Name: Sally WattertonDate 10/9/2022
Identifying Information: Sally Watterton is a preschooler who lives with her parents, Lisa and Jack Watterton. Sally’s physician recommended her because she was experiencing difficulty with social communication and relationships, as well as having repeating patterns of discomfort connected to changes in routine and familiarity, which resulted in disturbed school functioning and other social engagements outside the house.
Problem List (in order of priority)   Hyper & Hypo-reactive to sensory inputs (head banging on the floor & delayed or no response, disengaged in activities, intense focus on toy, repetitive toy turning, and irregular sleep pattern). Deficits in social-emotional reciprocity (Lower-than-Normal IQ of 65 & Verbal scores, failure to initiate or respond to social interactions, abnormal social approach, failure of back-and-forth conversation). Insistence of sameness, inflexible adherence to routine, extreme distress at small change (reflected by the need for the same pajamas, aversion to change of routine, babysitters, or new people, especially those wearing hats). The trancelike states with bouts of body/muscle rigidity. Highly restricted, fixation her abnormal and intense interests (focused on a toy she kept turning repetitively).  
DSM-5 TR Diagnosis: Based on the presenting symptoms and characteristics, Sally seems to meet the DSM 5 TR diagnostic criteria for Autism Spectrum Disorder Level 2 F84.0.    
Medications: No medication information was indicated in the case. The clinician can request a signed release of information to request complete medical and medication history.   Questions Does Sally take any prescribed or over-the-counter medical or psychotropic medications? If so, what medications (dose and how often)?   Has there been any changes to medications or supplements taken?        
Hypothesized Core Beliefs: I am alone Others are scary The world is a dangerous place The future is not going to change  Justification for hypothesized core beliefs: The core beliefs of Sally were speculated based on her presenting difficulty of being able to communicate and interact with the world around her.  
Recent Precipitants/Activating Situations: There does not seem to be a specific precipitating situation other than Sally has been described as inflexible to change in environment, routine and to new people.   Questions: Was there a change in school environment such as in classroom, teacher, or schedule?Does Sally’s reactions “Meltdown” occur around the same time every day?    
Working Hypothesis: If Sally’s social-emotional interactions, communication, and ability to cope with her interpersonal and intrapersonal environment improves then Sally’s ability to function more independently in society will increase.  
Developmental Origins: Developmental origins of Sally cannot be determined due to no information provided on specific occurrences or abnormalities during Lisa’s pregnancy were identified. A release of information can be requested to determine the presence of any potential risk factors identified during utero to reflect potential for long-term medical outcomes.   Questions Were there any complications during Lisa’s pregnancy?Was Sally born full-term?Was there any drug or alcohol use during pregnancy?  
Treatment Plan/ Goals Stop harmful head banging and expressions of frustration.Develop positive coping strategies to express frustration to change in a productive wayUse & understand nonverbal communicationInterpret facial expressionsDevelop conversational skills for interactions with peers and adultsForm friendships with other classmates      
Potential Obstacles to Goal Attainment (therapy-interfering factor):   Parents may present a potential barrier to maintaining treatment goals due to their ambivalence to the severity of Sally’s circumstances.   The inflexibility of the school to allow Sally to continue attending the school program while learning social engagement and coping strategies.   Sally may not respond well to treatment to due change in environment and new people and client’s inflexibility to change.  
Potential Aids to Goal Attainment (therapy-enhancing factors):   Parents currently open to finding help and resources for Sally.   Sally neurological test identified normal cognitive abilities.   Sally can learn and remember information when values are identified such as the client’s love for music.    

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