Child Planning: A Treatment Planning Overview for Children with Identity Problems

Transcription

1 COURSES ARTICLE - THERAPYTOOLS.US Child Planning: A Treatment Planning Overview for Children with Identity Problems A Treatment Overview for Children with Grief or Loss Duration: 3 hours Learning Objectives: Obtain a basic understanding of how to identifying, causes, symptoms of children with lying problems or history, and learn different options to complete a treatment plan that includes: a. Behavioral Definitions b. Long Term Goals c. Short Term Goals d. Strategies to Achieve Goals e. DSM V diagnosis Recommendations ***For a full list of 12 short term goals with dozens strategies listed next to each goal check the Child Treatment App for Windows or Apple PC and Android Devices, under our main menu Windows-Apple Apps. Download the Free Demo to Evaluate*** Course Syllabus:

2 Introduction Defining Sex, Gender, and Sexuality and Cultural Variations of Gender How to Support a Child Developing Gender Identity and Identify Symptoms Parental Establishment of Gender Roles Diagnosis and Treatment Steps to Develop a Treatment Plan that includes Behavioral Descriptors, Long Term Goals, Short Term Goals, Interventions/Strategies and DSM V CODE Paired with ICD_9 and 10-CM Codes for ODD Sample Treatment Plan Introduction: Being a boy or a girl, for children, feels very natural. At birth, we are assigned male or female based on physical characteristics. This refers to the "sex" of the child. When children can express themselves, they will declare to be a boy or a girl (or sometimes something in between); this is their "gender identity." Most children's gender identity aligns with their biological sex. However, for some children, the match between biological sex and gender identity is not so clear. Around two-years-old, children become conscious of the physical differences between boys and girls. Before the third birthday, most children are easily able to see themselves as either a boy or a girl. By age four, most children have a sense of their gender identity. During this same time of life, children learn gender role behavior-that is, do ing "things that boys do" or "things that girls do." By age of three, children can see the difference of toys typically used by boys or girls and begin to play with children of their own gender. For example, most girls will move toward dolls and playing house. By contrast, a boy may enjoy toy soldiers, blocks, and toy trucks. Defining Sex, Gender, and Sexuality: As a therapist working with gender issues one must be familiar with the following terms: A person s sex, as determined by their biology, does not always correspond with their gender. Therefore, the terms sex and gender are not

3 interchangeable. Sex refers to physical or physiological differences between male, female, and intersex bodies, including both primary sex characteristics (the reproductive system) and secondary sex characteristics (such as breasts and facial hair). Gender is a term that refers to social or cultural distinctions associated with a given sex; it is generally considered to be a socially constructed concept. Gender identity is the extent to which one identifies with their sex assigned at birth. In many Western cultures, individuals who identify with a role that is different from their biological sex are called transgender. Human sexuality refers to people s sexual interest in and attraction to others, as well as their capacity to have erotic experiences and responses. In addition the following key vocabulary: sex: The distinguishing property, quality, or assemblage of properties by which organisms are classified as female, male, or intersex on the basis of their reproductive organs and functions. gender: The socio-cultural phenomenon of the division of people into various categories according to their biological sex, with each having associated roles, clothing, stereotypes, etc.; those with male sex characteristics are perceived as boys and men, while those with female sex characteristics are perceived as girls and women. sexuality: People s sexual interest in and attraction to others; their capacity to have erotic experiences and responses.

