PSYCHODAIGNOSTIC CASE 3

Case History
Socio-Demographic Details
Name - Mr. Y
Age - 5 years 7-month-old
Sex -
Male
Address - Beta 1, Greater Noida
Occupation - student
Education - Play School
Religion - Hindu
Family structure - nuclear family
Socio-economic - Middle-middle Class Status
Date - 22/07/22
Referred by - GBU OPD

Informants
Relationship with the patient: patient’s mother and Father
Reliability and adequacy: Reliable and adequate.
Reliability and adequacy: Reliable and adequate as the informants were able to give coherent,
consistent information about the illness of the patient in a chronological manner.

Presenting chief complaints

 Repetition of words (echolalia) “baar baar ek hi chiz ko dohrata hai”
 Lack of social Interaction “Kisi se Jayda baat chit bhi nhi krta hai”
 Shows temper tantrums “bohot gussa karta hai, chize fekta hai dusron par”
 Repetitive movement “baar baar haatho ko hilaat hai”
 Poor eye contact “jab bhi iss se baat kro apni aankho ko jhukaye rakhta hai”

onset Insidious
course Continuous
Duration 4 years
Precipitating Factors: the patient had seizer 4 years back which is the main cause of the
illness.

History Of Present Illness

As per the patient’s mother reported that the patient was functioning well adjusted the
environment till 2018 when the patient turned one and a half years old, he had fever, and a
seizer. The patient was kept under observation in the ICU for one day for the same. After two
three months later of the seizer parents started observing that the patient started remain quiet
and started giving delayed responses whenever his parent asks something to the patient. As
per the patient’s mother “dore ke uthne ke bad se bohot slow ho gya tha kuch pucho to bohot
der baad jawab deta tha” due to having the seizure, the patient remained very slow and
sluggish and started giving less responses to everyone. According to the patient’s mother
“kisi se baat- cheet bhi nhi krta tha chup-chup bethe rhta tha, bohot shant ho gya tha”
according to the patient’s mother “ye shant to phle si hi rhta tha par dore ke baad Jayda ho
gya tha” further his mother reported that “bohot chup- chup rhta tha or kisi ke bulane pr
dekhta nhi tha or idhr udhar dekhta tha”. He was not paying the attention and he was not
making the eye contact with anyone as per his mother reported.
When the patient turned three years old the parent decided to enrolled their child in play
school. as per the patient “humne socha ki dusre bancho main ghulega milega to shayda thik
ho jayga in the school also the parents and his school teachers faced the same things. They
started noticing that he does not seems to comprehend information the way the other children
do of his age process the information. His parent reported that “or bancho ke mutabeek bohot
peeche hai, apni age ke bancho ke jaise chizo ko nhi samajh pata hai” his class teacher also
reported that “class main main chup -chap rhta hai, akela rhta hai, baar baar hantho ko
hilata hai” further his mother reported that his class teacher complained her that he is not able
to focus on anything and repeats words again and again as per the mother “naam kya hai-
naamkya hai, ghr jana ghr jana”. As per the mother “kuch padhane betho to usska dhyaan hi
nhi rtha bs neeche najar kr k bethe rhta hai”. She noticed that it is very difficult for him.
Later on, she added that his teacher also reported to his mother that she faced all these
difficulties with him too. His mother also reported that he would rather be alone than being
with others she reported “anpne aap main hi rhat hai akela rhta hai” His mother also
mentioned, that the patient cannot write, or speak simple words properly.
As his father reported that the patient faces academic difficulty in school which are associated
with having low attention span and reduced concentration; does not communicate with
others; he does not co-operate with his classmates. According to the teacher (as his parents
told), whenever he used to play with his classmates, he used to spit on them, show aggressive
behavior towards them as per the father “dusre bancho par thukta haior unpar gussa dikhata
hai”. His father also told that, the patient is stubborn, self-centered, irritable, and also does
not sit at one place calmly. As per the patient’s mother reported ye “ghar main idhr udhr
bhagta rht hai shanti se nhi bethta hai”
Further In 2019 the patient mother also reported that he cannot wait for his turn “jab bhi isske
papa kuch late to ye lene k liye bikul bhi intzar nhi kr pata, na do to rone lagta maarne
lagta”. He becomes impatient, that he could not wait for whatever he wanted which resulted
in him being aggressive and upset and started to harm himself. according to the father “issko
bikul bhi sabr nhi hota, ye khud ko bhi marne lagta hai” the parent noticed that he
persistently asked for something he wanted until he gets it “ek baat ko baar baar dohrat hai,
or baar baar baar ussi baat ko dohrata rhat hai” His mother noted that her child shows this
behavior at home and outside the home as well. As patient grew older, his anger increased too
much and also started showing temper tantrums and started disobeying his parents. She
reported “kuch bhi kaho to khud ko maarne lgta apne kaatne lagta, or humari baat bhi nhi
sunta” He would scream and throw things and spit on others. As per the parents “dusro par
thukat hai, maarta hai” the patient’s this behavior increased more after having his speech
therapy done in 2019. He also started repeating words “mumma khana khau, mumma khana
khau”, “bahar jau, bahar jau” as her mother reported.
In 2020 Further, the patient’s mother reported that the patient’s repeated movements
increased they reported that “apne haato ko bhot hilata hai, baar baar hatheli ko dekhta hai”
stereotype and repetitive behavior flapping hands increased by the patient. His mother also
reported that the patient lacks social interaction, and has lack of danger according to his
mother “kisi bhi chiz se darta nhi hai, kisi bhi chiz ko bina dare pakad leta hai” His mother
also reported, as he grew more, his aggressive behavior increased and started harming
himself increased. As per the patient’s mother she stared to interrupt his elder brother and
sisters “wo jab bhi koi kaam karte to ye ussko bigadne lagta” he also started to destroy their
important papers such as their book, notebook etc. “Copy- “kitabo ke paper ko bhi fadne lgta
hai”
In 2021- 2022 His mother reported that he could not take care of himself as other children of
similar age would do. He does not maintain eye contact as well. Even as he turned five, he
had difficulty in articulating his needs appropriately. Most of the times, the patient remains
aloof; he plays alone; plays with leaves. He interrupts his siblings and he showed aggressive
behavior when his parents try to stop him. The patient often could not respond to his name
being called as if he can’t hear them due to which his mother consulted to ENT specialist at
Yatharth Hospital to get his ear tested; all reports came to be normal. According to his
mother, the patient’s appetite and sleep is well and good. He takes his proper meal and sleep
well.
When similar concern was discussed with the school authorities, they asked the parents to
refer to a clinical psychologist. Currently the patient’s, psychological and socio-occupational
functioning has been disturbed hence they came GBU Clinical Psychology OPD.

