Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by persistent difficulties in communication and social interaction, coupled with restricted, repetitive patterns of behavior or interest (Hodges et al., 2020). Also, it affects as many as 1 out of 31 children age 4 to 8 years (Shaw, 2025). ASD more prevalent in the pediatric population than many other widely known disorders, such as Down syndrome, learning disabilities, ADHD and anxiety (Spinazzi et al., 2023). Children with ASD may present with additional maladaptive behaviors, including aggression, self-injury, and severe tantrums, which researchers suggest can cause families greater stress than the core features of ASD (Kalvin et al., 2021).

In light of this, routine disruptions are one of the common triggers that escalate aggressive behavior among individuals with ASD, which highlights the importance of evidence-based strategies (Fitzpatrick et al., 2016). Although few treatment options have been well documented for very young children with ASD, Applied Behavior Analysis (ABA) is the hallmark of evidence-based treatments (EBT) available for children with ASD (Gitimoghaddam et al., 2022). ABA encompasses a range of systematic strategies to change behavior in measurable ways, with the aim of reducing problem behavior, increasing social behavior, and teaching new skills (Espinosa-Salas & Gonzalez-Arias, 2023).

Therefore, in managing aggressive behaviors, differential reinforcement of low rates (DRL) has emerged as one of the core behavioral strategies and a common intervention within applied behavior analysis (ABA) in which concurrent schedules are manipulated for one or more responses (Jessel et al., 2015). Variations of this procedure have effectively increased appropriate behavior and decreased maladaptive behavior across a variety of populations (Rey & Gokey, 2023). Differential reinforcement of low rates (DRL) has been used to reduce rates of behavior across several response topographies and populations. For example, it has been reported to reduce rapid eating (Austin & Bevan, 2011) and stereotypy (Singh et al., 1981) in participants with profound developmental disabilities and inappropriate question asking in primary school children with behavioral disorders (Ahmad et al., 2022).

Additionally, Visual support (VS) can be an effective tool for managing challenging behaviors associated with ASD (Rutherford et al., 2019). VS are objects that can be seen or held, which are used to provide information visually to enhance an individual’s understanding of the physical environment; people and the social environment include communication, words, actions, rules and expectations and spoken or unspoken intentions or expectations, and more abstract concepts, such as the passage time, a sequence of events or socially abstract concepts such as emotions or reasons to do something in a particular way. This can include things like visual schedules, social stories, or picture cards (Rutherford et al., 2020).

Furthermore, caregiver training remains a cornerstone in the behavioral intervention framework. Across the literature base on both intensive ABA treatments and parent training for young children with ASD, several key components have resulted in the most substantive developmental gains (Deb et al., 2020). These components include behavioral based intervention, parent involvement, a focus on increasing communication, adaptive skills, and implementation of intervention in the natural environment (Brookman-Frazee et al., 2009).

In particular, Parent Training (PT) is an empirically supported and manualized parent coaching intervention that aims to increase children’s positive behavior, decrease negative behavior, and increase parents’ behavioral management skills (Lieneman et al., 2017). PT designed for children ages 2 to 7 years, is a behavioral intervention that uses parent management training, focusing on the parent as the agent of change, and implementing skills and strategies learned in sessions into the home setting (Calderone et al., 2025). Weekly coaching, along with daily practice at home, helps parents to master an authoritative parenting style over the course of approximately twelve 1-hr treatment sessions (Holliday, 2014).

Case Introduction:

MK is a 4.5-year-old boy from a middle-class nuclear family, came to Benazir Bhutto Hospital's child psychiatric ward with the complaints of poor eye contact, echolalia, repetitive behaviors, sensory issues, and delayed language skills. His history included mother iron deficiency during pregnancy and post-birth hypoxic-ischemic injury requiring nursery care. Developmental milestones were significantly delayed. He has been attending a special education center for seven months, focusing on early intervention strategies like language, social skills, and behavior management.

Assessment Process:

A multidisciplinary assessment, including behavioral observations, parent-rating scales, and a semi-structured autism evaluation, was conducted for diagnosis and intervention planning completed by mother.

Assessment measures:

Childhood Autism Rating Scale (CARS-II) is a four-point likert rating clinical tool used to assess and diagnose autism spectrum disorder (ASD) in children and adults. The CARS-II demonstrates good Cronbach's alpha reliability .79 (Schopler et al., 2010).

