cbt with Autistic client

Cognitive Behavioral Therapy (CBT) with an Autistic Client
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Abstract
Cognitive behavioral therapy (CBT) is a method of treating psychiatric challenges by changing the way a patient’s thought processing mechanism. In other words, it aims at changing the way people look at themselves and others. In this case, the patient in Question is an 11-year-old Arnold Fox. He was diagnosed with autism at five years old. Previously, his developmental progress has been within the range that is expected for a child within the autistic spectrum disorders. Shortly before his 10th birthday, his parents went through a difficult divorce. As a result, his father no longer stays with them and rarely visits. He has two brothers who live with him together with the mother in a middle-income neighborhood. He attends an education center for children with autism. After the parents’ divorce, Arnold presented with mild depression which resolved. However, in the previous three months, he has had seizures, sensory processing problems, depression and impulsive behavior. This article presents a write-up or the patient’s case from diagnosis to therapy.

COGNITIVE CASE WRITE-UP
Case History
Identifying Information: Arnold is an 11-year-old Caucasian male patient. He attends school in a private educational centre for children with autism and lives with a single female parent and two brothers (one older and one younger) in a neighbouring middle-income household.
Chief Complaint: Arnold’s parent reported seizures and increased loss of reception to stimuli.

Consequently, Arnold portrayed symptom of alternating depressive moments and hyper impulsive moments.
History of the Present Illness: Approximately three months ago, the mother found Arnold piercing his arm with a sharp object that he had collected in the garden. The mother was astonished that he did not react from the pain. In fact, it is almost as if it was not happening. Within the last three months, he has experiences about ten seizures whose duration has been increasing with time. The following are some of the symptoms that have been presented in the last three months:
There is an increased likelihood of self-harm. Even when every object that could predispose him to injuries is removed, he sometimes reacts by pulling off his hair and pushing the knuckles too hard. Arnold also hits his head on the wall when he is not able to achieve a pre-intended result.
When there are injuries from such events as hitting himself against the wall, he does not react to the pain. On one occasion, an x-ray of the hand that had become swollen revealed a fractured finger. Arnold had not expressed any discomfort or pain.
Arnold regularly refuses to participate in any form of communicative activity with the mother. In these depressive instances, he refuses to eat and to go out in the garden to play. He prefers to sit in his room with toys although there is little or no interaction with the toys.
When Arnold is not in the depressive state, he is likely to be hyper-reactive. In these instances, he reacts by hitting almost everything nearby and displaying high levels of aggression against people.
Early childhood records denote a normal childhood for a child with an autistic spectrum disorder. Apart from the lack of coordination of fine motor skills, speech and social skills, he was growing at par with the expected standards. However, slightly before Arnold’s 10th birthday, the parents separated through a hostile divorce process. Immediately afterwards, he began to show symptoms of depression alternated with instances of the impulsive activity. In the initial stages, no serious action was taken as it was presumed to be a natural reaction to the separation of the parents. These symptoms had diminished with time but reappeared about three months ago as described in the above history.
Psychiatric History: Arnold was diagnosed with autism when he was five years old. His parents moved him to an education centre for children with autism. Since then, he does not have any other medical record with psychiatric complications until the age of 10. At 10, he was diagnosed with mild depression which was addressed through the school social support mechanism. No medication was administered.
Personal and Social History: Arnold is the second born in the family of three siblings. His two brothers have a normal mental spectrum. Arnold’s parents divorced one year and four months ago. For some months before the divorce, there was constant arguing between parents. The mother complained about the difficulty of caring for the three children throughout the day especially due to Arnold’s demanding condition. The father retorted that it was difficult working to satisfy the needs of the family single-handedly and therefore he could not get the time to assist with caring for Arnold. As a result of these arguments, sometimes the other brother’s taunt Arnold as being the primary cause of the parent’s separation. Besides this, the bothers often pull pranks on Arnold which he is not able to interpret as jokes because of his conditions. He therefore often withdraws from the brothers. During Arnold’s impulsive moments, he has sometimes been overly rough with both brothers. Afterwards, he shows extreme remorse especially when he hurts his younger brothers. Arnold is mildly social at school. He is selective with friends and only communicates to particular students and teachers. Most of the time, he prefers to sit alone and interact with his games. He is very open to the mother and often wanted to stay close to his father.
Medical History: Arnold does not have any medical history that could have instigated the characteristics exhibited.
Mental status check: Arnold appears disorientated and is a depressive state.
DSM-IV-TR Diagnoses: (299.00 DSM-IV)
Axis I: does not respond to stimuli, bouts of depression, and bouts of impulsive behavior.
Axis II: delayed speech, unrefined motor skills, delayed social and cognitive skills, quick temperament, and impaired learning.
Axis III: None
Axis IV: Severity of psychosocial stressors: Severe; – the separation of parents.
Axis V: GAF Current—34. Best in Past Year—39.
CASE FORMULATION
Precipitants: Arnold’s case is precipitated by two factors. The primary factor is a pre-existing autistic disorder. Children with autism are likely displayed all the symptoms that Arnold presents with (Magnuson & Constantino, 2011). The second predisposing factor is the separation of the parent. Since Arnold loved staying with the father, it is stressful not to see him (Magnuson & Constantino, 2011) . The father has full visitation rights but does not visit partly due to possible quarrels with the mother. The brothers often taunt him as being the reason for the parent’s separation. This is likely to increase self-loathing and therefore the depressive and isolation tendencies.
Cross-Sectional View of Current Cognitions and Behaviors: Arnold currently presents with suicidal and self-loathing thoughts. When he becomes aggressive, he is more likely to attempt to hurt himself than the others. Due to the insensitivity of pain receptors, he attempts as often as possible to injure himself. He has often told his mother that he wants to die. There is an increased isolation both at home and school. He believes that no one loves him. He constantly justifies other people’s cruelty towards him, especially his brothers. He thinks that he deserves is since he has caused them so much trouble.
Longitudinal View of Cognitions and Behaviors: Arnold has always been compassionate albeit with mild instances of aggressive behaviors. He loves to be around other people and always thinks of others positively. However, even when in the presence of others, he remains quiet and does not interact with them directly. For example, he often preferred to play in his older brother’s room as his brother did his homework. He would also do the same with the father whenever he is in the house.
Strengths and Assets: very compassionate and possible sociable. Has a very open relationship with the mother.
Working Hypothesis (Summary of Conceptualization): For most of his life, Arnold has lived a good relationship with the family and the school. However, he has always compared himself as inferior to other members of the family. He is fascinated by the things that his brothers are able to do and does not like the fact that even the younger brother can do them better. However, he has always seemed content in watching the others participate in these activities. He is gravely affected by other’s negative remarks on him. This is especially so when the jabs are presented by the brothers.
TREATMENT PLAN
Problem List
Seizures
Insensitivity to pain receptors.
Isolation and depressive tendencies.
Impulsive Behavior
Treatment Goals
Encourage health are regular social interactions.
Manage the impulsive tendencies.
Reduce the tendency for self-loathing and suicidal thoughts.
Manage the seizures
Reduce sense of guilt.
Improve cognitive capabilities.
Plan for Treatment: Administer anti-epileptic drugs to reduce or completely eliminate seizures. After administration, monitor closely and manage any side effects. Provide therapies that can stimulate sensory processing capabilities in form of activities and diets. Provide anti-depression therapy that is friendly to children with autism. Manage his social environment by educating his brothers on the importance of relating properly with Arnold. Provide a safe environment that reduces chances of self-harm or harm to others.
COURSE OF TREATMENT
Therapeutic Relationship: initially, Arnold was suspicious and anxious around the therapist. However, a close relationship was developed rapidly and the patient responded well to therapy and treatment. In instances where group sessions were done with the family, the entire group was responsive to the therapeutic proposals.
Interventions/Procedures
Administered anti-epileptic dosage with regard to the severity of seizures.
Conducted interactive therapies for sensory activation three times a week.
Had a free interaction meeting with the entire family once every week.
Helped Arnold express positive thoughts about themselves.
Incorporated Arnold in creating a safe zone with fun activities to explain the risk associated with various tools and equipment is his immediate environment.
Obstacles:
Lack of trust in the initial phases of the therapy.
Inadequate time especially for the group meetings with the entire family.
Difficulty in communicating ideas due to low cognitive capabilities.
Obstacles: after one month of anti-epileptic medication, there were only mild symptoms of seizures. The seizures did not recur over the rest duration of the therapy. Over a course of three months in therapy, depression, impulsivity and isolation tendencies resolved and Arnold became his normal self.