Negative History
• No history of stealing, lying and destructive behavior.
• No H/O persistent and pervasive sadness, elated and elevated mood
• No history of irrational fear, suspiciousness.
• No H/O of hearing voices, seeing images
• No history of elated and elevated mood.
• No history of irrational fears, suspiciousness.
• No history of hearing voices, seeing things.
• No history of clouding of consciousness, loss of consciousness ..

Past Psychiatric and Medical Illness

 No past psychiatric illness was reported.
Medical History -
The patient had a seizure in 2018 when the child was one and a half years old got
admitted into the hospital for one day for the same. No history of any contributed
medical illness was reported.

Treatment History
Past Treatment History
The patient first started his medication in 2018 from Kailash hospital Noida for his Febrile
seizure the prescribed medication was Monocef-o (50mg), syp Zincovit (5ml), Tab Frisum
(5mg), syp.ibugesic plus 95ml) The patient showed improvement in symptoms through
taking these medicines. No treatment taken for the current symptoms.
According to the patient’s mother In 2019 he has consulted to the speech therapist due to
unclear speech, lack of social interaction and poor of contact.

Family History
Family Tree (Genogram)

Family Dynamics
The patient is 5.7 years old belongs to middle socio- economic status. There are six members
in the family. The patient is the youngest one. His father is the businessman and his mother is
homemaker. his mother has a warm and affectionate relationship specially with the patient.
The patient has special bound with his mother and elder sister. The patient has two elder
sisters according to the informants he is very affectionate and caring towards his eldest sister.
The family members very cooperative and understanding towards the patient’s illness and are
willing to provide a supportive environment to the child there is no history of any psychiatric
illness in the family.