4 Sex: Sex refers to physiological differences found among male, female, and various intersex bodies. Sex includes both primary sex characteristics (those related to the reproductive system) and secondary sex characteristics (those that are not directly related to the reproductive system, such as breasts and facial hair). In humans, the biological sex of a child is determined at birth based on several factors, including chromosomes, gonads, hormones, internal reproductive anatomy, and genitalia. Biological sex has traditionally been conceptualized as a binary in Western medicine, typically divided into male and female. However, anywhere from 1.0 to 1.7% of children are born intersex, having a variation in sex characteristics (including chromosomes, gonads, or genitals) that do not allow them to be distinctly identified as male or female. Due to the existence of multiple forms of intersex conditions (which are more prevalent than researchers once thought), many view sex as existing along a spectrum, rather than simply two mutually exclusive categories. Gender: A person s sex, as determined by his or her biology, does not always correspond with their gender; therefore, the terms sex and gender are not interchangeable. Gender is a term that refers to social or cultural distinctions associated with being male, female, or intersex. Typically, babies born with male sex characteristics (sex) are assigned as boys (gender); babies born with female sex characteristics (sex) are assigned as girls (gender). Because our society operates in a binary system when it comes to gender (in other words, seeing gender as only having two options), many children who are born intersex are forcibly assigned as either a boy or a girl and even surgically corrected to fit a particular gender. Scholars generally regard gender as a social construct-meaning that it does not exist naturally, but is instead a concept that is created by cultural and societal norms. Gender identity is a person s sense of self as a member of a particular gender. Individuals who identify with a role that corresponds to the sex assigned to them at birth (for example, they were born with male sex characteristics, were assigned as a boy, and identify today as a boy or man) are cisgender. Those who identify with a role that is different from their biological sex (for example, they were born with male sex characteristics, were assigned as a boy, but identify today as a girl, woman, or some other gender altogether) are often referred to as transgender. The term transgender encompasses a wide range of possible identities, including agender, genderfluid, genderqueer, two-spirit (for many indigenous people), androgynous, and many others. Cultural Variations of Gender: Since the term sex refers to biological or physical distinctions, characteristics of sex will not vary significantly between different human societies. For example, persons of the female sex, in general, regardless of culture, will eventually menstruate and develop breasts that can lactate. Characteristics of gender, on the other hand, may vary greatly between different societies. For example, in American culture, it is considered feminine (or a trait of the female gender) to wear a dress or skirt. However, in many Middle Eastern, Asian, and African cultures, dresses or skirts (often referred to as sarongs, robes, or gowns) can be considered masculine. Similarly, the kilt worn by a Scottish male does not make him appear feminine in his culture. Sexuality: Human sexuality refers to people s sexual interest in and attraction to others, as well as their capacity to have erotic experiences and responses. People s sexual orientation is their emotional and sexual attraction to particular sexes or genders, which often shapes their sexuality. Sexuality may be experienced and

5 expressed in a variety of ways, including thoughts, fantasies, desires, beliefs, attitudes, values, behaviors, practices, roles, and relationships. These may manifest themselves in biological, physical, emotional, social, or spiritual aspects. The biological and physical aspects of sexuality largely concern the human reproductive functions, including the human sexual-response cycle and the basic biological drive that exists in all species. Emotional aspects of sexuality include bonds between individuals that are expressed through profound feelings or physical manifestations of love, trust, and care. Social aspects deal with the effects of human society on one s sexuality, while spirituality concerns an individual s spiritual connection with others through sexuality. Sexuality also impacts and is impacted by cultural, political, legal, philosophical, moral, ethical, and religious aspects of life. How to Support a Child Developing Gender Identity and Identify Symptoms: If a child is persistent about gender identity feelings, best is to listen and talk to the child and ask questions without judgment. To support: Don't assume gender expression is a form of rebellion or defiance. Don't prevent the child from expressing gender in public or at family activities. Don't shame or punish the gender expression out of the child. Don't block access to gender-diverse friends, activities or resources. Don't blame the child for experiencing discrimination. Don't belittle or ridicule the child's gender expression or allow others to do so. Teach parents how to speak positively about their child, and how to show admiration for the child's identity and expression of it. Allow the child to demonstrate preferences and share them, and encourage a positive sense of self and keep the lines of communication open. Also, a parent may have to let go of specific dreams about a child's future and, instead, focus on what brings joy and security. A child living with supportive parents and caregivers

6 is likely to be a happier child. Symptoms to Watch for: Insisting that they are of the opposite sex Desire to be of the opposite sex Feels that he or she is of the opposite sex Prefers clothes worn by the opposite sex Prefers opposite sex roles in make-believe play Fantasies about opposite sex roles Prefers games that are typical of the opposite sex Prefers playmates of the opposite sex Frequently passes or dresses as the opposite sex Insists that he or she was born in the wrong sex Verbalizes a disgust with his or her sexual anatomy Verbalizes rejection of his or her sexual anatomy