Attention Deficit/Hyperactivity Disorder rating scale-IV: Preschool version is a four-point likert rating scale 0 to 3, to assess symptoms of ADHD in children or adults. This scale measures the frequency of specific behaviors related to inattention, hyperactivity, and impulsivity. ADHD Rating Scale showed a Cronbach's alpha of 0.87 (McGoey et al., 2007).

Child Behavior Checklist (CBCL) is a 4-point likert rating scale to assess behavioral and emotional problems in children. It is designed for children aged 1.5 to 5 years old and can be completed by parents or caregivers. The tool consists of various subscales that assess different areas of functioning, such as emotional reactivity, anxiety/depression, social withdrawal, and attention problems, and alphas ranging from 0.54 to 0.79 for parent-reported and from 0.67 to 0.85 for caregiver-reported (Chericoni et al., 2021).

The Portage Guide to Early Education is a developmental curriculum and assessment tool designed to support young children, particularly those with developmental delays or disabilities, from birth to age six. It provides a structured approach to assess a child's skills, identify areas for growth, and guide educators and parents in developing individualized intervention strategies (Brue & Oakland, 2001).

Pre-intervention Assessment Outcome:

The assessment process was carried out over a number of sessions of developing a comprehensive understanding of presenting problems and related issues. We carried out different types of assessment methods using observation, child centered assessment interview with parents and testing session using ADHD rating scale, CARS-II, CBCL and PGEI. Mother of the client helped in completing the preintervention assessment; On the ADHD Rating Scale, the score for inattentiveness was in the clinical range (17), whereas the score for hyperactivity/impulsivity was in the borderline range (16), as well as CARS-II indicated mild to moderate (32) score range. Moreover, CBCL scores indicated significant problems in the following domains: emotionally reactive, anxious/depressed, withdrawn, aggressive behavior and attention problems and portage guide indicated significantly below-average functioning across all developmental domains relative to his age.

Table 1. Functional Age Assessment across Developmental Domains

MK is a 4.5-year-old boy from a middle-class nuclear family who was presented to the child psychiatric ward of Benazir Bhutto Hospital with poor eye contact, echolalia, repetitive behaviors, sensory issues, and delayed language development. His history included maternal iron deficiency and postnatal hypoxic-ischemic injury, followed by delayed developmental milestones. Multidisciplinary assessment was conducted with parental involvement. The Portage Guide indicated significant delays across all domains (e.g., socialization 3 months, language 1 month, cognition 8 months). CBCL scores showed clinical levels of emotional reactivity, anxiety/depression, withdrawal, aggression, and attention problems. The ADHD scale indicated attention deficit, while CARS-II confirmed mild to moderate ASD severity. After brief on assessment outcomes the informed consent and a therapy contract were obtained from parents, who were briefed about the 12-session intervention plan. Treatment modalities included Differential Reinforcement of Low Rates (DRL) to reduce aggression, visual supports to improve routine predictability, and caregiver training to ensure consistency and generalization of skills.

Stage of the clinical case consultation process:

Figure 1. Structured stage of the consultation process.

This flowchart outlines the entire clinical consultation process starting with Pre-Assessment, followed by 14 sessions. It begins with detailed interview intake, psychological assessment and treatment information including DRL procedures and visual supports. Relationship enhancement (CDI) and compliance strategies (PDI) was introduced, followed by coaching, behavior maintenance, and generalization. The process concludes with a post-assessment to evaluate outcomes and followed by a 3 months follow-up to see either the outcome measures during the post-assessment phase remain stable.

The client was referred by his special school teacher for assessment and behavior management. Following a comprehensive assessment, feedback was provided to parents and the results was discussed in detail. A structured intervention plan was then developed and implemented during the consultation process. To develop a thorough understanding of the presenting problems and related issues, a series of assessment meetings were conducted, focusing on a child centered approach as discussed above.

Table 2. Session’s plan and activities implemented

In the pre-assessment assessment, the intensity of the problems was significantly higher before initiation of treatment (see CBCL pre, post and follow-up assessment table). However, parent ratings on the CBCL decreased over the course of treatment. A 3-month post-assessment and 3-month follow-up assessment, Mother’s ratings on CBCL were significantly shows emotional and behavioral improvements.

Table 3. Pre and Post Assessment Score on Child Behavior Checklist (CBCL)