Personal History
Perinatal History:
The patient was a full-term child (9 months) delivered with no complication. It was a normal
delivery; birth cry was present. The patient had normal birth weight and no perinatal
complications could not be observed.
Developmental History:
According to the informants that all the mild stones were achieved on time and all the mile
stones within the normal range except his speech. The patient’s motor development was
within the normal limits for the major milestone of sitting, standing and waking but his
language development was delayed he started waking in 8 to 9 months and started speaking
at the age of one year. At the age of three the parents stared noticing that whenever they give
the toy to the patient, he started breaking them and they observed there was a lack of speech.
He did not respond to anyone whenever somebody ask for anything.

Educational History:
currently, the patient goes to the play school blooming flower greater Noida. The patient
mother reported that he does not play cooperatively with the other children. He also spits on
others started he started his schooling at the age of three years. According to the informants,
the patient cannot write and speak simple words asper his mother reported. He participates in
few sport activities. He does not have any close friend and the peer relationship is also not
good and cooperative. According to the informant he does not follow the instruction whatever
his teachers give to him and he repeats those instructions again and again.
Play history -
According to the mother the patient indulged in isolated. The patient wants to play with
others and wants to participate in group activities but due to his aggressive and unethical
behaviour (spits on others, shows temper tantrums) nobody wants to play with him. So, most
of the time the patient used to play with leaves, he likes to break them. He has minimal
interaction with other children cannot initiate or maintain communication with them. Further
she also reported that he shows aggressive behaviour toward other children and cannot wait
for his turn and also unable to play competitive games. he also suffers to understand the rules
and the regulation of the games.

Premorbid temperament-
Premorbidly, the patient was physically active. However, he was unable to respond to social
and environmental cues as reported by the mother. As per the mother “jab bhi koi iss se baat
krta to ye jawab nhi deta tha or bohot kam hasta bhi tha” his mother reported he also showed
inappropriate emotional responses.

Behavioural observation and MSE-

The patient was of ectomorph built, well- groomed and dressed neatly. He was appropriately
according to the weather and culture the patient was restless when he arrived at clinic eye
contact was poor but was gradually maintained. His attention could be aroused but could not
be sustained for desirable period of time. The rapport with the patient was maintained with
difficulty. He was easily distracted and the examiner had to bring his attention back again and
again. He was also disobedient with his parents and he showed tantrums if force to engage in
joint attention activities. He was not listing the instruction carefully the patient was repeat or
echo question or statement asked by the examiner again and again such as – “tumara naam,
yha aao yha aao etc.” he was not responding his name being called most of the time. The
patient engaged in solitary and repetitive activities. The patient was unable to comprehend the
significance of taking turns in reciprocal interaction. The patient squalled, was making
bizarre noise and produced unintelligible speech like sound.

Diagnostic Formulation
The patient Mr. M, 5years old, male, studying in Play School R/o Beta 1, Greater Noida,
belonging to Middle socio-economic status, nuclear, urban Hindu family was brought by his
parents to GBU Clinical Psychology OPD with complaints of poor eye contact, low attention
span, lack of social interaction, repetition of words and movements, impaired cognitive
ability and disturbed socio- economic functioning since four years with a insidious onset,
continuous course, with no family history of major psychiatric illness and also having
significance finding on behavioral observation as repetition of words and movements,
irritability and impaired attention and concentration with no history of suggestive any
organic involvement, loss of consciousness, or any psychotic symptoms was diagnosed as a
case of Autism Spectrum Disorder.

Provisional Diagnosis
According to ICD-10- F84.0 Childhood Autism
According to ICD- 11- 6A02.Z Autism Spectrum Disorder
According to DSM-5- autism spectrum disorder
 Psychodiagnostics Assessment
Rationale of Assessments:
The patient had complaints of repetition, low concentration, poor eye contact, lack of social
interaction, temper tantrums thus there was a need to assess the psychopathology and its
severity. Further for effective management of the patient it is essential to understand the
interaction of intellectual functioning, personality and interpersonal relations with the
psychopathology of the patient. So, it was planned to assess these four areas. Areas to be
investigated-
 Intellectual and cognitive functioning
 Psychopathology
 Interpersonal deficits
The Purpose of conducting Seguin form bord test (SFBT)is to evaluate the patient’s eye-
hand coordination, shape concept, visual perception and cognitive ability. The purpose of
conducting developmental screening test (DST) was to assess the developmental level of
the child and the purpose of conducting the Indian scale for identification of autism
(ISSA) was used to assess the level of autism and percentage of disability of the child. To
detect emotional and behavioral problem Child Behavior checklist (CBCL)was
administered
Test Administered
● Vineland social maturity scale (VSMS)
● Developmental screening test (DST)
● Seguin form bord test (SFBT)
● Child behavior check list (CBCL)1.5 to 5
● Indian Scale for assessment of Autism (ISSA)
Test Behavior and Observation
The patient was ectomorphic built. The rapport with the patient has been established with
difficulty and eye contact was poor. He opened up in second session with the examiner. His
attention could be aroused but could not be sustained for desirable period of time. The patient
was easily distracted. The patient was unable to comprehend the instructions adequately
Test Findings
Cognitive and intellectual functioning
Vineland social maturity scale- (VSMS)-
Social Age (S.A.)- 49 months
Social Quotient (S.Q)- 73

