Client Name   : Zain (Name changed)
Age                       : 7.7yrs 
Gender               : Male
Diagnosis         : Mild to Moderate ASD
Treatments     : Behaviour Therapy, Occupational therapy, Special Education 

Background

Master Zain aged 7.7 years from Lakshadweep came with his parents for assessment and therapeutic interventions. He is the eldest son in the family and has a younger brother.  His father is an electrician, and his mother is a homemaker. Their mother tongue is Divehi. He’s studying in first grade in their native place. He is a quick learner, has a sharp memory, runs fast, learns people’s character quickly and acts accordingly.

He was diagnosed with mild to moderate Autism and has been taking early intervention since 2yrs of age at his native place. He had taken Speech, Occupational and Behaviour Therapies thereafter for 2yrs from his native place. He was also under medication to control his restlessness and impulsive behaviours. 

The age of the mother during conception was 28 years. Mother’s health was generally good during pregnancy. No history of abortion was reported. He was a full-term C-section baby with a 3.1kg birth weight. Birth cry was present, and the birth colour was normal. Regarding developmental milestones, motor milestones were normal whereas language milestones were delayed. Mother noticed the child’s developmental delay at 10 months. He was a difficult child to manage during his early childhood and was quite restless for which medication was started. With proper medication, his restlessness had greatly reduced.

Behaviour Therapy

Master Zain came with concerns about poor sitting tolerance, poor attention and concentration, poor peer relationships, issues in writing and reading, speech delay and behavioural issues (hitting and throwing objects, poor compliance with father).

Assessment Findings and Therapy

Tests Administered:

Seguin Form Board Test (SFBT)

Vineland Social Maturity Scale (VSMS)

Childhood Autism Rating Scale (CARS)

On Seguin Form Board Test (SFBT), he was found to have adequate visuomotor and spatial abilities, form perception and eye hand coordination. His mental age was found to be 6 years and 6 months.

On Childhood Autism Rating Scale (CARS), he was found to have a score of 32 indicating mild to moderate autism. Communication (verbal and non-verbal), adaptation to change, emotional response, listening response, relating to people, body use and object use, activity level are affected more than the other areas like imitation, intellectual responses, visual response, fear/nervousness and taste, smell and touch response.

On Vineland Social Maturity Scale (VSMS), the social age was found to be 6 years and 6 months.

Behavioral Observation 

During assessment, rapport was easily established. Attention was difficult to arouse. Eye contact was maintained. Joint attention and eye hand coordination was adequate. He was able to follow two step instructions and compliance was noted. Sitting tolerance was appropriate.

Goals

Behaviour Therapy was conducted based on the principles of ABA therapy. Goals were primarily focused on improving his attention, concentration, reducing his maladaptive behaviours and improving social interaction skills.

First goal focussed on improving his attention, where he will be able to sustain his attention till the completion of any activity with 100% accuracy on 5/5 trials. Second goal focussed on improving his social interaction skills, where he will be able to greet others and initiate conversation in appropriate manner independently with 100% accuracy on 5/5 occasions. The last goal focussed on reducing his undesirable behaviours, where he will be able to respond to multiple activities upon request from instructor without showing any behavioural issues on 5/5 trials. All the goals were taken for a duration of 3 months. As his maladaptive behaviour was more towards his father, the sessions were arranged in such a way that the father accompanied him in the sessions so that a good rapport between the father and son could be established. 

Management and Outcome

During initial therapy sessions, he was not cooperative with his father. Psycho-educated parents about the current condition of the child and discussed behaviour management techniques to improve his desirable behaviours and reduce undesirable behaviours. 

He showed remarkable improvement after therapy. He was able to sustain his attention till the completion of any activity with 80% accuracy in 5/5 trials. He started to greet others and initiate conversation independently in appropriate manner on all occasions. He was able to approach and respond to multiple activities upon request without showing any behaviour issues on 5/5 trials. 

Special Education

After one month of Behaviour Therapy and Occupational Therapy sessions, Special Education assessment was done. GLAD(Grade Level Assessment Device) was administered for the purpose of understanding his educational level and the cause of his learning difficulty. He could identify and read 4-5 words and also spell around 8 CVC words. He refused to write in lowercase letters. With respect to math, he was aware of numbers. 

Goals

Special education goals were taken to improve his academic performance and the areas focused were pre-math skills, English reading (phonics CVC, CCVC) and writing (by segmenting each words and sentences.

For pre-math skills, the goal was that Zain should be able to identify numbers more or less independently and to achieve this goal we practised using colour sticks, water, etc and then with numbers.

For reading, the goal was to read CVC words using phonics independently. For his writing skills, the goal was that he should be able to write words and sentences by segmenting each sound in a word independently.   

Regular Sessions

As his attention and concentration were improved through Behaviour and Occupational Therapy sessions, he was able to concentrate more on education. Zain understood and followed the instructions well when the concepts were presented in a structured manner. Within two to three weeks of special education sessions and home programs, he was able to read and write CVC words independently. Mother followed the same methods at home and it helped him practice more. 

Occupational Therapy

Zain attended occupational therapy sessions thrice a week for 3 months. He was restless in the first few sessions. When Child Sensory Profile (scale) was administered, it was found that he had sensory modulation difficulties.

Goals

Occupational therapy goals were taken to improve his functional area aspects such as eating, buttoning his shirt and writing.

For eating, the goal was that he would be able to eat at least 5 balls of rice with his right hand independently. 

For dressing (buttoning), the goal was that he would be able to button his shirt independently in 5/5 trials and for writing, the goal was that he would be able to write alphabets from A to Z without putting much pressure while maintaining tripod grasp. All the above-mentioned goals were taken for a duration of 3 months.

To achieve these goals the areas that had to be worked on included normalizing his sensory issues, and improving sitting tolerance, attention and eye-hand coordination.

Management and Outcome

Sensory integration therapy was given to normalize his sensory modulation difficulties which were affecting his functional areas mentioned above. Over the course of therapy, he improved socially and cognitively with great efforts from his parents. Since Zain was a quick learner, he achieved all the goals in a short span of time.

His initial performance in eating was that he needed maximal assistance while eating. After 3 months of therapy, he was able to eat independently

His mother used to button his shirt for him. He was able to button his shirt independently after 4 sessions of occupational therapy.

Coming to writing, initially, he used to write with a lot of pressure, but after 3 months of occupational therapy sessions, he was able to write alphabets while maintaining a tripod grasp with adequate pressure independently.

He also showed remarkable improvement in his social skills such as greeting someone and saying bye to the therapists after therapy sessions. Zain became independent in almost all his daily living skills with great effort from his parents.

Recommendations

Behavioural management techniques were elucidated to parents to control maladaptive behaviours along with activities to improve attention at home. Exposure to social settings was recommended to improve his social interaction skills.

Parents were also recommended to continue occupational therapy and group therapy to improve his quality of living by normalizing his sensory modulation difficulties. Providing more outdoor exposure was also recommended to improve his social skills. Regular review after every 6 months has been suggested to monitor his ongoing level of performance.

Discussions

Zain has been receiving early intervention since age 2, which has resulted in significant gains across the board. Also, the tremendous parental support and their total involvement in therapy enabled him to accomplish his goals over the years. Active parental involvement, early intervention and strict follow-up of regular home programs as advised by therapists have helped Zain to become independent in all areas.