7 Mannerisms are more identified with the opposite sex Refuses to take part in activities associated with their sex Refuses to pass urine as their biological sex do Expresses hopes that their genitals will change Extreme distress at the physical changes of puberty Comfortable only when in the gender role of preferred identity Suppress their feelings and attempt to live their gender role Not tomboyish or normal boys role play of opposite sex Parental Establishment of Gender Roles: In a society rife with gender biases, children regularly learn to adopt gender roles which are not always fair to both sexes. As children move through childhood and into adolescence, they are exposed to many factors which influence their attitudes and behaviors regarding gender roles. These attitudes and behaviors are generally learned first in the home and are then reinforced by the child's peers, school experience, and television viewing. The strongest influence on gender role development seems to occur within the family setting, with parents passing on, both overtly and covertly, their own beliefs about gender. This overview of the impact of parental influence on gender role development leads to the suggestion that an androgynous gender role orientation may be more beneficial to children than strict adherence to traditional gender roles.

8 Within a study conducted by Hilary Halpern it was hypothesized, and proven, that parent behaviors, rather than parent beliefs, regarding gender are better predictors for a child s attitude on gender. It was concluded that a mother s behavior was especially influential on a child s assumptions of the child s own gender. For example, mothers who practiced more traditional behaviors around their children resulted in the son displaying fewer stereotypes of male roles while the daughter displayed more stereotypes of female roles. No correlation was found between a father s behavior and his children s knowledge of stereotypes of their own gender. It was concluded, however, that fathers who held the belief of equality between the sexes had children, especially sons, who displayed fewer preconceptions of their opposite gender. Diagnosis and Treatment: Gender Dysphoria, while being a new addition to DSM-5, is the new term for Gender Identity Disorder. In order to prevent stigma guarantee clinical care for people who perceive and believe they are a different sex than their designated gender, the new term was introduced (American Psychiatric Publishing, 2013). The DSM-5 diagnostic measures for gender dysphoria include tough and unrelenting cross-gender classification that go further than a need for an alleged cultural benefit. Adults and teenagers may have a fixation with doing away of primary and secondary gender features, and have the thought that they are not being characterized by the right sex. One should realize that individuals, who have gender dysphoria, do not have a coexisting physical intersex situation. Noted pain or difficulty is seen in the workplace, dealing with others, as well as in other vital areas of life. This is the defining factor of gender dysphoria (American Psychiatric Publishing, 2013). It is significant to state that gender dysphoria is frequently seen in children, though many children do not end up being adults with gender dysphoria (Canadian Psychological Association, 2013). Psychological involvement may help patients with gender dysphoria. Individual therapy that pinpoints appreciating and handling gender problems should be central. In addition, involving the individual s support group through family, group and marital therapy can offer a safe and secure environment. If needed, the use of hormone therapy may also prove beneficial. Symptoms of Gender Dysphoria DSM-5 states that the initial condition for the identification of gender dysphoria in both adults and teenagers is a noticeable incongruence between the gender the patient believes they are, and what society perceives them to be. This disparity should be ongoing for at least 6 months and should consist of 2 or more of the subsequent criteria (American Psychiatric Association, 2013): Noticeable incongruence between the gender that the patient sees themselves are, and what their classified gender assignment

9 An intense need to do away with his or her primary or secondary sex features (or, in the case of young teenagers, to avert the maturity of the likely secondary features) An intense desire to have the primary or secondary sex features of the other gender A deep desire to transform into another gender A profound need for society to treat them as another gender A powerful assurance of having the characteristic feelings and responses of the other gender The second necessity is that the condition should be connected with clinically important distress, or affects the individual significantly socially, at work, and in other import areas of life. Epidemiology The DSM-5 indicates that the prevalence of gender dysphoria is % for adult born as males, whereas it is % for adult born as females (American Psychiatric Publishing, 2013). Among children, it is higher in those born as boys, where it is times greater than those born as girls. Among teenagers, there is no real difference, between males and females. Prognosis Current case reports offer no evidence that psychotherapy offers total and long-standing about face of cross-gender identity. It is important to state that all transsexuals are not the same, and thus are not part of a uniform group. Early diagnosis and treatment decreases the chance for individuals to suffer depression, emotional agony, and to attempt suicide. It is equally significant to state that gender dysphoria is not identical to homosexuality. Each individual goes through a unique change, some may want a short-term change, and be content with cross-dressing, while others may desire a complete change, and seek gender assignment surgery (Royal College of Psychiatrists, 2013). Those who are born having ambiguous genitalia may meet the criteria for the identification of gender dysphoria. Treatment for Gender Dysphoria Fortunately treatment options exist that are beneficial for gender dysphoria, and these consist of psychotherapy, pharmacologic therapy, as well as other nonpharmacologic