Cognitive Conceptualization Map
624840285115Diagnosed with Autism at five years
Parents divorced when he was 10 years old
0Diagnosed with Autism at five years
Parents divorced when he was 10 years old
Patient’s Name: Arnold Fox Date
41992555494020Become aggressive to others and self
Become aggressive to others and self
41922704761230Sadness
Sadness
6306221805086He isolates himself and inflicts self-harm
0He isolates himself and inflicts self-harm
-4667252564130Sensory processing delay
Sensory processing delay
18707102569210Seizures
Seizures
41852852569845Impulsive behavior and depression
Impulsive behavior and depression
41973503321685Suicidal thoughts
Suicidal thoughts
18694403313430Isolation from others
Isolation from others
-4514853324860Self-harm
Self-harm
6306221111403He loves his family and believes there are well intentioned and therefore is willing to sacrifice for them
He believes that his family will be happy I he is eliminated
0He loves his family and believes there are well intentioned and therefore is willing to sacrifice for them
He believes that his family will be happy I he is eliminated
630621338893He believes that he is a burden to others and especially his family.
0He believes that he is a burden to others and especially his family.
-4025905506720Hitting against the wall
Hitting against the wall
-4641854735195Anger
Anger
18707105591175Cut himself is possible
Cut himself is possible
18675354780280Sadness
Sadness
41890954047490Suicide will help escape current problems for himself and family.
Suicide will help escape current problems for himself and family.
18408654053840The isolation from others will make them happier
The isolation from others will make them happier
-4667254050665The self-harm will mask emotional pain
The self-harm will mask emotional pain

References
Magnuson, K., & Constantino, J. (2011). Characterization of Depression in Children With Autism Spectrum Disorders. Journal Of Developmental & Behavioral Pediatrics, 32(4), 332-340. http://dx.doi.org/10.1097/dbp.0b013e318213f56c