, she could improve

this recognition. Additionally, I incorporated a sensory play dough activity, encouraging her to

create shapes and objects related to body parts (e.g., a head, arms, etc.), which helped engage her

fine motor skills and attention.

Session 5

Session 5 focused on social and emotional skills development, particularly improving impulse

control and emotional regulation. We engaged in a calming tactile activity using scratch wooden

pencil diaries, which helped soothe the client during moments of agitation. The client displayed

some impulsivity and frustration when the activity didn’t go as expected, but through redirection

and positive reinforcement, she was able to complete the activity calmly. In addition, we worked

on managing emotions through turn-taking games, where the client practiced waiting her turn. I

reinforced positive behaviors and used praise to encourage cooperative play. These activities

were designed to help the client practice emotional regulation and social interaction in a

structured manner.
Session 6

The sixth session was dedicated to adaptive behavior development, specifically focusing on self-

feeding skills. The client had some difficulty with using utensils, so we began by practicing with

a spoon during snack time. I provided verbal and visual cues, and the client attempted to use the

utensils with varying levels of success. Throughout the session, I emphasized the importance of

practice and positive reinforcement. I also included a play dough activity to improve hand-eye

coordination. The client enjoyed manipulating the dough into shapes. While the client’s attention

span was inconsistent, the session was engaging and she had fun as well.

Session 7

In session 7, we focused on gross motor skills by engaging in ball passing games. The client

demonstrated some coordination and interest in the activity, although her attention was

inconsistent. I used visual prompts and encouraged her to pass the ball back and forth. She

enjoyed the activity, and it seemed to help channel her energy in a positive way. This physical

activity also helped her practice following simple instructions, such as “pass the ball” or “throw

the ball to me.” The session allowed the client to work on both her motor skills and social

interaction, as she had to wait her turn and engage with others during the game.

Session 8

The final session focused on reinforcing academic skills, specifically working on body parts

recognition and furthering the client’s understanding of these concepts. We used flashcards with

images of body parts to reinforce learning. The client responded well to the visual aids and was

able to identify several body parts correctly. Additionally, we continued with sensory play dough
activities, creating body part shapes to help solidify the learning. The client was engaged

throughout the session and demonstrated a growing understanding of the concepts. I provided

praise and positive feedback, emphasizing her progress and encouraging continued learning. This

last session helped establish a strong foundation for future academic development.

Long Term Goals/ Suggestions

 IEP plans for managing difficulties in academic domain.

 Speech Therapy to enhance communication skills, focusing on word production and

sentence formation.

 Cognitive Behavioral Therapy (CBT) for impulse control and emotional regulation,

addressing impulsivity and aggression.

 Occupational Therapy to improve fine and gross motor skills, particularly for self-help

tasks like feeding and dressing.