10 therapies, and sexual reassignment surgery (SRS) (Royal College of Psychiatrists, 2013). Professionals are changing pessimistic attitudes regarding SRS, plus more scientific evidence has shown the benefit of this procedure (Royal College of Psychiatrists, 2013). All the same, it should be stated that SRS does not automatically mean any issue is resolved, and much psychotherapy may be needed after the procedure in order to improve outcome generally (Cohen-Kettenis & Pfaf?in, 2009). Psychotherapy The use of psychotherapy, involving psychology and speech therapy, can help individual with gender dysphoria (Royal College of Psychiatrists, 2013) Individuals can be taught about self awareness and confidence needed to handle any issues arising in their daily lives. The support of family members can be engaged through the use of group, marital, and family therapy, which can help in creating an accommodating and encouraging environment (Royal College of Psychiatrists, 2013). Through the use of speech therapy, male-to-female individuals with gender dysphoria can learn how to engage their voice and sound a lot female while talking (Royal College of Psychiatrists, 2013). Additionally, hair therapy may be beneficial for males seeking to become females. Pharmacologic Therapy Many individuals, especially those desiring a complete transformation will need hormonal therapy to enable that process (Royal College of Psychiatrists, 2013). For males seeking a female transformation, certain sex features can be covered up with particular types of hormone known as luteinizing hormone releasing hormone (LHRH) agonists, progestational compounds, spironolactone, flutamide, and cyproterone acetate. For breast development, and to create a more female type of physical appearance, hormones such as ethinyl estradiol and conjugated estrogen are necessary. For females seeking a male transformation, the hormone testosterone will be helpful in promoting body hair. Some individuals may also have comorbid psychiatric diagnoses, such as depression, anxiety, or psychosis. These are best treated with medications like antidepressants, anxiolytics, and antipsychotics. Sexual Reassignment Surgery SRS among teenagers remains a controversial topic, and much debate continues on this issue. In many countries, SRS is not available to teenagers, on the other hand, having this treatment done in the early stages when secondary sex characteristics are not fully formed, may be helpful. In adults, there is a reported satisfactory result in 87 percent of male-to-female and 97 percent of female-to-male SRS patients (Royal College of Psychiatrists, 2013). While most SRS is successful, complications still exist (Royal College of Psychiatrists, 2013). For male to female gender surgery, in some cases, there may be scarring of the vagina, which can result in a shorter and narrower vagina, and increase the risks of recurrent cystitis. For those who desire the removal of breast tissue, while transforming from female to male, there can be substantial scarring. Furthermore, the creation of a penis, scrotum and testicles, known as phalloplasty, can also result in surgical complications.

11 Steps to Develop a Treatment Plan: The foundation of a good treatment plan is based on the gathering of the correct data. This involves following logical steps the built-in each other to help give a correct picture of the problem presented by the client or patient: The mental health clinician must be able to listen, to understand what are the struggles the client faces. this may include: issues with family of origin, current stressors, present and past emotional status, present and past social networks, present and past coping skills, present and past physical health, self-esteem, interpersonal conflicts financial issues cultural issues There are different sources of data that may be obtained from a: clinical interview, Gathering of social history, physical exam, psychological testing, contact with client s or patient s significant others at home, school, or work