Table – showing social age and social quotient in all domains of the overall social
Quotient.
 S. No. Dimensions SA Computation Formula SQ Interpretation
1 Self- help general 52 52/73*100 71.2 Borderline

2 Self- help eating 32 32/73*100 43.8 Moderate

3 Self -help dressing 88 88/73*100 120.5 Superior

4 Self -dressing 44 44/73*100 60.2 Mild

5 Occupation 40 40/73*100 54.7 Moderate

6 Communication 40 40/73*100 54.7 Moderate

7 Locomotion 44 44/73*100 60.2 Mild

8 Socialization 19.2 19.2/73*100 26.3 severe

Impression – The borderline level of impairment in socio -adaptive functioning, more

severity seen in the area of communication and socialization the course of which could be
linked to Autism.
Developmental screening test (DST)

Developmental Age (DA): 40 months

Developmental Quotient: 65.5
Table 1: showing developmental age and developmental quotient in all domains of the
overall developmental quotient.
S.no Dimensions DA Computation SQ Interpretation
. Formula
1. Cognitive 40 40/61*100 65.5 Mild
2. Emotional/social 24 24/61*100 39.3 Moderate
3. Motor 38 38/61*100 62.2 Mild
4. Speech 19.5 19.5/61*100 31.96 Moderate

Seguin Form Board test (SFBT)-

According to the time taken the patient’s Mental Age is 4 years. The child’s eye hand
coordination seemed appropriate, shape concept has not been developed properly yet, as the
child did many errors during the assessment, visual perception and cognitive ability seem to
be intact.
Rating scales
 Indian scale for assessment of Autism (ISSA)
 Child behaviour checklist (CBCL)
ISSA
Impression - The score on ISSA is indicative that of Moderate Autism (122) with 70% of
disability being present.

Child behaviour check list –

The child behaviour checklist for age 1 ½- 5 (CBCL) was competed by Mrs. P, Mr. Y’s
mother , to obtain her perception of Mr. A’s problems.
On the (CBCL) 1 ½ - 5 problem scales Mr. A internalizing problem where in the Borderline
Range his externalizing problem lies in the clinical range and the total problem score were all
in the normal range.
His score on the emotionally reactive, anxious depressed, somatic complains and sleep
problem are in the normal range. Withdrawn, attention problem and aggressive problem lie in
the clinical range.
On (CBCL)1 ½ - 5 – DSM oriented scale, Mr. M score on all rated scale were normal range
or clinical range. Affected problems anxiety problems were in the normal range but pervasive
developmental problem, attention deficit hyperactivity problems and oppositional problem
were in the clinical range.
 Case formulation

Delayed developmental milestone Difficulty modulating

Difficulty distinguishing between
Lack of social smile, delayed speech emotions and understanding information in several
them sensory channels

Insensitive to felling of
i
other/difficulty understanding Toe walking, flap hands
others emotions rocking back and forth
Avoid conversation and while sitting
social behavior

Behavioral problem such

Poor activity and social are being disobedient,
competence, withdrawn restricted pattern of
behavior, shy, performance to activities such as lining of
stay aloof Social withdrawn and toys and playing mobile
difficulty communicating, games.
going back and forth in a
communication, poor attention
and concentration

Marked impairment in social Repetitive stereotype

interaction behavior

Marked impairment in social

communication

AUTISIM SPECTRUM DISORDER

Adapted from- Integrative model of ASD (The Autism Community in action TAC, 2003)
Submitted by Supervised by

Vasundhara
MPhil clinical Psychology trainee 1st year Dr. Anand Pratap Singh
Head of the department
Department of Psychology
& Mental Health, GBU