12 The integration of all this data is very critical for the clinician s effect in treatment. It is important to understand the client s or patient s present awareness and the basis of the client's struggle, to assure that the treatment plan reflects the present status and needs of the client or patient. There 5 basic steps to follow that help assure the development of an effective treatment plan based on the collection of assessment data. Step 1, Problem Selection and Definition: Even though the client may present different issues during the assessment process is up to the clinician to discern the most significant problems on which to focus during treatment. The primary concern or problem will surface and secondary problems will be evident as the treatment process continues. The clinician may must be able to plan accordingly and set some secondary problems aside, as not urgent enough to require treatment at this time. It is important to remember that an effective treatment plan can only deal with one or a few problems at a time. Focusing in too many problems can lead to the lost of direction and focus in the treatment. It is important to be clear with the client or patient and include the client s or patient s own prioritization of the problems presented. The client s or patient s cooperation and motivation to participate in the treatment process is critical. Not aligning the client to participate my exclude some of the client s or patient s needs needing immediate attention. Every individual is unique in how he or she presents behaviorally as to how the problem affects their daily functioning. Any problems selected for treatment will require a clear definition how the problem affects the client or patient. It is important to identify the symptom patterns as presented by the DSM-5 or Diagnostic and Statistical Manual or the International Classification of Diseases (ICD). GENDER IDENTITY BEHAVIORAL DESCRIPTORS: 1. Expresses the desire to be, or feels that he or she is of the opposite sex. 2. Prefers dressing in clothes typically worn by the opposite sex. 3. Prefers opposite sex roles in make-believe play or fantasies. 4. Prefers games and pastimes that are typical of the opposite sex.

13 5. Prefers playmates of the opposite sex. 6. Frequently passes or dresses as the opposite sex. 7. Insists that he or she was born in the wrong sex. 8. Verbalizes a disgust with his or her sexual anatomy. 9. Verbalizes rejection of his or her sexual anatomy. 10. Mannerisms are more identified with the opposite sex. Step 2, Long Term Goal Development: This step requires that the treatment plan includes at least one broad goal that targets the problem and the resolution the problem. These long term goals must be stated in non-measurable terms but instead indicate a desired positive outcome at the end of treatment. LONG TERM GOALS FOR GENDER IDENTITY PROBLEMS IN CHILDREN: 1. End any confusion regarding sexual identity and allow the acceptance of his or her own gender and sexual anatomy. 2. Stop playing or dressing like the opposite sex. 3. Accept the genitalia as a normal part of the body, and end any repulsion or desire to change it. 4. Establish and develop lasting (six months or longer) same-sex friendships. Step 3, Objective or Short Term Goal Construction: Objectives or short term goals must be stated in measurable terms or language. They must clearly specify when the client or patient can achieve the established objectives. The use of subjective or vague objectives or short term goals is not acceptable. Most or all insurance companies or mental health clinics require measurables objectives or short term goals. It is important to include the patient s or client s input to which objectives are

14 most appropriate for the target problems. Short term goals or objectives must be defined as a number of steps that when completed will help achieve the long-term goal previously stated in none measurable terms. There should be at least two or three objectives or short-term goals for each target problem. This helps assure that the treatment plan remains dynamic and adaptable. It is important to include Target dates. A Target day must be listed for each objective or short-term goal. If needed, new objectives or short-term goals may be added or modified as treatment progresses. Any changes or modifications must include the client s or patient s input. When all the necessary steps required to accomplish the short-term goals or objectives are achieved the client or patient should be able to resolve the target problem or problems. If required all short term goals or objectives can be easily modify to show evidence based treatment objectives. The goal of evidence based treatment objectives (EBT) is to encourage the use of safe and effective treatments likely to achieve results and lessen the use of unproven, potentially unsafe treatments. To use EBT in treatment planning state restate short term goals in a way that steps to complete that goal and achieve results. For example, the short term goal 13. Increase positive self-descriptive statements. Can be restated as; By the end of the session the patient or client will list at least 5 positive self descriptions of himself or herself, and assess how they can help alleviate the presenting problem Remember, that it must be stated in a way one can measure effectiveness. It is important to note that traditional therapies usually rely more heavily on the relationship between therapist and patient and less on scientific evidence of proven practices. EXAMPLES OF SHORT TERM GOALS FOR GENDER IDENTITY PROBLEMS IN CHILDREN: 1. Help minor to agree to consistently wear clothes that are typical of same-sex without objections. 2. Identify and list same sex positive role models for own sexual identity, and explore why this role models are admired or respected. 3. Probe for any physical or sexual abuse history. 4. Increase the level of time spent in socialization with same-sex friends. 5. Identify the causes for rejection of gender identity.

15 Step 4, Strategies or Interventions: Strategies or interventions are the steps required to help complete the short-term goals and long-term goals. Every short term goal should have at least one strategy. In case, short term goals are not met, new short term goals should be implemented with new strategies or interventions. Interventions should be planned taking into account the client s needs and presenting problem EXAMPLES OF INTERVENTIONS FOR GENDER IDENTITY PROBLEMS IN CHILDREN: 1. Help minor identify positive aspects of own sexual identity. 2. Assign the mirror exercise, where the minor talks positively to self regarding his or her sexual identity. 3. Increase positive self-descriptive statements. 4. Use family therapy sessions to explore the dynamics that may encourage gender confusion. 5. Explore parents' attitudes and behaviors that may contribute to sexual identity confusion. Step 5 Diagnosis and Treatment: The diagnosis is based on the evaluation of the clients present clinical presentation. When completing diagnosis the clinician must take into account and compare cognitive, behavioral, interpersonal, and emotional symptoms as described on the DSM-5 Diagnostic Manual. A diagnosis is required in order to get reimbursement from a third-party provider. Integrating the information presented by the DSM-5 diagnostic manual and the current client s assessment data will contribute to a more reliable diagnosis. it is important to note that when completing a diagnosis the clinician must have a very clear picture all behavioral indicators as they relate to the DSM-5 diagnostic manual. DSM V CODE Paired with ICD_9-CM Codes (Parenthesis Represents ICD-10-CM Codes Effective ): Possible Diagnostic Suggestions for Children with Gender Issues:

16 302.6 (F64.2) Gender Dysphoria in Children Specify if: With a disorder of sex development (F64. 1) Gender Dysphoria in Adolescents and Adults Specify if: With a disorder of sex development Specify if: Post-transition Note: Code the disorder of sex development if present, in addition to gender dysphoria (F64.8) Other Specified Gender Dysphoria (F64.9) Unspecified Gender Dysphoria Overall Integration of a Treatment Plan: Choose one presenting problem. This problem must be identified through the assessment process. Select at least 1 to 3 behavioral definitions for the presenting problem. if a behavior definition is not listed feel free to define your own behavioral definition. Select at least long-term goal for the presenting problem. Select at least two short-term goals or objectives. Add a Target Date or the number of sessions required to meet this sure term goals. If none is listed feel free to include your own.

17 Based on the short-term goals selected previously choose relevant strategies or interventions related to each short term goal. If no strategy or intervention is listed feel free to include your own. Review the recommended diagnosis listed. Remember, these are only suggestions. Complete the diagnosis based on the client's assessment data. Sample Treatment Plan: Present Behavioral Descriptors of Problem: 1. Prefers dressing in clothes typically worn by the opposite sex. 2. Prefers playmates of the opposite sex. Long Term Goals: End any confusion regarding sexual identity and allow the acceptance of his or her own gender and sexual anatomy. Short Term Goals Objectives: 1. Identify the causes for rejection of gender identity. 2. Allow minor to increase the level of comfort with or even pride in sexual identity. Strategy or Intervention for Goal 1:

18 1. Conduct family therapy sessions to assess the dynamics that may reinforce the client's gender confusion. 2. Explore with parents their attitudes and behaviors that may contribute to their child s sexual identity confusion. Strategy or Intervention for Goal 2: 1. Conduct a family therapy session in where minor is allow to express his/her feelings toward the same-sex parent, and help work toward resolution of any negativity in these feelings. 2. Give positive feedback when there is appropriate peer socialization or gender behaviors. DSM V Diagnosis: (F64.2) Gender Dysphoria in Children Without a disorder of sex development Copyright 2011 THERAPYTOOLS.US All rights reserved